/ J7-2- GYNECOLOGY BY BROOKE M. ANSPACH, M.D. ASSOCIATE IN GYNECOLOGY, UNIVERSITY OF PENNSYLVANIA WITH AN INTRODUCTION BY JOHN G. CLARK m ILLUSTRATIONS PHILADELPHIA AND LONDON J. B. LIPPINCOTT COMPANY COPYRIGHT, 1921, BY J. B. LIPPINCOTT COMPANY Electroiyped and Printed by J. B. Lippincott Company The Washington Square Press, Philadelphia, U. S. A. APR 18 1921 ©CI.A611682 TO JOHX G. CLARK, M.D. PROFESSOR OF GYNECOLOGY UNIVERSITY OF PENNSYLVANIA PREFACE Gynecology is to-day so broad a subject that in order to deal with it ex- haustively a series of monographs would be required. While monographs undoubtedly enrich the literature and are invaluable, they do not altogether !meet the needs of either the student or the practitioner of medicine, for in order to cover the necessary ground the student must of necessity be a voluminous reader, and he would be unusually discerning indeed if he were capable of selecting the pertinent from the unessential or the imma- terial. The monograph, moreover, does not furnish the needed information in such a form as to enable the practitioner to gather his facts with a reason- able expenditure of time. There would seem to be, therefore, a distinct place for the text-book which presents the subject in a systematic form, giving all the necessary information, and omitting such details as are not immediately required for practical purposes. A thorough acquaintance with the subject presented in this way will provide the student with a fund of information that clinical teaching and clinical experience will tend to crystallize and render appli- cable. In the library of the busy general practitioner the comprehensive text-book stands as a ready guide to the accurate diagnosis and the success- ful treatment of the gynecologic conditions most frequently encountered. A logical plan for studying the pathology of any organ or group of organs and of the methods of treatment may be formulated to include : (i) A description of the normal structures and of the normal functions ; (2) a review of the causes that produce the abnormal; and (3) a summary of the manifestations of the abnormal and of the methods of treatment. Believing this to be a rational sequence, the author has arranged and discussed the subject matter in the following order: (1) Normal anatomy and physiology; (2) morbid anatomy and physiologic abnormalities that are dependent upon developmental defects; (3) the acquired causes of disease of the reproduc- tive organs; (4) the general symptomatology, both subjective and objective, of diseases peculiar to the pelvic organs, together with the approved methods of investigation; and finally (5) a systematic arrangement and description of the diseases affecting the organs and structures of the entire generative tract — their morbid anatomy, symptomatology, diagnosis and treatment. In addition to affections of the generative organs proper, such diseases of the intestinal and urinary tract as are most frequently encountered in women have been considered. Static backache, sacroiliac sprain, toxic arthritis, gonorrhoea, tuberculosis, syphilis, menstrual disorders, sterility, the selection and preparation of operative cases, operative technic, post-operative treatment, and the management of post-operative complications, local thera- peutic measures, radium and Rontgen ray therapy, and the use of vaccines, have been dealt with under separate heads. Although seemingly superfluous in a work of this nature, the chapters on anatomy and physiology have been included in the belief that they will vi PREFACE serve to refresh the memory of the student and of the practitioner regarding the details of anatomy and physiology of the generative organs, a knowledge of which is so essential to a full understanding of gynecologic symptoms and operative treatment, and which will render unnecessary a search through the more exhaustive treatises devoted exclusively to these subjects. The author has drawn freely from the literature, and has aimed to give full credit for these quotations in the bibliographic references at the end of each chapter. The bibliography is intended to serve the student as a guide for more extended reading. Some of the earlier writings of the author have also been included. The majority of the illustrations have been made from original photographs or drawings. The author wishes to acknowledge his indebtedness to Dr. John G. Clark for the clinical and teaching experience that facilitated the prepara- tion of this volume. He is under especial obligations also to Dr. Philip F. Williams, who has reviewed the entire manuscript, criticising, correcting, and adding to the text, and assisting in many ways too numerous to mention. The suggestions of Dr. Charles C. Norris in the chapter on tuberculosis, of Dr. Frank Crozier Knowles in the chapter dealing with cutaneous lesions of the external genitalia, and of Dr. Floyd E. Keene in the chapter on exami- nation of the urinary tract, have been most acceptable ; Dr. Wm. J. Merrill and Dr. Frank Dickson have given assistance in the preparation of the chap- ter on backache ; Dr. Leon Jonas, in the section on acidosis ; and Dr. Henry Pancoast, in the chapter on radium treatment and Rontgen ray therapy. The author's thanks are also due to the artists, particularly Mr. Aitken, for the excellence of their work ; to the publishers, for their unfailing courtesy; to Miss Lilian B. Mendel, for careful editorial work; and to Miss Lydia Stieglitz, for her painstaking efforts in typing the manuscript. The Author. January, 192 i. CONTENTS CHAPTER PAGE I. Embryology i Embryologic Structures: Wolffian Body and Wolffian Duct, Mullerian Duct, Sexual Gland. Foetal Structures: Ovary, Uterus, Tubes, Vagina, External Genitalia, Bladder and Urethra, Rectum, Ureter and Kidney. Generative Organs at Birth and During Childhood: Ovary, Uterus, Tube, Vagina. Embryonic Rests and the New Formations Originating in them. II. Developmental Anomalies of the Generative Organs 15 Morbid Anatomy: Ovary. — Absence of both; of one; rudimentary ovaries; supernumerary ovaries. Tubes. — Absence of both; of one; partial development; persistence of foetal type; supernumerary tubes; accessory ostia; diverticula. Uterus. — Complete absence; unicornis; duplex bicornis; duplex septus; bicornis; rudimentary; foetal type; infantile type; lateroposition; retroversion; retroflexion; anteflexion; stenosis of cervix. Vagina. — Complete absence; double; unilateral; atresia; septate. Hymen. — Atresia; double. Vulva. — Atresia or de- fectus; infantile. Bladder and Urethra. — Absence; double bladder; vesico-umbilical fistula; cyst of the urachus; epispadias; exstrophy of bladder; hypospadias. Ureter. — Duplication; absent; occlusion; ab- normal communications. Kidney. — Absent; rudimentary; foetal type; horseshoe; disciform. Anus and Rectum. — Complete absence of anus; imperforate anus; abnormally situated anus; partial and complete occlusion of the rectum; abnormal communications. Pseudohermaph- rodism. — Female; male. Gynatresia. — Forms; symptoms. Diag- nosis: External Genitalia; Uterus and Vagina, Imperfect, Double; Gynatresia. Treatment: Atresia Labia Minora; Hypertrophy of Clitoris; Hypertrophy of Labia Minora; Hypertrophy of Prepuce; Imperforate Hymen ; Rigid Hymen ; Epispadias ; Hypospadias ; Exstrophy of Bladder; Vaginal Adhesions; Atresia Vaginae, complete, partial; Vaginal Septa; Vaginal Stenosis; Hypertrophy of Cervix; Atresia of Cervix; Stenosis of Cervix; Infantile Uterus; Bicornate or Double Uterus; Hermaphrodism ; Gynatresia; Anus and Rectum. III. Anatomy of the Generative Organs 31 Perineum: Vulva. Mons; Labia Majora; Labia Minora; Clitoris; Vestibule; Bartholin's Glands; Vestibular Bulbs. Vagina; uterus; tubes; ovaries; bladder; urethra; ureters; rectum; anus; the pelvic peritoneum; the uterine ligaments; the pelvic cellular tissue; the pelvic floor. Muscles. — Levator ani; coccygeus; pyriformis; trans- versa perinei; bulbo-cavernosi ; external sphincter ani; internal sphincter ani. Fascia. Blood-vessels of Pelvis: Arteries. — Ovarian; internal iliac; uterine; superior vesical; inferior vesical; vaginal ; superior hemorrhoidal; middle hemorrhoidal; inferior hemorrhoidal; internal pudic. Veins. — Ovarian ; uterine ; vesical ; internal pudic ; internal iliac ; obturator; superior hemorrhoidal; middle hemorrhoidal; hemorrhoidal plexus; inferior hemorrhoidal. Lymphatics of Pelvis: Pelvic Lymph- nodes. — Iliac; hypogastric; sacral; inguinal. Lymphatic Radicles. — From external genitalia; from ovary; from tube; from uterus, large fundal, small fundal, lower body and cervix; from vagina, upper, middle, lower. Abdominal Wall. IV. Physiology 61 Reproductive Organs: Introduction. — Sexual maturity; nubility. Puberty. — Age; influences affecting; manifestations of puberty (psychical and physical) ; ovarian development. Functions of the Sex- ual Organs. — External genitalia ; internal genitalia ; glands of internal secretion; placenta; mammary glands. Menstruation. — Underlying impulse; phenomena of menstruation; menstrual flow; menstrual habit. Ovulation. — Rupture of follicle; corpus luteum; relation be- tween menstruation and ovulation. Anatomic changes incident to viii CONTENTS ovulation and mensturation. Fecundation. — Mechanics of insemi- nation; penetration of sperms to outer part of the tube. Nidation of the Ovum. — Decidua; chorion villi; trophoblast; intervillous blood spaces; placenta. Pregnancy. — Changes in uterus, fundus and cervix; tubes; ovaries (corpus luteum of pregnancy); vagina; ab- dominal wall; bladder. Labor. — Dilatation of cervix; formation of perineal gutter; dilatation of vaginal outlet; separation and expulsion of placenta; abortion or miscarriage. Puerperium. — Involution; struc- tures involved; residua indicative of pregnancy. Menopause. — Age; changes in ovaries; nervous manifestations; premature menopause; artificial menopause. Excretions of Genitalia. — Characteristics and source. Ureters: Excretion of Urine. — Gravity, peristalsis; back flow of kidney pelvis; back flow to ureter. Bladder: Free and fixed part of bladder; mechanics of retention and expulsion; reflexes in- volved. Rectum: Mechanics of defecation; reflexes involved. V. Causes of Pelvic Disorders 87 Congenital: Appearing at Birth. — Gross malformations or tumors. Appearing at Puberty. — Gynatresia. Appearing During Reproductive Period. — Fibroid Tumor; sarcoma. Appearing at Menopause or After. — Ovarian tumors; carcinomata. Acquired: General Causes. — Anaemia; heart disease; mumps; tuberculosis; exanthemata of child- hood; defective development; bad hygiene; depressing conditions of body and mind; unnatural sexual state; unstable nervous system. Complicating Pregnancy and Labor. — Displacements; laceration. Cause of Malignant Growth. — Factors seeming to influence the de- velopment of cancer of vulva; cancer of vagina; cancer of cervix; can- cer of fundus; cancer of ovary. Infections. — Gonorrheal; puerperal; abortal. Bacteriology of Generative Tract. — Bacterial forms and peculiarities: Tuberculosis infection; gonococcus infection; strepto- coccus infection; staphylococcus infection. VI. History- taking and Symptomatology 91 History: Attitude Toward Patient in Taking the History; Form of History Record; Chief Complaint; Age and Social State; Occupation and Habits of Life; Menstrual History; Pregnancies; Labor; Abortion; Family History; General Previous History; Onset of Present Trouble. Symptomatology: Present Symptoms. — Pain; location; quality. Menstrual Symptoms. — Amenorrhcea; menorrhagia; metrorrhagia, dysmenorrhoea. Leucorrhcea. — Amount; quality. Rectal Symptoms. — Constipation. Bladder Symptoms. — Frequency of urination; time of occurrence. Gastio-intestinal Symptoms; Respiratory Symptoms; Circulatory Symptoms; Nervous Symptoms; General Health. VII. General Physical Examination 103 General Appearance ; Temperature ; Circulation ; Pulse Rate ; Exam- ination of the Heart; Respiratory Rate; Examination of the Lungs; Examination of the Blood; Blood Count; Blood Culture; Wasser- mann Reaction; Abderhalden Serum Test: Complement-fixation Test for Gonorrhoea; Obtaining Blood for Serum Tests; Exam- ination of the Urine. Bacteriologic Examination of the Urine; Recognition of Tubercle Bacillus by Guinea-pig Inoculation. VIII. Examination of the Pelvis and Abdomen 112 General Consideration: Examination under Anaesthesia; Preparation for Examination. Positions for Pelvic and Abdominal Examination. — Dorsal; knee-chest; lithotomy; Sims'; supine; erect. Preparation of Physician's Hands. — Lubricant; gloves. Illumination. — Window; electric bulb. Instruments. — Specula, bivalve, trivalve, cylindric, rectal; vulsella; sound; dilators. Special methods of Examination; — Intrauterine digital palpation; Diagnostic Curettement and Test Excision. Smear Preparations as an aid to Diagnosis. Demonstra- tion of Treponema Pallidum. Pelvic Examination: Inspection. — External genitalia; vagina and cervix; pelvic viscera. Palpation. — Simple digital; bimanual; bimanual with cervix pulled down; bimanual with finger in rectum; trimanual palpation. Abdominal Examination: Inspection; Palpation; Percussion; Auscultation; Mensuration; Routine Examination of Remote Abdominal Organs. CONTEXTS ix IX. Examination of the Urinary Organs 158 Urinalysis: Significance of constituents. Palpation: Urethra; blad- der; ureter; kidney. Percussion: limited field of usefulness. In- spection: Urethra; Urethroscopy; Bladder and Ureteral Orifices; Cystoscopy. Methods; general preliminaries. Technic of the Direct Method with Atmospheric Distention of Bladder. — Local anaesthesia; dilatation of meatus; position; removal of urine; locating fixed ana- tomical points; unusual appearances. Technic of the Indirect Method with Water Distention of Bladder. — Position; picture presented by normal bladder; alterations and significance thereof; in capacity of bladder; color and transparency of mucosa; number, size, and outline of vessels; shape of the vesical interior; submucous trabecular; posi- tion of the ureteral orifices. Catheterization of the Ureters: Technic with the Direct Method. — Preparation and introduction of catheters. Technic of the Indirect Method. — Facts determined by catheteriza- tion; examination of the ureter and kidney by means of a wax-tipped bougie; collecting urine. Rontgenographic-ray Examination of the Kidney: Diagnostic Methods Combining the Ureteral Catheteri- zation, collargol Injection, and the Rontgenographic-ray: Bismuth Catheter; Pyelography. Estimation of the Functional Activity of the Kidneys, Combined or Separate: Chromocystoscopy. — Indigo- carmine; chromo-ureteroscopy ; phenolsulphonephthalein. Blood Urea. X. Examination of the Anus and Rectum 162 Preparation of Patient: Position. Inspection. — External, internal specula; Tuttle's, Kelly's', pneumatic proctoscope; appearance of healthy and of diseased bowel through the proctoscope; other useful instruments in making rectal examinations. Palpation. XI. Diseases of the External Genitalia 166 Skin Diseases. — Cutaneous diseases; herpes; parasitic diseases. Vul- var Adhesions; Vulvitis; Gangrene; Pruritus; Kraurosis Vulvas; Ele- phantiasis. Venereal Sores. — Chancre; secondary syphilitic; tertiary syphilitic; chancroid; warts. (Edema; Varicose Veins; Hematoma; Hypertrophy; Carcinoma; Sarcoma; Tuberculosis; Rodent Ulcer; Fibromyoma; Lipoma; Sebaceous Cysts. Vulvovaginal Glands. — Inflammation of ducts; abscess; cyst. Injuries of the External Geni- talia; Pudendal Hernia. XII. Diseases of the Hymen and Vagina 192 Hymen; Abnormal Rigidity or Elasticity of the Hymen; Cystic Tu- mors of the Hymen. Vagina; Vaginitis (Paravaginitis); Vaginismus. Cysts. — Fibromyoma; Sarcoma; Carcinoma; Chorioepithelioma. For- eign Bodies in Vagina; Leucorrhcea. XIII. Injuries to the Perineum and Their Results 200 Physiology of Support of the Pelvic Floor; The Production of Injuries During Labor; Forms of Laceration and Their Result; Symptoms of Relaxed Perineum; Diagnosis; Treatment; Cystocele; Treatment. XIV. Diseases of the Cervix 223 Atresia, Congenital and Acquired. — Causes: symptoms; treatment. Endocervicitis, Acute and Chronic. — Causes; symptoms; treatment, palliative and radical. Cervical Polyp. — Causes; symptoms; treat- ment. Laceration of Cervix; Secondary Lesions. — Eversion; Nabo- thian cysts. Hypertrophy of Cervix; Hypertrophy of Cervix in Nul- liparae. Symptoms of Lacerated Cervix. — Of simple; of complicated lacerations. Treatment of Lacerated Cervix; Indications for Opera- tion; Preparatory Local Treatment; Choice of Operation; Trachelor- rhaphy; Trachelectomy. XV. Changes in Form and Position of the Uterus 237 Normal Flexion and Position. — Relations of axis of body to the axis of the cervix; normal flexion and position; exaggerated flexion in ill- developed stenotic cervix; subnormal flexion in chronic metritis. Pathologic Flexions and Positions. — Retroflexion; retroposition; latero-position and flexion ; anteposition in chronic metritis; descensus; CONTENTS prolapse; changes in the axis of the uterus in relation to that of the vagina, preceding downward displacement; elevation of the uterus. Pathologic anteflexion; Varieties; Symptoms. Treatment — Forcible dilatation; Dudley's operation; Pozzi's operation; Wy lie's drain; Norris drain; Metranoikter. Retroflexion and Retroversion; Causes; Pathology; Symptoms. Treatment. — Replacing uterus, use of pes- sary; operations, discussion of choice; technic of Alexander, ventro- suspension, ventral fixation; Coffey's operation; Webster-Baldy operation; Simpson's operation; shortening utero-sacral ligaments. Descensus of Uterus and Prolapse; Mechanics and Etiology; Ac- companying Lesions; Diagnosis. Treatment. — Pessaries, choice of operation; technic of vaginal fixation; Watkin's operation; supra- vaginal hysterectomy and fixation of stump. Anteposition; Elevatio Uteri; Torsion; Causes and Associated Conditions. Inversion. — Causes; symptoms; treatment. XVI. Diseases of the Endometrium and Myometrium 277 Endometritis. Acute. — Causes; symptoms; diagnosis; treatment. Chronic. — Causes; conditions erroneously called chronic endometritis; symptoms; diagnosis; treatment. Endometrial Polyp. — Pathology; symptoms; treatment. Metritis. Acute. — Symptoms; treatment. Chronic. — Symptoms; diagnosis; treatment. Subinvolution. — Pa- thology ; symptoms ; treatment. Hyperinvolution. — Symptoms ; treat- ment. Perforation of the Uterus. — Causes; pathology; symptoms; treatment. Hematometra, Physometra, Pyometra. — Causes; symp- toms; treatment. Curettement, Curative and Diagnostic. XVII. Myomata of the Uterus; Adenomyoma 292 Etiology and Histology: Vascularization of Myomata. Capsule, Number, Shape, Consistency; Situation. — Interstitial, Submucous, Subperitoneal. Migration of Myomata; Parasitic Tumors; Intra- ligamentous Myomata; Retroperitoneal; Subvesical. Growth; Dis- appearance. Pathology: Effect of Myomata on the Uterine Cavity and Wall; Effect of Myomata on the Appendages; Effect of Myomata on Bladder, Urethra, Ureters and Rectum; Effect of Myomata on Cardio-vascular System; Degenerations of Myomata. Symptoms. — Frequency; age of occurrence ; race; hemorrhage; pain; leucorrhcea; anasmia. Diagnosis. — Abdominal examination; bimanual palpation; submucous; interstitial; subperitoneal. Differential Diagnosis. — Ovarian cyst ; pregnancy. Treatment. — Palliative. Radical. — Choice of operation; myomectomy; abdominal; vaginal; hystero-myomec- tomy; pan-hysterectomy for myomata. Adenomyomata : Histology and Etiology; Pathology; Symptoms and Diagnosis; Treatment. XVIII. AIalignaxt Tumors of the Uterus 330 Carcinoma of the Uterus. — Situation; etiology. Carcinoma of the Cervix. — Pathology; symptoms; diagnosis; "treatment; prognosis; the question of operability; treatment of inoperable cases; recurrence of carcinoma after operation. Carcinoma of the Body of the Uterus. — Pathology; symptoms; prognosis; treatment. Sarcoma of the Uterus. — Pathology; symptoms; diagnosis; treatment. Chorioepithelioma. — Pathology; symptoms; diagnosis; prognosis; treatment. Panhyster- ectomy for Malignant Tumors of the Cervix; Vaginal Hysterectomy for Malignant Tumors of the Cervix (Simple) ; Vaginal Hysterectomy for Malignant Tumors of the Cervix with Paravaginal Incision ; Cu- rettement and Cauterization ; High Amputation for Malignant Tumors of the Cervix with the Cautery Knife. XIX. Diseases of the Fallopian Tubes 359 Inflammatory Disease. Salpingitis. — Etiology; pathology. Endosal- pingitis; Perisalpingitis; Interstitial Salpingitis; End Results of Endosalpingitis; Pyosalpinx; Tubo-ovarian Abscess; End Results of Perisalpingitis; Hydrosalpinx; Tubo-ovarian Cyst; Hematosalpinx; New Formations of the Tube; Polyps; Papillomata; Cysts of the Tubes; Myomata; Embryomata; Carcinoma; Symptoms, Diagnosis and Treatment of Affections of the Fallopian Tubes. Acciden ts Affect- ing Tubal Enlargements. — Rupture of pyosalpinx; rupture of hydro- CONTENTS xi salpinx; torsion of tubal enlargements; treatment. Extrauterine Pregnancy. — Etiology; varieties of extrauterine pregnancy; pathol- ogy. Nidation of Ectopic Ovum; Tubal Abortion and Tubal Rup- ture; Fate of the Ovum; Abdominal Pregnancy; Hemorrhage; Pelvic Hematocele; Free Intraperitoneal Hemorrhage; Uterine Changes in Extrauterine Pregnancy; Fate of the Pregnant Tube; Symptoms Previous to Tubal Rupture or Abortion; Symptoms at the Time of Rupture or Abortion; Symptoms Following Rupture or Abortion in Case of Abdominal Pregnancy; Prognosis; Diagnosis before Rup- ture; at Rupture or Abortion; Hematocele Formation; Abdominal Pregnancy; Treatment. XX. Diseases of the Ovaries 381 Inflammation: Acute Interstitial Oophoritis. — Etiology; pathology. Acute Perioophoritis. — Etiology; pathology; end result of acute inter- stitial oophoritis; end result of acute perioophoritis; symptoms, diag- nos ; s, and treatment of inflammatory diseases of the ovaries. Chronic Oophoritis; Tumors of the Ovary; Epithelial; New Growths. Glandu- lar Cysts (Adenocystoma). — Etiology; pathology; symptoms; diag- nosis. Parovarian Cysts. — Etiology; pathology; symptoms; diagnosis. Papillomatous Cysts. — Etiology; pathology; symptoms; diagnosis. Carcinoma of the Ovary. — Etiology; pathology; symptoms; diagnosis. Connective Tissue New Growths: Fibromata, Fibromyomata. — Pathology; symptoms; diagnosis. Sarcomata. — Pathology; symp- toms; diagnosis. Combined Epithelial and Connective Tissue New Growths: Dermoid Cysts of the Ovary. — Etiology; pathology; symp- toms ; diagnosis. Treatment of Ovarian New Growths. Cystomata. — Uncomplicated glandular cystomata of the ovary; intraligamentous cysts; papillomatous cysts; cystoma complicating pregnancy. Car- cinomata; Fibromata; Sarcomata. Retention Cysts of the Ovary. Graafian Follicle Cysts. — Etiology. Hydrops Folliculi. — Etiology. Corpus Luteum Cysts. — Etiology; symptoms, diagnosis, and treat- ment of retention cysts. Compound theca-lutein cysts of the ovary. Accidents and Complications of Ovarian Tumors: Infection. — Etiology; symptoms; diagnosis. Torsion. — Etiology; symptoms; diagnosis. Rupture. — Etiology; symptoms; diagnosis. Malignant Degeneration. — Symptoms; diagnosis; treatment of accidents and complications of ovarian tumors. Atrophy of the Ovary; Hyper- trophy of the Ovary ; Hernia of the Ovary. Prolapse of the Ovary. — Cause; symptoms; diagnosis; treatment. XXL Pelvic Inflammatory Disease 41 1 Pelvic Inflammatory Disease. — Classification; etiology; pathology. Gonorrhceal Pelvic Inflammatory Disease. — Etiology; pathology; symptoms; treatment. Puerperal Pelvic- Inflammatory Disease. — Etiology; pathology; symptoms; diagnosis; prognosis; end results; treatment. Instrumental or Post-operative Pelvic Inflammatory Disease. — Etiology; pathology; symptoms; treatment. Pelvic Ab- scess. — Definition; treatment. Chronic Pelvic Inflammatory Dis- ease. — Etiology; pathology; symptoms; diagnosis; treatment. Cellu- litis.— Etiology; pathology; symptoms; diagnosis; treatment. Chronic Pelvic Cellulitis. — Symptoms; diagnosis; treatment. Pelvic Hema- toma. — Etiology; pathology; symptoms; diagnosis; prognosis; treat- ment. Hysterectomy for Pelvic Inflammatory Disease; Salpingo- oophorectomy; Salpingectomy; Salpingostomy; Vaginal Incision and Drainage. XXII. Diseases of the Urethra 440 Urethritis. — Causes. Acute. — Symptoms; diagnosis; prognosis; treat- ment. Chronic. Suburethral Abscess. — Cause ; symptoms; treatment. Fissure of Urethra. — Cause; symptoms; diagnosis; treatment. Pro- lapse of Urethral Mucosa. — Cause; symptoms; treatment. Dilata- tion of Urethra. — Cause; symptoms; treatment. Stricture of Urethra. — Cause; symptoms; diagnosis; treatment. Urethral Caruncle. — Symptoms; treatment. New Growths of Urethra. Xll CONTENTS XXIII. Diseases of the Bladder 453 Cystitis. Acute Cystitis. — Etiology; symptoms; diagnosis; treatment; prognosis. Chronic Cystitis. — Etiology; symptoms; diagnosis; treat- ment. Tuberculous Cystitis. — Etiology; symptoms; diagnosis; treat- ment. Vesical Calculus. — Etiology; symptoms; diagnosis; treatment. Hunner Type of Bladder Ulcer in Women. New Growths of the Blad- der: Papilloma. — Symptoms; diagnosis; treatment. XXIV. Urinary Fistula 463 Site and Varieties. Urogenital Fistula. — Etiology; symptoms; diag- nosis. Treatment. — Vaginal operations; extraperitoneal abdominal operations; nephrectomy. XXV. Diseases of the Kidney and Ureter 469 Diseases of the Kidney. Ptosis; Abnormally Movable Kidney. — Etiology; symptoms; diagnosis; treatment. Hydronephrosis. — Con- genital, acquired; etiology; symptoms; diagnosis; differential diag- nosis; treatment. Pyelonephritis, Pyelonephrosis, Empyema of the Kidney Pelvis and Kidney Abscess. — Etiology; symptoms; diagnosis; treatment. Tuberculosis of the Kidney. — Etiology; pathology; symp- toms; diagnosis; treatment; prognosis. Renal Calculus. — Etiology; symptoms; diagnosis; treatment. Tumors of the Kidney. — Nature; symptoms; diagnosis; treatment. Cystic Tumors of the Kidney; Polycystic Disease of the Kidney; Adenocystoma; Adrenal Tumors; Pararenal Tumors; Kidney Operations; Nephropexy; Nephrotomy; Nephrolithotomy; Nephrectomy. Pyelitis. — Acute, chronic, etiology; symptoms; diagnosis; prognosis; treatment. Diseases of the Ureter. Inflammation. — Symptoms; diagnosis; treatment. Ureteral Calcu- lus. — Symptoms; diagnosis; treatment; operative treatment; stone in the upper ureter; stone in the pelvic brim; stone on the pelvic floor; stone in the vesical portion of the ureter; stone in the intraparietal ureter. Stricture of the Ureter. — Etiology; symptoms; pathology; diagnosis; treatment. Obstruction of the Ureter. — Symptoms; treatment. Ureteral Fistula; Ureteral Ligation; Ureteral Tear or Injury. XXVI. Diseases of the Abdominal Viscera Related to, or Associated with. Pelvic Disorders 500 Introduction. Appendicitis. — Involvement of appendix in pelvic dis- ease; varieties of appendicitis. Acute Appendicitis. — Symptoms; diagnosis; differential diagnosis between acute appendicitis and acute adnexitis; history; symptoms; physical signs; course of the symptoms; treatment. Chronic Appendicitis. — Symptoms and diagnosis; dif- ferential diagnosis between chronic appendicitis and chronic adnexitis; treatment. Appendicectomy. — Interval operation; operation in acute cases: (a) Unruptured; (b) perforated appendix with spreading peri- tonitis; (c) appendicial abscess. Intestinal Stasis. — Acute, chronic. Varieties. — Chronic intestinal stasis from pelvic disease; chronic in- testinal stasis from enteroptosis; chronic intestinal stasis from ad- hesions between intestinal loops or between the intestine and the parietal peritoneum or the mesenteries or omentum; chronic intestinal stasis from redundancy and overdistention of the colon; symptoms; diagnosis. Treatment. — Gastropexy; colonopexy; release of adhesions; short-circuiting by intestinal anastomosis; resection of intestine; con- traction or expansion of the abdomen. Diverticulitis. — Etiology, symptoms; treatment. XXVII. Diseases of the Anus and Rectum 522 Fissure in Ano. — Etiology; symptoms; diagnosis; treatment; divul- sion of the sphincter; operation for fissure in ano. Fistula in Ano. — Etiology; symptoms; diagnosis; treatment; operation for fistula in ano. Pruritus Ani. — Etiology; symptoms; diagnosis; treatment. Hemorrhoids. — Etiology; symptoms; diagnosis; treatment; operative treatment. Prolapse of the Rectum. — Etiology; varieties; symptoms; diagnosis; treatment. Tumors of the Rectum. Polyps. — Etiology; CONTENTS xiii symptoms; diagnosis; treatment. Carcinoma of the Rectum. — Loca- tion; etiology; symptoms; diagnosis; treatment. Stricture of the Rectum. — Etiology; symptoms; diagnosis; treatment. XXVIII. Backache 536 Introduction ; Mechanics of Equilibrium. Static Backache. — Etiology ; symptoms; diagnosis; normal type; kangaroo type; gorilla type; differ- ential diagnosis; treatment; orthopedic treatment; mechanical treat- ment; gorilla type. Sacroiliac Sprain. — Etiology; symptoms; exami- nation; diagnosis; treatment; prognosis. Toxic Arthritis; Pendulous Fat Abdomen, Relaxed Abdominal Wall. Coccygodynia. — Etiology; symptoms; diagnosis; treatment. XXIX. Gonorrhoea 554 General Peculiarities; Latent and Residual Gonorrhoea; Symptoms; Diagnosis; Technic of the Preparation and the Examination of Smears for the Gonococcus; Prognosis; Prophylaxis; Treatment of the Acute Initial Stage. XXX. Tuberculosis of the Generative Organs 560 General Considerations; Incidence. Tubal Tuberculosis. — Symp- toms; treatment. Tuberculosis of the Peritoneum. — Pathology; symptoms; treatment. Tuberculosis of the Endometrium. — Symp- toms; treatment. Tuberculosis of the Ovary; Tuberculosis of the Cervix; Tuberculosis of the Vagina; Tuberculosis of the vulva. XXXI. Syphilis of the Generative Organs 569 General Considerations; Mode of Infection; Pathology; Syphilis of the Vulva; Syphilis of the Vagina; Syphilis of the Cervix; Syphilis of the Uterus; Syphilis of the Tube; Syphilis of the Ovary; Syphilis of the Cellular Tissue; Diagnosis of Syphilis of the Generative Tract in Women; Differential Diagnosis of Syphilitic Lesions of the Cervix; Prognosis of Syphilitic Conditions of the Generative Tract in Women; Treatment. XXXII. Disorders of Menstruation 579 Precocious Menstruation; Delayed Menstruation; Vicarious Men- struation; Amenorrhcea; Anatomical Defects Producing Amenorrhcea; Constitutional Diseases Producing Amenorrhcea; Psychic Influences Producing Amenorrhoea; Menorrhagia; Metrorrhagia; Dysmenorrhcea ; Dysmenorrhcea Due to Developmental Defects; Dysmenorrhoea Due to Acquired Lesions; Interval Dysmenorrhcea; Treatment of Dysmen- orrhcea; Membranous Dysmenorrhcea; Menopause; Premature Meno- pause; Artificial Menopause. XXXIII. Sterility 598 Etiology; Imperfect Development of Genital Organs; Acquired Dis- eases; Functional Defects. Diagnosis. — Huhner's method. Treat- ment. — Ovarian transplantation; artificial insemination. XXXIV. Hygiene and the Relation Between Nervous and Gynecologic Disorders 609 The Hygiene of Adolescence ; The Relation of Neuroses to Pelvic Dis- ease; Insanity in Its Relation to Gynecology. XXXV. The Selection and Preparation of Patients for Operation 613 The Selection of Cases; The Examination and Treatment of Patients Preparatory to Operation; Cardiac Risks; Anaemia Risks; Blood-pres- sure Risks; Crile's Anoci Association-, Kidney Risks. XXXVI. Operative Technic 620 General Preparation of the Patient. Preparation of the Operative Area. — Perineal operations; abdominal sections. Preparations of the Operator and Assistants; Preparation of Dressings and Utensils; Preparation of the Operating Room and Furniture; Preparation of Wash- Water; Preparation of Instruments; Ventilation and Lighting; Some General Points in Operative Technic to be Observed During the Operation. The Abdominal Incision. — Low paramedian celiotomy / XIV CONTENTS incision; right or left lateral celiotomy incision; high paramedian celi- otomy incision; transverse suprapubic incision; gridiron incision. Kidney Incisions. — Kelly's incision; Mayo's incision for lumbar ex- posure of the kidney; Israel's incision; Mayo-Robson's incision. •Di- rections Regarding All Incisions; Isolation and Exposure of the Operative Area; Exploration of the Abdomen; Hemostasis; Adhesions; Wounds of the Viscera; Ligation of the Ureters; Treatment of Sur- faces Denuded as the Result of Separation of Adhesions; Closing the Incision; Dressing the Incision; Sponges and Pads Used in Abdominal Surgery. Anaesthesia. — Ether; chloroform; nitrous oxide and oxygen; nitrous oxide, oxygen and ether; anaesthesia by combined general and local methods; ethyl chloride. Local Anaesthesia; Solutions for Producing Local Anaesthesia. Technic of Producing Local Anaes- thesia by the Injection of Novocaine. — Celiotomy incisions; vulvar or vaginal incisions; cervix operation or hysterotomy. Local Anaes- thesia by Freezing with Ethyl Chloride; Spinal Anaesthesia in Pelvic Surgery; Multiple Operations; Operations During Pregnancy. Drain- age. — Gall-bladder and gall-ducts; pancreas; kidney; bladder. Post- operative Care in Drainage Cases. XXXVII. Post-operative Treatment 663 Thirst; Pain Following Operation; The Diet; The Care of the Bowels; The Care of the Bladder; Enteroclysis; Posture After Operation; Fowler; Trendelenburg; Out of Bed; Dressing the Incision. XXXVIII. Post- operative Complications 670 Shock. — Etiology; symptoms; treatment. Hemorrhage. — Varie- ties: capillary oozing; venous and arterial hemorrhage; hemorrhage after plastic operations; symptoms; diagnosis; treatment. Excessive Nausea and Vomiting. Tympanites. Peritonitis. — Etiology; symptoms; diagnosis; treatment. Intestinal Obstruc- tion. — Etiology; symptoms; diagnosis; treatment. Acute Gastric Dilatation. — Etiology; symptoms; diagnosis; treatment. Bron- chitis. Pleurisy. Nephritis. Suppression of Urine from Ureteral Obstruction. Phlebitis. Pulmonary Embolism. — Etiology; symp- toms; diagnosis; treatment. Post-operative Renal Infection. Suppuration of the Incision. Local Inflammation or Suppuration in the Pelvis. Cystitis. Post-operative Cardiac Dilatation. Post-operative Parotitis. Acidosis. XXXIX. Mechanical and Medicinal Aids to Treatment 696 Abdominal Support: Binders and Bandages. — Binder; corsets. Ap- plications to the Endometrium; Applications to the Cervix; Applica- tions to the Vagina; Applications to Bartholin's Glands; Applications to the Urethra and Skene's Tubules; The Use of Heat in Pelvic In- flammatory Disease; Electricity; Pessaries; The Electro-cautery and the Thermo-cautery; The Uterine Pack; The Vaginal Douche; The Vaginal Tampon. XL. Radium and Rontgen-ray Therapy 713 Radium; Carcinoma of the Cervix; Carcinoma of the Fundus; Myo- mata Uteri; Hemorrhagic Uteri; Carcinoma of the Vulva; Papillomata and Carcinomata of the Bladder; Rectal Diseases; Abdominal Tumors. XLI. Vaccine and Serum Therapy in Gynecology 725 Specific Therapy; Auto-serum Therapy; Vaccine Therapy; dosage. ILLUSTRATIONS FIG. PAGE i . Schematic Outline Showing Development of Reproductive Organs 2 2. Enlarged Schematic Wolffian Tubule at Height of Development 3 3. Wolffian Bodies and Sexual Glands of a Human Embryo 3 4. Schematic Solid Reconstruction of the Reproductive Organs 4 5. Developing Ovary of Embryo 4 6. Development of the Cervix and the Vagina 5 7. Sketch Showing Formation of Bladder, Ureters, External Genitalia and Anus 5 8. External Genitalia of an Embryo 18 mm. Long 6 9. Indifferent Stage of External Genitals of Thirty-three- day Embryo 6 10. External Genitalia of Female Embryo of Xine Weeks 6 11. External Genitalia of Female Embryo of Eleven Weeks 6 12. External Genitalia of Female Embryo of Sixteen Weeks 6 13. Ovary of Xew-born Child 7 14. Ovarv of Xew-born Child; Relationship of Ovarian Arterv to Ovarv, Tube and Uterus 7 15. Ovary of Child Two Years Old " '. 8 16. Ovary of Girl Nine Years Old 9 17. Ovary of Girl Sixteen Years Old 10 18. Reconstructive Drawing Showing Ovary of Young Woman in Active Menstrual Life 10 19. Ovary of Woman Forty-two Years Old 11 20. Contents of Pelvis in Embryo of Three and One-half Months 12 2 1 . Fallopian Tube and Ovary 13 22. Uterus Unicornis 15 23. Uterus Didelphys 15 24. Uterus Pseudodidelphys 16 25. Uterus Duplex Bicornis 16 26. L'terus Duplex Septus 16 27. Uterus Duplex Subseptus 16 28. Uterus Bicornis 17 29. Uterus Bicornis, with Dwarfing of One Horn 17 30. Double Vagina and Double Cervix 18 31. Atresia of Vagina; Manner of Closing Wound After Removing Obstructing Septum. . 19 32. Nearly Imperforate Hymen 20 S3- Gynatresia; Bulging Imperforate Hymen, Simulating Large Cystocele 22 34. Gynatresia; Imperforate Hymen 23 35. Haematocolpos 24 36. Haematotrachelos ; Haematocolpos 24 37. Haematometra; Haematotrachelos; Haematocolpos 24 38. Haematosalpinx ; Haematometra; Haematotrachelos: Haematocolpos 24 39. Gynatresia of One-half of Double L'terus and Double Vagina 25 40. Gynatresia of One L'terus and Haematometra in Double Uterus 25 41. Division of Female Perineal Region Into L'rogenital and Rectal Triangles 31 42. Xormal Virginal Vulva Showing Component Parts 32 43. Histology of Various Parts of the Genital Tract 33 44. Vaginal Fornices; Posterior Fornix; Anterior Fornix 34 45. Sagittal Section Through Young Female Body 35 46. Vaginal Wall; Stratified Squamous Epithelial Surface and Connective Tissue 36 47. Anterior Aspect of Xulliparous Adult L'terus 36 48. Posterior Aspect of Xulliparous Adult L'terus 36 49. Lateral Aspect of Xulliparous Adult Uterus 37 50. Transverse Section of L'terus at Fundus 37 51. Transverse Section of L'terus Above Internal Os 38 52. Para-sagittal Section of the Pelvis 38 53. Histology of Cervix 39 54. Histology of Endometrium of Body of L'terus 40 55. Histology of Fallopian Tube 41 56. Histology of Ovary 42 57. Interior of Bladder and Relation of Ureter to Uterine Artery 44 58. View of Pelvis From Above 46 59. Lateral Sagittal Section of Female Pelvis 47 xv xvi ILLUSTRATIONS 60. Supporting Ligaments of Uterus; Their Relation to Other Pelvic Structures 48 61. Frontal Section of Pelvis Through Urogenital Triangle - 49 62. Semi-diagrammatic Picture Showing Course of Arteries, Veins and Lymphatics. ... 50 63. Fascia of Pelvic Floor 51 64. External Muscles, Fascia, and Structures of the Perineum 51 65. Muscles of Pelvic Floor from Below 52 66. Triangular Ligament in the Female 53 67. The Pelvic Diaphragm from Above 54 68. The Blood Supply of the Pelvic Viscera 55 69. Anatomy of L^reter: Course in Pelvis and Relation to L'terine Artery 56 70. Sagittal Section of Rectum : Hemorrhoidal Arteries, Veins and Lymphatics of Rectum and Anus 57 7 1 . Blood-vessels of the Pelvis 58 72. Lymph Vessels and Glands of Pelvic and Lumbar Regions 59 73. 74, 75, 76. Mucous Membrane of Uterus in Various Phases of Menstruation 67 77. Uterine Mucous Membrane in First Day of Menstruation 68 78. Schematic Drawings, Showing Relation Between Ovulation and Menstruation 69 79. Showing Collection of Blood Beneath Surface Epithelium, and Its Escape 70 80. Showing Two Layers of Decidua of Second Month, Decidua Compacta and Decidua Spongiosa 71 81. Showing Gland Duct of Decidua Compacta of the Second Month 72 82. Drawing Showing Relative Size of Imbedded Early Ovum and L'terus 73 83. Section Through Peters Ovum and Surrounding L'terine Mucous Membrane 74 84. Summit of the Peters Ovum 75 85. Chorionic Villus from the Second Month 76 86. Human Ovum, Showing Chorionic Villi 76 87. Anlage of Placenta from the Second Month 77 88. Pregnant Icterus at Term 7> 89. Pregnant Uterus at End of First Stage of Labor 7> 90. Height of Fundus of Pregnant L'terus at Different Periods 7 s 91. Softening of Lower L"terine Segment of Early Pregnancy 79 92. Gradual Obliteration of Internal Os and Cervical Canal at End of Pregnancy 79 93. Vaginal Wall Being Torn from Attachments and Pushed Forward 80 94. Bilateral Laceration and Elongation of Anterior Lip of Cervix 80 95. Distention of Perineal Muscles by Birth of Head 81 96. Distention of Perineum Just Before Birth of Head s 2 97. Atrophic Changes in a Senile ITterus with Shrunken Appendages 83 98. Form of History 92 99. Showing Positions of L'terus with Full Bladder or Rectum or Both 112 100. Position of Uterus, with Distended Bladder and Rectum 113 101. Dorsal or Lithotomy Position 114 102. Knee-chest Position 115 103. Sims' Position, Left Latero-prone Position 115 104. Supine Position 116 105. Showing Regions of Abdomen 116 106. Sims' Speculum : . 117 107. Bivalve and Tri valve Speculum; Collapsible Tube of Lubricant; Ultzmann Syringe 118 108. Kelly's Urethral Speculum 119 109. Double Tenaculum 119 no. Long Thumb Forceps, L'terine Sound, Applicator, Spatula, Curved Dressing Forceps 120 in. Goodell's Dilator 120 112. Sims' Curette 121 113. Martin's Curette 121 114. Excision of Diseased Cervical Tissue for Microscopic Examination 122 115. Inspection of External Genitalia: Expression of Discharge from Urethra 123 116. Inspection of External Genitalia; Expression of Discharge from Bartholin's Glands 123 117. Gonococci Stained in Smear 124 118. Spirochaeta Pallida 124 1 19. Exposure of Vagina and Cervix by Bivalve Speculum 125 120. Digital Examination and Schematic Outline of Anteflexion 126 121. Digital Examination and Schematic Outline of Retroflexioversion 126 122. Digital Examination and Schematic Outline of Pelvic Mass 126 123. Schematic Outline Showing Prolapsed Ovary Palpable on Digital Examination. ... 126 1 24. Bimanual Examination ; Schematic Outline of Anteversion and Pathologic Anteflexion 1 2 7 125. Bimanual Examination; Schematic Outline of Retroflexioversion 127 126. Bimanual Examination; Schematic Outline of Pelvic Mass 128 ILLUSTRATIONS xvii 27. Simple Digital Examination; Schematic Outline of Prolapsed Ovary 128 28. Position of Hands in Bimanual Examination of Pelvis 128 29. Outline Showing Position of Fingers in Examination of Tube and Ovary 129 30. Bimanual Examination with Uterus Drawn Down 129 3 1 . Combined Recto-vaginal Examination 1 29 32. Trimanual Examination, Case of Ovarian Cyst 130 33. Lateral Aspect of Abdomen with Large Myomatous Uterus 131 34. Anterior Aspect of Abdomen with Uterus Deviated to Right 132 35. Anterior Aspect of Abdomen with Extreme Ascitic Distention 133 36. Lateral Aspect of Abdomen with Extreme Ascitic Distention 133 37. Lateral Aspect of Abdomen in Case of Large Ovarian Cyst 134 38. Lateral Aspect of Abdomen in Case of Pregnancy Near Term 134 39. Lateral Aspect of Abdomen in Case of Ovarian Cyst with Carcinomatosis 135 40. Cross Section of Abdomen; Reason for Coronal Resonance 136 41. Cross Section of Abdomen; Reason for Central Resonance and Lateral Dulness. . . . 136 42. Trimanual Method of Percussion of Kidney 139 43. Kelly's Improved Cystoscope 140 44. Nitze Catheterizing Cystoscope 141 45. Nitze Examining Cystoscope 141 46. Cylindrical Jar for Sterilization of Cystoscopes 142 47. Ureteral Catheter 143 48. Sterilizing Ureteral Catheters 144 49. Ureteral Calibrator 144 50. Irrigating Apparatus 145 51-152. Two-way Irrigator or Catheter; Top and Bottom Views 148 53. Catheterization of the Ureter 149 54. Rontgenogram of Ureteral Stone 151 55. Shadows Cast by Vermiform Concretion and by Phlebolith 152 56. Rontgenogram of Suspected Renal Calculus with Sound in Ureter 153 57. Rontgenogram Showing Stone in Upper Calyx of Right Kidney 154 58. History in This Case Indicated Ureteral Calculus 155 59. Rontgenogram Failed to Demonstrate a Calculus 157 60. Ptosis of the Left Kidney with Hydronephrosis 158 61. Examination of Rectum; Patient in Dorsal Position with Tuttle's Pneumatic Speculum 1 62 62. Examination of Anus, Buttocks Separated 163 63. Tuttle's Pneumatic Speculum 163 64. Kelly's Proctoscope 164 65. Examination of Rectum and Lower Sigmoid with Proctoscope 164 66. Kelly's Sigmoidoscope 165 67. Elephantiasis of Vulva 172 68. Chancre of Vaginal Introitus 173 69. Gumma of Vulva, with Secondary Infection and Ulceration 174 70. Condylomata Lata, Secondary Syphilis, Surrounding Vulva (in Color) 174 71. Condylomata Lata of the Vulva and Anus 175 72. Syphilis (Secondary) of the Vulva and Anus 176 73. Syphilis (Secondary) of the Vulva and Anus 177 74. Syphilis (Secondary) of the Vulva and Anus 178 75. Gumma of the Vulva, Tertiary Syphilis 179 76. Chancroid 180 77. Venereal Warts 181 78. Varicose Veins of the Vulva 182 79. Haematoma of Vulva 183 80. Epithelioma of Vulva, Indurated Fungoid Ulcer 184 81. Lupus of Vulva, a Pre-ulcerative or Infiltrative Stage 185 82. Sarcoma of Left Labium Minus 186 83. Fibromyoma of Vulva (in Color) 186 84. Lipoma of Right Labium Majus 187 85. Abscess of Left Vulvovaginal Gland 188 86. Extreme Cystic Distention of Vulvovaginal Gland 189 87. Cyst of the Posterior Vaginal Wall 194 88. Sarcoma of Vagina in Child Two and One-half Years Old 195 89. Case of Adenocarcinoma of Posterior Vaginal Wall 196 90. Large Rectocele in a Multipara 201 91. Sulcus Tears and Thinning of Perineal Body in a Multipara 202 92. Showing Support Given by Levator Ani and Triangular Ligaments to Pelvic Viscera 203 xviii ILLUSTRATIONS 193. Showing Effect of Sulcus Lacerations of Levator Ani and Triangular Ligaments. . . 203 194. Complete Laceration of Perineum 204 195. Prolapse of Uterus; Prolapsed Rectal Mucosa; Fibrolipoma of Thigh 205 196. Cystocele; Rectocele 206 197. Normal Xulliparous Outlet, Patient Straining 207 198. Relaxed Outlet, Patient Straining 207 199. Relaxed Outlet 208 200. Emmet Perineorrhaphy; Outline of Denudation 209 201. Emmet Perineorrhaphy ; Denudation Completed 210 202. Emmet Perineorrhaphy; Sulcus Sutures Tied on Both Sides 210 203. Transverse Fascial Split and Introduction of Crown Sutures 211 204. Diagrammatic Sketches of Emmet Perineorrhaphy 211 205. Hegar Perineorrhaphy; Lines of Denudation 212 206. Hegar Perineorrhaphy; Denudation Completed 212 207. Hegar Perineorrhaphy; Crown Sutures Introduced 213 208. Hegar Perineorrhaphy; Levator Ani Suture 214 209. Hegar Perineorrhaphy; Levator Suture in Marked Cases 215 210. Completion of Subcuticular Suture of Emmet or Hegar Perineorrhaphy 216 211. Operation for Complete Tear of Perineum 217 212. Operation for Complete Perineal Tear 217 213. Suture of Rectovaginal Septum by Linen 217 214. Diagram Showing Introduction of Sutures in Operation for Complete Tear of Perineum 218 215. Sanger Anterior Colporrhaphy ; Vaginal Wall and L^nderlying Fascia Being Cut Away 218 216. Sanger Anterior Colporrhaphy; Suture Started at Anterior End of Incision on Vaginal Surface 218 217. Sanger Anterior Colporrhaphy; Suture Carried Through Vaginal Wall 219 218. Anterior Colporrhaphy or Cystopexy; Outline of Initial Incision 219 219. Anterior Colporrhaphy or Cystopexy; Separation of Bladder from Anterior Vaginal Wall 219 220. Anterior Colporrhaphy or Cystopexy; Further Separation of Bladder from Uterine Wall 219 221. Anterior Colporrhaphy or Cystopexy; Introduction of Sutures 220 222. Interposition Operation for Prolapse 221 223. Interposition Operation 221 224. Schematic Sagittal Section, Showing Result of Interposition Operation 221 225. Large Cervical Polyp Projecting from External Os 224 226. Cervical Polyps, Snowing Origin from Mucous Plicae of Cervix 224 227. Elongation and Hypertrophy of Cervix 225 228. Xulliparous Cervix 227 229. Parous Cervix; ~\\ ell Healed Bilateral Laceration; Mucus in Cervical Canal 227 230. Parous Cervix; Well Healed Bilateral Laceration 227 231. Deep Lnilateral Laceration with Irregular Tag of Cervical Tissue 227 232. Stehate Laceration 227 233. Deep Bilateral Laceration; Lnequal Division of Cervical Lips; Eversion 228 234. Deep Bilateral Laceration with Eversion of Lips 228 235. Nabothian Cysts of Cervix 228 236. Xulliparous Cervix; Extension of Cervical Mucosa 228 237. Xulliparous Cervix; Xo Extension; Xo Lacerations. 229 238. Parous Cervix. Deep Bilateral Laceration 229 239. Deep Bilateral Laceration; Eversion of Cervical Lips 230 240. Test Showing Red, Angry-looking Surface is the Cervical Mucosa 231 241. Deep Bilateral Laceration; Eversion of the Mucosa 231 242. Trachelorrhaphy ; Repair; Apex of Angle of Laceration Split 232 243. Trachelorrhaphy; Repair; Cervical Lips Denuded 233 244. Trachelorrhaphy; Repair; Two Upper Sutures are Tied 233 245. Trachelectomy ; Cervical Lips Split Laterally 234 246. Trachelectomy; Cervical Lips Excised 234 247. Trachelectomy; Sutures Tied 235 248. Sagittal Section Showing Xormal Anteflexion and Anteversion of L'terus 237 249. Outline Showing Arc of Imaginary Circle Through Which Fundus Moves 237 250. Xormal Position of Uterus 238 251. Retroflexion and Retroversion of Uterus 238 252. Pathologic Anteflexion; Ill-developed Cervix and Xarrow Canal 238 253. Retroversion; Slight Flexion; Descensus and Beginning of Prolapse 239 254. Showing Uterus .in Xormal Position, Ante-position and Retroposition 240 ILLUSTRATIONS xix 255. Showing Influence of Shortened Anterior Vaginal Wall 240 256. Divulsion of Cervix 241 257. Dudley Operation 242 258. Pozzi Operation 242 259-260. Norris Drain in Position 243 261. Sagittal Section Showing Uterus in Extreme Retroflexion 246 262. Replacement of Retroflexio-version of Uterus; Cervix Grasped with Tenaculum. . . . 248 263. Replacement of Retroflexio-version of Uterus; Uterus Straightened Out 248 264. Replacement of Retroflexio-version of Uterus ; Index Finger in Rectum 249 265. Replacement of Retroflexio-version of Uterus; Cervix Pushed Back 249 266. Replacement of Retroflexio-version of Uterus; Tenaculum Has Been Removed 249 267. Replacement of Retroflexio-version of Uterus; Uterus in Slightly Exaggerated Ante- flexion and Anteversion 249 268. Patient in Knee-chest Position; Vaginal Fornix Packed with Tampons 250 269. Introducing a Pessary 251 270. Diagram Snowing Mechanics of Pessary 252 271. Alexander's Operation 253 272. Ventrosuspension 254 273. Coffey's Operation, Steps 1 and 2 255 274. Coffey's Operation, Steps 3 and 4 255 275. Webster-Baldy Operation, Steps 1 and 2 256 276. Webster-Baldy Operation, Step 3 256 277. Simpson Operation; Skin and Fat Retracted 257 278. Simpson Operation; Ligament Pulled Up 258 279. Simpson Operation; Needle Passed Through Fascial Cut 259 280. Simpson Operation; Round Ligaments Sutured to Under Surface of Fascia 259 281. Pressure upon Uterus from All Sides Equal 264 282. Pelvic Floor Torn, Uterus is Now Part of Floor of Pelvis 264 283. Outline Showing Steps in Development of Procidentia Uteri 265 284. Prolapse of Uterus; Cervix Presenting at Vaginal Orifice 266 285. Complete Prolapse of Uterus with Bladder Diverticulum 267 286. Principle of Support of a Menge Pessary 269 287. Extraperitoneal Fixation of Fundus, Step 1 270 288. Extraperitoneal Fixation of Fundus, Step 2 270 289. Shortening of Uterosacral Ligaments 271 290. Diagnostic Curettage 280 291. Chronic Arteriosclerosis or Fibrosis Uteri 281 292. Diagram Illustrating Vascular Channels of Uterine Wall and Endometrium 282 293. Section of Wall of Nulliparous Uterus 283 294. Section of Wall of Muciparous Uterus 283 295. Group of Arteries from Vascular Layer of Multiparous Uterus 284 296. Small Artery of Vascular Layer of Multiparous Uterus 285 297. Large Vein from Vascular Layer of Multiparous Uterus 286 298. Hydatidiform Mole 290 299. Multiple Subserous Myomata 293 300. Longitudinal Sagittal Section of Uterus 294 301. Uterus Opened, Showing Pedunculated Submucous Myoma 295 302. Intraligamentous Fibroid 296 303. Myomatous Uterus Complicated by Inflammatory Lesions of Adnexa 297 304. Interstitial Myoma Undergoing Necrosis and Cyst Formation 298 305. Necrosis of Submucous Myoma 298 306. Necrotic Submucous Myoma Projecting from Cervix 299 307. Cervical Myoma 300 308. Multiple Myomata of Posterior Uterine Wall 301 309. Incarcerated Subserous Myoma 302 310. Myoma Uteri and Pregnancy 308 311. Abdominal Myomectomy; Incision Through Capsule of Myoma 314 312. Abdominal Myomectomy; After Making Incision 315 313. Abdominal Myomectomy ; After Exposing the Myoma 315 314. Abdominal Myomectomy; Bed of Myoma Filled up With Catgut Sutures 315 315. Abdominal Myomectomy; Uterine Incision Closed with Suture of Catgut 315 316. Supravaginal Hysteromyomectomy with Bilateral Salpingo-oophorectomy 316 317. Supravaginal Hysteromyomectomy with Bilateral Salpingo-oophorectomy. ....... 317 318. Supravaginal Hysteromyomectomy with Bilateral Salpingo-oophorectomy 318 319. Supravaginal Hysteromyomectomy with Bilateral Salpingo-oophorectomy 319 320. Hysteromyomectomy from Side to Side 320 xx ILLUSTRATIONS 321. Supravaginal Hysteromyomectomy with Bilateral Salpingo-Oophorectomy 321 322. Supravaginal Hysteromyomectomy with Bilateral Salpingo-Oophorectomy 322 323. Supravaginal Hysteromyomectomy with Bilateral Salpingo-Oophorectomy 323 324. Supravaginal Hysteromyomectomy with Conservation of Adnexa 324 325. Supravaginal Hysteromyomectomy with Conservation of Adnexa 325 326. Supravaginal Hysteromyomectomy with Conservation of Adnexa 325 327. Diffuse Adenomyoma of Uterus 326 328. Longitudinal Transverse Section of Uterus 326 329. Epithelioma of Cervix 331 330. Early Epithelioma of Cervix 332 33 1 . Squamous Cell Carcinoma of Vaginal Cervix 332 332. Showing Predisposition of Epithelioma to Spread by Continuity of Surface 333 333. Showing Spread of Epithelioma of Cervix, Sagittal and Transverse Sections 334 334. Showing Spread of Adeno-carcinoma of the Cervix 335 335. Advanced Epithelioma of the Cervix 336 336. Histological Section of Finger-like Projection from Cervix 337 337. Early Carcinoma of the Endometrium 343 338. Advanced Carcinoma of the Endometrium 344 339. Chorioepithelioma of the Fundus (in Color) {Frontispiece) 340. Metastases of Chorioepithelioma in Kidney, Liver, Lung and Pancreas 347 341. Panhysterectomy for Carcinoma 349 342. Passing Loop of Catgut about L^reter 350 343. Ligation of Uterine Vessels 351 344. Dissection of Bladder and Ureters 352 345. Application of Clamps to Vaginal Wall 353 346. Paravaginal Incisions 354 347. Vaginal Hysterectomy 355 348. Acute Gonorrhceal Salpingitis, Gross 359 349. Acute Gonorrhceal Salpingitis 360 350. Uterus and Appendages in Extensive Pelvic Inflammatory Disease Exposed in Incision 361 351. Uterus and Appendages in Extensive Pelvic Inflammatory Disease; Adhesions Divided 362 352. Pyosalpinx and Ovarian Abscess 363 353. Tubo-ovarian Abscess 364 354. Hydrosalpinx 365 355. Tubo-ovarian Cyst 366 356. Tuberculous Pyosalpinx, Torsion and Necrosis 369 357. Interstitial Pregnancy 370 358. Early Extrauterine Pregnancy, Rupture and Bleeding 371 359. Extrauterine Pregnancy with Beginning Tubal Abortion 372 360. Longitudinal Section of Tube Shown in Fig. 359 373 361. Longitudinal Section of Pregnant Tube 374 362. Abscess of the Ovary 382 363. Sagittal Section Showing Displacement of Small Uterus 385 364. Multilocular Cystadenoma of Ovary 386 365. Diagram Showing Difference in Effect Upon Cervix 387 366. Early Parovarian Cyst 390 367. Parovarian Cyst 391 368. Diagram Showing Intra- and Extraperitoneal Position of Cysts (in Color) 392 369. Fibroma of Ovary 392 370. Papillomatous Cystadenoma of Ovary 394 371. Dermoid Cyst of Ovary 397 372. Ovarian Teratoma with Histologic Sketches of Tissue 398 373. Displacement of Uterus and Stretching of Tube in Pelvic Intraligamentous Tumor. . 400 374. Corpus Luteum Cyst of Ovary 403 375. Ovarian Cyst Twisted on Its Pedicle 405 376. Ovarian Cyst with Torsion of Its Pedicle 406 377. Diagram illustrating Spread of Gonorrhceal Infection 413 378. Bilateral Pyosalpinx 417 379. Resection of the Ovary 418 380. Salpingostomy 419 381. Diagram Showing Streptococcus and Staphylococcus Infections 420 382. Vaginal Incision and Drainage; Posterior Lip of Cervix Held Forward «... 426 383. Vaginal Incision and Drainage; Abscess Located by Bimanual Palpation 427 384. Salpingo-oophorectomy; Points of Ligation and Line of Excision 435 ILLUSTRATIONS xxi 385. Salpingo-oophorectomy ; Suture of Cornua and Beginning Peritonealization 435 386. Salpingo-oophorectomy; Suture of Cornua and Completion of Peritonealization. . . . 435 387. Salpingo-oophorectomy; Posterior Fixation of Round Ligament 436 388. Salpingo-oophorectomy; Points of Ligation and Lines of Excision 436 389. Salpingectomy; Suture of Cornua 437 390. Salpingectomy; Peritonealization 437 391. Salpingectomy; Peritonealization, First Step 438 392. Salpingectomy; Peritonealization, Second Step 438 393. Disinfection of Skene's Tubules 441 394. Urethral Tampon in Position 444 395. Saturating Urethral Tampon 444 396. Self-Retaining or Mushroom Catheter 446 397. Prolapsed Urethral Alucosa; Outline of Denudation 447 398. Prolapsed Urethral Mucosa; Denudation Completed 447 399. Prolapsed Urethral Mucosa; Sutures Introduced 447 400. Operation for Relaxation of Vesical Xeck of Urethra, First Step 448 401. Operation for Relaxation of Vesical Xeck of Urethra, Second Step 448 402. Urethral Caruncle 450 403. Irrigation of Bladder With Two-way Catheter 455 404. Vesicovaginal Fistula 463 405. Urethrovaginal Fistula 463 406. Vesicocervical Fistula 464 407. Rectovaginal Fistula 464 408-409. Uretero vaginal Fistula 464 410. General Scheme of Operation in Vesicovaginal Fistula 467 41 1. Tuberculosis of Kidney; Upper Half Diseased 474 412. Suspension of Kidney by Edebohl's Technic 482 413. Bloodless Nephrotomy Incision 483 414. Resection of Last Rib in Nephrectomy 484 415. Ureteral Anastomosis 492 416. Uretero-vesical Anastomosis 493 417. Method of Implanting Ureter into Intestine 494 418. Method of Implanting Ureter into Intestine 495 419. Appendicectomy 504 420. Appendicectomy (Clark's Method) 506 421. Triangular Shape of Abdominal Cavity on Sagittal Section 507 422. General Ptosis 508 423. Midline Ptosis 509 424. Right-sided Ptosis 510 425. Exercises for Ptotic Patients; Simple Means of Obtaining Trendelenburg Position. . 511 426. Exercises for Ptotic Patients; Exaggerated Expansion of Chest 511 427. Exercises for Ptotic Patients; Leg Flexed Upon Thigh 5 12 428. Beyea's Operation; Suturing of Gastrohepatic Omentum 5H 429. Gastropexy ; Coffey's Operation 5 J 5 430. Diagram Illustrating Beyea's Operation 5 J 5 431. Scheme of Completed Beyea's and "Hammock" Operation 5 J 6 432. Suspension of Hepatic Flexure; Reed's Method 5 X 7 433. Suspension of Sigmoid 5 J 8 434. Points of Anastomosis and Obstruction in Gastro-intestinal Tract 519 435. Excision of Fistula in Ano 5 2 6 436. Removal of Hemorrhoids by Clamp and Cautery 5 2 9 437. Moschcowitz's Conception of Prolapse of Rectum; Incipient Prolapse (in Color). . . 530 438. Moschcowitz's Conception of Prolapse of Rectum; Partial Prolapse (in Color). . . . 530 439. Moschcowitz's Conception of Prolapse of Rectum; Incomplete Prolapse (in Color) . . 531 440. Moschcowitz's Conception of Prolapse of Rectum; Complete Prolapse (in Color) . . . 531 441. Scheme for Inserting Sutures in Moschcowitz's Operation 533 442. Normal Posture 537 443. Kangaroo Posture 539 444. Gorilla Posture 539 445. Slumped Visceroptotic Figure 54° 446. Overf eminine Figure 540 447. Patient's Outline Being Traced 541 448. Corset for Kangaroo Posture 544 449. Corset for Gorilla Posture 544 450. Bad Type of Corset. Hour-glass Shape 545 451 . Good Type of Corset 545 xxii ILLUSTRATIONS 452. Storm's Sacroiliac Belt 548 453. Merrill's Sacroiliac Splint 549 454. Fat Overhanging Abdomen 551 455. Smear of Pus from Urethra, Vagina, and Cervix 557 456. Appearance of Gonococci in Stained Preparation (in Color) 558 457. Tuberculous Pyosalpinx with Torsion of Ovary and Tube 565 458. Chancre of Cervix, Engrafted on an Erosion 572 459. Chancre of Cervix 573 460. Secondary Ulcer of Posterior Lip of Cervix 573 461. Schematic Outline of Generative Tract Showing Escape of Ovum, Penetration of Spermatic Particles, Fertilization of Egg 598 462. Semi -diagrammatic Outline of Uterus Showing Various Causes of Sterility 599 463. Semi- diagrammatic Outline of Uterus Showing Various Causes of Sterility 600 464. (A) Atrophic Ovary; (B) Thickened Capsule; (C) Abdominal Ostium of Tube. . . . 601 465. Sterility Produced Through Gonorrhoea Causing Pyosalpinx, Perioophoritis and Pelvic Adhesions 602 466. Abdominal Incisions 624 467. Battle's Incision: (^4) Skin Incision; (B) Fascial Incision 625 468. Battle's Incision: (A) Through Semilunar Line; (B) Through Anterior Lamella of Rectus; (c) Omentum; (d) Rectus Muscle 626 469. McBurney's Incision; Skin Incision 627 470. McBurney's Incision; External Oblique Split 628 471. McBurney's Incision; Internal Oblique Split 628 472. McBurney's Incision: (A) External Oblique; (B) Internal Oblique; (C) Peritoneum; (D) Appendix 629 473. Prone Position for Kidney Operations 629 474. Kelly's Incision 630 475. Mayo's Incision 630 476. Muscles of Lumbar Area, Showing Outline of Edebohl's Incision and Mayo's Incision 631 477. Israel's Incision 632 478. Robson's Incision 632 479. Towelling the Incision, One Side Completed 633 480. Towelling the Incision, Both Sides Completed 634 481. Incision Made, Sides Protected with Gauze Pads, Self -retaining Retractor in Position 634 482. Separation of Muscle Fibers 635 483. Opening the Peritoneum 635 484. Separation of Rectus Muscle from Its Lateral Attachments 636 485. Lengthening the Incision 636 486. Eversion of Peritoneum with Closing Suture; First Method 637 487. Trendelenburg (Elevated Pelvis) Position 638 488. Elliott Position (Elevated Thorax) for Upper Abdominal Operations 638 489. Eversion of Peritoneum; Closing Suture; Second Method 644 490. Closing Fascia, Showing Detail of Suture for Overlapping 645 491. Finish of Buttonhole Stitch 646 492. Suprapubic Pelvic Drain 647 493. Abdominal Dressing Applied 648 494. Enteroclysis Apparatus with Visible Drip 666 495. Visible Drip Glass Connecting Tube 666 496. Bed with Head Elevated 667 497. Fowler Bed 668 498. Portable Heat Cabinet 673 499. Short-circuiting for Intestinal Obstruction, Ileo-sigmoidostomy 683 500. Short-circuiting for Intestinal Obstruction, Ileo-colostomy 683 501. Abdominal Binder for Post-operative Use 697 502. Bivalve and Sims' Specula Introduced — Patient in Dorsal and Sims' Position — Exposure of Cervix and Vaginal Vault 699 503. Smith Pessary — Used in Treatment of Retroversion 701 504. Hodge Pessary — Used When Vaginal Vault is Shallow 701 505. Soft-rubber Ring Pessary; Useful in Elderly Women with Narrow Vaginal Orifice. . 702 506. Disk Pessary; Useful in Elderly Women with Descensus and Marked Cystocele. . . . 702 507. Menge Pessary (Assembled) ; Useful in Prolapsus in Elderly Women 703 508. Menge Pessary (with Stem Detached) 703 509. Intrauterine Douche Nozzle 704 510. Vaginal Vault Packed with Tampons 704 511. Uterine Pack 705 512. Vaginal Pack with Suprapubic Pressure 705 ILLUSTRATIONS xxiii 513. Vaginal Douche Nozzle of Glass 706 514. Sketch of Correct Position for Douche 706 515. Vaginal Tampon 707 516. Filling Vaginal Tampon 708 517. Good Type of Corset 709 518. Exercises for the Nervous Woman — First Exercise 710 519. Exercises for the Nervous Woman — Second Exercise 710 520. Exercises for the Nervous Woman — Third Exercise 710 521. Exercises for the Nervous Woman — Fourth Exercise 710 522. Exercises for the Nervous Woman — Fifth Exercise 710 523. Exercises for the Nervous Woman — Sixth Exercise 710 524. Exercises for the Nervous Woman — Seventh Exercise 710 525. Exercises for the Nervous Woman — Eighth Exercise 710 526. Means of applying Radium in Gynecological Diseases — Needles Containing Radium ; Radium Enclosed in Platinum Capsules 716 INTRODUCTION Medical text-books vary greatly in literary style and construction : thus, one embodies the complete individuality of the author, as exemplified by his daily clinical work, but scant reference being made to the literature con- tributing to his subject; another otters a digest of a vast bibliography, more or less well selected, depending on the competency of the author to act as a judge, and endeavors to feature the cardinal points that he considers worthy of imitation. Such text-books, however., evidence, on the one hand, a lack of judicial balance, and. on the other, an absence of a well-defined hall-mark stamped by the writer's own experience. Still a third author, as repre- sented by Doctor Anspach. selects his literary references with great care and. combining these with the observations gathered from his matured ex- perience, he constructs a well-balanced text-book. In Doctor Anspach's treatise on Gynecology ample reference is made to epoch-making and constructive contributions, but his text is so well arranged as to make it devoid of encyclopaedic dulness. Painstaking care has been devoted to the elucidation of all the basic factors in embryology, anatomy, and physiology, variations from which mark abnormal morphology, and morbid physical changes that lead to the many functional disturbances ob- served in gynecologic practice. It is a common observation among teachers in our medical schools that students well drilled in the cardinal branches of the first two years, all too frequently approach the clinical problems of the last two years so deficient in this fundamental knowledge as to make its translation into practical medicine of little or no value. To bridge this hiatus between the scientific and the clinical domain Doctor Anspach has drawn from the newest, as well as from the classic, sources of information, the specialized and general facts that will freshen up and adapt the student's mind for the fullest comprehen- sion of gynecologic problems. From the chapters on Embryology. Developmental Anomalies. Anatomy, and Physiology the reader is carried logically forward into the intricacies of anamnesis, physical examination, and laboratory investigations, these chap- ters being so closely correlated as to develop the deductive powers of the student, making of him a well-poised diagnostician, rather than the slave of a memorized symptomatology that, when the atypical case is encountered, inevitably leads him into a quagmire of doubt. When the chapters on the practice of gynecology are reached, all the capital procedures that have found a stable setting in practice are consid- ered, and usually more than one method is ottered for the reader's selection. A most instructive chapter is that devoted to the hygiene and proper care of adolescent girls, a subject that, because of its ultimate influence upon the welfare of the adult woman, is of far-reaching importance. All too fre- quently of late gynecologic text-books are so crammed with surgical thera- XXV xxvi INTRODUCTION peutics as largely to exclude prophylactic measures and immediate medical and hygienic treatment of conditions that, if not cured in the early stages, will certainly attain surgical proportions. In this book the general practitioner will find a wealth of suggestions as to office and bedside treatment of gynecologic patients. Special considera- tion is given to the endocrine system in its relation to the functional aberra- tions of women. Our knowledge of this abstruse subject is at best more or less inchoate,, but that which is required by the gynecologist has been clearly set forth. In such special complaints as local skin affections and backache, Doctor Anspach has called to his aid the services of skilled specialists, who give to these subjects a breadth of view that is not to be found in the usual text- books on gynecology. Here, for the first time, the therapeutic value of radium and the Rontgen ray has received adequate consideration. Full working instructions as to the choice of cases and the application of these remedies in the treatment of carcinoma and myoma of the uterus and myo- pathic hemorrhages are given. That able rontgenologist. Dr. Henry Pancoast. has brought this portion of Doctor Anspach's book well abreast of the times. To attempt to draw attention to all the excellent features of this text- book would encompass more space than has been allotted to the introduc- tory matter. Suffice it to say that the work is most comprehensive, and deals in a highly instructive way not only with diseases of women, but also with those coincident renal and abdominal lesions that are frequently en- countered in the course of gynecologic affections. In concluding this introductory note I take pleasure in extending a cor- dial commendation to a book that has had the well-balanced authorship of a specialist who has devoted a number of years to faithful work as an inves- tigator and as a teacher, and to the practice of gynecology and abdominal surgery in their broadest and best sense. John G. Clark. Philadelphia, Jan. 21, 1921. GYNECOLOGY CHAPTER I EMBRYOLOGY EMBRYOLOGIC STRUCTURES The Wolffian Body and the Wolffian Duct.— The Wolffian body and the Wolffian duct are the first structures to appear in the development of the genito-urinary system in man. Each Wolffian body is made up of a series of tubules terminating at one extremity in a convoluted vascular tuft form- ing a glomerulus, and at the other emptying into the Wolffian duct (Fig. i, a). Each tubule comprises a glomerulus and a secreting and a collecting area (Fig. 2). The Wolffian body is a functionating excretory organ — the primitive' kidney — that attains full development at about the end of the second month (Fig. 3). Its excretion is discharged into the Wolffian duct, which runs toward the tail of the embryo and empties into the cloaca or dilated terminal segment of the large gut. Almost as soon as it is fully formed the Wolffian body begins to atrophy, its function being gradually assumed by the true kidney, which has developed in the meantime. The Miillerian Duct. — The Miillerian duct develops at the side of, and is closely related to, the Wolffian duct (Fig. 1, b). The lower parts of both ducts on each side converge toward those of the opposite side. From the point at which they meet the ducts run toward the cloaca, forming the urogenital strand, the Miillerian ducts running in the median line and the Wolffian ducts to the outer side (Fig. 4). The Sexual Gland, — At about the time the Miillerian duct is formed, the cells on the median surface of the Wolffian body become aggregated, form- ing what is known as the sexual gland (Fig. i, c). In the female this aggre- gation ultimately develops into the ovary, some of the original cells, distin- guished by their large size, clear protoplasm, and conspicuous nucleus, con- stituting the primary germ cells or the primordial ova (Fig. 5), the remaining cells forming the germinal epithelium. FCETAL STRUCTURES The Ovary. — The cells of the sexual gland receive vascular connective tissue from the Wolffian body, separating them into large islands or strands in which the primitive ova are surrounded by the germinal epithelium. The larger islands are divided into smaller ones, until ultimately groups are formed that consist of one primordial ovum surrounded by a ring of ger- minal epithelium, constituting the primordial follicles of the ovary. These follicles are embedded in a vascular connective-tissue stroma that, at the periphery of the organ, is condensed and forms a capsule that, from its white appearance, is known as the tunica albuginea (Fig. 5). 1 GYNECOLOGY MM ^ The Uterus. — The apposed surfaces of the Miillerian ducts — one from each side — become fused at about the eighth week. The septum disappears, and the two tubes become converted into a single larger tube that forms the uterus (Fig. i,d). The Fallopian Tubes. — Above the point where they fuse to form the uterus, the Miillerian ducts remain separated and be- come the Fallopian tubes. The Vagina. — The vagina is derived from the lower extremities of the fused Miillerian ducts. For a time this portion of the duct is solid, but at about the fourth month it becomes hollowed out and com- municates with the cloaca (Fig. i, e and Fig. 6). The External Genitalia. — The enlarged terminal segment of the hind-gut known as the cloaca is closed externally by a mem- brane, becoming divided into two sections by the projection of the perineal ridge (Fig. 7). The anterior section is known as the urogenital sinus. At about the fifth week a rounded projection, the genital tubercle, is formed in front. Upon its under surface it is divided by a groove ; after rupture of the cloacal membrane the edges of this groove form the labia majora, labia minora, and the clitoris. The opening into the urogeni- tal sinus between the labia becomes the vulvar cleft, and the sinus itself is now the vestibule. The vagina communicates with the urogenital sinus by an aperture that later becomes the vaginal orifice. It is guarded by annular folds which subse- quently become the hymen. The posterior part of the cloacal space is the gut section, and between it and the urogenital section a wedge of tissue becomes the perineal body (Figs. 8-12). The Bladder and Urethra. — The an- terior part of the urogenital section of the cloaca is designated as the allantoic space ; the primitive ureters empty into it pos- part of the allantoic space becomes expanded and summit of the bladder, while the lower part, into Fig. I. — Schematic outline showing the de- velopment of the reproductive organs: (A) showing the Wolffian tubules, with glomeruli at the distal ends, entering the Wolffian duct; (B) the Miillerian duct developing parallel with, and to the mesial aspect of the Wolffian duct; _(C) fusion of the Miillerian ducts of both sides to form the primitive uterovaginal canal and the Fallopian tubes; development of the genital gland below the Wolffian tubules; (D) atrophy of the Wolffian tubules and dis- appearance of the glomeruli, further develop- ment of the genital gland, beginning formation of fimbria at the abdominal ostium of tube, development of the uterine cavity and the dif- ferentiation of it from the vaginal canal; (£) atrophic remains of the Wolffian structures, the genital gland has become the ovary, the free end of the Miillerian duct is represented by the fully developed Fallopian tube; the fused portion is represented by the uterus and the vagina. teriorly. The upper forms the body and which the ureters open, forms the vesical trigone and urethra (Fig. 7). The Rectum. — The posterior section of the cloaca forms the rudimentary EMBRYOLOGY Wolffian duct — A developin branc Mesoderm Glomerulus Epithelial layer Epithelial layer Fig. 2. — Enlarged schematic Wolffian tubule at the height of its develop- ment, from an embryo 10 mm. long. (Kollmann.) Plica phrenico- mesonephrica Sexual gland Wolffian body! Mesentery of gland Wolffian duct Sexual gland Genito ligamen Plica inguino--^- mesonephrica l inguinal ■ \ ■ ient \ -"^fr inp-uino- — " Ligament of gland Umbilical arteries Allantoic duct l T mbilical vein Fig. 3. — The Wolffian bodies and the sexual glands of a human embryo of about six weeks. (Piersol.) rectum. Towards this an invagination of the ectoderm is projected from the surface. The two finally meet, and fuse by the absorption of the inter- vening tissues ; the point of fusion marks the line of division between the anus and the rectum (Fig. 7). The Ureter and Kidney. — The ureter has its origin in a bud-like expan- GYNECOLOGY Abdominal ostium Tube, tubal part of Mullerian duct Urinary bladder Wolffian duct Uterine part of Mullerian duct Vaginal part of Mullerian ducts Uro-genital sinus. Fig. 4. — Showing a schematic solid reconstruction of the reproductive organs, especially the urogenital strand, from fetus 29 mm. long. (Kollmann.) i* Germinal epithelium «lffe - mw^:^f^~- 'C^C: ! Ova HI f^MSfe ^m»>«ssa -, ^ . Ovarian stroma Fig. 5. — -Developing ovary of embryo; germ cells being broken up by stroma and vascular tissue. (Piersol.) EMBRYOLOGY 5 sion from the lower end of the Wolffian duct, near the cloaca. It grows upward, behind the Wolffian body, and here its upper extremity dilates and Dorsal Ventral Cerv Portio vaginal Vaginj Proctodeum Ectoderm FlG. 6. — Development of the cervix and the vagina. Median longitudinal section of the utero-vaginal canal at the level of the portio vaginalis uteri of an embryo 260 mm. long. The portio vaginalis is beginning to be defined and the supravaginal circular muscle is developing. The lumen extends to its lower end, which is closed by an epithelial plug. The vagina is still altogether solid, its future lumen is indicated by the solid epithelial cord that traverses it. From this cord there grows into the surround- ing mesenchyme, forward and backward at different levels, two solid projections of epithelium, the anlagen of the anterior and posterior fornices. (Keibel and Mall.) Ovary Ccelom Urinary bladder- Clitoris and vestibule Symphysis Anus Wolffian duct Rectui Spinal medulla Spinal cord Fig. 7. — A and B: (A) sketch of a model exhibiting the formation of the bladder, ureters, external genitalia and anus, from a fetus 29 mm. long x 60; (B) detail of "A" showing formation. (Kollmann.) subdivides, forming the renal pelvis and calyces, and finally also the collect- ing tubules. The remainder of the kidney is developed from a surrounding 6 GYNECOLOGY area of tissue termed the renal blastema, the tubules of which subsequently unite with those growing from the renal pelvis. THE GENERATIVE ORGANS AT BIRTH AND DURING CHILDHOOD At birth the female generative organs have not attained their full devel- opment. This process goes on slowly during childhood, and is most marked in the years just preceding the establishment of the menstrual function. „ ,* Umbilical cord Lower extremity '% V Coccygeal tubercle Fig. 8. — External genitalia of an embryo 18 mm. long. Between the umbilicus and the coccygeal tubercle is the cloacal tubercle; on its anal slope are the ostium urogenitale and the anal groove. (Keibel and Mall.) -Glans — ^Genital folds y — Labio-scrotal folds -Opening of urogenital sinus Anal groove ' Coccygeal eminence Fig. q. — Indifferent stage of external genitals of embryo of thirty-three days. X8. (Keibel.) —Glans clitoridis Labium majus Nympha Urogenital sinus Anus Coccygeal eminence Fig. 10. — External genitalia of the female, embryo of nine weeks. (Keibel.) Glans clitoridis I Prepuce Urethra — Nympha W- Vaginal orifice Fig. 11.— External genitalia of the female, embryo of eleven weeks. (Kollmann.) Fig. 12. — External genitalia of the female, embryo of sixteen weeks. (Kollmann.) The Ovary. — At birth the ovary is long and narrow, somewhat resem- bling, on triangular cross-section, a dog's ear. In the earliest days it lies above the true pelvis, but during the first two years of life it drops below the pelvic brim. It grows slowly and attains its full development at EMBRYOLOGY Capillary system / ; ' in cortex^ Follicles Arteriae ovaricae 'propria? Veins' " Fig. 13. — Ovary of new-born child. Vessels injected with lamp-black gelatine. (Clark.) u ter Ift e t ^f.mb.MTt Fig. 14. — Ovary of new-born child showing the gross relationship of the ovarian artery to the ovary and tube and to the uterus. (Clark.) puberty. The maturation of primordial follicles goes on from earliest life, the follicles not rupturing, but undergoing atresia, until, by the deposit of connective tissue in the medullary portion and the penetration of the blood- 8 GYNECOLOGY vessels to the cortical areas, the follicles then begin to undergo develop- ment (Figs. 13-19). The Uterus. — At birth the cervix is disproportionately large, making up more than one-half of the organ. Its wall is much thicker and better devel- oped than the fundus. The fundus is less rounded than in the mature uterus, and the uterine angles merge directly with the tubes, suggesting previous fusion of the Miillerian ducts. The mucosa of the cervix, with its arbor- vitse-like arrangement, extends up into the fundus. The position of the uterus Follicular wreaths Follicular wreath - Follicular wreath - Arteriae ovaricae .- propria?' Follicular wreath * Veins Artery/ Fig. 15. -Ovary of a child two \-ears old. The vessels have become more tortuous, and numerous follicles lying- next to the parallel arteries are in the process of evolution. (Clark.) is high, the fundus being opposite the fifth lumbar vertebra. During child- hood the organ descends into the pelvis, the cervix and body assume mature proportions, the fundus becomes arched, and the mucosa of the cervix be- comes sharply differentiated from that of the fundus (Fig. 20). The Fallopian Tube. — At birth the Fallopian tubes are long, twisted, tor- tuous, and the fimbriated extremities are poorly developed. During child- hood they grow shorter, many of the convolutions disappear, and the fimbri- ated extremities attain their full development. The Vagina. — At birth the vagina is long and narrow ; its walls are EMBRYOLOGY thick, and the rugae extend to the vaginal vault. As the uterus descends it diminishes in length, the fornices widen, and the rugae in the upper portion disappear. EMBRYONIC RESTS AND THE NEW FORMATIONS ORIGINATING IN THEM In the generative organs of the adult female there are seen rests or remnants of certain embryonal structures that served their pur- pose in early fetal life, but later, after the embryo had been fully formed, became functionless and underwent atrophy. These fetal remnants are represented in the Wolffian tubules and the Wolffian duct (Fig. i, e). Embryonic rests are found principally in certain localities, as, for example, in the broad liga- ment between the tube and the ovary, in the ovarian hilus, at the cornua of the uterus, at the sides of the uterus and cervix, at the lower pole of the kidney, in the vault of the vagina or in the anterior vaginal wall as far for- ward as the external urinary meatus, in the rectal wall, and in the round ligament. The most conspicuous rem- nant of the Wolffian body and duct is the parovarium, a struc- ture embedded between the layers of that part of the broad liga- ment known as the mesosalpinx. It consists of a series of atrophic tubules, a long longitudinal and numerOUS Vertical Ones, reseill- Fig. 16.— Ovary of a girl rine years old. Klinrr +V>^ Ko^V nnr l +cmi-U ^-f tuosity of vessels and progressive enlargement and oblitera- ting tne DaCK ana leetn OI t i n of follicles toward periphery, d, d', vascular loops a COmb The lonp'itnrlimi wn i cn have surrounded follicles undergoing obliteration. tubule of the parovarium, known as Gartner's duct, is a remnant of the Wolffian duct; it is dis- cernible almost to the cornua of the uterus. Rests may also be found microscopically along the sides of the uterus, cervix, and in the lateral vaginal walls. From the outer extremity of Gartner's duct there occasion- increase in tor- 10 GYNECOLOGY d d Fig. 17. — Ovary of a girl sixteen years old: (a) (a') arteria? parallels ovarii; (b) typical organizing corpus luteum; (c), (c') t (c") different stages in the maturation of the follicle; {d), (d') stages in the obliteration of the follicle which has not ruptured ; (e) complete retrogression, the central vessels of the hyaline body having almost completely disappeared. (Clark.) ally develops a small, pedunculated cyst known as the stalked hydatid of Morgagni. From the lower extremity of the duct are derived a certain type of adenomyoma of the cervix and the majority of vaginal cysts. O- re - P - ■»|gp s » i*3 >? TO O J o 2. »•" re re c p to Wwft llliiil n " ' 3 S ,."^ H* rt-TJ 5 c o g « o o'5° 3 re 3 j^.— ;re 9 ».. rroq 3 .g.^ To n- re re ^p (-< o 3<>o 3'~ 3 ' p 3 ■ - 5*o P re '1/1 Cfi Z. p £ g < p H" O •-. o c t/> i re EMBRYOLOGY 11 The outer vertical tubules of the parovarium, known as Kobelt's tubes, give rise to small cysts about the size of grapes. The other tubules are the Hyaline changes in corpus fibrosum Hyaline changes in 3 - '"-^^^^^^^ o< s jy^^JJ^rus. ■ corpus fibrosum -•^1-^^^^jj^-^^ "^^^^ jjsyi v\\-^ J A Hyaline changes in _ j corpus fibrosum* "S Cortex deficient in blood-vessels- - Surface scars- Hyaline changes in corpus fibrosum Site of rupture of follicle Compressed vessels S.-~fV--.,at their entrance V 5 * as\ to stroma Vein/.... Artery, Fig. 19. — Ovary of a woman forty-two years old. Death occurred shortly after the menopause. (Clark.) seat of well-known intraligamentous parovarian cystomata, which some- times reach very large proportions. Other remnants of the Wolffian tubules may be found between the 12 GYNECOLOGY layers of the broad ligament, as well as in the hilus of the ovary itself. From these develop the true glandular cystomata of the ovary, the most common variety of ovarian cyst (Fig. 21). Some authorities assert that embryonal rests of the Wolffian tubules at the lower pole of the kidney, in the broad ligament, at the uterine cornua, and in the round ligament, may give rise to adenomyomata in these situa- tions. Others have shown that most of the adenomyomata that develop in the uterus are derived from the Miillerian ducts in the process of evolution of the uterine body and endometrium. Oscar Frankl has observed in the ski Fig. 20. — Contents of the pelvis in an embryo of thr^e and one-half months (X4): abdominal wall pulled downward; (A) appendix; (/) ileum; (U) ureter; (O.A.) ovarian artery (S.Fl.) sigmoid flexure; (0) ovary; (Ut.) bicornuate uterus; (23) bladder broad ligaments cornified nodes of epithelium derived from the Wolffian bodies. From these rests epidermoid cysts may spring. In the early stage of development aberrant cells from the ovum (mul- berry mass) may become detached from the other cells and subsequently become embedded in any part of the body. They are especially prone to be found as rests in the genito-urinary system, since this forms so large a por- tion of the early embryo. These aberrant cells may subsequently develop and give rise to tumors containing derivatives from any or all the layers of the blastoderm. The most common of these growths are the so-called dermoid cysts of the ovary (see Chapter XX). EMBRYOLOGY 13 Rests of suprarenal tissue may be found in the inguinal canal, the round ligament, and the fundus of the uterus. Their presence is due to the close proximity of the adrenal glands to the sexual organs during the period of development. From such embryologic remains hypernephromata may develop. \Ve ^cvcovj axwxiri EMBRYONAL RESTS— THE PAROVARIUM, consists of two rudimentary organs; istTHE EPOOPHORON {THE ORGAN OF ROSENMULLER) {equivalent to the epididymus in the male) consists of a number of epi- thelial lined tubes i; remains of tubules of the Wolffian body, ascending from the ovary and ending in the Wolffian {Gartners) duct 2-2; remains of tubules 3-3 sometimes forming hydatids; terminal bulb 4 hydatid cyst of Morgagnii: 2d THE PAROOPHORON 5 {EQUIVALENT TO THE PARADIDYMUS IN THE MALE); = 6-J epithelial lined remnants, others are occasionally found in body of uterus, cervix and vaginal wall, and are sometimes the seat of cysts; 8-8-8 atrophied remains of Wolffian {Gartner's) duct. [From standard authors and specimens in Doctor Clark's collection.] Fig. 21. — Fallopian tube and ovary, showing mesosalpinx and embryonal rests therein. Schematic view o f structures in the broad ligament. BIBLIOGRAPHY Clark, J. G. : " Histogenesis of Glandular Cysts of the Ovary." Tr. Am. Gyn. Soc., 1903, xxviii, 312-322. Cullen, T. S. : Adenomyoma of the Uterus. Saunders, Phila., 1908. Ellis, E. G., with Keen, W. W., and Pfahler, G. E. : " On Hypernephroma." Am. Med., 1904, viii, 1039. Frankl, Oscar: " Pathologische Anatomie und Histologic der Weiblichen Genitalorgane," in Liepmann's Handbuch der Frauenheilkunde. Band ii, Vogel, Leipzig, 1914. 14 GYNECOLOGY Keibel, Franz, and Mall, E. P. : Manual of Human Embryology. Lippincott, Phila.. 1910. Kollmaxx, J. : Handatlas der Entwickelungsgeschichte des Menschen. Fischer. Jena, 1907. Kollmaxx : Lehrbuch der Entwickelungsgeschichte. Fischer, Jena, 1898. Pick, L. : " 1st das Yorhandensein der Adenomyome des Epioophoron erweisen." Centralbl. f. Gynak.. 1900. xxiv, 389-397. Piersol, G. A. : Human Anatomy. Lippincott. Phila.. 1907. Recklixghausex vox. F. D. : Die Adenomyome und Cystadenome der Uterus — und Tubenwandung. Im Anhang : Klinische Xotizen zu den volumosen Adenomyome des Uterus. Freund, Berlin. 1896. Thumim, L. : " Ueber die adenomatose Flyperplasie am cervicalen Drusenanhang des Gartner'schen Ganges. (Nebst Mittheilung eines einschlagigen Falles.") Archiv f. Gynak.. 1900, lxi. 15-36. Tuttle. J. P. : Diseases of the Anus, Rectum and Pelvic Colon. Appleton. X. Y., 1907. CHAPTER II THE DEVELOPMENTAL ANOMALIES OF THE GENERATIVE ORGANS The Ovary. — Complete absence of both ovaries is seen only in mon- strosities. The absence of one ovary is quite unusual, but has been found associated with defect of one Miillerian duct. The kidney of the same side may be absent. Rudimentary or poorly-developed ovaries often co-exist with the various malformations of the uterus. Rudimentary ovaries are usually small, but may be almost normal in size. They contain few, if any, primordial follicles. So-called supernumerary ovaries are merely portions of the ovaries snared off by peritoneal bands or adhesions, or small fibro- myomata of the ovary in the broad ligament. Fig. 22. — Uterus unicornis. Fig. 23. -Uterus didelphys (uterus duplex separatus; vagina duplex separatus). The Fallopian Tubes. — Complete absence of both tubes occurs only in monstrosities. The absence or partial development of one tube is coinci- dent with a similar condition of the corresponding uterine horn. The con- voluted fetal type may persist, even in the adult. Supernumerary or double tubes are very rare. Accessory tubes and accessory abdominal ostia are not infrequent. Diverticula from the mucosa into the wall of the tube are common. The Uterus. — It is only necessary to bear in mind the successive steps in the development of the uterus in order to understand the various malfor- mations that may arise. The Miillerian ducts at first are solid strands throughout their entire length, with the exception of the upper extremity, which is hollowed out. Later on these strands become possessed of lumina, and join one another at the site of the future cervix. Union of the two above the cervix, as far as the fundus follows, and the intervening and approxi- mated septa then disappear, although atrophy of the septa is not so rapid as outside fusion. At first the uterus so formed is somewhat flattened on top, but at the end of intrauterine life the fundus has developed, forming the 15 16 GYNECOLOGY which is succeeded by the infantile and then by foetal type of uterus, the virginal type. Complete failure of both Miillerian ducts to develop is found only in mon- strosities. Many reported cases of complete failure were really cases of rudimentary development. Complete defection of one Miillerian duct (uterus unicornis) (Fig. 22) is usually associated with an absence of the correspond- ing ovary, kidney, and ureter, and occurs in non-viable feti, many of the FlG. 24. — Uterus pseudodidelphys (uterus bicornis septus, vagina septa). Fig. 25. — -Uterus duplex bicornis. cases described in adults being really instances of high-grade uterus bicor- nis septus with vagina septa, one side being rudimentary to an extreme degree (Figs. 22, 24 and 29). The two Miillerian horns may unite at the cervix, the septa between them remaining intact, and no fusion of the two sides above the cervix taking place, thus forming the uterus duplex bicornis (Fig. 25). This abnormality is found in well-developed adult females, and, together with the bicornate Fig. 26. — Uterus duplex septus. FlG. 27. — Uterus duplex subseptus. uterus, constitutes the most frequent form of uterine anomalies. As a rule, two vaginal canals surrounded by a common sheath exist, their orifices being guarded by a common hymen. The vaginal septum may extend either the entire distance from the cervix to the introitus or only part of the way. The two uterine horns are seldom equally well developed. In these cases men- struation and pregnancy may take place normally. Hsematometra may arise in the less well-developed side, and this may also tend to obstruct labor. The Miillerian ducts may develop and fuse from the cervix to a point DEVELOPMENTAL ANOMALIES 17 near the fundus, the intervening septum as far as the external os persisting. In this way is formed the uterus duplex septus (Fig. 26) ; the vagina may be double or single. The septum may not extend to the external os, and when this occurs the condition is known as uterus duplex subseptus (Fig. 27). As a rule, menstruation is normal, and pregnancy and labor may occur in either or in both sides at the one time. When the Miillerian ducts unite at the position of the cervix to the full normal extent, the intervening cervical septum having disappeared, but fail to fuse above this point, the condition is termed uterus bieornis (Fig. 28). One horn may be smaller than the other (Fig. 29), or may be imperforate, although furnished with a functionating endometrial cavity. The under- development of one side may be so marked that the condition will resemble the uterus unicornis. In the latter case the undeveloped half of the uterus is represented merely by a thin, band-like or rounded cord, having no cavity, and joining the fully-developed horn at about the site of the internal os. Occasionally in these cases the ovary is present, and the tubes are recognizable as connective-tissue strands having more or less well-developed fimbriae. In some cases neither the tube nor the ovarv can be found. Fig. 28. — Uterus bicoinis. Fig. 20. — Uterus bieornis, with dwarfing of one horn. A form of maldevelopment marked by congenital dwarfing of the entire uterovaginal tract, affects most often the uterus bieornis. At the site of the uterus in these cases there is seen a flattened or rounded body, from one to three centimetres long, the upper extremity of which is continued on both sides in the form of strands. The cervix and the lower part of the uterine horns may be relatively well developed. The ovaries are always present, but are usually of small size. The tubal fimbriae not infrequently are well formed. The mons pubis and the labia majora contain little fat. The labia minora are frequently well developed. The clitoris may be hypertrophied and hypospadias may be present, the parts presenting the appearance of a malformed male. The vagina is usually obliterated entirely. The uterus may show a persistence of the fetal type — the uterus fcetalis. It is considerably shorter than the normal adult form, cylindric in configura- tion, the fundus being flattened. The cervix is often as long as the body, and the small corpus is very sharply anteflexed upon it. The walls of every part are thin, but the cervii- is better developed than the fundus. The vaginal cervix is less prominent than the normal, and projects but slightly into the vagina. The external os takes the form of a round pit or a fine transverse 2 18 GYNECOLOGY slit. The uterine cavity is always present, and the ovaries are of the in- fantile type. The tubes are fetal in form, and are supplied with fimbriae. The vagina is usually abnormally short and narrow, although it may be normal. The mons pubis and the labia majora are not prominent, but the clitoris and especially the labia minora are well developed. The uterus may be relatively smaller than the normal virginal type. It is usually known as uterus infantilis, or congenital smallness of the uterus, the condition being the result either of defect at birth or of serious consti- tutional illness in the earlier years of life which arrested the growth of the organ. Certain congenital malpositions of the uterus occur, such as latero- position, when the uterus is drawn either toward the right or toward the left wall of the pelvis ; or the organ Xtf 33& . and by virtue of certain accessory muscles — the transversus perinaei and the constrictor vaginae — supporting the lower vagina and the external genitalia. The transt ersus periiuei muscles are made up of superficial and deep divi- sions. They arise on either side from the inferior ramus and tuberosity ot M^LKki '..i. levsrrr the ischium, and pass to the median line, where they unite with each other and with the central tendinous point of the perineal body. The bitlbocc: nosus, or constrictor ragince muscle, arises from the central tendon of the perineum ; it encircles the vaginal orifice, investing the vestibular bulbs, and is lost in the fascia about the clitoris. The external and internal sphi> muscles of the anus (spkmcte are intimately related to the levator ani and the central tendinous point of the perineum. The external sphincter muscle arises from the tip of the coccyx and the tendinous raphe, extend- ing between the coccyx and the anus. The libers encircle the anus — the superficial ones being in close relation with the skin — and are inserted into the central tendon of the perineum and the superficial fascia. Some of the libers decussate with the sphincter vaginae. The internal sphincter ani is ANATOMY OF THE GENERATIVE ORGANS 53 composed of involuntary muscle bundles, and is a thickening of the circular layer of the lower end of the rectum. It encircles the beginning of the anal canal. It is about 4 mm. thick and extends for a distance of from 2.5 to 3 cm. THE FASCIA OF THE PELVIC FLOOR The arrangement of the fascia of the pelvic floor is of considerable im- portance, because of the part it plays in the reenforcement and support of the muscles that form the pelvic diaphragm. The superficial fascia of the perineum is continuous anteriorly with that of the lower abdominal wall, and, like the latter, is composed of two layers. The superficial layer is in reality merely the panniculus adiposis of the skin. The deeper layer, known Fig. 66. — The triangular ligament in the female: (Ir.) triangular liga- ment; {pp.) window cut out, showing the deep transversus perinasi muscle. as Colles' fascia, is membranous in character and devoid of fat. It is con- tinuous in front with the deep layer of the superficial fascia of the abdominal wall ; laterally, it is attached to the sides of the pubic rami and the ischia, and posteriorly it blends with the posterior border of the triangular liga- ment along the lower margin of the superficial transversus perinsei muscles. Behind this line it unites with the superficial layer in a single sheet that becomes continuous with the superficial fascia of the gluteal region. The deep fascia of the perineum forms what is known as the triangular ligament. This is composed of tivo layers — a superior and an inferior. Each layer is attached in front to the corresponding rim of the pubes, and laterally to the corre- sponding edge of the ramus of the pubis and ischium. Behind, on an imaginary line drawn transversely between the tuber ischii, the two layers unite with each other and with the deep layer of the superficial fascia. The 54 GYNECOLOGY triangular ligament is perforated by the vagina and the urethra. Its superior layer fuses above with the vesical reflection of the rectovesical fascia (pubo- vesico-cervical ligaments), below with the levator fascia, whereas at the sides both layers are continuous with the obturator fascia (Fig. 67). THE BLOOD-VESSELS OF THE GENERATIVE ORGANS The pelvic organs and the external genitalia receive their blood supplv chiefly from the ovarian, the uterine, the vesical, the hemorrhoidal, and the Femoral ring Femoral artery and vein Gimbernat's ligament Space for blood-vessels Ligament ilio-pectineum Space for muscles Pelvic fascia \ \ \ Femoral nerve 1 Poupart's y^ ligament Fig. 67. — The pelvic diaphragm from above. The pelvic fascia on the right side has been removed: (v) vagina; (r) rectum; (P) promontory of sacrum; (a) pubococcygeus division of levator ani muscle; (b) ilio-coccygeus division of levator ani muscle; (c) ischio-coccygeus division of levator ani muscle; (d) ligament tubero-sacralis; (e) ligament spinoso sacralis; (/) ischiatic foramen, large and small; (o) obturator internus muscle; (a.t) arcus tendineus (white line) ; (f.o) obturator foramen. internal pudic arteries. Most of these vessels are derived from the ramifi- cations or the divisions of the internal iliac. The only arteries of impor- tance that arise from sources other than the internal iliac are the ovarian, which spring from the abdominal aorta, and the superior hemorrhoidal artery, which is derived from the inferior mesenteric (Fig. 68). Arteries. — The ovarian arteries are the analogue of the spermatic arteries in the male. They have their origin in the anterior surface of the aorta, a ANATOMY OF THE GENERATIVE ORGANS 55 little below the renal arteries. They run beneath the peritoneum to the pelvic brim, where they cross the common iliac vessels and enter the broad ligament at the pelvic attachment. They pass between the layers of the Right ovarian vein, B. Right ovarian" artery Left ovarian artery Left ovarian vein Inferior mesenteric arterv Superior hem- orrhoidal artery Right uterine artery Right internal pudic artery Right inferior hem- orrhoidal artery Vaginal branch from inferior vesical artery Artery to clitoris Artery to bulb Median sacral artery and vein Left uterine vein — Vein from rectum Deep vein from clitoris and vein from vestibular bulb Fig. 68. — The blood supply of the pelvic viscera. broad ligament to the cornua of the uterus, sending branches to the Fallopian tube, and anastomosing with the corresponding uterine artery beneath the isthmus of the tube. 56 GYNECOLOGY The internal iliac artery, also called the hypogastric artery, is, as its name implies, the internal terminal division of the common iliac. Its most impor- tant branch is the uterine artery, but the superior and inferior vesical, the vaginal, the obturator, and the middle hemorrhoidal vessels are also derived from it. The main stem divides into the internal pudic and sciatic arteries. The uterine artery runs through the base of the broad ligament toward the neck of the uterus. At a point about 2 cm. from the cervix it crosses the ureter (Fig. 69), and there turns upward and courses between the layers of the broad ligament to the side of the uterus. At the cornua it anasto- moses with the corresponding ovarian artery. From the anas- tomosis a branch is given off to the round ligament. The superior vesical artery sup- plies the upper and middle portions of the bladder; whereas the inferior vesical artery supplies the base and neck of the bladder. The vaginal arteries run to the sides of the vagina. Each vessel divides into numerous branches that anastomose w r ith the corre- sponding branches ot the opposite side. Along the median line of both the anterior and the pos- terior surface of the vagina a vessel, known as the azygous artery of the vagina, is more or less constantly present. The superior hemorrhoidal artery is the terminal portion of the inferior mesenteric, and descends between the layers of the pelvic mesocolon. The middle hemorrhoi- dal artery arises from the internal iliac, the inferior vesical, or the inter- nal pudic. The inferior hemorrhoidal artery arises from the internal pudic. The internal pudic artery passes through the lesser sacrosciatic notch to the ischiorectal fossa. It give's off the inferior hemorrhoidal, the superficial perineal artery, the artery of the bulbs, and the urethral artery, and ends in the dorsal artery of the clitoris. Veins. — The ovarian veins arise from the hilum of the ovary and anasto- mose w r ith the veins of the uterine fundus, Fallopian tube, and round liga- ment, forming what is known as the pampiniform plexus. This plexus lies with the ovarian artery between the layers of the broad ligament ; it merges into a single trunk which ascends along the course of the ovarian artery into the abdominal cavity. The right vein empties into the inferior vena cava; the left into the left renal vein. Fig. 69. — Anatomy of ureter, showing its course in the pelvis and its intimate relation to the uterine artery. The fundus of the uterus has been bisected and lifted away at its junction with the cervix. (After Tandler and Halban.) ANATOMY OF THE GENERATIVE ORGANS 57 The uterine vein takes its origin at a point opposite the external os. It is derived from the plexus uterovaginalis. At first it is double, both trunks following the course of the artery. Beyond the ureter the two become united, and the vessel empties into the internal iliac. The vesical veins originate in the vesicovaginal plexus. They empty into the internal iliac. Pig. 70. — Sagittal section of rectum, showing hemorrhoidal arteries, veins, and lymphatics of rectum and anus. Superior hemorrhoidal artery comes fromthe inferior mesenteric. Middle hemorrhoidal artery comes from internal iliac artery. Inferior hemorrhoidal artery comes from internal pudic artery. Supe- rior hemorrhoidal vein empties into the portal system through the inferior mesenteric vein. Middle hemorrhoidal vein empties into the inferior caval system through the internal iliac vein; it forms by its connections a communi- cation between portal and inferior caval systems. Inferior hemorrhoidal vein empties into the internal pudic vein. The lymphatics of the upper two- thirds of the rectum drain into the sacral glands on the front of the sacrum. The plexus around the anus and lower part of the rectum drains into the inguinal glands. The internal pudic vein enters the pelvis through the lower part of the great sacrosciatic foramen, and empties into the internal iliac. The internal iliac or hypogastric vein accompanies the internal iliac artery, lying to its inner and posterior aspect. At the level of the sacroiliac syn- chondrosis it unites with the external iliac to form the common iliac vein. The obturator vein accompanies the obturator artery and, as a rule, empties into the internal iliac. The superior hemorrhoidal vein originates in the hemorrhoidal plexus, and 58 GYNECOLOGY unites with the sigmoid veins to form the inferior mesenteric. It communicates with the middle and inferior hemorrhoidal veins, thus placing the portal and inferior caval systems in communication. The middle hemorrhoidal vein arises from the hemorrhoidal plexus and empties into the internal iliac or one of its tributaries. The hemorrhoidal plexus encircles the rectum. It is composed of two venous networks — the internal hemorrhoidal plexus in the submucosa of the rectum, and the external hemorrhoidal plexus on the outer surface of the Vena cava Aorta Common iliac artery Common iliac vein' Ilio-lumbar artery (abnormally large) £ Internal iliac artery- External iliac artery External iliac vein s Obturator ■ artery, vein and nerves- Deep circum-* flex iliac artery""" Round, \ ligament Deep epigastric""' artery --•Gluteal artery • "Lateral sacral artery .--Median sacral artery Hypogastric artery ^-Sciatic artery Internal pudic artery Middle hemor- rhoidal artery and vein Fig. 71. — Blood-vessels of the pelvis: (s) branches of superior vesical artery; (v) vaginal branch from inferior vesical artery; («) superior vesical artery merging with obliterated remains of hypogastric arteries; (i) inferior vesical artery; (ut) uterine artery. rectum. The inferior hemorrhoidal veins pass from the region of the anus through the ischiorectal space and empty into the internal oudic vein (Figs. 70 and 71). THE LYMPHATICS OF THE PELVIS The pelvic lymph-nodes are arranged along the course of the principal vessels, and for convenience may be divided into three groups : The iliac, the hypogastric, and the sacral. The iliac nodes lie along the course of the common and external iliac vessels, from Poupart's ligament to the bifurcation of the aorta. They receive after- ANATOMY OF THE GENERATIVE ORGANS 59 ent lymphatic vessels from the epigastric and circumflex iliac nodes, from the lower part of the ureter, bladder, cervicovaginal junction, clitoris, etc. They distribute efferent vessels to the lower lateral lumbar nodes. The internal iliac or hypogastric nodes are situated on the lateral walls of the pelvis, along the internal iliac vessel and its branches. They receive afferent vessels from all the pelvic organs supplied by the internal iliac artery or its branches. They send lymphatic vessels to the iliac nodes on the promon- tory of the sacrum. Sacral glands - -Of Iliac glands ?fgH Fig. 72. — Lymph vessels and glands of pelvic and lumbar regions, showing course of uterine lymph vessels to iliac, sacral and lumbar glands, the course of lymph vessels from fundus and round ligaments to the in- guinal glands, and the course of lymph vessels of the ovary to the lumbar glands. (After Poirier and Sabotta) The sacral nodes lie on the ventral surface of the sacrum, along the middle sacral vessels and lateral sacral arteries. They receive afferent vessels from the cervix by way of the uterosacral ligaments from the neighboring muscles, and from the sacrum, and they send vessels to the iliac nodes on the promontory of the sacrum. The inguinal nodes are really a single group, situated in the inguinal region over Scarpa's triangle, where they form a mass of considerable size. The 60 GYNECOLOGY upper nodes are termed the inguinal, whereas the lower are called the sub- inguinal. The lymphatics from the external genitalia pass to the inguinal or sub- inguinal nodes ; those from the clitoris may reach the lower iliac nodes. The lymphatics of the ovary and Fallopian tube follow the course of the ovarian blood-vessels and terminate in the lateral lumbar nodes. For convenience of description, the .lymphatics of the uterus may be divided into three groups : (i) The large fiuidal, which follow the ovarian lymphatics and terminate in the lumbar nodes. (2) The small fundal, which reach the inguinal nodes along the round ligament. (3) The lower corporeal and cervical. These pass laterally along the uterine vessels to the iliac nodes, in the angle between the external and the internal iliac arteries. Posteriorly, branches run through the uterosacral ligaments to one uterosacral gland. The lymphatics of the vagina are divided into three groups: ( 1) The lymphatics from the upper part, which terminate in the median iliac nodes. (2) The lymphatics from the middle part, terminating in the hypo- gastric nodes. (3) The lymphatics from the lower part, which terminate in the inner inguinal nodes (Fig. 72). THE ABDOMINAL WALL The abdominal wall, or parietes. is made up of muscles and fascia? which interlace and form a strong boundary for the abdominal cavity and false pelvis. In the median line are the two rectus muscles, running from the ensiform cartilage and lower ribs to the symphysis pubis. Beyond the rectus are the external and internal oblique and the trans versalis muscles and aponeuroses. The aponeuroses of the lateral group connect the fascia of the rectus muscles to their outer side in what is known as the linea semi- lunaris, which runs from the tip of the ninth costal cartilage to the spine of the pubis. The fascia of the rectus surrounds that muscle, except at its lower third, where it passes directly in front of it. The point of fascial union in the median line is known as the linea alba. The abdominal muscles are attached above to the costal margins and the associated musculature ; pos- teriorly, to the lumbar group, and below, to the pubes. iliac crests, and to the condensation of fasciae of the oblique and transverse muscles known as Poupart's and Gimbernat's ligaments. BIBLIOGRAPHY Huxxer, Lyox : " Mensuration and Capacity of the Female Bladder." J. A. M. A., Dec. 16, 1899. Piersol. G. A. : Human Anatomy. Lippincott. Phila.. 1907. Porrier, Cuneo and Delamere : The Lymphatics. Keener & Co.. Chicago. 111.. 1904. Sampson : " The Variations in the Blood Supply of the Ovary and Their Possible Opera- tive Importance." Trans. Amer. Gyn. Soc, 1916, vol. xli, p. 429. Savage: The Surgery, Surgical Pathology and Surgical Anatomy of the Female Pelvic Organs. Wm. Wood & Co.. New York. 1880. Tuttle, J. P. : Diseases of the Anus, Rectum and Pelvic Colon. Appleton. X. Y., 19,07. CHAPTER IV PHYSIOLOGY Introduction. — The generative organs remain functionless until puberty is reached. During the reproductive period, which extends from puberty to the menopause, these organs are highly specialized structures whose func- tions bear most important relations to the general physiologic activity of the individual, and, indeed, to a certain extent dominate it. Following the menopause the generative organs again become functionless and undergo atrophy. It is a peculiarity of the generative organs that they remain dormant up to a certain time, after which they become active for a period of years, comprising what is known as the prime of life, and then become extinct. Although reproduction may occur at puberty, children born during this early period are apt to be frail and weakly. A female is not sexually matured — that is, entirely fitted for wifehood and motherhood — until she is out of her teens, or even several years later. The stage of sexual maturity is known as nubility. The Age of Puberty. — Puberty [Latin: puber'tas, maturity], the age at which an individual begins to functionate sexually, occurs in women be- tween the twelfth and fifteenth year. In hot climates puberty is said to occur early, whereas in cold climates it occurs late. Englemann, after an analysis of 60,000 cases, declared that the difference in onset is less marked than is commonly supposed. The negro maiden of Somaliland sometimes matures at sixteen, as late as her Lapland and Samoyed sisters. Eskimo women, on the other hand, may become mothers at the age of twelve — just as early as Hindu women. Englemann attributes this to the oily diet of the arctics and the sluggish habits of the equatorial natives. It is a fact, never- theless, that warm climates do predispose to early puberty, and cold climates to late puberty ; the variation is more apparent relatively in distant parts of the same zone than in extreme zones, such as the tropical and the arctic. The onset of puberty is influenced also by race, social oosition, and mode of life. The effect of race and climate on puberty is illustrated by the observa- tion of Das, that Hindu and Mohammedan girls in India menstruate two or three years earlier than English girls born in India, and that the latter menstruate a year or so earlier than English girls born in England. Kisch asserts that girls in the higher planes of society menstruate earlier than those in the lower ; that city girls menstruate earlier than country girls ; that those of rugged constitution menstruate earlier than those who are frail and weakly ; brunettes menstruate earlier than blondes. The Hebrew (Semitic) and the oriental races menstruate early, the Aryans and the Slavs later. Manifestations of Puberty. — The onset of puberty is attended with many changes, both psychic and physical. The intellect, emotions, and will of the girl gradually become those of the woman. The range of voice is increased 61 62 GYNECOLOGY by a lengthening of the larynx, and the face and figure acquire the contour characteristic of the sex. The internal and the external sexual organs, with their accessory structures, increase in size and in vascularity ; the pelvis assumes a characteristic shape. The pubic and axillary hairs now make their appear- ance. The body or fundus of the uterus develops rapidly, until it constitutes two-thirds of the entire organ, whereas the cervix, which is larger than the fundus during infantile life, forms but about one-third of the entire structure. The infantile twisting of the tubes is gradually eliminated, and the tubal canal is somewhat reduced in length. Quite marked changes take place in the ovary. Clark has shown that during childhood the primordial follicles develop up to a certain point in about the same manner that they do after the age of puberty. The follicles affected are those lying in the most vascularized part of the young ovary, i.e.,- near the center; they never reach the surface and do not rupture. After attaining a fair size the granulosa cells degenerate, and the follicle is finally obliterated by a process that resembles the evolution in older ovaries of the corpus luteum and the corpus albicans. Nearly every vestige of the latter is absorbed, but the destruction of the follicles at the center of the ovary gradually causes an increase of connective tissue at this point, and at the age of puberty the undeveloped primordial follicles are in the cortex of the organ, and as the Graafian follicles reach their full growth, they distend the tunica albuginea and rupture. FUNCTIONS OF THE SEXUAL ORGANS The External Genitalia. — The labia protect the orifice of the vagina and the urethra ; the clitoris and the vestibular bulbs are erectile structures concerned with copulation. The Vagina. — The vagina is penetrated by the male organ during copu- lation. The vaginal fornices are the receptacle for the spermatic fluid, whence the spermatozoa gain access to the uterus. The vagina is also the passageway through which the foetus is born. Owing to its shape, which re- sembles the letter H, and to the reserve mucosa in its sulci, the vagina is capable of undergoing marked distention without serious injury during labor. The Uterus. — The uterus secretes the menstrual fluid. During preg- nancy the uterus nourishes and protects the ovum. The activity of the uterine muscle is one of the most important factors in the process of labor. The Fallopian Tubes. — The tubes transmit the ova to the interior of the uterus. They are a lurking place for the spermatic particles, and concep- tion is believed usually to occur in their outer third. Under exceptional cir- cumstances they may give off a bloody discharge during menstruation, but, as a rule, they take no part in the process. The Ovaries. — The ovaries are the dominating reproductive organs, and are responsible for the physiologic activity of the remaining organs. If the ovaries are healthy and active, the other organs are likely to be the same ; if the ovaries are poorly developed and functionally deficient, almost any abnormality in development may be found in the other organs. This may be somewhat in the nature of cause and effect, or the condition of the entire genital system may be primarily hypoplastic. It has long been the belief that the ovaries possessed an internal secre- PHYSIOLOGY 63 tion, and since the experimental work of Fraenkel the corpus luteum is recog- nized as the most actively secreting- portion. The follicles of the ovary and the interstitial gland also possess a secretion. This combined internal secretion of the ovary has a general effect upon the economy, which con- tributes to the well-being of the individual. 1 The truth of this statement is apparent from the numerous vasomotor and nervous disturbances that at times follow abrupt withdrawal of the secretion, as after bilateral oophorec- tomy (artificial menopause). The ovarian secretion brings about the phenomena of menstruation (see Ovulation), and on its withdrawal menstruation ceases. The ovarian secretion is also responsible for the formation of the decidua and the early enlargement of the uterus during pregnancy ; in other words, it aids in the nourishment and protection of the early ovum. Fraenkel has demonstrated the truth of these statements in experiments on rabbits. De- struction of the corpora lutea in both ovaries w r as followed by cessation of menstruation for a period of from one to two months ; destruction of the corpora lutea in the earliest stage of pregnancy resulted in degeneration of the embryo. The internal secretion of the ovary is the one stimulant 2 that is essential to the physiologic activity of the reproductive organs. Some of the other ductless glands also have an influence upon menstruation, and their secretion probably serves as an adjuvant to the ovarian products. The influence which these glands have upon the reproductive system may be learned from a study of the following structures : The Pituitary Body. — A definite relationship has been established be- tween the pituitary body and the generative organs. It may be stated in a general way that the hypophyseal secretion is antagonistically comple- mentary to that of the ovaries. The most frequently encountered mani- festation of a dysfunction of the pituitary body is evidenced in that symptom- complex resulting from a hypofunction after puberty, consisting of a marked adiposity, associated with genital atrophy and a lack of or diminution in the functioning of the genital organs. The early increase in genital activity in acromegaly, due to hyperfunction, is soon followed by a functional atrophy of the genital organs. That the gland is enlarged in pregnancy has been 1 Frank notes the secreting parts of the ovaries as the follicles, the corpus luteum, and the interstitial gland. The ovarian secretion is not essential to the continuance of life. Hyperfunction of the ovaries in adults produces menorrhagia ; hyperfunction in children gives rise to premature sexual development. Hypofunction in adults causes amenorrhoea and obesity ; in children it produces infantilism. Oophorectomy in adults is followed by an artificial menopause ; in children, by eunuchoid habits, genital atrophy, and a neuter type of development (no data bearing on the findings in humans are available). The reports on the therapeutic use of ovarian extracts show no uniformity of results. 2 There are a few well-authenticated reports of a continuance of menstruation after complete removal of both ovaries. This has led some observers to believe that the compensatory activity of some of the other glands of internal secretion normally associated with the ovary in the production of menstruation may be sufficient to con- tinue " the habit of menstruation," especially if, by reason of uterine adhesions, the blood supply to the uterus is above normal. While this possibility cannot be denied absolutely, the continuance of the menses in these cases is more probably due to the presence of supernumerary ovaries that have escaped observation. There are two varieties of supernumerary ovaries : First, contiguous supernumerary ovaries, which are situated on or close to the normal ovary ; secondly, aberrant ovaries, which lie at a point in the line of descent of the fcetal ovary (these are the size of a millet seed, a pea, or rarely of a cherry). 64 GYNECOLOGY shown by necropsy findings in women who have died during pregnancy, as well as by the facial changes, simulating those of acromegaly, that are prone to occur during pregnancy. The increase in the anterior lobe occasioned by pregnancy may persist for several years. Removal of the pituitary gland in pregnant dogs has been followed by abortion. Extracts of the posterior lobe have been used as oxytocics during par- turition and for the control of uterine hemorrhages in the non-pregnant state. Extracts of the anterior lobe have been used with some success in functional amenorrhcea associated with marked adiposity. The Thyroid Gland. — The most prominent symptom of the inter-rela- tionship of the genital organs and the thyroid gland consists in the marked enlargement of the gland that occurs during pregnancy. This increase in the size of the gland, with its correspondingly greater amount of secretion, is a physiologic hypertrophy, and is believed to assist in the regulation of the metabolism of the maternal organism during this period. A similar increase in the size of the gland, though of less marked degree, is often noted during menstruation. Disturbances of the thyroid gland may be responsible for amenorrhcea, menorrhagia, and metrorrhagia. That its physiologic relationship to the genital organs is as yet imperfectly under- stood is evidenced by the fact that these conditions, while of distinctly oppo- site nature, are often benefited clinically by thyroid therapy. Patients suffering from Graves' disease are usually sterile, and pregnancy exercises a decidedly unfavorable influence on the prognosis of Graves' disease. The undeveloped genitalia symptomatic of hypothyroidism, myxcedema, and cretinism are often stimulated to growth by the administration of the neces- sary thyroid tissue. Many cases of myoma of the uterus are associated with hypertrophic thyroid glands. The administration of thyroid gland extract, alone or in combination with other glandular substances, is indicated only in a few instances, and owing to the fact that an excessive secretion of this gland is easily produced, and may and often does cause serious nervous and func- tional disturbances, the original dose should be small — one-half grain three times a day, the dose gradually increased as may be found necessary. The Parathyroid Glands. — From the fact demonstrated experimentally in animals, that tetany follows removal of the parathyroid glands, the at- tempt has been made to prove that a similar condition in the human may be due to an insufficiency of parathyroid tissue. The administration of parathyroid glandular tissue in the tetany of pregnancy, eclampsia, and osteomalacia has not, however, been sufficiently successful to call for more than a brief mention. The Suprarenal Glands. — The inter-relationship of the suprarenal glands and the ovaries and other genital organs has been manifested in several conditions. The suprarenal glands are hypertrophied during menstruation and pregnancy in women as well as in animals. Precocious and abnormal sexual development is commonly found associated with a marked increase in the size of the suprarenal glands ; hypernephromata may be accompanied by an abnormal sexual development, even in children. Hyposuprarenalism, known clinically as Addison's disease, is often associated with diminished genital activity and even organic atrophy. PHYSIOLOGY 65 The Pineal Gland. — The relation of this gland to the physiologic activity of the female pelvic organs has been manifested in the pronounced over- development of the sexual organs before puberty in cases associated with tumor formation of the pineal gland. The Placenta. — The placenta contains a chemical substance that is known to be thermostabile (Frank) (very resistant in strong alkalis and acids and completely soluble in 95 per cent, alcohol), and that experimentally induces rapidly hyperplasia of the uterus and the breast. In its physical, chemical, and biologic properties it appears identical to a similar substance obtained from the corpus luteum. In view of this identity it is considered probable that the placenta acts merely as a storage reservoir for corpus luteum secretion during the latter half of pregnancy. The Mammary Glands. — That a close relationship exists between the genital organs and the breast is obvious. This is proved by the rapid development of the breasts at puberty, the swelling of the breasts at the menstrual periods, the hypertrophy of the breasts and secretion of milk incident to pregnancy and lactation, and the atrophy that takes place at the menopause. These changes seem to be brought about by some chemical agent that is present in the blood. The derivation of this substance has been ascribed to the ovary and the placenta, but no entirely satisfactory solution of the problem has as yet been offered. MENSTRUATION Menstruation [Latin: menstruus, monthly, from mensis, month] is a com- plex process of which the most obvious evidence is the menstrual flow. It recurs at periodic intervals of about four weeks from puberty to the meno- pause. The provocative impulse evidently lies in the ovaries, for if these organs are removed, menstruation ceases. The ovary has an internal secre- tion that gives rise to the menstrual molimina. An ovarian impulse and a uterine response are essential to the menstrual flow. The internal secretion of the ovary produces the impulse, and the endometrium excretes the menstrual fluid. The menstrual flow is but a part of menstruation. Besides its effect on the endometrium, the ovarian secretion, either alone or more probably in combination with the other ductless gland secretions, generally stimulates metabolism as the menstrual epoch draws near. This exaggeration of metabolic activity is recognized by an increase in the function of the muscu- lar, respiratory, circulatory, and nervous systems before the flow appears. After the flow sets in, there is a relative decrease. There are various sub- jective and objective manifestations of the metabolic disturbance; thus the patient may complain of lassitude, headache, and pain in the lower part of the abdomen, in the back, and in the thighs. The breasts may become engorged and painful. There is often some perversion of taste and of the other senses. Disturbances of the digestive tract are not uncommon. Vari- ous neuroses may become manifest, and spots of pigmentation and skin erup- tions may appear upon the face, thighs, abdomen, and breasts. The widest variation of these symptoms may obtain, depending upon the temperament and the physique of the individual. 5 66 GYNECOLOGY The Menstrual Fluid. — The menstrual fluid consists of blood mixed with the glandular secretions and the desquamated surface epithelium of the endometrium. As long as the normal proportion between its constituents is preserved, menstrual blood shows no tendency to clot. Bell ascribes this fact to a lack of fibrin ferment in the menstrual fluid, and Dienst be- lieves that the endometrial cells excrete a substance that inhibits coagula- tion. The hemal constituent is derived from the subepithelial capillary plexus of the endometrium, largely by diapedesis, partly by minute rup- tures in the capillary walls. The blood collects in the superficial part of the endometrium, beneath the surface epithelium, through which it finally passes, detaching the epithelium here and there and carrying away small portions (Fig. 73). The amount of menstrual blood lost at a single period is said to be from four to six ounces. The flow continues, on the average, for from three to five days, but it may vary between one and eight days. The Menstrual Habit. — So far as regularity, duration, and amount of the menstrual flow are concerned, a woman may exhibit certain peculiarities that are compatible with perfect health. Thus the menstrual interval may vary between three weeks and a full calendar month, the length of the period may be longer or shorter, and the amount of fluid lost may be more or less than the average. The individual's custom in this respect is known as her menstrual habit. This habit must always be taken into account when estimat- ing the significance of the menstrual symptoms. Menstruation does not always appear as a well-established function from the start. After its first appearance, several months or even a year or more may elapse before men- struation becomes periodic and regular. Ovulation. — Ovulation is believed by most observers to be coincident with menstruation. Thus Clark, in his brilliant work on the circulation of the ovary, gave it as his opinion that the increase in the amount of blood sent to the pelvic organs during menstruation caused a marked augmenta- tion of the intracapsular pressure of the ovary and directly resulted in the bursting of the Graaffian follicle. The more recently expressed views of Fraenkel, Peters, Schroder, Meyer-Ruge, and others are not in accord with those generally accepted in the past. By comparing the menstrual history, the histologic appearance of the endometrium (Figs. 73-77), and the results of gross and microscopic examination of ovaries removed at operation, these investigators conclude that ovulation commonly takes place from fourteen to sixteen days after the onset of menstruation. The corpus luteum which follows reaches the height of development from the eighteenth to the twenty-fifth day, and forms the stimulus for the next menstrual epoch (Fig. 78). Should conception occur, then the action of the corpus luteum is diverted to the formation of the decidua and the implantation of the ovum. Whether or not we accept the newer view, it has always been admitted that menstruation and ovulation do not necessarily occur at the same time. Thus, Leopold and Mironofr", who were adherents of the older theory, on examination of forty-two menstruating women at operation or at autopsy, found that ovulation had taken place in only thirty. Arnold made observa- tions of a similar nature, and in but thirty-nine out of fifty-four operative or post-mortem cases did he find a fresh corpus luteum at the close of the PHYSIOLOGY 67 menstrual period. Ovulation may occur in women who have had no men- strual flow. Thus ovulation continues after hysterectomy with retention of the ovaries, when there is not sufficient uterine mucosa to respond to the m -&&\ Fig. 73 Fig. 74 m. t-mm Fig. 75 I .- SI Fig. 76 Figs. 73, 74, 75, 76. — The mucous membrane of the uterus in the various phases of menstruation. Fig. 73. — Menstrual mucous membrane one day after menstruation. Fig. 74. — Endometrium during the interval. Fig. 75. — Premenstrual condition. Fig. 76. — Third day of menstruation, showing exfolia- tion of the superficial layer. (After Hitschmann and Adler, from Keibel and Mall.) ovarian impulse. A curious instance of ovulation in the absence of menstrua- tion is reported by Stengel. In this case pregnancy and childbirth occurred in a woman aged twenty-one who had never menstruated. The woman was in robust health, and had been married three years when conception took 68 GYNECOLOGY place. As a further example it may be noted that pregnancy frequently occurs during lactation when the periods have been entirely absent. Geb- hard cites a case of Kronig's in which, four days after labor, conception again occurred. It is evident, therefore, that while, as a rule, menstruation $c Fig. 77. — The uterine mucous membrane in the first day of menstruation: (H) hema- toma under the epithelium; (Bl) hemorrhage into the compacta; {Co) compacta; (Sp) spongiosa; (Po) gland of the post-menstrual type; (Pr) gland of the pre- menstrual type; (M) muscularis. Hitschmann and Adler, from Keibel and Mall.) and ovulation bear a certain time relation to each other, ovulation may take place without menstruation. Menstruation may occur at a different time than ovulation, but it is, nevertheless, dependent upon the activity of the ovary, for unless follicle-bearing tissue is present in the ovary, menstruation will not take place. Clark has shown that menstruation begins at the time PHYSIOLOGY 69 B the Graafian follicles have reached that stage in their development when they approach the surface of the ovary and rupture into the free peri- toneal cavity. When but few follicles remain and the organ is little more than a mass of scar tissue, menstruation ceases. The menstrual flow is dependent immediately upon an intense conges- tion of the uterine mucosa and a menstrual diapedesis (Fig. 79). The flow is modified by abnormalities both in the uterus and in the ovaries. If the uterus is imperfectly devel- oped, the diapedesis will be affected correspondingly. If the ovarian tissue is not nor- mal, the physiologic impulses of menstruation will be faulty and the process be variously modified. The ill-developed, atrophic, or infantile uterus excretes less menstrual blood than the larger normal organ, since its endometrial surface is smaller and its blood supply deficient. The enlarged uterus of chronic metritis or of sub- involution gives off more men- strual blood than is normal for the area of endometrium and the blood supply is increased. Deficient ovarian secretion leads to subnormal menstrual congestion and diminished menstrual flow. Congenital deficiency of the ovarian ac- tivity is commonly associated with ill-developed uteri. Ac- quired deficiency the result of resection of the ovaries or of } loss of one ovary may be fol- lowed by a diminution in the menstrual flow, since the men- strual impulse has been reduced. Abnormal production of the ovarian secretion (as in the presence of Graafian follicle cysts, corpus luteum cysts, cystic degeneration) may lead to irregularity, temporary cessation, diminution, or increase of the menstrual flow. A perverted ovarian func- tion has at times been attributed to nervous influences. According to Clark's original theory, the congestion of the ovary at the menstrual period, with the consequent increase of tension within the ovary, leads to bursting of the ripe follicle projecting from the surface. If the more recently expressed views as to the time of ovulation are correct, the follicular rupture may be attributed to an increasing accumulation of follicular fluid. -Schematic drawings to illustrate relation between ovu- lation and menstruation: (A) about 21 days after beginning of last period: ovulation taking place — mucosa resting; (B) be- ginning of new menstrual period: corpus luteum of menstrua- tion formed, menstrual endometrium. 70 GYNECOLOGY 4;\^\\\vlY\\vkv * ° o Anatomic Changes Incident to Ovulation and Menstruation. — According to Clark, the mature follicle about to rupture appears in the form of a bleb projecting from the stroma of the ovary above the level of the tunica fibrosa. At the point where this blister rises from the surface of the ovary many deeply injected vessels are seen springing from the depths of the ovarian stroma, and spreading out over the follicle as a fine net. These vessels, as a rule, become less numerous as the most prominent point is reached, where they may disappear entirely. It is at this latter point that the follicle ruptures, and the ovum with the follicular fluid escapes into the pelvis. Following rupture there is an extravasation of blood into the follicu- lar cavity. Into this blood-clot newly-formed veins and arteries are pro- jected from the connective tissue surrounding the follicle. The granulosa cells lining the follicle hypertrophy as the vascular loops are projected in- ward, and within the loops of the latter are carried toward the center, forming the lutein cells (corpus luteum, "yellow body"). When the cavity is completely filled in, the lutein cells ap- pear large and well nourished, rich in protoplasm, with large, oval, prominent nuclei. The lutein cells serve as supporting structures until perma- nent connective tissue from the periphery is produced. With the progressive proliferation of the new connective tissue the cells of the corpus luteum show evidence of fatty degeneration and undergo atrophy. The entire follicle gradually becomes filled with new connective tissue, forming the Su\iq\\Vi\\6V " uxexvxvB v)a\\ corpus albicans, which later undergoes hyaline fcatfxWax^ changes and is finally absorbed either in whole vv«-xvx& or j n p ar £ After its escape from the follicle the Fig. 79. — Schematic drawing to show ... . . . the collection of blood beneath the OVUm lies in Contact With the COntlgUOUS SUr- StaS^te^tSriZS^ faces of the pelvic peritoneum, Fallopian tube, intestine, omentum, or ovary. Just what posi- tion the ovum occupies primarily is dependent on chance and is of no consequence. It floats in the capillary layer of peritoneal fluid between these structures, and is ultimately swept into the fimbriated extremity of the corresponding tube by the current produced by the action of the cilia. It has been demonstrated that minute foreign bodies in the peritoneal cavity are ultimately carried into the Fallopian tubes by the ciliary current. Occa- sionally the ovum of one side will be carried into the tube of the opposite side, a process known as external migration of the ovum ; it is quite likely that its occurrence under normal conditions is not infrequent — it must take place in cases of pregnancy following removal of the ovary of one side and of the tube of the other. Hitschmann and Adler have recently shown that periodic and regu- larly recurring anatomic changes in the mucous membrane of the uterus take place from one menstrual cycle to the next. In the premenstrual stage (Fig. 75) the structure of the endometrium \F ■5 PHYSIOLOGY 71 Dr.l. more or less resembles a beginning formation of decidua; the superficial capillaries are engorged, the stroma is oedematous, the glands are enlarged, with swollen epithelium and diminished lumina. This period lasts from six to seven days. The second cycle is the menstrual one (Figs. 73 and 76). The stage of secretion and hemorrhage lasts from four to six days, during which the glands discharge secretion, the superficial areas of the endometrium are infiltrated with blood, the superficial epithelium is detached, or the cells : g|g are separated in certain places per- _ _, --it .*•/■'.. ' ■'• mitting the menstrual blood to /$%>- V "' ^'^^■ escape. The third stage is the post-men- strual one (Fig. 74). In this stage the epithelial surface is repaired by the proliferation of cells, the blood- vessels shrink, and the stroma cells lose their oedematous character. Fecundation. — T h e spermatic Comp particles are capable, by their own activity, of making their way in the uterine cavity and the tubes at the rate of 1 cm. in three minutes. It is possible that their entrance into the uterus is facilitated by reflex move- ments of the organ at the time of emission. In some of the lower ani- mals it has been observed that at this time the uterus descends into the vagina, the endorrietrial cavity becomes reduced in size, and the plug of cervical mucus is partly ex- pressed from the external os. Im- mediately after the orgasm the uterus resumes its previous condi- tion, during which process it aspirates into the uterine cavity a portion of the spermatic fluid that has combined with the cervical mucus, the alkaline cervical mucus possessing a certain attraction for the spermatic particles. That this is the process that occurs in the human cannot be asserted posi- tively, but it is not unlikely that such an occurrence takes place following the orgasm in the female. From the uterine cavity the spermatozoa, by their own motility, make their way to the outer third of the tube, where they lie in wait for the ovum. The ovum is fecundated by the penetration of one sperm-cell. The fertilized ovum then passes down the tube to the uterus, which it is said to reach within from three to seven days. The relation of ovulation to the menstrual periods is important in determining the time Spong Muse Dr. 2. Fig. 80. — Showing the two layers of the decidua of the second month, decidua compaeta and decidua spongiosa. (Keibel and Mall.) 72 GYNECOLOGY when coitus will most probably be followed by conception. If ovulation occurs simultaneously with menstruation, it is evident that spermatic par- ticles gaining entrance to the uterus and thence to the tubes immediately after menstruation will fecundate the recently discharged ovum and that pregnancy will date from the first coitus following the last normal menstrual period. If the more recently expressed view, that ovulation occurs within from fourteen to sixteen days after menstruation is correct, then, although the onset of pregnancy must be reckoned from the first day of the last men- strual flow, the duration of gestation is evidently shorter by a week than the classic period of two H j \<-l \ *', * ft' « \^ •.> c c*a (jr-j hundred and eighty days. M S#^ Y; If ff/jA ha^ married women who ave sexual intercourse at ,/.*/ $M re g u ^ ar intervals it has been shown that the tubes com- monly contain spermatic particles, and that, in con- sequence, a slight irregu- larity in ovulation may re- sult in conception taking place at any time during the month. This irregularity explains the apparent varia- tion in the duration of preg- nancy that at times occurs. Nidation of the Ovum. — As soon as fertilization occurs, certain changes take place in the endometrium; these have for their purpose suitable nidation and nour- ishment of the ovum. The endometrium becomes transformed into the mem- branous structure known as the decidua. The stroma cells of the endometrium become greatly hyper- trophied, forming large, round, oval, or polygonal cells with large, lightly-stained vesicular nuclei — the decidual cells. This metamorphosis of the stroma cells occurs chiefly in the superficial part of the endometrium, and during the process the glands are crowded into the deeper part. The superficial area, composed of the decidual cells, is known as the compact layer of the decidua {decidua compacta), whereas the deeper area, made up of the distended and hyperplastic glands, is termed the spongy layer (decidua spongiosa) (Figs. 80 and 81). When the fertilized ovum reaches the uterine cavity it finds the endo- Fig. 81. — Showing a gland duct of the decidua compacta of the second month, containing secretion, and surrounded by typical decidual cells and a few leucocytes. (Keibel and Mall.) PHYSIOLOGY 73 metrium transformed into a thick, succulent structure that serves admirably as a resting-place and as a source of nourishment (Fig. 82). The ovum at this time has not progressed beyond the stage of develop- ment when the blastodermic vesicle is formed, and does not possess any villi. The cells of the outer surface of the vesicle, known as the chorion, rapidly proliferate and form large, irregular, multinucleated masses of pro- toplasm that have peculiar properties and that serve the double purpose of implanting and of nourishing the ovum. These cells, owing to their func- tion, are known as trophoblasts, and possibly serve to convey nourishment to the ovum by osmosis merely through their contact with the decidua. Their most peculiar char- acteristic is the corrosive action they exert on the decidua, eating their way into the specialized de- cidual tissue. After a time, little shoots of connective tissue from the inner layer of the chorion project beneath the trophoblastic cells in the shape of finger-like processes and form the rudimentary villi (Figs. 85 and 86). The tropho- blast covering the connec- tive-tissue stalks is finally transformed into two layers of epithelium — an inner layer, made up of polygonal cells, and known as Langhan's layer, and an outer layer, made up of ribbon-like cells, termed the syncytium. As a result of the corrosive in- fluence of the trophoblast upon the decidua, the ovum penetrates and soon sinks into the depths of this structure, as a rule, at the upper part of the uterine cavity. As the trophoblast eats its way through the decidual tissue it erodes the walls of the capillary vessels along its path and permits blood to escape between the contiguous borders of the decidua and the advancing tropho- blast. Thus are formed the spaces filled with maternal blood — the earliest stage in the formation of the intervillous blood spaces of the future placenta (Fig. 87). Here and there a villus does not simply project or float, as it were, in the maternal blood, but passes to a more distant area and becomes securely embedded within the deeper layer of the decidua. These particular villi serve as points of attachment between the ovum and the maternal struc- tures, and are known as the " fastening " villi. Fig. >2. — Semi-schematic drawing to show relative size of imbedded early ovum and uterus. 74 GYNECOLOGY w'o PHYSIOLOGY 75 In time the chorionic villi become especially well developed in the area directly opposite the uterine wall. These villi cover that part of the chorion known as the chorion frondosum. This and the area of the decidua with which it is in relation {decidua serotina) together ultimately make up the placenta. The placental space lies between the chorion frondosum and the decidua serotina, and contains maternal blood. The blood is separated from the capillaries of the fetal villi by the thin layer of specialized chorionic epithe- lium known as the syncytium. The only means of communication between the maternal and the foetal blood is by osmosis through the syncytial cells. There is also possibly a direct cellular participation of the syncytium in this exchange, which is compared by Williams to a similar process that takes place in the tubules of the kidney and in other organs. Ue.R. " _ © © " " '* • e o ffge&M 2£S*«VJ f*®2gLi \ ^* r* y ' ■« og *%v*«*.« - v '•^••. -iSfc s \^* «V ' '%£?m&*lr : «8 TV. ?v* *Mw J • 6. Tr. Bl. Fig. 84. — Summit of the Peters ovum: (Bl) blood lacunae; (Ca) capsularis; (Sc) closing coagulum; (5/) its stalk; (Sy) syncytium; (Tr) trophoblast; (Ue) uterine epithelium; (Ue.R) the crumpled border of this;_ (a) trophoblast nucleus in the syncytium; (b and c) preparatory stages of the syncytium (wreath-like deposit in a blood lacuna.) (From Peters, 1899, Keibel and Mall.) PREGNANCY During the period of gestation the generative organs undergo a pro- nounced hypertrophy. The uterus, which, of course, is the organ most affected, increases from 6.5 to 7 cm. in length to 28 to 36 cm. There is an increase in capacity of more than 500 times, and an increase in weight of the organ of from one ounce to about two pounds (Figs. 88 and 89). The general enlargement is due to the increase in the size and in the number of the muscle cells, as well as of the blood-vessels, lymphatics, nerves, and elastic fibers. During the first half of pregnancy there is an actual hypertrophy of the constituents of the uterine wall. After this time the hypertrophic process ceases, and the thickened muscular sac bcomes distended. The wall of the 76 GYNECOLOGY h.-z. uterus at term measures about 5 to 7 mm. in diameter. From the very begin- ning of pregnancy the hypertrophy of the uterus affects all parts quite equally, but as pregnancy advances the fundus is almost exclusively the portion affected (Fig. 90). One of the early indications of pregnancy, appearing from the sixth to the eighth week, consists in an excessive softening of the lower uterine segment, so that it may be difficult, on bimanual palpation, to detect the connection between the slightly enlarged cervix and the mark- edly hypertrophied and softened body. This condition constitutes what is known as Hegar's sign (Fig. 91). Beyond moderate hyper- trophy and softening, the cervix itself remains unchanged until the last month of pregnancy, or even until the onset of the first stage of labor. The cervical glands secrete more actively, and the mucous dis- charge is increased. The ovaries do not functionate during pregnancy, but their vascularity is markedly in- creased. The corpus luteum of preg- nancy is greatly enlarged and may Fig. 85.— Chorionic villus from the second month; the OCCUOV at least One-half of the OVary, syncytium provided with prickle processes: (J. Cap) foetal m rj . J * capillary. (.H.-Z) Hofbauer cell. X400. (Keibel and projecting - from the Surface as a Mall.) r J ° more or less permanent hillock. It does not differ histologically from the menstrual corpus luteum, and its increased size has been attributed to the marked congestion of the vessels incident to pregnancy. Some authors, however, notably Fraenkel, believe that the corpus luteum is the actual secreting structure of the ovary and is directly concerned with the formation of the decidua and placenta and the nourishment of the early ovum. Later in pregnancy, when these changes have occurred, the corpus luteum undergoes atrophy. Fraenkel, by careful experimental investigations, has done much to substantiate his theory, and his views are now generally accepted. The vascularity of the Fallopian tubes is increased, and they undergo some hypertrophy. The vagina is more vascular, and its mus- cular and connective-tissue fibers become hyper- trophied. The vaginal mucosa becomes thicker and softer. The distention of the abdominal wall by the pregnant uterus is marked in more than 90 per cent, of cases by the formation of the striae gravidarum. These striae are shimmering, Fig. 86. — Human ovum, showing cho- rionic villi. (Specimen of Dr. G. A. Piersol.) PHYSIOLOGY 77 Ch.-P. ife '.ibes. Urban and Schwarzenburg, Vienna, 1907. Lebedinsky : " tiber pathologisch-anatomische Veranderungen an dem Eierstocke bei Scharlach." Centralbl. f. Gynak., 1877, i, no. Massin, W. N. : " Zur Frage iiber Endometritis bei akuter infectioser allegemein Erkrank- ungen." Arch. f. Gynak., 1891, xi, 146. Noble, C. A. : " The Constitutional Factor in Gynecology." Trans. Amer. Gyn. Soc, vol. xli, 1916, p. 656. Osler, W. : Principles and Practice of Medicine. Appleton, New York, 1912, 8th ed. Stengel, A., and Fox, H. : Text-Book on Pathology. Saunders, Phila., 1915. Tait, Lawson : Pathology and Treatment of Diseases of the Ovaries. Cornish, Birming- ham, 1883. Thorn, Wilhelm : " Beitrag zur Lehre von der Atrophia Uteri." Zeitschr. f . Geburtsh. u. Gynak, Bd. xvi, S. 57. Veit, J. : Handbuch der Gynakologie. Bergemann, Wiesbaden, 1897. CHAPTER VII GENERAL PHYSICAL EXAMINATION The diagnosis is based to a certain extent upon the results of physical examination. Much stress may be placed upon the importance of ascertain- ing the general physical and mental condition of the patient. Not infre- quently the patient has undergone a thorough physical examination before she is seen by the gynecologist. When a careful general investigation has not previously been made, it should be conducted in conjunction with the gynecologic examination. The assistance of an internist, an alienist, or possibly a specialist in diseases of the eye, ear, nose, and throat may be required in order to interpret correctly the symptoms presented and indicate the proper treatment. The gynecologist should note the general appearance of the patient — the build, whether emaciated, well rounded, or excessively fat ; the carriage, whether erect or stooped ; the color, whether it be the glow of health, the pallor of anaemia, or the yellowish tint of cachexia ; the facial expression, whether it indicates buoyancy of spirits or mental anxiety and depression ; the weazened face of the woman suffering from an ovarian cyst, or the per- turbed, anxious expression of one stricken with peritonitis. TEMPERATURE An elevation of temperature accompanies most of the acute infections of the pelvic organs. It may also be present as the result of the absorption of ferments or toxins from blood-clots and traumatized or necrotic tissue. The height of the temperature and the variations in its course are dependent upon the nature of the underlying lesion and the resisting powers of the individual. The temperature in gonococcus and tuberculous infections is lower than in infections due to the streptococcus, staphylococcus, colon bacillus, bacillus pyocyaneus, bacillus diphtheria?, and other pyogenic organ- isms. Infections of the lower genital tract, vulva, urethrovaginal glands, etc., are less likely to be accompanied by high fever than are those of the cervix, endometrium, uterine wall, cellular tissue, tube, ovary, and pelvic peritoneum. Rapidly growing or disintegrating malignant growths are accompanied with pyrexia. Necrotic decidua or retained placenta, slough- ing cervical polypi, or submucous myomata usually give rise to fever. In tubal pregnancy, pelvic hematocele, ovarian cyst, or pedunculated fibroid tumor with twisted pedicle the temperature is, as a rule, slightly elevated from absorption of fibrin ferment, even though no infection has occurred. The elevation of temperature accompanying pelvic disorders is usually continuous in type ; but if the progress of the disease is arrested and there is a localized collection of pus, it becomes remittent. If very little or no pus is formed and the septic products of the infection are absorbed, the temperature gradually recedes to normal. In the acute pyelitis of pregnancy and in acute phlebitis or cellulitis following abortion or labor, the temperature is 103 104 GYNECOLOGY remittent or intermittent in type from the beginning, and is accompanied by chills. Chills and high remittent fever are characteristic of the sudden entrance into the blood of large amounts of septic products, as in strepto- coccus infections of the uterine wall, the veins or lymphatics of the broad ligament, or the pelvic peritoneum. The elevation of temperature accompanying pure gonorrhceal pelvic in- flammatory disease, as a rule, subsides as the disorder disappears in the course of a week or ten days. The temperature of streptococcus infections is more apt to continue for a longer period, and to be subject to repeated exacerbations, finally reaching the normal or becoming intermittent if an abscess forms. CIRCULATION Pulse. — The pulse-rate is normally a little higher in women than in men. In febrile conditions the frequency is increased from eight to ten beats for each degree of temperature above the normal. The degree of acceleration of the pulse in direct ratio to the rise in temperature is often an indication of the virulence of the toxic products that are being absorbed. Thus a pulse-rate relatively lower than the temperature is an indication of a milder toxin, whereas a relatively more rapid increase is an indication of a more virulent toxic process. The full, high-tension pulse marks the strong reactions ; the weak, low-tension pulse indicates an inability to react ; the former indicates the antagonism of the economy to the toxic products, whereas the latter points to an overwhelming of the economy by the toxic products. Coldness of the extremities with a rapid, low-tension pulse and high fever are indica- tions of approaching dissolution from absorption of septic products. Rapid pulse unaccompanied by fever is observed in conditions in which excruciating pain is present, as, for instance, in twisting of the pedicle of an ovarian cyst or a pedunculated fibroid or during the passing of a renal cal^ cuius. In these conditions the patient is often in a state of collapse, and the temperature may be subnormal. An increased pulse-rate and a subnormal temperature are seen after acute hemorrhage, either external, as in miscarriage with profuse bleeding, or internal, as in a ruptured pregnant tube with free intraperitoneal hemor- rhage. The pulse is always of low tension in cases of hemorrhage. The rapid pulse of hemorrhage is not accompanied by dyspnoea until an extreme degree is reached. The pulse may be increased as the result of repeated hemorrhages occurring over a long period of time, after which anaemia and myocardial changes finally supervene, as in fibroid tumor. The rate may also be increased by pressure on the diaphragm exerted by abdominal tumors or ascites. An increase in pulse-rate may also occur in the general disorders accom- panying pelvic disease, such as hyperthyroidism, intrinsic cardiac disease, etc. A sudden increase of the pulse-rate followed by a rapid failure is ob- served in pulmonary embolism. The blood- pressure becomes higher with age. It is increased by arterio- sclerosis, cirrhosis of the liver, interstitial nephritis, obesity, etc., and is diminished by anaemia, hemorrhage, and septic toxaemia. GENERAL PHYSICAL EXAMINATION 105 After prolonged surgical operations, and in those attended with much loss of blood, the blood-pressure is subnormal. The significance of abnormalities in the blood-pressure and their bear- ing on prognosis in operations will be dealt with in Chapter XXXV. Heart. — Cardiac insufficiency may be responsible for menorrhagia, metrorrhagia, leucorrhcea, and other symptoms of chronic pelvic congestion. The pelvic condition that appears most frequently to produce cardiac disorders is fibroid tumor of the uterus. Murmurs, dilatation and hypertrophy, and fatty infiltration may occur. These are all due largely to anaemia, and if the fibroid tumor is removed before permanent changes have taken place, the heart may again become normal. When the tumor is of long standing, a form of myocarditis results ending in brown atrophy. The heart may be displaced upward and to the left by distention of the abdomen, as in ascites and large ovarian cysts. Epigastric pulsation of the abdominal aorta is a common cause of com- plaint in neurotic females and at the climacteric. Functional cardiac dis- turbances, manifested by palpitation, faintness, pallor, rapid breathing, etc., may be observed at puberty, at the recurring menstrual periods, during coitus, at the climacteric, etc. They are seen chiefly in those of unstable nervous temperament. Engorgement of the veins of the lower extremities, when bilateral, is frequently due to some general disturbance of the circulatory system ; when unilateral, it is due to obstruction of some or of all of the tributaries of the iliac veins on the affected side ; this may take the form of thrombophlebitis, carcinomatous infiltration, or compression. The effect of cardiac conditions on the prognosis of operations is de- scribed in Chapter XXXV. RESPIRATION Respiratory Rate. — An increase in the respiratory rate in febrile conditions is in direct proportion to the elevation of the temperature and the frequency of the pulse. It may, however, occur independently of either, or with a rapid pulse alone, in anaemia, myocardial affections, and comoression or displacement of the lungs by enormous distentions of the abdomen, as from tumors or ascites. Disproportionate acceleration of the respiratory rate is suggestive of intrinsic pulmonary disease — e.g., tuberculosis, emphysema, asthma. When such disease really exists, other indications of it. notably cough and expec- toration, are generally present. Rapid, sighing respirations are observed in acute profuse hemorrhage when the loss of blood has been great and dissolution is impending. Severe septic toxaemias may greatly augment the respiratory rate in oedema of the lungs and cardiac dilatation. Metastasis of chorio-epithelioma of the pelvic organs to the lungs is accompanied by pain, increase of respiration, cough, and bloody expectoration. Pulmon- ary embolism is marked by sudden and exaggerated dyspnoea. The normal type of respiration that is a combination of costal and abdom- inal motion is changed to the costal variety, or partly so, by conditions that produce large distentions of the abdomen, as tumors, ascites, tympanites, etc. The bearing of pulmonary diseases on the prognosis of surgical opera- tions is dealt with in Chapter XXXVI. 106 GYNECOLOGY Lungs. — Chronic bronchitis, emphysema, or asthma with cough may be a contributing cause of descensus uteri or incontinence of urine. A tuber- culous pulmonary lesion may be the initial focus of an inflammatory disease of the same type in the pelvis. Among the pulmonary affections following operations may be men- tioned bronchitis, pneumonia, pleurisy, and acute pulmonary oedema. BLOOD Blood Count. — A complete examination of the blood is always desir- able, for two purposes: First, to determine whether any form of anaemia is present, the blood picture showing, to a certain extent, at least, the general strength and resistance of the patient ; and, secondly, to ascertain whether there is evidence of any septic process, as may be indicated by an increase in the number of leucocytes. Leucocytosis is usually present in pelvic inflammation. It is less marked on the whole, in gonorrhoeal salpingitis (12,000-15,000) than in acute appen- dicitis (15,000-20,000). It is more marked in puerperal or post-abortal infec- tion than in either (20,000-30,000). The increase in the white blood-cells in infectious processes affects especially the polynuclear cells. A disproportionate increase of the poly- nuclear cells over the total leucocyte count occurs in suppurative and gangrenous conditions. The percentage of polynuclear cells, as shown by a differential count, may be taken as an index of the severity of the infection, as well as of the resisting power of the individual. As leucocytosis is an indication of re- sistance on the part of the patient, a steady increase usually points to an increasing lesion with increasing resistance, whereas a decrease indicates a subsiding or a localizing disorder. It must not be forgotten, however, that the white blood count may be low notwithstanding the presence of a serious and widespread local lesion if the patient is in poor condition and the natural defenses of the body are weak. 1 The anaemias encountered in gynecologic cases are, in a large majority of instances, those known as secondary, and result from hemorrhage or toxaemia or from both. In acute secondary anaemia the red blood-cells and the haemo- globin are reduced proportionately, whereas the white cells are relatively increased. In chronic secondary anaemia without toxaemia all the cells are proportionately reduced. In secondary anaemia with toxaemia (hemorrhage plus infection) the red cells and the haemoglobin are diminished, whereas the white cells are proportion- ately and absolutely increased. In that form of anaemia known as chlorosis, which is most frequent in young women and interferes with the establish- ment and course of menstruation, other changes in the blood occur. The haemoglobin is disproportionately diminished, and the red blood-cells may exhibit abortive or degenerate and malformed types. 1 The polynuclear cells represent the phagocytic powers, and they are therefore in- creased during the acute stage of an infectious process in proportion to its severity and to the resistance of the individual. When the acute process has been arrested a diminution in the relative proportion of polynuclear cells and an increase in the relative proportion of lymphocytes occur. GENERAL PHYSICAL EXAMINATION 107 Blood Culture. — A diagnosis of bacteriaemia can be made with certainty only when the organisms in the blood are identified. As a rule, the clinical evidences of bacterisemia are sufficient for all practical purposes, so that cul- tures need not be taken. As an aid to prognosis, or for the selection or preparation of an antagonistic serum or vaccine, the isolation of organisms from the blood may be extremely useful. The presence of the streptococcus in the blood renders the prognosis grave, and is an indication for the injec- tion of antistreptococcic serum. These organisms should always be demon- strated in the blood before the administration of antistreptococcic serum is begun. The staphylococcus and the colon bacillus may also be recovered from the blood. Repeated positive findings are necessary in order that faults in the technic may be excluded. An antistaphylococcic serum and an anti-colon serum are now on the market. (See Chapter XXI.) Wassermann Reaction. — This reaction or test for syphilis is dependent upon the formation, in the blood of an infected person, of a specific anti- body. This antibody has the power of combining with the complement (guinea-pig serum) in the Bordet-Gengou haemolytic system and rendering it inactive. This system consists of antigen (solution of syphilitic liver), complement (guinea-pig serum), and suspected serum in certain definite amounts. After incubation for a short time — usually one-half to one hour — sheep's blood-corpuscles and the haemolytic amboceptor are added and the whole again incubated. If the complement has been fixed by the antibody complement-fixing substance during the first incubation, it cannot combine with the other elements during the second incubation and cause a solution of the corpuscles, or haemolysis. A positive reaction is indicated by the ab- sence of, or a slight degree of, haemolysis. The reaction is not absolutely specific ; thus it has been found positive in f ramboesia, leprosy, and yaws. It is, however, the most reliable test at our command in making a diagnosis of a syphilitic infection. Abderhalden Serum Test. — The Abderhalden serum test was said to be of value in making the diagnosis of pregnancy. The test depends upon the appearance in the blood of ferments whose function it is to destroy foreign cells or their products invading the circulation. These invading elements in pregnancy are known as the syncytial cells. Owing to the elaborate detail of the technic and the uncertainty of the result, the test was not adopted generally for practical purposes. In view of the diverse and conflicting results obtained by various observers, the value of the test is doubtful. A positive reaction is of little value, since it may be found in conditions other than pregnancy, notably in carcinoma. A negative finding in a woman suspected of being pregnant is of considerable importance, since it is an indication of a lack of the specific ferments which are normally formed for the purpose of destroying the syncytial cells. Complement-fixation Test for Gonorrhoea. — This test depends upon the fixation of a complement by a specific antigen (gonococci), and a specific antibody (in the patient's serum), with a resulting inhibition of haemolysis or positive reaction. Schwartz and McNeil, whose work along this line has been most con- vincing, employed a polyvalent antigen (12 strains of gonococci). They 108 GYNECOLOGY used both antisheep and antihuman hemolytic sera, and followed the technic laid down in the well-known Wassermann test for syphilis and in Noguchi's modification of this test. A positive reaction is rarely attained until the third or fourth week of the disease. The reaction persists for seven or eight weeks after the patient has recovered. If only the anterior urethra is involved no reaction may be elicited. In adult women the test is seldom positive until the infection has reached the cervical canal. In little children with vulvovaginitis positive reactions occur early. This may be explained by the more delicate nature of the vulvar and vaginal mucosa and the increased absorption therefrom. A positive reaction may be regarded as evidence of gonococcus infection, but a negative reaction does not necessarily exclude the disease (Kolmer). The test is of especial value to the gynecologist, since it is often difficult to demonstrate the existence of chronic gonorrhoea in women by the discovery of the gonococcus in smears or by cultures. Lespinasse and Wolff believe the test to be of value in clearing up the etiology of certain obscure lesions — whether, for example, a certain leucor- rhoeal discharge is gonorrhceal or non-gonorrhceal ; in differentiating gonorrhoea of the tubes from other pelvic lesions ; in explaining the occurrence of puer- peral fever in cases where aseptic precautions have been observed. Thomas and Ivy point out that in the acute stage of the disease, when the fixation test is negative, it is usually easy to demonstrate the presence of the gonococcus bacteriologically, whereas in the chronic stage, when bacteriologic methods often fail entirely, the fixation test shows a positive reac- tion. The two methods of examination are, therefore, in a sense complementary. Method of Obtaining Blood for Serum Tests. — Blood for cultures and for Wassermann reactions, the Abderhalden test, and the complement- fixation test for gonorrhoea may be obtained by puncturing a vein. The skin over the median cephalic or basilic vein is painted with tincture of iodine. The vein is rendered prominent by the application of a moderately tight bandage about the upper arm. For blood cultures a glass syringe of 10 c.c. capacity, to which is fitted a sharp-pointed needle, is used. The needle is passed obliquely into the vein, and the blood obtained by slowly withdraw- ing the piston. The bandage should be removed before the needle is with- drawn. The blood is immediately injected into bouillon or agar-agar. Ex- treme care should be taken to prevent contamination, and all the instruments and utensils must be absolutely sterile. For the complement-fixation and other tests the blood may be allowed to drop directly from the needle into a sterile test-tube ; from 5 to 10 c.c. are required. The site of the puncture may be sealed w r ith cotton and collodion. URINE Urinalysis. — A study of the urinary excretion discloses the condition of the kidneys. As the term is commonly employed, urinalysis comprises a chemical and microscopic examination of the urine. A complete investiga- tion of the urinary function goes further and includes the determination of the total amount of urine excreted in twenty-four hours, and the ability of GENERAL PHYSICAL EXAMINATION 109 the kidneys to excrete certain substances that test their functional activity. In order to differentiate between the functional activity of the right and of the left kidney it is necessary to employ cystoscopy and catheterization of the ureters, which are dealt with in Chapter IX. We will confine ourselves here to a general survey of a study of the urine, such as is required in the diagnosis and treatment of diseases of the generative organs. A most important point to be emphasized at the beginning, and one that is frequently overlooked, is the fact that the discovery of certain abnormal constituents in the urine has no diagnostic value unless the specimen has been removed directly from the bladder with the aid of a catheter. If, for example, a voided specimen is found to contain albumin, pus, or blood, this is no indication that the bladder or upper urinary tract is the seat of disease, for the chemical or microscopic findings may be due to contamination with blood or pus escaping from the vaginal orifice. L T nless the examination of a voided specimen is entirely negative, the result has no value. If, there- fore, the voided specimen contains any abnormal constituents — and in a majority of patients coming under a phyiscian's care this will be the case unless the vagina and vulva have been douched with sterile water just before the bladder is emptied — a catheterized specimen will be required in order to make accurate deductions. The reaction of the urine is usually faintly acid. Alkalinity of a freshly obtained specimen indicates urinary stagnation and ammoniacal decomposi- tion or the undue ingestion of alkalies. A low specific gravity may be indicative of an abnormally large inhibi- tion of fluids or of a faulty eliminative power of the kidneys. A high specific gravity may indicate an excess of solids and a deficiency of fluids and of certain abnormal constituents, notably sugar. The urine may give off an ammoniacal odor as the result of stagnation and decomposition, as in cases of large cystocele. An offensive odor, not unlike that of decomposing fish, is present in chronic infections of the urinary tract associated with bacteriuria. When there is a fistulous communication between the intestinal and urinary tracts the urine takes on a fecal odor. The urinary fluid may be cloudy from an excess of phosphates, urates, or oxalates. It may be pink or reddish in color from the presence of urates, uric acid, or blood, yellow from contamination with bile-pigment ; black from the presence of old blood, and milky from admixture with pus. It may contain macroscopic shreds of pus, long, worm-like clots of blood indicative of renal or ureteral bleeding, or the finely granular, brick-dust sediment of uric acid. Albuminuria may point to interstitial or parenchymatous nephritis, pyelitis, ureteritis, or cystitis. Pus in the urine may be found in any of the diseases associated with suppuration of the kidney, ureter, or bladder ; if the specimen has not been obtained by catheterization, but was voided, diseases associated with sup- puration of the urethra, ovaries, tubes, uterus, vagina, and vulva may be included in the summary of possible explanatory lesions. Blood may be found in the urine in any disease of the urinary tract accompanied by trauma to the mucosa, fracture of friable masses, or destruc- 110 GYNECOLOGY tion of tissue. Among the most frequent of these conditions should be mentioned calculus, tuberculosis, and new growths of the kidney or bladder. Casts represent the albuminous products that have coagulated in the tubules of the kidney and were later expelled in the form of small cylinders. Hyaline casts in the urine are an indication of altered excretion and of the presence of albuminous products. Granular casts, blood casts or pus casts in the urine signify respectively the presence in the kidney of some process that causes destruction of the epithelium of the kidney tubules, a kidney disorder associated with hemor- rhage into the tubules, or a suppurative disease of the kidney. The urine as it is excreted from the kidney tubules may contain albumin, or the albumin may be derived later from the pus or blood that is mixed with it. Goldberg found that from 80,000 to 100,000 pus-cells per cubic centimeter of urine will produce 1 per cent, albumin. Albuminuria may be due to pressure on the renal veins, as from the pregnant uterus or from a tumor. It may also be due to fever and to the absorption of toxins in infectious diseases. It may likewise be caused by an excess of proteids in the diet, prolonged physical exercise, and alcoholic excesses. Glycosuria is usually indicative of diabetes, and may explain a per- sistent pruritus vulvae. Temporary glycosuria may be observed as a conse- quence of the increased consumption of sweets. Acetone may be found in the urine of patients suffering from the per- nicious vomiting of pregnancy, ectopic gestation, continued fever, and acidosis. It is significant of acid intoxication. Diacetic acid may be found in the urine of patients suffering from diabetes and acidosis. Its presence also is indicative of acid intoxication. Indican may be found in the urine of patients exhibiting conditions of diminished or inhibited peristalsis, constipation, peritonitis, or ptosis. It signifies that intestinal decomposition and putrefaction have occurred. In addition to these chemical and microscopic tests the sufficiency of the kidneys is indicated in a general way by the total amount of urine excreted in twenty-four hours. This normally averages from 1200 to 1600 c.c. (40 to 60 ounces). It is increased by cold, when perspiration is diminished, and decreased by heat, when perspiration is excessive. When more detailed information concerning the kidney function is desired, the tests described in Chapter IX should be undertaken. Bacteriologic Examination of the Urine in General. — The specimen of urine to be examined may be centrifugalized and a drop of the sediment placed on a slide together with a drop or two of Gruebler's methylene-blue solution. This will demonstrate the presence of pus, blood, and epithelium, as well as of bacteria. Smears may also be made from the sediment, and allowed to dry; they are fixed and stained with methylene-blue or gentian violet for the ordinary bacteria, and by Gabbett's method for acid-fast bacilli. It is impossible to distinguish absolutely between the tubercle bacillus and other acid-fast bacilli. A point in the differentiation, however, is the fact that the tubercle bacilli are found at the periphery of clumps of degenerated GENERAL PHYSICAL EXAMINATION 111 into a field of pus-cells. For positive identification the guinea-pig test should be made. Cultures may be made of the urine taken from the bladder or kidney by urethral or ureteral catheterization. The urine must be collected in sterile test-tubes which are then plugged with sterile corks and covered with rubber caps. The urine is transferred to the appropriate culture- i medium by the bacteriologist. Recognition of Tubercle Bacillus by Guinea-pig Inoculation. — The method of Bloch is the most rapid and satisfactory. A twenty-four hour specimen of urine is collected in a large sterile bottle. No preservative is added. The specimen is centrifugalized for from two to four hours ; about 10 c.c. of the lower portion is taken. This sediment is shaken with 5 ex. of sterile water, to make a suspension. Two healthy, normal guinea-pigs are inoculated. The inguinal glands of the animals are slightly injured by pressing and rolling them between the forefinger and thumb for a few moments prior to making the inoculation. About 2.5 c.c. of the prepared suspension is injected unheated into each animal subcutaneously in the inguinal region, below the glands. The glands are then again subjected to pressure for a few minutes, and this is repeated on the two succeeding days. At the end of ten days one of the animals is chloroformed, and the inguinal glands on the injected side are removed and sectioned and stained for the tubercle bacillus ; or the glands may be finely macerated, pressed between two slides, and fixed and stained. In a majority of positive cases the tubercle bacillus is immediately discovered ; if it is not, every part of the inguinal tissue is stained and subjected to examination. The other animal is kept for six weeks and is then examined for general tuberculosis. BIBLIOGRAPHY Bloch, A. : " Der rascher Nachweis des Tuberkelbacillus im Urin durch den Tierversuch." Berl. klin. Wchnschr., 1907, vol. xliv. p. 511. Butler, G. R. : The Diagnostics of Internal Medicine, 3rd ed. Appleton, New York, 1910. Dercum, C. T. : "The Nervous Disorders in Women Simulating Pelvic Disease." J. A. M. A., vol. Hi, p. 848. Gibson, C. L. : " The Value of the Differential Leucocyte Count in Acute Surgical Disease." Ann. Surg., 1906, vol. xliii, p. 485. Keene, F. E., and Laird, J. L. : " The Diagnosis of Tuberculosis of the Kidney." Am. Jour. Med. Sc, 1913, vol. cxlvi, p. 352. Kolmer, J. A.: Infection, Immunity and Specific Therapy. Saunders, Phila., 1915, p. 483. Lespinasse, V. D., and Wolff, M. : " The Clinical Value of the Gonorrhea Complement- Fixation Test," 111. Med. Jour., 1913. vol. xxiii, p. 26. Musser, J. H. : Medical Diagnosis. Lea and Febiger, Phila., 1913. Owen, R. T., and Snure, H. : "The Complement-Fixation Test in the Diagnosis of Gon- orrhoea." Jour. Mich. State Med. Soc, 1913, vol. xii, p. 247. Schwartz, Hans J., and McNeil, A. : " The Complement-Fixation Test in the Diagnosis of Gonococcic Infections." Am. J. Med. Sci., 1911, vol. cxli. p. 693; Ibid. : "Further Experiences with the Complement-Fixation Test in the Diagnosis of Gonococcus Infection of the Genito-Urinary Tract in the Male and Female." Am. J. Med. Sci., 1912, vol. cxliv, p. 815. Simon, C. E. : Clinical Diagnosis. Lea and Febiger, Phila., 191 1, 7th ed., p. 46. Stengel, A., and Fox, H. : Text-Book of Pathology. Saunders, Phila., 1915. Thomas, B. A., and Ivy, R. H. : " The Gonococcus Complement-Fixation Test and Analysis of Results from Its Use." Arch. Int. Med., 1914, vol. xiii, p. 143. Warden, C. C, and Schmidt, L. E. : "Gonococcus Complement-Fixation ; a New Lipoid Antigen," Jour, of Lab. and Clin. Med. 1916, vol. i, p. 333. Winter, G., and Ruge, C. : Gynecological Diagnosis, edited by J. G. Clark. Lippincott, Phila., 1912. CHAPTER VIII EXAMINATION OF THE PELVIS AND ABDOMEN In making the local physical examination both the pelvis and the abdomen should be included. The most satisfactory results are obtained with the patient in a conscious state. Examination Under Anaesthesia. — When, because of rigid abdominal walls, excessive adiposity, sensitiveness, or fear, a pelvic examination can- not be satisfactorily conducted, complete anaesthesia is advisable in order to Fig. 99. — Diagram showing different positions of uterus with full bladder Of rectum or both. Illustrates importance of having these organs empty at time of pelvic examination. (.4) normal position of uterus; (B) position with bladder and rectum filled; (C) position of uterus with bladder alone distended. rule out or to confirm the existence of a suspected lesion. As a rule, it is de- sirable, prior to examination, to obtain the permission of the patient to make such operative correction as the existing conditions may demand. Examination under anaesthesia is most frequently required in young vir- ginal women. In any case in which an abnormality is suspected and a bimanual rectal examination is unsatisfactory, examination under anaesthesia should be advised without delay. In young virginal women vaginal examination, except under anaesthesia, should be avoided. Every condition requiring operative correction should receive attention at this time, so that nothing 112 EXAMINATION OF THE PELVIS AND ABDOMEN 113 further will be required later. (See Relation of Neuroses to Pelvic Disease, Chapter XXXIV.) Ether is the safest and most satisfactory anaesthetic to use for purposes of examination. Nitrous oxide does not give complete relaxation. If the patient is tuberculous or if the kidneys are seriously damaged, chloroform is to be preferred. Preparation for Examination. — As a rule, some preparation for examina- tion is required. Most patients who have leucorrhcea will take a vaginal douche before consulting a gynecologist. This often destroys important evidence, and it may be necessary to direct the patient to omit douches for several days and then return. The urine should be held as long as possible before the examination, so that the physician can ascertain whether or not Skene's tubules or the urethra contain pus. The bladder and the bowel should be emptied before bimanual examina- tion (Figs. 99 and ioo). This may be impracticable at the first consultation, for an evacuation of the bowel may involve considerable delay. For that reason, if pos- sible, the patient may be instructed to take a purgative the night before and an enema on the morning of the examination. When a patient appears for examination and is insufficiently prepared, a second visit, with suitable preparation, should be ordered. To facilitate a gynecologic examination a number of positions have been used that render the parts more readily accessible to in- spection and simplify certain manceuvers that would otherwise be difficult. The Dorsal Position (Fig. 101). — The dor- sal position is the one commonly employed in bimanual palpation of the pelvic organs, in- spection of the external genitalia, and local applications to the urethra, vulva, vagina, and cervix. The patient lies upon her back with the thighs well flexed upon the abdomen and the knees widely separated. The legs are flexed on the thighs and the feet are held either by stirrups suspended from upright rods or by foot-rests at the end of the examining table. A portable stirrup or leg- holder has been devised by Robb, which facilitates examinations or opera- tions in the dorsal position, and is especially adapted to procedures at home. The buttocks should project slightly over the edge of the table. If neces- sary, the patient can be examined in bed. She should lie across it with her buttocks resting on the edge, the shoulders and head elevated by a pillow, the knees widely separated, drawn upward, and supported by assistants. When the feet are held in stirrups, they should not be widely separated. There will then be more separation of the knees than if the feet were held widely apart; the thighs will rotate outward, and the fullest relaxation of the lower abdominal wall will thus be secured. The dorsal position is modified at times for the purpose of making 8 Fig. ioo. — Position of uterus, with dis- tended bladder and rectum. 114 GYNECOLOGY bimanual palpation by slightly elevating the trunk; the examining table may be inclined somewhat toward the foot, or, if an examining chair is used, the patient is placed in a semi-sitting position. The dorsal position is that commonly used in performing plastic operations upon the cervix and the perineum. Knee-chest Position (Fig. 102). — In assuming this position the patient is ordered to kneel upon the table, spreading the arms out on each side and Fig. 10 1. — Dorsal or lithotomy position. flexing the elbows. The face should be turned to one side. The thighs must be vertical, the chest must rest upon the table, the spinal column must be relaxed, and the lumbar curve be exaggerated. The knee-chest position is useful principally in the treatment of retro- version and prolapse of the uterus, and for inspecting the bladder and rectum after atmospheric distention. When the woman assumes the knee-chest position it is usually neces- sary, except in the case of multiparas, to retract the posterior vaginal wall. Unless the uterus and base of the broad ligaments are fixed by inflammation EXAMINATION OF THE PELVIS AND ABDOMEN 117 that the front of the chest lies in contact with the table. The thighs are flexed at right angles to the abdomen, and the legs at right angles to the thighs ; the right thigh is flexed more than the left, so that the right knee lies above the left. A small, firm pillow placed beneath the hips will, by securing greater inclination of the pelvis, increase the efficiency of the position. This position is especially desirable for making an inspection of the anterior vaginal wall. It may also be used in place of the knee-chest position for making cystoscopic or proctoscopic examinations. In treating a patient for retroversion or prolapse of the uterus it is often a good plan to have her acquire the habit of falling asleep in the Sims' posi- tion, reversing it at will, and lying alternately on the right and on the left side. Supine Position (Fig. 104). — This is the position of choice in perform- ing palpation of the abdominal viscera. The patient lies flat upon the back with some elevation of the shoulders and head. The thighs are slightly flexed upon the abdomen ; the knees are bent and supported by a Fig. 106. — Sims' speculum. pillow beneath them, or by resting the feet upon a chair placed at the end of the table. The erect position is employed in inspecting the contour of the abdom- inal wall in cases of fat and overhanging abdomen, relaxed and protuberant abdomen, visceroptosis, etc. The erect position is also valuable in determining faulty and improper habits of dress and of carriage which pro- duce abnormal postures. Preparation of the Hands. — The examining hand should be protected by a rubber glove. In making palpation of the rectum great care should be observed to prevent carrying infection from the vagina to the rectum. For this reason, in passing from one region to the other the glove should be changed or thoroughly washed and immersed in an antiseptic solution. Lubricant. — Some form of lubricant is usually required, but should never be used when smears are to be taken from the urethra, Bartholin's glands, or the cervix. Glycerin is a very good lubricant; petroleum jelly and oil are quite commonly used. The most satisfactory lubricant is a vege- table jelly made up of gum tragacanth, 6 drams (25 gm.) ; phenol, 118 GYNECOLOGY (2 gm.) ; glycerin, iy 2 ounces (50 c.c.), and water enough to make two pints (1000 c.c). The lubricant should either be poured upon the fingers or ex- pressed from a collapsible tube. Fig. 107. — -(A), Bivalve speculum. (B) , Trivalve speculum. (C), Collapsible tube of lubricant,_ (D), Ultzmann syringe with roughened and perforated tip which may be wrapped with cotton for intrauterine injections. Illumination. — In making an examination it is very essential to have a good light. The examining table should be placed preferably before a window, but if this is not at hand, a strong light that can be reflected at will should be provided. For this purpose a portable electric lamp or an electric lamp and a head-mirror may be employed. EXAMINATION OF THE PELVIS AND ABDOMEN 119 Instruments. — A number of specula are required; at least one Sims' (Fig. 106), a bivalve and a trivalve speculum (Fig. 107), and a large-sized Kelly cysto- scope to be used as a vaginal speculum in virginal women (Fig. 108). The speculum should be well lubricated before it is introduced. It is generally well to determine the posi- tion of the cervix by simple digital examination previously, and then to introduce the instrument toward that point with its blades in the oblique axis of the vagina. The bivalve and the trivalve specula may be used with the pa- tient in the dorsal position, since they hold the vaginal walls well apart for inspection. By gently ro- tating the instrument the entire vaginal wall may be brought into view. The Sims' speculum is used with the knee-chest or the Sims' position, or with the dorsal position when as- sistants are at hand ; both the ante- rior and the posterior walls may be retracted by separate specula. Double Tenaculum. — A double tenaculum is often of great assist- ance in bringing the uterus within reach of the finger in the rectum, and for the purpose of assisting in making bimanual replacement of the uterus. J Fig. 108.- -Kelly's urethral specului ining virgins. useful in exam- SPECIAL METHODS OF EXAMINATION Exploration of the Uterus with a Sound. — The uterine sound (Fig. no) should not be inserted during an office examination unless the vagina has Fig. 109. — Double tenaculum been thoroughly disinfected. In rare instances it may be used for the purpose of determining the exact position and depth of the uterine cavity. Intrauterine Digital Palpation. — Digital palpation of the interior of the uterus is impracticable unless the organ is or has recently been pregnant. An exception to this rule may be found in the case of submucous myomata or 120 GYNECOLOGY cervical or endometrial polypi that are being extruded through a softened and dilated cervix. Dilatation of the cervix sufficient to permit the introduction of the finger ma}* be made with the graduated metal dilators of Hegar or the branched dilators of Goodell (Fig. in In most cases preparatory softening and dila- FlG. no. — Long thumb forceps, uterine sound, applicator, spatula, curved dressing forceps. Fig. in. — Goodell's dilator. tation are necessary and desirable. The introduction into the lower uterine segment, cervical canal, and vaginal vault of sterile gauze will usually effect sufficient softening and dilatation of the cervix within twenty-four hours to permit digital examination at once or after the use of moderate instrumental dilatation. If the size of the introitus will permit, the entire hand may be well lubricated and introduced into the vagina. Digital EXAMINATION OF THE PELVIS AND ABDOMEN 121 exploration should always precede the use of the blunt curette or the pla- cental forceps, and repeated explorations with the finger should be made during the removal of placental tissue. The finger alone can determine accurately the site of the retained portions and ascertain whether the uterus has been completely evacuated Diagnostic Curettement and Test Excision. — Curettement of the uterus for diagnostic purposes is of value for two reasons : First, the curette will reveal any unevenness or distortion of the uterine cavity to the trained hand ; and secondly, the scrapings obtained may be subjected to microscopic examina- tion (Figs. 112 and 113). In obtaining scrapings for microscopic examination the surgeon should be certain that every portion of the uterine interior has been reached by the curette, and that all the scrapings have been sent to the pathologist. (See Technic of Curettage, Chapter XII.) The endometrial fragments or shreds should be received in sterile salt solution, in which the blood-clot should be separated from the curettings ; the latter should then be placed in Fig. 112. — Sims' curette. Fig. 113. — Martin's curette. a 4 per cent, solution of formalin or in Zenker's fluid to fix and harden. Sections for histologic examination should be made from every part of the curettings. The differentiation between benign and malignant affections of the endometrium and cervix is possible in many instances only as the result of histologic examination. At this point a word may be said upon the advis- ability of having the examination made by a pathologist who is thoroughlv familiar with the appearance of the tissues in benign and malignant affec- tions of the pelvic organs. A reliable general pathologist or microscopist may often be led into serious error or uncertainty because of an unfamiliarity with the benign changes in structure that the cervical or intrauterine mucosa may undergo. Test excision of a piece of the cervix (Fig. 114) as a means of making a diagnosis is of great value, particularly in confirming or disproving a suspicion of malignancy. The excision may be made under local anaes- thesia, but, as a rule, mild general narcosis is preferable. Careful asepsis must be observed. The excised portion must include the entire extent of the suspicious area; it should be immediately placed in 4 per cent, formalin solution or Zenker's fluid for hardening and fixing. Catgut sutures should be at hand to coapt the cut surfaces. 122 GYNECOLOGY The gross examination of scrapings from the uterine interior and the macroscopic inspection of cervical lesions will often yield reliable informa- tion as to the nature of the disorder. Thus to the trained eye the villous appearance of fresh placental tissue from early embryos, the smooth, velvety thickening of the mucosa that has been transformed into decidua, the tough, Fig. 114. — Excision of diseased cervical tissue for microscopic examination. lumpy pieces of retained placenta, the friable fragments of carcinomata or sarcomata, and the scanty, thin shreds of atrophic endometrium, are all more or less easily recognized and characteristic. Of course, no one will rely upon this test alone, and histologic examination should always be made to confirm or disprove the diagnosis. Malignant affections of the cervix may almost invariably be recognized as such if the patient is anaesthetized and the suspected area is curetted. In the case of carcinoma or sarcoma the tissue is friable and brittle and easily detached from the surrounding healthy EXAMINATION OF THE PELVIS AND ABDOMEN 123 tissue, leaving a depression that may be small in early cases and large in later ones. Here, too, the gross evidence must not be regarded as conclu- sive, and histologic specimens must be prepared. It is only by microscopic examination that the very early carcinomata of both the endometrium and the cervix can be detected. (See Carcinoma of the Uterus, Chapter XVIII.) Smear Preparations as an Aid to Diagnosis. — In making a diagnosis of gonorrhoea it will usually be necessary to examine smears from the urethra, the glands of Bartholin, or the cervix. When the making of these smears is anticipated, the patient should be directed to omit douching and to hold the urine for some time previous to the consultation. No lubricant should be used on the examining finger. ' ,1.1-' Fig. 115. — Inspection of the external genitalia and expression of discharge from urethra. Fig. 116. — Inspection of the external genitalia, and expression of discharge from Bartholin's glands. After exposing the vulva any secretion upon the external surface should be lightly wiped away with a pledget of cotton. The urethra, Skene's tubules, and Bartholin's gland on each side should then in turn be emptied (Figs. 115 and 116), and the discharge gathered up on a probe or a platinum loop and transferred to a glass- slide. After the external genitalia have been carefully cleansed and disin- fected, the cervix may be exposed by means of a bivalve or a trivalve speculum. The discharge covering the vaginal cervix and portio should be removed, and an applicator wound with cotton should be passed into the cervical canal, moved about in all directions, and then rubbed upon a glass slide. It is useless, as a rule, to search for the gonococcus in a discharge that is found in the vagina or upon the vulvar surface, since so many other bacteria are present, and this association with other organisms causes the gonococcus to lose its identity. An exception to this rule must be noted in infants affected with vulvar or vaginal gonorrhoea of the florid type. 124 GYNECOLOGY Ftg. 117.- -Gonococci stained in smear. (Wilson.) After the smears have been made they should be permitted to dry and should then be fixed by passing them through the flame of a Bunsen burner three times, each passage being sufficiently slow to allow the glass to heat to a degree that is just unbearable to the touch. The smeared surface may next be covered with a saturated watery solution of methylene-blue or gentian violet, and allowed to stand for two or three minutes. The smear is washed in water, permitted to dry, and then examined tinder an oil-immersion lens (Fig. 117). This plan usually suffices for recogni- tion of the gonococcus. The organisms have a characteristic shape and grouping, and are generally found in the pus or in the epithelial cells. If any doubt as to their identity exists, a smear may be stained by Gram's method, in which the gonococcus is decolorized and takes the counterstain. In a case of Neisserian in- fection as time goes on the gonococcus becomes modified in appearance, a fact that probably accounts for the rarity with which they are found in chronic as com- pared with acute cases. The only abso- lutely positive method of identifying the gonococcus under these circum- stances is by means of cultures. These should be made only by an experi- enced bacteriologist. The search for the gonococcus in smears from the cervix is most likely to prove successful if the smears are taken just before or just after the menstrual periods. Old urethral infections may be brought to light by alcoholic excesses, especially the drinking of beer. The examina- tion of smears should repeat- edly prove negative before the patient is dismissed from medi- cal attention. Demonstration of Trepon- ema (Spirochasta) Pallidum.— The organism of syphilis may be found in smears from pri- mary and secondary syphilitic sores. In suspected cases the test should be made from any suspi- cious ulcerated areas. A drop of the serum or exudate should be mixed with a drop of India ink. Microscopic examination can be made immediately with a high-power lens, or later with an oil-immersion lens, if the mixture is spread out in a thin film and allowed to dry (Fig. 118). The spirochaeta may be detected in the serous transudate obtained by lightly curetting the edge of the lesion if stained with India ink or Goldhorn's or Giemsa's stains. The organism may also be recognized in the fresh unstained secretion from primary lesions and mucous patches with the aid of microscope and dark- field illumination. Fig. 118. — Spirochasta pallida. Smear made from chancre stained by india-ink method. (Hiss and Zinsser's Text Book of Bacteriology, D. Appleton & Co.) EXAMINATION OF THE PELVIS AND ABDOMEN 125 Pelvic Examination. — Inspection of the external genitalia should be the first step in a pelvic examination. By it the existence of leucorrhoeal discharge and the presence of venereal sores or of any other lesions of the vulva may be detected. In- m ^ spection will at once yield cer- t a i n valuable information. For example, a virginal in- troitus will exclude the dis- eases due to pregnancy and childbirth ; a reddening of the orifices of Skene's tubules and of the ducts of the vulvo- vaginal glands will suggest gonorrhoeal infection ; an im- perforate hymen will explain the absence of the menstrual flow ; extensive lacerations of the perineum, cystocele, rec- tocele, etc., are often revealed at a glance. The cervix and the vaginal fornices are next exposed by means of a speculum (Fig. 119). The state of the vaginal mucosa, whether bathed in leucorrhoeal discharge or be- reft of its natural moisture, and the presence of erosions or of inflammation are at once apparent. The contour of the cervix, the amount and the character of the cervical dis- charge, and the presence of gross lesions may be detected. Aside from the question of cervical diseases, inspection of the cervix gives evidence of previous labor or abortion. Palpation. — Evidence o f the presence of a gonorrhoeal infection may be obtained by " milking " Skene's tubules and the vulvovaginal glands. The friability and induration of a carcinomatous growth, the peculiar disk-like hardness of a chancre, the fluctuation of a vulvovaginal cyst, or the tenderness and induration of an inflammatory affection may be noted. The condition of the perineal floor may be ascertained, the presence of cystocele and Fig 119. — Exposure of vagina and cervix by bivalve speculum. 126 GYNECOLOGY rectocele, and the spastic contraction encountered in cases of vaginismus may be detected. The friability of a cervical growth, softening or induration of the cervix, or an increase in the patency of the cervical canal — all may be quickly ascertained. Palpation of the vaginal vault yields additional information. In front of the cervix the sharp kink of an anteflexion may be recognized ; in well- Fig. 120. — Touch picture. Simple digital examina- Fig. 121. — Touch picture. Simple digital examination tion and schematic outline of anteflexion. The index and schematic outline of retroflexioversion. The cervix finger feels the small conical cervix directed forward: is directed forward: the body of the uterus can be felt the body of the uterus can be felt through the ante- through the posterior wall, rior vaginal wall. marked cases of retroposition the body of the uterus may be felt through the posterior vaginal fornix, and often also an angle of flexion between the cervix and the body. An ovary prolapsed into Douglas' pouch is easily detected. While this simple digital examination yields considerable information, no examination is complete without bimanual palpation. By this method Fig. 122. — Touch picture. Simple digital examina- tion and schematic outline of pelvic mass. The cervix is forward under the symphysis: back of it through the posterior vaginal wall a rounded pro- jecting enlargement filling the hollow of the sacrum can be made out. Fig. 123. — Touch picture. Schematic outline show- ing prolapsed ovary palpable on digital examination. A body about the size of an olive is felt through the posterior vaginal fornix, slightly to one side of the median line. the pelvic organs are picked up one after the other between the palpating hands, and their size, mobility, consistency, and sensitiveness are esti- mated. The feasibility of a satisfactory bimanual palpation in a given case will depend upon the degree of relaxation of the abdominal muscles which the patient is able to induce voluntarily, and upon the amount of adipose tissue present in the abdominal walls. Rigid or thick abdominal parietes render bimanual examination difficult or unsatisfactory unless an anaes- thetic is employed. EXAMINATION OF THE PELVIS AND ABDOMEN 127 In bimanual palpation (Figs. 120 to 127) the palmar surface of one hand is placed upon the abdominal wall, and one or two fingers of the other hand are introduced into the vagina or into the rectum (Fig. 128). Palpation is made first with the organs in the posi- tion in which they are found. Later, except in acute or subacute pelvic in- flammatory disease, if it is found desir- able, bimanual palpation may be made with a finger in the rectum while the uterus is drawn downward by means of a tenaculum. This maneuver brings the entire posterior surface of the uterus within reach of the examin- ing finger and permits a minute ex- amination of the posterior surface of the broad ligaments and of the pouch of Douglas to be made. In bimanual palpation the cervix is located with the vaginal finger and fVi^ rlir^ntinn nf flip pprviral avid in re- £ IG ' I p 2 4-— Bimanual examination and schematic out- tne direction OI tne Cervical aXIS m re llne of anteversion and pathologic anteflexion. (To lation to that of the vagina is noted. ^^S^^lSd St £& cStHS. Normally the cervix is at almost a right The ^^^^^y^^**^ th. angle and points toward the coccyx. If it is found in the axis of the vagina, it is quite likely that the uterus is retroverted or that the patient is suffering from an acute anteflexion of the The body of the uterus is the next to be examined. If it is in nor- mal position — anteversion and anteflexion — it may be palpated between the vaginal finger placed upon the anterior vaginal wall, just in front of the cervix, and the abdominal hand pressed downward and toward the pelvic outlet in the median line above the symphysis. If the fundus is not located by such a maneuver, there is evidence of malposition. The vaginal finger is now carried back of the cervix along the posterior vaginal vault, while the abdominal hand is passed down- ward below the sacral promontory. In Fig. 125.— (Study in connection with Fig. 121.) cases of well-marked retroversion the pos- S^Sex^fe^T^bo^^&uSlterior surface of the body of the uterus cannot be felt between the finger in contact with ' w [\l ^g f e l t inclining backward toward the the anterior vaginal wall and the suprapubic ° fingers. The body of the uterus is posterior and sacrum, and if retroflexion is present, the is felt between a finger on the posterior vaginal . 1111 wail back of the cervix and the abdominal angle between the cervix and the body can readily be made out. In addition to the position, the size, consistency, mobility, shape, and sensitiveness of the uterus may be determined. In palpating the left adnexa (Fig. 129) the vaginal finger is carried to the cervix. 128 GYNECOLOGY extreme left lateral part of the vaginal fornix, and pressed upward along the pelvic wall as far as possible, while the abdominal hand is gently pressed downward and forward over the brim of the true pelvis to the left of the sacral promontory. The finger in the vagina and the fingers of the abdom- FiG. 126. — (Study in connection with Fig. 122.) Bimanual examination and schematic outline of pelvic mass. The uterus and the pelvic mass may be recognized as separate bodies. Fig. 127.— (Study in connection with Fig. 123). Simple digital examination and schematic outline of prolapsed ovary. ir \\sv\Vi \xv§ FlG. 128. — Position of hands in bimanual examination of the pelvis. The elbow supported by the hip indents the perineum and permits a free manipulation of the fingers of the palpating hand. mal hand are approximated at the highest lateral and posterior position possible and then drawn gently forward. By this means the normal ovary and tube are brought between the fingers. The normal ovary is felt as a smooth, elliptic body, about the size of an almond, which slips or slides from the touch and is freely movable. The normal tube is made out with EXAMINATION OF THE PELVIS AND ABDOMEN 129 difficulty, giving to the examining finger the impression of a very soft rubber tube about the caliber of a lead-pencil. It is only in exceptional cases that the examiner can be certain that the tube is felt. Muscular strands in the abdominal wall or the round ligament will often be mistaken for a normal tube. The right adnexa may be palpated by similar manceuvers on the opposite side. If the ovary is adherent, the organ will be felt to be immovable and somewhat enlarged, and as though it were attached to the pelvic wall or floor. If the tube and the ovary are enlarged and adherent, they form an irregular, retort-shaped mass in which it is difficult to distinguish one organ from the other. It must be remembered that the position of the uterus will influence the position of the ovary. Thus, if the UterUS is retroverted Or prolapsed, the Fig. 129.— Schematic outline showing the relative „ , . mi 1 „ 1 j „„ „„ *X,„ position of the vaginal and abdominal fingers in OVary Will be lOWer and nearer the y bimanual examination of the tube and ovary. median line; when the uterus is in the normal position, the ovary will be higher and more laterally situated. When the ovary is prolapsed (Fig. 127), it may be felt by turning the palmar surface of the finger backward and palpating Douglas' cul-de-sac by pushing back- ward and outward. The ovary will be recognized as a smooth, elliptic Fig. 130. — Bimanual examination with uterus drawn down and a finger in rectum. The entire posterior wall of the uterus is made accessible to the rectal finger in this way. Fig. 131. — Combined recto-vaginal examination. Index finger of lower hand in rectum, thumb in vagina. Other hand in usual position on abdomen. Method is useful in locating position of cervix in relation to intra-pelvic masses. body that slips away from the examining finger. A scybalous mass in the rectum gives to the finger a sensation much like that of a prolapsed ovary; but the latter may be excluded by noting that the former pits on pressure or as the result of an examination made per rectum. Bimanual rectal palpation (Figs. 130 and 131) with the uterus drawn downward by means of a tenaculum is a most valuable aid to diagnosis in affections of the tubes and ovaries. The finger is inserted into the rectum 9 130 GYNECOLOGY and pushed backward and downward until it passes between the uterosacral ligaments ; it is then turned upward upon the posterior surface of the uterus, and to either side upon the posterior surface of the broad ligaments. In making a bimanual examination with a finger in the rectum, it is some- times advantageous to insert the thumb in the vagina in order accurately to ascertain the position of the cervix; by this means also the thickness of the rectovaginal septum may be estimated. The method is chiefly useful, however, for distinguishing between uterine and other pelvic enlargements. In the case of inflammatory affections of the ovaries and tubes, irregular masses will be felt back of the uterus on one or on both sides, displacing it forward. When an inflammatory affection involves the cellular tissue of the Fig. 132. — Trimanual examination, case of ovarian cyst. (Clark.) broad ligaments, a dense, board-like induration is felt at the vaginal vault extending all the way to the pelvic wall and fusing with it. Pelvic masses occurring without induration of the vaginal fornices or the bases of the broad ligaments are usually uterine or ovarian in origin — uterine, if they are in connection or move with the uterus ; ovarian, if they are distinctly separate from, and independently movable of, the uterus. Indura- tion of the broad ligaments or the vaginal fornices, with immobility or partial fixation of the uterus, is suggestive of inflammatory disease involv- ing the tubes and the pelvic peritoneum; it is indicative also of carcinoma with extension to the broad ligament or of cellulitis. Pelvic enlargements aris- ing slightly above the pelvic brim and decidedly lateral in position are, as a rule, inflammatory or malignant in type. Those that occupy a more or less median position and extend well into the abdominal cavity are usually new growths of the uterus or of the ovaries. EXAMINATION OF THE PELVIS AND ABDOMEN 131 Trimanual examination (Fig. 132) is especially valuable for determin- ing whether a pelvic tumor is cystic or solid in nature. In conducting this examination the tumor mass is confined as closely as possible between the two examining hands, " while the percussion is made by an assistant. With light, quick taps, even small collections of fluid may be detected by the quick, responsive, pulsatile wave passing from the abdominal to the pelvic hand" (Clark). This method is valuable also in differentiating between semi-solid and cystic tumors ; as, for example, in differentiating between a soft intra- ligamentary myoma with associated inflammatory disease of the appendages and a pelvic abscess, or in distinguishing a dense hydrosalpinx or pyosalpinx from a solid tumor. Abdominal Examination. — The abdominal examination may precede or follow the pelvic examination. Fig. 133. — Lateral aspect of abdomen with large myomatous uterus. Note the slight irregularity of the surface, and the sharp suprapubic rise and epigastric fall. (University Hospital.) Inspection. — The abdomen should be inspected from the sides, from the foot, and from the head as the patient lies in the supine position, and from the side as she stands erect. Inspection at once discloses the color of the skin, the evidence of previous counter-irritation and the scar of former operations ; enlargement of the cutaneous veins significant of femoral, iliac, mediastinal or portal obstruction may also be observed. The linea albicantes, usually indicative of past or present pregnancy, may be seen. The uniform enlargement common in tympanites, large ascitic collections, and thin- walled cysts filling the entire abdomen is to be noted. The flattened sur- face and bulging flanks of the relaxed or the moderately ascitic abdomen, the scaphoid surface indicative of emaciation, the enormously thick pan- niculus adiposus of the abdominal wall, the pendulous abdomen when the patient is erect, are revealed at the first glance. If the abdomen is protuberant 132 GYNECOLOGY or distended in such a way as to suggest an abdominal tumor, the examiner should note whether the entire abdomen or only a particular area is affected ; whether, in the case of a median enlargement affecting the lower part of the abdomen, both sides are equally involved ; whether the surface of the enlargement is regular or irregular ; whether the abdominal respiratory wave affects the entire abdominal wall uniformly (tympanites, fat) ; whether a localized enlargement moves with respiration (kidney, gall- bladder, and stomach tumors, unless adherent) or is fixed ; and whether the respiratory wave stops at a point where the abdominal wall is splinted by the underlying tumor (uterus and ovary). Fig. 134. — Anterior aspect of abdomen, with large myomatous uterus, deviated to right. Note the slight irregularity of the surface and the greater prominence on the right side. (University Hospital.) Palpation.— Palpation confirms some of the observations made by in- spection, as, for example, the degree of abdominal distention and the local- ization of regional enlargements ; it also elicits much additional information. It determines the respiratory mobility or immobility of the tumor, and dis- closes rigidity or flabbiness of the abdominal muscles, tenderness, and muscle spasm. Palpation reveals the nature of an abdominal enlargement, making it possible to differentiate between the soft panniculus of the exces- sively fat abdomen, the tense elastic resistance of a cyst, and the hard, un- yielding mass of a solid abdominal tumor. The thickness of the adipose EXAMINATION OF THE PELVIS AND ABDOMEN 133 layer of the abdominal wall may be judged by picking up the layer of fat between the two hands. Palpation determines more or less accurately the point of origin of an abdominal tumor, and supplies information as to the organ from which it springs. In the case of an abdominal tumor springing from the pelvic organs the fingers pressed into the abdominal wall above the symphysis meet with firm resistance. Similarly in most ab- dominal tumors, the greater part of the periphery is usually free and distinctly palpable, whereas as the point of origin of the growth is approached it fuses with the organ from which it sprang and may be more or less indefinite in outline {e.g., gall-bladder enlargements, splenic growths). The passive mobility of tumors varies. Intraperitoneal neoplasms, pedunculated uterine and ovarian tumors, and intestinal and mesenteric growths are usually freely mobile — i.e., they can be moved freely toward the umbilicus — but they generally show a tendency to return to the area from which they grew. Conversely, retroperitoneal growths and kid- ney, suprarenal glands, and pancreatic tumors are more or less fixed. The same is true of inflammatory tumors and of those that are adherent, as well as of malignant infiltrating growths (Figs. 133 to 139). Fig. 135. — Anterior aspect of abdomen, with extreme ascitic distention; same case as Fig. 136. Note uniform and symmetrical dis- tention. (Stetson Hospital.) Fig. 136. — Lateral aspect of abdomen, with extreme ascitic distention. Note the gradual suprapubic rise and epigastric fall. (Stetson Hospital.) The presence of fluctuation is elicited by palpation and percussion. By this means collections of fluid may be distinguished from gaseous or solid enlargements. Fluctuation may be simulated by fat, but the percussion wave in the latter may be checked by pressure of the ulnar surface of an assistant's hand between the palpating and percussing fingers. Thick, tensely- walled cysts may give indefinite fluctuation, and may be mistaken for elastic resilient solid tumors. In large ovarian cysts which contain one large and many small cavities fluctuation may be elicited over the main cavity, 134 GYNECOLOGY but not over the smaller ones. Fluctuation is sometimes best elicited by the trimanual method of percussion (vide supra). Before making palpation the hands should be well warmed. The palmar surface should be pressed gently against the abdominal wall, making deeper ;,-.; ...US. ■■'■- 4A FlG. 137. — Lateral aspect of the abdomen in a case of large ovarian cyst. (Philadelphia Hospital.) Fig. 138. — Lateral aspect of the abdomen in a case of pregnancy near term, primigravida. (Philadelphia Hospital.) pressure with the fingers as the patient's confidence is gained and the abdom- inal wall relaxes. Percussion. — All intraperitoneal abdominal tumors having their origin in the pelvis and of sufficient size to cause abdominal distention exhibit a EXAMINATION OF THE PELVIS AND ABDOMEN 135 dull or a flat note over the summit of the growth. This is continued to- ward its point of origin — for example, in the case of pelvic tumors, as far as the symphysis — whereas the percussion-note becomes resonant or tym- panitic in the remaining peripheral areas (''coronal resonance"). These are dependent upon the approximation of the tumor with the abdominal parietes and the consequent displacement of the intestines. When an intra- peritoneal abdominal tumor is small and lies among the intestinal coils and not against the abdominal wall, the percussion-note over it may be un- changed or very slightly altered (Figs. 140 and 141). Retroperitoneal abdominal tumors, even when of large size, on percus- sion invariably exhibit resonance or tympany over the area of greatest con- vexity. In the case of extremely large growths, this resonant or tympanitic Fig. 139. — Lateral aspect of the abdomen in a case of ovarian cyst with extreme carcinoma- tosis of the abdominal cavity. (Philadelphia Hospital.) note may not be marked, but it is almost always recognizable on light percussion. The reason for this is obvious, since the growth, having its origin back of the peritoneal investments of the intestines, as it increases in size, necessarily pushes the intestines forward. Percussion is valuable also in detecting the presence of free fluid within the peritoneal cavity. Whenever an intraperitoneal collection of fluid comes in contact with the abdominal parietes, the percussion-note over the point of contact is dull. Thus, when a moderate ascites is present and the patient lies flat on the back, the fluid gravitates into the flanks, where it produces dulness upon percussion, whereas the intestines, floating upon the surface of the fluid and being, therefore, most prominent, give a resonant or tym- panitic note in the median line of the abdomen. If the patient is turned upon one side, the fluid gravitates to that side, increasing the area of dul- 136 GYNECOLOGY ness here, whereas the other side now clears up and the note becomes resonant or tympanitic. So, too, if the patient stands erect, the dulness is manifest over the lower part of the abdomen, directly across from one side to the other, and to a varying degree above the symphysis. It is only in r-Coron&l resonance of intestines Fig. 140. — Schematic cross section of the abdomen to show reason for coronal resonance in abdominal tumors. FlG. 141. — Schematic cross section of the abdomen to show reason for central resonance and lateral dulness in fluid collections, ascites. the case of intraperitoneal collections of fluid large enough to distend and fill the entire abdomen that the percussion-note is uniformly dull. When an intraperitoneal collection of fluid becomes encysted {e.g., in tuberculosis, peritonitis, carcinomatous ascites) there may be no alteration in the dulness produced by changes in posture. EXAMINATION OF THE PELVIS AND ABDOMEN 137 Auscultation. — Auscultation determines the activity of the intestines by demonstrating frequency and character of the peristaltic sounds. The nor- mal fine gurgling sounds of the intestine may be contrasted with the exag- gerated, almost continuous peristaltic borborygmi in flatulent distention and early obstruction, or with the diminished, infrequent, or entire absence of peristaltic action in a dynamic ileus or peritonitis. Auscultation discloses the foetal heart-sounds in pregnancy after the fifth month, and the placental bruit in the later months of gestation. Excep- tionally a bruit may be heard over abdominal tumors that press upon the large blood-vessels at the brim of the pelvis. Mensuration of the abdomen is valuable chiefly for noting accurately the growth of abdominal tumors. Fixed points on the circumference around which the measuring tape may be applied should be selected. When the comparative measurements are made within a few days of each other, the lines of measurement should be indicated with an indelible pencil. One cir- cumference passes through the anterior and the posterior iliac spines ; an- other, through the umbilicus, and a fixed point on the spine at the position of the forward limit of the lumbar curve ; another circumference cuts the lower costal margin on each side and is perpendicular to the spine. Longi- tudinal measurements are also of use, notably that made from the ensiform process to the upper limits of an abdominal tumor, and from that point to the symphysis pubis. Remote Abdominal Organs. — A routine examination should be made of the gastric, gall-bladder, appendiceal, and renal areas, to determine the presence of enlargements, tenderness, or displacements. It is hardly neces- sary to point out that tumors of the stomach, gall-bladder, appendix, and kidney may occasionally resemble new growths of pelvic origin, or that symptoms arising from diseased conditions of these organs may closely simulate those of pelvic disorders. Moreover, if operative procedure on the pelvic organs is contemplated, it may be advisable to correct lesions in the abdominal viscera at the same time, and thus the plan and scope of the operation may be modified. BIBLIOGRAPHY Anspach, Brooke M. : Martin's Surgical Diagnosis. Lea and Febiger, Phila., 1909. Kelly, H. A. : Operative Gynecology. Appleton, New York, 18Q9. Winter, G., and Ruge, C. : Gynecologic Diagnosis, Edited by J. G. Clark. Lippincott, Phila., 1909. CHAPTER IX EXAMINATION OF THE URINARY ORGANS Urinalysis. — The urinary output is an index of the condition of the secre- tory and excretory urinary organs. The chemical methods of examination do not differentiate between lesions of the kidney, ureter, and bladder, but when examined microscopically, some points of difference may be found. (See Urinalysis, Chapter VII, page 108.) PALPATION Urethra. — The urethra is palpable throughout its entire length, the pal- pation being made per vaginam. The finger is lubricated and applied to the anterior vaginal wall. The internal urinary meatus is situated about half- way between the vaginal introitus and the cervix. The contents of the urethral canal may be expressed by " milking " the urethra. Undue sensitiveness may be indicative of urethritis, and suburethral abscess or cyst may be detected by this method. Palpation should be combined with inspection. (See pages 123 and 140.) Bladder. — The bladder may be palpated during the course of the ordinary bimanual pelvic examination, and in this way a tumor or a calculus of large size may be discovered. Small calculi easily elude palpation, and for their detection a more effectual method of examination {e.g., cystoscopy) is neces- sary. A diagnosis of stone in the bladder may also be made by the use of a vesical sound. The bladder is distended with water and an ordinary searcher is introduced ; a finger in the vagina may serve as a point of resistance. Ureter. — Palpation of the ureter is performed through the vagina or the rectum. The position of the hands is similar to that employed in bimanual pelvic palpation. The vaginal finger is passed to the cervix and then to the right or the left side, upon the surface of the vaginal fornix. The abdom- inal hand is meanwhile pressed downward, as in palpation of the adnexa, and when the tissues of the broad ligament are thus fixed, the fingers of the two hands are approximated and brought forward in an attempt to roll the ureter between them. If the ureter is enlarged it may be felt just in front and to one side of the vaginal cervix ; it feels like a thick cord, of about the caliber of a pencil, and may be extremely tender to the touch. In making bimanual rectal palpation the procedure is similar to that just outlined; the cervix is readily located through the rectovaginal septum. Kidney. — In palpating the kidney the patient is placed upon her back, the shoulders being slightly raised, and the knees and thighs flexed and resting upon pillows. One hand of the examiner is placed posteriorly in the angle between the lower border of the ribs and the spine ; the other hand is placed anteriorly below the border of the ribs in a corresponding position. The patient is now directed to take deep breaths and then to allow the air to escape from the lungs by rapid expiration with full relaxation of the 1S8 EXAMINATION OF THE URINARY ORGANS 139 abdominal wall. At the very beginning of this expiratory act the tips of the examiner's fingers are pressed deeply into the abdomen beneath the border of the ribs, and then gradually downward, in an endeavor to get the kidney between the two hands. If the kidney occupies its normal position, the lower pole may be felt; but occasionally, especially in fat subjects, it is not palpable. In the moderately movable kidney of normal size the lower pole only may be palpable below the costal margin at the beginning of expira- tion. If the kidney is unduly mobile, the deep inspiration forces the organ downward and the examiner's fingers pressed into the abdomen below the ribs push it below the costal margin. Anterior and posterior pressure can then be maintained by the thumb and fingers of the posterior hand, the Fig. 142. — Trimanual method of percussion of kidney. (Clark.) anterior hand then being free directly to palpate the anterior surface of the displaced kidney. In this way the size, regularity of surface, consistency, etc., of the kidney may be ascertained. A movable kidney that is otherwise healthy is not, as a rule, tender, except during or immediately after a Dietl's crisis. At this time, however, the kidney is extremely sensitive, and the abdominal wall covering it may be very rigid and spastic ; this is true also of cases of pyelitis complicating pregnancy or of any acute surgical condition of the kidney. In chronic surgical affections of the kidney, as, for example, tumor, large hydronephrosis, etc., the enlargement of the organ is evident, and simple palpation of the suspected region will readily reveal the condition. In renal calculus the kidney may not be palpable, but on making pressure over the kidney area, especially in the costovertebral angle, tenderness will prob- ably be noted. 140 GYNECOLOGY Early tuberculosis of the kidney may be present without any apparent enlargement of the organ, although, as a rule, tenderness on deep pressure is noted. In many instances of inflammatory lesions of the kidney a certain degree of lumbar rigidity will be observed. In pronounced enlargement of the kidney, the mass is readily made out, occupying a position between the ribs and the anterior superior spines anteriorly, and filling up the loin pos- teriorly. If a fluid accumulation is present, fluctuation may readily be dis- tinguished, and for this purpose trimanual palpation will be found of particular advantage (Fig. 142). PERCUSSION Percussion as an aid to diagnosis of kidney condi- tions is of no value except in massive enlargement of the organ. It is not used in making the diagnosis of movable kidney, and has distinctly less value than palpation in determining the size and position of an enlarged kidney. It has great value, however, in diagnosing an abdominal tumor springing from the kidney. Such tumors may bear a resem- blance to gall-bladder or pelvic enlargements. As renal tumors are retroperitoneal, tympany over the ab- dominal surface of the enlargement, especially upon the mesial aspect, is a constant finding ; an intraperitoneal enlargement, on the other hand, shows dulness over the most prominent area, with a surrounding tympanitic zone. In order to differ- entiate between the two forms of growth light percussion may be necessary. Murphy's Kidney Punch. — This diagnostic aid is carried out as follows : The patient, from whom all the clothing above the waist has been removed, is seated upright on a stool and bends as far forward as possible. The examiner's left hand is then placed flat over the kidney of either side, and pressed scope, with electric fi rm i y against the body. With the clenched right fist a sharp blow is then struck on the dorsum of the left hand. If acute congestion, infarction, retention of fluid in the kidney pelvis, or ureteral obstruction exists, the patient will cry out with pain. As a rule, no expres- sion of pain is elicited by striking over a healthy organ. Pig. 143. — Kelly's improved cysto INSPECTION Urethra — Urethroscopy. — The external urinary meatus is exposed by separating the smaller labia. In the normal nulliparous woman the meatus is a small slit, often hard to detect in the surrounding mucosa of the vestibule. In the woman who has borne children the orifice may stand open, and may exhibit a tendency to gape and expose the mucosa of the urethra and the openings of Skene's tubules. Prolapse of the urethral mucosa and urethral caruncle may readily be observed. In acute urethritis the mucosa of the urethral orifice is seen to be swollen EXAMINATION OF THE URINARY ORGANS 141 and red. In chronic urethritis, which is almost invariably due to gonor- rhoea! infection, Skene's tubules are prominent, and their orifices may be elevated and reddened (gonorrhoeal macule) ; they often contain pus, which may be expressed by making slight pressure from below. The mucosa just inside the urethral orifice may be inspected by separating the lips of the urethra with a delicate wire speculum. For inspecting the deeper urethra a cylindric speculum with an obturator is required. The end of the instru- 1PQ Fig. 144. — Nitze catheterizing cystoscope, single. ment should be fitted with a small incandescent lamp, although light may be reflected through the barrel of the instrument by means of a head-mirror. In performing urethroscopy the bladder is emptied. The speculum is well lubricated and passed through the vesical neck into the bladder, and the obturator then removed. The instrument is now slowly withdrawn until the folds of the vesical sphincter begin to close over the end of the speculum. As the instrument is withdrawn the mucosa of the entire canal may Nitze examining cystoscope. t>e inspected from within outward. Fissure of the neck of the bladder, patches of chronic urethritis, the opening of a suburethral abscess, and the presence of infected follicles on the floor of the urethra may be discovered in this way. In order to correctly interpret the findings a certain amount of experience is necessary. The urethroscope should be short and the interior of the barrel darkened. A very fine, flexible, solid silver probe will be useful in locating infected follicles or in finding the opening of a suburethral abscess. __ 142 GYNECOLOGY Bladder and Ureteral Orifices — Cystoscopy. — Cystoscopy is probably the most valuable and certainly the most useful method of examination at our command in surgical conditions of the bladder, ureter, and kidney. Cystos- copy, as the name implies, is direct inspection of the interior of the blad- der. By its means the mucosa and the ure- teral orifices are directly exposed to view. In addition to morbid anatomic changes in both, the physiologic actions of the ureters can thus be studied. Since the activity of the ureters is dependent more or less directly upon the kidneys themselves, cystoscopic inspection yields considerable information concerning these organs. This is particu- larly true of chromo-uretero-cystoscopy. Furthermore, by sounding or catheterizing the ureters and by applying the methods that will subsequently be detailed, the con- dition of each kidney may be most accurately determined. Methods of Cystoscopy. — S e v e r a 1 methods of performing cystoscopy are in vogue at the present time, each of which has its advantages and disadvantages. A very efficient but somewhat difficult method is that suggested and elaborated by Kelly. It consists of introducing a cylindric speculum (Fig. 143) into the bladder, with the patient in the knee-chest, Sims', or elevated dorsal position, so that the bladder becomes dis- tended by atmospheric pressure and its in- terior is exposed for inspection directly through the barrel of the instrument. The disadvantages of this method are that the patient is placed in a somewhat uncomfort- able position, that dexterity and prolonged practice are required to secure good results, and that since a speculum of considerable size is necessary in order to obtain a good view, the examination is somewhat painful. It has the advantages of requiring no com- plicated apparatus and of giving a direct view. Furthermore, local applications may be made or even simple intravesical operations performed through the open barrel of the speculum. Another method of performing cystoscopy is to distend the bladder with fluid and introduce a cystoscope that carries a light for illumination at its extremity and that possesses a series of mirrors and lenses through which the bladder may be viewed (Fig. 144) . There is usually some magnification of Fig. 146. — Cylindrical jar for sterilization of cystoscopes. EXAMINATION OF THE URINARY ORGANS 143 the bladder mucosa. The method possesses the following advantages : For simple inspection an instrument only slightly larger than the ordinary cathe- ter is required (Fig. 145) ; it causes but little pain and no discomfort, since the patient may lie in the ordinary dorsal position ; less practice is required to perform the cystoscopy satisfactorily ; the urethral orifices may be located with comparative ease, and ureteral catheterization may be practised with- out much difficulty. Its disadvantages are that a complicated and expen- sive instrument is required, while intravesical operations or applications, although possible, become more difficult and make an especially designed instrument necessary. General Preliminaries. — All cystoscopic examinations should be con- ducted under aseptic precautions. The external genitalia should be washed with green soap, water, and bichloride solution (1:1000). For simple cystoscopic examinations the vulva need not be draped with sterile cover- ing, but if the ureters are to be catheterized, this forms a very important part of the technic. The Kelly cystoscopes may be sterilized by boiling. Cys- toscopes fitted with lenses should be sterilized by im- m e r s i n g them for thirty minutes before using in a 1 : 500 solution of formalin. Simple examining cystoscopes should be placed vertically in a narrow cylinder jar (Fig. 146), the eye lens-system not being immersed. Catheteriz- ing cystoscopes must be en- tirely immersed. • They are either provided with a cap that protects the eye lens-system during the immersion, or they are so constructed that the lens- system may be completely separated from the instrument and sterilized by the method used for the simple examining cystoscopes. Ureteral catheters (Fig. 147) should, after use, be thoroughly but gently washed with castile soap and cold water. The lumen should be repeatedly flushed with water. This is best done in the following way : The catheters are suspended over the edge of a pitcher filled with cold sterile water, the eyes of the instruments being near the bottom of the pitcher and the butts hang- ing outside, reaching a lower level, so that siphonage may take place. The result is a continuous washing of the lumina for two or three hours, according to the amount of water used. The catheters should now be flushed with a 1 : 500 formalin solution, hung up, and allowed to dry. They should then be placed in the formalin gas sterilizer (Fig. 148). 1 Fic. 147. — Ureteral catheter. 1 Catheters which are to be used with the Kelly cystoscope must be kept straight and rigid; this is best accomplished by introducing a wire stylet into their lumen. This facili- tates the introduction of the catheter through the open barrel of the cystoscope. 144 GYNECOLOGY If it is found necessary to use a catheter that has become infected within twenty-four hours, the instrument should be flushed and then immersed in a cold i : ioo solution of formalin for at least thirty minutes. Hot water and alcoholic solutions affect the varnish of a catheter and quickly ruin it. Technic of the Direct Method with Atmospheric Distention of the Bladder — Kelly's Method. — A small pledget of cotton soaked in 10 per cent, cocaine is introduced into the urethra. After a few minutes the pledget is removed and the patient is directed to empty the bladder. She is then placed in the knee-chest or in the Sims' position, and the external urethral orifice is dilated up to 10 mm. The dilator (Fig. 149) should be well lubri- cated and a gentle boring motion should be employed. The speculum is gently introduced into the bladder, making sure that the instrument is well k Fig. 148.— Sterilizing ureteral catheters; jar with, ground glass lid; formalin pastilles and vapor. Fig. 149. — Urethral calibrator. within the internal urethral orifice when the obturator is withdrawn. Upon its withdrawal the air rushes through the speculum and distends the vesical cavity. It is customary to inspect first that part of the bladder directly opposite the end of the speculum, and which corresponds usually to the vertex of the bladder ; then, by sweeping the end of the instrument in various directions, to go over the entire mucosa, finishing with that part at the base of the bladder, just within the internal urethral orifice, known as the trigone. The trigone is the triangular area between the internal urethral orifice and the two ureteral openings. It is bounded posteriorly by a fold known as the interureteric ridge. In order to locate these anatomic points it is advisable, after completing the general inspection of the bladder, to with- draw the speculum until the internal urethral orifice begins to fold over its extremity. The speculum is then pushed into the bladder for a distance of EXAMINATION OF THE URINARY ORGANS 145 3 cm., and the inner end is tipped toward the base of the organ, when, as a rule, the instrument will be in close proximity to the interureteric ridge. The ureteral orifices are situated at the right and left extremity of this ridge, equally distant from the midline. They may be located by directing the speculum to the right or the left in the arc of an angle of between fifteen and thirty degrees from the midline. Hunner believes it a good plan to locate the left orifice first, as it is usu- ally situated nearer the internal urethral orifice than the right, and is more easily found than the latter because of the depression of the left vesico- vaginal wall produced by the weight of the uterus and the cervix. The right orifice is farther up toward the sacrum. The opening of the ureter is situated nor- mally on a localized elevation of the mucosa termed the mons ureteris. As a rule, it is most prominent on the left side, and is especially w r ell developed in women who have borne children. The appearance of the ureteral orifice varies considerably in different persons. In some it may be almost imperceptible, resembling a fine watermark in a sheet of paper, whereas in others it may be contracted and obscured by inflamma- tory sw r ellings that make its detection almost impossible. A guide to the ureteral orifice is often furnished by the periodic ejection of urine. Technic of the Indirect Method with Disten- tion of the Bladder by Water. — In this method the patient is placed in the ordinary dorsal posi- tion, and the bladder is carefully irrigated with warm saline solution, the irrigation (Figs. 150, 151 and 152) being continued until the water returns perfectly clear. The bladder is now filled with sterile water, the patient being encouraged to retain as much as possible. With the bladder full the cystoscope is introduced. The electric lamp and lenses are so arranged that a large part of the bladder can be seen with equal clearness. The vertex of the bladder, including the area back of the symphysis, is first examined, then the sides are inspected, and finally the base of the bladder and the trigone are viewed. This inspection is accomplished by alternately advancing and withdrawing the instrument with the lens turned in various directions from the median line. The cystoscopist should be familiar with the appearance presented by the normal bladder. Unless the distention is marked, the bladder is not spheric in outline, but is somewhat flattened on its superior surface by the 10 Fig. 150. — Irrigating apparatus. 146 GYNECOLOGY fundus of the uterus and pouched on either side. At the junction of the superior movable portion of the bladder with the base or fixed portion shadows may be seen ; these can be eliminated only by pressing the end of the instrument close to the bladder wall in the darkened area. Looking toward the apex of the bladder, an air-bubble is almost invari- ably seen on the surface of the distending medium. The mucosa of the apex may now be studied. As a rule, it presents a clear, pinkish-white sur- face, in which the capillaries are distinctly traceable, sharply defined in out- line, and of a bright red color. As the lateral areas are approached the lateral folds, appearing more or less as shadows, are observed. Here and there the surface of the mucosa may be marked by an underlying ridge of connective tissue. The color of the mucosa takes on a deeper hue, and the blood-vessels are increased in num- ber and more richly supplied with branches. At the base, in the midline, the color of the mucosa is a dull red, and the surface is no longer smooth and shining, but is thrown into fine ridges running toward the internal ureteral orifice. By pushing the instrument back in the median line as far as it will go and elevating the beak, the uterovesical fold may be brought into view, with the depression caused by the uterus immediately beyond it. Just in front of this area is the trigone, a triangular area bounded by imaginary lines connecting the ureteral orifices and the internal urinary meatus. The instrument is now drawn forward toward the internal urinary meatus until the posterior margin of the latter begins to rise in the picture ; the beak is then pushed inward about 3 cm., and directed first on one side and then on the other to a point about 1^2 cm. from the median line ; in this area the ureteral orifice can usually be located. The ureters appear as fine openings or slits in the mucosa, generally situated upon a rounded eminence. Between the two ureteral orifices a ridge of the mucosa can be seen ; this is termed the interureteric ridge, and forms the base of the trigone, containing muscle-fibers that are continuous with those of the ureters. The vessels of the trigone radiate toward the ureteral orifices on either side. About the ureteral orifices may be noted the anastomosis between the ureteral and vesical capillaries. Upon close observation of the ureters, periodically — the frequency depending upon the activity of the kidneys — the eminence will be seen to pout, bringing into relief the position of the ureter embedded in the bladder wall; it then retracts, the orifice opens, and there is an outward gush of urine. The orifice immediately closes and again becomes immobile. The ureters on the two sides act independently of each other in this periodic ejection of urine. Departures from the normal may be noted in the capacity of the bladder ; in the color and transparency of the mucous membrane ; in the number, size, and outlines of the capillaries; in the shape of the interior of the bladder; in the ridges caused by the submucous connective tissue ; in the position of the ureteral orifices, and in the appearance of the orifices themselves. Capacity of the Bladder. — The average female bladder will hold from 250 to 300 c.c. of solution without causing marked discomfort to the patient. In EXAMINATION OF THE URINARY ORGANS 147 fixed tumors and enlargements of the uterus or adjacent parts the capacity of the bladder may be diminished because of the inability of the vesical walls to distend. In old cases of cystitis, particularly in those of tuberculous origin, the capacity is greatly diminished, due to actual contraction and shrinkage of the submucous connective and muscular constituents of the bladder wall. Color and Transparency of the Mucosa. — In hyperemia and acute cystitis the mucosa is of a deeper pink or red color, and the translucency is dim- inished. In chronic cystitis the mucosa is a deeper pink or grayish in color, lusterless, or presents a ground-glass appearance. The folds about the trigone may be greatly enlarged, swollen, and ©edematous. Deposits of phosphates and pus may be observed as whitish particles that are adherent to the mucosa, or detached and floating in the distending fluid. Ulcera- tions appear as irregular, punched-out areas covered with whitish in- crustations of pus or deposits of urinary salts. Number, Size, and Outline of the Vessels. — The number of capillaries is increased in hyperemia ; if the condition goes on to actual inflammation, the outlines become less distinct. The medium-sized and smaller vessels become larger, but less distinct and even partly obscured by the fogginess of the mucosa. Small, red, sharply-defined points representing ecchymoses may be discerned here and there, and the slightest touch with the cystoscope may cause bleeding. Shape of the Interior of the Bladder. — The interior of the bladder may undergo changes in shape as the result of enlargements or tumors of the uterus or adnexa, which displace or encroach upon it. In cases of chronic cystitis the contractions of the bladder wall may be irregular, deepening the shadows on one side, drawing the trigonal area more to one side, and form- ing asymmetric ridges and hollows. Submucous Trabecular. — In chronic cystitis, particularly in those cases associated with obstruction to the urinary flow, the surface of the bladder is marked with numerous trabecular that cross one another in various directions, thus forming depressions, pockets, or diverticula of the mucous surface between them. Position of the Ureteral Orifices. — Subvesical tumors may displace both orifices to one side of the median line, or produce such an irregularity in the contour of the trigone that the orifices will be completely hidden from view in the shadows or folds. In chronic cystitis with ulceration and contrac- tion the orifices may be drawn far from their normal position and be hidden from view in the folds of swollen or ulcerated mucosa. The ureteral orifices may be swollen and oedematous, wide open, and rigid, showing little or no tendency to periodic relaxation or contraction, and slight or no swelling or retraction of the intramural part. Or the orifices may be " dead," entirely inactive, and evincing no contractions and no ejec- tions. They may be plugged with pus or excavated as the result of ulceration. One orifice may eject twice as often as its fellow. Catheterization of the Ureters. — After inspection of the bladder, if it is found desirable to catheterize the ureters, the simple examining instrument is withdrawn and the catheterizing cystoscope is introduced in its stead. A 148 GYNECOLOGY rigid aseptic technic must now be observed. Theoretically, the direct method of cystoscopy is not so safe as the indirect method, for in the latter the catheters (Fig. 153) pass through a sterile medium (water) or a weak antiseptic solution (1 : 5000 mercury oxycyanide). If the bladder is sterile or has been thoroughly irrigated there is no great danger in either case. Never- theless, catheterization of the ureters should not be practised when the bladder is infected unless no other method of diagnosis will suffice. For the purpose of collecting the urine from each kidney separately the ureteral catheter need be inserted a distance of only a few centimeters. Catheterization of the Ureters by the Direct Method. — After having located the ureteral orifice, a sterile glove is slipped on the examiner's right hand by an assistant, who supports the tail of the catheter while the ex- aminer guides the tip through the lumen of the cystoscope into the ureteral orifice. After the tip is engaged in the ureter and as it is introduced fur- ther into the canal the stylet is withdrawn. A catheter of large size is Figs. 151-152. — Top and bottom view. Two-way irrigator or catheter. more practicable used with the Kelly open cystoscope than with the Nitze or any other form of catheterizing cystoscope. Through the open Kelly cystoscope may also be introduced ureteral cathe- ters or bougies that have been tipped with wax ; these will show the scratch- marks of ureteral calculi and are valuable as a means of diagnosis. A diagnosis of stricture of the ureter is more easily made by the direct than by the indirect passage of bougies, as the sense of resistance is more readily perceived. Ureteral sounds of increasing size may be used for the purpose of dilating strictures of the ureter in its lower part. Catheterization of the Ureters by the Indirect Method. — When the Nitze instrument is to be used, the examiner disinfects his hands and wears a gown and sterile rubber gloves. The cystoscope is rinsed in sterile water and dried. The ureteral catheter or catheters are threaded into the channels provided for them, the attachment for the electric current is protected by a sterile cover, and the cystoscope is introduced. The ureteral orifice on the side to be examined is exposed and the cysto- scope is maintained in that position. The ureteral catheter is now pushed through the barrel of the instrument until the point appears in the field of EXAMINATION OF THE URINARY ORGANS 149 vision. By means of the device provided in the instrument the tip of the catheter is directed toward the orifice and is made to engage. Still holding the cystoscope in the same position, the catheter is pushed onward as far as required (Fig. 153). The catheters used with this form of cystoscope are marked at one-centimeter intervals, so that the cystoscopist may know just how far the catheter has been inserted into the ureter. Where both ureters are to be catheterized it may be advantageous to use differently marked catheters on the two sides, so that the right does not become con- fused with the left. ^ If urine is to be collected from the catheterized ureter, the device used to direct the catheter may be turned back to the resting position ; the water in Fig. :S3. — Catheterization of the ureter. The cystoscope has been rotated to illuminate the trigone, and the shutter opened to assist in directing the catheter into the ureteral orifice. the bladder is then let out and the instrument is gently withdrawn, the ureteral catheter at the same time being pushed through the cystoscope until the tip of the latter emerges ; the catheter is then caught with the fingers and fixed as the cystoscope is detached from it. By this method obstruction of the ureter can be detected and treated. Catheters of varying sizes may be introduced in an effort to get past an obstruction or for the purpose of dilating a stricture of the ureteral orifice or lower ureter ; but the maneuvers are not so satisfactory as with the direct method of cystoscopy. In order to collect urine from one side, the catheter need not be passed for more than 5 or 6 cm. ; it is unnecessary to pass the instrument further than this, for traumatism of the ureter should be kept at a minimum, lest 150 GYNECOLOGY blood or leucocytes become mixed with the urine and impair the value of the microscopic urinalysis. The end of the ureteral catheter should now be placed in a sterile test- tube plugged with sterile cotton ; the tube should be properly supported, and the patient placed in a comfortable position. When a sufficient quantity for urinalysis has been collected, the catheter may be withdrawn. Although it may be necessary, for diagnostic purposes, to pass the ureteral catheter into the kidney pelvis, it should be borne in mind that if the catheter is introduced so far that it doubles up in the kidney pelvis or encroaches upon the calices or pelvic walls, bleeding will almost certainly follow, and the value of the collected specimen, so far as the blood content is concerned, will be rendered void. Under normal conditions the urine drops from the end of the catheter at intervals of from ten to fifteen seconds ; two, three, or four drops follow in succession, then a pause occurs, and the dropping is repeated. If the drop- ping is continuous, it is an indication that the catheter has either entered a collection of fluid in the kidney, pelvis, or ureter (hydronephrosis, hydro- ureter) or that it has been drawn down into the bladder or that the rate of excretion is extraordinarily rapid as after the ingestion of a large amount of water. At first there may be no escape of fluid from the ureteral catheter. (Care should always be exercised beforehand to see that the lumen of the catheter is unobstructed.) If the catheter has been previously tested, it may be that the eye of the instrument has become plugged with pus or blood. Under- these conditions a few centimeters of sterile water may be injected through the catheter in order to dislodge the obstruction. A reflex anuria is some- times observed. This rarely lasts for more than a few minutes — at most, five or ten. Examination of the Ureter and Kidney by Means of a Wax-tipped Bougie. — The passage of a wax-tipped bougie through the ureter into the kidney pelvis is a valuable diagnostic means in cases of ureteral or renal calculus. Kelly uses a renal bougie 2 mm. in diameter, with an olive point 3 by 2 mm., notched on two sides, the notch running lengthwise. Two parts of dental wax and one part of olive oil are melted together and the end of the catheter is dipped in the hot mixture and allowed to harden in the air. The wax gives the catheter a highly-polished surface, which is exceedingly sensitive, and becomes abraded by the slightest contact with a hard, rough substance. In order to ascertan the exact position of the stone, whether it is located in the ureter or in the kidney, it may be advisable to coat the entire length of the bougie. A stone that is low in the ureter produces a long, con- tinuous scratch along the extent of the catheter. The chief source of error in interpreting the marks on the wax is that they are apt to be confused with the scratches occasioned by contact with the cystoscope. (See Chapter XXV for the method of using wax-tipped catheters with the water cystoscope.) Kelly reports eighteen cases of kidney stone in which a positive diag- nosis was made by means of the wax-tipped catheter, and in which a sub- sequent nephrolithotomy confirmed the diagnosis. In two cases in which stones were present the waxed catheter gave no evidence of their existence. EXAMINATION OF THE URINARY ORGANS 151 Kelly states that the wax-tipped catheter may fail to locate a renal cal- culus if the pelvis of the kidney is greatly dilated and if the stone is small, if the calculi are lodged in cavities in the substance of the kidney, or if a large stone has fixed the pelvis of the kidney and the catheter pushes out the upper end of the ureter until it forms a small pocket. FIG. 154- — Rontgenogram of ureteral stone. In doubtful cases, when the suffering is protracted and tends to cripple the patient, an exploratory incision for confirming the diagnosis of renal calculus is justifiable. Rontgenographic Examination of the Kidney. — Rontgenographic exami- nation of the kidney is of value, especially in the diagnosis of renal calculus. 152 GYNECOLOGY According to Henry Fancoast, " the rontgenographic examination is the most uniformly accurate, and, therefore, the most valuable method at our command in the diagnosis of renal calculus, provided it is employed intelli- FlG. 155. — Shadows cast by vermiform concretion and by phlebolith; upper shadow upon the iliac crest is cast by a fecal concretion in appendix, small round shadow in pelvic area is a phlebolith. (After Fenwick, from Kelly and Burnham: "Diseases of Kidney, Ureter and Bladder," D. Appleton & Co.) gently. The rontgenographic findings cannot of themselves, however, be accepted as absolute in every case, because of the possible existence of certain sources of error, which, though comparatively rare, must not be overlooked. Therefore, this method of examination should always be used EXAMINATION OF THE URINARY ORGANS 153 in conjunction with the other clinical methods of diagnosis and the symp- toms which in the first place suggest the examination. The percentage of error in diagnosis of renal and ureteral stone is variously placed at from four to ten (Fig. 154). " The degree of error possible in any individual case may be more or less approximately determined by consideration of the following four defi- nite factors concerned in the accuracy of the results of the rontgenographic examination for renal calculus: (1) The making of the rontgenogram; (2) the interpretation of the rontgenogram; (3) anatomic difficulties; (4) other conditions or objects, normal or pathologic, which may be capable of simu- lating the rontgenographic appearance of calculus. Fig. 156. — Rontgenogram of suspected renal calculus with sound in ureter. The arrow points to a shadow which was shown to lie outside of the ureter by a shadowgraph bougie. The shadow proved to be a patch in an atheromatous artery. (After Fen wick.) From Eisendrath's " Surgical Diagnosis." (W. B. Saunders & Co.) " In connection with the first factor we may consider the skill and ex- perience of the rontgenologist, the efficiency of his apparatus, and the pre- liminary preparation of the patient. As a rule, no rontgenogram should be accepted as of value for the diagnosis of renal calculus unless the intestinal tract of the patient has previously been thoroughly emptied of fecal matter by mild but efficient purgation. The stomach also should be empty, espe- cially when the left kidney is suspected. The rontgenologist should be certain that there is no possibility of pills or foreign bodies of any kind being pres- ent in any part of the gastro-intestinal tract. " An accurate interpretation of the rontgenogram requires equally as 154 GYNECOLOGY much skill and experience as does the examination itself. The examination is essentially a consultation ; therefore the rontgenologist must possess a reasonable amount of knowledge of anatomy and surgery ; and, likewise, the surgeon should possess a corresponding degree of skill and experience in interpreting rontgenograms of this kind. " The anatomic difficulties likely to influence the accuracy of the ex- amination are an excessive amount of fat in the abdominal walls or omen- tum, thick muscular walls, tumors, and ascites. A reliable rontgenogram of the kidney area should show at least the shadows of the psoas and Fig. is?. — Rontgenogram showing stone in upper calyx of right kidney. Note outline of kidney and relation of stone to short twelfth rib. (Kellv and Burnham. " Diseases of Kidney, Ureter and Bladder." D. Appleton & Co.) quadratus muscles, and, to be accurate, the shadows of the kidneys in addi- tion. If the result of an examination is positive as to stone, it should be repeated before any operation is performed. Two negatives made at the same visit will not answer: the two examinations should be made on different days. " A rontgenogram is a shadow picture, and unfortunately there may be present somewhere between the Rontgen ray tube and the plate other objects, normal or abnormal, which are capable of making a shadow similar to that of a calculus. This must be classed as an unavoidable source of error, though the degree of error may be more or less modified by the skill and experi- EXAMINATION OF THE URINARY ORGANS 155 ence of the rontgenologist. The most frequent examples of objects in the abdominal cavity which may produce misleading shadows are calcified lymph-glands, gas and fecal matter remaining in the intestinal tract due to careless preparation, pills or tablets not broken up or dissolved, fecal concretions, especially in the appendix, and collections of pus in the kidneys (Figs. 155, 156, 157 and 158). A mole on the back may cast a shadow of suffi- cient density to simulate a calculus. In the pelvis one may be easily misled by the frequent occurrence of shadows due to phleboliths in the pelvic veins, intestinal contents and calcified lymph-glands." Kummell secured perfect Rontgen ray pictures of calculi in sixty-five out of eighty-four cases that came to operation. large number of other \ \ An equally kid- ney affections that simu- lated calculus were operated upon but failed to yield posi- t i v e Rontgen ray findings. To arrive at a positive diag- nosis, several skiagraphs must be made, and each plate must show the calcu- lus to be in the same posi- tion. Kummell regards this constancy of position as most important in the dif- ferential diagnosis, and re- gards it as a characteristic sign of stone. As a rule, the calculus occupies a position on the Rontgen ray plate sev- eral centimeters from the spinal column and a little below the twelfth rib. cor- responding to the anatomic position of the pelvis of the kidney. This is about the point where an imaginary horizontal line drawn through the body of the second lumbar vertebra would meet the twelfth rib. When renal cal- culus complicates pyonephrosis, a greater variation in the position occurs, because such stones sink into the dilated and altered pelvis and grow like coral branches into the enlarged calyces. The resulting dentate mass pre- sents a more or less characteristic appearance that differentiates it from intestinal contents and from other foreign confusing elements. The diag- nosis of renal calculus by means of the Rontgen ray is made with difficulty in very stout subjects. This difficulty may be overcome partly by compressing the abdominal wall at the time the picture is taken. Pure phosphatic stones, being soft, very often give no shadow. V Fig. 158. — History in this case indicated ureteral calculus. A small cystic mass lay to the side of the uterus and the rontgenogram showed" a shadow along the course of the ureter. Pyelography demonstrated a normal pelvis and ureter and an extraureteral shadow which operation proved to be a tooth in a dermoid cyst. (Keene and Pancoast). (Courtesy Journal American Med. Assoc.) 156 GYNECOLOGY DIAGNOSTIC METHODS COMBINING URETERAL CATHETERIZATION AND THE RONTGEN RAY Shadow Catheters. — Although the Rontgen ray is the most valuable method at our disposal in the diagnosis of ureteral calculus, shadows due to other foreign bodies, as, e.g., phleboliths, calcareous lymph-nodes, etc., may lie directly along the course of the ureter and lead to confusion (Figs. 156 and 158). To determine positively whether the shadow is due to a body within the ureter or external to it the suspected side should be catheterized, the catheter being impregnated with bismuth or some other substance that is impervious to the Rontgen ray. The juxtaposition of the catheter and the calculus may then be demonstrated ; or a stereoscopic Rontgen ray picture may be taken. The shadow catheter plus the Rontgen ray may be of value also in identifying renal calculi. Pyelography. — Another diagnostic method is that known as pyelography. It combines ureteral catheterization, injection into the ureter and kidney pelvis of a fluid that is impervious to the ray, and a Rontgen ray picture. It is one of the most recently devised and most valuable methods. The technic of injection is as follows: A catheter is passed into the ureter of the sus- pected side. 2 The cystoscope and catheter are maintained in a fixed position while a Rontgen ray plate is placed under the patient and the skiagrapher pre- pares to take the picture. A 25 per cent, solution of sodium bromide, a 10 to 15 per cent, solution of thorium nitrate, 3 or a 10 per cent, solution of collargol (colloidal silver) is placed in a burette and is then allowed to run very slowly into the catheter until the patient complains of a sensation of fullness in the kidney or the flow ceases ; at this instant the skiagraph is taken. The burette is now detached and the catheter left in position until the solution drains away. By means of pyelography the actual outlines of the renal pelvis and the ureter are shown. To interpret a pyelograph, the examiner must be familiar with the shadow of the normal pelvis and ureter, and with the variations in size and shape that occur in health. Surgical diseases of the kidney and ureter frequently produce modifications of the normal contour of the kidney pelvis and ureter, so that pyelography becomes a valuable aid to diagnosis. Pyelography is by far the best method of diagnosing hydronephrosis, particularly of the intermittent type. In diagnosing hydronephrosis by measuring the quantity of urine in the hydronephrotic sac, or by injecting the sac until the patient complains of pain, the sources of error are too evi- dent to need elaboration. It may, however, be pointed out that a reflex 2 For details of pyelography see Keene and Pancoast's paper, Jour. Amer. Med. Assoc, 1914, lxiii, p. 523. 3 Burns' method of preparing the thorium nitrate solution is as follows : " To make 100 c.c. of a 10 per cent, solution, 10 grains of thorium nitrate are dissolved in as little distilled water as possible ; to this solution, kept hot on a water- or steam-bath, are added 30 c.c. of a 50 per cent, solution of sodium citrate, the additions being made in small quan- tities, care being taken to shake the solution thoroughly after each addition. At first, after the addition of the citrate solution, a white, gummy precipitate is formed, which later be- comes granular, but finally dissolves on the addition of all the citrate solution. This solu- tion is then made neutral to litmus by the careful addition of a normal solution of sodium hydroxid and made up to the required volume of 100 c.c. with distilled water. Upon filtra- tion a clear, limpid solution is obtained which is not affected in the least by sterilization." EXAMINATION OF THE URINARY ORGANS 157 x polyuria may be induced at the time of catheterization, and that the hydro- nephrotic sac may be partially filled or entirely empty at the time of injec- tion. These sources of error may all be overcome by the pyelograph. If the presence of a stone is suspected, a picture should be taken prior to making the collargol injection, since the pyelograph may obscure the shadow cast by the stone. A stone within the ureter may sometimes be brought out with greater distinctness by the addition of the shadow of the pyelograph to the shadow of the stone (Fig. 159). It may also serve to demonstrate that the shadow is that of a _ stone within the ureter, rather than a phlebolith or other foreign body on the : / / / / exterior, by reason of the \ \\< fact that the ureter around \ N j | / //^ and above the stone will • -p show dilatation. Pyelography often dis- closes perfectly the kink in ■ j the ureter produced by dis- i __ location ofthekidney / / downward (Fig. 160). A / / picture is first taken with ' I X ■ the patient in the recumbent \ posture, followed by one with the patient standing \- upright after she has been / y ' \ directed to breathe deeply f I and the kidney has been dislocated downward. A pyelograph may also re- veal distortion of the kidney pelvis or calyces, as in the case of renal tumors or con- genital cystic disease of the kidney (Figs. 159 and 160). Pyelography is a method to be used only by those who are thoroughly familiar with cystoscopy and ureteral catheterization, since there is great danger of injecting the kidney pelvis to the degree of excessive tension. Under the latter circumstances death has resulted. Death following pyelography has been ascribed to shock, colloidal silver poisoning, colloidal silver embolism, rupture of a hydronephrotic sac, and rupture of the kidney pelvis with hemorrhage. In most of the fatal cases reported the quantity of solution used exceeded the capacity of the kidney pelvis and had been injected with a hand syringe ; or the solution used was of such a strength as to be chemically irritating. 4 4 Manges observes the kidney through a fluoroscope during the injection of the opaque solution ; this shows the position of the kidney, and whether or not the solution has reached the pelvis. Fig. 159. — The rontgenogram failed to demonstrate a calculus. The catheter met an obstruction 13 cm. from the ureteral orifice. By means of a collargol injection, the calculus was clearly defined together with a hydroureter and hydronephrosis. (Keene and Pancoast). (Courtesy Journal Amer. Med. Assoc.) 158 GYNECOLOGY Collargol, which was used by a majority of the investigators in the early days of pyelography, has been largely supplanted by the less irritating sodium bromide and thorium nitrate solutions suggested by Braasch and by Burns. Estimating the Functional Activity of the Kidneys — Combined and Separate. — The amount of urine excreted from each ureteral orifice may be estimated roughly by observing the frequency of the ejections. The actual amount excreted from either kidney during a given time may be determined accurately by catheterizing the ureter and collecting the urine. The total quantity collected from one ureter during a given portion of time will be an index to the activity of the corresponding kidney from which an estimate for the entire twenty-four hours may be made, provided the ingestion of solids and fluids is maintained at stated inter- vals and in equal quantities. Chrom o-cystoscopy. — Since catheterization of the ureters may be painful and is often undesirable or even absolutely contraindicated, the method known as chro- mo-cystoscopy may be em- ployed, and will serve as a useful substitute in estimat- ing the functional activity of the individual kidneys. This method is based on the fact that if a given amount of coloring matter dissolved in water is injected into the subcutaneous connective tis- sue, it will be absorbed into the circulation and be eliminated by the kidneys within a specified time and to a certain degree in health. The length of time required for the coloring matter to appear and the degree to which it tinges the urine are dependent upon the activity of the kidneys. 'Indigo-carmine. — Although other dyes have been used for this purpose, that which has proved most satisfactory is indigo-carmine. Chromo-cystoscopy not only gives an indication as to the total renal activity, but it also enables a fairly accurate comparison of the two sides to be made. It serves as a means for locating the ureteral orifices for the be- ginner, or for the expert as well when the orifices are hidden and difficult to find. L .. ______ . . -. . _ _ - Fig. 160. — Ptosis of the left kidney with hydronephrosis. The catheter met an obstruction 4 cm. from the ureteral orifice. Pyelography demonstrated the kink in the upper ureter and the distention of the kidney pelvis and calyces. (Keene and Pan- coast.) (Courtesy Journal Amer. Med. Assoc.) EXAMINATION OF THE URINARY ORGANS 159 Chromo-ureteroscopy. — The technic of this method is as follows : The patient is placed upon the examining table, and the external genitalia and buttocks are washed with green soap and warm water, followed by a i : iooo bichloride solution. The bladder is now irrigated, and the cystoscopic in- strument prepared for the examination. A solution of indigo-carmine, con- sisting of 8 eg. of indigo-carmine and 10 eg. of sodium chloride dissolved in 20 c.c. of water and sterilized, is now injected into the gluteal muscles of one side. The injection is made with a fine needle, and as soon as the needle is withdrawn the point of injection is covered with an alcohol compress. The cystoscopic examination is begun, the ureteral orifices located and care- fully observed, the cystoscope being turned first to one ureter and then to the other. The bladder must be well illuminated. Deductions as to the condition of the kidney are made from two facts : First, the time that elapses between the injection and the instant when the indigo-carmine first appears at the ureteral orifices ; and, secondly, the in- tensity of color that the dye lends to the urine. Indigo-carmine is elimi- nated by normally functioning kidneys in from three to twenty minutes. The color at first may be a light blue, but it soon becomes darker. In 90 per cent, of kidneys the color appears either as a light or a dark blue within fifteen minutes ; in 61 per cent., within ten minutes. If the urine does not take on a light blue color at the expiration of fifteen minutes, or a dark blue at the expiration of twenty, serious insufficiency of the renal function is pres- ent. If no elimination occurs, either the respective kidney or ureter is gravely diseased or the ureter is obstructed. The indigo-carmine test takes the place of the ureteral catheter in a large number of instances. It reveals clearly obstruction of the ureter of a particular side, or a deficiency in the secreting power of a diseased organ, but, of course, it does not differentiate between them. Error in the deductions made from the indigo-carmine test may arise as a result of a temporary reduction in the ingestion of fluids, with its consequent effect on the rapidity of excretion and dilution of the urine. This may be avoided by routinely directing the patient to drink two glasses of water immediately preceding the examination. If the solution of indigo-carmine is not accurately prepared, too much or too little of the dye may find its way into the blood. Great care should, therefore, be exercised to use the exact amount prescribed. If the injection is not made sufficiently deep and into a muscle, absorp- tion of the dye may be delayed. When it is especially desirable to avoid any error in this regard the injection should be made intravenously. Phenolsulphonephthalein. — Another method of estimating the functional activity of the kidney is by the injection intramuscularly or intravenously of phenolsulphonephthalein (1 c.c. of a solution containing 6 mg. of the drug). Healthy kidneys will eliminate 60 per cent, of the drug within two hours ; its presence in the urine may be detected by rendering the urine alkaline by the addition of a few drops of a 25 per cent, solution of sodium hydroxide, which brings out the carmine color. The percentage of elimination is then estimated by comparing the shade of the urine with a standard color con- trol in the Duboscq colorimeter, or by comparing the color with a series of solutions of known percentage. 160 GYNECOLOGY The phenolsulphonephthalein method is one of limited value in estimat- ing the function of a particular kidney. This is due to the fact that the naked eye observing the ureteral orifice is, of course, unable to detect the exact time at which elimination begins or to make any estimate of the amount excreted. The urine must be rendered alkaline in order to bring out the color. The kidneys may be tested separately by catheterizing both sides and allowing the ends of the ureteral catheters to empty into a test- tube containing sodium hydroxide. The disadvantage of this latter method is, however, apparent at once. The particular advantage of the phenolsulphonephthalein test is that the injection is practically painless, no more than i cm. of the solution being used, and that it is exceedingly reliable as a means of diagnosing the total or combined efficiency of both kidneys. In employing the test for this pur- pose the patient is directed to drink from 600 to 800 c.c. of water. One c.c. of a solution containing 6 mg. of the drug is then injected subcutaneously and the bladder immediately emptied by catheterization. At the end of an hour the bladder is again emptied by means of a catheter, the urine rendered alkaline, and the percentage of elimination estimated. At the end of the second hour the patient is again catheterized and an estimation is made of the second specimen. If the total elimination for two hours does not reach 60 per cent., this is evidence that the combined excretory power of the kidneys is deficient. That the phenolsulphonephthalein test is valuable used in conjunction with the indigo-carmine test is plainly evident ; for example, if the indigo- carmine test has shown that one kidney is inactive, a normal elimination of phenolsulphonephthalein will indicate that the other kidney is functionally sufficient. The Blood Urea Test. — An estimate of the functional capacity of the kidneys is afforded by a method for determining the blood content of cer- tain of the end-products of protein metabolism ; for example, of the total non-protein nitrogen, or of one of the following constituents : Urea, creatinin, uric acid. Of these, the blood urea test seems to be the most satisfactory. The amount of urea in the blood of a normal individual under ordinary conditions of life does not exceed about 35 mgm. per 100 c.c. If the func- tion of the kidneys becomes impaired, the amount of blood urea increases in proportion to the degree of insufficiency. A blood-urea content of over 200 mgm. per 100 c.c. with few exceptions portends the early death of the patient. Methods for Determining Blood Urea. — The method most generally employed is that of Van Slyke and Cullen, or one of the newer modifications that are constantly appearing in the literature. Because of the frequent changes suggested in the technic of this test and of the other blood chemical tests, in the selection of the method the student must be guided by the cur- rent literature. As a rule, 5 c.c. of blood removed from a vein suffice for the test. EXAMINATION OF THE URINARY ORGANS 161 BIBLIOGRAPHY Albarran : Exploration des fonctions renales. Paris, 1905. Braasch, W. F.: Pyelography. Saunders, Phila., 1915. Ibid. : "Clinical Data of Nephrolithiasis." Sur., Gyn. and Obst, 1917, vol. xxiv, No. 1, p. 8. Ibid. : "Recent Observations in Cystoscopic Technic." Annals of Surgery, 1917, vol. lxv, p. 615. Braasch, W. F., and Wildner, F. S. : " Pyelography." Int. Abst. of Sur., Feb., 1915, p. 117. Burns, E. : " Thorium — A New Agent for Pyelography." J. H. H. Bull., 1916, vol. xxvii, p. 157. Ibid. : " The Use of Thorium in Urology and Rontgenology." Amer. Jour. Rontgenology," 191 6, vol. iii, p. 482. Ibid. : " Thorium — A New Agent for Pyelog- raphy." J. A. M. A., 1915, vol. lxiv, p. 2126. Casper and Richter : Functionelle Nierendiagnostik. Berlin, 1901. Clark, J. G., and Keene, F. E. : " The Relationship Between the Urinary System and Dis- eases of the Female Pelvic Organs." Surg., Gynec. and Obst., 1914, vol. xviii, p. 10. Dowdall, G. G. : " Five Diagnostic Methods of John B. Murphy of Chicago." Arch, of Diag., 1910, vol. iii, p. 18. Eisendrath, D. : " The Effect of Injecting Collargol into the Renal Pelvis." Jour. Am. Med. Asso., 1914, vol. lxii, p. 1392. Goldberg, B. : " Uber das Verhaltniss von Eiweissgehalt und Eitergehalt in Urinen." Cen- tralbl. f. d. med. Wissensch., 1893, vol. xxxi, p. 593. Hunner, G. L. : " The Mensuration and Capacity of the Female Bladder." J. H. H. Bull., No. 105, Dec, 1899. Ibid. : " Forcible Dilatation of the Kidney Pelvis as a Means of Diagnosis." Surg., Gyn. and Obs., May, 1910, pp. 485-493- Ibid. : '" The Significance of the Urinary Examination in Women." Amer. Medicine, vol. ix, No. 14, pp. 559-562, April 8, 1905. Kelly, H. A. : " My Experiences with the Renal Catheter as a Means of Detecting Renal and Ureteral Calculi." Am. Jour. Urol., 1904, i, 14. Keene, F. E., and Pancoast, H. K. : " The Present Status of Pyelography." Jour. Am. Med. Assn., 1914, vol. lxiii, p. 523. Kelly and Burnham : Diseases of the Kidney, Ureters and Bladder. Appleton, New York, 1914. Kelly, H. A., and Lewis, R. M. : " Silver Iodide Emulsion — A New Medium for Skiag- raphy of the Urinary Tract." Surg., Gyn. and Obst., 1913, vol. xvi, p. 707. Keyes, E. L., and Mohan, H.. " The Damage Done by Pyelography." Amer. Jour. Med. Sci., 1915, vol. cxlix, p. 30. Kummell, H. : "Modern Surgery of the Kidney: The Achievements of Modern Surgery of the Kidney from the Standpoint of Diagnosis and Therapeutics." Surg., Gyn. and Obst., 1907, vol. iv, p. 21. Ibid. : " Uber moderne Nieren-Chirurgie, ihre Diagnose und Resultate." Berl. klin. Wchnschr., 1906, vol. xliii, 901 ; 952. Pilcher, P. M. : Practical Cystoscopy. Saunders, Phila., 1915. Rowntree, L. G., and Geraghty, T. G. : " An Experimental and Clinical Study of the Func- tional Activity of the Kidneys by Means of Phenolsulphonephthalein," J. Pharmacol. and Exper. Therap., 1910, vol. ii, p. 579. Thomas, B. A.: " Chromo-cystoscopy in Functional Renal Diagnosis Based upon the Em- ployment of Indigocarmin." Penn. Med. Jour., Sept., 1909. Ibid. : " Diagnosis of Renal Diseases and Sufficiency." Annals of Surgery, April, 1908. Ibid. : " Uber die Chromo-ureteroskopie in der funktionellen Nierendiagnostik." Zeit. f. Urologie, 191 1, Band V. Ibid. : " The Results of Two Hundred Chromo-ureteroscopies Employing Indigocarmin as a Functional Kidney Test." J. A. M. A., Jan. 18, 1913, vol. Ix, pp. 185-188. Ibid. : " The Quantitative Determination of Functional Renal Sufficiency by the Duboscq Colorometer ; Indigocarmin versus Phenolsulphonephthalein." Amer. Jour. Med. Sci., Sept., 191 1. Ibid. : "The Relative Value of the Various Methods for the Determination of Functional Kidney Sufficiency." Penna. Med. Jour., Feb., 191 1. Ibid. : "The Value of Chromo-ureteroscopy in Functional Kidney Diag- nosis." Surg., Gyn. and Obst., April, 191 1, pp. 345-353- Voelcker, F. : Diagnose der chirurgischen Nierenerkrankungen unter Vertwertung der Chromo-cystoskopie. 1906, Wiesbaden. Young, E. L. : " A New Preparation for Pyelography." Boston Med. and Surg. Asso.. 1915, vol. clxxii, p. 539. 11 CHAPTER X EXAMINATION OF THE ANUS AND RECTUM An examination of the anus and the rectum forms a valuable addition to the gynecologic examination, and should never be omitted when any symp- toms directly referable to these parts are present. If the rectum calls for special attention, the initial rectal examination should not be made until sev- eral hours after defecation has occurred. In this way the examiner may detect Fig. 161. — Examination of rectum — patient in dorsal position, with Tuttle's pneumatic speculum. the presence of any abnormal discharge. Ordinarily anal and rectal exami- nations are facilitated by giving the patient a preparatory enema. In making the examination the patient should be placed in the ordinary dorsal or Sims' position (Figs. 160 and 161). Simple inspection will reveal: The outlines of the external sphincter ; whether the anus is well tucked up or protruding; the existence of a mucous, purulent, or bloody discharge; the color of the mucosa and of its surrounding integument, and the pres- ence of external hemorrhoids, scars, ulcerations, or fistulous openings. Palpation will disclose the presence of tenderness and induration sug- gestive of fissure, fistula, or perirectal inflammation. A fine silver probe 162 EXAMINATION OF THE ANUS AND RECTUM 163 should be inserted lightly into any pits, fissures, or adventitious openings that may be present, for only in this way can some fistulas be detected. The buttc :ks may now be well separated and the patient directed to strain slightly, thus exposing the greater part of the anal canal (Fig. 162). Dryness and desquamation of the anal mucosa, swelling and inflammation of the anal folds, fissure, anal polypus, and hemorrhoids will be at once revealed. To the trained examining finger an anal ex- amination will yield valuable information. The examiner's hand should be protected by a rubber glove ; the finger should be well lubricated and introduced very slowly, and with a boring mo- tion. The irritability of the sphincter muscle, as well as its size, tonicity, and sensitiveness should be noted. After passing the external sphincter, the finger should be swept around the anal canal, palpating the crypts of Morgagni and the pillars of Glisson, to ascertain the presence of ulcers or hypertrophied papillae, small indurated areas sug- gestive of a blind internal fistula, or larger areas of induration or fluctuation indicative of peri- rectal inflammation or abscess. Unless their connective tissue is hypertro- phied, internal hemorrhoids cannot be felt. The , • j r mi 1 , 11 FlG. 162. — Examination of anus, practiced finger, will detect an unnatural dryness buttocks separated, or roughness of the mucosa, ulcers, polypi, tumors, strictures, foreign bodies, prolapse, and inflammation. Before withdrawing the finger from the rectum the coccyx should be palpated be- tween the finger and the thumb externally, moving the structure backward and forward in order to detect the presence of fracture, dislocation, or un- FiG. 163. — Tuttle's pneumatic speculum. usual sensitiveness. As the finger is withdrawn the patient is directed to bear down. This will frequently cause internal hemorrhoids to protrude from the anus, and any blood, mucus, or pus in the rectum will thus be discharged. Instrumental examination of the rectum is accomplished with the aid of certain specula. For inspecting the anus itself the bivalve speculum de- vised by Tuttle is most satisfactory. Tuttle recommends that a small iaryn- 164 GYNECOLOGY goscopic mirror be used in connection with this instrument, in order to obtain a good view of the mucosa covering the upper surface of the internal sphincter and the lower part of the rectum. For examinations of the rectum and the sigmoid flexure the tubular specula, fashioned after the instruments devised by Kelly (Fig. 164) are of most value. When they are to be used the patient should be placed in the knee-chest position (Fig. 165). With a little practice the entire length of the rectum and a part of the sigmoid flexure will be open to inspection. The pneumatic proctoscope facilitates the rectal examination, since the [65. — Examination of rectum and lower sig- moid with proctoscope. patient may assume the dorsal or Sims' position. With the longest instru- ments of this type the entire sigmoid flexure may be inspected or even the lower part of the descending colon. Ordinarily, no anaesthesia is required. This instrument gives the best and greatest degree of exposure of any form of proctoscope as yet devised. Tuttle warns the beginner that the brilliant illumination of the parts by an electric proctoscope heightens their color and may lead to false con- clusions. It is, therefore, wise, at first, to compare the findings secured by artificial light with those obtained by ordinary reflected daylight. Fogging of the window of the instrument may be prevented by heating it slightly. If the sphincter is relaxed as the air is pumped in for the purpose of inflating the canal, air may escape around the instrument ; this may be pre- EXAMINATION OF THE ANUS AND RECTUM 165 vented by applying a coil of wet cotton or gauze about the tube and press- ing it firmly against the anus. Before withdrawing the instrument the glass window should be taken off and the air be permitted to escape. Certain other instruments are useful in making anal examinations. A probe eight or ten inches long, made of pure silver, so that it can be bent in any direction without breaking, is useful in following up fistulous tracts. The instrument should have a handle that is flattened and rough on one side, so that the examiner can always determine the direction in which the end is pointing. Fig. 166. — Kelly's sigmoidoscope. An extremely fine probe is often useful in detecting blind internal fistulse, and especially in determining the presence of diseases of the crypts of Morgagni. A small scoop made of soft copper is very serviceable for re- moving hard fecal masses or for freeing the mucosa or ulcerated surfaces of discharge. It is a good plan, as a rule, to have at hand a number of appli- cators or dressing forceps by means of which the mucosa may be cleansed w xth cotton. BIBLIOGRAPHY Allingham, W. : The Diagnosis and Treatment of Diseases of the Rectum. Wood, New York, 1912. 7th ed. Earle, S. T. : Diseases of the Anus, Rectum and Sigmoid. Lippincott, Phila., 1914. Gaxt. S. G. : Diseases of the Rectum and Anus. Davis, Phila., igo6. Piersol, G. A. : Human Anatomy. Lippincott, Phila., 1907. Tuttle, J. P. : Diseases of the Anus, Rectum and Pelvic Colon. Appleton, New York, 1912. CHAPTER XI DISEASES OF THE EXTERNAL GENITALIA Cutaneous Diseases. — Erythema and superficial dermatitis may be caused by chafing, uncleanliness, leucorrhceal discharge, irritating substances in the urine, and varicose veins. The symptoms consist mainly of burning and itching. The skin of the vulva is reddened and usually moist, and the upper inner surface of the thighs may be affected coincidentally. The treatment consists in removing, so far as possible, all sources of mechanical irritation ; in rendering the urine bland and keeping the parts scrupulously clean, and in improving the circulation. Sedative remedies may be applied locally. The most effectual application consists of a 5 to 10 per cent, solution of silver nitrate, followed by zinc ointment. If the patient is excessively fat, and the moisture and perspiration are very free, a dusting powder may be em- ployed in place of the ointment. Probably the most useful combination con- sists of equal parts of tannic acid and lycopodium. Irritating soaps must be avoided. Herpes. — Herpes simplex, or so-called fever blisters or cold sores, may develop at the time of each menstrual period, and have occasionally been observed after coitus. In this condition the groups of vesicles are usually bilateral. No constitutional symptoms are present, but the patient complains of soreness and itching. The treatment of herpes consists, first, in thorough and gentle cleansing with warm water and Castile soap. The vesicles should be opened with a sterile needle and touched with a 5 to 10 per cent, solution of silver nitrate. Zinc oxide ointment or stearate of zinc in the form of a dusting powder should then be applied. Recurrent herpes of the genitalia should suggest careful inquiry into all the habits of the patient, and frequently not only extreme local cleanliness but general tonic treatment as well will be required. PARASITIC DISEASES Ringworm. — Ringworm involving the vulva or the inner surface of the upper thighs is best treated by local applications, three or four times daily, of liquor potassae chlorinatse (Javelle w T ater). Precipitated sulphur, one-half dram to one ounce of petrolatum, may also be applied. At the outset the strength of the lotion and of the ointment must be reduced. As many of these cases are aggravated by the discharges from the genitalia, vaginal douches must be employed. Mercurial ointment, ammoniated mercurial ointment, one-half dram of each to one ounce of petrolatum or cold cream, may be used, but are generally less effectual than the others mentioned. Pediculosis Pubis. — Under the microscope, the pediculus resembles a crab, hence the name " crab-louse " commonly applied to it. The finding of either the pediculus or its ova (nits) is diagnostic. The pediculus may be 166 DISEASES OF THE EXTERNAL GENITALIA 167 discovered crawling over the skin surface, in the region of the genitalia, or, as is generally the case, it may be seen as a small, blackish-brown spot at the entrance of the hair-follicle, the head of the insect being buried in the root of the hair. The nits are suspended from the hair-shaft, and are either of a shiny, pearl-white, or a dull, yellowish- white hue, if the egg is dead, hatched out, or killed. Intense itching is present, and numerous scratch- marks are seen on the pubes, the lower abdomen, and the thighs. The skin not infrequently exhibits a secondary pustular infection. The condition is best treated with an ammoniated mercurial ointment, from 30 to 40 grains to the ounce of petrolatum, or a mercury bichloride and glacial acetic acid lotion, one-quarter grain of the former and twenty minims of the latter to the ounce of water. Equal parts of alcohol, ether, and a 1 : 500 watery solution of mercury bichloride are also useful. Applications of the ointment or of the lotions should be made several times a day. Vulvar Adhesions. — Adhesions may occur between the labia majora and the labia minora, and between the glans and the clitoris and its prepuce. These adhesions are the result either of congenital blending or of desquama- tive inflammation which denudes opposed surfaces and is followed by union. A great deal of importance has been attached to these adhesions in young women, in whom they are said to be a cause of masturbation. The most common adhesions are those formed between the glans and the prepuce. They should be treated by immediate separation, the glans being peeled out of the pre- puce by means of a probe or a grooved director, the parts being dressed antiseptically until they have healed over without reuniting. It is prob- able that the importance of the condition has been somewhat exaggerated, but since a cure is so easily effected, it should never be neglected. Vulvitis. — In the young, vulvitis is caused by epidemic gonorrheal in- fection, as seen in children's homes and hospitals, or by gonorrhceal infec- tion conveyed by the mother or the nurse, or through the medium of infected napkins, towels, etc. Thread-worms and uncleanliness may be etiologic factors in the vulvitis of children. In adults the condition may be produced by repeated gonorrhceal infection, more or less constant contact of the parts wdth gonorrhceal pus, irritating discharges from a vesical fistula or an ulcerating carcinoma, diabetic urine, too frequent sexual intercourse, or masturbation. Streptococcus or diphtheritic infection of the vulva may occur in women during the puerperium. The rectal discharge in typhus fever and in dysentery may set up a vulvitis. The symptoms are a sense of fullness in the affected parts, discomfort, and burning and itching. A profuse irritating discharge is present. All the symptoms are aggravated by walking. The vulva is covered with a mucopurulent or a purulent discharge. The vulvar surface is seen to be swollen, reddened, and cedematous. In the gonorrhceal vulvitis of children, the vagina is, as a rule, affected coincident- ally. In adults the urethra and the vulvovaginal glands, and often the cervix as well, are involved. The sebaceous glands of the labia majora and the labia minora may be particularly involved, the lesions resembling those of acne (follicular vulvitis), and the vulvar mucosa between the follicles presenting a normal, or at most but a slightly reddened appearance. To 168 GYNECOLOGY determine the nature of the infection, smears and cultures should be made from the surface of the vulva, the vulvovaginal glands, and Skene's tubules. An infection in the adult involving simultaneously Skene's tubules, the vul- vovaginal glands, and the cervix is almost always gonorrheal in nature. In the non-infectious forms, cleanliness is the most important factor in the treatment. This may be maintained by means of a vulvar douche of sodium bicarbonate and sterile water (one dram to a pint), repeated several times a day. Cleanliness combined with appropriate treat- ment for the provocative lesions will often effect a cure. Thread-worms, diabetic urine, and irritating discharges from the rectum or vagina should be dealt with as will be described under the treatment of pruritus, page 170. When the inflammation is the result of a Neisserian or other infection, the vulva should be kept clean by repeated vulvar douches of mercury bichloride 1 : 4000, or lysol 0.5 to 1 per cent. Once or twice a day, after the antiseptic douche, the parts may be washed with sterile water, carefully dried with cotton, and painted with a 25 per cent, watery solution of argyrol or a weak solution (1 to 5 per cent.) of silver nitrate. Vaginal douches must be avoided unless the cervix is involved. When there is a severe itching or burning, hot applications of lead water and laudanum or of witch-hazel should be made. As the symptoms subside 1 per cent, of powdered burnt alum may be added to the hot applications, if their use has been found necessary, or an astringent vulvar douche of zinc sulphate and alum in water (15 grains of each to 1 pint of water) may be substituted. General measures, such as rest in bed, saline laxatives, and refrigerant diuretics, are important. The vulvar cleft should be filled with gauze or cotton, to catch the discharge and keep the inflamed surfaces apart. When there is no longer severe burning or tenderness, a stronger germicidal solu- tion, such as silver nitrate, 5 to 10 per cent., may be applied directly to the vulva. The opposed surfaces of the vulva should be kept separated, and protected either with plain or carbolized zinc oxide ointment, or with a dusting powder consisting of equal parts of calomel and bismuth, or of equal parts of tannic acid and lycopodium. Following gonorrhceal vulvitis infection is likely to remain in Bartholin's glands, and special attention should be given them. By means of a blunt hypodermic needle, 25 per cent, ichthyol or 25 per cent, argyrol should be in- jected into their ducts. Should the disease persist in spite of treatment, the glands must be laid open freely and cauterized with phenol or a hot silver probe, or dissected out entirely. For itching, the following lotion may be used : $. Phenolis 3j Glycerini f 3ij Alcoholis f 3ij Aq. rosae q. s. f Siv Or the following calamine lotion may be used : R . Calamini 3iy Zinc, oxidi 3iiss Aq. calcis, Aq. rosae • aa f 3x. DISEASES OF THE EXTERNAL GENITALIA 169 The therapy of gonorrheal vulvovaginitis in infants and young children is difficult to carry out. The child is usually terrified by any attempt at treatment, and the parts are so small and inaccessible that many mechani- cal difficulties are presented. If the disease is confined to the vulva, the task is less formidable, as it is limited to external applications. When the vagina also is involved — and this is usually the case — the best plan of local treatment is to administer copious douches to the vagina, carried out by means of a small, soft-rubber catheter, using a gallon of warm salt or boric acid solution (i dram to 2 pints of water) at each application. The douche should be given by the mother or nurse as often as two or three times a day, being careful to avoid traumatism and endeavoring to gain the child's confidence. Every two or three days the cleansing douche may be supplemented by a douche of silver nitrate (1 quart) 1 : 1000, followed by salt solution. The keynote of the treatment is the maintenance of absolute cleanliness plus occasional douching with an antiseptic solution. Instead of silver nitrate, ichthyol (5 per cent.) may be used, or the vagina may be flooded with argyrol solution (10 per cent.) applied by means of a soft-rubber ear syringe. The treatment of vulvovaginitis is often unsuccessful because it is in- adequately carried out. The affected parts must be kept clean and free from discharge, just as in the treatment of gonococcus conjunctivitis. If a watery solution shows signs of being irritating, the antiseptic (ichthyol, argyrol) may be combined with glycerine or mineral oil. If gonorrheal vaccines were effectual, this would be an ideal method of treating the vulvovaginitis of children. The results are, however, only fairly satisfactory, but if the case is resistant to local treatment, vaccines should be tried. Hamilton has obtained 85 per cent, of cures with vaccines, as com- pared with 60 per cent, of cures effected by irrigations. He used stock vac- cines, beginning with a dose of 50 million every five days, increasing the dose by 10 million at each injection. With larger doses — over 100 million — the injection is made at ten-day intervals. In acute cases six injections sufficed. Hamilton regards a case as cured when the smears are negative for gonococci for four successive weekly examinations, and for two additional examinations at intervals of two weeks. The average time necessary to obtain a cure in eighty-four cases treated by vaccines was a little less than two months. If there are other children in the same house or institution, complete isolation is advisable. The infected child should have its own individual nursing bottles, napkins, etc. No tub-baths should be given, and the cotton or gauze used in the treatment should be burned. Gangrene. — Gangrene of the vulva is the result of infection with the diphtheria bacillus or the streptococcus. It occurs in weakly children or in parturient women during the course of a prolonged septic condition. It is most prone to follow in the wake of contusions, cedema, or extravasations of blood. The parts should be left undisturbed as far as is compatible with cleanliness. The general treatment is of the greatest importance. Diph- theria antitoxin or antistreptococcic serum should be prescribed. Pruritus Vulvas. — Pruritus, or itching of the vulva, may be produced 170 GYNECOLOGY by an excess of certain substances in the blood, such as bile, uric acid, urea, sugar, morphine, alcohol, or iodine. It may also occur as the result of congestion or stasis of the blood-vessels of the vulva, as seen in heart disease, pregnancy, retroversion of the uterus, or uterine tumors. It may be a symptom in skin diseases, such as erythema, urticaria, herpes, eczema, and trichiasis. In carcinoma of the vulva it is an early symptom. Among the other etiologic factors are : Irritating discharges, such as hyper- idrosis, diabetic or ammoniacal urine, the leucorrhcea of gonorrhceal infec- tion of the cervix or the endometrium, carcinoma of the uterus, or decomposing fibroid tumor; rectal discharge, as in purulent and catarrhal inflamma- tions; parasites, e.g., pediculi, oxyuris vermicularis, and the leptothrix, leptomitus, and oidium albicans; heat (pruritus aestivalis) and cold (pruritus hiemalis) ; masturbation. The itching of the vulva may be intense ; it becomes worse at night, and under the influence of warmth and exercise ; it is exaggerated also during pregnancy and at the menstrual periods. Because of an uncontrollable desire to scratch the patient avoids society and becomes depressed and nervous. Relief may be sought in drugs. An examination of the vulvar surface usually discloses one of the local conditions just noted. Scratch-marks may be present. In old cases there is considerable thickening of the vulvar skin, which becomes leathery, and presents a dead white surface, broken here and there by the excoriations made by the patient's finger-nails. Urinalysis may disclose the presence of sugar, bile, or an excess of uric acid. In every case of pruritus it is very important to determine the underlying lesion. In the few instances in which none of the causes previously mentioned are found, the disease may be regarded as a pure neurosis. The treatment of a particular case of pruritus is largely governed by the cause that produced it. Whatever method may be selected to relieve the immediate suffering, the general health should be investigated, and such disorders as diabetes and heart disease should be actively treated. Locally the parts should be kept absolutely clean, and a sedative oint- ment, powder, or wash applied. If the symptoms are caused by pediculi, a solution of mercury bichloride (i : 500), in equal parts of alcohol, water, and ether or mercurial ointment will give good results. Pruritus due to the itch insect may be treated with sulphur ointment (U. S. P.) or betanaphthol (35 grains to 1 ounce of lanolin). Pruritus due to pin-worms will yield to rectal irrigations with an infu- sion of quassia (1 ounce to 1 pint of water), and to the fluidextract of senna and spigelia (^ to 1 fluiddram) every four hours until a purgative effect is produced. Pruritus caused by trichiasis, that is, the growth of short and stiff in- verted hairs, should be treated by extracting the hairs with suitable forceps, or their growth should be stopped by electrolysis. If an irritating discharge is present, a vaginal douche (sodium bicar- bonate and sodium biborate, of each, a half ounce to a gallon of warm water) should be administered two or three times a dav, after which the vulva DISEASES OF THE EXTERNAL GENITALIA 171 should be thoroughly dried and the vagina packed with tampons, so as to absorb any discharge that may come from the upper genital tract. If the urine is highly concentrated, potassium citrate, in full dose, with an abundance of water, should be given ; if the urine contains pus, sodium benzoate and hexamethylenamine, of each, 5 to 10 grains every three hours, combined with such measures as are necessary for the pus-producing lesions, will be efficacious. Rectal discharges should be controlled by frequent irrigation of the rectum with normal saline solution, followed by the injection of two ounces of a 25 per cent, solution of argyrol, or of a 2 to 5 per cent, solution of silver nitrate. If the discharge comes from a lesion situated far above the anus, high irrigation of the colon and the exhibition of intestinal antiseptics must be practised. After thorough cleansing of the vulva nothing is more soothing than the application of silver nitrate, 5 to 15 per cent., followed by the ordinary zinc ointment of the pharmacopoeia (5 pe 1 ' cent, of phenol sometimes increases its efficiency), or a dusting powder of zinc oxide and zinc stearate may be used. Irritated surfaces must be kept apart by the interposition of cotton. In very severe cases a strong solution of cocaine (20 per cent.) may be used, or a dusting powder of morphine (1 grain) and prepared chalk (2 grains) may be rubbed in daily ; or, better still, the patient should be kept in bed and hot applications of lead water and laudanum be made. Combinations almost innumerable have been devised to relieve the itch- ing. In obstinate cases various preparations may be tried in the hope of finding one that will be successful. Small obtained the best results from turpentine and unguentum petrolatum (1 to 2). Montgomery recommends equal parts of alum and sugar, also chloroform in glycerin (1 to 8), or hydro- cyanic acid 2 or 3 drops to the ounce of water, or 10 per cent, guaiacol in vaseline. Hirst mentions the infusion of tobacco, vinegar, vaginal supposi- tories of ichthyol and glycerin, the subcutaneous injection of normal salt solution (1 to 3 liters), the Rontgen ray, faradism, and the rapid interrupted gal- vanic and the high-frequency static current. Penrose speaks of equal parts of prepared chalk and bismuth subnitrate, or a mixture of corrosive sublimate (y 2 grain) and emulsion of bitter almonds (1 ounce). Monk states that Goulard's extract, menthol, and chloral ointment (5 to 10 per cent.) may be effectual. He also prescribes Hofmeister's emulsion : R. Potassii bromidi 3ij Lupulini 3ij Hydrargyri chloridi mitis 3x Ol. olivse f 3 xx Dudley employs pure phenol or pure ichthyol and an ethereal solution of iodoform. Noble asserts that nothing relieves the itching of a dermatitis better than black wash and bismuth. When pruritus is a symptom of a primarily cutaneous lesion of the vulva, the disease, whether it be eczema, intertrigo, or some other skin affection, requires the same treatment as when it occurs elsewhere in the body. In some cases pruritus cannot be ascribed to any demonstrable affection, and it may then be regarded as a neurosis and treated accordingly. 172 GYNECOLOGY In many instances the diet will require regulation. The patient should avoid highly seasoned or nitrogenous food, as well as the prolonged use of or addiction to certain drugs, such as morphine, quinine, and iodine. Alco- hol must also be forbidden. Hyperesthesia of the Vulva. (See Vaginismus, page 194.) Fig. 167. — Elephantiasis of vulva, (After Allbutt, Playfair and Eden.) (McMillan & Co. Ltd.) Kraurosis vulvae is a rare condition, characterized by atrophy and shrink- age of the vulvar parts. It is usually preceded by obstinate pruritus. Its most common symptoms are intense itching and interference with sexual intercourse. Treatment is usually of no permanent benefit. Relief from pain and pruritus may be obtained by the use of local applications (see Pruritus). Gradual dilatation of the vaginal orifice or surgical measures to relieve the contractions are usuallv inadvisable. DISEASES OF THE EXTERNAL GENITALIA 173 Elephantiasis of the Vulva. — Elephantiasis is a condition of brawny oedema and hypertrophy (Fig. 167). The lesion is due to a lymphatic obstruc- tion which may be caused by syphilis or the filaria sanguinis hominis. There are usually secondary infection and inflammation of an erysipelatous type. Occasionally an erysipelatous inflammation (streptococcus erysipe- latis dermatitis) appears to be the primary lesion. Uncleanliness predis- poses to the disease. The symptoms are due to mechanical irritation, and are most evident in walking and during sexual intercourse. The labia majora and minora are hypertrophied, pigmented, indurated, and oedematous. Fig. 168. — Chancre of vaginal introitus. (University Hospital.) Excoriations or warty outgrowths may appear upon the surface of the vulva. An offensive serous discharge is present. The treatment is more or less unsatisfactory, unless the disease is dis- tinctly confined to the vulva. When the latter is the case, the hypertrophied parts may be excised with as wide a margin as possible and the wound closed by plastic repair. If operation is not undertaken scrupulous cleanliness and the use of a dusting powder or a sedative ointment may help to make the patient more comfortable. Venereal Sores. — The appearance of venereal lesions in the female differs somewhat from that in the male. Neither the chancre nor the chancroid is so constant in form. Each may be modified by the personal cleanliness of the woman and by her habits. Associated with the venereal 174 GYNECOLOGY lesion, not infrequently there are oedema and induration of the labia majora produced by bruising of the vulvar parts during coitus and the use of strong disinfecting solutions. Chancre. — Chancre of the vulva is so rarely observed that exact infor- mation as to its appearance is lacking. For that reason, all cases should be described minutely and note made of variations in form. The primary sore in women may be considerably modified by the personal cleanliness of the woman and her habits. The most frequent seat of chancre, it is said, is the labia majora ; the fourchette, nymphse, clitoris, and mons veneris being next in frequency in the order named. On a skin surface as, e.g., the labia majora, induration develops in about a week and is usually parchment- like. On modified skin surfaces, " near " mucous membranes, in- duration may be absent. The pri- mary sore is smaller and clears up more rapidly in women than in men. The chancre usually appears as a superficial round or oval ero- sion, having a dusky red areola, and a purplish raw surface, in the center of which there is a gray false membrane that discharges a small quantity of sero-sanguine- ous fluid (Fig. 168). The chancre often takes the form of an indurated papule. It consists of a hard, elevated, dusky red tubercle, sharply defined from the surrounding tissues, having a dry surface whose height is fre- quently augmented by layers of exfoliated epithelium. The chancre may be deep enough to involve the true skin or even the subcutaneous tissues (Fig. 169), and in such cases a chancrous ulcer may form ; the latter may be superficial or deep, with sloping edges and covered with a gray false membrane and a sero-sanguineous discharge. The primary sore in women probably occurs more often on the cervix than is usually believed. The diagnosis is confirmed by identification of the treponema pallidum in suitably stained preparations, or by means of fresh smears examined by the dark-field microscope. The Wassermann re- action is always indicated in genital lesions as an aid in diagnosis. Secondary syphilitic lesions of the vulva are seen somewhat frequently. A papular syphilide developing upon the vulva soon exhibits an abraded and secreting surface, and may be partly or completely covered by a gray, FlG. 169.— Gumma of vulva, with secondary infection and ulceration. (Philadelphia Hospital.) FlG. 170. — Condylomata lata, secondary syphilis, surrounding vulva. (After Power and Murphy.) (Courtesy Potter & Stoughton.) DISEASES OF THE EXTERNAL GENITALIA 175 adherent, offensive pseudomembrane. This is known as a mucous patch. Sometimes the moist papule takes on a distinct papillary overgrowth (con- dyloma). Condylomata (Figs. 170 and 171) appear as elevated, flat, raw surfaces. The cellular infiltration is so abundant that the papillary nature of the growth is but imperfectly manifested, and can be observed only on careful inspection. When the mucous patch preceding the condyloma has developed from a large papular syphilide, the elevated surface varies in size from that of a shirt-button to a penny. Tertiary syphilitic lesions of the vulva are rare, and usually manifest themselves in the form of gumma of the labia majora (Fig. 175). The lesion Fig. 171. — Condylomata lata of the vulva and anus; on the latter they pre- sent a papillomatous or vegetative appearance. (After Taylor.) C Courtesy Lea & Febiger.) shows a tendency to break down and suppurate, producing serpiginous ulcers with grayish, ragged floors. The Treatment of Syphilitic Eruptions. — In these eruptions the general treatment is of the utmost importance, but will not be discussed here. No local treatment for chancre is absolutely necessary ; if the surface is hard and indurated and fairly dry, it may be protected with a mild ointment of ammoniated mercury (20 grains to 1 ounce of zinc oxide ointment) ; if the surface is moist, it may be bathed with 1 : 4000 bichloride solution and dusted with equal parts of acetanilide, boric acid, and calomel. The patient should, of course, be warned of the contagious nature of the infection. Mucous patches and condylomata should be painted with silver nitrate (5 to 10 per. 176 GYNECOLOGY cent.) and dusted with iodoform, aristol, or bismuth subiodide. One of the best local applications for condylomata is the following: R. Hydrarg. chloridi mitis gr. xl Ac. salicyl gr. x Ac. boric gr. xxx Pulv. alum, ex 5j. For tertiary syphilitic lesions a mild germicidal protective, consisting of either calomel or ammoniated mercury (20 grains to 1 ounce of boric acid ointment) may be applied several times daily. Fig. 172. — Syphilis (secondary) of the vulva and anus. (Philadelphia Hospital,) Chancroid. — Chancroids of the vulva usually affect the area immediately surrounding the vaginal orifice, but they may also occur upon the cervix. Chancroids in women are usually more extensive than in men. The ulcera- tions present a punched-out appearance, and the edges are undermined (Fig. 176). Secondary infections are quite common, and may be repeated indefinitely unless careful preventive measures are taken. DISEASES OF THE EXTERNAL GENITALIA 177 A chancroidal ulceration of a chancre may occur, or the chancroid and the syphilitic infection may occur coincidentally, the lesion of the first dis- appearing before the second one develops. When the lesions are combined, they may be indistinguishable, the only indication pointing to a chancre being the induration. Treatment of Chancroid. — Chancroidal ulcers should be immediately cauterized with nitric acid, acid nitrate of mercury, or phenol. When the lesions are small, the previous application of cocaine may be sufficient to : Fig. 173. — Syphilis (secondary) of the vulva and anus. (Philadelphia Hospital.) relieve pain. In extensive cases, or when the patient is nervous, nitrous oxide or a general anaesthetic must be employed. After cauterization the parts should be washed with a 1 : 2000 bichloride solution and a dusting powder of iodoform applied. The odor of iodoform may be disguised or kept at a minimum by carefully limiting its application to the ulcerating surfaces, or by mixing it with equal parts of powdered roasted coffee, or with 4 minims of the oil of peppermint or the oil of rose to 1 ounce of the powder. Aristol or iodol, or the preparation suggested by Knowles (calomel, 20 to 40 grains; salicylic acid, 10 to 20 grains; zinc oxide, 30 grains; and talcum, 1 ounce) may be used if it is found inexpedient to use the iodoform. The dressing should 12 178 GYNECOLOGY be repeated several times a day, and the vulvar cleft kept packed with a layer of absorbent cotton held in place by a T-bandage. After healthy granulations have appeared, a powder consisting of equal parts of acetanilide, boric acid, and calomel may be used. If the discharge is profuse, powdered tannin may be added to the dusting powder in the pro- portion of i to 4. If the granulations are exuberant, the solid stick or a strong solution of silver should be employed. In serpiginous cases, prolonged sitz-baths, a wash of nitric acid (1 dram) and water (1 pint), or hot compresses of bichloride solution (1 : 5000) or of lead- water and laudanum, may be used. After healthy granulations have appeared in extensive cases, a stimulating solution of the balsam of Peru and water (1 to 8) will be fo-und advantageous. Throughout the treatment emphasis should be laid upon the importance of observing scrupulous cleanliness by the use of soap and water. The general condition of the patient should receive careful attention. In these cases iron, quinine, and strych- nine, and cod-liver oil are often of service. At the first appearance of the symptoms of bubo the patient should be confined to bed and an ice-bag applied to the affected groin. If the pa- tient must be about, an oint- ment made of equal parts of ichthyol, mercury, belladonna, and iodine should be applied to the affected region. A snug bandage should be so placed as to exert firm, equable pressure upon the in- flamed gland. If suppuration is imminent, the entire gland should be extir- pated without rupture and the incision closed. If enucleation of the gland is not feasible, it should be incised, curetted, swabbed with pure phenol, and drained. Venereal Warts (Condylomata Acuminata). — Venereal warts result from uncleanliness or from the irritation produced by gonorrheal discharges. They are also associated at times with secondary syphilitic lesions. Venereal warts appear in the form of papillary excrescences, either as a single discrete group or as a coalescent, cauliflower-like mass (Fig. 177). They may occur on the vulva, mons veneris, perineum, or anus, and are also occasionally found in the vaginal vault and upon the cervix. In the pregnant they grow rapidly. They usually present a purplish-red color. The surface is moist, and divided into small projections that have pointed ends (condylomata acuminata). Fig. 174. — Syphilis (secondary) of the vulva and anus delphia Hospital.) (Phila- DISEASES OF THE EXTERNAL GENITALIA 179 The symptoms range between actual discomfort and pain. Usually they simply interfere mechanically with walking or with intercourse, but when inflamed, they become painful, and at times give off a thin and highly irritating discharge. The treatment is based on the observance of absolute cleanliness and the application of antiseptics. If the patient is syphilitic, general treatment is required. The parts should be washed frequently with bichloride (i : 2000), followed by normal salt solution. After drying, a dusting powder of equal parts of tannic acid and lycopodium, or boric acid, 20 to 40 grains, calomel, 15 to 20 grains, calcium, 1 dram, may be found useful. / Fig. 175.—- -Gumma of the vulva, tertiary syphilis. (Philadelphia Hospital.) Small outgrowths may be destroyed by nitric, chromic, or acetic acids or pure formalin. Before applying these remedies the surrounding skin must be protected with vaseline. The acids or the formalin should be applied with a glass pencil. Larger masses should be excised, and the wound closed with silkworm-gut sutures. Individual warts may at times be removed by ligation with fine silk or by freezing with a spray of ethyl chloride. Associated or provocative diseases, such as syphilis, gonorrhoea, and elephantiasis, must receive suitable attention. (Edema of the vulva occurs as the result of intrapelvic pressure from the head of the foetus, tumors, pelvic exudates, and infiltrations. It may be unilateral or bilateral, the latter being most frequently the case. It may also be part of a general oedema due to heart, kidney, or liver disease. CEdema of the vulva may be a precursor of elephantiasis, especially if the latter is also present in the lower extremities. When oedema is of long duration, hyper- trophy of the cutaneous papillae, with the formation of wart-like excrescences, 180 GYNECOLOGY occurs. If the cause is evident, the indications are plain : The removal of pelvic tumors, the absorption of pelvic exudates, the stimulation of a fail- ing heart, and of impaired renal or hepatic function. Varicose Veins of the Vulva. — Pregnancy, pelvic exudates, pelvic tumors, retroposition of the uterus with adhesions, straining at stool, prolonged standing, heavy work, and circulatory weakness are among the causes of this condition. Varicosities are usually found in the labia majora, but other parts, including the vagina, may be involved. The patient complains of itching and burning or of a sense of discom- fort or weight. An elongated, knotty, bluish enlargement, made up of dilated and tortuous veins, is pres- ent. Upon palpation the mass re- sembles a bag of earth-worms (Fig. 178). The condition ranges from a slight distention of the vulvar veins to a tumor as large as the foetal head. The underlying or causative lesion must, if possible, be corrected. If operation is inexpedient, the enlarged veins should be supported by means of a vulvar pad. In some cases relief can be obtained only by excision. During pregnancy the patient should assume the recumbent position as fre- quently as possible. Haematoma of the vulva is caused by the subcutaneous rupturing of varicose veins from increased tension during pregnancy or labor, or as the result of direct trauma, as by a fall or a blow. It is usually unilateral (Fig. 179). The symptoms consist of sudden pain in the affected part, with rectal or vesical tenesmus. Later there is also a feeling of fullness, and if suppuration occurs, as is likely after labor, the symptoms of abscess appear. Examination discloses a purplish, globular tumor that may be as large as the foetal head. It is tense and elastic at first, but later, as the fluid is absorbed, it becomes doughy to the touch. During the period of active bleeding, treatment consists of rest in bed and the application of an ice-bag or a firm compress. Later hot fomenta- tions may effect the absorption of the extravasated blood. If the haematoma persists, or if suppuration seems imminent or has occurred, a free incision should be made and the cavity packed with gauze and allowed to heal by granulation. Hypertrophy of the vulva, in part or as a whole, may be a congenital or an acquired lesion. It may accompany or follow oedema, and may constitute a form of elephantiasis. It is said to affect the labia minora, par- FiG. 176. — Chancroid. DISEASES OF THE EXTERNAL GENITALIA 181 ticularly in patients who practice masturbation. When the latter struc- tures alone are involved, especially if unusual pigmentation also exists, masturbation may be suspected. A colossal hypertrophy of the nymphae is observed in some orientals, the Hottentots, and the Bushmen. This condi- tion is known as the Hottentot apron. Carcinoma of the Vulva. — Primary carcinoma is usually of the squamous type — epithelioma (Fig. 180). It may be preceded by kraurosis, leuco- plakia vulvae, papillomata, or some form of trauma, or there may be no prior lesion. Secondary carci- noma of the vulva results from a malignant growth higher in the genital tract, and may be of the cylin- dric-cell variety (adeno- carcinoma). The growth begins in the sulcus be- tween the labium majus and the nymphae, upon the clitoris, or in the peri- urethral mucosa of the vestibule. It occurs with great frequency between the ages of sixty and seventy years, and is rarely seen in the young. (In 331 cases collected by Rothschild, only 11 were under thirty-one years.) The affection first ap- pears as a small, indur- a t e d, elevated nodule. Later inflammation and superficial ulceration occur. The surface is elevated and granular, and the adjacent tissues become thickened and indurated. The oppos- ing surfaces of the vulva may develop a carcinomatous growth as the result of contact. Pruritus is the most common early symptom, but is not characteristic of the disease. Early subjective symptoms may be absent. Later, when infection has occurred, pain is more or less constant. At about this time the inguinal or femoral (or both) glands on the affected side become enlarged ; in some cases this occurs much earlier. There is a serous, offensive discharge, and slight hemorrhage is observable. After the growth becomes extensive and ulceration has occurred the symptoms are all intensified and general ill-health and cachexia supervene. jH s FlG. 177. — Venereal warts. 182 GYNECOLOGY It is important to make a diagnosis of the condition in its earliest stage. To this end any suspected lesion should be immediately excised and subjected to microscopic examination. It is to be differentiated from lupus, which appears at an earlier age, progresses very slowly, and causes but little pain (Fig. 181). Instead of single, hard nodules, as in carcinoma, there are multiple soft growths. In lupus the discharge is not putrid, the ulceration tends to undergo cicatrization, healthy skin is frequently found between neighboring lesions, and the inguinal glands are not, as a rule, involved. FlG. 178, — Varicose veins of the vulva. (Kelly and Aoble's Operative Gynecology. W. B. Saunders Co.) The first step in the way of treatment in early cases consists of opera- tion. The carcinomatous area should be excised en bloc with the neighbor- ing lymphatic glands, a wide margin of healthy tissue being allowed to remain. The wound should be closed by flaps from the adjacent skin areas. If there is the least suspicion of enlargement, or in any case in which the disease is advanced or has existed for some time, the inguinal glands on both sides must be removed. In advanced cases, dissection of the entire super- ficial and deep inguinal and femoral lymphatic chain, by the method of Basset, as recommended by Taussig, should be adopted. The latter does this on both sides, as the first one of a two-stage operation. Two weeks later he performs excision of the vulvar tumor with the cautery knife. In DISEASES OF THE EXTERNAL GENITALIA 183 very old patients, and when surgical interference is dangerous, the Rontgen ray and radium may be used. When operation is undertaken in greatly advanced cases, supplementary treatment with the Rontgen ray or radium may be of value. (See Chapter XL.) Sarcoma of the vulva usually affects the labia majora. It begins as a hard, round nodule that is brown or black in color (Fig. 182). It grows Fig. 179. — Hematoma of vulva, occupying left labium majus and ex- tending downward to perineum. Patient fell astraddle a chair. (Kelly's Operative Gynecology. D. Appleton & Co.) rapidly and ulceration and involvement of the inguinal glands occur late. The disease is usually fatal. Death results from metastasis by way of the veins. The diagnosis can be made only from the microscopic findings. Early excision of the affected area and radium offer the only hope of cure. Tuberculosis of the vulva (lupus) is a rare condition. It occurs often before puberty, but more frequently between twenty and forty, and occa- sionally later in life. The lesion is produced by the tubercle bacillus, and is practically always secondary to genital tuberculosis higher up or to pul- 184 GYNECOLOGY monary tuberculosis. Early in the disease nodules, varying in size from a pinhead to a bean, are seen embedded rather deeply in the skin. They present a red, brown, or a yellow-red color. Later they enlarge and undergo cheesy or colloid degeneration. Finally ulceration takes place. The ulcers are soft and usually superficial in nature, but they may be deep, causing fistulous communications between the vagina and the surrounding parts. The ulcerated areas are the seat of bright red granulations, bleed easily, and are covered with pus which does not have an offensive odor. Cicatriza- tion occurs irregularly, and may produce stricture or stenosis of the urethra, vagina, or rectum. There is little pain, and the growth is very slow. I FlG. 180. — Epithelioma of vulva, indurated fungoid ulcer. . (Carnett from Martin.) (Courtesy Lea & Febiger.) The diseased area should be cauterized thoroughly, and then excised, leaving a wide margin of healthy tissue. The Finsen rays and cauterization with caustic potash or a paste of pyrogallol (40 per cent.) may be of benefit in some cases. Rodent ulcer is a term applied to a particular form of chronic ulceration of the vulva. It occurs especially in prostitutes, and syphilis seems to be a predisposing factor, although its active syphilitic nature is denied. In twenty cases observed by Fisichella during a period of six years, the Was- sermann reaction was positive in all. The etiology and identity of this disease are somewhat shrouded in doubt, but the clinical pathologic picture described may be designated as rodent ulcer, esthiom'ene, etc. The disease DISEASES OF THE EXTERNAL GENITALIA 185 is regarded by some as identical with lupus or tuberculosis of the vulva, and in some cases tubercles have been demonstrated in the ulcers. Such in- stances are, however, regarded as secondary infections, since, as a rule, no specific elements of any kind can be found in the ulcerated areas. The underlying cause of the lesion is believed to be a blocking of the lymph-channels of the vulva following extirpation or inflammation of the inguinal nodes. The connective tissue about the ulcerated areas is frequently hypertrophied and cedematous. The ulceration usually begins about the FlG. 181. — Lupus of vulva, a pre-ulcerative or infiltrative stage. (After Bender.) fossa navicularis, and extends by a serpiginous course to the lateral walls of the vagina, urethra, labia, and rectum, producing, often in the later stages, fistulous tracts. The parts should be kept scrupulously clean. The general health should be improved. Ulcers and fistulous tracts should be cauterized with nitric acid or the actual cautery at a dull red heat. Antisyphilitic or mixed treat- ment should be prescribed, and in some cases of supposed rodent ulcer has been of marked benefit. In three cases observed by Fisichella salvarsan effected a rapid cure. In rebellious cases radium may be tried. Fibromyoma of the vulva affects by preference the labia majora, and presents the same structural features as fibromyoma elsewhere in the body. 186 GYNECOLOGY The symptoms are the result of mechanical interference. The condition is ext: emely rare (Fig. 183). The tumor should be removed by operation, and the wound closed by plastic repair. Lipoma of the vulva is most often situated in the labia majora or on the mons veneris, and resembles lipomatous tumors found in other parts (Fig. 184). Excision of the growth with plastic repair is indicated. Sebaceous cysts may form in the larger and smaller labia. They appear as small, yellowish elevations. The treatment consists of excision. The Vulvovaginal Glands — Inflammation of the Ducts and Abscess. — Inflammation of the ducts of the vulvovaginal glands is usually of gonor- rhoeal origin, but it may be due to other infections, notably of the colon bacillus and the tubercle bacillus, ex- tending from the surface. Tuberculous vulvovaginal abscess is not infrequently observed in phthisis. In gonorrhceal inflammation of the duct the orifice is sur- rounded by a red, slightly elevated spot, known as the gonorrhceal macule. Pres- sure over the course of the duct will express a drop of pus. Inflammation of the ducts of the vulvovaginal glands may lead to the for- mation of a retention cyst or to an extension of the infec- tion to the gland substance, with the production of an abscess. Abscess of the vul- vovaginal gland is mani- fested by severe pain and marked swelling and oedema of the surrounding parts. The swelling may extend even to the anus. Fluctuation appears first upon the inner surface of the labium, and, if the pus is not evacuated by incision, it finally makes its way through several fistulous openings below the orifice of the duct. These openings may keep on discharging indefinitely. The treatment of an infection of the ducts of the vulvovaginal glands consists in keeping the duct patulous and in injecting an antiseptic solution by means of a blunt hypodermic needle. Before introducing the needle, all the pus should be expressed from the gland and the orifice wiped clean. The needle should then be passed gently as far as it will go, and the solu- tion injected, the needle being held in position for a few seconds and the duct compressed about the barrel. As a rule, only one or two drops can be FlG. 182. — Sarcoma of left labium minus (Hirst's Obstetrics. W. B. Saunders Co.) Fig. 183. — Fibromyoma of vulva, (After Collyer.) American Journal of Obstetrics. DISEASES OF THE EXTERNAL GENITALIA 187 injected. This treatment should be repeated daily. Pure ichthyol (25 per cent.), solution of argyrol, or 5 per cent, silver nitrate may be used. If the treatment is not successful, the duct of the gland should be laid open freely and cauterized, or the duct and the entire gland should be dissected out. In the early stage an abscess of the vulvovaginal gland (Fig. 185) may be treated by means of hot fomentations. As soon as fluctuation appears, a free incision should be made and the entire cavity swabbed out with pure phenol and the cavity packed with gauze and allowed to heal by gran- ulation. When there is a tendency for these abscesses to recur, the . glands should be totally excised. Cyst of the vulvovaginal glands either occurs as the result of an occlusion of the duct by an inflammatory process, or is due to a thickening of the glandular secretion. The symptoms of vul- vovaginal cysts are usually the result of mechanical interference with sitting, walking, or sexual intercourse. Vulvovaginal cysts vary in size from a walnut to a child's head. When they reach the dimensions of an egg or even larger, the mucosa to the inner side of the labium, overlying the surface of the cyst, is consider- ably thinned. The cyst contents are clear and colorless, or may be yellow or a turbid chocolate color from admixture with blood. Vulvovaginal cysts must be dis- tinguished from inguinal hernia, ■ hydrocele of the canal of Nuck, and cysts of old hernia sacs. In these conditions the enlargement is situated more to the upper and outer part of the labium majus, and is connected with the exter- nal inguinal ring. Vulvovaginal cysts should be excised. This is best done while the tumor is small, since in advanced cases the vulvar mucosa becomes so thin and attenuated, and the cyst so deeply attached that considerable dissection is necessary to effect its removal, and the wound may have to be packed and allowed to granulate. This is due to the fact that the flaps of thinned-out mucosa are poorly supplied with blood and show a tendency to slough. If, for any reason, excision of the gland is not feasible, a free in- FlG. 184. — Lipoma of right labium majus. 188 GYNECOLOGY cision may be made, and as much of the gland wall as possible cut away with scissors, the interior swabbed with pure phenol, packed with gauze, and allowed to heal by granulation. Injuries of the External Genitalia. — The vulva is often the seat of in- jury and violence. It may be injured as the result of a fall astride a fence, the edge of a bath-tub, the arm of a chair, or the frame of a bicycle ; it may be lacerated by a fall upon some protruding object, such as the paling of a fence or the handle of a rake, or by sitting upon a knife, a pair of scissors, Fig. 185. — Abscess of left vulvovaginal gland. Kelly's Operative Gynecology (D. Appleton & Co.). or a crochet-hook. The vulva may be seriously bruised and lacerated by the horns of a cow or as the result of a kick, or by violence inflicted during coitus. Insane persons sometimes mutilate the vulvar region. The wounds may be incised, lacerated, contused, or punctured. Such injuries are accom- panied by the usual symptoms of pain and hemorrhage. The latter is fre- quently profuse, owing to the vascularity of the parts affected. It may be partly or entirely concealed, forming a hematoma that appears as a dark, bluish-red mass, occupying the greater labium or the vaginal wall. Injury during the first coitus sometimes produces alarming hemorrhage. DISEASES OF THE EXTERNAL GENITALIA 189 The rape of young girls or infants by adults may result in injury or laceration of the vagina and perineum, or even in a tear of the rectovaginal septum or the sphincter. Bilateral splitting of the urethra as far up as the bladder, with the production of a vesico-urethrovaginal fistula, also a rupture of the posterior vaginal fornix, has been observed. The injury must be dealt with according to its nature and according to the character of the injuring force. Clean incised or punctured wounds may be disinfected and immediately closed with catgut or silkworm-gut sutures. Contused and lacerated wounds in which submucous and subcutaneous hemorrhages are present are best treated at first by local applications of ice and antiseptic compresses. After hemorrhage has ceased and the danger of infection no longer threatens, hot applications may be substituted in order to favor the absorption of extravasated blood. If this does not occur promptly and rapidly, the accumu- lated mass may be opened by free incision, the clot turned out, and the cavity closed with drainage. Pudendal Hernia. — Disten- tion of either labium majus from a complete inguinal hernia may occur, the condition being anal- ogous to a scrotal hernia in the male. A tumor of the affected part is formed that has the usual characteristics of a hernia, which need not be detailed here. Marked examples of pudendal hernia are not nearly so frequent in the female as extensive scrotal hernia is in the male. Inguinal hernias in women are more apt tr» bp small Hict^nrlin cr n-nUr tV-i^ FlG - l86 - — Extreme cystic distention of vulvovaginal gland. TO De Small, aiStenamg Only tne simulating a labial hernia. upper part of the corresponding labium majus and the corresponding area of the mons veneris. A rare form of hernia, known as perineal, manifests itself in the form of a protrusion of gut or omentum through a weakened area in the perineal floor, which is located either between neighboring fasciculi of the levator ani and the coccygeus muscle, or at the site of the rectal or vaginal sheath, which penetrates and is sur- rounded by the muscles and fascia of the perineal floor. In the most fre- quent form the protrusion descends along the vagina, forming a tumor to one or the other side of the vaginal orifice (Fig. 186). It may present all the usual characteristics of a hernia, being tympanitic on percussion, showing a marked impulse on coughing, and disappearing when the patient assumes 190 GYNECOLOGY the recumbent posture or when suitable manipulations are instituted. Peri- neal hernias must be distinguished from cystocele and rectocele, vaginal cysts, the ordinary enterocele associated with the bladder or rectum, diver- ticula in prolapse, etc. In a majority of instances the treatment is surgical. The operation consists in dividing the skin and fascia over the tumor, ex- posing the sac, separating it from surrounding structures, opening the sac, and releasing the intestine or omentum, excising the sac, and bringing the margins of the wound together by means of chromic or silkworm-gut sutures. When the hiatus in the pelvic floor is very extensive, any attempt to close the hernial ring may appear impracticable. In such cases, and in those in which, because of age or illness, operation is inadvisable, some form of pad and perineal strap may be found useful. BIBLIOGRAPHY Allbutt, Playfair, and Eden : System of Gynecology. MacMillan Co., N. Y., 1906. Bidwell and Carpenter : " Gonococcal Infections in Childhood." Brit. Jour. Children's Diseases, No. 10, 1904. Breisky: " Uber Kraurosis Vulva?." Zeitschrift f. Heilkunde, 1885, vi, 69-80. Bulkley, K.. "Tuberculosis of the Vulva." Amer. Tour. Med. Sci., 1915, vol. cxlix, p. 535. Cary, W. H. : " The Conservative Treatment of Gonorrhoea in Women." Am. Jour. Surg., 191 1, vol. xxv, p. 373. Collyer, H. L. : " Fibroma of Labium." Amer. Jour. Obst, 1889, vol. xxii, p. 1252. Curtis, A. H. : " On the Pathology and Treatment of Chronic Leucorrhcea." Surg., Gyn. and Obst., 1914, vol. xix, p. 25. Demme: " Beitrag zur Tuberculose des Kindesalters." Wien, Med. Blat., 1887, Bd. 1. Dudley, E. C. : The Principles and Practice of Gynecology. Lea and Febiger, Phila., 1913. Edgar, J. C. : Obstetrics. P. Blakiston's Sons & Co. Fisichella, V. : " La cura dell' Ulcera cronica Vulvare." II Policlinico, 1915, vol. xxii, P- 485. Fromme: " Gutartige Geschwulste in das grossere Labien." Monats. f. Geb. u. Gyn., 1904, Bd. xx, S. 961. Gunther : " Esthiom / ene." Amer. Jour. Obst., 1904, vol. xlix, 373. Hamilton, Wallace : " Gonococcus Vulvovaginitis in Children." J. Am. Med. Assn., 1910, vol. liv, p. 1 196. IJart: "Epithelioma Vulvae." London Practitioner, Feb., 1895, vol. liv, p. 118. Hensius, F. : " Vaccine Behandlung der weiblichen Gonorrhoe." Monatschr. f. Geburtsh u. Gynak., 191 1, vol. xxxiii, p. 426. Hurdon : " Pathology of the Reproductive Organs." Kelly-Noble's Gynecology and Abdom- inal Surgery, Saunders, Phila., 1907. Kimball: "Gonorrhoea in Infants, with a Report of Eight Cases of Pyaemia." Med. Records, N. Y., vol. lxiv, p. 761. Morrow, L., and Bridgman, O. : " Gonorrhoea in Girls ; Treatment of 300 Cases." J. A. M. A., May 25, 1912, vol. lviii, p. 1564. Munk, H. : " Ein Beitrage zur Kenntniss und Behandlung des Pruritus Vulvae." Prag. med. Wochenschr., 1902, No. 45. Norris : " The Diagnosis and Treatment of Gonococcal Vulvovaginitis in Infants and Young Children." J. A. M. A., 1915, vol. lxv, p. 327. Pichevin : " Esthiom'ene de la Vulve." La Sem. Gyn., 1905, T. x, p. 38. Powers, D., and Murphy, J. K. : "A System of Syphilis." Oxford Medical Publications, 1908. Ravogli, A.: A Text-book of Gynecology. C. A. L. Reed, 1901. Sanger : " Aetiologie u. Behand. der Vulvitis Pruriginosa." Cent, f . Gynak., 1894, S. 154. Sinclair, J. F. : Investigations in Vulvovaginitis by Means of Female Urethroscope." Arch. Ped., 1914, vol. xxxi, p. 29. Stein, A. : " Primary Carcinoma of the Vulva." Amer. Jour. Obst., 1896, vol. lxxiv, p. 577. Taussig, F. J. : " The Prevention and Treatment of Vulvovaginitis in Children." Am. Jour. Med. Sci., 1914, vol. cxlviii, p. 480; Ibid. : " Etiologic Study of Vulvar Carcinoma." Amer. Jour. Obst., 1917. vol. lxxvi, p. 794; Ibid.: "Etiologic Study of Vulvar Carci- noma." Trans. Amer. Gyn. Soc, 1917, vol. xlii, p. 463. DISEASES OF THE EXTERNAL GENITALIA 191 Taylor : " Venereal and Skm Diseases." Clinical Atlas, Lea and Febiger, Phila., 1889. Ibid. : Genitourinary and Venereal Diseases. Lea and Febiger, Phila., 1904. Wagner: " Zur Behandlung der Cervical Gonorrhoe." Berlin, klin. Woch., Dec. 25, 191 1, No. 52, p. 2339. Webster: "Nerve Endings in Labia Minora and Clitoris; Pathology of Puritus Vulvae." Edinburgh Med. Jour., July, 1891. Weinstein, E. : " Die Vaccinetherapie nach Wright bei der Vulvo Vaginitis der Kinder." Miinchen. med. Wochnschr., igio, vol. lvii, p. 762. White and Martin : Genito-Urinary Surgery and Venereal Diseases. By Martin, E., Thomas, B. A., Moorhead, S. W. J. B. Lippincott Company, Phila. and London, 1917. CHAPTER XII DISEASES OF THE HYMEN AND VAGINA Abnormal rigidity or abnormal elasticity cf the hymen may occasionally be found. The former may render intercourse impossible ; the latter may be compatible with coitus and miscarriage without injury. Cystic tumors of the hymen are at times observed. These are either congenital or have their beginning in the coalescence of the hymeneal folds following inflammation. Vaginitis. — Vaginitis is usually subacute or chronic, except in the case of children and elderly women. In the young and in the old the mucosa of the vagina and vulva is delicate and tender, so that it is more sus- ceptible to acute inflammatory lesions. When vaginitis occurs during the reproductive period, it is less likely to be acute, and depends upon repeated infection plus a mechanical irritation or injury, or upon some general condition that lowers the vitality of the vaginal mucosa. The predisposing factors of vaginitis are venous stasis, the hypersemia incident to pregnancy, small abrasions of the mucosa, and the irritation of foreign bodies. In infants and in young children gonorrhoea is the most frequent cause. A long-continued discharge of gonorrhoeal pus from the cervix is the most common cause in adults. Vesicovaginal fistula is almost always accompanied by vaginitis, and puerperal infections of different varie- ties may attack the vagina. Vaginitis may also complicate pneumonia, scarlet fever, diphtheria, typhus fever, dysentery, and measles, especially in children. In acute vaginitis the vaginal walls are red, swollen, hot, tender, and cov- ered with a mucopurulent or purulent discharge. As a rule, the entire length of the vaginal canal is not involved, except in children. The vulva is bathed in the discharge, which becomes highly offensive. In subacute or in chronic vaginitis the vaginal surface is covered with numerous small red spots, caused by inflammatory infiltration of the papillae in the mucosa. The overlying epithelium subsequently desquamates, and small eroded areas are formed. In old and in young persons such areas, when they are apposed, may become adherent. In this variety the vaginal walls are covered with a thinner and less purulent discharge than in the acute form. In old, chronic cases the lesions may be limited to eroded patches in the vaginal vault. In children the local examination should be confined to an inspection of the vaginal orifice or to the introduction of a small Kelly cystoscope into the vagina. In the adult, examination of the vagina is preferably made by means of a Sims' speculum, with the patient in the Sims' or in the knee-chest position. The treatment of acute vaginitis consists of rest in bed, the administra- tion of saline laxatives, and the use of warm vaginal douches of solutions of sodium chloride, sodium bicarbonate, or borax (i dram to I pint. If the 192 DISEASES OF THE HYMEN AND VAGINA 193 pain is very severe, these douches must be given with great gentleness, using a soft-rubber catheter instead of a douche nozzle. The vaginal dis- charge must be caught upon vulvar pads, which should be burned. If the attack is gonorrhoeal in origin, the patient should be warned of the danger of carrying the infection to the eyes. After the acute stage has passed, the vaginal walls should be cleansed with absorbent cotton and painted with a 5 to 10 per cent, solution of silver nitrate. Following this a tampon covered with zinc oxide ointment should be inserted and left in place twenty-four hours. This treatment should be repeated at weekly intervals. In addition a daily douche of salt or borax solution (5i— Oi) should be ordered, to be followed by an astringent and antiseptic douche, such as the following: I£. Ac. boric , o iv Phenol. Pulv. alum, ex , aa 3 iv Ol. gaultheria? . ., mx xxx Ol. menth. pip mx xv Sig. — 1 dram to 2 pints of water ; used as a douche. Applications of silver nitrate (10 per cent.), followed by zinc oxide oint- ment, are especially effectual in cases of so-called senile vaginitis, occurring in women past the menopause. In this condition there is a thin, acid, offen- sive discharge, with irritation and redness of the vulvar mucosa, intense itching, and burning. Two or three applications of the silver nitrate and zinc oxide ointment to the entire vagina and vulva are usually sufficient to clear up the condition for a month or six weeks, when it may be necessary to repeat the treatment. Block and Llewellyn, also Brindeau, have had grati- fying' results from the use of the Bulgarian lactic acid bacillus (see page 198). The yeast treatment, as devised by Landau, consists of the introduc- tion, within the vagina, of a quantity of yeast fungi under conditions that favor their rapid growth and the destruction of all other bacterial forms. Landau used brewers' yeast and a solution of cane-sugar. A more convenient method consists of applying to the vagina, after thor- ough preparatory cleansing, two or three tampons moistened with a 10 per cent, solution of glucose and filled with dry yeast powder. The tampons are left in place for twenty-four hours, when they are removed and a douche of sterile water administered. The treatment is repeated at inter- vals of forty-eight hours. Curtis recommends particularly the use of antiseptic powders. Some that have given the best results are as follows : I£. Alumin. acetat 1 part Kaolin. Talc of each 2 parts Ifc. Pulv. alum ex. Ac. boric. Bismuth, subnitrat. aa. I£. Ac. tannic. Lycopod. aa. Paravaginitis. — (See Cellulitis.) 13 194 GYNECOLOGY Vaginismus is the name given to hypersesthetic conditions of the vulva and vagina in which intercourse is rendered impossible because of painful contractions of the muscles of the vaginal outlet and perineum. The vaginal introitus may be too small or the hymen may be rigid, or the condition may be caused by some painful affection of the vulva (vulvitis, urethral caruncle), vagina (vaginitis), or pelvis (prolapsed ovary), or it may be neurotic in origin. In the first class of cases the treatment is obvious — viz., the removal of the cause. In the sec- ond class of cases gentle but persistent, gradual dilatation, supplemented by nerve sedatives and hy- gienic and tonic treatment, will effect a cure. In ob- stinate cases forcible dila- tation under ether or actual incision with plas- tic repair, so designed as to increase the caliber of the vaginal introitus or the vaginal canal itself, may be successful. The use of soothing ointments or washes, and the plan of gradually accustoming the patient to the presence of a foreign body are of value. The general health should be improved by suitable tonic or roborant treatment. Vaginal Cysts. — Vag- inal cysts, while the most frequent of the vaginal tumors, are nevertheless rare. They result from the distention of aberrant vaginal glands, inclusions of epithelium following operations, hsematomata, dilatation of lymph-vessels, and the echinococcus. Rarely dermoid cysts are found. Cysts may also have their origin in rests of the Wolffian duct in the upper part of the vaginal vault. Such cysts are often multiple, and occur in rows. Vaginal cysts are hemispherical or ovoid in shape, and pro- ject more or less into the vagina (Fig. 187). Occasionally they may be pedunculated. The overlying mucosa is thinned out. The contents of a cyst may be clear, thin, and watery, glairy and opalescent, or chocolate colored. > FlG. 1-87. — Cyst "of the posterior vaginal wall. DISEASES OF THE HYMEN AND VAGINA 195 When the tumor is small, symptoms may be absent. When the growth is large, there is interference with urination and defecation. The tumor may form an obstruction to intercourse or to labor. If the passage of the men- strual fluid is obstructed and an accumulation occurs above the tumor, a fetid leucorrhoea may be present. The condition must be distinguished from cystocele, rectocele, and suburethral abscess. The only treatment to be considered is excision. This is readily accom- plished by making an incision oyer the prominence of the tumor, in the Fig. i 88. — Sarcoma of vagina in a child 2V2 years old, showing the grapelike polypoid masses in the vaginal canal. (Kelly and Xoble's Gynecology and Abdominal Surgery. W. B. Saunders Co.) axis of the vagina, and shelling out the cyst wall from the surrounding tissues. The wound is then closed by buried and superficial sutures. The approach to a cyst in the upper part of the vagina may present some diffi- culty, and the difficulty of excision is always increased if the cyst ruptures before it is enucleated. When enucleation is impracticable, as much of the cyst wall as possible should be excised with scissors, and the remainder cauterized and packed. Fibromyoma of the vagina is an infrequent form of tumor. It presents the same peculiarities as fibromyoma elsewhere in the body. The treatment consists of enucleation followed by plastic repair. 196 GYNECOLOGY Sarcoma of the vagina is very rare. In adults it appears as a diffuse growth that may be situated in any part of the vaginal canal. In young children it is polypoid or grape-like in form (Fig. 188), and springs from the anterior vaginal wall. The only hope for cure of sarcoma of the vagina lies in early radical operation. Grape-like sarcoma of the vagina in children is FIG. 189. — A case of adenocarcinoma of posterior vaginal wall. (Kelly's Operative Gynecology. D. Appleton & Co.) practically hopeless, all but one of the reported cases having proved fatal, in spite of the fact that extensive radical operations had been performed. Carcinoma of the Vagina. — Primary cancer of the vagina is very rare; it is usually secondary to a growth situated higher in the genital tract (Fig. 189). The treatment of carcinoma of t- e vagina is unsatisfactory, since the primary tumor is almost invariably beyond the pale of radical cure. In the majority of cases about all that can be done is to perform thorough curette- DISEASES OF THE HYMEN AND VAGINA 197 ment and cauterization, and to apply the other measures advised for in- operable carcinoma. The remarkable results that have been achieved in recent years by the use of radium make this form of treatment a distinct and hopeful addition to the therapy of carcinoma of the vagina. Chorio-epithelioma of the vagina is a rare condition. It is caused by the deportation of chorionic villi from their original site in the uterus or tube to the vaginal blood-spaces and their subsequent growth and development in the new location. The appearance of the growth is suggestive of a vaginal varix. The treatment consists of prompt excision, together with removal of the primary seat of the growth. As in carcinoma of the vagina, radium constitutes the most hopeful form of treatment of chorio-epithelioma. Foreign Bodies in the Vagina. — Foreign bodies of all sorts have been found in the vagina. They may have been introduced by patients mentally deranged or have been left by accident or neglect of the patient, physician, or nurse. Among those most commonly found are broken glass douche nozzles, pessaries,, tampons, etc. Pessaries are not infrequently forgotten and while they give no inconvenience for a time, they gradually produce inflammation and ulceration. In elderly women the bloody, foul discharge may lead to a mistaken diagnosis of carcinoma. The symptoms usually subside on removal of the pessary, but considerable contraction and stenosis of the vagina may follow as a consequence. Not infrequently the pessary becomes practically embedded in the tissues and can be removed only piecemeal. In neglected cases of long standing, vesicovaginal or rectovaginal fistulas may result. Leucorrhcea. — Leucorrhcea (white discharge), in the common acceptance of the term, is the name given to a discharge from the genitalia that occurs independently of the menses. A leucorrhceal discharge is usually of a milky white color, but it may be yellow or tinged with blood ; it may be compara- tively odorless or very offensive. (See also Chapter VI, p. 99.) The treatment of a given case of leucorrhcea depends, of course, upon the underlying cause, which may be any lesion or group of lesions of the genital tract. Any case in which leucorrhcea is a prominent feature may require careful study, for there is hardly any symptom that causes greater discomfort and distress. The most troublesome cases are those in which the recognizable lesions are not marked. In fact, there may be no manifestations beyond the constant presence, on examination, of more or less discharge in the vaginal vault and about the external genitalia. If all possible sources of the disorder have been sought for and no cause can be found, or if the presumptive underlying condition has been corrected and no improvement results, the indications point to an abnormal vaginal flora as the causative factor. Curtis, who has studied these persistent cases, found that in a ma- jority anaerobic bacteria were present in the cervix, vagina, and vulva. The ordinary pathogenic organisms were rarely found. The gonococcus was not often present, but this investigator concluded that a gonococcus 198 GYNECOLOGY infection was frequently the precursor of the persistent and less virulent infection. The uterine cavity remains uninvolved. An examination of smears of the discharge shows, besides many bacteria, pus cells and epithelium in varying proportion. Not infrequently a dis- charge that resembles pure pus is made up almost entirely of mucus and desquamated epithelium. In these cases the aim is to destroy the lower grade anaerobic organisms and then restore the normal bacterial flora. This is done, first, by employ- ing disinfecting applications, tampons, or douches, and then by placing a culture of the bacillus Bulgaricus (lactic acid bacillus) in the vaginal vault. As a means of disinfection a thorough application to the cervical canal and entire vagina of silver nitrate, 10 per cent., is perhaps the most effectual of the older remedies, but the tincture of iodine may be equally efficient. Re- cently a solution of chlorazine, followed by dichloramine-T tampons (2 per cent, in eucalyptus oil) has given excellent results. Findley recommends packing the vagina daily for a week with Fuller's earth, placing as much as possible into the vagina at every sitting without removing that previously introduced. After the anaerobic bacteria have been destroyed or their number deci- mated by this plan, then cultures of the Bulgarian lactic-acid bacillus x mixed with sugar may be introduced. For this purpose tablets of the lactic-acid bacillus are most convenient; they should be moistened and mixed into a thick paste with sugar and a little water; this is spread upon the vaginal walls in the fornices. The treatment should be repeated every other day for 1 " Tcchnic. — The patient is placed in the usual dorsal gynecologic position, and a thor- ough pelvic examination made, including smears, when indicated. A bivalve speculum is then inserted into the vagina, and the cervix and the upper vaginal canal exposed. The re- action of the vagina is then taken by moistening a piece of litmus paper in the vaginal secretion, after which the vagina is thoroughly cleansed of mucus and leucorrhceal dis- charges by means of a simple alkaline spray, and the vagina is then dried with cotton pledgets. A lactic acid tablet, preferably one that is readily soluble and made with a lactose base, is placed in a medicine glass and moistened with one or two drops of sterile water dropped on the tablet by means of a small pipette or eye-dropper. It is important not to supply more than a few drops of water to the tablet, otherwise the tablet will completely disintegrate and cannot be readily handled. " If the proper kind of tablet is used, and only enough water is applied to moisten it will attain the consistency of thick cottage cheese, and may be readily lifted in toto by a pair of forceps. It is then placed in the upper vaginal canal, and spread over the walls and on the cervix by means of the forceps. If the tablet is of the proper consistency, it will adhere to the vaginal mucosa wherever placed, and will show no tendency to run out of the vagina, as is the case with ordinary solutions. The speculum is next withdrawn half way, with its blades open, to allow the upper vaginal canal to close over the tablet that has been applied. Finally the blades are closed and the instrument is withdrawn. No tampons are applied. The patient is instructed to return in a week, and all douching is absolutely interdicted. On her return the same technic is repeated, and she returns once a week for a reimplantation of the bacilli, until the vagina is acid — a, result which, in a favorable case, is attained in about three or four weeks. After the reaction has become acid, no treatment is given so long as it remains so, although the patient returns at gradu- ally increasing intervals to have the reaction taken. In favorable cases it is usually found necessary to reimplant organisms at intervals of from three to four weeks,- since after that time the organisms seem to die, or at any rate to lose their potency. We might, therefore, state here that the treatment is seldom a permanent cure, but rather a good palliative measure, requiring attention about once a month and superseding douches." — (Block and Llewellyn : J. A. M. A., vol. lxix, No. 24, p. 2025, Dec. 15, 1917.) DISEASES OF THE HYMEN AND VAGINA 199 a week, and in the interim no vaginal douches or tub-baths should be taken. Even in successful cases the implantation may need to be repeated occasionally. Working on the theory that bacteria cannot thrive in the absence of moisture, Nassauer recommends insufflation of the vagina with fine white clay powder (bolus alba). For this purpose he has devised an apparatus that distends the vagina while the insufflation is being made. (The same effect may be secured by packing the vagina with the powder while the patient is in the knee-chest position.) The treatment should be carried out at first three or four times a day, but later less frequently. Nassauer asserts that a cure was effected in the majority of instances in 300 cases in which this treatment was used. As a result of careful and scientific study of a large series of cases Curtis found that the most successful plan of treatment consisted in the use of autogenous vaccines, combined with dry cleansing of the vagina and applications of powder. This should be preceded by the destruction, by means of the cautery or otherwise, of cervical glands that are producing an excessive mucous discharge. Care of the general health, the use of active emunctories, and the treatment of associated pelvic lesions are all adjuncts not to be disregarded. BIBLIOGRAPHY Abrams, O. : " Neuere Versuche Uber die Hefebenhandlung des weiblichen Fluors." Monats. f. Geburtsh. u. Gynak.. 1910, vol. xxxi, p, 89. Block, F. B., and Lewellyn, Thos. H. : " The Treatment of Leucorrhcea with Lactic Acid Bacilli." Jour. Amer. Med. Assoc, vol. lxix. Xo. 24, Dec. 15, 1917. Brindeau, L. : " Les Cultures de Bacillus Lactiques dans Le Traitement de Tlnfection Puerperale." Arch. mens, d'obst. e. d. gynec, 1912, i, 225. Cullen, T. S. : " Vaginal Cysts." Trans. Amer. Gyn. Soc, 1904, vol. xxix, p. 459. Curtis, A. H. : " The the Pathology and Treatment of Chronic Leucorrhcea." Surg., Gyn. and Obst., 1914, vol. xix, p. 25; Ibid. : "On the Etiology and Bacteriology of Leucor- rhcea." Surg., Gyn. and Obst., 1914, vol. xviii, p. 299. Holt : " Gonococcus Infections in Children, with Especial Reference to the Prevalence in Institutions and Means of Prevention." X. Y. Medical Jour, and Phila. Med. Jour., March, 1905, vol. lxxxi, Xos. 11 and 12. Hunner, G. L. : " The Treatment of Leucorrhcea with the Actual Cautery." J. A. M. A., 1906, Xo. 3, vol. xlvi. McFarlaxd, J.: "Sarcoma of the Vagina." Am. Jour. Med. Sci., 1911, vol. cxli, p. 570. (Complete Literature.) Nassauer, M. : " Sur le Traitement des ficoulements chez da Femme." Annales de Gyn. et d'Obst., 191 1, vol. viii, 2 serie, p. 477. Taussig, F. J. : " The Prevention and Treatment of Vulvovaginitis in Children," Amer. Jour. Med. Sci., 1914, vol. cxlviii, p. 480. CHAPTER XIII INJURIES TO THE PERINEUM AND THEIR RESULTS Mechanics of Normal Support. — The anatomy of the perineum, the origin and insertion of the various muscles that make up the pelvic dia- phragm, and the arrangement of the pelvic fascia have been described. It only remains to state that the supporting power of the perineal floor does not depend exclusively upon the muscle or the fascia. For the greater part of the time one reinforces the other ; thus when the perineal diaphragm is in absolute repose, the fascia maintains its form ; during urination, defecation, labor, and on physical exertion the muscular tissues are chiefly called upon to functionate. The levator ani and the pelvic fascia support the rectum, and in doing so the posterior vaginal wall, which is closely connected with the anterior wall of the rectum, is also supported. The vaginal walls being in contact, the support of the anterior wall is partly dependent upon the posterior wall, and the base of the bladder is in turn supported by it. Needless to say, the constrictor vaginae, the transversus perinsei, the triangular ligaments, and the endopelvic reflection of the pelvic fascia play an important part in the support of these structures, and when the muscles of the pelvic floor are in repose, the vagina, bladder, and rectum are maintained in their normal position largely by means of their fascial attachments. While the contraction of the levator ani muscle elevates the rectum, the external sphincter, in addition to constricting the anus, has a tendency, by virtue of its attachment to the tip of the coccyx, to draw the anus back- ward. When both the levator ani and the external sphincter act in unison, a certain amount of antagonistic action takes place at the site of the anus, which has been compared by Kelly to a " cut-off " valve. The vagina and the urethra pass through both the anterior and the pos- terior layers of the triangular ligament. The base of the bladder is sup- ported by the anterior vaginal wall, a few small muscular slips, the triangu- lar ligament, and the pubo-vesico-cervical reflections of the pelvic fascia. The bladder is also attached lightly to the posterior surface of the symphysis and to the cervix. The intrinsic fascial and muscular supports of the blad- der are sufficient to maintain it in position so long as they are fortified by the supporting action of the levator ani (Fig. 192). Just as soon as this supporting action is removed, however, they become incapable of holding the bladder permanently in its proper position. Forms of Injury, Immediate and Remote. — A study of the mechanics of labor shows that, during the second stage, as the head advances through the parturient canal, lacerations of the vagina and perineum may occur in one of two ways — the advancing head may strip the vag- inal wall loose from its underlying attachments and push it bodily in front of it, or the muscular loops and fascia that surround the parturient canal and the vaginal outlet may be so greatly overstretched as to be completely severed, the tear either passing through the mucous membrane 200 INJURIES TO THE PERINEUM AND THEIR RESULTS 201 to the surface or being entirely submucous and not communicating with the exterior. Either form of tear may take place in the vaginal sulci or in the median line. When it occurs in the median line, it may involve the perineal body alone, or it may pass directly through the perineal body and the external sphincter into the rectum. Simultaneously the anterior vaginal wall, at the introitus, may undergo various forms of trauma, but the deepest and most pronounced lacerations are usually found posteriorly. A median laceration through the perineal body, since it does not involve the levator muscles and fascia, affects the perineal diaphragm but slightly. It does destroy in part the supporting action of the transversus perinaei muscles, the constrictor vaginae, and the triangular ligaments. Nevertheless, if the levator ani itself is intact, there is no great impairment of the pelvic diaphragm. Fig. 190. — Large rectocele in a multipara. A sulcus tear (Fig. 193) means a separation or an avulsion of the an- terior fibers of the levator sling and a tear of the levator fascia, with a consequent loss of support to the rectum to which these fibers are attached. If one sulcus is lacerated, the other is, as a rule, affected also, although it may be to a lesser degree. Consequently the lower part of the rectum loses its support, and this affects the corresponding part of the vagina and the bladder. 9 When such a laceration has occurred, the action of the external sphincter in drawing the anus backward becomes a factor of considerable importance in the subsequent course of anatomic changes. Being deprived of its natural support, the lower end of the rectum is drawn backward with each contrac- tion of the sphincter, and the column of faeces, instead of being driven toward 202 GYNECOLOGY the anus during defecation, is driven toward the vagina, the posterior wall of which tends to pouch, forming a rectocele (Figs. 190 and 193). When the anterior vaginal wall and the base of the bladder are deprived of the support that is normally afforded by an intact levator muscle and fascia, there is a tendency for the parts to sag, and their support now depends entirely upon their intrinsic fascial attachments and a few small muscles. When, in addition to levator incompetence, injuries have been in- flicted on the fascia of the anterior vaginal wall and the vesical base, asso- ciated, perhaps, with a separation of the anterior vaginal wall from its Fig. 191. — Sulcus tears and thinning of perineal body in a multipara. underlying tissue, a sagging of the base of the bladder during attempts at lifting or urination occurs, with the subsequent formation of a cystocele. The chief effect of a median tear that passes not only through the perineal body but also through the external sphincter muscle into the rectum, complete tear, consists in an inability to control the passage of flatus or of faeces from the bowel. The tear rarely may be entirely submucous, the rupture in the fibers of the external sphincter being unaccompanied by any lesion in the overlying skin or mucous membrane. After a difficult labor incontinence of gas or of faeces may be due to a temporary paralysis of the sphincter muscle, INJURIES TO THE PERINEUM AND THEIR RESULTS 203 the result of the pressure and the stretching to which it has been subjected. This temporary incontinence may simulate a submucous rupture of the sphincter. A complete tear, if uncomplicated, especially if it occurs directly in the median line, affects the support of the perineum but little (Fig. 194). The levator fibers are not greatly affected, and it is quite unusual, although, of course, it is possible, for a patient who suffers with a complete tear of the perineum to display many symptoms of general relaxation of the pelvic floor. In some cases this is probably due to the fact that the great distress caused by a complete tear usually leads to comparatively early operative treatment. ■cicXococtvjgeu.? VtMoXw ota X3\vvoLugu.\a.'c \\$ Fig. 192. — Schematic drawing to show the support given by the levator ani and triangular ligaments to the pelvic viscera; note the pull upward by these structures to counteract the downward intra-ab- dominal pressure. The rectum, anus and perineal body are well held up. Fig. 193. — Schematic drawing to show the effect of sulcus lacerations of the levator ani and triangular ligament; the rectum, anus and perineal body drop back, having lost their support, the recto-coccygeus slip of the external sphincter pulls the anus and the lower end of the rectum backward, the fecal current is directed toward the gaping vaginal orifice and the posterior vaginal wall; nothing now opposes the downward intra-abdominal pressure but the uter- ine ligaments and the intrinsic attachments of the bladder. Symptoms. — The symptoms of a relaxation of the perineum are attribut- able to a loss of the support that it normally affords to the generative tract, and to the secondary lesions which it may occasion, namely, cystocele, recto- cele, and descensus uteri (Fig. 195). The symptoms do not manifest them- selves until the patient has left her bed and has resumed her daily duties. There is a feeling as if the entrance to the vagina was open, and as if the supporting nower of the pelvic floor was lost. This feeling of weakness be- comes more marked when any unusual muscular effort is attempted. If the exertion is continued for any length of time, standing or walking, the patient complains of sacral backache, a dragging sensation in the lower abdomen, and a feeling as if the vaginal structures were about to protrude. The symptoms are all relieved on assuming the recumbent posture. 204 GYNECOLOGY If a well-marked rectocele (Fig. 190) develops there will be difficulty in defecation, associated with a peculiar pain that is caused by impingement of the fecal column upon the posterior vaginal wall. At times the attempt at defecation is successful only after the patient has taken an enema to liquefy the faeces, or she may learn that by pressing upon the posterior vaginal walls with the fingers she can deflect the fecal column through the anus. When a cystocele (Fig. 196) develops, the patient complains of an in- Fig. 194. — Complete laceration of perineum. Xote the sphincter pits and the nearly straight line of the divided muscle. creased desire to urinate, especially when she has been upon her feet any length of time, and urination may be accompanied by a burning sensation or pain. In w r ell-marked cystoceles the bladder becomes sacculated, and the patient is unable to empty the organ completely, so that there is always present a certain amount of residual urine which may undergo amm6niacal change and give rise to a low-grade cystitis. Occasionally the patient dis- covers that she is able to empty her bladder by pressing the cystocele up- ward with the fingers. Diagnosis.— All the symptoms of relaxation of the pelvic floor are improved by the recumbent posture or by vaginal tampons and the application of a snug perineal bandage. In most cases, on examination the relaxation will be INJURIES TO THE PERINEUM AND THEIR RESULTS 205 revealed by simple inspection, but occasionally a few associated symptoms may be especially brought out by palpation. In the normal individual the vaginal introitus is closed ; the perineal body is thick, and its surface is slightly concave ; the anus is well puckered and drawn up close to a line connecting the tuberosity of the ischia ; the natal and the gluteal clefts are deep. If the patient is directed to bear down, there will be a bulging of the ^' Fig. 195- — Prolapse of uterus with cervix projecting from vulva; prolapsed rectal mucosa; fibrolipoma of thigh. perineum (Fig. 197), but no opening of the vagina and no prolapse of its walls. The relaxed perineum presents quite a different appearance from that just described. The vaginal introitus is open; the anterior and the posterior vaginal walls are not in contact ; the perineal body is attenuated and bulging; the anus is retracted, the pucker of the sphincter muscle is less marked, and the natal and the gluteal clefts are shallow. If the woman is directed to bear down, the anterior and posterior walls of the vagina tend to descend, and if cystocele or rectocele is present, the characteristic protrusion will be noticed (Fig. 198). The perineal reflex is weak or absent. 206 GYNECOLOGY When the perineal diaphragm is intact, a finger inserted within the vagina perceives, at either side, the anterior border of the levator ani muscle and the substantial thickness of the perineal body. In the relaxed perineum the perineal body may be extremely thin, so that there is almost no fascia or muscle between the s.^n surface and the anterior rectal wall. If the levator muscle has been torn, a break in its anterior border may be felt, and the separation of its fibers may have left a distinct furrow or cleft in the vaginal sulcus into which the finger may be laid. In marked rectoceles the Fig. 196. — Cystocele: Rectocele; note the gaping vaginal orifice; the anterior and posterior walls are not in contact; the perineal body- is thin and dropped down; the perineal raphe is obliterated. posterior vaginal and the anterior rectal wall is readily everted through the anus, or slight pressure upon the posterior wall of the vagina with a finger in either sulcus may be sufficient to expose the cervix. If the woman is placed in the Sims' or the knee-chest posture, marked ballooning of the vaginal vault at once occurs. Retraction of the posterior vaginal wall with a speculum is unnecessary. The presence of a rectocele can readily be dem- onstrated by rectal examination : when the finger is directed forward into the anterior rectal pouch, it can carry the posterior vaginal wall before it, almost without any resistance, through the vaginal orifice. The relations INJURIES TO THE PERINEUM AND THEIR RESULTS 207 of a cystocele can be demonstrated with the aid of a catheter or a vesical sound. The symptoms and diagnosis of a complete perineal tear are dependent chiefly upon the observation of the patient that she has involuntary passages of faeces or flatus from the rectum. This lack of con. ol may not be absolute. Thus the woman may., under ordinary circumstances, be able to hold both faeces and gas, but when the intestinal contents is liquid, as following a laxa- tive or an enema, inhibition may be deficient or faulty. In such cases the Pig. 197. — Normal nulliparous outlet, patient straining. Fig. 198. — Relaxed outlet, patient straining. laceration may involve only the fibers of the external sphincter, leaving the internal sphincter intact, or fibrous union of the sphincter ends may have occurred and may be so nearly perfect that the muscle under usual condi- tions is competent. The objective symptoms of a complete tear consist chiefly in an altered appearance of the anus. This muscle, instead of being circular and puck- ered throughout its entire extent, is bow-shaped or straight, and more or less deficient anteriorly where the tear in the posterior wall of the vagina and the" recto-vaginal septum exposes the mucosa of the rectum, which pre- sents a bright-red color. The pucker of torn muscle ceases at a varying dis- 208 GYNECOLOGY tance to either side of the median line, depending upon the position and extent of the tear ; on both sides, directly over the point where the pucker- ing ends, there is a retraction or a dimpling of the skin surfaces. The median tear and the exposure of the rectal mucosa are the result of a laceration directly through the posterior vaginal wall, perineal body, and anterior wall of the rectum. The dimples on either side are known as the sphincter pits, and mark the position of the retracted ends of the divided sphincter. Fig. 199. — Relaxed outlet. Many variations of this typical picture may occur. The median tear may be insignificant, barely involving the external sphincter and not reach- ing the rectovaginal septum, or the tear in the sphincter may be almost completely submucous ; in the latter event no external injury is apparent, but the sphincter ends are retracted, and upon inserting the finger into the rectum the failure of the muscle to surround the anus completely can readily be determined. Treatment. — Needless to say, it is the duty of the obstetrician to repair, INJURIES TO THE PERINEUM AND THEIR RESULTS 209 H directly after labor, any small injuries of the perineum that are present. The question of operating at once when the labor has been prolonged or difficult ; when considerable bruising of the tissues has occurred and the chances of infection are multiplied, and when detachment of the vaginal walls and submucous injuries appear probable, is still a matter of doubt. It appears, however, that if the patient is subjected to operation a week or two after, rather than at the time of, delivery, she will ultimately be in better condition. Except in the case of very simple lacerations, swelling and cedema are so severe directly following labor that, in spite of the most painstaking care, an immediate perineorrhaphy is often disappointing in its result. At this time submucous injury may easily escape observation, and because of dis- ^ tortion the parts cannot be apposed perfectly. It is good practice in these cases, whenever possible, to obtain the patient's consent to postpone the opera- tion for about a week or ten days, when more satisfactory surgical measures may be undertaken, in submucous in- juries making a denudation and passing deep sutures. The more frequent use « of perineotomy, lateral or median, in the second stage of labor, with imme- diate primary repair, will obviate a ma- jority of extensive lacerations and pre- serve the integrity of the pelvic floor. This subject, however, belongs to the domain of obstetrics ; here we deal chiefly with the secondary operations of perineorrhaphy, which belong to the £ 1 j r i Eig. 20 °- — Emmet perineorrhaphy. Outline of the tieiQ OI gynecology. denudation, two vaginal and one perineal triangle. PERINEORRHAPHY Many operations have been devised for the restoration of the posterior segment of a relaxed pelvic floor, but two stand out preeminently : one is the operation of Emmet, and the other is the operation of Hegar. Although these remain as the two types of operation that are most efficient, excellent modifications of each have been devised. In all operations of this sort, two objects are to be achieved : the first is to take up the lax and redundant posterior vaginal wall, and the second is to bring together the lacerated borders of the levator muscle and fascia, as well as the retracted edges of the transversus perinaei and the constrictor vaginae muscles and the fasciae that meet in the median line and are interposed be- tween the vagina and the rectum or that surround the vaginal outlet. In the Emmet operation the denudations involve each lateral sulcus of the vagina; this operation is, therefore, particularly well adapted to those 14 210 GYNECOLOGY cases of relaxation that are due to sulcus tears. The sulcus denudation not only gives access to the torn and retracted fibers of the levator sling, but also takes up the redundancy of the posterior vaginal wall and attaches it to the fixed structures and fascia in the neighborhood of the pubic rami. Hegar's operation is better adapted to those cases in which the tear is in the median line, and involves especially the perineal body; it is also the operation of choice in cases of relaxation of long standing, in which restora- tion of the pelvic floor must depend largely upon the fascial rather than upon the muscular supports. It is especially useful in the relaxation asso- ciated with the atrophy that takes place at the time of the menopause. Both operations bring together structures that may have been divided or separated in the median line, and unite between the anus and the vaginal orifice, the transversus perinsei, triangular ligaments, and the most anterior fibers of the levator ani. n Fig. 201. — Emmet perineorrhaphy. The denuda- tion completed. Sutures in one sulcus introduced but not tied. Note that the sutures are placed in such a manner that they will elevate the rectocele. Fig. 202. — Emmet perineorrhaphy. The sulcus sutures tied on both sides. Crown sutures introduced. Note that they are inserted and brought out in- side the denuded area. The Emmet Operation. — Three points are selected and fixed with ten- acula : First, the middle of the rectocele ; second and third, a point just below Bartholin's duct, at either side of the vaginal orifice. By making- traction on the central and on a lateral tenaculum, first on one side and then on the other, the borders of three triangular areas are brought into prom- inence and outlined by a scalpel, the incision being carried through the mucous membrane (Fig. 200). These incisions mark the areas where acnudation is to be done, and should be carried up sufficiently high in either sulcus to embrace the entire extent of the relaxation or of the tear. The denudation is made in strips, by means of tissue forceps and curved scissors, care being taken to remove the mucosa and skin uniformly and to leave no undenuded areas. In the young, child-bearing woman as much INJURIES TO THE PERINEUM AND THEIR RESULTS 211 of the mucosa as possible should be preserved, the borders of the denuda- tion being undermined, if need be, to expose the muscles and fascia. The sulcus sutures are introduced, as shown in the illustration (Fig. 201). They are passed in such a way as to attach the loose posterior vaginal wall to the fixed lateral part, and to reunite and reattach to the muscular coat of the rectum the divided fibers or fascia of the levator ani muscle. The sutures of the perineal triangle are known as the crown sutures (Fig. 202). They unite the structures that have been separated in the median line, restoring the perineal body and the muscles and fascia that meet normally at that point, and also draw some of the fibers of the levator ani muscles to the front, between the anus and the vagina, attaching them to the corre- FiG. 203. — Showing transverse fascial split and introduction of crown sutures. sponding fibers of the opposite side. The most approved method of performing this operation varies some- what from the classic description of Emmet. Care is taken to push the tip of the rectocele up into the vagina so as to avoid making traction upon the posterior vaginal wall, which would pull on the cervix and have a tendency to displace the uterus backward. As was previously pointed out, the sutures should be so passed that the posterior vaginal wall will be elevated instead of pulled down (Fig. 204). Before introducing the crown sutures, it is a good plan to divide the fascia of the denuded perineal triangle by a transverse incision from one side to the other (Fig. 203). This separates the structures to be united into two layers, each one of which is united in turn to its fellow of the opposite side by several extra-fine catgut sutures. Fig. 204. — Diagrammatic sketches of Emmet perineorrhaphy. The crown sutures are introduced in the ordinary way, surrounding both layers. By this plan a firmer union of the muscle and fascia which are brought together in the median line is obtained. Hegar's Operation. — As in the Emmet operation, three points are fixed by tenacula. the tenaculum catching the rectocele being placed at a higher 212 GYNECOLOGY INJURIES TO THE PERINEUM AND THEIR RESULTS 213 point than in the Emmet operation ; indeed, in cases of marked relaxation the tenaculum is inserted nearly at the top of the vagina. Ordinarily, how- ever, the point of attachment is about an inch above where it would be for the Emmet operation. The area to be denuded is determined as follows: When traction is made on the three tenacula, a fold of the posterior vaginal wall will be lifted up in the median line; this fold is triangular in shape, with its sides slanting toward the vaginal sulcus on either side. The bor- ders of this fold are definitely established by drawing the rectal tenaculum upward and forward and the lateral ones to either side. The sides of this triangle are out- lined by an incision through the mucosa running along each bor- der to the corresponding vaginal sulcus. From the sulci the in- cision is carried upward and for- ward on either side to a point below the lateral tenaculum. A posterior incision is then made along the line of junction of the skin surface of the perineum with the posterior vaginal wall, be- tween the two lateral tenacula (Fig. 205). The area outlined in this way is then denuded in the manner described for the Emmet operation. The anterior wall of the rectum and the levator muscles and fascia are clearly exposed by blunt dissection. The adjacent borders of the posterior vaginal wall, the rectovaginal fascia, and the laterally lying fascia and fibers of the levator ani are now brought together by a series of interrupted sutures (Fig. 206). These sutures are continued in the median line to the base of the triangular denudation; as each succeeding suture is introduced, the pre- ceding one, which until that time has served as a point of retraction, is cut, and the tissue which it grasps is allowed to slip up into the vagina. These median sutures take up the redundancy of the posterior vaginal wall, fix the tissues to the underlying rectovaginal fascia, and pull up and reattach in the median line, the rectovaginal fascia, the rectal wall, the retracted levator ani fibers and the levator fascia. (See also Figs. 208, 209 and 210.) The perineal sutures or the crown sutures are introduced in much the same manner (Fig. 207) as in the Emmet operation, with a transverse split as described on page 211, and practically have the same effect, so that the Fig. 207. — Hegar perineorrhaphy. Crown sutures in- troduced. The drawing does not show the full out- ward sweep of the needle. The beginning of the subcuticular suture. 214 GYNECOLOGY chief difference between the two operations consists in the mode of dealing with the rectocele and with the torn and relaxed levator ani muscle and fascia. Operation for Complete Tear. — The essential points in the operation for a complete tear of the perineum are : (i) To restore the rectovaginal septum; and (2) to bring together the divided ends of the sphincter. Although, as has previously been stated, it is unusual to find a re- laxation of the levator ani fibers in connection with a complete tear, the de- nudation required for such an operation includes also the denudation made for either the Hegar or the Emmet operation (Figs. 200 and 205 ) . This is done not so much for the pur- pose of catching the re- tracted ends of the levator muscles as it is for the pur- pose of restoring fully the perineal body and the rectovaginal septum. For this reason the last part of the denudation fol- lows either the Emmet or the Hegar type of opera- tion, although it is not at all extensive. The lower border of the line of denu- dation runs from the tenacula fastened below Bartholin's duct downward over the perineal body to the sphincter end on each side, which it encircles, and is then continued along the border between the rectal and vaginal mucosa to the median line, at the apex of the tear in the rectovaginal septum (Fig. 211). When the tissue immediately over the sphincter pits has been denuded, the ends of the muscle are sought for with tissue forceps and separated slightly from the surrounding cicatricial tissue, so that they can be well drawn up and thoroughly exposed. The extreme ends of the sphincter may be snipped off in order to secure a better surface for approximation. The denudation along the margin of the tear in the rectal wall should be very carefully performed, so as to afford as clean and as broad a line for approxi- mation as possible. The first sutures restore the rectovaginal septum ; they should consist of No. 1 chromic gut (ten-day), and be introduced from the perineal side, em- bracing the tissue down to but not penetrating the rectal mucosa (Fig. 212) ; or FlG. 208. — Hegar perineorrhaphy. Levator ani suture in marked cases — upper sutures. INJURIES TO THE PERINEUM AND THEIR RESULTS 215 they should be of fine linen, introduced from the rectal mucosa and tied within the bowel (Fig. 213). The first suture should be passed through the very apex of the rectovaginal tear ; below this point they should be passed at intervals of one-eighth of an inch until the sphincter muscle is reached. Fig. 209. — Hegar perineorrhaphy. Levator Suture in marked cases. The upper sutures have been introduced. The introduction of the lower suture is indicated. The rectum is pushed back by the finger. The sphincter end on each side is now pulled directly into the wound, and two No. 1 ten-day chromic catgut sutures are introduced from side to side, each suture catching both sphincter ends (Fig. 212). A No. 1 ten-day chromic catgut suture is now passed from a point external to the sphincter end on one side, through the tissues external to the margin of the rectovaginal tear, carried around above the apex of the tear, continued through the tissues of the opposite side, and brought out at a point opposite the site of its intro- duction (Fig. 214, No. 3). This stitch takes the strain off the sutures that ap- proximate the sphincter ends. For the remainder of the operation the introduc- tion of sutures is identical with that described for either the Emmet or the Hegar type of operation, omitting the transverse split of the tissues at the outlet. The operation is completed by the introduction of subcuticular sutures of No. o chromic gut, as shown in Figs. 210 and 214. 216 GYNECOLOGY ANTERIOR COLPORRHAPHY; CYSTOPEXY The surgical treatment of relaxation or ptosis of the anterior vaginal wall and the base of the bladder (cystocele) depends upon the extent of the con- dition, and the structures involved ; this varies considerably in different cases. The anterior vaginal wall may be redundant and simulate a cystocele in appear- ance when in reality the lesion is nothing more than an overstretching of the vaginal mucosa and a separation of it from the underlying tissues. Or in con- nection with a stretching and a separation of the vaginal Avail there may be an actual rupture of the muscular and fascial sup- ports of the vesical trigone, an overstretch- ing or a tearing of the fascia that runs be- tween the bladder and the vagina from the cervix to the pubes (pubo-vesico-cer- vical fascia "bladder pillars"), or an ex- tensive separation of the normal attach- ment of the bladder to the cervix. While the simplest of these conditions requires nothing more than a resection of the redundant vaginal mucosa, the more complicated cases demand, in addition, a reduplication of the under surface of the bladder, a reuniting of the torn muscles and the fascia that support the bladder, and a reestablishment of the normal rela- tions of the bladder to the cervix. Many operations have been devised to meet these requirements. Cystocele Operations— Martin's Oper- ation. — Martin's operation is the simplest form of anterior colporrhaphy and cysto- pexy, and is applicable only to small cys- toceles. The operation consists of outlining an oval area upon the anterior vaginal wall, the longest diameter of the oval being in the median line. After removing the mucosa by means of tissue forceps and scissors, the adjacent areas on either side of the median line of the denuded oval are brought together by sutures introduced from side to side, through the vaginal wall. Sanger's Operation. — This type of operation is performed in all but the simplest cases, and was first elaborated by Sanger. By means of a tenaculum the anterior vaginal Avail is caught in two places — posteriorly, just in front of the cervix, and anteriorly, I cm. below the urinary meatus. The amount of redundancy of the anterior vaginal wall is determined by approximating, with tissue forceps, the vaginal tissues to either side of the median line, and then outlining the area with a knife. An incision is now made in the median line, from one tenaculum to the other, and the plane of separation between the FlG. 210.— Completion of the subcuticular suture of either the Emmet or Hegar per- ineorrhaphy. The end of the subcuticular suture is tied to the last crown suture. The knot is buried. INJURIES TO THE PERINEUM AND THEIR RESULTS 217 anterior vaginal wall and the bladder determined by blunt dissection. The anterior vaginal wall is separated from the base of the bladder on each side K *3P Fig. 2ii. — Operation for complete tear of per- ineum. The apex of the rectovaginal tear is held up by a tenaculum. The sphincter pits are shown. Fig. 212. — Operation for complete perineal tear. The sphincter ends have been dissected; the denuded surfaces comprise the sphincter areas, the margin of the rectovaginal septum, the vaginal sulci, and the perineal body; the upper part of the denudation is after the Emmet perineorrhaphy. of the median incision as far as the lateral outlines and then excised (Fig. 215). The exposed base of the bladder is infolded by interrupted or running catgut sutures. The vaginal wall and the pubo-vesico-cervical fascia are brought together in the median line by continuous or interrupted catgut sutures (Figs. 216 and 217). The extent of this operation can be varied to suit the degree of relaxation that is present. When the cystocele is large, an inverted T-shaped incision should be made (Fig. 218). The dissec- tion between the bladder and the vagina should be continued posteriorly as far as the cervix; the bladder is separated from the cervix and pushed up (Fig. 220). The pubo-vesico-cervical ligaments (" bladder pillars ") and the cardinal liga- ments are exposed and developed bv blunt Fig 213— Suture of rectovaginal septum by c r J linen mtroduced from the rectal side. dissection (Fig. 221). The cardinal ligaments and the pubo-vesico-cervical ligaments are united to each other and. to the cervix in the median line beneath the bladder which is pushed up. 218 GYNECOLOGY Fig. 214.- — Operation for complete tear of perineum. Schematic diagram to show the introduction of the sutures. They are introduced in order as numbered. The end of the subcuticular suture, number eight, is continued forward to the junction of the perineal and vaginal surfaces where it is tied. Fig. 215. — Sanger anterior colporrhaphy ; the vag- inal wall and underlying fascia corresponding to the area outlined are being cut away. Fig. 216. — Sanger anterior" colporrhaphy: the su- ture is started at the anterior end of the incision on the vaginal surface; it embraces in each turn the fascia beneath the mucosa and the wall of the blad- der. Each transverse passage of the suture _ is half-hitched in order to prevent antero-posterior shortening; this suture is continued to the pos- terior limits of the denudation. INJURIES TO THE PERINEUM AND THEIR RESULTS 219 Fig. 217. — Sanger anterior colporrhaphy. At the posterior limit of the incision the suture is carried through the vaginal wall and then con- tinued toward the starting point, each trans- verse passage catching the entire thickness of the vaginal mucosa and underlying fascia, and each one-half hitched to prevent anteropos- terior shortening. When the suture reaches the anterior limits of the vaginal incision it is tied. One strand of No. i, ten-day gut, one knot. Fig. 218. — Anterior colporrhaphy or cystopexy. Outline of initial incision in advanced cases. Fig. 219. — Anterior colporrhaphy or cystopexy. Exposure and separation of bladder from anterior vaginal wall and the cervix. Fig. 220. — Anterior colporrhaphy or cystopexy. Further separation of bladder from uterine wall, exposing vesico-uterine fold of peritoneum, bladder pillars and cardinal ligaments. 220 GYNECOLOGY Even in extensive cases this plan of operation will be satisfactory. If, however, the patient has passed the child-bearing period, other measures may be adopted that are more efficient, but partially or wholly incompatible with subsequent pregnancy and labor. One of these procedures consists of sepa- rating the bladder from the cervix beyond the uterovesical fold of the peri- toneum ; the bladder is then pushed up and its base united to the anterior surface of the body of the uterus above the internal os ; the bladder pillars and cardinal ligaments exposed on each side are brought together in the median line and attached to the anterior surface of the uterus below the Fig. 221. — Anterior colporrhaphy or cystopexy. Introduction of sutures, fixing the pubo-vesico- cervical fascia, "bladder pillars," and the cardinal ligaments to the cervix at the position of the internal os, and bringing the fascia together beneath the bladder. bladder ; the edges of the posterior extremity of the vaginal incision are now united by means of sutures to the cervix at about the position of the internal os. In very marked cases of cystocele GofTe sutures the base of the bladder to the uterus in the. median line and laterally to the broad ligaments. The line of attachment on the bladder is selected, so that all bulging downward is eliminated. Watkins' Interposition Operation. — In the case of very large cystoceles, in women past the menopause, the plan of operation elaborated by Watkins INJURIES TO THE PERINEUM AND THEIR RESULTS 221 is the procedure of choice. In this operation the body of the uterus is interposed between the base of the bladder and the anterior vaginal wall. This method is applicable without modification only when the uterus is Fig. 222. — Interposition operation for prolapse. For steps in operation preliminary to this, see Figs. 218, 210, 220. The vesico-uterine fold of perito- neum is split transversely and the fundus of the uterus pulled through the opening. Fig. 223. — Interposition operation. The bladder has been pushed up, the vesical peritoneum has been united to the posterior surface of the uterus at the internal os, and the fundus is being anchored to the fascia bordering the anterior extremity of the vagi- nal incision; the uterine body in this way is brought to lie beneath the bladder, between it and the vagina. small and freely movable, and when the adnexa are perfectly healthy. (See also pages 2~2 and 273.) After exposing the uterovesical fold of peritoneum the latter is divided trans- versely, opening the peritoneal cavity. The vaginal walls should be separated from the bladder somewhat extensively on either side of the median line. The fundus of the uterus is pulled forward through the peritoneal incision (Fig. 222), while the base of the bladder is pushed upward so that the posterior surface of the uterus supports it. The upper edge of the vesico-uterine fold of peritoneum is attached to the posterior surface of the uterus somewhat above the position of the internal os. Sutures are passed between the anterior surface of the uterus and the adjacent margins of the pubo-vesico-cervical fascia, tri^ 6 : 22 ^ e ££^^<^^°^^ angular ligament and vaginal walls (Fig. 223) ; these fix the uterus in its new position (Fig. 224). The redun- dant portion of the vaginal mucosa is trimmed off, and the edges are united in the median line by continuous or interrupted catgut sutures. 222 GYNECOLOGY BIBLIOGRAPHY Anspach, B. M. : " Buried Catgut and Subcuticular Stitch in Plastic Operations on the Perineum." International Clinics, vol. iv, eighteenth series, 1908. J. B. Lippincott, Phila. and London. Babcock, W. W. : " Submucous Perineorrhaphy." J. A. M. A., May 15, 1909, p. 1568. Emmet, T. A. : "A Study of the Etiology of Perineal Laceration, with a New Method for Its Proper Repair." Trans. Amer. Gyn. Soc, 1883, vol. viii, p. 198. Frank, R. T. : "A Study of the Anatomy, Pathology and Treatment of Uterine Prolapse, Rectocele and Cystocele." Surg., Gyn. and Obst., 1917, vol. xxiv, pp. 42-58. Goffe, J. R. : " An Improved and Perfected Operation for the Relief of Extreme Cases of Procidentia, Cystocele, and Rectocele." Am. Jour. Obst., 1910, vol. lxii, p. 611; Ibid.: " Operation for Extreme Cases of Procidentia, with Rectocele and Cystocele." Trans. Amer. Gyn. Soc, 1912, vol. xxxvii, p. 394. Goldspohn : " Fundamental Intrapelvic Perineorrhaphy." Trans. Sect. O. G. and A. S., A. M. A., 1914, p. 273. Hadra : " Remarks on Vaginal Prolapse, Cystocele, and Rectocele." Amer. Jour. Obst., May, 1889, vol. xxii, No. 5, p. 457. Hirst, B. C. : " The Technic of Pelvic Floor Repair." Ann. Surg., Phila., 1916, lxv, 247. Kelly, H. A. : " The Operation for Complete Tear of the Perineum." Amer. Jour. Obst., 1899, vol. xl, No. 2. Noble, C. P. : " A Contribution to the Technic of Operations for the Cure of Laceration of the Pelvic Floor in Women." Amer. Gyn. and Obst. Jour., April, 1897 ; Ibid. : Plastic Operations. Kelly-Noble, vol. i. Saunders, Phila., 1907. Sanger, Max : " Zur Technik der Prolapsoperation." Centralbl. f . Gynak., 1898, vol. xxii, P. 33- Savage: "The Surgery, Surgical Pathology, and Surgical Anatomy of the Female Pelvic Organs," 2nd Ed., London, 1870. Sims, M. : Sims' Uterine Surgery, 1886, p. 205. Wm. Wood & Co., New York. Studdiford, W. E. : " The Involuntary Muscle Fibers of the Pelvic Floor." Trans. Amer. Gyn. Soc, 1909, vol. xxxiv, p. 759. Ward, G. G. : " An Operation for the Cure of Rectocele and Restoration of the Function of the Pelvic Floor." Trans. Amer. Gyn. Soc, 1913, vol. xxxviii, p. 169; Ibid. : "The Problem of the Cystocele." Amer. Jour. Obstet, 1919, vol. lxxix, No. 5. CHAPTER XIV DISEASES OF THE CERVIX Atresia of the cervix, in the vast majority of cases, is congenital, and manifests itself at puberty. Rarely, it may be acquired. A certain amount of stenosis of the cervical canal always occurs after the menopause. This may be complete, but, as a rule, a fine probe can be introduced. Actual atresia that obstructs the menstrual flow may be the result of cervix opera- tions, especially trachelectomy, the application of caustics, or decubitus ulcerations that have destroyed the mucosa. Atresia of the cervix during the reproductive period leads to retention of the menstrual fluid and the production of hsematometra, pyometra, or physometra. In patients approaching the menopause, atresia combined with intra- uterine collections of blood and pus is often indicative of malignant growths affecting the cervix or the body of the uterus. Acquired atresia of the cervix may be accompanied not only by hsematometra, but also by haematosalpinx. The symptoms vary. When it occurs during the reproductive period, there is recurring monthly distress, with little or no bloody discharge and the gradual enlargement of the uterus. In atresia appearing after the meno- pause, there are no symptoms unless the uterine cavity is the seat of car- cinoma or sarcoma, when the bloody discharge cannot escape, and there is the gradual formation of an hsematometra or a pyometra. (See Chapter XVI.) The diagnosis is established by the passage of a probe, if necessary, under anaesthesia. In non-malignant cases the treatment consists in relieving the obstruc- tion by forcibly dilating the cervix, and performing such other operative treat- ment as may be required, which is described under gynatresia. In malignant cases the establishment of drainage is the first indication, to be followed by pan-hysterectomy if the case is operable. Endocervicitis. — Hyperplasia of the cervical mucosa may be the result of mechanical irritation after laceration and eversion of the cervical lips. Under such circumstances the lesion consists of a hypertrophy of the cer- vical glands, the discharge being a hypersecretion. Actual infection of the cervix occurs in acute gonorrhoea and in post-partal, post-abortal, and post- operative infections. The acute disorder is usually accompanied by lesions that greatly overshadow it in importance, as, e.g., an acute endometritis, metritis, or cellulitis, or it may be but one of an associated series of lesions, as in gonorrhoea. A discussion of the acute cervical infections will be found under the head of Gonorrhoea, Chapter XXIX, and Pelvic Inflammatory Disease, Chapter XXI, to which the reader is referred. We are concerned here only with chronic cervical infections. This is most frequently of gonorrhoeal origin. A staphylococcus or a streptococcus infection, once the acute attack is over, rapidly subsides and gives little further trouble except in so far as it leaves behind tissue that has been either altered in form or permanently injured. The infectious agent, however, disappears. 223 224 GYNECOLOGY Chronic gonorrhoea of the cervix may, on the other hand, be exceedingly resistant to all forms of treatment, and may remain partially latent, but none the less infectious, for many years. In many cases the gonococcus is most difficult to find, and no history of gonorrhceal infection or exposure can be elicited. In some of these cases it is possible that the original infection took place during infancy. Chronic endocervicitis is evidenced by a thick, mucopurulent discharge, and an erosion of the mucosa about the external os. The more chronic the condition, the fewer in number the pus-cells, and in old cases that per- sist because of the hypertrophy that remains as the residuum of the previous inflammation, the discharge may consist almost entirely of mucus. Careful and repeated examinations of smears, however, made just before or just after menstruation, will usually show the presence of pus-cells and of gonococci. In addition to the discharge, which may be so profuse as to require the patient to wear a perineal dressing to protect the clothing, the menstrual Fig. 225. — Cervical polyp of large size projecting from the external os. FlG. 226. — Cervical polyps, showing origin from mucous plicae of the cervix. periods may be profuse and painful, and the patient may complain of a sense of weight and discomfort in the pelvis. The treatment should be directed toward establishing complete and easy drainage, and the employment of suitable disinfecting solutions. In the nulliparous woman, when the external os is constricted and the cervical canal becomes rilled with the thickened secretion, it will be found advan- tageous to split the lips of the cervix so as to expose the entire mucosa, thus insuring free drainage and permitting applications of disinfecting solu- tions to be made. The cervical mucus should be coagulated or toughened by applying a solution of silver nitrate, when it may be withdrawn from the canal with a dressing forceps. Another method is. to dissolve the cervical mucus by applying a 10 per cent, solution of sodium hydroxide. The mucosa being ex- posed, the disinfecting agent is then applied directly. Pure phenol, fol- lowed by alcohol and silver nitrate (10 to 20 per cent.) followed by salt solution, are the most effectual means of disinfection. Tincture of iodine, pure ichthyol or argyrol, 25 per cent., may also be tried. Such applications DISEASES OF THE CERVIX 225 should be followed by the introduction of tampons medicated with ichthyol, 25 per cent, in petrolatum. After the tampons have been removed, hot douches should be adminis- tered, and the treatment repeated three times a week. Under this method the discharge will usually subside. In obstinate cases operative treatment will be required. Curettage of the endometrium and cervix, together with the application of pure phenol, followed by alcohol, may be sufficient. If, Fig. 2: -Elongation and hypertrophy of cervix resembling prolapsus uteri. however, the cervical lips are hypertrophied or are the seat of Nabothian cysts, amputation should be performed. (See also Gonorrhoea, Chapter XXIX, for prognosis.) In obstinate endocervicitis Hunner recommends linear cauterization of the cervical mucosa with the electric cautery. Destructive cauterization of this type or deep cauterization by means of powerful chemicals is objection- able because of the scar tissue and stenosis that are prone to ensue. Cervical Polyp. — Polypoid outgrowths may occur from the mucous raem- 15 226 GYNECOLOGY brane of the cervix, varying in size from that of a pea to an English walnut. These little tumors are composed of a fibrous tissue stroma and contain glands that resemble those of the cervical mucous membrane (Fig. 225). The growths are, as a rule, pedunculated. They begin as localized hypertrophies of the mucosa that gradually increase in size and become pedunculated (Fig. 226). The polyp may be entirely concealed within the cervi- cal canal, or it may present at the external os or project from the cervix into the vaginal vault. Small polyps springing from the cervical canal are usually covered with high columnar epithelium ; those originating about the external os may exhibit surface epithelium of the squamous type. When the polyp is large and projects from the cervix, the surface epithelium is usually rubbed off by contact with the vaginal vault. If the polyp springs from the mucosa near the position of the internal os, the tumor may con- tain glands that resemble those of the endometrium more than those of the cervical mucosa. Polyps of considerable size are often extruded from the cervical canal, in which event the stretching of the pedicle may interfere with the blood supply of the growth, resulting in necrosis and gangrene. The symptoms consist of the discharge of a thick, mucilaginous secre- tion, occasionally streaked with blood, increased -menstrual flow, and intra- menstrual hemorrhage following defecation, coitus, or vaginal irrigations. The diagnosis is easily made : on exposing the external os a bright red tumor, varying in size from a pea to a walnut, will be seen projecting from, or lying within, the orifice. Rarely it may be necessary to dilate the exter- nal os before the polyp can be brought into view. The tumor may be grasped with forceps and removed by torsion or avulsion of its pedicle, or, if the pedicle is accessible, it may be ligated and the tumor removed with scissors. As these polyps not infrequently display a tendency to undergo malignant change, it is usually advisable, except in very young women, to administer a general anaesthetic, and, after removing the polyp, curette the entire uterus thoroughly, and examine both the polyp and the endometrial scrapings microscopically. Cancer of the Cervix. — See Cancer of the Uterus. Atrophy of the Cervix. — See Malformation of the Cervix. Myomata of the Cervix. — See Myomata of the Uterus. Stenosis of the Cervix. — See Pathologic Anteflexion of the Uterus. Tuberculosis of the Cervix. — See Tuberculosis of the Pelvic Organs. LACERATIONS OF THE CERVIX Pathology. — A tear of the thinned-out rim of the cervix occurs almost in- variably during the first stage of labor. Although the laceration is not, as a rule, very extensive and heals without leaving any ill effects, some widening of the external os and slight exposure of the cervical canal generally occur. Furthermore, in a woman who has borne children it is nearly always possible to detect scars upon the cervix (Figs. 228 to 231). Lacerations of the cervix usually take place to one side of the os, in the plane between the anterior and the posterior lip. A tear may affect only one side (uni- lateral) or both sides (bilateral) may be involved. Bilateral lacerations DISEASES OF THE CERVIX 227 may be accompanied by tears involving the anterior or the posterior lip, the combined laceration being designated as stellate (Fig. 232). In many instances extensive lacerations of the cervix are the evidence that forceps operations were undertaken without full dilatation of the cervix. When the laceration is bilateral or stellate, or unilateral and deep, the lips of the cervix are inclined to separate, somewhat like the split end of a stalk of celery (eversion) (Fig. 233). This separation of the cervical lips FlG. 228. — NulHparous cervix. FlG. 229. — Parous cervix; well Fig. 230. — Parous cervix; well healed bilateral laceration, plug of healed bilateral laceration, mucus in cervical canal. tends to prevent healing by first intention and granulation, and the entire or the greater extent of the wound undergoes cicatrization. This results in more or less permanent alteration in the shape of the cervix : the cervical lips remain separated, mucous membrane from the vaginal surface of the cervix or from the cervical canal grows over the lacerated surfaces, and a consider- able amount of scar tissue is formed beneath the mucosa, espcially at the angles or at the upper limits of the laceration. Fig. 231. — Deep unilateral lacera- tion with irregular tag of cervical tissue. Fig. 232. — Stellate laceration. As a consequence of the permanent eversion the cervix is increased in its anteroposterior diameter, and the cervical canal is exposed (Fig. 234). The exposure of the cervical mucosa and the traumatism to which it is subjected, especially if there is associated prolapse of the pelvic floor or dis- placement of the uterus, result in an irritation and hypersecretion of the cervical glands — the so-called " catarrh of the cervix." In many instances a low-grade inflammation of the mucous membrane is present, accompanied 228 GYNECOLOGY by occlusion of the gland-ducts and the formation of small growths which are known as Nabothian cysts. These vary in size from a pinhead to a pea, and rarely may be a centimeter or two in diameter (Fig. 235). Accompanying low-grade inflammation of the cervical mucosa there is often hypertrophy of the fibromuscular tissues of the cervix, which is par- FiG. 23.3. — Deep bilateral laceration with unequal division of cervical lips; e version. Fig. 234- — Deep bilateral laceration with ever- sion of lips, cystic degeneration and hyper- trophy. ticularly apt to be marked when Xabothian cysts are present (Fig. 234). Thus, in the course of events, and solely as the result of a laceration, the cervix may become considerably increased in size and in density. As the result of walking, defecation, urination, etc., the epithelium of the exposed surface mav be rubbed oft from certain areas that come in contact with the Fig. 235. — Xabothian cysts of cervix. Fig. 236. — Xulliparous cervix, exten- sion of cervical mucosa beyond ex- ternal os to vaginal surface of the cervix. The so-called erosion of Ruge and Veit. vaginal mucosa. This condition is known as erosion. As a rule, it is merely superficial, but in cases of prolapse, when the cervix projects from the vaginal introitus, it is exposed to external trauma and deep ulcers (decu- bitus) may form. DISEASES OF THE CERVIX 229 Hypertrophy of the Cervix. — Although hypertrophy of the cervix is usu- ally a sequel of laceration with eversion and low-grade infection, it may be due to other causes. Among these may be mentioned chronic endocervicitis with cystic distention of the glands, and displacement of the cervix, as in prolapse, with its resulting circulatory disturbance and exposure to trauma (Fig. 234). In some cases of prolapse hypertrophy, especially elongation, is more apparent than real. Inversion of the vaginal fornices and their close application to the descending uterus may resemble a true hypertrophic elongation, but if the patient is placed in the knee-chest position and the uterus is displaced upward toward the abdominal cavity, the actual length of the vaginal portion of the cervix can be determined by inspection of the vaginal fornices. Fig. 237. — Nulliparous cervix. No erosion and no laceration. The cervical mucosa is not exposed. Fig. 238. -Parous cervix. Deep bilateral laceration with eversion of the cervical lips and exposure of the cervical mucosa. Hypertrophic elongation of the vaginal cervix is occasionally observed in uninfected nulliparous women. The cervix projects well into the vagina, and may even present at the vaginal outlet (Fig. 227) ; when this occurs, inspection of the presenting part reveals nothing abnormal beyond elonga- tion ; i.e., the distance from the os to the vaginal fornices is considerably increased. The vaginal fornices maintain their original position, and the hypertrophic elongation affects the cervix below its vaginal attachment. Symptoms and Results of Laceration of the Cervix. — The common- est symptom of a lacerated and everted cervix is a leucorrhoeal dsicharge. This is somewhat thick and tenacious, and varies in amount, at times being scarcely more than noticeable, and at others being so profuse as to be a source of constant annoyance. When there is no infection it may 230 GYNECOLOGY be made up of mucus alone, but when an infection exists it consists of mucus mixed with pus. When endocervicitis, Nabothian cysts, and hypertrophy complicate the laceration, the menses may be profuse and painful. As a matter of fact, lacerations of the cervix associated with hypertrophy and Nabothian cysts are frequently accompanied by displacement of the uterus and relaxation of the perineum, so that, in addition to the symptoms men- tioned, the patient presents those of displacement and loss of support. Diagnosis. — Upon inspection the rounded, knob-like normal cervix cov- ered with mucous membrane of the same color as the vaginal vault is no longer visible, but in its stead the cervix is seen to be more or less ellipti- form in outline ; the anterior and posterior lips diverge, and the bright red mucosa of the cervical canal, which contrasts sharply with the duller hued mucosa of the vaginal cervix, is exposed (Fig. 239). At first sight, this presents the appearance of an ulcerating surface. The cervix and vaginal vault frequently are bathed with a profuse dis- charge, which, if there is no infection, may be clear and gelatinous — pure mucus ; or, if the opposite is true, it may be yellowish and almost entirely purulent. Some- times the cervical mucosa has overgrown the angles of the laceration, so that many varia- tions in the appearance of the cervix may occur. If there are Nabothian cysts (Fig. 235) sago- or tapioca-like bodies may be seen embedded in the cervix ; these have a slightly bluish, translucent appearance, shimmering through the surface of the mucosa, and feel- ing like shot embedded beneath it. The formation of Nabothian cysts is fre- quently accompanied by hypertrophy, so that Fig. 239- — Deep bilateral laceration, \ . t ,. , \ 1 1 i • with eversion of the cervical lips and the cervical lips become enlarged and their exposure and inflammation of the cervi- . .. j -1*7-1 .• j cai mucosa. density increased. When cystic degeneration is marked, eversion of the cervical lips and expo- sure of the cervical mucous membrane are less noticeable ; the outline of the cervix is rounded, but irregular, owing to the shot-like cysts, and the cervi- cal tissue is very hard and sclerotic. When badly lacerated and complicated by eversion and erosion, the cervix may, upon superficial examination, strongly resemble a beginning carcinoma or an ulcerative lesion of tuberculosis or syphilis. The exposed cervical mucous membrane may bleed slightly when touched by the finger or wiped with a pledget of cotton. Close inspection, however, will usually disclose the fact that the folds of the cervical mucous membrane are regular, and that the arbor-vitse-like arrangement of the plicae is preserved. Actual destruction of the mucous membrane and of the underlying tissues by ulceration probably never occurs unless carcinoma, tuberculosis, or syphilis is present. As previously noted, an exception may be made in cases of laceration associated with marked descensus or prolapse, when there may be an ulceration that is clearly the result of the mechanical insults to which the cervix is subjected. DISEASES OF THE CERVIX 231 The true nature of bilateral laceration with eversion may be shown by grasping each lip of the cervix at the junction between the bright red and the duller mucous membrane, and bringing these points together (Figs. 240 and 241). This manceuver temporarily restores the external os, and approxi- mates the anterior and the posterior lip. It causes a disappearance of the bright red mucosa, and demonstrates that it is nothing more than the ex- posed membrane of the cervical canal. When the eversion is associated with hypertrophy of the cervical lips, this test will fail. In such cases the diagnosis of a benign condition may be assumed from the fact that the tissue is not friable and that stony induration is absent. Nabothian cysts Fig. 240. — A test to show that the red. angry-lookins? surface is the cervical mucosa ex- posed by the eversion of the lips. Indication for trachelorrhaphy, not trachelectomy. Fig. 241. — Deep bilateral laceration. Eversion of the mucosa. Nabothian cysts and exposure of the cervical mucosa. Amputation (trachelectomy), not repair (trachelorrhaphy), must be selected here. are diagnosed by their appearance and by means of palpation ; in doubtful cases the diagnosis can be confirmed by puncturing the cysts, when their contents will be at once expressed. All lesions of the cervix of doubtful quality should be at once subjected to diagnostic curettage and excision of tissue. The technic of this procedure has been discussed elsewhere (page 121). Treatment. — The treatment of laceration of the cervix, with or without eversion, cystic degeneration, or hypertrophy, depends upon the extent of the tear, the severity of the symptoms, the age of the patient, and the pres- 232 GYNECOLOGY ence of associated lesions. In the active child-bearing period uncomplicated cases should receive only such local treatment as is required to render the patient comfortable. After the next puerperium trachelorrhaphy may be performed. In women approaching the menopause, a cervical disorder should be subjected to operation without delay. When operative treat- ment for other lesions of the reproductive organs or abdomen is required, a diseased cervix should receive surgical attention whether or not it is giving rise to acute symptoms. The symptoms of a diseased cervix (leucorrhcea, menorrhagia, dysmenorrhoea, etc.) may be so annoying and so little affected by palliative treatment that operation is indicated forthwith, whether fur- ther reproduction is contemplated or not. Except where the indications for operation are urgent, it is a good plan to try palliative measures before resorting to operative treatment. Applications of Churchill's tincture of iodine, made directly to the cervix, followed by the introduction, into the vaginal vault, of boroglyceride tampons and the use of hot douches, may relieve the congestion and tend to lessen the discharge. Nabothian follicles that project prominently may be opened with a bistoury and their cavi- ties swabbed with pure phenol. By this pre- paratory treatment the cervical tissues are placed in a condition that favors union by first intention after operation. QEdema, erosion, and cystic distention are temporarily relieved, giving the surgeon a better opportunity to esti- mate correctly the amount of tissue to be removed. The operative treatment consists of per- forming either trachelorrhaphy or trachelec- tomy — the former when there is no disease of the cervical muscle itself and the cervical glands have not undergone extensive cystic degeneration, and the latter when the cervical lips are hypertrophied and cystic degeneration is marked. The operation of trachelorrhaphy (Figs. 242, 243, and 244) first reproduces the cervical laceration, and then reforms the cervix by uniting the torn surfaces. Trachelectomy (Figs. 245, 246, and 247), or amputation of the cervix, actually removes the hypertrophied and diseased parts of the cervical lips, forms a new external os, and shortens the entire cervix (Fig. 247). Trachelorrhaphy is applicable only to lacerations that are accompanied by little or no hypertrophy, cyst formation, or infection of the cervix — in other words, to those in which a denudation of the original traumatized area and the introduction of sutures approximating the edges will restore the normal contour of the cervix. The actual removal of a part or of the entire cervix is demanded where trachelorrhaphy alone is not sufficient to remove the diseased tissue. Trachelectomy is also employed in connection with Fig. 242. — Trachelorrhaphy; repair. The apex of the angle of laceration on both sides is split to a point well above the scar tissue. DISEASES OF THE CERVIX 233 Hf.fc The operations for prolapse in women who have passed the menopause, in order to eliminate the cervix as a possible cause of recurrence. When it is al- lowed to remain, the cervix may act like the acorn tip on a bougie and serve to guide the uterus down through the vaginal tract. The removal of the cervix may, therefore, be one of the necessary operative measures selected in the treatment of prolapse. Whenever possible, trachelectomy should be avoided during the child-bear- ing period, as it predisposes to abortion in subsequent pregnancies and to dystocia in subsequent labor. The preliminary treatment of a diseased cervix by the ap- plication of tampons, puncture of cysts, etc.. will sometimes permit the surgeon to substi- tute trachelorrhaphy for trachelectomy. Trachelorrhaphy. — This operation is performed as follows: After the custom- ary disinfection of the operative area, the cervix is exposed with a Sims' speculum. The anterior and the posterior lip are each caught with a tenaculum in the median line, at a point that corresponds to the original location of the external os. The cervical lips are separated and the lacer- ated area is exposed. The area for de- nudation is now outlined by making an incision on either side of the median line of both lips, from the external os to the position occupied by the original external os (Fig. 242). The lines should be run parallel and be about one-quarter of an inch apart. They bound a strip of that width which is left undenuded, and which constitutes the lining of the reconstructed cervical canal. The parallel median in- cisions are continued from their anterior termination outward, along the border of the lacerated area to a point above its upper limit, the incision on the anterior and the one on the posterior lip joining on the lateral surface of the cervix, well above the angle of laceration, and close to the attachment of the vaginal fornix. The areas thus outlined are next denuded by means of tissue forceps and a scalpel or by sharp-pointed scissors. Particular care should be taken to remove all the tissue at the apices of the cervical tear. After a clean denudation on either side has been effected, sutures are introduced for the purpose of approximating the denuded areas of the anterior to those of the posterior lip. The first suture is introduced at a point directly opposite Fig. 243. — Tracnelonhapny; repair, vical lips are denuded except for a strip of mu- cosa in the midline of each one at the site of the new cervical canal. The sutures are introduced as indicated. Fig. 244.- 1 rachelorrhaphy upper sutures are tied; the repair. The two everted lips are be- ing approximated. The cervical canal has been almost entirely restored. 234 GYNECOLOGY the upper limit of the denudation. The needle is inserted into the mucous membrane of the vaginal surface of the cervix, being carried under the denuded area of the posterior lip, and emerges just on the border of the undenuded strip that is to form the new cervical mucosa. It is reintroduced at a point opposite on the anterior lip, and carried through in a reverse direc- tion to a corresponding point (Fig. 243). A succession of sutures is intro- duced from above downward until the entire length of the denuded area is approximated. After the sutures have been placed on one side, the same method is pursued upon the other. No sutures are tied until all have been introduced. The anterior and posterior lips of the cervix should be approxi- mated with only slight tension. When the sutures are tied, the external shape of the cervix will have been restored to its original form, the exposed Fig. 245. — Trachelectomy: amputation of cervix, showing the cervical lips split laterally to the level of the proposed am- putation; lines of excision of the cervical lips outlined. Fig. 246. — Trachelectomy; amputation of cervix. The cervical lips have been excised; flaps must now be brought together with sutures, so passed that there will be a new external os and that all raw surfaces will be covered. The groups of sutures are passed as marked alphabetically. and everted mucous membrane will no longer be visible, and the external os will be in its normal position (Fig. 244). Trachelectomy. — For the operation of trachelectomy the cervix is ex- posed, and each lip is caught with a tenaculum. The cervix is then pulled down, and an estimate is made of the amount of tissue to be removed. When considerable hypertrophy is present, and especially if the condition is asso- ciated with a marked descensus or a prolapse, a high amputation is per- formed. If, however, the patient is a young woman, and it is desirable to save as much of the cervix as possible, a low amputation is indicated. The difference between the two operations lies in the amount of cervical tissue that is removed, and in the position of the outer cervical incisions. If a high amputation is to be done, the operation is begun by making an incision completely around the cervix, dividing the vaginal mucosa at the point where it is reflected from the vaginal fornices over the vaginal cervix. DISEASES OF THE CERVIX 235 After this circumcision the vaginal tissue is separated from its attachment to the cervix all around, and as high up as it is desirable to amputate. The cervix is then split laterally to the corresponding point, and by means of a wedge-shaped incision that forms an inner and an outer flap, each lip is removed. In a low amputation the wedge-shaped incision and the formation of flaps are carried out without a preliminary detachment of the vaginal for- nices from the cervix, the line of amputation falling well within the cervico- vaginal junction. Whichever form of operation is selected, the plan of introducing the sutures is about the same. The object is to cover the raw surfaces and fashion a new external os. The first suture is intro- duced in the median line posteriorly (Fig. 246), the needle being carried through the cervical mucosa, passing to the depths of the wedge-shaped incision, and withdrawn and then reinserted, passed through the remaining posterior part of the cervical lip, and, in the case of high amputation, addi- tionally, the corresponding part of the posterior vaginal fornix. One suture Fig. 247. — iracnelectomy; amputation of cer- vix. Sutures tied; there is now a new external os and all raw surfaces are covered. ' is introduced on each side of this single median suture. Similar sutures are now introduced anteriorly, and the two sets together serve the purpose of uniting the mucosa of the vaginal surface of the cervix to the mucosa of the cervical canal, thus insuring the formation of an external os (Fig. 247). The lateral sutures are now introduced, their purpose being simply to ap- proximate the raw areas on either side. The first suture is the uppermost, and extends from a point on the posterior lip immediately behind the upper limits of the excision, beneath the raw area of the posterior lip, into the cervical canal. From this point it is reintroduced through the cervical mucosa, and made to traverse the tissues of the anterior lip in an opposite direction. This suture approximates and embraces the depths of the cervi- cal incision and is haemostatic. The other lateral sutures are introduced in a corresponding manner, but in a more antero-posterior direction, care being taken to have them pass beneath all the raw tissue. No sutures are tied until all have been introduced, unless the hemorrhage is marked, when the haemostatic suture may be tied at once. 236 GYNECOLOGY active hemorrhage from the wounded branches of the uterine artery and vein. In passing the haemostatic suture care must be taken lest the needle be passed so deeply as to catch the ureter. If the lines of incision are correctly placed, there is little tension on the sutures when they are tied. BIBLIOGRAPHY Emmet, Thomas Addis : " Surgery of the Cervix in Connection with the Treatment of Certain Uterine Diseases." Am. Jour. Obst., 1869, vol. i, p. 339 ; Ibid. : " Laceration of Cervix as a Frequent and Unrecognized Cause of Disease." Amer. Jour. Obst., Novem- ber, 1874 ; Ibid. : "The Proper Treatment for Laceration of the Cervix." American Practitioner, 1877, vol. xv, p. 1. Leonard, V. N. : " The Post-operative Results of Trachelorrhaphy in Comparison with Those of Amputation of the Cervix." Surg., Gyn. and Obst., 1914, vol. xviii, p. 35. Noble, C. P. : " Ectropion of the Cervix in Nulliparae Resembling Laceration of the Cervix." Amer. Gyn. and Obst. Jour., February, 1897, p. 135. Penrose, C. B. : " Congenital Erosion and Split of the Cervix Uteri." Amer. Jour. Med. Sciences, May, 1896, p. 503. Sims, J. M. : "Amputation of the Cervix Uteri." Trans. Med. Soc, State of N. Y., 1861, p. 367. CHAPTER XV CHANGES IN FORM AND POSITION OF THE UTERUS Normally, the axis of the body of the uterus forms an obtuse angle with the axis of the cervix. The body of the uterus is flexed forward on the cervix; this is known as anteflexion (Fig. 248). If the conditions are re- versed and the uterine body is bent backward on the cervix, the relation between the body and the cervix is known as retroflexion. When the axis of the entire uterus is turned forward, swinging on an imaginary transverse line passing through the cervix at the level of the internal os (Fig. 249), the uterus is said to be anteverted (Fig. 250). When the axis of the entire uterus is turned backward, the organ is said to be retroverted (Fig. 250). Fig. 248. — Diagrammatic sagittal section, showing Fig. 249. — Schematic outline, showing arc of imagin- normal anteflexion and anteversion of the uterus. ary circle through which fundus moves during ante- version and retroversion; also the point at the inter- nal os which represents the imaginary transverse- axis on which the fundus rotates forward or back- ward. The pull of the round ligaments forward above the axis and the pull of the utero-sacral back- ward below the axis have the same effect on the uterus; it maintains anteversion. Anteversion is usually combined with anteflexion, and both are normal ; retroversion is usually combined with retroflexion, and both are pathologi- cal (Fig. 251). Occasionally anteflexion is so marked or is accompanied by such ill or faulty development of the cervix as to give rise to certain symp- toms ; this is known as pathologic anteflexion (Fig. 252). The uterus may also be latero-flexed or latero-verted, or both combined, as the result of faulty development, from the pressure of tumors, or from the tug of adhe- sions or thickened ligaments. Anteposition, retroposition, and right or left latero-position indicate total displacement of the uterus forward, backward, or to one side by pelvic tumors, exudates, or adhesions. 237 238 GYNECOLOGY The uterus may be totally displaced downward. As soon as the uterus drops below its normal level in the pelvis the condition is termed descensus uteri (Fig. 253) ; when it drops further down, it is known as prolapsus uteri; Fig. 250. — The normal position of the uterus (A) ; extreme anteversion (B), and retroversion (C). The uterus remains anteflexed in all. The direc- tion of intra-abdominal pressure is indicated by the arrows. Fig. 251. — Retroflexion and retroversion of the uterus (broken lines). The uterus is turned back- wards on the imaginary transverse axis passing through the cervix; the axis of the fundus is flexed backward on the axis of the cervix. Intra-abdominal pressure strikes the uterus on its anterior wall. if the downward displacement is extreme, so that the uterus projects out- side the body, the condition is known as procidentia (Fig. 285). The normally anteverted and anteflexed uterus does not commonly undergo downward displacement. Preceding descensus the axis of the entire uterus turns backward and corresponds more or less with the axis of the vagina. In some cases this retroversion is very slight, and the uterus may still be anteflexed, but the uterine axis is sufficiently posterior to permit its descent. The uterus may be entirely elevated above its normal position by the traction of adhesions or the growth of a tumor. It may also form part of the contents of a hernial sac. The displacements of most practical in- terest and importance are pathologic ante- flexion, retroversio-flexion, descensus, and pro- lapse. In other forms of displacement the position of the uterus is, with few exceptions, entirely secondary to the associated pelvic lesion, as, for example, anteposition from the occupation of Douglas' pouch by an ovarian cyst, or elevation of the uterus by the tug of a subperitoneal fibroid fixed above the pelvic brim. Fig. 252. — Pathologic anteflexion with associated ill-developed cervix and nar- row canal CHANGES IN FORM AND POSITION OF THE UTERUS 239 PATHOLOGIC ANTEFLEXION OF THE UTERUS Pathology. — Anteflexion is regarded as pathologic when it is of marked de- gree and accompanied with sufficient obstruction of the cervical canal to cause dysmenorrhcea and sterility (Fig. 252). At times the cervical canal is abnormally narrow, although the anteflexion of the uterus, as determined by bimanual examination, is not more marked than usual, and occasionally, even though the anteflexion seems more marked than normal, symptoms of obstruction may not exist. Cases of exaggerated anteflexion are usually Fig. 253. — Retroversion. Slight flexion and descensus and beginning of prolapse: pressure on rectum; hemorrhoids and constipation. The pressure of the uterus on the rectum causes an accumulation of fseces, and this in turn aggravates the descensus of the uterus. Rectocele and cystocele. associated with shortness of the anterior wall (Fig. 255), a small uterus, and a long, conical imperfectly developed cervix. The ligaments of the uterus may be in a state of spastic contraction, whereby the strong for- ward pull of the fundus by the round ligaments, the traction backward of the uterosacral ligaments on the isthmus, and the forward fixation of the cervix by a short anterior vaginal wall combine to form an acute angle between the uterine cavity and the cervical canal. Furthermore, when this spasticity is relieved by anaesthesia, the degree of flexion is diminished and the amount of stenosis or obstruction of the cervical canal is less marked. 240 GYNECOLOGY Symptoms. — The symptoms in pathologic anteflexion may be due not only to obstruction of the cervical canal, but also, in part, to a faulty development of the uterine muscle (too great a proportion of fibrous tissue), or of its vascular and nervous supply (see Dysmenorrhoea). The condition is usually- congenital, and the symptoms commonly appear with the onset of menstrual life. 1 The principal symptoms of pathologic anteflexion are dysmenor- rhoea and sterility. Pain begins a few hours to a day before the onset of the menstrual flow, and may be exceedingly severe for the first six to twelve hours of the flow, after which it gradually subsides. In addi- tion to this form of pain, typical of obstruction, there may be the more continuous distress, lasting for several days, which is the result of an asso- ciated imperfect development of other pelvic structures. Similarly the Fig. 254. — Schematic outline . showing uterus in normal position, ante-position and retroposition. There is no change in the normal anteflexion or anteversion but the uterus is bodily pushed for- ward, (A) or backward, (B). This is almost always the result of pelvic tumors lying in front of, or back of. the uterus. Fig. 255. — Schematic, outline showing the influence of a shortened anterior vaginal wall in the produc- tion of a retroflexio- version of uterus. Cervix pulled forward causes the uterus to turn backward on its transverse axis passing transversely through the cervix ; as soon as the backward displacement begins intra-abdominal pressure strikes the anterior wall of the uterus and presses the fundus further backward. sterility, although primarily ascribed to stenosis of the cervical canal, may be the result, in part, of faulty development of the uterine body, imperfectly developed ovaries, or abnormal tubes. 1 Reynolds declares that in many cases of hypoplasia of the uterus — so-called infantile uterus — there is a corresponding lack of development of the anterior vaginal wall, and of a fascia, described by Goffe, which runs from the cervicovaginal attachment to the pubic arch on each side of the urethral canal. This is a Y-shaped ligament, which holds the cervix forward in its vaginal position. The uterosacral ligaments attached above this posteriorly pull back on the supravaginal cervix. The round ligaments tilt the fundus forward, thus producing angulation in the supravaginal cervix. When menstruation occurs, the uterus attempts to straighten out and relieve the angulation. This can occur only by relaxation of the yielding supports, i.e., the round ligaments which are in part muscular. To relieve this condition Reynolds proposes to lengthen the anterior vaginal wall by making a transverse incision in the vaginal mucous membrane, split the fascial bands of Goffe transversely, and suture the wound longitudinally. The cervix is then subjected to a Pozzi or a Dudley operation, or a simple splitting is performed, and the uterus sus- pended by a round ligament operation. This investigator makes a strong point of noting the motility or mobility of the cervix in such cases, and advises that this plan be -followed in all such cases so that the cervix will drop back into the posterior vaginal fornix. CHANGES IN FORM AND POSITION OF THE UTERUS 241 Diagnosis. — A simple digital vaginal examination shows the cervix to be well back in the vagina, small in size, and conic in shape, with a minute depression in its extremity that marks the site of the external os (Fig. 120). In front of the cervix, through the anterior vaginal wall, the angle of flexion between the body of the uterus and the cervix may at times be made out. The cervix points forward directly in the axis of the vagina. On bimanual examination the vaginal finger pressed upward from the anterior vaginal wall, and the abdominal fingers pressed downward above the symphysis pal- pate the body of the uterus in an- teflexio-version between them. '„ The angle between the cervix and the body is markedly acute (Fig. 124). The entire uterus is small, or the body is disproportionately small, whereas the cervix is long and nar- row. As a rule, the adnexa show no abnormalities. Examination by the aid of a speculum confirms the existence of the conic cervix and the minute external os. The degree of steno- sis of the cervical canal, and espe- cially of the angle of flexion, is difficult to estimate without pass- ing a sound, but this is usually unnecessary, since the diagnosis can be made from the symptoms and as the result of the examina- tion previously detailed. The diagnosis of pathologic anteflexion and stenosis must sometimes be based on the symp- toms, since the anatomic changes are not well marked. Given the symptoms of stenosis of the cer- vix, dysmenorrhosa, or sterility, even moderate alterations in form justify the diagnosis. Prognosis. — The prognosis depends upon the effectiveness of the treat- ment in overcoming the cervical stenosis, as well as upon the associated conditions. The most effective method of overcoming cervical stenosis is by means of dilatation and the introduction of a cervical stem. If the symp- toms are due to obstruction alone, the proportion of cures following this treatment will be large. If general ill development of the pelvic structures and other associated causes of dysmenorrhoea and sterility are present, the prognosis is doubtful. As it is difficult to make an exact differentiation in all cases, and impossible in some, the prognosis should always be guardedly 16 Fig. 256. Divulsion of the cervix. Rapid, with branched metal dilators of Goodell. 242 GYNECOLOGY favorable. . In two-thirds of carefully selected cases, however, cures may confidently be expected. Treatment. — The treatment of pathologic anteflexion should be both general and local. General treatment is essential, since a depressed mental state may lead to an exaggeration of what may be termed normal menstrual distress. In a large number of healthy normal nulliparae pain is present for a few hours at the beginning of the menstrual periods. This may be quite severe, but is not unbearable, and the patient may seek relief in a sim- ple remedy, such as the local application of heat or a hot drink. In depressed conditions, on the other hand, a patient may find the menstrual distress unendurable, improvement again following a change of air and scene or pleasant recreation. It is desirable, therefore, to raise the general well-being of the patient to the highest degree by the administration of tonics, regula- FiG. 257. — Dudley operation. Fig. 258. — Pozzi operation. tion of the bowels, careful oversight of the diet, and suitable outdoor exer- cise. If sterility is the principal indication to be met, the simple measures described in the treatment of sterility (Chapter XXXIII) should be tried before anything more definite is undertaken. Non-operative local treat- ment, for the purpose of developing the pelvic organs, has been advocated by some ; this is practically limited to the application of an aseptic intra- uterine electrode several times a week. In unmarried women this practice is to be condemned, but in the married the method may be tried although it is of doubtful value. After a thorough preliminary disinfection of the vagina and the cervix a sterile electrode is introduced into the uterus, and 10 to 12 milliamperemeters of the galvanic current are applied for ten minutes. This treatment may be repeated twice a week. The negative pole is placed in the uterus ; the positive, on the abdominal wall. As a rule, if general measures fail, the patient should receive immediate operative treatment. The classic operation for pathologic anteflexion con- CHANGES IN FORM AND POSITION OF THE UTERUS 243 sists in forcible dilatation of the cervix by means of the branched dilators of Goodell (Fig. 256) or the graduated sounds of Hegar. This operation must be performed under aseptic precautions, and as much dilatation as possible should be maintained for at least fifteen minutes, so that altogether about thirty minutes are consumed in the operation. Another plan to overcome the acute angle formed by the cervical canal is the method proposed by Dudley, which consists essentially of splitting the posterior lip of the cervix from the angle of flexion to the vaginal vault (Fig. 257). Pozzi has recently introduced a plan of operation by which a bilateral laceration of the cervix is made, thus imitating the effect of labor in removing an obstruction of the cervical canal (Fig. 258). The most satisfac- Figs. 259-260. — Norris drain in position (as here drawn the bulbous extremity of the stem reaches too far above the internal os). tory method for overcoming the acute angle of flexion and securing perma- nent enlargement of the cervical canal is the combination of thorough instrumental dilatation of the cervix and the insertion of a cervical stem, which is left in situ in the cervical canal for varying lengths of time. The form of stem that is most satisfactory is that devised by C. C. Norris (Figs. 259 and 260). This is made of hard rubber and in three sizes. The drains should be sterilized by boiling for fifteen minutes. After the cervix has been fully dilated the length of the uterine cavity should be determined, and care exercised in selecting the size that is suited to the case ; when the drain is in situ, the bulbous extremity should reach well above the internal os and the flanges at the butt should be closely approximated to the vaginal cervix. The drain is made flexible by immersion in boiling water and bent slightly forward ; after fixing the shape in cold water, the drain is introduced. Ex- 244 GYNECOLOGY perience has shown that the uterus will expel the drain unless it is fixed in position, and this should always be done by attaching the flange on either side of the butt to the cervix by means of a silkworm-gut suture. The drain may be allowed to remain in situ over two or three menstrual periods. It can easily be removed by snipping the silkworm-gut sutures. The introduction of the uterine stem must be preceded by the most careful examination under anaesthesia and the most rigid aseptic precautions. If there is any indication of adnexal involvement, or if evidences of inflam- matory disturbances in the uterus or pelvis are present, the use of the uterine stem is absolutely contraindicated. Three days after the operation the patient may be allowed to get up, but douches and tub- and sitz-baths must be prohibited for a month. After the stem has been in position for a time the danger of infection of the uterine cavity from douche or bath water is lessened, but as long as the drain is in place it is well to avoid the douche and to limit bathing to the hot or cold shower or sponge baths. Another method of securing effectual dilatation of the cervix is by means of an instrument known as the metranoikter. This apparatus is inserted with the patient under anaesthesia; after dilatation of the cervix the blades are released, and the instrument is left in place for twenty-four hours. This method gives rise to considerable pain, which must be controlled by opiates, but good results have been reported from its use. RETROVERSION AND RETROFLEXION OF TFIE UTERUS Pathology. — Retroversion and retroflexion of the uterus are usually com- bined (Figs. 250 and 251). The degree of version and the degree of flexion vary considerably. There are three degrees of retroversion ; in the first, the axis of the uterus points toward the promontory of the sacrum; in the second, toward the hollow of the sacrum, and in the third, toward the sacrococcygeal articula- tion. The amount of backward flexion is usually proportionate to the degree of version ; in some cases the angle between the cervix and the fundus is obtuse, whereas in others it is acute. In exceptional cases an anteflexed uterus may be retroverted and in descensus. The most common cause of retroversio-flexion is childbirth. After labor, when the uterus is heavy and the ligaments are lax and overstretched, the uterus may fall into a posterior position, due to the fact that involution of the organ itself or of its ligaments is interrupted (subinvolution), that the dorsal position is maintained too long, that the binder is too tight, or that there is too early resumption of activity on the part of the woman, which brings increased intra-abdominal pressure to bear upon the uterus and forces it down into the pelvis. These causes are often coincident. In such cases the uterus is enlarged and softened, and the ligaments are stretched and elongated both anterioi J y and posteriorly. The same conditions may obtain after abortion, miscarriage, or premature labor. Retroversio-flexion may be produced gradually after labor, as the result of the loss of support to the pelvic structures normally afforded by the perineal floor. The me- chanics of displacement from this cause are fully dealt with elsewhere CHANGES IN FORM AND POSITION OF THE UTERUS 245 (page 264). Chronic constipation, with habitual distention of the sigmoid flexure, may exert a causative influence in certain cases of retroversio-flexion. Retroversio-flexion may also be congenital, in which case it is usually accompanied by shortening of the anterior vaginal wall, poorly developed round ligaments, and other developmental defects. In exceptional cases retroversio-flexion may be acquired as the result of heavy lifting or of un- usual exertion, which suddenly increases the intra-abdominal pressure. The sudden displacement that occurs in these cases may be accompanied by acute pelvic distress and other manifestations that subside in the course of a few days without the uterus being restored to its normal position. If these forces are brought to bear at a time when the bladder is fully distended with urine, they are especially prone to cause displacement. Under such conditions the intra-abdominal pressure may be exerted on the anterior instead of on the posterior wall of the uterus, in such a way as to drive the organ backward (Figs. 251 and 252). Falls or blows are said to be the cause of certain cases of retroflexio-version. While this is possible, its occurrence must be very rare. In aged multiparas the uterus is often retroflexed and ptosed, due probably to atrophy of the fundus and of the ligaments of the uterus. There is often an associated relaxation of the pelvic floor. Moder- ate degrees of uterine displacement taking place in active reproductive life may become exaggerated about the time of the menopause, owing to an atrophy of the ligaments of the uterus and of the muscles of the pelvic floor. Many of the patients who at the menopause develop symptoms of pelvic floor relaxation and its sequelae — cystocele, rectocele, and prolapse — never manifest subjective symptoms of these disorders previous to that time. The pregnant uterus may turn backward into retroversio-flexion or pregnancy may occur in an already retroversio-flexed organ. The size of the uterus varies. In puerperal cases it is large at first, but after the condition has persisted for some time, the uterus may undergo a certain amount of shrinkage. In displacements that occur slowly following the puerperium and that are due to a lack of support of the pelvic diaphragm, no decided enlargement may be present. In traumatic cases and in nulli- parous women the uterus may not be larger than normal. In congenital retroflexion the organ is often undeveloped, and in addition to the posterior flexion, the fundus may be flexed to one side. Retroversio-flexion is often accompanied by a certain amount of torsion, so that the body of the uterus is rotated on its long axis to the right or the left. In retroflexio-version the adnexa are invariably, and, as a matter of course, lower in the pelvis than normal. Usually they occupy a lateral position, but in some cases one or both of the ovaries may lie low down in Douglas' pouch, slightly to one side of the median line, in close relation to the fundus. The pregnant retroversio- flexed uterus, if uncorrected, either slowly rights itself and rises out of the pelvis, or becomes incarcerated beneath the sacral promontory and is finally emptied by abortion. In persistent retroversio-flexion the pressure of the uterus upon the rectum and upon the ovaries and tubes may result in the formation of adhesions be- tween these structures. At times an acquired displacement is coincident with inflammation of the adnexa following septic labor, or it may even be 246 GYNECOLOGY secondary to such conditions, the displacement being due to the traction of adhesions between the fundus of the uterus and the peritoneal surfaces of Douglas' pouch. Other factors concerned in displacement of the uterus will be considered more fully when dealing with descensus or prolapsus, since retroversio- flexion is usually the first stage of both. Symptoms. — The symptoms of retroflexion consist of backache, a sense of weight in the pelvis, pressure about the rectum, painful and prolonged Fig. 261. — Sagittal section, showing uterus in extreme retroflexion, causing pres- sure on the rectum and traction on the bladder: constipation and vesical irritability. menstrual periods, and leucorrhcea (Fig. 261). In exceptional cases retroflexion has been the only lesion present to account for headache and various reflex symp- toms, such as nausea and vomiting. Bladder symptoms, such as frequent or pain- ful micturition, may occur, and constipation is often marked, the patient com- plaining of a sensation as though an obstruction to fecal evacuation existed. Retroversio-flexion may, when the angle of flexion is acute, pre- vent conception. It is also a frequent cause of miscarriage. Leucorrhcea usually depends upon hypertrophy of the uterine mucosa with hypersecretion, brought about by congestion of the pelvic blood- vessels and possibly as the result of some obstruction to free drainage if the CHANGES IN FORM AND POSITION jOF THE UTERUS 247 angle of flexion is acute. Menorrhagia may be a prominent symptom, espe- cially if hypertrophy of the endometrium and subinvolution are present. The woman may complain of pain in the lower abdomen, on one or both sides, and this is especially marked if, associated with the retroflexion, there are adhesions that bind the uterus and the adnexa together or if one or both of the ovaries lie in Douglas' pouch. If but one ovary is prolapsed, the pain may be especially marked on that side. Under these circumstances dys- pareunia may be present, Dysmenorrhea usually persists throughout the menstrual period, the pain being due to the marked congestion of the uterus occurring at this time; gradually becoming less severe as the period subsides, occasionally persisting for a few days after the flow has ceased. If the angle of retro- flexion is acute, the menstrual pain may be of the obstructive type, i.e., most severe shortly before the appearance of the flow. The majority of the symp- toms are relieved when the patient is quiet and at rest, and most of them are exaggerated by the erect position, walking, or working. Vesical symp- toms, abdominal distress, and backache may be relieved by rest in the recumbent posture. Diagnosis. — Simple digital examination discloses the fact that the cervix is well forward in the vagina, and nearer than normal to the vaginal orifice. If the finger is pressed upward in front of the cervix, the uterine body can- not be felt; if it is carried back of the cervix, a rounded body (the fundus) can be outlined, and between it and the cervix an angle of flexion can be made out (Fig. 121). Bimanual examination confirms and amplifies these find- ings. The fundus cannot be palpated between the vaginal finger pressed upward on the anterior wall in front of the cervix and the abdominal fingers dipped down above the symphysis. If the vaginal finger is passed posteriorly and pressed against the fundus, and the abdominal hand is. dipped downward deep into the pelvis, just below the sacral promontory, the body of the uterus may be grasped between them (Fig. 125). The examination of a case of retroflexio-version of the uterus is not complete until it is ascertained whether the position of the organ is fixed, i.e., whether or not the uterus is adherent. An effort should at once be made to replace the organ (vide infra). This should be done with the utmost gentleness, especially in those cases in which the adnexa appear to be enlarged or fixed. There are some pelvic disorders that may simulate a retroversio-flexion of the uterus. Thus a fibroid springing from the posterior uterine wall, a hsematocele, a small ovarian cyst, or, indeed, any rounded adnexal tumor occupying the bottom of Douglas' pouch must be differentiated. The vaginal finger alone may be unable to detect the difference between them, but upon making bimanual palpation the body of the uterus can be outlined in front of the mass lying in Douglas' pouch and bulging the posterior vaginal fornix (Fig. 126). In certain obscure cases the passage of a sound may be required to settle the question. Treatment. — For the individual case of retroflexion of the uterus the treatment to be selected depends upon the condition of the pelvic floor, the 248 GYNECOLOGY mobility of the uterus, and the state of the adnexa. If the pelvic floor is sound, a pessary may be introduced to support the uterus, provided the latter can be replaced and maintained in a normal position and no abnor- malities of the adnexa are present. Even if a certain degree of relaxation of the pelvic floor exists, there may be enough support to retain a properly selected Smith pessary in correct position. If the pelvic floor is so greatly relaxed that a pessary cannot be kept in place ; if there are adhesions that prevent replacement of the uterus, or if the adnexa are diseased, operative treatment alone can be considered. During the active reproductive period a pessary should, if possible, be used. (See Selection and Preparation of Cases for Operation, Chapter XXXV.) The degree of support afforded by the perineum and the existence of adnexal tumors can be quickly and easily ascertained by the usual methods of examination. Whether or not the uterus or the adnexa are adherent is Fig. 262. — Replacement of retroflexio- version of the uterus. The cervix is grasped with a tenaculum. Fig. 263. — Replacement of retroflexio- version of uterus. The uterus is straightened out and the angle of flexion diminished by traction on the tenaculum. usually determined by the success or failure of the method used to replace the uterus. In simple cases, when the abdominal wall is neither fat nor rigid and the patient is not excessively tender, the uterus may be replaced by pushing up the fundus through the posterior vaginal vault, then pressing the cervix backward by the fingers placed in contact with the anterior sur- face of the cervix, at the same time engaging the fundus with the abdominal hand and drawing it gently forward. If the abdominal walls are fat or rigid ; if the patient is hypersensitive or easily frightened ; or if the uterus is large and heavy, this simple plan may fail, even though no adhesions are present. Under such circumstances the following method has usually been successful : The cervix is grasped with a double tenaculum and pulled down toward the vaginal orifice ; this maneuver straightens out the angle of the retroflexion, and brings the fundus within easy reach of the forefinger introduced into the rectum. Holding the cervix down, the fundus is now pressed upward by the rectal finger until the angle of posterior flexion is overcome, or the uterus CHANGES IN FORM AND POSITION OF THE UTERUS 249 is anteflexed. With the rectal finger in position the cervix is now pushed backward toward the hollow of the sacrum by the attached tenaculum, and an attempt is made by the abdominal hand to engage the posterior surface of the uterus through the abdominal wall. The tenaculum is now removed from the cervix, but the posterior position is maintained by pressing back- Fig. 264. — Replacement of retroflexio- version of Fig. 265. — Replacement of retroflexio-version of uterus, uterus. The index finger in the rectum pushes the The cervix is now pushed back into the hollow ot the fundus upward, entirely correcting the retroflexion, sacrum as far as it will go. anteflexing the uterus and beginning anteversion. Fig. 266. — Replacement of retroflexio-version of Fig. 267. — Replacement of retrofiexio version of uterus. The tenaculum has been removed. The uterus. By further pressure on the cervix backwards index finger of the vaginal hand continues pressure and pull on the fundus forwards, the uterus is backwards on the cervix; the fingers of the abdomi- brought into slightly exaggerated anteflexion and nal hand engage the fundus and pull it forward. anteversion. ward upon the cervix with the fingers of the left hand, while with the right hand the efforts to engage the posterior surface of the uterine body are continued, and the body is drawn gently upward and forward (Figs. 262 to 267). Occasionally, in order to avoid the sacral promontory, it is advisable to push the fundus to one side or the other of the median line with the rectal finger. In some cases in which this procedure is not successful the failure 250 GYNECOLOGY is due not to adhesions, but to the rigidity of the patient, or the thick- ness of the abdominal wall. In other cases there are slight adhesions that can be stretched by gradual replacement of the uterus with tampons. Consequently, if the effort at replacement fails, in spite of the fact that the history, associated symptoms, and absence of adnexal enlargement make adhesions or associated inflammatory conditions improbable, the gradual replacement method may be tried before operation is undertaken. This method consists of pushing the uterus bimanually to as nearly a normal position as possible, without using force or inflicting pain, and then placing the patient in the knee-chest position and packing the posterior vaginal vault with tampons in order to maintain, for a time, the gain that has been made in replacement (Fig. 268). The tampons are saturated with a 25 per cent, solution of glycerite of boroglyceride. This solution exerts a hygroscopic effect on and has a ten- dency to deplete the uterine vessels and to reduce the size of the uterus. In this way, usually after three or four treatments, or in the most stubborn cases after seven or eight, the uterus may be fully replaced without tension to its normal position, and a pessary can then be inserted. Much depends on the fitting of a pes- sary ; if properly fitted, it will do its work well and the patient will be comfortable, whereas under the opposite conditions it may fail utterly. Even though the uterus can easily be replaced, at the first exami- nation it is a good plan to use tampons Fig. 268.— The patient in the knee-chest position and several times before employing the pes- the vaginal fornix packed with tampons. 1 . ' ° sary. this preparatory treatment im- proves the condition of the mucous membrane and accustoms the patient to the presence of a foreign body in the vagina. The most suitable form of pessary for the treatment of retroversion is the Smith. This pessary is furnished in five sizes. The most important measurement to ascertain before selecting the pessary for the individual case is the distance between the posterior vaginal fornix and a point on the anterior vaginal wall a half inch within the external urinary meatus. This distance may be estimated by the first finger, or, if preferred, by means of a pair of dressing forceps and a cotton pledget. The width of the pessary, which is greatest at the upper curvature, is proportionate to the length, so that if the pessary is of the proper length, its width will be satisfactory. The desirable width may be determined, if necessary, by separating the blades of a pair of dressing forceps in the vaginal fornices, so that the blades im- pinge upon the lateral vaginal walls ; the amount of separation between the handles is then measured. After withdrawing the forceps the separation may be restored and the desired information obtained. CHANGES IN FORM AND POSITION OF THE UTERUS 251 After selecting the size that appears to be suitable, the pessary is intro- duced in the oblique axis of the vagina (Figs. 269 and 270), the upper part being inserted as far as the cervix. With the forefinger the upper bar is then depressed beneath the cervix, so that the vaginal cervix lies within the greater curve. If the pessary is of proper size, the lower bar will be in con- tact with the anterior vaginal wall at a point where elevation allows it to Fig. 269 — Introducing a pessary. The patient in the dorsal position; the sulcus on one side is retracted with the first finger. The pessary is introduced in the oblique diameter. ride easily back of the symphysis without pinching the urethral tissues between it and the pelvic arch. Furthermore, it should be possible to pass the finger without difficulty between the lateral bars of the pessary and the vaginal walls, and the vaginal vault should be comfortably spanned, but not stretched. If the vaginal vault is put on a tension, if the patient complains of pain when the finger is passed between the pessary and the vaginal wall, 252 GYNECOLOGY or if, on pressing the anterior bar upward, the pessary does not ride easily behind the symphysis, then a smaller size must be selected. If, on the con- trary, the pessary is so small that it lies loosely in the vagina or does not fit the vaginal vault snugly and ride up well back of the cervix, or if, upon straining, there is a tendency for the pessary to come out, a larger size should be selected. When the vault of the vagina is low, a modification of this form of pes- sary, known as the Emmet, may be found more suitable than the Smith, and occasionally, if there is some relaxation of the vaginal outlet, the Hodge pessary, which has a broader lower bar, may be found more effective. In extreme cases of retroflexion, when the vaginal vault is very roomy and the pelvic floor is relaxed, a ring pessary may be the only form that can be used. Such cases are more properly classed under the head of descensus or prolapsus uteri, and the plan to be "adopted will be considered in connection with the treatment of these lesions. After the pessary has been introduced it may be advisable in some cases to place the patient in the knee-chest position and to re- tract the posterior vaginal wall; this is done for a double purpose — first, for inspecting the vaginal vault to see that the upper bar of the pessary is in its proper place, and secondly, to allow the intestines to gravitate out of the pelvis so that, upon resuming the erect or recumbent position, there will be Fig. 270.— Schematic diagram illustrating no knuckle of gut between the anterior sur- mechanics of pessarj r . The posterior vaginal r r . , 1,11111 r wall stretched over the upper transverse bar face of the UterUS and the bladder tO faVOr a of the pessary pulls the cervix upward and . „„ „„„„ ^.C ±U ~ Al ^^.\„ ~~*~,n~,4- backward, thus throwing the fundus forward, recurrence of the displacement. The pessary imha^ Before a pessary is introduced one must always be sure that the uterus is in good position. The pessary does not act by pressing on the uterus itself, but by stretching the posterior vaginal vault and the uterosacral ligaments over its upper bar. This pulls back on the cervix and throws the fundus forward. In cases in which there has been prolapse of the ovary. care must be exercised in introducing the pessary ; in such cases, following the introduction of the pessary, the patient should be directed to assume the knee-chest position daily in order to prevent incarceration of the ovary in Douglas' pouch. After the patient has been properly fitted with a pessary, she should be directed to return at the end of twenty-four to forty-eight hours, when an examination should be made so as to determine positively that the uterus is held in good position, and that there is no undue tension of, or pressure upon, the vaginal walls. After that she may be directed to return at the end of a month, and should be told that if, in the meantime, she experiences pain or discomfort, or if an unusual discharge appears, to consult a physician immediately, or, if this is impossible, to remove the pessary herself. As a rule, douches are unnecessary and contraindicated while the pessary is CHANGES IN FORM AND POSITION OF THE UTERUS 253 worn. If an occasional douche is needed for purposes of cleanliness, sterile water or a very weak solution of lysol (i : 200) may be used. At the end of a month or six weeks the pessary should be removed for twenty-four hours, when, if the displacement has recurred, the uterus should be returned to its proper position and the pessary reinserted. This plan should be repeated every month or six weeks. In recent cases, following Fig. 271. — Alexander's operation. (Kelly and Xoble, Gynecology and Abdominal Surgery. W. B. Saunders Co.) labor or miscarriage, the uterus will, as a rule, remain in place at the end of three or four months. In some cases a longer time is required for the ligaments to undergo involution and hold the uterus securely. If a cure is not accomplished at the end of six months, the patient may choose between wearing the pessary indefinitely or submitting to an operation. (See Selec- tion of Cases for Operation, Chapter XXXV.) The treatment of a pregnant retroversio-flexed uterus consists of re- 254 GYNECOLOGY placement and the introduction of a pessary. If the case is seen early and there is no immediate danger of incarceration, the assumption of the knee- chest position twice daily may be sufficient. The uterus may gradually right itself, after which a pessary should be introduced. If this plan fails, or if incarceration is imminent, an attempt should be made to replace the uterus at one sitting by the usual methods, except that the cervix should not be caught with a tenaculum. It may be necessary to use general anaes- thesia before success can be achieved. The operative treatment of retroversio-flexion of the uterus consists of shortening some of the ligaments of the uterus or attaching them or the uterus itself by sutures directly to a neighboring organ or to the abdominal median line H.^ecKer Fig. 272. — Ventrosuspension. (Kelly and Noble, Gynecology and Abdominal Surgery. W. B. Saunders Co.) parietes. One of the earliest methods of treatment, and one that is still applicable in young women or in uncomplicated cases of retroversio-flexion in women of all classes, is shortening of the round ligaments as they lie within the inguinal canal. This is commonly known as Alexander's opera- tion (Fig. 271). The scope of this operation is limited, since in young women surgical measures for the correction of retroflexion are not fre- quently employed ; moreover, when operative treatment of this condition is required, the retroversio-flexion is often accompanied by some intra- abdominal condition that needs correction ; or the patient may declare that if she is to undergo an operation, the appendix should be removed at the same time. One of the chief advantages of the Alexander operation, when it was CHANGES IN FORM AND POSITION OF THE UTERUS 255 Fig. 273. j -Coffey's operation, bteos i and 2. Fig. 274. — Coffey's operation. Steps 3 and 4. After step 4 the peritoneum of the anterior leaflets of the broad ligament is drawn over the suture line of the round ligament and attached to the uterus by a continuous suture. 256 GYNECOLOGY Fig. 275. — Webster-Baldy operation. Steps* i and 2. Fig. 276. — Webster-Baldy operation. Step 3. CHANGES IN FORM AND POSITION OF THE UTERUS 257 first employed, was due to the fact that the peritoneal cavity was either not at all or only very little invaded. At the present time, with the perfection of aseptic detail, there is but little risk from a peritoneal opening, and if the patient objects to the scar of a median incision, the skin may be incised transversely just above the symphysis. Fig. 277- -Simpson operation. The skin and fat are retracted and freed from the f iseia of the rectus muscles on both sides of the lower extremity of the abdominal incision slightly below the level of the internal ring. The fascia is incited for half an inch about one inch from the median border of the fascia on each side, the fingers inside the incision giving support. The intraperitoneal operations for the cure of retroflexion are numerous. A number of years ago ventrosuspension of the uterus, or the attachment of the fundus to the anterior abdominal wall, was the method usually adopted, and when the operation was correctly performed, the immediate results were excellent (Fig. 2J2). The opportunities for later sequelae of a serious nature are numerous enough to abandon this form of uterine sus- pension during the reproductive period. 17 258 GYNECOLOGY The unfortunate and grave sequela? of ventrosuspension were the conse- quence of a too firm attachment of the uterus to the abdominal parietes. This was due to the fact that the operator included the fascia of the abdominal wall in his suture, or, as the result of suppuration of the incision or from a peritonitis, the attachment became permanent and extensive. The ideal result of ventrosuspension properly performed is the production of a new ligament running from the fundus of the uterus to the anterior abdominal wall, and made up largely of peritoneal and subperitoneal cellular tissue, and a few muscle-fibers that have been gradually pulled away from the peritoneal surface of the anterior abdominal wall, to which the uterus was attached. It can readily be seen how this band may, to a certain extent, be a menace to the intestines, and in some cases intestinal obstruction has occurred. Many forms of operation for the shortening of the round ligaments have been suggested. The original Mann operation consisted simply in redupli- cating the ligaments upon themselves and suturing the reduplications to- gether. The three forms of round ligament operations that seem best adapted to the majority of cases are: First, the plan elaborated by Coftey (Figs. 273 and 274), which consists of reduplicating and attaching the round ligaments to the anterior surface of the uterus; secondly, the type of operation de\~ised by Simpson and used with great satisfaction by many surgeons, which consists of attaching the round ligaments to the abdominal parietes ; each ligament in turn is caught and pulled through a slit in the peritoneum close Cm\ to the internal ring, and then guided between the peritoneum and the anterior abdominal wall to the rectus muscle ; the fascia of the rectus muscle is perforated, and the ligament ^ is drawn through and attached by means of q sutures (Figs. 277-280) ; thirdly, the method ^ suggested by AYebster and Baldy, of drawing $ the round ligaments through the broad liga- ment to the posterior surface of the uterus and attaching them at this point (Figs. 275 and 276), an operation that is particularly . j suited to those cases in which the ovaries are Fig. 278. — Simpson operation. The liga- eSOeciallv low. ment is pulled up and a small snip made «t»i 1 r r c in the peritoneum of the anterior surface 1 he real test Ol all tvpeS Ot Operation for COr- of the broad ligament directlv beneath the . . traction suture. rectmg retroflexion ot the uterus is the errect the operation has on pregnancy and labor, and whether the displacement is likely tc recur during the puerperium. Fixation of the uterus may prevent the physiologic enlargement incident to pregnancy, and lead to abortion or overstretching and thinning of certain parts of the uterus. Fixation of the uterus has resulted in grave dystocia, requiring craniotomy or Cesarean section, or serious forceps operations. During the child-bearing period the uterus should never be fixed, but always suspended. When, however, the patient has passed the child-bearing age, it is advisable CHANGES IN FORM AND POSITION OF THE UTERUS 259 Fig. 279. — Simpson operation. A specially curved needle is now- passed through the fascial cut, between the muscle bundles to the peritoneum, beneath this to the internal ring, then under the peri- toneum of the anterior leaflet of the broad ligament and through the peritoneal cut. The traction suture ends are then threaded through the eye of the needle, which is withdrawn. Fig. 280. — Simpson operation. The round ligaments are sutured to the under surface of the fascia by three interrupted sutures of fine linen or catgut. These also close the fascial incision. 260 GYNECOLOGY to furnish permanent support, and the uterus may then be fixed to the anterior abdominal wall. This is accomplished by attaching the fundus of the uterus to the fascia of the abdominal wall (Figs. 287 and 288), in the manner to be de- scribed later, under the Treatment of Descensus and Prolapse, page 268. The uterus may also be suspended or fixed through a vaginal incision that invades the abdominal cavity through the uterovesical peritoneum. This plan is regarded as eminently satisfactory by those gynecologists who have had much experience with it, but its scope is limited, since the tubes and ovaries are not so well exposed to surgical treatment, and lesions of the vermiform appendix or other intra-abdominal affections that need correc- tion cannot be treated. Alexander's Operation. — The technic detailed by Noble should be fol- lowed. An incision about two and one-half inches in length is made from the spine of the pubes, a little above but parallel with a line between the spine of the pubes and the anterior superior spine of the ilium. The incision is carried through the skin, subcutaneous fat, and superficial fascia down to the external oblique. Each bleeding point is caught and ligated — this is a cardinal point in the successful performance of the operation, for if it is neglected the tissues become blood-stained and identification of the round ligament is rendered difficult. When the external oblique is exposed, the superimposed fat is detached throughout the length of the incision, and on each side of its median line for about 1 cm. The external ring is now located either by sight or by touch, and the external oblique muscle is divided in the direction of its fibers about as far as the internal ring. The borders of the divided external oblique are now retracted, and the internal oblique muscle is separated from Poupart's ligament by blunt dissection. This completely exposes the inguinal canal. The round ligament and the ilio-inguinal nerve are identified, and the nerve is drawn to one side. When the ligament is seen, it should be caught with a blunt hook and drawn out until the reflection of the peritoneum is seen. As the ligament is drawn out the reflection of the peritoneum is detached by means of blunt dissection. The amount of shortening can be determined by palpating the lower surface of the abdominal wall just above the pubes ; with experience the operator will be able to estimate this correctly by muscular sense. The peritoneum is opened in from 30 to 50 per cent, of the cases ; when this occurs the adnexa may be palpated through the opening. After the ligaments have been suffi- ciently shortened, the excess is cut away and the ligament is stitched to the fibers of the internal oblique and Poupart's ligament, the external oblique fascia being united over them as in the Bassini operation for the radical cure of inguinal hernia (Fig. 271 ) . If the peritoneum is opened, it should, of course, be sutured with fine catgut. If there is difficulty in locating the round liga- ment, the best guide is the internal ring. The operation is applicable only when disease of the adnexa and adhesions can positively be excluded. Its field of application is, therefore, quite limited. Ventrosuspension. — A low paramedian cceliotomy incision is made to the right of the median line. The lower end of the incision should reach the symphysis pubis. The peritoneum to the left of the incision in the lower angle of the wound is caught with artery forceps and pulled out of the CHANGES IN FORM AND POSITION OF THE UTERUS 261 incision and to the right. A needle armed with celloidin thread is now passed through the exposed peritoneum at the extreme lower end of the incision, the point of entrance being two centimeters from the edge of the peritoneum. In its sweep the needle embraces the adjacent preperi- toneal connective tissue and a few fibers of the rectus muscle and emerges about a centimeter to the left of its point of entrance. The needle is then passed through the fundus of the uterus, slightly posterior to a line between the uterine insertion of the tubes, picking up tissue one centimeter in depth and breadth. A second suture is passed in exactly the same manner as the first, but a centimeter above it (Fig. 272). After both sutures have been placed they are tied with care, a finger in the abdominal cavity preventing the coils of intestine from slipping between the fundus and the inner sur- face of the abdominal wall. In this operation none of the fixed constituents of the abdominal wall are included in the suspension suture, so that subsequent to the operation a gradual separation between the fundus of the uterus and the anterior abdom- inal wall takes place, and a new ligament is formed by traction from the parietal peritoneum and the few fibers of the rectus muscle embraced by the sutures. The technic described is similar to that employed in the method of McMonagle. It fixes the fundus directly in the median line, but places the point of attachment a couple of centimeters away from the line of peritoneal closure, so that in the event of suppuration of the incision — which very rarely occurs — the inflammatory process does not reach the suspension sutures. Ventral Fixation. — The object of ventral fixation is totally different from that of ventrosuspension. By ventral fixation the fundus of the uterus is permanently attached to the fixed structures of the anterior abdominal wall. This operation is never justifiable unless future conception is impos- sible. It consists in making a low median coeliotomy incision, pulling the uterus upward into the lower angle of the incision, and attaching the peri- toneum to the periphery of the fundus, thus making it extraperitoneal. The rectus muscle on either side of the incision is now separated from the under surface of the fascia and the fundus is attached directly to the fascia by two or more sutures of No. 1 forty-day chromic catgut (Figs. 287 and 288). Coffey's Operation. — Coffey has devised an operation (Figs. 27$ and 274) in which he utilizes the round ligament and a portion of the broad ligament. In performing this operation a low median coeliotomy incision is made. A point on the round ligament is selected the approximation of which to the uterine cornu, the uterus being held in proper position, makes the ligament between the internal ring and the point of approximation taut. The apex of the loop thus formed is then attached to the anterior surface of the uterus, about an inch below the insertion of the round ligament. At the point originally selected the ligament is then drawn over to the cornu of the uterus, and attached immediately below the insertion of the round ligament. The peritoneum of the broad ligaments between these two fixed points is united to the peritoneum of the anterior uterine wall by a running catgut suture. The same plan is carried out upon the opposite side. Simpson Operation. — This is performed as follows: A low median 262 GYNECOLOGY coeliotomy incision is made. A point on the round ligament is selected the approximation of which to the anterior abdominal wall holds the fundus of the uterus in good position. The round ligament at this point is surrounded by a strand of catgut (traction loop). Sufficient traction is made upon the loop to expose the anterior face of the broad ligament, the peritoneum of which is snipped just below the point of traction. The lower outer surface of the rectus fascia is bared for an inch to one side of the incision. A longitudinal cut one centimeter in length is made through the fascia, two centimeters or slightly more from the edge of the fascia, on a level with the internal abdominal ring, ex- posing the rectus muscle (Fig. 2jj). A long and especially curved blunt pedicle needle is passed through the fascial opening and the fibers of the rectus until it is felt immediately beneath the peritoneum ; it is then turned outward and made to traverse the extraperitoneal space between it and the abdominal wall and the anterior surface of the broad ligament, until it can be pushed through the opening made in the anterior leaflet of the latter, just below the point selected on the round ligament (Fig. 278). The ends of the catgut loop are passed through the eye of the needle and the needle is with- drawn. Traction on the catgut draws the round ligament under the peri- toneum across the anterior face of the broad ligament to the internal ring, beneath the peritoneum of the anterior abdominal wall, to the outer border of the rectus muscle, through the muscle, and to the fascial incision. The loop of the round ligament presenting in the fascial incision is sutured to the under surface of the fascia with three interrupted sutures of linen thread. The sutures do not surround but perforate the ligament peripheral to the central artery. The sutures are so disposed as to close the fascial incision at the same time that they attach the ligament. Webster-Baldy Operation. — Webster and Baldy have devised a plan of operation whereby the round ligament is drawn through the broad ligament below the utero-ovarian ligament, and attached to the posterior surface of the uterus (Figs. 275 and 276). This operation is of value prin- cipally in cases associated with marked prolapse of the ovary. A point on the round ligament of one side is selected which, when approximated to the cornu of the uterus, will make the round ligament taut from the internal ring to the uterine cornu. At the junction of the parallel limbs thus formed, a strand of catgut (traction loop) is passed around but not through the ligament. With the forefinger beneath the utero-ovarian ligament, a clear space in the ligament is now found, and the ligament perforated from behind forward with a curved blunt artery forceps. The points of the instrument are slightly separated, so as to stretch the opening, and the ends of the catgut strand are caught in the grasp of the forceps. The round ligament is now drawn through the opening in the broad ligament to the pos- terior surface of the uterus. The same procedure is carried out on the opposite side. The round ligament is sutured to the posterior uterine sur- face, about an inch below the fundus, with interrupted linen sutures. When the ligaments are greatly relaxed, the loops of the two round liga- ments may be united in the median line, or in some cases they may even be CHANGES IN FORM AND POSITION OF THE UTERUS 263 overlapped. Great care should be exercised to avoid puncturing the round ligament vessels ; the openings in the broad ligaments should be large enough to obviate constriction of the round ligament. The ligaments should not be drawn tight. The linen sutures should not surround the ligaments, but should be made to perforate them to the peripheral side of the central artery. All these precautions have as their object the preservation of the circulation in the round ligament. Shortening of the Uterosacral Ligaments. — Shortening of the uterosacral ligaments may be performed in conjunction with other operations of uterine suspension when the ligaments appear unduly relaxed, as is indicated by the fact that the cervix itself seems particularly low in the pelvis ; in other words, when, in addition to retroversion or flexion, there is well-marked descensus. After the round ligament operation is completed and any necessary pelvic treatment has been carried out. the patient should be placed in an exaggerated Trendelenburg position, and the intestines well packed out of the pelvis. The fundus of the uterus is held forward with a long, narrow retractor. A mattress linen suture is passed on each side from the posterior surface of the uterus, below the position of the internal os. through the uterosacral ligament, about 2-3 cm. from the uterus. When tied, this suture will usually give the necessary amount of shortening of the ligament, but it must be adapted to the individual case. One or more additional mattress sutures are then passed to secure approximation of the reduplicated part of the ligament and the posterior surface of the uterus below the position of the internal os (Fig. 289). DESCENSUS AND PROLAPSE OF THE UTERUS Etiology, Pathology. — The terms descensus and prolapse of the uterus im- ply a descent or a dropping of the uterus below its normal level in the pelvis. De- scensus frequently complicates retroversio-flexion of the uterus. Indeed, the first stage of descensus is, as a rule, preceded by a turning backward of the uterine axis (retroversion), and this is combined, as usual, with back- ward flexion (retroflexion). The causes of descensus are the same in kind as those that produce retroversio-flexion, but greater in degree. The in- competency of the uterine ligaments, the pelvic floor, and the abdominal Avail is more marked than in retroversio-flexion. The forces that normally hold the uterus at its proper level may well be illustrated by the two simple experiments in physics noted by Penrose. The abdominopelvic cavity may be compared to a glass cylinder filled with water, and closed above and below by the finger and thumb. Normally, the bottom of the abdominopelvic cavity is the pelvic floor, the top is the diaphragm, and the sides are made up of the anterior, posterior, and lateral abdominal and pelvic parietes (Fig. 281). If the thumb is removed from the bottom of the glass tube, the water does not run out, but is held in the cylinder by atmospheric pressure and by virtue of the unyielding walls and the finger securely closing the top. Similarly in the abdominopelvic cavity (Fig. 282), when the perineal floor is injured, if the parietes of the abdomen retain their strength, the retentive 264 GYNECOLOGY power of the abdomen tends to prevent a descensus of the pelvic and the abdominal viscera. If, however, the anterior abdominal parietes are relaxed and weak, instead of being strong and unyielding, a similar effect is exerted upon the pelvic viscera as if a section of the glass cylinder were replaced by rubber-dam which would yield to atmospheric pressure — some of the water would then be lost. The influence of relaxation of the pelvic floor on the position of the uterus may also be illustrated in the following way: Given a vessel filled with water at rest, a molecule of water some distance from the bottom of the vessel is pressed upon equally in all directions — that is, the pressure beneath is equal to the weight of the column of water above. The pressure from Fig. 281. — The pressure upon the uterus from all sides is equal; it has been compared to the equilibrium of a molecule of water in a vessel; the sides of the vessel are the pelvic and abdominal walls. The floor of the vessel is the pelvic floor. The uterine ligaments act simply as guy ropes. Fig. 282. — The pelvic foor is torn and the uterus is now a part of the floor of the pelvis; the intra-abdominal pressure on the uterus must be met by the ligamentous and other attachments of the uterus. The anterior ab- dominal wall is relaxed and the retentive power of the abdomen is impaired. below is maintained partly by the strength of the bottom of the vessel. The latter may be represented by the pelvic floor, the intervening water by the vagina, the cellular tissue surrounding it, and the bases of the broad liga- ments, and the molecule of water in equilibrium by the uterus. When the pelvic floor is relaxed, the introitus vaginse gapes, the vaginal walls are not in contact, and the support to the cervix is greatly impaired. Instead of resting on the pelvic floor, the cervix really becomes a part of the pelvic floor (Fig. 282). Intra-abdominal pressure acting upon the uterus and tending to force it downward must then be met largely by the strength of the uterine ligaments. Every act of the woman that increases intra- abdominal pressure tends to augment the strain upon the pelvic structures, so that they slowly give way and the uterus descends through the vagina. Another factor in the descent of the uterus is the pull upon the cervix by CHANGES IN FORM AND POSITION OF THE UTERUS 265 the unsupported vaginal walls. As a result of relaxation of the pelvic floor, before there is any descent of the uterus, a cystocele or a rectocele may be produced. Attempts at defecation and urination give rise to a protrusion of the anterior or the posterior vaginal walls, or both, as the case may be, and this exerts a downward pull upon the cervix. The predisposing cause of descensus and prolapse may be congenital deficiencies in the pelvic and uterine supporting structures. This explains the complete prolapse in nulliparous women which occasionally occurs in those who habitually work hard or do heavy lifting. Descent or prolapse of the uterus is frequently associated with viscero- FiG. 283. — Schematic outline, showing various steps in the development of procidentia uteri. The uterus turns backward as it begins to descend; downward displacement of the uterus becomes more marked after the axis of the uterus lies in the axis of the vagina. ptosis. The latter may be coincident, depending upon the same factors that produced the prolapse, or it may precede the condition and be an evidence of a general lack of tone in the ligamentous structures formed by the peri- toneal reflexions in the abdominal wall and in the pelvic diaphragm. The uterus has been said to undergo acute prolapse in a previously normal woman as the result of sudden and unusually violent increase of intra- abdominal pressure, as by lifting a heavy weight. Such an occurrence must be exceedingly rare. In apparent cases of this description it may be taken for granted that there was a preceding slow but progressive descent of the uterus, with overstretching of its supports, which at the time of the prolapse suddenly gave way and produced pain and other localizing symptoms. 266 GYNECOLOGY Descensus of the uterus progresses slowly (Fig. 283). As the uterus traverses the vagina the vaginal walls become inverted. When the cervix has fallen so low that it presents at the vaginal introitus, the condition is usu- ally known as prolapse (Fig. 284). The degree of uterine prolapse is best described by mentioning the posi- tion of the cervix (Fig. 283) — that is to say, prolapse of the uterus with the Fig. 284. — -Prolapse of the uterus; cervix presenting at the vaginal orifice. Vesical and rectal diverticula. cervix at the vaginal entrance, prolapse of the uterus with the cervix an inch outside of the vaginal orifice, etc. When the entire uterus is displaced beyond the introitus, the condition is known as procidentia. Preceding or accompanying the descensus and prolapse there are usually pouchings of the anterior vaginal wall with the bladder, and of the posterior vaginal wall with the rectum. These may be regarded as vesical and rectal diverticula. In rare cases, as the vagina becomes inverted, it becomes sepa- rated from the contiguous vesical and rectal walls, so that there may be CHANGES IN FORM AND POSITION OF THE UTERUS 267 complete prolapse of the uterus and total inversion of the vagina, without much participation of either the bladder or the rectum. Although the cervix may project beyond the vulva in some cases of pro- lapse, this does not necessarily signify that the body of the uterus is pro- 1 • Fig. 285. — Complete prolapse of the uterus with bladder diverticulum. portionately displaced. On the contrary, in numerous instances the cervix seems particularly prone to descend, whereas the body and the fundus remain more or less fixed. This results in a thinning and an overstretching of the supra- vaginal cervix ; when this occurs the condition is known as a partial prolapse of the uterus with supravaginal elongation and thinning of the cervix. 268 GYNECOLOGY Accompanying descensus or prolapse, any of the lesions of the cervix due to labor may be present. The cervix seems to show an especial tendency to become hypertrophied. This may be the result of mechanical irritation inci- dent to the displacement, or the hypertrophy may have been primary and in itself a contributing factor. In cases of total prolapse of the uterus, or procidentia, the projecting mass often forms a mechanical hindrance to walking. At those points where the pressure is greatest and most continuous the mucous membrane is likely to undergo ulceration. If a vesical diverticulum is present, there may be a constant residuum of urine in the bladder, which finally causes a low-grade cystitis. If a rectal diverticulum exists, hemorrhoids are prone to follow as the result of the difficulty in defecation thus occasioned. Symptoms. — The symptoms of descensus or prolapsus of the uterus de- pend upon the degree of displacement and upon the accompanying lesions. The most characteristic complaint is of a bearing-down sensation in the lower abdomen, with a feeling of loss of support, backache, and pain in the thighs, exaggerated by exertion, and relieved by the recumbent posture. With these symptoms there may be associated : frequency and profuseness of the menstrual flow from pelvic congestion; leucorrhcea from inflammation of the vaginal or the cervical mucosa and overgrowth of the endometrial glands ; and vesical and rectal irritability from vesical and rectal diverticula. Diagnosis. — The diagnosis of the milder grades of descensus is made upon the findings of digital examination — i.e., the cervix and the entire uterus are found at a lower level than normal. The vagina is usually short- ened, and the axis of the cervix corresponds directly with that of the vagina, the body of the uterus, as a rule, being in retroversion. The uterus may, however, be anteflexed, particularly when the round ligaments are strong and the cause of the descensus is chiefly due to a pull upon the cervix from below. In extreme degrees of descensus and of prolapse, the diagnosis can be made simply by inspection ; upon directing the woman to bear down, the cervix appears either close to or at the vulvar orifice, or the entire, uterus may protrude from the vaginal introitus. When the patient has been in bed for a time, the degree of descent may not be apparent at once, nor be rendered so immediately by the patient's efforts. Under such circumstances, if the cervix is caught with a tenaculum and gently drawn downward, the desired information will be secured. The presence of a rectal diverticulum can easily be determined by mak- ing a digital examination of the rectum ; the presence of bladder diverticulum can be determined by the introduction of a sound. It is always advisable to ascertain exactly, by means of bimanual palpation, the position of the fundus of the uterus, so as to determine whether or not one is dealing with a complete or a partial prolapse. Treatment. — The treatment of descensus of the uterus and prolapse de- pends upon the amount of downward displacement, the age of the patient, and the associated conditions. During the reproductive period the lesser degrees of descensus may be treated in the manner described for retroversio- CHANGES IN FORM AND POSITION OF THE UTERUS 269 flexion, with which they are almost invariably associated. In the more marked degrees of descensus and prolapse, a Smith or a Hodge pessary may be maintained in position only with difficulty, on account of the relaxed con- dition of the perineum. Although one of the types of ring pessary will hold the uterus up, it may not maintain it in anteposition, so that the treatment will be unsatisfactory. Furthermore, ring pessaries, with the exception of the simple hard-rubber forms, interfere more or less with coitus, and may be objectionable from that standpoint. With the exception, therefore, of the lesser degrees, in which the uterus can be supported and maintained in normal position by a Smith or Hodge pessary, operation is the treatment of choice. In aged women and in those who present some contrain- dication to operation, non- operative treatment must of necessity be adopted. The mechanics of support by a ring pessary differ from the action of the Smith or the Hodge pessaries (Fig. 286). The latter not only support the uterus in position, but they throw the fundus forward. The ring pessary finds its support in the walls of the vagina, the muscles of the perineal floor, and the rami of the pubes. If the diameter of the vaginal fornices ex- ceeds that of the vaginal introitus, a hard-rubber ring pessary may be used; it should be of such a size as to keep the vaginal fornices spanned, the tissues sur- rounding the vaginal outlet helping to vaginal introitus is very much smaller, Fig. 286. — The principle of support of a Menge pessary. The knob or rudder keeps the rim with its greatest diameter transverse to the axis of the vagina: in such relation as indicated at A, it requires a canal of larger caliber to permit its escape than when it turns edge- wise as at B ; in this position it can pass through a canal of consider- ably smaller caliber, C. hold the pessary in place. If the it may be impossible to introduce a hard-rubber ring pessary that will span the vaginal fornices. Under such circumstances a soft-rubber pessary that can be compressed at the time of introduction may be selected. When it is necessary to use a ring pessary that is more than two inches in diameter in a case of descensus or prolapse with cystocele, the hard- rubber simple ring type is not always satisfactory, for the anterior vaginal wall shows a tendency to prolapse through the ring. Under these circum- stances the disk form may be used with advantage. The broad surface of the disk forms a satisfactory support for the anterior vaginal wall and base of the bladder. 270 GYNECOLOGY When the diameter of the outlet is greater than that of the vaginal fornices, and the ring does not secure sufficient support from the vaginal Avails and pelvic floor, the difficulty may be overcome by utilizing the sup- port afforded by the bony arch of the symphysis and rami of the pubes. This can be a factor only Avhere the plane of the pessary is maintained more or less at right angles to the axis of the vagina — in other words, when it pre- sents its surface, and not its edge, at the vaginal outlet. The ordinary ring pessary will not maintain the desired position, but Menge has devised a form that overcomes this difficulty. This has, in addition to the ring, an attachable stem that lies in the axis of the vagina, and therefore keeps the plane of the pessary at right angles. The Menge pessary has been a very valuable addition to the non-operative treatment of descensus and prolapse. It has rendered nearly every case amenable to this plan of treatment, so that pessaries of the Goddard type may be regarded as almost obsolete. Fig. 287. — Extraperitoneal fixation of fundus. Step 1. Fig. 288. -Extraperitoneal fixation of fundus. Step 2. The general rules of treatment by the pessary are the same here as in cases of retroposition. In aged patients, particularly, it is advisable not to allow the device to remain in place for more than a month at a time. The operative treatment of descensus and prolapse combines the opera- tions necessary for restoring the integrity of the pelvic floor, and those that suspend or fix the uterus at the normal or slightly above the normal level. Usually, in the child-bearing woman, some form of cystopexy and peri- neorrhaphy must be performed, in conjunction with Simpson's, Baldy's, or Coffey's operation. It is in these cases particularly that shortening of the uterosacral ligaments, when combined with the other operations, may be serviceable. A fixation operation is never selected unless the woman has passed the menopause or has been artificially rendered sterile. Plastic work in prolapse is, as a rule, more extensive than in descensus, and as prolapse occurs more frequently in older women, fixation operations are oftener desirable. The choice of the particular type of fixation operation for the individual case depends upon the associated conditions. Vaginal fixation may be the operation of choice if, by reason of obesity or the expressed wish CHANGES IN FORM AND POSITION OF THE UTERUS 271 of the patient, an abdominal incision is objectionable. Interposition of the uterus between the bladder and anterior vaginal wall is especially indicated when a cystocele is a prominent feature of the case, when the uterus is normal in size, and when the cervix does not prolapse beyond the vaginal introitus. Supravaginal hysterectomy and fixation of the stump to the abdominal wall are particularly suitable when relaxation of the uterine ligaments is extreme and the fundus can be drawn out of the incision to such an extent that the stump of the cervix, after removal of the body of the uterus, will just reach the anterior abdominal parietes. Supravaginal hysterectomy and suspension of the stump by the round ligaments may be selected when Fig. 289. — Shortening of uterosacral ligaments. relaxation of the uterine ligaments is not extreme, but the body of the uterus is enlarged and heavy and it is desirable to remove it. Simple extraperitoneal fixation of the fundus uteri may be selected when, upon pulling up the uterus as far as it will go, the fundus just about reaches the anterior abdominal wall, the body of the uterus is not enlarged, and there is no indication for hysterectomy (Figs. 287 and 288). In operations for descensus and prolapse, the treatment of the cervix de- serves particular mention. During the reproductive period high amputation should be avoided. Trachelorrhaphy is the procedure of choice, and should be selected unless the cervix is so greatly hypertrophied or there is such a distribution of Nabothian cysts that nothing short of amputation will re- store the cervix to a satisfactory condition. In women past the child- bearing period high amputation of the cervix is usually advisable, since it 272 GYNECOLOGY lessens the weight of the uterus and removes the vaginal portion, which, if let alone, might predispose to a recurrence of descensus, guiding the uterus down through the vagina just as the olive tip of a bougie guides it through the urethra. After high amputation the vaginal vault is concave, the tissues are more or less fixed to the bases of the broad ligaments, and are less dis- posed to downward displacement. An exception to this may be noted in the interposition operation. High operation does not lend itself to the technical execution of the latter, and if the condition of the cervix is such that amputa- tion is necessary, some other form of uterine fixation should be selected. As a preliminary step in any case that is to be subjected to operation, and in non-operative cases for palliative purposes, the prolapsed uterus may be restored to its normal position and held there by vaginal tampons of gauze or cotton. Either of these materials should be applied in the form of a long strip, first being disposed in a circular manner about the cervix until the whole vaginal vault is filled, pressure being then exerted laterally upon the vaginal fornices. Below this the packing may be loose. A dusting powder (boric acid or zinc stearate) or an ointment (petrolatum, zinc ointment, etc.) may be applied to the gauze or cotton. This tamponade forms a large spheric mass that embraces the cervix and finds support upon the lateral walls of the pelvis and upon the pubic rami. Such a tampon must not be left in place for more than twenty-four hours at a time. In case of ulceration of the vaginal mucosa in prolapse of the uterus, the organ should be replaced in the manner described, and kept there for several weeks before operation, the ulcer being cleansed and touched with silver nitrate (2 per cent.) daily before the tamponade is reintroduced. Within a week or two this treatment will result in healing of the ulcerations, and the mucous membrane of the vagina and the submucous areolar tissues will be less cedematous and in a much more favorable condition for operation. Vaginal Fixation. — Vaginal fixation of the uterus is an operation that has a very limited field of application. The operation is especially use- ful when there is a serious contraindication to an abdominal operation, such as excessive fat, or if the patient herself wishes to avoid an abdominal in- cision. It should be reserved for women who have passed the child-bearing period. If used in others, it must be in conjunction with an operation to render the individual sterile. In performing this operation a midline incision is made through the anterior vaginal wall, from a point one centimeter posterior to the external urinary meatus to the point where the vaginal wall joins the anterior lip of the cervix. Here the midline incision is crossed by a transverse incision that divides the vaginal wall along the line of its attach- ment to the cervix. The bladder is separated from the anterior vaginal wall and from the anterior surface of the uterus, and pushed up until a point is reached on the anterior uterine wall more than half-way between the in- ternal os and the fundus (Fig. 220). It is always advisable to open the peri- toneum. The anterior surface of the uterus is now sutured to the anterior vag- inal wall, the bladder being pushed up out of the way and the fixation sutures so disposed as to close the peritoneal opening. Watkins' Operation. — Interposition of the Uterus between the Bladder and the Vagina. — Interposition of the uterus is indicated chiefly in descensus CHANGES IN FORM AND POSITION OF THE UTERUS 273 or minor degrees of prolapse with particularly marked cystocele. The operation is not advisable in cases of complete prolapse, since in older to make it effec- tive some support must be left in the uterosacral ligaments and the tissues surrounding the cervix and the vaginal vault. (Sec page 221.) The anterior sur- face of the uterus and the base of the bladder are exposed by means of the T- shaped incision described under the head of vaginal fixation. The bladder is separated from the anterior vaginal wall and the cervix by blunt dissection and pushed upward. The vesico-uterine fold of peritoneum is divided and the uterovesical pouch is opened. The pelvis is then carefully explored with the finger, in order to determine the presence of adhesions or of intrapelvic disease. If the fundus is small and no adnexal complications exist, it is drawn through the opening in the uterovesical pouch, and the anterior edge of the peritoneum is united to the posterior surface of the uterus below the fundus somewhat above the position of the internal os. The excess of the vaginal wall is now excised from either side of the median line, and united over the anterior surface of the uterus, the latter being fixed in its new posi- tion by several interrupted catgut sutures. This operation must be supple- mented by some form of perineorrhaphy (Figs. 222 and 223). Fixation of the Uterine Stump after Supravaginal Hysterectomy. — The operation of supravaginal hysterectomy is carried out in the usual manner, without attaching the round ligaments to the cervix, up to the point of peri- tonealization of the raw surfaces. Instead of covering in the cervical stump with peritoneum, it is left bare, transfixed with two chromic catgut (No. 2) sutures, and drawn up into the lower end of the abdominal incision. The peritoneum of the lower angle of the incision is then united to the anterior surface of the cervix along the peritoneal reflection. The peritoneum on either side is now sutured over the ovarian and round-ligament stumps and the cut surface of the broad ligament. The peritoneum of the abdominal incision is then attached to the lateral and posterior surfaces of the cervix and closed above this point. Each end of the sutures transfixing the cervix is now carried through the fascia of the abdominal wall on its corresponding side, the under surface of the fascia being exposed by blunt dissection. The fascia is brought together with catgut in the usual manner, and the cervical sutures are tied. The raw surface of the cervical stump is thus brought into contact with the under surface of the fascia, and a broad and secure area of fixation is the result. The principles underlying this operation are the same as those of extraperitoneal fixation of the fundus (Figs. 287 and 288). Ante-position, Latero-position, Retro-position, Elevatio Uteri, and Tor- sion. — These variations from the normal in the position of the uterus are of less importance than those previously discussed. They, practically never produce symptoms other than those characteristic of the conditions with which they are associated. The uterus may be pushed forward against the symphysis {ante- position), to one side toward the wall of the pelvis (latero-position), and backward into the hollow of the sacrum (retro-position) by a tumor that crowds the uterus out of its way or by adhesions that, by contraction, draw the uterus out of its normal position. The uterus may also be elevated (elevatio uteri) considerably above its 18 274 GYNECOLOGY usual position by a tumor developing from the cervix or by adhesions form- ing between the fundus and the abdominal viscera. The uterus- may be elevated by an abdominal tumor of uterine origin, or displaced downward by an ascites or pseudomyxoma peritonei. The uterus may be twisted (torsio uteri) by the torsion of tumors at- tached to it or by an enlarged uterus twisting on the cervix as a pedicle. Latero-position of moderate degree and torsion are likewise to a certain extent physiologic, e.g., the normal rotation to the right of the pregnant uterus, and have no pathologic significance. The treatment of all these abnormalities must, of course, be directed to- ward the primary source of the trouble, i.e., tumors must be removed and adhesions broken up or divided. In very rare cases it may be advisable to attempt to correct the latero-flexion of an ill-developed uterus. INVERSION OF THE UTERUS Etiology and Pathology. — Inversion of the uterus, or turning of the uterus inside out, usually takes place at the end of labor, when the uterine muscle is relaxed and the lower uterine segment and the cervix are widely dilated. The improper management of the third stage of labor is usually responsible for this condition. Too forcible applications of Crede's method, pulling upon the umbilical cord, or faulty methods of manual extraction of an adherent placenta may be the exciting cause. If, in employing Crede's method, the fundus is too vigorously com- pressed and depressed, the organ may be driven down through the lower uterine segment and cervix, the walls everting as it passes. If the placenta is firmly attached to the uterine wall at the fundus, traction on the cord may cause inversion of the fundus. If the hand is introduced into the uterus to detach an adherent placenta, and, having accomplished this, the hand grasping the placenta is immediately and forcibly withdrawn, it may act like a piston in a syringe and draw the organ inside out. Forceps deliv- ery of a fcetus with an exceptionally short cord has been said to be a cause of acute inversion. Inversion of the uterus other than puerperal may occur as a complication of intra-uterine tumors that become pedunculated and are extruded through the cervix by uterine contraction. If the pedicle of the neoplasm is broad and attached to the fundus, inversion may take place. Symptoms. — Acute inversion is an alarming condition, and is usually accompanied by serious hemorrhage and shock. It may take place at the end of the second stage of labor, but it usually complicates the manipula- tions attending delivery of the placenta. At the moment of occurrence the patient complains of severe pain, the hemorrhage is excessive, and a state of shock rapidly develops. Hemorrhage and shock are less severe if the placenta is still attached to the uterine wall. A globular pyriform mass protrudes from the vulva or presents at the vulvar orifice. If the placenta is still attached, the condition is apparent. If the placenta has been delivered, the condition must be differentiated from extrusion of a submucous peduncu- lated fibroid. In the former, examination of the fundus reveals a funnel- shaped depression ; in the latter, the rounded fundus can be felt in its normal CHANGES IN FORM AND POSITION OF THE UTERUS 275 position. The mortality of acute inversion is 30 per cent. Inversion occur- ring slowly, as from the traction of a fibroid, or when of puerperal origin and allowed to remain unreduced, is the form with which we are most concerned here. The symptoms consist of irregular hemorrhage, menorrhagia. and leucorrhcea. Upon examination a pear-shaped tumor is found projecting from the vaginal vault. The surface is bright red. the growth bleeds readily, and the pedicle is surrounded by the rim of the cervix. Bimanual examination shows the normal contour of the fundus to be missing, and in its place there is a cup-shaped depression that can readily be distinguished by a digital examination per rectum. A sound introduced along the pedicle of the tumor, and between it and the rim of the cervix, soon meets with the resistance of the inverted cervical tissue. The condition bears some resemblance to a uterine polyp or to a submucous pedunculated fibroid tumor. The principal differential and diagnostic signs are the fol- lowing : The fact that the surface of the tumor is covered with endo- metrium, in which the tubal orifices may be distinguished ; obliteration of the uterine cavity ; and the cup-shaped depression at the fundus. Treatment. — In acute puerperal inversion, if the patient is in an extreme state of shock and the surroundings are unfavorable, simple tamponade and general supportive treatment should first be undertaken ; under opposite circumstances immediate replacement should be attempted. The woman should be placed in the Trendelenburg position, and an effort be made to push the inverted fundus up through the cervix. This procedure will be favored by grasping the entire fundus with the hand, compressing it as much as possible, and then making an effort to push it past the cervix. If the "effort is successful, as the fundus is restored to its normal position, the inversion is reduced. When the inversion has persisted for some time and partial involution has occurred, replacement is considerably more difficult. Division of the cervical ring is almost invariably required, but even when this is performed replacement is often impracticable. In most cases of long standing and in women past the age of thirty-live hysterectomy is the pro- cedure of choice. At times the inverted portion, owing to interference with its blood supply, becomes necrotic. Under such circumstances the gangrenous part may be removed with the cautery knife, and after the stump becomes cov- ered with healthy granulations, the remains of the uterus may be removed by vaginal or abdominal hysterectomy. BIBLIOGRAPHY Alexander. W. : " A New Method of Treating Inveterate and Troublesome Displacements of the Uterus.'' Med. Times and Gazette. 1882. i. 327. Axspach, B. M. : "Inversion of the Uterus, the Treatment in Cases Complicated by Ne- crosis of the Inverted Part." Amer. Medicine, viii. Xo. 22, November 26, 1904. Baldv, J. M. : "A Method of Preventing Vaginal Prolapse Following Abdominal Hyster- ectomy."' Am. Jour. Obst., 1857. xxxv, 81 : Ibid. : " Retrodisplacements of the Uterus and Their Treatment." X. Y. Med. Jour., 1903, lxxviii, 167: Ibid.: ''Prolapse of the Uterus.'' Trans. Amer. Gyn. Soc, 191 2, xxxvii, 385. Ballextvxe. J. \Y.. axd Thomson, J. : " Congenital Prolapsus Uteri."' Amer. Jour. Obst.. 1897. xxxv. 161. Bovf.f. J. W. : "The Surgical Treatment of the Uterosacral Ligaments Through the Vagina in Retroversion of the Uterus." J. A. M. A.. 1902, xxxix, 12; Ibid.: "Opera- 276 GYNECOLOGY tions on the Uterosacral Ligaments in the Treatment of Retroversion of the Uterus." Am. Gyn., 1902, i, 3?. Brickner. S. M. : " Results of the Dudley Operation." Surg., Gyn. and Obst., 191 1, xiii. 510. Coffey, R. C. : " Surgical Treatment of Displacements of the Uterus.'" Denver Med. Times, 1904-5, xxiv. 339. 362 : Ibid. : " The Principles on Which the Success of the Surgical Treatment of Retrodisplacements of the Uterus Depends."' Surg., Gvn. and Obst.. 1908, vii, 383-408. Dudley, E. C. : '* A Plastic Operation Designed to Straighten Out the Antefiexed Uterus." Amer. Jour. Obst.. 1891. xxiv, 142. Ferguson. A. H. : " Preliminary Report of Anterior Transplantation of the Round Liga- ments for Displacements of the Uterus."' J. A. M. A.. November 18, 1899. xxxiii, 1275. Gilliam, T. : " Round-Ligament Ventrosuspension of the Uterus." Amer. Jour. Obst., 1900. xli. Xo 3. Holden. F. C. : " Chief Factors in Failure of Operations for Retrodisplacement of the Uterus." Trans. Sec. O. G. and A. S., A. M. A. 1914, 279. Hutchixs : " Anteposed L~terus and Pelvic Svmptoms." Trans. Sec. O. G. and A. S., A. M. A.. 1916. 63. Kelly, H. A. : '" Hysterorrhaphy." Am. J. Obst., 1S87. xx, 33 : Ibid. : " Suspension of the L'terus." T. A. M. A., 1895, xxv. 1079. Martin: Der Haft-Apparat der Weiblichen Genitalien. Berlin. 191 1. Montgomery, E. E. : " Modern Method of Treatment of Prolapsus Uteri." Trans. Amer. Gyn. Soc, 1912. xxxvii. 3-6. Xoble, C. H. : '" Suspensio Uteri With Reference to Its Influence Upon Pregnancy and Labor.'" Trans. Amer. Gyn. Soc. 1896, xxi. 247 ; Ibid. : " Mechanical Principles In- volved in the Cause of Backward and Downward Displacements of the Uterus."' Trans. Amer. Gyn. Soc, 1914, xxxix, 23S. Olshausen, R. : " L'eber ventrale Operation bei Prolapsus und Retroversio Uteri.'" Cent. f. Gynak.. October. 1886. Xo. 43. 698. Pozzi, S. : " On the Surgical Treatment of a Most Frequent Cause of Dysmenorrhea and Sterility in Women."' Surg.. Gyn. and Obst.. 1909, ix. iii. Reynolds, *E. : "Anteflexion of the Cervix and Spasm of the Uterine Ligaments in Rela- tion to Retroversion, Dysmenorrhcea and Sterility." Surg., Gyn. and Obst., 191 1, xiii. 17: Ibid.: " Forward Fixation of the Cervix a Predisposing Cause of Some Retro- deviations of Uterus. Operation for Its Release.*' Surg.. Gyn. and Obst., 1914, xix. 588. Schultze : The Pathology and Treatment of Displacements of the Uterus. X. Y.. 1888. Simpson. F. F. : "Intra-abdominal but Retroperitoneal Fixation of the Round Ligaments for Posterior Uterine Displacements." Trans. Southern Surg, and Gyn. Soc, 1902, xv. 223. Somers. G. B.. and Blaisdell. F. E. : '" The Anatomy and Surgical Utility- of Sacro- uterine Ligaments."' T. A. M. A., 1913, lxi, 1247. No. 14. Tandler and Halban : Anatomie u. Aetiologie der Genitalprolapse beim Weibe. Wien u. Leipzig. 1907. Watkins, T. T. : "The Treatment of Cystocele and L'terine Prolapse .After the Meno- pause." Am. Gyn. and Obst. Jour.. 1899, xv. 420 : Ibid. : " Treatment of Cases of Exten- sive Cystocele and L'terine Prolapse."' Surg., Gyn. and Obst., 1506. ii, 659 ; Ibid. : " Treat- ment of Cystocele and L'terine Prolapse During the Child-bearing Period." Trans. Amer. Gyn. Soc, 1917. xiii. S94- Webster. T. C. : "A Satisfactory Operation for Certain Cases of Retroversion of the L'terus." J. A. M. A.. 1901. xxxvii. 913. Winter, G. : Zur Pathologie des Prolapses. Fest. f . C Ruge, 1896, 22. CHAPTER XVI DISEASES OF THE ENDOMETRIUM AND MYOMETRIUM Endometritis. — Endometritis, or an inflammation of the mucous mem- brane lining the body of the uterus, may be acute or chronic. Acute endometritis is the result of infection of the endometrium by the gonococcus during the course of gonorrhceal disease, or of infection by the staphylococcus, streptococcus, or other pus-producing organisms following abortion, premature labor, or intra-uterine manipulations or operation. Acute gonorrhceal endometritis is a sequel of gonorrhceal cervicitis, and usu- ally develops about the time of the menstrual period ; or it may follow mis- carriage, labor, or local applications to the cervix. It is marked at times by sudden cessation of the menstrual flow, a profuse discharge of purulent matter from the cervix, pyrexia, pain in the lower abdomen, and some of the symptoms of pelvic peritonitis. It is. indeed, very difficult to distinguish the latter clinically from acute gonorrhceal endometritis. Acute gonorrhceal endometritis frequently extends speedily into the tubes on either side, and thence to the pelvic peritoneum. Whether or not it does so, if the conservative measures presently to be outlined are adopted, the inflammatory process gradually subsides, although the disease does not tend to undergo a complete cure, but is likely to become subacute or chronic in type and most persistent. The fever, pain, etc.. dis- appear, the uterine discharge becomes less purulent in character, and may finally contain only a small amount of pus. In the chronic stage, as a result of the previous acute inflammation, the endometrium often shows hyper- trophy of the glands, so that there are hypersecretion and a considerable amount of leucorrhceal discharge. The infection remains, and the gonococcus, after invading the depths of the endometrial glands, lies dormant, not giving rise to any active symp- toms. Certain forms of irritation may, however, light up the infection when transplanted into fresh soil, and an active inflammation may be set up. Acute endometritis following labor, abortion, or instrumentation, and caused by the ordinary pyogenic organisms, is usually accompanied by a chill or chilly sensations, elevation of temperature, and increased pulse- rate. The pain may be very moderate, and the discharge is often insignifi- cant, unless placental or decidual tissue remains within the uterus. The patient may be greatly prostrated as the result of absorption of toxic prod- ucts with localizing symptoms appearing. Such an infection of the endo- metrium usually precedes a cellulitis, pelvic peritonitis, or ovarian abscess, the bacteria penetrating the wall of the uterus directly from the original nidus of infection, and reaching the periuterine tissues by way of the lymphatics. An acute endometritis of this variety may undergo complete and spon- taneous cure if the resistance of the patient is sufficiently strong to over- 277 278 GYNECOLOGY come the toxins elaborated by the infecting organisms and inhibit their growth. Following such an acute endometritis there may be no permanent alteration in the structure of the endometrium, and, indeed, this is the rule unless the infection has involved the uterine wall and the surrounding organs and tissues. Even in the latter event after the infection is overcome or localized the parts may return to the normal. Diagnosis. — The diagnosis of endometritis is frequently indicated by the history and symptoms. There is considerable tenderness in the lower abdo- men, with rigidity of the abdominal wall and a tendency to distention. The uterus is enlarged and may be soft and tender. The cervix is often more patulous than normal. As a rule, there is a profuse purulent discharge, although in cases of pure streptococcus infection there may be none what- ever. (See Acute Pelvic Peritonitis, Chapter XXI.) 1 Treatment. — The treatment of all forms of acute endometritis is prac- tically the same. Only those post-abortal or puerperal cases, in which there are marked evidences of retention within the uterus of placental or decidual tissue (profuse putrid discharge), lie within the operative sphere. In such cases it may be advisable gently to dilate the cervix and then, with a placental forceps or a dull curette, make sure that tissue remnants and detritus have been cleared away. The remainder of the treatment is purely non- operative. The patient should be kept quietly in bed, and an ice-bag should be applied to the lower abdomen. The bowels should be moved by enemas. The patient should be supported by nutritious food and stimulants, according to the requirements of the case. This will be more fully dealt with in a succeeding chapter. Chronic Endometritis. — Chronic endometritis is a sequel of acute endo- metritis. Not infrequently what is regarded as a chronic endometritis is not a true inflammatory process, but rather a hypertrophy of the endo- metrium. 2 Such a hypertrophy occurring without a previous acute inflam- mation may be due to a chronic congestion of the uterine mucous mem- brane brought about by displacements of the uterus, constipation, chronic 1 The gonococcus may be identified by the staining of smears made from the discharge. Other organisms may be identified by intrauterine cultures. It is impossible to distinguish clinically between acute endometritis and the first stages of the following conditions, with which it is often combined : acute salpingitis, oophoritis, cellulitis, pelvic peritonitis, and thrombophlebitis. 2 For the diagnosis of chronic endometritis Frankl believes that such symptoms as con- nective-tissue proliferation, increased vascularity, the occurrence of perivascular fibro- blasts, etc., as suggested by Albrecht. are perhaps of theoretic interest, but are too difficult of demonstration to be useful for practical purposes. Diffuse infiltration of the stroma by round cells, or numerous groups of these in the neighborhood of blood-vessels or lymph-spaces, are of considerable significance, provided the specimen was not taken during the late premenstruum or during menstruation, at which times Frank! justly de- clares such diffuse or scattered round-cell infiltration is entirely physiologic. Frankl, in common with Hitchmann and Adler, believes that the most reliable sign of chronic endometritis consists in the presence of considerable numbers of plasma cells. An oc- casional cell of this type may be present, Frankl asserts, in normal tissue but when they are found in any number, chronic inflammation may be diagnosed with certainty. Although it is true that in certain types of inflammation round-cell infiltration predominates, whereas in others, particularly in the gonorrhoeal form, plasma cells are especially prominent, Frrinkel does not believe that the distinction occurs with sufficient regularity to be available for the differential diagnosis of gonorrhoea, as has been claimed by Schriddae and others. DISEASES OF THE ENDOMETRIUM AND MYOMETRIUM 279 pelvic stasis, and any other cause that increases continuously the blood- supply of the uterine mucosa. Before it was recognized that the endo- metrium underwent a regular metamorphosis every month, many curetted fragments of endometrium were believed to be significant of chronic glandu- lar endometritis or a glandular hypertrophy, when it is probable that the condition was but one of the normal monthly variations taking place in the structure of the mucous membrane. There is no doubt, however, that forms of chronic endometritis and of glandular hypertrophy occur. A com- mon form of chronic endometritis is the result of an uncured infection by the gonococcus. The acute symptoms subside, but the organisms still re- main in the deeper layers of the mucous membrane, giving rise to a per- sistent low-grade irritation of the endometrium and the presence of a leucor- rhceal discharge. Tuberculous and syphilitic endometritis are dealt with in the chapters on Tuberculosis and on Syphilis (XXX, XXXI). As has previously been noted, instances are seen in which the endo- metrium is thickened and the glands are increased in number and in size, and yet no actual infection has ever occurred ; this is a true glandular hyper- trophy. At times the thickening of the mucosa appears in isolated areas and the mucosa presents a polypoid appearance — known as polypoid hyper- trophy. In some cases, especially in old women, in addition to the over- growth of the endometrium and the hypertrophy of the glands, many of the glands become cystic and distended with their secretion ; this condition is known as glandular hypertrophy with cystic degeneration. Ail these forms have been described as varieties of chronic endometritis, and have been given specific titles, as, e.g., glandular endometritis, cystic glandular endo- metritis, polypoid endometritis, and fungous endometritis, the descriptive adjective in each case indicating the gross anatomic findings. True chronic endometritis, as well as the hypertrophies just mentioned, very rarely exists alone as the sole and individual lesion of the generative tract. In other words, endometrial lesions of this type are usually combined with other disorders, such as inflammatory diseases of the adnexa, displace- ment of the uterus, etc. Symptoms. — The only symptoms that are directly attributable to chronic endometritis are leucorrhcea, menorrhagia, and dysmenorrhea. Other symp- toms believed to be due to chronic endometritis are usually the result of associated conditions, such as chronic pelvic congestion, displacement of the uterus, lacerations of the cervix, or chronic inflammatory diseases of the adnexa. Chronic endometritis alone may prevent conception or be provo- cative of abortion. Diagnosis. — The diagnosis may be suspected if there is a persistent uterine leucorrhcea that does not show the thick, tenacious character of a cervical leucorrhcea, and menorrhagia, without any gross lesion in the pelvis. The diagnosis can be confirmed only by performing thorough curettement of the uterus (Fig. 290) and making a careful examination of the uterine scrapings. Treatment. — The treatment of suspected endometritis that is not accom- panied by any other pelvic disorder consists in measures to stimulate the pelvic circulation, deplete the engorged blood-vessels, and promote free 280 GYNECOLOGY drainage of the endometrial cavity. The treatment is practically the same as that described under Chronic Pelvic Inflammation (Chapter XXI). So. far as any direct treatment of the endometrium itself is concerned, the only measure worth considering is curettement, followed by the application of the tincture of iodine or of phenol to the entire uterine interior. The use of local appli- cations to the endometrium is attended with considerable danger, and can- not be carried out unless the patient is anaesthetized and the os is fully dilated. It should never be attempted without the most elaborate aseptic preparation. Polyps of the Endometrium. — An endometrial polyp is a growth that springs from the endometrium, being at first, in a measure, a localized hyper- trophy of the endometrium. After the hypertrophy has attained a certain size it takes on the proportion of a distinct new formation, and may then be regarded as a polyp. The tumor is composed of glands and stroma, just as the endometrium itself, and the surface is covered by low columnar cells. It varies in size from a tumor no larger than the end of the finger to one Fig. 290. — Diagnostic curettage (pages 121, 289 and 345). that entirely fills the uterine cavity. The growth often corresponds in shape to that of the uterine interior, the polyp forming a more or less complete cast. The tumor is usually pedunculated, but small growths may be sessile. Various forms of degeneration may occur : The stroma may undergo myxo- matous degeneration ; cedema and infiltration with blood are frequent ; the surface epithelium may be eroded and the glands become cystic. If actual infection has taken place, the stroma is infiltrated with small round cells or polymorphonuclear leucocytes. Malignant degeneration of the epithelial constituents is not uncommon ; carcinoma of the endometrium at times begins in a polyp. If, by reason of uterine contraction and efforts to expel the growth, the pedicle of the tumor becomes attenuated, necrotic changes from strangulation are prone to occur. The uterus may succeed in expelling the growth, and a natural cure thus be afforded. The symptoms of a polyp are, first, a slightly increased discharge, which may escape the observation of the patient, to be followed later by menor- rhagia and metrorrhagia. Bleeding between the periods occurs only after DISEASES OF THE ENDOMETRIUM AND MYOMETRIUM 281 degeneration or circulatory changes in the tumor have resulted in actual rupture of some of its blood-vessels. In the event of necrosis, the discharge becomes putrid. The diagnosis of endometrial polyp may readily be made in those cases in which the growth protrudes through the cervix. In these instances in- spection alone reveals a soft, globular or flattened, tongue-like growth pro- jecting from the cervix. It is often impossible to distinguish such a tumor Thickened endometrium infiltrated with blood Fig. 291. — Chronic arteriosclerosis or fibrosis uteri: thick hypertrophied uterus; chronic metritis (after Donald); persistent hemorrhage from such uteri has been attributed to sclerosis of the uterine vessels or myofibrosis. from a cervical polyp, but the treatment is, fortunately, the same for both. A polyp may be suspected in cases of menorrhagia or metrorrhagia in which the patients present no enlargement or irregularity of the uterus or other gross pelvic lesion. A positive diagnosis may be only possible after dilatation and curette- ment of the uterine cavity. Treatment. — As the symptoms presented by polyp always resemble those due to cancer, a positive or a complete diagnosis should be withheld until the growth is removed by avulsion or curettement and subjected to 282 GYNECOLOGY expert microscopic examination. Avulsion of a polyp should always be followed by curettement unless the tumor projects from the cervix and is infected or necrotic. Under such circumstances the operation may be postponed until a later date, when all indica- tions of infection, etc., have disappeared. Acute Metritis. — Acute metritis is usually preceded by acute endo- metritis, and is most often due to in- fection by the staphylococcus and the streptococcus, or by some of the cus- tomary pus-producing organisms pres- ent in acute puerperal septic conditions. The symptoms of acute metritis closely resemble those of an acute septic endometritis, being, however, slightly greater in intensity and ac- companied probably by a moderate enlargement of the uterus itself. It is quite impossible, but fortunately un- necessary, to differentiate acute metritis from acute endometritis, acute cellulitis, and, in fact, from most of the pelvic inflammatory lesions fol- lowing post-partal or post-abortal infections. The treatment is essentially the same as that of acute endometritis. Acute metritis is much more likely than the latter to be followed by cellu- litis or inflammation of the ovary or of the pelvic peritoneum, and is at times complicated by destruction of foci of tissue in the uterine wall and the formation of intramural abscesses. In some of the most marked cases in which this abscess formation occurs it may be advisable ultimately to per- form hysterectomy, but in the acute stages of the disease this operation must not be considered. (See Post- abortal and Post-partal Pelvic Peri- tonitis, Chapter XXI.) Chronic Metritis. — Chronic metritis is a sequel of acute metritis, or it may take the form of a slowly produced and subacute affection closely akin to subinvolution. It usually occurs in multiparas and is marked by hyper- trophy or overgrowth of the uterus. 3 The organ is considerably larger than 3 Whitehouse has recently shown that syphilis may be a factor of importance in the etiology of chronic metritis. H yrtfrfAS Fig. 292. — Diagrammatic scheme to illustrate vas- cular channels of uterine wall and endometrium: tortuous vessels of the vascular layer (X) ; centrip- etal vessels of the submucosa (F); subepithelial capillary plexus (Z); arteries (A); veins (V); Glands (G). DISEASES OF THE ENDOMETRIUM AND MYOMETRIUM 283 normal, and may be remarkably increased in density (Fig. 291). The actual change in the structure of the uterus that accounts for the enlargement of the uterus has been the subject of considerable discussion, but the general opinion is that there is an increase of the fibrous at the expense of the mus- cular tissue. The production of chronic metritis is closely associated with s\v. ~4 5.5 V. 5.5. Fig. 293. — Section of wall of nulliparous uterus (Weigert's stain ). Observe the finely branching elas- tica, especially marked in the stratum subserosum (5. S.)\ note the general centripetal direction of the fibers. Stratum supra-vasculare (S. S. V.); outer limits of stratum vasculare (S. T'.). the process of involution of the uterus, and especially the involution of its vascular supply (Figs. 292 to 297). The vessels of the uterus, which have become greatly hypertrophied during pregnancy, normally degenerate, be- come obliterated, and undergo absorption during the puerperium. When, Fig. 294. — Section of wall of muciparous uterus (Weigert's stain). Observe the clumping of the elastica, the curling and coarseness of the fibrils. Subserous layer (S. S.) ; Supravascular layer (S. S. V.) for some reason, this process is imperfect, a certain amount of permanent enlargement takes place that predisposes the patient to chronic metritis. Symptoms. — The symptoms of chronic metritis consist in a serous leucor- rhceal discharge, menorrhagia. at times metrorrhagia, a feeling of heaviness or dull pain in the lower abdomen, and backache, especially when the woman is on her feet. 284 GYNECOLOGY Diagnosis. — On examination the uterus is found to be considerably en- larged and harder than normal. Occasionally it is in a state of retroversion, and at other times it is in anteversion, the fundus lying a little farther for- ward than normal, the axis of flexion between the body and the cervix being straightened out so that the cervix lies further backward. The cervix is often hypertrophied ; the os may be slightly dilated, and Nabothian cysts are not rarely present. The adnexa may show nothing abnormal, although not infrequently light adhesions or simple cysts of one or of both ovaries may be present. Treatment. — Measures that deplete the pelvic circulation should be Fig. 295. — Group of arteries from vascular layer of multiparous uterus (Weigert's stain). The internal elastic lamina (i. e. 1.) appears well preserved; there is no tendency to clumping of the elastic fibers in the media (M.). The adventitia (A.) presents solid clumps of elastic tissue. Periarterial degeneration. adopted immediately. These include hot douches, scarification of the cer- vix, saline laxatives, and enemas, and ergot, hydrastis, and digitalis by the mouth (see Menorrhagia, page 583). The use of boroglyceride tampons may also give good results. If these measures are not speedily effective, it is a good plan to do a curettement of the uterus for exploratory purposes, as well as to deplete the uterus through the resulting hemorrhage, stimulate the uterus to contraction, and remove the hypertrophied endometrium. This may be combined, when feasible, with a high amputation of the cervix. Such a course will often result in permanent cure. If the symptoms persist, it will be necessary to perform supravaginal or vaginal hysterectomy. The re- markable results that have been achieved in late years by the use of radium DISEASES OF THE ENDOMETRIUM AND MYOMETRIUM 285 make this form of treatment a distinct and hopeful addition to the therapy of metritis and its often intractable hemorrhage (see Radium and Rontgen Ray Therapy, Chapter XL). Subinvolution of the Uterus. — When the normal regression of the uterus from a puerperal to a resting or non-pregnant state is inhibited and the organ remains enlarged, softened, and congested, subinvolution is said to exist. The muscular and fibrous tissue elements of the uterine wall remain to a certain degree hypertrophied, and the myometrium becomes succulent from infiltration with blood and serum. Sclerosis and obliteration of the blood-vessels have not progressed to the usual extent, so that they remain more numerous and of larger caliber than in the non-pregnant state. Subinvolution of the uterus is usually accom- FiG. 296. — Small artery of vascular layer of multiparous uterus (Weigert's stain) : the internal elastic lamina (i. e. 1.) can still be seen in part well preserved; the adventitia (.4) and part of the media (M) are represented by a solid mass of elastic tissue. To the left is a sagittal section through the degenerated coats of the same vessels (5. S.); arterial obliteration. panied by certain other abnormalities that account for or occur pari passu with it ; these are : Retention within the uterus of ovular or placental re- mains ; posterior or downward displacement of the uterus, and chronic low- grade infection of the uterine wall, adnexa, or pelvic cellular tissue. The symptoms of subinvolution consist of hemorrhage (metrorrhagia or menorrhagia), backache, a feeling of weight and pressure in the lower abdo- men, leucorrhoea, and possibly vesical or rectal disturbances. If a portion of the placenta or ovum remains within the uterus, there may be a more or less constant foul-smelling and bloody discharge. The entire uterus is uniformly enlarged and softened, and the organ is often displaced backward or down- ward. The os uteri is patulous. The cervix may exhibit a recent laceration, and the cervical tissue is soft. Treatment. — The contributory causes should be removed ; thus the uterus should be replaced and held in position by means of a pessary, and 286 GYNECOLOGY placental or decidual remnants should be removed from the uterine cavity with the aid of the curette or the placental forceps. The cedematous condition of the uterine muscle should be relieved by the use of boroglyceride tam- pons and hot douches. Fecal stasis should be prevented by the administra- tion of a saline laxative daily, followed by a simple enema. The pelvic and uterine circulation should be improved by the exhibition of a pill of ergotin, digitalis, strychnine, and hydrastis ,( see Menorrhagia, page 583). Later, in order to complete the cure, amputation or repair of lacerated or hyper- trophied cervical lips may be undertaken. Fig. 297. — Large vein from vascular layer of multioarous uterus (Weigert's stain); the inner coat (i.e.) shews no change; the outer coat (o.c.) is represented by large deposits of elastic tissue in clumps; perivenous degeneration. Hyperinvolution of the uterus is much less frequent than subinvolution. This is a condition of uterine atrophy following pregnancy, and results from a regression of the constituents of the uterus beyond the normal, so that the various components of the uterine wall are reduced in number and in size. The most frequent cause of the disorder is prolonged lactation. It is asso- ciated with anaemia and malnutrition in poorly-fed and overworked mothers. It may occur in the course of certain constitutional diseases, such as dia- betes and tuberculosis. Septic infection during the puerperium may predis- pose to an atrophy of the uterus. A hyperinvolution of the uterus is found in the aged. DISEASES OF THE ENDOMETRIUM AND MYOMETRIUM 287 The symptoms are those of asthenia and anaemia, the particular symptom that may direct attention to the pelvis is amenorrhcea or scanty menstruation. It has been claimed that electric (galvanic) stimulation is of value in the treatment of lactation atrophy of the uterus, but in the permanent form produced by septic infection it is of little benefit. Perforation of the Uterus. — Perforation of the uterus is a not uncom- mon accident attending the introduction of the uterine sound, dilatation of the cervix, and curettement. The injury may be inflicted as the instrument is being introduced through the cervix, and then involves the lower uterine segment ; or it may take place after the instrument has reached the fundus. The accident is recognized by the lack of the normal resistance to the pas- sage of the instrument exerted by the fundus, the identification of the end of the instrument, by suprapubic palpation, free in the abdominal cavity, and by an excess of hemorrhage. When the accident occurs in the course of an aseptic operation, in experi- enced hands it will usually be detected at once, and there will be no further mutilation of the uterus by repeated passage of the instrument and no irri- gation of the uterus will be practised. A gauze drain may be placed in the uterus for twenty-four hours and the accident regarded with equanimity. The serious perforations of the uterus are those inflicted by unpractised or unclean operators. They often occur in connection with attempts at criminal abortion. The perforation made by the curette is not recognized, and the instrument is repeatedly plunged through the wound, or a placental forceps may be opened and shut after it has been introduced into the abdom- inal cavity, seriously injuring the mesentery or the intestinal loops. The uterus may be irrigated with unclean or strongly germicidal solutions, which may gain access to the peritoneal cavity. The amount of traumatism that may be inflicted by the unskilled operator is appalling. The body of the uterus has been completely separated from the cervix, both uterine arteries divided, and the uterus left attached only by the tops of the broad ligaments. In one case the bladder was torn and several feet of intestine had been pulled through the cervix. The symptoms of mutilation of the uterus of this type are those of shock and sepsis. Hemorrhage is usually profuse, and if the patient does react from the loss of blood, it is only to be stricken with the toxaemia of a peritonitis. The history of the injury may be difficult to elicit. The treatment must be prompt and thorough. It is only in the early cases that a successful result can be achieved. If possible, the patient should be removed at once to a well-appointed hospital. The first indica- tion is to combat the shock attending the injury and then to repair or remove the injured organ and provide suitable drainage. If there is no reason to suppose that the intestine or the mesentery has been torn, and if the uterus is severely injured, it should be removed through a vaginal incision ; otherwise an abdominal incision should be made, the intestinal tract carefully examined, and the injury repaired. In some cases extensive resection of the intestine has been required. Possibly no less favorable cases than many of these are encountered, and in spite of judi- cious and expert surgical treatment the patient may die of shock or sepsis. 288 GYNECOLOGY Haematometra, Physometra, Pyometra. — When the cervical canal is imperforate congenitally or becomes obstructed, the secretions of the endo- metrium or the discharge from an intra-uterine disease cannot escape, so that the uterine cavity becomes gradually dilated to accommodate the pent- up secretion, menstrual or other, which slowly increases in amount until the condition known as hcematometra results (Fig. 37). In congenital stenosis of the cervical canal this is one of the phenomena incident to that particular form of gynatresia. Haematometra of non-congenital origin may be due to the accidental clo- sure of the cervical canal by operations upon the cervix, or to the pressure of new growths that obstruct the cervix. The most common cause of an acquired haematometra is a carcinoma of the endometrium, affecting espe- cially the region of the internal os. This condition is seen most frequently in old women, in whom previously there have probably been more or less atrophy of the cervix and contraction of the cervical canal. The infiltrated wall of the uterus becomes eroded, and the uterine cavity is increased in size by the breaking down of the carcinomatous areas and by the bleeding that takes place from the growth, until a tumor of considerable size may be formed. This is composed of the thinned-out uterine wall as a capsule, and its contents, carcinomatous debris and blood. If this carcinomatous tissue and blood become infected, pus formation ensues, so that the haemato- metra is converted into a pyometra. When degeneration progresses further and putrefaction occurs, gas is formed and is retained within the uterus, producing what is known as a physometra. These conditions may be suspected in the presence of uterine enlargements in old women that are more or less fluctuant, and in which there is little or no discharge from the uterus. In cases of haematometra due to congenital stenosis the history is usually sufficient ground on which to base a tentative diag- nosis. The most prominent symptoms are amenorrhoea, severe abdominal pain recurring at monthly intervals, and the gradual appearance of a pelvic tumor. In acquired cases cessation of the menstrual flow, periodic distress in the lower abdomen, and the appearance of a uterine enlargement are suggestive. A symmetric enlargement of the uterus, which is fluctuant, in association with the symptoms mentioned, affords reliable evidence on which to base the diagnosis. A positive diagnosis can be made only by noting the obstruc- tion to the passage of a sound into the uterus and the nature of the uterine contents. The treatment of haematometra, physometra, and pyometra, due to car- cinoma or other malignant diseases of the uterus, consists first in providing free drainage. W T hen fever is present, and in all cases of pyometra and physometra, it is advisable to carry out this procedure as a preliminary operation, and subsequently, after the local infection has subsided and the patient is in better condition, to perform a radical hysterectomy, unless the disease is so far advanced as to make this impracticable. In a majority of cases of pyometra or physometra the carcinomatous lesion has advanced beyond the hope of radical cure. The only procedure left for the surgeon is to make the patient as comfortable as possible, to DISEASES OF THE ENDOMETRIUM AND MYOMETRIUM 289 reduce septic symptoms by keeping the cervical canal patulous, and to prevent a reaccumulation of the fluid within. The remarkable results that have been achieved in late years by the use of radium (see Chapter XL) make this form of treatment a distinct and hopeful addition to the therapy of advanced carcinoma. When radium is used there should be no curettement of the uterus. When radium is not available then the necrotic masses may be scraped away and the cavity packed with formalin (10 per cent.) or acetone (c. p.) gauze. Curettement. — By curettement of the uterus is meant a scraping away of the mucous membrane lining the uterine cavity. This is accomplished by means of an instrument known as the curette. Before introducing the curette into the uterine cavity the size and position of the uterus should have been determined by making a bimanual examina- tion. This should be confirmed by the passage of the uterine sound. After dilating the cervix, the curette is gently introduced into the uterus and passed on until it meets with the resistance of the fundus. The cutting surface of the instrument is then turned toward the posterior surface, and gently drawn forward toward the internal os in the median line. This procedure is re- peated in various directions until the entire posterior surface has been gone over. The scraping is then continued upon the lateral borders of the endo- metrial cavity and then upon the anterior surface. Up to this point the ordinary Sims' curette should be employed (Fig. 290). After the anterior and posterior surfaces of the endometrial cavity have been scraped clean, so that the direct impingement of the edge of the curette on the uterine muscle can be felt and heard, another form of instrument, known as the Martin curette, is passed to the tubal angle on either side, and swept across to the opposite tubal angle, and the procedure repeated several times. The thor- oughness of the scraping is important from the curative standpoint — the re- moval of every vestige of a diseased endometrium — and equally so from the diagnostic end, since all the endometrium must be removed and examined (the entire thickness of the endometrium cannot be removed, since the deeper parts are surrounded by the inner layers of the myometrium) in order to enable the surgeon to detect an incipient new growth which may occupy a small part of the endometrium and thus escape observation. During curettement the operator will be able to detect inequalities of the endometrial cavity caused by fibroid tumors that encroach upon it, or even endometrial polyps that project from the surface of the mucosa. If, owing to inequalities detected by the curette or from the history and symptoms, the presence of polyps is suspected, it is well to use a small curettement forceps, open- ing and closing the instrument in the suspected area and removing par- ticles of tissue thus secured. From the tissue removed during curettement the operator will often be able to determine correctly the nature of the endometrial lesion. In well-marked malignant disease, such as carcinoma or sarcoma, and in tuberculosis the particles removed will present a whitish, friable, cheese-like appearance, and the amount of curettings will be large. The endometrium may be markedly thickened, even in benign conditions, but the mucosa will come away in strips of considerable length, and when floated in salt solution the tissue will be pink and translucent. 19 290 GYNECOLOGY Placental tissue comes away in fair-sized pieces ; the tissue is infiltrated with blood-clot, and upon close inspection villi may be detected. In hydati- diform mole the small cyst-like bodies of the degenerated chorion may be identified (Fig. 29S). Furthermore, the operator will usually be able to determine that this tissue lies in apposition with, but projects from, the uterine wall, whereas in malignant growths the tissue brought away is Ai y\ i^'M^ v Fig. 298. — Hydatidiform mole. (University Hospital.) dug out from the uterine wall itself. These guides are trustworthy only to a limited extent and after some experience with them. In doubtful cases the diagnosis should be withheld until after microscopic examination. In those cases in which a clinical diagnosis is made and is taken as the basis for further immediate treatment, the clinical opinion should subsequently be verified by histologic examination. (See also Diagnostic Curettement and Test Excision, page 121.) DISEASES OF THE ENDOMETRIUM AND MYOMETRIUM 291 In order to prepare the curettings for microscopic sections, the entire quantity removed should be washed free of blood in salt solution and then placed in Zenker's fluid, in a 4 per cent, solution of formalin, or in 60 per cent, alcohol. The remainder of the technic belongs in the field of the pathologist, but it is incumbent upon him to embed the entire amount of tissue and take sec- tions from every part. Only in this way can error be prevented. If the uterus has been thoroughly scraped, it is unnecessary to use irrigation, and if bleeding does not occur, the introduction of a gauze pack is unnecessary. When the uterine cavity is enlarged, when hemorrhage is free, and particu- larly when placental or decidual tissue has been removed, a gauze pack for twenty-four hours is of considerable advantage. BIBLIOGRAPHY Axspach, B. M. : " Metrorrhagia Myopathica." Am. Jour. Obst, 1906, Hii, 1 ; Ibid. : " The Frequency and the Significance of Endometritis from the Standpoint of Treatment." Jour. Am. Med. Asso., 1908, 1, 842; Ibid. : "Hemorrhagic Uteri; Myopathic Uterine Hemorrhage." Surg., Gynec. and Ohst., 1908, ix, 315. Barrows, C. C. : " Intramural Abscess of the Uterus." Am. Jour. Obst., 191 1, lxiii, 575. Brothers, A. : " Accidental Perforation of the Uterus." Am. Gynec, 1903, ii, 323. Findley, O. : " Arteriosclerosis of the Uterus as a Casual Factor in Uterine Hemorrhage." Am. Jour. Obst., 1901, xliii. Gardner, W., and Goodall, J. R. : " Chronic Metritis and Arteriosclerotic Uteri." Brit. Med. Jour., 1906, iii, 1176. Gellhorn, G., and Ehrenfest, H. : " Syphilis of the Internal Genital Organs in the Female." Gyn. Trans., 1916, xli. 129. Goodall, J. R. : " The Involution of the Puerperal Uterus, with Special Reference to the Involution of Its Circulatory System." Am. Jour. Obst., 1909, lx, 921 ; Ibid. : " Climac- teric Hemorrhage." Am. Jour. Obst., 1910, lxi, 32. Kahlden, von, C. : " Ueber die sogenannte Apoplexia Uteri." Beitrage z. path. Anat., 1898, xxiii, 161. Kaji : " Zur Ovariellen yEtiologie uteriner Blutungen." Monatschr. f . Geburtsch. u. Gynak., 1910, xxxii, 427. McIlroy, A. L. : " The Significance of the Wassermann Reaction in Gynecological Diag- nosis, with Special Reference to Uterine Hemorrhage." Brit. Med. Jour., 1912, ii, 1002. Pankow, O. : " Die Metropathia Hemorrhagica." Ztschr. f . Geburtsch. u. Gynak., 1909, lxv, 336. Reinicke, E. A. : " Die Sklerose der Uterinarterien und die klimakterischen Blutungen." Arch. f. Gynak., 1897, liii, 340. Shaw, J. : Chronic Metritis ; Its Pathology and Its Relation to Chronic Endometritis. Sherratt and Hughes, London and Manchester, 1906. Theilhaber, A. : " Zur Lehre von der Enstehung der Uterusblutungen." Miinchen med. Wchnschr., 1902, lxii, 1249 ; Ibid. : " Die sogenannte chronische Metritis, ihre Ursachen und ihre Symptome." Arch. f. Gynak., 1903, vii, 411. Whitehouse, H. B. : "Hunterian Lecture on the Physiology and Pathology of Uterine Hemorrhage." Lancet, London, 1914, i, 877. Williams, P. F., and Kolmer, J. A. : " The Wassermann Reaction in Gynecology." Am. Jour. Obst., 1916, lxxiv, 638. CHAPTER XVII MYOMATA OF THE UTERUS ETIOLOGY AND PATHOLOGY The etiology of myomata is obscure. That these tumors are at times congenital may be assumed from their presence between the horns of bicornate or double uteri. It is easily conceivable that fibroid rests in the urogenital strand might prevent the union of the Miillerian ducts. This evidence, however, is not convincing, since in a series of 1912 myomata operated on at the Konigsburg Clinic, there were but two cases associated with maldevelopment of the uterus, and of twenty-four cases of poorly de- veloped reproductive organs, myomata were observed in only two. The etiology of myoma appearing after birth has been the subject of considerable speculation. The clinical fact that these tumors are frequently associated with sterility or nulliparity has given rise to the suggestion that the periodic recurrence of menstruation, without the physiologic rest ob- tained during pregnancy and lactation, may exert a causative influence. It is more reasonable to suppose, however, that the 1 myomata themselves are the cause, rather than the result, of the sterility. In 1149 cases observed by Kelly and Cullen, more than 50 per cent were in women who had never been pregnant ; 307 of the patients were single, and over 32 per cent, of the mar- riages had been sterile. Myomata are most common in middle life, being rarely observed before puberty or after the menopause. In a series of 100 consecutive cases, Hunner noted that 80 per cent, occurred between the thirtieth and the fortieth years. Laudau reports 42 cases occurring between twenty and thirty years — two were twenty years old. Myomata seem to affect the colored more often than the white race. In Hunner's series there were 31 colored to 69 white women. In the general run of cases the ratio of the two races is as one is to five. In the autopsy records of the Johns Hopkins Hospital 33.7 per cent, of all negresses over twenty had uterine myomata, whereas 10 per cent, of all white women over twenty were afflicted with these growths. Theilhaber believes that occasionally myomata are syphilitic in origin. It is not definitely known in what tissues of the uterine wall they origi- nate, but the blood-vessel walls are a suspected point, since the smallest seedling fibroids usually have a capillary in the center. Some authorities believe that myomata have their origin in the unstriped muscle-fibers of the myometrium. Histology. — Myomata are made up of unstriped muscle and fibrous tissue in varying amount. The fibrous tissue is ordinarily somewhat in excess of the proportion found in the wall of the uterus, and for this reason the tumors are often spoken of as fibro myomata. They are also commonly called fibroids. On gross section they present a glistening white surface, the fibrous tissue being arranged in concentric layers or whOrls ; the entire tumor may consist of one large whorl or of a number of smaller ones bound together by interlacing bundles of fibrous tissue (Fig. 304). The 292 MYOMATA OF THE UTERUS 293 tumor is usually sharply differentiated from the surrounding uterine muscle to which it is rather loosely attached by a zone of reticulated vascular tissue from which the nutrient blood-vessels are derived. Myomata, ordinarily, are not as well vascularized as the surrounding uterine muscle, the vessels which penetrate the tumor itself being small in Fig. 299. — Multiple subserous myomata. (Gynecological Laboratory, U. of P.) size and few in number. The surrounding uterine muscle may be very rich in blood-vessels, and sometimes the tumors themselves are well supplied, rarely even being angiomatous. The vessels in the capsule of the tumor are not infrequently enlarged, especially the veins, which present the ap- pearance of wide venous sinuses such as are commonly observed in sub- 294 GYNECOLOGY peritoneal tumors ( Fig. 299). The tumors, as a rule, are but slightly attached to their capsule, and can be shelled out rather easily. Myomata are usually multiple, and vary in size from that of a pinhead to enormous masses which fill the pelvic or abdominal cavity. In shape they are generally spherical, but irregular in contour, and so many combinations may occur that, as a result, the myomatous uterus may be of almost any conceivable shape. The consistency of the growth varies considerably, depending upon the propor- tion of fibrous and muscular tissue which it contains. The consistency and resiliency also may be affected by the various forms of degeneration which these tumors may undergo. Situation. — Myomata may occur in any part of the uterus, though they are more frequent in the fundus, and comparatively rare in the cervix. They very infrequently affect the vaginal cervix. Above the vagina the cervical tissue was the originating point of the tumor in 6.6 per cent, of the cases col- lected by Frankl. Smead found cervi- cal myomata in 5 per cent, of cases. They are usually multiple, from six to eight to as many as fifty tumors having been found in a single uterus. Fibroid tumors may be divided anatomically into three groups : First, interstitial ; secondly, subperitoneal, and thirdly, sub- mucous (Fig. 300). It is probable that the tumors all begin as interstitial growths, and that as they enlarge, they either remain at their point of origin, embedded in the muscle of the uterine wall, or migrate toward the serous sur- face and become subperitoneal, or to- ward the mucous surface and become submucous. Subperitoneal and submucous tumors may be extruded almost entirely, maintaining their connection to the uterus by a drawn-out portion of the uterine muscle, in this event becoming pedunculated (Fig. 301). The pedicle may undergo stretching and torsion, so that, finally, the tumor is released from its uterine attachment and is either extruded through the cervix in case it is a submucous growth, or detached from the uterus if it is a subperitoneal one. In the latter instance, the surface of the tumor has already become adher- ent to the omentum from which it receives a sufficient blood supply and upon which it is parasitic. When a myoma develops at the side of the uterine body and grows between the layers of the broad ligament, it is spoken of as intraligamentous (Fig. 302). If a tumor grows from the pos- terior surface of the cervix and enlarges beneath the peritoneum of Douglas' cul-de-sac, it is termed retroperitoneal. A tumor growing from the anterior wall, between the bladder and the vagina, is called subvesieal. Fig. 300. — Schematic longitudinal sagittal sec- tion of uterus showing various positions of myo- mata. (a) intramural; (b) subperitoneal; (c) submucous; (d) cervical. MYOMATA OF THE UTERUS 295 Growth. — The growth of myomata is usually slow. They may increase rapidly during pregnancy, or as the result of degeneration (cystic or sarco- matous) or suppuration. During involution following labor they diminish in size, and have been said in some instances to disappear. After the meno- pause, small tumors may stop growing, or even atrophy, but a great many of them show little tendency to do either, and in the latter event postpone indefinitely the cessation of menstrual life. On the contrary, there is great likelihood, at the time of the menopause, that myomata may undergo degen- eration or become complicated by malignant disease of the uterus. Uterine Changes. — The myomatous uterus is usually considerably hyper- trophied, and the endometrial cavity elongated and distorted. The hyper- trophy of the muscular wall of the uterus is greatest in the presence of interstitial tumors, and least where the growth is subperitoneal. Fig. 301. — Uterus opened, showing pedunculated submucous myoma. tory, U. of P.) (Gynecological labora- While the endometrium may be normal, it is very often affected by the pressure and circulatory disturbance produced by the tumor. Pressure causes overstretching, thinning and atrophy ; circulatory disturbance pro- duces oedema and hypertrophy. The apparent erosion and atrophy of the endometrium in submucous or interstitial centripetally developing myoma is in reality great attenuation and stretching of the endometrium. The stroma is very much thinned out and the few remaining glands lie parallel to the free surface of the tumor. In some cases the glands may entirely disappear. The blood-vessels of the endometrium may be dilated and ap- pear sinus-like. Usually they are displaced towards the periphery, where they present a concentric arrangement. Actual erosion is rare except where a submucous tumor is being extruded from the uterine cavity. There may be localized hypertrophies or polyps of the endometrium. Malignant affec- tions are not unusual, as will be considered later. 296 GYNECOLOGY Complications. — The complications which may be associated with myomata are many. The uterine appendages not infrequently are adherent, and may be the site of hydrosalpinx and of cystic degeneration of the ovaries. Sometimes the myoma is complicated by an acute and active infection of the tubes and ovaries (Fig. 303). The tubes are frequently involved. In a series of 1149 myomata re- ported by Kelly and Cullen, nearly one-half showed one or both tubes adherent. In this series hydrosalpinx (88) was the most frequent tubal lesion; chronic sal- A Fig. 302. — Intraligamentous fibroid. (University Hospital.) pingitis (48) and pyosalpinx (41) came next; tuberculosis (14), hematosal- pinx (12), tubo-ovarian abscess (14), cyst (2), and tubal pregnancy (6), were present. The ovaries showed pathologic changes as often as the tubes in this series, being adherent or showing some pathologic lesion in more than half the cases. Aside from adhesions, Graafian follicle cysts (68) and corpus luteum cysts (34) were the most frequent ovarian lesions — but dermoid cysts (17), papillomatous cystomata (12), multilocular adencmystoma (9), and adeno-carcinoma (8) were present. The ovaries were not infrequently hyper- MYOMATA OF THE UTERUS 297 trophied or cedematous, and actual fibromata (3) were found. Parovarian cyst was noted by Kelly and Cullen in 19 cases of this series. Degenerations. — The myomata themselves may undergo various forms of degeneration. In nearly every tumor in this series of Kelly and Cullen there were microscopic areas of hyaline degeneration. In many of these (114) the hyaline changes could be recognized macroscopically. When hyaline transformation is marked, liquefaction of the 7 degenerated areas may Fig. 303. — Myomatous uterus complicated by inflammatory lesions of the adnexa; pyosalpinx and ad- vanced peri-oophoritis. (Gynecological Laboratory, U. of P.) occur with the formation of smaller or larger collections of fluid (cystic degeneration) (Fig. 304). Circulatory obstruction may produce oedema; this usually occurs in association with hyaline degeneration. Calcareous infil- tration of a fibroid tumor is occasionally observed. This varies in degree from single to multiple " gritty " areas scattered throughout the myomatous tissue. Complete calcification is rare. Suppuration of myomata with the formation of abscess may occur, the infection reaching the previously de- generated (hyaline) tumor from the neighboring bowel in the case of sub- 298 GYNECOLOGY Fig. 304. — Interstitial myoma undergoing necrosis and cyst formation. (Stetson Hospital.) FlG. 305. — Necrosis or suomucous myoma. (Gynecological Laboratory, U. of P.) MYOMATA OF THE UTERUS 299 peritoneal tumors, and from the uterine cavity in the case of interstitial growths. Necrosis is the result of total, or nearly total, interference with the blood supply of a tumor. It is most common in pedunculated sub- mucous tumors (Figs. 305 and 306). A myoma may be so richly supplied with blood-vessels as to form an angioma. This is a rare occurrence. The lymphatic vessels upon the surface of a myomatous uterus, or even within the fibers of the tumor, are sometimes enormously dilated. Very rarely the myomatous tissue may be transformed into fat (lipomyoma). All benign forms of degeneration of myomata are more or less the result of an inter- Fig. 306. ■Necrotic submucous myoma projecting from cervix through vulvar orifice. (University Hospital.) ference with the blood supply. They may also result from traumatism or torsion if the tumor is pedunculated. A myoma may become directly transformed into a sarcoma (myosar- coma). The frequency with which this is reported to occur depends upon the thoroughness with which all myomata are routinely examined. Winter found sarcomatous transformation in 4 per cent, of all cases. In the sub- mucous variety of myoma, 9 per cent, showed the sarcomatous changes. Frankl has found sarcomatous change in 2.3 per cent, of 514 personally studied myomata. A myoma cannot degenerate or be transformed into a carcinoma, but car- 300 GYNECOLOGY cinoma of the endometrium or cervix may complicate myoma. Myomata of the uterus seem to predispose to the development of carcinoma of the endometrium. This is indicated by the fact that in myomatous uteri corpus carcinoma is relatively much more frequent than cervical carcinoma; whereas the usual ratio of cervical to fundus carcinomata is as 15 is to 1, in the fibroid uterus the ratio is as 0.62 is to 1 (Winter). In a series of nearly 5000 cases of myomata uteri (Kelly-Noble), carcinoma of the cervix was Fig. 307. — Cervical myor (Bryn Mawr Hospital.) present in 1% per cent.; carcinoma of the body of the uterus (Fig. 307) in 1^ per cent. Pressure Effects. — The effect of myomata upon surrounding organs is due almost entirely to the mechanical displacement and distortion which these tumors produce. When a tumor is situated so that as it increases in size it is held within the pelvis, as is true of intraligamentous and cervical growths, it compresses the pelvic structures against the unyielding bony pelvis (Fig. 308). In this way pressure is brought to bear upon the bladder, urethra, ureters, and rectum. The bladder may be either pressed upon or MYOMATA OF THE UTERUS 301 displaced. In tumors originating from the anterior surface of the uterus below the vesical reflection of the peritoneum, it is not uncommon to have the bladder pushed upwards above the symphysis (Fig. 309). Tumors origi- nating in other areas, when large and tightly impacted, may displace the bladder almost entirely out of the pelvis, or may compress certain areas of the bladder, leading to partial obstruction of the urinary outflow and saccula- tion. There may also be adhesions between the superior movable surface of ^'t-r . 7 Recturr Myomata Uterus Bladder : ^ \ \ Fig. 308. -Multiple myomata of the posterior uterine wall, incarcerated in pelvis, causing pressure symptoms, and simulating pregnancy in a retroflexed uterus. the bladder and the anterior surface of the myomatous uterus. In rare instances the myoma may be so situated as to displace the bladder down- wards, exaggerating in one case coming under the writer's observation, a previously existing cystocele. As a result of interference with its normal function, the bladder wall may be hypertrophied, there may be distention and sacculation with retention of urine, and a low-grade cystitis. Vesical calculus has been noted in association with myomata. The ureters may be displaced or compressed. They are affected, as a 302 GYNECOLOGY rule, only by intraligamentous or subvesical tumors. Growths originating in those localities may elevate the ureters so that they course over the lateral surface of the fibroid, or they may be compressed between it and the bony pelvis. The ureter above the point of compression may become very much dilated (hydro-ureter). Thus the kidneys may become secondarily the seat of hydronephrosis. The changes in both ureters and kidneys at first are purely mechanical, and if the myoma is removed in time they disappear. There may be adhesions between the rectum and the fibroid uterus ; espe- cially is this likely to occur when other pelvic inflammatory lesions coexist. The sigmoid may be elevated by a tumor which grows posteriorly beneath FlG. 309. — Incarcerated subserous myoma causing intra-pelvic presssure: (B) bladder pushed up and pressed against pubic bone and anterior abdominal wall; (U) uterus with multiple interstitial myomata; (M) myomata; (M') subperitoneal myoma filling pelvic cavity, pushing up uterus; (R) rectum; (S) symphysis pubis. the peritoneum and between the layers of the meso-sigmoid. The com- pression of the rectum may be sufficient to cause partial obstruction, result- ing in chronic constipation, with atony and distention of the large bowel followed by autointoxication and anaemia from the absorption of toxins. Absolute obstruction from compression of the rectum probably never takes place, although it is marvellous that it does not occur in those cases in which the tumor completely fills and is tightly wedged in the pelvis. Pressure on the nerve trunks passing through the pelvis may produce pain at nearby or remote points. Compression of the veins may cause venous dilatation and cedema of the lower extremities. Pressure on the large arteries at the pelvic brim may cause a bruit. Circulatory Lesions. — It has long been noted that myoma patients fre- MYOMATA OF THE UTERUS 303 quently (nearly 50 per cent, of the cases in Boldt's series) suffer from cardiac palpitation and dyspnoea, and exhibit murmurs and an increase or irregularity in pulse-rate. After operation thrombosis and embolism are more frequent in this than in any other class of cases. For these reasons myomata have been supposed to exert some peculiar specific effect upon the heart which produces a degeneration of the cardiac muscle. The mechanical resistance of the fibroid to the pumping of blood through its capsule, or the pressure exerted by the tumor upon the pelvic or abdominal vessels, has been alleged to be the cause of cardiac dilatation and insufficiency. Syphilis has been stated to be a cause of both myoma and heart disease. The cardiac condi- tion has been considered primary and the myoma secondary. A pathologic state of the ovary whereby it manufactures a noxious toxin has also been assigned as an explanation. When the facts are analyzed, we find that twenty-six cases of myoma uteri have been autopsied and recorded in which brown atrophy, fatty degeneration, and myofibrosis were found. Winter, analyzing these cases, concluded that there were but five in which no other cause but the myoma could explain the lesion. In 266 cases of myoma uteri of his own, which were carefully examined by an internist and then fol- lowed after operation, the heart was normal in 60 per cent. ; in 30 per cent, there were murmurs or impure tones ; in 6 per cent, there was dilatation and hypertrophy without valvular or myocardial disease ; in 1 per cent, there were valvular lesions, and in 1 per cent, myocardial lesions. All of these cases were reexamined after operation by the same internist as before, and fol- lowed up sufficiently to determine positively the condition of the heart after the benefit of the operation had made itself apparent. All of the valvular and myocardial lesions remained the same, while a large majority of the hyper- trophies and dilatations disappeared. Almost all of the murmurs or impure tones cleared up. As a result of this careful investigation Winter concludes that myomata influence the heart only by reason of the anaemia which they so commonly produce. The experience of Kelly and Cullen is in accord with this finding of Winter's, and in their series but two cases of myocarditis were noted. It can not be denied that in myoma advanced degeneration, as well as infection and necrosis, may produce toxins which cause changes in the cardiac muscle. Myoma patients in or beyond middle life commonly exhibit arteriosclerosis. The latter is not to be looked upon as a result of the myoma, but rather as an associated lesion. According to Theil- haber, the production of the myoma is the result of the arteriosclerotic ten- dency. The veins of the pelvis and lower extremities in myoma cases are not infrequently enormously enlarged and dilated as the result of pressure and interference with the return of the venous blood to the heart. This dila- tation of the veins, plus the impaired force of the circulation, plus the anaemia favors thrombosis and embolism. Anaemia is a common finding in patients suffering from myoma. This, as a rule, results directly from the profuse menstrual or intermenstrual flow. In more than half of the cases, according to Hunner, two-thirds according to Winter, at the time the patient comes under observation there is menorrhagia or metrorrhagia. In the worst cases with a very low haemo- 304 GYNECOLOGY globin percentage, the bleeding usually has been a very pronounced and recent feature ; so that there is a very apparent connection between impover- ishment of the blood and the amount lost. In a certain number of cases, however, the degree of anaemia seems excessive in comparison to the amount of blood lost. In such cases the production of specific toxins by the tumor has been suspected. Degenerative changes, necrosis, infection, and suppu- ration of the tumor itself often explain the condition, and careful inquiry will usually elicit the fact that bleeding in the past has been profuse or that there are other causes for the blood abnormality, such as constipation with absorption and toxaemia, kidney disease, or some other concomitant lesion. SYMPTOMS Menorrhagia and Metrorrhagia. — The most frequent symptom of myomata of the uterus is profuse menstruation (menorrhagia). In cer- tain cases, as will be noted later, there may be intermenstrual bleeding. When the myoma is interstitial, the menorrhagia is the result of an increase in the amount of blood pumped into the endometrium (menstrual conges- tion) and the interference with the return flow through the veins due to the pressure of the tumor. As the growth increases the menstrual hemorrhages increase. If the location of the tumor changes, i.e., if it migrates towards the peritoneal surface, the interference with the endometrial circulation is less and the menstrual flow may notably diminish or become normal. If, on the other hand, migration occurs toward the endometrial cavity, the menstrual hemorrhage increases, because the interference with the endometrial circula- tion is greater. Besides the increase in the amount of the menstrual flow, the periods are usually prolonged and occur more frequently than they would normally. Thus a woman who has been in the habit of menstruating every month finds her periods recurring every three or every two weeks. The menstrual blood is the result of a diapedesis through the walls of the endometrial capillaries, so that the hemorrhage, up to a certain point, may be simply an increased diapedesis due to venous obstruction. If, however, the tumor becomes submucous, there may be in extreme cases an actual erosion of the endometrium covering the growth ; more commonly the capil- laries in the thinned-out mucosa rupture, under the influence of the men- strual congestion, so that, in addition to the hemorrhage at the time of menstruation, there are intermenstrual hemorrhages (metrorrhagia). When intermenstrual bleeding supervenes upon increased frequency of the menses and menorrhagia the loss of blood may be nearly constant. Except in the worst cases the menses may be recognized by an increase in the amount of the hemorrhage at periodic intervals. In the individual patient afflicted with myomata more than one or all of the anatomic varieties of tumor may be combined, so that the mechanics of the hemorrhage which have been given here are not always typically illus- trated. Submucous growths or myomata which distort the endometrial cavity are almost invariably present when the menstrual hemorrhage is marked. A single submucous myoma, the size of a pea, may occasion more alarming hemorrhage than tumors of an interstitial or a subperitoneal type of a much greater size. MYOMATA OF THE UTERUS 305 Leucorrhoea. — Leucorrhoea may be noted during the menstrual interval. This may be mucus when the endometrium is hypertrophied, pus if there is infection of the cervix or endometrium, watery and foul-smelling if there is beginning necrosis of a submucous tumor, or putrid and purulent in the presence of a necrotic and infected submucous growth. The discharge, whatever its usual character, may be streaked with blood before and after the menstrual period. Pain. — Pain of some sort is present in over half of the cases observed by the clinician. It may be independent of the menstrual periods or limited to such times. The pain which is independent of the menses is usually due to the pressure of the myomatous uterus upon the surrounding parts. Subperitoneal myomata of moderate size, springing from the fundus of the uterus, rising free into the abdominal cavity, and uncomplicated by ad- hesions, give rise to no pain. After tumors attain a certain size and distend the abdomen, a feeling of fullness and distress, difficulty in breathing, etc., may be experienced. Intestinal or omental adhesions or neighboring in- flammatory processes (appendix, adnexa, etc.) may give rise to pain in connection with tumors of this type. Myomata springing from the body of the uterus or the cervix produce the greatest pressure pain; this is true especially of those tumors which grow between the layers of the broad ligament (intraligamentous) or distort and displace the bladder or the ureters. A myomatous uterus impacted in the pelvis may cause severe bladder or rectal symptoms or referred pain to nearby or distant parts (Figs. 308 and 309). Submucous tumors may give rise to painful uterine contractions. Acute agonizing pain may be occa- sioned by the torsion of a pedunculated fibroid tumor. Adherent, inflamed, or suppurating myomata may occasion pain. As is to be expected, myomata accompanied by adnexal lesions (salpingitis, oophoritis, pyosalpinx, ovarian abscess, etc.) are associated with more pain than uncomplicated cases. Frequent and painful urination is not an uncommon symptom and has been noted in nearly 25 per cent, of some series of consecutive cases of myo- mata. It varies in degree, depending upon the situation of the tumor and the associated changes that have been produced in the urinary system. There may be no discomfort except a frequent desire to empty the bladder as a result of the infringement of the tumor and a lessening of the bladder capacity, or the growth may be so placed that a complete emptying of the bladder is impossible, and there is constantly a certain amount of residual urine with ammoniacal decomposition, or there may be actual partial ob- struction to the outflow of urine, with consequent sacculation of the bladder and decomposition of the retained urine. In one case the urinary symptoms were typical of vesical stone, there being sudden stoppage of the stream, intense pain, and hematuria. Pressure upon the ureters may lead to obstruction of the ureteral output with renal crises. This in one patient was the first symptom which led to the discovery of a large fibroid tumor. Painful defecation is not uncommon when the tumor presses upon the rectum or there are hemorrhoids, and is very often accompanied by constipation and a feeling as if there were a foreign body in the rectum. 20 306 GYNECOLOGY Pain due to pressure on the pelvic nerves may be referred to the back, hips, or legs; numbness or loss of sensation in one or both legs is present in rare instances. The pain produced by myomata is usually increased just before and at the beginning of the menstrual periods, when the congestion of the pelvic organs is greater ; after the flow is well established there may be a subsidence of the pain to about its usual degree of severity, or even less, if the congestion has been much relieved by the hemorrhage. In the presence of submucous or interstitial growths there may be cramp-like pains through- out the flow. Circulatory Symptoms. — Myoma patients frequently (50 per cent.) ex- hibit an increase in the pulse-rate, palpitation, and dyspnoea. In such cases there are usually murmurs, systolic in time, heard best at the apex and transmitted to the axilla or pulmonary and aortic areas. There are many variations in these murmurs. They are, as a rule, the result of anaemia, deficient blood supply to the coronary arteries, and subsequent cardiac dila- tation. In rare instances brown atrophy or fatty degeneration has been present ; myocarditis or endocarditis may coexist with myoma without there being any relation between them. The heart murmurs and the cardiac symptoms so frequently observed in myoma cases usually disappear rapidly after removal of the myoma and cessation of the hemorrhage. The clinical evidences of anaemia and cardiac insufficiency are pallor, palpitation, dys- pnoea, chronic cough, and oedema of the lower extremities. The latter may also result from pressure of the tumor upon the pelvic veins, or it may be due to weakness of the heart or to renal insufficiency — sometimes to all of them combined. When the oedema is due to pressure alone it may be either uni- lateral or bilateral. (Edema produced by anaemia or by kidney insufficiency is bilateral. Anaemia. — The production of anaemia in fibroid tumor has already been explained (page 303). It is usually proportionate to the amount of hemorrhage, and the very marked degrees are almost never seen except in those patients who at the time of observation have considerable menorrhagia or metrorrhagia. Occasionally the anaemia, although not excessive, seems out of proportion to the bleeding. We must assume in such cases that at some time in the past the hemorrhage has been more profuse and that an anaemia produced at that time has persisted — the associated conditions preventing, or render- ing slow and difficult, a return of the blood to a normal state. In still other cases the anaemia may be associated with toxaemia from chronic constipation, kidney insufficiency, necrotic or infected tumors, etc. In the worst cases the haemoglobin may fall as low as 10 per cent., though it very rarely reaches this low point. Thirty to 40 per cent., however, is not uncommon. As a rule, the haemoglobin reading is between 60 and 70 per cent. The erythrocytes are usually diminished in proportion to the decrease in haemoglobin. DIAGNOSIS The ease with which a diagnosis can be made depends upon the number, size, and location of the tumors. Subperitoneal growths give the most char- acteristic physical signs. Interstitial and submucous tumors may present more difficulties. Large tumors are usually diagnosed more readily than MYOMATA OF THE UTERUS 307 small ones ; a multiplicity of nodules in the uterus is a valuable diagnostic point (see also Chapter VIII). Abdominal Examination. — When the myomatous uterus is large enough to form an abdominal tumor the appearance of the enlargement is often more or less characteristic. As a rule, the enlargement is asymmetrical ; the tumor is more prominent on one side of the median line than on the other, and the abdominal wall curves abruptly from the summit of the tumor in both directions, viz., toward the symphysis and toward the epigastrium. The abdo- men portrays the actual condition, i.e., a hard, resisting body within the abdominal cavity, pushing the abdominal wall forward. By palpation the observations made on inspection are confirmed and the consistency of the tumor is noted (Figs. 133 and 134). A myoma usually gives a distinct sense of hardness and denseness, which readily distinguishes it from a pregnant uterus or an ovarian cyst. The surface of the growth may be knobby, and there may be smaller tumors on the surface of larger ones. If it can be determined by palpation that these smaller tumors are pedunculated, the diagnosis is all but positive. Percussion of a myoma distending the abdomen gives dulness over the prominence of the tumor and resonance surrounding it, except to- ward the pelvic brim. There are no auscultatory indications of a myoma. A bruit is heard in exceptional cases when the tumor overlies and presses upon some of the large veins at the pelvic brim. If the fibroid is intramural and distends the uterus symmetrically, it may be impossible to distinguish it from early pregnancy. In such cases it is advisable to keep the patient under observation until foetal movements and foetal heart sounds will be mani- fest if the woman is pregnant. It should be remembered, also, that preg- nancy and myoma may coexist. Bimanual Palpation. — Submucous tumors: The uterus is enlarged and more or less symmetrical. It is harder than the pregnant uterus. If the tumor is pedunculated, it sometimes dilates the cervix and presents itself in the cervical canal, or it may be extruded from the canal and hang by its pedicle in the vagina. In the case of small submucous tumors, a positive diagnosis can be made only after dilatation of the cervix and intra-uterine exploration by means of the linger, sound, or curette. Interstitial tumors: The cervix fuses directly with the enlarged fundus. It sometimes projects from the surface of the latter like a nipple from the breast. The uterus is usually somewhat irregular and of increased density. The uterine body can- not be outlined distinctly from the mass. This form of tumor is most diffi- cult to distinguish from pregnancy. Subperitoneal tumors: The uterus is studded with hard, knob-like protuberances. If they are pedunculated, the diagnosis is clear. When the growths are confined to one side of the uterus or to the fundus, the uterus can be outlined as a distinct but attached body. When the tumor is single and pedunculated, an ovarian growth must be excluded ; an attempt should be made to isolate the ovary upon the affecte-d side. If a subperitoneal myoma which rises out of the pelvis and distends the abdomen is pushed upward by the external hand, the uterus will imme- diately follow. If the tumor is held in that position and the uterus is drawn downward, the pedicle of the tumor may be felt at its attachment to the uterus by rectal palpation. 308 GYNECOLOGY Myoma of the uterus must be distinguished from solid and cystic tumors of the ovary. Normal pregnancy, ectopic pregnancy, pelvic inflam- matory masses, and carcinoma of the uterus or of the ovary may also simu- late myoma. The distinguishing features between myoma of the uterus and ovarian cyst are as follows : The abdominal distention and projection in a myoma are more abrupt and irregular than in the case of an ovarian cyst. The abdominal enlargement in myoma is apt to be asymmetrical, whereas with an ovarian cyst of sufficient size to cause abdominal distention, the enlargement is more apt to be equal to the right and left of the median line. The surface of the tumor is often more uneven in mvoma than in ovarian Fig. 310. — Myoma uteri and pregnancy (University Hospital). cyst, and on palpation of a denser consistency. On percussion ovarian cysts give fluctuation, while myomata do not. The percussion wave in an ovarian cyst may be indistinct when the tumor is multilocular, and all the loculi are small and filled with gelatinous substance. Sometimes a myoma has under- gone cystic degeneration, and then it may show a wave of fluctuation, al- though this is a very exceptional occurrence. In myoma there is dulness over the greacer prominence of the growth and resonance surrounding it, but the area of dulness is neither as symmetrical nor as absolute as in the ovarian cyst which is apt to hug the anterior abdominal wall more closely than an irregular myoma. On bimanual palpation in a case of myoma it can be determined that the abdominal mass is in direct connection with the uterus. It is sometimes MYOMATA OF THE UTERUS 309 possible to distinguish between a myoma of the uterus and an ovarian cyst by picking up the ovaries on either side by bimanual palpation. Although it is not always possible to do this, in every doubtful case an effort should be made to find the ovaries, and especially the ovary on the suspected side. In some cases of ovarian cyst it is possible to outline the uterus lying either in front of or behind the cystic mass. In other cases the abdomen as well as the pelvis may be so distended that bimanual examination is unsatisfactory. In such cases occasionally a distinct wave of fluctuation may be felt through the vaginal wall upon tapping the abdominal surface. The chief difficulty in differentiating myomata from ovarian cysts will be found in those of moderate size. An ovarian cyst which is not adherent can be pushed away from the uterus without causing as direct a tug upon that organ as would be occasioned by pushing up a myoma. Likewise, in ovarian cyst an impulse transmitted to the growth above the pelvic brim is not felt so distinctly at the cervix. When the ovarian cyst is intraliga- mentous in type, or adherent, the distinguishing features between it and a fibroid tumor are the consistency of the enlargement, the presence of fluctua- tion, and the associated physical findings, such as the presence of other fibroid nodules in the uterus and the size of the uterus itself. The differential diagnosis between myoma and pregnancy is frequently very difficult, especially if the tumor is of the intramural or interstitial type (Fig. 310). The enlargement of a pregnant uterus in a great majority of instances is more symmetrical than that of a myomatous one. but there are some myoma cases in which it requires considerable study to make a diag- nosis. In order to differentiate between the two conditions the history and the associated signs of pregnancy must be relied upon. The softening of the lower uterine segment (Hegar's sign), fcetal movements, fcetal heart sounds, and ballottement should be looked for. In case of doubt, the solution of the question is found after observing the case for a couple of months. At the end of this period, with no appearance of the signs characteristic of preg- nancy, the diagnosis, as a rule, will be unmistakable. There have been in- stances where an abdominal pregnancy which had undergone lithopedion formation has been mistaken for a myoma, and the shape of some large sub- peritoneal tumors has at times suggested the outlines of a foetus in utero. The differential diagnosis may be facilitated by a rontgenogram. After the sixth month the Rontgen ray is useful in the differential diagnosis of pregnancy as the shadow of the fcetal skeleton may then be recognized in a well-executed negative. There is apparently no tendency to abortion or miscarriage from the use of this means of diagnosis. The Abderhalden serum reaction may be tried, but is not likely to be of value. In some cases anaesthesia may be required before a satisfactory diagnosis, can be made. The diagnosis between myoma and pelvic inflammatory masses, as a rule, is not difficult, but occasionally some doubt may arise. An abscess sur- rounded by a considerable amount of exudate and induration may exactly simulate a myoma. Usually, however, the induration, the sense of deep fluctuation, and the associated history and signs of inflammatory pelvic trouble serve to distinguish between them. 310 GYNECOLOGY TREATMENT From what has been said, it can be seen that myomata, although not essentially malignant, are capable of much mischief, and after a certain time may become very dangerous to their host. A small tumor of an inter- stitial or a subperitoneal type, developing late in life, showing no ten- dency to grow with any degree of rapidity, giving rise to no symptoms, and possibly discovered by accident during pelvic examination, may be regarded with equanimity and let alone. Such a patient should always be carefully watched, and from time to time examined, so that an increase in the rapidity of growth or any complications may be detected at once. If any rule were to be made in the treatment of myomata producing symptoms it should be to remove them by a surgical operation within a short time after they had been detected. This would be justified by the fact that most of the myomata producing symptoms ultimately require operative treatment, and many times when operation is delayed the case becomes complicated and dangerous or even fatal degenerations and compli- cations ensue, or the operation is rendered more difficult by an increase in the size of the tumor. Palliative treatment, therefore, is only considered because sometimes, on account of the condition of the woman as a result of the hemorrhage and other effects of the tumor or because of advanced age and general ill-health, it may be inadvisable to operate at all, or, at any rate, to proceed with an operation until the strength and resistance of the patient have been in- creased by suitable preparatory treatment. The control of hemorrhage is the most immediate and pressing indication in a majority of the cases in which anaemia is marked and the circulatory condition of the patient is bad. Absolute rest in bed during the menses, or whenever hemorrhage is apt to occur, and the use of remedies which arrest hemorrhage by contracting the uterus or by increasing the coagulability of the blood will often be effectual. Ergot, pituitary extract, stypticin, and horse-serum may be tried for this purpose. If more heroic measures are necessary a gauze tamponade of the cervix may be tried with full aseptic precautions. Curettement is not advis- able for the purpose of controlling hemorrhage because it may hasten the necrosis of a submucous tumor by interfering with the blood supply, and by favoring entrance of pathogenic organisms. The Rontgen ray and radium are valuable therapeutic agents ; either will check the bleeding in a ma- jority of cases so that the patient may be put in good shape for a subse- quent radical operation. At the present time the weight of evidence is against the use of the Rontgen ray or radium as curative agents in cases of myoma uteri, except under certain conditions (see Radium and Rontgen Ray Therapy, Chapter XL). With the measures to prevent further hemorrhage must be combined those which promote the restoration of the blood and circulatory system to a normal condition. Iron and arsenic, blood transfusion, cardiac and renal stimulants, all may be required. The indication for operation is all the more urgent when the myoma is MYOMATA OF THE UTERUS 311 growing rapidly, when the woman is approaching the menopause, or a recent irregularity in the hemorrhage suggests the probability of a compli- cating malignant growth of the endometrium. Choice of Operation. — The operative treatment of myoma uteri varies from the simplest to the most formidable undertaking. Myomectomy is the removal of the tumor from the uterus, the latter being left in situ. Hysteromyo- mectomy is the removal of the uterus with the tumor. Either of these opera- tions may be undertaken through an abdominal incision. The operation selected in a case of myoma depends upon the number and location of the tumors, and the desirability in the individual case of preserving the men- strual and the reproductive functions. A single tumor attached to the vaginal part of the cervix may be subjected to vaginal myomectomy. Kelly and Cullen report eighty-four cases of vaginal myomectomy with five deaths ; with one exception the patients who died were septic or in a desperate state when admitted, owing to infection, necrosis, or gangrene of the tumor. A submucous tumor which has become pedunculated and projects through the cervical canal can be removed by torsion or by ligation and division of the pedicle. A submucous tumor lying within the cervix or the lower uterine segment may be enucleated (vaginal myomectomy) after bisecting the anterior uterine wall to secure adequate exposure. Multiple submucous tumors or single ones not easily accessible demand hystero- myomectomy. Hysteromyomectomy for cervical myomata by the vaginal route is feasible when the myomatous uterus is small, but the abdominal route possesses so many advantages that it is generally recognized as the procedure of choice. In the operative treatment of myomata affecting the body of the uterus the abdominal operation is the only one which need be taken into consideration. The choice between myomectomy and hystero- myomectomy depends upon the factors already mentioned. The more numerous the tumors, the more is hysteromyomectomy indicated, and the greater the distortion of the uterine body the less likely is myomectomy to be satisfactory. Degeneration of the myoma and suppurative or malignant complications are absolute contraindications to myomectomy. The cases most suited to myomectomy are those in which the number of tumors is small ; single tumors or at most not more than four or five ; the tumors are favorably situated, especially subperitoneal or interstitial, so that they can be removed without serious technical difficulties and without encroaching upon the uterine cavity ; the cases give no evidence of degenerative changes ; there are no malignant complications ; there is no associated suppurative dis- ease of the adnexa, and there is not so much distortion of the uterus by the tumor that after myomectomy it would be a misshapen and useless organ. The age of the patient and her desire to bear children is another impor- tant factor in reaching a decision. While there is no reason to be conserva- tive in a patient nearing the menopause who would be unlikely to conceive or in one who had no desire to bear children, the probability of gratifying the maternal instinct should be preserved whenever possible in younger women. In this class conservative myomectomy may yield the most happy results. Objections to myomectomy are : That occasionally it is a more serious 312 GYNECOLOGY and a more dangerous operation than hysteromyomectomy ; that it must be done with the most refined aseptic technic in order to avoid infection and dangerous post-operative adhesions ; that it may be necessary subsequently to operate again to remove the uterus on account of the development of other myomata which escape detection at the time of the first operation, and that pregnancy, after myomectomy, may end in abortion, or that labor may be complicated by a rupture of the uterus. With the progressive refinement in operative technic, and a careful limi- tation to suitable cases, myomectomy has become a safe operative procedure (Mayo, \Ym. J., 157 consecutive cases with one death; Kelly and Cullen report a mortality of 5.4 per cent, in 296 abdominal myomectomies), the primary mortality being less than that of hysteromyomectomy when the cases are properly selected. Hysteromyomectomy is the operation of necessity in bad cases : myomectomy is the operation of choice in good operative risks with favorably situated tumors. If care is exercised and all of the nodules removed, the subsequent de- velopment of unrecognized myomata is uncommon (Mayo — two in 157 cases). Although no more than the " greater number " of the myomectomy patients (Mayo's series) were traced afterwards, 18 in their series of 296 cases required subsequent operation (hysterectomy in 12). JVhen the uterus is removed with the myomata, what shall be done with the adnexaf The advantage in preserving the ovaries lies in the avoidance thereby of the disagreeable and annoying symptoms of an artificial meno- pause. The disadvantage is that the adnexal organs left behind may subse- quently become diseased and require a second operation for their removal. Both possibilities have been exaggerated, the one by those who champion the conservative plan, and the other by those who favor the radical plan. An artificial menopause is not often distressing within a few years of the menopause, and if the adnexa are entirely normal the chances are that they will remain so if in the performance of hysteromyomectomy their blood supply is carefully preserved. In a patient approaching or past the meno- pause age it is better, as a rule, to remove the adnexa. while in younger women it is preferable to allow them to remain. In women under thirty-five every eftort should be made to preserve the ovaries. If one ovary is dis- eased and the other is healthy, the diseased one should be removed and the other left in situ. It is better to do this than merely to resect the diseased area and to allow the rest of the ovary to remain. If possible the rule of either letting an ovary alone or taking it out entirely should be adopted. The resection of a part of an ovary is often followed by a recurrence of trouble, so that it should be avoided if possible, especially if the opposite ovary is entirely healthy. Resection of both ovaries may be required when they are diseased, even though the woman is young, or the worst one may be removed in toto and the other one resected. If it is not possible technically tQ leave either ovary in situ, a portion of one of them may be transplanted into the fat of the abdominal wall. When the ovaries are conserved the tubes also should be allowed to remain if they are healthy. This assures a pres- ervation of the ovarian blood supply. If the tubes are diseased, however, and require removal, they should be neatly trimmed off the top of the MYOMATA OF THE UTERUS 313 broad ligament and the catgut sutures used to control the bleeding tied as closely as possible to the tube. When a myoma has undergone malignant degeneration, or is compli- cated by a carcinoma of the body of the uterus or of the cervix, removal of the entire uterus including the cervix, panhysterectomy, is absolutely neces- sary. On account of the danger of overlooking carcinoma of the cervix in a myomatous uterus and because a cervix left behind after supravaginal hys- terectomy has subsequently become carcinomatous, some operators recom- mend complete hysterectomy, as a rule, instead of supravaginal amputation. There are many objections to such a course. Complete hysterectomy is a more difficult and a more dangerous operation than supravaginal hysterectomy. It is objectionable in married women because it shortens the vagina. Fur- thermore, such a course is unnecessary. An early carcinoma of the cervix or the body of the uterus complicating myoma may be detected previous to, or at the time of, operation if the cervix is carefully examined and the endo- metrial cavity curetted. By this precaution the danger of overlooking malig- nant trouble is avoided. In doubtful cases the major operation should be postponed until curetted particles or excised pieces of tissue can be sub- mitted to microscopic examination. If curettement of the uterus has been unsatisfactory or impossible on account of distortion or inaccessibility of the endometrial cavity, the uterus should be opened in the operating room immedi- ately after the supravaginal amputation. If, then, there are any evidences of malignant complications the cervix should be removed forthwith. In spite of the precautions above detailed, occasionally an incipient cancer of the cervix will be overlooked or a cancer will develop in the cervix sub- sequent to a supravaginal hysteromyomectomy. Therefore, any patient who has bloody discharge following hysteromyomectomy should be examined without delay in order to detect trouble of this nature. Carcinoma of the cervical stump in an early stage should be dealt with by excision ; if the disease has not advanced beyond the cervix an abdom- inal operation, with dissection of the ureters and wide excision of the para- metrium and vaginal vault, is the procedure of choice. In late cases, vaginal excision with the cautery may be tried. If radium is available it is pref- erable to any form of operation. OPERATIVE TECHNIC All operations for myomata of the uterus are preceded by dilatation of the cervix and curettement. The purpose of this plan is three- fold. First, it insures thorough disinfection of the vagina so that if pan- hysterectomy becomes advisable the vaginal part of the operative field is already prepared. Furthermore, if there is any reason to believe that the cervix or uterine cavity is not sterile an attempt can be made to make it so, as described on page 324. Secondly, hypertrophied mucosa is removed by curettement for the reason that if the operation of removal of the tumor is limited to a conservative myomectomy, the uterus is left in a healthier state than if an hypertrophied endometrium were allowed to remain. Thirdly, a curettement prevents a failure to recognize already existing malignant dis- ease in the cervix or body of the uterus. If the character of the curetted 314 GYNECOLOGY particles is such as to leave no reasonable doubt of their malignant nature, a panhysterectomy is indicated. If the contrary is true and they are un- questionably benign, myomectomy or supravaginal hysteromyomectomy may be selected. If there is any doubt as to the existence of malignancy, further operative procedure should be postponed until careful microscopic study of the tissues can be made. Abdominal Myomectomy. — After a median incision and exposure of the uterus, the exact position and relations of the tumor or tumors is carefully investigated. If the ca^e is a suitable one for myomectomy, the uterus is surrounded by a double layer of gauze packs so as to completely isolate it from the neighboring areas. Pedunculated subperitoneal tumors may be removed by a simple wedge-shaped incision of the pedicle, the two lips of the wound being brought together with sutures. If the tumor is large, and the pedicle is small and vascular, the peritoneal reflection from the Fig. 311. — Abdominal myomectomy. Line of incision through capsule of myoma. uterus may be circumcised and pushed back toward the uterus and the pedicle ligated with fine catgut, the peritoneum then being drawn over the cut surface of the pedicle and united with a fine running suture. If the tumor is sessile or intramural, one of two methods may be used for its ex- traction. By the first, after the incision has divided the surrounding tissue down to the capsule of the growth, an attempt is made by a blunt dissection to follow its circumference, separating the tumor from the uterine wall. This will be successful in small and well encapsulated growths. In larger ones, and those more firmly attached, a better plan is to carry the incision directly through the tumor to its opposite pole ; in other words, to bisect the growth, and then, catching each half with a vulsellum, separate each side in turn from its bed in the uterine wall. Bleeding may be controlled during this process by manual compression of the vessels of the broad ligament on either side, or intestinal forceps protected with rubber may be applied to the broad ligaments. As a rule, manual compression is to be preferred. After MYOMATA OF THE UTERUS 315 the tumor has been enucleated the more prominent bleeding points should be caught with forceps and ligated free or with mattress sutures. The bed of the tumor is then filled up by the introduction of fine interrupted or con- tinuous catgut sutures, while the peritoneal wound is approximated by a running suture of fine catgut. It is very important that the entire bed of the tumor be completely approximated or filled up, and that the peritoneal inci- sion be closed in such a fashion that there is no raw area exposed to which adhesions might occur (Figs. 311 to 315). Fig. 312. — Abdominal myomectomy. After making Fig. 313. — Abdominal myomectomy. After ex- the incision the myoma may be bisected and each posing the myoma it may be shelled out [by half caught in turn and dissected out. blunt dissection. Fig. 314. — Abdominal myomectomy. The bed of the myoma is carefully filled up with running cat- gut sutures. Large bleeding points are tied. Fig. 315. — Abdominal myomectomy. The uterine incision is closed with a suture of fine catgut; care- ful approximation of the peritoneal edge is secured. Where a number of nodules are to be removed from the same uterus, it is an advantage, if possible, to so plan the incisions that they lie in the same general direction, or in such a way that one peritoneal incision will answer for the enucleation of more than one tumor. The latter is rarely feasible. In some cases it may be desirable, in order to avoid a dead space or badly coaptated surfaces, to remove some of the uterine wall. There is no objec- tion to this when it becomes necessary, although it should be avoided when possible. Although the uterus may appear quite misshapen and out of pro- 316 GYNECOLOGY portion at the conclusion of the operation, subsequent involution may restore the organ to approximately normal form. Vaginal Myomectomy. — Vaginal myomectomy may be a very simple operation consisting of no more than a V-shaped division of the pedicle of a small tumor. Great difficulty, however, is encountered in tumors of consid- erable size, which spring from the cervix and greatly distend the vagina and Fig. 316. — Supravaginal hysteromyomectomy with bilateral salpingo-oophorectomy. The ovarian vessels and the round ligament have been tied. The utero-vesical fold of peritoneum is about to be divided. perineum in nulliparous women, if the pedicle is broad, and the attachment of the cervix difficult to reach and expose by means of the usual specula and retractors, a paravaginal incision should be made as a preliminary step in the operation. This affords easier access to the operative area. The tumor should then be divided in the median line directly up to its attachment with the cervix, and each half shelled out separately. The excess of capsule should be cut away, and the wound closed with interrupted catgut MYOMATA OF THE UTERUS 317 sutures. Vaginal myomectomy is sometimes employed for submucous growths which cannot be exposed until the uterine cavity has been opened by hysterotomy. In performing this operation, the anterior surface of the cervix and uterus are exposed by dividing the anterior vaginal wall trans- versely, close to its reflection, and then pushing up the bladder from the uterine surface. The incision of the uterine wall is made directly in the median line, and a succession of vulsella are placed on either side, from below upward, as the uterus is drawn down, until a point sufficiently high to expose the tumor has been reached. After removal of the growth the line Fig. 317. — Supravaginal hysteromyomectomy with bilateral salpingo-oophorectomy. A curved clamp has secured the uterine extremity of the broad ligament. The tube and ovary have been cut away from the broad ligament as far as the clamp. of incision in the anterior uterine wall is closed with interrupted catgut sutures. The vaginal wall is then united to the cervix. Hysteromyomectomy. — After the preliminary preparations have been completed, a median abdominal incision should be made, the uterus exposed, and the intestines packed off from the pelvic cavity. The position and num- ber of the tumors are noted, as well as the condition of the adnexa. If the adnexa are adherent and easily accessible, they should be released from adhesions at once, and the fibroid uterus pulled up through the incision. This is always possible in tumors of moderate size which are not intraliga- mentous or subvesical in position. If the tumor has developed from a point 318 GYNECOLOG^ low in the uterus, from the cervix, for example, and has grown between the layers of the broad ligament or the mesosigmoid, or if it lies beneath the bladder, early delivery will not be feasible, and certain modifications of the operation will have to be carried out. A simple hysteromyomectomy with bilateral salpingo-oophorectomy is performed as follows : The uterus is drawn over to one side of the pelvis and a point in the opposite broad ligament outside the ovary, which is free from blood-vessels, is selected. A catgut ligature is passed through this space and Fig. 3i8. — Supravaginal hysteromyomectomy with bilateral salpingo-oophorectomy. The round ligament and the broad ligament have been divided, exposing the cellular tissue as far down as the cervix, the bladder has been pushed away from the front of the cervix. The position of the uterine artery is being located with the finger. tied over the top of the broad ligament, securing the ovarian artery and veins (Fig. 316). A second ligature is now passed about the round liga- ment at a point somewhat nearer the uterus than the first ligature. This procedure is carried out upon the opposite side. A clamp is then placed along the lateral surface of the uterus, embracing the origin of the round ligament, the uterine extremity of the tube, the utero-ovarian ligament, and the utero-ovarian anastomosis, the end of the clamp pressing close to the side of the uterus so as to occlude the uterine vessels above the point where the division of the cervix is contemplated (Fig. 317). The broad ligament MYOMATA OF THE UTERUS 319 on one side is divided to the median aspect of the ligatures which have been applied, down to the end of the clamp which has been placed on that side of the uterus (Fig. 318). The vesical reflection of the peritoneum is then picked up from the anterior surface of the cervix and divided from the in- cision which has been made in the broad ligament across the front of the cervix to a corresponding point on the opposite side. The division of the broad ligament on the opposite side is then carried out in a similar manner. The uterine artery and veins on each side are located by palpation, and a suture passed about them with a needle (Fig. 319) ), the suture embracing a few of the lateral muscular fibers of the cervix. These sutures are tied, and the vessels are cut half an inch above it. The cervix is now divided trans- versely, by means of a wedge-shaped incision. The operation may be car- Fig. . 319. — Supravaginal hysteromyomectomy with bilateral salpingo-oophorectomy. A ligature has been thrown around the uterine vessels. Division of the cervix may now be done. The clamp controls the reflux circulation. ried out from left to right, or from right to left, if the operator so desires, tying the vessels on the side of approach and catching them with forceps on the opposite side after division of the cervix ; or all the vessels on both sides may be clamped and ligatures applied after the uterus has been removed (Figs. 320 and 321). After double ligation of both uterine vessels, the lips of the cervix are brought together in an anteroposterior direction, the outer approximating suture at either side of the cervix being made to include the end of the round ligament which is drawn over to it. The raw surfaces are covered by approximating the vesical reflexion of the peritoneum to the peritoneum of the posterior surface of the broad ligament and Douglas' pouch (Figs. 322 and 323). When adhesions of the uterus itself, or the adnexa, complicate the method of operation just described, they should be freed at once and the operation reduced to an uncomplicated series of maneuvers. If, however, the adhe- 320 GYNECOLOGY sions are dense, it may be advisable to begin the hysterectomy on the most accessible side, approaching the difficult side from below, after division of the cervix (Fig. 320). When both sides are seriously involved, but the fundus is accessible, the uterus may first be bisected in the median line as far as the cervix. Each half of the uterus is then in turn divided, the uterine vessels secured, and the separation of adhesions effected by working from below upward. Fig. 320. — Hysteromyomectomy from side to side. If the fundus is also buried in adhesions, the vesical peritoneum should be divided, the bladder pushed off the anterior surface of the uterus, and the cervix located and divided transversely from the median line to either side, until the uterine vessels are exposed. After ligating them the proxi- mal section of the cervix should be caught with a tenaculum and pulled upward, and the separation of the uterus and adnexa proceeded with from below upward. MYOMATA OF THE UTERUS 321 The operator may thus vary the technic of operation to suit the condi- tions which confront him in the individual case. An intraligamentous tumor on one side may be approached from the opposite side, enucleation of the tumor being attempted only after the opposite broad ligament has been secured and divided, and the cervix cut across. The uterine vessels on the affected side may then be carefully secured and the enucleation of the tumor Fig. 321. — Supravaginal hysteromyomectomy with bilateral salpingo-oophorectomy. Showing detail of ligating the clamped uterine artery; the vessel is first tied against the cervix and then picked up with an artery forceps and ligated individually with the same suture. effected from below. Sometimes it may be of advantage and feasible to ligate the ovarian pedicle and the round ligament on the difficult side before attacking the opposite broad ligament. The point of division of the cervix must be sufficiently low to expose the cellular tissue of the broad ligament close to the lower pole of the tumor or beneath it. In the case of a subvesical development of the tumor the first step in the operation should be an incision of the vesico-uterine fold of peritoneum and the separation of the bladder from the front of the uterus and the tumor. 21 322 GYNECOLOGY After this has been accomplished the uterus will be more easily delivered, and the operation can be concluded often in the customary manner. All plans of operation remain more or less difficult and potentially danger- ous until the uterus and tumor are mobilized. Usually, it is desirable to have a firm grasp upon the myomatous uterus, and although this may be obtained in the case of small tumors by means of Museaux forceps, the corkscrew holder of Doyen is much to be preferred when the growth is large. Some mobility may be gained in almost every case by dividing the round ligament on one or both sides. FlG. 322. — Supravaginal hysteromyomectomy with bilateral salpingo- oophorectomy, showing the cupping of the cervix which has been done during the supravaginal amputation and the introduction of the figure of eight suture to close the cervical stump. The technic of hysteromyomectomy is varied, also, by the method of disposal decided upon for the tubes and ovaries. If the adnexa on one side are to be preserved, the division of the broad ligament on that side should be to the inner extremity of the tube, and through the utero-ovarian ligament. If the tube is diseased, and the ovary alone is to remain, the ligation of the mesosalpinx should be carried out in the same way as will be described under salpingectomy, the round ligament and the utero-ovarian ligament being ligated close to the uterus. If both adnexa are healthy, both ovaries and both tubes may be left. Conservation of the adnexa is unadvisable after the MYOMATA OF THE UTERUS 323 age of thirty-eight, not only because the conserved structures will soon be- come useless, but also because they may later become diseased. Whether the ovary of one or both sides is conserved in conjunction with the tube, care should be taken that it is not left in too much of a dependent position. To avoid such a disposal, suspension to the round ligament may be prac- tised (Figs. 324 to 326). After hysterectomy the cervix should be suspended by attaching to it the cut extremity of the round ligament on both sides. When the operator has Fig. 323. — Supravaginal hystero-myomectomy with bilateral salpingo-oophorectomy, showing the trans- fixion of the round ligament with a suture that draws it between the outer raw lips of the cervix and anchors it in that position ; showing also the suture of the peritoneum which covers in all the raw surfaces. this in view at the beginning of the operation, he may provide for it by dividing the ligaments close to the fundus of the uterus. It should never be practised if it places tension on the pedicle of the infundibulo-pelvic liga- ment. One side at least may almost without exception be handled in this way. In the performance of hysteromyomectomy, both the ovarian and the uterine vessels should be tied twice on each side. In addition to the two ligatures which secure each uterine artery, and are passed so as to include a little of the cervical tissue, the ends of the upper suture after the knot is tied should be passed about the uterine vessels themselves after the latter 324 GYNECOLOGY have been isolated and grasped by a forceps (Fig. 321). In cutting through the cervix a wedge-shaped incision should be made so as to secure easy approximation of the cervical flaps. If previous to operation the uterine cavity has not been invaded by any sort of intrauterine treatment, the cervical canal may be re- garded as sterile, and no particular precautions are necessary upon divid- ing it ; when, however, as a result of preliminary intrauterine treatment per- formed with a careless technic, or because of a necrotic submucous tumor in which the endometrium ma3^ be the site of infection, the cervical canal may be infected, the greatest care must be exercised at the time it is opened. In such cases, pre- vious to the abdominal section and after the preliminary dilata- tion and curettement, the entire uterine cavity, or as much of it as possible, should be packed with gauze saturated with the tincture of iodine. Under these circumstances the amputation of the uterus and the invasion of the cervical canal should be per- formed as the very last step in the abdominal removal of the uterus. The incision across the cervical canal should be made by means of a cautery knife, after very careful isolation of the area with gauze sponges. The ex- posed mucosa of the cervix should be destroyed with the cautery, or disinfected with car- bolic acid, and the instruments and sponges used in this particu- lar part of the operation should be discarded. Panhysterectomy. — Panhys- terectomy is the operation which may be preferred for myomatous uteri when the cervix is diseased, as by marked cystic degeneration, hypertrophy, or laceration with marked eversion ; pan- hysterectomy is demanded when a fibroid tumor is complicated by a cancer of the endometrium or the cervix; panhysterectomy is necessary when the tumor occupies such a low position, or is so intimately involved with the cervix that it cannot be removed to the exclusion of the cervix. Panhyster- ectomy for myomata may be easy or difficult, depending upon the size, number, and position of the nodules. In simple cases the technic resembles that of panhysterectomy for cancer of the endometrium (see page 345). Panhysterectomy for fibroid tumor complicated by cancer of the cervix Fig. 324. — Supravaginal hysteromyomectomy with con- servation of the adnexa. The position of the uterine clamp is the same as in Fig. 317, but the round ligament, the tube and the utero-ovarian ligament are ligated close to the clamp and the broad ligament is divided between. MYOMATA OF THE UTERUS 325 Fig. 325. — Supravaginal hysteromyomectomy with conservation of the adnexa. Anchoring the round ligaments to the cervix. ! \ V V A W # 3K* M Fig. 326. — Supravaginal hysteromyomectomy with conservation of the adnexa. The operation completed and the raw surfaces covered. 326 GYNECOLOGY FlG. 327. — Diffuse adenomyoma of uterus. From Cullen's Adeno myoma of the Uterus. (W. B. Saunders Co.) must be more radical, the same technic being employed as in panhysterec- tomy for cancer of the cervix (page 349). In difficult cases of pan- hysterectomy for fibroid tumor, especially when the tumor is intraligamentous, great care is necessary to protect the ureters from in- jury. The base of the broad |1 ligament may be so dis- torted that the uterine ves- sels are difficult to secure, and in ligating them the ureter may be inadvertently tied. The only way to pre- vent such a misfortune is to identify all structures as they are exposed. By far the best plan is to deliber- ately dissect the ureters, and then retract them out of harm's way. The ureter may be found displaced to the outer side of an intraligamentous tumor, or it may be lifted up by a tumor developing beneath, so that it courses over the superior aspect of the growth. ADENOMYOMA 1 Pathology. — An adeno- myoma of the uterus, as the name implies, is a new growth consisting of myo- m a t o u s and glandular tissue. The adenomatous formation may be a diffuse one (Fig. 327), more or less uniformly involving the entire uterine wall, and sometimes completely encircling the uterine cavity, or it may be limited to an area at one cornu of the uterus (Fig. 328), or along the lateral surface of the uterus in an intraligamentous 1 Adenomyositis uteri is the term applied by Frankl to cases of diffuse thickening of the uterine wall with infiltration of the myometrium by gland-like formations resembling those found in adenomyomata but without any circumscribed tumor. He believes the condition to be of inflammatory origin, although in some cases no trace of inflammation can be found ; these latter he calls "Adeno-Myosis Uteri." The glands may originate from Fig. 328. — Longitudinal transverse section of uterus, showing adeno myoma of tubal angle. (Gynecological Laboratory, U. of P.) MYOMATA OF THE UTERUS 327 position, or it may be within the inner layers of the myometrium, forming a submucous tumor. Adenomyomata are not well circumscribed like the myo - mata ; they cannot be shelled out from the area which they occupy. Adeno- myomata also affect the isthmal extremity of the tube and the inguinal part of the round ligament. Cases have been described in which they were situ- ated beneath the lower pole of the kidney and alongside the cervix, closely related to the vaginal vault. Adenomyomata of the rectovaginal septum 2 have been described by Cullen and others. The essential histological features of adenomyomata, in whatever posi- tion found, are interlacing bundles of fibrous and muscular tissue, enclosing within their strands patches of glands and stroma closely resembling the endo- metrium. In the diffuse adenomatous formation, this glandular tissue undoubt- edly is an ingrowth from the endometrium, and Cullen has shown that the same is true of a large proportion of cornual and intraligamentous adenomyoma. Symptoms. — Adenomyomata exhibit the general symptoms and course of the ordinary myomata. The first symptom usually is an increase in the post-foetal proliferation of the endometrium, or misplaced parts Of the Miillerian ducts — not from the Wolffian system. When the gland formations are found in the outer layers of the uterine wall, they may have originated in the serosa. It is possible that adenomyomata of the outer extremity of the round ligament, the lower pole of the kidney, and the mesosalpinx (epi-oophoron) may be derived from rests of the Wolffian body, as believed by von Recklinghausen. By reason of their structure, adenomyomata sometimes become cystic. Carcinomatous degeneration of the glands may also occur. 2 Adenomyoma of the recto-vaginal septum at first forms a very small tumor in the vaginal vault just behind the cervix; or it may be recognized first as a round or irregular thickening, not over one cm. in diameter, behind and usually attached to the cervix. The growth usually spreads in a diffuse and irregular manner, involves the adjacent anterior rectal wall, and spreads into one or both broad ligaments, until finally everything in the pelvis may be firmly glued into one mass. The symptoms depend largely on the manner in which the growth extends. Small adenomyomata give little trouble. Rectal involvement may cause pain ; neuralgic pain may be caused by implication of the pelvic nerves : kidney pain by compression of the ureters. The menses are sometimes painful. If the mucosa of the adenoma opens into the vagina there may be vaginal hemorrhage at the menses ; if the mucosa of the tumor extends through the rectal mucous membrane, there may be some rectal bleeding at the menses." Cullen's conclusions as to treatment are as follows : " First, when small discrete nodules exist in the posterior vaginal vault they may be readily removed through a vaginal incision, as was so successfully done by Stevens. " Second, when the growth occupies the posterior surface of the cervix and extends laterally, the ureters should be dissected out carefully and a complete abdominal hysterec- tomy be performed. " Third, if the growth be firmly adherent to the rectum a wedge of the rectum should be removed, together with the uterus. It has been found best, after freeing the uterus on all sides, to open up the vagina anteriorly and laterally. The uterus and the rectum can be then lifted further out of the pelvis, thus facilitating the removal of the necessary wedge of the anterior rectal wall. The uterus can be used as a handle and the necessary rectal tissue and the uterus removed as one piece. " Fourth, when the lumen of the bowel is greatly narrowed a complete segment of the rectum should be removed, together with the uterus, and an anastomosis made. " Fifth, in desperate cases, where everything in the pelvis is glued together, an ideal procedure is out of the question. The patient in such a case cannot stand a long operation, and if she could a satisfactory result could not be obtained. Under such conditions it would be better to cut across the sigmoid, invert the lower end, close it, and bring the upper end out through the abdominal wall of the left iliac fossa, making a permanent colostomy. When the patient has to some extent regained her strength, the uterus, the lower portion of the rectum, and the broad ligament tissue can be shelled out as one piece. " These growths, while histologically not malignant, remind one of glue. Unless they are completely removed, further trouble is liable to occur." (Cullen.) 328 GYNECOLOGY length of the menstrual periods. Pain at the menstrual period is particu- larly pronounced, and is evidently due to the increase in the tension within the 'tumor, the islands of mucosa being congested like the true endometrium, and hemorrhage occurring into the glands. Adenomyomata do not attain the enormous size of nbromyomata. Not infrequently they are associated with inflammation of the adnexa. Diagnosis. — The diagnosis of adenomyomata in distinction from nbro- myomata is rarely practicable. ' Treatment. — The treatment is hysterectomy with preservation of the ovaries in younger women. BIBLIOGRAPHY Baer. B F. : " Supravaginal Hysterectomy Without Ligature of the Cervix in Operation for Uterine Fibroids. A New Method"." Trans. Am. Gyn. Soc., Phila., 1892, xvii, 235. Beyea, H. D. : " Conservation of Ovaries and Functionating Uterine Tissue in Hystero- Myomectomy." Amer. Jour. Obst, 1901, xliv. Clark, J. G. : " Fibroid Tumor of the Uterus." Progressive Medicine, 1906 ; Ibid. : " The Cause and Significance of Uterine Hemorrhage in Cases of Myoma Uteri.*' J. H. H. Bull., 1899, x. 94-96. Clark, J. G., and Xorris, C. C. : " Conservative Surgery of the Pelvic Organs in Cases of Pelvic Peritonitis and of Uterine Myomata." Surg., Gyn. and Obst., 1910, xi, 398. Cullex, T. S. : " Adenomyoma of the Recto- Vaginal Septum." Trans. Amer. Gyn. Soc. 1917, xlii, 481 ; Ibid. : Adenomyoma of the Uterus. Saunders, Phila., 1908. Deaver, J. B. : " Operative Treatment of Fibromyomatous Uterine Tumors." Trans. Sect. O. G. and A. S., A. M. A., 1916, p. 319; Ibid.: "Hysterectomy for Fibroids of the L'terus." Amer. Jour. Obst., 1905, Hi, 858. Doran, A. : " The Disappearance or Absorption of Fibroid Tumors Before the Menopause." Jour. Obst. and Gynec. Brit. Empire, 1004, vi, 141 ; Ibid. : " The Disappearance or Absorption of Fibroid Tumors of the Uterus." Jour. Obst. and Gyn., Brit. Empire. 1904, vi. Doyen : " Hysterectomies Abdomenales." Arch. Prov. de Chir., Dec, 1892 ; Ibid. : Technique Chirurgicale. Paris, 1897. Fexwick, H. : " On Cardiac Defeneration from Pressure of Abdominal Tumors." The Lancet, 1888. i. Fleck: " Myom u. Herzerkrank, in ihren Genetischen Beziehung." Arch. f. Gynak., 1904, lxx, Xo. 1. Gebhard : Pathology Anat. des Weiblichen Sexualorgane. Leipzig, 1899. Goffe, J. R. : " A New Method of Supravaginal Hysterectomy, etc." Amer. Jour. Obst.. 1890, xxiii, 372. Huxxer, G. L. : " One Hundred Consecutive Cases of Myoma of the Uterus." American Medicine, July 11, 1903. Kelly, H. A. : " Hysteromyomectomy by Continuous Incision." J. H. H. Bull., 1896, vii, 27. Kelly, H. A., and Cullex, T. S. : Myomata of the Uterus. Saunders, Phila., 1909. Knox, J. H. Mason : " Compression of the Ureters by Myomata Uteri." Am. Jour. Obst., 1900, xlii. Legueu, F. : " Des troubles Urinaires Provoques, par les Fibromes du col Uterin." Jour. d'Urologie, 1912, i. 33. McGlinn, J. A. : " The Heart in Fibroid Tumors." Trans. Amer. Gyn. Soc, 1913, 38, 482. Mayo, Wm. J. : " Some Obervations on the Operation of Abdominal Myomectomy for Myomata of the Uterus." Surg., Gyn. and Obst., 1911, xii. 97: Ibid.: " Myomas of the Uterus." Jour. Am. Med. Assc, 1917, lxviii. 887. Noble, C. P.: "Myomectomy." N. Y. Med. Jour., 1906, lxxxiii : Ibid. : "The History of the Early Operations for Fibroid Tumor." Amer. Jour. Obst., 1899, xl : Ibid. : " Fibroid Tumors ; Degenerations and Complications." Jour. Am. Med. Asso., December 8, 1906. Olshausex : " liber die Wahl der Operation bei Myomen." Cent. f. Gynak., 1902, Xo. 1. Pellaxda : La Mort par Fibromyomes Uterins. Paris, 1905. Pfahler, G. E. : Rontgenotheraphy in Uterine Fibroids and L'terme Hemorrhage." Amer. Jour. Obst., 1915, lxxii, 79. Pick, L. : " 1st das Vorhandensein der Adenomyome des Epioophoron Erwiesen ? " Cen- tralbl. f. Gynak., 1900, xxiv, 389-397. MYOMATA OF THE UTERUS 329 Piquand: "Fibromes et Cancers Uterins.' r Annales de Gynecol, et d'Obstet, 1905. Prvor: "A New and Rapid Method of Dealing with Intraligamentous Fibromata." Med. News, 1894. Recklinghausen, von, F. D. : Die Adenomyome und Cystadenome der Uterus und Tubenwandung — In Anhang : Klinische Notizen zu den Volumonosen Adenomyome de Uterus. W. A. Freund, Hirschwald, Berlin, 1896. Sampson, J. A.: "The Blood Supply of Uterine Myomata." Trans Amer. Gyn Soc, 1911, xxxvi, 239; Ibid.: "The Influence of Myomata on the Blood Supply of the Uterus, with Special Reference to Abnormal Uterine Bleeding." Surg., Gyn. and Obst., 1913, xvi, 144 ; Ibid. : " The Influence of Myomata on the Blood Supply of the Uterus, etc." Trans. Amer. Gyn. Soc, 1912, xxvii, 156. Smead, L. F. : "Cervical Fibroids." Am. Jour. Obst., 191 1, lxiv, 790. Stimson : " Ligation of the Uterine Arteries in Their Continuity, in Hysterectomy." N. Y. Med. Jour., xlix, 1889. Sutton, J. B. : " Fibroids of the Uterus." Science Reviews, Ltd., London, 1913. Theilhaber, A. : " Der Zusammenhang von Myomen mit Internen Erkrankungen." Monatsch. f. Geb. u. Gynak., 1910, Bd. xxxii, H. S., 455. Veit, J. : " Ueber Vaginale Myomectomie." Zeit. f . G. u. G., 1896, xxxiv. Vineberg, H. N. : "What Is the Fate of the Ovaries Left in Situ After Hysterectomy? Surg., Gyn. and Obst., 1915, xxi, 559. Webster, J. C. : "A Consideration of Fibroid Tumors of the Uterus Based Upon a Study of a Series di Two Hundred and Ten Cases Treated Surgically." Am. Med., 1905, 401. Winter : " Die Wissenschaftlichen Grundlagen der Conservative Myomoperation." Zeit. f . Geb. u. Gynak., 1905, lv ; Ibid. : " Die Wissenschaftlichen Begrundung der Indika- tionen zur Myomoperation." Zeit. f . Geb. u. Gynak., 1905, lv ; Ibid. : " Die Malignen u. Benigen Degeneration der Uterusmyome." Zeitsch. f. Geb. u. Gynak., 1906, lvii, 8. Zweifel: Ueber die Behandlung der Myoma. Cent. f. Gyn., Bd., 1899, xxiii. CHAPTER XVIII MALIGNANT TUMORS OF THE UTERUS CARCINOMA OF THE UTERUS Situation. — Carcinoma may affect either the cervix or the body of the uterus. A cervical carcinoma may have its origin in the mucosa of the vaginal portion of the cervix or in that of the cervical canal. Carcinoma in the body of the uterus grows from the endometrium. Etiology. — The cause of carcinoma is not known. In the majority of cases it occurs at about the time of the menopause ; it is rare before the age of thirty-five, but sometimes develops after the age of fifty. The disease is believed to be less frequent in the negro than in the white race. The poorly nourished and those who live amid unhygienic surroundings are said to be predisposed. That the disease is infectious has been repeatedly insisted upon, and many instances of the apparent prevalence of cancer in certain localities, and of the development of the disease in different persons living in the same house (" cancer house "), at various times, have been observed. Direct transference of cancer from a patient to the attending physician or a nurse has not been observed, and the experimental proof of the infectious nature of the disease has yet to be adduced. Among other causes to which the occurrence of carcinoma has been attributed are the abnormal prolif- eration of embryologic inclusions of alien tissue. There seems to be little evidence that heredity plays an important part. What is known as the biologic theory, namely, that cancer is the result of repeated traumatisms which finally induce an unlimited proliferation of the irritated epithelial cells, seems to apply particularly to carcinoma of the cervix, for except in women who have borne children, the disease is very rare in this situation. The apparent exceptions to this rule, on careful inquiry, will often be found to have been the subjects of some operative procedure upon the cervix, such as dilatation. Although this clinical fact may admit of other interpreta- tions, it is, nevertheless, true that childbirth with its attendant laceration of the cervix predisposes to the development of carcinoma in the cervical por- tion of the uterus. Statistics collected by Frankl show that only 3 per cent, of cervical carcinomas develop in nulliparous women. This does not seem to apply to carcinoma of the body of the uterus, which affects nulliparae quite as often as women who have borne children, and in them some other explanation for the occurrence of carcinoma must be found. Sometimes, unquestionably, the irritation produced by a fibroid nodule in the wall of the uterus favors the development of carcinoma of the endometrium, and in these cases it may be that a diffuse or a circumscribed hypertrophy of the endometrium has preceded the development of the carcinoma. Carcinoma of the cervix occurs about ten times as frequently as carcinoma of the body of the uterus. 330 MALIGNANT TUMORS OF THE UTERUS 331 CARCINOMA OF THE CERVIX Pathology. — Carcinoma of the cervix may partake of one of two histo- logic types: (i) The squamous-celled carcinoma (epithelioma) when it springs from the squamous epithelium covering the vaginal surface of the cervix (Figs. 329, 330 and 331) ; (2) the columnar-celled or glandular variety, adenocarcinoma, when it springs from the high columnar epithelial cells of the folds and glands of the cervical mucosa (Fig. 336). As carcinoma de- velops most frequently in a cervix which has been lacerated and everted, it is often difficult, by gross examination, to determine in which of the situa- iW" f Fig. 329. — Epithelioma of the cervix (Cullen's Cancer of the Uterus, W. B. Saunders Co.). tions noted it has originated. EA'en by histologic examination it may be impossible in the later stages to determine whether the growth was origi- nally an epithelioma or an adenocarcinoma, since in advanced cases they both present very much the same features. Epithelial pearls may, how- ever, serve to distinguish an epithelioma and a glandular structure an adenocarcinoma. Carcinoma of the vaginal surface of the cervix has a tendency to spread to the neighboring mucous membrane of the vaginal vault, and then to in- volve the cervical canal. Carcinoma of the cervical canal is more likely to penetrate the wall of the cervix and invade the cellular tissue between the layers of the broad ligament. Both varieties, however, may extend in either 332 GYNECOLOGY Fig. 330. — Early epithelioma of the cervix. (Anspach in Martin's Surgical Diagnosis, Lea and Febiger.) of the directions mentioned, and as the disease progresses usually do. Carcinomata spread by a continuity of growth upon the surface and by the deportation of cancer cells along the lymph radicals of the broad and uterosacral ligaments (Figs. 332 to 334). These lymph-vessels pass from the cervix and the vaginal vault through the paravaginal and paracervical cellular tissue to the hypogastric and the iliac glands and to those lying alongside the rectum over the sacrum. In advanced of a more malignant type, the cases, and even in some of the early ones obturator glands may also be involved. In advanced carcinoma of the cervix, the involvement of both the sur- rounding and distant structures may be very extensive. The vesicovaginal septum may be extensively infiltrated, so that ultimately the tissue between the bladder and vagina breaks down with the formation of a vesicovaginal fistula. Infiltration of the rectovaginal sep- tum may also occur, but, as a rule, much later, and it is not so likely to result in a fistulous communica- tion between the bowel and the vagina. The bases of the broad liga- ments and of the utero- sacral ligaments may be converted into in- d u r a t e d, unyielding areas of stony hard- n e s s , which fix the structures within their grasp. The ureters may be completely sur- rounded, and there may be some obstruction to the passage of urine through them, causing hydroureter and hydro- nephrosis, even though Fig. 331.— Squamous cell carcinoma of the vaginal cervix. The entire vagi- nal surface ot the cervix is mvolvpH fr,vn P rn1ntri^i T ~v,™-o<-,-v~r tt ~t r> \ (Gynecological Laboratory, U. of P.) MALIGNANT TUMORS OF THE UTERUS 333 O m 1*8 i ->P — -J ~ 3 5 5L p " a> 3 P o 5? ^ 3 ~ D-i« gS.3 2 3 < — O Cl <5 3 F fD O ^ 5-0 "< 0> 2. S 3" 3°^ P 0> -t p 3^ < O 334 GYNECOLOGY there is no actual carcinomatous infiltration of the ureter itself. Carcinomatous infiltration of the pelvic nerves occurs in late cases. The infiltration and lymphatic enlargement may exert sufficient pressure upon the veins to produce oedema of the lower extremities. When the lymphatic involvement has progressed to a certain extent, the lumbar glands become diseased, and then there may be metastasis to distant parts of the body. Remote metastasis is not so frequent, except in the last stages, in carcinoma of the cervix as in carcinoma of the body of the uterus. Though carcinoma of the cervix spreads in all directions, it does not affect the fundus of the uterus except in the most advanced cases. Coincident with the progressive extension and advancement of the car- FiG. 333- — Diagrammatic sketch to show the spread of epithelioma of the cervix, sagittal and transverse sections; black area represents original site; dots, the early areas of extension; crossed lines, the ultimate involvement. cinomatous disease into new areas, there is a breaking down, a necrosis, and an infection of the areas previously or originally involved. Thus, in an ad- vanced case, the cervix is often entirely destroyed, and in its place an excavated ulcer, with hard, indurated edges bleeding easily on touch, is found which may be covered with a necrotic, foul-smelling discharge. The ulceration is the result of an insufficient blood supply to the new growth plus an infection (Fig. 335). The streptococcus is a frequent dweller in carcinomatous ulcers. Carcinomatous stenosis, or occlusion of the cervical canal, with coincident infection, may lead to the production of pyometra. From what has been said it is evident that cancer of the cervix may appear in three clinical forms : First, the proliferating or vegetating (cauliflower) form — usually an epi- MALIGNANT TUMORS OF THE UTERUS 335 thelioma beginning on the vaginal part of the cervix and forming a luxuri- ant mass which projects into the vaginal vault. Second, the infiltrating or indurated — usually an adenocarcinoma begin- ning in the cervical canal and infiltrating its way into the broad ligament, causing stony induration and hardness. Third, the ulcerating or the excavating form — either the proliferating or infiltrating type — after the carcinomatous tissue has broken down and been discharged, with the formation of large ulcers or craters. Symptoms. — There are no symptoms pathognomonic of cancer. The most frequent symptom of cervical cancer is hemorrhage (Fig. 336). Rarely Fig. 334. — Diagrammatic sketch to show the spread of adeno-car- cinoma of the cervix: sagittal and transverse sections; black area represents original site; dots, the early areas of extension; crossed lines, the ultimate involvement. at the start this may take the form of an increased menstrual flow ; usually, in the early, and always in the later stage, it occurs between the menstrual periods, either without any apparent reason, or induced by douching, sexual intercourse, defecation, riding over a rough road, or by something that acts as a trauma to the delicate carcinomatous villus, which consists of a capil- lary blood-vessel surrounded by a thin layer of carcinoma cells. The amount of hemorrhage may be very slight, and usually in the early case consists of but a few drops ; in exceptional cases, however, it may be profuse. Preced- ing the onset of hemorrhage there may be a discharge having the appear- ance of a leucorrhoea or an increase in one which existed previously, or again the discharge may become streaked with blood, or assume a reddish or a brownish appearance. These are the only subjective symptoms of an early 336 GYNECOLOGY carcinoma ; they are often regarded with equanimity by the patient, and considered a natural phenomena incident to the menopause. Later on, when the disease has become advanced and hemorrhage is more frequent and profuse, there is a discharge of putrid, broken-down car- cinomatous tissue ; the woman complains of pain from carcinomatous infil- tration of the broad ligaments, bladder, bowel, ureters, or pelvic nerves ; functional disorders of the neighboring viscera occur, and a cachexia de- velops, w T hich is partly the result of hemorrhage and partly due to disturb- ance of the excretory functions and the absorption of toxins from the necrotic cancer tissue. It. should never be forgotten that the latter symptoms are those of a hopeless case of carcinoma! The recognition of malignant disease Fig. 33S-— Advanced epithelioma of the cervix. The vaginal cervix has been destroyed by the growth which has reached the internal os. Typical cauliflower type of growth. (Gynecological Laboratory, U. of P.) after such symptoms have appeared is usually of no avail. As soon, there- fore, as a patient complains of the slightest irregular hemorrhage, a thor- ough examination should be made, for it is only in this way that carcinoma may be recognized in an early stage. Diagnosis. — The physical characteristics of an early carcinoma of the cervix depend upon the variety of the growth and its point of origin. As the most common form is the squamous-celled variety arising from the vaginal surface of the cervix, it is usually plainly evident to inspection after exposing the cervical lips. Its appearance is suggestive of the ordinary cer- vical erosion or eversion of the cervical lips, but it has certain points of variation from a benign eversion or erosion which may be brought out by a closer examination. MALIGNANT TUMORS OF THE UTERUS 337 jnox.&roctel , /«. Fig. 336. — Histological section of finger-like projection from cervix, showing cause of hemorrhage; (a) indicates a delicate capillary, which is surrounded by from two to three layers of squamous epithelium, and appears in a cross section of a typical finger-like outgrowth. At (b) is a finger of tissue containing two blood-vessels, or possibly two sections of the same vessel, if it has been a very tortuous one. (c) is a large blood-vessel. Note the very fragile walls, consisting of a layer of endothelium (d) and external to this a few young connective tissue cells. Covering the surface of this vessel are a varying number of layers of squamous cells; at (e) three or four layers, the one next the vessel being cuboidal; at (/) only one layer, (g) indicates solid areas, rich in epithelial cells. In some places blood-vessels are scattered sparingly throughout them. (?) indicates cell nests, which render the diagnosis of squamous cell car- cinoma fairly easy; (k) is a stroma of the growth, very scanty in amount, and consisting of a few spindle- shaped cells, but principally of small round cells. At point (I) in the large vessel (c) is a clump of poly- morphonuclear leucocytes. The entire picture bears a striking resemblance to angiosarcoma, more especially the area enclosed by (h). (Cullen's Cancer of the Uterus, W. B. Saunders Co.). 22 338 GYNECOLOGY In a benign erosion or eversion of the cervical lips the exposed mucosa of the cervical canal, even though hypertrophied, preserves the regular arrangement of its folds. In carcinoma the surface is covered with finger- like projections which have no regularity of arrangement. The mucous membrane in a benign erosion is frequently covered by a clear mucus. The finger-like projections of a carcinoma are usually matted together by a blood- tinged mucus. If each lip of an everted cervix is caught with a tenaculum and ap- proximated at the position of the external os, the eversion of the mucous mem- brane will be corrected and the suspicious area will be rolled into the cervical canal. An attempt to do this, in the presence of carcinoma, will fail. Palpation of an everted mucosa reveals a soft, velvety surface which does not bleed upon gentle palpation, while palpation of a carcinomatous surface reveals an in- durated, friable tissue, and results in considerable bleeding. Induration of the cervical tissue surrounding the suspicious area is more apt to be found in carcinoma than in a benign condition. In doubtful cases, by using a small curette, it will be found that a carcinomatous area is very friable and may be scraped away easily, whereas, in a benign erosion, the tissue does not show the same tendency to be broken up and scraped away. In every case, irre- spective of the clinical findings, recourse should be had to excision of the suspected area and microscopic examination. Carcinoma beginning within the cervical canal presents more difficulties in the way of an early diagnosis than does carcinoma of the vaginal surface of the cervix. In some instances the carcinomatous infiltration extends into the substance of the cervix with little external evidence of its existence upon the vaginal surface. The cervix, in such cases, is harder than normal, and quite likely to be distinctly nodular. If the external os has been opened by a laceration or otherwise, the same finger-like projections may be observed within the cervical canal. Palpation of the cervix is likely to be followed by hemorrhage, and the introduction of a sound will almost invariably produce bleeding. By the introduction of a curette within the cervical canal it can be determined that the tissue is more friable than normal, and it may be possible, without using much force, to excavate an area of some size about the cervical canal, the tissue coming away in small pieces, like hard cheese. Fortunately, carcinoma originating within the cervical canal is not as frequent as carcinoma beginning upon the vaginal surface, and as carcinoma of the cervix is usually found in a lacerated cervix, the cervical canal is more accessible than in a nulliparous woman, or if no laceration existed. In every doubtful case recourse must be had immediately to curettement and ex- cision of a portion of the cervical lips, with subsequent microscopic examination. Carcinoma of the cervix in the early stage may appear as a small ulcer. Ulceration and excavation of a carcinomatous area do not occur, as a rule, except in well-developed cases, but occasionally a beginning new growth may appear as a small ulcer with indurated base and irregular margins bleeding freely upon palpation. Unless it is very superficial an actual ulcera- tion of the cervix is commonly malignant. The clinical forms of early carcinoma above described may be confused with MALIGNANT TUMORS OF THE UTERUS 339 sarcoma, syphilis, or tuberculosis of the cervix The distinction between them can be made positively only by means of a microscopic examinaton. Cervical polyps and submucous pedunculated myomata projecting from the external os may be mistaken at first sight for cervical carcinoma. A careful examination, however, will show at once that the tumors lie within the cervical canal and are attached by a pedicle to a point above the internal os. As cervical polyps not infrequently undergo malignant degeneration, and as 9 per cent, of submucous myomata become sarcomatous, the indica- tion in both instances is immediate operation — avulsion and curettement — and microscopic examination of the specimens. Treatment. — The treatment of carcinoma of the cervix, to be of any avail, must be carried out, as a rule, in the early stage. If a carcinoma has over- spread the limits of the cervix, the case is hopeless, with few exceptions, whether treated by operation or otherwise. Even in some very early cases, by the time the patient is exposed to surgical treatment, metastasis to some of the pelvic glands has occurred, and operation does not permanently cure. It is, therefore, of the utmost importance that cases should be recognized at the earliest possible moment. The operation for carcinoma of the cervix consists of a panhysterectomy in which the entire uterus and the adnexa are removed, together with the vaginal vault, and the paracervical and the upper paravaginal connective tissue (Fig. 344). In addition to the removal of these structures, in certain cases it will be found advisable to remove enlarged pelvic lymph-glands ; as a rule, however, if there is any glandular involvement, the disease will return, no matter how extensive the operation. The reason for adopting as wide an excision of the diseased cervix as possible is that a carcinoma of the cervix frequently has microscopic extensions about it which are not recognizable grossly, so that, although macroscopically the disease may appear strictly limited to the cervix, there may be some small metastases in the structures surrounding it. For that reason the parts mentioned are removed with the uterus and the adnexa. This is the most serious operation which the gynecologist is called upon to perform, the danger arising, in part, from the extensive dissection which is necessary, and which imperils the integrity of such structures as the rectum, the bladder, and the ureters. Furthermore, carcinoma is frequently the abode of the streptococcus, and the cellular tissue of the pelvis, exposed during operation, is a favorable nidus for the growth and extension of a streptococcus inflammation. Another remote danger which obtains in a radical operation for carcinoma is that pieces of carcinomatous tissue which are broken off during the operation may be implanted in the operative area and subsequently developed there. For all these reasons, certain steps are taken to sterilize the carcino- matous area, as far as possible, before operation, and to prevent the carcino- matous tissue itself from coming in contact with the operative field. In stout women, or in those in whom, for general reasons, an extensive abdominal operation w 7 ould be either very dangerous or very difficult, a 340 GYNECOLOGY vaginal hysterectomy may be substituted for the abdominal operation. This may be aided by what is known as a paravaginal incision (Fig. 346) if the perineum is rigid, or done without it if the patient has a roomy vaginal introitus and the cervix is easily exposed. The preparatory treatment is the same for all forms of operation. Under nitrous oxide-oxygen anaesthesia, all friable tissue in the carcinomatous area should be removed, and the base of the excavation remaining cauterized, with a thermo- or electric cautery. If an abdominal hysterectomy is to be performed, the vagina is then thoroughly washed out with a solution of bichloride, 1 : 2000, and packed with bichloride gauze. In the event of a vaginal hysterectomy, after cauterizing the carcinomatous area and using the cautery, the vaginal wall is circumcised a short distance below the cervix, and a cuff of vaginal tissue turned over the projecting cer- vix and united with sutures ; in this way the carcinoma is effectually closed off from the operative field (see also Chapter XL for the use of radium in the preparatory treatment). Prognosis. — The prognosis in carcinoma of the cervix is bad, unless the case is discovered in its incipiency. At the present time scarcely more than 40 per cent, of cases seeking surgical advice are operable — that is to say, are suitable for a radical operation, with the hope of removing all the carcino- matous disease. European operators give an average operability of 65 per cent. ; American figures show only 35 per cent, of carcinomas in an operable condition. In nearly 60 per cent, of carcinomas a radical operation is impos- sible. In untreated cases death usually results in from twelve to eighteen months. The best results in the treatment of carcinoma of the cervix show 20 to 25 per cent, of cures after five years; in other words, 20 to 25 out of 100 women with carcinoma of the cervix applying for treatment were cured by the radical operation. Of the cases which survived the operation, 45 to 55 per cent, remained cured for more than five years. These statistics may be improved by constant watchfulness on the part of the physician in order to detect carcinoma in its earliest stage. For this reason, in all suspicious cases, the physician should satisfy himself as to the true nature of the affec- tion by at once preparing sections for histological examination. The Question of Operability. — What is there to guide the surgeon in determining which cases are operable and which are inoperable? As a rule, when the carcinomatous area has not encroached upon the vaginal vault, or is separated from it by a rim of healthy tissue, and there is no fixation of the cervix, or induration at the base of the broad ligaments, the carcinoma is limited, and there is good hope of removing it by a radical operation ; such cases are operable. If the carcinoma has destroyed the cervix, or involved its entire extent, or spread to the vaginal vault, and if, in addition, the bases of the broad ligaments are indurated, and the uterus is fixed, such a case is not amenable to the radical operation and may be classed as inoperable. There are certain border-line cases in which it will be impossible to say, without an examina- MALIGNANT TUMORS OF THE UTERUS 341 tion under anaesthesia, or even without an exploratory laparotomy, whether there is any hope of curing the patient by a radical operation. Induration along the sides of the cervix is not always due to extension of the carcinomatous process, but may be simply an inflammatory reaction and infiltration. On the other hand, carcinoma may have extended beyond the cervix into the broad ligaments without giving rise to much induration, or it may have given glandular metastasis before any induration or fixation of the uterus, or broad ligaments, is demonstrable. If one is convinced that the carcinoma has extended beyond the con- fines of the cervix or there are any glandular enlargements, it is good practice to take the position that the case is hopeless, unless it can be influenced by radium and that a radical operation is unjustifiable. In some cases in which one is in doubt, an exploratory incision may be made and one may decide by what he finds whether to go ahead with the radical plan or not. Cystoscopic exami- nation is sometimes of considerable value in determining whether there is involvement of the bladder. Cases in which the bladder wall is involved almost invariably show bullous oedema and some retraction or contraction of the vesical base. Treatment of Inoperable Cases. — A new hope may be offered to patients suffering with inoperable cancer in the use of radium. If this precious element is available, it gives the best promise of relief and sometimes causes the tumor to disappear even in advanced cases. Our experience with radium is still too recent to speak much of " cures." All we can say now is that in some patients after the use of radium the growth disappears and the patients are free from symptoms — in the oldest case on record for a period of seven years. An application of radium is the least disturbing and painful of any method of healing inoperable cases. All that is required is to place the radium in the diseased area and leave it there for a certain number of hours. (For the statistics, dose, and technic, see Radium and Rontgen Ray Therapy, Chapter XL.) If radium is not available, then the cold cautery method of Percy should be used. This method depends upon the assumption, apparently a fact, that a certain degree of heat, short of scorching or burning, will cause the disin- tegration of cancer cells while it does not exert a deleterious influence on normal tissue. Percy has devised instruments and elaborated the technic of this method of treatment. The principle of his operation is to thrust a " cold " cautery iron into the midst of the carcinomatous area and then by gradual radiation to influence not only the cancer cells immediately in con- tact with the iron, but also those at a distance. This requires time, and it is not unusual to leave the iron in position for two hours. In addition to cautery irons Percy has devised various water-cooled specula, which are used for the protection of the surrounding areas. Combined with the cold cautery the ligation of the arteries which supply the uterus and pelvic viscera with blood has a further favorable influence. When the blood supply is shut off from the diseased areas they are more 342 GYNECOLOGY inclined to disintegration. To this end, as a preliminary to the application of the " cold cautery," the internal iliac, ovarian, and round ligament arteries are tied with non-absorbable ligatures. This method is not devoid of danger. Percy has recently published his mortality rate which shows that there have been deaths directly following the use of his plan. It must be remembered, however, that all such cases are poor operative risks and that if let alone death would be inevitable. (See technic of Percy method, page 356.) If neither radium nor the Percy method is available, then the hope of a cure mUst be abandoned, but the relief of certain symptoms, such as fetid discharge, hemorrhage, and pain may be secured by a very thorough curette- ment of the carcinomatous area and subsequent cauterization ; for this either the actual cautery or a chemical solution, such as saturated chloride of zinc, 10 per cent, formalin, or pure acetone may be employed. The appli- cation should be made to the carcinomatous crater by means of small pledgets of cotton which have been pressed out of the solution. The vaginal wall and the surrounding healthy tissue -should be protected by a thick application of boric ointment. The cotton pledgets are removed at the end of forty-eight hours, after which douches of permanganate of potassium, 1 : 5000, or lysol, T /\ of 1 per cent., may be given to keep the parts clean and reduce the odor. For the relief of pain an opiate will ultimately be required. It is best to begin with codeine or heroin and later use morphine itself. Recurrence of Carcinoma after Operation. — Recurrence of carcinoma fol- lowing radical operations for the removal of the uterus is found in approxi- mately 45 per cent, of carcinoma of the cervix. The majority of the recurrences take place during the first year. Recurrence may be due to implantation metas- tasis or the incomplete removal of the carcinomatous tissue, especially in the vaginal vault, parametrium, and the lymph-glands. Involvement of the para- metrium recognizable at the time of the operation has been followed by recurrence in many cases. Clinical indications of a recurrence are beginning cachexia with persistent and localized pain. In the majority of cases the recurrence takes place in the hypogastric or iliac lymph-glands. These form an irregular mass spread out upon the surface of the pelvic bones, often best palpable through the rectum. Recurrence in some instances may not take place until after the assumed limit of cure of five years has elapsed. A decrease in the frequency of recurrence is dependent upon earlier recog- nition and operative treatment, as well as perfection in the technic of the operation. CARCINOMA OF THE BODY OF THE UTERUS Pathology .—Carcinoma of the body of the uterus, as a rule, occurs later in life than carcinoma of the cervix. It is even more insidious than cervical cancer, and affects women who have not borne children as much as those MALIGNANT TUMORS OF THE UTERUS 345 who have. Fibroid tumor of the uterus is complicated by cancer of the uterine body in 1.54 per cent, of the cases. Stone has called attention to what he terms precancerous changes in the uterus. Under this designa- tion he includes, in addition to myomata, leucoplakia, uterine polyps, and glandular hypertrophy. Although usually of the glandular type, springing from the cylindrical epithelium of the endometrial surface, or the glands (Figs. 337 and 338), it also may be, though rarely, of the squamous-celled variety, the surface epithelium having undergone a metaplastic change be- fore the beginning of the carcinoma. Carcinoma of the body of the uterus has a tendency to invade the uterine wall and to extend through- out the entire endometrium. In the late stage it may per- forate the wall of the uterus and involve the peritoneal surface or the parametrium, or it may extend down be- vond the confines of the in- ternal os and involve the cervix. It usually requires some time before this degree of extension takes place. Carcinoma of the body of the uterus has been regarded as little disposed to give metastasis, except in the late stages ; according to Weibel, lymphatic involvement i s more frequent and when it occurs the metastasis is usu- ally to the lumbar and iliac glands, or general metas- tasis may take place. Metas- tasis of carcinoma of the body of the uterus, in late cases, may also invade the inguinal glands through the lymphatics of the round ligaments. The adnexa are sometimes the seat of metastasis, even when the uterus is small and the carcinoma not very extensive. The adnexal lesion may sometimes overshadow the uterine lesion in its clinical manifestations. Symptoms. — There are no pathognomic symptoms of cancer of the fundus. The most frequent early symptom is irregular hemorrhage or a leucorrhceal discharge. The hemorrhage is intermenstrual, and varies from a mere show to a brisk hemorrhage. It is brought on by exertion or by some slight jolting or movement of the uterus. At first the hemorrhage may be regarded as an increase of the menstrual flow incident to the menopause. Very often the bleeding begins months or years after the menses have ceased ; it is then a striking symptom and likely to attract attention. Fig. 337. — Early carcinoma of the endometrium. Diagnosed from curettings. (Stetson Hospital.) 344 GYNECOLOGY The leucorrhoeal discharge is commonly thin, milky, and foul-smelling, and may suddenly appear as something entirely new, or gradually show itself as an exaggeration of a previously existing leucorrhcea. If hemor- rhage and the leucorrhceal discharge begin after a woman has ceased to menstruate and has presumably passed the menopause, they are especially significant, and in a large majority of cases are indicative of malignant disease. /% »*y5 ''•£. Fig. 338. — Advanced carcinoma of the endometrium and small interstitial myoma. The uterine cavity was filled with a necrotic putrid mass. The walls of the uterus at the area of the attach- ment of the tumor were destroyed almost to the peritoneal coat. (Gynecological Laboratory, U. of P.) In the later stages, when the carcinoma has involved a good part of the uterine wall (Fig. 338), and necrosis of the carcinomatous tissue has begun, to those symptoms already mentioned will be added a more or less constant putrid discharge, and the symptom-complex known as cachexia. Diagnosis. — A positive diagnosis is not possible in the early stages without the aid of digital or instrumental intrauterine exploration, supplemented in early or doubtful cases by a microscopic examination of endometrial scrapings. There may be very little enlargement of the uterus in a case of early carcinoma. Perhaps in a majority of early cases the uterus is not enlarged, MALIGNANT TUMORS OF THE UTERUS 345 the disease frequently beginning after the menopause in women who have not borne children, so that the uterus may be entirely normal in size, or even small. Dilatation of the cervix, with curettement, is the diagnostic means par excellence. The practised hand will often obtain positive information from curettage. This may reveal a roughness or thickness of the endometrium; the amount of tissue removed is commonly greatly in excess of that in a case of simple hypertrophy of the endometrium. It is whitish, like old cheese, in appear- ance, quite friable, and comes away in disconnected pieces rather than in long strips or ribbons. In any doubtful case the operator must wait until a microscopic examination of the curetted particles can be made. Every case diagnosed clinically as carcinoma must be confirmed by histologic examina- tion. Serological and biological methods proposed in recent years for the diagnosis of carcinoma have not proved specific in a sufficient degree of accuracy to be accepted. Treatment. — The treatment of carcinoma of the body of the uterus con- sists of panhysterectomy. Early cases, in which the entire uterus and the tubes and ovaries are removed, will almost invariably remain permanently cured. Even some of the later cases in which the carcinoma has advanced, almost but not entirely, through the muscular wall of the uterus, will be permanently cured by complete hysterectomy. Fortunately, in cancer of the fundus metastasis occurs later than in cancer of the cervix, and the disease does not ea+ its way through the uterine wall until far advanced. Complete hysterectomy for cancer of the fundus may be done by the abdominal or by the vaginal route. There is no need for a wide resection of the vaginal vault or the base of the broad ligaments. The abdominal is preferable to the vaginal route unless the woman is excessively stout. In nulliparae a paravaginal incision may be used to facilitate vaginal hysterec- tomy. If the uterine fundus is enlarged to any considerable extent, if it contains a fibroid tumor or tumors in addition to the cancer, if there are any adnexal complications, or if there are any intestinal or intra-abdominal symptoms which make abdominal exploration advisable, the vaginal route is unsatisfactory. The treatment preparatory to hysterectomy for carcinoma of the 'fundus should consist of an application of the tincture of iodine to the interior of the uterus, the introduction of a tight uterine pack, and the closure of the cervix with several sutures. This preparatory treatment should immedi- ately precede the radical operation, and is for the purpose of disinfecting and shutting off the carcinomatous growth from the operative area. Advanced cases of carcinoma of the fundus which are not amenable to radical operation may be exposed to radium or the Rontgen ray (see Chapter XL). Prognosis. — The prognosis of carcinoma of the fundus is much better than that of carcinoma of the cervix. While statistics vary and depend upon the stage of the disease and the technic of the operator, about 75 per cent, are cured. 346 GYNECOLOGY SARCOMA OF THE UTERUS Pathology. — Sarcoma may originate in the connective tissue of the cer- vix, or in the body of the uterus, or it may represent the transformation of a myoma of the uterus into a myosarcoma. Sarcoma of the cervix is rare, being most frequently found in infants or in young children, and likewise primary sarcoma of the body of the uterus is very rare ; in a series of 3000 operative cases at the University Hospital, it has only occurred twice. The most frequent form of sarcoma of the uterus is the myosarcoma, a degen- eration of the ordinary myoma. Primary sarcoma of the uterus may be of the round or spindle-celled type. Metastasis may take place to various organs, notably the lungs, liver, ovaries, and intestinal tract. Symptoms. — Sarcoma of the cervix occurring in young children first draws attention to itself by the hemorrhage which it occasions and by the appearance of a purplish-red, grape-like mass at the vulvar orifice. It begins upon either the cervix or the vaginal vault, grows very rapidly, and even though it is removed by a radical operation, very few cases recover. Sar- Qoma in the adult, whether of the cervix or the body of the uterus, differs in no wise symptomatically from carcinoma. Diagnosis. — The diagnosis of sarcoma of the cervix is justified clinically when a tumor having the characteristics mentioned appears in a young child or infant. A microscopic examination should be made for verification. In the adult, sarcoma of the cervix can only be positively distinguished from carcinoma by a microscopic examination, the symptoms, subjective and physical, being practically the same as those of carcinoma. Sarcoma of the fundus also exhibits exactly the same symptoms as carcinoma, and can be distin- guished therefrom only by a histologic examination of scrapings. Treatment. — Sarcoma developing in a myoma is usually not detected until a histological examination is made of the tumor after removal. It may, however, be suspected in a growth which has been quiescent for some time and then begins to increase rapidly in size; such a degen- eration is especially frequent in submucous fibroids. The treatment of sarcoma of the uterus is the same as that of carcinoma. It must be detected at an early stage and subjected to a radical operation to ensure a favorable outcome. CHORIOEPITHELIOMA Pathology. — As its name implies, chorioepithelioma is a new growth originating in the epithelium of the chorion. It is the result of an irregular and abnormal proliferation of the chorion epithelium. The chorion epithe- lium normally possesses a destructive action which, early in pregnancy, assists in the formation of the placenta. As soon as the placenta is formed the destructive activity of the chorion epithelium ceases. This is almost certainly the result of specific antagonistic substances (syncytiolysins) cir- culating in the blood. Under certain circumstances the inhibitory action of the antibodies is too weak and the impulse of the chorion epithelium to MALIGNANT TUMORS OF THE UTERUS 347 proliferate and destroy is unusually strong; it keeps on proliferating and destroying, becomes irregular and unlimited in growth, and constitutes a chorioepithelioma. Even after the development of a tumor mass the resist- ance of the individual may be so increased that the proliferating and de- structive powers of the tumor become neutralized and it shrinks and dis- appears. If this fortunate increase in resistance does not occur, the growth is rapidly fatal. While chorioepithelioma sometimes makes its appearance after normal pregnancy and labor (growing from masses of chorion epithelium embedded in the wall of the uterus at the placental site), as a rule, it follows an abor- tion. In this the feet us and the placenta may have exhibited no abnormali- ties ; yet there often exists the evidence of some disease of the placenta ; the most frequent being hydatidiform mole. While hydatidiform mole is by no means invariably followed by a chorioepithelioma, it certainly predis- FlG. 340. — Metastases of chorioepithelioma in kidney, liver, lung and pancreas. (University Hospital.) poses to the latter as can be gathered from the fact that about half of the cases of chorioepithelioma follow hydatidiform mole. The proliferating chorioepithelioma eats its way into the muscle of the uterus, eroding blood-vessels, causing interstitial hemorrhage between the muscle fibers, and by its proliferation producing interstitial hsematomata, with a definite enlargement, softening, and altered appearance of the af- fected part (Fig. 339, frontispiece). The proliferating cells quickly gain access to the blood stream and are deported to all parts of the body — brain, lungs, liver, kidneys, spleen, etc., where metastatic growths are set up having the same destructive properties as the original tumor (Fig. 340). Metastasis is fol- lowed shortly by death. The original chorioepithelioma is always at the site of the chorion or placenta, and therefore in the uterus (uterine gestation) or in the tube (tubal gestation). In a few instances the original tumor has been cast off or 348 GYNECOLOGY curetted away while the first recognized evidence of the disease has been a metastatic deposit. This is spoken of as " a chorioepithelioma outside the placental site ; " it has been found most often in the vault of the vagina of which the rich venous plexuses favor metastasis. It is interesting to note that in a fairly large number of cases of chorio- epithelioma, as well as of hydatidiform mole, bilateral lutein-cell cystomata of the ovaries have been found. The size of such cystic ovaries varies ; they have been observed as large as a foetal head. The cause of lutein cysts and the relationship between them and the chorioepithelial diseases are as yet unexplained. Symptoms. — The symptoms of chorioepithelioma are hemorrhage and tumor. These develop shortly after the expulsion of an hydatidiform mole, abortion, or labor at term. Exceptionally a much longer time (several years) may intervene, or the disease may make its appearance in association with hydatidiform mole, even before the mole is discharged. Hemorrhage occurring several weeks after the uterus has discharged its pregnant con- tent is always suggestive of hydatidiform mole. After hydatidiform mole symptoms such as described are especially likely to mean a chorioepi- thelioma. In a few cases a vaginal or a labial nodule or metastasis has attracted the attention of the patient to her condition. Sometimes she may be conscious of an enlargement of the uterus — abdominal tumor. The pa- tient becomes rapidly anaemic ; toxaemia from infection and necrosis of the tumor mass develop, evidences of metastasis — thoracic pain, cough, rusty sputum, etc. — appear, and the patient rapidly succumbs. Death may occur within a few months of the first appearance of symptoms. Diagnosis. — Once the suspicion of chorioepithelioma is entertained, ex- ploration of the uterus with diagnostic curettage and microscopic examina- tion is immediately demanded. Metastatic nodules in the vagina and about the vulva which appear like varicosities or haematomata should be excised. The microscopic appearance of the uterine scrapings should be considered in connection with, the clinical evidence. A tumor mass plus the character- istic appearance of chorioepithelioma is diagnostic. But the histological appearance of chorioepithelioma is so little different from the picture that might be furnished by a small portion of placenta and decidua attached to the uterine wall, that both clinical and microscopic evidence must be taken in making the diagnosis positive. Tissue which is taken from any other locality than the placental site and exhibits the histological appearance of chorioepithelioma is, of course, positively diagnostic. Prognosis. — The prognosis, as a rule, is bad, but in the individual case it depends upon the stage at which the disease is detected. Even the incom- plete removal of the tumor has been followed by recovery. When primary in the uterus the removal of the tumor has been followed by the spontaneous disappearance of metastatic growths. About 80 per cent, of cases of chorio- epithelioma die within six months after the appearance of the tumor. In 188 cases collected from the literature with 99 radical operations, Teacher reports 63.6 per cent, of recoveries. MALIGNANT TUMORS OF THE UTERUS 349 Treatment. — For chorioepithelioma of the uterus immediate panhyster- ectomy is indicated. The broad ligament should be excised to as great an extent as possible in order to get rid of veins containing metastatic par- ticles. Vaginal and labial nodes should be taken out with a wide marg-in of healthy tissue. Radium may be used when it is evident that the dis- eased tissue has not been entirely removed, or the case has passed beyond the bounds of operability, or when there is a recurrence after operation. OPERATIVE TECH NIC Panhysterectomy for Malignant Tumors of the Cervix (Wertheim). — In performing a panhysterectomy for a malignant tumor, the diseased area must be prepared in such a manner as to get rid of the friable cancerous tissue, and to kill, as far as feasible, any bacteria which have found lodg- ment there. To accomplish this, the patient is placed in the dorsal position \ and, after the usual preliminaries, the diseased cervix is thoroughly cauter- ized, removing the exuberant carcinomatous tissue. The anterior and posterior lips of the cervix are united by catgut sutures over the car- cinomatous area, if possible. Unless the disease is limited in extent, this cannot be done. The vagina is thor- oughly washed with sterile water and bichloride solution, and a wet bichlo- ride gauze pack is left in the vagina. The patient is then placed in the cus- tomary position for laparotomy, and after the usual preparations have been completed, a median incision is made from near the umbilicus to the symphysis, and the intestines are packed of! from the pelvic cavity with a double layer of pads. The incision should be long enough to give ready access to the pelvis, and the patient should lie in an exaggerated Trendelenburg position while the pads are being introduced so as to isolate and expose the operative area to the greatest possible extent. The fundus of the uterus is now grasped with a forceps in order to afford a point of fixation, and the hysterectomy is started on one side. The infundi- bulo-pelvic and round ligaments are ligated close to the brim of the pelvis, and divided, reflex bleeding being prevented by forceps applied along the sides of the uterus. The broad ligament is divided to the outer side of the ovary and tube, and the anterior and posterior leaflets separated by blunt dissection down to the base of the broad ligament. The ureter adhering to the posterior leaflet, a little above and to the outer side of the utero- sacral ligament, is now sought for. Some practice is required for the orientation of the ureter, but usually it can be found by palpation (Fig. 341) ; in very fat subjects this is facilitated by the preparatory intro- Fig. 34 T - — Panhysterectomy for carcinoma. After ligation of the ovarian (shown in picture) and round ligament arteries the leaves of the broad ligament are separated and the ureter recognized by rolling it between the thumb and first finger (right side). 350 GYNECOLOGY duction of a ureteral catheter. After locating the ureter a loop of catgut is thrown about it (Fig. 342), and the free ends of the catgut knotted and left lying outside of the celiotomy incision. The incision through the anterior surface of the broad ligament is now continued through the vesical reflection of the peritoneum to the opposite side, where a similar dissection of the ureters is carried out. After exposing the ureters care should be taken to protect them, handling them as little as possible to avoid traumatism. Fig. 342. — Passing loop of catgut about ureter; facilitates orientation during the operation. By means of the catgut loops, the ureters may easily be exposed when desirable during the course of the operation. The finger is pushed through the base of the broad ligament from behind forward, along the upper surface of the ureter, picking up the uterine vessels and the cellu- lar tissue of the base of the broad ligament; the uterine artery and veins are ligated as far out toward the pelvic wall as possible (Fig. 343)- The same plan is carried out upon the opposite side. Both utero- sacral ligaments are ligated and divided about one-quarter of an inch away MALIGNANT TUMORS OF THE UTERUS 351 \>«sseVs from the uterus, and the peritoneal incision on the posterior surface of the broad ligament is continued down over the anterior wall of Douglas' pouch to the opposite side. The bladder is pushed away from the anterior surface of the cervix, at first in the median line, and then at either side at the posi- tion of the ureters, so as to expose these structures entirely (Fig. 344). The parametrium is then separated from the pelvic wall and floor, on either side, the bleeding points being caught with long clamps and tied. This dissection is carried down into the cellular tissue surrounding the upper part of the vagina. At this stage of the operation the uterus with the adnexa, broad ligaments, parametrium, upper part of the vagina, and paracolpium, have been freed from the surrounding structures and are connected with the pelvis by the vaginal attachment only. The bichloride gauze pack in the vagina is now removed, and the vagina irrigated by an assistant. One right-angle clamp is applied to the vagina below the cervix, at least a half inch below the diseased area, as can be determined by palpation ; another clamp is placed a quarter of an inch below the first (Fig. 345). The vagina is divided between the clamps by means of a cautery knife, and the dis- eased uterus with its attached broad liga- ment, cellular tissue, and vaginal cuff, is removed. Sutures are passed above the second clamp which close the vagina and insure hsemostasis. Such diseased glands remaining in the base of the pelvis as are palpable are dissected out. Bleeding points are caught with forceps and ligated, and the raw surfaces which have been exposed are covered with the vesi- cal reflection of the peritoneum. Where the oozing from the divided capil- lary vessels is free and cannot be entirely controlled, a gauze wick may be placed to drain the subperitoneal space through the middle of the vaginal vault, but this drain should not be allowed to come in contact with the ureters. Vaginal Hysterectomy for Malignant Tumors of the Cervix (Simple). — After the customary preliminary disinfection of the perineum and vagina, and the preparation of the carcinomatous area, the anterior and posterior lips of the cervix are united by sutures in such a way as to cover the cancer- ous crater, or, if that is impossible, the carcinomatous crater is packed with bichloride gauze and sewn over with sutures ; or the vaginal fornices are circumcised about an inch from their reflexion to the cervix, and a cuff is turned over the diseased area. The bladder is separated from the anterior surface of the uterus, pushed up, and the vesicouterine fold of peritoneum incised. Douglas' pouch is opened by a posterior incision, the anterior and posterior incisions not meeting, but being separated by tissue at the sides of the cervix which contains the uterine vessels. The fundus of the uterus FlG. 343. — Ligation of uterine vessels, isolated on finger. Vessels 352 GYNECOLOGY is pulled into the vagina, the infundibulo-pelvic and round ligaments ligated on either side, provisional clamps placed along the borders of the uterus to prevent reflux bleeding, and the broad ligaments divided down to about the position of the uterine arteries (Fig. 347). At this point the operator makes sure that the base of the bladder and the ureters on either side have been separated from the uterus and are held out of the way by means of a long retractor. The base of the broad ligament is then ligated close to the uterus Fig. 344. — Dissection of bladder and ureters. on either side, and the attachments which remain between the uterus and the base of the broad ligaments and the vagina are divided. The stump of the broad ligament on either side is drawn gently into the vault of the vagina and fixed in its corresponding angle by an extra suture. The anterior and the posterior peritoneal borders are united in the median line between the stumps of the broad ligaments. The vaginal vault is closed by interrupted or continuous sutures. Vaginal Hysterectomy for Malignant Tumors of the Cervix with Para- MALIGNANT TUMORS OF THE UTERUS 353 vaginal Incision. — Vaginal hysterectomy, according to the technic of Schauta, requires a very free exposure of the vaginal vault. As this is only practicable in relaxed multipara, he secures good exposure and easy access in other cases by dividing the levator ani muscle in one or both vaginal sulci (Fig. 346). The carcinomatous area is prepared by cauterization, and a cuff of the vaginal fornix is sewn over the diseased area. The operator separates the bladder from the cervix, and by careful dissec- tion exposes the ureter, holds it out of the way, and isolates and divides the \iOw£. ^cj* Fig. 345. — Application of clamps to vaginal wall. uterine artery well out toward the pelvic wall. The fundus of the uterus is then anteverted through the vesico-uterine incision, and the ovarian and round ligament vessels securely ligated. The uterus is removed and the operation completed as has been described under simple vaginal hyster- ectomy. Drainage is usually employed. Destructive Cauterization. — The carcinomatous tissue is destroyed with a cautery iron heated to a cherry red. A cutting blade is used at first, in order to remove exuberant masses. Thereafter, a blunt iron is passed re- peatedly over the carcinomatous area, thoroughly destroying all gross 23 354 GYNECOLOGY vestiges of the disease. The prognosis depends, to some extent, upon the thoroughness with which this is done. Care must be taken lest perforation of adjacent organs — bladder, rectum — take place, or the peritoneal cavity be invaded. The burned area is then packed with pledgets of cotton satur- ated with acetone, and the vaginal vault and the vagina are filled with gauze impregnated with sterile oil. High Amputation for Malignant Tumors of the Cervix with a Cautery Knife. — In very early cancers of the vaginal cervix (squamous-celled car- cinoma, epithelioma), which are limited to the vicinity of the external os, high amputation of the cervical lips with a cautery knife may be as effectual as any form of opera- t i o n . After a preparatory cauterization, the cervix is firmly grasped with a diverg- ing volsellum in the canal and pulled down, and with a cau- tery knife, heated to a cherry red, the attachments of the vaginal fornices to the cervix, well outside the limits of the new growth, are slowly divided. The bladder is separated from the anterior surface of the cer- vix as far as possible, and the vaginal fornices are pushed away posteriorly, up to the peritoneal reflection of Doug- las' pouch. The lips of the cervix are now amputated by means of a cautery knife, and the cervical canal thoroughly cauterized. By guiding the knife blade upward and in- ward, a large amount of the uterine body may be included in the amputation. The wound is allowed to heal by granula- tion. In using the cautery knife in vascular areas care should be taken that it is cold when applied to the tissues and heated to a cherry red when in action; it should be allowed to cool before changing its position or reapplying. The reason for this is that if the knife, though heated only to a dull red, be applied to parts at all vascular more or less hemorrhage will follow, whereas if the cool platinum blade is already in contact with the tissues as the current is being transformed into heat, the vessels are shrunken or closed before they are severed. Percy Method.— Percy objects strongly to his treatment being classed as a cauterization because when the word cautery is used the average per- son gets an entirely wrong impression of the object to be attained. To the L Fig. 346. — Paravaginal incisions (after Ward, Surgery, Gyne- cology and Obstetrics). MALIGNANT TUMORS OF THE UTERUS 355 novice in the- application of this technic, one of the surprises is the slowness with which the heat penetrates the cancer mass ; it requires from twenty to forty minutes before an appreciable degree of heat is felt in the involved organs. This frequently leads the operator, unfamiliar with the proper way of applying the technic, to turn on more heat, which merely causes charring ■^ D-road li yam eat •-x- Fig. 347. — Vaginal hysterectomy. Application of clamps to broad ligament (Mayo, Surgery, Gynecology and Obstetrics). of the tissues and the formation of a carbon core which does not transmit the heat well; then more heat is turned on until the degree of heat reaches a dangerous point. In order to illustrate the proper degree of heat to be used, Percy states that when cotton is wrapped around the heated cautery, it should not even change color. The curette should never be used before apply- 356 GYNECOLOGY ing the treatment, even to get a portion of the diseased tissue for diagnostic purposes ; when the tissues are thoroughly permeated by the heat, the cells are fixed in such a way as to become immediately available for sectioning and staining without the use of the usual hardening fluids. At the same time, the heat at once seals the lymphatic and blood-vessels, preventing the further dissemination of the cancer and mixed infection. In addition, the immediate nerve supply is cut off; this explains the freedom from shock and local pain which is the rule following this treatment. It is not a part of the technic to remove any of the pelvic structures which are the seat of cancer. The exception to this statement is that both ovaries are removed; first, to limit the blood supply, and secondly, to bring on the menopause where it has not yet occurred. If this is not done, a torturing form of menstruation may occur for a few periods because of the cervical stenosis which occasionally follows the application of the heat. The most distressing class of cases to treat are those in which recurrences follow a panhysterectomy, because in these there is no exuberant mass to use as kindling to develop heat. When recurrence follows a total hysterectomy, it is usually of the infiltrating type and the invaded tissues left after the hysterectomy are not of sufficient thickness to permit of the development of a degree of heat necessary to kill the carcinoma cells. As a cauterizing temperature cannot be regulated it has a distressingly destructive effect which will probably obliterate the most important part of the urethra or make a hole in the bladder. In order to overcome this difficulty caused by lack of tissue in recurrent cases, Percy has tried filling the vagina with a tightly bound mass of beef, in which a hole has been made with an apple corer for the heating iron. In this way he has succeeded very well in irradiating heat through the vaginal walls to a degree that is destructive to the cancer cells. Technic. — The technic of the treatment as practised by Percy may he briefly outlined as follows : The abdomen is opened, the extent of metas- tases determined, and the internal iliac arteries ligated, after packing off the intestines, or, if this is difficult to do, the uterine arteries are ligated as near the pelvic wall as possible. When high degrees of heat are used, late hemorrhages are rare, but with the low degrees of heat used in this method, they become more frequent. It is an advantage, therefore, to tie off all the pelvic blood supply in order to aid in the starvation of the tissues which might otherwise become involved in the malignant process. This is accom- plished by ligating the internal iliac arteries and removing the ovaries. Since doing this, Percy has had no hemorrhages, whereas before this be- came a part of his technic, hemorrhages occurred in 2.5 per cent, of his cases, usually about two weeks after the operation, and were responsible for the death of four patients. The vagina is then dilated and a water-cooled speculum inserted. The heating iron is introduced through the speculum to the fundus of the uterus and held there until everything abnormal is too hot to hold in the hand of the assistant, which is encased in a medium weight rubber glove. If the heating iron is moved aimlessly about, no area will become sufficiently heated to destroy the carcinoma. After the heat has penetrated the uterus to the desired degree, the heating iron is moved to a new position, and the procedure repeated. This is continued until all the MALIGNANT TUMORS OF THE UTERUS 357 pelvic tisues are freely movable, the complete seance sometimes lasting sev- eral hours ; but during this time the patient requires only the very lightest anaesthesia. After the treatment there is usually an offensive discharge lasting about two weeks, and uterovesical and uterorectal fistulas occasionally result from the treatment, but they usually heal spontaneously. At times, however, when the fistula is in the vagina, it is a difficult matter to secure closure. In about 50 per cent, of the cases a reapplication of the heat is necessary. In two cases Percy has repeated the treatment five times. The abdomen must be opened at each application and the hand inserted in order to determine the amount of heat required. Percy insists that a secondary radical operation should not be performed even if the case seems to be operable, as nothing is to be gained thereby, but, on the contrary, the cicatricial tissue is broken down and may be the starting-point of a recurrence, inasmuch as nature's defense is removed. " It must be remembered that the majority of the cases which Percy has treated are of the utterly hopeless type, most of whom have been refused operation by other surgeons, so that a cure in any of them is of great significance " (Clark, J. G., " Progressive Medicine," 1916, p. 215). BIBLIOGRAPHY Anspach, B. M. : " The Value of Histological Examinations in Carcinoma of the Uterus." Proceedings Phila. Co. Med. Soc, Dec, 1903. Baisch : " Der Werth der Driisenausraumung bei der Operation des Uteruscarcinoms.'' Arch. f. Gynak., lxxv, 273. Balfour, D. C. : " The Relative Merits of the Operations for Cancer of the Uterus." S., G. & O., 1916, xxii, 74. Barth, C. : " Die Prognostische Bedeutung Bakteriologischer Untersuchungen bei Ab- dominalen Uterus exstirpationen wegen Carcinom." Arch. f. Gyn., 1909, lxxxvii, 350. Behla, R. : " Ueber Beziehungen Zwischen Wasser und Krebs." Zeitschr. f . Krebsf orsch, 1907, v, 137. Berkley, C, and Bonney, V. : " The Radical Abdominal Operation for Carcinoma of the Cervix Uteri." Brit. Med. Jour., 1916, ii, 445. Bland, P. B. : " Chorioepithelioma Malignum." J. A. M. A., June 10, 1905. Byrne, J. : " Rules to be Observed in Performing High Amputation and Other Operative Measures for Cancer of the Uterus by Galvano-Cautery." Brooklyn Med. Jour., 1892, vi, 760-766 ; Ibid. : " Vaginal Hysterectomy and High Amputation or Partial Extirpa- tion by Galvano-Cautery in Cancer or Cervix Uteri — An Inquiry Into Their Relative Merits." Brooklyn Med. Jour., 1892, vi, 729-760. Caturani, M. : " Hydatidiform Mole and Chorionepithelioma." Amer. Jour. Obst., 1917, lxxv, 591. Clark, J. G. : "A More Radical Method of Performing Hysterectomy for Cancer of the Uterus." J. H. H. Bull, 1895, No. 52-53 ; Ibid. : " Education of the Public Concerning Cancer of the Uterus." Penna. Med. Jour., 1909, Nov., 113. Clark, Peterson, Taylor, Taussig, Cullen : " Symposium on the Result of Radical Operations for Cancer of the Uterus." Trans. Amer. Gyn. Soc, 1912, 2>7- Councilman, W. T. : " Some General Considerations Regarding Tumors." Boston Med. and Surg. Jour., 1907, clvii, 313. Cullen : Cancer of the Uterus. D. Appleton, New York, 1900. Freund : " Zu Meiner Methode der Totalen Uterus-extirpation." Cent, f . Gyn., 1878, No. 12. Gaylord, H. R. : " Etiology of Cancer in the Light of Recent Cancer Research." J. A. M. A., 1915, lxiv, 968; Ibid.: "The Clinical Course of Cancer in the Light of Cancer Re- search." Trans. Amer. Gyn. Soc, 1916, 41, 404. Gellhorn, G. : " The Treatment of Inoperable Cancer of the Uterus." Amer. Jour. Obst., 1909, lx, 799. Israel : " Die Probleme der Krebsatiologie." Arch, f . Klin. Chirurgie, Bd. lxvii. Jacobsohn, J. H. : " Recent Progress in the Treatment of Uterine Cancer." J. A. M. A., 1916, lxvii, 1219. 358 GYNECOLOGY Kundrat : " Ueber die Ausbreitung des Carcinoms in Parametranen Gewebe bie Krebs des Collum Uteri." Arch. f. Gynak., lxix. Ladinski, L. J. : " Complete Removal of Adenocarcinoma of Uterus by Exploratory Curet- tage." S., G. and O., 1915, xx, 325. Leyden, v. : " Ueber die Parasitarie Theorie in der Aetiologie der Krebse." Berlin, Klin. Wochenschr., xlii, No. 13. Mackenrodt : " Ergebnisse des Abdominalen Radikaloperation des Gebarmutterscheiden- krebses Mittels Laparotomia Hypogastrica." Zeit. f. Geb. u. Gyn., 1905, liv, 514; Ibid. : " Weitere Mitteilungen zur Abdominalin Radikaloperation bei Uteruskarzinom." Centralbl. f. Gyn., 1909, No. 17, 593. Marchand, F. : " Ueber die Sogenannten ' Deciduales ' Geschwiilste im Anschluss an Normale Geburt, Abort., Blasenmole und Extrauterinschwangerschaft." M. f. G. u. G., 1895, 1, 418-513. Markowsky, A. : " Der Wert der Radikaloperationen der Kollumkrebse nach den Letzten Wertheim'schen Angaben im Lichte der Kritik." Monatschr. f. Geb. u. Gyn., 1912, xxxv, 715. Mayo, Wm. J.: "The Cancer Problem." Jour. Lancet, 1915, xxxv, 339. Offergeld, H. : " Ueber die Metastasierung des Uteruskarzinoms in das Zentralnerven- system und die Hoheren Sinnesorgane." Zeit. f . Geb. u. Gyn., 1908, lxiii, 1 ; Ibid. : " Die Beitung des Hamatopoetischen Systemes an der Metastaseierung beim Uteruskarzinom." Zeit. f. Geburts. u. Gyn., 1908, lxiii, 217; Ibid. : " Die Metastasen in der Bauchhohle beim Uteruscarcinom." Arch, f . Gyn., 1909, lxxxvii, 298 ; Ibid. : Hautmetastasen beim Uterus- karzinom." Monats. f. G. u. G., 1909, xxix, 870. Ott, von. : "Vergleichende Schatzung der Verschiedenen .Methoden der Chirurgischen Behandlung des Gebarmutterkrebses." Zentralbl. f. Gynak., 1909, xxxiii 1391. Percy, J; F. : " The Treatment of Inoperable Carcinoma of the Uterus by Application of Heat." S., G. and O., 1914, xix, 636; Ibid. : "The Technic of Applying Heat in the Treatment of Inoperable Uterine Carcinoma." Amer. Jour. Obst, 1915, lxxii, 298; Ibid. : " The End Results of the Treatment of Inoperable Uterine Cancer by Heat." Amer. Jour. Obst., 1918, lxxvii, 93 ; Ibid. : " The Problem of Heat as a Method of Treatment in Inoperable Uterine Cancer." Trans. Amer. Gyn. Soc, 1916, 41, 542. Peterson, R. : " The Extended Operation for Carcinoma of the Uterus." S., G. and O., 1916, xxiii, 237. Reynolds, E. : " The Newer Views of ' Cancer ' and Their Present Relations to the ' Respon- sibility ' of the Practitioner." Boston Med. and Surg. Jour., 1915, clxxiii, 75. Ribbert : Das Karzinom des Alenschen : Sein Bau, Sein Waschstum, Seine Entstehung. Bonn, 1911. Ries : " Eine Neue Operationsmethode des Uteruscarcinoma." Zeit. f . Geb. u. Gyn., 1895. Ries, E. : " Theoretical and Practical Foundations of a Radical Operation for Carcinoma of the Cervix Uteri." Trans. Sect. O. G. and A. S. — A. M. A., 1913, p. 164. Sampson, J. M. : " The Invasion of Carcinoma Cervicis Uteri into the Surrounding Tissues." J. A. M. A., Oct. 29, 1904. Sanger : " Ueber Deciduome." Cent, f . Gyn., 1889, xiii, 132. Schauta, F. : "Die Erweiterte Vaginale Operationen bei Carcinoma Colli Uteri auf Grund Zehnjahriger Erfahrung." Monat. f. Geb. u. Gyn., 1911, xxxiii, 680 ; Ibid. . " Die Berechtigung der Vaginale Totalextirpation bei Gemarmutter krebs." Monat. f . Geb. u. Gyn., 1904, xix. Schottlaender u. Kermauner : " Zur Kenntniss des Uteruskarzinoms." Berlin, 1912. Schuchardt: "Ueber die Paravaginale Methode der Extirpatio Uteri und Ihre Enderfolge beim Uteruskrebs." Monats. f. Geb. u. Gyn., 1901. Stone : " Precancerous Changes in the Uterus." Trans. Amer. Gyn. Soc, 1916, xli, 470. Teacher, J. H. : " On Chorionepithelicma and the Occurrence of Chrionepitheliomatous and Mole-like Structures in Teratomata A Pathological and Clinical Study." Jour. Obst. and Gyn., Brit. Empire, 1913, iv, 145 ; Ibid. : " On Chorionepithelioma (the So- called Deciduoma Malignum) and the Occurrence of Chorionephitheliomatous and Hydatidiform-mole-like Structures in Tumors of the Testis." Trans. London Obst. Soc, 1903, xlv, 256. Weibel, W. : " Die Klinische Stellung des Carcinoma Corporis Uteri." Arch, f . Gyn., 1913, 135- Weibel, W. : " Weitere Beobachtungen liber das Verhalten der Ureteren nach der Erwei- terten Abdominalen Karzinomoperation." Zeitsch. f. Gyn. u. Urol., 1913, iv, 138. Werder, X. O. : "The Byrne Operation and Its Application in the Radical Treatment of Cancer of the Uterus." Amer. Jour, of Obst., 1905, Hi, 700. Wertheim : " Die Erweiterte Adominale Operation bei Carcinoma Colli Uteri." Berlin und Wien, 191 1. CHAPTER XIX DISEASES OF THE FALLOPIAN TUBES SALPINGITIS Etiology. — Inflammation is the most frequent affection of the Fal- lopian tubes. Salpingitis is invariably caused by a bacterial infection. Mechanical, thermal, or chemical irritation may cause circulatory dis- turbance and tissue hypertrophy or atrophy, but not a true inflammation. The gonococcus is the organism which is especially prone to attack the tubes. Gonorrhoea! salpingitis constitutes a very large part of tubal pathology. Other organisms which may produce inflammatory lesions of the tubes are the streptococcus, staphylococcus, colon bacillus, and tubercle bacillus ; and rarely also the pneumococcus, typhoid bacillus, and ray fungus. The infecting organisms reach the tubes (i) by extension upward from the endo- metrium along the mucosa (gonorrhoeal endometritis), or (2) by extension 3 Fig. 348. — Acute gonorrhceal salpingitis, gross (Norris. Gonorrhoea in Women, W. B. Saunders Co.). downward from the peritoneal cavity, through the open abdominal ostium (peritonitis, enteritis, appendicitis — tubercle bacillus, colon bacillus, strep- tococcus) ; (3) by extension from distant foci through the blood stream (tuber- culosis — tubercle bacillus ; typhoid fever — typhoid bacillus ; actinomycosis — ray fungus) ; or (4) by direct extension through the peritoneal coat from adherent and diseased structures (ovaritis, cellulitis, peritonitis — strepto- coccus, staphylococcus, colon bacillus, etc.). It is possible that streptococcus, staphylococcus, tubercle bacillus, and colon bacillus infections may extend along the mucous surface from the uterus into the tube, but such is not the rule. This is in direct contrast to gonorrhceal infection which almost invariably advances along the mucous surfaces. Streptococci, staphylococci, and colon bacilli are most apt to attack the tube from infected neighboring or adherent structures. In the great majority of cases salpingitis is caused by the gonococcus, and next in order of frequency by the streptococcus, staphylococcus, colon bacillus, and tubercle bacillus. Pathology. — Gonococcus infections attack primarily the mucosa (endo- salpingitis) and lead to closure of the abdominal ostium, destruction of the 359 360 GYNECOLOGY mucous plicae, and distention of the tube with pus ; streptococcus, staphylo- coccus, and colon bacillus infections attack primarily the outer serous coat (perisalpingitis) and may lead to adhesions, angulation, thickening, and in- filtration of the tube wall (interstitial salpingitis), or even to closure of the abdominal ostium (hydrosalpinx), but they rarely produce pyosalpinx (Figs. 348 and 349). The infections caused by the streptococcus, staphylo- coccus, and colon bacillus are usually an extension from diseased and neighboring parts (metritis, cellulitis, ovaritis, peritonitis, appendicitis) ; the lesion is a perisalpingitis and the involvement of the tube is of secondary importance. Next to the gonococcus the tubercle bacillus is the most fre- quent cause of suppurative inflammation of the tubal mucosa. Tuberculous Fig. 349. — Acute gonorrficeal salpingitis. (Gynecological Laboratorj', U. of P.) salpingitis is marked by characteristic lesions which are dealt with in Chapter XXX (page 561). In gonorrhoeal salpingitis, both tubes are affected in a large majority of cases. The disease in one tube, however, may slightly precede the infec- tion of the other, so that the pathological change on one side may be fur- ther advanced or more marked than on the other side. Streptococcus, staphylococcus, and colon bacillus salpingitis are often unilateral. Endosalpingitis. — In endosalpingitis the infection attacks the mucosa, the folds of which become congested and covered with pus. The tube wall becomes cedematous and thickened. The diameter and the length of the tube are increased. From a soft, almost impalpable structure it becomes indur- ated and well defined. On microscopic examination the stroma of the plica is found to be swollen, cedematous, and infiltrated with small round cells, polymorphonuclear leucocytes, and plasma cells ; the surface epithelium is proliferated, swollen, imperfectly stained, and in many places detached from the stroma. The muscle and fibrous tissue of the tube wall are infiltrated with leucocytes ; the lumen of the tube is filled with pus. DISEASES OF THE FALLOPIAN TUBES 361 Perisalpingitis. — In this condition the infection attacks the outer sur- face of the tube, which becomes congested and adhesive ; the peritoneum loses its glistening appearance, exudate is thrown out which binds the tube to neighboring structures, and the ovary and pelvic peritoneum are usually coincidently involved. If the amount of exudate is large the abdominal ostium of the tube may be occluded. Interstitial Salpingitis. — When the infection attacks the wall of the tube from within or from without, the condition is described as interstitial sal- pingitis. The muscular coats are cedematous and thick; there is a widespread infiltration with polymorphonuclear leucocytes ; at certain points minute Fig. 350. — Uterus and appendages in extensive pelvic inflammatory disease exposed in the incision. foci of suppuration may appear ; later, as the acuteness of the condition sub- sides, there may be connective tissue hypertrophy about these minute foci. Irregular enlargement of the tube from intramural foci of suppuration is most frequent in the isthmic or interstitial part. To this condition the name salpingitis isthmica nodosa has been given. The disease may be limited to the area of enlargement. The middle and outer parts of the tube may appear quite normal. End-results of Endosalpingitis. — The formation of pus in gonorrhoeal endosalpingitis is free, and except in very mild cases is extruded in greater or less amount from the abdominal ostium of the tube upon the surface of the pelvic peritoneum. From this there results a localized pelvic peritonitis, more or less extensive, with the formation of exudate and inflammatory in- 362 GYNECOLOGY filtration. As the result of the exudate, and the adhesions which form be- tween the ostium of the inflamed tube and the pelvic peritoneum, by the time the inflammatory symptoms are abating, or even during their progress if the case is a severe one, the abdominal ostium of the tube becomes sealed, and the pus forming within, being no longer able to escape from the abdom- inal ostium, begins to distend the tube itself (Fig. 349). As the process goes on, the tubal plicse may be destroyed to a great extent, the only part escaping destruction being the bases which are compressed and flattened against the wall of the tube by the purulent content, or the individual plicse bereft of surface epithelium at certain points, become more or less exten- Fig. 351. — Uterus and appendages in extensive pelvic infllrmmatory disease; the adhesions divided, the parts mobilized and ready for extirpation. sively adherent to each other, leaving between them completely isolated gland-like spaces representing remnants of the tube lumen. Under rare circumstances the pent-up pus, after reaching a certain degree of compression, may be discharged through the uterine end of the tube into the cavity of the uterus. But this is not a frequent occurrence, for the infiltration of the tubal wall, the fixation and distortion of the tube which are incident to the inflammation, and the complicating peritonitis with adhesions and exudate, usually block the uterine extremity. Pyosalpinx. — When the tube has become distended with pus, the result- ing tubal enlargement is known as a pyosalpinx (Fig. 352). The tube by this time almost invariably has contracted adhesions to neighboring struc- tures, has been pulled out of position, and has become variously distorted in DISEASES OF THE FALLOPIAN TUBES 363 shape. It may vary in size from that of a finger to that of a sausage or a sweet potato. The wall may be quite thin when it is simply distended or overstretched, or quite thick when it has been invaded by the septic process. The changes in the ovary which accompany endosalpingitis are the result of, and secondary to, the complicating pelvic peritonitis. The ovary itself is not primarily involved. The exudate thrown out by the inflamed peri- toneum at first buries the ovary and later leads to adhesion or a permanent thickening of the ovarian capsule. A Graafian follicle or a fresh corpus luteum may become infected by the exudate and form an abscess. If the endosalpingitis has been mild, and the peritoneal involvement slight, the inflammatory process may subside without a closure of the ab- dominal ostium or the formation of a pyosalpinx. But usually there are permanent residua of the disease, such as enlargement and distortion of the Pig, 352. — Pyosalpinx and ovanan abscess. (Norris, Gonorrhoea in Women, W. B. Saunders Co.) tube, adhesions, thickening of the plicae, proliferation of the surface epi- thelium, and the formation of little pockets or cystic spaces in the mucosa brought about by the coalescence of the tips of neighboring folds. Though the gonococcus infection remains latent in the tubal mucosa or the endo- metrium, the patient may, and usually does, experience a repetition of the acute attacks. Repetition of the attack is usually precipitated by some trauma, such as rough examination, coitus, straining at stool, douching, etc. ; the activity of the gonococcus is renewed ; pus is again discharged from the abdominal ostium upon the peritoneum, and there is a fresh pelvic peri- tonitis. The destructive lesions become greater each time, so that finally the extreme changes (pyosalpinx, etc.) already noted may take place. The gonococci in the pus of a pyosalpinx may die in the course of several months, and a secondary infection with the colon bacillus or the streptococcus or the staphylococcus from neighboring or adherent intestines may take place, but 364 GYNECOLOGY DISEASES OF THE FALLOPIAN TUBES 365 very often this does not occur and the pus becomes non-infectious. The exudate thrown out at the height of the inflammation is absorbed and the infiltration of the peritoneum, tubal walls, ovarian capsule, and uterus dis- appears to a greater or less extent, but the tube remains permanently dam- aged and the ovary adherent or cystic. Tubo-ovarian Abscess. — If an ovarian abscess happens to lie in apposi- tion with the distended outer extremity of a pyosalpinx, the septum be- tween them may break down so that the tubal and ovarian collections of pus merge and a tubo-ovarian abscess is formed (Fig. 353). If the outer extremity of a pus tube becomes adherent to the ovary at the site of an unruptured Graafian follicle, the intervening septum may become thinned out and rupture, allowing the pus and the serous contents to merge, secondarily infecting the follicle, and leading to the formation of a tubo-ovarian abscess. Fig. 354. — Hydrosalpinx (Bryn Mawr Hospital;. End-result of Perisalpingitis, — In some cases perisalpingitis may sub- side with the formation of only a small amount of exudate, which may be entirely absorbed, so that the tube is restored to a normal condition and no evidence of the trouble remains. In other instances, where the infec- tion has been marked and the exudate massive, the outer surface of the tube remains permanently attached to the surrounding structures by adhesions. If the adhesions are sufficiently extensive and so placed as to close the abdominal ostia of the tubes, the lumen may become distended with clear, watery fluid, forming a hydrosalpinx. Hydrosalpinx. — A hydrosalpinx is a tube closed at its abdominal ex- tremity and distended with clear fluid (Fig. 354). Several factors, as a rule, play a part in the etiology ; first, an inflammation of bacterial origin, which closes the abdominal ostium by adhesions ; secondly, a closure of the uterine 36o GYNECOLOGY end of the tube by distention or kinking, and thirdly, the gradual accumula- tion of the normal tubal secretion. Mechanical irritation alone, as, for ex- ample, the rubbing of the tubal ostium by a uterine fibroid, or a retro- flexed uterus, is not considered sufficient to produce a closure of the tube. But such a tumor or displacement of the uterus may predispose to hydro- salpinx when the bacterial infection is of slight degree and when it would under ordinary conditions subside without notice and without a residuum of adhesions. The weight of evidence is that most cases of hydrosalpinx follow perisalpingitis of streptococcus, staphylococcus, or colon bacillus origin, associated with the post-partal or the post-abortal state. Never- FiG. 355- — Tubo-ovarian cyst. (Norris, Gonorrhoea in Women, W. B. Saunders Co.) theless, a certain proportion of hydrosalpinx represents a terminal stage of pyosalpinx. This statement is based on clinical evidence, such as the revelation at operation of hydrosalpinx months or years after well-established cases of gonorrhceal pyosalpinx, and upon the histologic features of certain cases of hydrosalpinx (hydrosalpinx follicularis) in which the serous fluid is confined, not in one large cavity representing the lumen of the tube (hydrosalpinx simplex), but in multiple cystic spaces between the stunted, partially destroyed, and coalesced folds of mucosa. In such instances an antecedent suppurative inflammation of the mucosa is difficult to deny. The wall of the tube in simple hydrosalpinx (Fig. 354) is considerably stretched and thinned, the degree of distention varying. The hydrosalpinx DISEASES OF THE FALLOPIAN TUBES 367 may be the size of a linger, or it may form a tumor large enough to be pal- pated through the abdominal wall, and contain a liter of fluid. In follicular hydrosalpinx the total amount of the fluid contained in the numerous cystic spaces is comparatively small and enlargement is usually moderate, a hydro- salpinx of this sort being rarely thicker than a finger. There are some cases of hydrosalpinx which intermittently discharge their contents through the uterine end of the tube into the uterus {hydrops tubcc proflncns). Tubo-ovarian Cyst. — A tubo-ovarian cyst is a combined cystic disten- tion of the tube and ovary. The cyst is filled with clear or blood-tinged fluid. A tubo-ovarian cyst may be formed by adhesions between a hydro- salpinx and a cystic ovary and the coalescence of their fluid contents by rupture or atrophy of the dividing septum. It is likely that some tubo- ovarian cysts represent the end stage of a tubo-ovarian abscess — the puru- lent material having been absorbed and then replaced by watery fluid (Fig. 355). A tubo-ovarian cyst forms a retort-shaped tumor. From the outer surface it may be difficult to distinguish where the tubal part of the cyst ends and the ovarian part begins. Usually, upon opening the tumor, the remains of the fimbria, flattened out upon the inner wall at the original position of the abdominal ostium, may be distinguished. Hematosalpinx, or a distention of the closed tube with blood, may result from hemorrhage into a hydrosalpinx which has become twisted on its pedicle, or has been subjected to some form of trauma. Usually it is the result of an ectopic pregnancy in the affected tube. The consideration of haematosalpinx, therefore, naturally falls under accidents to hydrosalpinx or tubal gestation. NEW FORMATIONS OF THE TUBE Polyps. — Polyps are very rare. They are often confused with cir- cumscribed thickenings of the mucosa. Papillomata. — Papillomata are difficult to distinguish from cancers which have a papillary structure, or, on the other hand, from unusually marked folding of the tubal mucous membrane. Cyst of the Tube. — Cysts of the tube may be miliary, studding the peri- toneal surface of the tube and the broad ligament. They may project from the abdominal fimbria, and may also occur in the wall of the tube, or under the mucous membrane. Tubal cysts may be true hydatids of Morgagni ; they may be caused by peritoneal irritation with invagination of the periph- eral endothelium, or they may result from lymphangiectasis. Myomata. — Myomata have been mistaken for salpingitis nodosa. The same is true of adenomyoma. True cases of myoma are rare. These tumors vary in size from a hazel nut to an egg. The uterine end of the tube is in the usual situation. Microscopically, the tumor consists of fibrous and muscle tissue. Adenomyoma is much more frequent and has been discussed. (Page 326.) . Embryomata of the Tube. — These are usually dermoids. They are very rare. Products of an old tubal pregnancy have been mistaken for embryoma. The contents resemble those of dermoid cysts elsewhere. Grossly, the tube looks like an ordinary sactosalpinx with adhesions. 368 GYNECOLOGY Carcinoma of the Tube. — Carcinoma of the tube is rare. Secondary cancer is more frequent than primary. Primary cancer of the tube had been reported eighty-six times in 1909. The disease is usually unilateral. Once in four or five times it is bilateral. Inflammatory disease of the tube seems to predispose to cancer. Carcinoma may begin as a degeneration of a benign papilloma, but this is unusual. The tube is, as a rule, enlarged, appears like a hydrosalpinx, and is surrounded by adhesions. The tumor is rapid in growth, and gives early metastasis. There are no characteristic symptoms, the clinical manifestations being usually those of chronic pelvic inflammatory trouble. There may be a watery, blood-stained leucorrhoea, and at about the cancer age atypical hemorrhage. Pelvic examination usually shows a condition simulating pelvic inflammatory trouble. Norris recom- mends that, when operating on patients for pelvic inflammatory disease at the cancer age, the tubes should be opened before the abdomen is closed and, if a papilloma is found, a radical operation should be carried out. SYMPTOMS, DIAGNOSIS, AND TREATMENT OF AFFECTIONS OF THE FALLOPIAN TUBES Acute salpingitis is so uniformly associated with acute pelvic peri- tonitis and acute oophoritis that the symptoms, diagnosis, and treatment of all three conditions may be logically and conveniently combined under the term acute pelvic inflammatory disease (see Chapter XXI, page 411). Chronic salpingitis, hydrosalpinx, etc., are likewise so frequently coin- cident with chronic oophoritis and pelvic peritonitis that their symptoms, diagnosis, and treatment have been considered together under chronic pelvic inflammatory disease, page 428. New growths of the tube are acci- dental findings or resemble chronic inflammatory disease of the tubes to such an extent that they may very properly be included in the latter group, at least in so far as symptoms and diagnosis are concerned. In regard to treatment, new growths of the tube must be removed by salpingectomy or, if the growth is benign, by partial resection of the tube. In the case of car- cinoma of the tube, both adnexa and the uterus should be removed. ACCIDENTS AFFECTING TUBAL ENLARGEMENTS Rupture of Pyosalpinx. — A pyosalpinx rarely may rupture. Bovee, in 19 10, was able to find 55 cases recorded in the literature, and Norris found 99 cases in 1913. The accident has usually followed trauma of some sort, such as coitus, straining at stool, etc. As a result of the rupture and the escape of pus, there may be a rapid peritonitis if the pus is infectious. Otherwise the escaped pus may be absorbed. The symptoms are acute, agonizing pain in the lower abdomen, followed shortly by shock, and later by the evidences of an acute peritonitis. If the pus is sterile, the last-mentioned symptoms do not appear, although the absorption of the toxic products from the dead bac- teria in the tubes may occasion some fever, acceleration of pulse, etc. The treatment consists of immediate operation, with the removal of the affected tube. Both adnexa and the uterus should be extirpated if they are diseased, and if the condition of the patient will permit. Rupture of a Hydrosalpinx. — This accident, too, is very infrequent. DISEASES OF THE FALLOPIAN TUBES 369 The symptoms are sudden, acute pain, followed by shock or the evidence of internal hemorrhage. Often it will be impossible to make the exact diag- nosis. Operation is advisable, at which time the diseased pelvic organs must be removed. Torsion of Tubal Enlargements. — Torsion of tubal enlargements occurs rarely, there being about eighty-eight cases recorded in the literature in 1912. In twelve cases a pyosalpinx underwent torsion (Fig. 356). Hydro- salpinx is much more likely to undergo this complication on account of its retort shape, since the isthmus acts as a pedicle. Other enlarge- ments were new growths and ectopic pregnancy. The symptoms have most frequently resembled those of acute torsion of an ovarian cyst, Fig. 356. — Tuberculous pyosalpinx, torsion and necrosis (University Hospital). namely, sudden agonizing pain, shock, rapid pulse, and rapid respirations, or of a ruptured ectopic, or acute appendicitis. A positive diagnosis is almost impossible, but the condition should be kept in mind. If a twisted tubal enlargement is strongly suspected, immediate operation is indicated. The twisted tube with its ovary, if that is involved, should be removed. If the patient's condition is good, other abnormalities found in the pelvis may be dealt with secundum artem. EXTRAUTERINE PREGNANCY When the fertilized ovum develops outside the uterine cavity the preg- nancy is spoken of as extrauterine or ectopic. Etiology. — The cause of this condition is some interference with the 24 370 GYNECOLOGY passage of the fertilized ovum from the ampulla of the tube, where fer- tilization usually occurs, into the uterus. Conception need not necessarily take place in the tube, for the spermatic particle may advance as far as the ovarian fimbriae to meet the ovum or, indeed, penetrate the spot of rupture on the Graafian follicle and fertilize an ovum which has remained therein. Again, the spermatic particle may wander from the extremity of the tube on one side and fertilize an ovum from the opposite ovary, or an ovum of one ovary may be fertilized by a spermatic particle in the opposite tube. Or, again, an ovum fertilized at the outer extremity of one tube may be carried across the pelvis and be swept down the opposite tube into the uterus. The factors which may interfere with the passage of the fertilized ovum into the uterus are numerous : fibroid tumor in the uterine cornua, congenital diverticula in the tube, polyps of the tubal mucosa, obstruction of the lumen of the tube by congenital angulation or by an angulation caused by adhe- sions, obstruction of the lumen of the tube by inflammatory processes which ^^^^ Fig. 357. — Interstitial pregnancy, (University Hospital). form little blind pockets, by reason of the adhesions at the tips of neigh- boring plica — all of these may obstruct the passage of a fertilized ovum into the uterus. The most common cause, it must be admitted, from both clinical and pathological evidence, is some inflammatory lesion of the adnexa. Ectopic pregnancy may coexist with normal intrauterine pregnancy. Re- peated tubal pregnancy, first in one tube and later in the other, occurs occa- sionally. Rarely twin, or even triplet, tubal pregnancy has been observed. Varieties of Ectopic Pregnancy.— The fertilized ovum may rest and subse- quently develop in a Graafian follicle of the ovary (ovarian pregnancy), upon the ovarian fimbriae (tubo-ovarian pregnancy), or within the ampulla (ampullar pregnancy), isthmic (isthmial pregnancy), or interstitial (interstitial pregnancy) ( Fi g- 357) Parts of the tube. Development in some part of the tube is far more common than outside of it. It is doubtful whether primary nidation upon the peritoneal surface (abdominal pregnancy) occurs— although, secondarily, the ovum may become attached in that position after it has escaped from its primary resting-place in the tube or the ovary. DISEASES OF THE FALLOPIAN TUBES 371 Pathology — Nidation of the Ectopic Ovum. — The nidation of the ectopic ovum must be somewhat different from the normal intrauterine process because the structures with which the ovum comes into immediate relation are not like the soft, succulent, decidual endometrium lining the uterine cavity. The coverings of the ovum, however, are the same and its outer capsule, the chorion, is furnished with the same trophoblast cells and villi — so that it has the power of burrowing into tissue and, by osmosis and the corrosion and opening up of blood-vessels, of providing itself with nourishment. There is some doubt as to the development within the tube of a decidual tissue either as a provocative cause of retention of the fertilized ovum, or as a result of its retention, or as a common occurrence incident to pregnancy. It is likely that there is a slight decidual reaction of the lymphoid stroma cells of the plica in most cases of tubal pregnancy. Whether or not this is true, the ovum burrows its way either into a fold of the mucosa or between adjoining folds. As it goes on growing, the wall of the tube, which has be- come somewhat hypertrophied and more succulent than during the non-pregnant state, is invaded by the ovum which finally takes a position within its layers and out- side the lumen of the tube. As the ovum develops within the wall, the lumen is pressed toward the opposite side so that on cross-section it may be represented by no more than a crescentic slit. The chorionic villi take root in the maternal tissues by virtue of the corrosive action of their syncytial covering. A hemorrhage into the tissues surrounding the ovum may interrupt its further development. This is the fate of a certain proportion of tubal pregnancies. Thus a tubal mole is formed, which in rare instances may be absorbed. the tube remains, sooner or later giving rise to symptoms. It is possible that the chorion may keep on groAving for a time after the ovum itself has per- ished, otherwise it is hard to understand the number of cases of tubal pregnancy giving rise to active symptoms (abortion or rupture) in which no trace of the ovum itself can be found. Tubal Abortion and Tubal Rupture.— In the majority of cases after the tubal gestation has progressed to a certain extent — eight or twelve weeks in the most common (ampullar) form — there is a rupture in the surrounding muscular and connective-tissue capsule of the developing embryo. This rupture may occur either toward the serous coat of the tube if the ovum has eaten its way furthest in that direction, or toward the mucous coat if the opposite is true. As a result of the former the outer coat of the tube is torn and there is free intraperitoneal hemorrhage (Fig. 358) ; the ovum may or may not be discharged into the peritoneal cavity. As a result of the latter, the ovum escapes into the lumen of the tube, where it excites periodic con- FiG. 358. — Early extrauterine pregnancy, rup- ture and bleeding, (Bryn Mawr Hospital.) In other cases the enlargement of 372 GYNECOLOGY tractions of the muscular coat which may expel it through the abdominal ostium into the peritoneal cavity. In rare instances the weakening and corrosion of the tube wall may be toward the mesosalpinx, so that the ovum escapes into the broad ligament between its peritoneal layers. Fate of the Ovum. — In the majority of cases there is no trace of the embryo (Figs. 359 and 360). As the result of hemorrhage into the fcetal envelope, as noted above, the ovum has usually perished before abortion or rupture occurs. When the ovum is viable at the time of abortion or rup- ture, its subsequent fate depends upon whether a placenta has already formed and whether it remains attached. Thus the ovum may go on grow- Fig. 3.SQ. — Extrauterine pregnancy with beginning tubal abortion. (Bri'n Mawr Hospital.) ing outside the tube, being connected by the umbilical cord to the placenta, which remains undisturbed therein. Or, if the amniotic sac is unbroken (Fig. 361) and the ovum is young, even though the chorion is detached from its original nest, the ovum may find a new point of attachment and new source of nourishment in the free peritoneal cavity '(abdominal pregnancy). Abdominal Pregnancy. — In some cases full development of the ovum has taken place in the abdominal cavity. When this occurs, if the foetus is not removed by abdominal section at term, it will die. The fat may be con- verted into adipocere (lithopedion formation). Such a condition has usu- DISEASES OF THE FALLOPIAN TUBES 373 ally been mistaken for an abdominal tumor of one of the more common varieties, and the true state of affairs has been recognized only at operation. There will probably be the customary history of tubal pregnancy which can be elicited on close questioning, and the patient may recall a consider- able amount of pain at the time when labor was due. The pregnancy may not go on to term, the growth of the foetus being interrupted at some time prior to that period of gestation. Under these circumstances the body usually mummifies, or undergoes lithopedion for- mation, or the soft parts are absorbed and the skeleton remains. The foetal structures may become infected, with the formation of an abscess, which subsequently may rupture into the neighboring intestine or bladder, the true nature of the process being revealed by the discharge of skeletal parts. Fig. 360. — Longitudinal section of tube shown in Fig. 359, blood-clot removed from one side, tubal mole in the other side; no gross trace of the ovum. Hemorrhage, Pelvic Hematocele, Free Intraperitoneal; Bleeding. — Hemorrhage into the peritoneal cavity from external rupture of an ectopic ovum is usually great, and the patient may be rapidly exsanguinated. The. nearer the point of rupture to the uterine cornu, the larger are the blood- vessels which are torn and the more likely is the bleeding to be uninterrupted and serious. In tubal abortion the amount of blood lost is less and the hemorrhage is slower. When only a small amount of blood escapes into the peritoneal cavity, it may become absorbed; when it escapes in larger quantity it collects in the dependent parts — Douglas' pouch. Here the fluid constituent is absorbed, the blood-clot becomes encapsulated by the organ- ization of the peripheral layer and the adhesions which are contracted be- 374 GYNECOLOGY tween the latter and the surrounding intestines and peritoneum. In the course of time the blood may become entirely absorbed, intestinal and peri- toneal adhesions being the only evidence of the previous hematocele. Unless the hematocele is small, absorption is not the rule. The pelvic mass per- sists, gives rise to symptoms — pain, moderate fever, diarrhoea — and, if the blood-clot is not evacuated by operation, infection almost always occurs with the formation of a pelvic abscess. Uterine Changes in Ectopic Pregnancy. — The uterus undergoes some hypertrophy in the early weeks of tubal pregnancy. The endometrium is transformed into a decidua consisting of the superficial compact and the deep spongy layer. The cervix may be very slightly softened, and there may be some bluish discoloration of the anterior vaginal wall. Between the eighth and twelfth week the compact layer of the decidua begins to separate from the underlying spongy part and the decidual tissue, acting more or less like a foreign body, excites contractions of the uterus. Hemorrhage also occurs from rupture of the small decidual vessels. The decidua may be discharged in one piece, exhibiting a per- fect mould or cast of the inside of the uterus; or as is more commonly the case, in small separate portions. After the decidua is all discharged the bleeding may be continued by subinvolution of the uterus, which usually persists until the pregnancy has been removed by operation. Fate of the Pregnant Tube.— The enlarged pregnant tube frequently excites local inflammatory changes in the structures surrounding it, which result in adhesions. The pregnant tube may become enveloped in omentum ; it may become adherent to the peritoneum over the bladder or at the bot- tom or sides of the pelvis. Symptoms — Previous to Tubal Rupture or Abortion. — The most common symptom of ectopic pregnancy before rupture or abortion is an irregular but persistent slight bleeding or spotting, occurring with or without a pre- ceding cessation of the menses for one or two months. Usually the patient has missed a period, but there are many cases in which there has been no cessation of menstruation, although something atypical has been noticed about the last one. It has been scanty, or long drawn out, or quite profuse and then has stopped entirely for a day, only to reappear every day or two, a few drops at a time. The patient often believes herself pregnant and speculates as to the significance of the returning or atypical menstrual flow. Exceptionally, shreds of decidua or even a decidual cast of the uterine interior may be recovered by the patient from the bloody discharge. As a Fig. 361. — Longitudinal section of pregnant tube; ovum in amniotic sac. (Laboratory, Gynecean Hospital.) DISEASES OF THE FALLOPIAN TUBES 375 rule, the decidua is expelled in such small disintegrated portions that it escapes observation. The associated signs and symptoms of pregnancy are not constant or well marked. Morning nausea, fullness, and heat in the breasts, and discoloration of the vaginal mucosa may or may not be recog- nizable. With the irregular hemorrhage or spotting there is some pain which may be more severe on one side, a slight elevation of temperature, 99 F., and a small increase in the leucocytes, 9000-11,000. These symptoms occurring in a woman who has borne children previously, but thereafter has remained unproductive for a considerable time, are very significant. All the more so if there is a history of some intervening pelvic inflammatory trouble at the time of labor or abortion. Symptoms of Tubal Rupture or Abortion. — To the above symptoms may be added suddenly those which indicate rupture of the tube or a tubal abortion. These are acute lancinating pains in one or the other side of the lower abdomen, followed by faintness, pallor, rapid respiration, and rapid, feeble pulse. If the hemorrhage is free, the severity of the symp- toms will be much greater than those resulting from slow or intermittent bleeding. Preceding the rupture, there may be a period during which the patient suffers at intervals with severe colicky pains in one side of the lower abdomen (contractions of the tube, stretching of the peritoneal coat) ; rupture of the tube may then be followed by a cessation of the greater part of the pain, and the rapid development of the indications of internal hemorrhage. The shock attending the pain and the evidences of internal hemorrhage may often be progressive up to a certain point and then subside, this depending upon whether or not abortion of the ovum with cessation of hemorrhage or a rupture of the tube with limited and non- recurring hemorrhage has occurred. Sometimes such a history may be elicited after the patient has been operated on for another purpose and old blood-clots and cicatrices have been found in the tube. Symptoms Following Rupture or Abortion in Case of Abdominal Preg- nancy. — After the early indications of pregnancy and the symptoms in mod- erate degree of rupture or tubal abortion, the subjective manifestations of pregnancy may continue and increase even up to term. The abdomen will gradually enlarge, foetal movements will be recognized, and the patient may consider herself normally pregnant. At term there may be cramp-like pain, some hemorrhage, and the discharge of decidual shreds — without expulsion of the embryo. At this time, if the condition is recognized, prompt abdom- inal section may possibly result in a living foetus. Quite often the true state of affairs is not recognized at the time ; the pain and the uterine hemorrhage are regarded as false labor, the foetus perishes and undergoes mummification or lithopedion formation, and the actual condition is revealed months or years afterward. Diagnosis — Before Rupture. — The symptoms of an ectopic pregnancy vary according to its location, accidents of growth, and termination. No other pelvic condition is so frequently mistaken for something else. Never- theless, many cases are so typical that a correct diagnosis can be made from the history alone. Some irregularity in menstruation, particularly amenorrhoea, for six 376 GYNECOLOGY to eight weeks and then " spotting " and abdominal pain in a woman a long time married and sterile, or in one who was at first prolific but has not been pregnant for some years, often correctly indicate extra- uterine pregnancy. If combined with these symptoms the uterus is slightly increased in size and a sensitive enlargement on either side to the front or back of it can be made out, a diagnosis of unruptured ectopic preg- nancy is justified. From threatened or incomplete miscarriage with pelvic tumors, inflammatory or otherwise, it often may be distinguished by the size of the uterus which does not correspond to the probable duration of pregnancy, or by the condition of the os which is not open and is not as soft as in intrauterine gestation. The temperature in tubal pregnancy before rupture is rarely over 99 ° F. ; there is usually a slight increase in the leuco- cytes — 9000-11,000 — rarely more; there is not the dense infiltration and fixation of a fresh inflammatory case, and yet the symptoms indicate that the condition is something new, something comparatively recent in- the his- tory of the patient. Intrauterine pregnancy, with threatened miscarriage and a twisted hydrosalpinx or ovarian cyst, may simulate closely. an extra- uterine gestation. The indications of a miscarriage, however, are more positive, and a true cyst of the ovary is usually larger. Diagnosis — At Rupture or Abortion. — The acute pain, shock, and symp- toms of hemorrhage at the time of rupture or abortion quite frequently pre- vent a satisfactory pelvic examination, and the physician should bear in mind that in such an extremity the greatest gentleness must be exercised to prevent an exaggeration of the hemorrhage by manipulations of the pelvic organs. Under these conditions the diagnosis must be based on the subjective symp- toms and history, and upon very gentle examination. It may be evident upon inspection that the bluish discoloration of pregnancy is present, that the breasts are slightly enlarged, the cervix is softened, and that a very sensitive, ill-defined mass exists to one side of, and behind or in front of, the uterus, possibly barely felt by the abdominal palpating hand. If the hemor- rhage is free, the evidence of fluid blood in the abdomen — dull flanks, fluc- tuation, etc. — may be made out. In some cases the pelvic examination is absolutely negative and the diagnosis must be based upon the history and the subjective indications. The pregnant tube may be enlarged so slightly, notwithstanding the fact that a perforation of its wall or the escape of the ovum through its outer ostium is causing serious hemorrhage, that even intra-abdominal palpation discovers nothing, and actual inspection of the tube is necessary to be sure of the source of the trouble. A very consider- able amount of free fluid blood in the peritoneal cavity may be unrecog- nizable by any method of physical examination. Under such circumstances the pallor of the patient is a striking symptom; the conjunctiva and the lips are blanched; the skin has a bluish-white or a yellowish hue; the finger- nails no longer exhibit the pink capillary flush. When shock without hemor- rhage is difficult to distinguish from shock with hemorrhage, a red blood count and haemoglobin estimation often afford valuable evidence one way or the other. Diagnosis of Haematocele Formation.— After the critical symptoms have subsided and the blood which has been poured out into the pelvis has formed a DISEASES OF THE FALLOPIAN TUBES 377 clot, a very characteristic, sensation may be imparted to the vaginal or rectal finger on bimanual examination ; namely, the peculiar crepitation which may be felt upon breaking up a thick jelly. When the clots are older and an actual hematocele has formed, the pouch of Douglas may be filled with a fairly resistant mass closely incorporated with the uterus and adnexa. Some of the blood is usually fluid and may occupy the center of the mass, so that the fluctuation may be detected. If infection and suppuration occur, the temperature increases and the leucocytosis becomes more marked. When the hemorrhage continues slowly and many clots are formed, lying among the intestinal coils with beginning organization and plastic peritonitis, there may be tenderness and rigidity of the abdominal wall and a considerable degree of leucocytosis. Diagnosis of Abdominal Pregnancy. — A tubal pregnancy which has rup- tured and been extruded into the abdominal cavity and continues to grow may give rise to abdominal enlargement, foetal movements, and heart sounds almost identical with what is observed during normal intrauterine pregnancy. Early in extrauterine pregnancy the enlargement may be a little to one side of the median line and later the long axis of the enlargement may be transverse or diagonal oftener than in normal pregnancy. The normal out- line of the uterus and the uterine contractions, of course, are not apparent, but the sensitiveness of the abdomen, and the spasm of the abdominal muscles during palpation, may explain this to the physician's satisfaction. In doubtful cases, under general narcosis, the discovery by palpation of the uterine body, normal or but slightly increased in size, quite distinct and separate from the foetal parts, gives sufficient information to establish the diagnosis. When the pregnancy has gone on to the third or fourth month and the foetus has perished and become mummified or petrified, it forms a peculiar enlargement to one side of or behind the uterus, which at once impresses the examiner with the fact that he is dealing with something unusual. It may be possible to make out the various foetal parts. The greatest difficulty in doing this may arise if a recent intrauterine pregnancy complicates an old extrauterine pregnancy. Prognosis. — The prognosis of extrauterine pregnancy is always doubt- ful. At the present time, in good hands, few cases will progress beyond the first two or three months of gestation without being recognized, and as soon as the diagnosis is certain will be exposed to operation. The mortality rate in operation en ectopic gestation is no higher than in any uncomplicated aseptic celiotomy. Neglected cases, whether early or late, may end dis- astrously. Cases seen for the first time when rupture or tubal abortion has occurred or is imminent, if dealt with promptly and properly, will usually recover. Cases which are exposed to operation some time after free intra- peritoneal hemorrhage has occurred with the subsequent formation of clots, show a mortality a bit higher than the usual celiotomy cases because of the greater tendency to post-operative infection, bacteria already being pres- ent in the hematocele or the clots left after the enucleation and forming an unusually favorable nidus for the growth of germs introduced by accident. The prognosis of cases not submitted to operation early or late is unfavor- able. Suppuration of the hematocele and spontaneous evacuation into the 378 GYNECOLOGY bowel or bladder have been observed. The hemorrhage may continue and the amount of blood in the peritoneal cavity gradually increase with the extensive distribution of clot, plastic or septic peritonitis, and death. Treatment. — There is but one form of treatment for tubal pregnancy and that is operation. The only questions to be decided are when to operate and what the nature of the operation shall be. As a rule, it may be said that operation should be undertaken as soon after the diagnosis is made as the patient can be properly prepared. This applies to unruptured as well as ruptured and tubal abortion cases. The only exception to this rule is in advanced cases of abdominal pregnancy, in which operation is deferred, hop- ing that a viable child may be secured by celiotomy at term. In the early stage of extrauterine pregnancy the patient should be immediately placed under such conditions that she can be exposed to operation at short notice. After the usual preliminary examination and preparation, which is advis- able in all but emergency cases, operation should be carried out. At this time the pregnant tube should be removed by salpingectomy, and other pelvic lesions found at the time treated secundum art em. Operation at the time of rupture or abortion, when the patient's condi- tion is critical, must be consummated with the least possible delay. Every- thing should be prepared, the operator and his assistants, the instruments, the sutures, the abdominal surface, and the patient on the operating table, before anaesthesia is begun. In this way not a moment is lost. Nitrous oxide- oxygen and ether anaesthesia is the best for this operation. Apparatus for the subcutaneous injection or the intravenous infusion of salt solution must be at hand. In the most desperate cases the intravenous cannula should be in posi- tion and everything ready to start the injection as soon as pelvic haemostasis is secured. As soon as the abdomen is opened the site of the pregnancy should be determined by palpation and a clamp placed on the broad liga- ment, close to the uterus on the affected side, to secure the utero-ovarian anastomosis, and another close to the pelvic extremity of the broad liga- ment to secure the ovarian vessels. This may be done by touch alone, if necessary, and no attention should be paid to the fluid blood or clots which may gush from the incision as soon as it is made. After the bleeding area has been caught between clamps in this way and hemorrhage can no longer occur, the excess of bloody fluid and clots may be removed by sponging, and the pelvis sufficiently exposed and isolated to carry out salpingectomy or salpingo-oophorectomy, whichever is required. In desperate cases the simplest technic should be used, the chief aim of the operator being to get the abdomen closed quickly after ligating the vessels and removing the bleeding tumor. The gross fluid and clotted blood should be scooped out and the incision closed without delay. If the hemorrhage is recent, and the pa- tient's condition serious, the abdominal cavity should be filled with salt solution before closing the peritoneum. If there is much old blood in the pelvis, and the operation has taken place during a recurrence of the hemor- rhage, drainage through Douglas' pouch or a suprapubic opening should be employed. The advice here given is not in accord with the teachings of a few gyne- cologists who in desperate cases advocate delay until reaction occurs. The DISEASES OF THE FALLOPIAN TUBES 379 assumption underlying this position is that the hemorrhage will cease when the blood-pressure has been reduced to a certain point, provided the patient is not disturbed by pelvic examination, transportation to a hospital, and stimulation. The application of this teaching has not been successful in practice and is generally considered pernicious. But the discussion of the question has emphasized several very important points : First, that a pelvic examination in ruptured tubal pregnancy or tubal abortion may seri- ously increase the amount of hemorrhage ; that nothing but the gentlest examination is permissible, and that it should not be repeated. Secondly, that the active use of cardiac stimulants, hypodermoclysis, etc., may prolong the hemorrhage, prevent the formation of clots, and actually exsan- guinate the patient. The practical deductions from these facts are : To rely upon the history or to make but one examination, and that in the gentlest manner ; to use morphine hypodermically to quiet the patient after a positive diagnosis is made ; to transport the patient with the greatest care compatible with speed to the nearest operating room ; to avoid any but the mildest and most carefully guarded stimulation until the bleeding vessels are controlled by ligature. When the case is of long standing, the hematocele well organized, and the patient in such a state that there need be no undue haste, careful attention should be paid to technic ; the ovary on the affected side may be conserved, the opposite adnexa examined and dealt with in approved fashion. When the hematocele has been everywhere adherent, so that small pieces of blood-clot must be left attached to peritoneal surfaces in the pelvis, or in any case in which the possibility of infection seems more pronounced than usual, drain- age through a posterior vaginal or suprapubic incision should be instituted. In the case of suppurating pelvic hematocele, the most suitable method of treatment consists in a posterior vaginal incision, evacuation of the pus, and drainage. In advanced abdominal pregnancy the sac may be surrounded by dense adhesions or it may be free, hence its removal may be either very difficult or quite as easy as the removal of an ordinary cyst. The chief difficulty, however, is in dealing with the placenta. The hemorrhage caused by removing this at once may be rapidly fatal. At term or near term it should never be attempted ; instead, the margins of the foetal sac should be stitched to the abdominal incision, the umbilical cord cut short, the cavity packed with gauze, and the placenta permitted to separate slowly. When the foetus in abdominal pregnancy dies near term, operation should be deferred for three or four weeks, to allow the vessels at the placental site to become at least partially obliterated. BIBLIOGRAPHY Anspach, B. M. : "Torsion of Tubal Enlargements with Special Reference to Pyosalpinx." Amer. Jour. Obst., 1912, lxvi, 553 ; Ibid. : " Four Cases of Extrauterine Pregnancy with Reference Especially to Their Etiology." U. of P. Bull., July, 1902. Eovee, J. W. : " Acute Diffuse Suppurative Peritonitis from a Ruptured Pus Tube." Surg., Gyn. and Obst., 1910, x, 406-411. Clark, J. G., and Norms, C. C. : " Conservative Surgery of the Pelvic Organs in Cases of Pelvic Peritonitis and of Uterine Myomata." S., G. and O., 1910, xi, 398; Ibid.: " Results Following the Treatment of Pelvic Inflammatory Lesions by Surgical Meas- ures." S.. G. and O., 1917, xxv, 33. 380 GYNECOLOGY Cragin, E. B. : " The Treatment of Full Term Ectopic Gestation." Am. J. Obst., igoo, xli, 740. Dorland, W. A. N. : " Repeated Extrauterine Pregnancy." Am. Jour. Obst., 1898,. xxxvii, 478. Frank, R. T. : " An Analysis of Eighty Consecutive Cases of Ectopic Gestation." Amer. J. Obst., 1909, lix, 211. Fromme u. Heyneman : "Die Hydrosalpinx." Veits Handbuch, 2nd Edt, p. 137. Futh : " Studien iiber die Einbettung des Eies in der Tube." Monats. f. Geb. u. Gyn., 1898, 590-613. Gellhorn, G. : " Salpingostomy and Pregnancy." Trans. Amer. Gyn. Soc, 191 1, xxxvi, 186. Glitsch : " Zur Aetiologie der Tubenschwangerschaft." Arch. f. Gynak., 1900, lx, 385. Hofmeier : " Zur Pathologie der Extrauterinschwangerschaft." Berlin, Klin. Woch., 1905, xxvii, 847. Kleinhans : " Die Erkrankungen der Tube." Veits Handbuch, iii, 1st Edition. Landau u. Rheinstein : " Beitrage zur Pathologische Anatomie der Tube." Archiv f . G. r 1891, xxxix, 273. Mandl u. Schmidt: "Beitrage zur Aetiologie und Pathologischen Anatomie der Eileiter- schwangerschaften." Arch. f. Gyn., 1898, S. 401. Martin : " Ueber Partielle Ovarien und Tubal Extirpationen." Volk. Samm. Klin. Vrot, 1889; Ibid. : Die Krankheiten der Eileiter. Leipzig, 1895, Bd. 1. Martin u. Orthman: Eileiterschwangerschaft. Die Krankheiten der Eileiter. Berlin und Leipzig, 1895. Norris, C. C. : "Primary Carcinoma of the Fallopian Tube and the Report of a Case." S., G, and O., 1909, viii, 272. Opitz : " Ueber die Ursachen der x\nsiedelung des Eies im Eileter." Zeit. f . Geburtsch. u. Gynak., 1902, Bd. xlviii. Parry : Extrauterine Pregnancy. 1876. Pozzi : De la re'section et de L'ignipuncture de gyn. 1897. Robb, H. : " Ectopic Gestation with Special Reference to the Treatment of Tubal Rupture." Amer. Jour. Obst., 1907, lvi, 6. Robson : " Primary Ovarian Gestation." Trans. London Obst. Soc, 1902, xliv, 215. Rubin, I. C. : " The Simulation of Corpus Luteum and Retention Cysts of the Ovary with Ectopic Pregnancy and Early Uterine Abortion." Surg., Gyn. and Obst., 191 7, xxiv, 443. Runge: " Beitrag zur Anatomie der Tubargraviditat." Arch. f. Gyn., 1904, lxxi, 652. Sampson, J. A. : " Influence of Ectopic Pregnancy on the Uterus." Trans. Amer. Gyn. Soc, 1913, xxxviii, 121. Simpson, F. F. : " Deferred Operation for Ruptured Ectopic Gestation." Surg., Gyn. and Obst., 1907, v, 503; Ibid. : "Deferred Operation for Intra-abdominal Hemorrhage Due to Tubal Pregnancy." Trans. Amer. Gyn. Soc, 1908, xxxiii, 19. Skutsch : " Beitrag zur Operativen Therapie der Tubenerkrankungen." Centr. f . Gyn., 1889. Smith, R. R. : "Repeated Ectopic Pregnancy." Trans. Amer. Gyn. Soc, 1911, xxxvi, 425; Ibid.: "Final Results (after five years) in 192 Patients Operated Upon for Ectopic Pregnancy ; with Special Reference to Subsequent Uterine and Repeated Ectopic Preg- nancies." Surg., Gyn. and Obst., 1914, pp. 684-695. Spalding: "Relative Frequency of Ectopic Gestation." Trans. Sec. O. G. and A. S. — A. M. A., 1915, p. 114. Tait, L. : Lectures on Ectopic Gestation and Pelvic Hematocele. Birmingham, 1888. Veit, J. : Die Verschleppung der Chorionzotten. Wiesbaden, 1905. Webster, J. C. : Ectopic Pregnancy. 1895 ; Ibid. : " Study of a Specimen of Ovarian Preg- nancy." Am. Jour. Obst., 1904. Werth : " Die Extrauterinschwangerschaft." Winckels Handbuch der Geburtshiilfe iqoj Bd. ii, 2, 655- Williams, J. W. : " Extrauterine Pregnancy." Kelly-Noble Gyn. and A. Surg., ii, 30. (Complete literature.) CHAPTER XX DISEASES OF THE OVARIES INFLAMMATORY DISEASES Acute Interstitial Oophoritis — Etiology. — Acute interstitial oophoritis may be caused by the direct extension, via the lymphatics, of an infection deposited in the uterus, incident to abortion, labor, or instrumentation (strep- tococcus, staphylococcus, colon bacillus, etc.). Acute interstitial oophoritis may also occur secondary to acute endosalpingitis, an open Graafian follicle or corpus luteum being infected by purulent material escaping from the tube (gonococcus). It is a matter of clinical observation that acute interstitial oophoritis may complicate parotitis, scarlet fever, varioloid, measles, diphtheria, and typhoid fever (Frankl). The work of Rosenow and Davis shows that interstitial oophoritis may be hsemogenic, the organisms being transported to the ovary from the site of focal infections, notably the tonsils or the teeth. In a series of fibrocystic ovaries exhibiting fibrocystic changes, Davis found the strep- tococcus viridans in 50 per cent. Other bacteria isolated were the staphylo- coccus albus, the pneumococcus, and an organism resembling the diphtheria bacillus. Davis regards this study as conclusive proof of the occurrence of hematogenous involvement of the ovaries from some of the more common foci of chronic infection. Pathology. — Acute interstitial oophoritis complicating post-abortal, post- partal, or instrumental infection is marked by cedema and swelling of the ovary and infiltration of the ovarian stroma with polymorphonuclear leuco- cytes. In the milder grades of infection the disease may subside without producing gross lesions. In the severer forms there is destruction of tissue with the formation of an abscess. An ovarian abscess of this type varies in size from that of a hazelnut to that of an orange (Fig. 362). There may be a number of small purulent collections at first, but these usually merge into one as the disease advances. When the acute interstitial oophoritis is the consequence of a direct infection of an open Graafian follicle or corpus luteum by gonorrhceal pus from the tube, the inflammatory process is more or less limited to the infected follicle or corpus luteum. Abscess is not so frequent, and if it ocurs is usually smaller and confined to the follicle or the corpus luteum, as the case may be. Acute Perioophoritis — Etiology and Pathology. — Acute perioophoritis or acute inflammation of the ovarian capsule is most frequent in association with gonorrhceal salpingitis and pelvic peritonitis. The ovarian capsule be- comes inflamed and very quickly covered with or embedded in the inflamma- tory products of the pelvic peritonitis. As a rule, in these cases the ovarian involvement is limited to the capsule, but, as noted above, exceptionally an interstitial oophoritis may be produced. Perioophoritis also may accom- pany and be a part of interstitial oophoritis or pelvic peritonitis caused by a 381 382 GYNECOLOGY post-abortal, post-partal, or post-instrumental infection. The changes in the capsule in this instance are not so marked, and the condition is usually sec- ondary in importance and significance to the lesions which it complicates. End-result cf Acute Interstitial Oophoritis. — Following an acute inter- stitial oophoritis the inflammation may subside without any recognizable gross or histologic lesion, or the ovary may be permanently damaged and exhibit sclerosis, hypertrophy, or cystic degeneration. An abscess of the ovary, the size of an orange, causes active symptoms and must usually be evacuated by surgical interference, or, if the case is neglected, it may rup- ture spontaneously into the vagina, the intestine, or the bladder. The ovary may then return to an approximately normal size and appearance, or, if the greater part of the organ has been destroyed, it may be shrivelled and sclerotic. In the case of small abscesses, especially those secondary to gonorrhceal salpingitis and peritonitis, the acute process may subside and the purulent content be gradually disintegrated and partially absorbed. End-result of Acute Peri- oophoritis. — A cute peri- oophoritis of gonorrhoeal origin, associated with gonorrhceal salpingitis and pelvic peri- tonitis, leaves the ovary with a thickened capsule and adhe- sions to the surrounding struc- tures. In the course of time the ovary becomes cystic from the interference with the peri- odic rupture of ripe Graafian follicles (see Retention Cysts. page 402) . Acute peri- oophoritis, associated with interstitial oophoritis without abscess formation, may leave no permanent residue, the adhesions formed during the acute stage often entirely disappear- ing as the trouble subsides. Perioophoritis associated with ovarian abscess is more likely to be followed by permanent adhesions ; this is especially true when the abscess is of small size and has not been evacuated. Symptoms, Diagnosis, and Treatment of Acute Inflammatory Diseases of the Ovaries. — Acute oophoritis, both the interstitial and perioophoritic varieties, are almost invariably combined with cellulitis, peritonitis, or salpingitis. The symptoms, diagnosis, and treatment of all these conditions are so intimately combined that they are considered together under pelvic inflammatory diseases. Oophoritis is a more common incident of post-partal, post-abortal or instrumental pelvic inflammatory disease than of gonorrhoeal pelvic inflammatory disease. The subject is dealt with in Chapter XXI, page 411. Chronic Oophoritis. — Chronic oophoritis, either interstitial or peri- oophoritic, is the end-result of an originally acute lesion (vide supra). It 362. Abscess of the ovarv (Gynecological laboratory U. of P.). DISEASES OF THE OVARIES 383 is usually associated with chronic salpingitis or chronic pelvic peritonitis, and is a part, therefore, of chronic pelvic inflammatory disease. The symp- toms, diagnosis, and treatment are described in Chapter XXI, page 411. TUMORS OF THE OVARY The ovary may be the seat of a variety of tumors. Tumors of an epithelial type originate in the epithelium of the Graafian follicle or the germinal epithelium, or in rests of the Wolffian system embedded in the ovary, while connective-tissue growths develop from the ovarian stroma. The epithelial tumors are almost uniformly cystic and far out- number the solid tumors. Both solid and cystic growths may be either benign or malignant. Another form of ovarian tumor, etiologically and structurally different from either of the above, is the teratoma. These are usually cystic and take the form of the so-called dermoid cyst. Rarely they are solid or nearly so. In addition to these actual new growths of the ovary, there are other enlargments of the organ due to hyperplasia and hyper- trophy of its constituents, and not in any sense true tumor formations. They result from abnormalities in the growth, development, and regression of the Graafian follicle and the corpus luteum. 1 1 For convenience the tumors of the ovary may be grouped as follows : Tumors of the Ovary. { Glandular cysts ] Pseudomucinous i -d ■ ( Ovary proper , V SX Fig. 379. — Resection of the ovary. PELVIC INFLAMMATORY DISEASE 419 ovary in the hope of subsequent pregnancy, but otherwise the surgeon will do well to remove any such organs. Every effort should be made, however, to preserve the menstrual func- tion, for upon this much of the happiness of the individual depends, and the complete removal of the pelvic organs at an early age is often followed by nervous phenomena which are disastrous and permanent. There are numer- ous cases, however, in which it is utterly impossible to conserve even a vestige of either tube or ovary, and under such circumstances the surgeon should not hesitate, but pro- ceed to remove both adnexa with the fundus of the uterus (see Ovarian Trans- plantation, Chapter XXXIII). PUERPERAL PELVIC INFLAM- MATORY DISEASE Etiology and Pa- thology. — Pelvic inflamma- tory disease of this variety is due to the introduction of infectious material into the genital tract, usually into the uterus, after labor, miscarriage, or abortion. The organisms commonly involved are the strepto- coccus, the bacillus coli communis, and the staphy- lococcus ; the gonococcus and the saprophytic organ- isms, also, are occasionally found. In contradistinc- t i o n to the gonococcus. which travels along the mucous membranes of the genital tract, as a rule, and shows feeble powers of penetration, the streptococcus enters the uterine wall by inoculation at some point and, by means of the lymphatics or veins, passes directly through the wall of the uterus. Thus when the cervix or the lower uterine segment is infected by the streptococcus (Fig. 381), the infection extends through the uterine wall into the cellular tissue at the base of and between the layers of the broad liga- ments (cellulitis). When the infection is deposited at a higher point it may reach the ovary (ovarian abscess) through the lymphatics of the broad and the utero-ovarian ligaments. Ovarian abscess is the most common adnexal lesion in puerperal pelvic inflammatory disease. Again, the infection may pass through all the coats of the uterus and attack the peritoneum (pelvic peritonitis) Fig. 380. — Salpingostomy (page 438). 420 GYNECOLOGY or the adnexa (perisalpingitis-perioophoritis) ; or it may infect the thrombi and veins at the placental site (thrombophlebitis). Very often, not one, but several of these avenues are traversed by the infection, so that there may be various combinations of septic lesions. Puerperal pelvic peritonitis due to the strep- tococcus is much more apt to extend into the abdomen than gonococcus peritonitis. Infections of the mucosa of the tube, endosalpingitis and pyo- salpinx are quite unusual in puerperal pelvic inflammatory disease ; but a hydrosalpinx may be formed by inflammation of the outer serous coat of the tube with occlusion of the abdominal ostium. The progress of the infecting organisms may be stopped at any point by the resistance of the tissues. The symptoms resulting from the entrance of the toxins (toxaemia) of the bacteria themselves (bacteriaemia, septicaemia, Fig. 381. — Diagram, illustrating streptococcus and staphylococcus infections spreading through the veins and lymphatics. (See Fig. 377.) pyaemia) into the general circulation are often a prominent feature of puerperal pelvic inflammatory disease. Sometimes the toxins overwhelm the patient and death occurs before there are any demonstrable local evi- dences of infection. The pelvic lesions which may result from puerperal pelvic inflammatory disease are any one or any group of the following: Acute endometritis; acute metritis; uterine abscess; cellulitis; abscess of the cellular tissue ; ovaritis ; ovarian abscess ; peritonitis, localized, pelvic, or diffuse ; lymphangitis of the broad ligaments and pelvic lymphatics ; throm- bophlebitis of the veins at the placental site, and in the broad ligaments, etc. Symptoms. — The trouble dates from labor or abortion, or some intra- uterine manipulation or operation during pregnancy. The disease is either ushered in suddenly by a chill and by pyrexia of an alarming degree, some- times as high as 105 F., or the fever gradually develops during the first days or week of the puerperium. There is a leucocytosis of from 15,000 to PELVIC INFLAMMATORY DISEASE 421 25,000, sometimes as much as 40,000. The pulse-rate is usually more rapid than would correspond to the height of the temperature. Indeed, the first symptom of puerperal infection may be an undue rapidity of the pulse. There may be actual chills associated with hyperpyrexia, or merely chilly sensations without any marked variation in the temperature curve. The patient may complain of pain in the lower abdomen, worse, perhaps, upon one side, though in many cases the pain is very slight. Constipation is the rule, although there may be diarrhoea later in the more septic cases. Head- ache is often present. The lochial discharge has no odor unless there are retained and putrefying secundines, and except in such cases the amount of the lochial discharge is diminished. Diagnosis. — Puerperal peritonitis follows labor, abortion, or some intra- uterine manipulation or operation during pregnancy. Careful inquiry as to the course and conduct of the labor or the abortion may indicate the probability of the direct introduction of infectious germs into the utero- vaginal tract. In cases of criminal abortion, the patient may often deliber- ately attempt to deceive the physician. The general symptoms are much more violent, as a rule, in the puerperal than in the gonorrhoeal form of peritonitis. The disease may manifest itself within a few hours or several days of the infection. There is often but little pain. The general symptoms of intoxication, however, such as pyrexia, rapidity of the pulse, etc., are always greater than in the gonorrhoeal form. Examination of the birth canal and the pelvic organs must be made with the utmost care and gentleness. In the earlier stages of puerperal pelvic inflammatory disease examination may show nothing ; local evidences of infection may not be present. As the disease progresses, unless the patient is overwhelmed and dies of the toxaemia, the local evidences develop. The external genitalia, perineum, vagina, and cervix should be inspected and carefully palpated for evidences of inflammatory and infectious processes (induration, tenderness, false membrane). The size of the uterus is usually greater than would normally correspond to the day of the puerperium (arrested involution) ; the cervix may be patulous (arrested involution or retained secundines). The uterus may be fixed with areas of induration on one or both sides (cellulitis, adnexitis, pelvic peritonitis). The uterus may be displaced by a mass on one side or back of it (ovarian abscess). The lower abdomen may be tender and rigid (metritis, adnexitis, peritonitis) ; the uterus may be very distinctly enlarged and palpable (subinvolution, metritis) ; the abdomen may be distended ; peristalsis may be diminished or absent (peritonitis) ; there may be an area of tenderness over Poupart's liga- ment at the femoral sheath, or along the femoral vein ; there may be oedema of the corresponding leg (femoral thrombophlebitis). Prognosis. — The outcome of the attack is always doubtful. A rapid absorption of toxic products from the infected pelvic organs or from a spreading peritonitis may quickly end in death. Except in the most virulent forms of infection and those associated with perforation or rupture of the uterus, or in neglected or badly treated cases, the outlook is more hopeful. The prognosis is of necessity dependent to a considerable degree upon the virulence of the infecting organism and upon the strength of the patient. An 422 GYNECOLOGY estimation of the white blood corpuscles may be of some value as an indica- tion of the patient's resistance to the infection. A comparatively high leuco- cytosis is favorable. A low count in the presence of severe general symp- toms is bad. The worst cases are those in which the general symptoms are marked and yet the localized evidences are slow in appearing, or do not appear at all. The patient under such circumstances suffers from the pres- ence in the blood of the infectious organism and its products — bacterisemia. If the toxin alone is present, the prognosis is less serious. Blood cultures should be made, if possible, in every suspected case. If the streptococcus is found, the outlook is dubious ; the staphylococcus and the bacillus coli communis are less dangerous, although bacteriaemia of any variety is often fatal. When the infection becomes localized in the pelvis, as is evidenced by the development of pelvic masses (ovarian abscess, pelvic peritonitis), or areas of stony hardness (cellulitis), the prognosis is better. If pus forms in an easily accessible position (ovarian abscess in Douglas' pouch ; abscess in the cellular tissue of the broad ligament), vaginal puncture and drainage will usually result in immediate improvement in the general condition, and may be followed by a speedy resolution of all the surrounding inflammatory changes in the pelvic organs. While in puerperal thrombophlebitis there may be nothing abnormally palpable in the pelvis at any time ; as a rule, some time during the course of the inflammation there will develop tenderness in the lower abdomen, broad ligament, inguinal and femoral region of the affected side, with more or less marked oedema of the corresponding lower extremity. There may be re- peated chills and alarming elevation of temperature without bacteriaemia. When there are no bacteria in the blood-stream the general condition re- mains fair in most cases, and while recovery is protracted, it finally occurs. End-results. — Puerperal pelvic inflammatory disease leaves little re- siduum in the way of structural changes. Infiltrates and exudates which do not progress to the formation of pus are gradually absorbed. If pus forms and is not evacuated by surgical means it gradually burrows its way until the abscess ruptures into the vagina, rectum, bladder, small intestine, or " points " externally above Poupart's ligament. The pelvic organs may return entirely to the normal, after the subsidence of the inflammation, even though extensive pelvic exudates have been present during the acute attacks. Adhesions between neighboring organs may become entirely absorbed, so that months or years afterwards a pelvic examination does not show the slightest evidence of the previous affection. For this and other reasons which will be shown later, the removal of organs for the cure of puerperal infection is seldom indicated. Treatment. — Puerperal pelvic inflammatory disease is a wound infec- tion. By the time the clinical evidences make their appearance the tissues have already been invaded by bacteria. Surgery can do nothing at this time, except in a few instances provide external drainage of the infected area ; it cannot cope with the infectious germs embedded in the tissues. The resistance of the patient must be the main reliance, and that can be lowered by injudicious or meddlesome treatment or increased by careful nursing and non-operative measures w T hich help to check the spread of the PELVIC INFLAMMATORY DISEASE 423 disease. If there are indications of trouble in a perineal or a cervical tear which has been repaired, the sutures should be removed at once and the wound freely drained, so that there may be a minimum amount of absorp- tion from the infected surfaces. When the testimony of the medical at- tendant is clear that the entire foetus and placenta have been removed from the uterus, nothing should be done to disturb the interior of the uterus. Any intrauterine manipulation may do much harm by breaking down the pro- tecting layer of leucocytes, which may have formed beneath the endometrium, and thus opening up new channels of invasion. In some cases the testi- mony of the attendant is doubtful and it is impossible to say whether or not there is necrotic material within the uterus, in which infectious organisms are swarming and from which toxins are being absorbed. Under such cir- cumstances, if the os is unduly patulous, if the lochial discharge is free and of a putrid odor, if there are no indications of cellulitis or pelvic peritonitis, and if the pulse and temperature elevation are not excessive, the uterus may be gently explored with the finger and portions of placenta w r ithin easy reach removed with blunt placental forceps ; following this the lower uterine ligament and cervix may be packed with gauze. The gauze pack promotes further dilatation of the cervix, and separation and expulsion of remain- ing fragments of placenta. The pack is removed at the end of twenty-four hours, when gentle exploration of the uterine interior may be repeated unless one can be quite sure that the remainder of the placental tissue has been expelled. If the uterus is fixed and surrounded by areas of induration in the pelvis, if there is any evidence of peritonitis, if the temperature and pulse are high, and the general condition bad, the uterine interior should be let alone. An exception to this latter statement is found in those cases accompanied with profuse hemorrhage ; in them the uterus should be packed with gauze. All of these manipulations must be done with the most rigid aseptic technic. General anaesthesia may be required, but should be avoided if possible. The use of an operating table, support of the legs by stirrups, good light, and plenty of assistance facilitate the manipulations and often render the use of general anaesthesia unnecessary. Intrauterine douching and curetting are meddlesome and dangerous. Both have been the cause of immeasurable harm. No intrauterine antisepsis can do any good and curetting only serves to drive an infection deeper into the uterus than it was before. The patient should be placed in the Fowler position to favor a localization of the inflammatory process to the pelvis. Ice-bags should be placed upon the lower abdomen. The bowels should be moved daily with an enema, simple or compound, but no cathartics should be administered. Eight ounces of normal salt solution or two per cent, soda bicarbonate solu- tion should be infused slowly into the rectum every three hours. Nothing but liquids in small quantities should be permitted by the mouth. Ergotin (Bonjean) in dose of two or three grains every three hours may be pre- scribed with advantage, as it induces firm contraction of the uterus, favors the expulsion of placental fragments, and hinders absorption by diminish- ing the caliber of the veins and lymphatics in the uterine wall. After a few days, when the danger of a spreading peritonitis has passed, the amount of nourishment given may be increased, and a concentrated and nutritious diet 424 GYNECOLOGY given. Milk, broths, koumyss, eggs beaten up with milk or broths, pre- digested beef, or any of the highly concentrated, nourishing forms of food should be given up to the point of toleration. The exhibition of drugs by the mouth should be limited, so that the stomach can be kept in good condi- tion for the digestion of food. Stimulants should be withheld until needed and then given in small dose, and gradually increased if more is required. Strychnia sulphate and alcohol in some form (whiskey, brandy, and cham- pagne) are the most useful. Digitalis, caffeine, and camphor may be held in reserve. The temperature, if excessive, can be controlled by the use of the cold sponge. If the patient complains of headache, an ice-cap should be applied. Many different antiseptic solutions have been recommended and used in the intravenous treatment of puerperal bacteriaemia, but none have survived the test of clinical experience. Of late, intravenous injections of arseno- benzol have been tried by Miller and Chalfant 1 in eleven cases. The use of sera — anti-streptococcus, anti-staphylococcus, and anti-colon bacillus — is still on trial ; on the whole, the results have been disappointing. Nevertheless, in all cases a blood culture should be taken and, if the strep- tococcus, colon bacillus, or staphylococcus is recovered, the corresponding serum or combination of sera should be injected. It appears from the observations of Hare, Davis, and others that the benefit sometimes derived from the use of these sera comes more from the foreign protein substance which they contain than from any specific anti- toxic effect. Horse serum is said to do as much good as a serum prepared from the specific organism. Vaccines have been used to hasten the resolution and absorption of pelvic exudates in the subacute stage of puerperal infection. An autogenous 1 There were seven recoveries and four deaths. In seven cases the blood showed the presence of various strains of streptococcus. Two of these cases died. In two* cases there was a Gramnegative bacillus with two recoveries. Two cases are included in the series who had a negative culture, but they were included as they were clinically blood- stream infections, and both proved fatal. Ten of the infections followed delivery at term and one self -induced abortion at three months. As a result of their observations, they concluded as follows : (i) " With the use of intravenous injections of arseno-benzol we have been able in every instance to rid the blood-stream of its invading organism; (2) all varieties of organisms we have so far encountered seem to be equally influenced; (3) cul- tures from localized abscesses are usually identical with cultures from the blood-stream. Cultures from the uterus, although this same organism is predominant, are rarely pure cultures ; (4) reinfections from focal infections may and do occur, but are not so readily influenced by the arseno-benzol as the original infections; (5) the leucocyte count is usually low in comparison with the temperature and pulse. After arseno-benzol has been given there is a marked increase in the count. If after this time there is a decided de- crease in the leucocyte count without a corresponding improvement in the patient, it is probable that the patient has reinfected herself and arseno-benzol may be given without waiting for confirmation of this by laboratory report; (6) in the cases we have had the blood-stream is usually found to be sterile in twenty-four hours, always in forty-eight hours; (7) rabbit experiments made by Dr. C. S. Allison, of the Singer Memorial Lab- oratory, would indicate that a dose of 6 decigrams is necessary to secure prompt results ; (8) in suspected blood-stream infections arseno-benzol may be given immediately after a culture has been taken in order to avoid the delay incident upon waiting for a lab- oratory report." In the discussion of this paper, Hare denied that the arseno-benzol could have any antiseptic destructive action upon germs in the blood-stream. He said that Ehrlich had admitted that " neosalvarsan and salvarsan had no specific direct effect upon the spirochseta PELVIC INFLAMMATORY DISEASE 425 vaccine may be prepared from intra-uterine culture or stock vaccines of mixed streptococcus, staphylococcus, and colon bacillus may be used (see Chapter XLI). These questions at the present time are still in abeyance. In animal experimentation the results with bacterial vaccine and serum treatment are so remarkable that there is little doubt that some day this will be the solu- tion of the problem, but at the present time we know so little about it that no definite rules of practice can be formulated. Operation in puerperal pelvic inflammatory disease should be limited to the uterine exploration already described during the acute stage and to the evacuation of collections of pus which become manifest at a later date. When in the course of puerperal pelvic inflammatory disease a mass forms on one side of or behind the uterus which softens or " points " in Douglas' pouch, and the daily marked remissions of temperature and the leucocyte count indicate an abscess, posterior vaginal incision and drainage should be made. Likewise collections of pus in the cellular tissue of the broad liga- ments which " point " upon the surface of the lower abdomen above Pou- part's ligament should be evacuated. Otherwise the pelvis should be let alone ; after the temperature has returned to normal or nearly so and the disease is plainly under control, when the uterus is still enlarged (subin- volution), or there are masses on either side or back of it (cellular, adnexal, or peritoneal exudates), resolution may be hastened by hot douches. Opera- tion to correct permanent residua of inflammation, subinvolution, retroposi- tion, adherent or enlarged adnexa is not often required ; if so, it should be postponed as long as practicable, weeks or months, after all of the acute symptoms have subsided. INSTRUMENTAL OR POST-OPERATIVE PELVIC INFLAMMATORY DISEASE Etiology and Pathology. — Pelvic inflammatory disease may follow intra- uterine manipulation and operation on the uterovaginal canal. It results from the direct introduction of infectious organisms or from the spread of an infection already present. Infection may be directly introduced in the course of a plastic operation upon the vagina or the cervix, or during curet- of syphilis." He pointed out that if you " put neosalvarsan in a test-tube with spirochseta, the spirochseta is not destroyed by the salvarsan. If, however, you add to the test-tube blood serum, which acts as a complemental body, the spirochseta is at once destroyed by the salvarsan " ; that is, he showed that there was no germicidal action by the salvarsan " per se, but complementary or other bodies are produced which in turn destroy the parasite. If we accept this drug as having a specific influence upon bacteria which belong to another class than the protozoa or the parasites of syphilis, or' of sleeping-sickness, we have to believe that Ehrlich thought he had found a remedy for only one thing when he really dis- covered a remedy for many things. There is no evidence to date to indicate in any way what- ever in experimental pharmacology that salvarsan or neosalvarsan destroys bacteria belonging to the vegetable kingdom in contradistinction to the spirochseta which belongs to the animal kingdom. " The whole question of the specificity of salvarsan in respect to syphilis has particular relationship to the problem placed before us. It seems that an interesting series of experi- ments might well be made by taking the microorganisms derived by culture from the affected blood and putting them in test-tubes with salvarsan or neosalvarsan in the presence of, and without the presence of, blood-serum and determining whether under such circum- stances salvarsan and neosalvarsan would have any germicidal effect upon these vegetable parasites in the same way that it has an effect upon the spirochseta." 426 GYNECOLOGY tage. Such an accident, however, is very rare in the hands of an operator who employs care in his technic. The use of soiled instruments in the course of an examination, or the passage of a sound into the uterus, with- out the thorough scrubbing and disinfection of the vagina and the cervix which should always precede it, has been a fertile source of infection in the past. At the present day no competent and intelligent physician would be guilty of such an error. Attempts to produce abortion by the unskilled or the uncleanly are very often v J followed by septic infection and sometimes by perfora- tion of the uterine wall. There are some instances, also, in which infection has occurred from the introduc- tion of a foreign body into the uterus with the purpose of producing abortion when pregnancy did not exist. Infections of this sort are produced by the strepto- coccus, staphylococcus, and colon bacillus. Pelvic inflammatory disease fol- lowing an aseptic operation is usually the result of the extension of an inflamma- tion which previously existed, but was not recog- nized at thev time, of the operation. Such infection is usually of a gonococcus type, and may have been localized in the endome- trium, in the tubes, or in the ovaries. While it is sometimes very difficult to detect an inflammatory proc- ess of this sort, the possi- bility of its existence should always be kept in mind, and every curettement or plastic operation on the uterus should be preceded by a careful pelvic examination. In case pelvic inflammatory lesions are recognized, the manipulations must be practised with as little disturbance as possible ; and in the majority of cases it will be advisable to open the abdomen directly after- wards and correct the diseased condition. Symptoms. — The symptoms depend upon the nature of the infection. If it is gonorrhceal and has resulted from an extension of the disease to the tubes or to the pelvic peritoneum, the symptoms will be those of gonorrhceal r^^vXoxvaNiwwv ^ IG - 382. — Vaginal incision and drainage. First step. The posterior lip of the cervix is held forward. A transverse incision is made through the posterior vaginal wall exposing the peritoneum which is pushed out of the way. PELVIC INFLAMMATORY DISEASE 427 salpingitis or peritonitis. If the trouble results from the introduction of septic organisms during an operation, or during the passage of soiled instru- ments or of foreign bodies into the uterus, the symptoms will develop soon after the operation or instrumentation, and will resemble those of puerperal infection (see also Perforation of the Uterus, page 287). Treatment. — If there is good reason to believe that the symptoms depend Fig. 383. — Vaginal incision and drainage. The abscess is located by bimanual palpation and the end of a sharp-pointed curved scissors is guided upon the examining finger to the most dependent point of softening and fluctuation. The scissors are then thrust in and the pus evacuated. Separation of the points of the scissors as they are withdrawn enlarges the drainage opening. upon the extension of a gonorrhceal infection to the pelvic peritoneum, the palliative and conservative measures described under the treatment of gonorrhceal pelvic inflammatory disease are advisable. When the symp- toms appear to have followed the introduction of microorganisms during a plastic operation, the operative field should be exposed, the sutures removed if there is any evidence of infection, and drainage provided. Aside from the provision of drainage for the operative field, an expectant policy should be 428 GYNECOLOGY adopted. The patient should be kept in the Fowler position in bed; the bowels should be opened daily ; a light nutritious diet should be given, and stimulants should be prescribed if necessary. Infection following attempts by the unskilled or the uncleanly to produce abortion is most dangerous. If, at the same time, the uterus is perforated the outlook is bad. The symptoms, prognosis, and treatment are the same as in puerperal infection. Pelvic Abscess. — A pelvic abscess, as the term is generally employed, signifies a collection of pus somewhere within the true pelvis, presenting a well-defined outline recognizable upon physical examination and giving rise to characteristic symptoms (intermittent fever, leucocytosis, etc.). A pelvic abscess may be a periappendicular collection of pus ; a large pyosal- pinx ; an ovarian abscess ; an intraperitoneal collection of pus surrounding a primarily infected ovary or tube, or a collection of pus in the cellular tissue of the broad ligaments. The most frequent cause of pelvic abscess is post- abortal, post-partal, and post-operative infection. The most frequent loca- tion is the ovary. The symptoms of pelvic abscess are those of acute pelvic inflammatory disease in which, notwithstanding the lapse of time and appropriate treat- ment (pages 416 and 420), the fever remains high and becomes remittent, leuco- cytosis increases, and a well-defined fluctuant mass forms in the pelvis. Treatment. — If the abscess occupies the pouch of Douglas and produces bulging of the posterior vaginal fornix, it should be evacuated by a pos- terior vaginal incision (Figs. 382 and 383). If the abscess is the result of a suppurative cellulitis and is extraperitoneal— within the layers of the broad ligament (see differential diagnosis, cellulitis and adnexal disease), operation should be delayed until the abscess points upon the lower surface of the abdominal wall above Poupart's ligament. If this does not tend to occur and there is no indication of a regression of the inflamma- tory trouble, the pus may be evacuated by means of posterior vaginal in- cision. Pelvic abscess high up which in spite of prolonged treatment does not point in an accessible location is unusual. When it occurs, a median abdominal incision may be made in order to accurately locate the exact situation of the trouble, and then through an extraperi- toneal incision in the lower abdominal region, parallel to Poupart's ligament, the abscess cavity may be drained without contamination of the peritoneum. CHRONIC PELVIC INFLAMMATORY DISEASE Etiology and Pathology. — Chronic pelvic inflammatory disease is a term used to designate the residuum of a previous acute pelvic inflammation. Such a residuum occurs much more frequently after gonorrhceal than after the post-abortal, puerperal, or instrumental forms of inflammatory disease. Gonorrhceal pelvic inflammatory disease in the chronic stage exhibits such pelvic lesions as endosalpingitis, pyosalpinx, or hydrosalpinx, perioophoritis, tubo-ovarian abscess or tubo-ovarian cyst, cystic degeneration of the ovary, simple retention cyst (corpus luteum or Graafian follicle cyst), and peritoneal adhesions. Puerperal or post-abortal inflammatory disease is less likelv to leave a PELVIC INFLAMMATORY DISEASE 429 permanent defect in the pelvic organs. In favorable cases the infecting organisms are overwhelmed by the resistance of the patient ; the structural changes are few and rapidly subside. In the severer forms there may be certain residua, which result from an actual destruction of tissue during the acute process. Puerperal pelvic inflammatory disease in the chronic form may exhibit such lesions as subinvolution of the uterus, chronic metritis, atrophy of the uterus, perisalpingitis, hydrosalpinx, chronic oophoritis, ovarian abscess (sterile disintegrated pus), cystic ovary (cystic generation of a Graafian follicle or corpus luteum), and sclerotic ovary. For a more detailed description of the morbid anatomy of chronic pelvic inflammatory disease, see Chapters XIX and XX. Symptoms. — The symptoms of chronic pelvic peritonitis arise from me- chanical interference with the function of the pelvic organs produced by structural lesions and by recurrences of inflammation in the pelvic organs, arising from either new or latent infection. Dysmenorrhcea is a frequent symptom ; the pain begins before the flow appears and lasts until near the end of the period. There is congestion of the ovary and interference with rupture of distended follicles. The periods may be irregular, with a ten- dency to increased frequency and menorrhagia. Subinvolution — chronic metritis — may be present. When most of the follicle-bearing area of both ovaries has been destroyed, or in the rare cases of uterine atrophy, the inter- menstrual time may be lengthened and the flow scant. Leucorrhoea is a very common symptom ; the discharge may come from the cervix (chronic gonorrhoea — thick muco-pus) or from the endometrium (glandular hypertrophy — thin mucus). There is pain in the lower abdomen on one or both sides — worse at the menses, increased by exertion and constipation, and not relieved by the recumbent position. Vesical irritability is a common complaint — either frequency of urination or pain during or after the act. The bowels are usually constipated, and the patient complains of gaseous distention of the bowels, flatulence, etc. Pain during defecation, and dyspareunia are not uncommon symptoms, especially if the ovary is diseased and lies in Douglas' pouch in close proximity to the rectum or the vaginal fornix. Added to these chronic complaints, from time to time, especially in the gonorrhceal pelvic inflammatory cases, there may be an acute exacerbation of symp- toms. This results : from trauma, which releases some of the encapsulated bacteria or their toxins ; from the accumulation of faeces or gas above a point of constriction in the intestinal coils adherent to the pelvic structures, or to a new or fresh infection of the pelvic organs. Sterility is common in chronic pelvic inflammatory disease. Diagnosis. — The diagnosis of chronic pelvic inflammatory disease is made from the history of previous acute attacks, the symptoms, and the findings upon bimanual pelvic examination. The uterus is more or less fixed in a normal, retroverted, lateral, or descended position ; it may be slightly increased in size. The adnexa are enlarged, tender, and restricted in mobility. The elongated retort shape of a pyosalpinx or hydrosalpinx may often be distinguished from the spherical or elliptical shape of an affected ovary. When the lesion consists principally of adhesions and there 430 GYNECOLOGY is but slight enlargement of the tube or ovary there may be little recog- nizable abnormality in the adnexa by palpation, except a feeling of restricted mobility. A thin-walled, flaccid hydrosalpinx may escape observation entirely. Treatment. — The treatment of chronic pelvic inflammatory disease may be non-operative or operative. The former plan may be adopted when the lesion is moderate in degree and the suffering of the patient not excessive ; this plan relieves the patient's sufferings, or at least renders them endur- able. The measures which have been found serviceable are those which prevent pelvic congestion, favor the absorption of inflammatory products, and reduce traumatism to a minimum. The bowels should be kept freely open so as to prevent accumulation of faeces or gas; hot saline douches (i to 2 gallons) should be taken, according to the requirements of the case, from several times a day to that often in a week. Hot sitz baths, the electric hip bath, and the general cabinet bath may be useful. Sexual inter- course must be restricted ; graduated exercise, walking, etc., without violent exertion, is beneficial. If these things do not relieve the patient sufficiently, or if the woman has been made sterile by the disease, operation may be undertaken. Adhesions may be released, diseased organs removed or par- tially resected, and the uterus may be placed in good position. (For a detailed discussion of the treatment of the tube or ovary see page 417.) CELLULITIS Etiology and Pathology. — Cellulitis is usually the result of post-partal or post-abortal infection. It may be produced by intrauterine instru- mentation or operation, and may also result from infected wounds following vaginal or perineal operations. When the disease is associated with labor or abortion, very often there are lacerations of the cervix which extend more or less deeply into the cervical tissues, or entirely through them, and into the parametrium. The infectious organism gains access to the cellular tissue by way of the lym- phatics or the veins. Primarily, the disease is either a lymphangitis or a thrombophlebitis ; secondarily, all the constituents of the cellular tissue are involved in the inflammation. Early in the disease there is an infiltration of the parts with small round cells and polymorphonuclear leucocytes. This inflammatory infiltrate gives a stony hardness to the tissues and fixes the pelvic organs. The induration usually extends from the uterus to the pelvic walls and fuses with the fascia and the muscles overlying the bony pelvis. It is often unilateral, affecting the broad ligament on one side only, though it may be found on both sides. When unilateral it may involve the uterosacral ligament on the affected side posteriorly (the paraproctium) , and the uterovesical liga- ment on the same side anteriorly (the paracystium). The paracolpium especially is invaded when the trouble starts from an infected wound of the vagina or the perineum. The areas involved in the process depend upon the course of the lymph vessels or veins draining the infected w r ound. Cellulitis may be combined with peritonitis. When this happens the two conditions may be coincident, though more commonly the peritonitis is PELVIC INFLAMMATORY DISESAE 431 secondary to the cellulitis, and results from a direct extension of the inflam- mation from the cellular tissue to the pelvic peritoneum. The inflammatory process either undergoes resolution with absorption of the exudate or it softens and forms an abscess. The pus, as a rule, bur- rows along the wall of the vagina, causing the vaginal fornix to bulge, and if not released by incision, it bursts into the vagina or into the rectum. The pus may also be discharged into the bladder, or rarely into an adherent loop of intestine. Or, the abscess being extraperitoneal, the pus may lift up the peritoneum, reflected from the anterior surface of the broad ligament to the anterior abdominal wall, and make its appearance in the groin above Poupart's ligament. Rarely it may pass behind the posterior layer of the pelvic peritoneum to the mesosigmoid and present itself externally in the loin. Cases are on record where the pus has burrowed through the pelvic fascia from the paracolpium and the paraproctium to the ischiorectal fossa. When such collections of pus are discharged spontaneously, the abscess cavity rapidly closes and the patient usually makes a prompt recovery. Symptoms. — The subjective symptoms of cellulitis are similar to those of acute pelvic inflammatory disease following abortion, labor, or septic instrumentation. If suppuration occurs, the temperature assumes a hectic type unless prompt incision is practised. When the paraproctium is in- volved, rectal irritability may be a prominent feature ; when the paracystium is involved, there is usually frequent and painful urination. The objective signs are somewhat different from those of pelvic peri- tonitis with salpingitis and ovaritis, unless accompanying the latter there is a considerable amount of plastic exudate ; the differential diagnosis then may be nearly or quite impossible. As a rule, upon bimanual palpation, the vault of the vagina, on one or both sides, or entirely around the cervix, is densely hard. The mucosa feels as if it closely overlaid tissues carved out of wood. The cervix is fixed as if frozen into an area of dense induration, which extends without interruption to the bony pelvic wall. If both broad ligaments are involved the uterus may be absolutely immobile. Examination per rectum will show the same dense hardness of the pelvic mass. If the exudate involves the paraproctium at the point where the uterosacral ligaments surround the rectum, the lumen of the bowel will be narrowed, and to the palpating finger at this point it will feel like an auger- hole in a board, covered with the rectal mucosa. If suppuration occurs, the parts lose their stony hardness, and fluctuation becomes manifest within several days. W T hen the abscess is small and does not bulge into the vagina, it may be difficult to detect fluctuation. In such cases the tissues of the vaginal vault may feel cedematous and there may be slight pitting upon pressure. Quite frequently the abscess points at one side of the vaginal vault. Diagnosis. — The mass in pelvic cellulitis, as contrasted with that in pelvic peritonitis with salpingitis and ovaritis, is more apt to extend con- tinuously from the cervix to the pelvic wall and to be firmly fixed to the bony pelvis. In peritonitis the mass can often be recognized, occupying a posi- tion posterior to the broad ligament. When there is much exudate asso- ciated with pelvic peritonitis, the differential diagnosis is more difficult or 432 GYNECOLOGY impossible. In such cases the pelvic mass is apt to fill up Douglas' pouch and press the anterior rectal wall backward, instead of surrounding it as it does in cellulitis. Treatment. — The general treatment of septic or of puerperal cellulitis differs but little from that of puerperal pelvic inflammatory disease. Under the influence of rest in the Fowler position, liquid diet, daily enemas, cold to the hypogastrium and later heat to the abdomen, and hot vaginal douches, a considerable percentage of cases of pelvic cellulitis undergo resolution and spontaneous recovery. At times exudates filling half the pelvis disappear. When pus forms it should be evacuated promptly as soon as an area of pointing or softening can be detected ; an incision sometimes hastens absorption in the case of large exudates even though suppuration has not occurred. Whenever pos- sible, the broad ligament should be opened from the vagina, the folds of the broad ligament being separated with the fingers, when necessary, in order to reach deep-seated abscesses. At times the incision must be made in the inguinal or the lumbar region. Chronic Pelvic Cellulitis. — Chronic cellulitis occasionally occurs as the sequel of an acute attack. In some of these cases there is an actual chronic inflammation of the cellular tissue and by a painstaking microscopic ex- amination areas which show inflammatory infiltration may be found. In other cases the inflammatory process has ceased, but a residuum of hyper- plastic or cicatricial tissue is left in the cellular tissues. It is often impos- sible to distinguish clinically between these two forms. According to 111, cellulitis may also be chronic from the beginning. Thus ulceration of the bladder and dysenteric and follicular ulceration of the rectum may produce a localized low-grade inflammation of the neighboring cellular tissue which finally results in a contracting cicatrix and atrophy of the cellular tissue. It should be remembered that normally the pelvic connective tissue varies in different individuals, and that the rectum and the uterosacral folds in many women are sensitive to pressure through the vaginal vault. The con- clusion, therefore, that an actual lesion of the cellular tissue is present be- cause the uterosacral ligaments feel thicker than normal or are tender on pressure, is not justifiable. Symptoms. — The patient complains of the usual train of gynecologic symptoms — backache, dysmenorrhcea, leucorrhcea, etc., depending in the individual case upon the part of the cellular tissue affected and the amount of dislocation of the pelvic organs which has been produced. Diagnosis. — Scars in the vaginal vault extending from the cervix may be readily felt upon palpation. Contraction of the cellular tissue elsewhere is harder to distinguish positively from intraperitoneal adhesions. Need- less to say, a positive diagnosis is sometimes impossible. Treatment.— The purpose of treatment is to absorb the cellular exudate and to stretch cicatricial bands. To secure absorption a daily vaginal douche of hot normal saline solution should be ordered, followed by rest in the recumbent posture for at least an hour, saline laxatives, and the use of tampons. The tampons soaked in glycerite of boroglycerine should be introduced three times a week. . In order to stretch cicatricial bands, the PELVIC INFLAMMATORY DISEASE 433 vagina should be systematically tamponed with the patient in the knee- chest position, which most favors the restoration of the uterus to its normal position. With these tampons considerable pressure may be made without danger. The smaller sizes should be used and the vaginal canal packed as firmly as is consistent with comfort. Pelvic massage, if it is ever useful, is indicated in chronic uncomplicated cellulitis. It may be employed by the physician each time before he makes an application of tampons. PELVIC H JEM ATOM A Etiology and Pathology. — Collections of blood confined to the cellular tissue of the pelvis are spoken of as hsematoma. They are of extreme rarity. Haematorna may be caused by the rupture of varicose veins in the broad ligament ; by hemorrhage from the cervical branches of the uterus after extensive operation on the cervix, or by the rupture of a tubal preg- nancy between the layers of the broad ligament. This is the rarest of all modes of termination of a tubal pregnancy. Symptoms. — The symptoms come on suddenly and consist of intense pain, and, if the bleeding is marked, the symptoms of internal hemorrhage will be present. Diagnosis. — A diagnosis will rarely be made, as the condition is so in- frequent. In the presence of pelvic hsematoma examination shows a mass in the broad ligament intimately associated with and to one side of the uterus, not behind it. There are no signs of peritonitis. Prognosis. — A hematoma usually undergoes absorption. It may burst into the vagina, rectum, bladder, or the free peritoneal cavity. It may be- come infected and suppurate. Absorption of the blood is slow, but there is less tendency to bad after-results than in the case of hematocele, be- cause the peritoneum has not been involved and there are no intra- peritoneal adhesions. Treatment. — The patient should be kept quiet in bed. An ice-cap should be placed over the lower abdomen. After the haematorna is fully developed, hot douches and local and general depletory measures should be adopted. In those cases in which improvement does not follow, palliative measures should be discarded and the haematorna should be opened and drained by means of a vaginal incision (Figs. 382 and 383). OPERATIVE TECHXIC Hysterectomy for Pelvic Inflammatory Disease. — After the usual pre- liminary preparations, an incision is made in the median line, the patient being in the horizontal position. If there is any fluid in the pelvis, it should be carefully sponged away. The patient is placed in the Trendelenburg posture, and the intestines packed or! as extensively as possible from the pelvis. The diseased ovaries and tubes should be gently freed from the structures to which they are adherent. This may be done entirely by the sense of touch, but it is preferable to keep the operative area in constant view, so as to avoid injury of the rectum, the small intestine, or the bladder. The finger should seek first for a spot of cleavage and the enucleation should 28 434 GYNECOLOGY begin on that side where it appears to be most feasible. No force should be employed in separating the adhesions, the palmar surface of the finger being always directed anteriorly toward the broad ligament rather than posteriorly, as, with this precaution, injury to the sigmoid or the rectum is less likely. An occasional snip with the scissors or nick with a sharp scalpel will be advisable when the adhesions are difficult to separate. After the adnexa and the posterior surface of the uterus are free, the fundus is caught with forceps, pulled up into the incision, and then hysterectomy proceeded with in the usual way, as has been described in Chapter XVII, page 317, the succes- sive steps of the operation being: (1) Ligation of the ovarian and the round ligament vessels on each side ; (2) clamping the uterine extremity of the tube, round ligament, and utero-ovarian ligament on each side to control the reflux circulation; (3) dividing the broad ligaments down to the supra- vaginal cervix; (4) incising the vesical reflexion of the peritoneum; (5) ligating the uterine artery on each side ; (6) amputating the body of the uterus by means of a wedge-shaped incision through the cervix ; (7) closure of the cervical stump with catgut ; (8) suspension of the cervix to the round ligaments ; (9) peritonealization, making use of the vesical reflexion of the peritoneum. Variations from the usual technic will be required according to the exigencies of the case. When there are adhesions between the pelvic struc- tures and the omentum, they must be freed before the abdomen is walled off; this is done either by separating the adherent surfaces, or by dividing the omentum between two ligatures. Lightly adherent coils of small or large intestine must be released. The pelvis is now cleared of fluid and the patient having been placed in the Trendelenburg position, the omentum with the free coils of intestine may then be displaced upward above the brim of the pelvis, and the gauze pack introduced. If there is any portion of the intestine so adherent that one fears its liberation may release a collection of pus, no attempts should be made to free the gut until the Availing off has been completed. After such intestinal coils have been released, usually they may be covered with hot, moist packs and kept in Douglas' pouch without increasing the technical difficulties of the operation. If it appears very de- sirable to get them out of the operative area and no pus has been set free, the pelvis and the intestine should be carefully cleansed with hot, moist sponges, the original walling-off gauze should be removed, the intestines lifted above the pelvic brim, and a fresh gauze pack introduced. In cases of tubal or ovarian abscess, it may be at once apparent upon inspecting the pelvic organs that the adhesions are so widespread or the amount of exudate is so great that any attempt at a radical removal of the diseased organs will expose the patient to unwarranted danger. Under such circumstances the intraperitoneal collection of pus should be drained from below through a posterior vaginal incision (Figs. 382 and 383). In difficult cases the hand inside the abdomen may be used as a guide in reaching the abscess. If evacuation from below is not feasible on account of the inter- vention of intestine between the posterior vaginal fornix and the diseased area, an extraperitoneal incision through the abdominal parietes may be possible, the hand in the abdomen again being a guide, or if there is no extra- PELVIC INFLAMMATORY DISEASE 435 peritoneal method practicable, the abscess ma}- be drained through the lower end of the celiotomy incision, the area being well walled off with rubber- dam and gauze. If the adnexal adhesions of one side are especially dense, or the adnexal mass is so low in the pouch of Douglas that there is danger of wounding the Pig. 384 Fig. 385 Fig. 386 X, Fig. 384.- — Salpingo-oophorectomy. Points of ligation and line of excision. Fig. 385. — Salpingo-oophorectomy". Suture of cornua and beginning peri- tonealization. Fig. 386. — Salpingo-oophorectomy. Suture of cornua and completion of peri- tonealization. intestine or the large pelvic veins by forcible or persistent attempts to re- lease them from above, the hysterectomy may be started on the least affected side, and after the cervix has been cut through and disinfected, the difficult side may be approached from below upward. This will often prove the solution of an otherwise perplexing and dangerous situation. 436 GYNECOLOGY There are some cases in which the uterus is so densely bound down by adhesions, and both adnexa are so intimately incorporated with the sur- rounding structures, that a more favorable method of approaching enuclea- tion is by first bisecting the uterus in the median line from the fundus to the supravaginal cervix, then cutting through the cervix on one side to the uterine artery and ligating it, next enucleating the half uterus and the adnexa Fig. 387. — Salpingo-oophorectomy Posterior fixation of round ligament on left and Webster- Baldy suspension on right. of that side, the enucleation being carried out from below upward, and the vessels tied in that sequence, and then carrying out the same procedure on the opposite side. No drainage is required unless the case is recent. Salpingo-oophorectomy. — After the preliminary preparations have been carried out, a median abdominal incision is made and the affected area iso- lated by means of gauze pads. A ligature is then passed through the clear Fig. 388. — Salpingectomy. Points of ligation and lines of excisic space in the infundibulo-pelvic ligament and tied, thus controlling the ovarian circulation. A second ligature is then placed about the utero- ovarian ligament close to the uterus and a third about the utero-ovarian anastomosis at the uterine cornu just beneath the inner extremity of the tube (Fig. 384). The circulation of the ovary and tube being then secured, the infundibulo-pelvic and the utero-ovarian ligaments should be cut, the ovary PELVIC INFLAMMATORY DISEASE 437 and tube pulled up, and the broad ligament divided close to the adnexa as far as the uterine insertion of the tube. At this point the tube is removed from the uterine cornu by a wedge-shaped incision. The V-shaped open- ing of the uterine cornu is closed with a series of interrupted sutures, and any bleeding points along the cut surface of the broad ligament are caught with forceps and ligated individually (Fig. 385). A running suture is then carried from the infundibulo-pelvic ligament stump to the uterine cornu, tic. 389. — Salpingectomy. Sutuie of cornua. approximating the cut edges of the anterior and posterior surfaces of the broad ligament and covering all raw areas (Fig. 386). Salpingectomy. — After the usual preliminary preparations, median in- cision, and isolation of the operative area, the tube is released from adhesions and held up so that the vessels in the mesosalpinx can be plainly seen. The blood supply of the tube is then secured by a series of ligatures, usually three, from the outer to the inner extremity, placed close to the under sur face of the tube, so as to disturb the ovarian branches as little as possible Fig. 390. —Salpingectomy. Peritonealization, when short- ening of round ligament is not required. As a rule, there is an outer, a middle, and an inner uterine branch to be secured (see Fig. 388). The mesosalpinx should be divided along the line of its attachment to the tube. The tube is separated from the uterine cornu by a wedge-shaped incision. The incision is closed with interrupted sutures (Fig. 389). Bleeding points are caught and tied individually and the raw surface of the mesosalpinx is turned in with a continuous suture (Figs. 390, 391, and 392). 438 GYNECOLOGY Salpingostomy. — After the usual preparations — median abdominal in- cision and isolation of the affected part — the diseased outer portion of the tube is cut away. The division of the peritoneal coat and the division of the mucosa are made in different planes, so that the mucosa will project slightly beyond the serosa. The line of excision should be oblique to the long axis Fig. 391. — Salpingectomy. Peritonealization, with short- ening of round ligaments, first step. of the tube. The mucous membrane lining the tube is then united to the outer peritoneal surface by a series of interrupted sutures of fine catgut (Fig. 380). A fine probe should be passed as far as the isthmus to demon- strate that the tube is patulous. It is usually impracticable without trauma to pass the ordinal surgical probe even of small caliber beyond that point Fig. 392. — Salpingectomy. Peritonealization, with shortening of round ligaments, second step. • ■ even in normal tubes. The tube should be washed out thoroughly with sterile salt solution. Vaginal Incision and Drainage. — After the usual preliminary prepara- tions, the site of the abscess is accurately located by means of bimanual palpation. The posterior lip of the cervix is grasped with a tenaculum and steadied, and a transverse incision is made back of the cervix at the reflexion of the posterior vaginal fornix (Fig. 382). The finger is then introduced PELVIC INFLAMMATORY DISEASE 439 into the cellular tissue, and a further careful palpation made. After the site of the proposed puncture has been accurately located, the end of a sharp-pointed curved scissors is thrust into the objective point. A char- acteristic sensation will be imparted to the hand as the point of the scissors enters the abscess cavity. The blade of the instrument is separated as it is withdrawn, thus enlarging the opening (Fig. 383). After the evacuation of the pus a T-shaped soft-rubber drainage tube is introduced, and packing is placed in the vagina to hold the tube in position. BIBLIOGRAPHY Anspach, B. M. : " Inflammatory Diseases of the Pelvis.'' International Clinics, 1917, ii, 27th Series. Baldy, J. M. : " Hysterectomy for Suppurative Disease of the Pelvic Organs." Am. Gyn. and Obst. Jour., Sept., 1895. Bernutz: Pelvic Peritonitis, Clinical Memoirs of the Diseases of Women. Bernutz and Goupil, vol. xi, New Sydenham Soc, London. 1867. Bublitschenko : " liber Sepsis puerperalis Staphylococcia." Zent. f . Gyn., 1914, xxxviii. Emmet, T. A. : " Pelvic Inflammations or Cellulitis versus Peritonitis." Trans. Amer. Gyn. Soc, 1887, ii, 101. Gellhorn, G. : " Salpingostomy and Pregnancy." Trans. Amer, Gyn. Soc, 191 1, xxxvi, 186. Harrar, J. A.: " Puerperal Infections." Bull. N. Y. Lying-in Hosp., 191 1, p. 166. Ill, E. J. : " The Cause, Diagnosis and Nonsurgical Treatment of Pelvic Inflammation." Amer. Gyn. and Obst. J., Sept., 1900. Kelly, H. A. : "Vaginal Drainage for Pelvic Abscess." Kelly and Noble, Gynec. and Abdom. Surg., 1, xviii ; Ibid.: "The Removal of Pelvic Inflammatory Masses by the Abdominal Bisection of the Uterus." Amer. J. Obst., 1900, xvii. Martin : Die Krankh. des Beckenbindegewebes u. des Beckenbauchfells. Handb. der Krankh. der Weib. Adnexorgane. Berlin, 1906. Miller,, quoted by Kelly: Operative Gynecology, 1899, vol. ii, p. 211. Miller, G. B. : " The Occurrence of the Streptococcus Pyogenes in Gynecological Diseases." Amer. Jour. Obst., 1899, xxxix, 780. Miller, H., and Chalfant, S. : " Treatment of Puerperal Blood-stream Infection by the Means of Arseno-Benzol." Trans. Amer. Gynec. Society, 1918, p. 269. Marmorek : " Sur le Steptococque." Comptes rendus de la Soc. de Biol., 1895, 10 me. Serie ii, 122; Ibid.: " Streptococque et le Serum Antistreptococque." Annales de lTnstitut Pasteur, 1895, vol. ix, p. 593. Noble, C. P.: "Puerperal Pelvic Cellulitis and Puerperal Peritonitis." Amer. Gyn. and Obst. Jour., Jan., 1895. Polak, J. O. : " The Preservation of the Menstrual Function." Jour. A. M. A., 1917, lxix, 1938 ; Ibid. : " Observations of Two Hundred Twenty-seven Cases of Ectopic Preg- nancy." Amer. Jour. Obst., 1915, lxxi, 946 ; Ibid. : " Preservation of Menses in Double Suppurative Disease of the Adnexa." Trans. Sec. O. G. and A. S. — A. M. A., 1917, p. 174. Polk: "Hysterectomy (Suprapubic) for Salpingitis and Ovaritis." N. Y. Jour. Gyn. and Obst., Dec, 1893. Pozzi : " De la resection et de L'ignipuncture de L'ovaire." Rev. de Gyn., 1897. Simpson : "A Precise Method of Choosing a Safe Time for Operation in Pelvic Inflam- mation of Tubal Origin." Trans. Amer. Gyn. Soc, 1915, xi, 166 : Ibid. : " Choice of Time for Operation for Pelvic Inflammation of Tubal Origin." Trans. Amer. Gyn. Soc, 1909, p. 161. Tait : Diseases of Women and Abdominal Surgery. Phila., 1889. Williams, J. W. : Obstetrics. N. Y., Appleton, 1903. CHAPTER XXII DISEASES OF THE URETHRA URETHRITIS Etiology. — Urethritis, or inflammation of the urethra, is due, in the majority of cases, to direct gonorrhceal infection during coitus. Urethritis may also be caused by infection resulting from the introduction of an un- clean catheter or sound. Irritation from the use of strong chemical solu- tions and the trauma incident to difficult labor may be factors in the produc- tion of urethritis. In urethritis caused by the gonococcus the disease passes through an acute stage and then gradually becomes chronic. Urethritis due to other forms of infection and secondary to irritation caused by powerful chemical solutions or to traumatism, almost never becomes chronic, and tends to undergo spontaneous and complete cure. Both acute and chronic urethritis may be associated with involvement of the bladder. ACUTE GONORRHCEAL URETHRITIS Symptoms. — As the female urethra is comparatively short, the symp- toms are not so violent as are those of acute gonorrhceal urethritis in the male. The most common symptom is a frequent desire to empty the bladder. Urination is accompanied by a burning and scalding pain, fol- lowed, in the most severe cases, by the passage of a small quantity of blood. There is a purulent discharge from the urethra, which irritates the vestibule and the surrounding vulvar mucous membrane. There may be slight eleva- tion of temperature. Diagnosis. — On inspection the external meatus is found to be reddened and swollen, and filled with a purulent discharge. At times the mucous membrane is seen to bulge, as in urethral prolapse. Upon making pressure along the under surface of the urethra at the vaginal introitus pus may be expressed from the urethra or from Skene's tubules (Fig. 115). Immedi- ately after urination the urethra may be free from purulent discharge, but pus may usually be expressed from Skene's tubules or other crypts in the urethral floor near the meatus. Prognosis. — After a few days, as a rule, the subjective symptoms be- come less violent, the formation of pus decreases, and the other local mani- festations of inflammation subside. In the course of a few weeks the urethra may to a great extent rid itself of the disease, but the infection is likely to persist in Skene's tubules and in the crypts and lacunae along the floor of the urethra. Treatment. — Acute gonorrhceal urethritis may be followed by cystitis, but this is not especially likely to occur unless the patient is catheterized or local applications are made to the urethra. For this reason local treatment of the urethra during the acute stage of gonorrhceal urethritis is absolutely contraindicated. The patient should be placed upon a bland liquid diet, and 440 DISEASES OF THE URETHRA 441 be instructed to drink large quantities of water. A mild urinary antiseptic, such as salol, combined with a diuretic salt, to render the urine as bland as possible, should be prescribed. For this purpose such a combination as salol and sodium bicarbonate is of particular value. If the urethritis is accom- panied by vulvitis, the treatment outlined in Chapter XI, page 167, may be combined with that just described. Other Forms of Acute Urethritis. — Acute urethritis, the result of strep- tococcus, diphtheritic, or virulent staphylococcus infection, may rarely be observed as a part of instrumental, post-abortal, or post-partal infection, and is usually accompanied by severe systemic disturbance. In these cases no treatment directed specifically toward the urethra itself is required. A urinary antiseptic, such as hexamethylenamine, may be prescribed. The k Fig. 393. — Disinfection of Skene's tubules with hypodermic syringe and blunt needle. patient should be encouraged to drink large quantities of water, and gen- eral supportive treatment should be instituted. Acute urethritis due to powerful chemical irritants, such as strong solutions of silver nitrate, phenol, or mercury bichloride, in the early stage requires no treatment beyond rest and the administration of soothing diuretic mixtures. The patient should be given large quantities of water, and combinations such as have been suggested for acute gonorrhceal urethritis should be prescribed. As the disease subsides and the purulent discharge disappears the occasional pas- sage of a well-lubricated urethral sound may prevent the formation of a stricture. CHRONIC GONORRHCEAL URETHRITIS Acute gonorrhceal urethritis subsides in the course of a few weeks, to be followed by the subacute and later by the chronic stage. If no treatment whatever is instituted, the manifestations of the disease be- 442 GYNECOLOGY come progressively less and the subjective symptoms may even disappear entirely. At this time the urethral mucosa throughout the greater part of its extent has become restored to its normal condition. In the crypts of the urethral floor, toward the external urinary meatus, and in Skene's tubules the disease persists, and the infectious products are from time to time discharged from these foci into the urethra. Under such cir- cumstances the acute symptoms of urethritis may be relighted by certain forms of irritation (unfamiliar coitus, alcoholic excesses) ; it may extend to other parts of the genital tract, or it may be transmitted to another person. Symptoms. — There may be no subjective symptoms. As a rule, there is frequency of urination accompanied by pain during or after the act, and the patient may be conscious of a slight moisture or discharge about the vestibule. Diagnosis. — The diagnosis of chronic gonococcal urethritis is dependent upon the presence of pus in the urethra or in Skene's tubules, about the external urinary meatus, and the demonstration of the gonococcus in stained smears. If the patient uses a vaginal douche or empties her bladder imme- diately before the examination, the evidence of chronic urethritis may be destroyed. The examination should, therefore, be made while the bladder is full and without preparatory douching. In the majority of cases inspec- tion of the meatus shows an everted, reddened, granular mucosa, with the orifices of Skene's tubules exposed to view. The reddening of the mucosa may be limited or especially pronounced in the immediate vicinity of the orifices of Skene's tubules, with the formation of the so-called gonorrhceal macules. At times, especially in nulliparae, the lips of the meatus must be separated to expose the orifices of the tubules, but this is exceptional. The meatus and the surrounding mucosa of the vestibule should now be cleansed of surface discharge ; the examiner's finger should be inserted its full length into the vagina, and the contents of the urethra milked out by forward pressure upon the anterior vaginal wall. A whitish, creamy, or thin, murky discharge will be expressed from the urethra itself, from Skene's tubules, or from lacunae in the floor of the urethra just within the orifice. Smears of this discharge should be made as described on page 123. In cases giving rise to symptoms, or in those in which the process has recently been relighted by unaccustomed sexual intercourse or other forms of irritation, the gonococcus will usually be unmistakably recognizable. In mixed infections, or in the very old, latent cases in which no symptoms are manifest, it may be impossible to demonstrate the presence of the gono- coccus. Under such circumstances the complement-fixation test may be applied. If this is not available, the diagnosis must rest on the clinical evidences of the disease (see Gonorrhoea, page 556). A whitish discharge from the urethra is not always purulent, but may be made up almost entirely of desquamated epithelium. This is especially prone to occur in chronic cases that have been exposed to active local treatment. Treatment. — The treatment of subacute or chronic gonorrhoeal urethritis consists of the administration of urinary antiseptics and direct applications of gonococcides to the urethra. DISEASES OF THE URETHRA 443 The bland refrigerant diuretics prescribed in the acute stage should be replaced by hexamethylenamine and sodium benzoate, or by the oil of sandalwood and copaiba. Local Treatment. — Local treatment should be carried out by the phy- sician, for it is impracticable for the patient to apply it herself. In the subacute or chronic stage the disease is confined largely to the vicinity of the external meatus. This local treatment consists, first, of massage, applied for the purpose of emptying the urethra and all the urethral crypts of dis- charge, the manipulations being made through the anterior vaginal wall, and performed at a time when the bladder is full. After the urethra and the crypts have been emptied of pus, the patient is instructed to urinate, thus washing clean the urethral mucosa. By means of a blunt-pointed hypo- dermic needle Skene's tubules may then be injected with a solution of ichthyol, argyrol, or silver nitrate (Fig. 393). The tubules or crypts are located, the blunt needle carefully introduced as far as it will go, and the crypt washed out first with sterile water. As a gonocide there is noth- ing superior to silver nitrate, the solutions varying in strength from 2 to 10 per cent. Later normal salt solution may be injected to inhibit the action of the silver nitrate. 1 Argyrol (20 per cent.) and protargol (1 to 5 per cent.) are valuable gonocides, and may be used instead of the silver nitrate. Ichthyol (25 to 50 per cent.) and Churchill's tincture of iodine are also reliable preparations. The urethra itself may now be treated. The hypodermic syringe should be fitted with a probe-pointed cannula of small caliber and two inches in length. The cannula is passed to the neck of the bladder, which is com- pressed by a finger in the vagina, and the urethra is flushed with sterile water. This maneuver is repeated several times, each withdrawal of the cannula being followed by gentle massage. The solution of gonocide is now injected, care being taken to compress the vesical end of the urethra beyond the point of the cannula. For this purpose one of the following preparations may be used: Silver nitrate (2 to 10 per cent.), followed by salt solution; argyrol (20 per cent.) ; protargol (5 to 20 per cent.) ; iodine (2 to 5 per cent.) ; ichthyol (10 to 50 per cent.). In order to further the action of the antiseptic, a urethral tampon saturated with a bland anti- septic solution should be applied (Fig. 394). The tampon is made by roll- ing a thin layer of cotton loosely upon the end of an applicator. The entire length of the tampon should not be over one and one-quarter inches. It is moistened with the solution, and introduced by means of the applicator into the urethra, up to the internal urinary sphincter. The applicator is then withdrawn. From ten to fifteen drops of the solution are now in- jected into the urethra by means of the probe-pointed cannula or blunt hypodermic needle (Fig. 395), the tampon taking up the injected fluid, and securing a more or less continuous application of the remedy to the urethral 1 For the injection of silver nitrate an all-glass hypodermic syringe should be used in preference to the all-metal or partly metal ones, since the precipitate formed by the action of the silver nitrate on the metal will obstruct the lumen of the needle. For the same reason silver solution should not be allowed to remain in contact with the needle for any length of time. After injecting the solution the needle should be flushed out and a stvlet introduced. 444 GYNECOLOGY mucosa until the next act of urination, when it is expelled. The urethral tampon may be saturated with any of the solutions mentioned, but where silver nitrate or iodine is employed, weak solutions (i per cent.) must be used at first, and the effect carefully noted before their strength is increased. As a rule, it is better to use silver nitrate and iodine for the urethral injec- tion, and argyrol, protargol, or ichthyol for the tampon. The treatment should be repeated daily, or as often as is practicable, in order quickly to rid the patient of the disorder and prevent it from becoming chronic. As a result of this treatment the discharge becomes diminished in amount, and a microscopic examination shows that many epithelial and few pus-cells are present, while the gonococci are few in number. At this stage it is well to substitute a slightly astringent antiseptic solution, such as zinc sulphate (15 grains), powdered burnt alum (15 grains), phenol (4 grains), water (enough to make 4 ounces). Careful treatment, repeated at intervals, and Fig. 394. — Urethral tampon in position. Fig. 395. — Saturating urethral tampon with hypodermic syringe and bulbed cannula. the avoidance of reinfection are almost certain to effect a cure. In those persistent cases in which it seems impossible, in spite of treatment, to free Skene's tubules of the infection, a favorable result may be secured by lay- ing them open freely with a sharp bistoury and cauterizing with pure phenol. (For the vaccine treatment of chronic gonorrheal urethritis see Chapter XLI.) Other Forms of Chronic Urethritis. — A form of chronic posterior ure- thritis, with or without contraction or stricture formation of large caliber, is declared by Hunner to be the sequel of infection and inflammation of the tonsils and accessory nasal sinuses, teeth, gastro-intestinal tract, etc. In these cases the urethritis may be difficult to explain on other grounds in virginal, chaste women. The urethroscopic picture and symptoms are not characteristic. The condition is quite amenable to local treatment — e.g., dilatation of the urethra and the application of silver nitrate — but recurs at more or less frequent intervals. Removal of the focus of infection has given very striking results in some of Hunner's cases. DISEASES OF THE URETHRA 445 SUBURETHRAL ABSCESS Etiology. — A suburethral abscess results from infection of a suburethral crypt, with subsequent complete or partial blocking of the communication of the crypt with the urethra. The collection of pus lies within the floor of the urethra, in close approximation to the anterior vaginal wall. The size of the abscess is, on the average, that of a marble, but it may vary in dimen- sions from a pea to an egg. Symptoms. — The subjective symptoms are similar to those of acute or chronic urethritis, but are somewhat exaggerated, depending upon the ex- tent of the disease. In addition there is a feeling of fullness and distress in the affected parts, entirely independent of urination. Diagnosis. — By palpation the abscess may readily be detected as a tender nodule or globular tumor embedded in the urethrovaginal septum. In the case of larger abscesses there may be a considerable projection of the mass into the vagina. Upon passing a fine probe along the floor of the urethra the original opening of the crypt may occasionally be found, and the probe introduced through it to the bottom of the sac, where the end of the probe may be felt by the vaginal finger. The mouth of the infected crypt may be brought into view by means of the urethroscope, and pressure on the sac may result in the escape of pus into the urethra. Treatment. — When a communication can be found with the urethra and the sac is small, the pus may be evacuated by gentle pressure, and a cure effected by keeping the crypt open and using repeated injections of anti- septic solutions. If the sac is of considerable size, however, a cure will not be obtained without free drainage, and this can best be secured by making vaginal incision. The pus should be evacuated and the interior of the sac swabbed with pure phenol and allowed to heal by granulation. If the com- munication between the abscess and the urethra is completely sealed, the sac should be enucleated from the vaginal side, without rupture, if possible, and the wound immediately closed. URETHRAL FISSURE Urethral fissure usually occurs at the internal urinary meatus, and con- sists of a linear crack or ulcer in the mucosa embraced by the sphincter muscle. Etiology. — The condition results from urethritis or traumatism, such as follows repeated catheterization or the passage of a calculus. It is similar to a fissure in ano, and may be as troublesome and as persistent. The vesical sphincter is usually hypersensitive and spastic. Symptoms. — The symptoms consist of pain after urination, with or without a frequent desire to repeat the act. The urine may contain red blood-cells. Diagnosis. — The diagnosis may be made by means of a cylindric (Kelly) cystoscope. The instrument is passed into the bladder, the urine is evacu- ated, and the speculum is slowly withdrawn. As the internal meatus closes over the end of the speculum the fine linear fissure or fissures may be discerned. Gentleness, to avoid traumatism, an excellent light, and 446 GYNECOLOGY small pledgets of cotton for sponging are essential to success. The treat- ment consists in overstretching and temporarily paralyzing the vesical sphincter by the passage of a sound several sizes too large. This pro- cedure alone may be sufficient. If it is not, in addition to the passage of the sound the fissure should be painted with a solution of silver nitrate, or the muscle may be incised with a small, delicate, especially constructed knife. Usually, however, such heroic treatment will not be required. PROLAPSE OF THE URETHRAL MUCOSA Etiology. — The mucosa of the urethra may become loosened from the underlying tissues and protrude through the external urinary meatus (Fig. 397). This condition is commonly a late result of injury received during labor. It is usually accompanied by other evidences of traumatism, such as Fig. 396. — Self -retaining or mushroom catheter. vaginal scars in the anterior or posterior wall, cystocele, and rectocele. The associated lesions often are slight and manifest no symptoms. Prolapse of the urethra is seen especially about the time of the menopause, when there is a certain amount of atrophy and shrinkage of the vulvar parts. Prolapse of the urethral mucosa may be a complication of urethritis, or it may follow long-continued cystitis or vesical tenesmus. In some cases occurring in virgins, the causative factor cannot be determined. Symptoms. — There may be few or no symptoms or the prolapsed mucosa may be exquisitely tender and sensitive and give rise to an almost constant desire to urinate, pain and soreness accompanying the act. These cases resemble closely those of urethral caruncle, and, indeed, in some, in addi- tion to prolapse of the entire circumference of the meatal mucosa, there is a localized and sensitive hypertrophy that resembles a caruncle. Treatment. — In mild cases the prolapsed and sensitive mucosa may be treated with silver nitrate (10 per cent, solution) followed by the applica- DISEASES OF THE URETHRA 447 tion of a soothing ointment. In marked cases the parts should be cocainized and the protruding mucosa ligated in sections and snipped off. When the prolapse is ex- tensive, general anaesthesia may be in- duced, and excision of the prolapsed mucosa, followed by the formation of a new external meatus, carried out. Care should be taken, in the construction of the latter, to obviate the tendency to protru- sion of the mucous membrane. This may be done as indicated in the accompanying illustrations (Figs. 397 to 399). When the prolapse of the mucosa is complicated with a cystocele or other lesions of the adjacent structures, such as cystitis, ure- thritis, etc., appropriate treatment for these conditions should be instituted. Fig. 397 URETHRAL DILATATION Etiology. — The urethra may possess an abnormally large lumen congenitally, but dilatation of the urethra, as a rule, results from various forms of traumatism. When the external genitalia are defective, e.g., when there is atresia of the vagina, etc., repeated attempts at copulation in rare instances result in a gradual dilata- tion of the urethra. This may become so marked that the penis may enter the blad- der during coitus. Copulation per ure- thram has been said to be compatible with excellent control of the bladder. In one case recently observed, the urethra had been split bilaterally back to the in- ternal urinary meatus, the resulting pas- sage being used regularly for copulation, in spite of the fact that the patient suffered from constant dribbling of urine. Urethral dilatation occurs most com- monly in the child-bearing woman, and is caused by lacerations of the urethral mus- culature, especially of the fibers at the in- ternal urinary meatus, and by the loss of sup- port normally afforded to the urethra by the anterior vaginal wail. Other causes may be: An overstretching of the canal, with rupture of some of the circular muscle-fibers, as from the passage of a cystoscope or sound that is too large. A stricture or a new growth of the urethra or of the neighboring parts that Fig. 398 0S f 4 Fig. 399 Fig. 397.- Fig. 398.- Fig. 399.- Prolapsed urethral mucosa. Outline of denudation. Prolapsed urethral mucosa. Denu- dation completed. Prolapsed urethral mucosa. Sutures introduced. 448 GYNECOLOGY Co^veX exr impedes the expulsion of urine may produce a dilatation of the urethra be- hind the point of obstruction. Incontinence of urine due only to a lesion of the vesical sphincter is relatively infrequent. Incontinence due to a lesion of the sphincter plus other pelvic lesions is frequent. Symptoms. — The most common symptom of dilatation of the urethra is an inability to control the pas- sage of urine. In the usual type, i.e., that seen in the child- bearing woman, any sudden or violent increase of intra- abdominal pressure, such as is induced by lifting, coughing, sneezing, or laughing, will be followed by a more or less free and continuous leakage of urine. In some instances a perineal dressing must be worn almost constantly. Diagnosis. — In a majority of cases the external orifice gapes widely, exposing the mucosa of the interior. The neighboring parts are erythe- matous from the constant moisture, and coughing, bear- ing down, etc., result in drib- bling of urine. A sound is passed without difficulty, and the external urinary meatus will admit a much larger sized instrument than under normal conditions, e.g., Nos. 28 to 30 F. An acorn bougie will help determine whether the condition is localized or gen- eral. In the ordinary case the dilatation is particularly notice- able at the external urinary meatus, and there are asso- ciated lesions that have been produced by the same agency that caused the urethral dilata- tion, viz., the traumatism inci- dent to labor. There is almost always some degree of cystocele and rectocele. The vaginal outlet may be moderately or excessively relaxed, and the uterus is often in a state of descensus or prolapse. Treatment. — In the very rare cases of excessive dilatation of the urethra resulting from coitus per urethram, an effort must be made to restore the Fig. 400. — Operation for relaxation of vesical neck of urethra. First step; mucosa dissected and a mattress suture inserted. Fig. 401. — Operation for relaxation of vesical neck of urethra. Second step, mattress suture tied, outline for removal of redundant mucosa. DISEASES OF THE URETHRA 449 vagina (see Atresia, page 28) and then to narrow the urethral canal by performing plastic operations, to be described further on. In the common form of urethral dilatation, that due to injuries received during labor, the associated conditions of relaxation and displacement must be corrected. Temporary relief is often secured by the wearing of a pessary, which replaces and supports the sagging parts and compresses the lumen of the urethra. The surgical treatment of the urethra itself consists in reduplicating its inferior wall by sutures passed through the adjacent tissues and tied in the median line, as in the operation for cystocele (Chapter XIII). This is the general principle of lessening the caliber of the urethra and giving support to the structures. It should be supplemented by the plan here outlined, of locating accurately the vesical sphincter and endeavoring to catch in the grasp of the sutures the actual muscle fibers of the sphincter (Figs. 400 and 401). In addition to the infolding of the vesical sphincter, care should be observed to remove all dragging or downward traction on the anterior vaginal wall. If the external urinary meatus is dilated and the mucosa exposed, the orifice should be resected, as shown in the accompanying illustrations (Figs. 397 t° 399). The operations upon the urethra should be supplemented by an anterior colporrhaphy (Chapter XIII). STRICTURE OF THE URETHRA Etiology. — Whereas the external meatus may be very small congenitally, acquired stricture of the urethra is most uncommon in the female. It may result from a severe urethritis, from traumatism inflicted during labor or by instrumentation, or it may follow destructive cauterization or disinfec- tion of the urethral mucosa. It may occur in any part of the urethral canal. Symptoms. — The symptoms are a frequent desire to urinate, with diffi- culty in expulsion, accompanied by pain and vesical tenesmus. A certain amount of residual urine is often constantly present. Diagnosis. — The diagnosis is made as the result of the passage of sounds or acorn-tipped bougies. Treatment. — The treatment consists in performing gradual dilatation. This is usually readily accomplished, as the female urethra is comparatively short. In obstinate cases forced divulsion under general anaesthesia, with frequent passage of the sound during convalescence, may effect a cure ; or a permanent catheter may be left in situ until healing has occurred. URETHRAL CARUNCLE A urethral caruncle is a small tumor springing from the urethral mucous membrane at the site of the external urinary meatus. It is often flattened from side to side, presenting the appearance of a cock's comb (Fig. 402). Its long diameter, as a rule, lies in the median line, and it usu- ally springs from the posterior urethral wall. It is seen most commonly in women of mature years. Symptoms. — The tumor is exquisitely sensitive to touch, and urina- 29 450 GYNECOLOGY tion is accompanied by severe, sometimes excruciating, pain. Urethral caruncle often simulates prolapse, or a redundancy of the urethral mucosa at the site of the external urinary meatus. The size of a caruncle is not in direct proportion to the amount of pain it induces, a large growth some- times being accompanied by very few symptoms, whereas a small one may be exceedingly tender. The caruncle ranges in size from a pinhead to a hickory-nut, and its color varies from a pale to a bright red. The tumor may be sessile or pedunculated, and bleeds easily. Ftg. 402. — Urethral caruncle (Dr. Philip Williams, Presbyterian Hospital), shows base attached to floor of urethra. Detail Treatment. — The treatment consists of removal of the tumor. For this purpose infiltration anaesthesia with novocaine { l /\. per cent.) and adrenalin may be sufficient ; but in nervous hypersesthetic individuals, or when the pain is excruciating, a general anaesthetic should be given. The growth may be either excised from the mucosa by a V-shaped incision, and the resulting wound sutured with fine catgut, or, if it is pedunculated, the pedicle may be ligated close to its base and the tumor snipped off. DISEASES OF THE URETHRA 451 Redundancy and prolapse of the urethra, simulating in appearance small urethral caruncles, are not infrequently encountered in old multiparas This swollen mucous membrane is exquisitely sensitive and painful at times, whereas at other times it gives rise to no symptoms whatever (see Urethral Prolapse, page 446). NEW GROWTHS OF THE URETHRA Benign tumors, such as mucous polypus, fibroma, myoma, and fibro- myoma, are rarely encountered. The symptoms consist of frequent, painful, and difficuk urination, simple inspection, digital examination, or the urethro- scope revealing the presence of the tumor in the wall of the urethra. Enu- cleation and plastic repair constitute the treatment. Malignant tumors, such as carcinoma and sarcoma, are occasionally seen. Carcinoma is usually secondary to carcinoma of the clitoris or ves- tibule, but it may be primary in the meatus. Crossen has collected twenty- five cases of primary urethral carcinoma. Sarcoma is the rarest of all urethral tumors. Symptoms. — The symptoms of carcinoma and sarcoma of the urethra consist of frequent and painful urination and hematuria. The growth usu- ally presents at the external meatus and is surrounded by an area of indura- tion. A positive diagnosis can be made only as the result of a microscopic examination. Treatment. — The treatment consists of excision; not infrequently, however, the growth is not discovered early enough to permit removal without extensive mutilation and resulting permanent incontinence of urine. Moreover, metastasis takes place directly into the deep glands of the pelvis. On account of the direction of the lymphatic drainage, the first metastasis makes recurrence certain, for the affected glands are beyond reach (Crossen). When the case is seen early, the following plan, described by Crossen, should be carried out : First: The formation of a temporary vesicovaginal fistula for continu- ous drainage of the bladder ; it should be placed in the median line, near the posterior margin of the trigone ; a permanent catheter is introduced, and secured in place with a non-absorbable suture. Second. The growth is excised, and with it the surrounding portion of the vestibule and the urethra and the periurethral tissues back to the bladder. Third : The muscular tissue in the vicinity of the internal urinary meatus is now piled up above the opening by a series of two or three purse-string sutures of fine chromic catgut. A small catheter should be placed in the opening while the sutures are being tied. The mucosa should be kept carefully drawn out beyond the ring of piled-up tissue, so that it may subse- quently be sutured to the transplanted flaps. Fourth. Flaps for covering the raw surface are taken from the anterior vaginal wall. After being suitably disposed, they are sutured to each other and also to the stump of the urethral mucosa. (For further details the reader is referred to Crossen's paper.) The prognosis in early cases, as collected by Crossen, is fair; thus, of 452 GYNECOLOGY twenty-five cases in the literature, eight cures (three years old) and three probable cures (two years old) were reported. In fourteen there was recurrence or the patient had been lost sight of. In all cases subjected to operation, radium should subsequently be used in an effort to avoid recurrence. In far-advanced cases radium is the only recourse, but it offers little hope of permanent cure. BIBLIOGRAPHY Crossen: "Primary Cancer of the Female Urethra; Plastic Work and Late Results." Trans. Amer. Gyn. Soc, 1915, xl, in. Hunner, G. L. : " Diseases of the Bladder and Urethra." Kelly-Noble Gynecology and Abdominal Surgery, Saunders, Phila., 1917 ; Ibid. : " Chronic Urethritis and Chronic Ureteritis Caused by Tonsillitis." Jour. Amer. Med. Asso., April 1, 191 1, lvi, 937-941. Keefe: " Prolapse of the Female Urethra." Trans. Sect. O. G. and A. S., A. M. A., 1917, I3 1 - Kelly, H. A. : " Incontinence of Urine in Women." Urol, and Cutan. Rev., June, 1913, xvii, 291. Miller, G. B. : " Incontinence of Urine Following Labor." Trans. Amer. Gyn. Soc, 1909, 745- Nitze : Lehrbuch der Kytoscopie, 1889. Pawlik, C. : " Ueber die Harnleitersondirung beim Weibe." Arch. f. Klin. Chir., 1886, xxxiii, 717-739. Simon : tiber die Methoden die weibliche Urinblase zugangig zu machen und iiber die Sondirung der Harnleiter beim Weibe. Samml. klin. Vortrage, Volkmann, Leipzig. Skene, J. C. : " The Anatomy and Pathology of Two Important Glands of the Female Urethra." Amer. Jour. Obst, 1880, xiii, 265. Taussig : " Urethral Bacteria as a Factor in the Etiology of Cystitis in Women." Amer. Jour. Obst., October, 1906. Taylor, H. C, and Watt, C. H. : " Incontinence of Urine in Women." Surg., Gyn. and Obst., 1917, No. 3, xxiv, 296. CHAPTER XXIII DISEASES OF THE BLADDER CYSTITIS Cystitis, or inflammation of the bladder, may be caused by direct and primary infection of the organ, resulting from the introduction of unclean instruments, as in catheterization after labor or following operation. The condition may follow the extension backward of a urethritis. It may be secondary to an infection of the kidney (pyelitis), or may result from infec- tion after injury to the bladder mucosa by strong antiseptic solutions, by rough catheterization, or by operations upon adjacent parts during which the bladder has been traumatized. It may have its origin in the retention of urine following displacements of the uterus or obstruction to the urinary outflow by the pressure of extravesical tumors. It may be the result of the damage that has been caused by a neoplasm or a vesical calculus. Rupture of extravesical collections of pus into the bladder may also be the causative factor. It has been stated that neither the introduction of microorganisms nor trauma alone is sufficient to produce cystitis — that both must be com- bined. The most common organism found in acute cystitis is the colon bacillus, next in frequency being the gonococcus and the staphylococcus. In chronic forms the tubercle bacillus and the bacillus proteus also play a part. Cystitis may be acute or chronic. acute cystitis Etiology. — Acute cystitis of a mild type, limited to the trigone and rapidly subsiding under expectant treatment, is frequently observed in con- nection with acute gonorrhceal urethritis. The condition is also seen after operation, when the blood supply of the bladder has been disturbed and the mucosa has been traumatized. Acute cystitis may also follow septic and rough catheterization, but this is but rarely encountered as a cause at the present day. The condition may be secondary to and accompany an acute pyelitis. Symptoms. — The symptoms of an acute cystitis are a frequent desire to urinate ; burning pain during micturition, and a feeling afterward that the bladder has not been emptied ; an uncontrollable desire to strain,, and possibly the passage of a little blood. Combined with these manifestations there may be in the most severe cases (those due to septic catheterization), chilliness, elevation of temperature, and suprapubic and vaginal tenderness. The urine is turbid in appearance, acid in reaction, and contains a large amount of vesical epithelium, many bacteria, pus, and possibly blood. Diagnosis. — At the beginning of the attack cystoscopic examination is very painful, and quite unnecessary. A presumptive diagnosis may be for- mulated from the symptoms, and treatment instituted. As the disease sub- sides or passes into the chronic stage, the cystoscope will be useful in con- 453 454 GYNECOLOGY firming the diagnosis and in definitely locating the extent of the affection. In most cases the inflammation affects primarily the trigonum. the mucosa of which appears thickened, and its color a diffuse, intense red. the outlines of the individual blood-vessels being less distinct. In severe cases ecchy- motic areas and superficial ulcerations may be noted. Treatment. — The patient should be kept in bed. The diet should be limited to liquids, preferably milk. Large quantities of water should be taken. A refrigerant diuretic, such as the liquor potassi citratis. should be prescribed in full dose. Hot applications to the lower abdomen and peri- neum give relief, and the same is true of a prolonged hot vaginal douche. After the severity of the symptoms has abated somewhat, or in stubborn cases that show no improvement under the expectant plan of treatment, gentle irrigation of the bladder (Fig. 403') with warm normal salt solution may be advised : this often gives marked and speedy relief. The bladder should not be left empty after the irrigation, but partly tilled with one or two ounces of a 10 per cent, solution of argyrol or a 5 per cent, emulsion of silver iodide. The patient should be directed to hold this solution as long as possible. Prognosis. — Acute cystitis in the female usually yields rapidly to treat- ment, so that within a few days the patient will be comfortable. Treat- ment should be continued until all evidences of the disturbance have disap- peared, and until cystoscopic examination and urinalysis reveal normal conditions. If the cystitis persists, the measures described in the treatment of chronic cystitis must be undertaken. CHROXIC CYSTITIS Etiology. — Chronic cystitis may be secondary to an acute cystitis due to any cause, but it is more likely to be the result of a mild but progressive infection associated with conditions that prevent free vesical drainage, as in cases of urethral stricture, cystocele. prolapse of the uterus, and compression of the urethra and distortion of the bladder by pelvic new growths. Hunner has recently described a form of persistent chronic cystitis apparentlv due to hematogenous infection of the vesical mucosa from distant foci. In this there are small linear ulcers, especially in the fundus of the bladder, and ex- cision of the diseased area is often necessarv to effect a cure. The most severe form of chronic cystitis is the tuberculous. This con- dition is almost never primary, but follows tuberculosis of the kidnev. A chronic cystitis that persists in spite of treatment is usually tuberculous. Rarely there may be infection with the bilharzia. distoma haematobium, and the echinococcus. Symptoms. — The symptoms of chronic cystitis consist of frequent and painful micturition. The severity of the manifestations varies considerablv in different cases. The urine is cloudy in appearance and contains pus. When the disease is of recent origin and secondary to acute cystitis of the infectious type (caused by catheterization or gonorrhoea), the urine may be acid in reaction. In tuberculous cystitis the urine is also acid. If the con- dition is largely the result of urinary retention and decomposition, and in most cases of long standing, the pus-cells are less numerous, but the urine DISEASES OF THE BLADDER 455 contains myriads of bacteria and has a foul, ammoniacal or stale-fish odor, due to the splitting of the urea content by the staphylococcus and the proteus vulgaris. Diagnosis. — In cases of chronic cystitis produced by septic and traumatic catheterization or by gonorrhoea, cystoscopic examination usually shows that the principal seat of involvement is in the triangular area, bounded by the internal urethral orifice and the ureters, which is known as the trigone. In this area small, inflamed patches may be discerned, partaking of the nature of a superficial ulceration or a papillary erosion. The inflamed parts may be entirely confined to one area, usually that about the internal urethral orifice, or there may be discrete patches here and there over the entire trigonum and the surrounding region. In cases of cystitis due to retention of urine, with secondary decomposi- FlG. 403. — Irrigation of the bladder with a two-way catheter. tion and infection, as in cystocele or prolapse, there is usually a diffuse reddening of the mucous membrane of the affected part of the bladder, and frequently this area shows precipitations of urinary salts, which at first sight give the impression of being purulent. Upon irrigating the bladder, however, these precipitates may be dissolved or washed away ; microscopic examination will demonstrate their true nature. The urine contains pus- cells, myriads of bacteria, a considerable amount of mucus, and a large quantity of desquamated epithelium. Retention cystitis from urethral ob- struction often results in hypertrophy of the bladder as a whole, and par- ticularly of the muscular tissues of the bladder wall. Upon cystoscopic examination this condition is evidenced by a trabeculated appearance of the bladder wall, due to a hypertrophy of the muscular constituents, with a tendency to sacculation of the intervening areas. When the obstruction has been marked and persistent, this tendency results, in certain areas, in the formation of diverticula, which, at first sight, may resemble diseased. 456 GYNECOLOGY open, and rigid ureteral orifices, and may be mistaken for them. Such diverticula are also due to congenital causes. Treatment. — The treatment of chronic cystitis other than the tubercu- lous variety should consist in the use of an autogenous vaccine, the administra- tion of urinary antiseptics, direct applications of cleansing and antiseptic solutions, and measures to correct conditions that produce urinary reten- tion. Cultures most frequently show the colon bacillus and the staphylo- coccus. A vaccine should be prepared from the combined growth of whatever organisms are found. The most reliable urinary antiseptics are hexamethy- lenamine and salol. The former is the most effective. Since it acts best in an acid medium, it should be combined with sodium benzoate if the urine is weakly acid, neutral, or alkaline. Salol is effective in either acid or alkaline urine, but an attempt should, nevertheless, invariably be made to restore the normal urinary reaction. Copaiba and sandalwood are efficient in chronic gonococcus cystitis. Daily gentle irrigations of the bladder with nitrate of silver 1 : 10,000 followed by normal salt solution should be used, or the bladder should be irrigated with boric acid and 1 or 2 ounces of 10 per cent, solution of argyrol, protargol, or the emulsion of silver iodide left in the bladder. In obstinate cases ulcerated spots may be lightly curetted or touched with strong solutions of silver nitrate. After the local coiidition has improved, the sources of retention should be removed. Thus cystocele and prolapse should be subjected to operation, urethral stricture should be dilated, and tumors compressing or distorting the bladder or urethra should be excised. Continuous drainage, such as can be provided by a vesicovaginal fistula, may be demanded when the case has resisted every other plan of treat- ment and the bladder has become intolerant of retention catheters. This method should be avoided except as a last resort. The formation of an arti- ficial vesicovaginal fistula is a simple operation. The bladder should be filled with boric-acid solution and the anterior wall exposed with a Sims' speculum. A longitudinal incision, about three-quarters of an inch in length, is made exactly in the median line, through the vesicovaginal septum. This incision should bisect the trigonum without injuring the internal sphincter or the ureters. The edges of the vesical and of the vaginal mucosa should be united by sutures. When the mucosa has healed — usually at the end of about six weeks — such a fistula will require opera- tion for closure. After making a vesicovaginal fistula for the purpose of securing permanent bladder drainage, care must be taken to see that the urine has ready exit from the vagina, or it will back up into the bladder. In nulliparous women and in virgins the vulvar outlet should be stretched or divided, if necessary, and the patient kept in the Fowler position. TUBERCULOUS CYSTITIS Etiology. — This is the most common and most serious form of chronic cystitis. Tuberculous cystitis is almost invariably secondary to tuber- culosis of the kidney. Pathology and Symptoms. — The condition develops insidiously. The first symptoms are increased frequency of urination and the presence of pus or blood DISEASES OF THE BLADDER 457 in the urine. Cultures of the urine usually show no growth. In early cases c-ysto- scopic examination will generally reveal the fact that the bladder involve- ment is limited to the region of one ureteral orifice. The orifice is no longer linear, but, on account of the thickening and infiltration of the ureter, becomes rounded, open, and rigid, somewhat resembling in appear- ance a golf hole. The edge of the orifice may seem to be cedematous, or it may be dotted w T ith small, grayish miliary tubercules ; if the process is an older one, there may be ulcers ; in the later stage ulceration becomes more extensive, the ureteral opening retracts, and the entire ureteral area is converted into a funnel-shaped depression covered with indolent granulation tissue. The trigonum may be involved from the diseased ureteral orifice to the internal urinary meatus, the affection first appearing in the form of small grayish tubercles ; or if the tubercles have broken down, discrete ulcerated areas are seen covered with a yellowish-gray slough or pus. The discrete appearance of these areas, surrounded by a mucous membrane that, except for the reddening, is but little altered, has been compared to footprints in freshly fallen snow. In advanced cases of bladder tuberculosis there may be very extensive ulceration of the entire organ. This ulceration may have been followed by infiltration and contraction of the submucous and muscular coats, so that the normal capacity of the bladder has been very materially decreased, and cystoscopic examination at first is unsatisfactory, and no information can be ascertained from it. This is due to the fact that distention of the bladder and the introduction of the cystoscope are very painful, and the patient complains bitterly. The bladder admits of very little distention, and the mucous membrane is beset with ulcers covered with a grayish-yellow slough, or a thick yellow pus that conceals or marks the landmarks. After the in- gestion of large quantities of fluids and following gentle irrigation of the bladder daily for a time, the cystoscopic picture is much clearer, and although there may be considerable ulceration, oedema, or distortion of the bladder, it is usually possible to distinguish both the ureteral orifices. If the cysto- scopist is in doubt regarding them, he may have recourse to an injection of indigo-carmine, when the excretion of the colored urine will mark the ureteral site. The sensitiveness of the parts may be lessened by applying a 10 per cent, solution of cocaine to the urethra and by administering a pre- liminary injection of morphine (*4 grain) and scopolamine (1/150 grain). Diagnosis.— The gradual development of frequent and painful urination, a persistently acid pyuria, a rebelliousness to any form of treatment, a diminution in the capacity of the bladder, and an extreme sensitiveness are all suggestive of tuberculous cystitis. As a rule, there has been a previous indication, well marked or perhaps very vague, of a tuberculous focus else- where in the body. The positive diagnosis must be based upon the cysto- scopic findings and upon the recovery of the tubercle bacillus from the bladder, as shown by the injection of guinea-pigs with the urinary sedi- ment (recovery of the tubercle bacillus from the lymphatic glands), or the recognition of the bacillus in smears, as well as the detection of tuberculous infection in one or both kidneys. 458 GYNECOLOGY Treatment. — The treatment of tuberculosis of the bladder is secondary in importance to that of tuberculosis of the kidney. After the tuberculous kidney has been removed there is usually a marked and continued improve- ment in the vesical condition. The improvement may be hastened by performing gentle irrigation of the bladder with warm salt solution and the instillation of iodoform in sweet oil. These instillations must be practised with great gentleness and care, the strength of the solution and the quantity instilled being gradually increased. The capacity of the bladder may be in- creased by encouraging the patient to retain the urine for as long a time as possible, and by making gentle hydrostatic pressure during the course of the irrigation. Direct application of strong solutions of silver nitrate to persistently ulcerated areas may be made through a Kelly cystoscope. Many methods of treatment have been suggested for the relief of tuber- culous cystitis, but none of these is satisfactory unless the focus of infection in the kidney is eliminated. Many of the advanced cases never recover completely, and in some local treatment appears to aggravate rather than relieve the condition (see pages in and 473). VESICAL CALCULUS The surgeon is less often called upon to treat vesical calculus in women than in men, for the reason that the female urethra is short and that the stone is discharged while it is still small, and before it gives rise to symptoms. Etiology. — The calculus may be the result of the agglutination of pre- cipitated urinary salts, but often a foreign body of some sort serves as a nucleus about which the concretion is formed. Such a foreign body mav have been introduced through the urethra, e.g., the end of a catheter, a hair-pin, etc. Small papillomatous vegetations of the bladder mucosa, non- absorbable sutures introduced in the course of an operation through the mucosa, etc., may also form the nucleus of a vesical calculus. Symptoms. — The symptoms are those of chronic cystitis, with which stones of any size are always complicated, plus an obstruction to the urinary outflow, manifested by a sudden cessation of the stream during the act of micturition. Diagnosis. — Cystoscopy examination will at once reveal the presence of a vesical calculus if it lies free in the bladder, but if the stone lies within a diverticulum, it may easily be overlooked by the cystoscopist. When the calculus is of considerable size and free, a metal sound or a searcher intro- duced while the bladder is full, will elicit the characteristic feel of a hard body within and a clinking sound audible upon suprapubic auscultation. Large stones may often be felt upon making bimanual palpation. In strongly suspected cases, if the methods just outlined have failed to reveal a calculus, the Rontgen ray should be used. According to Henry Pancoast : " The Rontgen examination for vesical calculus is also to be regarded as a most reliable means of diagnosis. The sources of error are somewhat greater than in calculus in the kidney or ureter, especially since uric-acid stones are more common. Occasionallv very large uric-acid stones may cast no perceptible shadow in perfectly satisfactory rontgenograms. Soft phosphatic stones may also escape detec- DISEASES OF THE BLADDER 459 tion, especially in stout individuals and in those with thick bladder-walls. Large phleboliths, calcified lymph-glands, and fecal concretions are the usual objects whose shadows may cause confusion. The examination is valuable in detecting encysted stones that might readily escape discovery by the cystoscope or searcher. The Rontgen examination may be regarded as an efficient and reliable means of determining the presence, shape, and size of a vesical calculus, if it is borne in mind that negative findings do not always exclude stone." " Diverticula in the bladder may be detected by injections of the opaque solutions used in pyelography — collargol, thorium nitrate, or sodium bromide." Treatment. — The treatment of vesical calculus in females is simple. Stones of almost any size may be removed through an anterior vaginal in- cision. If the vaginal introitus is small, the suprapubic extraperitoneal route may be the preferable one. If the mucous membrane of the bladder is ex- tensively ulcerated, continuous drainage should be provided for a time. This may be accomplished by the formation of a vesicovaginal fistula, but in most cases a self-retaining catheter will be sufficient. In any event, the treatment for chronic cystitis, which is always present, should be carried out. HUNNER TYPE OF BLADDER ULCER IN WOMEN Hunner describes a type of ulcer observed by him in twenty-five women, which differs in several ways from the solitary ulcer of Fenwick. There is no ap- parent cause for the ulcer, and the average age at which it appears is twenty years. It is always found on the summit, or free portion of the bladder, in contra- distinction to the ulcer of Fenwick, which is found in the fixed portion or base of the bladder. The history is one of insidious onset, without apparent cause, and persistence in spite of various forms of treatment. All the cases have exhibited symptoms of chronic urethritis and some of them, remote foci of infection. The most characteristic feature is the insignificance of the lesion as com- pared with the prolonged duration and the intensity of the patient's suffer- ing. Slight, smooth, white scars of former ulcerations, as well as moderate hypersemia or inflammatory spots near the scars may be present. In other cases there is a small area of granulation that bleeds because of the disten- tion of the bladder, or will bleed easily on being touched. The inflamma- tory spot may be surrounded by oedema. Macroscopically the urine from such a case appears normal, but under the microscope the centrifuged speci- men will show a few leucocytes and red blood corpuscles. The diagnosis depends mainly on the resistance of the ulcer to the ordinary forms of treat- ment. The proper treatment of these cases consists in excising the ulcer through a suprapubic incision, operating extraperitoneally. (See Hunner's papers for further details.) NEW GROWTHS OF THE BLADDER Tumors of the bladder arise from the mucosa (epithelial) or the mus- cularis (connective tissue). The epithelial new growths, especially papil- loma and carcinoma, are the most frequent, but cystoma and adenoma are also encountered. The connective-tissue neoplasms are myxoma, fibroma, sarcoma, myoma, and angioma. Dermoid tumor, rhabdomyoma, and chon- droma constitute the mixed varieties. 460 GYNECOLOGY Vesical tumors are more frequent in men than in women. Two-thirds of all bladder tumors are malignant. Papilloma. — This is the most frequently observed vesical tumor seen in women. While some papillomata are benign, a large majority are malig- nant, and all should be regarded as malignant until proved otherwise by microscopic examination. Their most common seat is the base of the blad- der. Papillomata are made up of branching papillae ; they are composed of a connective-tissue framework with a covering of epithelium made up of many layers. The growth may be pedunculate or sessile, and vary in size from a pinhead to an egg. They may be single, are often multiple, and rarely may be so numerous as almost entirely to fill the bladder. Carcinoma. — Carcinoma of the bladder may be of papillary or of infiltrating form. In the early stage papillary carcinoma may be indistinguishable from benign papilloma except on microscopic examination. Infiltrating carcinoma penetrates the connective tissue of the bladder wall, forming flat, indurated nodes with ulceration of the superficial areas within the bladder. Symptoms. — The commonest symptom of bladder tumor is hematuria. To this may be added difficulty in emptying the bladder or a sudden cessa- tion of the stream, depending upon the relation of the new growth to the internal urinary meatus. In a large number of instances cystitis supervenes, and then urination becomes frequent and painful. Later, if ulceration or necrosis of the new growth takes place, there may be toxaemia, loss of w r eight, fever, etc. The urine at first contains blood, the amount of which gradually in- creases as the case advances ; pus, bacteria, and broken-down particles of the new growth are added later. The urine is alkaline and foul smelling, except when there is no retention. Diagnosis. — The diagnosis of bladder tumor is dependent on cystoscopic examination. Papillomata with a well-defined, narrow pedicle are less prone to be malignant than are those with a broad, base. An irregular, bossed, infiltrated, and ulcerating surface must be looked upon as malig- nant until it is proved otherwise. The histologic examination of portions of the tumor excised or snared off by the cystoscopist may show certain evidences of malignancy ; these have been described by Buerger. The objections to this plan are the pro- duction of hemorrhage and the danger of implanting small portions of the growth in other parts of the bladder. Probably the best method is to base the diagnosis on the cystoscopic appearance (narrow pedicle, without infil- tration of the base in benign papillomata ; broad pedicle or sessile tumors with infiltration of the bladder wall in malignant papillomata, etc.). If electrocauterization of a papilloma adjudged to be benign is not quickly fol- lowed by destruction and disappearance of the growth, malignancy should be suspected. Treatment. — Benign papillomata should be treated by electrocauteriza- tion. When the pedicle is narrow, it should be the special object of attack, for if this is destroyed, the tumor will drop off. In sessile growths the application should be made all over the periphery of the tumor, so as to destroy as much as possible at one sitting. For the narrow-pedicled villous DISEASES OF THE BLADDER 461 type of papilloma the Oudin current is preferable, because it sears over and destroys the delicate villi, with little or no consequent bleeding. The fibrous root of such and of all papillomata with broader pedicles requires the stronger D'Arsonval current. When marked hemorrhage takes place at each attempt at fulguration, or if the growth is inaccessible or the patient is intolerant, as well as in cases of papillomatosis, usually the result of mul- tiple implantations following a previous operation, this method of treat- ment is impracticable. In these cases cystotomy should be performed and the tumors attacked directly with a cautery. Malignant papillomata should be treated by electrocauterization plus radium. Geraghty used 103.7 m g m - of radium in practically all his cases. A brass capsule was employed, so as to use both the gamma and the beta rays. The radium was applied directly to the growth, under full cystoscopic exposure. The seances usually consumed an hour, and were repeated from one to three times weekly. Papillary carcinoma of the bladder is not amenable either to electro- cauterization or to radium, unless the growth is exposed by a suprapubic incision (see Chapter XL). If the growth is not too large, radical excision should be done, with transplantation of the ureter. Excision of bladder growths should be performed, whenever practicable, through an extraperitoneal incision. The bladder should previously have been rendered as sterile as possible by antiseptic irrigation. A transverse suprapubic incision gives the best exposure. The viscus should be distended with air to facilitate orientation. The neighboring cellular tissue and mar- gin of the incision should be protected by gauze pads. Single pedunculated tumors should be surrounded with gauze, the pedicle crushed with forceps, and divided with the cautery knife. When the growth is sessile, an attempt should be made to evert the area of the bladder, which is the seat of the growth through the vesical incision. The diseased part should then be excised together with a portion of the sur- rounding healthy area. When it is evident that the growth is malignant, the entire thickness of the bladder wall should be taken, the line of excision being made at a considerable distance from the infiltrated margins. When a ureteral orifice lies directly in the path of excision, the ureter should be catheterized, dissected free, and the diseased part excised, and the healthy extremity reimplanted in an uninvolved area. BIBLIOGRAPHY Beer, Edwin : " The Surgical Therapy of Benign and Malignant Tumors of the Urinary Bladder." J. A. M. A., 1917, lxviii, 680. Buerger, Leo. : " The Pathological Diagnosis of Tumors of the Bladder, with Particular Reference to Papilloma and Carcinoma." S., G. and O., 1915, No. 2, xxi, 179. Casper : " Zur Pathologie u. Therapie der Blasentuberculose." Monats. f . Urologie, 1900, Bd. v, S. 499. Dudley : " Incontinence of Urine in Women." J. A. M. A., June 3, 1905. Geraghty, J. T. : " Fulguration in the Treatment of Bladder Tumors." S., G. and O., 1915, No. 2, xxi, 150; Ibid. : "The Results of Treatment of Bladder Tumors." J. A. M. A., 1917, lxix, 1336; Ibid.: "Treatment of Bladder Tumors." N. Y. Med. Jour., 1916, civ, 838. 462 GYNECOLOGY Hunner, G. L. : " Ureterovesical Anastomosis — An Improved Method ; Report of Two Cases." Amer. Gynecology, December, 1902; 'Ibid.: "A Rare type of Bladder Ulcer in Women; Report of Cases," Boston Med. and Sur. Jour., 1915, clxxii, 660: Ibid. : " Elusive Ulcer of the Bladder. Further Notes on a Rare Type of Bladder Ulcer, with a Report of Twenty-five Cases." Trans. Am. Gyn. Soc, 1918, xliii, 27-63. Keene and Laird : " The Diagnosis of Tuberculosis of the Kidney." Amer. Jour. Med. Sci., September, 1913, No. 3.. Meyer, W. : " Early Diagnosis and Early Nephrectomy for Tuberculosis of the Kidney." Med. News, May 1, 1897. Rovsing, T. : Die Blasenentzundungen, ihre Aetiologie, Pathogenese, und Behandlung. Berlin, 1900. Uhle and MacKinney : " High-Frequency Destruction of Tumors of the Bladder." Penna. Med. Jour., March, 1916, 423. CHAPTER XXIV URINARY FISTULA The most common site of a urinary fistula is between the bladder and the vagina; this is known as a vesicovaginal fistula (Fig. 404). Fistulous communication may take place between other parts, such as the urethra and the vagina (urethrovaginal) (Fig. 405), the bladder and the cervix (vesicocervical) (Fig. 406), and between the ureter and the vagina (uretero- vaginal (Figs. 408 and 409). Etiology. — Fistulse involving the urinary tract may be produced in sev- eral ways. Probably the most common cause of fistula is necrosis following dystocia, in which a part of the urinary apparatus has been caught between Fig. 404. — Vesicovaginal fistula— result Fig. 405. — Urethrovaginal fistula; — result of of trauma of labor or operation. trauma of labor or operation. the fcetal head and the unyielding pelvic bones, and so compressed that necrosis of the affected part has subsequently occurred. The most common fistula due to this cause is the vesicovaginal. Fistula may be the result of injury to the bladder or ureters after cer- tain operative procedures, such as panhysterectomy for carcinoma. Opera- tions for the cure of cystocele or uterine prolapse, as well as certain surgical obstetric procedures, such as vaginal Csesarean section or pubiotomy, may occasionally be causative factors. Fistulse also occur in cases of advanced carcinoma of the cervix, or as the result of syphilitic or tuberculous ulcera- tion, or of ulceration produced by a foreign body, such as a pessary. Symptoms. — A urinary fistula following a difficult labor usually mani- fests itself at some time during the puerperium, being preceded by febrile 463 464 GYNECOLOGY disturbance, vaginal discharge, and hematuria. The early symptoms are due to a necrosis of the devitalized tissue, and when the slough has separated, the incontinence becomes manifest. Ureteral fistulse following hysterec- tomy usually make their appearance within two to three weeks after operation. The urinary incontinence of vesical fistula varies in degree with the size Fig. 406. — Vesicocervical fistula — result of trauma of labor, operation or carcinomatous ulceration. Fig. 407. — Rectovaginal fistula — result of trauma of labor, operation or syphilitic ulceration. Fig. 408 Fig. 409 Figs. 408 and 409. — Ureterovaginal fistula — result of trauma of labor or operation. and the site of the fistula and with the posture of the patient. The incon- tinence of a ureteral fistula is constant and not dependent on the position of the patient. The dribbling from a vesical fistula may be constant if the fistulous opening is large and if it is situated at the trigone ; or it may be apparent only after distention of the bladder has taken place, or, when the fistulous opening is small and the opening is high up near the cervix, only in the reclining posture. URINARY FISTULA 465 As a result of the incontinence there is maceration of the tissues about the fistulous opening, and a deposit of urinary salts upon the vaginal walls and the external genitalia. There may also be excoriation of the external genitalia and of the inner surface of the thighs. Beneath the in- crustation of urinary salts ulceration of the mucous membrane may take place. The urine often undergoes ammoniacal decomposition and gives off a foul odor. Emaciation, depression of spirits, and general ill health may occur. Ureteral fistulae are less likely persistently to discharge urine in consid- erable amount than are vesical fistulae. As a rule, the dribbling of urine gradually grows less, and sooner or later it is markedly diminished, either from spontaneous closure or because there is sufficient contraction of the fistulous opening to obstruct the ureter, reduce the excretory activity of the affected kidney, and produce a hydronephrosis. About 50 per cent, of post- operative ureteral fistulae close spontaneously in from four to six weeks. In most of those that do not close spontaneously, stenosis of the ureter, hydro- nephrosis, pyelitis, and pyelonephritis take place. It is also usually evi- dent that the site of the fistula is the ureter, owing to the fact that the bladder becomes filled with normal urine from the uninjured ureter, and is emptied at regular intervals, whereas in the case of vesical fistulae very little or no urine may be passed through the urethra. Diagnosis. — The diagnosis of a urinary fistula can usually be formulated from the symptoms, although a functional incontinence of urine may be mistaken by the patient for the evidence of a fistula. Examination is impor- tant chiefly for determining the exact site and position of the fistula ; this is not always easy. The difficulty in locating the position may be due to sev- eral causes. If the laceration or necrosis of tissue that produced the fistula is extensive, there may be considerable scar tissue in the vagina or about the vaginal vault, making exposure of the parts difficult. The incrustations of urinary salts and the tenderness incident to a low- grade inflammation of the mucous membrane may render any manipulation painful and difficult. In simple cases the fistulous opening may be located by means of a probe introduced through the vagina or the bladder. The site of the fistula may also be indicated by filling the bladder with a colored solution, such as methylene-blue, or with sterile milk, and exposing the anterior vaginal wall to view. The exact position of the vesical fistula and the condition of the bladder mucosa may also be ascertained by cystoscopic examination, the patient being placed of necessity in the Sims' or the knee- chest position in order to secure atmospheric distention. In cases of ureteral fistula that do not involve the vesical part of the ureter, the fluid injected into the bladder will not escape, and the urinary excretion from the sound side, obtained by catheterizing the bladder, may show no abnormal constituent. In cases of ureteral fistula cystoscopic examination will show the in- terior of the bladder to be uninvolved ; inspection of the orifice of the affected ureter will fail to disclose the periodic retraction and discharge of urine, and a catheter introduced into the affected ureter will usually meet with obstruction before it has passed very far. As a rule, it is possible to 30 466 GYNECOLOGY pass a ureteral catheter through the vaginal opening of the fistula into the affected ureter, and possibly into the pelvis of the corresponding kidney. This, combined with an obstruction close to the bladder in the vesical part, will be sufficient ground on which to base the diagnosis. Treatment. — The treatment of vesical fistula is usually operative. In early cases, when the fistulous opening is small, a spontaneous cure may be looked for and encouraged by draining the bladder with a self-retaining catheter, and touching the edges of the fistulous opening with silver nitrate. Most cases, however, will require some form of operative procedure. In these the patient should be prepared for operation by treatment directed to rendering the operative area as nearly normal and free from infection as possible. To this end the patient should be instructed to drink water freely. The diet should be bland, and a urinary antiseptic should be pre- scribed. For this purpose a combination of sodium benzoate and hexa- methylenamine, 5 grains of each four times a day, will usually be satisfac- tory. The incrustations may be removed with warm alkaline solutions, and the irritated mucous membranes touched with silver nitrate and protected with a thick ointment. After this preparatory treatment, which will suc- ceed in removing urinary incrustations and in relieving inflammation of the vesical mucous membrane and of the vaginal mucosa, an operation for closure of the fistula may be undertaken. The success and ease of perform- ance of the operation will depend upon the size and the position of the fistulous opening and upon its accessibility. The typical operation for vesicovaginal fistula consists of making a boat-shaped denudation about the fistulous opening, upon the anterior vaginal wall, the margins of the denudation sloping from the vagina toward the bladder. The denuded area is then approximated by means of sutures that are passed down to, but that do not include, the vesical mucous membrane. It is usually preferable to make the denudation in the long axis of the vagina, so that the sutures may be passed and tied in a transverse direction, thus causing less traction upon the cervix, and lessen- ing the tendency to shorten the anterior vaginal wall. The direction of the denudation will, however, depend somewhat upon the conditions of the indi- vidual case, and, as a general rule, the denudation should be made in that position in which coaptation of the denuded margins will cause the least traction. Fistulous openings high in the vagina, and especially those following hysterectomy, may be difficult to expose and to treat in the manner just de- scribed. In such cases it will be advisable, as advocated by Ward, to free the bladder wall, as far as possible, from its surrounding attachments to the broad ligament, the cervical stump, or the vaginal fornix ; draw it into the incision, and prepare the vesical opening separately from the vaginal opening. The vaginal wall is divided by a longitudinal incision that passes directly through the fistulous opening and extends for an equal distance in front of and in back of that point. If the incision alone does not permit of sufficient mobilization of the bladder, a second transverse incision, bisecting the first at the fistulous opening, is made. In closing the fistula the vesical and the vaginal sutures should pref- URINARY FISTULA 467 erably be placed in different sagittal planes, i.e., they should not be in apposi- tion (Fig. 410). When the vesical injury is close to the ureteral area, so that in passing the sutures there is danger of injuring or obstructing the vesical portion of the ureter, it will be advantageous at times to make an incision into the bladder, of sufficient length to expose the ureteral orifices, and then to place catheters in these orifices while the sutures are being passed. Ureterovaginal fistula may be treated by operation from below (vaginal), operation from above (extraperitoneal laparotomy), or by removal of the affected kidney. Fig. 410. — General scheme of operation in vesicovaginal fistula: 1, incision to one side of fistulous opening; 2, excision of vaginal wall about fistulous orifice; 3, denudation of fistulous opening in the bladder wall and separation of vaginal flaps from bladder wall; 4, parts denuded, ready for suture; 5, scheme of suture of bladder opening; 6, bladder opening sutured; 7, suture of vaginal incision com- pleted and relation of suture line to suture line of the vesical orifice. I. Vaginal Operation. — The vaginal route is applicable to fistulae situ- ated near the bladder. The vaginal mucosa is divided over a line that cor- responds to the position of the ureter within the bladder wall. The vaginal wall is then separated, on each side of the incision, from the bladder and the ureter, a catheter is inserted into the fistulous opening, and the lower end of the upper segment of the ureter is dissected free. The freed lower end is turned into a small opening made in the bladder wall at an adjacent con- venient point, and anchored with sutures, the butt-end of the catheter having previously been passed into the bladder through the anastomotic opening and brought out through the urethra. The divided vaginal mucosa is now brought together over the operative area and secured with separate sutures. The ureteral catheter should be left in situ for two or three days. 468 GYNECOLOGY 2. Extraperitoneal Abdominal Operation. — In this method an incision is made in the semilunar line, directly over the pelvis. The peritoneum is pushed up, and the lower end of the upper ureteral segment is gently freed. An anastomosis with the bladder is now made, the guide to the vesical open- ing being a pair of closed forceps introduced into the bladder through the urethra. The ureteral end, which has been slit bilaterally for a short dis- tance, is now drawn into the bladder and fixed to the vesical wall with catgut sutures. The muscular wall of the bladder is then united to the ureteral wall with fine linen sutures. The bladder itself is drawn up and attached to the ureter above the anastomosis, so that it partly envelops the lower ex- tremity of the ureter. The downward pull of the bladder should be relieved by releasing the lateral attachments of the bladder and by suturing the organ to the pelvic wall at some convenient point. The wound should be closed with drainage, but great care must be taken that the drain does not come in contact with the area operated on. Uretero-ureteral anastomosis is not so satisfactory as ureterovesical anastomosis, but in some cases the former may appear to be desirable. In performing this operation the end of the distal ureter is divided in the median line for a distance of half a centimeter. This slightly increases the circumference of the distal opening. The proximal end is now drawn into the distal opening, well beyond its margins, and fixed in position by a trac- tion suture of catgut. The operation is completed by inserting interrupted sutures of catgut uniting the outer walls of the proximal and distal seg- ments at their junction. Ureterorectal or sigmoidal anastomosis, after the method of Stiles, may be performed as follows: The proximal end of the ureter is implanted into the lowest part of the pelvic colon by traction sutures of catgut that include all the coats of both intestine and ureter. Permanent fixation of the ureter to the intestine is now made by uniting two parallel folds of the intestinal wall over the implanted ureter, from a point three-fourths of an inch below the anastomotic site to one inch above it. For this purpose fine linen sutures are used. Nephrectomy is the operation of choice when either of the operations just described promises to be especially difficult or has been unsuccessful, and when the opposite kidney is healthy and able to carry on the renal function. Nephrectomy is indicated also when there is evidence of hydro- nephrosis or pyelonephritis on the affected side, and when the opposite kidney is healthy. BIBLIOGRAPHY Emmett: Vesicovaginal Fistula, etc. New York, 1868. Kelly : " The Treatment of Vesicovaginal and Rectovaginal Fistulse High up in the Vagina." J. H. H. Bulletin, igo2, vol. xiii. Lamballe, Jobert de: Traite des Fistules Vesico-Uterines, Vesico-Utero-Vaginales, etc. Paris, 1852. Simon : tiber die Heilung der Blasenscheiden-Fisteln. Giessen, 1854. Sims, J. M. : " On the Treatment of Vesicovaginal Fistula." Amer. Jour. Med. Sci., 1852, xxiii, 59. Stiles, H. J. : " Epispadias in the Female, and Its Surgical Treatment." Surg., Gynec. and Obst., 191 1, xiii, 127. Ward, G. G. : " The Operative Treatment of Inaccessible Vesicovaginal Fistulae." S., G. and O., 1917, No. 2, xxv, 126. CHAPTER XXV DISEASES OF THE KIDNEY AND URETER The diseases of the kidney that are of particular interest to the gyne- cologist are ptosis, hydronephrosis, pyelonephritis, tuberculosis, calculus, and tumor. ptosis (abnormally movable kidney) Etiology and Pathology. — The kidney is considered to be abnor- mally movable when it can be brought entirely below the costal mar- gin. Ptosis is seen in about 25 per cent, of women. 1 Movable kidney is favored by congenital defects in the kidney fascia and the kidney fossse, and by the diminution of intra-abdominal pressure incident to relaxation of the abdominal wall following pregnancy. Ptosis may also be produced by the wearing of improper corsets, with constriction at the waist, and pos- sibly, under predisposing conditions, by trauma. Movable kidney is often found in thin women with long waists, who manifest a tendency to a gen- eral ptosis of the abdominal viscera ; in these cases the renal fascia is poorly developed and the kidney fossa is shallow. Symptoms. — An abnormally movable kidney may give rise to no symptoms. When symptoms are present, they are occasioned by kinking of the ureter, torsion of the renal vessels, and traction upon the duodenum. Acute attacks of pain (Dietl's crisis) may occur when the ureter is kinked as the result of obstruction of the ureteral lumen and distention of the renal pelvis by the urine that is dammed up behind the seat of obstruction. Intense congestion of the entire kidney, caused by torsion and obstruction of the renal vessels in the kidney pedicle, may also give rise to acute attacks of pain. The less severe symptoms of abnormal mobility are : A sensation of weight or of dragging after prolonged standing or walking; digestive disturbances, due to traction of the displaced kidney upon the intestine. Diagnosis. — The diagnosis of movable kidney is easily made. The directions for palpation of the kidney have been given elsewhere (page 138). By conjoint manipulation the kidney can readily be palpated, its shape and size noted, its ready displacement upward beneath the margin of the ribs observed, as well as a return to its former location when the examiner's hands no longer support it. Movable kidney does not call for treatment so long as it is not giving rise to positive and actual symptoms. When attacks of kidney colic occur, there is usually a kink of the ureter, and this can be demonstrated, if deemed desirable, by pyelography, the picture being taken with the patient in the erect or nearly erect posture. When the movable kidney is believed to be the cause of digestive disturbances or of a dragging or heavy sensation upon standing or walking, the actual part of the kidney in the production of these 1 The right kidney is more frequently abnormally movable than the left ; both kidneys are more often movable than the left kidney alone ; in but 7.5 per cent, of cases of abnor- mally movable kidney is the left side only involved. 469 470 GYNECOLOGY symptoms may be ascertained by supporting the organ with a pad. Great care should, however, be taken to differentiate symptoms actually due to the kidney itself from those resulting from a general tendency to visceroptosis. Treatment. — The treatment of nephroptosis consists in the wearing of a suit- able corset or pad or in operative procedure. A well-constructed corset with a pad so placed as to exert pressure on the abdominal wall beneath the kidney area may result in relief of symptoms, and if the patient takes on fat, may be curative. As a rule, abnormally movable kidneys that give rise to repeated acute attacks of pain require the operation of nephropexy for their relief. HYDRONEPHROSIS Etiology and Pathology. — Hydronephrosis, or the accumulation of urine in the pelvis of the kidney, may be congenital or acquired. The immediate cause of the congenital variety may be complete or partial stricture of the ureter; malformations of the ureterovesical or the ureteropelvic junction ; kinks or twists in the course of the ureter ; a too oblique or too high insertion of the ureter into the kidney pelvis ; kinking of the ureter over anomalous kidney vessels ; congenital displacement or congenital tumors of the ureter, blad- der, or adjacent organs. The acquired form of hydronephrosis may be the result of trauma to the kidney pelvis or the ureter, with subsequent displacement, adhesions, dis- tortion, or cicatricial contraction. Compression of the ureter by pelvic tumors or infiltrations, stricture of the ureter following inflammatory lesions, renal or ureteral calculi, in short, any form of obstruction that develops slowly but continuously may produce a hydronephrosis. The most common form of hydronephrosis seen in women is that which is intimately related to floating kidney. Pyelitis also may lead to hydro- nephrosis, for when the mucous membrane of the ureter and kidney pelvis becomes swollen, a tendency to valve formation frequently develops, the mucosa of the kidney pelvis becoming displaced downward and invaginating itself into the narrow ureteral orifice. As the hydronephrosis develops and the resulting cyst becomes larger, the kidney pelvis becomes so distorted as further to increase the obstruction to the outflow of urine through the ureter. After distention of the kidney pelvis has reached a certain stage the calyces of the kidney begin to distend, and finally the medulla and the cortex are thinned and stretched, and the kidney takes on the form of an irregular cystic tumor in whose walls may be found the remnants of the original kidney tissue. Symptoms. — Up to a certain point in the development of hydronephrosis the accumulation of urine is intermittent, being interrupted by periods of relief ; that is, the patient will suffer at repeated intervals from attacks of renal colic, followed by an increased discharge of urine as the pain subsides. Between the attacks the symptoms may be nil, or there may be a feeling of constant distress, fullness, tension, or soreness on the affected side. In severe cases, during the period of distention, a well-marked enlargement may readily be detected in the kidney region. If, however, the examination is made at a time when the distention has been relieved and the walls of the hydronephrotic sac are flaccid, no enlargement may be apparent on palpa- DISEASES OF THE KIDNEY AND URETER 471 tion. It is in these cases that pyelography proves a very valuable aid to diagnosis. If the ureter of the affected side is catheterized and the pelvis injected with sodium bromide, thorium nitrate, or collargol, the outline of the kidney may be determined with absolute certainty. These patients usually take a large amount of the injection fluid before complaining of pain, as much as 30 to 40 c.c. being injected in some cases. Diagnosis. — The differential diagnosis between hydronephrosis, cystic dis- tention of the gall-bladder, and cystic tumors of the ovary and intestine has been much simplified by pyelography. The enlarged mass also will present the char- acteristic features of kidney enlargements. (See pages 135 and 138.) Treatment. — In the early stage the treatment consists in removing the source of the obstruction. When the case is advanced and the kidney parenchyma is atrophied, extirpation may be considered if the opposite kidney is healthy and is already bearing the bulk of the excretory function. Removal of the obstruction may require various procedures and operations, such as excision of pelvic tumors, dilatation of a constricted ureter, removal of ureteral calculi, suspension of a ptosed kidney, etc. Local treatment of pyelitis and plastic operations for the removal of valve-like formations in the kidney pelvis and the ureter may also be required. When the kidney substance itself forms part of the wall of the hydronephrotic sac, or if the distention of the kidney pelvis itself has reached such a degree that there is a valve-like formation between the kidney pelvis and the ureter, a nephrectomy is often advisable. Plastic operations on the kidney pelvis designed to cor- rect abnormal relations between the kidney pelvis and the ureter, although occasionally brilliant successes, in the majority of cases simply put off the day when nephrectomy must be performed. PYELONEPHRITIS, PYELONEPHROSIS, EMPYEMA OF THE KIDNEY PELVIS, AND KIDNEY ABSCESS Etiology and Pathology. — Infections may reach the kidney through the blood, by way of the urinary passages, or from neighboring organs. Recent ob- servations have shown that the haematogenous form of infection is the most fre- quent. Hematogenous infection is possible whenever bacteriaemia is pres- ent, and occurs in such diseases as pneumonia, typhoid fever, diphtheria, osteomyelitis, puerperal sepsis, erysipelas, phlegmons, furuncles, infected wounds, etc. The streptococcus is the organism most often concerned in this form of infection, but the staphylococcus, the gonococcus, the pneumo- coccus, and the bacillus typhosus may also cause haematogenous infection of the kidney. Infection from the urinary passages occurs usually by exten- sion from the bladder along the mucous membrane of the ureter, or through the peri-ureteral lymphatics to the kidney pelvis ; it may also be carried through the lymphatics and the veins from various septic areas along the course of the ureter. In ascending infections the colon bacillus plays a very prominent part, and the proteus vulgaris is not infrequently found. The gonococcus is not, as a rule, a source of infection of the upper urinary pas- sages. Its chief role undoubtedly consists in the alterations it produces in the lower urinary passages, notably stricture and partial obstruction of the urinary outflow. The stagnation of urine favors the development and 472 GYNECOLOGY growth of other organisms. All kidney infections are aggravated by ob- struction to the excretion of urine. Cabot and Crabtree assert that the coccal infections of the kidney affect the cortical portion and produce the lesions that have generally been re- garded as indicative of a haematogenous infection ; the colon-typhoid group of organisms, on the other hand, produce their changes in the kidney pelvis and neighboring tubules — the lesions generally regarded as significant of an ascending infection. The diseases of neighboring organs that may extend to the kidney are appendicitis, caries of the vertebrae, and abscess of the liver or the spleen. Hsematogenous pyelonephritis may affect both sides. In the severest forms death may occur before many alterations take place in the kidney. Marked hemorrhages may occur throughout the kidney, or minute ab- scesses may develop. Finally, the entire kidney may be honeycombed with abscesses, the pus eventually finding its way into the kidney pelvis, and resulting in pyelitis and obstruction of the ureter. The streptococcus and the staphylococcus, or other so-called pus cocci, are usually the infecting agents. In the form due to the colon bacillus, and generally regarded as secondary to infection of the bladder and ureter, ureteritis and pyelitis are the first symptoms observed, followed by involvement of the medullary part of the kidney. The path of the infection is shown by red stripes running from the pelvis to the capsule, along which rows of abscesses quickly de- velop. Many cases of so-called ascending infection are in reality instances of haematogenous infection with the colon bacillus. Stagnation of the urine and dilatation of the kidney pelvis increase the urinary tension within the kidney and favor the coalescence of abscess cavities with one another and with the kidney pelvis, so that finally the organ becomes transformed into a large abscess sac, with but very little kidney tissue remaining. Symptoms. — The symptoms of an acute haematogenous suppuration (usu- ally streptococcus, staphylococcus, or pus cocci) may be entirely general, with no indications pointing to localized infection. This is true in those cases that rapidly prove fatal. When the infection is less virulent, there may be acute pain in the loins, with scanty or no urine. The urinary findings that are most suggestive are granular casts, blood, and albumin. Bacteria will be found only in the earlier stages, and pus is not found, as a rule. In the earlier stages the phthalein test is negative or nearly so. The kidney region may be sensitive from the first, but no demonstrable enlargement may be manifest until later. The early general symptoms are those indicative of sepsis elsewhere, such as high temperature, chills, etc. Later, when suppu- ration is established, the fever becomes remittent, and as the case progresses uraemia supervenes. Leucocytosis is present throughout the infection, vary- ing in accordance with the severity and the resistance of the individual. The symptoms of colon-bacillus haematogenous infections of the kidney and of the ascending forms of pyelonephritis are less sudden in onset and in general less serious. Usually a history of previous lesion in the lower tract may be elicited. Whatever the nature of this previous illness was, it must have been followed by some obstruction in the ureter, bladder, or DISEASES OF THE KIDNEY AND URETER 473 urethra. Often a bacteriuria has existed for some time, the patient having observed that the urine has a disagreeable odor. Ascending pyelonephritis may be precipitated by instrumentation. Pain develops along the course of the ureter of the affected side, gradually extends to the loin, and becomes more severe and constant. As the disease progresses fever, leucocytosis, enlargement and tenderness of the kidney, and anaemia develop, and bacteria and pus are present in the urine, which is very often alkaline. The phthalein test shows a diminution of function. The pain increases periodically, and is followed by a profuse discharge of pus from the ureter, after which the symptoms subside until pus reaccumulates within the kidney. Treatment. — The treatment varies with the severity of the affection. In the severest form dry cups and ice may be used in the early stage. As a rule, as soon as the organ becomes palpably enlarged and the evidences of sup- puration are definitely established, nephrotomy should be performed and drainage established. The general condition should receive treatment at the same time, and an effort should be made to remove the primary focus of infection. In the milder (colon-bacillus), so-called ascending form, when only one kidney is involved, the indications are to relieve any obstruction that may be present in the lower part of the urinary tract, and, second, to increase the amount of urine secreted and render it as bland as possible. With these points in mind, a stone blocking the ureter, a stricture, or a violent cystitis should be exposed to active treatment, and urinary antiseptics and diluents prescribed. When the symptoms point to a beginning suppurative lesion of the kidney substance itself, immediate operation should be advised. After ex- posing the kidney, if it seems probable that the infection is confined entirely to the pelvis, its posterior wall should be incised and the edges sutured to the border of the lumbar wound, so as to provide sufficient drainage. If the suppuration has extended to the medulla or to the cortex of the kidney, a nephrotomy incision should be made along Brodel's white line, and the pelvis and calyces exposed to examination. If the kidney is destroyed en- tirely or nearly so, and the other kidney is in good condition, nephrectomy should be performed. TUBERCULOSIS OF THE KIDNEY Etiology and Pathology. — Tuberculosis of the kidney is almost invari- ably secondary to tuberculosis elsewhere in the body. In a considerable proportion of cases, however, the primary focus cannot be demonstrated clinically. One case of tuberculosis of the kidney in which, at autopsy, no other tuberculous lesion could be found anywhere in the body, has been reported by Stewart and Kelly. Tuberculosis of the kidney may occur as a part of an acute miliary tubercular process, in which case it is usually bilateral, and occurs most frequently in children. This form of infection is of no surgical interest, and need not be considered here. The form of tuber- culosis of the kidney or tuberculous disease of the kidney which is amenable to surgical treatment is known as the caseocavernous variety. With few exceptions the route of infection is through the blood. Extension from 474 GYNECOLOGY neighboring tuberculous foci has been reported, and an ascending form of infection from the bladder has also been encountered. Trauma to or any disease that lowers the resistance of the kidney may predispose the organ to tubercular infection. Although it may occur in early life, caseocavernous tuberculosis of the kidney is usually encountered in adults, the average age being thirty-two and a half years. The disease is generally unilateral at first, and remains so for a long time, especially in those patients who are not suffering from Fig. 411. — Tuberculosis of the kidney, upper half diseased. First symptoms four years before removal. (Stetson Hospital). active tuberculous lesions elsewhere. According to Israel, with whom Kelly agrees, 90 per cent, of the cases that reach the surgeon are unilateral. The disease usually begins in the glomeruli, near the medulla, where tubercles, surrounded by marked round-cell infiltration, make their appear- ance. A number of these areas may coalesce, forming nodules that undergo caseation and softening in the center, and appear as grayish-white or yellowish-gray masses. These may remain discrete and scattered throughout the cortex and medulla, or a number of them may coalesce, forming cavities of greater or lesser size (Fig. 411). With this cavity formation there may be degeneration of the neighboring parenchymatous kidney cells, and the substitution of fibrous tissue. If the pelvis of the DISEASES OF THE KIDNEY AND URETER 475 kidney has not been invaded and the ureter is patulous, the kidney may not be enlarged. The organ is usually irregularly lobulated, some of the lobule? being hard, and others soft. Sooner or later some of the caseous cavities open into the kidney pelvis and involvement of the ureter then takes place. This is manifested by the formation of tubercles in the mucosa, with caseation and ulceration, and marked infiltration and thickening of the muscular wall. Stricture of the ureter may result, or the lumen may become plugged with caseous matter. Obstruction of the ureter may lead to an increase in the kidney lesion, with the formation of larger cavities and destruction of the remaining parenchyma. If secondary infection occurs, the process may be intensified, suppuration may take place, and the kidney be transformed into a huge multilocular abscess sac. Perirenal abscess is especially likely to follow secondary infection. Symptoms. — As a rule, the earliest manifestation is increased frequency of urination. This may occur even before any recognizable changes in the bladder or ureteral orifice take place, which may be explained on the ground of a reflex pain or an irritating toxin in the urine. When, later, the bladder is involved, there is increased ferquency of urination, the desire to urinate becomes intense and even uncontrollable, and the act is associated with pain. The severity of the bladder symptoms corresponds in the main to the extent of the vesical involvement, but many exceptions occur. Increased frequency of urination without recognizable pelvic lesions, without altera- tions in the bladder that are detectable by the cystoscope, and with no abnor- mal constituent in the urine, is always at least suggestive of early renal tuberculosis. Sooner or later pus and blood make their appearance in the urine, varying in amount according to the location of the kidney lesion and the patency of the ureter. The attention of the patient is drawn to the urinary abnormality by turbidity in the case of pus, or by the change in color in the case of blood. If the tuberculous focus does not communicate with the kidney pelvis or the ureter is blocked there may be little pus. The amount of pus may sud- denly increase if a focus bursts into the pelvis or a ureteral obstruction is removed. Haematuria is most pronounced when the tuberculous focus affects principally the papillae. The first symptom of renal tuberculosis may consist of haematuria or an attack of renal colic. In two-thirds of the cases there is a certain amount of distress in the kidney; usually this is merely a fairly constant feeling of pressure or a dull ache, but occasionally there are paroxysmal attacks of renal colic. The colic is due either to inflammatory swelling of the mucosa of the ureter obstructing the urinary outflow, or to the attempted passage of tuberculous detritus, blood-clots, etc. In the later stages, when pyonephrosis or perirenal abscess is present, the local pain and tenderness are usually well marked and unmistakable. The general symptoms of renal tuberculosis, like all the others, depend on the exact location and extent of the disease and the associated conditions. In early or moderately advanced cases there may be no more than a slight evening rise of temperature, with malaise and anaemia. In advanced cases, when the ureter is blocked and pyonephrosis or perinephritis or both are 476 GYNECOLOGY present, there may be high fever, exhausting sweats, and rapid emaciation. Between these two extremes there are many variations. So long as there is no secondary infection, leucocytosis is usually absent. In the early stages the kidney is, as a rule, slightly enlarged, but this enlargement can be recognized by palpation in less than half of the cases. It is more frequently recognized when the right kidney is affected than when the left is the seat of disease. If the ureter is blocked and there is more than the usual increase in size, or if secondary infection and pyone- phrosis or perinephritis are present, the kidney is generally palpably en- larged. There is often some tenderness in the costovertebral angle, especially if perinephritis is present. It must be remembered that the unaffected kidney may be larger than the diseased organ, owing to compensatory hypertrophy. The urine usually contains pus and blood, the amount varying accord- ing to the location of the tuberculous foci, the patency of the ureter, and the vesical alterations. The pus from a tuberculous kidney is grayish and granular, and gives to the urine a ground-glass appearance in contrast to the soft, yellowish appearance given by the pus in other conditions (Keene and Laird). The reaction of the urine is persistently acid. In the absence of mixed infection no bacteria may be found by smear or culture. Tubercle bacilli may be found in the urinary sediment by staining, but they cannot be abso- lutely differentiated from the other acid-fast organisms by microscopic ex- amination. The presence of tubercle bacilli in the urine must be confirmed by animal inoculation (see page in). The tuberculous ureter may be tender along its entire course, but the enlargement is usually difficult to demonstrate, except in its lower part, where it passes through the parametrium at its point of entrance into the bladder. Upon simple digital examination per vaginam the affected ureter may be felt as a tender, rigid cord, about the thickness of a lead-pencil, running from the trigone outward under the vaginal wall, to the side of the cervix, where it is lost in the broad ligament. By bimanual palpation with one finger in the rectum the course of the ureter may be followed out to the pelvic wall. Any abnormality may be emphasized by comparing it with the ureter of the opposite side. Pressure upon the ureter often gives rise to an intense desire to urinate. The cystoscopic examination is possibly the most important of any single method of diagnosing tuberculosis of the kidney. The cystoscopic findings have been described under the head of Tuberculous Cystitis, page 457. Diagnosis. — The diagnosis of renal tuberculosis should be based on the results of a combined clinical and laboratory examination. Cystoscopic ex- amination is the most valuable single diagnostic aid, and in a majority of cases forms the basis from which conclusions are to be drawn. The appear- ance of the bladder may be more or less characteristic. The ureteral orifices may at once indicate the particular kidney affected. It now remains only to catheterize the suspected side and collect a specimen for guinea-pig inocula- tion. If the laboratory examination yields a positive result, an injection of indigo-carmine should be given in order to determine the relative activity of the two kidneys. The phenolsulphonephthalein test should also be em- DISEASES OF THE KIDNEY AND URETER 477 ployed to determine the total renal efficiency. Catheterization of the appar- ently normal side should be avoided if the diseased kidney is failing to excrete and the indigo-carmine and phenolsulphonephthalein tests indicate that the other organ is maintaining alone a normal renal excretory function. Otherwise a catheter may be passed a few centimeters into the ureter of the sound side, in order to exclude, so far as possible, any involvement. Enlargement and tenderness of the lower part of the ureter are not diagnostic of tuberculosis, and may be found in ureteral stone or in stricture at the lower end of the ureter with ureteritis. A single negative laboratory result, no matter how thoroughly the exami- nation was conducted, does not determine an absolutely negative diagnosis of renal tuberculosis, as the manifestations of this disease are essentially intermittent. Negative results obtained in three successive weekly exami- nations should, however, have considerable bearing on the diagnosis (Keene and Laird). Treatment. — A tuberculous kidney should be removed by nephrectomy if the opposite organ is functionally able to meet the increased demands that will be made upon it. That this kidney is in good condition is evident when the diseased side excretes no indigo-carmine, when a dark-blue cloud is ejected from the opposite ureter a few minutes after an intramuscular injec- tion of the coloring matter has been made, and when the total phenolsul- phonephthalein output is normal. These findings indicate that the diseased kidney is functionally incompetent, and that its fellow is doing all the work. Under these circumstances the diseased kidney may be removed with the assurance that the remaining organ has already taken over and will continue to carry on the renal function. When the diseased kidney is still excreting, a careful relative estimate should be made of the amount of work each organ is doing. The indigo-carmine may appear on the diseased side much later, and the intensity of the blue color be much lower, than on the healthy side ; if, together with such a rinding, the phthalein test is normal, one may be sure that the opposite kidney is functionally competent. When desirable, each kidney may be tested separately by the phenolsul- phonephthalein test : As large a ureteral catheter as can be introduced is laid into each ureter, and the injection is made directly into a vein; the urine, as it drops from the ends of the catheters, is received in separate tubes. The time required for excretion is estimated for each side and then the total amount excreted is measured. It is often impracticable to continue this test for more than thirty minutes, and in some cases even less, so that a comparison of the two sides for the usual duration of the phthalein test cannot be made. But if the total phthalein output and the quickness of the reaction are previously known, a comparison of the two sides, even for two periods of fifteen minutes each, will yield valuable information as to the relative activity of the two kidneys. When tuberculosis of the kidneys is bilateral, operation is contraindicated except in the rarest instances, as, for example, when fever is continuous and is due to a mixed infection in the kidney most involved; when the bladder is being severely irritated by the discharge into it of large quantities of pus from the most affected side ; when the more involved side 478 GYNECOLOGY is so extensively diseased that its removal will have no effect on the renal function (Zuckerkandl) ; or when, although both kidneys are involved, the disease in one is of recent origin and the less involved organ is capable of bearing the entire burden of urinary excretion. When nephrectomy for tuberculosis is undertaken in the early stage of the disease, no unusual difficulties are encountered. Later, when the peri- nephritic fat has been affected or the kidney is much increased in size or adherent to neighboring structures, the operation may be attended by difficulties. Certain points in connection with the operation are worth keeping in mind : First, sufficient exposure must be obtained, either by division or excision of the twelfth rib, or by an anterior transverse incision at right angles to the loin incision — about its middle — the so-called frying-pan in- cision ; second, thorough mobilization of the kidney must be effected before ligating the pedicle; third, double ligation of the pedicle in sections should be performed, preparing the vessels separately, if possible, by dissection of the fat ; fourth, the ureter should be divided as low down as practicable with- out unduly prolonging or increasing the dangers of the operation. In large pyonephrotic tuberculous kidneys intracapsular nephrectomy is the procedure of choice. This is performed by cutting directly through the capsule and enucleating the kidney from within outwards ; occasionally in advanced cases it may come away in pieces. As the separation proceeds and the kidney substance is drawn out of its bed, the pedicle is brought into view and secured with clamps. After the kidney is cut away the pedicle is ligated with catgut. Removal of the entire ureter is unnecessary, nor should one go to any great amount of trouble to secure a large part of it. As was shown by W. J. Mayo, the only tuberculous ureters that require removal are those in which there is a stricture close to the bladder, which causes more or less retention. In other cases the injection into the ureter of from five to ten minims of 95 per cent, phenol, with secure ligation, is the most satisfactory procedure. Prognosis. — In the early stage of the disease, when the process is limited to one kidney, permanent recovery may confidently be expected. If there is extensive involvement of the bladder, the primary mortality may reach 5 per cent, and the later mortality 20 per cent. About 60 per cent, are perma- nently cured, whereas in the remainder abnormal urine and other symptoms persist. The prognosis is better in women than in men. RENAL CALCULUS Etiology and Pathology. — Renal calculus occurs most frequently in those between the ages of twenty and fifty. Predisposing factors are a very rich diet, composed largely of nitrogenous food, and the consumption of minimum amounts of water in the dietary. It is directly produced by precipitation of the urinary salts. This precipitation may collect upon foreign bodies in the kidney pelvis, such as a bit of mucus, a shred of necrotic epithelium, detached par- ticles of a new growth, or tuberculous detritus. After the nucleus has been formed the stone increases in size by successive deposits of urinary salts DISEASES OF THE KIDNEY AND URETER 479 upon its surface. Kidney stones may be composed of uric acid, urates, oxalates, or phosphates. The configuration of kidney calculi is dependent upon their position and number ; at first they are small and oval, but as they increase in size they gradually take the form of the part in which they lie. A large calculus may fill the entire pelvis of the kidney, being branched like a piece of coral, and fitting closely into the calyces. A stone overlying the ureteral orifice may be tunneled, or have a groove on one side, through which the urine gains entrance to the ureter. Kidney calculi are often bilateral. Symptoms. — The symptoms of kidney calculus are pain in the affected kid- ney or lower abdominal quadrant, increased by movement, by jolting, and by pressure. If the stone becomes so displaced that it blocks the ureter, renal colic ensues. This consists of a violent paroxysmal pain, radiating along the course of the ureter to the genitalia and the inner surface of the thighs. The suffering in some cases is extreme, so that the patient presents all the appearances of severe shock or collapse. Nausea, retching, and vomiting are common. There is marked vesical tenesmus, the patient straining even after the bladder is emptied, and voiding a few drops of dark-colored or even bloody urine. The abdominal muscles on the affected side are rigid, and the patient assumes various positions in an effort to find one that is comfortable. The attack may last from one to two hours to as many days. It may end as suddenly as it began. Relief is experienced as soon as the obstruction is overcome by the stone passing through the ureter into the bladder, or being displaced from the mouth of the ureter into some other part of the kidney pelvis, or by the urine finding its way around the stone. Renal colic is not peculiar to kidney stone, being nothing more than an indication of great tension within the kidney ; it is occasioned also by twisting of the vessels at the hilus or obstruction of the ureter from any cause whatever. The urine in kidney calculus usually contains blood, at times in micro- scopic amounts only. The amount of blood usually varies from time to time, being more profuse after riding, active exercise, etc. Long and narrow hyaline casts, albumin, and high specific gravity are generally found. If the outflow of urine on the diseased side is completely blocked, nothing abnor- mal may appear in the urine. The kidney may become infected second- arily, under which conditions the symptoms of a pyelonephritis are added to those of the kidney stone. Diagnosis. — The diagnosis of renal calculus is made from a consideration of the symptoms plus a Rontgen-ray examination. The latter should be made after suitable preparation of the patient, i.e., thorough evacuation of the intestinal tract with castor oil. Pills should not be taken by the patient for several days before examination. Correct interpretation of the skiagraph is impor- tant, as shadows believed to be the result of calculi may be due to calcified lymph-glands, gas, pills or tablets, fecal concretions, especially in the appen- dix, collections of pus in the kidneys, phleboliths in the pelvic veins, and sesamoids in the tendons arising from the spine of the ischium. In order to confirm the diagnosis of renal calculus two or more Rontgen-ray pictures taken at different times should agree. Stones in the ureter may be differentiated from stones outside by a picture taken after catheterization of the ureter with a shadow (bismuth) catheter or by a stereoscopic picture. 480 GYNECOLOGY Treatment. — The treatment of kidney stone depends upon its size and posi- tion. If it is small, lies near the pelvis of the kidney, and is not giving rise to acute distress, it may be left undisturbed in the hope that it will be expelled spon- taneously. The patient should be directed to drink an abundance of water containing as little saline matter as possible (distilled water), and the diet should be restricted in quantity and in its nitrogenous element. During an attack of renal colic the pain should be relieved by a hypodermic injection of morphine and atropin and the local application of heat. In cases in which the symptoms are active and the stone is of considerable size or in such a posi- tion that spontaneous cure cannot be expected, operation should be per- formed at once. The kidney should be exposed, pyelotomy or nephrotomy should be done, and the stone extracted. If the case is clean, the kidney wound may be sutured and drainage omitted. If the kidney is markedly diseased, and it has been determined that the opposite kidney is perfectly healthy and has been assuming the bulk of the renal function, nephrectomy may be done, but the frequency of bilateral involvement in cases of kidney stone must be remembered, and nephrotomy with drainage relied upon, un- less it can be demonstrated that the affected organ is useless and its fellow kidney in good condition. TUMORS OF THE KIDNEY Tumors of the kidney are not very frequent. The most common variety is hypernephroma. Other forms are papillary cystoma, endothelioma, sar- coma, carcinoma, and adenoma. The symptoms are hematuria, pain, and enlargement of the kidney. Haematuria is the most common early symptom, and occurs with or without renal colic. In women the growths very often escape observation until the tumor is of considerable size, and when operation is unlikely to prove curative. Al- though renal colic does not always occur, there may be a disagreeable sense of pressure in the loin on the affected side. The urine may have the color of fresh blood, and may vary from almost pure blood to a straw-colored serum, or it may be clear and contain coagula. Worm-like clots, 10 cm. long, are significant of coagulation within the ureter. Casts and albumin usually appear sooner or later. Palpation of the kidney may show a smooth, sym- metric enlargement of the entire organ, or a nodular enlargement project- ing from the anterior surface of the lower pole. A positive diagnosis at times cannot be arrived at without an exploratory incision. A kidney tumor must be differentiated principally from tuber- culosis and renal calculus. This can usually be accomplished by the methods of diagnosis already given for these two conditions. As soon as the diag- nosis is made nephrectomy is indicated, provided the opposite kidney is healthy. Cystic Tumors of the Kidney. — Cystic tumors springing from the outer region of the cortex and bordered by the compressed parenchyma may be found associated with contracted kidney. The symptoms are those of nephritis, pressure, and tumor. Partial nephrectomy is the operation of choice. Polycystic Disease of the Kidney. — Polycystic disease of the kidney may DISEASES OF THE KIDNEY AND URETER 481 be present at birth or appear later in life. In its external appearance the kidney may resemble a bunch of grapes. The symptoms vary, but usually there are polyuria, intense thirst, slight oedema, and later uraemic indications, combined with the development of a palpable tumor in one or both kidney regions. The diagnostic points are the frequency of bilateral involvement, the knobbv surface and the deficient elimination from each kidney. The treatment should be medical, and not operative, unless it can be determined absolutely that the disease is unilateral and that the unaffected kidney is functionally competent. Adenocystoma. — Adenocystoma may be benign or malignant. The benign form resembles the early stage of polycystic disease of the kidney and requires the same treatment. The malignant form presents the same general features of other malignant renal growths. The differential diag- nosis can be made only as the result of an exploratory incision. Echinococcus Cysts. — The kidney is said to be affected in from 5 to 8 per cent, of all cases of hydatid disease. Urinary constituents on which to base a diagnosis are found only when the cyst is evacuated into the kidney pelvis. When this occurs, booklets and daughter cysts may be found in the urine. The treatment consists in incision and suture of the sac wall to the lumbar wound. If the situation of the cyst is favorable, resection may be done. Adrenal Tumors. — Adrenal tumors are exceedingly malignant and can- not be differentiated from kidney tumors except by making an exploratory incision. Pararenal Tumors. — Pararenal tumors differ from those of the kidney in that they are not associated with alterations of the urine. The prognosis is unfavorable. Operative removal is difficult, but unless this is done they almost invariably prove fatal. OPERATIVE TECHXIC Incision. — The kidney may be exposed by various incisions, the choice of which depends upon the operation that is to be performed. For nephro- pexy, for decapsulation of the kidney, for nephrotomy, and for many nephrec- tomies an incision running from the twelfth rib to the crest of the ilium. along the outer margin of the erector spinae, is the most suitable. The fibers of the latissimus dorsi are divided close to its point of coalescence with the fascia of the erector spinae. but without opening the sheath of the latter. The fibers of the quadratus lumborum muscle are bluntly separated along their course without cutting, or the muscle may preferably be displaced in- ward. The ileohypogastric nerve is sought for in front of and along the outer margin of the quadratus, and turned to one side. The transversalis fascia is divided, exposing the perirenal fat. which is caught with artery forceps and divided well to the inner and posterior part of the wound, in order to avoid the colon. The separation of the perirenal fat is completed by means of the finger, until the kidney is felt and seen in the depths of the wound. Instead of making a vertical incision, it may be made slightly oblique, running downward and outward toward the anterior-superior spine. 31 482 GYNECOLOGY A muscle-splitting incision, which can be increased to almost any extent, is begun to the inner side of the anterior superior spine of the ilium, and is carried backward obliquely toward the tip of the last rib. The fibers of the external oblique and its aponeurosis are separated and retracted, ex- posing the internal oblique muscle, the muscular fibers of which are split on a line between the ninth costal cartilage and the posterior superior spine of the ilium, in which position they are longer than in front of or behind that line. The fibers of the transversus are split and retracted along with the oblique muscle. A diamond-shaped space is thus formed, at the bottom of which the transverse fascia is seen; this is incised, exposing the perirenal fat, and on pushing through the fat, the kidney is easily reached, whatever the position it may occupy. This incision gives ample room, and, if neces- sary, the whole hand may be introduced into the circumrenal space. If it becomes necessary to expose the ureter, the incision may be continued ob- Fig. 412. — Suspension of the kidney by Edebohl's technic. The capsule of the kidney has been reflected and the suspension sutures introduced. (Kelly and Noble's Gynecology and Abdominal Surgery.) liquely downward toward Poupart's ligament. The internal oblique will then require suturing in order to bring the divided ends together. Pref- erably a second lower incision through the outer border of the rectus muscle may be made to reach the ureter. Whether a vertical, an oblique, or a muscle-splitting incision is used, the muscle-fibers should be separated, rather than divided, as far as possible; the ileohypogastric nerve should be located and pushed to one side, and the transversalis fascia should be opened close to the spinal margin of the wound, in order to avoid the peritoneum. After exposing the kidney the organ may be delivered by hooking the finger under the lower pole and lifting it out of the wound by making gentle traction on the fatty capsule. If it is found that extirpation of the kidney and the ureter is absolutely necessary, the parts may be exposed by an oblique incision beginning at the junction of the erector spinae with the twelfth rib, running forward and downward to a point two or three fingerbreadths to the median side of the anterior superior spine or che ilium. An incision in this direction has the DISEASES OF THE KIDNEY AND URETER 483 advantage of exposing the upper segment of the ureter. The incision may be lengthened downward, on a line parallel with Poupart's ligament. When the kidney enlargement is extreme, forming an abdominal tumor, a transperitoneal incision may be made. This incision runs along the outer border of the rectus muscle of the affected side, its midpoint corresponding to about the center of the kidney mass. The peritoneum is opened, and the kidney exposed by incising the outer layer of the mesocolon (see Chapter XXXVI). Nephropexy. — After the kidney has been delivered, the convex border is freed from fat, the capsule proper is nicked over the dorsum of the kidney, a grooved director is thrust between the capsule and the kidney substance, and the former is divided in a straight line from one pole to the other. The capsule is now stripped on both sides half way to the hilum, and sutures are passed through the capsule at four points, pucker- ing the capsule at the point of suture as indicated (Fig. 412). When the capsule has been secured at four points on both surfaces, the kidney is replaced, and the fatty capsule is disposed principally about the lower pole, where it is sutured with fine catgut to the surrounding tissues. The sutures that were pre- viously introduced through the capsule are then passed through the fibers of the quadratus muscle, bringing the raw surface of the kidney directly in apposition with the surfaces of that muscle. The wound is then closed with interrupted sutures of silkworm gut that embrace the entire depth of the wound, care being taken to avoid inclusion of the ileohypogastric nerve. Nephrotomy. — After exposure and delivery the kidney and accessible part of the ureter should be carefully palpated. On account of the great ad- vancement that has been made in skiagraphv of the FlG - 413— Bloodless nephrot- o r ^ omy incision; immediately pos- kidnev and pyelography, nephrotomv is becoming- terior to the outer convex . J . . r " x f , r 1 ' - border. (Kellv and Noble's ieSS and leSS necessary. In doubtful Cases, however, Gynecology and Abdominal in which stone, beginning tumor, or early tuberculosis is urger -' suspected, the kidney may be split by an incision through Brodel's white line. The technic of this procedure is indicated in the accompanying illus- tration (Fig. 413). If the kidney is not infected and no further operative treatment is required, the wound may be closed by through-and-through sutures of catgut introduced by means of a blunt needle. If the kidney is infected, a small drainage-tube may be introduced. Nephrolithotomy and Pyelotomy. — For these operations the kidney is exposed and delivered in the usual way. The incision for the removal of the stone depends upon the position of the latter. A single stone in the cortex may be remo\~ed by making a simple incision directly over it. If the stones lying entirely in the kidney pelvis are small, they may be removed by mak- ing an incision through the pelvis that does not involve the kidney sub- 484 GYNECOLOGY stance. In some cases complete hemisection of the kidney will facilitate the operation and lessen the danger of leaving stones behind. The incision should be made along Brodel's white line. The upper end of the ureter should be palpated rather than sounded for stone, since sounding may cause impaction. In some cases it may be necessary to crush a stone before re- moval. As a rule, however, they may be removed by the finger, a scoop, a curette, or a pair of slender forceps. Flushing the kidney with a stream of normal salt solution under some pressure is especially valuable when the stone has been fractured, or numerous small stones are present. If the case is clean, and there has been little bruising, the kidney wound may be closed trigonvm Fig. 414. — Resection of last rib in nephrectomy. (After Cullen, from Kelly and Noble's Gynecology and Abdominal Surgery, W. B. Saunders Co.) with sutures. Incisions into the renal pelvis should be closed with fine sutures of catgut, comprising only the outer surface. If the case is infected, or the kidney is much damaged, drainage must be employed. Nephrectomy. — Nephrectomy is performed as follows : After exposure of the kidney in the usual way, it is freed from the surrounding tissues and delivered through the incision. The separation from the surrounding tissues should be continued until the renal artery and vein, as well as the pelvis and ureter, are isolated. A ligature should be passed around the vessels of the pedicle and tied separately, without including the ureter. After the vessels have been divided the ureter should be separated as far down as necessary DISEASES OF THE KIDNEY AND URETER 485 and divided between two ligatures, the exposed mucous membrane of the lower end being carefully disinfected with phenol and alcohol. If the kidney is very large, some difficulty may be experienced in effecting its delivery. A cystic kidney may be reduced in size by aspiration. Deliv- ery of the kidney is sometimes facilitated by introducing the fingers be- neath the lower ribs, and forcibly pulling them up ; at other times division of the twelfth rib near its vertebral articulation or resection of the twelfth rib simplifies delivery (Fig. 414). If the transperitoneal route is selected for the removal of kidney tumors of large size, resection of the rib will not often be necessary, and exposure and delivery of the kidney will be rendered less difficult. PYELITIS Etiology and Pathology. — Pyelitis as seen by the gynecologist occurs as a complication of pregnancy or the puerperium, in the course of development of intrapelvic growths and after operations. It may appear suddenly in the form of acute attack, or slowly as a chronic condition. The latter may be the result of an acute pyelitis or of a moderate but progressive obstruction to the ureter, such as may be observed in prolapse of the uterus with a marked cystocele. As a rule, two causes are responsible for the occurrence of pyelitis : First, an ob- struction to the urinary outflow ; and secondly, an infection. De Lee asserts that 15 per cent, of pregnant women have bacteriuria. This fact, together with the pressure of the enlarging uterus and the distortion of the ureters incident to pregnancy, furnishes the reason for the comparative frequency with which the condition appears in pregnant women. According to De Lee, the normal pressure of urine in the kidney pelvis is only 10 mm. Hg, so that slight causes may impede or check the outflow. The ureters, moreover, par- ticularly the right, have been found dilated and filled with urine in about two- thirds of the pregnant women coming to autopsy. The infecting organism is usually the colon bacillus, but others, such as the tubercle bacillus, the bacillus proteus, the staphylococcus albus and aureus, the bacillus typhosus, the gonococcus, the streptococcus, etc., have been reported. The organisms reach the pelvis of the kidney and ureter through the kidney tubules, being excreted through the kidney (bacteriuria), through the blood-stream, or by way of the lymph-channels, from neigh- boring structures (appendix, colon), and by ascending from the bladder either along the mucosa, as was previously believed, or by floating from a lower to a higher level in a collection of stagnant urine in an obstructed ureter, or through the periureteral lymphatics to the subpelvic areolar tissue that surrounds the blood-vessels of the kidney as they enter the pelvis. Cabot and Crabtree have recently declared that the colon bacillus and the typhoid bacillus produce a different set of lesions in the kidney than do the streptococcus, staphylococcus, etc. The colon-typhoid group causes acute pyelitis, acute pyelonephritis, chronic pyelonephritis, and pyonephrosis, whereas the coccus group causes perinephritic abscess, capsular abscess, capsulitis, cortical abscess, septic infarct, and diffuse suppuration. A mixed infection will show lesions char- acteristic of both groups. 486 GYNECOLOGY Acute pyelitis is more frequently associated with the rapidly growing tumor of pregnancy than with other pelvic tumors. Occasionally, how- ever, it develops suddenly during the course of the growth of a fibroid. Pyeloureteritis may also follow septic catheterization or an acute gonor- rhoeal or a post-operative cystitis. In pregnancy it may develop as early as the eighth week. Usually it occurs about the fifth month or later. Occasionally it is observed during the puerperium, when it may be mis- taken for septic infection. The right kidney is more frequently involved than the left. Chronic pyelitis is much less violent than acute pyelitis in its manifesta- tions. It results from gradually produced stasis of urine plus an infection. The latter is usually caused by the colon bacillus, less often by the gono- coccus and the tubercle bacillus. The infection may come from the kidney, from the bladder, from the neighboring parts, or through the blood-stream. The cause of the obstruction may be a dislocation downward of the uterus and bladder, a slowly growing tumor compressing or constricting the ureter (fibroid tumor, carcinoma), a ureteral calculus, or contraction of the ureter following operative trauma, etc. Symptoms. — Although symptoms such as frequent and painful urina- tion may precede the onset, acute pyelitis usually presents itself with chill, fever, and pain along the course of the ureter and in the back. Vesical tenesmus, pain on urination, and a diminution of the urinary output are also present. The temperature often reaches 104 to 105 F., the rise usually being preceded by a prolonged and exhausting chill. The kidney on the affected side is markedly tender, and enlargement may be perceptible. Ex- amination of the urine shows the presence of large numbers of pus-cells, epithelial cells, and albumin. The ureter can sometimes be palpated through the vagina as an enlarged and tender cord. In the course of several hours or days the subjective symptoms may abate, the temperature declines, the pain subsides, the urine is voided in larger quantities, and contains an increased amount of pus and albumin. All may then go well for from twenty-four to seventy-two hours, when the symptoms may suddenly reappear. The attacks follow one another at different intervals and with varying intensity. In the milder cases prostration may not be marked, but in the severer ones the patient becomes emaciated, and the face assumes a hectic appearance. At first, at least, but one kidney, and that the right, is usually involved, but after several days or a week there may be pain along the oppo- site ureter and indications of an extension of the disease in that direction. The presence of kidney involvement is indicated by the disproportionate increase of albumin as compared with the number of leucocytes in the urine. Casts will also appear if there is any extension of the inflammatory process to the kidney structure. Prognosis. — Acute pyelitis may yield rapidly to treatment, or it may prove exceedingly stubborn and resistant to all methods of treatment. The prognosis in general is favorable, i.e., recovery usually occurs in from two to eight weeks. Labor and the emptying of the uterus are, as a rule, fol- lowed by rapid disappearance of the symptoms. Pyelitis may manifest itself DISEASES OF THE KIDNEY AND URETER 487 during the puerperium, constituting a form of puerperal sepsis. Acute pyelitis due to the pressure of pelvic tumors is cured by the removal or displacement of such growths, the pressure on the ureter being relieved. The prognosis in chronic pyelitis is dependent upon the nature of the infec- tion and the organic changes that have occurred, e.g., whether the infection is caused by the colon bacillus, on the one hand, or by the tubercle bacillus, on the other ; whether the obstruction can be overcome, the amount of dilatation of the ureter that is present, and the extent to which the kidney pelvis is distended. The prognosis in chronic pyelitis in cases of long standing and in those associated with recurring or permanent dilatation of the kidney pelvis and residual urine is less favorable (see Hydronephrosis, page 470). In such cases, when no more radical measures are practicable, local treatment should be em- ployed, even though nothing more than temporary improvement is to be expected. According to Geraghty, in these cases formaldehyde solutions, varying in strength from 1 : 5000 to 1 : 2000, seem more effectual than the silver preparations. Treatment. — The treatment of acute pyelitis complicating pregnancy is postural, general, medicinal, and local. The patient should be placed in the Sims' position, on the healthy side, the elevation of the hips being exag- gerated by means of a hard pillow. The knee-chest position should be assumed several times within the twenty-four hours. The bowels should be kept open. Vegetable soups, milk in any form, and buttermilk may be taken. Water should be drunk freely. Solids and meat broths are to be prohibited. A urinary antiseptic, such as hexamethylenamine (5 grains) with sodium benzoate (5 grains) should be administered every three hours. Salol, 5 grains every three hours, is often the most effectual urinary antiseptic. If this treatment does not alleviate the symptoms, the ureter of the af- fected side should be catheterized and the ureter and kidney pelvis irrigated with a boric acid or normal salt solution, followed by a 10 per cent, solution of argyrol. This has two objects: First, to relieve obstruction of the ureter and drain accumulated urine and pus; and secondly, to destroy or weaken the infecting organisms. This last may need to be repeated, or one thorough irrigation may be sufficient to mark the beginning of an improvement which is gradually followed by complete disappearance of the symptoms. If, in spite of every effort, the symptoms persist or even increase in violence, and the patient is almost constantly in pain, the anaemia increasing rapidly, and a typhoid-like condition making its appearance, labor should be induced without hesitation. Acute pyelitis occurring as a symptom of pelvic tumors should be treated in the same way as the acute pyelitis of pregnancy. When the acute symptoms have subsided, the patient should be subjected to opera- tion, in order to avoid a repetition of the attacks. If the symptoms persist in spite of rest in bed, urinary antiseptics, and irrigation, operation should be undertaken at once, nitrous oxide-oxygen-ether anaesthesia being employed. The treatment of chronic pyelitis is dependent upon the form of infec- tion and the nature and source of the obstruction. Tuberculous cases need not be discussed here further than to state that as soon as the diagnosis is made, nephrectomy should be undertaken, provided the other kidney is healthy. 488 GYNECOLOGY The local treatment of other forms of chronic pyelitis comprises relief of the urinary stasis in the affected ureter if this exists, the use of antiseptic solutions, and the injection of vaccines. The measures taken to relieve the urinary stasis depend upon the nature of the obstruction to the ureter. If this is caused by external pressure on the ureter, as in pregnancy, postural treatment, in addition to ureteral catheterization, may be effectual. Tumors or inflammatory masses pressing upon the ureter must be removed. A ureteral stone will, of course, require appropriate . treatment, which is discussed elsewhere. Obstruction due to prolapse of the uterus and bladder may be temporarily relieved by wearing a pessary, or may be permanently cured by operation. Obstruction caused by infiltration of the broad ligament by carcinoma is usually irremediable. Obstruction of the ureter associated with ptosis of the kidney and kinking may be relieved by wearing a belt and a pad, or by means of the suspension operation. A narrowing of the ureteral lumen or stricture may be corrected by the passage of ureteral catheters or bougies (see Ureteral Stricture, page 495). Indeed, in some cases this, in addition to urinary antiseptics and diluents, seems to be all that is needed. In the majority of cases, however, lavage of the kidney pelvis with boric acid solution, aluminum acetate, 2 per cent., argyrol, 25 per cent., or silver nitrate, 1 : 1000 will prove of value and will hasten the cure. Silver nitrate irrigation should be followed by normal salt solution. In practising lavage of the kidney pelvis the affected ureter should be catheterized by means of a small catheter. It should be of such size relative to the diameter of the ureteral lumen that there will be abundant space for a return flow of the irrigating solution into the bladder, whence it should be conducted immediately by a self-retaining catheter. After introducing the ureteral catheter, a little time should be allowed for drainage of the kidney pelvis. The irrigating solution is then permitted to flow into the catheter by means of gravity, using a burette or funnel. On the average, about 75 c.c. of the combined irrigating solution may be used at one sitting. The treatment may be repeated at intervals of from three to four days to several weeks, depending upon the effect produced and the urgency of the symptoms. If the treatment is carefully carried out, no unfavorable reaction will result. The slight discomfort that immediately follows the procedure sub- sides in the course of a few hours. The patient should not be considered cured until repeated examinations of the urine show it to be free from pus- cells and bacteria. Although the use of vaccines in the treatment of chronic pyelitis has not been encouraging, so far as can be judged from the literature, good results unquestionably follow in some cases : it may be used either alone or in conjunction with other treatment. At the time of the first ureteral catheterization a culture should be taken of the urine and a vaccine made therefrom; autogenous vaccines are prefer- able to stock vaccine. DISEASES OE THE KIDXEY AXD URETER 489 URETERITIS Inflammatory diseases of the ureter usually coexist with cystitis or pyelitis, or with both. Thus the ureter may become diseased from the descent of an infection from the kidney above, or the condition may be the result of the ascent of an infection from the bladder below. The three most common infections of the ureter correspond, therefore, to those most frequently encountered in the kidney and in the bladder. They are colon bacillus, tubercle bacillus, and gonococcus infections. Primary ureter- itis may follow the lodgement of a stone in the ureter, or it may be caused by trauma during operation. Symptoms. — Ureteritis secondary to pyelitis manifests no symptoms. for pyelitis is associated almost immediately with pain along the course of the ureter. The onset of pain radiating from the pubes to the lumbar region on one side during the course of cystitis may. however, indicate the begin- ning of a ureteritis secondary to cystitis. Diagnosis. — Inspection of the ureteral orifices and bimanual palpation of the ureter are the only reliable physical methods for determining the existence of ureteritis, but they may fail to confirm the diagnosis unless the ureter is seriously diseased. Changes in the ureteral orifice, such as marked infection. bullous oedema, dilatation and fixation {i.e., a lack of contractile power) are indicative of ureteritis. Palpation of the ureters in the anterior vaginal vault, from a point about one and one-half inches from the urethral orifice and a half inch on either side of the median line, outward and upward to- ward the bases of the broad ligaments, may reveal tender cords, the thick- ness of a lead-pencil. " passing in a flat curve with the concavity directed upward from the vaginal vault to the lateral wall of the pelvis." Treatment. — The treatment of ureteritis is the treatment of pyelitis (page 487). URETERAL CALCULUS Etiology and Pathology. — Stone in the ureter is secondary to renal calculus. i.e.. the stone has its origin in the kidney, but escapes from the calyces of pelvis and lodges in the ureter. It may be found at the ureteropelvic junc- tion, in the upper third of the ureter, at the brim of the pelvis, in the pelvis at the ureterovesical junction, or within the intramural portion of the ureter. In the series of cases reported by Braasch and Moore, one-fourth of the ureteral calculi were lodged at the ureteropelvic junction or in the upper third of the ureter : three-fourths were lodged in the lower third : of the latter more than half were in the pelvic portion of the ureter and less than one-third were lodged at the ureterovesical junction, while most of the remainder were found in the intramural part of the ureter. A calculus may move at intervals of a few hours, days, weeks, or months to a position further down the ureter. Such stones are often passed spontane- ously into the bladder, from which they are discharged with the urine. If a calculus lodges in the ureter, the mucous coat of the ureter at this point gradually undergoes pressure atrophy or necrosis : the wall of the ureter in the adjacent region becomes dilated, permitting the urine to pass around the stone. The amount of ureteral dilatation that takes place depends upon 490 GYNECOLOGY the degree of the obstruction. In well-marked cases of long standing the entire ureter above the stone becomes dilated (hydroureter), and even the kidney pelvis (hydronephrosis) may be affected. If the obstruction to the ureter is complete or nearly so, hydronephrosis with atrophy of the kidney substance may follow within a comparatively short interval. The presence of a stone in the ureter predisposes to infection, and this occurs ultimately in a large majority of the cases. Ureteritis, pyelitis, pyonephrosis, and peri- renal abscess may occur as sequelae. Symptoms. — In cases of ureteral calculus it is usually possible to elicit a history of an acute attack of sharp pain in the loin or hypogastrium, radiat- ing toward the bladder, accompanied by vesical irritability and gross or microscopic hsematuria. The pain is due to an increase of intrarenal ten- sion, the result of the urinary obstruction. The pain recurs in paroxysms and increases in severity until the stone is passed, or until the accumulated urine succeeds in forcing its way past the stone. When the stone escapes from the ureter, the attack subsides suddenly, but when the excretion of urine is diminished by the intrapelvic tension or enough dilatation of the ureter in the vicinity of the stone occurs to permit passage of the urine around it, the attack subsides slowly. As a rule, the attacks are repeated from time to time until the stone is passed, or permanent changes take place in the ureter or kidney that markedly diminish the kidney excretion or over- come the obstruction to the urinary outflow. Although the severest pain is usually felt in the loin, it is sometimes referred to the upper abdominal quadrant, and occasionally to the region of the lower ureter. Vesical irri- tability is almost invariably present during the attacks of renal colic due to ureteral calculus. In nearly half of the cases the urine is bloody, but in a very few no blood may be visible even microscopically. In the intervals between attacks the patient may be perfectly well, or there may be a feeling of uneasiness or distress in the loin or along the course of the ureter, this being increased by riding or by active exercise. The urine may be free of red blood-cells, but, as a rule, they are present coincidentally with an aggrava- tion of localizing symptoms. Sooner or later infection takes place, bacteri- uria and pyuria make their appearance, and to the symptoms previously noted may be added those of pyelitis, pyonephrosis, etc. When the acute paroxysms of pain in ureteral calculus are referred prin- cipally to the area of the lower ureter, they may simulate appendicitis, tor- sion or tubal or ovarian tumors, or the pain of tubal abortion or rupture in ectopic pregnancy. Diagnosis. — Most important and most difficult in such cases is the dif- ferentiation of ureteral colic on the right side from appendicitis. The chief points of difference between them are found in the constituents of the urine, the white blood count, and the temperature. Although an inflamed appendix that has become adherent to the ureter may give rise to sufficiently marked ureteritis to result in the appearance of blood and pus in the urine (Hunner's cases), this is most unusual, so that a catheterized urine highly charged with oxalates or urates and containing blood-cells, with or without leucocytes, points strongly to the presence of a ureteral calculus. In uncomplicated cases of ureteral colic there is no elevation of tern- i DISEASES OF THE KIDNEY AND URETER 491 perature. When the ureteral stone is complicated by infection, indubitable evidence of the condition is found in the urine (pyuria, bacteriuria, etc.). Elevation of temperature, therefore, with normal urine points to appendix involvement. Increase in the white blood-cells is not the rule in ureteral stone unless evidences of infection are present in the urine, but this increase is quite customary and almost invariably present in appendicitis (see page 106). There are other points of differentiation : For example, the pain of an appendicitis is usually most marked about McBurney's point, whereas in right ureteral colic, at the height of the paroxysms, the pain, even though most severe in the lower ureteral area, is nearly always present to some degree in the loin, and follows the course of the ureter. Bladder symptoms are almost invariably present in ureteral calculus, but are quite unusual in appendicitis. A positive diagnosis of ureteral calculus often demands cystoscopic ex- amination, ureteral catheterization, a rontgenogram, or pyelography. In some cases cystoscopic exposure of the ureteral orifice on the suspected side will reveal the presence of a stone projecting from or plugging the ureter. If the stone is higher up, it may be recognized as a point of obstruction to the passage of a ureteral catheter, either rendering difficult or absolutely pre- venting further introduction of the instrument. The Rontgen ray, as a rule, furnishes the most positive and reliable informa- tion. Before the picture is taken the bowels should be thoroughly moved with castor-oil. If, after one picture has been taken, the position of a shadow gives rise to doubt as to whether the stone is a ureteral calculus or a phle- bolith, the ureter should first be catheterized with a styletted or bismuth catheter, and then another picture taken. Stereoscopic rontgenograms are some- times required to determine whether a given shadow is due to the presence of an object within or just over the ureter. The limitations of the rontgenogram are shown by Israel's report of sixty operations for ureteral stone. In almost 12 per cent, the picture was negative in spite of the fact that a stone was present. In one case seen by Clark and Keene, the injection of the ureter with collargol prior to taking the rontgenogram greatly strengthened the shadow of a calculus that had previously not interrupted the rays to a marked degree. From this it may be seen that we have in pyelography a useful additional diagnostic measure. Kelly has advocated the passage of wax-tipped catheters into the sus- pected ureter, the presence of a stone being indicated by scratch-marks on the wax of the catheter. This procedure may be carried out in conjunction with his direct method of cystoscopy and catheterization of the ureters, or with the indirect cystoscopic examination in a water-distended bladder. " The technic which Geraghty and Hinman employ in the use of the wax- tipped catheter consists in passing the waxed end into the bladder; the butt end is threaded backward into a catheterizing cystoscope, which is then passed into the bladder over the catheter as a guide. At no time must the wax portion come in contact with the metal of the instrument. After the instrument is in the bladder the catheter is slowly withdrawn until the wax tip appears in the cysto- 492 GYNECOLOGY scopic field, when it should be carefully examined to preclude the possi- bility of its having been scratched by any of the previous maneuvers. After the examination the instrument is removed first and then the catheter. As a rule, scratches produced by the contact of a stone are very definite and unmistakable" (Clark, Prog. Med., 1916, p. 307). Treatment. — During an acute attack of ureteral colic the patient should be kept in bed, where she will unconsciously assume the most comfortable position, i.e., lie on the affected side with the knee strongly flexed on the abdomen. A vigorous purgative (castor-oil or epsom salts), supplemented, if need be, with a high enema, should be administered. Heat should be applied to the loin and to the lower anterior abdominal surface. If, in spite of these measures, the pain continues to be unbearable, hypodermic injec- tions of morphine and atropin should be given. These not only relieve pain, but also, by relaxing the ureteral muscles, apparently favor the passage of the calculus into the bladder. A ^\XNXXNN\N\N\N\\\\\N\\\\\N\\\N\\\\^ B m\Mi\^\^\\\\\\\\\\\m\YA ^^«^ Fig. 415. — Ureteral anastomosis. End to side. Van Hook's method. If the attack is especially severe, cystoscopic examination may be at- tempted. If, fortunately, the stone presents at the ureteral orifice, it may be removed, by the method subsequently to be described. If it is situated higher up, a ureteral catheter should be passed a short distance into the urethra and a small quantity of sterile oil injected. During the attack the patient should drink water freely. As the pain subsides, water should be taken in large quantities, together with a diuretic, to render the urine less acid or less alkaline, as the case may be. If a ureteral calculus presents at the ureteral orifice, attempts may be made to dislodge it by performing bimanual stroking or massage. The ureter may be located by inserting two fingers into the vagina, approxi- mating the tips of the fingers and the abdominal palpating hand along the course of the ureter and above the stone. The ureter is now stroked downwards toward the bladder, a maneuver that sometimes proves suc- cessful. The stone may be removed from the bladder with a delicate forceps passed through or alongside of a cystoscopy If the stone cannot be dislodged with bimanual manipulation, an attempt may be made to grasp it from inside the bladder with an alligator forceps. DISEASES OF THE KIDNEY AND URETER 493 If, however, the ureteral orifice is so constricted as to prevent the securing of a good purchase by the instrument or as to hinder extraction, the orifice may be dilated with a bougie or forceps. The injection of a small quantity of sweet oil into the ureter may facilitate the escape of the stone. Operative Treatment. — A stone in the ureter that is giving rise to no active symptoms may be disregarded for a time in the hope that it will pass. When it shows no tendency to do so, and all attempts to dislodge it by bimanual stroking, catheterization, or injection of oil fail; when characteristic pain persists, with no change in the position of the calculus ; and when the stone is so large as to preclude its spontaneous passage, operation is advisable. The form of operative procedure is dependent upon the location of the stone. Stone in the Upper Ureter. — The kidney and ureter are exposed by a lumbar incision and the stone is located by palpation. The ureter is sepa- rated from the surrounding fat, and a longitudinal incision I to i^ cm. in length, is made over the lower pole of the stone, which is then grasped with forceps and withdrawn. Fig. 416. — Ureterovesical anastomosis. (After Judd.) Stone at the Pelvic Brim. — The ureter is exposed by a muscle-splitting incision at about the level of the anterior-superior spine. The peritoneum is displaced mesially, and the iliac vessels are exposed. The ureter will be found close by, remaining attached to the peritoneum as it is lifted up and away from the vessels. The stone is located by palpation, the ureter is exposed, the calculus is fixed by grasping the ureter above and below, and a longitudinal incision is made directly over the upper or lower pole, which- ever one is most convenient. The stone is expressed or removed with forceps. Stone at the Pelvic Floor. — An incision is made in the semilunar line, below the anterior-superior spine. The peritoneum is pushed to the median line, and the iliac vessels and ureter are exposed. The stone is located by palpation, and one of two plans is adopted : either the stone is gently pressed upward, by palpation, to a higher level, where it can be easily reached, or the ureter is opened above the stone, at a convenient point and the stone extracted with a long, slender ureteral forceps. Stone in the Vesical Portion of the Ureter. — A stone in this situation may present many difficulties. If it is palpable per vaginam, the ureter 494 GYNECOLOGY should be exposed by an incision through the vaginal wall, the ureter opened by a longitudinal incision, and the stone extracted. When the stone is not palpable per vaginam, the ureter should be ex- posed extraperitoneally by an incision in the semilunar line. The dissection of the ureter is carried down to the point where the ureter passes beneath the uterine vessels. The latter are hooked up on the finger, tied in two places, a centimeter apart, and divided. The ureter can then be safely ex- posed in its lowest part. A longitudinal incision is made, and the stone extracted. Counter-pressure in the vaginal vault and base of the bladder by an assistant may greatly facilitate this procedure. Stone in the Intraparietal Ureter. — If a stone in that portion of the ureter that is situated in the bladder wall can plainly be felt per vaginam, it should be dealt with by division of the vaginal wall, dissection of the base of the bladder and terminal ureter, incision, and extraction. Fig. 417. — Method of implanting ureter into the intestine. (After Stiles.) When attack from below promises to be difficult, a transvesical exposure of the ureter may be made, after exposing the trigone by a suprapubic extra- peritoneal incision. But in most cases in women the procedure of choice consists in vaginal cystotomy with the patient in the knee-chest position. The incision through the vesicovaginal septum is made in the midline, about half-way between the internal ureteral orifice and the cervix. The position of the calculus is then determined by palpation, after which the correspond- ing area of the mucosa is exposed by means of suitable retraction. An in- cision is then made either through the rim of the ureteral orifice or close to the orifice in the line of the ureter, and the stone extracted. Closure of the vesicovaginal incision and the institution of continuous drainage of the bladder for a few days complete the operation. In all operations for stone in the ureter the periureteral sheath and its blood supply must be carefully conserved. When the stone is located it should be fixed by making compression of the ureter above and below, either by light, rubber-covered clamps or by the fingers of the operator or his assistant. DISEASES OF THE KIDNEY AND URETER 495 The ureteral incision should always be as small as will suffice for the ex- traction of the calculus, and always placed exactly in the median line. In every instance an attempt should be made to coapt the edges of the ureteral incision with a suture of fine catgut that includes the periureteral sheath and the muscular coat of the ureter, but not the mucosa. In extraperitoneal operations the wound should be drained for a few hours, but care should be taken that the drain does not come in contact with the ureter. After vaginal exposure of the ureter the vaginal incision should be closed with interrupted sutures. STRICTURE OF THE URETER Etiology. — Stricture of the ureter has been attributed to a variety of causes, among which may be mentioned congenital narrowing ; ureteritis from Fig. 418. — Method of implanting ureter into the intestine. (After Stiles.) the ordinary pyogenic organisms, the gonococcus, and the tubercle bacillus ; healing of a ureteral fistula following injury incident to labor, the Wertheim operation for carcinoma of cervix ; direct trauma, syphilis, and infection of the cervix. Hunner, who has made an exhaustive study of the subject, although admitting that any of the foregoing factors may play an active role in the etiology of ureteral stricture, is convinced that " the majority of ureter strictures, excluding those of tuberculous origin, should be classified as simple, chronic stricture ; they originate in an infec- tion carried to the ureter walls from some distant focus, such as diseased tonsils, sinuses, the teeth, or gastro-intestinal tract." " This conception of stricture," he asserts, " postulates that in the majority of cases ureter infil- tration is primary, and that the other urinary tract lesions, so often asso- ciated with stricture, such as stone in the ureter, hydronephrosis, pyelitis, and pyelonephrosis, are secondary." Symptoms. — Pain (i.e., nagging discomfort) at the site of the stricture is usual. With this there may be pain radiating upward toward the kidney, 496 GYNECOLOGY laterally into the hips or groin, posteriorly, simulating a sacroiliac joint condition or sciatica, and downward into the thigh and leg in front or back. There is also in many cases intermittent pain in the kidney region, due to overdistention of the kidney pelvis. Bladder discomfort and frequency of urination are quite common in connection with the recurring renal attacks. Fever, chills, and leucocytosis, as in pyelitis, may occur intermittently when active urinary infection is present and the obstruction for some reason becomes more marked. Infected cases may go for weeks or months with- out chills or appreciable fever, the only symptoms being malaise and gen- eral depression. In rare cases febrile symptoms may be present when there is no infection of the urine ; in one case of this sort reported by Hunner the symptoms subsided after tonsillectomy had been performed. If there is an associated pyelitis, the urine displays the pathologic find- ings and variations common to that condition. If there is no urinary infec- tion, a few leucocytes or erythrocytes or both may, nevertheless, be found, or the urine may be quite normal. Gastro-intestinal symptoms are common, and consist of slight nausea and aversion to food or extreme and persistent nausea and vomiting, gase- ous distention, rectal tenesmus, and frequent desire to defecate, with pain just before or during the stool. As a result of the stricture colitis may occur. General symptoms indicative of disturbed kidney function have been noted, such as headache, nausea, etc., and in some cases morbid mental conditions have been observed. Pathology. — The inflammatory area varies from a slight, annular thick- ening in the wall of the ureter to a diffuse cartilaginous thickening that may be several centimeters in length and a centimeter in diameter. Multiple annular strictures are not uncommon. Associated with this condition there may be periureteritis; thus Hunner states that at operation he has often been unable to determine by palpation whether he is dealing only with a stricture or with a stricture plus stone. In by far the greatest number of cases the site of the stricture is in the broad ligament region, within 6 cm. of the bladder; the next most frequent location is at the bifurcation of the internal iliac vessels, or about 8 to io cm. above the bladder (3 to 5 cm. below the pelvic brim). In a series of 100 cases, 70 were unilateral and the remainder bilateral. As regards the coexistence, in these cases, of urinary stasis, dilatation of the kidney pelvis, and urinary infection, which Hunner believes are secondary to stricture formation, an analysis of his cases showed that of the first 50 (an examination of urine for pus and cultures was not made in all) there were 16 non-infected and 18 infected cases (colon, 13; staphylococcus, 4; typhoid, 1). The average capacity of the kidney pelvis in the non-infected group was 19 c.c. ; in the infected cases it was 98 c.c. (the average normal capacity is from 6 to 8 c.c.) ; the average duration of symptoms was greater in the first than in the second group. In the second group of cases, which were all studied bacteriologically, 11 were infected (colon, 8 ; staphylococcus, 1 ; streptococcus, 1 ; unidentified, 1). Four of the infected cases showed a pelvic capacity ranging from 15 to 20 c.c; the average pelvic capacity was 16 c.c. The average duration of symptoms in the infected cases was shorter than in the non-infected. DISEASES OF THE KIDNEY AND URETER 497 Hunner believes that many ureteral stones are unquestionably caused by ureteral stricture and are formed at the site of constriction. Diagnosis. — The diagnosis is based on the symptoms previously noted. In addition, local tenderness over the ureter at the pelvic brim may be elicited by palpation. In the vast majority of cases vaginal palpation will show the greatest tenderness in the broad ligament region, and at times the enlargement of the ureter can be detected. Cystoscopy is usually negative, but urethral stricture is quite often found. In Hunner's last 28 cases of ureteral stricture 27 had stricture of the urethra. When the stricture is in the bladder Avail region, slight redness and oedema may be found about the ureteral orifice. The decisive test is made by passing a wax-bulbed ureteral catheter. It is not the obstruction that is met on introduction, but the " hang " or catch of the wax bulb upon withdrawal of the catheter from the ureter, that is the determining factor. Pyeloureterograms after a sodium bromide or a thorium injection are useful, especially when the ureteral catheter cannot be made to pass the obstruction. Treatment. — The ideal method of treatment has for its object dilatation of the stricture from below. For this purpose ureteral catheters of various sorts and sizes may be used, either armed with a waxed bulb (pure bees- wax) or plain. In strictures of small caliber the passage of the catheter is often difficult or impossible. In these cases the olive, round-point, and whistle-tip catheter should be tried in succession. If all fail, a whalebone filiform bougie should be introduced to the point of obstruction, succeeded by another and still another until one finally engages in the lumen and passes through. This last filiform should be left in place and a smaller catheter be tried. Waxing the end of the catheter may facilitate its intro- duction, especially if the wax is given a corkscrew configuration and rotated as it engages the obstructed area. Dilatation of the stricture should be made either with plain catheters or with catheters with waxed bulbs of increasing size. For the first dilatation Hunner advises a waxed bulb no larger than 3 to 5 mm. ; even at later periods the maximum size should not exceed 5 to 6 mm. The treatment should not be repeated oftener than once in ten days. thus permitting the traumatic oedema that follows the dilatation to subside. When pyelitis is present, lavage may be practised at ten-day intervals until some dilatation has been effected, when it may be employed oftener (twice a week). If the condition is bilateral, both sides should not be treated at the same sitting. When the stricture cannot be dilated from below, and especially if it is situated high up. some form of ureteroplasty may be required. A valve- like obstruction at the ureteropelvic junction, such as is seen in floating kid- ney, may sometimes be overcome by suspension of the kidney. Retrograde dilatation will often be more useful than ureteroplasty. The ureter is exposed by operation above the obstructed point, and cathe- ters or sounds of increasing size are passed downward through the stricture, dilating it from 5 to 7 mm. After this operative dilatation the stricture can usually be passed from below. Obstruction of the Ureter. — Obstruction of the ureter may be caused by compression due to a pelvic growth pressing; upon or invading its walls and 32 498 GYNECOLOGY sheath, as, for example, myomata of the uterus (especially the intraligament- ous and subvesical varieties) or carcinoma of the cervix or neighboring organs, which involves the cellular tissue in the bases of the broad ligaments. The condi- tion is slow in onset and may escape observation, being merged in the symptoms of the pelvic lesion producing the obstruction. In such cases it aggravates the condition of the patient and may be a very potent factor in hastening her decline. Thus, for example, obstruction of the ureter due to carcinomatous infiltration, often gives rise to no striking symptoms, and yet the gradually developing hydroureter, hydronephrosis, diminution in kidney function, and uraemia are solely due to the obstruction. This may also be true, but to a lesser degree, of a myoma or of any tumor that presses upon the ureter. Symptoms. — The symptoms that first attract attention to the condition are usually those of pyelitis, which occurs secondarily to the obstruction, and which will subside as soon as the obstruction is removed. Treatment. — The treatment of obstruction of the ureter from all these causes is the treatment of the provocative lesion. URETERAL FISTULA See Urinary Fistulse (Chapter XXIV, page 463). URETERAL LIGATION See Post-operative Complications — Suppression of Urine (Chapter XXXVIII, page 686). URETERAL TEAR OR INJURY See General Operative Technic — Injury to Viscera During Operation (Chapter XXX VI, page 642). BIBLIOGRAPHY Bacharach, R. : " Nephrektomie bei bilateraler Tuberkulose." Zeitsch. f . Urol., 1914, viii, 98. Binney, Horace: "The Value of High-Frequency Current in the Treatment of Vesical Papillomata." Boston Med. and Surg. Jour., 1913, clxviii, 308. Bissell, D. : "The Surgical Treatment of the Tubercular Ureter in the Female.'' S., G. and O., No. 5, 1915, xxi, 615. Braasch, Wm. F., and Moore, A. B. : " Stones in the Ureter." J. A. M. A., 1915, lxv, 1234. Cabot, H. : " Stone in the Kidney and Ureter." J. A. M. A., 1915, lxv, 1233. Cabot, H., and Crabtree, E. G. : " The Etiology and Pathology of Non-Tuberculous Renal Infections." S., G. and O., 1916, No. 5, xxiii, 495 ; Ibid. : " The End-Results of Seventy Cases of Renal Tuberculosis Treated by Nephrectomy." S., G. and O., 1915, No. 6, xxi, 669. Clark, J. G., and Block, F. B ; : " Ultimate Results Following Nephropexy in Cases of Symptomatic Nephroptosis." Annals of Surgery, 1917, lxvi, 479. Clark, W. L. : " The Uses of Desiccation Surgery in Gynecology." Am. Jour. Obst, 1915, lxxii, 63. David, V. C. : "A Bacteriologic Study of Fifty Cases of Non-Tuberculous Diseases of the Bladder and Kidney." Surg., Gynec. and Obst., 1914, xviii, 432. Dietl: "Wandernde Nieren und deren Einklemmung." Wien. med. Wochenschr., 1864, Bd. xiv. Edebohls : " The Technic of Nephropexy." Annals of Surgery, 1902, xxxv. Eisendrath, D. N., and Kahn, J. V. : " Role of the Lymphatics in Ascending Renal In- fection." J. A. M. A., 1916, lxvi, 561. Ellis, E. G., with W. W. Keen and G. E. Pfahler : " On Hypernephroma." Amer. Med., 1904, viii, 1039. Fenger: "Conservative Operative Treatment of Sacculated Kidney-Cystonephrosis." An- nals of Surgery, June, 1896, xxiii. Garceau, Edgar : " Treatment of Tubercular and Non-Tubercular Cystitis in the Female." Amer. Jour. Obst., 1907, lvi, 289. DISEASES OF THE KIDNEY AND URETER 499 Geraghty, J. T. : "The Treatment of Chronic Pyelitis." J. A. M. A., 1914, lxiii, 2211. Geraghty, J. T., and Hinman, F. : " Ureteral Calculi ; Special Means of Diagnosis and Newer Methods of Intravesical Treatment." Surg., Gynec. and Obst, 191 5, No. 5, r xx, 515. Glenard : Les ptoses viscerales (estomac, intestin, rein, foie, rate) diagnostic et noso- graphie (enteroptoe, hepatisme). Paris, 1899. Hahn : " Die operative Behandlung der beweglichen Niere durch Fixation." Cent. f. Chir., 1881, Bd. viii, No. 29. Hunner, G. L. : "Ureter Stricture in Women." Trans. Amer. Gyn. Soc, 1917, xlii, 520; Ibid. : " Chronic Urethritis and Chronic Ureteritis Caused by Tonsillitis." Jour. Amer. Med. Asso., 191 1, lvi, 937; Ibid.: "The Diagnosis of Renal Calculus." Jour. Amer. Med. Asso., March 24, 1906; Ibid.: "Surgery of Urinary Tuberculosis in Women." Amer. Medicine, vii, No. 18, 701-707, April 30, 1904; Ibid.'. "Treatment of the Renal Pelvis and Ureter by Means of the Renal Catheter." Trans. Amer. Urological Asso., 1909; Ibid.: "The Diagnosis and Treatment of Obscure Cases of Pyelitis and Hydro- nephrosis." International Clinics, iv, 22d Series ; Ibid. : " Malposition of the Kidney." Charlotte Medical Journal ; Ibid. : " Ureteral Stricture — Report of 100 Cases." Johns Hopkins Hospital Bulletin, January, 1918, No. s 2 3, xxix : Ibid.: "Tuberculosis of the Urinary System in Women." Johns Hopkins Hospital Bulletin, 1904, xv, 8 : Ibid. : Diseases of the Bladder and Urethra." Kelly-Noble, Gynecology and Abdominal Surgery, i, 438, 1907, W. B. Saunders Co., Phila. Israel, J. : " tiber Operationen wegen Uretersteinen." Folio Urologica, 1912, vii, 1 ; Ibid. : Chirurgische Klink der Nierenkrankheiten. Berlin, 1901. Kelly, H. A., and Burnam, C. F. : The Diseases of the Kidneys, Ureters and Bladder. D. Appleton & Co., N. Y. and London, 1914. Koll, I. S. : " The Experimental Effect of the Colon Bacillus on the Kidney." Jour. Amer. Med. Asso., 1915, lxiv, 297. Kretschmar, H. L., and Gaarde, F. W. : " The Treatment of Chronic Colon Bacillus Pyelitis by Pelvic Lavage." Jour. Amer. Med. Asso., 1916, lxvi, 2052. Kummell: " Modern Surgery of the Kidney." Surg., Gyn. and Obstet., January, 1907. Kuster: "Die Chirurgie der Nieren." Lief 52 b., Deutsche Chirurgie, Stuttgart, 1896. Montgomery, E. E. r Practical Gynecology. Blakiston, Phila., 1907, 2nd Edition, 920. Morris : Surgical Diseases of the Kidney and Ureter. London, 1901. Mayo, Wm. J. : " The Removal of Stones from the Kidney." Surg., Gyn. and Obst., 1917, xxiv, 1 ; Ibid. : " Procedures Following Nephrectomy." " The Managemnt of the Ureter After Nephrectomy for Tuberculous Kidney." Jour. Amer. Med. Asso., 1915, lxiv, 954, 957- Morton, J. J. : "A Rapid Method for the Diagnosis of Renal Tuberculosis by the Use of the X-rayed Guinea-pig." Jour. Exper. Med., 1916, xxiv, 419. Noble: " Some of the More Unusual Results of Movable Kidney." N. Y. Med. Jour., 1904, lxxix, 341. Oppenheimer, R. : " Die Pyelitis." Zeitschr. f . L T rol. Chir., 1913, i, 17. Pawlik, Carl: " Ueber die Harnleitersondirung beim Weibe." Archiv f. Klin. Chir., 1886, xxxiii, 717-739- Schede: Diseases of the Kidney. System of Surgery by v. Bergmann, edited by W. T. Bull, Phila., 1904, 262. Schenck : " Renal Hematuria of Unexplained Origin." Med. News, 1904, lxxxv. Stewart, D. D., and Kelly, A. O. J. : " On the Occurrence of Primary Tuberculosis of the Kidney, with Special Reference to a Primary Miliary Form." Med. News, August 14-21, 1897, 193- Sweet, J. E., and Stewart, L. F. : " The Ascending Infection of the Kidney." Surg., Gyn. and Obst., 1914, vol. xix, 195. Taussig, F. J. : " Urethral Bacteria as a Factor in the Etiology of Cystitis in Women." Amer. Jour. Obst., 1906, liv, 465. Walker, G. : " Tuberculosis of the Kidney." Kelly-Noble, Gynecology and Abdominal Surgery, ii, 783. Walker: "Renal Tuberculosis." Johns Hopkins Hospital Reports, 1904, xii. Watson, B. P. : " Primary Malignant Tumors of the Female Urethra." Amer. Jour. Obst., 1914, lxix, 795. CHAPTER XXVI DISEASES OF THE ABDOMINAL VISCERA RELATED TO, OR ASSOCIATED WITH, PELVIC DISORDERS Introduction. — The treatment of pelvic disorders by operation will fre- quently reveal lesions of the neighboring abdominal organs that demand immediate relief. Certain diseases of the suprapelvic or true abdominal viscera may give rise to symptoms that closely resemble those that are entirely pelvic in origin. The proper differentiation of the former from the latter, the recognition of disorders within the true abdomen in connection with pelvic disorders, and the complete and satisfactory management of the entire intrapelvic and intra-abdominal derangement, whatever it may be, require a familiarity with the symptoms, differential diagnosis, and treat- ment of the diseases of the entire abdominal viscera. In this volume our discussion will be limited to those organs situated near the pelvis and most frequently associated with pelvic diseases, i.e., the appendix, sigmoid flex- ure, and the rectum; appended to this is a discussion of the subject of visceroptosis, a condition that is more frequent in women than in men. APPENDICITIS Involvement of the Appendix in Pelvic Disease. — Involvement of the appendix is frequently associated with intrapelvic disorders, particularly with those of an inflammatory nature. In the latter case the participation of the appendix in the process is usually altogether a secondary matter, and only the outer coats of the appendix are involved — periappendicitis. The mucosa is unaffected except indirectly, by reason of the interference with its blood supply or with the continuity of its lumen because of angulation re- sulting from adhesions. The appendix suffers because it is in bad company. Secondary involvement of the right adnexa after a primary appendicitis is less common. This is due to a number of reasons: First, because opera- tion is usually undertaken at an early stage in appendicitis and the diseased organ is removed ; secondly, in neglected or perforating cases with spreading peritonitis, death ensues or recovery follows appendicectomy and drainage. The source of infection having been removed, the inflammatory process in the neighborhood rapidly declines, the inflammatory exudate is absorbed, and no permanent evidence whatever, or at most but a few adhesions imme- diately about the caecum, may be left behind. An appendiceal abscess may gravitate into the pelvis, especially if the appendix originally was unusually long or the caecum particularly low, in which event the ovary and the tube may be involved for a time. After evacuation of the abscess and drainage, the disorder will, in a majority of cases, rapidly subside and may leave no permanent mark. In some instances, nevertheless, chronic pelvic inflamma- tory disease is secondary to a previous attack of pelvic peritonitis compli- cating appendicitis (see Chapter VI, p. 96). The lesions consist of adhe- 500 DISEASES OF THE ABDOMINAL VISCERA 501 sions between the uterus, adnexa, and pelvic peritoneum, closure of the tubes, thickening of the ovarian capsule, and cystic degeneration of the ovary. Secondary involvement of the appendix is more frequent after primary adnexitis, since in a vast majority of the latter cases the process is slower and runs a protracted course, during which the pelvic peritonitis with its exudate is likely to involve every structure lying within or at the brim of the pelvis. Infection sometimes extends to the appendix from the broad ligament along the right infundibulo-pelvic ligament. Appendicitis may be acute or chronic. The differential diagnosis between appendicitis and in- flammatory lesions of the right adnexa is of great importance. Differential Diagnosis Between Acute Appendicitis and Acute Adnex- itis. — The differential diagnosis is based upon a careful estimate of the history, symptoms, signs, and course of the disease. The history will show that an acute appendicitis is often preceded by digestive disturbances. It is more prone to come on without any preceding disability than are adnexal disorders. The onset frequently follows over- indulgence at the table, the ingestion of unwholesome food, and neglect of the bowels. The onset bears no relation to the menstrual periods, mis- carriage, or labor. Acute salpingitis and acute ovaritis are usually preceded by evidences of pelvic disturbance such as irritable bladder, leucorrhcea, disorders of menstruation, backache, etc. Inflammatory attacks most often take place about the time of the menses and shortly after abortion or labor. The symptoms of acute appendicitis consist, first, of pain in the epi- gastrium, nausea, vomiting, etc. ; later there are a localization of pain and tenderness about McBurney's point, and rigidity and spasm of the right rectus muscle, the pain is relieved by flexion and increased by extension of the right thigh. The temperature may be decidedly elevated (ioi° to 102 F.), but is fre- quently not much above normal (99° to ioo° F.) ; the pulse is affected more often than the temperature (90 to 120) ; nausea, vomiting, and constipation usually are marked; leucocytosis is rarely lower than 15,000, and may be 20,000 or 25,000. In right adnexitis the pain is lower, nearer the median line, and may extend to the left side ; nausea and vomiting are less severe, but distention with gas probably more marked ; vesical or rectal irritability and pain are more frequently present, and the rigidity and tenderness affects the entire lower abdomen. Although flexion of the thighs relieves the pain, and ex- tension increases it, the movement of the right thigh alone does not so directly affect the pain as in appendicitis. The temperature is usually high (101 to 103 F.), and the pulse-rate correspondingly increased (100 to 130) ; the leucocytes are increased, but usually to a lesser degree in gonorrhoeal infections (10,000 to 15,000), and to a greater degree in post-abortal or post-partal ones (20,000 to 40,000). Streptococcus, staphylococcus, and colon bacillus infections almost invariably follow septic abortion or labor, or intrauterine manipulations, so that the history is especially important in making the diagnosis. The physical signs are of great value. The tenderness of acute appen- 502 GYNECOLOGY dicitis is usually higher (McBurney's point) than in adnexitis, and more likely to extend to the right flank or upward toward the hypochondrium. The tenderness of adnexitis, as stated, is lower (just above Poupart's liga- ment), extending toward the median line to the opposite side, and to the front or the back of the thigh. A palpable mass above the pelvic brim on the right side is more likely to indicate an inflamed appendix than an in- flammatory enlargement of the right adnexa which is not detectable, as a rule, by simple palpation through the abdominal wall. Upon inspection of the genitalia in gonorrhoeal cases, one finds pus in the urethra or in Batholin's glands, or in a profuse, irritating, purulent dis- charge from the cervix ; in infections following labor or abortion, there may be recent abrasions, lacerations, ulceration, and false membrane. In the early stage, if the attack is an initial one, bimanual pelvic exami- nation may disclose nothing more than great tenderness, local heat, and swelling. The adnexa cannot be palpated because the abdominal wall is too rigid and the resistance of the patient is too great. The uterus may be found to be slightly enlarged, very tender, and somewhat fixed. In the course of from twenty-four to thirty-six hours the physical signs in the pelvis undergo a change. By this time there is less impediment to palpation, and the struc- tural changes that have occurred can be recognized. The uterus is fixed, the vaginal vault is hard, infiltrated, and very tender, and the evidence of pelvic exudate and inflammation are unmistakable. As regards the course of the disease, the symptoms of an adnexal inflam- mation rapidly subside, as a rule, under conservative treatment (see pages 414- 416). By the end of twenty-four hours the pain will begin to diminish, the distention grow less, the fever and the pulse-rate be reduced, and the patient be decidedly on the mend. This is true, for the most part, of gonorrhoeal infections, but may not be so of a serious streptococcus infection. Since, however, the history or examination makes the evidences of the latter in- fection so clear, they need not be discussed here. While it is undoubtedly true that the milder forms of appendicitis frequently subside under appro- priate treatment, in appendix inflammations of the severe type, a subsidence is less likely to take place, the rigidity, tenderness, distention, and slight elevation of temperature and pulse continue, while the leucocyte count steadily rises. A word of caution must be spoken regarding the significance of a sudden relief from pain in bad cases of appendicitis. It often means that perforation has taken place. If this possibility is remembered, the flushed face, coated tongue, tender abdomen, gaseous distention, limita- tion of peristalsis, increased pulse-rate, etc., will leave no doubt in the mind of the examiner as to the true state of affairs. Treatment; — If appendicitis is positively diagnosticated and the patient is seen at the very onset and is in favorable condition, operation should be performed at once. In mild cases, if. the patient objects to operation or desires to postpone it until a more convenient time, palliative measures may be adopted for from twelve to twenty-four hours. When cases are seen late, the treatment should be modified according to the conditions that are found. If there are evidences of a spreading peri- tonitis, progressive distention, limitation of peristalsis, increase in pulse-rate DISEASES OF THE ABDOMINAL VISCERA 503 and in the number of leucocytes, etc., operation should be performed at once. If tumor formation has occurred and there are no indications of a diffuse peritonitis, the case may be treated expectantly for a few hours, in order to determine, as nearly as possible, whether the condition is advancing or retrogressing. If the symptoms do not abate, operation is indicated. Not infrequently the symptoms remain in abeyance or tend to subside, and the tumor shrinks and finally disappears, or nearly so. In such cases operation should invariably be advised, but a later date selected. The ad- vantages gained by waiting are a clean operation, less danger of spreading infection, fewer adhesions, and less trauma to the intestine. Every surgeon of experience has regretted operating in the stage of plastic exudate, when the appendix is buried and both it and the surrounding intestines are friable and difficult to handle. If the operation is performed two months later, when the process has subsided, it becomes as simple as the interval opera- tion of a recurrent catarrhal appendicitis. The palliative treatment of acute appendicitis comprises rest in bed, abstinence from food, and the application of an ice-bag to the right iliac fossa. If distention is distressing, the lower bowel may be emptied by a small enema (i pint), by the passage of a rectal tube, or by the exhibition of suppositories of asafetida. No cathartics should be administered. In cases seen later, with tumor formation but without evidences of spreading peritonitis, abstinence from food, the Fowler position, proc- toclysis, and the application of an ice-bag to the affected area should be prescribed. After the symptoms have begun to subside, resolution may be hastened by the application of heat. The bowels may be moved daily by means of a small, carefully given enema, and the return to food be begun very cautiously and the diet increased only as the symptoms continue to subside. Only after complete subsidence has occurred is the administration of a cathartic permissible. CHRONIC APPENDICITIS Chronic appendicitis is usually a low-grade inflammation, the sequel to an acute attack. It may develop without acute manifestations. The appendix may be elongated and hypertrophied, adherent, kinked, and distended with gas or with fecal concretions. Whatever the pathologic con- dition, there is interference with the normal drainage of the appendix into the caecum or with the peristaltic action of the neighboring intestine. Symptoms and Diagnosis. — The symptoms of chronic appendicitis con- sist of pain and soreness about McBurney's point, general abdominal dis- tention and flatulence, diarrhoea, and constipation. Indiscretions in diet, neglect of the intestinal functions, and overexertion usually increase the symptoms. A rigid enforcement of dietary regulations, a daily laxative, and avoidance of exertion tend to diminish them. When the appendix is adher- ent to the pelvic structures, the recurring menstrual function may cause a periodic aggravation of symptoms, due to a congestion in the blood supply. Differential Diagnosis Between Chronic Appendicitis and Chronic Ad- nexitis. — A differential diagnosis between chronic appendicitis and a lesion of the right tube and ovary may be necessary when the appendix is low and 504 GYNECOLOGY the ovarian or tubal disturbance consists merely of adhesions to the sur- rounding structures. Such attachment of the tube and ovary may be diffi- cult to diagnose if the adnexa are not enlarged and if they retain a fair degree of mobility. In the case of adnexal disease the symptoms are usually more marked at the menstrual periods. If the lesion is in the appendix, there is a predominance of the intestinal symptoms, tympanites, flatulence, occasional abdominal distress after eat- ing, constipation, and diarrhoea. Fig. 419. — Appendicectomy: (A) ligation of meso-appendix; [B) ligation of appendix and line of divi- sion of meso-appendix; (C) circular suture with loop at vascular area; (.D) inversion of stump; (E) stump of meso-appendix drawn over inverted base. In adnexal lesions, chronic pelvic symptoms, backache, irregular menses, dysmenorrhoea, vesical irritability, leucorrhcea, etc., are more prone to occur. Bastedo's sign (the production of pain in the appendix region on disten- tion of the colon with air) may be looked for. When both the appendix and the adnexa are involved, the symptoms of both conditions are combined. Recurrent exaggeration of appendix symp- toms at the menstrual periods is often indicative of adhesions between the right adnexa and the appendix. DISEASES OF THE ABDOMINAL VISCERA 505 When a positive differential diagnosis can be made only with difficulty, examination under anaesthesia may be useful. The complete relaxation thus obtained permits detection of even slight enlargement or restriction of mobility of the adnexa. OPERATIVE TECH NIC The treatment consists in appendicectomy. This may be performed in a number of ways, as may be seen from the accompanying illustrations. The operation is a simple one except when the appendix is densely adherent. In performing operations upon acute cases, with spreading peritonitis, several important points must be borne in mind : i. The patient should be kept in the elevated (semi-Fowler) position before, during, and after the operation. 2. A right rectus (Battle's) incision, of ample proportions to give a good exposure, should be made. 3. The appendix should be located by palpation and exposed by packing the intestines away from the appendix area with gauze wrung out of hot salt solution. 4. The appendix should be removed by the simplest method, and no attempt should be made to peritonealize the stump unless the caecum is not involved and the procedure can be easily and rapidly carried out (Figs. 419 and 420). 5. Drainage should be provided by rubber tubes with gauze wicks — ■ one going to the bottom of the pelvis, and the other to the right iliac fossa. The gauze packs should be left in situ until the drains are placed in position. 6. The peritoneum may be closed by continuous suture, but the fascia and skin should be closed with interrupted sutures placed a good distance apart, so as to encourage free external drainage. Most of the sutures should be of catgut, but a few supporting sutures of silkworm gut should also be used. 7. Nitrous oxide-oxygen-ether anaesthesia gives the best results. 8. Continuous enteroclysis and postural drainage (Fowler or semi- Fowler position) should supplement the operative treatment (for man- agement of drains see page 661). INTESTINAL STASIS Acute Intestinal Stasis. — Acute intestinal stasis, or acute intestinal ob- struction, is rare as a complication of pelvic disease, and its differentiation from pelvic disorders is not often demanded. Disease originating in the pelvis very rarely produces an acute obstruction of the alimentary canal. That acute obstruction may follow pelvic operations is true, and such a condition is discussed on page 680. Certain forms of acute intestinal ob- struction, as, for example, intussusception, volvulus, etc., are prone to occur at the extremes of life, when acute pelvic disorders, with the possible exception of twisted pedicles, may be excluded. It is remarkable that pelvic inflammatory disease and pelvic tumors, although they encroach upon or compress or bind with adhesions the large and small intestinal loops that are found in the pelvis, almost never cause more than moderately 506 GYNECOLOGY ^v- Fig. 420. — Appendicectomj*. _ Clark's method. (A) Ligation of meso-appendix; (B) division of meso-appendix and crushing of base; t-he appendix is cut away close to the clamp with a cautery knife; (C) inversion of stump; (D) sero-serous suture. DISEASES OF THE ABDOMINAL VISCERA 507 severe and rapidly subsiding indications of acute obstruction of the intes- tinal tract. For a discussion of the varieties, causes, etc., of acute intestinal stasis the reader is, therefore, referred to works on abdominal surgery. The symptoms and treatment of the condition, so far, at least, as they apply to the post-operative complications of intestinal obstruction, will be found in Chapter XXXVIII. Chronic Intestinal Stasis. — Chronic intestinal stasis frequently occurs in women. It may be the result of intrinsic pelvic disease, enteroptosis, re- dundancy, overdistention and angulation of certain parts of the intestinal tube, and intestinal adhesions. Chronic Intestinal Stasis from Pelvic Diseases. — Pelvic diseases are fre- quently responsible for chronic stasis of the intestinal tract. The inter- ference with the function of the bowel may be due to direct compression of the large intestine by pelvic tumors, as in the case of nbromyomata of the uterus, or by reason of pelvic exudates or adhe- sions that bind the intestinal loops to- gether or to adjacent structures, and pro- duce angulation. It is often a source of wonder to the pelvic surgeon that the dis- tortion or compression of the intestines within the pelvis met so frequently with inflammatory lesions has not given rise to acute obstructive symptoms. Relaxa- tion of the pelvic floor, with rectocele and impairment of the forces normally en- gaged in defecation, is a frequent source of chronic engorgement of the rectum and sigmoid. Chronic Intestinal Stasis from Ente- roptosis. — Enteroptosis is frequently seen in women who have borne children, and is commonly associated with a relaxed and pendulous abdomen. In a certain proportion of cases it con- stitutes a developmental defect, being the result of ill nourishment during adolescence or earlier life, insufficient exercise, improper clothing, faulty habits of work, etc. Whatever the cause, the end-result in one case has certain features common to all other cases. In the normal individual the shape of the abdominal and the pelvic cavity on sagittal section is grossly triangular (Fig. 421), the base of the triangle being directed toward the diaphragm. In the erect position the posterior abdominal wall is consid- erably inclined forward. This furnishes a sort of shelf from which the mesenteries and retroperitoneal supports arise, and upon which the viscera find partial support. The preservation of this triangle depends largely upon the strength and tonicity of its anterior face, viz. the anterior abdominal wall. In individuals of poor general muscular development this may be flabby and relaxed, or it may have undergone atrophy from disuse and pressure after the individual began to wear corsets ; or its strength may have become impaired by overstretching, as in pregnancy, or by the presence of > r- Diaphragm --/---Spin&l Column -II ice Crest Fig. 421. — Triangular shape of the abdominal cavity on sagittal section. (After Dickinson.) 508 GYNECOLOGY an abdominal tumor. Defects in body, form, or posture affect the inclination of the posterior abdominal wall, which becomes almost vertical. This takes away a certain amount of support from the abdominal viscera, which then display a tendency to slide downward. Intestinal stasis from enteroptosis is less likely to occur when the ptosis affects all the abdominal viscera than when it is limited to certain parts of the intestinal tract. If all the viscera are equally ptosed, without adhesions (Fig. 422), angulation and kinking of the intestinal tube may not occur. Diaphragm — ._ Anterior surface of stomach G&stro-splenic I I Ligament rl Post surface of Stomach — Transverse Meso-colon Transverse colon — I Tcvi\ of P&ocreos Duodenum Left "kidney ""-Sigmoid Small intestine Fig. 422.— General ptosis. Sagittal section through left side of abdominal cavity showing absorption of extraperitoneal fat and the downward displacement of all abdominal organs constituting a general ptosis. The belly is pendulous, the lumbar curve is gone and the patient has assumed the "carry- ing position." C After Coffey.) When only a part is ptosed, the other parts being fixed or held in their normal position, angulation and obstruction are quite the rule. The most common variety of partial enteroptosis is midline ptosis — that is, the trans- verse colon and the middle part of the stomach are prolapsed below their normal level (Fig. 423)- The pyloric and the cardiac ends of the stomach and the duo- denum, as well as the splenic flexure of the colon, remain fixed. Partial enteroptosis may affect also the caecum (Fig. 424) (caecum mobile) and the ascending loop of the colon, under which conditions, par- DISEASES OF THE ABDOMINAL VISCERA 509 ticularly, obstruction may occur at the splenic flexure or at the ileocecal junction. Partial enteroptoses are frequently associated with ptosis of the right kidney. When both kidneys are involved, all the abdominal viscera are prolapsed. Redundancy, Kinking, and Overdistention of the Colon. — Redundancy and overdistention of the colon may result from constipation, the frequent Fig. 423. — Midline ptosis. Middle pyloric portion of stomach and transverse colon prolapsed while the fixed points at the esophagus, duodenum and colonic flexures, as well as the kidneys, remain in normal position. (After Coffey. ) use of enemas, or atony of the intrinsic muscle of the intestinal coats. As seen clinically, it is often difficult to decide whether the condition of the bowel is the cause or the result of the symptoms that are present. What- ever its significance, the affected portion of the intestine is distended, its walls are thinned out and atonic, increased in length, and therefore abnor- mally coiled and angulated. The sigmoid is the part of the intestinal tract that is most often redundant and overdistended, but the entire colon — de- scending, transverse, and ascending — may be affected. In advanced cases 510 GYNECOLOGY of intestinal stasis due to enteroptosis this is usually the case, especially it the subject has been neglectful as regards the intestinal function and is of a relaxed, asthenic habit. Chronic Intestinal Stasis from Adhesions Between Intestinal Loops or Between the Intestinal and the Parietal Peritoneum or the Mesenteries or Omentum. — Such adhesions may be congenital or acquired, and are found in various situations : First: About the ileocecal junction, involving especially the terminal portion of the ileum. The adhesion may take the form of an accessory mesentery, attaching the normally free surface of the ileum to the peritoneum of the iliac fossa or pelvis, or to the intrinsic mesentery of the ileum itself, or a band of adhesions may form be- tween the ileum and the pelvic organs or the caecum ; or the ileum may be rolled, as it were, in its own mesentery, and be adherent there. A n y of these varieties of adhesions may produce a kink or an angulation of the ileum. Attention was first drawn to them by Lane. They interfere with the proper discharge of the con- tents of the ileum into the caecum, and thus are a fac- tor in many cases of intes- tinalstasis. Adhesions may also be found about the head of the caecum and the first part of due to incomplete rotation and fusion of colon. The colon hangs +V, P ocppnrlino- rolnn TVlf^P from the bottom and under border of the kidney and duodenum. inC d^cliumg cuiUIl. J. IICSC (After Coffey.) bind the intestine to the lateral and posterior parietal peritoneum or to the neighboring omentum, fixing the intestine in that position and producing stasis by interference with peristalsis or by actual kinking, especially if such adhesions coexist with midline ptosis, as is often the case. Secondly : Adhesions not infrequently form between the loops of the sig- moid flexure. These often involve the mesosigmoid, which is folded or contracted upon itself, bringing two contiguous parts of the intestinal tube almost parallel and kinked at their junction. This is another source of obstruction to the fecal current. The genesis of such adhesions is not always clear. They must often, Fig. 424. — Right-sided ptosis. Unfused caecum and ascending colon, DISEASES OF THE ABDOMINAL VISCERA 511 however, be congenital, and result from abnormalities in fusion and forma- tion during embryonal life or be due to foetal peritonitis. They are also occa- sioned by inflammatory processes originating in the appendix (residua of an acute or chronic appendicitis), sigmoid (extension from a diverticulitis), or the intestine itself (catarrhal enteritis). Constipation may undoubtedly pro- Fig. 425. — Exercises for ptotic patients. Simple means of obtaining Trendelenburg position. Position advised for exercises prescribed for ptotic patients. (.After Martin.) duce them as a secondary manifestation which is often mistaken for the primary cause. Symptoms. — The symptoms of chronic intestinal stasis consist of chronic constipation, possibly interrupted with occasional attacks of diarrhoea, intes- tinal pain, gaseous distention, general digestive unrest, anorexia, coated Fig. 426. — Exercises for ptotic patients. • Exaggerated expansion of the chest with arms above the head. (After Martin.) tongue, foetid breath, headache, malaise, lack of assimilation, anaemia, toxic dermatitis, etc. The severity of the symptoms usually corresponds to the degree of constipation that is present. Diagnosis. — The degree of constipation may be estimated by the meas- ures that are required to secure a satisfactory movement of the bowels. 512 GYNECOLOGY Treatment. — In the treatment of intestinal stasis conservative measures should invariably be exhausted before surgical aid is sought. When, how- ever, the cause is evidently an organic lesion that will not yield to palliative measures, operative intervention should be undertaken. To be specific : if pelvic inflammatory disease, a pelvic tumor, or a chronically diseased appen- dix is present, the seat of the disease may be removed at once. In entero- ptosis, however, either with or without adhesions, the best that surgery can offer is not always easy to determine, and it is well, therefore, to hold this form of treatment in reserve. Even with the help of the Rontgen ray one is often unable to predict what surgery can accomplish. In spite of anything the Rontgen ray may show, there- fore, in the way of ptosis, kinks, obstruction, etc., one should first learn the FlG. 427. — Exercises for ptotic patients. After extreme extension of the legs, one at a time and then together, leg is flexed upon thigh and thigh upon abdomen, followed by return to extended horizontal position. (After Martin.) effect of non-operative measures that aim to restore the ptosed organs to their normal position. This last is best accomplished by postural treat- ment ; when the trunk is inclined toward the diaphragm (Trendelenburg position, knee-chest, or Sims' position), the abdominal viscera gravitate in that direction. Even when the erect posture is resumed the restoration may be maintained, at least for a time, by properly supporting the anterior abdominal wall. The postural treatment may be combined with exercise that tends to strengthen the anterior abdominal muscles (Figs. 425, 426, and 427). The anterior abdominal wall is best supported by means of a corset. The frequency and power of the intestinal movements may be influenced, first of all, by a diet that leaves a large residue in the intestine, lubricates the intestinal lining, or stimulates the production of the normal peristaltic- persuading juice (bile). The bulky vegetables and cereals, such as potatoes, DISEASES OF THE ABDOMINAL VISCERA 513 baked or mashed, spinach, cabbage, turnips, parsnips, beets, oatmeal and cream, mush and cream, etc., are useful for this purpose. Fat meat, prunes, figs, dates, and baked apples are also helpful. The articles of diet that should be taken sparingly are those that are almost entirely digested in the intes- tinal tract, such as milk, eggs, lean beef or mutton, etc. In addition to regulating the diet, exercise is of paramount importance ; besides the postural exercises mentioned, walking, tennis, golf, dancing, with the abdominal wall well supported, if not carried to the point of fatigue, may be of some value. Massage of the abdominal wall has a distinct field of usefulness. The establishment of the habit of going to stool at a definite hour, when there is plenty of time, and making an effort to defecate, whether the impulse is present or not, are helpful. Immediate relief cannot be ex- pected from any of these measures or from a combination of them but, except in the worst cases, persistence will bring success. Until success- ful results are secured, and especially if improvement is slow, laxa- tives of some sort must be prescribed. Of these the most satisfactory is a combination of cascara (2 grains), rhubarb (1 grain), licorice (1 grain), and podophyllin (1/24 grain). Other formulas are as follows: B Aloini gr. 1/5 Strychninse gr. 1/120 Ext. belladonnas fol gr. 1/8 Ext. rhamnus purshianse gr. 1/2 One or two such pills to be taken at night. or B Fl. ext. rhamnus pursh Fl. ext. rhei aa Si Fl. ext. sennae Hii M et Sig. : One to two fluiddrams at night. These remedies may be administered in decreasing dose as the case pro- gresses, and finally, if possible, discontinued. In making a selection of the particular formula, it is well to bear the idiosyncrasies and preferences of the patient in mind. Of late much use has been made of chemically pure paraffine oil. This is a tasteless and odorless intestinal lubricant. It is marketed under various trade names. When this oil is exhibited (1 to 4 drams thrice daily), the patients acquire, in the course of a few days, a feeling of insecurity as regards the restraining power of the sphincter ani, and may be inclined to discontinue the remedy. A little encouragement, careful regulation of the dose, and the assurance that this feeling will dis- appear or be under control within a short time will serve to restore the patient's confidence. The patient sometimes prefers to take a single large dose at bed-time (4 to 8 fluid drams). As the oil is a lubricant only, it is often advantageous to combine with it a laxative such as the fluidextract of cascara (10 to 60 drops). If anything more is required, suppositories and enemas may be employed, the latter being the most satisfactory. Either hot water and Castile soap, or the combinations mentioned under post-operative treatment (page 665), may 33 514 GYNECOLOGY be used. Gluten or glycerin suppositories may serve to supply the impetus for evacuation. Injections of paraffine oil are occasionally successful. About four to eight ounces of the warmed oil should be injected slowly through a large catheter passed high into the bowel, the patient lying on her left side with the hips elevated. After fifteen minutes in this position the patient may turn upon her back, the hips still being kept elevated. The patient should sleep upon the right side, with the hips higher than the trunk. The quantity of oil given should not be large enough to induce violent peristalsis. Oil administered in this Fig. 428. — Beyea's operation. Suturing of the gastrohepatic omentum. way upon retiring will sometimes secure a satisfactory stool the following morning. Granulated agar-agar (vegetable gelatin), taken with a cereal in the morning, is often of much benefit in softening the faeces and lubricating the intestinal mucosa. For emaciated patients Coffey advocates the rest cure, with forced feed- ing and the frequent assumption of the " elevated hips " position. In this way he seeks to deposit fat within the leaves of the lean and overstretched mesenteries, with a consequent shortening and increase in tone. Under such a plan he has in a number of cases improved the position of the abdom- DISEASES OF THE ABDOMINAL VISCERA 515 inal viscera, and recommends that this method be used before resorting to surgical treatment. The surgical treatment of intestinal stasis may consist of any one or any combination of two or more of the following operations : I. Elevation of the stomach (gastropexy). Suspension of the colon (colopexy). Division of adhesions. Intestinal anastomosis and short circuiting. Resection of the intestine. Contraction or expansion of the abdominal parietes. The particular operation or operations chosen will depend on the nature and number of the lesions revealed by an exploratory incision. The Rontgen ray Fig. 429. — Gastropexy; Coffey's opera- tion. The omentum is sutured to the anterior abdominal wall. (.After Coffey.) Fig. 430. — Diagram illustrating the placing of the sutures for shortening the gastro- hepatic omentum, Beyea's operation, and for suturing of great omentum to the ante- rior abdominal wall, Coffey's operation. (After Coffey.) will often furnish accurate knowledge of the lesions before operating. Nevertheless, the interpretation of the Rontgen ray is not free from error, and its findings should be verified or confirmed by making an examination after the abdomen is open. 1. Gastropexy. — The stomach participates in midline ptoses. Although the dropping of the stomach below its normal level does not produce intes- tinal stasis, if it is giving rise to symptoms as an associated condition, such as gastric retention, etc., it requires correction. The best type of operation is that devised by Beyea, which consists in shortening the gastrohepatic liga- ment. The technic of the operation may be learned from the accompanying illustrations (Figs. 428, 430, and 431). 2. Colopexy. — Midline ptosis of the colon with angulation at the splenic flexure, or at both the hepatic and the splenic flexure, may be corrected by 516 GYNECOLOGY the operation of Coffey, which attaches the gastrocolic and the upper areas of the great omentum to the anterior abdominal parietes (see the accompanying illustrations, Figs. 429, 430, and 431). Ptosis of the ascending colon or of the caecum (caecum mobile) may be treated by the operation of Wilms, as practised by Frazier. He makes a vertical incision in the parietal peritoneum about one inch from the peri- toneal reflexion on the outer side of the caecum. A pocket is made for the caecum by dissecting the peritoneum off a distance of an inch above and below the line of incision. The caecum is then secured in place by a con- tinuous suture of linen introduced through the margin of the peritoneal in- cision above described, and the longitudinal band of the caecum. Ptosis of the sigmoid flexure may be treated after the plan of Murphy. For this operation an incision is made through the outer margin of the left rectus. The sigmoid and the rectum are drawn up as high as they will go Fig. 431. — Scheme of completed Beyea and "hammock" operation. (After Coffey.) with moderate traction. The peritoneum of the posterior abdominal wall is then divided above the pelvic brim and the outer side of the ureter for a distance of four to five inches. A flap of peritoneum is next freed from its posterior attachments in a direction outward from this incision. The sig- moid is rolled into the raw, denuded area, and is secured to the muscles be- hind the peritoneum by means of a continuous catgut suture. The peri- toneal flap is folded medianward around the sigmoid, and accurately sutured to it near the mesosigmoid. The under surface of the peritoneum becomes fixed, and the sigmoid, in turn, becomes permanently adherent to the retro- peritoneal muscles and aponeurosis (Fig. 433). 3. Division of Adhesions. — Pericolic adhesions should not be interfered with unless they give rise to obstruction by anchoring the caecum too high or too low. If this is the case, they should be divided and the raw surfaces peri- tonealized or protected as far as possible. Adhesions and supernumerary mesenteries about the lower ileum caus- DISEASES OF THE ABDOMINAL VISCERA 517 ing Lane kinks should be divided, and the raw surfaces so disposed as to prevent their reformation and yet release the bowel. Adhesions between the loops of the sigmoid flexure may be prevented from reforming by performing suspension after Murphy's plan, or if the bowel is exceedingly redundant, the denuded part of the intestines may be resected. Adhesions between loops of the small bowel should not be interfered with if there is no angulation ; if they cause a kink or an angulation, they O \Xvt\VvY\cu.* Fig. 432. — Suspension of the hepatic flexure, Reed's method. The colon covered by the base of the omentum is being attached to the everted transversalis fascia. should be freed and the raw surfaces protected (see pages 641 and 643). If the released bowel is in bad condition, resection may be performed. The release of post-operative adhesions between the omentum and the lower abdominal wall or appendicular or pelvic region may at once dispose of a ptosis of the stomach or colon entirely due to traction. If, however, the colon and stomach are in their normal position and the adhesions of the omentum are high attaching the colon to the abdominal parietes, they may often, with advantage, be disregarded. 518 GYNECOLOGY After the release of adhesions in any part of the abdomen the posture of the patient should be such as to insure the retention of the viscera in or above their normal position, or nearly so. For this purpose the foot of the bed should be slightly elevated, and the patient encouraged to turn from side to side ; if adhesions then reform, the obstructive symptoms will not necessarily recur. It is also wise to stimulate peristalsis by the exhibition of pituitrin and the early administration of a laxative. 4. Intestinal Anastomosis and Short Circuiting. — An area of obstruction Fig. 433. — Suspension of sigmoid (after Murphy, from Kelly and Noble) ; (bbb) shows ele- vation of retroperitoneal flap and subperitoneal suture line to sigmoid. (Courtesy W. B. Saunders Co.) in the intestinal tract may be excluded by anastomosing a point above to a point below the obstructed area. This method is known as short circuiting. Aside from obstruction due to new growths, which is not perti- nent to this discussion, such an anastomosis is most frequently made be- tween the terminal part of the ileum and the sigmoid flexure. This excludes the ileocsecal junction, hepatic and splenic flexure, and with them the ob- struction to the fecal current so frequently observed in those localities. Technically, the operation is a simple one. As experience accumulates, the frequency of backflow and accumulation of faeces in the excluded area will DISEASES OF THE ABDOMINAL VISCERA 519 be determined. Upon this depends the ultimate place in surgery of the short-circuiting operation. 5. Resection of the Intestine. — Resection of the intestine may be indicated by: (1) Extensive tearing of the intestine after separation of adhesions. #. x- ~i-x x~ - Fig. 434. — Points of anastomosis and obstruction in the gastro-intestinal tract. (2) Redundancy, dilatation, and an unhealthy condition of the bowel. Resection may be applied to the ileum, the ileum and caecum, the sig- moid and the ilium and the entire lower colon as far as the sigmoid flexure. In the most extensive form, resection of the bowel for intestinal stasis 520 GYNECOLOGY rids the patient of intestine that cannot be placed in a normal position, of intestine that is almost certain to become adherent and cause obstruction, or of intestine that is so badly damaged or so distended, elongated, ptosed, and atonic, that it will probably never functionate properly. This is often a serious operation. The form most commonly applicable is resection of the terminal ileum, caecum, and ascending and part of the transverse colon. The proximal end of the ileum is then anastomosed with the transverse colon. 6. Contraction or Expansion of the Abdominal Parietes. — Although Coffey has devised operations for the purpose of expanding the upper and con- tracting the lower abdomen, they are so difficult to execute successfully as to be rarely of practical use. Expansion of the upper abdomen is best secured by the adoption of postural methods combined with exercises that tend to develop the lower thorax. When relaxation of the lower abdomen is largely featured by diastasis of the rectus muscles, a reduplication of the overstretched fascia between them after the plan of Webster, gives excel- lent results. In these cases we need not, however, rely on surgery alone to support the abdominal wall, for the median overlapping of fascia and the excision of redundant fat may be satisfactorily augmented by the applica- tion of a suitable corset or an abdominal bandage. DIVERTICULITIS Etiology. — Inflammation of diverticula of the mucosa of the intestine affects principally the sigmoid. Meckel's diverticulum of the lower end of the ileum also may be the seat of a diverticulitis. It is a rarely recognized condition, but is more common than is generally believed. Small pockets of the mucosa are formed which penetrate the wall of the gut, following the course of the veins. The diverticulum may end beneath the serous coat or pass further into an epiploic appendage, or it may not go beyond the muscu- lar coat. The condition is usually multiple. The diverticula may be congenital or acquired (as from constipation). They are, generally, for a time, the seat of a subacute or chronic inflamma- tory process. This finally results in either a gradually formed hypertrophy of the intestine in the area of the diverticulum resembling a new growth, or the inflammatory process may extend to the peritoneal surface or into an epiploic appendage and produce a sharp attack of pelvic peritonitis or epiploitis. Symptoms. — The symptoms are usually slow in origin, and extend over a long period of time. There is a tendency toward diarrhoea, blood and mucus appearing in the stools, and pain is present. When, conjoined with these symptoms, a mass develops in the left iliac region, the suggestion of malignancy is very strong, and nothing but an exploratory operation, or even a laboratory examination of the removed section of the bowel, will show the process to be entirely inflammatory and not malignant. If the process suddenly becomes acute, the symptoms strongly resemble those of an appendicitis, except that the pain, rigidity, and tenderness are on the left side. DISEASES OF THE ABDOMINAL VISCERA 521 Treatment. — In the chronic forms, with tumor formation, the diseased area should be resected. In acute cases the affected epiploic appendage should be removed, the communication with the bowel closed, and drainage provided, if necessary. BIBLIOGRAPHY Beyea, H. D. : " The Elevation of the Stomach in Gastroptosis by the Surgical Plication of the Gastrohepatic and Gastrophrenic Ligaments." Phila. Med. Jour., 1903. Clark, J. G. : " Anatomical Considerations in Peritoneal Adhesions." Trans. Amer. Gyn. Soc, 1909, 401 ; Ibid. : " The Surgical Consideration of Congenital and Developmental Defects Leading to Obstinate Constipation." Jour. Amer. Med. Asso., August 16, 1910, lv, 449- Coffey, R. C. : " The Principles Underlying the Surgical Treatment of Gastro-intestinal Stasis, Due to Causes Other Than Structural or Ulcerative Conditions." Surg., Gyn. and Obst., 1912, xv, 365 ; Ibid. : " The Significance of the Fixation of Certain Abdominal Organs in the Human Body." Trans. Sect. Obst., Gyn. and Abdom. Surg., A. M. A., 1915, 205. Eastman, J. R. : " Colon Stasis." Trans. Sect. Obst., Gyn. and Abd. Surg., A. M. A., 1914, 78. Frazier, Chas. H. : " The Recognition and Treatment of Lesions of the Right Iliac Fossa, Other than Appendicitis." Annals of Surgery, October, 1912. Horsley, J. S. : " Surgical Treatment of Intestinal Stasis." Trans. Sect. Obst., Gyn. and Abd. Surg., A. M. A., 1917, 228. Lathrop, W. : " Lipectomy and Umbilical Hernia." Trans. Sect. Obst., Gyn. and Abd. Surg., A. M. A., 1916, 263. Martin, F. H. : " Gymnastics and Other Mechanical Means in the Treatment of Visceral Prolapse and Its Complications." Trans. Amer. Gyn. Soc, 191 2, xxxvii, 133. Mayo, Wm. J. : "Diverticulitis of the Large Intestine." Trans. O., G. and A. S., J. A. M. A., 1917, p. 216. Murphy, J. B. : Intestinal Surgery. Kelly-Noble, ii, xxxiv. Saunders, Phila., 1907. Reed, C. A. L. : "The Redundant Sigmoid." Trans. Sect. Obst., Gyn. and Abd. Surg., A. M. A., 1914, 103 ; Ibid. : " Treatment of Constipation." Trans. Sect. Obst., Gyn. and Abd. Surg., A. M. A., 1916, 143 ; Ibid. : " Physiologic Colectomy." Trans. Sect. Obst., Gyn. and Abd. Surg., A. M. A., 191 7, 290. Smith, R. R. : " Enteroptosis." Surg., Gyn. and Obst., 1906, iii, 130. Tuttle, J. P. : " Relationship Between Rectal Disease and Those of the Female Pelvic Organs." Amer. Jour. Obst-, lxi, 784. CHAPTER XXVII DISEASES OF THE ANUS AND RECTUM FISSURE IN ANO Anal fissure is a crack or a linear ulcer of the mucous membrane on the margin of or within the sphincter ani muscle. It is produced by chronic constipation with straining at stool, and the passage of hard, scybalous masses that lacerate or abrade the mucous membrane. Small particles of fecal matter lodge in these abrasions or cracks, and are retained there for a time by reason of the infrequent action of the bowels. The sphincter muscles become irritated and spastic, so that they grasp the mucosa closely and further enclose the particles of foreign matter. Sooner or later the small abrasion or crack becomes a linear ulcer, which shows no tendency to heal. Since, by reason of the spastic sphincter, the walls are kept constantly in contact, there is no drainage and the condition pro- gresses from bad to worse. The base of the fissure may become inflamed,* and infiltration and induration of the parts beneath and on each side of it may take place. The ulcer may be small and linear and entirely concealed by the folds of the anal mucosa, or it may be larger and of an oval shape, so as plainly to be visible when the anus is exposed. Ulcers that are in- flamed and have their seat upon an inflammatory base are particularly evi- dent upon inspection. Fissure in ano is at times associated with a single mucocutaneous hemorrhoid, the latter probably being secondary to the former and caused by local blockage of the venous trunks by inflammatory products. The con- dition is predisposed to by dryness of the anal mucosa, and may exist in association with eczema of the anus. Although, as a rule, the ulcer is single, more than one may be present, but one is always more pronounced than the others. Symptoms. — The symptom characteristic of fissure in ano is pain dur- ing and after defecation. During defecation the anal folds are partially smoothed out by the passage of the fecal mass, the surface of the ulcer is irritated, and the patient complains of pain. Pain is most severe after defe- cation, when the sphincter contracts, holding the base of the ulcer tightly within its grasp, and compressing the recently irritated surface, covered with particles of fecal matter ; or the base of the ulcer may have been torn afresh during defecation. The stools often contain blood, and at times a thin, highly irritating discharge takes place from the anus, giving rise to intense itching — pruritus ani. The patient is usually constipated, and makes little effort to move the bowels systematically, avoiding the painful ordeal as long as possible. Diagnosis. — Pain during, but particularly just after, defecation, asso- ciated with bloody stools and constipation, is the symptom-complex strongly diagnostic of fissure. The latter may be detected at once on slightly sepa- rating the edges of the anus, or it can often be felt by the finger as a local- 522 DISEASES OF THE ANUS AND RECTUM 523 ized point of induration and tenderness. A speculum may be introduced and the suspected area exposed. In some cases, however, the patient is so apprehensive, the sphincter is so tight, and examination causes so much pain, that the symptoms alone will justify the use of a general anaesthetic for a confirmation of the diagnosis, the treatment being carried out at the same time. Treatment. — The essential features of all methods of treatment are to clean the surface of the ulcer and to reduce or obviate the action of the sphincter. In mild cases the best results are obtained by cleansing the ulcer and the anal mucosa and keeping them clean, cauterizing the base of the ulcer, and overcoming the spasticity of the sphincter by performing gradual dilatation and by the application of a soothing ointment. Thus the fissure may be exposed through a speculum and thoroughly cauterized. A daily saline laxative should be prescribed and the patient instructed to wash the lower bowel thoroughly with repeated flushing of salt solution in the morn- ing after the bowels have moved. A sedative and astringent ointment, such as equal parts of unguentum gallae (U.S. P.) and unguentum stramonii (U.S.P.), should be applied by means of the forefinger, protected with a rubber finger-cot, the entire anal surface, external and internal, being gone over. The finger should be passed gently through both sphincters, using a boring motion. A daily treatment of this sort keeps the ulcer clean, lessens irritability of the sphincter, and hastens a cure. The patient should be instructed to use a soft washcloth or wet toilet paper after a bowel movement. When the case is of a severe type, the tenderness being marked, the sphincter very tight, or tjie ulcer old and indurated, an anaesthetic must be given and the sphincter either thoroughly divulsed or incised. Divulsion of the sphincter should be performed slowly, so as to over- stretch but not to rupture the muscle-fibers. The finger-tips of one hand should be so approximated as to form a cone, which should be well lubricated with sterile vaseline and inserted into the anus with a boring motion. This should be repeated until the muscle yields and sufficient dilatation has been secured to admit three fingers, one alongside of the other, without resist- ance. The muscle may also be stretched by inserting the forefinger or the thumb of each hand in the anus and gently pulling in opposite directions. Rough or forcible stretching of the sphincter may result in subcutaneous rupture, hsematoma formation, and, rarely, in permanent incompetency of the sphincter. Operation for Fissure In Ano. — Divulsion of the sphincter alone will suffice for the cure of mild cases of anal fissure. If, however, the ulcer is of considerable size and depth, or if induration is marked, it should be thor- oughly curetted, overhanging edges should be cut away, and the base should be touched lightly with pure phenol and alcohol. When the ulcer has become so chronic, or the case has proved so resist- ant to previous treatment, that division of the sphincter and total suspen- sion of its function for a time are regarded as necessary, then the sphincter muscle may be divided completely. The line of division should run through the base of the ulcer, at right angles to the muscle-fibers. The sphincter should always be divided at right angles. 524 GYNECOLOGY FISTULA IN ANO Fistula in ano is a false passage or sinus between two or more of the following parts : The lower rectum, the anus, the perianal skin, and the cellular tissue of the ischiorectal fossae. The most common type takes the form of a fistulous channel between the anus and the peri- anal skin, the fistula beginning about the junction of the anus and rectum, passing externally to the sphincter muscles, through the cellular tissue of the ischiorectal fossae immediately alongside of the rectum, and opening on the skin surface surrounding the anal orifice. A blind anal fistula is a tract running between the ischiorectal fossae and the lower rectum or anus. The two varieties just described undergo many modifications, as regards both their relations to the anatomic parts involved and their extent. Fistula in ano has its origin in an abscess or a focus of suppuration in the cellular tissue surrounding the anus or lower rectum. Commonly an abra- sion or injury of the lower rectum or anus produces, by lymphatic absorp- tion, a suppurative focus in the cellular tissue. This burrows its way out- ward and finally discharges externally about the margins of the anus. The formation of the abscess and its rupture may be accompanied by violent or by barely noticeable manifestations. In other words, the patient presents the symptoms of an acute ischiorectal abscess, or all that may be remem- bered afterward is that a " boil " or some trivial inflammatory mass was present. Tuberculosis is believed to play an important role in the produc- tion of fistula in ano. A tuberculous erosion takes place in the lower rectum, which leads to infection of the neighboring cellular tissue, the tuberculous area breaks down, becomes secondarily infected, perhaps, with one of the varieties of intestinal bacteria, and then discharges externally or into the bowel, or in both directions, as the case may be. Before the pus or tuber- culous products find an exit the inflammatory process may have extended in various directions, following planes of fascia or cellular tissue. Occasion- ally the most extensive undermining and ramification of the inflammatory process take place before the external opening is formed. Of the influence of syphilis in the production of fistula, little positive information is available. Nearly all the cases of fistula attributed to syphilis have been secondary to stricture of the rectum. In such cases the fistula is usually a complicated or complex one, due to perfora- tion of the rectal wall by ulcerative processes and the subsequent in- fection of the perirectal tisues. The fistula, therefore, becomes one of simple infection, and not of a specific nature itself. The extent of the influ- ence of syphilis in the production of fistula is as yet undetermined, but there is no doubt as to the effect it has in delaying healing after operation. Because of the imperfect drainage that the external opening usually affords, or owing to the continuous entrance of gas or faeces from the bowel, or as a consequence of tuberculous or syphilitic processes in the areas affected, fistula in ano shows but little tendency to undergo spon- taneous cure. The inflammatory process along the line of the fistula may, therefore, continue gradually to extend, burrowing in one or more directions. DISEi\SES OF THE ANUS AND RECTUM 525 Symptoms. — The most prominent symptom of a fistula in ano is an involuntary discharge of gas or liquid faeces and pus through the external opening. In the case of a blind internal fistula this does not, of course, occur. Other symptoms are repeated attacks of pain, swelling, and tender- ness in the affected regions, followed by the discharge of pus externally or from the bowel, and the subsidence of symptoms. Between these exacerbations the patient may be quite comfortable, the only manifestation being a constant moisture about the anus, or a feeling of weight or heaviness in the perineum, with painful defecation and the presence of blood and pus in the stools. Diagnosis. — The external opening of a fistula is usually readily dis- cerned, but it may be so small as to be demonstrable as an opening only by the passage of a fine probe. As a rule, a discolored spot or indurated ele- vated area marks the site of the opening. The site of the internal opening can often be detected by the induration surrounding it, but the only proof is the passage of a probe entirely through the fistulous tract. The internal orifice of a blind fistula may be exposed by means of a rectal speculum and a small laryngoscopic mirror. When the existence of a blind internal fistula is suspected, even though no internal opening can be felt or seen, the anal and the rectal crypts should gently but systematically be examined with a fine probe. In this way small Jistulae may be discovered that would otherwise escape detection. Treatment. — An effort at cure may be made by insuring daily evacua- tion of the bowels, irrigation, gradual dilatation of the sphincter, and re- peated and systematic cleansing of the fistulous tract, but, as a rule, recourse must be had to operation. The oldest method of operative intervention was to thread the fistulous tract upon a grooved director, bring the extremity of the director through the anus, and divide the overlying tissues, cutting the sphincter as it lay in the path of the knife. The fistulous tract, laid bare, was then thoroughly curetted, cauterized with pure phenol and alcohol, and allowed to heal by granulation. At the present time such a method should be reserved only for the worst cases, i.e., those in which the undermining and burrowing have been so extensive that copious drainage is the prime object of the operation. The ideal method in the majority of cases is excision of the fistulous tract, followed by immediate closure of the wound (see Fig. 435). This is usually feasible with suitable preparatory treatment of the fistulous tract. The treatment consists of dilatation of the external opening to secure free drainage, daily irrigation and thorough cleansing, and the application or in- jection of antiseptic solutions (iodine, 5 per cent.; ichthyol, 10 to 25 per cent., etc.). Just before the operation is begun, the fistula should be thoroughly cleansed and disinfected with hydrogen peroxide and tincture of iodine. The sinus is threaded upon a silver probe and the entire tract extirpated from the surrounding healthy tissue (Fig. 435). It may be necessary to divide the sphincter, but this may be done with impunity at right angles to the fibers. The wound after excision may at once be repaired with catgut sutures. If the sphincter has been divided, the ends must be aporoximated by two special sutures of fine chromic gut. 526 GYNECOLOGY When there are several or many ramifications of the fistula, all running- in the same general direction, and if the tracts may be excised without great loss of tissue, a single division of the sphincter may be sufficient, and immediate repair may be successfully carried out. If the wound is very . /\+-T - I I I \ .V* Fig. 435. — Excision of fistula in ano. extensive and it is evident that healing must take place by granulation, the incision in the rectal wall and mucosa and in the sphincter may be closed, and free drainage provided externally. Care should be taken, however, to stretch the muscle thoroughly, otherwise its contraction may interfere with the healing of the wound. DISEASES OF THE ANUS AND RECTUM 527 PRURITUS ANI Pruritus about the anus may be produced by an irritating discharge from the bladder, vagina, or rectum, as in diabetes, leucorrhcea, fis- sure, fistula, proctitis, or rectal neoplasm. It may also be caused by eczema or other skin diseases affecting the anal mucosa and integument. Intestinal parasites (pin-worms), constipation, gout, nervousness, and habit may be factors in its production. It is prone to occur in stout, full-blooded, well-nourished women. Symptoms. — Intense itching, with an almost uncontrollable desire to scratch, is the chief symptom. The itching is most intense at night. The bowels are usually constipated. If fissure, fistula, or hemorrhoids coexist, blood and mucus appear in the stools. Diagnosis. — Since pruritus is but a symptom of several diseases, it has no subjective diagnostic signs of its own. Pruritus ani deserves individual consideration only when no gross lesion can be found to explain it. In these cases the cause is probably neurotic, and the local manifestations are more often the effect of the scratching than the cause of the itching. It may, of course, be quite impossible to distinguish between the two. The skin usually appears thickened, excoriated, and broken here and there by scratch marks ; the surface is either dry and scaly or moist and foetid. Treatment. — The aim of the treatment is the cure or alleviation of the underlying provocative cause. What has been said relative to pruritus vulvae is applicable here (see Chapter XI, page 170). HEMORRHOIDS Hemorrhoids are vascular tumors composed of dilated veins of the hemorrhoidal plexus, surrounded by the overstretched and hypertro- phied mucous membrane or skin of the lower rectum and anus. In women they may be due to the congestion of the hemorrhoidal plexus that takes place in those who follow sedentary occupations and suffer from constipation. The pressure of the child's head in the later months of preg- nancy is another factor, whereas the distortion and injury to the lower rectum and anus incident to labor almost invariably aggravate the ten- dency. Relaxation of the vaginal outlet and the pelvic floor is frequently accompanied by hemorrhoids. According to their location, hemorrhoids are designated as external when they protrude from the margin of the anus, and as internal when they lie within the grasp of or above the external sphincter and appear only on straining. They may be covered entirely by mucous membrane. Usually they are situated at the junction of the mucous membrane and skin, so that toward the lumen of the rectum they are covered by mucous membrane, whereas toward the perianal region the covering is cutaneous. Symptoms. — The symptoms of hemorrhoids are pain and bleeding after defecation, and a feeling of weight and protrusion about the anus. There may be considerable itching. Other symptoms dependent upon complica- 528 GYNECOLOGY tions at times occur, the most common of which are thrombosis and inflam- mation of the hemorrhoidal masses. A thrombotic hemorrhoid is tense and painful, and generally protrudes from the anus, so that its pedicle or base lies within the grasp of the sphincter. In addition to the constant pain and tenderness of the swollen hemorrhoidal tumor there are severe pain on defecation and painful spasm of the sphincter muscle. Thrombosis may affect one or the entire group of hemorrhoids. The attack subsides in from three to ten days, the clot soft- ening and tension being relieved. The hemorrhoid may remain somewhat enlarged. Occasionally the clot may not be entirely absorbed, but may remain as a small, hard thrombus or vein stone. A hemorrhoid may also become infected and inflamed. These complica- tions are often associated with fissure or fistula. The tumor becomes slightly enlarged, may be more or less surrounded by inflammatory infiltrate, and is tender and painful. Diagnosis. — Cutaneous and mucocutaneous hemorrhoids are readily diagnosed by simple inspection while the patient is told to bear down. Hemorrhoids within the sphincter are visible often only after evacua- tion of the lower bowel and the introduction of a short proctoscope, or they may be made to protrude by having the patient assume a squatting posi- tion, bear down, and strain over a vessel of hot water. A thrombotic hemor- rhoid is tense, hard, exquisitely tender, and bluish in color. Thrombotic and inflamed hemorrhoids can be felt as well as seen, but an internal hemorrhoid that is neither thrombosed nor inflamed may escape recognition by the palpating finger. Treatment. — The cure of hemorrhoids is best and most surely accom- plished by operation. Some cases of moderate or mild degree may be ren- dered comfortable by non-operative methods of treatment. These include the administration of a daily laxative, irrigation of the lower bowel with salt solution, the use of the bidet, cold water enemas, and the exhibition of an astringent and sedative ointment 1 or suppository. 2 As contributing factors to successful treatment may be mentioned improvement of the general cir- culation by cardiac stimulants, replacement of a prolapsed or retroverted uterus, and the use of a pessary to correct a retrocele. A thrombotic hemorrhoid that is outside the grasp of the sphincter should be incised and the clot turned out. This can usually be done under local anaesthesia, but 1 R. Ung. gallse. Ung. stramonii (U. S. P.) aa M. et ft. ung. Sig. : Apply locally as directed. Ext. stramon. gr. y 2 Ac. tannic, gr. y 2 Plumbi carbonat. gr. i Sol. plumbi acetat. dil. TU 2 Creosot. ffi y 2 M. et ft. suppository No. i. Sig. : Insert one at night. DISEASES OF THE ANUS AND RECTUM 529 in some cases, when the pain is very severe, general anaesthesia may be necessary. Inflamed hemorrhoids should be treated by the application of soothing lotions, either cold or hot, whichever gives most relief. Hot or cold solu- tions of dilute alcohol, lead-water and laudanum, or witch-hazel are favorite remedies. An injection of warm olive oil (i to 4 drams) with laudanum (5 to 10 drops), administered through a small, soft-rubber catheter or a soft- rubber ear syringe, will often be prompt in its results. An opium and bella- donna suppository may be effectual. The operative treatment of hemorrohids consists in removal of the growths by excision or ligation. The former is the preferable method and Fig. 436. — Removal of hemorrhoids by clamp and cautery. may be accomplished in a number of ways. The clamp and cautery method is rapid, the danger of infection is reduced to a minimum, sloughing is in- considerable, and the pain is not as severe as when the hemorrhoid is ligated or when sutures are employed. The technic is as follows : After divulsion of the sphincter, the hemorrhoids usually are well ex- posed. As they project from the anal margin they divide into several groups. Each group in turn is subjected to the following plan of treatment : The tip is caught with a blunt hemostat, and traction is made upon it. The skin in the peripheral aspect is divided by a V-shaped incision, the base being directed toward the anus. When the mucous membrane is reached, the incision is continued into the membrane, completing the base of the V, which runs parallel to the rim of the anus. The skin and mucous mem- 34 530 GYNECOLOGY brane above the incision are now pushed away by blunt dissection, and a hemorrhoid clamp placed along the raw area thus exposed, the heel of the clamp pointing toward the lumen of the gut. The clamp is tightly closed, and the projecting hemorrhoidal mass cut away with scissors at a point about one-eighth of an inch from the surface of the clamp. The remaining tissue beyond the clamp is now cauterized until it is thoroughly charred. Upon removing the clamp a charred ribbon of tissue is found extending in a radial direction from the anus outward along the path of excision (Fig. 436). Bleeding seldom follows the operation if the clamp is properly placed, i.e., with the heel pointing toward the gut, so that the greatest amount of pressure is exerted upon the source of the most active blood supply, and if the charred area of tissue projects a little from the surface of the clamp and has not been burned off flush with its surface. A narrow strip of drainage gauze thickly coated with sterile vaseline is now introduced within the Fig. 437. — Moschcowitz s conception of prolapse of rectum; incipient prolapse. (.Courtesy Surgery, Gynecology and Obstetrics. ■~-~-Partial prolapi. of rectum Fig. 438. — Moschcowitz's conception of prolapse of rectum; partial prolapse. Courtes}' Surgery, Gynecology and Obstetrics. 1 ) rectum. This will serve to direct attention immediately to any hemorrhage that may take place within the bowel. This strip is removed at the end of five days, when the bowels are opened with castor-oil. PROLAPSE OF THE RECTUM Prolapse of the rectum not infrequently occurs in connection with extensive prolapse of the uterus or with marked relaxation of the vaginal outlet with rectocele. It is then a part of a general relaxation and loss of supporting power of the muscles and fascia of the pelvic floor. Prolapse may affect the mucosa alone (partial prolapse) or the entire wall of the rectum (complete prolapse). The predisposing causes of rectal prolapse are multiple childbirth and consequent injuries to the pelvic floor, relaxation of the sphincter muscles of the anus from paralysis, exhausting diseases, injury to the sacral plexus-, etc. Straining at stool, as in some cases of rectocele, urethral obstruction, chronic constipation, and chronic diarrhoea, is a prolific source of prolapse. Tumors of the lower bowel, hemorrhoids, polyps, etc., which drag upon the mucous membrane, are occasional causes. DISEASES OF THE ANUS AND RECTUM 531 Abnormal and possibly congenital elongation of the mesosigmoid and meso- rectum are said to be among the provocative lesions. According to Moschcowitz and Jones, many of the so-called prolapses of the rectum are in reality hernias (Figs. 437 to 440). The anterior wall of the rectum is pushed through the anus by the hernial contents, and the sac of the hernia is a prolongation or a deepening of the peritoneal cul-de-sac. known in the female as the pouch of Douglas. 3 The usual contents of the hernia is small bowel. Defects in the transversalis fascia, known as the pelvic fascia in this region, with which the peritoneum is so intimately related, are uniformly present and may be either congenital or acquired. This conception of the subject which unquestionably is correct, applies to all cases except those of simple prolapse of the rectal mucosa. Symptoms. — The symptoms depend on the degree of prolapse that is present. In early cases there may be no subjective symptoms. In well- 'Periloneum. Rsciun Fig. 439. — Moschcowitz's conception of prolapse of rectum; incomplete prolapse. 'Courtesy Surgery, Gynecology and Obstetrics.) Fig. 440. — Moschcowitz's conception of prolapse of rectum: complete prolapse. marked cases there are irregular and unsatisfactory bowel movements, a sensation as if the movement was incomplete, pain and discomfort about the anus, partial or total incontinence of flatus and faeces, discharge of mucus and blood, and the protrusion of the inverted rectum, either constantly or upon attempts at defecation. 3 There are three varieties of deep cul-de-sac: First: The cul-de-sac may be very deep congenitally. The rectum and the bladder appear flattened against the pelvic walls and the peritoneal lining of the deep pelvis is smooth and adheres closely to the pelvic walls. In this type the fascia is exceedingly weak, and the weight of the intestine causes rectal and vaginal protrusions. To this group belongs virginal prolapse. Secondly: The cul-de-sac becomes very deep in multipara with lacerated perineums ; the peritoneum is redundant, but not densely adherent to the pelvic wall or to the pelvic organs. The fascia, although torn, is still able to support certain of the pelvic structures, and the peritoneum also acts as a suspensory support to the vagina and the rectum. Although this anatomic peculiarity is frequent in multiparas, prolapse of the uterus and large rectocele are relatively infrequent. Thirdly: Another and rare type is seen in which there is an opening in the fascia between the vagina and the rectum, extending from the posterior cul-de-sac to the levator muscles, and accompanied with a vaginal protrusion that is somewhat analogous anatomically to an inguinal hernia. 532 GYNECOLOGY Diagnosis. — The diagnosis of rectal prolapse is readily made by inspec- tion of the anus while the patient is in the dorsosacral or in the squatting position and attempting to defecate. Further examination is required to de- termine whether the mucosa alone or the entire rectal wall is involved. Treatment. — Prolapse of the rectal mucosa may be treated by linear cauterization or by excision of the prolapsed part. In conjunction there- with, the rectal wall may be supported by a slight modification of the ordi- nary operation done for rectocele, a condition with which prolapse of the rectal mucosa is frequently associated. When this plan is adopted, the an- terior wall of the rectum should be freely exposed after division of the posterior vaginal wall. The rectum should be freed from its surrounding attachments, above the level of the levator ani, and sutures introduced in two directions so as to shorten the rectum, as well as to narrow its lumen. 4 Whatever method of posterior colporrhaphy is contemplated may now be carried out and completed in the usual manner. In mild cases, all that may be necessary is to make a long incision through the posterior vaginal wall, extending well up toward the cervix, separate the rectum from the surrounding tissues, and fix it at as high a level as possible, by means of sutures that embrace the upper angle of the posterior vaginal incision, the pelvic fascia, and rectal wall. These are continued downwards at intervals, the lowermost approxi- mating the fibers of the levator ani. The basis of the operative treatment suggested by Moschcowitz and Jones consists in obliteration of the posterior cul-de-sac. This throws the weight of the intestine against the uterus, broad ligaments, bladder, and symphysis, just the opposite to the condition that obtains with an open deep cul-de-sac. In the latter case the weight of the intestines is thrown on the anterior rectal and the posterior vaginal wall. Moschcowitz, in closing the cul-de-sac, inserts purse-string sutures from below upward, tying each one as it is completed (Fig. 441). He passes the sutures through the serous coat of the bowel, and when he reaches the supravaginal cervix and the uterus, he includes them. He directs that one must carefully avoid the internal iliac vessels, which can be recognized by palpation, and the ureters, which may be located by catheterization, if this is required. In aged women fixation of the uterus may be done in connec- tion with the other operation. It is not necessary to suspend the sigmoid. Usually the bowels move of their own accord in less than a week. As a rule, catheterization is necessary. TUMORS OF THE RECTUM ' New growths of the rectum may spring from muscle, connective tissue, or mucosa. Among those most frequently encountered, therefore, are adenoma, papilloma, myoma, fibroma, myxoma, sarcoma, and carcinoma, although teratomata are also found at times. 4 Such sutures may be passed also after the method of Lane, i.e.-, through an incision from the lower end of the sacrum to the anus. The coccyx is removed, exposing the posterior rectal wall, catgut sutures are passed through the muscular coat in the long axis of the gut for a distance that corresponds to the requisite amount of shortening. After the longitudinal sutures are tied, interrupted transverse sutures are passed that approximate the lateral walls of the rectum and narrow the lumen of the gut. DISEASES OF THE ANUS AND RECTUM 533 POLYPS Benign rectal growths are frequently pedunculated, when they are known as polyps. The most common form seen in children is formed by hypertrophy of a solitary follicle. The surface is covered by epithelium and the connective tissue is myxomatous. Other forms of rectal polyp are adenoma, papilloma, fibroma, and lipoma. Polypoid adenomata and papil- lomata are most often seen in adults. Adenoma is most often multiple, and is said to recur. When multiple the individual tumors vary in size, form, and appearance. Instead of being polypoid, they may have a broad base of attachment. The sigmoid and the colon may be involved coincidentally. The tumors are prone ultimately to undergo malignant degeneration. Symptoms. — The occa- sional presence of mucus and blood in the stools may be the only indication of a polyp if the growth occupies a position well above the sphincter. Active symptoms appear only when the polyp comes down within the grasp of the sphincter, when there is a sensation of fullness, a fre- quent desire to defecate, spasm of the sphincter, and mucous and bloody discharge from the rectum. Diagnosis. — The diagnosis can be made by inspection or by digital examination. The differentiation of benign hy- pertrophied follicles, adeno- mata, and papillomata from j mallPfnant PTOWtllS Of Similar ^ on ^ or cure °^ P r °l a P se of rectum by obliterating cul-de-sac of & . s Douglas. form is made partly from the fact that there is no induration at the point of their insertion into the mucous membrane. Treatment. — The treatment consists in snaring the pedicle, if the tumor is high, or in crushing the pedicle with a clamp and division by a cautery knife, if the tumor is low. If the tumor is attached broadly to the bowel, after excising the base down to the muscular coat, the edges of the mucosa should be brought together with sutures. If the pedicle is at such a height that invagination of the peritoneum therein is possible, the pedicle should be securely tied. Medicinal treatment of multiple adenomata is of little value, and even surgical treatment is likely to prove unsatisfactory. If malignant degenera- tion takes place, complete extirpation of the affected parts holds out the only hope for cure. In some cases the involvement may be so extensive as to make removal impossible. 534 GYNECOLOGY CARCINOMA OF THE RECTUM Carcinoma may involve the anal, the extraperitoneal, and the intra- peritoneal portions of the rectum, as well as the sigmoid. More than half of all rectal carcinomata involve the intraperitoneal portion, and 10 per cent, are confined to the anal part. About the anus the most frequent variety seen is epithelioma ; above that point adenocarcinoma is the rule. Etiology. — Cancer of the rectum is less common in women (40 per cent.) than in men (60 per cent.). Other diseases of the rectum, such as multiple polyps, adenomata, and mucous colitis, frequently precede cancer. Symptoms. — There are no characteristic symptoms in the earliest stage. Vague pain in the sacral region, with increasing constipation or a tendency to diarrhoea and slight digestive disturbance, may be the first indications. Later on loss of weight, pain in the rectum, and the discharge of mucus and blood from the anus appear. When carcinoma develops secondarily, the symptoms of the primary condition, of course, precede it. Diagnosis. — Every patient with symptoms suggestive of malignant dis- ease demands a digital examination of the lower bowel and a proctoscopic and a sigmoidoscopic examination of the upper rectum and sigmoid flexure. In the earliest stages, carcinomata appear as plaque-like, slightly mov- able deposits beneath the mucosa. The underlying mucosa is congested, thickened, and smoother than normal. In some varieties small papillary excrescences, connected with the mucous and submucous tissues by an in- durated base, are seen. Early scirrhus cancer may appear in the form of an annular deposit in the submucosa, closely resembling a fibrous stricture. A microscopic examination should always be made in order to distin- guish between benign and malignant conditions if it is easy to obtain tissue for this purpose through the proctoscope ; otherwise the clinical findings may be accepted as conclusive and treatment advised accordingly. Exploratory celiotomy may be indicated in growths situated high up. Treatment. — The only hope of cure lies in early extirpation of the dis- eased portion of the bowel with a surrounding border of healthy tissue. The one exception to this statement is found in cases of epithelioma of the anus — here radium may be effectual (see Radium and Rontgen Ray Therapy. Chapter XL). Very early epithelioma may be treated also by local excision or destruction with the cautery. Epithelioma and adenocarcinoma of the lower bowel require total extirpation of the diseased bowel, including the anus ; the inguinal lymphatics also should be removed. The technic of Cripps or Kraske may be selected. Operation for cancer of the second and third portions of the rectum and the recto-sigmoid should be performed in two stages. In the first, the abdomen is opened, a thorough exploration is made of the lymph-glands, liver, etc., and in favorable cases the diseased area of the bowel is excised. If the line of division below leaves a half inch or more of peritoneum-cov- ered bowel and the length of bowel resected is not too great, an end-to-end tube anastomosis may be performed between the proximal and the distal ends. If the rectum is so extensively involved that complete extirpation is re- DISEASES OF THE ANUS AND RECTUM 535 quired, the sigmoid should be divided above the growth and the proximal end implanted into the abdominal wall so as to form a new anus. The dis- eased area is then separated by ligation of its mesenteric attachments and the distal end turned in and pushed down into the pelvis with the growth. The pelvis is then excluded from the peritoneal cavity by peritoneal suture, utilizing the back of the bladder, the uterus, the broad ligaments, and any peritoneal folds that are available. After six days a perineal incision is made and a Kraske resection of the lower sacrum with removal of the recto- sigmoid and rectum, including the anus, is performed. For the technic of these operations the reader should consult the writ- ings of Cripps and Charles Mayo. STRICTURE OF THE RECTUM Stricture of the rectum may be annular, valvular, tubular, or linear. Strictures may be due to congenital malformations or acquired lesions. They may be spasmodic or organic in nature. Acquired organic strictures are due to neoplasms growing into and contracting the rectal walls, to destructive lesions of the submucosa (tuberculous, syphilitic, dysenteric ulcerations, traumatism, perirectal abscess, etc.), and to inflam- matory lesions of the surrounding tissues that extend into and compress or constrict the gut. Symptoms. — The symptoms consist in gradually increasing and persist- ent constipation, alternating or combined at times with diarrhoea. The latter results from the irritation of hard fecal masses retained above the point of obstruction. Later fecal concretions may be felt in the sigmoid and colon. Anorexia, foul breath, coated tongue, skin eruptions, and other evidences of intestinal intoxication are present. In the severe forms mucus and blood are found in the stools. Diagnosis. — When the stricture is within a finger's length of the anus, the diagnosis is made without difficulty. In strictures higher up, the pneu- matic proctoscope and sigmoidoscope are the most valuable aids to diag- nosis, but exploratory celiotomy may be required in some cases. Treatment.— A nutritious mixed diet should be ordered. Milk produces hard faeces and is unsuitable in these cases. Powerful purgatives should be avoided, but laxatives may be taken regularly. Of the latter, the best is olive oil or one of the refined paraffine oils, taken several times daily. Although not often curative, gradual dilatation is the most used and most satisfactory method of treatment. BIBLIOGRAPHY Brettauer, J. : " The Rectum and Bowel in Their Relation to Pelvic Disease." Amer. Jour. Obst, ixi, yyy. Cripps, W. H. : Diseases of the Rectum and Anus. London, Churchill, 1907. Jones : " Relation of the Deep Cul-De-Sac to Prolapse of the Rectum and Uterus and to Rectocele." Post. Med. and Surg. Jour., 1916, clxxv, 623. Lynch, J. M. : Diseases of the Rectum and Colon and Their Surgical Treatment. Phila- delphia, Lea, 1914. Mayo, C. H. : " The Choice of Operative Procedure in Cancer of the Rectum and Pelvic Colon." Annals Surg., 1917, lxv, 129. Moschcowitz, A. V. : " The Pathogenesis, Anatomy and Cure of Prolapse of the Rectum.'' Surg., Gynec. and Obst., 1912, xv, 7. Murphy, J. B. : Intestinal Surgery, Chapter xxiv, in Kelly and Xoble, Gynecology and Abdominal Surgery, vol. ii. Philadelphia, Saunders, 1907 ; Ibid. : " Resection of the Rectum per Vaginam." Phila. Med. Jour., 1901, vii. Tuttle, J. F„ : " The Relationship Between Rectal Diseases and Those of the Female Pelvic Organs." Amer. Jour. Obst., 1911, lxi, 784. CHAPTER XXVIII BACKACHE Backache may be indicative of abdominal or pelvic disease, as well as of disorders of the bones, muscles, and joints of the lower abdomen, back, and thighs. The reason for it may be at once apparent — a quickly ascer- tained cause and effect — and the treatment obvious, or, in spite of careful search, no definite cause may be found. Not infrequently backache has been ascribed to abdominal or pelvic disorders, and yet, when the latter were corrected, the pain persisted and the patient did not improve. Atten- tion has then been directed to those disorders of the constituent structures of the parts which are well known, such as spinal curvature, hip-joint dis- ease, disproportionate length of the lower extremities, tuberculosis of the vertebrae or the sacroiliac joints, hypertrophic arthritis (spondylitis defor- mans), Charcot's spine, and spinal injuries. If, upon careful examination, none of these was found, the symptoms were spoken of as rheumatic or gouty, and finally, when appropriate treatment did not bring relief, the con- dition was given up as hysteric or neurasthenic. All of which is mentioned here to preface the statement that certain factors that are operative in the production of backache may easily be overlooked. It is to these that atten- tion has been drawn by the work of Reynolds, Lovett, Dickinson, Gold- thwaite, Truslow and others. The first is the constant demand that is made upon certain muscle groups and joints in the maintenance of equilibrium. The assumption of the erect posture without conscious effort depends upon the maintenance of equilibrium. 1 In the normal erect posture (Fig. 442), maintained without conscious effort, a vertical line drawn through the center of gravity of the body must drop within a trapezoid formed by the outer borders of the feet and imaginary lines con- necting the tips of the toes and the back of the heels. The supporting structures are the arches of the feet, secured by their pillars, the heel bones, and the heads of the metatarsal bones. The line of the center of gravity, when the body is in a state of perfect equilibrium, coincides with a plane that would cut the occipito-atlantoid joint, a portion of the cervical, thoracic, and lumbar vetebrse, the pelvis between the anterior spine and the anterior rim of the acetabulum, the knee-joint near the patella, and the foot near the tarsometatarsal junction, these relationships being altered in 1 Both lateral and anteroposterior equilibrium must be maintained. Lateral equilibrium is easily maintained by placing the feet nearer together or further apart : disturbance in lateral equilibrium is associated with well-marked orthopedic deformities (spinal curvature, tilted pelvis, shortened leg). These are readily recognized, their significance is well under- stood, and the treatment has been well established, so that they need not be discussed here further than to say that disturbance of lateral may complicate or precede disturbance in anteroposterior equilibrium. They must always be looked for and corrected when found. We are concerned here chiefly with the less easily recognized, less easily cured, and less generally appreciated defects in anteroposterior equilibrium. 536 BACKACHE 537 accordance with the anatomic peculiarities of the individual. If the equi- librium is to be maintained, projection of a part of the body in front of this line must be compensated for by projection of another part back of the line. In the normal erect posture, the parts in front of the line of the center of gravity are equal to those back of it, except where muscular stress exerted on adjacent parts compensates the overbalance. Some of the joints permit forward, and some backward, bending, some both, the limitation in one direction or the other being due to the arrangement of the ligamentous or bony features. 2 When the body is erect and perfect equilibrium is main- tained, the line of the center of gravity runs through or near to all the points of anteroposterior movement, and the effort of the muscles and ligaments anterior to the line is equal to the effort of those posterior to the line; none are too greatly taxed; none too seldom called upon. When the center of gravity is displaced forward, the posterior muscle and ligament groups must perform extra work ; when it is displaced backward (rare), the anterior muscle and ligament groups are under increased stress. The joints that are especially concerned in the mainte- nance of equilibrium are the vertebral, the lumbosacral, the sacroiliac, and the tarsometatarsal. These are the joints of limited motion, and are subjected to greater strain than are the hip-, knee-, and ankle-joints. The vertebral and lumbosacral joints are supplied with very strong ligaments and are well splinted by muscles. The sacroiliac and the tarsometatarsal joints are those subjected to the greatest strain and are those that have the least natural protection. The sacroiliac joint connects the trunk and the pelvis; in the erect, in the sitting, and even, but to a much less degree, in the supine position, this joint is subject to stress. It is dependent for endurance upon the relation of the articulating surfaces of the sacrum to those of the innominate bones, and the strength of its cartilaginous and ligamentous attachments. It is not splinted or reinforced, except to a very limited extent, by muscles or tendons passing over it. The weight of the trunk transmitted through the spine may carry the promontory slightly downward and forward into the pelvis, the sacrum rotating on a transverse axis' passing through the second piece. The arches of the feet, which bear the weight of the entire body in the erect position, depend for their strength essentially upon the ligamentous attachments between the calcaneum, cuboid, external cuneiform, and third metatarsal bone. In addition they are reinforced bv the tendons of the Fig. 442. — Nor- mal posture. (After Dickinson and Truslow.) Thus the chin falls forward, but backward bending of the head is limited by the occi- put : the trunk bends forward to more than right angles on the thighs, but only slightlv backward by virtue of the iliofemoral ligaments ; the knees can be flexed, but not bent forward ; the ankles can be more extended than flexed. 538 GYNECOLOGY peroneus longus and the tibialis posticus muscles. To these may be added the plantar fascia and the muscles to the toes arising from the calcaneum. In disturbances of equilibrium, either forward (usual) or backward (rare) displacement of the center of gravity, the vertebral, lumbosacral, sacro- iliac, and tarsometatarsal joints are placed under unusual stress. Excessive demands of this sort upon the muscles and joints give rise to irritability and fatigue of the muscles, and to congestion and relaxation of the joints, thus giving rise to a symptom-complex known as static backache. The second of the factors in the production of backache is the predisposi- tion in women to faulty development of the muscles, to joint sprains, and to incorrect postures. That a large proportion of women are deficient in muscular development in general needs no proof; this is due to their rela- tive inactivity after the age of puberty. This faulty muscular development is especially evident in the muscles of the back and abdomen, particularly in women who have worn corsets. The joints that women are prone most often to overtax and strain are the sacroiliac and the tarsometatarsal. The former may be injured during labor, while the arches of the feet may be weakened by the wearing of shoes that interfere with normal development. Excessive weight, out of all pro- portion to the muscular and bony development, is also a cause of fallen arches. Faulty postures in women may be due to the wearing of unsuitable corsets or shoes, weak muscles, developmental defects of the chest and ab- domen, pelvic and abdominal ptoses, pelvic inflammation, and obesity. A third factor to be considered in a study of backache of obscure origin is the effect of remote foci of infection upon the spine and the sacroiliac articulation. In individuals already exhibiting a strain or sprain of the joint a toxic arthritis usually attacks these parts. These remarks may serve to correlate the following conditions, which, for convenience, will be considered separately. STATIC BACKACHE Etiology. — Backache is known as static when it is caused by the fatigue or strain of certain groups of muscles and ligaments the result of excessive demand made upon them in order to maintain equilibrium. The disturbance of equilibrium usually consists in a displacement of the center of gravity for- ward, which throws an increased burden on the lower posterior group of muscles. Occasionally the center of gravity is displaced backward, and when this occurs the back muscles are strained above and the iliopsoas ante- riorly and below. Disturbance of lateral balance may occur in combination with disturbance of anteroposterior balance. Disturbances in equilibrium are due to the following causes : 1. Flat-foot. — The. feet are pronated and the tarsus sinks to the ground. This results in changes and readjustments of the entire weight-bearing column, and may cause so marked a disturbance of balance as to produce severe backache, as well as pain in the feet, legs, and thighs. 2. Pelvic disorders of an inflammatory nature that compel the woman to assume a forward position in order to ease sensitive pelvic parts. BACKACHE 539 Fig. 443. Fig. 444. 3. Pelvic tumors, or excessive accumulations of fat in the abdomen or anterior abdominal wall, which, by their weight, lead the patient to assume a forward position. 4. Relaxed and pendulous abdomen, often associated with displacements of the abdominal and pelvic organs or prolapse. 5. Skeletal defects, such as knock-knees, difference in the length of the extremities, and defective articulation be- tween the vertebrae, usually between the fifth lumbar vertebra and the sacrum. 6. Faulty posture, of which there are two varieties — first and most frequent, the " kan- garoo " type (Fig. 443), in which the center of gravity is displaced forward; secondly, the "gorilla" type (Fig. 444), in which the center of gravity is displaced backward. The kangaroo type of posture may be asso- ciated with — (a) the slumped, visceroptotic figure (Fig. 445), with shoulders drooping forward, narrow intercostal angle, long waist, and relaxed abdominal parietes ; (b) the " overfeminine figure" of Reynolds (Fig. 446), trunk atrophy (corset pressure), small bones, narrow intercostal angle, slender, tapering waist, with broad and excessively padded hips, a deformity due to tight lacing and insufficient exercise. Symptoms. — The principal symptom is backache, which affects especially the lower lumbar and sacral region when the patient is erect. In severe cases it is more or less constant, but it may be intermittent in milder ones. The discomfort may be de- scribed as a feeling of extreme fatigue or an aching, dragging pain. Relief is not ob- tained by the recumbent posture alone, but the patient may have found that a certain position that relaxes the strained and fatigued parts gradually brings relief. The pain may be referred to the occipital and upper dorsal region. If there is an associated sacroiliac sprain, pain may be present in the coccygeal area and along the distribution of the great sciatic nerve. If the feet are pronated or flat, there is pain in the legs and feet. As a rule, the pain is bilateral, although one side may be more painful than the other. Tender- ness is often present over the sacroiliac joint, since in severe cases of static backache the faulty posture has put excessive strain on this articulation. Muscle spasm, either on one or on both sides, is always present in static backache. When static backache is unilateral, the sacroiliac joint of the 443. — Kangaroo posture. (After Dickinson and Truslow." Fig. 444. — Gorilla posture. (After Dick- inson and Truslow.) 540 GYNECOLOGY affected side is especially likely to be tender and painful. There may be some limitation of motion, both laterally and anteroposteriorly, but this finding is not constant. Diagnosis. — In making a diagnosis of static backache the most pains- taking effort often is required. The patient must be examined systematic- ally, with special regard to the following : . (a) The attitude in general, whether bent forward (kangaroo), back- ward (gorilla), or normal. (b) Shoulders back and square or forward and round. (c) Abdomen rounded and pendulous, or well held up and flat. (d) Feet well arched or flat; shoes with high or low heels, roomy or tight. (e) Constriction of waist. (/) Width of buttocks. Preliminary observations may be made with the outer clothing re- moved, the patient standing clothed in corsets and shoes. A graphic method Fig. 446. Fig. 445. — Slumped visceroptotic figure. (After Smith.) Fig. 446. — Overfeminine figure. (After Reynolds.) of recording the posture (Dickinson) and the anteroposterior equilibrium is made by tracing the outlines of the patient upon a large sheet of paper hung upon the wall. The patient is directed to stand with the side to the wall, the backs of the heels touching a strip of wood fixed to the floor at right angles to the wall. A tracing is then made as shown in the illustration (Fig. 447). At this point in the examination the corset and shoes should be carefully in- spected (see page 543). The corset and shoes should then be removed and another tracing made. A comparison of the tracings, shows the normal attitude of the patient and the extent to which it has been modified by her dress, especially by her corsets and shoes. Normal Type. 3 — The head is level. The line of the dorsal spine is gently 3 The following notes descriptive of the normal posture and of the two most frequent deviations have been modified from Truslow. BACKACHE 541 rounded and touches the " rear perpendicular.'' 4 The line of the lower dorsal and lumbar spines curves gently forward and then backward, the top directly above the bottom. The angle of the plane of the pelvic inlet is about 60 degrees with the horizon. The thighs and the legs, the hip-joint, and the knee-joints are in or adjacent to the plane of the center of gravity. with a proper balance maintained between the flexor and the extensor muscles, and therefore no strain. The body weight is well distributed be- tween the heels and the balls of the feet, and there is good control in walking. Kangaroo Type. — The head is prone to tilt upward. The shoulders are in front of the rear perpendicular. The lower dorsal and lumbar curves are less marked, and the line of the lower dorsal and lumbar spines slants downward and backward. The sacrum tends to rotate forward between the ilia, straining the sacroiliac joints, the erector spinae group of muscles are stretched and strained. The pelvis is rotated forward on the hip-joints, and the plane of the inlet is at an angle of more than 60 degrees. The line of the center of gravity is in front of the hip-joints, the ham-strings are stretched, the flexors are relaxed, the knees are displaced backward (extreme ex- tension), the center of gravity is in front of the joint, the extensor muscles of the leg are over- stretched, the flexors are relaxed, and the weight of the body is unequally distributed upon the feet, most of the strain falling on the balls and arches. Gorilla Type. — This type is much less fre- quent than the others mentioned. The head is prone to tilt downward, the shoulders are back of the rear perpendicular, and the line of the lower dorsal and lumbar spine is forward. The sacrum tends to rotate backward between the ilia, putting a strain on the joints. The iliopsoas _ r ° 1111 -1 1 FlG * 44 ? • — Patient s outline being muscles are stretched ; the abdominal muscles are traced. (After Dickinson and on tension. The pelvic inlet is at an angle of less than 60 degrees to the plane of the horizon. The center of gravity is back of the hip-joint; there is strain on the iliopsoas ligament and flexor groups of muscles. The knees are forward; the extensors of the feet are on tension; the weight of the body is borne especially by the heels, but in an effort to equalize the strain there is tension of the tendons of the extensor group of the legs. After determining the anteroposterior balance of the individual (center of gravity normal or displaced forward or backward), the examiner may 4 A perpendicular line passing through the upper extremity of the gluteal crease. 542 GYNECOLOGY devote his attention to a search for contributory causes of disturbances of the equilibrium. Chest Defects. — In women, with the notable exception of singers, ath- letes, and those who have not worn corsets, the epigastric angle is more acute than normal, and the lower part of the thorax is compressed from side to side. Muscular Development. — Almost all women, except those who have fol- lowed athletic pursuits and those who have avoided the use of corsets, show deficient development and lack of tone of the muscles. In women who have borne children this is most noticeable in the abdominal wall and back. Feet. — When the arches of the feet are flat, the tarsus sinks to the ground and the feet are pronated. This results in changes and readjustments in the entire weight-bearing column above, and may result in so marked a dis- turbance in balance as to produce pain in the feet, legs, and thighs, as well as backache. Constriction About the Waist. — Many women who wear corsets show narrowing of the lower thorax and constriction about the waist. Marked cases are invariably accompanied by visceroptosis, and pendulous abdomen and excessive fat pads are commonly associated. Fat Pads. — Normally, the layer of fat on the abdominal wall above the umbilicus should be thicker than the layer below it. In many women, as a consequence of corsets, the fat is thicker below the navel ; pads of fat are also present over the iliac crests, over the trochanters, and beneath the buttocks. These pads may vary in size from the rotundity of form con- sidered characteristic of the sex, to gross and fleshy protuberances and actual deformities. Differential Diagnosis.— Before a positive diagnosis of static backache can be made, the influence of existing pelvic and vertebral disorders must be ruled out. Pendulous abdomen, visceroptosis, and displacement of the pelvic viscera may precede or accompany postural defects. Pelvic disease of an inflam- matory nature may precede postural defects, the patient unconsciously leaning forward and relaxing the abdominal wall in order to lessen intra-abdominal ten- sion and relieve pressure on the sensitive viscera. Backache due to downward displacement of abdominal or pelvic viscera is usually promptly relieved by the recumbent posture, and even in the erect position the patient can be made com- fortable by the replacement and support of the affected structures. Backache due to pelvic disorders is usually most severe just before or during the menstrual period, and is often accompanied by bladder and rectal symptoms. When postural defects are accompanied by inflammatory or neoplastic disorders of the pelvis, it may be necessary to cure the pelvic disease before one can determine how much of the pain is pelvic and how much is static in origin. Structural and organic disease of the spine should not be difficult to recognize. In Pott's disease and following injuries, the back pain is definitely localized. Referred pain, due to pressure on the posterior roots, is frequent, and traceable to the involved area. Malignant disease of the vertebrae, which occurs at times as the result of metastasis following the removal of pelvic or abdominal neoplasms, is char- acterized by intense local and referred pain, which is exceedingly difficult BACKACHE 543 to control. Spondylitis deformans (hypertrophic arthritis) occurs most fre- quently in men after the age of thirty-five ; the general and spinal rigidity, rounded kyphosis, and characteristic referred pain due to root pressure should make the diagnosis clear. Finally, the Rontgen ray will demonstrate the presence of definite lesions. Static backache may so closely simulate a sacroiliac sprain as to be almost indistinguishable ; in fact, with static backache there is always strain or tension on the sacroiliac joints. At times this is the most noticeable result of faulty posture. In sacroiliac sprain due to falls or blows or the result of traumatism incident to labor, the history of the case will reveal the origin of the trouble. Treatment.— It is obvious that in many cases gynecologic and ortho- pedic treatment must be combined. Displaced pelvic viscera must be re- stored to good position and these must be maintained by operation or by mechanical support {e.g., a pessary). Displaced abdominal viscera must be returned to their normal position, and a relaxed abdominal wall must be supported. The measures adopted for the latter purpose {e.g., a properly constructed corset) form a part of the treatment of static backache, as will be seen later. Orthopedic Treatment. — Since static backache is due to a disturbance of balance in the direction of forward or backward shifting of the center of gravity, and consequent strain and fatigue of joints and muscle groups, to be successful any method of treatment must restore the equilibrium and relieve joint and muscle strain. In restoring balance one must remember that he is dealing with the entire weight-bearing column, and not with one particular part of it. Two important factors that require consideration at the beginning of the treatment are the shoes and the corsets — shoes, to give the individual an efficient base of support, and corsets, to secure the proper relation between the trunk and the lower extremities. Shoes may be so constructed as to correct flattening of the arch and pro- nation of the foot. Flattening of the arches should be treated by having foot-plates built into the shoe or by wearing leather and felt inlays under the arch. Pronation that is not corrected by wearing the proper arch sup- port may be dealt with by raising the inner edge of the shoe from three- sixteenths to one-quarter of an inch. The heel of a shoe has an important bearing upon the distribution of the weight superimposed upon the foot. The higher the heel, the greater the weight that must be borne by the ball and arch of the foot. For this reason, and because their use leads to de- formity of the toes and heads of the metatarsal bones, excessively high heels must be regarded as injurious. The height of the heel also has an impor- tant bearing upon the equilibrium of the body above, and the relationship between the lower extremities and the trunk in the position of the line of the center of gravity. By raising the heels of the feet (in cases of forward displacement of the center of gravity), high-heeled shoes tend to effect a spontaneous and unconscious correction of attitude and a displacement backward of the center of gravity. For this reason they may be prescribed successfully in cases of static backache of the " kangaroo " variety of de- 544 GYNECOLOGY formity. In backache due to deformities of the " gorilla " type, the heels may be lowered in order to favor a forward displacement of the center of gravity. Whatever form of shoe is selected, the physician should impress upon his patient the desirability of wearing shoes of the same size, form, and heel throughout the entire day. Corsets are used in the treatment of static backache for the purpose of Fig. 448. Fig. 449. Fig. 448. — Corset for kangaroo posture. (After Dickinson and Truslow.) Fig. 449. — Corset for gorilla posture. (After Dickinson and Truslow.) correcting postural abnormalities of the " kangaroo " or " gorilla " type (Figs. 448 and 449). These corsets should be so fashioned as to throw the trunk backward (usual) or forward (rare) upon the pelvis. In order to do this the corset must grip the pelvis firmly, thus fixing it and adding strength to the sacroiliac articulation. It must also support the lower ab- domen, and in this way correct the visceroptosis that is present. The proper corset, therefore, fits the patient snugly about the pelvis, so that it is capable of binding the bones together and of forming a fixed base, from BACKACHE 545 which its shape will influence the relation of the trunk to the pelvis. The front is straight and begins over, or immediately above, the pubic crest; it is not high in front ; its back is so curved in at the wast-line as to correspond to the normal dorsolumbosacral curve, and it is slightly incurved at the sides. The good corset firmly encircles the pelvis, supports the lower ab- domen, elevates the chest and shoulders, throws the center of gravity back- ward, and reinforces the muscles of the back. The corset required for the unusual " gorilla " type must be longer behind, so as to throw the shoulders slightly forward, and its incurve behind must be flattened in the dorsal region. A properly devised corset (Figs. 450 and 451) does not constrict the waist, and the pressure it exerts is greatest at its lowest point and becomes progressively less as its upper borders are approached. Fig. 4SO. Fig. 451. Fig. 450. — Bad type of corset. (After Dickinson and Truslow.) Hour-glass shape, maximum pressure at waist line, chin and shoulders thrown forward, inlet leveled. Fig. 451. — Good type of corset. (After Dickinson and Truslow.) When the backache is very severe and marked lordosis is present, the corset may be supplemented advantageously by a support of the Jones type. This consists of a triangular leather back-piece, reinforced with two light steel uprights and an abdominal pad attached to the back-piece by straps. The back-piece should extend from the end of the sacrum to a point just below the shoulder-blades. It is worn under the corset, and when prop- erly applied and adjusted, aids materially in splinting the back and lifting the abdomen. Merrill has designed an excellent splint (see Fig. 453). A properly fitted corset or corset and brace may be almost unendurable at first ; it often so radically changes the carriage and figure of the woman as to cause mental as well as physical distress. The clothing needs alteration, since the waist-line is larger, etc. ; but if she is encouraged to persist in wear- ing the new corset, and proper carriage and dress are insisted upon, after a little time the corset that at first appeared unendurable becomes almost in- 35 546 GYNECOLOGY dispensable to her comfort, and the improvement in figure becomes a source of gratification. For women engaged in hard work the snugly fitting corset is especially trying at- first. After fitting the patient with the proper shoes and corsets, she should be directed to rest for the greater part of each day until muscle irritability, spasm, and tenderness have subsided. Suitable exercises should now be prescribed, which will improve the poise and strengthen the muscles gen- erally, but especially those of the back and abdomen. In poorly developed and weak subjects massage may be a valuable preliminary. The aim of the treatment should be to so strengthen the muscles and correct the carriage that proper equilibrium may be maintained without artificial support. Never- theless, in spite of the most painstaking efforts, the patient may always require the assistance of specially constructed corsets and shoes. In emaci- ated subjects it is highly important to increase the weight, and every effort toward effecting that end should be employed. Probably the most difficult cases occur in the very fat, and here strict regulation of the diet is imperative. 5 SACROILIAC SPRAIN Etiology. — The sacroiliac articulation is exposed to considerable strain. Being the joint connecting the spine and the pelvis, it must bear the weight of the superimposed spinal column, thorax, upper extremities, and head when 5 The treatment outlined by Dickinson and Truslow is as follows : The Mechanical Treatment of the " Kangaroo " Type A. Supportive. i. The corset (Fig. 448) must have: (a) Low abdominal support; (b) front lines straight, slanting slightly forward as carried upward and with inside pressure de- creasing as ascending; (c) about the pelvis, tight circumferential lines, requiring reinforcement with inelastic webbing; if there is sacroiliac strain (d) the back ascending lines should be made more nearly perpendicular than is the patient's back. Sometimes light steel reinforcement is necessary. 2. Support of the feet: (a) The patient may at first wear higher heels than in the other type of posture, but the corset correction of the poise of the trunk tends auto- matically to adjustment of the knee and foot balances; (b) special foot-braces may be used, if otherwise indicated, but the plantar arch unbalances are not usually due to the malpositions of faulty anteroposterior posture. B. Gymnastic. 1. Educative : train posture. 2. Muscle building : especially abdominal, buttocks, and calf muscles. The Mechanical Treatment of the " Gorilla " Type A. Supportive. 1. The corset (Fig. 449) must have: (a) Back lines curved in and forward for the hollow of the back. A special sacral pad, thicker and broader above than below, may be inserted at the proper place inside the corset to help in shifting the lower spine forward, (b) About the pelvis, tight circumferential reinforcement, especially if there is sacroiliac strain; (c) low abdominal support; (d) the front ascending lines should be straighter than the present pendulous abdomen deformity, and carried as much forward as ascending. 2. Support of the feet: (a) Height of the heels should be reduced as rapidly as pos- sible. Here the corset correction tends automatically to correct the faulty knee and 1 foot balance, but the_ general correction of the position must not be retarded by j high heels; (/;) special foot-braces or specially constructed shoes are often indi- cated to raise the depressed and painful metatarsal arches. B. Gymnastic. t. Educative: train posture.^ 2. Muscle building : especially scapulovertebral, abdominal, anterior thigh (knee ex- tensors), calf, and toe flexor muscles. BACKACHE 547 the individual is standing or sitting. The sacroiliac joints are also exposed to strains upon the bony ring and arches of the pelvis, from within or from without, e.g., the passage of the fcetal head during labor falls upon the but- tocks, jars while riding astride, etc. Every movement of flexion or extension of the trunk throws some strain on this joint, which depends for its integrity upon the interlocking of the opposed bony surfaces and the strength of the ligaments binding them together. The strongest ligaments of the joint are those that run between the posterior surfaces of the iliac bones and the pos- terior surface of the sacrum. The anterior ligaments are much thinner and weaker, but they are reinforced by the iliopsoas and pyriformis muscles. The sacroiliac joint is protected from lateral strain by the bony girdle which is formed by the junction of the innominate bones in the symphysis pubis. The firmness of the articulation at the symphysis is sometimes imp-aired during pregnancy, and the continuity of the anterior bony ring may be broken by faulty union following symphysiotomy and pubiotomy. When- ever this anterior bony ring is broken, the anterior surface of the sacro- iliac articulations is exposed to lateral strain. Difficult labors result in sacroiliac strains, produced either by the pressure exerted by the fcetal head as it is molded or dragged through the pelvis with forceps, or by positions such as the Walcher, which are designed to increase the diameter of the pelvic inlet by employing all the mobility in the pelvic joints. Acute trauma is a prolific cause of sacroiliac sprain. It may also be due to violent falls upon the buttocks; twisting falls, the result of slipping; the sudden placing of a heavy strain upon one leg, or of violent muscular effort on one side to regain the equilibrium. A fact not widely recognized is that the sacroiliac joint may be exposed to undue strain in the course of abdominal operations if no provision is made for the support of the lumbar spine and the lumbosacral curve, or for the knees when the legs are straight. There is often considerable downward pressure on the pelvis by the operator or his assistants, and in the uncon- scious patient the strain of the sacroiliac articulation so imposed cannot be overcome by muscular action or support. Many persistent backaches fol- lowing operation may be laid to this source. General diseases or conditions of wasting and ill-health may impair the muscular and ligamentous strength of the articulations in general, and since the sacroiliac joint is the one that bears the greatest strain, it may be affected first. Sacroiliac weakness is often present in patients exhibiting postural defects, obesity, muscle atrophy, general relaxation of the muscular tissues, or visceroptosis. Symptoms. — When the sacroiliac joints are taxed beyond their strength, the ligaments are overstretched, an osteo-arthritis of mild or severe grade may be set up. and every tax or strain upon the joint may become painful. The pain may be localized directly over the articulation posteriorly, on one or on both sides, corresponding to the lesion, or, by virtue of the intimate association of the lower part of the joint anteriorly with the lumbosacral cord, it may extend down the backs of the thighs (sciatica). The pain in sacroiliac sprain is increased by any position or exertion that puts tension on the ligaments or that necessitates motion, however slight, of the joint. Bending the spine forward, backward, or to one side, 548 GYNECOLOGY assuming the recumbent or the erect posture after lying flat on the back, rising from a chair, etc., are among the common movements that cause pain. The patient is usually most comfortable lying on the back with the thighs flexed and the lumbar curve supported by a pillow. In getting out of bed or rising from a chair the patient may turn to one side and use the arms to push the body up into the desired posture. Occasionally the prone position is uncomfortable and only a lateral posture may give relief. Examination and Diagnosis. — In marked cases of sacroiliac sprains the diagnosis is easy, but in mild cases it may be difficult. The following tests may be made : With the patient lying supine, the leg and thigh, with the knee extended, of each side in turn is grasped by the hand and carried as far as possible over the abdominal surface (hyperflexion). Then, with the patient lying prone, the thighs are hyperextended. The patient is now placed on her left side ; the sacrum and lower spine are grasped with the left hand of the ex- aminer and fixed, while with the right hand the thigh is hyperextended. The same maneuvers are carried out on the opposite side. Massive per- cussion of the hip is performed at this time, using the fist of the right hand as the plexor, and the outstretched left hand, placed over the upper ilium and the ilio- femoral articulation, as the pleximeter. The patient now stands erect, with the knees fixed. She is directed to bend for- ward, backward, to the right, and to the left as far as possible, and to twist the body first to one side and then to the other. Direct pressure or percussion may now be made over the articulation itself. , These movements are all designed to bring Fig. 452.— Storm's sacro-ihac belt. . , « «. . , ° some tension to bear on the ligaments of the sacroiliac articulation, or to produce motion in the joint. In case of a sore or sprained articulation, one or more of these movements will cause pain, the seat of greatest intensity corresponding to the affected articulation. Nevertheless, mod- erate degrees of sacroiliac sprain may be encountered in which, even after these tests have been made, the examiner may be uncertain as to how important a factor relaxation of this joint may be in the production of a given set of symp- toms. Under such circumstances the therapeutic test will serve to differ- entiate pain due to sacroiliac sprain from that due to other causes. The treatment for the relief of sacroiliac pain should be applied and the effect observed. Treatment. — The treatment of sacroiliac sprain consists in fixation of the joint. The degree to which this is desirable depends upon the severity of the lesion. For the severest cases, a plaster cast will be required. For those that fall into the hands of the gynecologist, fixation by means of a sacral pad and adhesive plaster straps, corsets, or braces will be sufficient. In suspected cases a pad may be placed over the sacrum, and a leather belt may be strapped tightly about the pelvis, care being taken to see that it envelops the bony pelvis and passes below the iliac crests; adhesive plaster BACKACHE 549 Fig. 453. — Merrill's sacroiliac splint. B. Same as .4 , with the exception of the postero-lateral steel uprights, attached to corset, with straps for adjustment. C. Same as A, with posterior uprights and shoulder straps. D and D l . Caliper splint. Same as A, with posterior uprights rigid and two lateral uprights movable, the latter adjusted by posterior straps. Upper ends lateral uprights pass in front of shoulders to force shoulder girdle backward, to give support to spine in direction of sagittal plane. Lateral bars adjustable by posterior strap. 550 GYNECOLOGY may be applied with a similar object in view. Relief of pain may be almost immediate. Should the therapeutic test be positive, the patient may be provided with a more permanent means of support in the form of a brace or a corset (Figs. 452 and 453), or a combination of the two. Sacroiliac sprains are often present in conjunction with static backache, relaxation of the abdom- inal parietes, and visceroptosis, so that treatment for the relief of the pain- ful articulation must be combined with that of the other condition present: Thus a brace may be combined with a corset that corrects a habitual faulty posture of the patient or that supports the lower abdomen and ptotic viscera. Prognosis. — As a rule, the prognosis of sacroiliac sprains is good. The ulti- mate result depends upon the degree of the injury, the thoroughness of the treat- ment, and the general health of the patient. In severe cases complete fixation by means of a plaster cast does much to insure a satisfactory outcome. TOXIC ARTHRITIS An actual inflammation of the articular cartilages and ligaments of the vertebral, lumbosacral, or sacroiliac joints may be the source of per- sistent backache. It is caused by a deportation of bacteria from distant foci of infection, particularly from the teeth, tonsils, and nasal sinuses. Toxic arthritis is usually engrafted upon chronically congested and strained joint surfaces. This condition must always be suspected in rebellious cases of static backache or sacroiliac sprain. The symptoms persist in spite of correction of posture and the wearing of suitable corsets, braces, and shoes. As a rule, the lower spine and sacroiliac joints are particularly tender and the symptoms out of proportion to the degree of postural defect. There may be no history of acute trauma, such as follows a fall or labor. The condition may arise without any previous indication of static or sacroiliac disability. The treatment of toxic arthritis is the treatment of static backache or of sacroiliac sprain, plus the localization and eradication of foci of infection in the teeth, tonsils, nasal sinuses, and gall-bladder. PENDULOUS FAT ABDOMEN J RELAXED ABDOMINAL WALL An excessively fat and pendulous abdomen is a frequent source of distress to women past middle age (Fig. 454). It may be the result of insufficient exercise combined with errors in diet; it may be an evidence of a diminution of the ovarian secretion as observed in the premature, artificial, or natural meno- pause. The exact cause is often undeterminable. Apart from the aesthetic reasons for which the patient may seek relief, the overhanging fat is a source of annoyance and results in maceration and low-grade inflammation of the skin beneath it. In a large proportion of cases the pendulous accumulation of fat is asso- ciated with and undoubtedly aggravates the symptoms of insufficiency of the abdominal wall, separation of the rectus muscles, and ventral hernia. Under such circumstances, the condition ceases to be a mere cosmetic defect, and requires attention because of the part it plays in the production of symptoms. If the latter are treated surgically and no attention is paid to BACKACHE 551 the fat, the result may be unsatisfactory, because of the fact that a con- tributing factor to the discomfort of which the patient complained has been left undisturbed. The intelligent and well-to-do woman will overcome an unwelcome addi- tion to her girth by the use of a suitable corset or an abdominal binder. A properly fitted straight-front corset will elevate and support the pendulous folds. If the accumulation of fat is associated with relaxation of the ab- dominal wall, such a corset or binder will also relieve the symptoms of abdominal insufficiency. It is absolutely necessary, however, that careful attention be given Fig. 454. — Fat overhanging abdomen; -f marks anterior superior spine. the application of the corset, and that it be renewed from time to time. A corset of this sort is above the average in cost, since it must often be con- structed especially for the patient. The carrying out of these measures for the correction of the defect by the use of a corset means the expenditure of time, money, and care. Surgical treatment, on the other hand, offers a speedy relief. If the pendulous fat is not associated with relaxation of the abdominal wall, hernia, or an intra-abdominal disease that requires operation, resection be- comes a very simple matter, requiring but brief anaesthesia, and an opera- tion that is practically free from danger. When the fat is associated with 552 GYNECOLOGY other lesions requiring operation, its resection involves no added risk and consumes but a few extra minutes. The lines of excision should be transverse. The flaps of fat should be brought together with interrupted sutures, and the wound should be drained at each angle for twenty-four hours. COCCYGODYNIA Coccygodynia is the term applied to painful sensations originating in the region of the coccyx, and produced by lesions of its constituent bony segments and the joints between them or the sacrococcygeal articulation. The exciting cause is an injury to the coccyx affecting the continuity of its bony segments or its joints. Solution of continuity takes place most com- monly in labor, the foetal head, in its passage through the pelvic outlet, over- extending the sacrococcygeal articulation with resulting fracture of its bones or rupture of its joints. Other causes may be operative, such as kicks or falls, the trauma being received directly upon the bone, with resulting osteitis and pericoccygeal cellulitis. Symptoms. — The symptoms consist of pain in the affecte-d area when sitting, or especially in rising after being seated, the pain being brought about by muscular action that pulls upon or moves the coccyx. The pain may be excited, also, by defecation. The patient commonly sits more upon one buttock than upon the other, so that the weight rests on one ischial tuberosity and does not reach the coccyx. In rising from the sitting posture the patient assists herself by using the hands and arms, pushing herself up from the seat or along the back of the chair. The pain may be of a more jiidefinite type also, occurring now and then, and apparently not depending upon any particular or special muscular effort. Diagnosis. — The diagnosis can usually be established by making a com- bined examination of the coccyx with a finger in the rectum and the thumb over the coccygeal raphe. Abnormal mobility with exacerbation of the pain, marked deformity of the coccyx, with ankylosis, and thickening of the articulation may be found. If no striking abnormality is discovered, and the symptoms complained of do not manifest themselves as the result of the examination, one must be wary of ascribing the symptoms to the coccyx, or of expecting a cure to follow its removal. Treatment. — The treatment consists in removing the coccyx, although palliative measures, such as counter-irritation and the exhibition of sali- cylates, may afford temporary relief. A median incision is made directly over the coccyx through the raphe, from the tip to the point of its articulation with the sacrum. The surface of the bone is freed up past the sacral joint. With heavy, blunt-pointed scissors it is then cut loose from its attachments all around. After the bone is entirely freed, it should be grasped with a sequestrum forceps, bent forward at the coccygeosacral junction, and the ligaments of the joint divided with a heavy knife; bleeding vessels should be ligated and the wound closed with interrupted sutures of silkworm gut. A strip of rubber dam may be left in the lower angle of the wound for twenty-four hours to insure sufficient drainage. BACKACHE 553 BIBLIOGRAPHY Dickinson, R. L. : "Toleration of the Corset, Prescribing Where One Cannot Proscribe.' 3 Am. Jour. Obst.. 191 i. lxiii. Xo. 6. Dickinson. R. L.. and Truslow, W. : "'Averages in Attitude and Trunk Development in Women and Their Relation to Pain."' Jour. Am. Med. Asso., 1912, lix, 2128. Goldthwaite, J. E. : " The Relation of Posture to Human Efficiency and the Influence of Poise Upon the Support and Function of the Viscera." Bost. Med. and Surg. Jour.. 1909, clxi. 839. Litzenberg. J. C : " Sacroiliac Joints in Obstetrics and Gynecology." Trans. Sect. O., G. and A. S.. A. M. A.. 1917. 93. Lovett, R. W. : " The Causes and Treatment of Chronic Backache." Jour. Am. Med. Asso., 1914, lxii, 1615. Meisenbach. R. O. : " Sacroiliac Relaxation, with Analysis of Eighty-four Cases.'" Surg., Gynec. and Obst. 191 1. xii. 411. Reynolds, E., and Lovett, R. W. : " An Experimental Study of Certain Phases of Chronic Backache." Jour. Am. Med. Asso.. 1910. lvi, 1033. Smith, R. R. : " Enteroptosis with Special Reference to Its Etiology and Development/' Jour. Am. Med. Asso., 1910, lvii. i860; Ibid.: "A Study of Children with Reference to Enteroptosis."' Jour. Am. Med. Asso., 1912, lviii. 385. Wetherill, H. G. : " Subinfection from Foci in the Pelvis and Abdomen." Trans. Sect. O., G. and A. S.. A. M. A.. 1915. 172. CHAPTER XXIX GONORRHOEA General Peculiarities. — The initial s) T mptoms of gonorrhoea are prone to be less acute in the female than in the male, and the disease is, therefore, more insidious in the former. It is also capable of producing more harm and its ravages frequently lead to chronic invalidism or even to death. The frequency of gonorrhoea in the female is difficult to estimate, since it varies greatly in the different classes of society. Johnson reports that in 1901 the Section on Hygiene and Sanitary Science of the American Medical Asso- ciation sent the following question to many of the leading gynecologists in this country and in Europe : " What is the proportion of cases of pelvic inflammation coming under your care which are attributable to gonorrhoeal infection ? " The general average of the proportions given was 40 per cent. Noeggerath first drew attention to the frequency and the seriousness of the disease in women. He believed that eight out of every ten married men in New York city had been infected with gonorrhoea before their marriage, and that a majority of them subsequently infected their wives. While this is undoubtedly an exaggeration, it is nevertheless probably true that no single disease of the genital organs causes half so much suffering, mutila- tion, and direct mortality as gonorrhoea. Bumm estimates that one-third of the cases of sterility in women is due to the gonococcus. The number of instances of race suicide due to this disease, if it could be ascertained, asserted Johnson, would equal the number of lives lost from pneumonia, tuberculosis, or typhoid fever, or perhaps from all these combined. The gonococcus is a peculiar organism. While it is extremely hard to grow upon culture media, and is incapable of producing gonorrhoea in ani- mals, it is nevertheless one of the most difficult organisms to eradicate from the generative organs of women once they have been infected. As com- pared with the streptococcus, the gonococcus has little power of penetration. Its influence upon the cutaneous surface or the modified skin covering of the vagina or the vulva is but slight. Within glandular structures, however, it produces a serious, persistent inflammation that manifests but little ten- dency to undergo spontaneous cure. Wertheim has shown that the gono- coccus does not affect the mucous membranes solely, but occasionally in- vades and becomes embedded in other tissues, where it grows and produces a reaction. Thus the organism may rarely be the cause of parametritis. It has also been found in the wall of the Fallopian tube, at a considerable dis- tance from the mucosa. Gonorrhoeal arthritis and gonorrhoeal endocarditis are further evidences of the truth of Wertheim's assertion. A peculiarity of the transmission of gonorrhoea is that infection from an old gleety discharge (morning drop), when no acute symptoms have occurred and the incumbent is perhaps unaware of the true condition, may produce a gonorrhoea of the most virulent form in a second person. Again, married persons infected 554 GONORRHCEA 555 with the gonococcus may become more or less immune to their own par- ticular organism, so that the symptoms and signs of the disease may sub- side completely. If these persons live apart from each other for a consid- erable period of time, upon resuming sexual intercourse a violent gonorrhoea may be set up in either individual, although both have been virtuous during their separation. Or if the infection is transferred from a married couple to a third person and then again to one of the original incumbents, it is capa- ble of producing a violent attack. Latent and Residual Gonorrhoea. — Chronic gonorrhoea may exist in an individual without producing noticeable symptoms. Under such conditions the host may be entirely unaware of its existence until, following some unusual irritation of the sexual organs, it reappears in an acute or in a sub- acute form. This fact was first noted by Noeggerath, who spoke of it as * l the latency of gonorrhoea." Luther believes that a more nearly correct phrase would be " the latency of the gonococcus." Fritsch speaks of gonor- rhoea without symptoms. Residual gonorrhoea is a chronic affection, which, as Saenger asserts, depends less upon the presence and the activity of the gonococcus than upon the tissue changes produced by the organism during a previous infection. Symptoms. — Gonorrhoea in the female does not pursue so virulent an initiative course as it does in the male. Indeed, in an uncleanly woman or in one of sluggish habits the disease may exist for some time before the patient is aware of it. This is due to the fact that the urethra in the female, being short and not surrounded by erectile tissue, as in the male, an inflam- mation of the mucous membrane is not so painful and difficulty in urination is not so marked. Furthermore, in the female, gonorrhoea is not necessarily first localized in the urethra, but may occur primarily in the cervix or in the vulvovaginal glands — in either situation it is less likely to produce acute initial symptoms than when it occurs in the urethra. Occasionally, either because the infection is highly virulent or the affected parts are unusually susceptible, gonorrhoea does produce severe initial symptoms. In such cases, in addition to a violent local reaction in the affected parts (see urethritis, page 440; vulvitis, page 167; endocervicitis, page 223), slight con- stitutional disturbances may be present. The urethra is the seat of an initial attack of gonorrhoea more often than are the glands of Bartholin or the cervix. For this reason the symptoms at the onset of a gonococcus infection in women are often vesical. The patient complains of frequent and painful urination, a burning pain about the external urinary meatus, and a leucorrhceal discharge. It is a grave mistake at this time to make a vaginal examination or to introduce a speculum unless there is a leucorrhceal discharge from the vagina. If the vulva is carefully cleansed with pledgets of cotton, and the lips of the smaller labia are separated so that the vaginal introitus is exposed to view, the presence of a vaginal discharge can at once be detected. In cases of doubt it is better to permit a cervical nidus of infection to go untreated for a short time than to run the risk of infecting a healthy cervix by making an examination or carrying out a treatment inside the vaginal orifice. In the subacute or in the chronic stage of gonorrhoea the infection is frequently 556 GYNECOLOGY localized in the glands of Skene, the glands of Bartholin, and the cervix. At this time there very often appear, at the urinary meatus (Skene's tubules) and about the orifices of the ducts of the vulvovaginal (Bartholin's) glands, small areas that resemble flea-bites in appearance. These are known as the macula? gonorrhccica, or gonorrhoeal macules. They may be found also in the posterior vaginal fornix when the cervix is the seat of gonorrhoea and the posterior vaginal fornix is constantly bathed with gonorrhoeal pus. In old cases of gonorrhoea .ill gross evidences of the disease may disappear from the external genitalia and the cervix, although the disease may still be present and be capable of infecting another person. The discharge from the glands of Skene, from Bartholin's glands, and from the cervix, though it appears as only a small amount of turbid mucus, will sometimes show the gonococcus. Under such circumstances it may be necessary, in making a search for the gonococcus, to examine smears taken at different times between the menstrual periods ; occasionally the organism will be found in the cervical discharge only preceding or following a menstrual period. From what has been said it will readily be seen that in the chronic latent forms of gonorrhoea a woman can, by careful douching, etc., remove all gross evidences of the disease. Physicians should make it an unvarying practice to instruct patients not to use a douche before coming for examina- tion. Unless such instructions are given, most women, from motives of cleanliness, will take a douche immediately before consulting a physician. The other structures affected by gonorrhoea are the vagina, the endo- metrium, the Fallopian tubes, and the pelvic peritoneum. The disease is considered under the sections that deal with these structures. Diagnosis. — Brose and Schiller believe that the recognition of the gono- coccus in smears is not necessary for confirming the diagnosis of gonorrhoea. The coincident infection of the urethra, Bartholin's glands, and the cervix, and especially the presence of gonorrhoeal macules at one of these situations, are sufficiently significant to' warrant a diagnosis. Neisser and his pupils insist upon the recognition of the gonococcus, and this is important if it is desired to establish the diagnosis for forensic purposes. The Technic of the Preparation and the Examination of Smears for the Gonococcus. — In the preparation of smears for the detection of the gono- coccus it is important to avoid the transference of infectious matter from one point to another. For this reason the platinum wire, or the applicator, or whatever instrument is used to transfer the suspected discharge to a glass slide, should be carefully wiped clean and sterilized in an alcohol flame after each smear is made. The glass slides should be well cleaned before using, and each one should be labelled immediately after it is prepared. The smears must be made very thin. Glass slides are preferable to cover- glasses. If the smears are contaminated with a lubricant of any kind — vaseline, glycerine, etc. — they will not stain well ; hence, in making the smears care should be taken that the physician's hands be free from these substances. It is unnecessary to obtain smears from the vulva or the vagina, except in cases of actual vulvitis or vaginitis in young children. Under such circumstances it would be difficult to procure the discharge, as GONORRHCEA 557 is done in the adult, from the cervix, the urethra, and the vulvovaginal glands, and for that reason the platinum loop may be scraped along the vulvar surface or passed directly into the vagina (Fig. 455). At least three hours after the passage of urine and twenty-four hours follow- ing the use of a vulvar or vaginal douche the patient should be placed in the dor- sal position upon an examining table, and the external genitalia exposed to view. The entire vulva should be gently wiped free from discharge. The forefinger of the left hand should be introduced into the vagina and the palmar sur- face turned upward. The contents of the urethra are now expressed by drawing the finger forward and pressing it steadily against the floor of the urethra. The end of a platinum wire or an applicator is used to transfer a portion of the mucopus to a glass slide. In chronic cases it may be neces- sary to strip the urethra several times in order to secure a sufficient quan- tity of discharge. In such cases, too, the excretion from Skene's tubules is more prone to contain the gonococcus than is the secretion from the urethra itself. The orifices of Skene's tubules are about 2 mm. within the urinary meatus, on the floor of the urethra. In the parous woman, in whom there is some eversion of the meatus, these orifices can readily be Fig. 455. — Smear of pus from urethra (u), vagina (v), and cervix (c). seen ; in nulliparae the lips of the meatus must be slightly everted in order to expose the orifices. To collect the discharge from the ducts themselves the end of a straight platinum wire should be passed directly into them, or they may be stripped, in the manner previously described for the urethra. Practically it makes no essential difference whether the gonococcus is found in the urethra or in Skene's tubules, and the discharge from the tubules may be collected together with that from the urethra. In chronic cases, however, the urethra may be entirely free, whereas the tubules will be the seat of a chronic infection. Even a small amount of thin, yellowish-white discharge may contain large numbers of gonococci. The secretion of the vulvovaginal glands should next be secured by gently compressing the glands, first on one side and then on the other, between the thumb and forefinger. In doing this the forefinger is introduced just w r ithin the vaginal orifice. A smear may also be taken by passing a straight platinum wire directly into the duct of the gland. Smears from the cervix are taken by exposing the part with a bivalve speculum. The portio vaginalis and vaginal cervix are thoroughly cleansed of discharge, and the platinum wire or applicator is introduced 558 GYNECOLOGY into the cervical canal, care being taken not to pass the limits of the internal os. The loop of the platinum wire or the applicator should be made to engage the folds of the cervical mucosa at the circumference of the cervical canal. In this way one is more apt to find lurking gonococcL The slides should be fixed and stained as described on page 128. For the detection of the gonococcus an oil-immersion lens will be required. As a rule, if the discharge is purulent and the smears show myriads of bacteria, the gonococcus will not be found. A number of cocci that slightly re- semble the gonococcus may confuse the beginner and give rise to error. When the gonococcus is present, it can usually be recognized from its form or from its position within the epithelial or the pus-cells. If the investigator is unaccustomed to bacteriologic work, it is well for him to have at hand a type specimen of the gonococcus, and to compare it with the specimen for diagnosis. Prognosis. — If the disease is carefully treated during the initial stages, and if reinfection can be prevented, the prog- nosis is favorable. In old cases, where the dis- ease has persisted either as the result of insuffi- cient or of careless treatment or because of repeated infection, the prognosis is doubtful. Much depends, of course, upon the organs in- volved. Once the disease has passed into the uterine cavity or into the Fallopian tubes, cure becomes difficult. Gonorrhceal salpingitis or pyosalpinx usually demands operation. Even after both tubes have been removed in cases of bilateral pyosalpinx a gonococcal infection may Fig. 456.— Appearance of gonococci persist in the endometrium, cervix, vagina, and m stained preparation. r _ » • o ' vulvovaginal and Skene's glands. This is, how- ever, rare, most cases recovering entirely after a radical operation if proper medical treatment of those foci of infection has been instituted. Prophylaxis. — Much has been written upon the subject of prophylaxis. Some of the plans suggested for preventing the spread of gonorrhceal in- fection have failed signally, whereas others are clearly impracticable. The segregation of prostitutes and the examination of them at regular intervals has not been entirely satisfactory. This failure is due partly to the fact that a woman with chronic gonorrhoea can often, by employing cleansing douches, etc., conceal her condition from the physician unless a painstaking examina- tion is made and the patient is observed for a length of time and under certain conditions that have been discussed elsewhere. The same is equally true of the male. It has been suggested that marriage should not be per- mitted to take place until a careful examination of the male by a physician shows him to be perfectly sound. Such a plan is at present to a great extent impracticable. Both sexes should, however, be told of the serious nature of the disease and should be made to feel its dangers and the responsibility of transmitting it to others. If the truth about gonorrhoea were commonly known, few males who were at some time incumbents of the disease would marry without seeking professional advice. A knowl- GONORRHOEA 559 edge of the suffering and the dangers incident to gonorrhoea would also go far toward discouraging intercourse in the infected and unmarried. For the details of the treatment of urethritis, vulvitis, vaginitis, endocer- vicitis, endometritis, salpingitis, peritonitis, etc., caused by the gonococcus, see the chapters devoted to these subjects. BIBLIOGRAPHY Bumm : "Die Mikro-organisms gonorrhoischen Schleimhauterkrankungen." Wiesbaden, 1885 ; Ibid. : " Die gonorrhoischen Erkrankungen der weiblichen Harn und Geschlechts- organe." Veit's Handbuch der Gynakologie, Bd. 1. Mexge : Handbuch der Geschlechtsk., Vienna, 1910. Neisser, A. : " tiber Eine der Gonorrhce eigentiimliche Micrococcusform." Cent, f . d. med. Wissens., July 12, 1879, 32 ; Ibid. : " Die Mikrokokken der Gonorrhce." Deutsche med. Woch., 1882, xiii, 279 ; Ibid. : " Forensische Gonorrhcef ragen." Aertzl. Sachverst. Zeit, 1895, No. 12. Koeggerath, E. J. : Die latente Gonorrhce im weiblichen Geschlecht. Bonn, 1872. Norris, C. C. : Gonorrhoea in Women. Saunders, Phila., 1913. Wassermann, A. : " tiber Gonokokken-Cultur und Gonokokken-Gift." Berlin klin. Woch., 1897, No. 32, 685 ; Ibid. : " tiber Gonokokken-Cultur und Gonokokken-Gift." Verhand., Berl., Arztlicher Med. Gesellschaft, Berlin klin. Wochenschr., 1897, No. 32, 700. ' Wertheim, E. : " Zur Frankfurter Gonorrhce-Debatte." Cent, f . Gyn., 1896, No. 48, 1209.. CHAPTER XXX TUBERCULOSIS OF THE GENERATIVE ORGANS Tuberculosis may affect any part of the genital tract, but its most fre- quent site is the Fallopian tube. The latter is found to be affected in about 90 per cent, of all cases of genital tuberculosis. Very frequently the peri- toneum is infected coincidentally with involvement of the tube. In 194 cases of secondary tuberculosis of the tube the peritoneum was involved in no. The next most frequent site of genital tuberculosis is the fundus of the uterus ; the cervix is seldom involved. The ovaries are not often invaded. Tuberculosis of the vagina is exceedingly rare, and tuberculosis of the vulva is the most uncommon variety. The incidence in general of tuberculosis of the generative organs in woman is about 1 per cent. This proportion has been determined by post- mortem examination ; 1 per cent, of all autopsies in females showing tuber- culosis of the genital tract. According to Berkeley, in tuberculous women there is tubercular disease of the pelvic organs in j.j per cent. According to Freriche, Turner, and Stopler, tubal tuberculosis occurs in from 12 to 20 per cent, of tuberculous women. The proportion of pyosalpinx that is due to tuberculous infection is given by various authors as ranging from 3 to 10 per cent. Grange reported that in 20 per cent, of all cases of tuberculosis of the female generative tract coming to autopsy at the St. Georg Hospital at Hamburg, the age of the patient was under fifteen ; the greatest number occurring the first and the fifth year and the next largest between the tenth and the fifteenth year. Schlimpert found the greatest incidence (32.9 per cent.) between the ages of twenty-one and thirty, and 17.8 per cent, between thirty-one and forty, and 17.8 per cent, between forty-one and fifty. Tuberculosis of the generative organs is usually secondary to a nidus of tuberculous infection elsewhere in the body. The genital tract is affected secondarily, the disease reaching the tract by the metastatic deposit of tubercle bacilli from the blood-stream. This is the most frequent mode of infection. The next most common mode of infection is by direct extension from a neighboring organ, as, for example, from the peritoneum to the tube. In rare instances tuberculosis of the genital organs may be primary, but in order to establish the diagnosis positively, a complete autopsy must have failed to show a primary focus of infection elsewhere in the body. A pri- mary infection may, however, occur as the result of direct inoculation of tuberculous material during coitus, examination, and instrumentation. Since primary tuberculosis of the vulva, vagina, and even of the cervix, is so exceedingly rare, the occurrence of a primary direct infection has been doubted. It is probable, however, that the vulva and vagina are more resistant to this infection than are the parts higher up. The anatomic manifestations, as well as the symptoms and diagnosis of 560 TUBERCULOSIS OF THE GENERATIVE ORGANS 561 genital tuberculosis, vary according to the parts that are involved. The disease may, therefore, be considered, as it affects the individual parts, bearing in mind that in advanced cases the entire generative tract may be involved. TUBERCULOSIS OF THE TUBES Pathology. — As a rule, both tubes are affected. A preliminary in- flammation or catarrh of the mucosa favors the development of tuber- culous salpingitis. Faulty development or hypoplasia of the genitalia is a predisposing factor. Not infrequently it has its inception during the puer- perium. At first the bacilli lodge in the mucosa, in which they produce the typical tubercles that sooner or later become necrotic and then caseate. Later calcareous infiltration of the caseated areas may take place. These changes vary in extent and in degree. Thus in one case the mucosa alone may be affected, whereas in another the muscular and serous layer also are invaded. The outer part of the tube is usually the portion most extensively affected, and shows the greatest increase in diameter. The lesions may. however, be most marked toward the isthmus, in which case general dis- tention of the tube is not so marked as is the formation of discrete nodules or nodular thickenings. The abdominal ostium may be open or closed, and the tube may or may not be adherent to the surrounding structures. It is usually abnormally convoluted, and shows a certain stiffness and hardness. It varies in diameter from that of a lead-pencil to that of a finger or thumb : some of the largest pyosalpinges ever observed have been tuberculous. The contents usually consist of a grayish-yellow, cheesy material, in which areas of calcareous deposits may be seen. In large tuberculous pyosalpinges the contents may be somewhat fluid and resemble the whitish-yellow suppurative material of a tuberculous abscess elsewhere. After removal of the contents the inner surface of the tube may exhibit small, grayish-yellow tubercles. The tubal wall itself is usually more or less thickened, and if the serous coat is involved. the surface is dotted with the small, grayish-yellow tubercles. The secondary form of tuberculous salpingitis is believed to run a more acute course than the primary form, the abdominal ostium remaining open comparatively longer, and adhesions to surrounding structures occurring relatively late. There is also more likelihood of the muscular layer becom- ing involved. The primary form runs a more chronic course, the abdominal ostium closing early, considerable enlargement of the tube taking place, and adhesions being widespread. In some of the more chronic cases there is a rich overgrowth of fibrous connective tissue and but little tendency to break down is manifested. The three forms described by Williams as miliary, chronic diffuse, and chronic fibroid are regarded respectively as the begin- ning stage of the tuberculous process, the advanced form, and the variety in which there is an overgrowth of connective tissue. It is important to remember that cases of tuberculosis are encountered that are not even remotely suggestive of a tuberculous process. They resemble closely the ordinary suppurative conditions, and only by making microscopic and bacteriologic examinations can the true nature of the dis- 36 562 GYNECOLOGY ease be recognized. Other cases are seen in which the diagnosis can be made only as a result of a bacteriologic examination, and identification is possible only after stained tubercle bacilli have been recognized in the pus. Infection of the peritoneum from the tube occurs either through the ab- dominal ostium or by direct passage of the infection through the tubal wall. Tubal tuberculosis may extend to the endometrium. Only rarely does it attack the ovaries, the vagina, and the vulva. In the presence of a mixed infection a tuberculous salpingitis may be attended with suppuration. Symptoms. — The symptoms of tuberculous salpingitis may in no way be distinctive. A salpingitis occurring in a young virgin may be suspected of being of tuberculous origin. Salpingitis occurring secondary to a focus of tuberculous disease elsewhere in the body, without a history of possible gonorrhceal or septic infection, should be examined carefully for evidences of a tuberculous nature. Probably the most common symptoms are tenderness and pain. A gen- eral ill-defined soreness, interrupted by attacks of acute pain, not so severe as in the usual form of salpingitis or peritonitis, with elevation of tempera- ture, rigidity of the lower abdomen, etc. After the attack passes off — which may occur within a week or ten days — the uterus and adnexa are less likely to be fixed than after gonorrhceal salpingitis or ordinary pelvic in- flammatory attacks of septic origin. The enlargement of the tubes may readily be recognized, and in some cases, especially when the isthmus of the tube is chiefly involved, with the development of localized thickenings, a rosary-like formation can be outlined. Sterility is the rule. No constant effect of the disease on the menstrual periods has been noted. Fever of a regularly remittent type may be present. Some vesical irritability is often observed. The general health may fail, and a leucorrhceal discharge may be present. When, in addition to the tuberculous salpingitis, the peritoneum is in- volved, and there is a tuberculous peritonitis of the disseminated serous variety, diarrhoea, pain and tenderness of the iliac fossae, and enlargement of the abdomen may supervene. Examination may not disclose anything char- acteristic of a tuberculous disease. The nodular condition of the isthmus of the tube, believed by some investigators to be characteristic of tuberculosis, has been known to exist in gonorrhoeal lesions. The infiltration and exudate found in the ordinary gonorrhceal and septic cases are more marked than in those of tubercular origin, except in the later stages, when the changes have been extremely marked. When peritonitis accompanies the tubal disease, ascites may be present. The collection of fluid in tuberculous peritonitis is often more or less local- ized, and may be so completely localized as to form a tumor that resembles an ovarian cyst. The collection of fluid may be situated in the center of the abdomen or to one side. Movable dulness is less likely to be present than in other forms of ascites. Treatment. — The only treatment that can be considered is complete ex- tirpation of the tubes. This is done preferably through an abdominal in- cision, the ovaries and uterus being spared if possible. TUBERCULOSIS OF THE GENERATIVE ORGANS 563 TUBERCULOSIS OF THE PERITONEUM Pathology. — Tuberculosis of the peritoneum is considerably more common in the female than in the male. The ratio is about three to one. In females the peritoneum is most frequently infected from the tubes. The tubercle bacillus also reaches the peritoneal cavity through the intestine, into which they have been introduced through the medium of infected milk or meat. The intestine may be involved primarily and the peritoneum secondarily, or the bacilli may pass through the intestine without causing any lesion and attack the peritoneum primarily. Bacilli may be deposited also through the blood current from the mesenteric glands or the pleura. Four varieties of tuberculosis of the peritoneum have been described by Murphy : (i) The most usual one, the ascitic or serous variety, also known as disseminated, miliary, and non-confluent tuberculosis ; (2) the adhesive, cystic, or obliterative variety; (3) the nodular, ulcerative, or perforative variety ; and (4) the suppurative, circumscribed, or general mixed infection. As has been stated, the ascitic is the most common variety. The peri- toneum presents a congested appearance, with here and there gray fibrous plaques and fresh deposits of miliary tubercles, most numerous near the ends of the tubes. Cheesy material may be seen escaping from the tube. In the adhesive variety the endothelial lining of the peritonal cavity is de- stroyed, and connective-tissue products are formed that result in cyst for- mation and isolation of certain areas in the peritoneal cavity. There is considerable agglutination between adjacent intestinal walls and the peri- toneum. In the ulcerative form the tuberculous process has been most de- structive, and the involved intestine, mesentery, or pelvic organs are destroyed, and are represented by caseous masses surrounded by " dense connective-tissue barriers and adhesions" (Murphy). Tuberculous peri- tonitis with mixed infection may take the form of any of the three varieties just described, plus infection by other organisms. Symptoms. — The symptoms of tuberculous peritonitis may come on very slowly or appear suddenly. There are tenderness and pain in the pelvis or lower abdomen, diarrhoea, and attacks of exaggerated pain combined with nausea and vomiting. The general health may be considerably disturbed. The menses may or may not be affected. The temperature may be subnormal in the morning, and elevated in the afternoon. The abdomen enlarges, and the patient becomes pale and emaciated. On abdominal examination the findings vary. Ascites may be present, which gives the impression of being encysted. The area of fluctuation may take in almost the entire abdomen, be limited to the region below the umbilicus, or it may be confined to one or the other hypogastric region. " Plaque-like thickenings of the deeper parts of the abdominal wall " (Murphy) were pointed out by Edebohls as a sign of great value in making an early diagnosis of peritoneal tuberculosis with- out ascites. The skin may take on a deep brown, discolored appearance. The abdomen may feel " doughy " to the palpating hand. The pain and tenderness may undergo periodic exacerbations, with leucocytosis, eleva- tion of temperature, increased pulse, nausea, and vomiting. These attacks are especially prone to be repeated in the disseminated variety, and are due 564 GYNECOLOGY to an outpouring of tuberculous material from the tubes. The attacks last from eight to fourteen days, and bear some resemblance to attacks of appen- dicitis, except that the remission is not complete, and an unusual sensitiveness continues. In the more advanced cases, when the tubes are closed and sealed off, the pain is irregular and sharp attacks do not occur. There is more continuous pain and tenderness, with recurrent seizures of colic and slight elevation of temperature. In the fibrous variety the circumscribed cysts are a more or less prominent feature, and when present in the pelvis are frequently mis- taken for cysts of the broad ligament. Irregular cystic collection in- volving almost any part of the abdominal cavity may also be present. " In the mixed infection cases, there may be chills, pronounced elevation of tem- perature, diarrhoea, and rapid emaciation" (Murphy). The distinguishing features between the tuberculous and the ordinary varieties of general peri- tonitis are dependent largely upon the history. Treatment. — The treatment of tuberculous peritonitis should be directed toward removal of the tuberculous focus, if that is possible, as it is when the tuberculous lesion of the peritoneum is secondary to a tuberculous infec- tion of the tubes or the appendix. In addition to removing the focus of the disease, tuberculous ascites or exudates must be evacuated. Care should be taken during the progress of the operation not to add another source of in- fection, and a certain amount of reaction in the peritoneum is desirable as the result of the laparotomy, in order to produce tissue proliferation which may overwhelm and encapsulate the tuberculous peritoneal deposits. When the disease is so far advanced that actual destruction of the pelvic viscera has occurred and the intestines are very extensively involved, laparotomy can do little more than definitely determine the diagnosis. TUBERCULOSIS OF THE ENDOMETRIUM Pathology. — Tuberculosis of the endometrium is next in frequency to tuberculosis of the peritoneum. The lesion is usually secondary to a similar process in the tubes. The endometrium about the tubal orifices is most frequently invaded. The endometrium is believed to be somewhat protected against tuberculosis by the regular monthly ana- tomic changes that take place in its structure. Tuberculosis is more fre- quent before puberty and after the menopause. The disease may be found in the early stage, when it is marked by small, scattered tubercles, or in a later stage, when the tubercles have undergone necrosis and caseous degen- eration ; when the condition is more advanced, there may be considerable involvement of the muscular coat of the uterus, so that the diseased uterus may be represented merely by a fibrous bag containing caseous material, or the caseous material may undergo secondary infection, with the formation of a pyometra. In the early stages there may be no enlargement of the uterus, but in advanced cases considerable enlargement may take place. The disease ap- pears to be more frequent in multipara?, and at times the onset of the disease can be traced back to the puerperium. The formation of thrombi at the TUBERCULOSIS OF THE GENERATIVE ORGANS 565 placental site is believed to furnish an attractive resting-place for tubercle bacilli in the circulation. A tuberculous placenta may be the starting-point, and it is well known that a latent tuberculous process frequently lights up during pregnancy and the puerperium. Symptoms. — The symptoms are not pathognomonic of the condition, although the most frequent manifestation is a profuse and stubborn leucorrhcea. This symptom, when it occurs before puberty and after the menopause, may be particularly significant. The menstrual function may be normal, or scanty or profuse menstruation, or even amenorrhcea, may be observed. Treatment. — Whenever tuberculosis of the endometrium is strongly sus- pected, curettement should be performed immediately. As soon as the diag- nosis is made, unless the disease is discovered in the very early stages, and the tuberculous process appears to be limited to the superficial parts of the endometrium, panhysterectomy is indicated. For these cases discovered in Fig. 457- — Tuberculous pyosalpinx with torsion of ovary and tube. (University Hospital.) the earliest stage curettement may suffice. If the uterus is removed, both tubes should likewise be extirpated. One or both ovaries should, if possible, be allowed to remain. TUBERCULOSIS OF THE OVARY Pathology. — Tuberculosis of the ovary is somewhat infrequent. Ovarian involvement occurs in less than one-third of the cases of genital tuberculosis. Some authors report the percentage to be as low as 12.6. In one or two reported cases tuberculosis of the ovaries appears to have been primary in origin. Infection may be hematogenous, or occur by direct extension from the Fallopian tubes and peritoneum. The latter is the commonest route. The infection may ako be carried to the ovary by way of the lymphatics. Tuberculosis of the ovary resembles tubercular infection of the testicle. In the early stages the disease in the ovary may be limited to the periphery, but later on the ovarian stroma is penetrated. There may be simple superficial tubercles or caseous foci, or ovarian ab- scesses the size of an egg may be seen. In the latter case, a mixed infection 566 GYNECOLOGY has probably occurred. At times there is considerable enlargement of the ovary, without softening, the stroma of the ovary being infiltrated with yellow nodes. Symptoms. — The symptoms of tuberculosis of the ovary are not char- acteristic, and are usually combined with those of tubal or peritoneal tuberculosis. Treatment. — The treatment consists in extirpation of the diseased struc- tures. If the tuberculous disease is limited the ovary may be resected. TUBERCULOSIS OF THE CERVIX Pathology. — This is a rare form. Beyea was able to collect 69 cases. The cervix may be diseased without any other parts of the genital tract participating in the affection. In Beyea's collection of 69 cases 30 were associated with far-advanced lesions of distant parts of the genital tract. In two primary cervical tuberculosis was discovered at autopsy. Twenty-two were clinical cases, and of these three were asso- ciated with lesions in other parts of the genital tract and in distant parts of the body. Symptoms. — The symptoms are not especially characteristic. As a rule, they consist of leucorrhoea, at times of an offensive odor, and metrorrhagia. Menstruation is generally profuse. The only positive method of determining the presence of a tuberculous lesion is by making a microscopic examination and by injecting fragments of the diseased tissue into guinea-pigs. The condition has often been mistaken for carcinoma or sarcoma, or has been erroneously classified as ulcer or vegetations. The disease may appear in the form of miliary tubercles scattered over the cervix, or as a papillary mass that resembles carcinoma or a tuberculous ulcer. Treatment. — The treatment will depend upon the associated lesions and the condition of the patient. If the disease appears to be restricted entirely to a small area of the cervix, a high amputation may be done. If the condition of the tubes is in doubt, it would be justifiable to perform an exploratory abdom- inal or vaginal section. In advanced cases panhysterectomy is the opera- tion of choice. TUBERCULOSIS OF THE VAGINA Pathology. — This is usually secondary, and associated with other tuber- culous lesions higher up in the genital tract. It may, however, be the only part affected, one case having been recorded in which a tuberculous ulcer of the vagina was primary. Symptoms. — The disease usually appears in the form of an ulcer. Tubercles are almost always present, however, on the floor of the ulcer or at the periphery. In the later stages ulceration is multiple, confluent, and displays a tendency to extend into the rectum or the bladder. The disease resembles carcinoma and syphilis, and a differentiation can be made only as the result of microscopic and bacteriologic examination. Treatment. — In mild cases destructive cauterization may suffice, but in more advanced cases radical excision may be demanded. TUBERCULOSIS OF THE GENERATIVE ORGANS 567 TUBERCULOSIS OF THE VULVA Pathology. — The vulva is the most infrequent site of genital tuber- culosis. The rarity of a tuberculous infection of the external genitals has been used as an argument against a direct primary infection, but it is probable that the tubercle bacillus passes over the vulva to find a more fertile soil higher up. Many of the cases described in the literature as lupus, rodent ulcer, and esthiomene, are really tuberculous diseases of the vulva. Symptoms. — At first there is a dull red or livid discoloration of the skin, which is indurated, and slowly increases in size. After a variable length of time these tumor-like masses soften and break down, forming ulcers. These ulcers vary considerably in size, and are round, oval, or irregular in shape. The edges are infiltrated at first, but later become ragged and undermined. The base is uneven, granular, and covered with a yellow crust. Miliary tubercles are often seen about the borders. The ulcers do not bleed readily ; they advance slowly and heal irregularly. After a time, owing to coalescence, extensive destruction of tissue may take place, with the formation of fistula. In other cases there is great proliferation of tissue, with the pro- duction of nodules and polypi. If the disease involves the clitoris, this structure may be so much enlarged as to simulate elephantiasis. The in- guinal lymph-glands are not involved for some time. Pain is absent, the first symptom observed being, as in Kelly's case, pain on urination after a well-defined ulcer has formed. In many cases the disease is of such slow growth that it remains unnoticed for years. The syphilitic, chancroidal, and carcinomatous ulcers must be distin- guished. The differential diagnosis of syphilis may be made as the result of serum reactions and of anti-luetic treatment. In most cases a microscopic or bacteriologic examination may be necessary. Treatment. — The only treatment is complete excision. The Rontgen ray may be useful. BIBLIOGRAPHY Archambault, J. L, and Pearce, R. M. : " Tuberculose d'un adenomyome de l'uterus." Rev. d. gynec. e. d. chir. abd., 1907, xi, 3. Beyea, H. D. : " Tuberculosis of the Portio Vaginalis and Cervix Uteri, Its Pathology, Diagnosis and Treatment." Am. J. Med. Sci., 1901, cxxii, 612. Borchgrevixk : " Zur Kritik der Laparotomie bei serosen Bauchfalltuberkulose " Mitt, a. d. Grenzgeb. d. Med. u. Chir., Jena, 1000, vi. Bulkley, K. : "Tuberculosis of the Vulva." Am. J. Med. Sci., 1915, cli, 535. (Very exten- sive bibliography.) Hartz: " Uber die Tuberkulose der weiblichen Genitalorgane." Monats. f. Geburt. u. Gynak., xvi, 3. Hunner, G. L. : " Tuberculosis of the Urinary System in Women. Report of Thirty-five Cases." Johns Hopkins Hosp. Bull., 1904, 8. Konig : " Die peritoneale Tuberkulose und ihre Heilung durch den Bauchschnitt." Cent, f. Chir., Leipzig, 1900, xvii. Martin, A. : " Zur genitaltuberkulose." Berl. klin. Woch., 1908, xlv, 89. Mayo, W. J. : " Surgical Tuberculosis in the Abdominal Cavity with Special Reference to . Tuberculous Peritonitis." J. Am. Med. Asso., 1905, xliv; Ibid.: " Second a ry Tuber- culous Peritonitis, Its Cause and Cure." Trans. Sect. O., G. and A. S., A. M. A., 1918, 72. Menge: "Tiber tuberkulose Pyosalpinx." Cent. f. Gyn., 1894, 24. Murphy, J. B.: "Tuberculosis of the Female Genitalia and Peritoneum." Am. J. Obst, 1903, lxviii, 72>7\ 1904, lxix, 6 and 205. 568 GYNECOLOGY Neff : " Resume of the Literature on Tuberculosis of the Peritoneum." Trans. South. Surg, and Gyn. Asso.. 1901, xiii. Schlimpert, H. : " Die Tuberkulose bei der Frau, inbesondere die Bauchfell — und die Genitaltuberkulose, die Tuberkulose des Uropoetischen Systems, die Tuberkulose wahrand Schwangerschaft und Wochenbett, auf Grund von 3514 Sektionen." Arch. f. Gynak., 191 1, xciv, 863. Shattuck: "On the Prognosis and Treatment of Tuberculosis Peritonitis." Amer. Med.. Phila., 1902. Taylor: "Tuberculosis of the Uterine Appendages.'' Trans. Sect. O.. G. and A. S., M. A., 1915, 88. Truesdale, P. E. : " Tuberculous Salpingitis." Trans. Sect. O., G. and A. S.. A. M. A., 1913. 132. Williams, J. W. : " Tuberculosis of the Female Generative Organs." J. H. Hosp. Reports, 1893, "i, 85. Wunderlich : " tiber die Misserfolge der operativen Behandlung der Bauchfelltuberku- ldse." Arch. f. Gynak., 1899, lix. CHAPTER XXXI SYPHILIS OF THE GENERATIVE ORGANS It is unnecessary in this volume to take up a general description of syphilis, or to discuss its nature, course, manifestations, or treatment. Only those facts that especially concern the female will be considered here. The excellent review of Gellhorn and Ehrenfest has been freely quoted from in this chapter. Syphilis is generally believed to be commoner among men than among women. From the statistics of Hubert, who studied the history of suspected cases and made routine Wassermann tests in all patients who came to his clinic, it appears that syphilis may be more prevalent among women than has heretofore been believed. Whereas in men the primary lesion is usually discovered by the patient or is readily detected by the physician, and whereas in men the primary sore leaves behind unmistakable traces that may persist for prolonged periods, the opposite is true in women. Several factors contribute toward making the demonstration of the initial lesion in women difficult : First, the female genitalia, being more complex than the male, the sore may develope in a hidden location and thus escape discovery. Secondly, in women the chancre does not present the typical in- duration with which we are familiar in male patients, unless it is situated on the cutaneous surfaces about the genitalia. When the primary sore is situated upon mucous membranes, there is usually no parchment-like in- duration of the base; its occurrence there is rare. Thirdly, the primary lesion clears up more rapidly in women than in men. In the former it is so transient that, given marked symptoms of secondary syphilis, the diagnosis is never uncertain even if one has failed to find the original sore. The general health of the patient is affected more in women than in men. Disturbed menstrual function, menorrhagia or metrorrhagia is fre- quently observed. Fever and anaemia are common. One of the striking differences is the greater frequency in men of paresis and tabes. This fact may possibly be explained on the ground that the thyroid gland is more active in females than in males, and that the principal secretion of the gland, i.e., iodothyrin, as is well known, in common with all iodine compounds, exerts a marked influence on syphilis. That women may be infected through the medium of the spermatic par- ticles is quite within the range of possibility. Neisser successfully inocu- lated the skin of monkeys with the parenchyma of the testicles of other in- fected monkeys. Finger twice succeeded in inoculating monkeys with the sperma of syphilitic men. " It is permissible to conclude that any part of the genital tract may be infected by the sperm, and that the syphilitic virus may reach even the peritoneal cavity by way of the tubes " (G. and E.). These deductions are 569 570 GYNECOLOGY not vitiated by the fact that spirochsetse have not yet been demonstrated in the testes of adult men, or by the acknowledgment of the fact that the virus may have been added to the sperma from a prostatic or urethral nidus of infection. As the spirochsetse are motile, it is conceivable that they may travel up- ward into the generative tract against the current caused by the cilia of the uterine and tubal mucosa. The variations in the local and general manifestations of syphilis give rise to the questions as to whether or not certain organs or tissues are more susceptible than others to luetic infection, and whether the spirochseta pallida shows a predilection for certain organs. Although these questions are un- answerable at present, it would seem possible that the variations are due to differences in the strains of the spirochsetse. The dearth of observations on luetic lesions of the internal genitalia in women, however, suggests that these structures are endowed with a relative immunity. The primary sore is the result of the introduction of the spirochseta pallida into a minute abrasion on a surface covered with squamous epithe- lium. The parasite shows a marked predilection for this type of epithelium, so marked, in fact, that chancres are almost never observed on other epithelial surfaces. A chancre exhibits the same structure wherever it is found, although it is subject to modification according to the tissue affected. " There is in the very early stages a new formation of capillaries, with an in- filtration about them of lymphocytes and plasma cells. In the early stage the infiltration is sharply limited ; in the later stages it is diffusely scattered throughout the corium. The endothelium of the capillaries is swollen and proliferated, so that the lumen is narrowed or altogether occluded, and the larger vessels, with an external coat, are increased in thickness. Sometimes giant-cells are found. The epidermis suffers secondarily, and presents a varied picture, such as atrophy, hypertrophy, erosion, or ulceration. From the newly formed granulation tissue connective tissue is produced which later scleroses and leads to fibrosis, interference with nutrition, and retro- gressive metamorphosis. Spirochsetae can always be demonstrated in the chancre by appropriate staining methods; of these, the new method by Levaditi seems to give the best results. Spirochsetse usually appear in enormous numbers between and within the cells" (G. and E.). There is little essential difference between the lesions of the three stages of syphilitic infection. " The microscopic picture of secondary syphilitic lesions reproduces that of chancre. The characteristic features are newly formed and dilated blood-vessels exhibiting changes such as those described above, and perivascular infiltrations with lymphocytes and plasma cells. Giant-cells are usually more abundant" (G. and E.). " Tertiary lesions differ from secondary ones only in the extent of granu- lomatous infiltration. This is satisfactorily explained by altered tissue reac- tion, the * Gewebsumstimmung ' of Neisser. Weakened by the long-lasting and all-pervading influence of the syphilitic virus, the tissues offer a less- ened resistance to the parasites, although the latter have greatly diminished in number " (G. and E.). SYPHILIS OF THE GENERATIVE ORGANS 571 SYPHILIS OF THE VULVA Chancre of the vulva is so rarely observed that exact information as to its appearance is lacking. For that reason all cases should be described minutely and note made of variations in form. The primary sore in women may be considerably modified by the personal cleanliness of the woman and her habits. The most frequent seat of chancre, it is said, is the labia majora, the fourchette, nymphse, clitoris, and mons veneris being next in frequency in the order named. The primary sore is smaller and clears up more rapidly in women than in men. The so-called chancrous erosion is round or oval in shape, with a dusky-red areola and a shining raw surface, the center of which is covered with a gray, false membrane that is slightly moistened with a serosanguine- ous fluid. On a skin surface, as, e.g., the labia majora, induration developes in about a week and usually presents a parchment-like appearance. On modified skin surfaces near mucous membranes, for example, the labia minora or introitus vaginae, induration may be absent. The chancre may take the form of an ulcer (chancrous ulceration) with sloping edges, covered "with a gray, false membrane, and the seat of a serosanguineous discharge. A third variety of chancre, known as the indurated papule, consists of a hard, elevated, dusky-red tubercle, sharply defined from the surrounding tissues ; its surface is dry and frequently encrusted with layers of exfoliated epithelium, Fig. 168. The appearance of the chancre may be modified as the result of simple inflammation, chancroidal infection, traumatism, and the application of powerful antiseptics. When infection with chancroid and with syphilis takes place at the same time, the chancroid may heal before the chancre appears. As a rule, the chancroid persists and takes the form of a punched-out, sloughing ulcer, around which an induration gradually developes. When chancroidal virus is engrafted upon a well-developed chancre, a chancroidal ulceration takes place ; under such conditions the only indication of the earlier lesion is the induration. The secondary lesions on the vulva may appear as moist papules (mucous patch) or as broad, flat elevations, the result of hypertrophy of the papillary bodies of the skin ; these are known as condylomata lata. Condylomata lata are usually multiple, and frequently affect surfaces that are in apposi- tion, as, for example, the labia. Parts that are subject to the irritating influ- ences of heat and moisture are particularly prone to be affected. Associated with mucous patches there may be an abundant outgrowth of venereal warts These are due to irritation, and not to any specific virus. The secretions from condylomata lata or mucous patches are prolific sources of infection with the syphilitic virus, Fig. 170. Gumma of the vulva is rare. It usually developes in the labia majora, which becomes oedematous ; it has a tendency to break down and to suppu- rate. The differential diagnosis is often difficult to make. Ulceration fre- quently leads to the development of fistulae, Fig. 169. 572 GYNECOLOGY SYPHILIS OF THE VAGINA The primary lesion of syphilis, the chancre, is rarely observed on the vaginal mucosa. When it appears here it resembles closely the primary in- durated ulcer seen elsewhere, except that the induration quickly disappears and but little scar tissue remains. The apparent rarity of the vaginal lesion may be due to the fact that it is overlooked in examination, to the absence of symptoms, or to the anatomic peculiarities of the vaginal tract, which usually presents no abrasions in which the spirochsetse may lodge. The secondary lesions of syphilis in the vagina are rare. Moist papules have been seen in the lower third of the vagina and also in the fornices, where their presence is probably the result of inoculation from a cervical lesion. These maculopapules are described as very small lesions, having a sharp outline, brownish red in color, and covered with a tenacious exudate. The tertiary lesion of syphilis, the gumma, is seldom found in the vagina. It rarely appears here except as the result of extension of a similar infec- tious process in a neighboring organ. Fig. 458. — Chancre of cervix, en- grafted on an erosion. (From Gellhorn and Ehrenfest, after Oppenheim.) SYPHILIS OF THE CERVIX Primary chancre of the cervix has very frequently been overlooked. Statistical reports show that of all primary chancres found on the genitalia, not over 1.5 per cent, are on the cervix. It is probable, how r ever, that primary chancre of the cervix occurs in from 4 to 10 per cent, of all cases of genital syphilis. It gives rise to no symptoms. It may affect either labium, but it has been more frequently found on the anterior lip. It may be engrafted upon an erosion due to a laceration, hence it is more frequent in parous women. Pregnancy and the congestion at the menstrual periods seem to favor the entrance of the spirochaetse (Figs. 458 and 459). A cervical chancre never presents a really characteristic or pathog- nomonic appearance, on account of its rapid and changing evolution from an uneroded induration to an ulcer that in turn either heals quickly or be- comes transformed into a simple erosion. As enlargement of the inguinal glands does not occur, and because of the difficulty in eliciting induration at its base, a suspicious-looking sore on the cervix can be identified as a primary hard chancre only if the spirochaeta pallida is recovered from its surface, and if the cervical lesion SYPHILIS OF THE GENERATIVE ORGANS 573 is followed in due time by a typical secondary exanthema. In those in- stances in which the cervical ulcer appears in conjunction with other typi- cal hard chancres in the vagina or on the external genitalia the presence of a multiplicity of initial lesions must be assumed. " Secondary syphilis manifests itself upon the cervix in the form of macules, papules, and ulcerations. These forms probably represent three successive stages in the development of a lesion caused by scattered accu- FiG. 459. — Chancre of cervix. (From Gellhorn and Ehrenfest, after Fournier.) mulations of the spirochaeta pallida in the squamous mucosa of the cervix. The parasite can be recovered readily from the secretion of any of the three forms, and this explains the great infectiousness of secondary lesions. Wassermann is positive in this stage. Macules and papules have no symp- tomatology of their own, while ulcers may give rise to profuse yellowish discharge. Occasionally a peculiar puffiness of the fornices (empatement) Fig. 460. — Secondary ulcer of pos- terior lip of cervix. (After Gellhorn and Ehrenfest.) may be present. The leucoplastic appearance of macules, the characteristic form of papules, and the typical yellowish color of ulceration render diag- nosis comparatively easy. Secondaries in other parts of the body form a valuable aid. Cervical lesions, as a rule, heal quickly and may disappear without leaving any trace. Specific treatment, energetically applied, brings about resolution in a very short time " (G. and E.) (Fig. 460). " The essential form of tertiary lesion of the cervix is that of a gumma, which, in the majority of instances, undergoes necrosis and ulceration. If 574 GYNECOLOGY the tissue proliferation predominates, we speak of gumma ; if retrogressive changes prevail, we speak of tertiary or gummous ulcer. The process may involve the vagina or extend into the cervical canal, and is frequently asso- ciated with similar lesions elsewhere. The consistency is firm, but becomes soft under the influence of tissue necrosis. The most characteristic color is yellow, though various other shades may be observed. Bleeding or pro- fuse mucopurulent discharge is present in most cases, but no pain. These lesions, which may heal spontaneously, with the formation of scar tissue, disappear very quickly when specific treatment is instituted. Local treat- ment is altogether useless " (G. and E.). SYPHILIS OF THE UTERUS " Our knowledge concerning syphilitic lesions of the uterine body is ex- tremely meager. Primary and secondary manifestations have not yet been observed in the uterus, but a few instances of gumma in the uterine wall have been recorded. An isolated observation by Hoffmann proves the pos- sibility of gummatous changes taking place in the endometrium. This in- frequency of tertiary lesions is somewhat remarkable in view of the fact that the uterus, more than any other internal organ of the body, is exposed to direct infection. Spirochaetae may reach the uterine cavity by way of the vagina or from lesions of the cervix. Older writers have pointed out that in pregnancy the uterus is exposed to infection from the foetus, which acquired its syphilitic condition from the father. In the light of modern knowledge, however, in practically every instance the disease is known to be transmitted to the foetus from the mother, even though syphilis may at the time be latent in the latter. Aside from the question of paternal and maternal infection, it is certain that an actively syphilitic mother invariably infects the foetus. The logical conclusion to be drawn is that in every pregnant syphilitic woman spirochaetae must be present in the maternal portion of the placenta, i.e., the endometrium. The finding, by Huebschmann, of spirochaetae in the decidua prove this point. Unless, as Whitehouse suggests, syphilitic lesions of the uterus have been overlooked in the past, we are forced to assume that a relative immunity on the part of the uterus exists. It is a very striking fact, says Pusey, in view of their being purely genital structures, that the body of the uterus and its analogue in the male, the prostate, are probably the most rarely involved of any structures in the body affected by tertiary syphilis " (G. and E.). SYPHILIS OF THE TUBE " It seems possible that the tubes may be the seat of luetic lesions, but the pathologic and clinical material on record is yet too incomplete to per- mit of positive assertions. Spirochaetae have never been found in the tubes of syphilitic women " (G. and E.). SYPHILIS OF THE OVARY " Various changes in the ovaries (simple enlargement, syphilitic oophor- itis, tertiary sclerosis of ovary, ovarian gumma) have been described as typical expressions of the secondary and tertiary stages of luetic infection, SYPHILIS OF THE GENERATIVE ORGANS 575 but in no instance (with the possible exception of Hoffmann's case) has positive proof been furnished that such alterations are actually due to a local luetic process. " The fact that in some syphilitic patients either an amenorrhoea or, more commonly, a metrorrhagia, disappears after specific medication can- not be accepted as evidence of a syphilitic ovarian lesion. Spirochetal have as yet not been demonstrated in the ovaries of adults" (G. and E.). SYPHILIS OF THE CELLULAR TISSUE " Syphilis of the pelvic cellular tissue appears in the form of a diffuse gummatous infiltration which secondarily involves the pelvic peritoneum " (G. and E.). To the few cases on record a personal observation by Gellhorn and Ehrenfest has been added. In almost all instances a wrong diagnosis of malignancy has been made. In the case of Gellhorn and Ehrenfest the positive outcome of the Wassermann reaction, together with other unmistakable signs of tertiary syphilis about the outer genitalia, aided in establishing the correct diagnosis. " Specific treatment produces amaz- ingly quick improvement of an apparently hopeless condition " (G. and E.). DIAGNOSIS OF SYPHILIS OF THE GENITAL TRACT IN WOMEN An absolute diagnosis of the syphilitic nature of an ulcerative lesion of the genitalia can be established only as the result of the demonstration of spirochete in the secretion. The large percentage of women afflicted with a latent syphilis and giving positive Wassermann reactions must, to a certain degree, lessen the value of this test as confirmatory of syphilis being the cause of ulcerative lesions about the external genital tract. Syphilitic lesions of the vulva must be differentiated from herpes genitalis, lupus, esthiomene, condylomata acuminata, chancroid, and gonorrhceal macule. Syphilitic lesions of the vagina must be differentiated from herpes geni- talis, ulcerative processes following the prolonged and continuous wearing of a pessary, ulceration from the use of caustic drugs, aphthous ulcers, and various forms of vaginitis that may show a tendency to produce discrete ulcerative lesions and malignant conditions, such as carcinoma. Syphilitic lesions of the cervix must be differentiated from simple ero- sion, chancroid, tuberculous ulcer, gonorrhceal macule, herpes genitalis, aphthous ulcers, carcinoma of the cervix, and perhaps cervical polyp and fibroids. DIFFERENTIAL DIAGNOSIS OF SYPHILITIC LESIONS OF THE CERVIX " The prototypes of the three stages of syphilitic infection, the chancre, the macule or papule, and the gumma, offer no particular difficulty to the diagnosis, but ulcerative changes are apt to obscure their characteristic features. It may, then, be helpful to remember certain general character- istics of luetic lesions of the cervix, viz.: "(a) Specific ulcers, as a rule, produce very little secretion; only exten- sive tertiary ulcers or necrotic gummata cause a pathologic discharge. "(b) There is no pain, either spontaneous or on touch. 576 GYNECOLOGY "(c) Luetic lesions are frequently at some distance from the external os, which hardly ever occurs in non-specific ulcerations of the cervix. "(d) Syphilitic ulcers are characterized by their sharp outline. "(e) Syphilitic ulcers are usually covered with a film-like deposit which may be wiped off easily and exhibits a characteristic fatty luster. "(/) Syphilitic ulcers show very little, if any, inflammatory reaction of the surrounding mucosa. " These common characteristics, however, may be invalidated to a lesser or greater degree by pregnancy, lacerations, coexisting inflammations, or local applications. Thus Mehanos speaks of the misleading fatty luster produced on erosions by the use of caustics. " In the diagnosis of the primary lesion the demonstration of the spirochaetae pallida is the prime requisite. Next in importance is the char- acteristic induration of the base, if present. Wassermann is as yet negative. The appearance, in due time, of typical secondaries clinches the diagnosis. " The diagnosis of secondary ulcerations is based primarily upon the presence of the specific parasite. The positive outcome of the Wassermann reaction is a highly suggestive, but not a conclusive, aid in the diagnosis. The history of infection, coexisting secondary lesions in other parts of the body, and the prompt effect of specific treatment are contributory factors. Occasionally exploratory excision and microscopic examination may be found necessary. " Tertiary lesions may so quickly develop from secondary ulcerations that differentiation between the two stages may not always be possible. Spirochetal are not found in the secretion. Wassermann may be negative, especially if the infection has occurred a long time previously. As a rule, other tertiary manifestations are present. The actual findings and the im- mediate effect of specific treatment will establish the diagnosis. Microscopic examination is frequently a conditio sine qua non " (G. and E.). Chancroid. — Chancroids are, as a rule, multiple. A chancroid of the cervix is usually complicated by a similar lesion on the external genitalia. In contrast to the well-defined contour of a syphilitic ulcer, the edges of the lesion are usually irregular, notched, and undermined, and the base is granular and uneven. The secretion contains the bacillus of Ducrey. The regional lymph-glands are always infected. Tuberculous Ulcers. — Tuberculous ulcers are regular in shape, their edges heing thinned out and deeply undermined. The most important distinction between tuberculous ulcers and syphilitic lesions is found in the marked tenderness of the former. Gonorrhoeal Maculae. — " Syphilis and gonorrhoea are so frequently com- bined in the same individual that the differentiation of gonorrhoeal macules from macular syphilids is of great practical importance. Gonorrhoeal maculae are less distinctly outlined, vary in size, often forming ill-defined, confluent blotches. Their color is lighter than that of the syphilitic maculae, appear- ing as a bright yellowish red. Usually they are lying flat in the level of the mucosa, but they may be elevated, especially when their surface becomes granular, indicating the beginning of a transformation into a condyloma , SYPHILIS OF THE GENERATIVE ORGANS 577 acuminatum. In this form the gonorrhoeal lesion resembles the luetic papule, which, however, is well distinguished by its flat top " (G. and E.). " Herpes genitalia is very rarely observed on the cervix. It manifests itself in the form of single or grouped minute vesicles, with either clear or purulent contents. Each vesicle is surrounded by a bright red zone of in- flammation. The vesicles are apt to form polycyclic figures. As a rule, they soon rupture and change into superficial erosions, which preserve a polycyclic arrangement. When infected, they lead to the formation of aphthous ulcers " (G. and E.). Aphthous Ulcers. — " These have a smooth surface and are covered with a yellowish-white, adherent pseudomembrane. In this form they closely resemble small secondary ulcers or even small primary chancres. Oppen- heim emphasizes as a distinguishing feature the firmness with which the covering film adheres, and the distinctness of the surrounding reactive zone in the mucosa." Myoma. — " Occasionally an intact gumma of the cervix may simulate a fibroid." In one case of Gellhorn and Ehrenfest a nodule in the cervix of a fibro- matous uterus was recognized as a gumma only upon microscopic examination. Carcinoma.—" The correct differentiation between syphilis and car- cinoma of the cervix is by far the most important problem to be discussed here." Hysterectomies or amputations of the cervix have been done in cases where later developments demonstrated the presence of syphilis. In some instances the error in diagnosis was not recognized until the patient was on the operating table. " The similarity of the two affections is indeed striking if the lesion appears in the form of a cauliflower growth ; or if a chancre is located within the external os, as described by Mrazek, and causes sloughing of the lower- most part of the cervical canal. " Neumann believes that infiltration of the parametrium and immo- bilization of the cervix are common in cancer and rare in luetic ulcers, even in advanced necrotic gummata. It has frequently been stated that cancer bleeds easily, as contrasted with luetic ulcers, and while this may be true in a general way, there are exceptions. Suspicious ulcerations upon the cervix which are separated from the external os by a zone of normal mucosa are more likely to be of a luetic nature. " The final diagnosis, however, will depend upon the microscope. " A search for spirochsetse should be made in every doubtful instance. Dark-field examination is superior to other methods, as it enables us to dis- tinguish between the spirochseta pallida, on one hand, and the spirochseta refringens and balanitidis, on the other. The two last-named are commonly found in the vagina and occasionally on necrotic cancers. " In daily practice the proposition amounts to this : The overwhelming majority of cancers present themselves in an inoperable state. If there be the slightest doubt as to the true nature of the disease, an attempt with anti- luetic treatment should be made. We know that syphilitic lesions respond very promptly to appropriate treatment, and, therefore, not much time would 'have been wasted even if specific therapy proved to be a failure " (G. and E.). 37 578 GYNECOLOGY Prognosis of Syphilitic Conditions of the Genital Tract in Women. — The prognosis is favorable, the disease is quickly controlled, and the progress toward healing may be gauged not only by inspection and symp- tomatology, but also by the serum reactions. Treatment. — A cure may be effected by the use of arsphenamine (sal- varsan), neoarsphenamine (neosalvarsan), mercury, and the iodides, either alone or supplementing one another. BIBLIOGRAPHY Gellhorn, G., and Ehrenfest, H. : " Syphilis of the Internal Genital Organs in the Female." Am. J. Obst., 1916, lxxiii, 864. (With complete bibliography.) CHAPTER XXXII DISORDERS OF MENSTRUATION The physiology of menstruation has previously been considered. Its phenomena depend upon processes involving chiefly the ovaries and the uterus ; from this it follows that abnormalities of these organs, whether of a congenital or an acquired nature, may alter the menstrual phenomena in various ways. The menstrual function • is influenced also by the glands of internal secretion, the central nervous system, and the general health ; it may be modified, therefore, by abnormal functions of the ductless glands, nervous disorders, and constitutional diseases. The men- strual phenomena may vary considerably in different individuals within physiologic limits. Thus, while early puberty usually denotes hyperfunc- tion and late puberty hypofunction of the ovaries, etc., either condition may occur without manifesting any apparent defect in the general health, physical characteristics, or reproductive powers (see Physiology, Chapter IV). The menstrual flow most commonly recurs every twenty-eight days, but it may vary in periodicity from twenty-one to thirty days. 1 The duration may vary from two days to a full week, and the amount of menstrual blood lost may vary from a scant flow, sufficient to soil but a few napkins a day. to a profuse discharge requiring from eight to ten. Either extreme may occur in a woman who may be free from illness or disturbance of any kind. Of course, those who present variations from the common menstrual type more frequently exhibit pathologic states, local or general, than those in whom menstruation recurs every twenty-eight days and persists for the usual time. Nevertheless, the menstrual habit, or custom of the individual, may deviate considerably from the common type, and the subject still be entirely normal. PRECOCIOUS MENSTRUATION When puberty begins before the usual period, menstruation is said to be pre- cocious. Those in whom this phenomenon appears show physical and mental in- dications of sexual maturity beyond their years. In some cases the condition appears to be due to an abnormal development and hyperf unction of the ovaries, and in others sarcoma of the ovary has been found. In some cases a pathologic condition of the pineal gland has been held responsible for the condition. Occa- sionally the subjects have been hydrocephalic or rachitic. Hemorrhages from the uterus have been known to occur during the first few weeks of life, but this is not regarded as precocious menstruation, but rather an evidence of a stimulation of the endometrium by the hormones in the mother's milk. Forty-four cases of precocious menstruation have been collected by Ploss, the youngest patient being two months old. 3 Twenty-eight-, thirty- or twenty-one-day type in 83 per cent, of cases. (K. Das.) 579 580 GYNECOLOGY DELAYED MENSTRUATION Menstruation may be regarded as delayed when it does not appear until after the usual age of puberty. This condition is normal in certain indi- viduals, and may have no significance, or it may indicate a general lack of development of the generative organs, hypofunction of the ovaries, or in some cases disease of the pituitary gland or general ill health. VICARIOUS MENSTRUATION In some instances hemorrhage from mucous membranes other than the endometrium has been observed at the time of the menstrual flow ; this is termed vicarious menstruation. It most frequently takes the form of epistaxis. AMENORRHCEA An absence of the menstrual flow during the reproductive period from puberty to the menopause, except during pregnancy or lactation, is abnor- mal, and is due to pathologic causes, either general or local. A pseudo-amenorrhoea may exist in which the patient exhibits the gen- eral signs of menstruation, without any external evidence of a menstrual flow; this is due to an obstruction in the genital canal. Under such circum- stances the menstrual fluid is pent up behind the point of obstruction, con- stituting a form of gynatresia (see Developmental Anomalies and Malfor- mations, Chapter II). Etiology. — Amenorrhcea is dependent upon various conditions, and may be classified as anatomic, constitutional and psychic. Anatomic Defects Producing Amenorrhcea. — These pertain particularly to the ovaries and the uterus. If the ovaries are well developed and the uterus is rudimentary or absent, the ovarian influence is normally present but the uterus is unable to respond in the usual way, and the menstrual flow may either be very scanty or be absent altogether. When these conditions obtain, the patient usually suffers severely from the general phenomena of menstrua- tion, which are known as the molimina mcnstrualia. When the conditions are reversed, that is to say, when the uterus is well developed but the ovaries have undergone degeneration or are poorly developed, the menstrual impulse is weaker than normal, and may be insuffi- cient to produce a menstrual discharge. Total absence of menstruation, however, with a well-developed uterus, is quite unusual, although not infre- quently both the uterus and the ovaries are poorly developed and the men- strual discharge is irregular and scanty. Amenorrhcea of a more or less marked and persistent type may occur from acquired lesions that involve both ovaries extensively; for example, bilateral cystic or solid tumors of the ovary of a malignant type, or of the type that destroys the ovarian parenchyma. Inflammation of the ovary complicating mumps is at times responsible for an abrogation of the men- strual flow, and certain cases of atrophy of the ovary have been attributed to ovaritis complicating small-pox and scarlet fever. Amenorrhcea may also be due to hyperinvolution of the uterus, the result of prolonged lactation, or DISORDERS OF MENSTRUATION 581 may be traceable to septic postpartal infection with resulting sclerosis. In some cases repeated or excessive curettage of the uterus destroys the endo- metrium beyond the power of sufficient regeneration, and scanty menstrua- tion or a partial amenorrhoea may result. Amenorrhoea is sometimes ob- served coincident with, or subsequent to, a general increase in fat at about the age of thirty (see Premature Menopause, p. 594). It has been stated that female morphine habitues do not menstruate. Constitutional Diseases Producing Amenorrhoea. — It is natural that the most prominent general diseases in which scanty or absent menstrual flow is a symptom should be those that affect the blood. The most common of these is chlorosis. According to Virchow, in chlorotic girls not only the blood, but the entire circulatory apparatus, is defective, and this results in faulty development of the genitalia at the time of puberty. Stieda regarded chlorosis as an occasional sign of degeneracy, placing it in the same category with infantile genitalia, infantile pelvis, or abnormalities of the cranial bones. Chlorosis may be attributable to outside influences ; that is to say, improper hygiene, etc., although chlorotic individuals usually show other evidences of physical defects. Chlorotic girls do not invariably suffer from amenor- rhoea, but may occasionally have a profuse menstrual flow. In some cases the ovaries are unusually large. After the depressing general influence of certain infectious diseases, such as typhoid fever, amenorrhoea may be present for a time. It may also be observed in tuberculosis, Basedow's disease, diabetes, malignant growths, chronic gastritis, and leucaemia. Amenorrhoea may be one of the earliest symptoms of acromegaly or of Addison's disease. Psychic Influences Producing Amenorrhoea. — The psychic influences that produce amenorrhoea are hope and fear ; that is to say, there may be some delay in the appearance of the menstrual flow in a woman who desires pregnancy or in one who fears it. Such instances are exceptional, however, and the delay does not usually cover more than a week. Cases are on record in which a terrible fright or a fearful catastrophe has produced amenorrhoea, but in such instances it is likely that the cessation of the menstrual flow is only one of the manifesta- tions of mental and physical disaster. A change of climate or altered social relations are frequently responsible for temporary amenorrhoea. In a few cases the exact cause of amenorrhoea cannot be determined positively. The menstrual flow may cease suddenly in women who other- wise show no derangement in health. Such women may exhibit none of the accepted causes of amenorrhoea, even upon the most careful examination, and after a certain time menstruation may be resumed without any treat- ment, and with no more apparent reason for its resumption than for its cessation. Treatment. — It is always desirable to endeavor to find a cause for amenor- rhoea before resorting to any definite or prolonged plan of treatment. If the pa- tient has passed the age of puberty without ever having menstruated, or if she has had recurring subjective symptoms of menstruation without a menstrual flow, it may be advisable to make an immediate pelvic examination. As these patients are young, nulliparous women, the examination should in- variably be made under anaesthesia. If there are no painful menstrual 582 GYNECOLOGY molimina, but if evidences of ill health are apparent, this examination need not be insisted upon at once, but the general condition of the patient may be improved in the hope that the function will be established normally. In chlorotic patients the use of iron, arsenic, and cod-liver oil, regulation of the diet, abundant exercise in the open air, and general improvement of the hygienic conditions should be immediately instituted. When amenorrhoea is apparently due to psychic influences, much can be accomplished by suggestion, and in case pregnancy is feared, by the absolute assurance that pregnancy does not exist, or by reassuring the patient upon any other point upon which the mind has dwelt. When general measures do not result speedily in the resumption of the menstrual flow, a careful ex- amination should always be made in order to exclude the commonest cause of amenorrhoea — namely, pregnancy. This Avill usually be true only of patients who have already started to menstruate, and in whom the amenor- rhoea might be said to be acquired ; pregnancy is not likely to be the cause of the delayed appearance of the function of menstruation. Pregnancy must always be positively excluded before prescribing any drugs that have, or are believed to have, a direct stimulating effect upon the menstrual flow. At the time of the examination, the cause of the amenor- rhoea may be ascertained by finding that the uterus or the ovaries are imperfectly developed. The defect may be more in the nature of an under- development than of an actual deformity. In the first instance, if the uterus is well shaped and of fair length, and if the cervical canal is patulous, toning up the general health may result in marked improvement, especially if a beginning is made during adolescence. In many cases of functional amenor- rhoea due to insufficient ovarian development the administration, by the mouth or by hypodermic injection, of extracts of ovarian substance or of the corpus luteum of the cow or sow will stimulate the ovarian secretion or assist it to such a degree that a practically normal flow will ensue. The most satisfactory preparation is said to be the freshly prepared extract of the entire ovary. Either this or the extract of the corpus luteum may be given in doses of from 2 to 5 grains three or four times a day. The extracts of the other glands of internal secretion may sometimes be advantageously combined ; thus thyroid extract, ^ to 2 grains three times daily, or the extract of the anterior lobe of the pituitary gland may be used in cases associated with adiposity. In older women, and in younger ones if general treatment does not suffice, the intrauterine application of the galvanic current may be em- ployed, or an intrauterine stem may be inserted. When the uterus is very small — distinctly below normal in size — and irregular in shape ; when the cervical canal is extremely narrow ; when the cervix is poorly developed and the ovaries are small or cannot be recognized by bimanual palpation, the outcome of any form of treatment is exceedingly doubtful, and in a ma- jority of cases not much can be achieved. If the ovaries are sufficiently developed to give a decided menstrual im- pulse and the uterus is so defective that no menstrual flow is possible, the recurring subjective symptoms may be so painful as to require extirpation of the rudimentary uterus with conservation of the adnexa. When preg- DISORDERS OF MENSTRUATION 583 nancy can be excluded, and after general measures have been instituted, emmenagogues or drugs that are said directly to stimulate the menstrual flow may be prescribed. Cantharides, black oxide of manganese, savin, rue, tansy, pennyroyal, and apiol are believed to stimulate the menstrual flow. Dewees' emmenagogue mixture, which consists of cantharides in combina- tion with iron, aloes, and guaiac, is one of the most effective formulae. If pregnancy exists, these drugs will usually have no effect in bringing on the menstrual flow. They may be used as an added stimulant to the menstrual impulse after general and hygienic measures have been adopted, but they should never be pushed beyond the physiologic dose. It is to be understood that what has been said in relation to amenorrhcea applies equally to an absolute non-appearance or abrogation of the menstrual flow, to delay in the monthly recurrence, and to a diminution in the amount of the menstrual discharge. MENORRHAGIA Etiology. — Menorrhagia, or an increase in the amount or in the dura- tion of the menstrual flow, may be due to an excessive ovarian impulse, to an enlargement of the area in the uterus that responds to the impulse, or to any local or general condition that produces congestion of the blood-vessels of the uterus and the endometrium. In some women the menstrual flow is naturally profuse without any gross lesion being present ; in these cases the condition is probably an evi- dence of hyperf unction of the ovaries. The flow may recur at periods of from twenty-one to twenty-five days. This may be within the bounds of health, and may have no pathologic significance. Such women are usually large and of the plethoric type. Excess of the ovarian impulse may be found in conjunction with such local conditions as prolapse, simple reten- tion cysts, or cystic degeneration of the ovaries. An increase in the surface that sheds the menstrual blood and a congestion of the endometrial vessels are found in such local lesions as hypertrophy of the endometrium, chronic metritis, subinvolution, retro flexio-version or prolapse of the uterus, adenoma or polyp of the endometrium, myoma, sarcoma, and carcinoma of the uterus. The general causes of menorrhagia are frequently overlooked. Among the general causes of pelvic congestion predisposing to menorrhagia may be mentioned cardiac insufficiency, cirrhosis of the liver, and chronic nephritis. Menorrhagia may be a manifestation of hemophilia and scurvy, and be the direct result of alterations in the venous and arterial walls. The frequent occurrence of menorrhagia or metrorrhagia in connection with a positive Wassermann reaction is responsible for the belief that numerous cases of intractable uterine hemorrhage may be attributed to syphilitic changes. Since, however, a large number of cases are found in non-luetic women, and in many no benefit follows anti-syphilitic medication, it is doubtful whether local alterations are as largely responsible for uterine hemorrhage in a syphilitic as is the general effect of the disease upon the system as a whole, reflected in disordered ovarian and uterine function. So, too, the amenorrhcea of secondary syphilis may logically be ascribed to a luetic anaemia or secondarv dvsfunction of the ovaries. 584 GYNECOLOGY Menorrhagia is also at times associated with certain acute diseases, such as typhoid fever, cholera, variola, scarlatina, influenza, and acute articular rheumatism. This may be explained either on the ground of a general im- pairment of the circulatory force, such as is commonly observed in the course of these diseases, or possibly by an exanthematous involvement of the uterine mucosa. Menorrhagia appears at times to originate in nervous influences affecting the vasomotor svstem. Thus a fright or any mental shock mav result in menorrhagia. It is observed in hysteria and neurasthenia. It is just as reasonable to believe that impulses from the central nervous system may alter the normal menstrual function of the uterus as it is to believe that the pains of labor are affected by psychic impressions. Noble has tabulated the common causes of menorrhagia according to the age and social condition. While it is our belief that in young virgins disorders of ovarian function or a disarrangement of the coordination in function of the glands of internal secretion are chiefly responsible for menorrhagia, Noble de- clares that it may be due to a disturbance of the vasomotor system and a lack of vasomotor stability, caused by the active growth that sometimes takes place about the time of puberty. It is quite evident that the vasomotor instability may be secondary to the derangement in the glands of internal secretion. Menorrhagia in a child-bearing woman is most frequently due to some complication of pregnancy, labor, or the puerperium. Subinvolution and displacement of the uterus, adnexal inflammation, retention within the uterus of decidua or placenta, and severe lacerations of the cervix, with subsequent hypertrophy and chronic congestion, are most frequently responsible for the hemorrhage. In unmarried women, especially in those approaching the age of forty, myomata or an endometrial polyp will frequently be found. Malignant disorders must always be suspected and be carefully excluded before any plan of treatment is adopted. Treatment. — Except in young unmarried women, a pelvic examination is al- ways imperative before any form of medication is adopted. This rule becomes increasingly important with advancing years. The treatment of menorrhagia, therefore, depends upon the underlying condition. The relaxed, overgrown young woman should be carefully instructed in hygienic regulations, diet, and exercise, and suitable tonics should be prescribed. Hypodermic injec- tions of extracts of the pituitary gland at intervals of several days may be found of service. In such cases when menorrhagia is accompanied by leucorrhcea, hyperplasia of the endometrium may be suspected, and curette- ment employed as a curative measure. A subinvoluted uterus should be depleted by hot douches, glycerine tampons, or curettement ; displacements of the uterus should be corrected ; chronic constipation should be overcome ; cervical lacerations should be repaired or exposed to local depletory meas- ures ; myomata, endometrial polyps, and malignant growths should be ex- posed to operation ; enlargement of the ovary, with a persistence of menor- rhagia, would usually justify an exploratory abdominal incision. If no local lesions to account for the symptom are found or if, in addi- tion to the local lesion, or without it, a defect in the circulation is demon- strable, as evidenced by cardiac lesions, contracted kidnev, cirrhotic liver, DISORDERS OF MENSTRUATION 585 varicose veins in the lower extremities, hemorrhoids, swelling of the ankles, dyspnoea, and palpation, the use of digitalis and strychnine will do much to diminish the amount of flow. Ergot, given by mouth or by hypodermic injection, is universally em- ployed to control the hemorrhage ; this it does by increasing the contractions of the uterus ; it may be combined with hydrastis and its derivatives. Stypticin has been of no particular advantage. It is an expensive remedy, and, according to Boldt, to be effectual it must be given in very large dose — from i to 5 grains every two to eight hours. The following prescription of ergotin (Bonjean's), digitalis, and powdered hydrastis is one of the most effectual combinations: f£ Ergotin. (Bonjean's) gr. ij Pulv. ext. digital gr. 1/6 Pulv. hydrast gr. iij q. 3 hrs. In some cases, as previously noted, hypodermic injections of extract of the pituitary gland may prove effective. Bab reports very favorable results from the use of pituitrin. The intrauterine application of radium is almost invariably effective in checking the recurrence of profuse menorrhagia. It acts by causing obliteration of some of the endometrial capillaries. The Rontgen ray is also effectual. Its favorable influence, it is presumed, is the result of an impairment of follicular development, and hence there is a decrease in the ovarian impulse. The Rontgen ray must be used guardedly. It affects particularly the follicle-bearing area of the ovary, and undue exposure may result in an entire destruction of the ovarian function (see Radium and Rontgen Ray Therapy, Chapter XL). Much can be done for patients the subjects of menorrhagia by having them rest during the menstrual period. In serious cases the movements should be restricted absolutely, the patient being kept in bed for from a day or so before the time at which the flow is due until the usual period is past. The application of an ice-bag to the abdomen may assist in reducing the flow. Before the expected time for the flow the bowels should be thoroughly moved by saline laxatives. METRORRHAGIA Etiology. — Metrorrhagia, or bleeding between the menstrual epochs, is caused by many of the conditions that produce menorrhagia. As a rule, the underlying cause is further advanced and more pronounced than in the case of menorrhagia. In addition, bleeding between the periods is more often indicative of malignant lesions, such as carcinoma or sarcoma, and also of tubal pregnancy, myomata that have caused pressure atrophy or ulcera- tion of the uterine mucosa, cystic glandular endometritis, and endometrial polyp. Metrorrhagia due to lesions of the myometrium (myopathic metror- rhagia), such as chronic metritis, fibrosis of the uterus, arteriosclerosis of the uterine vessels, etc., is observed in women who are approaching the menopause. 586 GYNECOLOGY Treatment. — In treating a case of metrorrhagia the first aim of the physician should be to discover its cause. In patients past the age of thirty-five the possi- bility of carcinoma or sarcoma should be borne in mind, and care must be taken to exclude or confirm this possibility by the diagnostic methods already de- scribed (Malignant Tumors of the Uterus, Chapter XVIII). When the metror- rhagia has been extremely severe and the patient is suddenly weakened from loss of blood, it may be desirable to take immediate steps for relief, such as rest in bed, the application of cold to the lower abdomen, and the exhibition of horse serum. It may also be wise to pack the vagina, or in some cases the uterus, wath gauze ; it is very rarely necessary to pack the uterus if the vaginal vault is snugly filled with gauze disposed in a circular manner about the cervix, so as to cause compression and occlusion of the cervical canal. Such a vaginal pack, combined with a suprapubic pad and binder, will, in a ma- jority of cases, be effective. A uterine pack should not be carried out with- out complete aseptic precautions. As a rule, rest in bed, an ice-bag applied to the lower abdomen, and a vaginal pack after a copious douche of hot water will control hemorrhage. The treatment with drugs is similar to that described for menorrhagia. For the more chronic cases, the exciting cause, whatever it may be, should be removed — that is to say, an endometrial polyp, a thickened endo- metrium, or a submucous myoma should be treated operatively. Myoma of the uterus, carcinoma, uterine displacement, and pelvic inflammatory dis- ease should be dealt with in the usual way. Difficulty in the treatment of metrorrhagia is encountered chiefly in those cases in which the bleeding is evidently myopathic (uterine fibrosis, arteriosclerosis, etc.) in origin, or is due to such general lesions as hemo- philia, lymphatic obstruction, chronic nephritis, arteriosclerosis, cirrhosis of the liver, etc. In such cases any surgical treatment short of hysterectomy is of little avail. In radium and the Rontgen ray, but especially in radium (see Radium and Rontgen Ray Therapy, Chapter XL), we have a certain and effectual means of giving relief. When malignant disease of the uterus and adnexa can be excluded, radium is the remedy par excellence. It may also be used when the pa- tient's condition is such as to preclude operation, even though surgical interven- tion is otherwise indicated. After the hemorrhage is controlled, the patient's con- dition improves and then the operative procedure may be carried out. When menorrhagia or metrorrhagia is caused by visceral lesions asso- ciated with high blood-pressure, caution must be used in the employment of radium or of any other measure to check the bloody flux ; for the latter may be of actual benefit to the patient and for the time being at least prevent a rise of the blood-pressure in the arteries to the breaking point. If the patient is not suffering from the loss of blood (anaemia-asthenia, etc.), diagnostic curettage should be done in order to determine that no malignant condition is present in the uterus. When this has been assured, general measures to reduce the blood-pressure should be instituted, but neither local nor oper- ative treatment to check the flow should be undertaken. DISORDERS OF MENSTRUATION 587 DYSMENORRHEA A woman is said to be suffering from dysmenorrhoea when the sub- jective manifestations of the menstrual period are so exaggerated that she complains of marked pain or discomfort in the lower abdomen and pelvis, thighs., or sacral region. Severe headache, occurring regu- larly at the menstrual periods, whether or not accompanied by pain elsewhere, may be considered a form of dysmenorrhoea, although in many instances its relation to the menstrual process is not entirely clear. 2 Severe dysmenorrhoea is often accompanied by such extragenital symp- toms as eye-strain and contraction of the field of vision, cutaneous eruptions, such as acne and eczema, and by neuralgic conditions, for example, tooth- ache and joint pains. Etiology. — Dysmenorrhea may be the result of a large number of different causes. It is not a disease, but a symptom, the reason for which, however, it is sometimes extremely difficult to find. The treatment of dysmenorrhoea should never be continued indefinitely without the fullest sort of an investigation being made to determine whether or not it is dependent upon demonstrable organic alteration. If this is not done, symptomatic treatment may be carried on for a considerable length of time without giving relief, when some simple operative plan might effect an immediate cure. The cases in which dysmenorrhoea is most likely to be looked upon as a disease and not as a symptom are those in which no organic lesion can be found to explain it, or the anatomic variation from the normal may be so slight as to make it doubtful whether it is really responsible for the trouble. Dysmenor- rhoea of this type may be ascribed to a certain degree of hypoplasia of the uterus or adnexa, of which little gross evidence exists. Such a con- dition would be difficult to demonstrate even microscopically, as it probably affects mostly the blood and nerve supply. For convenience of description and study, dysmenorrhoea may be divided into two classes: (i) That due to congenital defects, and (2) that due to acquired lesions. It is to be understood that developmental defects of the genital apparatus include not only those that are demonstrable, but also those that are of such degree as almost to deserve the name of hypothetic. To the latter we have given the term " vascular and nervous " for want of a better one; they are often associated with general hypoplasia — the subjects are physically subnormal and have an unstable nervous organization. Dysmenorrhoea Due to Development Defects. — These defects usually consist of abnormalities in the size and the shape of the uterus. They may be very well marked or only slight. The uterus may be infantile, and the body of the organ may be acutely anteflexed on the cervix, which is long, narrow, and tapering, or short and knob-like. The cervical canal itself may 2 The belief that physiologic and pathologic states of the female generative organs often produce headache is widespread. Text-books list dysmenorrhoea, " uterine disease," disease of the ovaries and even of the bladder, as causes of headache, and yet no real justification for these beliefs has been attempted. Headache is, of course, exceedingly com- mon during menstruation, but so it is in eclampsia, and yet no one to-day connects the eclamptic headache in any direct way with the condition of the uterus. Toxemia of the menstrual period is a much more plausible, though not a demonstrable, hypothesis. — Cabot, R. C. : Differential Diagnosis. Saunders, Phila., igii. 588 GYNECOLOGY be very narrow and stenotic, or it may be kinked and obstructed by a sharp anteflexion. There may be double formation (uterus didelphys or uterus bicornis), with equal or unequal development of the two halves; this condi- tion may be associated with stenosis, with retention of the menstrual fluid behind the point of obstruction (see Gynatresia, page 23). In addition to such defects, which are easily recognized, many cases of dysmenorrhcea are seen in which no apparent cause can be demonstrated, the pain being explainable only on the ground of a deficiency in the mus- cular tissue of the uterus or an abnormal nerve or blood supply to the uterus and ovaries ; or the individual may be so constituted that what would cause but slight discomfort in the average person would in her produce severe pain (psychoneurosis). As moderate degrees of anteflexion and stenosis may be combined with developmental defects in the vascular or nervous apparatus, it is often quite impossible in an individual case to say that the pain is or is not due entirely to an obstruction of the cervical canal. If the surgeon does not bear the possibility of this combination of causes in mind, he will often be disap- pointed in the results of an operation to overcome the stenosis or anteflexion. 5 The influence of cervical stenosis as contrasted with the influence of the developmental deficiency of the vascular and nervous supply may be differ- entiated, or an attempt may be made to differentiate between the conditions by observing with particular care the time of appearance of the pain and other peculiarities. Thus, when dysmenorrhcea is due to obstruction of the cervical canal, it usually precedes the appearance of the menstrual flow, and begins to subside as soon as the flow is well established. It may recur at intervals even after the flow appears, but there is a tendency for the paroxysms of pain to become less frequent and less severe. The pain is situated in the lower abdomen — suprapubic ; it may be felt more on one side of the midline than on the other; it may radiate to the sacral region or down the thighs. The paroxysms of pain mark a succession of uterine contrac- tions that recur until additional menstrual fluid is expelled, when the pain subsides for a time (see Pathologic Anteflexion, page 239). The type of dysmenorrhoea due to nervous or vascular defects often begins several days before the flow sets in, and may persist throughout the period. Preceding the period there may be severe, dull, aching pain in the lower abdomen, back, and limbs, with an exaggeration of the usual nervous phenomena of menstruation. During the flow the pain is most severe in the ovarian and sacral regions ; it is described as boring or burning in nature, or as " great soreness," etc. The patient is often poorly developed physically and of a nervous temperament. Dysmenorrhoea due to developmental defects dates from the very onset of the menstrual function — the age of puberty. As the obstructive form of pain may be combined with the nervous or l3 Kelly and other observers have expressed a doubt as to whether stenosis of the cervix alone produces painful menstruation, basing their doubt upon the following reasons : First, because it is said that the pain begins when there is no blood in the uterus ; secondly, the amount of blood is too small ; thirdly, menstrual blood will pass through an exceedingly narrow lumen; and fourthly, only one-half of the cases of stenosis have dysmenorrhoea. DISORDERS OF MENSTRUATION 589 vascular and nervous type, it may readily be seen that the surgeon must always be guarded in making a prognosis of an operation to overcome stenosis or obstruction of the cervical canal. Dysmenorrhea Due to Acquired Lesions. — Dysmenorrhoea may be a :z)tom of almost any pelvic disease : for example, uterine displacement. cervical polyp, chronic endometritis or hyperplasia of the endometrium, pelvic inflammatory disease, and ovarian tumors. Displacement downward and backward of the small anteflexed uterus is regarded by Graves as a more or less frequent source of dysmenorrhoea. In all these conditions the pain is but a symptom, and its cure lies in the correction of the lesion producing it. Certain changes in the ovaries that are difficult to recognize upon pelvic examination are believed in some cases to be responsible for dysmenorrhoea : these are probably predisposed to by repeated pelvic congestion, as from prolongd sitting, chronic constipation, and insufficient exercise. The extent of the influence of masturbation and ungratified sexual inclinations on their production is not known. The anatomic alterations consist of a thickening of the tunica albuginea. increased density of the ovarian stroma, and the immature development of numerous follicles, so that the ovary undergoes a form of cystic degeneration ( microcystic i . The anatomic changes in the ovary may be responsible for the dysmenorrhoea. and are also an evidence of faulty ovarian function, as well as of disturbance in the vascular and nervous supply of the entire pelvis. Acquired dysmenorrhoea assumes the aspect of a d:sr?.st r: se in those rs in which it cannot be explained satisfactorily by the gross local condi- tions found on pelvic examination. Here we again approach the vascular and nervous type above discussed under the developmental defects. Such menstrual pain may develop after puberty, and be due entirely to the influ- ence upon the general health of faulty hygiene, intercurrent diseases, ex- :essive tax upon the nervous system, and mental strain. Mental depression, neurasthenia, and general hyperesthesia are predisposing factors in the pro- duction of the painful subjective phenomena associated with menstruation ychoneurosis i. The same processes, occurring in vigorous, healthy in- dividuals, would not be regarded or appreciated as constituting actual pain. On the contrary, dysmenorrhoea may, in the course of time, have a marked effect upon the nervous equilibrium of the individual, even though she were previously essentially normal in this respect, and lead to nervous irri- tability, exhaustion, and depression. In the acquired forms of dysmenorrhoea the history may show that nor- mal and uncomplicated menstruation occurred for a longer or shorter period after puberty and that the dysmenorrhoea developed pari passu with the acquired lesion. It need not be explained, of course, that all acquired lesions may be engrafted upon a developmental defect existing at puberty. Treatment. — It is to be understood that the treatment here laid down does not necessarily apply to cases in which dysmenorrhoea is but a symptom of a gross disease of the pelvis, nor to those cases in which it is quite certain that marked anteflexion and stenosis of the cervix are responsible for the condi- tion. Under these circumstances the treatment is self-evident, and is de- scribed elsewhere. Onlv those cases will be dealt with here in which there 590 GYNECOLOGY is no gross disease to account for the suffering, and those in which some doubt exists as to whether a stenosis of the cervix or an acute anteflexion is or is not responsible for the pain. Every patient should at the outset be examined most carefully with regard to her general condition, physical and mental, and suitable measures pre- scribed to place her in good condition. The anaemic, constipated, over- worked girl of sedentary occupation should be instructed in regard to the care of the bowels, the taking of regular exercise in the open air, the selec- tion of food, and the habit in dress (see Hygiene of Adolescence, p. 609). An effort should be made to remove any source of mental anxiety and worry, or so to encourage and fortify the patient by suggestion that she will be able to overcome any mental distress. These conditions may be difficult to correct, but an earnest effort should, nevertheless, be made to do so. At the time of the menstrual period the bowels should be moved freery with the aid of salines. Hot sitz-baths, hot rectal injections, or the applica^ tion of an ice-bag to the sacrum may give relief from the pain. The remedies that have been recommended and prescribed are almost number- less, and in many cases useless. Of the simpler drugs most likely to prove effectual may be mentioned aspirin and the bromides. In many cases of the congestive type, as well as in some of the obstructive form, considerable relief has been gained from the administration of ovarian substance or ex- tract of the corpus luteum of the cow and sow. Failure in the use of these remedies may be due to insufficient dose. In some cases of the obstructive type with paroxysms of uterine colic the administration of atropin sulphate in doses of 1/100 grain three to six times a day for several days preceding the onset of the period has been followed by relief. Atropin has been advantageously combined with aspirin. The most recent addition to the therapeutics of dysmenorrhoea is benzyl benzoate. It is said to have a selective anti-spasmodic effect on smooth muscle-fibers. It is recommended chiefly in that form of dysmenorrhoea, designated as vagotonic by Block, which is marked by spasm and increased irritability of the uterine muscle. Any form, however, may be benefited. The drug is exhibited in a 20 per cent, emulsion, one to two drams at a dose. There is also a hypodermic preparation on the market. The nasal treatment of dysmenorrhoea, first advised by Fliess, has been favorably reported on by a number of reliable observers. Fliess discovered that if the areas on the anterior half of the lower turbinate bones and the tuberculum of the septum, which may be found to be congested during the menses, were cocainized, menstrua, pain was relieved. In the beginning of the treatment cocaine may be used as a test to indicate whether success is likely to follow. To secure a permanent effect, cauterization with trichlor- acetic acid or the cautery, preferably the former, may be carried out be- tween the periods — about four times during the interval. It may be desir- able to repeat the treatment -at intervals over a period of two months. To this end the patient should be placed in the hands of a skilled rhinologist- (For the technic of this treatment the reader is referred to the paper of Brettauer; see bibliography at end of chapter.) Often none of these measures will be effectual, and relief from medicines can DISORDERS OF MENSTRUATION 591 be obtained only by using a derivative of opium in combination with a coal-tar preparation. A favorite prescription is a capsule containing codein (y 3 grain) and compound acetanilide powder (5 grains). These should be used very spar- ingly, however, and the patient should be made aware of what she is taking. The minimum amount— no more — that will control or render the pain bear- able should be taken. One or two capsules at a period will tide the patient over the worst of her suffering. If more are required, the case should be treated surgically. Stimulation of the uterine muscles and development of the canal of the cervix by the application of the intrauterine galvanic electrode have brought a certain measure of relief in some cases. This form of treatment is gen- erally objectionable, however; when it succeeds in dysmenorrhcea of the obstructive type, the dilatation of the canal incident to the treatment is pos- sibly largely responsible for the results. When other measures, drugs, and operation fail, galvanism may be tried. In at least one case this form of treatment successfully relieved violent menstrual pain in the sacral region and thighs after dilatation of the cervix, cocainization of the nasal septum, and numerous drugs had been used without result. When a sufficient time has been allowed to elapse for improvement in the general conditions to exert an influence on the menstrual periods, and if no relief has been obtained as the result of the methods here described, oper- ative measures must be considered. The simplest and most effectual con- sists of dilatation of the cervical canal under anaesthesia, followed by the introduction of an intrauterine stem, that of Norris being preferred. When the pain is due solely to obstruction of the cervical canal, such a procedure will favorably influence the discomfort, and may result in a complete and permanent cure ; even when the pain is due, at least in part, to faulty vascular or nervous development, improvement may follow the adoption of this plan. (For the technic of this procedure see page 243.) The effect of the drain is not only to overcome the stenosis or kinking of the cervical canal, but also to increase the nutrition of the part and improve its vascular supply. When this plan is not followed by success, the surgeon will do well to hesitate before suggesting further operative interference. At times the suffering is so great that other measures must be considered. Thus, if the cervix is very acutely anteflexed and the anterior vaginal wall is short, Reynolds' plan of separating the cervix from its anterior vaginal attach- ment by a transverse incision, followed by longitudinal suture, may be adopted, or Pozzi's or Dudley's operation may be used, either alone or com- bined with the introduction of a Norris drain. In very severe cases, in which there is probable or undoubted ovarian enlargement, an exploratory laparotomy for the purpose of ascertaining the condition of the ovaries is justifiable. Unless the ovary is positively and un- mistakably diseased, its removal usually has but little influence on the con- dition. In some cases, where the ovarian capsule is thickened and the ovary is filled with small, unruptured Graafian follicles, an attempt has often been made to relieve the pain by resecting a portion of the ovary or removing it entirely. This plan has frequently been followed by failure, and occasionally 592 GYNECOLOGY the condition of the ovaries and of the patient has been rendered worse than before. If, therefore, the ovary is not distinctly diseased, it is best to allow it to remain, suspending it if prolapsed, or freeing it, if adherent. The veins of the broad ligaments should be carefully examined, and if they are varicose, a portion of them should be excised. In a majority of instances it is advis- able to avoid any operative treatment except that directed to the cervix. In many cases nothing short of pregnancy and labor will cure the patient, so that the most the physician can do after the simpler operative plans have failed is to tide her along as best he can. It is exceptional to find a case in which general measures or operation on the cervix do not at least greatly relieve, if not cure, the patient. In the exceptional cases the best that can be done is to prescribe suitable medicinal treatment, and to observe the pelvis closely, so that any diseases may be detected early in their develop- ment. It has been said that in very rare instances supravaginal hyster- ectomy with bilateral salpingo-oophorectomy is justifiable in order to cure an otherwise hopeless case. INTERVAL DYSMENORRHEA Attacks of pain resembling dysmenorrhcea may recur periodically (half- way or thereabouts) between the menstrual periods (interval pain). This has been said to be due to aberrant ovulation occurring in chronically dis- eased ovaries. In many of these cases, however, ovarian disease cannot be demonstrated. 4 MEMBRANOUS DYSMENORRHCEA A severe, cramp-like, paroxysmal pain accompanying the menstrual flow is sometimes associated with a discharge from the uterus of portions of the uterine mucosa; occasionally a considerable portion of the endometrium w T ill be dis- charged in one piece. Under such circumstances the discharged tissue with the attached blood-clot presents the appearance of a more or less perfect cast of the 4 Heaney, in a paper upon Periodic Intermenstrual Pain, gives a review of 66 cases. 3 of which he observed personally. The frequency of the condition is given by Rosner as 12 in 2350. The majority of the cases occurred between the ages of twenty-five and thirty- five. The frequency in patients above and below these ages was about the same. The largest number of cases seemed to correspond to the period of greatest sexual activity. There was a high percentage of sterility — about 33 per cent. The menstrual type in the cases varied. Almost all the patients were regular as regards their periods, but there were quite a number in whom the iow was scanty. In a few intermenstrual pain 1 began at puberty. In most of the others it occurred quite a number of years afterward. The pain is somewhat characteristic. It starts at any time midway between the menstrual periods, on or about the fourteenth day after the onset of the last menstruation. The pain is distinctly periodic, and occurs every month with as much regularity as menstruation itself. When once established, it rarely fails to appear unless amenorrhcea occurs, when as a rule, it ceases. The pain usually begins on one side of the lower abdomen or groin, the left more often than the right ; it is cramp-like, spasmodic, and intermittent, with periods of relative or complete recession. Radiation to the leg, to the opposite side, or occasionally to the groin is noted. The pains become more frequent and of longer duration, and generally become diffused over the entire lower abdomen, with tenderness on pressure. Rarely the pain is dull and aching ; more often it is sharp, tearing and lancinating in character. In the milder cases the suffering is relieved by the application of heat; in severe cases opiates are necessary. The duration is usually two or three days; it may, however, continue until near the next menstrual period. The time of greatest relief is usually just after DISORDERS OF MENSTRUATION 593 uterine cavity. The diagnosis can be arrived at only by making a microscopic ex- amination of the discharged tissue, since there is difficulty in distinguishing macroscopically between endometrial tissue and clotted blood. Etiology. — The cause of membranous dysmenorrhcea is not known abso- lutely. Three factors have been held responsible : First, an interstitial endo- metritis that interferes with the separation and expulsion of the endometrium in fragments (Winter ascribes the pain to the exudation previous to the detach- ment of the membrane, and not alone to uterine contraction) ; secondly, a diminution in the tryptic ferment of the uterine mucosa, which normally softens and digests the mucosa preparatory to its extrusion; and thirdly, some as yet unexplained reaction in the endometrium resulting from a reduction in the ovarian hormones. Some authorities have denied the possibility of an inflammatory disease of the endometrium serving as the cause of membranous dysmenorrhcea, on the ground that the condition often occurs in virgins and in sterile but otherwise healthy women. Others believe that the inflammatory lesion may have dated from infantile gonorrhoea ; or that the endometrial change may be the late result of an acute exanthematous disease in childhood. In these cases the menses are often irregular and sterility is the rule. When preg- nancy does occur, it is frequently interrupted. Treatment. — The condition is difficult to overcome ; before resorting to oper- ative measures, the various anti-dysmenorrhceic drugs and ovarian substance should be used. The operative treatment consists in dilating the cervix, curette- ment, and the introduction of an intrauterine stem. In the most severe cases supravaginal hysterectomy with conservation of the adnexa may ultimately be required. THE MENOPAUSE The menopause, or the cessation of the menstrual function, marks the end of the reproductive period of a woman's life. As a rule, the menopause occurs at about the age of forty-five, although it may take place at any time between the fortieth and the fiftieth year. It is frequently the case that menstruation. Purefoy mentions a case in which the patient had intermenstrual pain in the breasts and none in the abdomen. At times the pain is accompanied by a colorless vaginal discharge. All cases show pathologic alterations, and the author states that it has been difficult to separate the essential from the complicating lesions. Out of 29 cases which the author collected from the literature, laparotomy is recorded as having been performed in 6; in 5 a fibroid uterus was found, and in all the ovaries were either sclerotic or had undergone cystic degeneration. Rosner, in a series of 12 private patients, found only one with normal pelvic organs ; the others showed increased sensitiveness or enlargement of the ovary or ovarian prolapse. There was also a general increase in the uterine dimensions which he called " diffuse pathologic hypertrophy." Various theories have been adduced to explain intermenstrual pain. Drennan believes the pain to be due to the escape of a non-fertilized ovum, associated with expulsive efforts on the part of the uterus. Addinsell ascribed the symptom to hydrops tubes proiluens, the pain being thought to occur when the tube expels its contents. Kiistner asserts that the dis- turbance is the result of ovulation which is asynchronous with menstruation, and that the pain is due to the resistance met by the follicle in its effort to burst and release the ovum. After discussing these theories and others that have been proposed, as well as the relation between menstruation and ovulation, the author states that he believes that periodic intermenstrual pain is an insufficient or abortive attempt at menstruation, the pain being a form of dysmenorrhcea, the whole picture depending upon degenerative and sclerotic con- ditions in the ovaries and uterus. 38 594 GYNECOLOGY when menstruation begins early in life, it ends late, and that when • it begins late, it ends early. Symptoms. — The menstrual flow, as a rule, does not cease at once, but the menstrual periods become gradually less frequent and the flow less profuse, finally disappearing altogether. During the time the menstrual function is disappearing certain subjective symptoms appear that may be regarded as evidence of the alterations in metabolism that necessarily take place upon the abrogation of such intricate processes as ovulation and menstruation. The woman experiences general or local sensations of heat or cold, attacks of profuse perspiration, nervousness, and irritability, headache, and depression of spirits. In the healthy, robust woman, such symptoms may be disregarded ; but in the neurotic and weak they may be bitterly complained of and associated with mental irregularities. Treatment. — For healthy women no especial management is necessary dur- ing the time of the menopause. When the nervous manifestations are marked, and when they cause considerable distress, it is advisable to put the patient in as good general condition as possible, to tone up the nervous system, and to employ ovarian or corpus luteum extract and nerve sedatives, such as sumbul, viburnum, and the bromides. The rest cure is sometimes of benefit. The most important part of the management of the menopause is to be constantly on guard lest early symptoms of beginning malignant disorders are overlooked. For this reason any woman coming under the care of a physician at this period of her life should be questioned regarding leucor- rhoeal discharge, irregular bleeding, and local symptoms of any sort refer- able to the pelvic organs. Unless the patient is absolutely free from abnor- mal symptoms of any kind, a thorough examination should be made. It need not be stated that the indication for this examination is all the more urgent when the amount of blood lost at a period increases or when bleed- ing occurs between the periods or long after the menopause is believed to have been past. There is a very deeply rooted impression that any menstrual irregularity at the time of the menopause is more or less peculiar to that time of life and entirety within the bounds of health. This is a fallacy. In normal women the menstrual epochs become more and more infrequent, and with each period the flow grows less. Although a deviation from the normal does not, by any means, always indicate malignancy, it occasionally does so, and has often been disregarded until the patient's condition is hopeless. For that reason patients at the menopause should be questioned regarding their menstruation, and if there is any irregularity or variation from the normal, a thorough examination should be undertaken immediately, so as to exclude diseases of a malignant type. Women should be acquainted of these facts by their family physician, so that they will voluntarily seek his advice immediately upon the appearance of pelvic symptoms. PREMATURE MENOPAUSE Etiology.— The menopause may occur considerably earlier in life than normal. Not infrequently it takes place during the early thirties, and is often accompanied or preceded by a considerable increase of adi- DISORDERS OF MENSTRUATION 595 pose tissue throughout the body. Such women have usually had a late puberty, are short in stature, suffer from amenorrhcea, dysmenorrhcea, and sterility, and give the general impression of incomplete sexual development. There may be some pernicious influence of the thyroid gland to explain the cessation of ovarian activity. Amenorrhcea and obesity are observed in hypothyroidism. The pituitary gland may also be concerned in the prema- ture menopause — hypofunction of the gland has been found clinically to be associated with irregular menses, amenorrhcea, and sterility. Similarly the adrenal glands, when defective, may be associated with diminished func- tion and even with atrophy of the genitalia. In a few cases acquired changes in the ovary (oophoritis associated with acute febrile diseases, lactation, atrophy, etc.) are probably the important factors. Treatment. — The treatment is very unsatisfactory and often of no avail. An attempt may be made to secure results by treating the adiposity, the reduction of which, in some cases at least, may have a beneficent effect on the menstrual periods. In addition, thyroid, pituitary, adrenal, and ovarian extracts, tonics, and various emmenagogues may be prescribed. Finally, the cervix may be dilated and a Norris stem introduced, in the hope that the nutrition of the uterus may be improved and a return of the menstrual flow thus secured. ARTIFICIAL MENOPAUSE Etiology. — The artificial menopause is the abrupt cessation of the menstrual function occasioned by the removal of both ovaries during the course of a pelvic operation. In women past thirty this artificial meno- pause may be accompanied by no more serious symptoms than those that attend the normal menopause. In highly neurotic women of this age, or in women under twenty, however, the condition may be accompanied with the most exaggerated nervous symptoms and complaints. In mentally weak individuals a form of mental perversion may develop, the patient continu- ally indulging in morbid introspection, and in severe cases becoming mentally deranged. In adolescence ovariectomy is a serious matter, sometimes changing the entire life of the individual, rendering her prematurely old, and being con- ducive to general ill health and many forms of nervous disorders. There may be a tendency to obesity and an overgrowth of hair upon the face. Such women are said to show a tendency to approach the male type and to lose sexual feeling. Castration before marriage interferes with the develop- ment of a libido sexualis. In women who have been married for some time and in whom the libido sexualis is matured, there is usually no diminution of sexual feeling. Indeed, the removal of diseased and painful ovaries may make coitus more agreeable or at least less objectionable. To every woman the knowledge that she is incapacitated for motherhood brings a certain measure of regret, determined by the intensity of her feelings. To avoid such distressing sequelae removal of both ovaries is to be most scrupulously avoided up to the age of thirty-five. Some gynecologists, notably Graves, believe that the artificial meno- pause in itself causes no more marked disturbances than does the normal 596 GYNECOLOGY change of life. He divides the nervous symptoms of the menopause into two distinct groups — the vasomotor and the neurotic. The first are due to the loss of the ovarian secretion, and last, on the average, from two to three months ; they are almost invariably relieved by the exhibition of ovarian extract. The second group, the psychoneuroses, he believes are by no means " definitely consequent " on the loss of the ovaries. They may be brought about by carelessly performed operations that leave the patient with distressing post-operative sequelae, such as adhesions, painful stumps, prolapse of the cervix, incisional hernia, etc., or by mental suggestion — a sense of degradation induced by the criticism of an unfeeling husband or the remarks of unwise friends. Treatment. — The treatment of the artificial menopause is unnecessary, of course, in women in whom the symptoms are not distressing. In others the dis- agreeable nervous symptoms may be relieved by the administration of the desic- cated entire ovary or the desiccated corpus luteum, attempting to supply in this way what is believed to be the internal secreting structure of the ovary. The most satisfactory preparation is the freshly desiccated entire ovary. This may be given in tablet form, 2 to 5 grains three times daily. The extract of the corpus luteum is preferred by some, and in many cases has undoubtedly given excellent results ; the dose is 5 grains three times daily. A fluid preparation of the extract of corpus luteum for hypodermic use is on the market. As with all organic extracts, the initial dose should be small and gradually increased, if necessary. Nerve sedatives, such as the bromides, viburnum-opulum, sumbul, and asafetida, at times do good. Abundant exercise or an active out-of-door life is of the greatest benefit. An effort should be made to minimize the importance of the symptoms, and the patient should be encouraged to take a matter-of-fact view of her condition. Many foolish notions and depressing beliefs relative to castration may be in the patient's mind. BIBLIOGRx\PHY Bab. H. : " Organotherapeutische Erfahrungen und Andwendung von Aphrodisiaka in der Gynakologie." Frauenarzt, 1913, xxviii, 543. Brettauer, J. : " Further Report of Cases of Dysmenorrhea Relieved by Nasal Treatment." Trans. Am. Gyn. Soc., 1913, xxxviii, 80. Busey, S.C. : "Vulvar or Vaginal Hemorrage in the Newly-born." Trans. Obst. and Gyn. Soc, Wash., D. C. 1889-90, iii, 25. Cabot, R. C. ; Differential Diagnosis. Saunders, Phila., 1911. Coe, H. C. : "Menstrual Disorders of Obscure Origin.'' Am. Jour. Obst., 191 1, lxiii, 790. Dickinson, R. L. : " Conservation of Sound Ovaries and Tubes in Hysterectomies Near the Menopause, Except in Malignant Disease." Trans. Am. Gyn. Soc, 191 1, xxxvi, 324. Ehrenfest, H. : " The Influence of the Central Nervous System in the Causation of Uterine Hemorrhage." Am. Jour. Obst., 1908, lvii, 161. Fliess : " Die Nasale Reflexneurose." Verhandl. Cong, f . innere Med., Zwolfter Congress, S. 384, Wiesbaden ; Ibid. : " Magenschmerz u. Dysmenorrhea in neuen Zusammen- hang." Wien. klin. Rundschau. 1895, ix, 1. Fr.enkel, L. : " Normale u. Pathologische sexual Physiologie des Wiebes." Handbuch der gesammten Frauenheilkunde, W. Liepmann, ii, Vogel, Leipzig, 1914. Frank, R. T. : " The Clinical Manifestations of Disease of the Glands of Internal Secre- tion in Gynecological and Obstetrical Patients." Surg., Gynec. and Obst., 1914, xix, 618. Frankl, O. : " Pathologische Anatomie u. Histologic der weiblichen Genitalorgane." Hand- buch der gesammten Frauenheilkunde, W. Liepmann, iii, Vogel, Leipzig, 1914. Franoue, V.: " Beitrage zur pathologische Anatomie der Endometritis Exfoliativa." Ztschr, f. Geburtsch u. Gynak., 1891, xxii, 1. DISORDERS OF MENSTRUATION 597 Graves, W. P. : " Influence of the Ovary as an Organ of Internal Secretion.'" Am. Jour. Obst., 1913, lxvii, 649: Ibid.: "Ovarian Organotherapy." Trans. O.. G. and A. S.. A. M. A., 1917, 147. Heaney, N. S. : " Periodic Intermenstrual Pain." Surg., Gyn. and Obst., 1910, xi, 361. Kelly, H. A. : " Dysmenorrhcea — Its Causes and Treatment." Am. Jour. Obst., 1894, xxix. 502. Litzenberg, J. C. : " The Use of Benzyl Benzoate in Dysmenorrhcea." Jour. Am. Med. Asso., 1919, lxxiii, 601. McRae, F. W. : " Conservative Surgery of the Pelvic Organs and the Lower Abdominal Wall." Jour. Am. Med. Asso., 1910. lvii, 2215. Montgomery, E. E. : "Premature Menopause." Med. News, 1894, lxv, 461. • Noble, C. P. : " Profuse Menstruation." Ann. f. Gyn. et Pediat., 1894, vii, 334. Norris, C. C. : " The Menopause." Am. Jour. Obst., 1910, lxi, 203. Novak, E. : " Some Neglected Principles in the Causation of Menstrual Disorders." Am. Jour. Obst., 1910, lxii, 601 ; Ibid. : " The Atropin Treatment of Dysmenorrhcea." Jour. Am. Med. Asso., 1915, lxiv, 120: Ibid. : "The Corpus Luteum." Trans. O., G. and A. S.. A. M. A., 1916, 44; Ibid. : "The Pathologic Physiology of Uterine Bleeding." Trans. Sect. O., G. and A. S., A. M. A., 1914, 220. Ploss : Das Weib in der Natur u. Volkerkunde. Leipzig, 1905. Saxes, K. I. : " Is Membranous Dysmenorrhcea Caused by Endometritis? " Trans. Sect. O., G. and A. S.. A. M. A., 1913, 304. Stephenson : " On the Relation Between Chlorosis and Menstruation, an Analysis of 252 Cases." Trans. Obst. Soc, London, 1889, xxxi, 104. Stieda : " Chiorose u. Entwickelungstorungen." Ztschr. f . Geburtsch. u. Gynak., xxxii, 60 and 97. Tait, L. : Diseases of Women and Abdominal Surgery. Phila., 18S9. Thorn : " Beitrage z. Lehre von der Atrophia Uteri." Ztschr. f. Geburtsch. u. Gynak., xvi, 57- Virchow : " liber die Chiorose u. die damit zusammenhangenden Anomalien im Gefassap- parate." Beitrage f. Geburtsch. u. Gynak., 1898, i. Wood, H. C. : Therapeutics. Lippincott, Phila., 1907. CHAPTER XXXIII STERILITY A woman may be said to be sterile when conception does not occur within several years of marriage. The truth of this statement rests upon the fact that no measures have been taken to prevent impregnation and that the male is healthy. Sterility may be either relative or absolute. Relative sterility is comparative sterility ; that is, a woman may bear a child within a short time of marriage and none after that. This is frequently spoken of as one-child sterility, and is usually dependent upon an accident or a com- plication attending the first labor, which prevents another conception from v&rcvvrvoA FlG. 461. — Schematic outline of generative tract showing: Escape of ovum; penetration of spermatic particles; fertilization of egg. taking place. Before declaring that a woman is sterile one must be certain that all the conditions favorable to conception exist in the interested person of the opposite sex. Etiology. — The causes of sterility are numerous, and include all the con- ditions that may interfere in any way with the physiology of normal im- pregnation. Conception takes place usually in the outer third of the tube ; the spermatic particles by their own motility penetrate to this point, and there lie in wait for the ovum, which is discharged by the Graafian follicle, is caught up by the fimbria, and is carried down into the tube (Fig. 461). After impregnation the ovum passes slowly through the tube into the uterus ; 598 STERILITY 599 a period of from five to seven days is believed to be consumed in its passage. In the meantime the uterine mucosa has undergone certain changes in preparation for the reception and nourishment of the gravid ovum. A more detailed description of this process can be found on page 71. Granting that the masculine function is perfect, sterility on the part of the female may be dependent upon imperfect development or disease of any part of the genital tract that: (1) Prevents ovulation or produces unhealthy ova; (2) renders the sexual act incomplete or imperfect; (3) prevents the spermatic particles and the ovum from meeting ; or (4) favors the destruc- tion of the ovum after it has become impregnated. Polak declares that there is a definite chemico-physio- logic factor in conception that is at present unexplain- able which is a cause of sterility. Imperfect Development. 1 — The ovary may be small and the ova few and imper- fectly developed. This is usually a part of a general hypoplasia especially marked in the generative organs, and may be the re- sult of ancestral syphilis, alcoholism, or epilepsy. Other causes of deficient ovulation are wasting dis- eases, hypophyseal and D other internal glandular dyscrasias, chronic poison- ing, as by lead, etc., con- , " FlG. 4 62 - — Semi-diagrammatic outline of uterus showing various I he Capsule Of the OVarv causes of sterility: (A) infantile type of uterus, cervix long and ste- , t1 , \ notic with acute anteflexion causing obstruction; (B) submucous may be UnUSUallv tOUgh and myoma causing obstruction or interference with nidation; (C) inter- 1 1 ,\ r+ n stitial myoma causing obstruction or interference with nidation. dense, and the Graafian follicles, after attaining a certain size, may undergo regression and partial absorption — ovulation does not occur. Ovulation may be prevented by cystic degeneration of the ovary or by a persistent corpus luteum. The Fallopian tubes may be of the fcetal type ; that is to say, they may be very long and greatly twisted, so that the impregnated ovum must travel a considerable distance before it reaches the uterus ; hence it may perish on the way, or the tube may present diverticula in which the impregnated ovum 1 For a complete list of the developmental defects of the genitalia, any of which, under certain circumstances, may be the cause of sterility, see the section on Malforma- tions^ Only the abnormalities most frequently associated with sterility as seen in practice will be discussed here. 600 GYNECOLOGY is caught, or there may be constriction of the tube or poorly developed fimbriae, or the musculature may be ill developed and peristalsis weak. The uterus may be of an infantile or foetal type, so that proper embedment and nourishment of the ovum cannot be provided by the small, fibrous organ, with its attenuated and poorly vascularized endometrium. The cervical canal may be stenotic, so that the spermatic particles are prevented from entering the uterus. The cervix may be so elongated and sharply anteflexed that the seminal fluid does not bathe the external os (Fig. 462, a), and the vaginal fornix may be so shallow that the seminal fluid runs out of the vagina soon after coitus (Fig. 463, b). The vagina and vulva may be so greatly distorted as the result of malformation as to constitute a more or less complete barrier to copulation. Acquired Diseases. — Acquired diseases that produce sterility are chiefly inflammatory in nature. 2 Such diseases close the abdominal ostia of the tubes by reason of adhesions (Fig. 464, c), obstruct the lumen of the tubes Fig. 463. — Semi-diagrammatic outline of uterus showing various causes of sterility: (/I) Sal- pingitis or adenomyoma of interstitial portion of tube acting as an obstruction to the sperma- tozoa; {B) cervico- vaginal junction with shallow fornices allowing semen to escape. by chronic inflammatory changes in the mucosa (Fig. 463, a), cause destruc- tion of the ciliated epithelium; produce infiltration of the tube wall, and angulation, so that the sperm and the ovum cannot meet. Such diseases also, by producing ovarian adhesions or a thickening of the ovarian capsule and internal circulatory changes in the ovary, may end in a premature atrophy of the Graafian follicles or interfere with the rupture of the follicle and the liberation of the ova (Figs. 464, a and b). 3 Endo- 2 According to Lier and Asher, the woman is responsible in 60 per cent, of sterile marriages and the man in 40 per cent. ; and 33 per cent, of sterility in women is due to gonococcal infection. 3 Reynolds describes the ovaries of fertile and those of sterile women as follows : " The ovaries of a fertile woman are, then, characteristically organs of uniform outline which show not more than one thin-walled and projecting follicle or corpus. They have throughout a characteristic soft and elastic feel when taken between the fingers, except when a single mature follicle or active corpus distends one portion of an ovary and yields its characteristic tactile sensation at the point. " In contrast, the ovaries of sterile women usually show on gross examination the presence of numerous thin-walled projecting follicles, or of numerous small, imperfect- looking corpora, or both. They are of lobulated outline, and on tactile examination between the fingers are tense and resistant in feel over the whole or at all events the greater part of the organ." STERILITY 601 <65y metritis, cervicitis, or vaginitis may prevent conception by generating a discharge that destroys or weakens the spermatic particle or the ovum or renders the decidua unhealthy. The normal uterine secretion is alkaline, which quality favors the activity of the spermatic particles — there is a cer- tain attraction between the plug of alkaline cervical mucus and the sper- matozoa. Excessive secretion or a purulent or muco-purulent secretion is inimical to the sperm. Excessive acidity of the vaginal secretion may prevent conception. Abnormal bacterial flora in the vagina may destroy or render less active spermatic particles deposited in the vaginal canal. Fibroid tumors, endometrial polyps, and retro- flexion of the uterus may, by mechanical obstruc- tion to the ingress of the spermatozoa, either hinder the occurrence of conception or be inimical to the development of the ovum after it has been impreg- nated (Figs. 462, A and B) . Such lesions prevent the union of the sexual elements, or if conception occurs, they retard the ovum's descent into the uterus, so that it perishes on the way, or render the development of the decidua so abnormal that the ovum is not properly embedded or nourished in the uterus and is soon cast off. Functional Defects. — Functional defects may play an important role in the production of sterility. In order for the coitus to be fruitful it is not neces- sary that a woman have a keen sexual feeling or that she experience an orgasm, although both favor the occurrence of conception. The spermatic par- ticles, if deposited at the vaginal orifice, are capable, by their own motility, of reaching the interior of the uterus and the tubes, but the completely con- summated sexual act favors their penetration and increases their number. Painful contraction of the vagina (vaginismus) may be responsible for C ^lu&y sterility. Forcible penetration in early married Fig. 464.— (A) Atrophicovary.no ,.- - . , , . . , . ova produced; (B) thickened cap- lite may result in a hyperesthesia of the external rupt-u?ITf° P foSicie S aS" escaped genitalia sufficiently marked to render complete ovum; (O abdominal ostia of tube ~ r .;+ 1 . 10 I'mr^cciKI a closed preventing ovum from COltUS impOSSlDie. entering tube. Diagnosis.— The cause of sterility in a given case may be difficult and often impossible to determine. Some of the anatomic causes may be of such a minor degree as to render them unrecognizable. Careful obser- vation and study of the spermatic fluid and of its behavior after it is deposited in the genital canal will often throw much light on the subject. Huhner points out that the male should first be examined as to his ability to provide active spermatozoa. This test, as usually carried out, consists in making an examination of the semen obtained in a condom as soon as pos- sible after coitus. There are several reasons why the mere finding of live spermatozoa in the fluid is not sufficient evidence to prove that the male 602 GYNECOLOGY element is satisfactory. Hypospadias or epispadias may be present, and, as a consequence, live spermatozoa may be recovered from a condom when, in the normal act, they would not reach the cervix. So, too, if emission is premature, semen that might never have entered even the vaginal tract will be found in the condom. Similarly in some cases of stricture of the urethra live spermatozoa may be found in semen that has dribbled through the stricture and been retained in the cover after withdrawal of the penis. For these reasons Huhner proposed to examine the vaginal, cervical, and uterine (fundus) secretions at varying periods of time after coitus, with a view to determining the presence of spermatozoa and their condition. For this purpose he uses a small syringe and a cannula resembling a Eustachian tube catheter. The fundus should not be examined for a day or two after coitus, for the finding of live spermatozoa in the fundus soon after copulation may lead to the supposition that the spermatozoa may have been pushed in ahead of the examining instru- ment or may have adhered to it upon its withdrawal through the cervix. The examination of the fundus should, therefore, be de- layed until a day or two following coitus ; the finding of live sper- matozoa at this time will serve to rule out any abnormal flexion or stenosis of the cervix as a cause of the sterility. The spermatozoa deposited upon the vulva die quickly — those in the vagina within a few hours ; within the cervical canal they live for a longer period and in the in- -Sterilitv produced through gonorrhoea causing , _„• £ -t-U^. 4-~ ,,o +V.^ *^-,^ U fl pyosalpinx, perioophoritis and pelvic adhesions. leriOr OI ine UterUS iney may DC found alive after several days. In conducting a test, the wife presents herself for examination within an hour of coitus ; if live normal spermatozoa are found in the vaginal vault or the cervical canal, the husband is absolved from blame. If dead spermatozoa are found, a condom specimen should be obtained in order to ascertain whether the spermatozoa were dead when ejaculation took place, or whether they were destroyed later by the vaginal or cervical secretions. Ultzmann has pointed out that the spermatozoa that are dead when ejaculated have their tails curled up, whereas in those that die later the tails are straight. If live spermatozoa are found in the cervix, but not beyond an angle in the canal, this flexion must be regarded as the obstacle which prevents their penetration. If live spermatozoa are found in the fundus, the sterility may be due to defects in the development of the uterus, such as infantilism, or to a patho- logic condition of the adnexa. Should measurements of the uterus by the sound and specula and bimanual examination show no uterine maldevelop- ment, and if no pathologic condition of the adnexa is demonstrated on Vy.S Fig. 46; STERILITY 603 bimanual examination, then a stenosis or a kinking of the tubes may be present or some ovarian condition may be responsible for the sterility. Should live spermatozoa be found in the cervix and dead spermatozoa be discovered in the fundus, it is to be assumed that the endometrial secretion of the uterine interior is inimical to the spermatozoa. Hiihner's method eliminates almost entirely the necessity for question- ing the male, although in doubtful cases he should be subjected to a careful examination for signs of disease of the genito-urinary tract. To this work of Hiihner's may be added the important observations of Reynolds on the spermatic particles. If these are examined upon the warm stage of the microscope, either from a condom specimen or one taken from the vaginal vault after coitus, five types of spermatic particles may be distinguished: (i) The spermatozoon swims in a straight line and pref- erably against a current ; the end of the tail lashes from side to side so rapidly that it is impossible to follow its movements ; this is the first phase in the life of normal ejaculated spermatozoa, and may be called the " progressive vibratile." 5 (2) The spermatozoon swims with much reduced speed ; the tail move- ment is a long, slow stroke from side to side ; the head and middle piece sway ; the outline is of an S shape ; the purpose of movement is direction more than speed; the spermatozoa seem, by a sort of tactile reaction, to avoid objects in the medium ; this stage is the " undulatory tactile." (3) The spermatozoon shows a tendency to push itself against or into any small masses of cells, bunting itself into any small cavity, and maintain- ing a slight burrowing motion effected by a lashing tail movement, not un- like the movements of the caudal fin of a fish. From time to time the organisms back out of the cavity and seek another mooring place. That is the " stationary bunting " phase. (4) The spermatozoon moves forward with a spiral, screw-like process ; it progresses with fair rapidity, but the swimming appears awkward and it is easily recognized. This is the " rotary swimming " phase. (5) The spermatozoon makes progress very slowly; the middle and upper portions of the tail lose their flexibility and balance to a considerable degree, and the lower tail motion swings the forward part of the sper- matozoon forward with a to-and-fro pendulum movement. This is the " pendulum swimming " phase. The first three of these types may be regarded as normal ; they take place in regular sequence in a fresh specimen ; the last two types are abnor- mal in fresh specimens, and indicate impaired ability to fertilize. Repeated observations should be made, if possible, in order to verify the findings in a given case. Treatment. — The treatment of sterility is as varied as the factors that pro- duce it and in many instances, as has been said, there is great difficulty in deter- mining the exact cause. When a pelvic examination discloses gross disease of the pelvic organs, the probable cause of the sterility is plain, and the treatment 3 Semen, when freshly ejaculated, is exceedingly viscid and thick. After a time it undergoes rapid liquefaction. The progressive vibratile stage rarely becomes well established until after this change has occurred. 604 GYNECOLOGY must be directed largely to the correction of the existing disorder. In such cases the indications are clear and well defined. The difficult cases are those in which sterility is absolute, and due either to developmental or to func- tional defects, and those in which the acquired lesions are so slight as to render their influence doubtful. In many instances the elimination of all possible abnormalities must be undertaken in the hope that the causative factor will be removed with the others. The developmental defects are, of course, the most difficult to cure. The deformity most amenable to treat- ment is anteflexion and stenosis of the cervix. For this dilatation and the introduction of a Norris stem may be curative. If, in addition, the vaginal cervix is elongated, or if it occupies an anterior position so that the external os is not in proper relation to the vaginal fornices, the lips may be split, as in Dudley's or Pozzi's operation, or Reynold's plan of lengthening the an- terior vaginal wall may be adopted. If the vaginal fornices are shallow, an attempt may be made to increase their capacity by the use of tampons, and the patient may be directed to elevate the hips during coitus, and to remain in that position for several hours afterward. Mechanical impediments to coitus in the vagina and vulva, such as rigid hymen, small introitus, septate vagina, or atresia, may occasionally be relieved by operation. A rigid hymen may be excised. A rigid narrow orifice that resists dilatation by means of specula can be enlarged by cutting the anterior border of the levator muscles and fascia in each sulcus, and suturing the incision in such a way as to make the division permanent. Vaginal septa should be ex- cised. A small, ill-developed uterus, even if no marked anteflexion or stenosis is present, may be increased in size, it has been asserted, by the introduction of the stem pessary. The intra-uterine galvanic elec- trode has been recommended, but it is troublesome to use, requiring rigid aseptic precautions, and is of doubtful efficiency. The advisa- bility of performing an operation for the correction of developmental defects in the hope that conception will subsequently occur must depend upon the condition of the genitalia as a whole (see Gynatresia, page 23). If the ovaries are small and poorly developed, the outlook is doubtful. Women with defective ovarian development usually begin to menstruate late, the periods being often irregular, delayed (five to eight weeks), and scanty. These functional indications of insufficient ovarian activity are fre- quently found in the excessively stout and in those exhibiting evidence of a faulty or perverted internal secretion from the thyroid, adrenal, and pituitary glands. Regular exercise, proper diet, reducing the weight, the applica- tion of the stem pessary, and the exhibition of ovarian or lutein powder, desiccated thyroids, and pituitary gland extract may be useful in some of these cases. When sterility is due to inflammatory disease of the lower genital tract, the treatment must be suited to the conditions present. (See the treatment of vaginitis, page 192; endocervicitis, page 224; endometritis, page 279; leucor- rhoea, page 197, etc.) An infected cervix or endometrium may be cured in obstinate and chronic cases by curetment followed by iodine or phenol applied locally ; if the external os is tight and the cervix is poorly drained, free lateral incisions may be made. Nabothian cysts may be punctured and STERILITY 605 cauterized. In cervices that are greatly diseased partial amputation may be necessary. In obstinate leucorrhcea Reynolds especially recommends the use of powdered protargol insufflated into the vaginal fornices with a powder blower ; after the discharge becomes scanty and colorless, aristol is substituted. If the discharge is excessively acid, a normal salt or a sodium bicarbonate solution may be prescribed to be given in the form of a douche immediately preceding coitus. Needless to say, the proper treatment of gross pelvic diseases that may be the cause of sterility, operations for the removal of pelvic tumors (fibro- myoma, unilateral cystoma), resection or unilateral excision of an affected tube and ovary (hydrosalpinx, cystic ovary), or restoration to the normal of a displaced uterus may be followed by conception. Sterility due to retro- position of the uterus is often amenable to replacement and the use of a pessary. A submucous myoma or an endometrial polyp may admit of easy removal and be followed by conception. In these gross cases there is no question as to the advisability of operation and treatment, and the opportunity it affords. Among the most difficult cases are those in which no gross abnormality exists and still, from the entire aspect of the case, the presence of pelvic adhesions is suspected. Pelvic inflammatory disease may give rise to the forma- tion of adhesions that occlude the abdominal ostia of the tubes without leav- ing any evidence, on bimanual examination, of the true state of affairs. A history of pelvic infection, therefore, combined with one-child sterility, may be regarded as presumptive evidence of tubal adhesions if there is no other explanation of the sterility. In cases that have resisted all other plans of treatment, and in which pregnancy is greatly desired, the entire situation may be explained to the patient and her husband, and at their solicitation exploratory celiotomy may be performed for the purpose of directly inspecting the tubes and, if need be, opening them. When the tubes are found but slightly involved and the occlusion of the ostia is due to light and filmy adhesions, separation of the latter, fol- lowed by salpingostomy (see page 419), may effect a cure. If, however, evidences of serious trouble are found, the tubal wall being thickened and the mucosa atrophied, or the tubal plications largely destroyed or obliter- ated, operation does not promise much. In some unpromising cases, how- ever, pregnancy may follow excision of an outer more seriously diseased portion of a tube and the formation of a new ostium for the inner, less severely affected portion. In some cases light ovarian adhesions cannot be detected by bimanual palpation, and while their presence may be suspected, one cannot be certain as to their existence. They usually occur in conjunction with tubal adhe- sions. What has been said relative to exploratory celiotomy in suspected closure of the tubes applies equally well to the ovaries. The release of the ovary from adhesions may permit the rupture of follicles and the escape of ova which were previously lost. Operations upon cirrhotic ovaries or upon ovaries with thickened capsules or those the seat of numerous unrup- tured Graafian follicle cysts give little result. Excision of a corpus luteum cyst of the ovary, it has been claimed, has resulted in the resumption of 606 GYNECOLOGY ovulation, which was temporarily inhibited by the persistent lutein tissue. If the diseased area is limited to one pole of the ovary, resection may im- prove the chance of conception (see page 418). Any operation on the tubes or ovaries for the purpose of removing adhesions and mechanical obstacles to the meeting of the ovum and the spermatic particles should be accompanied by thor- ough disinfection of the lower genital tract and excision of diseased tissue. Ovarian Transplantation. — It is conceivable that, in the case of very seriously diseased adnexa, when it is impossible to leave any of the ovarian tissue in situ, a portion of the ovary enucleated from the diseased mass (autograft) or a foreign ovary (heterograft) may be transplanted into the region of a resected and freshly opened tube, and, as a consequence, con- ception may subsequently occur. Such cases (all autografts) have been reported, but this possibility is so slight as to be almost undeserving of serious consideration. Nevertheless, in selected cases, with the patient fully cognizant of the facts, the procedure may, at her request, be tried. 6 Artificial Insemination. — Artificial insemination may be practised in cases in which there is a good reason to believe that the semen does not enter the uterus. Certain cases of vaginismus, stenosis of the vagina, elongation, acute anteflexion, and contraction of the cervical canal may be indications for the adoption of this procedure. The semen is obtained im- mediately after ejaculation, kept warm, and about 0.5 c.c. of it is injected into the uterine cavity by means of a glass syringe with a long intra- uterine stem. A warm tampon covered with the remainder of the semen is placed against the external os, and the patient is kept in the recumbent posture with the hips elevated for twelve hours. Many successful results in the human have been reported, and it is well known that artificial im- pregnation is quite commonly resorted to in the breeding of horses. It should not be forgotten, however, that these animals are not sterile. 6 Tuffier states that after transplantation, in favorable cases, the ovary lies dormant in its new position for several months, then becomes painful and swollen for a few days. These symptoms subside and five or ten days' later menstruation appears. This investigator endeavors to leave the uterus in situ. He transplants the ovary about 5 cm. from the abdominal incision subperitoneally. When possible, he uses both ovaries, and has not found any regularity or rhythm in the swelling of one or the other. In 19 of his earlier homotransplants — 145 altogether — he had only one failure — i.e., menstruation did not appear. He says that hot flashes and vasomotor phenomena are overcome by trans- plants. In some cases it has been found necessary to remove the grafted ovary, but the mere fact that it is transplanted does not make it any more likely 1 to undergo degenerative changes. Whitehouse reports one case in which the patient menstruated for a year after ovarian transplantation. He prefers " seedling " grafts, i.e., cutting the ovary into small pieces and placing these between the rectus muscle and the subperitoneal tissue. He places the ovary in Douglas' culdesac to keep it warm until he has finished his abdominal work. He draws the following conclusion, among others : . " It seems to be established that a small portion of ovary successfully engrafted anywhere furnishes to the subject of the graft the secretion or influence that preserves her sexuality and prevents atrophy of the genital^ organs and other changes in the individual that are coincident with complete castration." Heterotransplantation is not so successful as homo-transplantation. There seems to be a blood or tissue antagonism to hetero grafts. This is less marked in those of close consanguinity, and is not present in the case of homo-transplantations. W. L. Estes had two cases of pregnancy following homoplastic grafts. Morris had one case, believed to be the only one on record, of pregnancy following a hetero-transplantation. Morris and Frank each report cases of pregnancy following homoplastic grafts. STERILITY 607 The most favorable time for practising artificial impregnation in the woman is immediately after or just before a menstrual period. Careful aseptic precau- tions must be observed, but antiseptics must, of course, be avoided. Artificial insemination is applicable to certain selected cases, and is likely to be efficient when other measures have failed provided there is some mechanical obstacle that cannot otherwise be avoided. 7 Since one of the most frequent remediable causes of sterility appears to be stenosis of the cervix with anteflexion and a shallow vaginal vault, the patient in whom no gross disease can be demonstrated should be instructed to elevate the hips during coitus, and to remain in that position for at least twelve hours afterward. This prevents dissipation of the seminal lake, keeps the external os bathed in the semen for a longer period of time, and favors penetration of the spermatic particles. Intercourse should be limited to the first week after or the week before menstruation. Rohleder has recommended coitus on the last day of the period in sterile marriages with success. The alkaline menstrual blood is believed to be favorable to the life and activity of the spermatozoon. The husband should be instructed that frequent intercourse or multiplicity of ejaculation does not favorably influence the case. One completely physiologic coitus at the proper time is more valuable than numerous more or less abortive attempts. BIBLIOGRAPHY Bumm : " Uber Behand. u. Heilungsaussicht der Sterilitat bei der Frau." Deutsch. med- Woch., xxx, 1756. Chalfaxt, S. A. : " Subcutaneous Transplantation of Ovarian Tissue." Trans. Amer. Gyn. Soc., 1915, xl, 444. Frank, R. T. : "The Clinical Manifestations of Diseases of the Glands of Internal Secretion in Gynecological and Obstetrical Patients." Trans. Amer. Gyn. Soc, 1914, xxxix, 286. Goldberger, F. M. : " The Relation of the Cervix to Sterility and Pregnancy." Internat. Jour. Surg., 191 3, xxvi, 169. Graves, W. P. : " Sterility." Trans. Amer. Gyn. Soc, 1913, xxxviii, 526. Huhxer, M. : "The Practical, Scientific Diagnosis and Treatment of Sterility in the Male and Female." Med. Record. 1914, xxxv, 840; Ibid.: "Sterility in the Male and Female and Its Treatment." Rebman and Company, New York, 1913. 7 Rohleder discusses the historic, moral, religious, economic, medicolegal, and tech- nical aspects of artificial impregnation and reproduction. He refers to- the necessity of examining both wife and husband, especially as regards venereal disease in the latter. Given favorable conditions, with an apparently unknown cause, with the exception of impotentia cceundi. etc., he has found reports in the literature of seventy-one cases treated by the so-called uterine method (injection of semen into the uterus), with twenty-five successes, and four cases treated by the vaginal plan (placing the semen in the vagina), with four successes. This makes a total of seventy-five cases with twenty- nine successes. Rohleder is willing to exclude ten cases reported by Girault, whose premises do not seem to be correct, and to accept as reliable sixty-five cases with twenty-one successes. His method is to obtain the semen immediately after a coitus, in the first day or so after menstruation, and, by means of a sterile and warm Braun syringe, to inject a few drops, if possible, into the uterine cavity; if this is impossible, the injection is made into the cervical canal. The remaining semen is placed on a warm tampon against the external os. The woman remains in bed for twenty-four hours, with knees together and pelvis elevated in order to retain the semen. In his own practice Rohleder has obtained one positive (delivery at term) and one presumable success; early absorption took place in six cases. The apparent cause of the trouble in the latter was stenosis of the cervix in two, and hypospadias in four. He regards this procedure with great favor. 608 GYNECOLOGY Martin, F. H. : "Ovarian Transplantation." Trans. Amer. Gyn. Soc, 1915, xl, 33; Ibid.: " Ovarian Transplantation in the Lower Animals and Women." Surg., Gynec. and Obst, 1911, xiii, 53; Ibid. : "Progress in the Study of Ovarian Transplantation and Ovarian Secretion." Trans. Amer. Gyn. Soc., 1917, xlii, 257. Noble, C. P.. " Salpingitis and Sterility." Trans. Amer. Gyn. Soc, 1891, xvi, 480. Noegerrath, E. : Die latente Gonorrhea in weiblichen Geschlecht. Bonn, 1872. Polak, J. O. : "A Study of the Pathology in Its Relation to the Etiology with the End Results of Treatment of Sterility." Trans. Amer. Gyn. Soc, 1916, xli, 598. Prochownik, L. : " Ein beitrag zu den Versuchen kunstlicher Befruchtung beim Men- schen." Centralbl. f. Gynak., 191 5, xxxix, 145. Reynolds, E. : " The Theory and Practice of the Treatment of Sterility in Women." Jour. Amer. Med. Assn., 1913, lx, 93; Ibid.: "The Principles Underlying the Successful Treatment of Sterility in Women." N. Y. State Jour. Med., 1914, xiv, 4; Ibid. : "The Causes and Treatment of Sterility in W r omen." Amer. Jour. Med. Sci., 1907, cxxxiv, 209 ; Ibid. : " Forward Fixation of the Cervix as Predisposing Cause of Some Retro- deviations of the Uterus. Operation for Its Release." Surg., Gynec and Obst., 1914, xix, 588 ; Ibid. : " Fertility and Sterility." Trans. Sec. Obst., Gyn. and Abdom. Surgery, A. M. A., 1916, 17. Rohleder, H. : Die Zeugung beim Menschen ; Mit Anhang ; die kiinstliche Zeugung (Befruchtung) beim Menschen." Thieme, Leipzig, 191 1. Runge, E. : " Beitrag zur Aetiologie and Therapie der Weiblichen Sterilitat." Arch, f . Gyn., 1909, lxxxvii, 572. Tuffier, T.: "Transplantation of the Ovaries." Surg., Gynec and Obst., 1915, xx, 30; Ibid. : " Les Graffes Ovariennes Humaines ; Suites eliognes." Jour. d. Chir., 1913, x, P- 529- Whitehouse, B. : " The Autoplastic Ovarian Graft and Its Clinical Value." Clin. Jour., 1913, xliii, 107. CHAPTER XXXIV HYGIENE AND THE RELATION BETWEEN NERVOUS AND GYNECOLOGIC DISORDERS THE HYGIENE OF ADOLESCENCE There is not so much difference in the physical inclinations of the male and the female before, as there is after, puberty. During childhood the average healthy girl will be quite as active as a boy, although her activities may be along less boisterous channels. Puberty begins earlier in the female than in the male, and coincident with it there are instinctive changes in deportment and in inclinations. Although in healthy individuals there may be a disposition to give up some of the physical activities of childhood, the sexual development will not lead to serious or morbid introspection. There may be a slight indisposition about the menstrual periods, but when this has passed there will be no pelvic symptoms or indications until the next period is due. Inherited physical or mental weakness, improper hygiene, faulty habits of dress, too little exercise in the open air. ill-chosen diet, hard work, and mental anxiety may decidedly interfere with the healthy normal condition. The menstrual periods may be excessively painful, and with it leucorrhoeal discharge, backache, disinclination for exercise, and morbid introspection may make their appearance. The importance of exercise for the young woman can hardly be overesti- mated (see page 710). The muscles are vitally concerned with many of the metabolic processes, and the normal heat production, the expenditure of energy. the proper circulation of the blood, and the excretory activities depend largely upon healthy muscles and muscular contractions. The demands of the muscular system are not always to be found in performing household duties and never in the duties of the school-room. For that reason the young woman should be encouraged in all suitable outdoor sports, such as walking, tennis, basket- ball, bicycling, rowing, skating, horseback riding, and the use of dumb-bells or of Indian clubs. A healthy body is conducive to a healthy mind. School hours should never be allowed to interfere with daily exercise in the open air. The diet is of considerable importance ; the food should be plain and wholesome, and tea, coffee, candy, condiments, and alcohol in any form should be restricted. In a healthy woman there need be no variation in the daily routine at the menstrual period. Exposure to cold and dampness should be avoided; tub- baths are usually contraindicated at this time, and shower- or sponge-baths should be substituted. To those women who experience more or less pain, rest and quiet will prove grateful. Young unmarried virginal women who exhibit symptoms of pelvic dis- orders necessitating an examination should not be dealt with in the ordi- nary way. In selected cases a gentle, careful bimanual pelvic palpation may be attempted without anaesthesia, and inspection of the vaginal cervix and 39 609 610 GYNECOLOGY fornices may be made with a large Kelly cystoscopic speculum, with the patient in the knee-chest or the Sims' position. Anaesthesia is usually re- quired and generally advisable, and should be used except in simple and generally favorable cases (see Chapter VIII, page 112). Uncertain and equivocal diagnoses should not be rendered to young women, nor should tedious methods of treatment be employed for a local pelvic disorder. The patient should be dealt with by general measures or by operation. Local treatment is never justifiable in young virgins, and elusive and ambiguous terms, such as " congested ovaries," " stricture of the womb," etc., should never be mentioned to them. By adopting such a course there will be less danger of inducing morbid introspection and of engendering a psychosis that cannot fail to have an unfavorable effect upon the patient. THE RELATION OF NEUROSES TO PELVIC DISEASES The importance of pelvic disease in the production of neuroses in women has been greatly exaggerated. Pelvic disease in itself does not excite a neurosis, but the influence of a pathologic condition in the pelvis on the general health in a neurotic subject may predispose to the formation of one. In neurotic women the nervous condition may be associated with faulty general development in which the pelvic organs share. Thus, if a neurosis is combined with poorly developed or improperly formed pelvic organs, the neurosis may be de- pendent upon the same cause as the imperfect development of the pelvic organs, but one does not depend primarily upon the other. As a conse- quence of the physical and nervous disability, the most striking and impor- tant function of the female, menstruation, is incompletely or painfully per- formed. The importance that the patient attaches to the menstrual func- tion and the anxiety aroused by any abnormality concerning it may influence the neurosis secondarily through psychic impression. A neurosis in which pelvic pain that has no anatomic foundation is com- plained of has no more significance than a neurosis that produces pain in other parts of the body or in persons of the opposite sex. In women pain that is purely neurotic in type is more likely to be referred to the pelvis than to any other part of the body. This naturally leads to the fear that the pelvic organs are diseased, but it must be remembered that the symptoms may be purely neurotic and compatible with absolutely healthy pelvic organs. Such symptoms as dysmenorrhcea, backache, or dragging pain in the lower abdomen may be present without any anatomic or other recognizable cause. On the other hand, neuroses may exist with actual acquired lesions of the pelvic organs. These lesions, through the suffering they occasion, may exaggerate the neurosis to a certain extent, and when they are cured, the patient's condition may improve to a similar degree. 1 1 Graves distinguishes two types of " genital psychoneurosis " : the first, in which there is a condition of mind continually reverting to imaginary ills in the pelvic organs. he calls the " genital neurosis of imagination"; the second, in which the mind reverts to real pelvic disorders, he terms the " genital neurosis of overvaluation." The first belongs to the neurologist and the psychiatrist ; the second belongs first to the gynecologist, and later to the alienist. In the first, the individual is conscious of functions that normally " belong to the NERVOUS AND GYNECOLOGIC DISORDERS 611 From these facts it is apparent that when neurotic persons complain of pelvic symptoms, it is very important to make a thorough examination, under anaesthesia, if necessary, to determine once and for all whether any pelvic lesion exists. If a lesion is present, it should be corrected at once; if there is not a lesion, or if it is of such a doubtful character that the physician is uncertain, the patient should positively be assured that her pelvic organs are healthy and her mind thus set at ease (see also pages 112 and 610). Women with neuroses should never be subjected to local treatment un- less they have a real pelvic lesion, and one that is quickly and certainly amenable to local treatment. When a neurosis coexists with actual pelvic disease, the patient should be subjected to the most effectual treatment known for the condition, whatever it may be, whether medical or surgical. In treating all neurasthenic or neurotic patients the physician should be very careful not to use terms that may fill the individual with morbid apprehension. The use of such expressions as " congestion of the ovary," " neuralgia of the ovary," and " ulcer of the womb," should be avoided. INSANITY IN ITS RELATION TO GYNECOLOGY Insanity is a disease of the nervous system. It is usually entirely independent of disease of the generative organs. It may be complicated by disorders of the sexual organs, or the latter, by their influence upon the general health, may favor the development of insanity, more especially in neuropathic women. When in- sane women present symptoms of disease of the sexual organs, it is advis- able to have an examination made by an expert gynecologist, so that a correct diagnosis of the condition of these organs may be made. Insane women whose sexual organs are normal, are in no sense gynecologic cases, and should receive treatment directed to the mental condition alone. On the other hand, an insane woman whose sexual organs are the seat of a disease that impairs her physical well-being, or that threatens her life, should receive the same treatment that would be indicated if insanity did not exist as a complication. When the history shows that the disease of the sexual organs antedated the mental disorder and that it has undermined the health of the patient, and particularly the stability of the nervous system, gynecologic treatment is much more strongly indicated than in the class of cases previously considered. In such cases, even more than in those of the first class, there is reason to expect that the cure of the pelvic disease may exert a favorable influence upon the mental condition and may assist in restoring the patient's sanity. From the investigations of Taussig and the report of Gibson, little im- provement has been noted after the operative correction of pelvic disorders in patients exhibiting some form of dementia, such as dementia prsecox, general paresis, epilepsy, and senile dementia. realm of the subconscious," such as movements of the intestines, heart, and stomach, the attention having been directed to them accidentally or by pain or some temporary aberra- tion of function. In the second the pelvic lesion is apt to be a minor one, which, " without causing severe symptoms, maintains a nagging discomfort and keeps the searchlight of attention constantly turned upon them." Among them may be mentioned pelvic adhesions and descensus of the uterus. 612 GYNECOLOGY On the other hand, in those forms of insanity in which dementia does not appear, manic-depressive insanity, melancholia, and paranoia, the patient may be benefited by surgical treatment; this is especially true in cases of manic-depressive insanity. Insanity is one of the least common post-operative complications, and occurs after operations upon the sexual organs with about the same relative frequency as it does after operations upon other parts of the body. It occurs as frequently in the male as in the female. The usual type of mental disease that developes after operation is that known as confusional insanity. Neuropathic individuals and those who have undergone great physical or mental strain before operation are those in whom insanity is most apt to develop, especially if annoying and per- sistent painful symptoms make their appearance after operation ; for ex- ample, such symptoms as infection of the bladder, leading to frequent and painful urination, and infection elsewhere, necessitating the use of dress- ings, with long-continued pain and annoyance incident to them. In certain cases there is no doubt that the insanity is toxic in nature and due to infec- tion, but in most instances it appears to be due to a disturbance of the mental equilibrium, brought about by the stress and strain attending the operation, superadded to worry, grief, or mental excitement antedating the surgical procedure. Trifling operations are as apt to be followed by in- sanity as are those of a graver type. In Noble's experience, insanity has usually followed plastic operations and has almost never complicated hys- terectomy or ovariotomy. Confusional insanity arising after operation in a woman who possessed a normal or a fairly normal mind previous to the operation, usually ends in recovery within six weeks or sooner. In Noble's experience, comprising about twenty cases, one was fatal ; the others ended in prompt recovery. These general principles may be regarded as a summary of the present views of both alienists and gynecologists concerning the relation of insanity to gynecology. BIBLIOGRAPHY Broun : " Preliminary Report of the Gynecological Surgery in the Manhattan State Hospital, West." Trans. Amer. Medico-Psychological Assoc, 1005. Gibson, G. : " Gynecological Operations Upon the Insane." N. Y. Med. Jour., 1915, ci, 293. Hobbs : " The Relation of Insanity to Pelvic Diseases and Other Lesions." Amer. Jour. Obst, 1900, lxi, 1. Manton, W. P.: "The Relations of Visceral Disorders to the Delusions of the Insane." Amer. Jour. Obst., N. Y., 1896, xxxiv. Rohe: "The Relations of Pelvic Disease and Psychical Disturbances in Women." Amer. Jour Obst, 1892, ii, 694. Smith, R. R. : "Notes on the Relationship Between Gynecology and Neurology." Trans. Amer. Gyn. Soc, 191 5, xl, 150. Taussig, F. J. : " Gynecologic Disease in the Insane and Its Relationship to the Various Forms of Psychoses." Jour. Amer. Med. Asso., 1912, lix, 713. CHAPTER XXXV THE SELECTION AND PREPARATION OF PATIENTS FOR OPERATION THE SELECTION OF CASES Few operations undertaken for lesions of the generative tract are de- manded suddenly or must be immediately executed. Most of them are planned deliberately and carried out at a set time. A few gynecologic dis- eases necessitate immediate operation ; others may require it only within a limited time. In some the symptoms may be relieved by palliative meas- ures, and operative treatment may be deferred according to the will of the patient. In many cases the operation is elective. It is, therefore, necessary for the physician to be able to determine when operation is indi- cated and when it may be delayed ; when it is imperative, and when it is a matter of choice ; which case must be handled surgically, and which will derive all possible benefit from non-operative treatment. The disease itself, the age, the general health, and the social position all have a bearing on these points. The choice between operative and non-operative treatment will often depend upon the circumstances surrounding the case. Those diseases that usually require operation as soon as they are dis- covered include ectopic pregnancy, ovarian cysts, and malignant disorders in the early stage. Myomata of the uterus do not always demand treat- ment, but a great majority of them must sooner or later be subjected to radical surgical, radium, or Rontgen ray treatment. Displacements of the uterus or lacerations of the cervix and perineum may require immediate operation during the child-bearing period if they are productive of marked suffering, and especially if the patient is un- likely to bear more children. If, however, the opposite is true, the patient may be tided over the active child-bearing period by adopting palliative measures, and as the reproductive age draws to a close operation may be undertaken. (See Treatment of Retroflexion, page 247.) In the extreme cases of prolapse seen in advanced years an effort should be made to relieve the patient by the use of a suitable pessary, in order to avoid an operation that is contraindicated by the age or the general condition. In pelvic inflammatory diseases the patient should not be operated upon during the acute stages, whether they are of gonorrhceal, puerperal, or of surgical origin. It is always safer to wait until the infection has subsided, and the morphologic changes, the result of acute exudation and infiltration, have disappeared. The indication for operation in an inflammatory disease after the lesion has become chronic is somewhat dependent upon the ex- tent of the lesion, the number of attacks of pelvic peritonitis that the patient has undergone, the symptoms which she presents, and the time that she can afford to consume to get well. Unless the patient earnestly desires to 613 614 GYNECOLOGY avoid an operation and is willing to remain an invalid for a considerable time, and to carry out certain palliative measures every day, operation should be performed as soon as the chronic stage has been reached. Dercum has shown that operations on the pelvic and other viscera for the relief of functional nervous disorders have no justification. This em- phasizes the desirability of making a very careful diagnosis of the lesions in any case exhibiting neuroses. Only in this way will operations that are without benefit be avoided. THE EXAMINATION AND TREATMENT OF PATIENTS PREPARATORY TO OPERATION The physical and mental condition of every patient should be carefully investigated before operations of election. Since general disorders may be responsible for many, if not all, of the symptoms for which she seeks sur- gical advice, it is important that none be overlooked, lest the patient expect too much from the operation or be disappointed in the result. Certain die- eases also contraindicate or rer.der operation hazardous, and make it ad- visable to limit the procedure as much as possible, or to carry it out with additional precautions and safeguards. Care in the execution of the pre- paratory examinations and treatment will sometimes disclose unsuspected lesions, and in this way loss of life or, at least, unfortunate complications or sequelae to operative treatment may be prevented. The diseases that contraindicate operation, unless the procedure is urgently demanded to save life, include severe diabetes mellitus, Addison's disease, advanced and active tuberculosis, advanced cardiac, hepatic, or renal disorders, chronic alcoholism, etc. Anaemia, hepatic or renal inactivity, un- healthy conditions of the skin, chronic constipation, moderate degrees of cardiac insufficiency, nervous exhaustion, and mental fatigue or excitement may make it desirable that considerable time be spent in preparing the patient for the ordeal which she is about to undergo. The condition of the part or parts to be operated on may often be im- proved to a considerable extent by rest in bed, the use of hot douches, and the application of suitable remedies. Thus subinvoluted uteri and ©edema- tous vaginal walls may be depleted and erosions of the mucosa may be healed. The surgeon should always endeavor to place the operative area in as healthy and aseptic a condition as possible before undertaking the surgical measures. In certain pelvic inflammatory cases it may be some time before the infectious properties of the invading bacteria are destroyed and the inflam- matory exudate is absorbed. Although this may require several weeks or months or even longer, the time will be well spent (pages 415 and 425). To this end patients should be kept in bed, or at partial rest, and the particular condition should be treated secundum artem until the general and the local condition have returned as nearly as possible toward the normal before the operative treatment is carried out. Thus chronic constipation and intestinal and hepatic inactivity may be overcome and a weakened circulation may be so fortified that all symptoms of insufficiency will disappear. In anaemic patients the condition of the blood may be improved, a chronic bronchitis SELECTION AND PREPARATION OF PATIENTS 615 may be cleared up, and sluggish kidneys may be aroused to renewed activity. The mental attitude of the patient may be changed from one of terror and apprehension to one of patient confidence, and the exhausted and weakened nervous system may be rejuvenated. The individual should be placed in all respects in the best possible condition to secure rapid convalescence and to promote healing. Cardiac Risks. — The individual cardiac lesion is of less importance than the condition of the heart muscle and the degree of compensation. An operation done under the most favorable conditions of modern surgery may be regarded as the equivalent of a very moderate unusual exertion (Reynolds). The patient should be studied in consultation with an internist, and if practicable, with the anaesthetist. With rest, suitable food, and the use of strophanthus or digitalis the patient should be kept under observa- tion until compensation is reestablished. " A subject of valvular or other cardiac disease, who is able to go up a flight of stairs at an ordinary walk without provoking more than slight breathlessness, is fitted to endure an abdominal operation of average grade without suffering any grave increase of the ordinary risks " (Reynolds), provided expert medical care before and after operation, thoroughly expert anaesthesia, and rapid, gentle operating- are provided. Anaesthesia should be preceded by the administration of morphine and atropin or scopolamine. Nitrous-oxide-oxygen anaesthesia without ether. or with as little as possible, should be used, with local novocaine infiltra- tion of the operative area (see Crile's technic, page 617). The anaesthesia should be started with the patient in the reclining position. During the early stages of the anaesthesia struggling and cyanosis are especially to be avoided. The Trendelenburg posture should not be em- ployed, or if its use becomes necessary, it should be limited to a few minutes. During the greater part of the operation the table should be level and the shoulders of the patient should be slightly raised. Pressure on the abdom- inal viscera should be avoided ; exposure and handling of the intestines should be limited. That plan of operation should be selected that can be con- summated with a maximum of speed and a minimum amount of traumatism. If symptoms of right-sided cardiac hypertension or acute dilatation (rise of pulse-rate, cyanosis, etc.) supervene, prompt phlebotomy, digalen and camphor, oxygen, and small doses of morphine, together with surface heat applied locally, constitute the treatment. When large intra-abdominal tumors have been removed, compensatory support and pressure should be maintained during the first few days of the convalescence. Following the operation the patient should be closely observed by the internist, and her treatment should be directed in cooperation with him. It is most desirable to avoid excessive vomiting and distention of the stomach or intestine. This can usually be secured by careful pre-operative empty- ing of the gastro-intestinal tract and strict regulation of diet. If they should, nevertheless, develop after operation, such symptoms must be met promptly but with the most gentle measures that are effective. Anaemia Risks. — Anaemia carries with it a certain operative risk, de- pending, of course, upon its degree and upon the associated conditions that 616 GYNECOLOGY obtain in the individual patient. The principal causes of anaemia in gyne- cologic cases have been discussed elsewhere. In a few cases it is possible to restore the blood-picture to the normal by suitable pre-operative treatment. In others such a fortunate outcome is not possible, since the etiologic factors of the anaemia — hemorrhage and toxaemia — will persist until the operation is performed. Nevertheless, in almost all instances, except when the operative procedure is to be trivial, the condition of the patient should be improved to the maximum degree. In the case of myomata that bleed periodically, suitable regulations and treatment (de- scribed on page 310) will greatly improve, and in some cases actually restore, the condition of the blood. In anaemic cases with menorrhagia the best time for undertaking the operative procedure should be just before a menstrual period is due. When anaemia is due either in part or in whole to toxaemia, especial steps should be taken to minimize the absorption of septic products and to increase the eliminating functions of the body. Anaemia is to be regarded as especially hazardous from the operative standpoint when the haemoglobin falls to 40 per cent, or lower. In a re- view of the material at the Johns Hopkins Hospital, Cullen found that in the period from 1889 to 1912 there had been 170 cases of that description. Seven were unfit for operation and died without it ; in three the myomatous disease and the anaemia were the direct cause of death ; in four others com- plications (toxic absorption, etc.) were present. Thirteen cases died after operation, death being due to peritonitis, intestinal obstruction, circulatory failure, etc. One hundred and fifty-two cases recovered, the haemoglobin in them varying from 40 to 10 per cent, as follows: 40 to 36 per cent 49 cases 35 to 31 per cent 30 cases 30 to 26 per cent 29 cases 25 to 20 per cent 30 cases Below 20 per cent 14 cases 152 In serious cases transfusion should be a routine procedure either before or after operation; as simplified by Bernheim, it can be carried out in from twenty to thirty minutes. Every surgeon should familiarize himself with the technic of blood transfusion. The resistance of anaemic patients is usually much impaired, and the post-operative treatment should be regulated accordingly. The patient should be disturbed as little as is consistent with careful stimulation and support. Blood-pressure Risks. — High blood-pressure (hypertension) and low blood-pressure (hypotension) increase the dangers of ration and predis- pose the patient to apoplexy, embolism, thrombose, renal insufficiency, angina, pneumonia, and cardiac failure. The pulse-pressure reading (i.e.. the difference between the systolic and thp ^istolic) is to a certain extent a more reliable index of these conditions th. i is the systolic maximum. Hypertension may be temporary and remediable, or permanent and irremediable. Hypertension is caused by continued and intense emotions, such as worry, grief, and anger, acute or chronic infections, exophthalmic SELECTION AND PREPARATION OF PATIENTS 617 goitre, increased intracranial pressure, cardiovascular disease, and physical changes in the walls of the blood-vessels. While the hazard of hypertension must at times be undergone, as a rule the operation may be delayed until the risk is eliminated or at least much reduced. In the case of continued emotional disturbance, the plan of treat- ment will be obvious : in Graves' disease, lobectomy or ligation ; in toxaemia, the control or eradication of acute or chronic infection ; and in cardiovascu- lar cases, as indeed in all cases, a meat-free diet, rest, nitroglycerine, and diversion are indicated. Hypotension cases are principally those associated with hemorrhage and anaemia. These should be treated as has been described. Here transfusion is a sovereign remedy when the operation cannot be deferred. Crilc's Anoci Association. — In performing operations upon cases of hy- pertension and hypotension, the procedure of Crile, known as anoci asso- ciation, should be followed. His own description of this method is as follows : " Our complete technic in abdominal operations is as follows : When the pre-operative strain is great, an hour or so before the operation we admin- ister to the patient a hypodermic injection of yi of a grain of morphine and i 150 of a grain of scopolamine, that he may receive the solace and quiet which come from the use of these drugs. The inhalation anaesthetic may be administered in the patient's room ; or else in the apathetic state produced by the morphine and scopolamine, the patient, with eyes and ears closed to external impressions, is conveyed to the operating room, where a specially trained anaesthetist administers nitrous oxide. When the patient is anaes- thetized, the division of tissue is preceded by nerve blocking by means of the local administration of 1 : 400 novocaine. Each division of tissue in the course of the operation is preceded by the infiltration of this local anaes- thetic, the blocking being made so complete that no nerve is left free to carry a single activating impulse to the brain. First the skin, therefore. then the subcutaneous tissue, then the fascia, and finally the remaining muscle or posterior sheath and the peritoneum are in turn no\'ocainized, subjected to momentary pressure to spread the anaesthetic, and then divided within the blocked zone. If the blocking has been complete, then upon opening the abdomen there will be found no increased intra-abdominal pressure, no tendency to expulsion of the intestines, and no muscular rigidity. " The peritoneum is next everted, and a 0.5 per cent, solution of quinine and urea hydrochloride is massively infiltrated at a distance from the in- cision about the line of proposed sutures, and as before, the parts are then subjected to momentary pressure. This infiltration serves as a block, and as its effects last r everal days, it should prevent or at least minimize the post-operative woun. pain and the post-operative gas pain, and thereby minimize post-operative shock. Quinine and urea cause a certain amount of oedema of tissue which las for some time after the wound is healed. The relaxed abdominal wall w.* permit exploration of the entire abdominal cavity with ease. If there is no cancer nor acute infection in the field of operation, then the following regions may be blocked as completely and in the same manner as the abdominal wall — the mesoappendix, the base of the 618 GYNECOLOGY gall-bladder, the uterus, the broad ligaments and the round ligaments, the mesentery, and any portion of the peritoneum. After a hysterectomy the stumps may be completely infiltrated with quinine and urea hydrochloride, thus giving a degree of anaesthesia for at least two days. On account of the absence of nociceptors, operations on the stomach and intestines made without pulling on their attachment cause no pain, and hence the novocaine infiltration of these viscera is not required. If the brain has received no stimuli during the operation, then the closure of the upper abdomen is as easy as the closure of the lower — all is done with the ease of relaxation. What is the result? No matter how extensive the operation, no matter how weak the patient, no matter what part is involved, if anoci technic is perfectly carried out, the pulse-rate at the end of the operation is the same as, at the beginning. The post-operative rise of temperature, the accelera- tion of the pulse, the pain, the nausea, and the distention are minimized or wholly prevented. " As the operation does not end in the operating room, so the protective effects of this technic follow the patient to his room, and help him far on the road to easy recovery. Post-operative pain is wholly eliminated if quinine and urea hydrochloride are injected into the entire wound ; post-operative gas pain is largely or wholly prevented ; painful scar is eliminated ; and post-operative nervousness and aseptic wound fever are avoided. The pa- tient quietly, with care-free mind and comfortable body, passes quickly to complete recovery from the disease, at least, for which operative procedure was required, while the very condition which made an operation seem a menacing danger may also have been relieved." Kidney Risks. — Under kidney risks may be grouped those cases that show kidney insufficiency and those that show the presence, in the urine, of some constituent that is indicative of metabolic disturbance. A small amount of albumin and a few hyaline casts in the urine do not contraindicate operation, but call for the exhibition of water and the regula- tion of the diet, and indicate that the operation should be delayed until the urine has cleared up or until functional tests show that the kidney excretion is within the bounds of safety. Granular casts, except in very small numbers, indicate a more active and recent lesion of the kidney, and imperatively demand preparatory treatment; thus rest in bed, a milk diet, and a simple diuretic will, in a majority of cases, result in rapid improvement and a disappearance from the urine of the abnormal constituents. Nevertheless, in such cases, the tests of the functions of the kidney should always be made. Albuminuria without casts means excessive consumption of animal food or contamination of the urine with pus or blood — the source of the latter must be determined, and a fil- tered specimen examined for albumin, in order to determine whether the albumin is excreted with the urine or is due entirely to the admixture with Hood or pus (see ratio of albumin to pus corpuscles per cubic centimeter, page no). Albuminuria without casts, except as the result of errors in diet, is very unusual. Indican in the urine is an indication of intestinal torpor and absorption. It usually disappears after thorough catharsis and evacuation of the intestinal tract. SELECTION AND PREPARATION OF PATIENTS 619 Bile in the urine indicates the presence of hepatic or biliary complica- tions — it has no significance beyond that of the lesion which produces it. Acetone in the urine is an evidence of a disturbance of metabolism, and is found in starvation, carcinoma, high fever, glycosuria, and diabetes. It is an important finding, and demands careful investigation and treatment. Aside from the significance and treatment of the underlying cause, patients with acetonuria should receive sodium bicarbonate by the mouth, and be- fore proceeding with an operation enteroclysis or intravenous injections should be given until the symptom disappears. After the operation the sodium should be given in order to obviate the development of acetonuria, which is particularly prone to develop in such subjects after ether or chloroform narcosis. Diacetic acid has the same import as acetone in the urine, but to a greater degree. It is most frequently found in diabetes or in connection with serious metabolic disturbance of the liver; occasionally its presence may be explained by a marked decrease in the ingestion of carbohydrates. As with acetonuria, the significance and the treatment vary with the underlying lesion. Sodium bicarbonate should be used freely in the pre-operative and post- operative treatment. In operations that involve the kidney itself, and especially in nephrec- tomy, an estimation of the renal function is particularly important. (For a discussion of the question see Tuberculosis of the Kidney, Chapter XXV, page 477; also Chapter IX, page 158.) An abnormality in the urinary constituents and a moderate diminution in the kidney function need not be regarded as contraindicating a contem- plated operation that will rid the patient of a lesion that has predisposed to or aggravated the kidney disorder (e.g., the removal of a pelvic tumor that presses upon the ureter, etc.). Under these circumstances medicinal treat- ment alone will not suffice to clear up the condition. BIBLIOGRAPHY Berxheim, B. W. : Blood Transfusion, Hemorrhage and the Anemias. Lippincott, Phila., 1917. Brackett, E. G., Stoxe, J. S., and Low, H. C. : " Aciduria (Acetonuria) Associated with Death after Anaesthesia." Boston M. and S. Jour., 1904, cli, 2. Crile, G. W. : " The Newer Methods of Reducing the Mortality of Operations on the Pelvic Organs." Trans. Sect. O., G. and A. S., A. M. A., 1913, 37 : Ibid. : " The Relation between the Blood Pressure and the Prognosis in Abdominal Operations." Trans. Am. Gyn. Soc, 1913, xxxviii, 179. Cullen, T. S. : " Operations on Patients with a Hemoglobin of 40 per cent, or less. ' Trans. Am. Gyn. Soc, 1913, xxxviii, 248. , Faught, F. A. : Blood Pressure. Saunders, Phila., 1916. Flexxer, S. : "A Statistical and Experimental Study of Terminal Infections." Jour. Exp. Med., 1896, ii. Freuxd: Beziehungen der weiblichen Geschlechtsorgane zu andern Organen. Lubarsch u. Ostertags Ergebniss den allgemeines Pathologie, Wiesbaden, 1898. Freuxd, H. A. : " The Diagnostic Value of the Electro-Cardiograph before Gynecological and Obstetrical Operations." Trans. Am. Gyn. Soc, 1913, xxxviii, 210. Noble, C. P. : " Personal Experience in Operations Upon Diabetic Patients." Amer. Med., 1903, vi, 13. Polak, J. O. : " The Conduct of Gynecological Operations in the Presence of Acute and Chronic Endocarditis," Trans. Am. Gyn. Soc, 1913. xxxviii, 112. Reynolds, E. : " Conduct of Gynecological Operations in the Presence of Chrome Affec- tions of the Heart." Trans. Am. Gyn. Soc, 1913, xxxviii, 368. CHAPTER XXXVI OPERATIVE TECHNIC The technic of an operation comprises, first, the methods used in the preparation of the patient, the operative area, the operator and his assistants, and the operating room ; the sterilization of the instruments, the dressings, and the utensils that are to be used in the course of the operative procedure. The principle underlying operative technic is that of asepsis — that is, the exclusion of infectious agents from the field of operation. To this end those who are directly concerned with the operation, the room in which the opera- tion is to be done, and the utensils or the dressings that are used must be suitably prepared and protected from contamination during the course of the operation. GENERAL PREPARATION OF THE PATIENT It is important to have the gastro-intestinal canal empty or nearly so. An active cathartic should be given twenty-four hours (in lower intestinal, sigmoid and rectum cases, thirty-six hours) before the time set for the operation. Castor- oil, i fluidounce, or one or two compound cathartic capsules x are the most effec- tive. Thereafter the diet should be liquid, or at most semi-solid, and easily diges- tible. At least three hours before the time set for operation an enema of epsom salts (2 ounces), glycerine (2 ounces), sweet oil (4 ounces), and water (1 pint) should be injected into the sigmoid by means of a rectal tube. After the bowels have ceased to act, the rectum should be irrigated with salt solu- tion until the water returns clear. No food, liquid or solid, should be given within twelve hours of the operation, although an occasional sip of water or of weak tea may be al- lowed. If the operation threatens to involve the upper intestinal tract or the stomach, for three days preceding the operation the food and drink should be as nearly sterile as possible (boiled water and milk; cooked or roasted food served hot). An antiseptic mouth-wash and a tooth-brush should be used several times a day, and if there is any likelihood of food retention, lavage may be practised just before the anaesthetic is administered. The night before the operation the patient should be given a full bath, with special attention to the axillae, umbilicus, and pubes. Fresh night-clothes and a change of bed linen should be provided. PREPARATION OF THE OPERATIVE AREA Perineal Operations. — The hair about the pubes and vulva should be re- moved with scissors and safety razor. If the operation is solely a perineal 1 I£ Ext. colocynthidis comp g r# j 1/^ Hydrarg. chloridi mitis g r . Ij Resin. Jalapae gr. y$, Cambogise pulv gr . 14' Misce et fiat one capsule. 620 OPERATIVE TECHNIC 621 one, in clean cases no other local preparation is necessary until the patient is under anaesthesia. In infected cases, such as sloughing fibroid tumor or retained secundines, preparatory vaginal douching with formalin (i : iooo) may be carried out several times prior to the operation. When a deodorizing solution is re- quired, lysol (i per cent.) or a weak solution of potassium permanganate (i : 5000) is satisfactory. After the patient has been anaesthetized the vulva, vagina, anus, and the adjacent parts should be scrubbed with green soap and hot water, and rinsed with sterile water and bichloride solution (1 : 1000). When an intravaginal operation is to be performed that will possibly involve the peritoneal cavity, e.g., anterior or posterior vaginal celiotomy, vaginal myomectomy, or hysterectomy, it is advisable to prepare the patient as if a celiotomy were contemplated, for sometimes it will be, found requisite to switch from the vaginal to the suprapubic route, and then such previous abdominal preparation will stand the surgeon in good stead. Abdominal Sections. — The pubes and abdominal surface should be shaved ; no other local preparation need be given until the morning of the day of operation. On this day, after the bowels have been cleared out, and with no previous wetting of the skin, the abdominal surface, from ensiform to pubes, and from flank to flank, is painted with a 5 per cent, solution of iodine crystals in 95 per cent, alcohol. After the solution has dried the surface is covered with sterile gauze held in place by a binder. When the anaesthetic has been administered, and just before the operation is begun, the iodine application to the abdominal surface is repeated. PREPARATION OF THE OPERATOR AND ASSISTANTS No one should engage in an operation who has, within twenty-four hours. been exposed to a contagious disease or is in ill health. Those who have unavoid- ably or accidentally come in contact with such diseases as scarlet fever and diph- theria should not enter the operating room until they have had an opportunity to disinfect their clothing and take a full tub-bath and a shampoo. No one should take part in an abdominal operation whose unprotected hand has come in contact with pus or infectious fluid of any kind. If, during such exposure, the hands were protected with rubber gloves, there will be no risk of spreading infection provided the gloves were whole and in removing them the hands were not contaminated. If there is any reason to fear infec- tion, it is a good plan, as a rule, to allow twenty-four hours to elapse before another operation is undertaken, whether or not gloves were worn. Those engaged in surgical work should carefully avoid soiling their hands with discharges or excretions of any kind. In making pelvic examinations, dress- ing wounds, etc., the wearing of rubber gloves should be made the rule. The clothing worn by the operator and his assistants should be such that it can readily be cleansed and disinfected, and should preferably con- sist of muslin trousers, sleeveless shirt, and rubber-soled canvas shoes. Sterilization of the clothing is usually not required after laundering; but clothes that have become soiled with infectious fluids should be soaked in a disinfecting solution before sending them to the laundry. Shoes should be washed and redressed after each use. 622 GYNECOLOGY Nurses should wear fresh linen suits and canvas shoes. The heads of the operator, assistants, and nurses should be covered with gauze or muslin caps. The hands and arms should be disinfected by scrubbing them from the finger-tips to the elbows with hot running water and green soap, using a moderately stiff nail-brush or a wash-cloth, for at least ten minutes. Dur- ing this preparatory scrubbing the nails should be trimmed and cleaned. After the preparatory scrubbing a disinfecting solution should be used — alcohol and bichloride solution make a suitable combination. Two minutes should be consumed in scrubbing the hands and arms with alcohol, and one minute, at least, in immersing the arms and hands in a I : iooo bichloride solution. If alcohol alone is used, the alcohol scrub should last three minutes. The time consumed in the preparation should be accurately timed by the clock. The hands should be dried with a sterile towel and dusted with sterile talcum. After disinfection of the hands and arms has been accomplished, the sur- geon should put on a sterile gown, with sleeves long enough to reach below the wrists. Dry, sterile gloves well dusted with sterile talcum powder should then be drawn over the hands. The sleeves at the wrists are tucked under the gauntlets of the gloves. Care should be taken to see that the gloves are air- and water-tight. If facilities for preparing gloves by the dry method are not at hand the gloves should be boiled, but the dry method is vastly superior. Boiled gloves may be put on more easily if they are first filled with sterile water. When an abdominal section is to be per- formed gauze masks for the nose and mouth should be worn by the operator and his assistants. PREPARATION OF DRESSINGS AND UTENSILS Towels, sheets, gauze pads and dressings, cigarette drains, etc., should be sterilized in the autoclave, and exposed to a temperature of 21 2° F., under a pres- sure of forty pounds, for an hour on three successive days (fractional method). The dressings, etc., should be wrapped singly or in packages of convenient size, to protect them from contamination after removal from the autoclave. Basins and rubber or glass drainage-tubes should be boiled for twenty minutes. Glass jars and hard- or soft-rubber materials that are too bulky or that might be injured by boiling should be sterilized by scrubbing with hot water and soap and then immersing them for at least one-half hour in a warm solution of mercury bichloride (1 : 500). Linen or celloidin thread should be cut into lengths of six feet, wound upon glass bobbins, and placed within glass ignition tubes, well stoppered with non-absorbent cotton, and sterilized in the autoclave by the fractional method. Silkworm gut should be rolled into rings (six strands to a ring), placed within well-stoppered glass ignition tubes, and sterilized in the auto- clave, or the silkworm gut may be boiled with the instruments. Catgut is prepared in various ways that need not be discussed at this point. A method that has been used with greatest success consists of first hardening the catgut by soaking it in a 10 per cent, solution of formalin, dry- ing it out thoroughly, and then submitting it to the cumol process of sterilization. Any method, however, that produces strong, flexible, sterile gut that OPERATIVE TECHNIC 623 will not be absorbed in less than ten days will serve the purpose. Many of the commercial guts on the market are highly satisfactory and may be used with good results. The best are those in which the gut is enclosed in sealed glass tubes containing alcohol and chloroform. The precaution should be taken, however, to boil the glass tubes for five minutes before using them, in order to sterilize the outer surface, or, if the gut will not stand this boiling, the tubes should be scrubbed thoroughly with hot water and soap, and then immersed in a bichloride solution (i : 500) for thirty minutes. In gynecological work chromic gut is generally more satisfactory than the plain, since it has greater strength and is not absorbed so quickly. The smallest caliber compatible with safety should be used. Plain catgut of small caliber is useful for the ligation of small vessels. The choice of the catgut depends, however, upon the individual preference of the operator. PREPARATION OF THE OPERATING ROOM AND FURNITURE The ceiling, sides, and floor of the room should be of such material that they may be washed or scrubbed without injury. At the close of an operating day the room should be thoroughly aired ; the furniture should be washed with soap and hot water, and then thoroughly gone over with a solution of bichloride or formalin (1 : 1000). The floor of the room should be scrubbed with soap and hot water. The room should then be closed and kept so until the next operating day, when the furniture should be washed with a solution of bichloride or formalin (1 : 1000). PREPARATION OF WASH-WATER The water used for washing the hands or for making up solutions for the pur- pose of cleaning the room or the furniture may be taken directly from the house taps, provided it has been filtered and is clean. Water that is used for other pur- poses, e.g., for disinfecting solutions for the hands, for irrigating solutions, and for all general operative purposes, should be taken from steam sterilizers, or boiled for at least one-half hour and then allowed to cool in closed vessels. Sterile water or salt solution for use in the abdominal cavity should be kept in flasks of one liter capacity, and sterilized in the autoclave on three successive days for one hour. PREPARATION OF INSTRUMENTS Non-cutting instruments should be sterilized by boiling for twenty minutes in water containing sodium sulphate 1 per cent. The edges of knives and scissors are dulled by prolonged exposure to heat. Such instruments may be sterilized by scrubbing them thoroughly with soap and water and immersing them in an 80 per cent, alcohol solution for thirty minutes. After operation the instruments should be cleaned carefully in running water, boiled, polished, oiled, when neces- sary, and placed in a closed cabinet. VENTILATION AND LIGHTING The operating room should be ventilated by means of a forced draft fan placed in one corner of the room near the ceiling; the inlets should provide fresh air warmed during its passage into the room. 624 GYNECOLOGY For artificial illumination of the operating room an indirect method will be found preferable, since it obviates glare. For illumination of the operative field the electric bulbs may be hung directly above the table, or, in order to avoid shadows, they may be placed at equal intervals in the form of a circle. In deep pelvic work it may at times be found useful to have a portable light of high power that may be directed at will toward any desired area. Daylight, preferably from the north, is the most satisfactory 9 9 O Fig. 466. — Abdominal incisions: low paramedian, right or left lateral, high paramedian, high right lateral. form of light. It is desirable to have the windows on the north side of the room extend to the floor level, so as to provide good daylight for vaginal and plastic operations. THE ABDOMINAL INCISION Low Paramedian Celiotomy Incision. — The incision for exposure of the pelvis should be made slightly to the right or left of the linea alba, from a point below the umbilicus to the symphysis ; the fascia of the rectus muscle is cut; the muscle is pushed to one side, or the muscle-fibers are separated by blunt dissection, carefully avoiding or ligating the deep epigastric branches (Fig. 466). If it is desired to increase the upper limits of the OPERATIVE TECHNIC 625 incision, bilicus. directly this may be continued to the right or the left around the urn- Such an incision can be closed with more security than one made in the median line through the linea alba, the muscle-fibers but- tressing the overlapped fascia of the rectus. Right or Left Lateral Celiotomy Incision. — A right or a left lateral celiotomy incision may be made along the outer border of the rectus muscle, from about the upper level of the umbilicus downward (Fig. 466). The fascia is divided close to the linea semilunaris, and the outer border of the V __ Fig. 467. — Battle's incision: (.4) skin incision; {B) fascial incision. rectus muscle is retracted toward the median line. Such an incision is espe- cially useful when made on the right, since it affords easy access to the appendix and has an advantage over a gridiron incision in that it permits an exploration of the pelvis and upper abdomen to be made at the same time. In making the incision the deep epigastric vessels must be carefully retracted, or as is usually more practical in the average case, divided be- tween ligatures (Figs. 467 and 468). High Paramedian Celiotomy Incision. — For exposure of the viscera of the upper abdomen the incision is usually carried through the right rectus muscle, either close to the median line or along its external border, midway 40 626 GYNECOLOGY between the costal border and the umbilicus (Fig. 466). In operations on the liver and hepatic flexure of the colon the incision is made along the external border, and may be extended above by continuing it one-half inch below and parallel to the costal border, as far as the ensiform. 2 An incision close to the midline is usually selected for operations on the stomach, duodenum, pancreas, and transverse colon. For operations on the spleen the incision is made preferably through the outer border of the left rectus muscle. Transverse Suprapubic Incision. — The transverse suprapubic incision is 4 Jfc^ ~?3£ r ~£f&K>jfc4Bt. ■ "V Fig. 468. — Battle's incision. (.4) skin incision through semilunar line; (B) incision through anterior lamella of rectus; (b) incision through pos- terior lamella of rectus and peritoneum; (c) omentum showing through incision; (d) rectus muscle turned toward median line. bow-shaped, with its central point about an inch above the symphysis, and either extremity curving slightly upward toward the anterior-superior spine. It is carried through the skin and fat; the flap of skin is separated from the underlying tissues and turned upward, exposing the fascia of the rectus and the external oblique. The fascia and fibers of the rectus are dealt with as in the usual median incision. The cicatrix of a transverse suprapubic incision is hidden by the growth 2 A number of incisions have been proposed for frank gall-bladder and gall-duct cases. For a description of them the original papers of Mayo-Robson, Bevan. and McArthur should be consulted. OPERATIVE TECHNIC 627 of the pubic hair. This incision is particularly adapted to operations for retroposition of the uterus in uncomplicated, clean cases. Mackenrodt recommended and practised a bow-shaped incision on the line of an arch from one anterior spine to the other. The fascia and fibers of the rectus and oblique muscles were divided transversely, as was also the peritoneum as far as the deep epigastric vessels on each side. This incision gives excellent exposure, but is not popular, since it possesses no advantage over a long right or left rectus incision. Fig. 469. — McBurney's incision; skin incision. Gridiron Incision. — Operations for removal of the vermiform appendix in uninfected cases may conveniently be made through a muscle-splitting incision, with the central point over the base of the appendix (Figs. 469 to 472). The great advantage of such an incision is that it leaves the strength of the abdominal wall unimpaired. Such an incision should not be used in acute cases, except in the earliest stage. When a mass is palpable and pro- tection of the surrounding areas is desirable, the right lateral celiotomy incision should be preferred. If the muscle-splitting incision is selected, and upon opening the abdomen is found to be inadequate, it may be enlarged according to Weir's plan, or it incision made. may be closed and a second right rectus 628 GYNECOLOGY Fig. 470. — McBurney's incision; external oblique split. FlG. 471. — McBurney's incision; internal oblique split. OPERATIVE TECHNIC 629 In order to enlarge the gridiron incision Weir continues the transverse split of the internal oblique and transversalis muscles through the sheath of .-D FlG. 472. — McBurney's incision: caecum, ileum and appendix protruding into incision. {A) External oblique; {B) Internal oblique; (C) Peritoneum; (D) Appendix. Fig. 473. — Prone position for kidney operations. the rectus, cutting the anterior sheath along with the external oblique fascia, pulling the border of the rectus toward the midline, and then cutting the posterior sheath (transversalis fascia) in combination with the peritoneum. 630 GYNECOLOGY In cases of high-lying and bound-down appendices that cannot be de- livered through the first incision, Judd enlarges the incision through the external oblique aponeurosis as much as neces- sary, and makes a second incision through the internal oblique and transverse muscles i]/ 2 to 2 inches higher than and parallel to the first. Kidney Incisions (Fig. 473). — For exposing the kidney and ureter several incisions may be used. For exposure of the kidney alone in the loin, as in nephrorrhaphy or nephrotomy, Kelly's incision is the most useful. For lumbar Fig. 474. — Kelly's incision. nephro-ureterectomy either Mayo's or Israel's incision is well adapted. If the kidney is to be removed transperito- neally, a straight incision through the outer border of the right rectus muscle will be satisfactory. In uncompli- cated nephrectomies, when the kidney is not greatly enlarged, the muscle-splitting incision of Robson is most useful. Kelly's Incision. — K e 1 1 y finds the superior lumbar tri- angle the most satisfactory / avenue for the exposure of the kidney, except in malig- ^ nant cases (Fig. 474). The boundaries of the triangle are the posterior margins of the oblique muscles of the ab- dominal wall, the quadratus lumborum, and the twelfth FlG - 475.— Mayo's incision. (Courtesy Surgery, Gynecology and • Obstetrics.) rib. Its floor is formed by the aponeurosis of the oblique muscles, and the latissimus covers it. The oblique incision which Kelly uses is about three inches long, extending OPERATIVE TECHNIC 631 downward and outward from the little, soft, yielding spot in the angle be- tween the quadratus lumborum and the rib, exposing the latissimus, which can be lifted up like a lid or separated in the direction of its fibers or simply divided transversely. The whitish area of the apex of the triangle is thus exposed. A pair of closed forceps is then pushed through the aponeurosis and withdrawn, when the golden-yellow fat pops out. The opening is enlarged by blunt force, P ^# ^uotocW V AV «V>QO'CW- \JJ giving command of the entire field without the ligation of a single vessel. Enlargement of the incision is easily ef- fected by further sepa- rating the oblique muscle-fibers, or by dividing them in a direction downward and outward. Care must be taken not to injure either the last dorsal or the first lum- bar nerve (Kelly). Mayo's Incision for Lumbar Exposure of the Kidney. — Begin- ning at a point two or two and a half inches lateral to the dorsal spines, near the outer margin of the erector spinse muscle, a longi- t u d i n a 1 incision is made, two to three inches in length, through the skin, su- perficial fascia, and pos- t e r i o r layer of the lumbodorsal fascia (vertebral aponeurosis) that covers the erector spinse muscle. The incision lies behind the twelfth rib, from the angle, if present, nearly to the head, and reaches downward to a point one-half inch below the angle. From this point the incision passes obliquely downward and forward along the anterior margin of the quadratus lumborum muscle to a point an inch above the crest of the ilium, and, turning, runs forward parallel to the iliac crest as far as is necessary (Figs. 475 and 476). The posterior superior lumbar triangle (Kelly) just beneath the twelfth rib is then exposed by cutting an opening through the external and internal oblique, transversalis, and latissimus dorsi muscles, exposing the trans- versalis fascia in its lumbar portion. This fascia is then opened freely, ex- .4/ .0. Fig. 476. Muscles of lumbar area, showing outline of Edebohls' incision and Mayo's incision. 632 GYNECOLOGY posing the perirenal fat. The ilioinguinal and iliohypogastric nerves are identified and retracted out of the operator's way, and the lower part of the incision completed. The twelfth rib is then cleared in its posterior portion upward and backward to a point near to the articulation of the rib with the transverse process of the twelfth dorsal vertebra, and the pleura pushed upward. By retracting the erector spinas muscle, on the one hand, and the costal margin, on the other, a wide exposure at the point of previous inaccessibility is effected. As a rule, the kidney can readily be drawn through the incision to the surface with but little traction. The incision is easily closed and there is little or no danger of hernia (Mayo). Israel's Incision. — Israel exposes the kidney by an oblique incision, begin- ning at the junction of the erector spinse with the twelfth rib, running for- ward and downward to a point two or three finger- breadths to the median side of the anterior superior spine of the ilium (Fig. 477). This direction has the advantage of exposing the upper segment of the ureter. If it is desirable to expose this further down- ward toward the bladder, the incision is lengthened from its lower end down- ward and forward parallel to Poupart's ligament. To palpate the ureter as far as its insertion into the blad- be lengthened to the outer or to operate on the vesical section under good exposure the rectus may be incised. If this incision does not give sufficient room in difficult nephrec- tomies, Israel uses a second incision — a transverse, beginning two finger- breadths below the border of the ribs, and running anteriorly toward the rectus muscle at right angles. Israel's incision is especially applicable to nephrolithotomy and nephrectomy. Robson's incision is suitable for nephrotomy and for nephrectomy. It has the advantage of exposing the kidney by splitting the muscles in their course, without dividing muscle-fibers or weakening the abdominal wall, and without wounding vessels or nerves. Robson's operative incision is begun to the inner side of the anterior-superior spine of the ilium, and is carried backward obliquely toward the tip of the last rib (Fig. 478). The fibers of the external oblique and its aponeurosis are separated and retracted, exposing the internal oblique muscle, the muscular fibers of which are split on a line between the ninth costal cartilage and the posterior-superior spine Fig. 477. — Israel's incision. der, the incision mav Fig. 47! border ol Robson's incision. the rectus, OPERATIVE TECHNIC 633 of the ilium, in which position they are longer than in front of or behind that line. The fibers of the transversus are split and retracted along with the oblique muscle. A diamond-shaped space is thus formed, at the bottom of which is seen the transverse fascia ; this is incised, exposing the perirenal fat, and on push- ing through the fat, the kidney is easily reached in whatever position it may lie. This incision gives plenty of room, and if needful, the whole hand can be introduced into the circumrenal space. If it becomes necessary to expose the ureter, the incision may be continued obliquely downward toward Pou- > Fig. 479. — Towelling the incision, one side completed. part's ligament. The internal oblique will then require suture to bring the divided ends together. Preferably a second lower incision through the outer border of the rectus muscle may be made to reach the ureter (Robson). DIRECTIONS REGARDING ALL INCISIONS Whatever the site of the incision, it may be stated as a general rule that all incisions should be sufficiently long to expose the operative area freely. As a rule, the skin incision should be slightly longer than the incision through the fascia. After making the first stroke, which is carried just through the skin, the blade of the knife and the cut exposed edges of the skin may be wiped with 634 GYNECOLOGY alcohol ; the subcutaneous fat is then divided down to the underlying fascia. The fascia may now be cleared of fat on either side of the median line for about one-quarter of an inch, thus facilitating the subsequent overlapping Fig. 480. — Towelling the incision, both sides completed. and suture of the fascia. At this point towels should be clamped to the edges of the skin on either side of the wound (Figs. 479 and 480) ; this pre- vents contact with the skin throughout the subsequent steps of the opera- '''• Fig. 48] -Incision made: sides protected with gauze pads; self-retaining retrac- tor in position; myoma uteri exposed. tion. When the incision is cleared, the fascia is divided in the line of the skin incision and the underlying muscle exposed. In celiotomy incisions, as a rule, the muscle-fibers are not incised, but separated by blunt dissection down to the underlying preperitoneal fat (Fig. 481), or the neighboring OPERATIVE TECHNIC 635 border of the muscle is separated from its attachments and the muscle is retracted to one side (Fig. 484). In certain areas this blunt dissection must be assisted by an occasional nick with the knife. When the preperitoneal fat is exposed, it is picked up between two forceps and incised (Fig. 483). The fingers are introduced into the wound, and the fat is stretched or torn Fig. 482. Fig. 483. Fig. 482. — Separation of muscle fibers. Fig. 483. — Opening the peritoneum. so as freely to expose the peritoneum. This is caught lightly with tissue forceps on either side of the median line, the grasp being released and re- newed once or twice on either side until it is certain that the forceps holds nothing but peritoneum, when a small nick is made between the forceps points. Air at once enters the opening, and the omentum and intestines fall 636 GYNECOLOGY away from the incision. The peritoneal, and if need be the fascial and skin wounds, are now enlarged sufficiently to expose the operative area by cut- ting one after the other with heavy scissors or knife (Fig. 485), the intestines and omentum being protected by the first two fingers of the operator's left hand placed inside, with the palmar surfaces upward, along the line of the proposed incision. After the incision has been enlarged to a suitable degree, the edges should be protected with flat pads of wash-cloth material, which are held in position by means of retractors, or secured to the corresponding edges of the peritoneum with clamps. One of the advantages of the self-retain- ing retractor is that it holds these pads in a fixed position and prevents soiling of the subcutaneous fat, fascia, and muscle. Fig. 484. — Separation of the rectus muscle from its lateral attachments along the linea alba. Fig. 485. — Lengthening the incision. ISOLATION AND EXPOSURE OF THE OPERATIVE AREA Isolation and exposure of the operative area are secured by suitable posture and the introduction of gauze sponges or pads. In pelvic operations the intestines are made to gravitate out of the pelvis by raising the pelvis and lowering the chest (Trendelenburg's position) (Fig. 487). In operations involving the upper abdomen the position is reversed, i.e., the chest and upper abdomen are elevated, whereas the pelvis is lowered. In operations on the gall-bladder and bile-ducts the lower thorax is elevated by means of a sand-bag or an air- cushion, or by a special elevating platform attached to the table (Elliott's OPERATIVE TECHNIC 637 position) (Fig. 488). This brings the parts nearer to the surface, and causes the stomach, transverse colon, omentum, and intestines to fall away from the operative area. It also facilitates rotation of the left lobe of the liver forward and upward out of the incision. After the operative area has been freed of coils of intestine as far as possible by posture, the intestines and other adjacent viscera are gently held to one side and gauze wrung out of hot normal salt solution or hot sterile water is packed in one continuous strip about the area to be ex- posed, so as to keep the neighboring and encroaching viscera out of the way. This procedure has two objects: First, satisfactory exposure of the field of operation; and secondly, avoidance of contamination of the surrounding parts. Instead of the continuous gauze roll, large gauze pads to each of which a tape is attached may be used, the tape being always left outside the abdomen and secured with a hemostat. Before the protective gauze pack is introduced the abdominal walls should be relaxed thoroughly, so that the intes- tines need not be pushed forcibly out of the way. Neglect to observe this pre- caution is believed to be one of the causes of adynamic ileus. Before introducing the gauze pack it is often advisable and necessary to break up any adhesions that may have formed between the omentum and the abdom- inal parietes or the diseased structures in the operative area. The extent to which this separation is done before packing off is determined by the density of the adhe- sions and the probability of the release of pus or other infectious material. In pelvic operations the omentum can usually be freed of its attachments to the pelvic viscera, so that the intestine may be rolled up above the pelvic brim and packed away. If, however, the adhesions are very extensive, or apparently cover and protect collections of pus, the omentum may be tied off at a free point above and divided; or if a portion of the small intestine itself is adherent and intimately associated with the focus of pelvic infection, it may be left undisturbed, the surrounding coils of gut being displaced upwards as far as possible or simply protected with folds of gauze. In the case of suppurative appendicitis with tumor formation, the adhe- sions between the appendix and the neighboring intestine should never be disturbed until the adjoining areas have been thoroughly walled off. Fig. .86. — Eversion of peritoneum with closing sature; first method. 638 GYNECOLOGY In gall-bladder and stomach operations the same precautions should be observed. The surrounding areas should be carefully protected, and the free coils of intestine held out of the way before any extensive or dense ad- FiG. 487. — Trendelenburg (elevated pelvis) position. Fig. 4! -Elliott position (elevated thorax; for upper abdominal operations. hesions are broken up. Gauze should be placed above the right kidney, in the case of gall-bladder operations particularly, in order to prevent the collection of fluid in the right kidney fossa. In all cases of intestinal anastomosis or resection the involved coils of OPERATIVE TECHNIC 639 intestine should be drawn outside the incision and gauze pads packed below and around the operative area, so that contaminating fluid will not find its way into the peritoneal cavity. At the close of an operation, before the gauze pack is removed, the oper- ative field should be thoroughly cleansed with sponges wrung out of salt solution. If drainage is to be employed, it should be put in place before the packs are disturbed. A careful record should be made of the gauze rolls or pads that were prepared for use during the operation, and the count made after the packs are removed should correspond absolutely to the one made before the operation. Only after they agree should the abdomen be closed. EXPLORATION OF THE ABDOMEN In a certain number of cases it is impossible to differentiate between neigh- boring and related lesions unless the abdomen is opened. If, therefore, every other means of differentiating between two intra-abdominal con- ditions have been exhausted, and if operation is plainly indicated in any case, an exploratory celiotomy should be advised. Every celiotomy is to a certain extent exploratory, for the details of diagnosis are brought out and confirmed, or. a mistaken diagnosis is corrected. The more skilled the surgeon is in diagnosis, and the more complete his methods are, the less likelihood there will be of error. It is advisable, as a matter of routine, to investigate, as far as prac- ticable, the condition of some of the most frequently affected abdominal structures after the operation for which the abdomen was opened has been completed. This general exploration should never be carried out if the field invaded by the operation is the focus of septic infection. It is only in clean cases that general exploration is permissible, unless there are symp- toms that clearly indicate a second lesion at a distance from the most urgent one, and the exploration should then be made as soon as the abdomen is opened. To be specific, in undertaking an operation for pelvic inflammatory disease, the appendix should be exposed at once, and if necessary removed, before the pelvis is invaded. If symptoms strongly suggestive of chole- cystitis or duodenal ulcer are present, exploration of the upper abdomen should be made by the hand introduced through the pelvic incision before the pelvis is touched, but never afterward. Furthermore, after clean intra- pelvic operations, when the patient is in good condition, it should be a routine practice to examine and inspect or palpate systematically the kid- neys, gall-bladder, pylorus, appendix, lower ileum, and sigmoid. In this way lesions will be detected and may be treated that would otherwise escape observation and continue to render the patient uncomfortable and prevent the full restoration to health which she expects will follow opera- tion. Among these may be mentioned chronic appendicitis, adherent appendix, displacements and enlargements of the kidney, adhesions that distort the lower ileum, caecum mobile, gall-stones, redundant or kinked sig- moid flexure, and midline ptosis of the stomach and transverse colon. 640 GYNECOLOGY HiEMOSTASIS In the performance of pelvic operations haemostasis is secured with liga- tion, clamping and torsion of individual vessels, and compression of bleed- ing surfaces with hot gauze packs. The bleeding vessels in the skin and subcutaneous fat that have been divided in making the incision should be caught with forceps. The instruments may be removed after the in- cision is completed, the vessel being twisted until the forceps is released. Vessels in the preperitoneal fat, especially the deep and the superior epigastric vessels, should be divided between two clamps, and both cut ends ligated at once. Haemostasis in pelvic operations, whatever their nature, should be completed as the operation progresses ; the blood supply may be secured with ligatures before division of the various structures is accomplished, or it may be left until the parts have been extirpated, the vessels being clamped temporarily. Some oper- ators prefer one method, some another. By first clamping and then tying the vessels the operator is enabled to complete the extirpation of the diseased structures in a shorter period of time, but it is questionable whether this method is as safe as ligation in the course of the operation. It is good practice to ligate the larger vessels singly and in their course pre- paratory to excision. After excision has been completed, the larger trunks are secured a second time. If, during the course of a pelvic opera- tion, a vessel is accidentally punctured with a needle, a ligature is placed upon its proximal side in order to avoid the slight risk of embolism which the wounding of a vessel necessarily entails. In removing the tube of one side without the ovary, care should be taken to preserve the ovarian circula- tion, as has been described under the head of Salpingectomy (page 437). In performing hysterectomy and bilateral salpingectomy with conserva- tion of one or both ovaries, the ligation of the ovarian branch to the tube must be done most carefully, for otherwise the ovarian supply itself may be interfered with. For this reason, if the tube is healthy, it may invariably be conserved with the corresponding ovary, the utero-ovarian ligament and the inner extremity of the mesosalpinx and tube being ligated without interfering with the intrinsic ovarian supply. In perforating the broad ligament, as in the Webster-Baldy operation, a clear space should be selected carefully, but if a vein is accidentally torn, a clamp must at once be applied on both sides of the bleeding spot, and later liga- tures that secure the injured vessel well to each side of the ruptured area. Hemorrhage from an incision or a needle prick in the uterine wall is best controlled by figure-of-eight or mattress sutures. Hemorrhage from a tear in the capsule of the ovary may be controlled by the passage of a fine suture completely through the ovary and back to the surface of entry, the suture being tied so as gently to compress but not to cut the ovarian stroma. Bleeding points on the floor of the pelvis from vascularized adhesions or vessels in the cel- lular tissue, rectal wall, broad ligament, etc., if of any consequence, should be picked up individually with forceps and tied with fine catgut, or mattress or circular sutures of fine gut may be used. A gauze pack wrung out of very hot water and firmly applied for a few minutes will usually suffice to check the capillary oozing. If the operator is absolutelv certain that the OPERATIVE TECHNIC 641 main vessels are properly secured, slight venous or capillary oozing may be disregarded so far as danger to life is concerned, but from the viewpoint of speedy and normal restitutio ad integrum of the tissues even this should, so far as possible, be checked. If the oozing is so marked as to make the formation of a hematocele probable, and if it cannot be controlled by liga- tion or pressure, particularly if the operator is pressed for time, a gauze pack surrounded with rubber may be used. If time allows, a little patience and painstaking effort will in most cases be successful. ADHESIONS Adhesions may be found between any of the intrapelvic or abdom- inal viscera. They vary in degree from the simple attachment of a tag of omentum to an inflamed ovary or tube to the most widespread coales- cence of intestines, omentum, pelvic viscera, and parietal peritoneum. Ad- hesions between the omentum and the parietal peritoneum of the anterior abdominal wall may usually be detected on making the peritoneal incision. As the peritoneum is picked up with forceps preparatory to the in- cision, it feels thicker and more fixed than normal. Under such circum- stances it is desirable to open the peritoneum at a higher point, so that an exact orientation may be made of the parts involved. For example, if the adherent structure is the gastro-colic omentum, it would be well, under cer- tain circumstances, to refrain from separating the adhesions, lest damage to the omentum would necessitate resection of a portion of the transverse colon. The first consideration, therefore, is to identify the areas involved. The separation of adhesions is usually readily effected by making gentle pres- sure with the gloved finger or the finger wrapped in moist gauze, supple- mented by the immediate ligation of bleeding points. If the adhesions are dense, it is better to cut than to tear them. For this purpose a very sharp knife is used, and the line of division is determined by making traction on either side of the line of adhesion. In bad cases blunt dissection is more likely to cause visceral injury. If the adhesions are exceedingly vascular, clamps or ligatures should be applied and division made between them. No matter how complex and hopeless the separation of adhesions seems at first sight, patience and gentle persistence will usually overcome them. If the adhesions are very extensive, it is at times unwise to separate every attach- ment. If the small intestines are markedly adherent to each other, no attempt should be made to free them all, since if this is done a recurrence is most likely to take place. In such cases the separation should be reserved for such adherent coils as are kinked or obstructed, and such as conceal or render inaccessible other organs that the operator desires to expose. In separating the uterus or adnexa from the rectum, sigmoid, or small intes- tines, thorough exposure to view, as well as to palpation, will avoid trouble- some and dangerous tears of the hollow viscera. The fingers should hug the uterus or adnexa closely, and the lines of natural cleavage and of less resistance should be sought, while the occasional use of the knife or scissors will open up planes of tissue and serve to prevent laceration of important viscera. At times, when it is evident that the separation of adhesions be- tween the pelvic viscera or growths and the intestines will almost certainly 41 642 GYNECOLOGY be attended by injury, the capsule or outer coat of the adherent viscus or tumor may be shelled of! and left attached to the bowel; the raw surface should be whipped over, or flaps may be made and approximated by sutures in such a way as to prevent compression or constriction of the bowel. In some cases, especially in those in which an ovarian or tubal abscess has previously been connected with the bowel by means of a fistulous opening, it will be impossible to free the adhesions without tearing the bowel. When the two limbs of a coil of intestine lie parallel and are intimately adherent, forming a partial obstruction, and there is great danger, from separating the adhesions, of inflicting serious injury that will require resection of bowel and anastomosis, a simple enteroenterostomy with clamps between the two coils will be the most advantageous procedure. WOUNDS OF THE VISCERA Whenever the bladder, intestine, or ureters are torn during the separation of adhesions or in the course of an operation the injury should be repaired at once. When the bowel is the seat of injury this usually is accomplished by the passage of two rows of continuous or inter- rupted linen or celloidin thread sutures, closing the opening and bringing healthy serous surfaces together, transversely to the axis of the gut. If the laceration is extensive, or if the blood supply is so greatly impaired by injury to the mesentery that the gut would be likely to become gangrenous, resection of the affected area, with end-to-end or lateral anastomosis, must be practised. The latter is usually to be preferred. When speed is a matter of importance, the Murphy button is valuable. When the rectum is injured low in the pelvis, with loss of tissue, and if the site of injury is such as to render excision and anastomosis exceedingly difficult, if the uterus is available, its posterior surface may be sutured into the rectal opening, its serous covering temporarily forming a part of the anterior rectal wall. If the uterus has been or must be removed, the stump of the cervix may be used, or the posterior vaginal wall, the bladder, or a flap of peritoneum. After repairing an injury to the rectum a test of the completeness of the closure should be made by injecting salt solution into the bowel. The ureters and the bladder may be injured during the separation of adhesions, but they are more often wounded during the course of an opera- tion requiring separation of the bladder from the neighboring uterus or the anterior vaginal wall. Supravaginal hysterectomy for a fibroid tumor that has displaced or distorted the bladder and the extensive panhysterectomy for cancer of the cervix especially predispose to such an accident. The wound is usually above the trigonum, and may readily be closed by an inner row of catgut and an outer row of linen or celloidin thread sutures. If the injury involves the trigone, the ureters must be orientated accurately before the sutures are passed. If the ureter itself is merely cut without being completely divided, and the structure is not bruised or lacerated, immediate repair may be effected by introducing interrupted sutures of fine catgut passed through the outer coats and coaptating the cut surfaces. If the ureter is completely divided, OPERATIVE TECHXIC 643 or if it is bruised or lacerated as well as cut. several plans are available. If the injury is near the bladder, the proximal end of the ureter should be im- planted into the bladder, or the proximal end may be implanted into the distal end. If neither of these plans appears feasible, an anastomosis may be made between the ureter and the rectum. When the ureteral anasto- mosis threatens to be difficult, and rapid completion of the operation is desirable, if the kidney on the uninjured side is sound, the cut ureter should be doubly ligated and dropped. This causes pain for a few hours or days. but the kidney on the ligated side soon ceases to function and may give no further trouble : should it do so. the organ may be removed later by nephrectomy. After all forms of ureteral anastomosis the anastomotic area should be covered or enveloped with peritoneum or a pad of fat or omentum. The technic of these operations is considered on pages 492-495. Ligation of the Ureters. — See Post-operative Complications. Chapter XXXVII 1. TREATMENT OF DENUDED SURFACES The treatment of surfaces denuded as the result of the separation of adhesions is a difficult but most important problem in order to avoid their post-operative recurrence. As a rule, after every salpingectomy, salpingo- oophorectomy. or hysterectomy the raw surfaces may be covered by prop- erly disposing the peritoneal reflection of the bladder or the peritoneal sur- faces of the broad and round ligaments. The anterior wall of the rectum. the sigmoid flexure, and the omentum — all may be so disposed by sutures as to assist in covering raw surfaces, and thus lessening the liability to the formation of adhesions. A study of the technic of the various operations in pelvic surgery will show this peritonealization to be the final step in all. It would be extremely fortunate if a material were discovered that could be spread over raw surfaces and so prevent the formation of adhesions. Up to the present no satisfactory substance has been found. The most promising of those recommended have been cargile membrane (the dried serous membrane of the ox I and various oily preparations. X'one of these has a constant or a positive value. Some raw surfaces may be covered up by bringing one-half of the sur- face in contact with the other half or by attaching the entire surface to a neighboring structure,, taking care that no small pockets or openings are formed that would predispose to strangulation of the intestine. Raw areas on the intestine or mesentery may be covered with omentum or attached to the parietal peritoneum, provided the intestine is in such a position that it can functionate normally and no small openings or pockets are formed in which a knuckle of gut might be caught. A raw edge of omentum should be rolled up into the healthy surface of the omentum and secured by sutures. After extensive separation of adhesions and the exposure of considerable raw surface on the pos- terior aspect of the broad ligament, if hysterectomy is to be done, the anterior peritoneal surface of the broad ligament and bladder should be conserved as far as possible, so that there will be sufficient loose peritoneum to draw over the floor of the pelvis and the posterior surface of the base of 644 GYNECOLOGY the broad ligament. Occasionally all that one can do is to wash the raw surfaces thoroughly with salt solution and move the bowels shortly after operation in the hope that, by exciting active peristalsis, the formation of new adhesions may be prevented. CLOSING THE INCISION The peritoneum is closed with a running suture of fine gut, so placed as to evert the edges of the peritoneum (Figs. 486 and 489). This is done in an endeavor to avoid the formation of adhesions between the inner surface of the incision and the abdominal viscera. It is very important ; otherwise adhe- sions will form in a large proportion of cases. Muscle sutures may be omitted in closing incisions involving the rectus muscle, for if the fascia is overlapped, the separated fibers of the muscle will lie in apposition and hence a suture is unnecessary. If the operator prefers, he may unite the muscle borders with a running suture of fine catgut or a few fine interrupted sutures. In muscle- splitting incisions, notably the McBurney incision for removal of the appendix, the borders of the split muscle may be approxi- mated by one or two sutures. If a muscle is cut across its fibers, one must reunite the cut ends. These are approximated with fine gut while splint sutures of the mattress type are placed at some distance from the cut edges. The fascial suture is the most important. The general principle in suturing the fascia is that of overlapping. In the ordinary right rectus incision the superior surface of the fascia on the left side of the incision is cleared of fat, whereas the under surface of the fascia on the opposite side is freed from the underlying muscle. Sutures are now introduced so as to unite the superior surface of the fascia on one side to the under surface of the fascia on the other side. This may be done by interrupted or con- tinuous sutures, as the operator prefers (Fig. 490). A combination of inter- rupted sutures at one-inch intervals and a continuous suture for the entire length will prove very satisfactory. The fat layer may be disregarded except when it is abnormally thick ; it then should be drawn together with interrupted through-and-through sutures of silkworm gut. The skin suture should be of fine catgut. It may be used as a sub- cuticular or as a buttonhole stitch (Fig. 490) ; the latter is the easier to introduce, and gives an equally good approximation ; it permits better drain- age of the subcutaneous fat, but leaves a more unsightly early scar. Later Fig. 489. — Eversion of peritoneum; closing suture; second method. OPERATIVE TECHNIC 645 the line of incision is less likely to undergo hypertrophy or to stretch than after the subcuticular stitch. Mass suture or through-and-through suture of the incision may be used when rapidity of closure is the first requisite. The needle is passed through the skin, subcutaneous fat, fascia, muscle, and peritoneum. It is introduced Fig. 490. — Closing fascia, showing detail of suture for overlapping. about a quarter of an inch from the edge of the skin incision, passed with a full sweep outward through the fat, fascia, and muscle, and made to emerge on the under surface of the abdominal wall one-eighth inch from the edge of the peritoneum ; the suture is then continued in an opposite direction through the other side. A closure of this sort, in a majority of cases, secures good approximation of the borders of the wound; the point where the stitch is 646 GYNECOLOGY SWuv exposed upon the under peritoneal surface is sealed over in the course of a few hours, so that there is little risk of adhesions. Nevertheless, except in the most hazardous cases, when every minute counts, through-and- through mass sutures are inadvisable. In very stout individuals, or when drainage is used, or if, for any other reason, it appears desirable to make the incision particularly secure, the combination of splint sutures, em- bracing all the layers of the abdom- inal wall except the peritoneum, should be. used with a continuous suture of the peritoneum and fascia. The splint sutures are placed after closure of the peritoneum, an inch or more apart, and held with hemostats to either side of the in- cision ; a continuous suture of the fascia is then introduced, after which the splint sutures are tied. If necessary, additional interrupted skin sutures may be introduced. When drainage is used in the in- cision, whatever the form of suture selected, two through-and-through sutures, taking in all the coats of the abdominal wall, including the peritoneum, should be placed one just above and one just below the drain. If the drain is put for the purpose of controlling hemorrhage and is to be removed during the course of twenty-four hours, another suture may be in- serted, but not tied at the site of the drain ; this may be tied after the drain is taken out, completing the closure. I L Pig. 491. — Finish of buttonhole stitch. DRESSING THE INCISION After the skin suture is completed, the line of incision should be carefully dried, touched with a 5 per cent, solution of iodine, and sev- eral thicknesses of dry folded gauze applied, the surrounding skin areas having first been carefully cleansed. The dressing should be held in place by broad strips of perforated adhesive plaster, running from flank to flank, and covering the entire abdominal surface from above the upper limits of the dressing to the symphysis pubis. If the plaster is applied snugly, no other support is needed. To prevent it from becoming loose in the groins a perineal pad of sterile gauze (this is usually required) OPERATIVE TECHNIC 647 and a "T" bandage should be applied. A plan which Clark has recently used with success is illustrated in Fig. 493 ; this facilitates examination and dressing of the wound with a minimum amount of discomfort to the patient. When drainage has been employed, the end of the drain is transfixed with a safety-pin about a quarter of an inch from the skin surface, and a layer of gauze wrung out of 1 : 4000 bichloride solution is interposed, a straight cut being made in the gauze so as to facilitate this arrangement. Additional folds of moist bichloride gauze are now put over the end of the drain, and over these dry gauze and a layer of cotton. These dressings may be anchored in place by a few strips of adhesive plaster, and the abdo- Fig. 492. — Suprapubic pelvic drain. men should be enveloped in a Scultetus bandage for the first few days. The dressings are changed or reinforced as soon as they become soiled ; usually a daily dressing is sufficient. Later, especially when frequent dressing is required, side straps of adhesive plaster with tapes attached, which can be tied over the dressings, are most satisfactory. The ordinary clean incision that gives no evidence of faulty union, severe pain, rise of temperature, etc., need not be dressed for ten days after the operation. At that time the gauze and plaster should be removed, the skin cleansed with alcohol, and a fresh dressing applied. When the incision has been a large one, when drainage has been employed, and when the abdominal wall is heavy and relaxed or very fat, it is advisable for the patient to wear a binder for several months. 648 GYNECOLOGY For small incisions that have healed per primam, in young individuals with good muscular development, a special binder is not important, since the ordinary corset answers all the necessary requirements. SPONGES AND PADS USED IN ABDOMINAL SURGERY In abdominal and pelvic surgery sponges and pads are used for three pur- poses : (i) To remove blood (sponging) and detritus from the field of opera- tion; (2) to pack off the intestines from the general peritoneal cavity; and (3) to protect the edges of the incision. For the first purpose marine sponges would be preferable if their physical properties alone were considered, but be- cause of the difficulty in sterilizing them and the fact that they are expensive, their use has been generally abandoned. Nevertheless, they are still occasionally seen t» /; Fig. 493. — Abdominal dressing applied. in operating rooms, and for ordinary sponging they are much superior to gauze pads. Gauze sponges are made of folded squares of gauze, the rough and selvedge edges being turned in, and sometimes additionally secured by stitching. Several sizes are usually available, and to the larger ones tapes may be attached so that when they are placed within the pelvic or abdom- inal cavity for walling-ofl purposes the tapes are left hanging outside and secured with hemostats. Gauze in the form of pads or sponges, however, should be used only exceptionally for this purpose. The routine packing-oft and extraperitonealization should be done with a roll of gauze with edges folded in, the dimensions of the roll for the usual intrapelvic work being 1 by 3 feet. For appendix, gall-bladder, and kidney operations a roll six inches in width may be preferred. If one roll is not sufficient, a second or a third may be used, the end of each strip being left to project from a suitable OPERATIVE TECHNIC 649 part of the incision and being caught with a hemostat. Gauze pads or sponges should be packed in bundles of a fixed number and a single variety; rolls of gauze should be wrapped separately in muslin covers ; the number of gauze pads, sponges, and rolls used should be carefully recorded. When rolls of gauze are employed for packing-off no pads should be placed inside the abdomen, except under unusual and urgent circumstances. All gauze sponges, pads, or rolls used during an abdominal operation, either internally or externally, should be counted and recorded before the operation is begun and after it is completed ; the two counts must agree before the incision is closed. All gauze used within the peritoneal cavity should be moist, i.e., it should have been wrung out of hot sterile water or hot normal salt solution. By this means irritation of the peritoneal surface is reduced to a minimum. ANESTHESIA One of the most important details in connection with an operation is that of rendering the patient insensible to the procedure, with a minimum of shock to the nervous system and the least possible depression of the vital functions. Anaesthesia is produced in various ways ; the most customary method is by the inhalation of nitrous oxide, oxygen, and ether. Ether and chloro- form have been very popular in the past, ether being generally preferred be- cause of the fact that it is less dangerous, but chloroform has, nevertheless, many advocates. During recent years nitrous oxide has been very generally employed previous to the ether, narcosis being induced by the nitrous oxide and continued with the ether. At present nitrous oxide and oxygen are em- ployed extensively for operations of short duration ; for prolonged opera- tions nitrous oxide, oxygen, and ether constitute the most efficacious and the safest combination. Ether. — For routine administration ether is the safest of all anaesthetics. It has, however, certain disadvantages and dangers. The after-effects of ether consist of nausea, vomiting, and extreme thirst. Its use may light up an old tuberculous lesion ; it may produce pneumonia or nephritis, or may aggravate an old renal condition. In fat, thick-necked people and in asth- matics, it may be impossible to administer ether without causing strangula- tion. By reason of its effect on the body heat or on the excretory func- tions, serious shock or profound toxaemias may be increased by the use of ether. Nevertheless, for the average surgical case, when carefully and properly administered, preceded or not by nitrous oxide, it is the least harm- ful and the most satisfactory of all anaesthetics. Chloroform. — Chloroform is more rapid in its action than ether, and the anaesthetization is effected with less struggling and less general disturb- ance. It is not so irritating to the mucous membranes of the respiratory tract, and probably irritates the excretory cells of the kidney less than ether does. Chloroform is much more dangerous, however, since it is de- pressing to the circulation ; it may, with very little or no warning, cause cardiac arrest and death ; in a small proportion of cases also, when anaes- thesia is prolonged, it may cause acute yellow atrophy of the liver. Its dis- advantages appear, therefore, to exceed its advantages, and for major pelvic or gynecologic operations chloroform anaesthesia has fallen into disfavor. 650 GYNECOLOGY Nitrous Oxide and Oxygen. — The administration of nitrous oxide, when combined with oxygen, may be continued almost indefinitely. This has become a favorite method of anaesthesia for brief operations. Pelvic opera- tions, in which perfect relaxation of the abdominal wall is required, are not adapted to the use of nitrous-oxide-oxygen anaesthesia, but in abdominal operations in which absolute relaxation is not required this form of anaes- thesia may be employed with satisfaction. The anaesthesia should be pre- ceded for a half hour or so by the exhibition of morphine (gr. }i) and atropin (gr. 1/150). This helps to quiet the patient and promotes muscular relaxation. The nitrous oxide and oxygen are administered by means of a special apparatus that permits a mixture of any relative proportion desired. Nitrous oxide has the disadvantage of raising the blood-pressure, so that in patients with high blood-pressure or cardiac disease it is contraindicated or must be used with extreme caution, and with a large admixture of oxygen. Nitrous Oxide, Oxygen, and Ether. — By combining nitrous oxide, oxy- gen, and ether an anaesthesia may be effected that will meet nearly all requirements. The anaesthesia may be quickly induced with the nitrous oxide, continued in combination with oxygen for brief operations, when deep intra-abdominal or pelvic work is not being done, or supplemented with ether when the operation is of longer duration or demands more complete relaxation. Anaesthesia by Combined General and Local Methods. — Crile believes that when an operation is performed under general anaesthesia continual shocks are sustained by the central nervous system from the impressions of trauma that are conveyed there by the sensory nerves in the operative region. These subconscious impressions, he asserts, are largely responsible for what is known as surgical shock. He seeks to eliminate these impres- sions by his method of " Anoci Association " (see Chapter XXXV, page 617). Ethyl Chloride. — Ethyl chloride by inhalation is suitable only for very brief anaesthesia. It is not generally applicable to gynecologic operations, although it may be used for minor surgical procedures, as, for example, the incision of a vulvovaginal abscess. When used longer than momentarily, it becomes a dangerous and harmful anaesthetic, since it produces at times a spasm of the respiratory muscles. Local Anaesthesia. — Local anaesthesia is the method of producing anal- gesia by the application of an anaesthetic solution either directly to a body surface or by injecting it into the underlying substance. The range of usefulness of local analgesia in gynecologic and pelvic surgery is generally limited to minor operations upon the external genitalia, as, e.g., the removal of a urethral caruncle, and to celiotomies in which little more than an ab- dominal incision need be made, as when the operation is performed for non-adherent ovarian cyst, localized collection of pus, and the like. The field of usefulness of local anaesthesia may, by painstaking technic and patience, be extended to herniotomy and anterior vaginal hysterotomy, but in the absence of distinct contraindication to general anaesthesia, its use is not to be recommended. Solutions for Producing Local Anaesthesia — Eucaine, Cocaine. — Local anaesthesia of the bladder and urethra may be induced by the injection, OPERATIVE TECHNIC 651 into the bladder, of a 4 per cent, solution of eucaine or cocaine. The solu- tion should be applied directly to the trigone through a Kelly cystoscope, or injected by means of a catheter or a syringe with a long curved beak. A few drops also may be instilled into the urethra as the instrument is withdrawn. Local anaesthesia of this type may occasionally be re- quired in making cystoscopic examinations, particularly in performing catheterization of the ureters in highly nervous and neurotic individuals or in those with exceedingly painful affections of the urethra or blad- der. Anesthetization of the external urinary meatus is effected by appli- cation, directly to the mucosa, of a pledget of cotton wet with a 10 per cent, solution of cocaine. Cocaine is the most effectual local anaesthetic. When the anaesthetic solution is to be injected, novocaine is much to be preferred to cocaine. Novocaine in a ^4 of a 1 per cent, solution, combined with suprarenal extract, is comparatively without danger, and may be used freely. The tissues must be infiltrated with the solution. Novocaine may be sterilized without undergoing decomposition. Quinine hydrobromide and urea may be used in a ^ to ^ of a 1 per cent, solution in conjunction with local novocaine anaesthesia, as in the method of anoci association of Crile, or in certain operations in conjunction with general anaesthesia. Its use must be accompanied by massive infiltra- tion of the tissues at a distance from the seat of operation. Its anaesthetic effect does not begin immediately, but usually within fifteen minutes, and continues for from thirty-six to forty-eight hours. It is, therefore, most useful in operations associated with marked post-operative pain, as, e.g., perineal and anal operations. Technic of Producing Local Anaesthesia by the Injection of Novocaine — Celiotomy Incision. — With a fine needle a drop or two of the solution should be injected into the substance of the skin (intracutaneously), not beneath it, in the projected line of incision. Into the periphery of the little welt thus raised another injection should be made, and still another, until the entire length of the contemplated incision has been treated. Division of the skin and subcutaneous fat is now painless ; the fascia and the perito- neum must be infiltrated in the same manner as the skin. A razor-edged knife should be used, and the incisions should be confined strictly to the infiltrated area. After the peritoneal cavity is opened the abdominal wall may be infiltrated with quinine and urea (}i per cent, solution) at a point about an inch from the incision. Vulvar or Vaginal Incisions. — The same procedure is followed as in the case of celiotomy incisions. The solution is injected into the substance of the skin or the mucosa. After dividing the anaesthetized skin, if the exposed subcutaneous tisues are sensitive, they must be infiltrated in turn. In vaginal, as in abdominal celiotomy, the peritoneum must be dealt with sepa- rately. After perineal operations infiltration of the tissues with quinine and urea (% per cent, solution) may be made at the periphery of the operative area and about an inch from it. Cervix Operation or Hysterotomy. — The cervix may be anaesthetized for performing dilatation by injecting a novocaine solution into its sub- stance at numerous points in the periphery of the canal. . In anterior hys- 652 GYNECOLOGY terotomy a line of infiltration on the anterior lip is begun at its lower margin, and continued to the reflection of the vaginal mucosa. A transverse line of infiltration is now made, and the anterior vaginal attachment is divided. The bladder is next pushed up, exposing the anterior surface of the cervix and the lower uterine segment ; the anterior wall of the uterus is then infiltrated, and the anterior hysterotomy incision is made. Local Anaesthesia by Freezing with Ethyl Chloride. — Local anaesthesia by freezing with ethyl chloride may be used for such minor operations as opening a vulvovaginal abscess or removing venereal warts. The tube should be held from 12 to 18 inches from the area to be frozen, and the spray run up and down the line of the proposed incision until the area be- comes white. Evaporation will be increased by fanning the area. Deep freezing is inadvisable for fear of causing sloughing of the tissue. Spinal Anaesthesia in Pelvic Surgery. — The administration of a general anaesthetic may be undesirable or dangerous in: (1) Cardiac , pulmonary, or renal lesions of such a nature that general anaesthesia will embarrass or injure the circulatory, respiratory, or urinary symptoms. (2) Toxic states in which the excretory organs have already been taxed to their utmost, and in which the addition of another poison will mean excretory insufficiency. When operation is imperative, or is highly desirable in patients who are unfavorable subjects for general anaesthesia, we turn naturally to local anaesthesia — i.e., the concentration and limitation of the anaesthetic sub- stance, whatever it may be, to the operative area, so that analgesia is pro- duced, without any general influence being induced. Without going into a discussion of local anaesthesia, it may be said in a general way that for pelvic operations in which full relaxation of the ab- dominal wall is required, infiltration of the operative area with anaesthetic solutions is unsatisfactory. This leads us more or less logically to spinal anaesthesia, which is really a form of local anaesthesia ; by this method, how- ever, the anaesthetic selected is applied directly to the root of the nerves, instead of to their peripheral branches. It would seem, a priori, that a much smaller quantity of any drug would be required if the anaesthesia were localized at such a point, and that the effects would be more strongly marked. In a successful case of spinal anaesthesia, the anaesthetic drug becomes mixed with the spinal fluid, bathing the motor and sensory roots of the cord at and below an elected point, inducing motor and sensory paralysis of the areas supplied by those nerve-roots ; in other words, an inhibition of pain in the operative area and full muscular relaxation. The patient is prepared for the injection of the anaesthetic by a dose of morphine (gr. %) and scopolamine (gr. 1/150). Usually one dose is suffi- cient, but if the patient is extremely nervous, the dose may be repeated. In some cases bromide or veronal the evening before operation will be ad- visable. If the preliminary injections are given at least an hour before the time set for operation ; if the patient's ears are lightly plugged with cotton ; if a bandage is placed over the eyes, and she is kept in a quiet room, she is usually in a drowsy condition or is actually asleep when the time for operation arrives. OPERATIVE TECHNIC 653 The after-condition of the patient usually is ideal. A majority complain of no discomfort whatever. As a rule, there is no nausea. Occasionally a patient will complain of headache, but it is scarcely ever of sufficient severity or duration to become a serious matter. The post-operative suffering is less than after the use of ether or chloroform, and probably a trifle more than after nitrous oxide anaesthesia. The best technic is that elaborated by Babcock. The solution em- ployed consists of stovain (0.08 gm. ), to which is added a small amount of lactic acid (0.04 c.c.) for the purpose of holding the drug in suspension in the alkaline spinal fluid, and a small quantity of alcohol (0.2 c.c. ; water, 1.8 c.c), to make the solution of lower specific gravity than the spinal fluid, which is constantly between 1.00055 an< ^ 1.00065. Another solution of a specific gravity greater than that of the spinal fluid is composed of stovain (0.08 gm.). lactic acid (0.04 c.c), milk-sugar (0.10 gm.), and water (2 c.c). The first and lighter solution rises in the spinal fluid ; the second is heavier, and sinks, so that extension of the analgesia above the point of injection, or limitation to the areas below, may be secured by selecting the appropriate solution and by elevating the head or the pelvis of the patient. The spinal cord ends at about the level of the disk, between the first and second lumbar vertebrae ; below this is the cauda equina. The second lum- bar interspace is a favorite site for injecting the spinal anaesthetic when it is desirable to secure a loss of pain sense in the perineum, external genitalia, and lower abdominal wall. If the upper abdomen is to be invaded or the incision is to reach as far as the umbilicus, the injection must be made in the first lumbar interspace. The technic is as follows : The patient is seated upon the side of the operating table with the legs hanging over ; the arms are folded over the lower abdomen ; the head is bent forward, and the back is arched. The skin surface is disinfected by the application of iodine and alcohol. The fourth lumbar interspace is located by so placing a towel that its edge runs across the line of the posterior iliac crests. This marks the fourth lumbar spine or the fourth lumbar inter- space. The second or the first lumbar interspace is now located, and the skin is marked at the lower border of the spinous process above it. After the mark has been made, the patient must be warned not to move. The needle is next thrust through the skin, about 2 mm. to one side of the median line, and then pushed toward the spinal canal, being held perpen- dicularly to the surface. It is carried forward until the resistance of the ligamentum subflavum is felt, when the mandrin is withdrawn. As soon as the resistance of the ligament is overcome, the needle is pushed cautiously onward, a few millimeters at a time, until the slight resistance of the dura is felt. Puncture is often accompanied by a palpable snap, after which spinal fluid drops from the needle. The needle is carefully rotated, to make sure that the bevelled point is entirely through the membrane. The syringe, filled with the anaesthetic solution, is attached to the needle, and about 1 c.c of the spinal fluid is drawn into the barrel. The mixture of spinal fluid and stovain solution is now steadily and somewhat rapidly injected, the needle is quickly withdrawn, and the patient is immediately placed in the recum- bent posture, with the head slightly raised. Analgesia is usually complete 654 GYNECOLOGY by the time the operative area is prepared, which generally consumes from three to five minutes. If celiotomy is to be performed, the injection must be made in the first lumbar interspace. Injections in the second lumbar interspace occasionally produced analgesia as high as the umbilicus, but this is the exception, rather than the rule. The dose of the stovain solution is determined by the age and weight of the patient. The determination of the dose of stovain is one of the difficult problems connected with spinal anaesthesia. Even though the anaesthetic solution is composed after a set formula, its strength varies, either because the chemi- cal composition of the drug itself varies, or because its activity has been modified by sterilization. In a clinic where spinal anaesthesia is used con- stantly each new lot of anaesthetic ampoules must be tested in order to deter- mine the maximum and the minimum dose. The ampules as prepared for use contain 8 cgm. of stovain. The largest amount used in a series of gyne- cological operations was 6 cgm., but in most cases it was 4.5 and 5, or 5.5 cgm. No preliminary dose of morphine and scopolamine is given in the young. In those over thirty the average dose of morphine is 1/6 grain, and of scopo- lamine 1/150 grain. In some patients this has no appreciable effect, and the dose of one or both drugs may be repeated. This is determined by the condition of the patient (pulse, respiratory tract, pupils, etc.), and whether she is drowsy and inclined to sleep, or is wide-awake and nervous. It is an important part of spinal anaesthesia, therefore, to determine just how much morphine, scopolamine, and stovain are needed, for if too small a dose is given, anaesthesia will fail, and if too large a dose is administered the patient will be placed in great danger. Emphasis must be laid upon the necessity of immediately lowering the patient from the sitting position as soon as the injection is given. This. as is commonly the case, obtains particularly when a solution of lower specific gravity than the spinal fluid is used. If, under such circum- stances, the patient is allowed to sit up, or if she is permitted to lie down with the shoulders and head higher than the pelvis, the anaesthetic solu- tion will rise in the spinal canal and influence the higher nerve-roots. It should be remembered that in cleansing the syringe and the needle, alcohol should not be used, for it tends to diminish the specific gravity of the injec- tion, and may lead to a rapid diffusion. upward of the anaesthetic solution. Deaths on the operating table from spinal anaesthesia occur more fre- quently than in ether, chloroform, or nitrous oxide anaesthesia. Spinal anaesthesia is especially dangerous in patients with low pulse pressure. Not only the record of these accidents, but also the care that must be taken to guard against them, bears evidence of the dangers attending this method, and how constantly those who use it must be on their guard. Sudden death also occurs, but not so frequently, during the course of general inhalation narcosis. The greater risk in spinal anaesthesia is readily understood. If a patient under inhalation anaesthesia shows toxic symptoms, the anaesthetic can be withdrawn, whereas under spinal anaesthesia if toxic symptoms ap- pear, all that we can do is to tide the patient over until the effect of the anaesthetic has worn off. OPERATIVE TECHNIC 655 Nevertheless, in contrasting the mortality of spinal anaesthesia with that of ether and chloroform, one must not lose sight of the fact that post- operative morbidity and the number of deaths from pneumonia, kidney insufficiency, etc., are greater after ether or chloroform anaesthesia than after spinal anaesthesia. Post-operative deaths and post-operative morbidity as the result of the administration of ether are undoubtedly much greater than is generally supposed. Gellhorn, in a recent paper on Spinal Anaes- thesia, says : " There are no statistics in existence which give a true picture of the alleged harmlessness of the open ether-inhalation narcosis. The exact number of fatalities due to ether will never be known, nor has the role of ether in the causation of post-operative complications which injure life and health of the patient ever been exhaustively considered. Few men have the courage to publish their failures, and the medical journals, as Sellheim remarks, serve as a medium for recounting accidental success rather than the reverse." MULTIPLE OPERATIONS It is frequently desirable, or even necessary, to perform a number of operations at one time. Thus, not uncommonly, a dilatation of the cervix, curettement, trachelorrhaphy, or trachelectomy, anterior and pos- terior colporrhaphy, and a round-ligament suspension of some variety are performed at the one operation. Very often, in addition to the plastic operations mentioned, the sphincter ani may be stretched, a fissure incised or curetted, or hemorrhoids removed. After the abdominal cavity is opened it may be found desirable to remove a tube, an ovary, or the appen- dix; there may be intestinal adhesions to be divided (Lane's kink) and even gall-stones to remove. To what extent these multiple operations should be carried depends upon the condition of the patient, the urgency with which each of them is demanded, and the skill and speed of the operator. When it is inadvisable to correct all. the abnormalities existing, those giving rise to the most pressing symptoms should be selected. If, by careful examina- tion, the operator has acquainted himself with the amount of surgery that needs to be done, he can usually so modify or hasten his operative pro- cedures as to accomplish them all without detriment to the patient. Thus, if the examination under ether just previous to operation has shown that, in addition to plastic operations, the patient requires an intrapelvic opera- tion of considerable magnitude, the simplest and most rapid methods for the plastic work should be adopted. This possibility means, in a few cases, a less complete restoration of the parts than if undivided attention had been given to the plastic work, and yet it will be vastly better than to neglect this aspect of the case entirely. Familiarity of the operator with his sur- roundings and assistants will be conducive to speed, and the opposite, of course, is true. It is unwise, when the abdomen is opened for other purposes, invariably to remove the appendix, regardless of its condition and of that of the patient. Gall-stones, if quiescent, should not be removed if the addi- tional time under anaesthesia required would be of detriment to the patient. It is better deliberately to plan two operations on the same patient than to jeopardize her life by attempting to do too much at one time. 656 GYNECOLOGY OPERATIONS DURING PREGNANCY It need not be stated that operations should, if possible, be avoided during pregnancy. Nevertheless, there are certain diseases that demand operation as soon as they are discovered, and other conditions are encountered that may re- quire operation if pregnancy is to continue or to terminate successfully. In the first class are malignant growths and acute intra-abdominal or pelvic disorders. Among them may be mentioned carcinoma of the cervix, acute appendicitis, tor- sion or rupture of an ovarian cyst, or torsion of a pedunculated myoma. In this condition pregnancy does not constitute a contraindication to operation ; indeed, pregnancy makes the operation even more imperative. The exact procedure in such cases will depend upon the month of pregnancy. If the child is viable, Csesarean section should precede a hysterectomy for carcinoma. If the woman is in the last month of pregnancy, a small muscle-splitting incision may be successful in exposing and permitting removal of a clean appendix, and the woman may be allowed to go to term ; if, however, a larger median or muscle-splitting incision is required, Caesarean section is advisable. Ovari- otomy for twisted or ruptured ovarian cyst at or near term should be fol- lowed by Caesarean section. In the earlier months both operations may be undertaken with the least possible disturbance of the uterus, and the administration of bromides and morphine should constitute a part of the post-operative treatment. The most difficult cases in which to reach a decision are those of suppurative appendicitis with spreading peritonitis, in which drainage must be instituted, and in which Caesarean section adds decidedly to the risk of sepsis. This is really a problem of obstetrics. DeLee declares that a mild attack of appendicitis should always indicate an operation within the first five months of pregnancy. Only perforating cases should be operated on within the last four months, and then as soon as the condition is diagnosed. In cases of doubt, operation is the safer course. Every effort should be made to prevent premature labor. Should it, how- ever, set in, it should be allowed to run as natural a course as possible. If abortion is impending at the time of operation the uterus should first be emptied and then drainage of the abdomen carried out. DeLee believes that the question of a Porro Caesarean section at the time of operation on the appendix must be considered. The plan of Gerster should be borne in mind. This observer first re- moves the appendix and packs the diseased area or abscessed cavity with gauze, over which he tightly closes and seals the abdominal incision with collodion. The patient is then delivered in the ordinary way, and after labor is completed, the sutures are removed and drainage instituted. Another problem is presented by the adherent and pregnant, retroverted and retroflexed uterus, or by a pregnant uterus that is securely anchored to the anterior abdominal wall. In the first case it is best to treat the patient expectantly, for the adhesions sometimes stretch as the uterus enlarges. The outlook is improved by the regular use of the knee-chest position (five minutes), followed by the Sims' position for twenty minutes three times a day. Although an operation could be performed and the uterus restored to its normal position, miscarriage is very apt to follow, and a recent opera- OPERATIVE TECHNIC 657 tion on the uterine ligaments would increase the difficulties of handling an abortion. If abortion occurs while the expectant plan is being pursued, the uterus can be cleaned out, if need be, without danger, and an operation to correct the malposition carried out at a later date. When the pregnancy takes place in a uterus that is fixed to the abdominal wall, the patient should be carefully observed — in a certain proportion of cases the attachment will stretch and the pregnancy go on. If abortion occurs, the case should be handled secundum artem; later an operation for the release of the uterus should be advised. If the case progresses to term, any dystocia should be promptly met with Csesarean section or other suitable operative procedure. DRAINAGE Drainage after intraperitoneal operations is employed much less fre- quently than formerly. This is due partly to the improved technic and to the selection of cases at a more favorable stage for operation. It is also partly due to the disadvantages incident to drainage, viz., a more pro- longed convalescence, repeated dressing of the wound, which may be pain- ful, and faulty healing of the incision, predisposing to hernia. The first drains were used for the purpose of removing what was believed to be septic fluid from the site of operation. This is the original and more common idea in the use of a drain following operation. In addition to being useful for the purpose of removing infectious products and directing the flow of toxic fluids externally, thus preventing their absorption by the peri- toneum, a drain also serves the purpose of what may be called a protective pack ; in other words, by virtue of the adhesions that form about the drainage mate- rial within six or eight hours, the drain effectually shuts off the healthy peritoneal cavity from the operative or infected region. There should, therefore, be a distinction between a drain and a protective pack. Drainage, in the true sense of the word, may be maintained for some time from an encapsulated abscess or from a hollow viscus, such as the gall-bladder, but in any other position after a short period a drain becomes a protective pack. It serves, therefore, no longer as a drain for anything more than the fluids that are thrown off by the surface immediately in contact with it. As it is impossible, for this reason, to drain the peritoneal cavity for any length of time, all drainage after a brief period, becomes a protective pack. It is true, however, that during this short interval drains may serve their purpose of removing toxic fluids and preventing their accumulation in the peritoneal cavity. The absorption of toxic products from the peritoneal cavity has been shown by a number of investigators to be most active in the upper part, toward the diaphragmatic area. The peritoneum possesses naturally a considerable amount of resistance to infection, and this resistance is enhanced by the omentum, which quickly adheres to and surrounds inflamed and infected areas, and helps to destroy infectious material or to neutralize it, by throwing out large numbers of white blood-corpuscles, which have a phagocytic action and encapsulate or destroy bacteria. Since, as has been stated, the upper part of the peritoneal cavity is the most active area of absorption, and since the use of drains in an endeavor to drain the entire peritoneal cavity is no longer considered reasonable, postural drain- 42 658 GYNECOLOGY age is becoming the common method of dealing with intraperitoneal infec- tions ; in other words, although we cannot drain the entire peritoneal cavity by means of drainage-tubes of any variety or in any position for any length of time, by elevating the trunk of the patient intraperitoneal fluids may be made to gravitate toward the pelvis, where absorption of toxic products will be at a minimum, where, from the anatomy of the abdominal cavity septic products are most likely to be encapsulated, and where they will interfere less with the functions of digestion and assimilation. If, then, in combination with posture, a drain is placed at a dependent point, actual drainage will occur during the first six or eight hours, and thereafter a drain will serve the purpose of a protective pack. In many cases this is all that is required to turn the tide of battle between the toxic products of the infec- tion and the vital resistance of the patient in favor of the latter. At the present time drainage is rarely used except in acute conditions of the pelvis or the abdomen. As it is a well-established practice at the present day to avoid operation during the acute stage of gonorrhoeal and other forms of pelvic peritonitis, and as operation is not performed in the presence of puerperal infection, except when a rapidly spreading general peritonitis or a localized collection of pus is present, drainage will be demanded only in cases of spreading peritonitis caused by perforation of the appendix, a duodenal ulcer, or similar conditions. In a spreading peritonitis, whatever the cause, the operation must be performed rapidly under that form of anaesthesia which will produce the least depression and lowering of the vital resistance. The infected focus should be removed with as little disturbance and manipu- lation of the surrounding parts as possible. One or two drains should be placed in the most dependent part of the abdomen or pelvis, and the patient placed in the sitting position. In the course of the ordinary pelvic opera- tions drainage need be used only in exceptional cases. Such cases may be. divided into three groups, as follows : (i) When the small intestine, the rectum, or the sigmoid has been in- jured in the separation of adhesions and there is doubt as to the security of the sutures closing the rent. (2) When a large amount of exudate or a considerable portion of an abscess sac must be left behind. (3) To favor hsemostasis and to provide free exit in case of extensive oozing. In the case of intestinal injury the greatest care should be observed to render the intestinal sutures absolutely secure, in which case, of course, a drain will be unnecessary. If a drain is used, it should be so disposed that it does not come in contact with the row of sutures, otherwise the drain may actually interfere with perfect union. The second group of cases is very exceptional, but may be found in puerperal or post-abortal cases of pelvic inflammatory disease. Under such circumstances the broad ligament is often markedly thickened and infil- trated, and the raw surfaces exposed cannot be satisfactorily covered by peritoneum. As such surfaces will necessarily " weep " and discharge septic fluid into the pelvis, a drain or a protective pack is introduced to carry this fluid away externally, so that it neither accumulates in the pelvis, OPERATIVE TECHNIC 659 where it might set up peritonitis, nor is absorbed in the general circulation., where it might produce a toxaemia. Whenever practicable, pelvic drainage should be conducted through Douglas' pouch. The opening between the vagina and Douglas' sac may be made by having an assistant pass a pair of long curved artery-forceps to the posterior vaginal cul-de-sac. The blades are then separated laterally for about an inch, and the operator makes an incision directly between them. One end of the rubber drainage-tube with a gauze wick is then pulled into the vagina with the aid of forceps. In some cases drainage through the posterior vaginal incision will not be so feasible as drainage immediately above the symphysis. Fig. 492. This will be true when the surfaces to be drained or excluded are high, also when the drain is used for the control of hemorrhage and when haste is necessary. Under such circumstances rub- ber tubing with gauze wicks should be used, or the gauze should be sur- rounded with rubber-dam, so as to prevent the formation of adhesions between the drain and the surrounding intestines, and thus facilitate removal of the gauze. Care should be taken that the incision is not closed tightly about the point of exit of the drain. In acute appendicitis with abscess or spreading peritonitis, a rubber tube with a gauze wick should be passed to the bottom of Douglas' pouch, and another one to the most involved area in the right iliac fossa. It may be advantageous to bring this drain out through a stab wound in the loin, directly above the crest of the ilium, and an inch and a half behind the anterior spine, especially when the damaged area lies to the right of the caecum or beneath it. Gall-bladder and Gall-duct. — It is always advisable to drain the gall-bladder after performing cholelithotomy. This should be done by fastening a piece of rubber tubing, about the caliber of a lead pencil, in the center of the gall- bladder incision. The tube should be fixed and the remainder of the in- cision into the gall-bladder closed with catgut sutures. A circular suture of catgut is now placed around the gall-bladder about an inch below its summit, and the gall-bladder inverted as the suture is tied. This prevents leakage, and when the rubber tube is removed, serous surfaces will lie in apposition and union rapidly take place. It is not necessary and quite un- desirable to attach the gall-bladder to the peritoneum of the abdominal in- cision. (The tube is usually removed about the tenth day, when the catgut sutures are absorbed.) If the gall-bladder is infected or the surrounding parts have become soiled, a cigarette drain should be placed in the peritoneal cavity below the gall-bladder. After simple cholcdochotomy the incision in the common duct may be closed, and drainage provided through the gall-bladder. When the gall- ducts are infected, a rubber tube should be passed upward toward the hepatic ducts, and fixed in the line of incision with a catgut suture. After cholecystectomy a drainage-tube should be inserted down to the stump of the cystic duct. After an operation for perforating ulcer drainage will be indicated at the site of the lesion and elsewhere, if there has been extensive soiling of the 660 GYNECOLOGY peritoneum. Drainage may not be required if the case is operated on within six hours. When, however, twelve hours have elapsed, it is safer to employ drainage. Pancreas. — Drainage should be employed in connection with every form of surgical operation on the pancreas. According to Moynihan, the only exceptions to this rule are cases in which no pancreatic fluid has escaped during the procedure, and the peritoneal incision used to expose the pancreas has been closed by suture. Kidney. — A paranephric abscess demands free drainage. After aseptic cases of nephrotomy, pyelotomy, or nephrolithotomy, when the kidney in- cision is clean cut and can be accurately approximated, no drainage is re- quired. If the incision is ragged or if there has been much traumatism, the paranephric tissues should be drained. Septic cases require drainage of the kidney wound itself and of the paranephric fat. After ureterotomy for stone or stricture, if the wound is ciean and well approximated, no drains are necessary, but otherwise a small rubber tube should be fixed at some distance from the line of sutures. Bladder. — Drainage of the female bladder is required after operation for vesical stone and fistula, and is readily accomplished by the introduction of a self-retaining (mushroom) catheter through the urethra. If the bladder is greatly inflamed and complete and constant drainage is desired, the organ should be opened at its base by an incision through the anterior vaginal wall. The vesicovaginal fistula thus made is kept open by the introduction of a mushroom catheter or by uniting the vesical to the vaginal mucosa. Post-operative Care in Drainage Cases. — Gauze packing introduced into the vagina or the uterus for the purpose of controlling hemorrhage should be removed w T ithin from twenty-four to thirty-six hours. Twenty-four hours after the introduction of gauze and rubber drains into the peritoneal cavity for the purpose of controlling hemorrhage, both the gauze and the rubber tubing may be removed, and the incision closed by tying the suture or sutures previously placed for that purpose. In cases of pelvic or abdominal infection drains must be allowed to remain much longer. The gauze inlays, if they fit the rubber tube loosely and do not project beyond it, should be removed at the end of twenty-four hours/ The rubber tubes are left in place until the fifth post-operative day. At that time the tubes are started (loosened), and every day after this an inch or more is cut off. The abdom- inal wound is dressed daily, particular care being used to keep the line of incision clean. It is advantageous to moisten the layers of gauze cover- ing the incision and the layer covering the drainage-tubes with a I : 2000 solution of mercury bichloride. When gauze has been used in septic cases without a protecting rubber envelope, as in vaginal drainage into the pouch of Douglas, or when the gauze w T icks project considerably beyond the ends of the tubes, no attempt should be made to remove the gauze for from five to seven days. After this period a little at a time may be gently loosened each day, pulled out, and cut off. No force dare be used. Gauze drains loosen about the time they should be removed. Undue haste will break up protecting adhesions and may OPERATIVE TECHNIC 661 cause an extension of the infection and peritonitis. Solutions of any sort must never be injected into an intra-abdominal drainage tract. Gall-bladder or bile-duct drainage is usually maintained for about ten days ; after this the tubes are gently tugged upon each day until they come away easily. In infected cases the drainage is allowed to remain for a longer time, or until the symptoms subside. Intraperitoneal drains intro- duced in connection with gall-bladder or gall-duct operations are treated in the same way as intraperitoneal drains in other localities. Kidney drainage, in septic cases, is continued until the symptoms sub- side and the wound is clean. When drains have been introduced for the purpose of effecting hsemostasis they may be removed at the end of twenty- four hours. (For a description of enteroclysis, which is frequently invalu- able when combined with drainage, see Chapter XXXVII, page 667.) BIBLIOGRAPHY Axspach, B. M. : " Experiences with Spinal Anesthesia in Pelvic Surgery." Amer. Jour. Obst., 1914, lxix, 3. Baldy, J. M. : "Surgical Injuries to the Ureters." Amer. Gyn. and Obst. Jour., 1894, v. Bevax, A. D. : " The Choice and Technique of the Anesthetic." Jour. Amer. Med. Assoc, 1915, lxv, 1418; Ibid.: "On the Surgical Anatomy of the Bile-Ducts and a New Incision for Their Exposure." Annals of Surgery, 1899, xxx, 15. Bovee, J. W. : "Complete Sterilization of - the Skin by Iodine." Trans. Amer. Gyn. Soc, 1914, xxxix, 379 ; Ibid. : " An Investigation of the Use of Iodine in Skin Sterilization for Surgical Purposes." Amer. Jour. Obst., 1911, lxiv, 91-106; Ibid.: "The Influence of the Trendelenburg Position on the Quantity of Urine Excreted During Anesthesia." Trans. Amer. Gyn. Soc, 1910, 443. Clark, J. G. : " A Critical Review of Seventeen Hundred Cases of Abdominal Section from the Standpoint of Intraperitoneal Drainage." Amer. Jour. Obst., 1897, xxxv ; Ibid. : " Intraperitoneal Drainage." Amer. Jour. Obst., 1897, xxxv, No. 4, 481. Coffey, R. C. : " Abdominal Adhesions." Trans. Sect. O. G. and A. S., A. M. A., 1913, 201. Crile, Lower : Anoci — Association. Saunders, Philadelphia, 1914. Farr : " Local Anesthesia in Abdominal Surgery," Trans. Sect. O. G. & A. S., A. M. A., 1917, 164. Fixdley, P. : " Appendicitis Complicating Pregnancy, Labor, and the Puerperium." Amer. Jour. Obst., 1909, lx, 993. Fowler, G. R. : " The Toilet of the Peritoneum in Appendicitis." Trans. Amer. Surg. Assoc, 1903, xxi. Fowler, R. S. : The Treatment of Diffuse Septic Peritonitis Following xAppendicitis." New York Jour. Med., 1907, vii ; Ibid. : " Results in Diffuse Septic Peritonitis Treated by the Elevated Head and Trunk Pos-ition." Med. News, May 28, 1904. Franz, K. : " Die Schadigungen des Harnapparates nach abdominalen Uteruskarzinom- operationen." Zentralbl. f. Gyn., 1909, 601. Gellhorn, G. : " Spinal Anesthesia in Gynecology." Trans. Amer. Gyn. Soc, 1914, xxxix, 212. Gerster, O. G. : " On the Technical Considerations Influencing the Surgical Treatment of Appendicitis Occurring During Pregnancy." Phila. Month. Med. Jour., March, 1899, 170. Grassich, A. : " Eine neue Sterilizierungs Methode der Haut bei Operationen, Vorlaufige Mitteilung." Zentralbl. f. Chir., 1908, xxxv, 1289. Graves, W. P. : " Division of the Ureter in Pelvic Operation." Boston Med. and Surg. Jour., 1917, clxxvi, 149. Hertzler, A. E. : " Local Anesthesia in Prevention of After-Pain and Shock." Jour. Amer. Med.' Assoc, 1914, lxiii, 2037; Ibid.: "Quinine and Urea Hydrochloride as a Local Anesthetic." ' "Jour. Amer. Med. Assoc, 1919, liii, 1393. Howland, J., and Richards, A. N. : "Experimental Study of the Metabolism and Path- ology'of Delaved Chloroform Poisoning." Jour. Exper. Med., 1909. Judd, E. S. : " Transplantation of the Ureter Following Traumatism and Resection of the Bladder for Cancer." Surg., Gyn. and Obst., 1917, xxiv, 635. 662 GYNECOLOGY McArthur, L. L. : " A Modified Incision for Approaching the Gall-bladder." Surgery, Gynecology and Obstetrics, 191 5, xx, 83. McBurney : " The Incision Made in the Abdominal Wall for Appendicitis, with the Description of a New Method." Annals of Surgery, 1894, xx. Mayo, W. J. : " The Incision for Lumbar Exposure of the Kidney." Annals of Surgery, 1912, lv, 63. Mayo-Robson, A. W. : " Modifications and Improvements in Operations on the Biliary Pas- sages." Brit. Med. Jour., January 24, 1903, 181. Murphy, J. B. : " Diffuse Suppurative Peritonitis." Trans. Amer. Assoc. Obst. and Gynecol., 1906, xix, 176. Noble, C. P. : " Overlapping the Aponeuroses in the Closure of Wounds of the Abdominal Wall." Annals of Surgery, March, 1906, 349. Norris, R. C. : " Operations During* Pregnancy." Chap, xxviii, Kelly-Noble Gynecology, vol. ii, Phila., Saunders, 1907. Olshausen : " tJber die Drainage." Zeit. f . Geb. u. Gynak., 1903, xlviii. Peaslee : " Infections into the Peritoneal Cavity after Ovariotomy." Amer. Jour. Obst., 1871, iii, 300. Pfannenstiel : " liber die Vortheile des suprasymphysaren Fascienquerschnitt fur die gynakologischen Koliotomien, zugleich ein Beitrag zu der Indikationsstellung der Operationswege." Samml. klin. Vortr., Leipzig, 1900, No. 268. Sampson, J. A. : " Ligating and Clamping the Ureter as Complications of Surgical Opera- tions." Amer. Med., 1902, lv. Scheib, A. : " Klinische und anatomische Beitrage zur operativen Behandlung des Uterus Carcinoms." Archiv f. Gyn., 1909, lxxxvii, 1-233. Stoeckel : " liber die Behandlung des Verletzten und Unverletzten Ureters bei Gynakolo- gischen Operationen." Zeit. f. Gyn., Urologie, 1911, Bd. iii, S. 51. Sweet, J. E., Chaney, R. H., Wilson, H. L. : " Prevention of Post-operative Adhesions in Peritoneal Cavity." Annals of Surgery, 191 5, lxi, 300. Teter, C. K. : " Nitrous Oxid-Oxygen in General Surgery and Obstetrics." Lancet Clinic, Cincinnati, O., 1914, cxii, 627. Trendelenburg, F. : " liber Blasenscheiden — Fistel Operationen, und liber Beckenhoch- lagerung bei Operationen in der Bauchhohle." Volkmann's Sammlung klinischer Vortrage, 1890, No. 355 (Chirurgie No. 109). Whipple, G. H., Sperry, J. A. : " Chloroform Poisoning, Liver Necrosis and Repair." Bulletin Johns Hopkins Hospital, September, 1909. CHAPTER XXXVII POST-OPERATIVE TREATMENT Nausea and Vomiting. — After ether, and to a less extent after chloroform anaesthesia, there may be considerable nausea and vomiting; this usually subsides in from six to eighteen hours. It may be difficult to relieve. The patient should be carefully observed, so that none of the vomitus is aspi- rated into the trachea. For this reason, during the retching and straining, the head of the patient should be turned to one side, the angles of the jaws pressed forward, and the mouth held open, in order to permit ready escape of the regurgitated material. Most patients complain of thirst, but water, except in small amount, is promptly ejected from the stomach. Where the vomiting is not attended by danger to the patient, she should be encour- aged to drink freely of warm water containing a little (2 per cent.) bicar- bonate of soda or common salt. This is either quickly rejected by the stomach, or passes through the pylorus into the bowel. In either case relief will be obtained, which may indeed be but temporary, so that the expedient may have to be repeated when the retching and nausea return. If it is especially desirable to keep the patient quiet and to avoid violent contractions of the diaphragm and the abdominal wall, then one gives no water by mouth but relieves the thirst, as far as possible, by applying cold compresses to the lips and giving small bits of cracked ice. In the mean- time enteroclysis, with 2 per cent, soda bicarbonate solution, will gradually relieve the intense thirst. Thirst. — Post-operative thirst may be in a measure anticipated by intro- ducing a quart or two of 2 per cent, soda bicarbonate solution into the sigmoid and colon before the patient leaves the operating table. The enteroclysis may be repeated at intervals of from three to six hours, from eight ounces to a pint of solution being used at a time. The solution is run slowly into the rectum through a soft-rubber catheter ; this can be accom- plished easily in thirty minutes, when the catheter should be removed. For most patients interrupted is more comfortable than continuous enteroclysis. After the patient is able to take fluids by the mouth, the quantity and fre- quency of the saline infusions may be reduced. Pain. — When morphine and atropin are given routinely either be- fore or immediately after operation, the patient does not complain much of pain within the first few hours. As a rule, she sleeps or is drowsy. If, after the patient is well out of the anaesthetic and the effect of the hypo- dermic injection has worn off, there is marked pain, or if she is restless or apprehensive, heroin in 1/12 grain doses by hypodermic injection may be given, and repeated as required, but at most not oftener than every three hours. By this means the patient is kept quite easy during the first twenty- four hours, and in the majority of cases is spared the great distress and discomfort which would otherwise follow. 663 664 GYNECOLOGY Diet. — Immediately after operation the patient has no desire for solid or semi-solid food ; but there is a great craving for liquids, and after the first six or eight hours, or as soon as the stomach displays a tendency to be retentive, the patient should be allowed small sips of plain hot water, albumin water, milk and lime water (equal parts), or buttermilk or weak tea (i to 4 drams every half hour). As the stomach becomes more reten- tive, the amount taken may be increased to I to 2 ounces every hour. Dur- ing the first three days of the convalescence nothing but fluids should be given, but after the third day, if the bowels have been moved satisfactorily and the patient manifests no disquieting abdominal or general symptoms, soft, semi-solid food may be given, and in the course of two or three days more this may be increased to the regular house diet. Departures from this course must be made under some circumstances. If the operation has involved the upper part of the alimentary canal, the amount of liquid taken by the mouth must be restricted, the thirst and crav- ing for liquids being assuaged by the use of soda solution introduced into the bowel. When the operation has involved the lower part of the intestinal tract, there is little danger from the use of liquids by the mouth, even in considerable quantities, but if the colon, or especially the sigmoid flexure or the rectum, has been affected, enteroclysis must be avoided. After com- plete tear operations, or when it is desirable to avoid abdominal distention or the use of enemas or purgatives for a considerable time, the diet should be restricted entirely to albumin water, which is readily absorbed and quite fully digested, so that little residue is left in the bowel. Bowels. — In the average patient (drainage cases and complete tear operations excepted) it is Avell to leave the bowels undisturbed until seventy- two hours have elapsed from the time of operation, when a simple enema, con- sisting of soapy water (1 to 2 pints) may be given. This usually has the desired effect, the bowels moving freely and considerable gas being expelled. If the simple enema is not effectual, a compound enema (Epsom salts, 2 ounces; glycerine, 2 fluidounces ; sweet oil 4 fluidounces ; water, sufficient to make 1 pint) should be introduced through a tube, passed into the sig- moid flexure; or an enema of glycerine (4 ounces) or one of alum (1 to 4 drams to 1 pint of water) may be tried. Plenty of time should be given for one enema to act before another is ordered. The patient may be much distressed by too great haste. For the first five days the bowels should be moved daily with an enema. At the end of that time when the temperature is normal and there are no indications of peritonitis or obstruc- tion of the bowel it is well to give the patient some simple laxative every night (paraffine oil, 4 drams with cascara, 2 grains or phenolphthalein, 2 grains), supplemented by an enema in the morning, if necessary. In drainage cases it is good practice to make no attempt to move the bowels for five days, the only indications for the use of the rectal tube or a simple enema being undue distention of the abdomen and inability of the patient to pass flatus. If the abdomen remains fairly flat and the patient does not complain of gas pains, it is well not to disturb her until the end of the fifth day, when an enema may be given. This should be repeated daily until the tenth day, when mild laxatives may be started (see page 665). POST-OPERATIVE TREATMENT 665 After complete tear operations, the bowels should be kept locked for a week, no enemas being permitted during that time, and the patient being allowed nothing but liquid food in minimum amount. About the fifth day, paraffin oil should be given in dose of 4 fluid drams three times a day, and on the seventh day, an ounce or two of castor-oil. Thereafter, the mineral oil should be continued daily combined with cascara or phenolphthalein. If, during the first post-operative week the patient becomes very uncom- fortable by reason of an accumulation of gas or faeces in the lower bowel, a small enema may be given through a soft-rubber catheter, well lubri- cated, and passed w T ith great care through the sphincter. During the insertion of the catheter, it should be pressed against the posterior com- missure so as to avoid the line of suture. The nurse must be carefully instructed upon this point. The use of cathartics immediately after operation is contraindicated. If the patient has been properly prepared, there is nothing in the intestinal tract that must be expelled at once, so that there is no need for active catharsis. On the contrary, it is generally better to limit peristalsis for the first forty-eight hours. This is particularly true if there is imminent danger of peritonitis, for then peristaltic action will tend to spread infec- tion. Cathartics are capable of much mischief if there is partial obstruc- tion or a kink in the bowel or if the integrity of the alimentary tract has been threatened by the operation. In other words, in the early post-opera- tive days cathartics are troublesome and produce discomfort ; they are unnecessary, and they are often harmful. Their use should be avoided until the danger of peritoneal and gastro-intestinal complications is over. After the bowels have been well moved by enemas, the temperature and the peristalsis have returned to normal, and the patient takes food without discomfort, a mild laxative may be employed daily if necessary. Bladder. — The urinary excretion is always diminished after opera- tion because of the restriction of liquids and the thorough evacuation of the intestinal tract previous to anesthetization. If salt solution has been given subcutaneously or soda solution has been injected into the bowel, at the close of the operation the urinary excretion will be increased, but it rarely exceeds 24 fluidounces during the first post-operative day ; after this, in normal cases, it increases with the amount of liquids ingested. As so many gynecologic operations involve the bladder or its neighboring structures, it is generally advisable to avoid any great distention of the bladder within the first few days of the operation. It is a good rule, there- fore, to have the patient void urine or to catheterize her within eight hours, and to repeat the process at eight-hour intervals. After suspension of the uterus, operations for shortening the round ligaments, extensive operations for cystocele, etc., the bladder should be emptied every six hours during the first two days. If the amount excreted during the first twenty-four hours falls below 16 fluidounces, the urine should be examined and a careful investigation made for possible sources of suppression or retention. Most patients are able to empty their bladder voluntarily after the second or third day. There are some exceptions, however, in which repeated catheter- ization is necessary for a week or more. Taussig showed that retention 666 GYNECOLOGY was most common after interposition operations for prolapse and radical operations for cancer of the cervix. He says that the important factors in urinary retention are interference with the blood-supply of the bladder, direct or indirect pressure or irritation about the urethral sphincter, excision of the nerve supply of the bladder, and interference with the control of the central nervous system, through anaesthetics, narcotics, or mental pro- cesses. As the continued use of the cathe- ter predisposes to cystitis, the patient should be encouraged to void urine volun- tarily ; during the effort an elevated pos- FiG. 494. — Enteroclysis ap- paratus with visible drip. Fig. 495. — Visible drip glass con- necting tube. ture may be assumed and will often prove helpful ; the sound of running water acts sometimes as a suggestion. Late in the convalescence the patient may be allowed to step out of bed and use a commode. Injec- tions of the extract of the pituitary gland (pituitrin, 1 ampoule) will often stimulate the smooth muscle-fiber of the bladder sufficiently to bring about evacuation of the bladder. The sphincter muscle of the bladder is some- POST-OPERATIVE TREATMENT 667 times relaxed by a low enema of warm saline solution, and this may have the desired result. A plan that is sometimes successful consists in inject- ing into the bladder, when the patient expresses a desire to void urine, one ounce of sterile glycerine. If no result follows the first effort, it may be repeated several times, since it does no harm. If there is no result within thirty minutes of the injection, the patient should be catheterized. The most scrupulous care must always be taken in performing catheterization in post-operative cases. Fig. 496. — Bed with head elevated. Enteroclysis is an important part of the after-treatment in many cases. Two per cent, sodium bicarbonate solution, normal salt solution, or tap water may be used. Ordinarily, sodium bicarbonate (2 per cent.) solution is preferable. The solution may be thrown into the bowel at the close of the operation in one large injection (1 to 2 liters) while the patient is still under the influence of the anaesthetic, or it may be given later by continuous or interrupted enteroclysis. Enteroclysis is a valuable method of supplying fluids to the body when they cannot be ingested or when it is inadvisable to give them by the mouth. 668 GYNECOLOGY By the term continuous enteroclysis is understood the continuous intro- duction of solution in quantities proportionate to the rate of absorption. By interrupted enteroclysis is meant the introduction into the rectum, at inter- vals, of fluid in such quantity as can be retained comfortably and readily absorbed within an estimated period of time. For either method a small rubber catheter is passed as high into the rectum as it will go without causing discomfort, and attached to a reservoir containing the solution. In continuous enteroclysis a visible drip may be used, so that the rate of flow can easily be regulated ; this is done either by compression of the hose or by the degree of elevation of the reservoir. Thirty drops a minute amount to nearly six pints in twenty-four hours. By the interrupted method one pint of solution may be run into the bowel immediately after the operation ; from eight to twelve ounces may be slowly introduced every three hours, about a half hour being consumed with each injection. Fig. 497- — Fowler bed. In desperate cases continuous enteroclysis will be the most satisfactory method, whereas for the ordinary post-operative treatment, the interrupted form will be associated with less discomfort to the patient. As convalescence progresses, the frequency of the rectal infusion may be lessened as the intake by the mouth is increased. Posture. — During the first post-operative hours the patient is al- lowed to remain flat on her back. When the effect of the anaesthetic begins to wear off the trunk should be elevated (Fig. 497). This may be accomplished in several ways : blocks may be placed under the head of the bed, a portable elevating frame may be placed on the bed, or the shoulders and head may be raised with pillows. In any of these plans the tendency of the patient to slip down may be combatted by placing a sand-bag and pillow beneath the buttocks ; these are held in place with a length of stout muslin bandage fastened to the frame of the bed. Such elevation of the trunk and support of the buttocks are much facilitated when the bed is fitted with a Gatch frame, as shown in Fig. 497. POST-OPERATIVE TREATMENT 669 Elevation of the trunk or the Fowler position is more conducive to com- fort than the horizontal position. It promotes the drainage of peritoneal fluids into the pelvis, localizes peritoneal infection to that region, and hin- ders the development of a general peritonitis. In cases of threatened cardiac 1 dilatation it relieves the congested right heart. It also prevents hypo- static congestion of the lungs. Elevation of the pelvis, or the Trendelenburg position, which is the opposite of the Fowler position, is used as a post-operative measure only in shock and cardiac failure from hemorrhage. In this position the weight of the venous column of blood upon the right heart promotes contraction of that organ and stimulates the circulatory function ; it is never used for any length of time. As soon as reaction is established the Fowler position is resumed. In cardiac failure from right-sided hypertension or dilatation, this posi- tion is contraindicated. Under such circumstances the Fowler position should be instituted at once (see Post-operative Cardiac Dilatation, p. 692). Out of Bed. — Following the average laparotomy or perineal operation, the patient is permitted to get out of bed on the tenth day- In the case of extensive plastic and suspensory operations this may be delayed until the fourteenth day. In all cases in which convalescence has progressed normally the patient may walk about at the end of two weeks and from that time onward gradu- ally resume her usual activities. Six weeks should be allowed for complete convalescence, and strenuous exercise and hard work should be avoided for at least that period. Dressing the Incision. — Unless there are symptoms of infection or hemorrhage, the celiotomy incision should not be disturbed for a week or ten days. At that time the wound is inspected, non-absorbable sutures are removed, the skin is cleansed with alcohol, and a fresh dressing is applied. The wound should be protected with a gauze dressing until healing is complete and the scar is smooth and dry. CHAPTER XXXVIII POST-OPERATIVE COMPLICATIONS SHOCK Cause. — Shock is the depressing influence on the cerebrospinal system that results from hemorrhage, prolonged anaesthesia, severe pain, extensive trauma, and exposure and handling of the abdominal viscera. The effect is believed to be brought about by afferent nerve impulses or by impoverish- ment of the circulating blood. The most frequent cause is loss of blood, but all the other factors play a part, and occasionally they play the leading role. The pathologic condition is not definitely known ; but an anaemia of the brain, a loss of control of the vasomotor centers, a diminution in the tone of the blood-vessels, an accumulation of the blood in the larger venous trunks of the splanchnic plexus, and a weakening in the force of the circulation are said to be present. Shock is observed during, immediately after, or within a few hours of operation. Symptoms. — The symptoms of shock are pallor and cold perspiration ; the pulse is rapid, weak, and easily compressed, and in severe cases it is almost imperceptible ; the respirations are rapid and shallow ; the face is ex- pressionless ; the jaw drops, the eyes are dull and staring, the pupils react very slowly, and the temperature is one or two degrees below the normal. Shock must be differentiated from secondary hemorrhage and acute post- operative dilatation of the heart (see Hemorrhage, p. 6j2, and Acute Post- operative Dilatation of the Heart, p. 690). Treatment. — Treatment must be promptly and energetically applied. The foot of the bed should be elevated, the head and chest of the patient should be low, in order to favor the return of venous blood to the heart. If operative hemorrhage has been the cause, the lower extremities from the soles to the groins may be tightly bandaged. The patient should be surrounded by hot-water bottles and blankets ; in extreme cases massage and vigorous rubbing may do some good. Stimu- lants, such as extract of the pituitary gland (pituitrin, 1 ampoule), strychnine (1/30 to 1/15 grain), camphor (1 to 2 grains), in sterile sweet oil, should be administered hypodermically. A hot enema of black coffee is often of con- siderable benefit, and whiskey (1 ounce to 2 pints of saline solution) may be administered in the same manner. Hypodermoclysis, or the intravenous injection of normal saline solu- tion, is of the greatest value. The addition of suprarenal extract (adrenalin chloride, 5 to 10 minims to each pint of the salt solution) will help restore vasomotor tone. If the patient is restless or complains of pain while these procedures are being carried out. hypodermic injections of morphine and atropin may be used with great advantage. Improvement in the patient's condition may be rapid or slow, or the symptoms may become increasingly 670 POST-OPERATIVE COMPLICATIONS 671 worse and death ensue. If improvement sets in, the treatment just out- lined may be continued, guarding the patient against overstimulation. Shock may be avoided by carefully preparing the patient for operation, curtailing the anaesthesia, limiting the loss of blood, and avoiding as much as possible undue exposure and handling of important viscera (see Chapter XXXVI). HEMORRHAGE Varieties. — Hemorrhage following operation may occur in a number of forms. Thus it may be: (i) A slow, continuous ooze from the capillaries of a raw surface ; (2) a steady flow from a vein ; or (3) an active spurt from an artery. Post-operative hemorrhage may be a continuation of the hemor- rhage that took place at the time of the operation, and that was not entirely controlled, or it may be due to the slipping of a ligature some time later, or it may be the result of the infection and disintegration of an occluding thrombus. Capillary Oozing. — A certain amount of capillary bleeding is bound to occur when Extensive adhesions have been separated, and although the hemor- rhage usually ceases spontaneously, at times it persists in sufficient amount to re- quire treatment. Just to what extent this bleeding should be checked must be left to the discretion of the operator. The more actively bleeding areas should in- variably be controlled with mattress sutures ; for the less active ones, and for those in such a position that the application of sutures is impracticable or dan- gerous, compression for a few minutes with a sponge wrung out of very hot water will often suffice. In doubtful cases a safe plan is to use a gauze pack for twenty-four hours ; the objections to this plan are, however, as numerous as to drains in general. Nevertheless, if the oozing is free, a pack may be necessary. In the less marked cases, if it is certain that the main vessels have been tied securely, the oozing may be disregarded, the operator being justified in believing that a clot will form and the hemorrhage cease within a reasonable time. Occasionally, even under such circumstances it will continue, and a consider- able amount of blood accumulate in Douglas' pouch ; here it may be absorbed or encapsulated (hematocele). These cases do not, however, present the alarming symptoms of a secondary hemorrhage ; very often, unless infec- tion occurs, a slight increase in the pulse-rate being the only early symptom, and those attending the formation of a hsematocele the only late ones. Venous and Arterial Hemorrhage. — Venous and arterial hemorrhage is usually the result of the slipping, breaking, or premature absorption of a ligature. The most frequent cause of hemorrhage of this form is the tying of vessels or pedicles en masse and cutting too close to the ligature. If the pedicle is on tension, the straining incident to post-operative vomiting may release it from the grasp of the ligature. To avoid such a catastrophe, it is advisable to tie all large vessels individually in their course, or when tying en masse to transfix the stump, tie both ways, and leave the stump at least a centimeter in length and free of any tension. If catgut is selected as the ligature material, a gut that is not absorbed in less than ten days should be used, and all large vessels, such as the uterine and the ovarian, should be doubly secured. If silk is used, one ligature usually is sufficient, but in case of doubt, an additional one of catgut may be tied. 672 GYNECOLOGY Hemorrhage from cervical or vaginal wounds occasionally occurs as late as ten days or two weeks following operation, after absorption of the catgut, which either releases an arterial or a venous trunk or permits the sepa- ration of two surfaces, as, e.g., the lips of the cervix, whose vessels have been controlled by close approximation. Even when this occurs, if infection has not taken place, hemorrhage is unlikely to ensue. A vessel that has been secured successfully by an aseptic ligature is soon occluded by an obliter- ating angeitis, or by an aseptic blood-clot that undergoes organization within a short time, so that absorption of the ligature after ten days under normal conditions would make no difference. If, however, there has been an infection, or if the inner coats of the vessel beyond the point of ligation have been injured by compression, the obliteration is delayed or an infected clot is formed that is prone to undergo disintegration and to be discharged from the vessel, thus promoting hemorrhage. Hemorrhage after plastic operations is usually limited and readily con- trolled. Occasionally, because of the extensive loss of blood, the hemor- rhage may give rise to alarming symptoms, and owing to the narrowing of the vaginal introitus, the bleeding area may be hard to expose and the hemorrhage difficult to stop. If simple packing does not suffice, the patient should be placed in the lithotomy position, an anaesthetic administered if need be, the parts freely and carefully exposed and illuminated, and addi- tional sutures introduced to catch the bleeding points, Hemorrhage of the grave and serious type occurs from operative areas within the pelvis where the bleeding cannot be seen, and the general symp- toms are the only indication. Such hemorrhage may vary from an exceedingly rapid type in which the patient dies within thirty minutes, to those in w T hich the loss of blood is less rapid and the patient succumbs in the course of hours, or in the event of alternate clotting, and renewed bleed- ing in the course of days. Symptoms. — The most striking symptoms of this complication are a sud- den increase in the pulse-rate, with diminished volume, and a subnormal temperature. The patient may complain of severe pain at the site of the bleeding vessel. The face is pale and anxious, the respirations are hurried, and in severe cases the auxiliary muscles are called into play. The mind is clear, but the speech is hurried and broken, and the patient is restless. If the bleeding continues the pulse becomes imperceptible at the wrist; the skin is cold and clammy, the dyspnoea is marked, consciousness is lost, the pupils dilate, and death finally ensues. Diagnosis.— The symptoms are those of shock, already described (see page 671). Shock from hemorrhage and shock from other causes have few points of differentiation. Many cases of serious shock are in reality instances of hemorrhage. In true shock there is an accumulation of most of the blood in the splanchnic vessels. Whether or not hemorrhage is actually taking place may be judged best by the nature of the operation that has been performed, the care exercised, and the difficulty experienced in securing haemostasis. Other factors, such as the general condition of the POST-OPERATIVE COMPLICATIONS 673 patient previous to operation, the duration of the anaesthesia, and the amount of traumatism and exposure of the viscera, must also be taken into account, and will usually assist the examiner in reaching a correct diagnosis. Certain rapid cases of peritonitis may show symptoms closely resembling those of serious internal hemorrhage, but in the former there is usually a slight elevation of temperature and other signs, such as diminished peri- stalsis, which serve to distinguish between the two conditions. The appearance of the subcutaneous blood-vessels may help to dis- tinguish between a rapid, feeble pulse due to internal hemorrhage and one due to other causes. If the blood-vessels on the back of the hand, upon the forearm, at the bend of the elbow, and on the temples are well filled, it is unlikely that serious loss of blood has taken place. An estimation of the haemoglobin or a red and white blood count may also form a basis for differentiation. With a severe internal hemorrhage, all constituents except the leucocytes are greatly diminished ; in the presence of sepsis, there is no marked change in the haemoglobin and the red cells, but the white cells are increased in number. Treatment. — The treatment of in- ternal hemorrhage is that previously advised for shock, plus prompt liga- tion of the bleeding vessel or vessels. Cases of internal hemorrhage of mod- erate degree undoubtedly occur in which absolute rest and quiet, with gentle stimulation, will tide the pa- tient over the critical period and the bleeding will cease ; the attainment of so fortunate a result is never certain, and if the symptoms are marked and the diagnosis is reasonably positive, prompt action must be taken to secure the bleeding vessels. The patient should, with as little disturbance as possible, be placed upon an operating table, an anaesthetic administered, the dress- ings removed, the wound opened, and the pelvis well exposed, so as to learn, with the\east possible delay, the source of the hemorrhage. If the continu- ous bleeding makes it manifestly impossible to expose the operative area quickly, clamps may at once be applied by the sense of touch alone, upon the uterine, ovarian, and round ligament vessels on each side. If the patient is in a desperate condition and the bleeding point is situated deep in the pelvis, as after a total hysterectomy, the pelvis may be packed with gauze, a firm pack placed in the vagina, and suprapubic and perineal counter-pressure may be maintained for a time until clots have had time to form. This may be of no avail in the case of a spurting artery, but will often be useful in venous hemorrhage or in oozing. The intravenous injection of horse serum may be tried. Stimulation in a case of internal hemorrhage should be postponed until the bleeding vessel is caught (see also Extrauterine Pregnancy, page 373). 43 Fig. 498. — Portable heat cabinet, useful in treat- ment of pelvic inflammatory disease. 674 GYNECOLOGY EXCESSIVE NAUSEA AND VOMITING Etiology. — Nausea and vomiting are common after anaesthesia, but usually subside gradually within the first twenty-four hours. Occasionally they persist in an aggravated form for a much longer period, giving rise to considerable apprehension that all is not going well with the patient and that peritonitis or obstruction is impending. Although these symp- toms may actually be due to an incipient peritonitis that undergoes resolution, or to a partial slight obstruction that is subsequently relieved, they are apparently frequently due to a hypersusceptibility on the part of the patient toward emesis, and a marked aversion to ether or to the anaes- thetic that has been used. Nausea and vomiting have been ascribed to an increased action of the ether on the vomiting center in the medulla, or to an excess of mucus, which becomes impregnated with ether and is swallowed, giving rise to irritation of the gastric mucosa. Treatment. — As exaggerated nausea and vomiting may be an indication of serious post-operative disorders, such as acidosis or acute gastric dilatation, peri- tonitis, or obstruction, the following measures may be employed until the diagnosis is clear : Ice-bags should be placed upon the lower abdomen ; the patient should be kept in the Fowler position. If the abdomen is dis- tended, a simple enema may be given. When the distention involves the upper abdomen especially, the stomach-tube should be passed and lavage practised. The urine should be examined for acetone and diacetic acid, and if either is present, sodium bicarbonate, 10 grains, should be given by mouth every three hours, or continuous enteroclysis with a 2 per cent, solu- tion should be used. In desperate cases the intravenous injection of one pint of a 1 per cent, solution of sodium bicarbonate should be employed. Regardless of all treatment, and without the development of any serious disturbance, the vomiting may continue. Under such circumstances the plan previously outlined should be followed until the symptoms subside. Nothing should be given by the mouth except sufficient water to control the thirst. TYMPANITES Etiology. — Extreme distention may be an indication of peritonitis, obstruc- tion, or acute gastric dilatation. It may be; the result of a transient paralysis of the bowel following operations in which the intestine has been considerably handled, or it may result from chronic gastritis or enteritis, plus incomplete evacuation of the intestinal tract before operation, and subsequent fermentation. There is usually recurring colicky abdominal pain (gas-pains). The condition may be accompanied by other disturbing symptoms, such as increased pulse-rate, elevation of temperature, and nausea and vomiting, or it may exist alone. Treatment. — If peristalsis is normal, the distention may be regarded with equanimity, as it will usually be relieved promptly by a high compound enema and the application of heat to the abdomen. If violent peristalsis is present, so as to be audible to those about the patient, obstruction is quite possible, and the case assumes a more serious aspect, especially if other indications of obstruction, such as nausea and vomiting, are present. ! POST-OPERATIVE COMPLICATIONS 675 The complete absence of peristalsis is almost invariably an ominous sign, and often indicates peritonitis, but here again the pulse and temperature must be taken into account. Faint peristaltic sounds may point to a tran- sient post-operative paresis of the bowel. The treatment of simple tympanites consists in the application of heat to the abdomen, and the use of rectal suppositories of asafetida (5 grains) every three hours. If flatus is not soon expelled, a simple enema of soapy water (1 pint) may be given; later, if necessary, an enema composed of epsom salts (2 ounces), glycerine (2 ounces), sweet oil (4 ounces), and water (2 pints) should be injected through a soft rectal tube passed high up into the bowel. Occasionally if the rectal tube is left in situ this will result in the passage of gas. An enema of pure glycerine or of alum (1 dram to 1 pint) or the milk of asafetida (1 ounce to 1 pint) may be effectual. Various drugs have been recommended ; of these the best is pituitary extract (pituitrin, 1 c.c.) given hypodermically. Eserine (gr. 1/60) and atropin (gr. 1/150) every three hours are recommended by some clinicians. The use of cathartics is unwise. The patient should receive practically nothing by the mouth if the thirst can be controlled with saline enemas, about 8 ounces every three or four hours. This has also frequently a benefi- cent effect on peristalsis and on the expulsion of gas. PERITONITIS Etiology and Pathology. — Peritonitis following operation is caused by the deposit of infectious organisms in the peritoneal cavity during the surgi- cal procedure. These organisms may be carried on the hands of the oper- ator or of his assistants, or be transmitted on the sutures, dressings, water, and other materials used in the operation, or they may come from foci of infection in the patient which have been invaded and liberated during the course of the operative procedure. Peritonitis may be limited in its extent and localized to a particular" region, or be unlimited and diffuse. Following almost every operation there is more or less inflammatory reaction in the operative area, due chiefly to the mechanical insults to which the parts have been subjected. This quickly subsides, and does not give rise to constant or serious symptoms. When infection is added to the trauma, a bacterial invasion of the peritoneal surface takes place, with the formation of inflammatory products and the production of certain clinical manifestations. The inflammation of the peritoneum becomes limited or unlimited, ac- cording to the virulence of the infecting organism, the resistance of the patient, the treatment employed, and the mechanical factors predisposing to one or the other. Thus, for example, a streptococcus infection is more apt to spread throughout the peritoneal cavity than is one that is caused by the gonococcus or the colon bacillus. Pelvic infections are more likely to re- main localized than are those occurring above the brim of the pelvis, since the location and the surroundings of the pelvis favor localization to that area; furthermore, the Fowler position, the application of cold, the avoid- ance of cathartics, and the use of opiates will arrest peristalsis and be con- 676 GYNECOLOGY ducive to localization, whereas the horizontal position, cathartics, and the omission of the local application and the opiate will favor peristaltic move- ment of the intestines, extension of the infection, and generalization of the inflammatory process. The gross appearances of the peritoneal cavity at operation or post- mortem have led to various classifications of peritonitis ; these are both un- necessary and arbitrary, so far as the clinician is concerned. The morbid changes that take place depend upon the nature and virulence of the infect- ing organism, the resistance of the patient, the duration of the disease, and the peculiar circumstances of the case. Certain infections are of so virulent a type that the patient succumbs before marked changes take place in the peritoneum ; others are so slow that any of the various stages of inflammation, effusion, lymph-formation and exudate, and finally pus formation may be observed. In some of the violent and fulminating types following operation, the peritoneal cavity contains only bloody serum with a few flakes of lymph, although the. serous mem- brane itself has lost its clear, translucent appearance, is injected and red, and the intestines are distended with gas. When a later stage is reached, the intestinal coils are covered with flakes and patches of lymph that adhere closely, neighboring coils are more or less bound together with the plastic lymph, the fluid is a cloudy gray, less bloody than at first, and smaller in amount. To this succeeds the purulent stage, when the lymph is replaced by pus, the peritoneal fluid is purulent, the intestines are covered with a yellowish, adherent, membranous deposit, and many adjacent loops are closely matted and bound together, surrounding pools of purulent material. All these manifestations may be more pronounced in the area where the infection has begun, gradually diminishing the deeper one looks into the peritoneal cavity. Indeed, a peritonitis involving every part of the peri- toneal cavity is somewhat rare, except in the very latest stages. In the rapidly fatal forms the patient is killed by toxins before there is any attempt at localization, such as a matting together of the intestinal loops by lymph always indicates. Any peritonitis, even though it threatens to become general, may, with proper treatment, if taken in time, become localized. If the toxic products are but moderately poisonous ; if the resistance of the patient is good ; if the intestinal coats have not been damaged beyond repair, and the integrity of the intestinal tube is not destroyed by adhesions and inflammatory deposits, the general condition of the patient may gradually improve as the pus be- comes localized and the disease confines itself to a certain area. Symptoms. — The symptoms of peritonitis are many and varied. No one of them alone is a certain indication of the disease, and it is only by a combination of several that a conclusion can be reached. Increase of the pulse-rate, elevation of temperature, intestinal paresis, tympanites, nausea, vomiting, and a peculiar fades make up the symptom-complex. In the early stages rapidity of the pulse and a limitation or an abrogation of in- testinal peristalsis are the most significant symptoms. The temperature is usually elevated to a point higher than is common in the normal post- operative convalescence (ioo°), and at times it is elevated to 103 or 104 F. POST-OPERATIVE COMPLICATIONS 677 In some cases, however, the temperature is only moderately elevated until the patient is in extremis. The abdomen is distended and tense, the walls are rigid and spastic, and the patient complains of pain when the ear of the examiner or a stethoscope is applied to detect the peristaltic sounds. As a rule, these are greatly diminished or absent, and nothing is heard but the rapid beating of the abdominal aorta. Enemas given for the relief of tympanites are usually ineffective, or but slightly successful ; in any case, they fail to relieve the distention. The patient complains of nausea, and rejects anything given by the mouth from time to time. At first the stomach may show some tolerance, but this stage does not last long. Even if fluids are withheld, in the later stages there is vomiting of bile, and at length of fecal matter, which has been driven into the stomach from the distended and paretic small intestine. The patient is toxic, feverish, restless, and presents the flushed cheeks and bright eyes that accompany an elevation of temperature. At first the mind may be clear, but it soon becomes confused; delirium, hiccough, and a semi-stuporous condition often supervene. The pulse becomes progressively faster (150 to 160) and weaker, later intermittent, and finally, imperceptible. The respiratory rate is proportionately increased. The course of the case varies with the virulence of the infection, the extent of the lesion, and its complicating or associated conditions. A peri- tonitis engrafted upon an already shocked or acutely anaemic person is much more likely to spread quickly and end fatally than is one in which the opposite conditions prevail. So, too, if a partial obstruction of the intestinal tract coexists, the case will run a decidedly less favorable course than it would otherwise. Perforation of the gut or leakage from a wounded ureter or bladder exerts a decidedly deleterious influence and makes resolution improbable and almost impossible. Leucocytosis is usually present, and except in very rapidly fatal cases, or in shocked or weakened individuals, it is high (20,000 to 40,000). The increase affects particularly the polymorphonuclear leuco- cytes (see Leucocytosis, page 106). Diagnosis.— It is evident that other conditions may closely resemble a peritonitis in its incipient stage, or that these very conditions are due to a beginning peritonitis that subsides spontaneously or as the result of treat- ment. Thus, rapid pulse, high temperature, restlessness, tympanites, hic- cough, absent or restricted peristalsis, and nausea and vomiting may each be entirely independent of peritoneal infection, and may yield to proper symp- tomatic treatment. It is only when these symptoms are associated, and persistently so, that a diagnosis of peritonitis can be positively made. In the advanced stages these symptoms are all present, but any one or a group of them may be the first indication of trouble. The diagnosis must also be influenced by the nature of and the compli- cations attendant on the preceding operation. If the procedure has been performed under favorable auspices, with good surroundings and proper technic ; if no focus of infection has been invaded, and if there has been no intestinal trauma, peritonitis is, of course, unlikely to occur. If, on the other hand, a collection of pus has ruptured into the peritoneal cavity ; if an 678 GYNECOLOGY infected area has been invaded by the operator ; if the intestine has been traumatized ; if the operation has been prolonged, the amount of traumatism great, and the technic faulty, then peritonitis is more to be expected. Treatment. — When there is more reason than usual to fear post-operative peritonitis, the case should immediately receive such treatment as will tend to localize the process, to eliminate the toxins, and to fortify the patient so that she may be able to resist the attack. To this end the head of the bed should be elevated at once, so as to favor, by gravity, the limitation of the condition to the pelvis or to the lower abdominal cavity. Ice-bags should be placed over the operative area, enteroclysis started, and the patient closely observed. If symptoms of peritonitis appear, the treatment should be continued. An attempt may be made to relieve the distention by means of enemas, but if a simple and a high compound enema an hour apart are not provocative of results, there is nothing to be gained and much harm may result from a repetition of this treatment. If the pain is severe, if nausea and vomiting are pronounced, and if the patient is exceedingly apprehensive, morphine and atropin or heroin may be given with advantage. Liquids by the mouth must be restricted. Stimulants should be administered hypodermically, the main reliance being placed on strychnine, digitalis, and camphor. Whiskey, ammonium carbonate, or strong coffee may be given by the bowel. Cham- pagne is at times well borne by the stomach. The aim of the attendant must be to keep the infection limited by posture and the application of cold, and to avoid undue stimulation of the intestine, since an increase of peristalsis will almost undoubtedly spread the infection. Furthermore, it is of the greatest importance to supply fluids to the body (sodium chloride or sodium bicarbonate by enteroclysis) and to stimulate the patient in the hope that she may successfully resist the infection and overcome it. If the treatment seems to be unavailing and the process tends to grow worse, and it becomes evident that general involvement of the peritoneum has come about, there is nothing to be gained by an abdominal incision and the insti- tution of drainage, for by this time the disease is so fully developed that better results are obtained by a continuance of the conservative plan. INTESTINAL OBSTRUCTION Etiology and Pathology. — Obstruction to the lumen of the intestines may be brought about in various ways ; possibly the commonest is by the formation of an adhesion, between a loop of the gut and some part of the operative area, that constricts or kinks the intestine, or by the incarceration or strangulation of a loop of the bowel that has slipped through an opening bridged by adhesions. The essential feature of both forms is adhesions. Obstruction may also ocur as the result of the twisting of a loop of in- testine on its mesentery, or the slipping of a loop through an adventitious opening in the omentum or mesentery. Occasionally obstruction is the result of a localized constriction of a part of the bowel from some unknown cause (dynamic ileus). Another form of so-called obstruction (adynamic ileus) is marked by extreme distention of the entire intestinal tract — a POST-OPERATIVE COMPLICATIONS 679 paralysis of the bowel probably due to vasomotor or trophic disturbances, but the true nature of which is probably unknown. Obstruction of the intestinal lumen may be complete or partial. It is rarely complete at first, but many incomplete cases become complete sec- ondarily, by reason of swelling and thickening of the intestinal coat at the point of constriction incident to secondary peritonitis and inva- sion of the intestinal wall, distention of the gut above the obstructed point, and kinking. The obstruction to the passage of the gas and faeces results in an increase of the peristaltic action of the bowel above the obstructed point. This usually serves only to increase the constriction of the lumen, and results in distention of the bowel, impairment of its circula- tion, and invasion of its walls by bacteria. If a loop of bowel has slipped beneath a band of adhesions or a rent in the mesentery or omentum and becomes constricted, its circulation may be so completely shut off that it rapidly loses its vitality and becomes gangrenous. The intestinal contents above the point of obstruction soon become ex- tremely toxic, give off a more or less sour, offensive odor, and the intestinal walls show hemorrhagic infarcts. After a time invasion of the intestinal wall by bacteria becomes so marked that peritonitis ensues. The bowel above the site of obstruction becomes more and more distended, until, in an effort to empty itself, the peristaltic action of the intestines is reversed, and the intestinal contents is driven back into the stomach. Intestinal obstruction may develop within a few hours of, or several weeks after, an operation. It is usually sudden in onset, and the symptoms become rapidly more severe unless the lumen of the intestine is restored by operation. Intestinal obstruction is one of the most frequently fatal post- operative complications. Symptoms. — The symptoms of obstruction are pain, nausea and vomit- ing, tympanites, violent peristalsis, and obstipation. (In adynamic ileus there is no peristalsis, but the condition is more a paresis than an obstruction of the intestine.) The pain is violent, sharp, and agonizing, and is usually referred to the affected area, but it may be reflected to a consid- erable distance, Obstipation rarely appears at once. As a rule, a stool, and possibly the passage of considerable flatus may be secured by means of enemas. Nevertheless, the movement is not quite satisfactory in that it is not free, and does not relieve the pain or the distention. Peristalsis is generally marked — so much so that it may be noticed by the patient, and be distinctly heard by the attendants. Nausea and vomiting are common symptoms, appearing earlier and being more severe when the obstruction is high, and coming on late and being less severe, except in the later stage, when the obstruction is low. There is usually but little elevation of temperature until the later stages, when peritonitis has supervened or the patient has become decidedly toxic. Almost from the first the pulse is increased in frequency. As the disease progresses, all the symptoms except the pain become intensified. With the onset of structural changes in the intestines pain is complained of less and less, until finally the patient may express herself as being comfortable. This is an ominous symptom and usually indicates a gangrenous condition. In- 680 GYNECOLOGY testinal paresis, absence of peristalsis, and extreme distention follow. The vomiting is persistent, and takes the form more of a regurgitation than of an actual ejection, being dependent somewhat upon the intake by the mouth at first; soon, however, it becomes almost continuous and independent of food or drink. Early in the disease the vomitus consists of the fluid taken into the stomach mixed with bile and mucus ; later it is made up of the acid, sour, foul-smelling contents of the small intestine, and finally of liquid fecal matter. In the earlier stages of obstruction the mind is clear, and the patient is apprehensive regarding her condition. In the later stages the mind is dulled, the talk is rambling, and finally, semi-consciousness or stupor supervene. Diagnosis. — It is at times difficult to distinguish between intestinal ob- struction in the early stages and peritonitis. In the late stages of both con- ditions the one is associated with the other, and, of course, no differentia- tion can be made. In the early stage of obstruction sharp pain, increased peristalsis, abdominal distention, recurrent vomiting, absolute or partial constipation, with normal or but slightly elevated temperature and pulse- rate, are characteristic. Attempts to move the bowels by enema may be partly successful, but are never altogether satisfactory, the distention is un- relieved, and the symptoms persist. Treatment. — The treatment of intestinal obstruction must be prompt if it is to be of any benefit. As soon as the diagnosis is made, surgical inter- vention is demanded. If the condition is strongly suspected and palliative measures afford no relief, an exploratory operation is justifiable. Since other conditions of a much less serious nature may resemble the early stage of an obstruction, palliative measures should be employed at first in the hope that they will give relief. Thus, enemas may be given to re- lieve distention ; lavage may be employed to empty and cleanse the irri- table stomach ; hot stupes or poultices may be applied to the abdomen to favor the expulsion of gas. In actual obstruction, however, none of these measures will give relief, and it is then that surgery must be invoked. It can scarcely be too strongly urged that in a suspected case of intes- tinal obstruction cathartics must be carefully avoided. Nothing has a more unfavorable influence upon an obstructed bowel than the increase in fluid contents and the forcible peristalsis occasioned by the use of a cathartic. In cases, of suspected obstruction the administration of a purgative will often clear up all doubt as to the nature of the lesion, and if the symptoms were not due to obstruction, they will disappear as if by magic. Nevertheless, under such conditions the patient would ultimately have been relieved with- out the aid of a purgative. On the other hand, if an obstruction -had been present, the administration of a cathartic, by increasing the injury to the in- testine itself, might have rendered the case hopeless. It is evident, there- fore, that in cases of suspected obstruction purgatives by the mouth are un- necessary and dangerous. What surgical procedure should be employed? Nowhere in surgery more than in these cases is experience the mother of wisdom. As soon as it has been decided that surgical interference is required, all preparations for carrying out a rapid abdominal section should be made. All the instru- POST-OPERATIVE COMPLICATIONS 681 ments should be at hand, the needles threaded, and the ligatures ready be- fore anaesthesia is begun. Forceps for intestinal anastomosis, Murphy but- tons, and Paul's tubes must be provided. Nitrous oxide-oxygen, and ether anaesthesia or local anaesthesia should be used. If the original incision is clean and in the median line, it may be reopened ; otherwise, the new incision may be made to one side of, above, or below the original incision. It should be made, by preference, in the median line. According to Moynihan, the most distended part of the intestine or that directly above the point of constriction, will usually float higher than the remainder and be in the median line, so that the loop that first pre- sents itself may be caught up and followed for a short distance below and above, in an attempt to locate the obstruction. If this plan reveals nothing, the hand may be passed to certain points where, from the nature of the operation, adhesions would be most likely to have formed, or to those areas, as, e.g., the ileocaecal junction and the hernial rings, where obstruction from other causes is most prone to occur. Nothing being found, the loop that is most distended should again be picked up and followed systematically downward until the point of obstruction is discovered. As the intestine is followed in this way the portion that has been in- spected may be pushed into the upper abdomen, or if distention is so great as to render that plan impracticable, the loops of gut should be surrounded by gauze pads saturated with hot salt solution. Evisceration should, if possible, be avoided. After the point of obstruction is located, the existing conditions will determine the course to be pursued. The bowel may be in such good con- dition that apparently nothing more than the relief of the obstruction will be required. On the other hand, it may at once be evident that resection of a badly diseased or gangrenous intestine is imperative. Whatever operation is contemplated, unless the patient's condition is so alarming that nothing beyond an enterostomy dare be attempted, the dilated and distended part of the intestine, especially if the obstruction is high, should be emptied by means of a glass tube, after the method of Moynihan. The bowel should be opened in the center of an area about which a circular suture has been introduced. The incision should be made in the long axis of the bowel, and the intestine above and below the point clamped or compressed so as to prevent the escape of fluids or gas. The free end of the glass tube, with a rubber hose attached for drainage, should then be introduced, and the suture tied so as effectually to control any tendency to leakage from the intestine. The clamps are removed and the tube is then pushed further into the intestine, evacuating loop after loop of the bowel as it is threaded, so to speak, upon the glass tube. After the tube has been covered with as much of the bowel as it will hold, the tube may be removed, the opening closed by suture, and the process repeated at a higher point. The latter is rarely required, however, and should not be attempted if it can be avoided. It is of marked advan- tage thus to rid the bowel of the fluid contents, which is often highly toxic and exposes the patient to great danger, even though the obstruction is 682 GYNECOLOGY overcome. After emptying the bowel, the resection and anastomosis may be. carried out secundum artcm. . If the condition of the patient is so grave that any extensive procedure is inadvisable, or if, although the immediate obstruction is overcome, it is likely to recur, or if so large a part of the intestine is involved in adhe- sions that resection would be exceedingly dangerous, one of two plans may be adopted : either a short-circuiting operation may be performed or Paul's tubes may be introduced for drainage. The first is applicable only to cases of obstruction of the small intestine fairly low down ; here a rapid lateral anastomosis with clamp and suture or a Murphy button applied to the gut above the sigmoid flexure, may be a life-saving measure. In extremely desperate cases, with marked distention, when the intes- tine is in badly diseased condition and the patient is so weak as to preclude any but the most rapid operation, a loop of the bowel may be pulled out of the incision and fixed there, the peritoneal cavity being excluded with a running catgut suture ; in the course of several hours it may be opened, and a Paul's tube inserted into each limb of the loop. This provides drainage if any peristaltic activity of the gut remains, and may tide the patient over until an operation for the relief of the obstruction and the restoration of the integrity of the intestinal canal can be undertaken. In cases of dynamic or adynamic ileus but little can be accomplished. Neither condition is clearly understood, and those cases that have come to operation have usually been unsuccessful. Adynamic ileus is possibly a form of paralysis of the intestine due to injury of the motor nerves that supply it. This injury is believed in some cases to have been due to exces- sive or rough handling of the intestines, as in making a thorough explora- tion of the abdomen, or exerting too much pressure upon the bowel with gauze pads in walling-ofl an area from the seat of operation. Dynamic iieus is a strange condition that in some cases is inexplicable. In some of the reported cases the curiously localized contraction of a few inches or more of the intestine may have been a post-mortem change. ACUTE GASTRIC DILATATION Etiology and Pathology. — Acute gastric dilatation is one of the rare com- plications following operation. The condition usually occurs after opera- tions for disorders of an inflammatory nature, but not necessarily in the upper abdomen. There is commonly an obstruction of the duodenum at the point where it is crossed by the superior mesenteric artery, so that the con- dition has been attributed to a dislocation downward of the stomach with a drag on the duodenum. The obstruction is not always primary, but may be secondary to a marked relaxation or atony the result of paresis of the gastric motor nerves, which gives rise to an enormous dilatation of the stomach and a kink in the neighboring duodenum. Symptoms. — The symptoms of acute gastric dilatation are extreme dis- tention of the upper abdomen, epigastric distress, persistent nausea, pro- fuse vomiting, rapid pulse, and prostration. The condition is troublesome, ■dangerous, and usually persists in spite of treatment. POST-OPERATIVE COMPLICATIONS 683 Diagnosis. — The diagnosis may be confirmed by passing a stomach- tube, when a considerable quantity of gas and fluid will be evacuated. Treatment. — The treatment consists in repeated emptying of the stomach by means of a stomach-tube, washing with salt or soda solution, leaving a portion of the fluid in the stomach, and placing of the patient in the left latero- prone or Sims' position. The injection, hypodermically, of extract of pituitary gland has been recommended because of its stimulating action on the smooth muscle-fibers. In the repeated lavage which is necessary it has been found useful to pass a duodenal tube with a weighted end into the stomach, fixing the free distal end outside of the mouth. The presence of the tube in the cesoph- FiG. 499.— Short circuiting for intestinal ob- struction, ileo-sigmoidostomy, diagrammatic. FlG. 500. — Short circuiting for intestinal ob- struction, ileo-colostomy, diagrammatic. agus does not give rise to much annoyance, and relieves the patient of the disagreeable necessity of repeated passage of the stomach-tube. For the same reason it has been suggested that the proximal end of the stomach-tube be brought out through the pharynx, posterior nares, and one nostril, and fastened in situ. BRONCHITIS Etiology. — Bronchitis is one of the most frequent pulmonary complica- tions that follow operation. It is a common sequel to etherization when the patient at the time has a rhinitis, pharyngitis, or tracheitis. In order to avoid this complication operations should be postponed, when possible, until acute affections of the nose and throat have entirely cleared up. Bronchitis may be the result also of prolonged etherization or of ex- posure during the operation. 684 GYNECOLOGY Symptoms. — Post-operative bronchitis manifests the same symptoms and runs the same course as other forms of bronchitis. The frequent cough, the accumulation of mucus in the throat, the increased respiratory rate, etc., all tend considerably to increase the post-operative discomfort. Treatment. — The treatment of post-operative bronchitis differs in no way from the treatment of bronchitis in general. The patient should be placed in the Fowler position. Counter-irritation with mustard should be employed, and heroin prescribed for the cough. If any other medication is considered advisable, Brown's mixture (i to 4 drams) with 5 to 10 grains of am- monium chloride, may be added. PLEURISY Pathology and Treatment. — Well-marked pleurisy following operation is usually associated with pneumonia or with an acute exacerbation of a tuberculous process. Severe pain in the chest, with a pleuritic friction-rub and pyrexia, apparently independent of pneumonia or tuberculous proc- esses, is not infrequently observed. These symptoms, as a rule, are promptly relieved by strapping and the administration of the salicylates. The con- dition subsides within a few days. Miller points out that many of these cases are secondary to small hemorrhagic infarcts in the lungs, which result from minute emboli ; phlebitis may appear later in the course of the convalescence. NEPHRITIS Etiology and Prophylaxis. — Nephritis as a post-operative complication is a rare occurrence when the patient has been properly prepared for opera- tion. In order to avoid nephritis, a careful examination of the urine before operation and an estimation of the total quantity eliminated should be made, and suitable measures instituted to correct any abnormalities. When the symptoms of kidney insufficiency persist in spite of treatment, the patient should not be given ether or chloroform. Nitrous oxide and oxygen, or, preferably, local or spinal anaesthesia, should be employed instead. The routine practice of throwing one or two liters of sterile tap water, 2 per cent, soda bicarbonate solution, or salt solution into the bowel before the patient leaves the operating table, or of administering from 8 to 16 ounces every three hours, will do much to alleviate the renal irritation which ether produces, even in healthy kidneys, and act as a prophylactic. When nephritis is especially feared, sodium bicarbonate (2 per cent.) solution or tap water should be used instead of salt solution, which is said to be less favor- able in its influence. In a large proportion of cases casts and albumin may appear in the urine during the first twenty-four to thirty-six hours following operation, but this may be regarded merely as the result of irritation of the renal structure — i.e., a mechanical or chemical irritation, which is transient in character, and not a real hazard to the patient. Actual nephritis must be dealt with in the customary manner, as when it occurs under other circumstances. POST-OPERATIVE COMPLICATIONS 685 SUPPRESSION OF URINE FROM URETERAL OBSTRUCTION Etiology and Symptoms. — In panhysterectomy for cancer or cervical myomata, in difficult supravaginal hysteromyomectomies, in hysterectomy for densely adherent adnexa, or intraligamentous cysts, the ureters may be exposed to the risk of injury. This risk is lessened by constant orientation of the ureters during the course of the operation, whether they are actually exposed by dissection or not. In spite of these precautions, the surgeon may feel anxious about them after operations which have been unusually difficult. A diminution in the excretion of urine after operation is to be expected. Usually less than 24 ounces are excreted during the first twenty-four hours. The decrease in the total amount is less marked when soda bicarbonate or salt solution or tap water is given at the close of the operation or immedi- ately thereafter. If, in spite of enteroclysis or hypodermoclysis, the excre- tion of urine remains much diminished — 1 to 8 ounces in twenty-four hours — there are two possibilities, at least ; either suppression of the kidney func- tion or an injury or accident that occludes the ureters. Diagnosis. — Suppression of the kidney function may be due to a decided fall in blood-pressure which sometimes takes place when a large amount of blood has been lost during the operation. An estimation of the blood-pressure will clear up this point. Suppression of the urinary function from nephritis is not likely to be absolute ; the urine which collects in the bladder con- tains albumin and casts, and the general symptoms of nephritis (uraemia, oedema, changes in the eye-grounds, etc.) are present. When the anuria is absolute or nearly so, for more than twenty-four hours, and the associated symptoms do not clearly point to a nephritis, it is desirable to determine at once whether any injury has been inflicted on the ureters. The only way to settle this question is by introducing a cystoscope into the bladder and catheterizing the ureters. If, on exposing the ureteral orifices, the examiner is rewarded by observing the ejection of urine from each, he need look no further unless the question of partial obstruction on one or on both sides must be decided. When the orifices are quiet, each ureter should be catheterized. If the catheter passes easily it signifies that the ureters are patulous ; when an obstruction is found on one or both sides, it is almost invariably close to the bladder, within 5 cm. of the ureteral orifice. An obstruction more than 10 cm. from the bladder may indicate a constricting ligature at that point, but it may also be due to a distortion or kinking of the ureter at the pelvic brim, which prevents the passage of the smallest catheter. Treatment. — If absolute or nearly absolute obstruction is actually present on both sides, the only hope for the patient lies in immediate operation. Ureteral catheters should be introduced as far as they will go on each side, and the incision should be opened under nitrous oxide-oxygen-ether anaesthesia; the operative area should be exposed, and the ureters examined. This may be facilitated if the catheters are left in situ; furthermore, the ureters may be distended above the point of obstruction and thus be readily located by pal- pation ; if this is not done, they must be deliberately sought for and dis- sected, as in the operation of panhysterectomy. 686 GYNECOLOGY When the point of obstruction is found, the constricting ligatures should be removed. If the ureteral wall or sheath has not been injured, this maneuver will be sufficient to restore its function. When the wall, or sheath has been bruised or torn and necrosis threatens, the ureter should be divided above the injured area, the distal end ligated and cauterized, and the proximal end implanted into the bladder. If the proximal end will not reach the bladder, it should be implanted into the rectum or the sigmoid. If the ureter on one side has been easily freed ; if a minimum amount of damage has been done and the kidney on that side is in good condition, in desperate cases, where haste is urgent, the other ureter may be ligated. If both kidneys are involved by accidental ligation, the release of the ureters is demanded in order to save the patient's life. In serious cases of complete suppression from bilateral ureteral obstruction, lumbar neph- rotomy may be performed to tide the patient over for a time. Ligation of one ureter, the other remaining undisturbed, with a healthy kidney on the good side, does not result in any marked reduction in the urinary output nor in symptoms of uraemia. Usually the patient will com- plain for several days of a severe pain in the loin of the affected side, with tenderness, but without perceptible enlargement of the affected kidney. The pain may disappear entirely in the course of a few days, and no subsequent symptoms develop, so that the condition may remain unrecognized. If occlusion of the ureter is not absolute and the kidney continues to func- tionate, the symptoms of pyelitis, hydroureter, and hydronephrosis gradu- ally develop, and make the diagnosis clear. A ligature passed about the ureter may so injure its sheath and nutrient blood supply that gangrene sets in ; the urine escapes and infiltrates the tisues, producing a cellulitis with the formation of pus, which discharges externally, either through the cervical stump, the vaginal incision, or the abdominal incision. This is the most frequently recognized result of liga- tion or other injury to the ureters during operation. Bilateral ligation or obstruction of the ureters incident to operation is fortunately rare, and will continue so if the operator bears constantly in mind the exact position of the ureters and guards against injuring them, or, if they are necessarily in the operative field, as in panhysterectomy, he ex- poses them deliberately to sight and touch (see page 349). PHLEBITIS Etiology and Pathology. — Phlebitis is one of the most annoying and troublesome post-operative complications. It may follow the simplest aseptic abdominal section. It rarely, and practically never, occurs after plastic operations and those performed by the vaginal route. Its occurrence has been ascribed to infection and to injuries (puncture, contusion) of the deep epigastric veins, especially in anaemic patients. The most frequent causes seem to be injury of the deep epigastric veins as the result of forcible or prolonged retraction of the abdominal incision (Clark), anaemia, circulatory weakness, and the restriction of motion fol- lowing a celiotomy. POST-OPERATIVE COMPLICATIONS 687 Puncture or bruising of the deep epigastric veins may occur during the process of making or of closing the abdominal incision. Injury of the pelvic veins may give rise to phlebitis of the broad ligament, a condition that is often unrecognized. There may or may not be oedema of the lower ex- tremities. To all traumatic causes may be added the hemolytic action of bacteria ; these usually are so feebly virulent or are present in such small numbers as to produce no gross infection. Phlebitis is occasionally a precursor of embolism and minute emboli from the site of operation may produce pulmonary infarcts and localized patches of pneumonia or pleurisy before the symptoms of thrombophlebitis appear (see Pleurisy, page 685). Post-operative thrombophlebitis usually affects the femoral veins, and is more frequent on the left than on the right side. The process apparently begins in the deep epigastric vein, and extends to the point of its junction with the femoral vein above Poupart's ligament. Here the walls of the vein are more or less fixed by the surrounding fascia, and the smaller volume of venous blood being poured into the larger vessel from the epigastrics is believed to result in a sort of whirling motion [wirbelbewegung) of the blood at this point; the flow of blood is retarded, a thrombus forms, the vein becomes partly or wholly occluded, and the walls become irritated and inflamed. Symptoms. — The earliest symptoms of phlebitis (embolic pleurisy may have been observed in the first post-operative days) are rapid pulse, increas- ing in periodic waves, and unaccompanied by a corresponding rise in the temperature ; later there are slight elevation of temperature, pain and tender- ness in the calf or along the course of the femoral vein, and oedema of the affected extremity. These symptoms all vary in degree, and occupy a more or less prominent place in the symptom-complex. Treatment. — The treatment consists in elevating the affected limb and in applying ice to the calf and the groin. At a later stage, after the acute symptoms have subsided, a fly-blister may be put over the line of the femoral vein below Poupart's ligament. The leg should be wrapped in cotton and snugly bandaged. Elevation should be maintained until oedema over the tibia and about the ankle has subsided. The limb should not be used until the induration, tenderness, and oedema have disappeared and the temperature and pulse are normal. Massage should be prohibited for from four to six weeks afterward. The use of the limb should be gradually in- creased, and a recurrence of the symptoms, even in the slightest degree, should be regarded as an indication to resume the treatment by rest and elevation of the affected limb. Before arising in the morning, a snug bandage of flannel or elastic crepe should be applied, beginning at the bottom, encircling the foot, and reach- ing to the groin. As has been stated, phlebitis is one of the most annoying and obstinate complications following operation. Even after prolonged rest and careful treatment full compensatory collateral circulation may not be established, the leg thus remaining more or less disabled, and becoming swollen when any unusual exertion is undertaken. 688 GYNECOLOGY PULMONARY EMBOLISM Etiology. — Pulmonary embolism is one of the catastrophes that may follow any abdominal operation. It occurs particularly after hysterectomy for uterine myomata, and is probably explainable by the fact that anaemia and circulatory weakness are often found in myoma patients. In a large number of instances embolism follows simple appendicectomy or salpingo-oophorectomy, so that it is by no means limited to any one type of operation. * Altogether it is a rare complication, but it occurs so suddenly, often with no warning whatever, in patients who, up to the moment of seiz- ure, have undergone an uncomplicated convalescence, that it must always be taken into account. The possibility of this complication alone makes the prognosis of celiotomy guarded. Symptoms. — The symptoms usually come on without the slightest warn- ing, or they may be preceded by those of embolic pneumonia, pleurisy, or thrombophlebitis ; they consist of sudden dyspnoea, precordial distress, and increase of the pulse and the respiratory rate. Death quickly ensues. As a rule, pulmonary embolism takes place within a week or ten days after the operation — often when the patient sits up or gets out of bed for the first time. It is usually rapidly fatal, the embolic clot being of such a size as completely to block the pulmonary artery. Embolism may occur shortly after operation, within a few hours, or during the first post-operative days. Here, too, it may be rapidly fatal, but undoubtedly cases of embolism occur at this time in which the emboli are minute and death does not take place ; the grave and alarming symptoms gradually subside, and are succeeded by those produced by infarcts in the peripheral distribution of the pulmonary artery. Miller believes that most cases of post-operative pneumonia are embolic in origin. To the sudden symptoms of embolus previously described, in the cases not immediately fatal there are added the symptoms of pulmonary infarction or embolic pneumonia, mild or severe in type, depending upon the size of the area that has been deprived of its blood supply. Diagnosis. — In the fatal cases the condition may be mistaken for a rapid and profuse internal hemorrhage or an acute dilatation of the heart. Except for those occurring within a few hours of operation, these conditions hardly require consideration here. Internal hemorrhage is almost never so rapidly fatal, even immediately after operation, and certainly never after the tenth post-operative day. Acute dilatation of the heart may be suspected if the heart was affected at the beginning, and if the operation was prolonged and the patient was kept for a long time in the Trendelenburg position. As a rule, the symptoms of acute dilatation are not so sudden in onset. The subse- quent course of the case will serve to clear up the diagnosis. In fatal cases only an autopsy will serve to make the diagnosis positive. Prophylactic Treatment. — Thrombosis must, of course, precede embol- ism, although in the majority of these cases it gives no evidence of its exist- ence, and is limited to the pelvis. Nevertheless, the causes of thrombosis must be eliminated in order to guard against embolism. To this end, in all celiotomies, care should be exercised lest a vein be contused or punctured. When, in spite of care, injury of a vein occurs and is recognized, the POST-OPERATIVE COMPLICATIONS 689 affected area should be excluded from the circulation by ligating the vessel on one or both sides of the injured part. A high Trendelenburg posture, with flexion of the knees, is to be avoided. Forcible and prolonged retraction should be guarded against in order to avoid thrombosis in the epigastric vessels. The treatment, after operation, of those pa- tients in whom thrombosis and embolism are especially to be feared (i.e., those suffering from uterine myoma, anaemia, or circulatory weakness) includes mainte- nance of the heart action and blood-pressure by continuous moderate stimu- lation, and by active and passive movements of the legs from the very begin- ning of convalescence. With these immediate post-operative measures, it is advisable to get the patient out of bed a little sooner than in the average case. POST-OPERATIVE RENAL INFECTION Etiology, Pathology, and Treatment. — Obscure and otherwise unac- countable elevation of temperature following operation may be due to a post-operative renal infection. The condition usually sets in some time after the operation, and may be preceded by cystitis or a focus of pus formation, such as a suppurating abdominal incision. Many of the cases are really hematogenous infections due to the colon bacillus. The clinical picture of the milder forms is that of pyelitis, and the case responds readily to treatment (see p. 487). More severe forms, due to the colon bacillus or the pyogenic cocci, have been observed. These are also hematogenous. The kidney is affected by a pyelonephritis. Some cases are rapidly fatal, and operative treatment may be required (see p. 473). SUPPURATION OF THE INCISION Etiology. — At the present day suppuration of the incision is rarely encoun- tered. It may be caused by infection alone or infection combined with traumatism and devitalization of the tissues, imperfect hsemostasis, and accumulation of blood in the wound, etc. Symptoms. — An active infection will manifest itself by marked pain and tenderness in the wound, with an unusual rise of temperature during the first post-operative days. Examination of the incision will reveal the usual signs of inflammation. Suppuration occurs rapidly. Separation of the margins of the incision results in the discharge of pus. In the average case no active symptoms occur to direct the attention to the wound during the early days of the convalescence ; but toward the end of the first week the temperature does not recede to the normal, to remain there permanently. About this time the incision may open spontaneously and discharge purulent or bloody fluid, or upon examination signs of in- flammation and the presence of fluid beneath the skin will at once be apparent. Treatment. — Free drainage of the suppurative area is essential to rapid heal- ing and should be instituted without delay. Great care should be taken to avoid 44 690 GYNECOLOGY extension of the infection to the deeper layers of the incision. The abscess cavity should not be cleansed by syringing, but by gentle pressure and sponging with moist pledgets of cotton. All manipulations must be very carefully carried out. After free drainage is provided the application of heat will tend to hasten resolution. Later, granulating surfaces may be stimulated by silver nitrate or scarlet salve. Suitable strapping of the borders of the wound will hasten union. LOCAL INFLAMMATION OR SUPPURATION IN THE PELVIS Etiology, Symptoms, and Treatment. — Occasionally, following pelvic oper- ations, there will be noted an elevation of temperature that persists beyond what may be termed the normal post-operative febrile period. Associated with this there may be lower abdominal or pelvic pain and soreness. Bi- manual examination reveals the presence of induration and tenderness some- where in the pelvis, varying with the nature of the operation and the degree of inflammation. The pelvic structures appear to be more or less fixed. In many cases the actual condition is a localized peritonitis or cellulitis rather than an actual infection. It is the result of traumatism and devital- ization of tissue from ligatures, sutures, etc. As a rule, the application of heat to the lower abdomen, hot vaginal douches, and rest in bed result in a gradual amelioration of the symptoms. Occasionally, in the case of a hysterectomy, the symptoms subside sud- denly after a discharge of purulent material through the cervix. CYSTITIS Post-operative cystitis is usually the result of frequent or unclean cathe- terization. (For prophylaxis see page 453; for pathology and treatment see page 454.) POST-OPERATIVE CARDIAC DILATATION Simpson has drawn attention to right-sided hypertension and occasional dilatation of the heart following operation. This observer reports that Wertheim had a death-rate of 4.4 per cent, from acute dilatation alone, following abdominal hysterectomy for cancer. Etiology. — This post-operative complication is most likely to occur in patients who display the usual clinical evidences of a weakened myocardium, as well as those in whom the myocardium is believed to have been weakened by excessive business or social cares ; hyperthyroidism, long- continued or very recent absorption of bacterial toxins (pneumococcus, streptococcus, diphtheria bacillus, etc.) ; biliary poisons; toxins from malig- nant neoplasms ; marked or chronic anaemia, etc. Prolonged anaesthesia, the Trendelenburg position, and the injection of large quantities of salt solution increase the burden of the heart and favor the occurrence of cardiac dilatation. Symptoms. — The clinical picture of hypertension or beginning cardiac dilatation shows : An abrupt increase of the pulse-rate — 20 or more beats — POST-OPERATIVE COMPLICATIONS 691 slight cyanosis, sudden marked weakness, great apprehension, and an in- creased area of the right heart. Treatment. — The treatment consists in elevating the head of the bed, the administration of morphine by hypodermic injection, and the cautious use of cardiac stimulants. POST-OPERATIVE PAROTITIS Parotitis may occur as an occasional complication during operative convalescence, usually appearing within the first week or ten days following operation. It occurs with much greater frequency (one observer claiming it appears ten times as often) after operations on the pelvic or abdominal viscera than following operations on other parts of the body. The condi- tion may occur as a sequel to septic abortion. Post-operative parotitis is usually unilateral. Less than half of the cases develop suppuration. Etiology. — While a close glandular and sympathetic relationship exists be- tween the parotid gland and the pelvic organs, as is evidenced by the ovaritis that developes during the course of mumps, and the increased salivary secretion of early pregnancy and menstruation, it is unlikely that this plays any part in the etiology. In most cases of post-operative parotitis the infecting agent has its origin in some septic condition of the mouth or upper air- passages, as, for example, carious teeth, Vincent's angina, pyorrhoea, sordes, and other evidences of faulty oral hygiene, infected tonsils and adenoids, and chronic posterior rhinitis and pharyngitis. In the majority of cases some of these findings have been noted, and the infecting organism is be- lieved to gain access to the gland by passing up Stenson's duct. The staphylococcus pyogenes aureus has been found more frequently than any other organism in the pus of post-operative parotid abscess. The conditions favoring the development of parotitis are the dry condi- tion of the mouth induced by the anaesthetic, as well as the nervous influ- ences that affect the secretions, the lowered intake of water, the removal of fluid from the body due to vomiting, and the mechanical insult to the tissues by swabbing the mouth during anesthetization. The fact, too, that of the three salivary glands the parotid is the only one supplied with lym- phatics may have a part in favoring the development of this condition. Symptoms. — The infection is recognized by a reddened and painful swelling in the parotid region, accompanied by fever, and rarely chills, de- veloping a few days after operation. The swelling may subside under treat- ment or go on to the formation of an abscess, with characteristic symptoms. Treatment. — Treatment begins with prophylaxis. Carious teeth should be ex- tracted, infected tonsils removed, pyorrhoea and other manifestations of oral and nasal sepsis treated. These cavities should be brought to the highest degree of surgical cleanliness by the use of the tooth-brush, mouth-washes, and nasal irrigations of weak potassium permanganate (i : io s ooo) or other suit- able antiseptic solutions. The body should be well supplied with fluids both before and after opera- tion, and during anesthetization intraoral manipulation should be avoided as much as possible. 692 GYNECOLOGY Should parotitis develope, it may be successfully combated by con- tinued use of the mouth-washes in order to favor drainage from the gland, and the local application of compresses wet with cold solutions, such as saturated boric acid, i per cent, aluminum acetate, or I : 5000 mercury bichloride. An ice-collar may be applied to the gland. Stimulating oint- ments, such as 10 to 25 per cent, ichthyol or isarol, may be applied, or the gland may be painted with tincture of iodine. If an abscess forms, it should be opened by a free incision, the pus evacuated, the cavity irrigated and packed with narrow strips of gauze impreg- nated with 2 per cent. dichloramine-T, with proper renewal of dressings. ACIDOSIS Etiology. — All alkaline bases that are left after the non-volatile acids have been neutralized are converted into bicarbonate, and since the bicarbonate con- tent of the blood in the normal individual is constant, any decrease in the alkalinity may be regarded as an acidosis. Acidosis is due either to the incomplete combustion of fat with the for- mation of ketone bodies, beta-oxybutyric acid, diacetic acid, and acetone, or to the failure of the kidneys to eliminate the acids normally eliminated by them. In acidosis due to the first cause the ketones appear in the blood and urine, and the breath takes on an aromatic odor. Symptoms. — Frequently a mild acidosis may exist without evincing symp- toms. If, however, the acidosis becomes more severe, the patient will exhibit a symptom-complex such as the following : A peculiar hyperpnoea without cyanosis (air hunger) ; vomiting ; headache ; acetone and diacetic acid in the urine if the acidosis follows anaesthesia, diabetes mellitus, or starvation, but not if the acidosis is due to renal disease ; aromatic odor on the breath in the cases exhibiting ketones in the urine. Diagnosis. — In order to make a diagnosis of acidosis a number of methods are available. In the first place, the condition may be suspected if the symptom- complex of acid intoxication just described, with its peculiar respiration, vomiting, and headache, is present. To base the diagnosis on this finding alone, will, however, lead to a considerable percentage of error, for in a certain number of cases further investigation by special methods has re- peatedly failed to confirm it. When, however, in conjunction with the char- acteristic symptom-complex, acetone and diacetic acid are found in the urine, the diagnosis is much more justifiable. It must be remembered that: acetone and diacetic acid appear in the urine in many mild cases of acidosis, . and has no bearing on the prognosis. This is especially frequent in chil- dren. Thus, Holt has found acetonuria in 70 per cent, of the pneumonias of children. For the recognition of and to insure the more accurate diag- nosis of all forms of acidosis, one of the newer methods now available, such as the Van Slyke method for determining the bicarbonate content of the blood, or the Marriot, Fredericia, or Plesh-Higgins method for determining the alveolar C0 2 tension of the expired air, should be employed. One of these methods ought to form part of the equipment of every hospital labora- tory for routine use in the study of all patients in whom acidosis may be I POST-OPERATIVE COMPLICATIONS 693 suspected or, indeed, until we have acquired further knowledge of this sub- ject. The Marriot method is very simple, and can be carried out in a few minutes in the physician's office as well as in the hospital ward. The Van Slyke method can be conducted in any well-developed hospital laboratory, and does not require any special cooperation on the part of the patient. The methods for determining the C0 2 tension of the alveolar air may give incor- rect results if the patient has an irritable respiratory center or if a pathologic pulmonary condition is present, or one that will cause too rapid or embarrassed breathing. For routine use the methods just mentioned are the best. Other methods that are available are the hydrogen ion determination of concentration in the urine and blood ; also the quantitative determination of the ketone bodies in the urine and blood, and finally the method for ascertaining the ammonia content of the urine in cases in which there is a ketonuria. These last de- scribed methods are valuable if they can be carried out in conjunction with the first-mentioned methods, since they tend to make the study of the case more thorough. Treatment. — The treatment is largely prophylactic. All operative cases should be examined for acetone and diacetic acid, and where these are found, the degree of acidosis should be determined and treatment should be directed accordingly. When there is apparent a predisposition to acidosis, immediately after operation sodium bicarbonate (2 per cent.) and glucose (5 per cent.) solution should be given per rectum by means of continued or interrupted enteroclysis. In the treatment of post-operative acidosis, if there is no contraindica- tion from a surgical standpoint, the gastro-intestinal tract should be cleared by the administration of castor-oil and enemas. Diuresis should be pro- moted in cases of renal or cardiorenal deficiency. Sodium bicarbonate should be given by mouth, by rectum in 2 to 5 per cent, solution, or in- travenously, 1 to 2 per cent. (500 to 1000 c.c). Glucose may be exhibited by the mouth or given in 5 to 10 per cent, solution by the rectum, or Kahlbaum's dextrose may be injected intravenously (2.5 per cent.) in nor- mal salt solution. The dose should be regulated by observing the effect of the remedy on the reaction of the urine. The urinary fluid should be ren- dered neutral, but not distinctly alkaline. 1 BIBLIOGRAPHY Axders, J. M. : " Ether Pneumonia." University Med. Mag., Phila., 1897. Axspach, B. M. : " Enterostomy and Enterocolostomy in the Treatment of Acute Intes- tinal Obstruction Following Pelvic Operations." Jour. Amer. Med. Assoc, 1918. Austin, J. H. : " Acidosis." Penn. Med. Jour., 1916-17, xx, 356. 1 Farrar has recently reviewed the chemical constituents of the blood and their relation to lung ventilation in health. She notes the importance of the bicarbonates in the blood as constituting the alkali reserve in the body, and the standard C0 2 combining power of the blood plasma in women. There is a fall in the alkali reserve during operation, and this bears a certain relation to the blood pressure and respiration. There is a certain incidence of acute acidosis in operation, and it has considerable importance as a factor in shock. Farrar reports a series of cases at the Woman's Hospital in New York, which were treated during operation with glucose (20 per cent.) and gum acacia (6 per cent.) given intravenously, and shows their value in maintaining blood pressure, nitrition, and diuresis. I 694 GYNECOLOGY Baisch, K. : " Die Prophylaxe der post-operativen Cystitis." Munch, med. Wochenschr., 1903, No. 38, 1628 ; Ibid. : " Erf olge in der prophylaktischen Bekampfung des post- operativen Cystitis." Cent. f. Gynak., 1904, Bd. lxxviii. Baldy, J. M. : " The Mortality in Operations Upon Fibroid Tumors of the Uterus." Amer. Jour. Obst, 1905, Hi. Bonney : " The After-treatment and Post-operative Complications of Coeliotomy for Pelvic Disease in Women." Lancet, London, 1899. Bovee, J. W. : "The Influence of the Trendelenburg Position in the Quantity of Urine Excreted During Anaesthesia." Trans. Amer. Gyn. Soc, 1910, 443. Clark, J. G. : " Etiology of Post-operative Femoral Thrombophlebitis." Univ. of Penna. Med. Bulletin, July, 1902. Collins, G. H. : " Parotitis as a Post-operative Complication." Surg., Gynec. and Obstet., 1 91 9, xxvii, 404. Dyball: "Parotitis Following Injury or Disease of the Abdominal and Pelvic Viscera." Annals of Surgery, Phila., 1904. Fakrar, Dr. Lilian K. P. : " Acidosis in Operative Surgery and Its Treatment by Glucose and Gum Acacia Given Intravenously." Trans, of Amer. Gyn. Soc, 1920. Furniss : " Post-operative Renal Infection." Trans. Sect. O. G. and A. S., A. M. A., 1913, 49- Gatch : " The Effect of Laparotomy Upon Circulation." Trans. Amer. Gyn. Soc, 1914, xxxix, 180. Gebele : " Uber embolische Lungen-Affektionen nach Bauch-operationen." Beitr. z. klin. Chir., Bd. xliii. Gerulanos : " Lungen Complicationen nach operativen Eingriffen." Deutsch. Zeitsch. f . Chir., Leipzig, 1900. Holscher : " Experimentelle Untersuchungen uber die Entstehung der Erkrankungen der Luftwege nach Aethernarkose." Archiv f. klin. Chir. ; Bd. lvii. Hurd : " Post-operative Insanities and Undetected Tendencies to Mental Disease." Amer. Jour. Obst., N. Y., 1899. Kelly, H. A. : " Post-operative Psychoses." Trans. Amer. Gyn. Soc, 1909, 426. Kelly, Jas. A. : " Acid Intoxication : Its Significance in Surgical Conditions." Annals of Surgery, Phila., 1905, xli, 161-200. Manton, W. P. : " Parotitis Following Induced Abortion in a Case of Pernicious Vomit- ing of Pregnancy." Trans. Sect. O. G. and A. S., A. M. A., 1918, 146. Mikulicz, von : " Pneumonic" Centralbl. f. Chir., 1901, No. 29. Miller, G. B. : " Complications Following Operations." Kelly-Noble, Gynecology, chap, xxvi, ii, Phila., Saunders, 1907 ; Ibid. : " Post-operative Thrombosis and Embolism." Amer. Jour. Obst., 1907, lvi, No. 3, 347. Moynihan, B. G. A. : Abdominal Operations, 2905, W. B. Saunders & Co., Phila. and London. Neugebauer, von : " 87 neue Beobachtungen von zufalliger Zuriicklassung eines Sub- operatione benutzten Fremdkorpers in der Bauchhohle, etc." Zent. f. Gynak., Leipzig, 1904. Olshausen : " Uber eine bisher unerkannte Todesursache nach Laparotomien mit Eventra- tion der Darmschlingen." Zeitsch. f. G. u. G., Leipzig, 1888, xii, 238-241. Polak, J. O. : " Acute Gastric Dilatation as a Post-operative Complication." Trans. Amer. Gyn. Soc, 1909, xxxiv, 466 ; Ibid. : " A Clinical Study of Blood-Pressure, Pulse-Pres- sure and Hemoglobin Estimations, in Post-operative Shock, Hemorrhage and Cardiac Dilatation." Trans. Amer. Gyn. Soc, 1917, xlii, 583; Ibid. : "The Conduct of Gyneco- logical and Obstetrical Operations in the Presence of Acute and Chronic Endocarditis." Trans. Amer. Gyn. Soc, 1913, No. 38. Schenck : " Thrombosis and Embolism Following Operation and Childbirth." Trans. Amer. Gyn. Soc> 1913, xxxviii, 295. Simpson, F. F. : " Post-operative Complications Involving the Alimentary Tract." Amer. Jour. Obst., 1907, lvi, No. 3, 332; Ibid.: "Right-sided Hypertension with Occasional Cardiac Dilatation as Post-operative Complications." Trans. Sec. Obst., Gyn., and Abdom. Surgery, A. M. A., 1913. Taussig, F. L. : " Bladder Function After Confinement and After Gynecological Opera- tions." S., G. and O., 1915, xxi, 416; also in Trans. Amer. Gyn. Soc, 1915, No. 40, 351. Thomson and Kemp: "Experimental Researches on the Effects of Different Anaes- thetics," Med. Rec, N. Y., 1898. POST-OPERATIVE COMPLICATIONS 695 Tracy, S. E. : "A Simple and Efficient Means of Applying Artificial Heat." Jour. Amer. Med. Assoc, October 22, 1910, 144. Veit, J.: "Die Prophylaxe der Embolie nach gynakologischen Operationen." Zentralblatt f. Gynakologie, 1910, xxxiv, No. 1, 1. Ward, G. G. : " Post-operative Renal Infection." Trans. Amer. Gyn. Soc, 1915, xl, 337. Weibel, M. : " Weitere Beobachtungen iiber das Verhalten der Ureteren nach der erwei- terten abdominalen Karzinomoperation." Zeits. f. Gyn. u. Urol., 1913, iv, 138. Welsh : Albutt's System of Medicine, 1898. CHAPTER XXXIX MECHANICAL AND MEDICINAL AIDS TO TREATMENT ABDOMINAL SUPPORT: BINDERS AND BANDAGES Abdominal binders are used for the purpose of lending support to the abdominal walls in cases of pendulous abdomen, diastases of the rectus muscles, umbilical hernia, floating kidney, gastroptosis or visceroptosis, sacroiliac sprain, and recent celiotomy incisions. After abdominal section an abdominal bandage does little actually to prevent the formation of a hernia, but it tends to remind the patient of her late experience and affords a certain amount of protection to the scar, which at this time is not so firm and strong as it subsequently becomes. Such bandages should be very simple ones, and may be discarded after two or three months, unless the patient is extremely stout or has a pendulous abdomen, when the support afforded by a corset or a binder should be continued. In cases of pendulous abdomen, general visceroptosis, floating kidney, or separation of the recti, a properly fitting corset 1 will, in the majority of instances, be more comfortable and more effectual than a binder. The corset should be designed especially for this purpose, and should be made in one piece. When properly fitted and applied, the support given to the abdomen by such a corset comes not directly from in front, but from below and in front, and in that way the entire lower abdomen is supported (see Figs. 450, 45!>and 501). _ The patient should lie in the recumbent position while putting on her corset. The corset should fit the lower abdomen snugly, and it should exert no constriction or pressure about the waist-line and the epigastrium. Corsets may be designated as neutral, bad and good. The majority of corsets are neutral, that is, they are of such construction, and worn so loosely that they affect the carriage in no important manner. The features of the bad corset are: 1. They are long- behind (especially at the top) and short in front (especially at the bottom). 2. They are cut to exert their greatest pressure at the waist. 3. They have strongly marked sacral curves, and are highly incurved at the waist in front. The features of the good corset are : 1. They lace in front. 2. They reach to the level of the trochanters. 3. They are not high enough in front to touch the breasts. 4. They fit tightly around the pelvis (especially in the space between the iliac crests and the trochanters, and decrease regularly in the pressure which they exert from the lower to the upper edge. 5. They are slightly incurved at the waist line at the back and sides, but show no waist curve in front. Briefly, so far as posture is concerned, the bad corset throws the center of gravity forward; the good corset holds it in its proper position. In addition to its effect on equilibrium, the bad corset constricts the waist, depresses the lower abdomen, and affords no support to the pelvis or the sacroiliac articulation. The good corset, in addition to maintaining correct equilibrium, supports the pelvis, sacroiliac joint, and lower abdomen, and exerts no constriction at the waist. The correction of the equilibrium may be graphically determined by the change in the posterior and anterior outlines of the body. (Reynolds and Lovett. Dickinson.) 696 MECHANICAL AND MEDICINAL AIDS TO TREATMENT 697 There are a number of binders on the market which in some cases — for example, very obese women and those who are not accustomed to wearing corsets — will be more satisfactory than a corset. Such a binder supports the abdomen from below, is attached to the garters that hold it in place, does not contain any whalebone, rubber, or leather, and may be washed without injury. In some cases of nephroptosis a pad may be attached to the corset in such a position that when adjusted it lends additional support to the kidney. In the average case the kidney pad is not required. In cases of ventral or umbilical hernia a specially devised pad of hard rubber may be attached to the binder or corset. In cases of sacroiliac sprain, static backache, etc., a steel brace or an inner reinforcing belt may be attached to the corset. Fig. soi. — Abdominal binder for post- operative use. (Storm.) LOCAL APPLICATIONS To the Endometrium. — Not many years ago the accepted method of treatment for patients who had a discharge from the uterus con- sisted in making intrauterine application of disinfecting solutions. At the present day, with the perfection of operating technic, in- creasing accuracy in diagnosis, etc., it has become recognized that applications to the endometrium are rarely indicated, except in connection with instrumental dilatation and curettement of the uterine cavity. During the acute stage of an infection all local treatment is harmful, and in the chronic stage there are almost invariably present lesions of the adnexa that forbid intrauterine applications except in connection with other operative treatment. It is quite difficult, moreover, to make an application to the endometrium with any degree of thoroughness or uniformity unless the patient is anaes- thetized and the cervical canal is thoroughly dilated. The truth of this statement can easily be appreciated if one remembers the shape of the uterine cavity and the difficulty experienced in passing a sound through the undilated cervix m an unanaesthetized subject. Even if it were possible to pass a sound wrapped with cotton, the solution in the cotton will be expressed long before the sound reaches the endometrium. Various forms of intrauterine syringes for the purpose of injecting solu- tions have been devised, but all must be used with caution. When the endometrial cavity is filled under pressure, some of the fluid may escape into the tubes or even into the peritoneal cavity. To prevent such a disaster, the cervical canal must not be obstructed at the moment of injection, and only a small and limited amount of solution must be used at a time. A form of syringe that renders injection safe is one fitted with a long nozzle, the end of which is roughened and contains lateral perforations. This nozzle is wrapped with sterile cotton and introduced into the endometrial cavity ; the solution is then injected into the cotton and brought into contact with 698 GYNECOLOGY all parts of the endometrium. Even this is quite unsatisfactory without the aid of general anaesthesia and full dilatation of the cervix ; when these condi- tions exist, it is advisable to curette the uterus and wash out the blood and endometrial debris with a two-way catheter before making the application. The solution that is best adapted for intrauterine application is tincture o^ iodine. Others that have been recommended are alcohol, 95 per cent. ; argyrol, 25 per cent. ; silver nitrate, 10 per cent, (followed by salt solution) ; formalin, 1 per cent., etc. To the Cervix. — Applications to the cervix are frequently made for the purpose of treating a cervical leucorrhcea. Such a discharge may be due to primary infection by the gonococcus, or it may simply be a hypersecre- tion of the cervical glands when the cervical lips have been everted by laceration and the cervical mucosa has been exposed to various forms of trauma. In either event applications are not entirely satisfactory. It k difficult to apply a distinfecting solution to the entire cervical canal with- out overstepping its boundaries and encroaching upon the endometrium. Moreover, the cervical mucosa is so rich in folds and is covered by so thick and tenacious a mucus that it is exceedingly difficult to reach the bottom of these folds and get at the nidus of infection. It is evident that no application will cure a cervical discharge that is due to an eversion of the cervical mucosa and mechanical irritation. The most that can be done under such conditions is to hold the symptoms in abeyance. Before the application of a disinfectant an effort should be made to re- move the thick mucus ; this is often almost impossible to accomplish with any satisfaction. Various solutions have been employed for the purpose, such as alcohol, silver nitrate, and dilute alkaline solutions of various kinds. After the mucus has been removed the disinfecting solution may be applied by means of a cotton applicator, care being taken to reach all parts of the cervical canal but not to go beyond the internal os. The difficulty of deter- mining just when the instrument has reached the internal os may be appre- ciated at once. The most effectual method of destroying a cervical infection is by means of the actual cautery (see page 704). Cervical infections may also be influenced by the introduction and appli- cation of glycerine tampons to the external os and the use of prolonged hot douching; dilatation of the external os may be of service where the orifice is narrow and the pus is retained within the canal. To the Vagina. — Applications to the vagina may be made directly through a bivalve speculum (see Fig. 502) with a cotton-wound applicator, the mucosa being cleansed with cotton before the solution is applied. In certain cases the therapeutic solution may be simply poured into a tubular or a bivalve speculum while the patient lies in the dorsal position with the hips elevated; the excess of solution is removed with cotton. Applications cf disinfecting solutions to the vaginal mucosa should be supplemented with vaginal tampons. To Bartholin's Glands. — Applications to Bartholin's glands or ducts can be made with a fair degree of satisfaction by means of a hypodermic needle MECHANICAL AND MEDICINAL AIDS TO TREATMENT 699 Fig. 502. — Bivalve and Sims' specula introduced. (Anspach, in Hare & Landis' Modern Treatment, Lea & Febiger.) Patient in the dorsal andin the Sims' position; exposure of cervix and vaginal vault for inspection and treatment. 700 GYNECOLOGY with a blunt point. The needle is guided into the duct as far as it will go, and a few drops of the fluid are expressed under pressure. To the Urethra and Skene's Tubules. — Application to the urethra may be made by means of a small cylinder of cotton wrapped upon an applicator, which is passed into the urethra and then detached from the applicator and allowed to remain. Applications to Skene's tubules may be made with a blunt hypodermic needle. The technic of these applications has been de- scribed on pages 441 and 444. THE USE OF HEAT IN THE TREATMENT OF PELVIC INFLAMMATORY DISEASES For the local application of heat in pelvic inflammatory cases Gelhorn de- vised a hot-air apparatus that may easily be constructed and is not expen- sive. The heat can be very effectually applied without discomfort, and the degree of heat can easily be regulated. 1 The mode of application is exceedingly simple. The apparatus, with the thermometer carefully adjusted, is placed over the exposed abdomen, and the electric light is turned on. It is preferable that the heat be increased gradually, and for this purpose the apparatus is not covered with blankets until after a few moments' exposure. The degree of heat obtained can be noted at any time, and may be reduced or increased at will. While the temperature can be easily raised to 300 , from 200 to 220° seems the most suitable temperature ; with eight 16-candle-power bulbs this degree is reached within from fifteen to twenty minutes. As the reaction to the treat- ment may vary in the individual case, patients should not be left alone, and the pulse should be watched carefully. A cold cloth is placed on the fore- head of the patient, and she is urged to drink cool water freely. The patients, at first, feel quite comfortable. In about ten minutes, however, when the temperature reaches 180 , they frequently complain of intense burning. It is imperative, then, to discontinue the treatment for the time being. The sensitiveness decreases with each application, so that after a few days the baking process may be continued for one-half hour or even longer, the temperature being raised to 220 . The patients perspire 1 Gelhorn's apparatus consists of two semi-circular cradles made of thin sheet- iron and covered on the inside with asbestos. These two cradles fit over each other and may be pulled apart, after the fashion of a telescope. Electric-light bulbs, eight in number, are attached to the inside of the free edges, and there is a long, suitable attachment for the nearest socket. In the convexity of the cradle a hole is provided for a thermometer. The mercury bulb of the latter should be only about two or three inches above the abdomen, so as to register the actual temperature of the immediate surroundings and not the temperature of the air in the upper portion of the chamber, which naturally is warmer than in the lower portion. If no thermometer is used, this hole may serve as a chimney through which the hot, moist air can escape. A number of hooks are present, from which gauze bags filled with calcium chloride may be suspended, in order to absorb any excess of moisture within the air chamber. This apparatus has many advantages. It is light, portable, and clean. There is no danger from fire, although care must be taken to prevent the calcium bags from touching the electric bulbs, lest they explode. The heat can easily be regulated by eliminating one or more bulbs, thus avoiding burns of the skin. By changing the candle-power of the bulbs any desired degree of heat may be obtained. By pulling the cradles apart a larger portion of the body, or even the entire body, according to the indication, can be heated. Convenient electro-thermic heating apparatus — adapted to the pelvis — is now on the market. MECHANICAL AND MEDICINAL AIDS TO TREATMENT 701 freely over the entire body, especially on the abdomen. The exposed skin becomes an intense red, either diffuse or in more circumscribed areas. The immediate effects of the treatment consist in a marked decrease of pain and improved appetite, and large quantities of water can be taken. Many women gain in weight, and constipation is relieved. Some experience a pleasant sensation of relaxation and fall into a refreshing sleep. Burns of a mild degree may occur, but with proper precautions can be avoided. Gelhorn has observed small blisters in two cases only, and in these there was profuse per- spiration and the skin had not been wiped off promptly. There is no absolute rule as regards the dura- tion of the treatment or the degree of heat that should be used. It is best to go slowly, and the temperature should never be increased when the patient complains of heat. After the treat- ment the patient should be permitted to cool gradually, remaining in the apparatus for one- half hour or being wrapped in warm blan- kets. A cool sponge-bath may be given directly after the treatment. The principal indica- tions for this treatment are found in chronic in- flammatory lesions of the pelvis. It should not be used while the patient shows any elevation of temperature, and if an elevation of temperature follows its use, the treatment should be suspended. The number of treatments re- quired in individual cases varies from eight to thirty-five. Fig. 503. -Smith pessary; the form most frequently used in the treat- ment of retroversion. Fig. 504. — Hodge pessary; has a slightly concave upper bar with less marked upper curve and a broader lower bar than the Smith pessary, useful when the posterior vaginal vault is shallow and the perineum is relaxed. ELECTRICITY The use of electrotherapy in gynecology is more or less in disrepute, and in recent years it has probably fallen into disuse among reliable practitioners. Under certain conditions and in some affections its use may be justified. The negative pole of the galvanic current is occasion- 702 GYNECOLOGY ally an effectual treatment for amenorrhea. An ill-developed uterus is said by some authorities to have been increased in size as the result of the use of intrauterine galvanism or faradism. In employing intrauterine electric treatment great care must be taken to sterilize the vaginal canal and the electrode. The elec- trodes must be boiled. The cervix should be exposed through a bivalve speculum, the os cleansed with cotton, moistened with a weak bi- chloride solution, and the sterile electrodes should be passed directly into the uterine cavity without touch- ing anything but the cervix. A large, flat, moist electrode should be placed externally upon the abdomen. PESSARIES The pessary that is most useful in the treatment of re- troversion is that devised by Smith (see page 250). The Smith pessary may be used also in descensus and in slight degrees of prolapse in younger women during the reproductive period. When the pessary is not satisfactory in such cases, operation should be advised (see page 613). Most cases of prolapse are seen in women past the meno- pause, and here the ring pessary is the one of choice. A ring pessary is held in place by the lateral attach- ments of the vagina, and is supported to a certain extent by the rami of the pubes. A hard- or a soft-rubber ring pessary, a hard-rubber disk pessary, or a Menge pessary, according to the varying conditions of the case, will be indicated. In mild cases, when the vaginal introitus is not contracted and the vaginal walls are not excessively redundant, a hard-rubber ring pessary may be used. When the vaginal introitus is of such size that a pessary large enough to distend the vaginal fornices could not be passed through it with- Fig. 505. — Soft-rubber ring pessary; useful in descensus in elderly women with narrow vaginal orifice. Fig. 506. -Disk pessary; useful in elderly women with descensus and marked cystocele. MECHANICAL AND MEDICINAL AIDS TO TREATMENT 703 out causing great pain, a soft-rubber one should be substituted. This may be compressed during its introduction through the vaginal orifice. When the anterior vaginal wall especially is redundant and has a ten- dency to prolapse through the central opening of a ring pes- sary, a disk pessary (Fig. 506), which affords a larger base of support, may be used. Menge has modified the ring pessary by at- taching to it a sort of rudder that holds the pessary with its plane transverse to the long axis of the vagina (see Figs. 286, 507, and 508). Altogether this is the most satisfactory form of pessary for use in prolapse case.s. Certain principles must be observed in the use of a pessary in order to in- sure its success. A pessary must never be employed for the purpose of exerting pressure ; if this is necessary in order to hold the uterus in a Fig. 507. — Menge pessary (assembled); useful in prolapsus in elderly- women. **•- Fig. 508. — Menge pessary (with stem detached). proper position, then pessary treatment is not indicated. Adnexal diseases contraindicate the use of a pessary. The pessary should always be carefully selected and fitted for the indi- 704 GYNECOLOGY vidual case. It should be removed every four to six weeks for cleansing, in order to prevent any irritation or soreness of the vaginal walls with which it comes in contact. It should be left out for a few days and then replaced. Fig. 509. — Intrauterine douche nozzle. Bozeman-Fritsch model. If douches are required, they should be made of sterile water with a liquid antiseptic only. Douche powders should not be used, thus avoiding the deposition of salty incrustations on' the pessary. THE ELECTROCAUTERY AND THE THERMOCAUTERY Hunner has used the cautery especially in the treatment of cervical infections, his method being to make radical strokes into the mucosa to a depth of nearly Fig. 510. — Vaginal vault packed with tampons. (Anspach, in Hare & Landis' Modern Treatment, Lea & Febiger.) i cm. He uses this method in office practice, and claims to have had considerable success with it. The only objection to the method is the fact that it is followed by sloughing, with its consequent danger and annoyance to the patient. In MECHANICAL AND MEDICINAL AIDS TO TREATMENT 705 most cases in which its use would be indicated a surgical operation would be preferable, but if the patient has a decided objection to surgical meas- ures, the cautery may be employed (see Hunner's original paper for technic). THE UTERINE PACK The use of an intrauterine tampon is very rarely required except in connection with some form of operative treatment, as, for example, Fig. si i. — Uterine pack. ~feo^,3i Fig. 512. — Vaginal pack with suprapubic pressure. after the removal of retained secundines from the uterine cavity, or in emergency cases, when profuse bleeding is associated with cancer, sar- coma, or fibroid tumor. Before introducing the tampon the oper- ator should know the exact size and length of the uterine cavity, and 45 706 GYNECOLOGY the vagina and cervix should be carefully disinfected. A narrow pack is used, and the greater bulk of it is passed into the body of the uterus, a single strip usually being placed in the cervix, so that drainage from the body of the uterus will be perfectly free. Such a uterine tampon or pack may, be- Fig. 513. — Vaginal douche nozzle of glass. Fig. 514. — Sketch of correct position for douche. fore its introduction, be moistened with an antiseptic, such as the tincture of iodine, or with an astringent, such as a solution of suprarenal extract (Figs. 510 and 511). THE VAGINAL DOUCHE A vaginal douche may be used for three purposes: (1) Simply to cleanse the vagina ; (2) for the purpose of applying heat to the pelvis, so MECHANICAL AND MEDICINAL AIDS TO TREATMENT 707 as to favor the absorption of intrapelvic inflammations and exudates ; (3) in order to bring an antiseptic, disinfecting, or astringent solution into contact with infected or inflamed cervical and vaginal surfaces. To be effectual, a vaginal douche should be taken with the patient in the recumbent posture (Fig. 517) ; if it is taken while in a sitting or semi- sitting position the douche water escapes almost as soon as it enters the vagina, and the solution may not reach all parts of the vaginal vault. The benefit derived from a douche used to promote absorption of pelvic exu- dates depends upon the degree of heat that is carried in this way to the bases of the broad ligaments and the pouch of Douglas, and the length of time it is maintained. In order to distend the vaginal vault as much as possible in such cases, the patient should lie in bed with the hips elevated upon a douche pan, but with no pillow under the shoulders. The douche Fig. 515- — Vaginal tampon, bag or reservoir should be suspended only a short distance above the level of the bed, so that the water will run very slowly. The water should be as hot as the patient can endure without discom- fort (110 R). A large quantity — a gallon and even two or three gallons of solution — is desirable, and at least from fifteen to twenty minutes should be consumed in giving the douche. The douche nozzle may be of glass or of hard rubber, with lateral perforations ; it should be carefully cleansed after using, and kept in a weak antiseptic solution (bichloride 1 : 4000). When the douche is used simply for its cleansing and thermic effect, it may be rendered bland by adding a tablespoonful of common table salt or borax to a gallon of water. When douches are used to allay inflammation or destroy infectious organisms in the vagina and upon the vaginal surface of the cervix, antiseptic and disinfecting agents are added to the water in various proportions, for example: Formalin, 1:1000; mercury bichloride, 1:4000; lysol, 1 : 200 or 400, etc.; for deodorizing purposes, potassium per- manganate, 1 : 5000; for astringent purposes, powdered burnt alum or zinc 708 GYNECOLOGY sulphate, of each, I to 4 drams to a quart of water; or a douche powder that combines antiseptic and astringent properties may be prescribed, as, the ABC douche : Alum, y 2 ounce ; boric acid, 3 ounces ; phenol, y 2 ounce ; Fig. 516. — Filling vaginal tampon. (Anspach, in Hare & Landis' Modern Treatment. Lea & Febiger.) oil of gaultheria, 30 minims. Mix and use teaspoonful to quart of water as directed. THE VAGINAL TAMPON Vaginal tampons (Fig. 515) are used for the purpose: (1) Of applying hygroscopic, emollient, disinfecting, or astringent solutions to MECHANICAL AND MEDICINAL AIDS TO TREATMENT 709 the vaginal walls or the vaginal portion of the cervix; (2) of exerting pres- sure upon the vaginal walls and giving a certain measure of temporary support to the uterus. They are made of absorbent cotton and lamb's wool — the latter being added for the reason that it does not " mat " when wet, helps to preserve the shape of the tampon, and is somewhat more resilient than cotton, and therefore capable of exerting more pressure. Tampons are made by placing over a strip of absorbent cotton a smaller strip of lamb's wool, and binding them together in the center. They may be made of any size. For hygroscopic purposes, as, e.g., to secure depletion of the uterus in cases of subinvolution, chronic pelvic inflamma- Fig. 517. — Good type of corset. tion, etc., glycerine is most commonly used ; epsom salts in finely powdered form is also effectual. For emollient purposes, as after the application of silver nitrate or the tincture of iodine to the vaginal surface, cold cream or zinc ointment is the most effectual ; when an antiseptic effect also is desired, phenol, 10 grains to 1 ounce, may be added to the zinc oxide, or a 10 per cent, ointment of ichthyol in petrolatum may be used. For antiseptic and disinfecting purposes aqueous solutions of argyrol and protargol (10 to 25 per cent.) ; silver nitrate, 1 per cent. ; ichthyol, 10 to 20 per cent. ; dichloramine-T (2 per cent, in eucalyptol), etc., may be used. For astringent purposes dust- ing powders, such as equal parts of powdered burnt alum, boric acid, and bismuth subnitrate, or equal parts of tannic acid and lycopodium are most satisfactory. 710 GYNECOLOGY MECHANICAL AND MEDICINAL AIDS TO TREATMENT 711 CVT3 T3 w - o ro-£ ^o-d C C T)a^ . cd «9 I'm UfiU S C^ ^ 2 =3 H * 1 "2» a* * l 551 £ H£ O. ^S 6 o. - o o .Sou d C s o^ s-h^ ft^^l^ic^el:^ § +j (A— W h+ J ;=: w o <" '£,£ ^- rt vj ^"5 o-™ o c •S3 S« -2 S ° «? u^E^S- ^^- 2 ^^* i ,3^ - ocftl B^|«M5^&^5&8^g= s fil"! x O UJ >s c g 2^ ^•- s mo ftrt-g a &£ 6o^ >.-e« M S u ?TJ«2 ;^ a5 ^<1 M >>o-£ 10 co O 53 "> g) ^^ >^§ E-3 "> g-2 - ^ io.oo ^^ ^- ^^ 2 § c |s * 52 g g «"g | 2 S^ji 2Q2^S-| , S1 fV£ § ofo.^PlH S'jfe ft" SfH N-S^pHOfHOfo C^Cd Cd 712 GYNECOLOGY Tampons are either rilled with the solution (Fig. 519), ointment, or powder, as the case may be, and then introduced with a dressing forceps through a bivalve speculum, or the therapeutic agent is first introduced and the tampons inserted afterward. The patient should be told how many have been used, and she should be directed to remove them at the end of twenty- four hours. Tampons are used for the purpose of exciting pressure and giving sup- port in the gradual replacement of a retroverted uterus, previous to the fitting of a pessary. In such cases the tampons should be of small size, and the string to each one should be long enough to reach from the vaginal vault to a point well outside of the introitus. The tampons should be soaked in glycerine and packed into the vaginal vault with the patient in the knee- chest position (see page 704). CHAPTER XL RADIUM AND RONTGEN RAY THERAPY Radium. — Radium is a metallic element. It is used in the form of one of the salts (sulphate or bromide) ; the amount is always expressed in terms signifiying the amount of radium element in the salt. During some of its radio-active changes radium takes the form of a gas which is called the emanation. This emanation can be used for therapeutic purposes. Radium produces three varieties of radiations, designated as alpha, beta, and gamma radiations. The alpha rays have little penetrating power and no therapeutic value and may be confined by glass ; the beta rays are more penetrating and have therapeutic properties, but all except the most pene- trating are arrested by 2 mm. of lead; the gamma rays have the greatest penetrating power and are also used therapeutically. Although exposure to these rays has an injurious influence on all living cells, the normal tissues are more resistant than many of the tumor cells. On many tumor cells radium and the Rontgen ray have a selective action and the therapeutic use depends on this fact. 1 In a general way. in the case of normal tissues, the more highly special- ized cells, especially glandular secreting cells as those of the skin, testicle, ovary, thyroid, and certain lymphoid structures as the thymus, are more susceptible to radium rays and the Rontgen rays. Cartilage, bone, fibrous connective tissue, and nervous tissue are very resistant. The effect of the rays on different tumor cells is very variable. Radium rays may disseminate a lymphosarcoma within forty-eight hours ; no visible change whatever may be noticed for five or six days after expo- sure of a carcinoma of the cervix to the same rays and yet the growth may disappear entirely in from five to six weeks. " From actual clinical experiences, taking account of the various physical factors in- volved: we feel that the ovary is at least ten times as easily injured as normal skin; that the vaginal wall is four or five times as tolerant ; that the mucous membrane and bladder wall are twice as tolerant ; that the lining of the uterus is about equally as tolerant as the skin ; that the rectal mucous membrane is equally tolerant ; that the cervix uteri is at least twenty times as tolerant. The figures are confessedly only rough estimates, but afford a good working basis for actual treatment. " The difference in toleration between the normal tissues and the epithelial new-growths in gynecologic cases is much more pronounced than in the dermatologic, which we have taken as our standard. The adenocarcinomata of the cervix uteri and of the body of the uterus are, on the average, more easily injured by radiation than are the epitheliomata of the same organs. It is our impression that most of the vaginal and cervical cancers are, as to tolerance, to be classified as more sensitive than the basal-celled epitheliomata of the skin. " Some rectal cancers of the adeno-type are four or five times as susceptible as the skin epithelioma, and all of them except the pearl-forming, squamous-cell cancer met with at the anal margin are decidedly more easily injured by radiation than the skin epitheliomata. The ordinary papilloma and the malignant papilloma of the bladder require about the same dosage as skin epithelioma of the basal-cell type. Uterine fibroid tissue is very much more susceptible to radiation than the normal skin — perhaps four or five times as easily influenced."' (Burnham.) 713 714 GYNECOLOGY Filters of various substances are used to lessen the local effect of the rays, e.g., lead, gold, platinum, silver, rubber, etc. The local reaction is also diminished by distance and increased by immediate contact. For example, packing the vaginal walls away from the cervix which is being exposed protects the vagina even better than a metal filter in contact with the vaginal wall. With an exposure sufficient to cause local necrosis at the point of con- tact, it has been proven that the destructive effect upon malignant cells is not exerted beyond a distance of 2 to 4 cm. The gamma rays of radium are practically identical with the Rontgen rays. The therapeutic action of each is practically the same, but in many gynecological cases radium can be used with advantage in place of the Rontgen ray, since it can be applied more directly. Histologically, the general changes noted in a malignant growth after radiations are disintegration of the tumor cells and formation of new con- nective tissue poor in blood-vessels. CARCINOMA OF THE CERVIX Radium is the most valuable therapeutic agent at our command in the treatment of advanced carcinoma of the cervix. Experience has shown that recurrences following operation or radium treatment are not as amenable as primary growths. In the early and distinctly operable stage, radium treat- ment cannot yet be regarded as the procedure of choice. The best treatment for early and distinctly operable cases at the present time seems to be operation immediately following radium treatment of the carcinomatous area. This immediate preparatory treatment with radium is supposed to affect some of the cancerous cells beyond the operative area, and possibly also to prevent lymphatic dissemination. In borderline cases, that is. those in which the disease has evidently passed through the cervix on one side, but in which the uterus retains enough mobility to encourage the operator to remove it, radium alone should be used. Operation some time after radium treatment, the treatment having been given for the purpose of rendering inoperable or borderline cases operable, and which has been advised and practised, is not to be encouraged. Radia- tion renders the operation technically difficult, and the operation subjects the patient to the risk of disseminating quiescent and walled-off cancerous cells. Radium treatment is the most effective treatment for recurrences after operation, but after all, it is not very succesful. Nevertheless, in even the most hopeless cases, it may be of the utmost benefit short of a complete cure. Radiation is the treatment par excellence in cases of cancer of the cervix that are advanced and inoperable at the time they come under observation, but there are cases in which the disease is so far advanced locally that destruc- tion of the carcinomatous growth will produce rectal or vesical fistula with- out any hope of permanent benefit. Curiously enough, even in some cases which present distinct metastases at a distance, radium treatment may be considered justifiable for the purpose of relieving disagreeable local manifestation. RADIUM AND RONTGEN RAY THERAPY 715 In carcinoma of the cervix, radium treatment is supplied by the introduc- tion of the radium salt or of the radium emanation directly into the cancerous area. In no case should radium treatment be preceded by curettement. No disturbance of the carcinomatous mass is permissible further than the use of a cautery knife, and this only when it is necessary to make room for the radium tube or to secure tissue for histologic diagnosis. When needles are avail- able, they may be plunged directly into the mass. The radium salt or ema- nation should be introduced into the center of the carcinomatous tissue. The dose should be at least 2000 mg. hours. It is not practicable to use less than 50 mg. of radium in the treatment of cancer of the cervix. The usual dose, as, for example, that used by Clark, is 100 mg. of radium screened with platinum and rubber, with an exposure of twenty-four hours. The rectum and bladder are protected by malleable lead plates, or by gauze packing which holds the vesicovaginal and the rectovaginal wall at some distance. Kelly and Burnham use a larger amount of radium element for shorter periods of time, as, for example, as much as 500 mg. for eight hours, to 3000 mg. for one hour. Miller uses 75 to 85 mg. of radium intermit- tently, giving from 3000 to 5000 milligram hours within a week or ten days. When radium is used, the vesicovaginal and rectovaginal septa must be protected by suitable screens of lead or gold. These tissues may be pro- tected also by the interposition of gauze packing which separates them from the radium. Distance is a good protector, the effect of radium on tissues being inversely as the square of the distance. If the vesicovaginal and recto- vaginal walls are not sufficiently protected, cystitis, proctitis, ulceration, fistula formation, and infection may ensue. More than half of the cases are benefited : hemorrhage, discharge, and pain disappear ; the appetite improves, the color returns, and the patient gains in weight. In most cases this improvement lasts for at least six months, when the pain, emaciation, etc., reappear. Although nothing may be noted at the immediate original site of the cancer, upon making bimanual examination extensions from it may be discovered in the broad and utero- sacral ligaments and in the rectovaginal and the vesicovaginal septa (Clark). In some cases the general and local indications of the disease disappear for a longer period. In those extending over a period of five years, the result may be considered a cure. Kelly and Burnham report one case alive after seven years and six after six years. The use of radium is too recent to warrant an estimate as to the durability of its effects. Of Kelly and Burnham's series of 327 cases one is alive after seven years, six after six years, three after three years, 19 after two years, 22 after one year, etc. Clark reports a total of 209 cases. Seventy-three are living: one after five years, four after four years ; 1 1 after three years ; 23 after two years, and 34 after one year. Twenty-five could not be traced ; 1 1 1 are dead. Recasens, in a series of 200 cases treated with radium and the Rontgen ray, claims to have secured 70 per cent, of relief for the inoperable cases, 716 GYNECOLOGY and ioo per cent, relief for the operable cases. He speaks of the condition as a " clinical cure,'' but only 2*j of his cases at the time of his report (1917) were of more than two years' duration and but 45 were more than one year old. Kelly and Burnham, Recasens, and others advise a combination of radium and the Rontgen ray, the applications being made externally, through the abdomen or through the sacrum by cross-firing through several ports of entry. Case calls attention to the fact that the Rontgen ray is a I Fig. 526. — Means of applying radium in gynecological diseases; to the left, needles contain- ing radium which may be thrust into malignant tumors; to the right, radium enclosed in platinum capsules and encased in rubber tubing, ready for intrauterine application. much more powerful agent than radium in proportion to the time consumed. Radium is to be used in the uterus where it can be applied more directly to the cancerous area, whereas the Rontgen ray, directed from the outside, affects the deeper tissues and lymphatics that have escaped the influence of the radium. A repetition of the radium application may be undertaken within a period of from four to eight weeks. RADIUM AND RONTGEN RAY THERAPY 717 The Rontgen ray applications are made in series of seances conducted about three to four weeks apart. CARCINOMA OF THE FUNDUS The results of operation, except in advanced cases, are so good that dependence upon radiation is not often justified. It should be used only as a palliative measure in advanced inoperable cases or when there is some grave counter-indication to hysterectomy. MYOMATA UTERI The application of either radium or the Rontgen ray will control the hemorrhage of myomata uteri, the growths in most cases being gradually reduced in size and some finally becoming unrecognizable. In view of this fact and others, it might at first sight appear that radiation was the procedure of choice in the treatment of myoma uteri. This is not the case, for, while radiation is to be preferred for certain myomata, the majority of cases require operation. The following are the disadvantages of radiation : 1. Although radiation arrests hemorrhage and tends to reduce the tumor, a nucleus of the latter may remain which later will give trouble. 2. Malignant complications may be overlooked either in the tumor itself (sarcoma) or in the endometrium (carcinoma). Myomata are sarcomatous in 2 per cent, of all cases ; in 9 per cent, of submucous tumors. Although a diagnostic curettage can effectually rule out malignant degeneration in the endometrium, in many cases of myoma uteri there is such distortion of the uterine cavity that it is imposible to reach all parts of the endometrium with a curette. Frank insists that radiation is not permissible unless a thor- ough diagnostic curettage is possible. 3. Certain intrapelvic complicating lesions, such as adherent and closed adnexa, ovarian cysts, etc., may be overlooked ; in a small proportion of cases these give trouble after radiation, and while they do not threaten life, a certain amount of morbidity must be entailed. Stein quotes many cases in which the Rontgen ray failed to reduce the tumor, and upon operation sarcoma, at times inoperable, was discovered. Tracy, in a collection of 3561 cases of myomata, estimated that 33 per cent, could not have been cured by the Rontgen ray because of malignant degeneration and adnexal lesions. 4. In young women radiation may destroy or seriously impair the re- productive functions. While the condition of the patient may be such as to make this a secondary consideration, in most instances it is a most impor- tant matter. When the myomata are single or pedunculated, myomectomy removes the growth without mutilation of the pelvic organs or impairment of their function. 5. While the effect of radiation on hemorrhage in myomata is in any case suf- ficiently prompt, when the growths are producing serious pressure symptoms, as, e.g., vesical and ureteral obstruction, with cystitis and pyelitis, etc., it may be inadvisable to wait for the shrinkage of the radiated growths, as this may cover a period of months or even years. 718 GYNECOLOGY 6. When myomata are complicated by inflammatory adnexal lesions or ovarian tumors, radiation is inadvisable for two reasons : First, because radiation sometimes renders them worse, and secondly, because it never effects a cure. J. When myomata are necrotic, radiation tends to aggravate the condi- tion by predisposing to infection and diminishing the blood supply. The advantages of radiation are as follows: i. There is practically no operative mortality: in Rontgen ray cases there is no anaesthesia risk; there are no post-operative complications. The patient is ambulant, and there are fewer hospital days. While in a selected series of cases the risk of operation has been as low as or lower than i per cent., Kelly draws attention to the higher death-rate in general following operations for myomata, and also to the morbidity that follows operations. He thinks, therefore, that radiation by radium is the procedure of choice. 2. Radiation for the control of hemorrhage can be used with success and without hesitation in any patient, no matter how serious her condition. 3. If radiation fails, operation may later be undertaken without detri- ment to the patient. Pfahler observes that in 1915 from 2000 to 3000 fibroid cases had been treated by the Rontgen ray. If, later on, malignant degen- eration were common, many cases would by this time have been reported in the literature. Furthermore, since radiation is successful in curing some in- operable carcinomata, why may it not be curative of unsuspected malignant growths? 4. The menopausal symptoms after cure by radium treatment are not so marked as after operation with complete ablation of the ovaries. The consensus of opinion to-day among gynecologists in this country is that, in a majority of cases operation is to be preferred to radiation, and that the latter should be reserved for those in whom the advantages to be gained by operation are overbalanced by the dangers incident to the patient's condition. Radiation is admittedly not suitable for complicated cases {e.g., degenera- tions of tumor, endometrial disease, adnexal lesions), and it is in these cases that the operative mortality is highest. In the uncomplicated cases the operative mortality is exceedingly low (less than 1 per cent.) ; the patient is permanently cured, and there is no danger of a subsequent growth or of degeneration of the shrivelled remains. Radiation is, therefore, reserved for : 1. Myomata in which the preponderating symptom is hemorrhage ; espe- cially in intramural tumors, when the uterus is smaller in size than a four months' pregnancy (Clark), and all parts of the endometrium may be reached in a diagnostic curettage. 2. Myomata complicated by anaemia, organic heart disease, diabetes, chronic nephritis, serious pulmonary disorders, goitre with heart symp- toms, and other general lesions that increase the risk of operation. Radiation is contraindicated : 1. When myomectomy is possible without impairing the reproductive functions. 2. When the dominating symptoms are due to pressure and the uterus is larger than a four months' pregnancy ; especially in multiple tumors of the RADIUM AND RONTGEN RAY THERAPY 719 submucous and the subserous type, as well as in a degenerating tumor or tumors complicated by adnexal lesions, or in cases in which these factors cannot be excluded. Radium is the form of radiation that is particularly useful, since it can be introduced directly into any part of the uterovaginal canal. Radium should, therefore, be used as a rule, but in extremely large growths the Rontgen ray may be used with advantage to supplement the action of the radium ; when the latter is not available, the Rontgen ray is an almost equally efficient alternative, although not so convenient or so rapid in its effect. The results of radium treatment have been gratifying. Kelly and Burnham state that, in their opinion, with increasing experience 90 per cent, of myomata may be dissipated by radium without serious discomfort or risk. They report 210 cases in which the age ranged between 26 and 67. In some the tumor reached almost to the umbilicus. In nearly every case shrinkage or disappearance followed in from two to 18 months. Clark and Keene, Miller, and others report similar results. The technic of application varies. Kelly and Burnham believe in giving large doses over a short period of time. They use, as a rule, a single intra- uterine dose of 1500 millicurie hours. Extremely large tumors are also at- tacked by supplementary massive treatment through the abdominal wall. Clark and Keene, and Miller use 50 mg. of radium, screened by a platinum capsule and a rubber sheath, for 24 hours. This is a most success- ful and rational plan of treatment. A preliminary curettage is performed under local, nitrous oxide and oxygen, or ether anaesthesia. The depth of the uterine cavity is then measured, and the radium capsules, in either single, double, or tandem formation, are inserted to the fundus. Care must be taken not to allow the radium to remain in contact with the cervical canal. Nausea and sometimes lower abdominal pain and tenderness follow, as a rule, but in a majority of cases subside rapidly after removal of the radium. In some cases these symptoms may persist for a few days. Radium produces its effect by causing an obliterative endoarteritis affecting the endometrial vessels ; there may also be an influence upon the ovaries (destruction or inhibition of follicular development), but this is somewhat doubtful from an intrauterine application. To affect the ovaries Boggs applies 25 mg. of radium to the vaginal vault on each side of the cervix. Following the use of radium, bleeding is checked and may not return ; sometimes there is increased hemorrhage for a time, or the bleeding may be irregular. If the first application does not produce the desired result, a second application may be made after a period of several months. Follow- ing the use of radium, a slight irritating leucorrhcea may occur for a time. The Rontgen ray may be used as supplementary to radium or, when radium is not available, it may be used alone. Deep therapy, cross-firing, and filtration are necessary. Definitely local- ized single myomata may be treated directly, the ovaries being screened for protection. There is no danger to the skin when the correct technic is carried out 720 GYNECOLOGY and there is no visceral disturbance. Constitutional symptoms, such as lassi- tude, etc., are due to the absorption of gases that collect about high- tension currents. Lange, who believes that malaise, nausea, anorexia, glandular enlarge- ments, and metallic taste are due to acidosis, prescribes 30 grains of sodium bicarbonate every three or four hours. The proper ventilation of the treat- ment room is of the utmost importance (Pancoast). HEMORRHAGIC UTERI Almost every form of benign uterine hemorrhage is favorably influ- enced by radium treatment. Under this heading may be grouped hemor- rhages due: (1) To myopathic changes; (2) to glandular hyperplasia of the endometrium ; (3) to functional disturbances of the ovary or ductless glands ; (4) to general diseases, such as heart, kidney, and liver disorders, circulatory lesions, etc. These hemorrhages may either threaten life, by producing anaemia, or they may merely be a constant source of annoyance. Radium is more satisfactory than the Rontgen ray for the reason that it can be applied in conjunction with a diagnostic curettage and because its effect is produced locally upon the capillaries of the endometrium, whereas the Rontgen ray must first influence the ovary and secondarily the circula- tion of the uterus. One radium treatment is usually sufficient. Kelly and Burnham, Clark and Keene, and Miller, have used radium ■) with success in these cases, and together report upward of 72 cases. There are two plans of applying the radium. Kelly and Burnham ' use a tiny capsule of radium emanation (500 to 1000 mc.) which is fastened to the end of a uterine sound. The emanation bulb is then placed in con- tact with successive areas of the uterine interior for a certain number of minutes at a time. The patient is maintained in position by means of pil- • lows placed under the knees and by sand-bags placed on each side. The sound is kept in position by strapping it to sand-bags placed between the ' patient's knees. When a 500 mc. application is used there should be eight areas, and the application to each one should last fifteen minutes. When 1 these observers consider complete and rapid cessation urgent, in addition | to the internal radiation they make external applications, 1 gm. of radium 1 being placed on either side of the lower abdomen over the true pelvis, 3 inches ' from the skin, and allowed to remain for from four to six hours. External Rontgen ray treatment also may be used in conjunction with internal radium treatment. Clark and Keene, and Miller apply the radium element or salt to the uterine cavity, screened with a platinum capsule and a rubber tube. The radium capsules are placed in single, double, or tandem formation, depend- ing on the strength of the capsules, the dose, and the length of the endo- metrial cavity beyond the internal os. When the hemorrhage is serious and the patient is over forty, and it is immaterial whether or not the menopause is induced, 50 mg. are used with twenty-four hours' exposure. In young women, when the symptoms are RADIUM AND RONTGEN RAY THERAPY 721 less urgent and it is undesirable to produce a permanent amenorrhoea or a premature menopause, a dose of from 25 to 50 mg. is used, and the exposure lasts from three to eight hours. Radium treatment should, in all cases, be preceded by a diagnostic curet- tage, otherwise it is not permissible. In the presence of adnexal lesions radium treatment is contraindicated, for it often aggravates them. Cessation of the bleeding is usually prompt, but occasionally there are one or two free periods following the treatment ; this, too, even if complete cessation of the periods has been desired and is subsequently accomplished. It has been stated that radium treatment with a larger dose and for a shorter period is followed by less abdominal tenderness, also a diminution in the watery leucorrhcea that is almost always observed for a time. When complete and permanent amenorrhoea takes place, only one-third of the patients complain greatly of menopausal symptoms ; one-third experi- ence very slight discomfort, and one-third complain of no discomfort whatever. CARCINOMA OF THE VULVA There is some reason to doubt the efficacy of radium in the treatment of vul- var growths. In one case in which a carcinomatous area in the labium majus was excised, with implantation in the wound of 50 mg. of radium for eight hours, a carcinomatous superficial inguinal gland was removed, and an enlargement of the deep inguinal glands was exposed to the Rontgen ray, improvement oc- curred and there was no recurrence after eight months. Another ex- tensive (3 by 5 cm.) carcinoma of the labium majus, treated by radium alone, grew rapidly worse. The only patient in Janeway's series did badly, in spite of the fact that the lesion did not seem far advanced (1^2 inches in diameter). Duane and Greenough treated three cases of vulvar carcinoma without securing any improvement. No doubt in malignant tumors of the vulva operation is the procedure of choice, applications of radium being made later to prevent recurrence. Nevertheless, in late inoperable cases, radium is the only recourse, and should always be tried. Sarcoma of the vulva, especially of the melanotic type, rodent ulcer, and lupus vulvae may be favorably influenced. Pruritus vulvae is rapidly and favorably influenced by radium in many instances (50 per cent, cured, 25 per cent, improved, 25 per cent, unimproved) (Pancoast). The Rontgen ray is also useful here, as reported by Steiger, who treated pruritus ani by the same method. PAPILLOMATA AND CARCINOMATA OF THE BLADDER Geraghty has employed radium for the past two years in bladder papillomata that have shown histologic changes characteristic of malignant papillomata, or those in which the growths were unusually resistant to fulguration. There have been eighteen cases, seven of them multiple. Two patients discontinued treat- ment, but in the remaining sixteen the tumors were completely destroyed. In all but one cystoscopic examinations had been made subsequently, and four recurrences were noted. Six other cases of the malignant papilloma 46 722 GYNECOLOGY type that had responded only slightly to fulguration, after varying amounts of radium, yielded readily to the high-frequency current. In twenty-four cases of papillary carcinoma Geraghty concluded that radium was of no use, either alone or in combination with fulguration. Barringer used radium in twenty-five cases of carcinoma of the bladder, of whom twenty-three were impossible operative risks. In four (three con- firmed as cancer by microscopic examination) radium removed the growth locally (ten and one-half months, five months, and less), and one showed slight symptoms of local recurrence, the microscopic examination, however, being negative. Of the twenty-one remaining cases, eight had died at the time of his report (1918) ; two were improving, one was hopeless, one had shown some indication of having been benefited ; four had not been heard from, and the remainder were too recent (1917) to be conclusive. Geraghty employed about 103.7 mg. of radium in a brass capsule (some- times the /3-rays were filtered with platinum). The capsule was introduced in the beak of an instrument through which an observation cystoscope could be passed. After accurate placing of the radium, the instrument was held in a fixed position by means of a mechanical arm attached to the cystoscope table. The radiations were given for an hour at a time, and the seances were repeated from one to three times weekly, depending upon the tumor and the reaction of the patient. Barringer's plan was to introduce the radium tubes (emanation screened with silver and rubber, 50 to 100 mc.) into the bladder through a cystoscope. As most tumors are situated in the trigone, the patient was placed in the recumbent posture and the radium was kept in close contact with the growth. If the growths were in the vault or upon one of the lateral walls, the patient was placed upon the abdomen or upon one or the other side. Hirst and Pancoast have one patient who had an extensive papillary car- cinoma involving the base of the bladder upon whom they did a suprapubic cystotomy, and then with free exposure of the growth, used desiccation fol- lowed by radium treatment. She remains without symptoms and free, so far as they are able to determine of a recurrence of the tumor after three months. In women suprapubic cystotomy and free exposure are advisable, as a rule, preliminary to fulguration and radium treatment. RECTAL DISEASES Both adenocarcinoma of the rectal mucosa above the sphincter region and squamous epithelioma of the anus have shown some sus- ceptibility to radium treatment. Adenocarcinoma is definitely curable in rare instances and favorably influenced in a few cases. Radiation may be tried in early cases, when operation w r ould mean serious mutilation. If radiation fails, operation can still be resorted to. The difficulty in the use of radium in the treatment of cancer of the rectum lies in the technic of its application ; this difficulty is increased by the fact that the function of the bowel is of necessity more or less continuous. A satisfactory plan is to expose the entire tumor-bearing area through a speculum. A piece of RADIUM AND RONTGEN RAY THERAPY 723 muslin containing the radium tubes is then introduced and spread over the tumor. Over this sufficient gauze packing may be placed to push away and protect the opposite rectal wall. A more exact method consists in making a cast of the cavity of the rectum out of dental composition and embedding the radium tubes on its surface in contact with the lesion ; or a disk contain- ing the radium may be attached to the proctoscope and applied, under direct observation, to the tumor. In advanced annular carcinomata of the rectum, after performing colos- tomy, a string may be washed through the rectum out of the anus, and by this means radium tubes may be drawn through into successive positions in order to expose every part of the affected bowel. The technic of application in epithelioma of the anus is simple. These tumors are more malignant and less amenable to the treatment than adeno- carcinoma. Metastases from the anus to the inguinal lymphatic glands is a factor that exerts an unfavorable influence on the prospects of cure. Janeway reported thirty-four cases of cancer of the rectum treated with radium. Two had completely retrogressed and showed no evidence of disease at the time his report was made (1917) ; fourteen had been improved, whereas eighteen were classed as unimproved. ABDOMINAL TUMORS Burnham and Kelly report that immense growths of this type have completely disappeared under radium treatment. Favorable results also were observed in colloid carcinoma of the intestine, cancer of the liver and stomach, ascites from abdominal cancer, hypertrophy of the spleen, and sarcoma of the kidney. One case of bilateral papillocarcinoma of the ovary with diffuse peri- toneal metastases has been observed in which, after removal of the pelvic tumors and recurrence of tumor formation and ascites in the abdo- men, the Rontgen ray caused a recrudescence of the abdominal masses and disappearance of the ascites for a period of two years. The ascites then reappeared and in spite of repeated tappings and Rontgen ray treatment the patient died within a year. In the treatment of such conditions with radium immense quantities are required, so that the treatment is available in few localities. Rontgen ray treatment is more generally applicable in these cases. BIBLIOGRAPHY Abbe, R. : "Uterine Fibroids, Menorrhagia, and Radium." Med. Record, 191 5, lxxxvii, 379. Bailey, H. : " Radium in Uterine Cancer." Trans. Amer. Gyn. Soc, 1917, xlii, 438. Brettauer, J. : " Final Results of Rontgen Ray Treatment of Fibroids of the Uterus." Trans. Amer. Gyn. Soc., 1918, 364. Burnham, C. F. : "A Brief Outline of the Status of Radium Therapeutics." Bull. J. H. H., 1915, xxvi, 190. Case, J. T. : " The Rontgen Treatment of Uterine Carcinoma." S., G. and O., 1916, xxii, No. 4, 429; Ibid. : " The Present Status of Rontgentherapy in the Management of Deep- seated Malignancy." S., G. and O., 1917, xxiv, No. 5, 580; Ibid.: "Rontgen Therapy." P. M., 1918, 171. Clark, J. G. : " The Therapeutic Use of Radium in Gynecology." S., G. and O., June, 1918. Clark, J. G., and Keene, F. E. : " The Use of Radium in Cases of Benign Uterine Hemor- rhage." Trans. Amer. Gyn. Soc, 1917, xlii, 424. 724 GYNECOLOGY Cole, C. G. : " Technic and Experimental Application of Hard Rays for Deep Rontgen Therapy." Trans. Amer. Gyn. Soc, 191 5, xl, 215. Duane and Greexough : " Report of Results of Radium Treatment at the Collis P. Hunt- ington Memorial Hospital by the Cancer Commission of Harvard University." Boston Med. and Surg. Jour., 1917, clxxvii, 359. Frank, R. T. : " X-Ray Treatment of Uterine Hemorrhage." Trans. Amer. Gyn. Soc, 1916, xl, 460; Ibid. : S., G. and O., 1916, xxiii, 243. Heynemann, Th. : " Gynakologische Strahlentherapie." Therap. Monatschrift, 1915, xxix, 78. Janeway, Barringer and Failla : Radium Therapy in Cancer. Hoeber, New York, 1917. Kelly, H. A. : " Radium Therapy in Cancer of the Uterus." Trans. Amer. Gyn. Soc, 1916, No. 41, 532; Ibid.: "Methods and Results of Radium Treatment of Uterine Hemor- rhage Due to Other Causes Than Malignancy." Trans. Amer. Gyn. Soc, 1917, xlii, 408; Ibid. : "The Radium Treatment of Fibroid Tumors." S., G. and O., 1915, xx, 271. Kelly, H. A., and Burnham, C. F. : " Radium in the Treatment of Uterine Hemorrhage and Fibroid Tumors." Trans. Sect., O., G. and A. S., A. M. A., 1914, 237; Ibid.: " Radium in the Treatment of Carcinomas of the Cervix Uteri and Vagina." J. A. M. A., 1917, lxv, 1874; Ibid. : "Two Hundred and Ten Fibroid Tumors Treated by Radium." Trans. Amer. Gyn. Soc, 1918, 317. Lange, S. : " The Cause and Prevention of the Constitutional Symptoms Following Deep Rontgentherapy." Amer. Jour Rontgenology, 1916, iii, 356. Miller, C. J. : " Radium in the Treatment of Carcinoma of the Cervix Uteri." S., G. and O., 1916, xxii, No. 4, 437; Ibid.: "Radium in the Treatment of Certain Types of Uterine Hemorrhage and Uterine Fibroids." Trans. Amer. Gyn. Soc, 1917, xlii, 2>77- Pfahler : " Rontgenotherapy in Uterine Hemorrhage." Trans. Sect., O., G. and A. S., A. M. A., 1914, 251 ; Ibid. : Rontgen Therapy in Uterine Fibroids and Uterine Hemor- rhage." Trans. Amer. Gyn. Soc, 1915, xl, 199. Pfahler, G. E. : " Rontgenotherapy in Uterine Fibroids and Uterine Hemorrhage." Amer. Jour. Obst, 1915, lxxii, 79. Pfahler and McGlinn : Rontgenotherapy Successful in Uterine Fibroid Without Affect- ing the Ovaries." Amer. Jour. Obst., 1917, lxxvi, 262. Prime : " Radium and Cancer Experimental Work." Prog. Med., 1918, 163. Recasens, S. : " La Radiumtherapie dans le cancer de l'uterus." Arch. mens, d'obst. et de gyn., 1917, 34- Schmitz, H. : " An Additional Contribution to the Therapeutic Value of Radium in Pelvic Cancers." S., G. and O., 1916, xxiii, No. 2, 191. Steiger, M. : " Bisherige Erfahrungen und Resultate aus dem Rontgeninstitut der Univer- sitatsfrauenklinik." Bern. Cor.-Bl. f. Schweiz. Aerzte, 1915, February 27, xlv, 257. Stein, A. : " The X-Ray Treatment of Uterine Myomata — A Warning Based on a Study of the Literature." Med. Record, Wm. Wood & Co., New York, 1916, lxxxix, 991. Shoemaker, G. E. : " Sarcomatous Degeneration of a Uterine Fibroma Five Years After Rontgen Ray Treatment for Pressure and Hemorrhage." Jour. Amer. Med. Assoc, 1915, lxiv, 1653. Tracy, S. E.. "A Report of 100 Consecutive Cases of Fibromyomata Subjected to Opera- tion." Trans. Sec, O., G. and A. S., A. M. A., 1916, 299. CHAPTER XLI VACCINE AND SERUM THERAPY IN GYNECOLOGY Specific therapy — by vaccines and sera — in the treatment of gonococcus infections of the female pelvic organs has not achieved the marked curative results seen in other diseases. However, in many instances marked im- provement of the lesion and amelioration of the symptoms has followed the use of specific measures either alone or used to supplement appropriate local treatment. Injection of specific serum has not been in frequent use, due to the diffi- culty in most cases of establishing the exact identity of the causative organ- ism. Sera for gonococcus infections are usually prepared by immunizing rabbits and sheep. They should not be used during the acute period of the disease, the so-called negative phase of the infection, but better later when the patient is not so overwhelmed with toxins, yet still has a moderately active infection. The serum confers a passive immunity rather than an active one. The dosage may vary from 20 to 100 c.c. given every twenty-four hours or more. In general it may be said that the serum is more efficacious in such complications as arthritis, endocarditis, and general septic conditions associated with gonococcus infections of the genito-urinary tract than in the treatment of the simple forms of gonococcal urethritis, vulvitis and cervicitis. Auto Serum Therapy. — In the treatment of gonorrhceal arthritis good results have followed the injection of 5 to 10 c.c. of the patient's own serum. Vaccine therapy of gonococcus infections of the female pelvic organs has shown different results in the hands of various observers. Vaccines may be autogenous, polyvalent, or mixed, i.e., with other organisms. The gono- coccus is hard to cultivate. It grows best in original culture on haemoglobin or hydrocele fluid agar. After once establishing the growth the gonococcus will grow readily upon most media. Naturally an autogenous vaccine is to be preferred. But lacking this, and due to the variances in the different strains of the organism, it is advisable to use a polyvalent or stock vaccine. In some instances a mixed vaccine is of value, when to the polyvalent gonococcus vaccine is added various combinations of vaccines, such as colon bacillus, micrococcus catarrhalis, staphylococci and diphtheroid bacilli. Whatever the nature of the vaccine it should always be used as a comple- ment to the necessary and appropriate local therapeutic measures. Vaccines have been used extensively in the vulvovaginitis of children. The poor results from vaccines in the hands of some observers may be due, as Louise Pearce has shown, to the fact that the organism found on the vulva of infants differs immunologically from the organism found in adult urethritis. Here, preferably, an autogenous vaccine should be used. In the treatment of leucorrhcea, vaginitis, and cervicitis, Curtis found that vaccine therapy gave very satisfactory results for a time. A considerable number showed decrease in the discharge while under treatment without attainment 725 726 GYNECOLOGY of a point of absolute cure. Many had a slight return of discharge on cessation of treatment. Most important in his investigation was the cure or relief of such associated symptoms as malaise and backache when an autog- enous vaccine was used. Vaccines have not been used in sufficient degree in salpingitis, oophoritis, or metritis to warrant conclusions being drawn as to their therapeutic value. In the treatment of arthritis, which frequently complicates gonococcus infection of the genito-urinary tract, vaccines have proved to be valuable adjuncts. The dosage should be from 50 to 100 million every three to five or six days, and may be increased to as high as 500 millions. Reactions should be looked for, and may occur as local, focal, or general. In case of a severe reaction of any nature the dose should be cut in half for the next injection and treatment continued cautiously. The local reaction has been made use of at times as a diagnostic means. A few drops of a gonococcus vaccine are injected intracutaneously after the manner of producing the well-known tuberculin reaction. A positive reaction is manifested by the appearance in from twenty-four to thirty-six hours of a small papule at the point of injec- tion, surrounded by an areola of erythema. This disappears in a few days. A negative reaction is a slightly yellowish discoloration at the point of injec- tion. A diagnostic focal reaction following a subcutaneous injection might be expressed by lessened tenderness and softening of the mass, as in a pelvic lesion. In general, it may be said that vaccines and sera are often valuable aids to treatment and merit extended use in many cases (see also Treatment of Puerperal Pelvic Inflammatory Disease, p. 424). BIBLIOGRAPHY. Curtis, A. H. : " On the Pathology and Treatment of Chronic Leucorrhea." Surg., Gyn. and Obst., 1914, vol. xix, 25. Hamilton, B. W. : "Gonococcus Vulvovaginitis in Children." Jour. Am. Med. Assn., 1910, liv, 1 196. Hensius, F. : " Versuche zur Vaccine Behandlung der weiblichen Gonnorrhoe." Monatschr. f. Geburtsch. u. Gynak., 191 1, xxxiii, 426. Morrow, L., and Bridgmax, O. : " Gonnorhcea in Girls, Treatment of Three Hundred Cases." Jour. Am. Med. Assn., 1912, lviii, 1564. Neu: " Vakzinetherapie." Monatschr. f. Geburtsh. u. Gynak., 1913, xxxviii, 182. Sternberg, A. J. : " Zur Vakzindiagnostik der Gonorrhoe des Weibes." Gyn. Rundschau. 1912, vi, 701. Taussig, F. J. : " The Prevention and Treatment of Vulvovaginitis in Children." Am. Jour. Med. Sci., 1914, cxl. Weinstein, E. : " Die Vakzinetherapie nach Wright bei der Vulvovaginitis der Kinder." Miinchen. med. Wochnschr., 1910, lvii, 762. INDEX Abderhalden serum test in pelvic disease, 107 Abdomen, examination of, 131, 520 exploration of, 639 mensuration of, 137 pendulous fat, 550 treatment of, 551 regions of, 116 Abdominal, bandages, 696 binder, 696 examination, 131, 520 by auscultation, 137 by palpation, 131, 132 by percussion, 134 hysterectomy, 317 incisions, 624 Battle's, 505, 625, 626 closing, with drainage, 646 directions regarding, 633 dressing, 646 gridiron, 627 high paramedian, 625 lateral, 625 local anaesthesia in, 652 low paramedian, 624 operations, preparations for, 621 organs, remote from pelvis, 137 ptosis, 508, 550 support, 551, 696 tumors, radium in, 723 viscera, diseases of, 500 associated with pelvic disorders, 500 exploratory laparotomy for, 639 related to pelvic disorders, 500 wall, 60 examination of, 520 relaxation of, 550 treatment of, 551 Abortion, 80, 95 in relation to pelvic disease, 95 tubal, 371 Abscess, of appendix, 500 of Bartholin's gland, 186 of incision, post-operative, 689 of kidney pelvis, 471 (see also Pyelo- nephritis) of ovary, 381 of pelvis, 428, 690 of uterus, intramural, 282 suburethral, 445 _ tubo-ovarian, 365 Acidosis, in operative cases, 619 post-operative, 693 diagnosis of, 692 etiology of, 692 symptoms of, 692 treatment of, 693 Acute gastric dilatation, diagnosis of, 683 etiology of, 682 symptoms of, 682 treatment of, 683 Addison's disease, and amenorrhea, 581 in relation to generative organs, 581 Adeno-carcinoma of uterus, 331, 343 (see also Carcinoma of Cervix and Carcinoma of Body of Uterus) Adenocystoma of kidney, 481 Adenomyoma, of Fallopian tube, 326 of recto-vaginal septum, 327 pathology of, 327 symptoms of, 327 treatment of, 328 of uterus, diagnosis of, 328 etiology of, 12, 326, 327 histology of, 327 pathology of, 327 symptoms of, 327 treatment of, 328 origin of, 12 Adeno-myosis uteri, 326 Adenomyositis uteri, 326 Adhesions, pelvic, treatment of, 641 Adnexitis, acute, differential diagnosis of, from acute appendicitis, 414, 501 chronic, differential diagnosis of, from chronic appendicitis, 503 Adolescence, hygiene of, 609 Adrenal gland, extract of, in shock, 670 in relation to genital organs, 64 Adrenal tumors of kidney, 481 Age, in relation to history of pelvic disease, 91 Alexander operation, in retroversion of uterus, 254 technic of, 260 Amenorrhea, a symptom of pelvic disease, 98 etiology of, 580 factors in, anatomic, 580 constitutional, 581 psychic, 581 general considerations of, 580 pseudo, 580 treatment of, 5.81 Amputation of cervix, 234, 235, 236 Anaemia, in myomata of uterus, 303, 306, 310, 616 in pelvic disease, 87, 106 risks in operative cases, 615 treatment of, 616 Anaesthesia, chloroform in, 649 combined local and general, 650 ether in, 649 ethyl chloride in, 650 examination of pelvis under, 112, 610 general considerations of, 649 local, 650 727 728 INDEX Anaesthesia, local, by ethyl chloride, 652 cocaine in, 650 eucain in, 650 solutions for producing, 650 technic of, in cervix operations, 651 in celiotomy incisions, 651 in hysterotomy, 651 in vaginal operations, 651 in vulvar incisions, 651 morphine in, 650, 652 nitrous oxide and oxygen, 650 oxygen and ether, 650 spinal, 652 (see also Spinal Anesthesia) Anal, fissure, 522 fistula, 524 Anastomosis of intestine, 518, 679, 681 of ureter, 468 Animal inoculation in tuberculous disease of kidney, in in tuberculous cystitis, 456 Anoci association of Crile, 617, 651 Anteflexion of uterus, 237, 239 {see also Uterus, Pathologic Anteflexion of) in dysmenorrhea, 587 Anterior colporrhaphy, 218 Antigonococcic serum, 725 vaccine, 725 Antistreptococcic serum, 424 Anus, anatomy of, 45 diseases of, 522 examination of, 162 by inspection, 163 by palpation, 162 by specula, 163 position for, 162 preparation for, 162 malformations of, 21 abnormal communications, 21 situations, 21 > absence of, 21 imperforate, 21 treatment of, 29 Appendicectomy, 505 Appendicitis, acute, 414, 501 differential diagnosis of, from acute adnexitis, 414, 501 involvement of, in pelvic disease, 500 symptoms of, 502 treatment of, 502, 505, 656 chronic, Bastedo's sign in, 504 diagnosis of, 503 differential diagnosis of, from • chronic adnexitis, 503 pathology of, 503 symptoms of, 503 treatment of, operations in, 505 during pregnancy, 656 Csesarean section in, 656 Gerster's plan in, 656 operations in, 656 suppurative, differential diagnosis of, from salpingitis, 414, 501 drainage in, 660 relation to pelvic disease, 96 Appendix, inflammation of, acute, 500 chronic, 503 Applications, to Bartholin's gland, 698 to cervix, 698 to endometrium, 697 to Skene's tubules, 700 to urethra, 700 to vagina, 698 Arseno-benzol, in treatment of puerperal pelvic inflammatory disease, 424 Artificial, anus, formation of, 30 insemination, 606 menopause, 595 vagina, formation of, 28 Arthritis, gonorrheal, 726 toxic, etiology of, 550 symptoms of, 550 treatment of, 550 Ascites, differential diagnosis of, from ovarian cyst, 391, 396 Aspiration of cystic kidney, 485 Atresia, 23, 28 (see also Gynatresia) Atropin in treatment of dysmenorrhea, 590 B Babcock's method of spinal anaesthesia, 653 Backache, equilibrium in, 536 etiology of, 536 factors in production of, 536, 538 foci of infection in, 538 static, 538 (see also Static Backache) Bacteriology in cystitis, 453 in pelvic inflammatory disease, 411 in pyelitis, 486 of generative organs, 88, 89 of pelvis, 88 of urine, 109 diagnosis of, by guinea-pig inocula- tion, in of vagina, 89 Baldwin's operation for artificial vagina, 28 Baldy's operation in prolapse of ovary, 410 in retroversion of uterus, 256, 262 hsemostasis in, 640 technic of, 262 Bartholin's glands, abscess of, 186 treatment of, 186, 187 anatomy, 33 applications to, 698 cyst of, 187 inflammation of, 186 Basedow's disease and amenorrhea, 581 Bastedo's sign in appendicitis, 504 Benzyl benzoate in dysmenorrhea, 590 Beyea's operation for elevation of stomach 515 Bimanual examination of pelvic organs, 127 Biologic theory of carcinoma, 330 Bladder, abnormal picture of, in cystoscopy, 146 anatomy of , 43 atmospheric distention of, in cystoscopy, 144 INDEX 729 Bladder, calculus, 458 capacity of, 43, l 4& carcinoma of, 460 carcinomata of, radium m 721 care of, after operation, 665 developmental anomalies of, 21 absence, 21 duplication, 21 extrophy, 21 fistula, 21 treatment of, 27 diseases of, 453 . , _ distention of, by water, in cystoscopy, 145 drainage of, 456, 660 embryology of, 2 incisions of, 456 inflammation of, 453 (see also Cystitis) injuries to, 642 interior of, in chronic cystitis, 147 local anaesthesia in, 651 mucosa of, 147 color of, 147 transparency of, 147 new growths of, 459 treatment of, 460 orifices of, inspection of, 142 palpation of, 138 papilloma of, 460 papillomata of, radium in, 721 physiology of, 84 picture of normal, in cystoscopy, 145 pillars, 216, 217, 219, 220 shape of interior of, H7. stone, 458 (see also Vesical Calculus) tuberculosis of, 456 ulcer of, Fenwick type of, 459 Hunner type of, 459 vessels of, 147 number of, 147 position of, 147 size of, 147 Block's test for tubercle bacillus in urine, in 456 . Blood count, in pelvic disease, 100 culture in pelvic disease, 106 examination of, in pelvic disease, 100 in pelvic disease, 104, 105 in peritonitis, 677 methods of obtaining, for tests, 108 pressure risks in operative cases, 616 Crile's anoci association in, 617 urea, methods for determining, 160 test, 160 Blood-vessels of generative organs, 54 of pelvis, 54 Bowels, post-operative care of, 664 enemas for, 664 Breast, in relation to generative organs, 65 Brodel's white line in kidney, 484 Bronchitis, post-operative, etiology of, 683 symptoms of, 684 treatment of, 684 Byrne's treatment of carcinoma of cervix "with cautery knife, 354 Csesarean section in pregnancy with appen- dicitis, 656 . Calculus of bladder, 458 (see also Vesical Calculus) . of kidney, 478 (see also Renal Calculus) of ureter, 489 (see also Ureteral Cal- culus) Canal of Nuck, 48 hydrocele of, 187 Carcinoma of bladder, 460 diagnosis of, 460 symptoms of, 460 treatment of, 460, 461 of body of uterus, 342 diagnosis of. 344. curettement in, 345 digital exploration, 345 instrumental exploration, 345 ... microscopic examination m, 345 extension of, 343 lymphatic involvement in, 343 myoma with, 343 pathology, 34 2 precancerous changes in, 343 prognosis in, 345 spread of, 343 symptoms of, 344 cachexia in, 344 hemorrhage in, 343 leucorrhcea in, 344 treatment, 345 hysterectomy, 345 abdominal, 345 vaginal, 345 palliative measures, 340 panhysterectomy in, 345 preliminary treatment in, 345 radium in, 717 of cervix, clinical forms of, 334 cauliflower, 334 excavating, 335 indurated, 335 infiltrating, 335 proliferating, 334 ulcerating, 336 vegetating, 334 diagnosis of, 336 by inspection, 338 . by microscopic examination, 338 differential diagnosis of, from ever- sion and erosion, 338 from myomata, 339 from polyps, 339 from sarcoma, 339 from syphilis, 339 from tuberculosis, 339 extension of, 33L 332, 334 . involvement of lymphatics in, 332, 334 of surrounding tissue in, 332, 334 730 INDEX Carcinoma of cervix, metastasis of, 334, 335 operability of, 340 pathology of, 331 columnar-cell type, 331 squamous-cell type, 331 prognosis in, 340 American statistics, 340 European statistics, 340 five-year period, 340 question of operability in, 340 radium in, 714 recurrence of, after operation, 342 symptoms of, 342 symptoms, 335 hemorrhage, 336 cause of, 336 leucorrhcea, 336 pain, 336 treatment, 339 destructive cauterization in, 353 high amputation with cautery knife, 354 hysterectomy, 340 abdominal, 340 vaginal, 340, 351 with paravaginal in- cisions, 352, 353 inoperable cases, 341 cautery, 342 Percy method, 341, 342, 35b radium, 341 Rontgen ray, 341 operations in, 339 panhysterectomy, 339, 349 Percy method, 354 technic of, 356 of Fallopian tube, 368 of ovary, 395 (see also Ovary, Carci- noma of) of rectum, 534 diagnosis, 534 etiology, 534 symptoms, 534 treatment, 534 operations for, 534 radium in, 534, 722 varieties, 534 of urethra, 451 symptoms of, 451 treatment of, 451 Crossen's plan in, 45i of uterus, etiology, 330 age in, 330 biologic theory in, 330 childbirth in, 330 heredity in, 330 race in, 330 relative frequency of, 330 pathology, 331 recurrence, 342 relation to menopause, 594 situation, 330 of vagina, 196 primary, 196 treatment, 196 Carcinoma of vulva, 181 diagnosis, 182 symptom, 181 treatment, 182 radium in, 721 Cardiac condition in pelvic disease, 105 complications in myomata of uterus, 303, 306 dilatation, post-operative, 690 etiology, 690 symptoms, 690 treatment, 691 risks in operative cases, 615 anaesthesia in, 615 complications in, 303, 306, 615 posture in, 615 treatment of, 615 Caruncle of urethra, 449 (see also Urethral Caruncle) Cases, record of, form for, 92 Catgut, preparation of, for operation, 622 Cathartics, use of, after operations, 665 Catheter, bismuth, 156, 491 self -retaining, 446 shadow, 156 sty letted, 491 ureteral, 143 sterilization of, 143 wax-tipped, 150 Catheterization after operation, 666 of ureters, 147 Causes of pelvic disorders, 87 acquired, 88 congenital, 87 evident at birth, 87 at menopause, 87 at puberty, 87 in reproductive period, 8 7 Cauterization of cervix, 353, 354 Cautery, electro, 704 thermo, 704 Cellulitis, pelvic, 430 chronic, 432 diagnosis, 432 etiology, 432 pathology, 432 symptoms, 432 treatment, 432 pelvic massage in, 433 vaginal tampons in, 433 diagnosis of, 431 etiology of, 430 pathology of, 430 symptoms of, 431 treatment of, 432 Cervix, amputation of, 234 high, 234 low, 234 atresia of, 24, 28, 223 carcinoma of, 331 (see also Carcinoma of Cervix) catarrh of, 227 chancre of, 572 INDEX 731 Cervix, conical, 28 cystic degeneration of, 228, 230 dilatation of, 120 diseases of, 223 elongation of, 228, 229 endometrium of, inflammation of, 223 hyperplasia of, 223 infections of, 223 erosion of, 228 eve rs ion of, 227 excision of, test, 121 gonorrhoea of, 224 hypertrophic elongation of, 229 hypertrophy of, 229 infection of, treatment of, 224 lacerations of, 226 amputation for, 234 causes of, 226 diagnosis of, 230 results of, 227-229 symptoms of, 229 tracfielectomy for, 234 trachelorrhaphy for, 233 treatment of, 231 operative measures in, 232 palliative measures in, 232 varieties of, 226 local applications to, 698 Nabothian cysts of, 228 obliteration of, in labor, 79 in pregnancy, 79 operations on, local anaesthesia in, 652 polyp of, 225 etiology of, 225 symptoms of, 226 treatment of, 226 softening of, in pregnancy, 76 stenosis of, 28 treatment of, 28 supravaginal elongation of, 267 syphilis of, 572 tuberculosis of, 566 vaginal elongation of, 229 Chancre of vulva, 174 Chancroid of vulva, 176 treatment of, 177, 178 Childbirth, in relation to pelvic disease, 95 Chloroform anaesthesia, 649 Chromo-cystoscopy, by indigo carmine, 158 Chromo-ureteroscopy, technic of method of, 159 Chronic pelvic inflammatory disease, 428 diagnosis of, 429 etiology of, 428 pathology of, 428 symptoms of, 429 treatment of, 430 Chorioepithelioma of uterus, 346 diagnosis, 348 etiology, 347 hydatidiform mole in, 347 metastasis of, 347 pathology, 346 ovarian cysts with, 348, 404 Chorioepithelioma of uterus, prognosis, 348 situation of, 348 abnormal, 348 symptoms, 348 hemorrhage, 348 tumor, 348 treatment, 349 of vagina, 197 Chorion, 73 frondosum, 75 villi of, 73 Circulatory symptoms, in myomata, 302, 303, 306 in pelvic disease, 101, 105 Clark's theory of histogenesis of ovarian cysts, 384 Climacteric, 82, 94 Clitoris, 33 Coccygodynia, diagnosis of, 552 etiology of, 552 symptoms of, 552 treatment of, 552 Coccyx, injuries to, 552 Coffey operation in retroversion of uterus, 258 technic of, 261 Colon, disorders of, in intestinal stasis, 509 operations on, 515 Colopexy, 515 Colporrhaphy, anterior, 216 posterior, 209, 210, 213 Complaint, chief, 91 Complete tear of perineum, 202 {see also Perineum, Injuries to) Condylomata acuminata, 178 treatment of, 179 lata, 175 of vulva, 571 Congenital causes of pelvic disease, 87 Conservation of adnexa, 312, 324, 640 Constipation, as symptom of pelvic disease, 100 {see also Chronic Intestinal Stasis), 507 Corpus luteum, 66 cysts of, 403 formation of, 70 of menstruation, 69 of pregnancy, 76 Corsets, features of good, 696 use of, 696 Crile's anoci association, 617, 651 Crossen's plan in carcinoma of urethra, 451 Crown sutures, 209, 211, 213 Curettement, diagnostic, 121 findings in, 289 in carcinoma of cervix, 339 in endometritis, 280 preservation of tissues from, 291 results of, 289 technic of, 289 Curettings, preservation of, 291 Cutaneous diseases of external genitalia, 166 Cystadenoma of ovary, 384 Cystic degeneration of ovary, 383 tumors of kidney, 480 732 INDEX Cystitis, 453 acute, 453 diagnosis of, 453 etiology of , 453 prognosis of, 454 symptoms of. 453 treatment of, 454 bacteriology in, 453 chronic, 454 diagnosis, 455 etiology, 454 symptoms, 454 treatment, 456 operations in, 456 drainage in, 660 etiology of, 453 post-operative. 690 tuberculous, 456 chromocystoscopy in, 456 cystoscopic findings in, 456 diagnosis of, 456 animal inoculations in, in, 456 etiology of. 456 symptoms of. 456 treatment of, 458 ureteral orifices in, 456 Cystocele, diagnosis of, 216 mode of production of, 202 operations for, 216 Goffe's, 220 interposition of uterus, 220 large cystocele, 220 Martin's. 216 Sanger's, 216 Watkins', 220 treatment of, 216 Cystopexy, 216 Cystoscopes, sterilization of. 143 Cystoscopy, abnormal appearance of bladder in. 146 appearance of bladder in, 145 atmospheric distention of bladder in, 144 direct method, 144 distention of bladder by water in. 145 general preliminaries to, 143 in diagnosis of ureteral fistula, 465 indirect method. 145 in kidney functional tests, 158 in tuberculous cystitis, 457 Kelly's method, 144 landmarks in, 144 locating fixed anatomical points in, 145 position for. 145 ureteral calculus, 491 urinary fistula, 465 Cystotomy, 456, 459 Decidua. 72 cells, 72 compacta, 72 serotina, 75 spongiosa. 72 Deciduoma malignum, 346 (see also Chorio- epithelioma of Uterus) Defecation, difficult, in rectocele, 204 mechanics of, 85 Delayed menstruation, 580 Dermoid cysts of ovary, 383 Descensus uteri, 238 Developmental anomalies of generative or- gans, 15 defects in etiology of dysmenorrhcea, 587 in etiology of sterility, 599 Diabetes in pruritus vulva, 170 Diagnostic curettement, 121 Diet after operations, 664 Dilatation of bladder, 145, 458 cervix in treatment of dysmenorrhcea, 591 heart, post-operative, 690 stomach, acute, post-operative, 682 Disorders of menstruation, 579 Diverticulitis, etiology of, 520 symptoms of, 520 treatment of, 520 Doderlein. bacillus of, 89 Doran's theory of histogenesis of ovarian cysts, 384 Dorsal position, 113 Douche, vaginal, the, 706 Douglas, pouch of, 46 incision of, 652, 659 Drainage, as protective pack, 657 general considerations of, 657 in appendicitis, 659 in bladder, 456, 660 indications for. 659 in gall-bladder, 659 techmc of, 660 in gall-duct, 659 in kidney, 660 in pancreas, 660 in peritonitis, 659 method of closing incision in drainage cases, 646 position of patient to favor, 658 post-operative care of, 660 purpose of. 657 technic of abdominal. 647 through Douglas' cul-de-sac, 659 vaginal, 659 when placed in pelvis, 639 Dressings, preparation of, for operation, 622 Duct, gall, 660 Gartner's, 9 Miillerian, 1 Skene's, 34 Wolffian, 1 Ductless glands, relation to genital organs, 63. 595 Dudley's operation in pathologic anteflexion of uterus, 243 Dysmenorrhcea, 87, 587 etiology of, 587 acquired lesions in, 589 anteflexion of uterus in, 588 congenital defects in. 587 developmental defects in, 588 gynatresia in, 589 extragenital manifestations in, 587 INDEX 733 Dysmenorrhea, headache in, 587 in endometritis, 279 in pathologic anteflexion of uterus, 240 in relation to disease, 94 in retroversion of uterus, 247 in symptomatology, 98 interval, 592 membranous, 592 etiology of, 592 treatment, 591 menstrual molimina in, 587 mental features in, 589 stenosis of cervix in, 588 treatment of, 589 atropin in, 590 benzyl benzoate in, 590 dilatation of cervix in, 591 electrical treatment in, 591 general considerations in, 590 nasal treatment in, 590 Norris drain in, 591 operations in, 591 abdominal, 591 on cervix, 591 on ovary, 591 on vaginal wall, 591 ovarian therapy in, 590 Dyspareunia, 172, 194, 601 E Echinococcus cysts of kidney, 481 Ectopic pregnancy, 370 (see also Extrauterine Pregnancy) Edebohl's suspension of kidney, 482 Electricity, uses of, in gynecology, 701 Electrocauterization in bladder tumors, 460 Electrocautery, 704 Elephantiasis of vulva, 173 Embolism, pulmonary, 688 Embryologic structures, 1 Embryology, 1 Embryonic rests and new formations origi- nating in them, 8, 88, 327, 330, 384, 385, 388, 391, 395. Emmet, operation for lacerated cervix, 2^3 perineum, 210 Empyema of kidney pelvis, 471 (see also Pyelonephritis) Endocervicitis, 223 symptoms of, 224 treatment of, 224 Endometrial cavity, curettement of, in gonor- rhceal pelvic inflammatory disease, 417 Endometritis, acute, 277 diagnosis of, 278 etiology of, 277 gonococcus on, 277 pathology of, 278 symptoms of, 277 treatment of, 278 chronic, 278 diagnosis of, 279 etiology of, 278, 279 pathology of, 279 Endometritis, chronic, symptoms of, 279 treatment of, 279 curettement in, 280 local applications in, 280 cystic glandular, 279 fungous, 279 glandular, 279 polypoid, 279 Endometrium, 39 application to, 698 changes of, in myomata, 295 histology of, in inflammation of, 278 inflammation of, 277 (see also Endome- tritis) menstrual changes in, 67 polyps of, 280 degenerations of, 280 diagnosis of, 281 pathology of, 280 symptoms of, 280 treatment of, 281 tuberculosis of, 564 Endosalpingitis, 359, 360 end results of, 361 Enemas, for post-operative care of bowels, 664 Enteroclysis, post-operative, 663 continuous, 668 interrupted, 668 solutions used in, 667 Enteroptosis, 507 midline ptosis, 508 partial, 508 treatment of, 512 Epispadias, 21, 27 Epoophoron, 13 Equilibrium, antero-posterior, 536 centre of gravity in, 537 disturbances of, 538 joints concerned in, 537 lateral, 536 mechanics of, 536 muscles concerned in, 538 Esthiomene, vulva, 184 Ether anaesthesia, 649 Ethyl chloride, anaesthesia by, 650 local anaesthesia by, 652 Examination of abdomen, 112 general physical, in pelvic disease, 103 of anus, 162 of blood, in pelvic disease, 106 of patients, preparatory to operation, 614 general, 614 local, 614 of pelvis, 112, 125 instruments for, 119 local physical, 112 preparation for, 113 special methods of, 119 under anaesthesia, 112 of rectum, 162 of urine, bacteriologic, no in pelvic disease, 108 for tubercle bacillus, in Excretions, the, of the genitalia, 83 734 INDEX Exercises for ptotic patients, 511, 512 Exfoliative dysmenorrhcea, 592 Exploratory celiotomy, 639 laparotomy, 591, 639 External genitalia, 25 (see also Genitalia, Ex- ternal) Extrauterine pregnancy, abdominal preg- nancy in, 372-377 diagnosis of, 377 with lithopedion formation, 372 diagnosis before rupture, 375 at rupture or abortion, 376 of abdominal pregnancy, 377 of hematocele formation, 376 etiology of, 369 factors concerned in, 370 fate of the ovum in, 372 of the pregnant tube in, 374 hematocele formation in, 373, 377 hematoma in, 433 etiology of, 433 hemorrhage in, 373 pelvic hematocele in, 373, 377 intraperitoneal bleeding in, 373 multiple pregnancy in, 370 pathology of, 371 nidation of the ectopic ovum, 371 prognosis of, 377 symptoms of, abortion, 374 case of abdominal pregnancy, 375 previous to tubal rupture, 374 tubal rupture or abortion, 375 treatment of, 378 at time of rupture, 378 early, 378 of abdominal pregnancy, 379 of old cases, 379 time of operation in, 378 vaginal puncture in, 379 tubal abortion in, 371 rupture in, 371 fate of ovum in, 372 uterine changes in, 374 varieties of, 370 abdominal, 370 ampullar, 370 interstitial, 370 isthmic, 370 ovarian, 370 tubo-ovarian, 370 Extraperitoneal operations in urinary fistula, 468 F Fallopian tubes, adenomyoma of, 326, 327 anatomy of, 40 at birth, 8 carcinoma of, 368 cysts of, 367 developmental anomalies of, 15 absence, 15 accessory ostia, 15 diverticula, 15 fcetal type, 15 Fallopian tubes, developmental anomalies in, partial development of, 15 supernumerary, 15 diseases of, 359 embryology of, 2 embryomata of, 367 enlargements of, 368 accidents affecting, 368 rupture of, 368 torsion of, 369 symptoms of, 369 treatment of, 369 excision of, 437 inflammation of, 359 (see also Sal- pingitis) myomata of, 367 new formations of, 367 operations on, 436-438 papillomata of, 367 physiology of, 62 polyps of, 367 pregnancy in, 369 (see also Extra- uterine Pregnancy) resection of, 418 syphilis of, 574 tuberculosis of, 561 Family history, in relation to pelvic disease, 95 Faulty posture, types of, 539 gorilla, 539, 541 kangaroo, 539, 541 overfeminine, 539 slumped visceroptotic, 539 Fecundation, 71 Female pseudohermaphrodism, 22 Fenwick type of bladder ulcer, 459 Fibroid tumors of uterus, 295 (see also Myomata of Uterus) Fibromata of ovary, 396 Fibromyoma of vulva, 185 Fibrosis uteri, 283 Fissure in ano, 522 diagnosis of, 522 symptoms of, 522 treatment of, 523 divulsion of sphincter, 523 operation for, 523 of urethra, 445 Fistula in ano, 524 diagnosis of, 525 symptoms of, 525 treatment of, 525 operations for, 525 urinary, 463 (see also Urinary Fistula) vesico-umbilical, 21 Fluid, menstrual, 66 Flushing at menopause, 594 infections in etiology of, oophoritis, 381 post-operative parotitis, 691 urethritis, 444 toxic arthritis, 550 Fcetal structures, 1 Follicles, Graafian, 9, 69 maturation of, 9, 69 Form for history, 92 INDEX 735 Fornices, vaginal, 34 anterior, 35 posterior, 35 Fossa navicularis, 32 Fourchette, 33 Fowler, bed, 668 position, 669 Frankl's theory, of cystic degeneration of ovary, 402 of histogenesis of ovarian cysts, 384 Frazier's operation for ptosis of colon, 516 Figuration in bladder tumors, 460 Fundus of uterus, 37 carcinoma of, 342 Gall-bladder, drainage of, 659 post-operative care of, 661 Galvanism in treatment of dysmenorrhcea, 591 Gartner's duct, 9, 13 Gastric dilatation, acute post-operative, 682 Gastro-intestinal symptoms in pelvic disease, 100 Gastropexy, 515 Gauze drains, 647 pads, in isolation of operative area, 637 use of, in abdominal surgery, 648 Gelhorn's method of using heat in treatment of pelvic disease, 701 General health in pelvic disease, 101 Generative organs, anatomy of, 31 anomalies of, 15 changes of, in pregnancy, 75, 78 developmental anomalies of, 15 embryology of, 1 excretions, the, of the, 83 physiology of, 61 relation of, to glands of internal secretion, 63-65 syphilis of, 569 tuberculosis of, 560 (see also Tuber- culosis of Generative Organs) Genital fistula, 463 Genitalia, external, abnormalities of, 25 treatment of, 2j anatomy of, 31 cutaneous diseases of, 166 developmental anomalies of, 20 diseases of, 166 embryology of, 2 hernia in, 189 herpes of, 166 injuries of, 188 malformations of, 20 diagnosis of, 25 treatment of, 27 parasitic diseases of, 166 pediculosis of, 166 physiology of, 62 ringworm of, 166 venereal conditions of, 173 Genito-urinary system, 440, 453, 469 Gestation (see Pregnancy) Gland of Bartholin, 33 (see also Bartholin's Glands) mammary, 65 of internal secretion, 63-65 parathyroid, 64 pineal, 65 pituitary, 63 sexual, 1, 42 suprarenal, 64 thyroid, 64 Glands of internal secretion in premature menopause, 595 Glans clitoris, 33 Gloves, preparation of, for operation, 622 Glycosuria, in pruritis, 170 Goitre in women, 64 Gonococcus, characteristics of, 554 diagnosis of, 123 examination of smears for, 556 immunity to, 554 in endometritis, 277, 278 infection from, in chronic cases, 554 in pelvic inflammatory disease, 411 latency of, 555 lesions due to, 554 mode of invasion, 89 smear preparation in, 124 staining of, 124 technic of preparation of smears for, 556 glass slides in, 556 time of obtaining, 557 Gonorrhoea, cause of endometritis, 277 complement-fixation test for, 107 diagnosis of, 556 gonococcus in, 556 smears in, 556 symptomatology in, 555 douches in, 556 general peculiarities, 554 latent, 556 pelvic inflammation due to, 554 prognosis of, 558 in acute cases, 558 in chronic cases, 558 prophylaxis of, 558 education in, 559 residual, 555 sterility due to, 554 symptoms of, 555 localization of lesions, 556 macules in, 556 mildness of, 555 seat of initial attack, 555 smears in, 556 treatment, 559 Gonorrhceal arthritis, 725 macules, 556 pelvic inflammatory disease, conservation of adnexa in, 418 diagnosis of, 414 differential diagnosis of, 414 from appendicitis, 414 puerperal inflammatory disease, 415 etiology of, 412 736 INDEX Gonorrhceal pelvic inflammatory disease, hys- terectomy in, 417 technic of, 417 pathology of, 412 results of, 414 symptoms of, 414 treatment of, 415 acute, 415 cauterization in, 417 chronic stage, 416 curettement in, 417 hysterectomy in, 417 technic of, 417 palliative measures in, 415 resection of ovary in, 418 sera in, 725 subacute stage, 416 time of operation in, 415 vaccines in, 726 vaginal douches in, 415 puncture in, 416 Gorilla type of faulty posture, 539, 541 treatment of, gymnastic, 546 mechanical, 546 supportive, 546 Graafian follicle, cysts of, 402 development of, 9, 69 Grafts, ovarian, 606 Graves' disease in relation to generative or- gans, 64 Gumma of vulva, 571 Gynatresia, 23, 89 diagnosis of, 25-27 in dysmenorrhcea, 588 symptoms of, 23 treatment of, 27 Gynecologic postures, 113 H Habit, the menstrual, 579 Habits of life, in relation to disease, 93 Hematocele in extrauterine pregnancy, 373 Hematocolpos, 24 Hematogenous infections in oophoritis, 381 in pyelonephritis, 471 Hematoma of pelvis, diagnosis of, 433 etiology of, 433 prognosis, 433 symptoms of, 433 treatment of, 433 of vulva, 180 Haematometra, degenerations of, 288 etiology of, 288 symptoms of, 288 treatment of, 288 Hematosalpinx, 24, 367 Hematotrachelos, 24 Hematuria in tuberculosis of kidney, 475 Hemostasis, 640 Hands, preparation of, for operation, 622 Headache, as symptom of pelvic disease, 99 in dysmenorrhcea, 587 Heart, disease of, in operative cases, 615 (see also Cardiac Risks) dilatation of, post-operative, 690 in myomata, 303, 306 in pelvic disease, 105 Heat, in treatment of pelvic inflammatory disease, 700 Hegar's sign of pregnancy, 76-79 operation for lacerated perineum, 211 Hemorrhage, arterial, 671 after abdominal operations, 671 diagnosis, 672, 673 symptoms, 672 treatment of, 673 after plastic operations, 672 capillary oozing, 671 in ectopic pregnancy, 373 intraperitoneal, 373 menstrual, mechanics of, 66 post-operative, varieties of, 671 venous, 671 Hemorrhagic uteri, radium in, 720 Hemorrhoids, diagnosis of, 528 pathology of, 527 symptoms of, 527 treatment of, 528 operations in, 529 Heredity in etiology of carcinoma of uterus, 330 Hermaphrodism, 22 Hernia, of ovary, 409 of rectum, 531 of uterus, 238 perineal, 189 pudendal, 189 Herpes, of genitalia, 166 History taking, 91 form of record, 92 family, in relation to pelvic disease, 95 general previous, to pelvic disease, 96 menstrual, in relation to disease, 94 Hodge pessary, 701 Hot flashes at menopause, 594 Hiihner's method in diagnosis of sterility, 601 Hunner type of bladder ulcer, 459 pathology of, 459 treatment of, 460 Hydatid, stalked, of Morgagni, 10, 367 Hydatidiform mole, in etiology of chorio- epithelioma, 347 -like structure in cyst of ovary, 399 recognition of, 290 Hydrocele of canal of Nuck, 187 Hydronephrosis, 470 diagnosis, 471 etiology, 470 pathology, 470 treatment, 471 Hydrops folliculi, 402 tube profluens, 367, 593 in dysmenorrhea, interval type, 592 Hydrosalpinx, 360, 365 etiology of, 365 follicularis, 366 INDEX 737 Hydrosalpinx, rupture of, 368 simplex, 366 torsion of, 369 Hygiene of adolescence, 609 Hymen, developmental anomalies of, 20 atresia, 20 double, 20 diseases of, 192 abnormal elasticity of, 192 cystic tumors of, 192 rigidity of, 192 Hyperinvolution of uterus, 286 etiology of, 286 symptoms of, 287 treatment of, 287 Hypernephromata, origin of, 13 relation to pelvic disease, 64 Hypertension in operative cases, 616 Hypertrophy of cervix, 229 Hypospadias, 21, 27 Hvposuprarenalism, relation to pelvic disease, 64 Hypotension in operative cases, 616, 617 Hysterectomy, abdominal, 317 bisection of uterus in, 436 for carcinoma of uterus, 340, 345 for myomata, 317 for pelvic inflammatory disease, 433 vaginal, 340, 345, 351 for carcinoma of uterus, 340, 345 for myomata of uterus, 351 with paravaginal incisions, 352, 353 variations in technic of, 434 Hysterocele, 238, 263 Hysteromyomectomy, 317 Hysteropexy, 257, 260 Hysterotomy, local anaesthesia in, 651 Ileus, adynamic, 678, 682 dynamic, 678, 682 mechanical>678, 682 paralytic, 678, 682 Illumination for pelvic examination, 118 with head mirror, 118 Incisions for abdominal operations, 624 technic of, 635 directions regarding, 633 dressing, 646 for kidney operations, 630 post-operative care of, 669 suppuration of, post-operative, 689 treatment of, 689 technic of closing, 644 in drainage cases, 646 Incontinence of urine, 447, 448 Indigo-carmine in kidney function tests, 158 Infectious diseases, relation of, to pelvic dis- eases, 93 Insanity, as a post-operative complication, 612 at_ menopause, 595 etiology of, 612 in relation to gynecology, 611 47 Insanity, types of, benefited by operation, 612 not benefited by operation, 611 Insemination, 71 artificial, 606 Instruments for pelvic examination, 119 Intermenstrual pain, periodic, 592 Internal secretion, glands of, in premature menopause, 595 in relation to generative organs, 63-65 Interposition operation for cystocele, 220 of Watkins, 220 for prolapse of uterus, 272 of Watkins, 272 Interval dysmenorrhea, 592 Intestinal obstruction, acute, 505, 678 causes of, 678 diagnosis of, 680 etiology of, 678 pathology of, 678 forms of, 678 post-operative, 678 symptoms of, 679 treatment of, 681 operative, 681 stasis, acute, 505 chronic, from pelvic disease, 507 diagnosis of, 511 from adhesions between intestines and peritoneum, 510 intestinal loops, 510 the mesenteries, 510 . the mesentery and omentum, 510 from enteroptosis, 507 from kinking of colon, 509 from redundancy of colon, 509 from overdistention of colon, 509 symptoms of, 511 treatment, 512 dietetic, 512 medical, 513 postural, 512 surgical, 515 Beyea's operation, 515 Coffey's operation, 516 colopexy, 515 contraction of the abdomi- nal parietes, 520 division of adhesions, 516 gastropexy, 515 intestinal anastomosis, 518 resection of the intestine, 519 Wilms' operation, 516 Intrauterine tampon, 705 Involution of uterus, 285 Israel's kidney incision, 632 K Kangaroo type of faulty posture, 539, 541 treatment of, gymnastic, 546 mechanical, 546 supportive, 546 738 INDEX Kelly's kidney incision, 630 Kidney, absence of, 21 rudimentary, 21 abscess, 471 (see also Pyelonephritis) drainage in, 660 post-operative care of, 661 adenocystoma of, 481 adrenal tumors in, 481 aspiration of, 485 Brodel's white line in, 484 calculus, 478 (see also Renal Calculus) cystic tumors of, 480 diseases of, 469 echinococcus cysts of, 481 Edebohl's suspension of, 482 embryology of, 3 empyema of pelvis of, 471 examination of, with wax-tipped bougie, 150 foetal type, 21 functional activity of, estimation of, 158, 619 blood urea test of, 160 by chromocystoscopy, 158 by chromoureteroscopy, 159 combined, 158 by indigo-carmine, 158 by phenolsulphonephthalein, 159 separate, 158 horseshoe, 21 hydronephrosis of, 470 incisions for exposure of, 481 directions regarding, 633 Israel's 632 Kelly' £, 630 Mayo-Robson's, 632 Mayo's, 631 infection of, post-operative, 689 inflammation of, post-operative, 684 lithotomy, 483 malformations of, 21 movable, 469 nephropexy, 483 nephrotomy, 483 nephrectomy, 484 operation technic in treatment of, 481 palpation of, 138 pararenal tumors with, 481 pelvis, lavage of, 488 percussion of, 140 punch, Murphy's, 140 trimanual method of, 139 polycystic disease of, 480 ptosis of, 509 pyelitis, 485 pyelonephritis, 471 pyelonephrosis, 471 pyelotomy, 483 • risks in operative cases, 618 (see also Urinalysis) Rontgenographic examination of, 151 percentage of error in, 153 source of error in, 153, 155 stone, 478 (see also Renal Calculus) diagnosis of, 150 Kidney, suspension of, 482, 483 tuberculosis of, 473 tumors of, 480 white line in, 484 Knee-chest position, 114, 115 Kobelt's tubules, 11 Kraurosis of vulva, 172 Kruckenberg tumor of ovary, 397 Labia, majora, anatomy of, 32 minora, anatomy of, 33 hypertrophy of, 20 Labor, 79 in relation to pelvic disease, 95 Lacerations of cervix, 226 perineum, 201 Lane's kink, 510 Langhan's layer, ys Lavage of kidney pelvis, 488 Leucocytosis in pelvic disease, 106 in peritonitis, 677 Leucorrhcea, as symptom of carcinoma, 344 of endometritis, 279 of metritis. 283 of pelvic disease, 99 of retroversion of uterus, 246 bacteriology of, 198 definition of, 197 etiology of, 197 lactic acid bacillus, treatment of, 198 treatment of, 198 vaccines in, 199 Levator ani muscle, 50 function of, 200 laceration of, 201 Ligaments of uterus, 46 of ovary, 42 of pelvis, 46 triangular, 53 Lochia, 81 Lubricant, 117 Lungs, in pelvic disease, 106 disease of, post-operative, 684 Lupus, of vulva, 182 Lutein cystoma ovarii, 404 Lymphatics of external genitalia, 60 of pelvis, 58 of uterus, 60 of vagina, 60 Lymph-nodes, pelvic, 58 hypogastric, 59 iliac, 58 inguinal, 59 internal iliac, 59 sacral, 59 M Maculae gonorrhceica, 556 Male pseudohermaphrodism, 23 Mammary gland, relationship of, to genera- tive organs, 65 Martin's operation for cystocele, 216 Mayo's kidney incision, 631 Mayo-Robson's kidney incision, 632 INDEX 739 McBurney's incision, 627 Meatus, urinary, 43 Mechanics of normal support of perineum, 200 Meckel's diverticulum, inflammation of, 5 20 Menge pessary in descensus of uterus, 270, 703 Menstrual cycle, 65-70 fluid, 66 source of, 40 habit, 66, 579 variations of, in pelvic disease, 94 history in pelvic disease, 94 molimina, 580 symptoms in pelvic disease, 98 Menstruation, absence of, 580 anatomic changes incident to, 66 cessation of, 580 delayed, 580 disorders of, 579 false, 23 mechanics of, 66 pain in intervals between, 592 painful, 587 phenomena of, 65 precocious, S79 relationship of, to ovulation, 66-69 retarded, 580 vicarious, 580 with expulsion of membrane, 592 Mental features in dysmenorrhcea, 589 Menopause, 82, 94 age of, 82 artificial, etiology of, 83, 595 ovariectomy in, 595 symptoms of, 596 vasomotor, 596 neurotic, 596 treatment of, 596 ovarian therapy in, 596 blood-pressure changes at, 594 changes in ovaries in, 82 menorrhagia at. 594 mental changes in, 594 metrorrhagia at, 594 nervous manifestations in, 83 premature, 83, 594 etiology of, 594 gland of internal secretion in, 595 treatment, 595 relation to carcinoma, 594 symptoms of, 594 time of, 593 Menorrhagia, as symptom of endometritis, 279 of pelvic disease, 99 of retroversion of uterus, 246 etiology of, 583 in metritis, 283 in myomata, 303 treatment of, 584 Metritis, acute, 282 symptoms of, 282 treatment of, 282 Metritis, chronic, 282 diagnosis of, 284 etiology of, 282 syphilis in, 282 pathology of, 283 symptoms of, 283 treatment of, 284 Metrorrhagia, as symptom of endometritis, 279 of pelvic disease, 99 of retroversion of uterus, 246 etiology of, 585 in metritis, 283 in myomata, 303 treatment of, 586 Micturition (see Urination) Miscarriage, 79 Mittelschmerz, 592 Mole, hydatidiform, with ovarian cysts, 404 in etiology of chorioepithelioma, 347 Molimina menstrualis, 580, 587 Morgagni, stalked hydatid of, 10 Morphine as preanesthetic agent, 650, 653 Movable kidney, 469 Miillerian duct, 1 failure of fusion of, 16-19 in etiology of adenomyoma, 327 Multiple operations, 655 Murphy button, 682 kidney punch, 140 Myomata of uterus, blood supply of, 293 carcinoma of uterus with, 300 changes in uterus in, 295 of endometrium, 295 of muscular wall, 295 choice of operation in, 311 circulatory lesions in, 302 ansemia, 303 cardiac degeneration, 303 dilatation, 303 murmurs, 303 palpitation, 303 thrombosis, 303 complications of, 296 degenerations of, 297 abscess, 297 angiomatous, 299 calcareous infiltration, 297 carcinomatous, 299 cystic, 297 hyaline, 297 lipomyomatous, 299 necrosis, 299 sarcomatous, 299, 339, 346 suppurative. 297 diagnosis of, 306 by abdominal examination, 307 by bimanual palpation, 307 interstitial, 307 submucous, 307 subperitoneal, 307 differential diagnosis from cystic tumors of ovary, 308 pelvic inflammatory masses, 309 740 INDEX Myomata of uterus, differential diagnosis from pregnancy, 309 solid tumors of ovary, 308 enucleation, 311 etiology of, 292, 303 congenital anomalies in, 292 racial element in, 292 reproduction in, 292 syphilis in, 292 growth of, 295 histology of, 292 hysteromyomectomy in, 311, 317 conservation of adnexa in, 312 indication for operation in, 310 myomectomy in, 311, 312, 314 objections to, 311 vaginal, 311 operative technic of, 313 abdominal myomectomy, 314 for multiple myomata, 315 hysteromyomectomy, 317 with conservation of adnexa, 322 modifications of. 319-321 treatment of cervical canal in, 324 stump after, 323 panhysterectomy, 324 treatment of ureters in, 324 vaginal myomectomy, 316 origin of, 292 panhysterectomy in, 313, 324 with carcinoma of cervix, 313 pressure effects of, 300 on bladder, 300 on nerves, 302 on pelvic vessels, 302 on rectum, 302 on ureters, 301 situation of, 294 cervical, 294 interstitial, 294 intraligamentous, 294 submucous, 294 subperitoneal, 294 subvesical, 294 symptoms of, 304 anaemia in, 303 circulatory symptoms in, 306 leucorrhcea, 305 menorrhagia, 304 metrorrhagia, 304 causes of, 304 pain, 305 at menstruation, 305, 306 from adhesions, 305 from pressure, 305 on defecation, 305 on urination. 305 referred to distant parts, 306 severest, 305 treatment of anaemia in, 310 curettement in, 310 for hemorrhage, 310 operative, 311 Myomata of uterus, treatment of, palliative, 310 radium in, 310, 718 Rontgen ray in, 310, 718 Myomectomy, abdominal, 314 vaginal, 316 Myometrium, 40 N Nabothian cysts, 228, 230 Nasal treatment in dysmenorrhcea, 590 Nausea and vomiting, post-operative, exces- sive, 674 treatment of, 674 Nephrectomy, 484 incisions for, 630 in urinary fistulae, 468 Nephritis, in operative cases, 618 post-operative, etiology of, 684 treatment of, 684 Nephrolithotomy, 483 Nephropexy, 483 Nephroptosis, 509 Nephrotomy, 483 Nervous manifestations in pelvic disease, 101 Neuroses, relation of, to pelvic diseases, 610 prognosis in, 611 treatment of, 611 with acquired lesions of pelvis, 610 without acquired lesions of pelvis, 610 varieties of, 610 New formations originating in embryonic rests, 9 Nidation of ovum, y2 Nitrous oxide, and oxygen anaesthesia, 650 oxygen and ether anaesthesia, 650 Normal support of perineum, mechanics of, 200 type of posture, 540 Norris drain, in pathologic anteflexion of uterus. 243 in treatment of dysmenorrhcea, 591 Nose, applications to, in dysmenorrhcea, 590 Nubility, 61 Nuck, canal of, 48, 187 Nurses, preparation of, for operations, 622 Nymphae (see Labia Minora) Obesity, 550 Obstruction of intestine, 505 post-operative, 680 Occupation in relation to pelvic disease, 93 Oligomenorrhcea, 580 (see also Amenorrhoea) Omentum, in treatment of denuded surfaces, 643 Oophorectomy, 400, 435 Oophoritis, acute interstitial, diagnosis of, 382 chronic, 382 end-results of, 382 etiology of, 381 pathology of, 381 symptoms of, 382 treatment of, 382 INDEX 741 Operating room, lighting of, 623 ventilation of, 623 Operations during pregnancy. 656 Operative area, exposure of, 637 gauze pack in, 637 isolation of. 636 preparation of, 620 technic. in abdominal incisions, 624 closing the incision, 644 drainage in, 639, 647, 657 during pregnancy, 656 gauze pack in, 637 hsemostasis in, 640 in dressing the incision, 646 with drainage, 647 in kidney operations, 630 in multiple operations, 656 in treatment of adhesions. 641 of denuded surfaces, 643 of incisions, 635 of wounds of viscera, 642 Operator, preparation of, for operation, 621 Ovarian abscess, 381 therapy in amenorrhcea, 581 in artificial menopause, 596 in dysmenorrhea, 590 transplantation in sterility, 606 heterografts in. 606 homografts in, 606 Ovariectomy, 400, 435 Ovaritis. 381 Ovary, abscess of, 381 absence of, 15 adenocystomata of, 384 etiology of, 384 pathology of, 384 anatomy of, 42 at birth, 6 atrophy of, 408 causes of, 409 carcinoma of, diagnosis of, 395 etiology of, 395 metastatic, 408 pathology of, 395 symptoms of, 395 changes in, at menopause, 82 during menstruation, 69 combined epithelial and connective-tissue tumors of, 397 compound theca-lutein tumors of, 404 connective tissue, new growths of, 396 benign, 396 fibromata, 396 degenerations of, 396 pathology of. 396 malignant, 396 sarcomata, 396 Kruckenberg tumor, 397 pathology of, 396 cystic degeneration of. 402 cysts of, 383 classification of, 383 theories regarding histogenesis of, 384 Ovary, cysts of, with hydatid mole, 404 daughter cysts of, 387 dermoid cysts of, 383, 397 origin of, 12, 397 pathology of, 399 thyroid tissue in, 399 developmental anomalies of, 15 effect of radium on, 719 removal of, 595 embryology of, 1 epithelial new growths of, 384 glandular cysts of, 384 adenocystoma, 384 diagnosis of, 389 differential diagnosis of, from ascites, 391 from fat, 391 from myomata, 389 from pregnancy, 389 from tympanites, 391 etiology of, 384 theories of, 384 papillomatous, 388 pathology of, 384 pseudomucinous, 388 serous, 388 symptoms of, 388 grafts of, 606 hernia of, 409 hyperplasia of, 383 hypertrophy of, 383, 409 inflammation of, 381 (see also Peri- oophoritis) inflammatory diseases of, 382 diagnosis of, 382 symptoms of, 382 treatment of, 382 internal secretions of, 62, 63 Kruckenberg tumor of, 397 lymphatics of. 60 malformations of, 15 menopause and, 595 mixed tumor of, 397 mother cysts of, 387 new growths of, treatment of, 399 carcinoma, 401 cystomata, 399 during pregnancy, 401 fibromata, 402 intraligamentous cysts, 400 papillomatous cysts, 401 sarcomata, 402 operations on, 404, 418, 435 papillomatous cysts of, 393 malignant degenerations of, 393 pathology of, 394 symptoms of, 394 physiology of, 62 prolapse of, diagnosis of, 409 etiology of, 409 symptoms of, 409 treatment of, 409 relation of, to glands of internal secre- tion, 62, 63 retention cysts of, 402 742 INDEX Ovary, retention cysts of, corpus luteum cysts, 403 cystic degeneration, 402 diagnosis of, 403 Graafian follicle cysts, 402 hydrops folliculi, 402 simple, 402 symptoms of, 403 treatment of, 403 resection of ovary in, 404 rudimentary, 15 supernumerary, 15, 63 syphilis of, 574 teratomata of, 383 thyroid tissue in, 399 transplantation of, 606 tuberculosis of, 565 tumors of, accidents to, 405 classification of, 383 complicating pregnancy, 401 complications of, 405 connective-tissue type of, 383 epithelial type of, 383 infection of, 405 malignant degeneration of, 407 rupture of, 407 causes of, 407 results of, 407 torsion of, 406 cause of, 406 treatment of, 406 Ovula, Nabothi, 228, 230 Ovulation, anatomic changes incident to, 70 relationship of, to menstruation, 66, 69 Ovum, nidation of, 72 Pain in symptomatology of pelvic disease, 97 Pampiniform plexus, 56 Panhysterectomy, 313, 324 for carcinoma of uterus, 324 for myomata of uterus, 313 treatment of ureters in, 324 Wertheim's technic in, 349 Paracolpium, 49 Paracystium, 49 inflammation of, 430 Parametritis, 282, 419, 430 Parametrium, 49 Paraoophoron, 9 Paraproctium, 49 inflammation of, 430 Pararenal tumors, 481 Parasitic diseases of the external genitalia, 106 Parathyroid glands, relations of, to genera- tive organs, 64 Paravaginitis, 193 Parotitis, post-operative, 691 Parovarian cysts, 391 diagnosis of, 393 differential diagnosis of, from myomata, 393 etiology of, 11, 391 Parovarian cysts, growth of, 392 symptoms of, 392 Parovarium, 9 papillomatous cysts of, 393 malignant degenerations in, 393 Parturition (see Labor) Pathologic anteflexion of uterus, 237 Paul's tube, 683 Pediculosis pubis, 166 Pelvic abscess, 428, 431 adhesions, treatment of, 641 arteries, 54 bacteriology, 88, 411 cellular tissue, 48 syphilis of, 575 cellulitis, 430 (see also Cellulitis, Pelvic) connective tissue, 48 diseases, onset of, 96 relation of neuroses to, 610 examination, by inspection, 125 by palpation, 125 bimanual, 126 with cervix pulled down, 129 with finger in rectum, 129 simple digital, 126 trimanual, 130, 131 local physical, 112 under anaesthesia, 112 floor, fascia of, 53 injuries to, 200 muscles of, 50 physiology of support of, 200 triangular ligament of, 53 inflammatory disease, acute, 411 chronic, 428 (see also Chronic Pelvic Inflammatory Disease) classification of, 411 etiology of, 411 factors in etiology of, 412 gonorrhceal, 412 (see also Gon- orrhceal Pelvic Inflammatory Disease) in etiology of dysmenorrhea, 589 instrumental, 425 (sec also Post- operative Pelvic Inflammatory Disease) pathology of, 411 post-operative, 425 (see also Post-operative Pelvic Inflam- matory Disease) puerperal, 419 (see also Puer- peral Pelvic Inflammatory Disease) treatment of, operative technic in, 433 hysterectomy, 433 salpingectomy, 437 salpingo-oophorectomy, 436 salpingostomy, 438 vaginal incision and drain- age, 438 use of heat in, 700 Gelhorn's method of, 700 INDEX 743 Pelvic ligaments, 46 lymphatics of, 58 massage in chronic pelvic cellulitis, 433 peritoneum, 45 veins, 56 Pendulous abdomen, 550 Percussion, trimanual method of, 134, 393 Percy's method in carcinoma of cervix, 354, 355 Perforation of uterus, accidents in, 287 etiology of, 287 injury to intestine in, 287 symptoms of, 287 treatment of, 287 Perimetritis, 430 Perineal operations, preparations for, 620 Perineorrhaphy, 209, 210, 213 Periodic intermenstrual pain, 592 Perioophoritis, diagnosis of, 382 end-results of, 382 etiology of, 381 pathology of, 381 symptoms of, 381 treatment of, 381 Perineum, injuries to, 200 forms of, 200 immediate, 200 remote, 200 mode of production of, 201 results of, 200 lacerations of, 201 complete, 202 symptoms of, 207 lateral, 201 effects of, 201 median, 201 operations for, complete tear of, 214 Emmet, 209, 210 Hegar, 211 relaxation of, diagnosis of, 205 treatment of, 204, 208 Perisalpingitis, 360, 361 end-results of, 365 Peritoneum, of pelvis, 45 abdominal, tuberculosis of, 563 Peritonitis, post-operative, 675 diagnosis, 677 localization of, 676 symptoms, 676 treatment of, 678 Pessaries, use of, 702 care of, 704 disk, 702 fitting of, 250 Hodge, 701 indications for, 250, 251, 269, 270, 702 Menge, 703 Smith, 701 soft rubber, 702 types of, 702, 703 Pfannensteil's theory of histogenesis of ovarian cysts, 384 Pfluger's tubules, 384 Phenolphthalein, estimation of elimination of, 160 Phenolphthalein in kidney function test, 159 Phlebitis, etiology of, 686 placental, 420 post-operative, 686 treatment of, 687 Physical examination, in pelvic disease, 103 Physiology of generative organs, 61 Physometra, etiology of, 288 symptoms of, 288 treatment of, 288 Pick's theory of histogenesis of ovarian cysts, 384 Pineal gland, relationship of, to generative organs, 65 Pituitary body, extract of, in shock, 670 relationship of, to generative organs, 63 Placenta, formation of, 73 relationship of, to generative organs, 65 Placental thrombophlebitis, 420 Placentation, 73, 75 Plastic operations (see Colporrhaphy, Perine- orrhaphy and Trachelorrhaphy) hemorrhage after, 673 Pleurisy, post-operative, 684 Polycystic disease of kidney, 480 Polyps of rectum, 532 Position, dorsal, 113 erect, 116 for examinations, 113 knee-chest, 114, 115 recumbent, 116 Sims', 115 supine, 116, 117 Posture, after operations, 668 errors in, 539 Fowler, 669 in cardiac cases, 615 normal type of, 540 Trendelenburg, 669 Post-operative care of drainage cases, 661 complications, acidosis, 692 acute gastric dilatation, 682 bronchitis, 683 cardiac dilatation, 690 cystitis, 690 hemorrhage, 671 intestinal obstruction, 678 nausea and vomiting, 674 nephritis, 684 parotitis, 691 peritonitis, 675 phlebitis, 686 pleurisy, 684 pulmonary, embolism, 688 renal infection, 689 shock, 670 suppression of urine, from ureteral obstruction, 685 suppuration in incision, 689 in pelvis, 690 tympanites, 674 pelvic inflammatory disease, 425 etiology of, 425 pathology of, 425 744 INDEX Post-operative pelvic inflammatory disease, symptoms of, 426 treatment of, 427 operative measures in, 427 palliative measures in, 428 vaginal puncture in, 428 treatment, of bladder, 665 diet in, 664 dressing incision, 669 enteroclysis in, 667 nausea, 663 of bowels, 664 pain, 663 posture, 668 thirst, 663 vomiting, 663 Pouch of Douglas, 46 Pozzi's operation in pathologic anteflexion of uterus, 243 Precancerous changes in uterus, 343 Precocious menstruation, 579 Pregnancy, complicated by appendicitis, 656, 657 by ovarian cysts, treatment of, 401 corpus luteum of, 76 diagnosis of, from myomata, 309 from ovarian cysts, 389 Hegar's sign of, 76 in relation to pelvic disease, 94 in retroverted uterus, 656 treatment of, 253, 254, 656 operations during, 401, 656 pyelitis in, 486, 487 Premature menopause, 594 Preparation of, for operation, assistants, catgut, 622, 623 dressings, 622 furniture, 62^ gloves, 622 hands, 622 for pelvic examination, 117 instruments, 623 nurses, 622 operating room, 623 operative area, 620 for abdominal operations.. 621 for perineal operations, 620 patients, 613, 621 Preparatory measures in hysterectomy, 345 in operative cases, 614 Procidentia uteri, 238, 263 Proctoscopes, Kelly, 164 Tuttle, 163 Proctoscopic examination of rectum, 163 Prolapse of ovary, 409 of rectum, 532 of the urethral mucosa, 446, 447 of uterus, 238, 263 Pruritis ani, 527 vulva, 169-171 radium in, 721 Pseudoamenorrhcea, 580 Pseudohermaphrodism, female, 22 male, 23 Pseudomucin, 388 Pseudomyxomata ovarii, 407 oeritoneii, 407 Ptosis of intestines, 507 of kidney, 469 Puberty, age of, 61 influences affecting, 61 manifestations of, 61 ovarian development at, 62 Puerperal pelvic inflammatory disease, 419 diagnosis of, 421 examination in, 421 of pelvic lesions in, 421 end results of, 422 etiology of, 419 gonococcus in, 419 streptococcus in, 419 mode of invasion of, 419 pathology of, 420 pelvic abscess in, 422 lesions resulting from, 420 prognosis, 421 factors influencing, 421 symptoms of, 420 treatment of, 422 arseno-benzol in, 424 exploration of uterus in, 423 horse serum in, 424 palliative measures in, 422 sera in, 424 tamponade of uterus in, 423 vaccines in, 424 vaginal puncture in, 425 Puerperium, pyelitis in, 485 Pulmonary diseases, post-operative, 683 in etiology of pelvic disease, 106 embolism, 688 Pulse in pelvic disease, 104 Pyelitis, bacteriology of, 486 etiology of, 485 in pregnancy, 486 pathology of, 485 prognosis of, 486 symptoms of, 486 treatment of, 487 vaccines in, 488 Pyelography, death following, 157 in diagnosis of movable kidney, 469 in hydronephrosis. 471 in kidney disease, 157 in ureteral calculus, 157 obstruction, 157 solutions for, 156. 158 preparation of, 156 technic of, 156 Pyelonephritis, 471 etiology of, 471 hematogenous infection in, 471 urinary passages, infection of, in, 47i pathology of, 471 INDEX 745 Pyelonephritis, symptoms, 472 treatment of, 473 operations in, 473 Pyelonephrosis, 471 Pyelotomy, 483 Pyometra, etiology of, 288, 335 symptoms of, 288 treatment of, 288 Pyosalpinx, 360-362 infectiousness of contents, 363, 365 rupture of, 368 Radium, combined with Rontgen ray, 716 complications following use of, 715 distance of effect of, 714 dose of, 715 effect of filters on, 714 upon ovaries, 719 fistula following use of, 715 histological changes in tissue after use of, 714 in abdominal tumors, 72^ in carcinoma of cervix, 341, 714 complicating myomata, 313 in early cases, 714 of fundus, 346, 717 indications for, 717 of ovary, 402 of urethra, 452 of vagina, 197 of vulva, 721 in carcinomata of bladder, 461, 721 results of, 721 technic of using, 722 in chorioepithelioma of uterus, 349 in chronic metritis, 284 in diseases of rectum, 722 in hemorrhagic uteri, 720 advantages of, 720 curettage in, 721 results of, 721 Rontgen ray in conjunction with, 720 technic of using, 720 varieties influenced by, 720 in myomata of uterus, 717 advantages of, 718 complications in, 720 contraindications for use of, 718 disadvantages of, 717 effects of, 717, 719 indications for use of, 718 results of, 719 technic of, 719 in papillomata of bladder, 721 results of, 721 in pruritus vulva. 72^ in treatment of bladder tumors, 460 method of use of, 714 physical properties of, 713 radiations of, 713 resistance of tissues to, 713 standard of, 713 Radium, resistance of tumor cells to, 713 results of, 714 statistics in, 715, 716 Reaction, Abderhalden, 107 complement-fixation for gonorrhoea, 107 for syphilis, 108 Wassermann, 108 Recto-abdominal examination of pelvic or- gans, 129 Rectocele, mode of production of, 202 Rectum, anatomy of, 45 carcinoma of, 534 (see also Carcinoma of Rectum) diseases of, radium in, 722 embryology of, 2 examination of, 162 by proctoscope, 164 by sigmoidoscope, 165 by specula, 163 irritability of, in extrauterine pregnancy, 8 5 malformations of, 21 treatment of, 259 polyps of, 533 prolapse of, diagnosis of, 532 etiology of, 530 symptoms of, 531 treatment of, 532 Moschcowitz plan in, 532 operations in, 532 stricture of, 535 tumors of, 534 Renal, blastema, 6 calculus, diagnosis of, 479 etiology of, 478 pathology of, 478 treatment of, 480 operations in, 480 findings, no infection, post-operative, etiology of, 689 sufficiency, test for, no Resection of Fallopian tube, 418 in gonorrhceal pelvic inflammatory dis- ease, 418 technic of, 418 of ovary, 404 Respiration in pelvic disease, 105 Respiratory symptoms in pelvic disease, 101, 106 Retarded menstruation, 580 Retrodisplacements of uterus, 244 (see also Uterus, Displacements of) Retroversion of uterus, 237-244 (see also Uterus, Retroversion of) Reynolds' observations on spermatozoa in diagnosis of sterility, 603 Ringworm of external genitalia, 166 Rodent ulcer of vulva, 184 Rontgen ray, in abdominal tumors, 723 in carcinoma of the cervix with radium, 716 of the ovary, 402 of the vulva, 721 in diagnosis of myomata, 309 746 INDEX Rontgen ray, in diagnosis of vesical calculus, 458 in examination of the kidney, 151, 152 of renal calculi, 153, 479 of ureteral calculus, 156, 491 in hemorrhagic uteri, 720 in myoma ta of uterus, 717 advantages of, 718 contraindications to, 718 disadvantages of, 717 effects of, 718 indications for, 718 in pruritus vulva, 721 in pyelography, 157 in treatment of carcinoma of body of uterus, 346 of menorrhagia, 584 of metrorrhagia, 585 of myomata, 310 of tuberculosis of vulva, 567 of vulvitis, 171 in vulvar lesions, 721 therapy, 713 Rosenmiiller, organ of, 13 Rosenow's observations on etiology of oopho- ritis, 381 Rupture of ovarian cyst, 407 of tubal enlargements, 368 pregnancy, 375 of uterus, 287 of varicose veins in broad ligament, 433 Sacroiliac sprain, diagnosis of, 548 differentiation of, from static back- ache, 543 etiology of, 546 examinations in, 548 prognosis of, 550 symptoms of, 547 treatment of, 548 Sactosalpinx, 367 Salpingectomy in pelvic inflammatory disease, 437 Salpingitis, 359 and ovarian abscess, 365 diagnosis, 415 (see also Pelvic Inflamma- tory Disease) differential diagnosis from appendicitis, 414 etiology of, 359 _ gonococcus in, 359 mode of invasion of infecting or- ganism, 359 relative frequency of infecting or- ganisms, 359 interstitial, 361 isthmica nodosa, 361, 418 pathology, 359 bilateral involvement, 360 endosalpingitis, 359, 360 hydrosalpinx in, 360 interstitial changes in, 360, 361 Salpingitis, pathology, perisalpingitis, 360, 361 pyosalpinx in, 360 unilateral involvement, 360 with various infecting organisms, 360 symptoms (see Pelvic Inflammatory Disease) treatment (see Pelvic Inflammatory Disease) tuberculous, 561 (see also Tuberculosis of Tubes) Salpingo-oophorectomy for pelvic inflamma- tory disease, 436 Salpingostomy, 418, 419 in pelvic inflammatory disease, 438 Sanger's operation for cystocele, 216 Sarcoma of ovary, 396 of uterus, 346 of vulva, 183 radium in, 721 Schatz pessary, 703 Selection of cases for operation, 613 of operations of urgency, 613 of election, 613 of patients for operation, 613 of time of operation in pelvic inflamma- tory disease, 613 Serum, auto-therapy, 725 dose in, 725 in puerperal inflammatory pelvic disease, 424 preparation of, 725 specific, 725 therapy, 725 Sexual gland, 1, 42 maturity, 61 Shock, post-operative, cause of, 670 diagnosis of, 670 symptoms, 670 treatment of, 670 Simpson's operation in retroversion, 261 technic of, 262 Sims' curette, 121 position, 115 speculum, 117 Skene's ducts, 33 infection of, 440 tubules, applications to, 701 Smear preparations as an aid to diagnosis, 123 Smith, pessary, 702 Social state in relation to disease, 91 Specific therapy in gynecology, 725 Spermatozoa in diagnosis of sterility, 601-603 Sphincter ani muscle, divulsion of, for fissure, 523 lacerations of, 202 effect of, 202 repair of complete tear of, 215 Spinal anaesthesia in pelvic surgery, 652 Babcock's plan in, 653 deaths from, 654 determination of dosage in, 654 in abdominal operation, 653 indications for, 652 INDEX 747 Spinal anaesthesia in pelvic surgery, solutions for, 653 technic of, 653 Spirochete pallidum, demonstration of, 124, 1/4 Sponges, use of, in abdominal surgery, 648 Static backache, diagnosis of, 540 recording tracing in, 540 differential diagnosis in, 542 from pelvic disease, 542 from sacroiliac disease, 542, 543 from spinal disease, 543 etiology of, 538 faulty posture in, 539 flat foot in, 538 pelvic disorders in, 538 tumors in, 539 pendulous abdomen in, 539 skeletal defects in, 539 symptoms of, 539 treatment of, general, plan of, 543 diet in, 546 orthopaedic, 543 corsets in, 543, 544 exercises in, 546 shoes in, 543 Sterility, absolute, 598 as symptom of pathologic anteflexion of uterus, 240 definition of, 598 diagnosis of, 601 examination of male in, 601 Hiihner's method in, 601, 602 Reynolds' observations in, 603 spermatozoa in, 601, 602 etiology of, 601 functional defects in, 601 gonococcus infections in, 554, 600 one-child sterility, 598 relative, 598 responsibility of male and female in, 600 treatment of, 603 artificial insemination in, 606 of developmental defects in, 604 of gross pelvic diseases in, 605 of inflammatory diseases of the lower genital tract in, 604 ovarian transplantation in, 606 posture in, 607 time of coitus in, 607 Stiles' operation in urinary fistula, 468 Stitch abscess, 691 Stomach, acute dilatation of, post-operative, 684 operations on, 515 Streptococcus, in pelvic inflammatory disease, 411 infection in carcinoma of the cervix, 335 mode of invasion of pelvic organs by, 89, 420 Stricture of the rectum, diagnosis of, 535 etiology of, 535 pathology of, 535 Stricture of the rectum, treatment of, 535 of the ureter, diagnosis of, 497 etiology of, 495 pathology of, 496 symptoms of, 495 treatment of, 497 operations in, 497 of the urethra, diagnosis of, 449 etiology of, 449 symptoms of, 449 treatment of, 449 Struma ovarii, 399 Subinvolution of uterus, etiology of, 285 symptoms of, 285 treatment of, 285 Suburethral abscess, 445 Support of perineum, normal, mechanics of, 200 Suppression of urine from ureteral obstruc- tion, post-operative, 685 Suppuration, of incision, post-operative, 691 in pelvis, post-operative, 691 etiology of, 691 treatment of, 692 Suprarenal gland, in relation to genital or- gans, 64 glands, relationship of, to generative or- gans, 64 tumors, 481 Suspension of kidney, 482, 483 Symptomatology, 91 circulatory disorders in, 101 constipation in, 100 gastro-intestinal disorders in, 100 general health in, 101 headache in, 99 leucorrhcea in, 99 menstruation in, 98 nervous manifestations in, 101 pain in, 97 Syncytium, 73 Syphilis, in chronic metritis, 282 in myomata, 292 of the cervix, 572 differential diagnosis of from, aphthous ulcers, 577 carcinoma of cervix, 577 chancroid, 576 gonorrhoeal macules, 576 herpes genitalis, 577 myomata, 577 tuberculous ulcers, 576 primary lesion in, 572 secondary lesion in, 573 tertiary lesion in, 573 of the Fallopian tube, 574 of the generative organs, 569 diagnosis of, 575 factors in difficulty in establish- ing diagnosis, 569 general considerations of, 569 mode of infection, 569 pathological findings in, 569, 570 prognosis of, 578 748 INDEX Syphilis of the generative organs, symptoms of, 569 treatment of, 578 of the ovary, 574 of the pelvic cellular tissue, 575 of the uterus, 574 of the vagina, 572 of the vulva, 174, 571 primary lesion in, 174, 571 varieties of, 571 secondary lesion in, 174, 571 condylomata lata, 571 varieties of, 571 tertiary lesions in, 571 gumma in, 571 organism of, demonstration of, 124 Temperature in pelvic disease, 103 Thermo-cautery, 704 Thrombophlebitis, placental, 420 Thyroid tissue in ovary, 399 gland, relationship of, to generative or- gans, 64 Time of getting out of bed after operations, 669 Trachelectomy, 234 indications for, 232 Trachelorrhaphy of Emmet, 233 indication for, 232 Transplantation of ovaries, 606 Treatment of patients preparatory to opera- tion, 614 Trendelenburg position, 669 Treponema pallidum, demonstration of, 124 Triangular ligament of pelvic floor, 53 Trimanual method of percussion, 130 Toxic arthritis, 550 Tuberculosis, of cervix, 566 of the endometrium, 564 of the generative organs, 89, 560 manifestations of, 560 primary, 560 relative frequency of, 560 secondary, 560 site of, relative frequency of, 560 of the kidney, 473 diagnosis of, 475 animal inoculations in, 475 etiology of, 473 pathology of, 473 prognosis of, 478 symptoms of, 475 cystoscopy in, 457, 476 urine in, 476 treatment of, 477 operations in, 478 of the ovary, pathology of, 565 symptoms of, 565, 566 treatment of, 566 of the peritoneum, etiology of, 563 pathology of, 563 varieties of, 563 Symptoms of, 563 Syphilis of the peritoneum, treatment of, 564 of the tubes, diagnosis of, 562 pathology of, primary form of, 561 secondary form of, 561 symptoms of, 562 ascites in, 562 treatment of, 562 of the vagina, 566 of the vulva, diagnosis of, 567 differential diagnosis of, 567 from chancroid, 567 from carcinoma, 567 from syphilis, 567 pathology of, 567 symptoms of, 567 treatment of, 567 Tubo-ovarian abscess, 365 cyst, 366, 367 Tubules, Kobelt's, 11 paraurethral, 34 Pfiiiger's, 385 Skene's, 700 Tunica albuginea, 1 Tympanites, post-operative, 674 treatment of, 674 U Urachus, cyst of, 21 Urea, in blood, method of determining, 160 Ureter, anatomy of, 43 calculus in, 489 diagnosis of, 156 shadow catheter in, 156 catheterization of, 147 by direct method, 148 by indirect method, 148 in pyelitis, 487 reflex anuria in, 150 collection of urine from, 149 diseases of, 469 displacements of, 147 embryology of, 3 examination of, by wax-tipped bougie, inflammation of, 489 in hysterectomy, 324 injuries to, 642 inspection of orifice of, 142 ligation of, 643 malformations of, 21 absence of, 21 duplication of, 21 fistula of, 21 occlusion of, 21 obstruction of, 149, 497, 686 suppression of urine by, 686 symptoms of, 498 treatment of, 498 orifices of, position of, 147 locating by chromo-ureterocysto- scopy, 159 palpation of, 138 physiology of, 84 INDEX 749 Ureter, relation of, to uterine artery, 44 stone in, 489 stricture of, 495 (see also Stricture of Ureter) Ureteral, calculus, diagnosis of, 490 methods in, 490 differential diagnosis of, from appen- dicitis, 490 etiology of, 489 pathology of, 489 sequelse of, 490 symptoms of, 490 treatment of, 492 operations in, 493 extraperitoneal, 495 for stone at pelvic brim, 493 in the intraparietal ureter, 494 in upper ureter, 493 in vesical portion, 493 per vaginam, 495 catheters, sterilization of, 143 bismuth, 156 shadow, 156 colic, 490 differentiation of, from appendicitis, 490 treatment, 492 obstruction, post-operative, 686 stricture, 495 anastomosis in, 468 Ureteritis, diagnosis of, 489 symptoms, 489 treatment, 487, 489 Uretero-rectal anastomosis in urinary fistula, 468 Uretero-ureteral anastomosis in urinary fis- tula, 468 Uretero-vaginal fistula, 463 Urethra, abscess of, 445 anatomy of, 43 application to, 700 carcinoma of, 451 caruncle of, 449 developmental anomalies of, 21 dilatation of, 447 diseases of, 440 embryology of, 2 fissure of, 445 inflammation of, 440 inspection of, 140 local anaesthesia for, 650 mucosa of, prolapse of, 446 new growths of, 451 palpation of, 138 physiology of, 84 stricture of, 449 Urethral caruncle, diagnosis of, 449 symptoms of, 449 treatment of, 450 dilatation, diagnosis of, 448 etiology of, 447 symptoms of, 448 treatment of, 448 Urethral dilatation, treatment of, operations in, 449 Urethritis, acute gonorrhceal, 440 diagnosis of, 440 prognosis of, 440 symptoms of, 440 treatment of, 440 types of, 441 chronic gonorrhceal, 441 diagnosis of, 442 local treatment in, 443 symptoms of, 442 treatment of, 443 types of, 444 Urethroscopy, 140 Urethro-vaginal fistula, 463 Urinalysis, 108, 138 Urinary, fistula, diagnosis of, 465 etiology of, 463 prognosis of, 465 symptoms of, 463 treatment of, 466 extraperitoneal abdominal, 468 nephrectomy in, 468 operations in, 466 vaginal operations in, 467 Ward's plan in, 466 varieties, 463 organs, examination of, 138 symptoms in pelvic disease, 100 Urination, mechanics of, 84 Urine, bacteria of, 109 bacteriologic examination of, 100 collection of, from ureters, 149 examination of, for tubercle bacillus, ill incontinence of, 447, 448 in pelvic disease, 108 Uterus, abscess of, 282 adenomyoma of, 326 (see also Adeno- myoinata of Uterus) anatomy of, 36 anteflexion of, 237 anteposition of, 273 at birth, 8 carcinoma of, 330 (see also Carcinoma of Uterus) changes in form of, 237 in position of, 237 chorioepithelioma of, 346 (see also Chorioepithelioma of Uterus) descensus of, 238, 263 accompanying lesions, 266 diagnosis of, 268 etiology of, 265 mechanics of, 263 symptoms of, 268 treatment of, 268 by pessaries, 269 Menge pessary in, 270 operations in, 270 developmental anomalies of, 15, 18, 25, 288 bicornis, 17 congenital dwarfing, 17 duplex bicornis, 16, 26 750 INDEX Uterus, developmental anomalies of, duplex septus, 17 subseptus, 17 fcetalis, 17 infantilis, 18 latero-position, 18 retroflexion, 18 retroversion, 18 unicornis, 16 during childhood, 8 elevation of, 238, 273 embryology, 2 exploration of, in puerperal pelvic in- flammatory disease, 423 with sound, 19 gas in, 288 (see also Physometra) hypoplasia of, 240 hernia of, 238 hyperinvolution of, 286 (see also Hyper- involution of Uterus) inflammation of, acute, 282 chronic, 282 interposition of, for cystocele, 220 inversion of, 274 latero-position of, 237, 273 ligaments of, 46 lymphatics of, 60 malformations of, 25 diagnosis of, 25 didelphys, 26 treatment of, 28 malignant tumors of, 330 myomata of, 292 (see also Myomata of Uterus) normal position of, 237 pathologic anteflexion of, associated con- ditions with, 239 diagnosis of, 241 Dudley's operation for, 243 Norris drain in, 243 Pozzi's operation in, 243 prognosis of, 241 symptoms of, 240 treatment of, 242 varieties of, 239 flexion of, 237 position of, 237 perforation of, 287 (see also Perforation of Uterus) precancerous changes in, 343 prolapse of, 238, 263 (see also Descensus of Uterus) treatment of, 268 by pessaries, 269 cervix, attention to, in, 271 choice of operations in, 270 interposition operation, 272 Menge pessary in, 270 operations in, 270 supravaginal hysterectomy in, vaginal fixation in, 272 ventral fixation in, 271 physiology of, 63 Uterus, procidentia of, 238, 266 (see also De- scensus of Uterus) pus in, 238 (see also Pyometra) retroflexion of, 237, 244 (see also Retro- version of Uterus) retroposition of, 273 retroversiofiexion of (see also Retro- version) retroversion of, 244 causes of, 244 diagnosis of, 247 in pregnancy, 253, 657 treatment of, 253, 659 mechanics of production of, 203 symptoms of, 246 treatment of, 247 Alexander operation in, 254, 260 Coffey operation, 258, 261 knee-chest position in, 250 manual "replacement of, 249 operations in, 254 test of, 258 pessaries in, 250-253 replacement of uterus in, 248 round ligament operations in, 258 shortening of utero-sacral liga- ments in, 263 Simpson operation in, 261 uterosacral ligaments in, 263 ventrofixation in, 261 ventrosuspension in, 257, 260 Webster-Baldy operation in, 259, 262 varieties of, 244 sarcoma of, 346 subinvolution of, 285 syphilis of, 574 torsion of, 274 Uterine, intra-, digital palpation, 119 pack, 705 sound, 119 Utero-vaginal tract, congenital dwarfing of, 17 V Vaccine therapy, dosage in, 726 gonococcus, 725 in arthritis, 726 in leucorrhcea, 199 in pelvic inflammatory disease, 725 in puerperal pelvic inflammatory dis- ease, 425 in pyelitis, 488 in vaginitis of infants, 725 in vulvo-vaginitis, 725 mixed, 725 reactions to, 726 diagnostic value of, 726 Vagina, anatomy of, 34 artificial formation of, 28 at birth, 8 bacteriology of, 89 Baldwin's operation on, 28 carcinoma of, 196 chorioepithelioma of, 197 INDEX 751 Vagina, cysts of, 194 developmental anomalies of, 25 absence of, 18 atresia of, 18 defectus vagina, 18 double, 18, 26 septate, 19 unilateral, 18 diseases of, 192 embryology of, 2 fibromyoma of, 195 foreign bodies in, 197 inflammation of, 192 local applications to, 699 lymphatics of, 60 malformations of, 25 diagnosis of, 25 physiology of, 62 sarcoma of, 196 grape-like, 196 syphilis of, 572 tuberculosis of, 566 Vaginal, douche, indications for, 706 method of giving, 707 solutions for, 707 drainage, 659 examination of pelvic organs, 126 fixation for descensus and prolapsus of uterus, 272 incision and drainage, 659 local anaesthesia for, 651 operations in urinary fistula, 467 pack, 705 puncture, in extrauterine pregnancy, 379, 659 in gonorrhceal pelvic inflammatory disease, 416, 438 in pelvic abscess, 428 in puerperal pelvic inflammatory dis- ease, 425 technic of, 427 tampon, medicaments for, 709 in chronic pelvic cellulitis, 433 methods of using, 709 uses of, 708 vaults, 34 Vaginismus, 172, 194 treatment of, 194 Vaginitis, 192 acute, 192 chronic, 192 gonorrhceal, 193 senile, 193 subacute, 192 symptoms, 192 treatment, 192, 193 ■ by lactic acid, 198 Van Hook's method of ureteral anastomosis, 492 Varicose veins of broad ligament, rupture of, 433 of vulva, 180 Venereal sores, 173 warts, 178 Ventrofixation of uterus, in retroversion, 261 Ventrosuspension in retroversion, 257, 260 Vesical calculus, diagnosis of, 458 etiology of, 458 Rontgen ray in, 458 symptoms of, 458 treatment of, 459 operation in, 459 vesico-vaginal fistula, 459 Vesico-cervical fistula, 463 Vesico-vaginal fistula, 463 in cystitis, 456 in treatment of vesical calculus, 459 Vestibule, 33 Vicarious menstruation, 580 Virgins, examination of, 112, 610 Visceroptosis, associated with prolapse of uterus, 265 Vulva, adhesions of, 167 anatomy of, 31 atresia of, 20 carcinoma of, 181 chancre of, 174 chancroid of, 176 condylomata of, 178 developmental anomalies of, 20 double, 20 elephantiasis of, r.73 fibromyoma of, 185 gonorrhceal inflammation of, 169 hematoma of, 180 hyperesthesia of, 172 hypertrophy of, 180 infantile, 20 inflammation of, 167 kraurosis of, 172 lipoma of, 186 lupus of, 183 lymphatics of, 60 oedema of, 179 pruritis of, 169 radium in, 722 rodent ulcer, 184 sarcoma of, 183 sebaceous cysts of, 186 syphilis of, 571 syphilitic eruptions on, 174, 175 tuberculosis of, 183, 567 varicose veins of, 180 Vulvar, incisions, local anaesthesia in, 652 Vulvectomy, 182 Vulvitis, 167 Vulvo-vaginitis, of children, treatment of, 169 vaccines in, 169 gonorrhceal, 169 treatment of, 169 Vulvo-vaginal glands, abscess of, 186 treatment of, 186, 187 cysts of, 187 inflammation of, 186 W Waldeyer's theory of histogenesis of ovarian cysts, 384 752 INDEX ~% Walthard's theory of histogenesis of ovarian cysts, 384 Ward's operation in urinary fistula, 466 Wassermann reaction, in pelvic disease, 107 in vulvar diseases, 174 Watkins' operation for cystocele, 220 in prolapse of the uterus, 272 Webster's operation in retroversion of uterus, 259 hsemostasis in, 640 in prolapse of uterus, 410 technic of, 262 Wertheim's panhysterectomy for malignant disease of uterus, 349 Williams' theory of histogenesis of ovarian cysts, 384 Wilms' operation for intestinal stasis, 516 Wolffian body, 1 in etiology of adenomyoma, 327 duct, 1 glomeruli, in etiology of pseudomucinous cysts of the ovary, 388 tubules, in ovarian cysts, 384 in etiology of carcinoma of ovary. 395 of paraovarian cysts, 391 Wounds of viscera, treatment of, 642 X X-ray (see Rontgen Ray) AUG ~i \0t •A