Columbia ?Hnibergitj> \ <9 1 ^ in tfie Citp of i^elu l^orfe CoUege of ^tj>sician£f anb ^urgeonsi ji^ef erence Xi&rarp Digitized by the Internet Archive in 2010. with funding from Open Knowledge Commons http://www.archive.org/details/gynecologyOOgrav 1 GYNECOLOGY By WILLIAM P. GRAVES, A. B., M. D., F. A. C. S. Professor of Gynecology at Harvard Medical School; Surgeon-in-Chief to the Free Hospital for Women, Brookhne; Consulting Physician to the Boston Lying-in Hospital With 368 Half-Tone and Pen Drawings by The Author And 123 Microscopic Drawings by Margaret Concree and Ruth Huestis With 100 of the Illustrations in Colors SECOND EDITION, THOROUGHLY REVISED PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1918 Copyright, 1916, by W. B. Saunders Company. Reprinted February, 1917- Revised •^ reprinted, and recopyrighted July, 1918 Copyright, 1918, by W. B. Saunders Company PRINTED iN AMERICA PRESS OF W. B. SAUNDERS COMPANY PHILADELPHIA TO THE MEMORY OF Dr. MtlUam M. Baker TEACHER AND FRIEND THIS BOOK IS GRATEFULLY AND AFFECTIONATELY DEDICATED PREFACE TO THE SECOND EDITION An attempt has been made in this edition to bring the book as completely as possible up to date. Special attention has therefore been paid to those subjects in which the science of gynecology has made the greatest recent advances. Thus the section on the Relationship of Gynecology to the Internal Secretions has been almost entirely rewritten and considerably amplified. Much new material has been added to the discussion of such subjects as ovarian organotherapy', ovarian transplantation, the radium treatment of cancer, radium therapy in non-mahgnant gynecologic diseases, etc. A new section has been introduced dealing with the relationship of gynecology to the sex impulse, based chiefl}' on the now generally accepted theories of Freud regarding infant sexuality. In Part III, which deals exclusively with oper- ative gynecologj^ a number of new operations have been described and illus- trated, most of which have not appeared before in text-books. Manj^ draw- ings have been added, most of them illustrating new material. Some of them have been substituted for such illustrations in the first edition as seemed inadequate. W. P. Graves. Boston, Mass., July, 1918. 7 PREFACE This work is designed both as a text-book and general reference book of Gynecology. In order to meet these two requirements a special classification has been adopted dividing the subject matter into three distinct parts: Part I deals with the physiology of the pelvic organs and with the relation- ship of gynecology to the general organism. The latter subject is a compara- tively new departure, and is presented in conformity with the latest methods of medical teaching which strive to impress on the student's mind the importance of the correlation of all branches of medicine and surgery. It is hoped that this part of the work will prove of value both to the advanced special student and to the general practitioner who includes gynecologic patients in his chentele. Part II is designed primarily for the undergraduate student who is taking his initial course in gynecology. It includes a description of those diseases which are essentially gynecologic, and is thus isolated in a somewhat compact form in order that the student may not be confronted by a too formidable array of facts in his collateral reading and in his preparation for his final examination in the subject. In order to accomplish this purpose certain encumbering details have been subordinated. Thus, in the description of each disease, the underlying pathologic processes are enumerated. Microscopic detail, however, can better be learned from pictures than from tedious descriptions. For that reason draw- ings from microscopic sections illustrating the respective diseases are presented under each subject with full descriptive legends appended to them. In like manner the surgical principles involved in the treatment of the various dis- eases are recounted, but the technic of the operations and the pictures illustrating their performance, matters of secondary interest to the student of the theory of gynecology, are reserved for a separate section. Part III is devoted exclusively to the technic of gynecologic surgery and is written for the assistance of the advanced student and practitioner. Surgical devices for the cure of gynecologic diseases are innumerable, and it is impossible to include them all in a book of this scope. Only those operations which from the personal experience or judgment of the author seem best suited for the special requirements are presented. Many excellent procedures have, there- fore, been unavoidably omitted. In preparing a work of this kind material must be gathered not only from the author's personal experience, but to a still greater extent from the work of others. Out of a great number of authorities consulted there have been several to which I have had such frequent recourse, both for new material and for cor- 9 10 PREFACE roboration of personal observations, that I must make a general acknowledg- ment of indebtedness to them. In writing the sections on the relationship of g;ymecology to the general organism I have received the greatest assistance from the monumental work entitled "Die Erkrankungen des Weiblichen Genitales in Beziehung ziu- imieren INIedizin/' published by Prof. Frankl-Hochwart as a supplement to Nothnagel's "Pathologie und Therapie." In writing Part II the authorities to which I owe most are the great "Handbuch" of Veit, the "Handbuch" of Opitz and IMenge, the "Lehrbuch" of Ktistner, and the various works of Dr. Howard A. Kelly and his associates. In making the half-tone drawings I owe much to the instruction of ]\Ir. IMax Brodel, who manj^ years ago showed me the technic which he has developed and which has been universally imitated, but never equalled, in the field of medi- cal illustration. To ]\Iiss H. J. Ewin, Superintendent of the Brookline Free Hospital for Women, I am indebted for the accumulation and tabulation of a vast number of statistics gathered from hospital records and patients' letters. On the basis of these statistics I have been able to draw many valuable conclu- sions. To my associate, Dr. F. A. Pemberton, belongs the credit of selecting the pathologic sections and of supervising the microscopic drawings, most of which have been executed bj^ Miss Margaret Concree. Several of the illustrations have been pubHshed previous^ in an article by the author in the American Practice of Surgery. William P. Graves. Boston, Mass. CONTENTS PIRT I— PHYSIOLOGY AXD RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANIS^I PAGE Physiology of the Uterits axd Ovaries 1" The Uterus 1" Physiologic Anatomy of the Ovary 31 Relationship of Gynecology to the Gen-er.al Okg-^nism 44 Relationship of G}-necolog>- to the Organs of Internal Secretion 44 Ovary 46 H^■poph3'sis ■ ^3 Th^vToid ' " ParathjToids °3 Suprarenal System - ^"^ Pineal Gland (Epiphysis) 90 Thj-mus 91 Uterus 91 Placenta 9^ Relationship of Cxj-necology to the Mammary Glands 93 Relationship of GjTiecolog\- to the Skin 94 Relationship of Gjmecology- to the Organs of Sense 98 Relationship of G^^lecolog^- to the Digestive Tract 100 Relationship of G^-necolog}- to the Organs of Respiration 103 . Relationship of Gj-necology to the Blood 105 Serodiagnosis HO Relationship of GjTiecologj' to the Organs of Circulation 112 Heart 113 Blood-vessels H^ Relationship of GjTiecologj" to the Nervous System 120 Relationship of G^mecology to the Sex Impulse 129 Infantile Sexuahty 130 Sexual Deviations 134 Relationship of Gjmecolog}- to the Xeighboring Organs 141 Relationship of Gj-necolog\- to the Gall-bladder 14' Relationship of G>-necolog>- to the Peritoneum and Omentum 150 Relationship of GvTiecology to the Bones and Joints 156 Relationship of Gj-necologj- to Acute Infectious Diseases 157 Enteroptosis "'^ Movable Kidnev Intestinal Bands 172 PART II— GYNECOLOGIC DISEASES Special Infl-anoiatory Processes 1 ' Gonorrhea . i: Gonorrhea in Children 1 ^^ Gonorrhea in the Adult 1^1 11 12 CONTENTS Special Inflammatory Processes — Gonorrhea — Gonorrhea in the Adult — page Urethritis Igl- Inflammation of Skene's Glands 183 Inflammation of Barthohn's Glands 184 Endocervicitis 189 Endometritis 192 Salpingitis 192 Chronic Pelvic Inflammation as a Result of Gonorrheal Salpingitis 209 Serum and Vaccines in Gonorrhea 214 Genital Tuberculosis 215 Tubes 216 Uterus 219 Ovaries 220 Cervix 220 Vagina . 220 Vulva 220 Peritoneum 221 General Inflammatory Processes 224 Inflammations of the Vulva 224 Soft Chancre 224 Skin Lesions 225 Esthiomene 229 Elephantiasis 230 Kraurosis 232 Pruritus 234 Vaginitis (or Colpitis) 236 Cervicitis and Endocervicitis 241 Endometritis 242 Infectious Endometritis 244 Chronic Interstitial Endometritis , 247 Gland Hypertrophy 249 Metritis 251 Inflammations of the Ovary ; 252 Infectious Oophoritis 252 Interstitial Oophoritis 253 Parametritis and Pelvic CeUuhtis 255 Inflammations of the Pelvic Cellular Tissue 256 Parametrial Hematoma 260 Urethritis .261 Cystitis 262 Tuberculosis of the Bladder 271 Syphilis of the Bladder 272 Cystitis Vetularum 272 Pyelitis 273 Inflammations of the Colon and Rectum 277 Diverticiilitis 277 Ischiorectal Abscess 280 Fistula in Ano • 281 Fissure in Ano 282 Inflammatory Stricture of the Rectimi 283 New Growths 286 Tumors of the Vulva 286 Fibroma and Fibromyoma 286 Lipoma 287 CONTENTS 13 New Growths — Tumors of the Vulva — p^eg Carcinoma 287 Sarcoma 292 Varicocele 293 Urethral Caruncle 293 Urethral Prolapse 294 Tumors of the Chtoris 295 Tumors of the Vagina 296 Sarcoma 296 Carcinoma 297 Cysts 299 Tumors of the Uterus 307 Myoma 307 Adenomyoma 327 Sarcoma 328 Cervical Polyps 332 Cancer of the Cervix 334 Cancer of the Body of the Uterus 362 Chorio-epithelioma Malignum " 370 Tumors of the Ovaries ; . 381 FolHcle Cysts 381 Corpus Luteum Cysts 385 Parenchymatous Tumors 387 Cystadenoma 387 Carcinoma 398 Dermoid Cysts 401 Teratoma 404 Stromatogenous Tumors 407 Sarcoma 410 Symptoms 412 Diagnosis 415 Treatment 416 Prognosis 417 Parovarian Cysts 418 Tumors of the Tubes 420 Carcinoma 420 Other Tumors of the Tube 421 Tumors of the Round Ligament 422 Tumors of the Pelvic Connective Tissue 423 Tumors of the Bladder 426 Papilloma 426 Carcinoma 427 Vesical Calculus 428 Tumors of the Rectum 429 Cancer • 429 Adenoma 431 Prolapse 431 Hemorrhoids 432 Defects of Development 436 Congenital Defects of the Uterus 441 Vagina 444 Ovaries and Tubes 445 Urethra and Bladder 445 Atresia of the Anus 449 Pseudohermaphroditism 451 14 CONTENTS PAGE Malpositions of the Uterus 453 Retroversion and Retroflexion 458 Retroversion due to Relaxation 459 Retroversion due to Adhesions 468 Retroversion due to Displacement by Tumors 470 Prolapse and Procidentia 470 Prolapse 470 Procidentia 475 Anteflexion 480 Inversion 482 Injuries Due to Childbirth 485 Lacerations of Cervix 485 Cystocele 487 Lacerated Perineum 490 Vesical Fistula . 498 Abdominal Hernia 500 Umbilical Hernia 502 Postoperative Hernia 503 Special Gynecologic Diseases. 506 Ectopic Pregnancy 506 Dysmenorrhea 515 Essential Dysmenorrhea 515 Membranous Dysmenorrhea 522 Amenorrhea of Youth ; 523 Menorrhagia of Youth 524 Radium in the Treatment of Non-malignant Gynecologic Diseases 525 Vaginismus 533 Gynatresia 535 Genital Atrophy 540 Uterine Insufficiency 547 Infantalism and Sterility 549 General Symptomatology in Gynecology 568 Symptoms due to Abnormal Secretions 568 Abnormahties of Menstruation 571 Amenorrhea 571 Menorrhagia 573 Metrorrhagia 575 Pain. 576 PART III— OPERATIVE GYNECOLOGY Operations on the Vulva ■. 582 Vulvectomy 582 Special Operation for Cancer of Vulva 584 Operations on Bartholin's Glands 588 Operations on the Cervix 591 Dilatation of the Cervix 591 Curetage 592 Tracheloplasty 593 Amputation of the Cervix 599 Schroder's Operation 604 Operations on the Vagina 608 Anterior Colpoplasty (Author's Method) 608 Operation for Functional Incontinence of Urine 614 CONTENTS 15 Operations on the Vagina — • page Anterior Colpoplasty (Clark's Technic) 617 Combined Amputation of Cervix and Anterior Colpoplasty (SO Emmet's Perineoplasty (Author's Technic) 625 Clark's Perineoplasty 633 Studdiford's Perineoplasty 638 ObHteration of Douglas' Pouch for Rectocele (Author's Method) 643 Enlarging a Tight Perineum 646 Operations for Complete Laceration of the Perineum 647 Operations for Vesical Fistulse 653 Operations for Atresia of the Vagina 665 Operations for Absence of Vagina 667 Schubert's 670 Baldwin's , 670 Vaginal Celiotomy 675 Anterior and Posterior Colpotomy 675 Operations for Uterine Malposition 678 Operations for Retroversion 678 Olshausen's Operation for Suspension of the Uterus (Author's Technic) 678 Various Forms of the Gilliam Operation 680 Simpson's Operation 681 Mayo's Modification of Gilliam's Operation (Internal Alexander) 683 Kelly's Modification of Gilliam's Operation 685 Baldy's Operation (also called the Baldy-Webster Operation) 685 Alexander's Operation -688 Operations for Anteflexion 691 Pessaries for Anteflexion of the Cervix 691 Operations on the Cervix for Anteflexion 693 Abdominal Operation for Anteflexion (Author's Method) 695 Operations for Prolapse and Procidentia 696 Procidentia 696 . Watkins' Interposition Operation 699 GofTe's Operation 706 Mayo's Operation 709 Conservative Operation for Inversion of the Uterus 710 Spinelli's Operation for Inversion of the Uterus 711 Hysterectomy Operations 713 Supravaginal Hysterectomy 713 Complete Hysterectomy 724 Vaginal Hysterectomy , 728 Wertheim's Extended Operation for Cancer of the Uterus 731 Extended Vaginal Hysterectomy for Cancer of the Cervix 744 Myomectomy Operations 750 Abdominal Myomectomy 750 Vaginal Myomectomy 756 Operations on the Tubes 757 Salpingo-oophorectomy 757 Salpingectomy 758 Salpingostomy (Stomatoplastic) 760 Operation for Tubal Sterilization 762 Operations on the Ovaries 764 Resection of the Ovary 764 Transplantation of Ovarian Tissue 765 16 CONTENTS PAGE Operations on the Abdominal Wall 768 Bardenheuer's Incision 768 The Pfannenstiel Incision 769 Operation for Diastasis of the Rectus Muscles : , 771 Operation for Umbihcal Hernia (Author's Method) 775 Mayo's Operation for Umbihcal Hernia 781 Operation for Postoperative Hernia 782 Transplantation of Fascia for Postoi>erative Hernia 782 Operation for Femoral Hernia 787 The Percy Cautery for Cancer of Cervix 790 Technic in the Application of Radium 792 Operations on the Kidney 796 Minor Operations , 796 Suspension of the Ividney (Kelly's Technic) 800 Incision for Major Operations on the Kidney 803 Nephrectomy 803 Operations on the Ureters 810 Uretero-ureterostomy 810 Ureterocystanastomosis 812 Extirpation of the Kidney 813 Ligation of the Proximal End of the Ureter ^ 813 Formation of Ureteral Fistula 814 Operations on the Bladder : 815 Suprapubic Cystotomy 815 Vaginal Cystotoiny 815 Operations on the Rectum , 817 Operations for Prolapse 817 Operations for Hemorrhoids 819 Operations for Fistula in Ano 824 Elting's Operation for Fistula in Ano 827 Operations for Varicose Veins of the Leg 828 Technic 831 Examination of the Patient 831 Pelvic Examination in a Private House 834 Abdominal Operations 835 Technical Detail in Conduct of Abdominal Pelvic Operations 836 Postoperative Treatment of Abdominal Cases 840 Technic of Plastic Surgery 842 Technical Details 843 After-care 845 Index 849 GYNECOLOGY PART I PHYSIOLOGY AND RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM PHYSIOLOGY OF THE UTERUS AND OVARIES THE UTERUS During the first decade of life the female genitalia play a very unimportant physiologic role. In the last months of intra-uterine life there is a somewhat rapid development of the uterus, and at birth is often seen a discharge which appears hke true menstrual blood. The uterus then for several months under- goes a process of regression, from which period there is a very slow growth until the time of puberty. The hypertrophic changes in the uterus just before and after birth are at present supposed to be due to the action of hormones from the placenta, which influence the development of the maternal uterus and that of the child, both of which undergo involution when the stimulus of the placenta is removed (Halban). At birth the uterus is high in the pelvis and pressed backward by the intes- tines which lie in the utero vesical space. At this time it is pointing upward and its axis is practically straight. During the first ten years of life it sinks gradually deeper in the pelvis, and acquires the angulation between body and cervix known as anteflexion. There is also a tendency to sag backward toward the sacrum into the position of retrocession. The persistence of this position after maturity constitutes the typical condition of local infantiUsm. The growth of the inner genitaha during the first ten years is comparatively slight, but toward the age of puberty there is a very marked and rapid develop- ment. The uterus does not usually attain its full growth in the virgin until several years after puberty. Child-bearing increases the size and weight of the uterus, so that it measures on an average 1 cm. more in each dimension than does the virgin uterus and weighs about 20 gm. more. The length of the virgin uterus is 7 to 8 cm., and its weight from 40 to 50 gm. During lactation the uterus undergoes a tempo- 2 17 18 GYNECOLOGY rary atrophy due to a shrinking, but not a loss of the muscle-fibers, and normally regains its proper size after lactation ceases. At the menopause the uterus becomes permanently atrophied as a result of a diminution both in size and amount of muscle tissue. The ovaries of the child during the first ten years also show an insignificant growth. The infantile ovary is narrow and slender. Toward puberty there is a rapid development, and the organ assumes a rounder, more oval contour. The dimensions of the mature ovary are 3 to 5 cm. long, 2 to 3 cm. wide, and 1 to If cm. thick. In the fetus the tube is twisted into tight convolutions, which straighten out somewhat toward the end of intra-uterine fife, especially near the isthmus. As the child grows older the tube gradually becomes straighter, so that at puberty there are only moderate convolutions. After child-bearing the tube becomes nearly straight. The twisting of the tube sometimes persists after maturity, and is regarded as one of the stigmata of infantihsm. It is thought to be one of the causes of sterility and of tubal pregnancy. At puberty the secondary sexual characteristics become more pronounced and differentiated from those of the male. Most important of these are the development of the breasts, relative width of the hips, slenderness of the waist, length of the hair of the head, small bony structure, general undulating contour of the body, and absence of body hair, except in the axillse and on the pubes. The breasts at the time of birth, both in boys and girls, are enlarged, and, like the female uterus, undergo retrogression in the first fev\^ weeks. It is thought that this enlargement of the breasts at birth is due to the influence of the placenta, to which is also ascribed the growth of the maternal breasts during pregnancy. The rapid mammary development at puberty and the temporary enlargement during menstruation is probably referable to the in- fluence of the ovarian inner secretion (Halban-Schrdder) . Woman reaches her highest period of development and her greatest fertifity about the middle of the third decade of life. Physiology of Menstruation. — Menstruation is probably established at the time of the first complete ripening of an ovum. The first appearance of blood usually takes place at about the fourteenth year, though in some it begins as early as eleven and in others as late as sixteen. These may be regarded as the normal Hmits. Precocious menstruation in infants is usually due to some disturbance in the glands of internal secretion, while late menstruation (i. e., after sixteen) is commonly the result of some ovarian deficiency, either primary in the ovaries themselves or secondary to the influence of other glands of in- ternal secretion. There are, however, numerous factors which influence the establishment of the menses; one of these is cHmate. CHmate apparently affects the period of puberty somewhat, but not to the extent formerly supposed. It is commonljr stated that in tropical regions menstruation begins usually from eight to nine, PHYSIOLOGY OF THE UTERUS AND OVARIES 19 while in the colder regions it is much later than the general average. Engleman has, however, showTi in extensive statistics that this is an error, and that the average age of puberty is very nearly the same in the tropics and in the arctic zones — namely, about fourteen and one-half j^ears. In the Polar regions women are said to menstruate from two to four times a year, as a rule, and not at all during the winter months. Heredity plays a certain role, as do general racial characteristics, but the variations from these causes are not wide. Social conditions also make some difference, for statistics show that the poor begin to menstruate later on an average than the well-to-do and reach the menopause earlier. This is thought to be due to hard work and poor nourishment. It has also been observed that those who live in the country come to puberty later than those who hve in the city, probably for the same general reasons. It must be remembered that these figures have been compiled from European countries, where social conditions differ from those in this country. Statistics on this subject in America are scanty. The duration of menstrual life is usually between thirty and thirty-five years. Kniger's table is as follows : Menopause at 36^0 12 per cent. Menopause at 41-45 26 " " Menopause at 46-50 41 " " iMenopause at 51-55 15 " " Menopause before 35 and after 55 7 " " As a rule, those in whom puberty comes early have the menopause some- what later than the normal. Women of this type tend to menstruate more profusely and have a special predisposition to myoma formation, which of-^' itself prolongs menstrual life. Nulliparous women and virgins reach the climacteric somewhat sooner than do parous women. « Women of the upper classes menstruate distinctly later than women of the poorer classes, the menopause of the former averaging nearer fifty than fortj^- five. Undoubtedly better nourishment and freedom from hard work explain this fact. It is usually stated that the menopause appears earlier in hot chmates than it does in cold. Statistics on this point are conflicting. It is probable that chmate has no very decided influence on the menopause, but that in those countries where it appears abnormally early it is affected chiefly by the very early child-bearing to which the women are subjected and by which they pre- maturely lose their bloom. When the function of menstruation is estabhshed it is apt to be irregular at first, but when fully instituted the typical intermenstrual period is from twenty-seven to thirty-one days. There seems to be a special tj'pe of women who menstruate evevy twenty-three days. This type is usually of the class who begin early and have a late climacteric. It is probable that in most women 20 GYNECOLOGY who menstruate every twenty-one to twenty-three days there is some under- lying pathologic condition. In healthy women the average length of the menses is three to four days, These limits may fluctuate somewhat and still be regarded as normal. In general, however, women who menstruate only one or two days, and those who flow more than five days are not to be regarded as entirely within physiologic limits. ' ■ The amount of blood lost at each menstruation has been variously estimated by different investigators. It probably averages about 50 gm. in the unmar- ried and somewhat more in the married and parous (Hoppe-Seilet) . Menstrual blood is more watery and paler than normal blood, and is mixed with detritus and the secretions of the uterus, cervix, and vagina. The most important characteristic of the menstrual blood is its non-coagula- bility. This was formerly supposed to be due to the influence of the alkahne cervical mucus, on the ground that blood when alkahne is less coagulable than when acid. The cervical mucus, however, is probably not account- able for the phenomenon. Birnbaum and Osten have shown that the body blood of a menstruating woman is only one-half as coagulable as it is when she is not menstruating, but this has recently been denied. The change was thought to be due to some agent which affects the entire organism of the woman, and was referred to the influence of the ovarian secretion. It is now supposed to be due to a local influence of the ovarian secretion exerted on the endometrium. During menstruation there is marked congestion of all the pelvic blood- vessels, and as a result the uterus is larger and softer and more compressible. The tubes and ovaries are also swollen. The external genitals exhibit a decided hyperemia. The breasts are somewhat fuller and often tender and painful, and in some there is a noticeable enlargement of the thyroid gland. A few women experience a special sense of well-being during the menstrual period, but in most women there is a general physical and mental depression which is manifested in many different ways. The nervous equilibrium especi- ally is unstable. There is increased irritabiUty and susceptibihty to psychic excitement. All neurotic tendencies are accentuated and often appear at this time only. Headaches periodically associated with some particular time of the menstrual period are very common. (See also section on Neurology.) The majority of women have some form of pelvic discomfort during cata- menia. Under physiologic conditions this may be merely a sense of heavi- ness or pelvic pressure. If there is actual pain, the condition is one of dys- menorrhea (g. v.). The symptoms of any pathologic process, especially of the lower abdomen,, like appendicitis or salpingitis, are exaggerated by the menstrual congestion. Practically, all of the functions of the body may share in the general depres- sion and exhibit symptoms more or less disturbing. In the digestive system PHYSIOLOGY OF THE UTERUS AND OVARIES 21 there may be loss of appetite, tendency to vomiting and formation of gas in the intestines, increased mucus from the colon, and constipation or diarrhea. The circulatory system may show irregular pulse and palpitation of the heart. Various vasomotor chsturbances are frequent, such as hot flushes, cold ex- tremities, sweating, etc. The mucous membrane of the nose and throat is often swollen, causing mouth-breathing. Nose-bleeds are frequent. The vocal chords become swollen, so that there is a change in the voice. Singers experience a change in the quality and trueness of their notes, and often are obhged to refrain from singing in pubhc during the menstrual period. The hearing is apt to be less acute, while the eyes, too, maj'' suffer from granulation of the lids, lessening of the field of \dsion, and impairment of color sense. Various skin manifestations are common during .the menstrual period, examples of which are exanthematous rashes, herpes of the hps, urticaria, acne, etc. The sexual impulse is, as a rule, increased just before and just after the catamenial flow. It is usually decreased during the period, but may be in- creased. Some patients suffer pain and discomfort about half-way between their periods, resembhng. that which they have at their regular flow. This intermenstrual pain is. usually due to some pathologic process, most com- monly an intramural fibroid. In other cases it cannot be explained by any anatomic lesion. Precocious menstruation relates to the appearan.ce of the menses in infants of two,' to four years old, associated wdth abnormal development of the breasts and external genitals, growth of pubic hair, and awakening of the sexual im- pulse, usually shown by masturbation. This condition is the result of abnor- malities in the glands of internal secretion, and is referred to in detail in the section on the Internal Secretory Organs. Vicarious menstruation is a phenomenon about which little is known but which undoubtedly occurs at times. Instead of the regular menstrual flow, bleeding takes place more or less periodical^ from some other organ of the body, usually the nose. Other sites of vicarious bleeding described are the hps, breasts, lungs, rectum, hemorrhoids, ulcerations, and wounds. Vicarious menstruation from the nose is sometimes seen after hysterectomy operations, where an ovary has been left in situ or where a piece of it has been transplanted. The menses may be influenced to some extent by psychic excitement, especi- ally that due to fright or anxiety. In women who menstruate normally the flow after having started may be Suppressed by a sudden nervous shock, or such a shock may bring on the menses out of the regular time. It is a com- mon experience in a gynecologic clinic that women whose periods are usually regular menstruate out of time under the mental excitement of waiting for operation. ^Menstruation is often delaj'ed for several days and even a week in women who are laboring under the fear of impregnation, and also in women who, being extremely anxious to become pregnant, have their minds tensely concentrated on the function. 22 GYNECOLOGY The question of performing pelvic operations during the menstrual period is one of some importance and one concerning which there is difference of opinion. Some operators make it a rule never to operate at this time, while others pay little attention to the matter. It is probable that in the majority of instances patients operated on during the catamenia have a normal con- valescence, but occasionally it happens that a constitutional effect is pro- duced by the operation that results in alarming symptoms. These appear within thirty-six or forty-eight hours after the operation and simulate closely the condition of profound shock. Patients in this state have had their abdomens reopened in the belief that they were suffering from a secondary internal hem- orrhage. The condition lasts for several hours and then passes away. No entirely satisfactory explanation has been made of this phenomenon. The effects of menstruation on the general organism mentioned above are treated in greater detail in other sections. The Climacteric. — The menopause is usually a slow change extending over several months to several years. Menstruation in rare instances ceases abruptly; more commonly there is. a gradual cessation, consisting either of a progressive diminution in the amount of flow or in a lengthening of the intermenstrual period. Many women before the end of the menopause exhibit a greater pro- fuseness in the flow and shorter intermenstrual periods. An increase of blood during the menopause is not to be regarded as physiologic, a misconception which often leads to grave errors. The most common pathologic causes of menorrhagia at the menopause are cancer, fibroids, and polyps. In many cases, however, no definite anatomic changes can be discovered, and the bleed- ing must be referred to an insufficiency of contractile power on the part of the uterine musculature. This uterine insufficiency is not normal or physiologic, for it subjects the patient to a period of semi-invalidism which may last over several years. When the menopause is established all the genital organs undergo a process of atrophy, which in extent varies greatly in different women. (For a detailed description of Genital Atrophy, see page 540.) Many women pass through the menopause with little or no trouble and this may be considered the norm. There are, however, certain constitutional and psychic disturbances of a quasiphysiologic nature which perhaps the major- ity of women experience to a greater or less extent. These may occur only at the time of the actual menopause, but they may make their appearance several years before any change takes place in the function of menstruation and may last long after it has ceased. The most typical of these disturbances are hot flushes, palpitation, buzzing in the ears, dizzy feelings, nervous irritability, tendency to depression, various forms of neuroses, and often serious psychoses. It is a common belief also that certain physical changes take place, such as a deepening of the voice, appear- ance of hair on the upper hp and chin, accumulation of fat, and a general coarsen- PHYSIOLOGY OF THE UTERUS AND OVARIES 23 ing of feature and contour. This last so-called reversion to the masculine type has been greatly exaggerated. Women who have a tendency to obesity begin to grow fat long before the menopause, as a rule, while those who eventually develop coarseness of feature show this characteristic as soon as the bloom of youth begins to pass. The appearance of hair on the face in middle age is not a universal attribute, but only an individual peculiarity, and is merely evidence of advancing age. Women of innate physical refinement often show a greater delicacy of lineaments as they approach and pass the climacteric. The vasomotor and psychic disturbances referred to above are thought to be the result of the loss of ovarian secretion. Doubtless the atrophy of the ovaries does account for some of these manifestations, especially those of the vasomotor type, but this influence has also been greatly exaggerated. Severe manifestations of this kind nearly always appear in individuals with well- marked neurotic predisposition, while women of the well-balanced type usually suffer little. As Walthard has pointed out, the so-called critical period of a woman's life comes at a time when domestic responsibilities and worries are at their height, while the consciousness of approaching old age and the loss of physical attractiveness constitutes a most important factor in the discon- tent and mental despondency that women of middle age, especially of the social classes, are wont to exhibit. Just before the climacteric there is usually an increase of the sexual impulse. This may last for a considerable time, but, as a rule, it gradually diminishes. . After the age of fifty or thereabouts women often undergo a complete change in temperament. Relieved of the anxieties of child-raising, and reconciled to the changes of age, they acquire a mental and physical strength never before experienced, and live for a decade or two the best years of their life. Physiology of Conception.^During coitus there takes place a hypersecre- tion of the glands of the vestibule and of Bartholin's glands, the evident pur- pose of which is for lubricating the parts. The semen is deposited in the poste- rior vault of the vagina, which is termed the receptaculum seminis, into which under normal conditions the cervix dips. It was formerly supposed that the semen was received directly into the cervical canal, but this cannot be so, as the cervix normally points at right angles to the axis of the vagina. Another proof that the semen does not enter directly into the cervix is the fact that in retroversion or anteflexion, where the cervix points in the direction of the canal, and in a more favorable position for receiving the semen, conception usually does not take place. From the receptaculum seminis the spermatozoon reaches the cervical canal chiefly by its own power of locomotion, but it is undoubtedly assisted by the cervix and its mucous secretion. During orgasm the cervical glands pour forth strings of mucus from their ducts, which, dipping into the pool of semen, act as channels for the passage of the spermatozoa into the canal. It has been claimed that "the cervix during orgasm undergoes certain muscular movements 24 GYNECOLOGY which serve to aspirate the semen into the lumen. The normal alkaline reac- tion of the cervical mucus undoubtedly, also plays an important part in the process, for spermatozoa soon die in the acid medium of the vaginal secretions. The chief factor for motion in the upward progress of the spermatozoon is un- questionably its own motihty. As proof of this is the occasional conception that takes place where the cervix has been amputated, in which there is little question of cervical secretion or aspirating movements. That the spermato- zoon is capable of .weathering a journey through acid secretions the length of the vagina is shown by the not infrequent cases of conception where there has been no introition. It is now well accepted that the unioii of the spermatozoon and ovum takes place either at the fimbriated end of the tube or on the surface of the ovary. The union of the two germ-cells (amphimixis) is consummated by the success of one spermatozoon in piercing the surrounding envelope of the egg. Only the head which contains the nucleus of the male germ-cell enters the ovum, the tail breaking off. On the entrance of the spermatozoon the envelope of the ovum immediately becomes thickened, preventing penetration by other aspirants. The impregnated ovum is then guided by the fimbriae of the tube to the canal where it is swept on to the uterus, partly by the current of the cilia of the surface epithelium and partly by peristaltic motions of the tubal wall. The passage of the ovum to the uterine canal occupies several days to possibly. a week. During this time it acquires the power of corrosion, which is characteristic of fetal tissue, and when it reaches the uterine canal it digs a bed for itself in the endometrium where it proceeds to develop, nourished as a parasite by the mother's blood. If the passage into the uterine canal is in any way interrupted the egg sinks into the mucous membrane of the tube and produces an ectopic pregnancy. Orgasm on the part of the woman is not necessary to conception, although its absence is often associated with sterihty, especially in cases of hypoplasia. That orgasm and libido are not essential factors in conception is proved by the frequency with which frigid women become mothers, and by the recorded instances of impregnation during narcosis. Physiologic Anatomy of the Menstruating Endometrium. — That the uterine mucosa passes through definite cyclic changes each month is a comparatively recent addition to our knowledge, due chiefly to the researches of Hitschmann and Adler, who rediscovered facts that had already been announced years before. The cycle of change is divided into three phases: (1) Premenstrual con- gestion, (2) period of menstruation, and (3) postmenstrual involution. The premenstrual congestion begins about ten days before the expected period. By this process there is a marked thickening of the mucosa, due to an hypertrophy and hyperplasia of the endometrial glands and a transudation- and exudation into the stroma. The mucosa becomes two or three times thicker PHYSIOLOGY OF THE UTERUS AND OVARIES 25 Fig. 1. — Premenstrual Endometrium. Low power. At the bottom is the muscle of the uterine wall, sharply demarcated from the endometrium. The glands in the deepest part of the endometrium are small, their epithelial cells low, for this part of the gland remains inactive. The stroma cells are small and lie close together. At the middle of the endometrium the glands are dilated, the epithelium wavy, and the epithelial cells swollen and actively secreting mucus. The stroma cells are larger and lie further apart. On the right the dilatation of the blood-vessels is well shown. Near the top the glands have the same characteristic as at the middle, but there is more edema of the stroma. Throughout there is a slight infiltration with round cells. 26 GYNECOLOGY than the normal, and may reach 6 to 7 mm. in depth. The surface becomes irregular and furrowed as a result of the general swelling beneath. At this stage the endometrium resembles closely an early decidua vera. The stroma cells are large, pale and swollen, and separated by the edematous exudate. The mucosa is distinguished by two fairly well-defined layers, the deeper con- taining the dilated and hypertrophied glands, termed the spongy layer, and ^2l. ^^S" Fig. 2. — Premenstrual Endometrium. High power. This drawing shows the enlargement of the nuclei of the epithelial cells, which, instead of being small and lying at the bottom as in inactive glands, have enlarged and nearly fill the cells. The cells crowd each other and a papilla can be seen in the central gland. the outer, denser, and less glandular portion, called the compact layer. The dilated blood-vessels (seen chiefly between the spongy and compact layers) are surcharged with blood. By diapedesis and by actual rupture (rhexis) blood is poured into the stroma of the mucosa, and by following the line of least resistance toward the surface forms subepithelial hematomas. It is probable that at this point uterine contractions force the blood through the surface of the mucosa into the uterine canal, marking the second phase of the cycle, the PHYSIOLOGY OF THE UTERUS AND OVARIES 27 j^<2f l^"" €^y£ ^^^ m tf* es9 e'C' , *23 isS> ft. -^ te^ =^ o ■a I -M %^tf 4 ®^^4 fe ^iw5 ^ 7P <5. # ^§1 ^ 2^ >f3i .^ '^£ .7% {9 «*«! €5 © (2/ ^ <^ , ■^,^iSi ..-^ "'' 0^^ n '^ -,0 ^3) J© &^ ^-;^ ^'1 if ^ ■f. •til." J <^(^ jj w^m.. y ^a®^:^' '^ :<^ fe>" «s^ 9 .a.. ^ -.„._. 4,t)J & 17>' $^ 'MllMh^^g^ Fig. 3. — Premenstrual Endometrium. High power of part of a gland. This shows especially well how the epithelium of the glands is thrown out in tuft-like projections during this stage. The lower part of the gland is dilated, while the neck near the surface is narrow, holding the secretion in the gland. 28 GYNECOLOGY menstrual flow. The blood escapes into the lumen, partly through the inter- stices between the epithehal cells and partly by actual rupture of the cell layers, small clumps of which may be desquamated and discharged mixed with the menstrual blood. errs* '^.: ■■■■'■rSS)--'.:. ••;:.'(<5 ^ - ./K&(. ^© '<3- ^& ©' ®^S 0® (j'^ ---■■* oS.©*^ ^';?9m J V^;®''® Ills ^?^4f^''^U*^^^^^®4 tfe^^F^^ ^^ ^|l^<.s>/' ^^^z.<^S^%^ s,^^;^.lf J«^^1' Fig. 4. — Premenstetjal Endomethitjm. High power. The glands are dilated and several show invaginations of epithelium, the begin- ning of one of which is seen in the lower left-hand corner. The epithelial cells are swollen, the nuclei la,rge and nearly filling the cells. The stroma cells are swollen and lie far apart, due to edema. A dilated blood-vessel is seen in the upper right corner. A few round cells are scattered through the tissue. With the cessation of the bleeding begins a regeneration of the mucosa. The secretion becomes clearer and finally disappears. The mucosa returns to its previous thickness of 2 or 3 mm. The blood-vessels shrink to their normal size, and the extravasated blood in the stroma gradually becomes absorbed, leaving for a time small brownish pigmented spots. The broken surface epi- PHYSIOLOGY OF THE UTERUS AND OVARIES 29 thelial layer becomes regenerated by the growth of new cells. The hjqjer- trophied glands, which during the premenstrual stage became lengthened, spiral-shaped, and distended with secretion, discharge their contents during the period of menstrual flow and then resume their original small narrow form Fig. 5. — Menstruating Endometrium. Low power. At the top the surface epithelium is gone on the left. The glands throughout have discharged their contents and collapsed. The epithelial cells are still swollen. The stroma is very edematous and infiltrated with blood, especially on the left. At the bottom the glands are still somewhat dilated, but there is very little edema of the stroma. and straight direction. When the bleeding has ceased, the edema of the stroma disappears and the pale swollen stroma cells regain their former appearance. The postmenstrual regenerative stage lasts about fourteen days, when the rhythmical changes in the mucosa begin anew. If no menstruation takes place, or, in other words, if conception has 30 GYNECOLOGY occurred, the premenstrual mucosa maintains its character and merges into a true decidua. It has been shown that during the cycHcal change there is an increasing glycogen production from the mucosa, which reaches its height during the menstrual flow, after which it disappears, until the premenstrual stage begins again. This glycogen production is undoubtedly a provision for the nourish- ment of the egg. During the period of flow the superficial epithehal cells of the mucosa are said to lose their ciha. These are restored during the postmenstrual regenera- tive stage. .>%^;. I^^/^^ ■■■• vXi<":, =>5-'')j Fig. 6. — Endometrium At Beginning of Menstruation. The glands, except for the one seen in the center, have collapsed, having discharged the mate- rial which was secreted during the premenstrual stage. The blood-vessels have been eroded by the ferment contained in the secretion, allowing the blood to exude into the tissue and on the sur- face of the endometrium. The surface epithelium in this section is still intact. The cervical mucous membrane takes no part in the menstrual bleeding, but secretes an increased amount of mucus. There is a question as to whether the tubal mucous membrane shares in the bleeding. It probably does not, as a rule, but there is evidence from abdominal operations done during the men- strual period, where the tube can be inspected, that there is sometimes an associated tubal menstruation. The researches of Hitschmann and Adler have been questioned to some extent, but in the main they are now nearly universally accepted. PHYSIOLOGY OF THE UTERUS AND OVARIES 31 Fig. 7. — -Postmenstrual Endometrium. Low power. The surface epithelium is regenerated. The glands are still dilated, but the epi- thelium is low, the nuclei of the cells small and lying at the bases. There is some edema of the stroma near the top, but the cells are smaller, the blood-vessels collapsed. There is a slight infiltration with round cells and blood-corpuscles. PHYSIOLOGIC ANATOMY OF THE OVARY^ In our present knowledge of gynecologic physiology the ovary has assumed such a commanding position that it is necessary to devote special attention to its functional anatomy. The ovary is covered by a single layer of low cuboidal cells, called the ger- minal epithehum, which unites with the peritoneal endothelium in an irregular line at the hilum. This germinal epithelium is emhryologically continuous with the epithelium of the tubal and uterine mucosa. Though modified and appar- ently insignificant in its role as a covering of the ovary, it nevertheless has extraordinary potentiahties for growth, and is probably the chief factor in the etiology of parenchymatous ovarian cysts. During childhood the surface of the ovary is for the most part smooth, but ^ Chief authority, Schroder in Opitz and Menge. 32 GYNECOLOGY after puberty the scarring process of ovulation gives it an irregular furrowed appearance. Under the germinal epithelium is a thin, rather dense layer of fibrous tissue, which gives the ovary its whitish appearance and which is called the albuginea. This structure is not fully developed until the time of puberty, and at that time consists of three layers of connective tissue. In old age and certain pathologic conditions it becomes much thickened, and if abnormally thick may play a part in the causation of sterility. Beneath the albuginea is the parenchymatous layer, which consists of a characteristic cellular connective tissue in which are contained the follicles. Merging into the parenchymatous layer is the medullary layer at the hilum, through which pass the blood- and lymph-vessels, nerves and connective tissue, Gxrerrvi.Tv&V epitKeliuirv. ToU\CS«.S Fig. 8. — Formation of Follicles, from the Ovary of a Newborn Infant. Germ-cells can be seen in the outer germinal layer of epithelium. The germinal epithelium can be seen growing inward and eventually suj^rounding the germ-cells by a single layer of cells. (After Kiistner.) and muscle-fibers from the broad ligament. In this layer are found small glandular ducts, which are by some thought to be the remains of the Wolffian ducts and are supposed to connect with the parovarium. A more recent theory is that they are off-shoots from the germinal epithelium. The follicles are confined exclusively to the parenchymatous layer. It is estimated that at birth the individual is endowed with about 30,000 of these follicles, and it is generally accepted at the present time that no new ones are created after birth. The-*Bsential function of the ovary consists in the development and ripening of the follicles. This process begins verj^^ early, probably at the end of intra-uterine life. Up to the age of puberty the ripening follicles become atretic or aborted, and only at that time do they begin, to develop into true corpora lutea. From puberty there is a continuous process PHYSIOLOGY OF THE UTERUS AND OVARIES 33 of development of the follicles until the menopause, when they disappear entirely. In the maturing process there are three stages to be distinguished: (1) the primordial follicle, (2) the ripening follicle, and (3) the ripe Graafian follicle. (1) The primordial follicle lies embedded in the stroma of the ovary, imme- diately under the albuginea. It consists of the naked egg surrounded by a single layer of low flat epithelium. The primordial egg is an ellipsoid, mem- braneless cell fairly constant in size. The cell-body is composed of a clear protoplasm in which can be distinguished a very fine network. In the cehter k%.'^' ^ -^ ft fr <^-"*v\ i%r :*-^ > ^^^ -^-"^ Fig. 9.— Primordial Follicles from the Ovary of a Woman of Twenty-five. The central protoplasmic mass is the germ-cell or egg. It is enveloped by a single layer of epithelium. (After Veit.) of the body is a round nucleus with a definite surrounding membrane. The nucleus contains an eccentrically lying nucleolus, which is not always observable in the fetus and newborn, its absence showing probably an immature stage of development. The epithelial layer of the follicle has been shown to be derived from the germinal epithehum which surrounds the ovary, and, as will be seen, is a structure of much importance. The fundamental function of the ovary represents a repeated ripening of the primordial follicles. They can be seen in lessening numbers up to the time when ovulation ceases at the menopause. (2) The Ripening Follicle.— When the folHcle begins to ripen the surround- ing epithehal cells begin to multiply by mitosis and to heap up into several 3 34 GYNECOLOGY layers. The cells now assume a larger and more cuboidal form and lie closely around the egg. Soon in this mass of cells there appears a vacuohzation, or clear space, which becomes filled with fluid, the so-called liquor folliculi. The clear place containing the liquid is crescentic in form, partly encompassing the egg. Several layers of epithelial cells continue to envelop the egg, and the mass thus formed juts out into the liquor like a peninsula. The collection of protecting cells that surround the egg is called the discus "proligeriis (or cumulus oophorus), while the- rest of the epithelium around the periphery of the follicle is called the membrana granulosa. Fig. 10. — Graafian Follicle. High power. Three foUicles are seen which are in the earliest stages. The center one has begun to show proHferation of the cells. These cells were originally derived from the germinal epi- thelium covering the ovary. No ova are seen. At the same time that these changes are going on inside the follicle, it is being surrounded on the outside by a concentric envelope of connective tissue, termed the theca folliculi. This envelope is plainly divided into two layers, that lying farthest away from the follicle being termed the tunica or theca ex- terna, and that lying next to the follicle being called the tunica or theca interna. The tunica externa is thick and dense and consists of circularly arranged connective-tissue fibers. It contains the blood- and lymph- vessels that supply PHYSIOLOGY OF THE UTERUS AND OVARIES 35 t«pi y/ 'Vi\" Fig. 11. — Early Development of the. Follicle. On the left are two primordial follicles, the upper showing the egg and surrounding follicle epi- thelium ; the lower showing the manner in which the follicle epithelium completely surrounds the egg. The middle picture shows the earliest stage of ripening in which the follicle epithelium multiplies into several layers. The third picture shows a further development of the follicle epithelium and the beginning of the crescentic clear space containing, the liquor folliculi. (After Bumm.) b'd o & ,f?© Fig. 12. — Graafian Follicle from the Ovary of a Newborn Infant. The clear space around the layer of epithelium is the result of an artefact in preparing the section. (After von Winckel.) 36 GYNECOLOGY the follicle. The tunica interna is also composed of connective tissue, but is much more cellular than the externa. These cells are large and rich in proto- plasm and are epithelioid in character. Toward the end of the ripening stage they are actually larger than the epithelial cells of the membrana granulosa. Meanwhile the egg also undergoes a change. It becomes surrounded by a strong homogeneous capsule, the zona pellucida. The protoplasm of the egg does not come in direct contact with the zona pellucida, there being between the two the so-called perivitelhne space, which contains fluid and in which the t' m ^ ■^J/J^ m i ^§, ■^ 'i> (. ^ ^ ^^"^ M Fig. 13. — Graafian Follicle. High power. In the center of the drawing is a follicle undergoing development. In the center of the follicle is the ovum, which is surrounded by layers of cells constituting the membrana granulosa. The theca f oUiculi is not differentiated as yet. To the lower left side are two primordial follicles. egg enjoys a free movement. As the follicle develops the crescentic lake con- taining the liquor folliculi becomes more and more filled with fluid, which forms from a transudation of the vessels of the theca and from vacuolization of the granulosa cells. It is a thin serous fluid containing albumin and is undoubt- edly a source of nourishment for the egg. The egg surrounded as it is by several radiating layers of granulosa cells (the discus proligerus) does not come in direct contact with this fluid, but evidently receives nourishment from it through the medium of a fine intercellular network (paladinos), the fibrils of which reach the zona pellucida. PHYSIOLOGY OF THE UTERUS AND OVARIES 37 The follicle as it grows larger recedes from the albuginea, and lies more deeply embedded than do the primordial follicles. When the changes described above are completed the follicle is said to be ripe, and at this stage it is termed a Graafian follicle. Up to the time of the menopause foUicles in all stages of development, from the primordial to the rip- ened form, may be seen in the ovarian parenchyma. In all the follicles, even the smallest, nmnerous nerve-fibers accompany and surround the capillary vessels, extending to the folhcle epithelium and existing in small nodes in the membrana granulosa of the larger follicles. Fig. 14. — Ripening Follicle from an Ovary of a Woman of Twenty. (After Veit.) In some of the follicles can be seen two and, rarely, three eggs. This appear- ance is usually seen in the unripe follicles. It is not known whether this appear- ance represents twin eggs from the start, or whether it signifies a merging of two primordial follicles or a division of one follicle. (3) The Graafian Follicle. — When the follicle is ripe it moves slowly toward the surface and thins out the outer layer of the ovary. This pressure on the surface of the ovary creates a pale translucent spot, called the stigma, through which the egg is finally discharged. The internal force which serves to burst the follicle is a subject of some debate. It is usually explained as follows: With the energetic development 38 GYNECOLOGY of thre vessels of the tunica externa there is a corresponding increase in the size ' and number of the cells of the tunica interna, which force themselves toward the center of the follicle and gradually push the proligerus with its egg toward the stigma. The internal force is also enhanced by the gradual increase in the amount of liquor in the follicle, especially during the menstrual congestion. Corpus Luteum. — When the follicle has ruptured and the egg discharged the formation of the corpus luteum begins. The center of the collapsed follicle soon fills with blood, which issues partly from the vessels of the theca and Fig. 15. — Graafian Follicle. Surrounding the follicle can be seen the two connective- tissue envelopes, the outer (theca externa) being fibrous in character and the inner (theca interna) being more cellular. The egg is seen jutting out into the clear space surrounded by a mass of epithelial cells, the discus (or cumulus) proligerus. The several layers of epithelium lining the follicle constitute the membrana granulosa. The crescen- tic clear space is filled with serous fluid, the liquor foUiculi. (After Veit.) partly from the small wound in the stigma. In animals this blood coagulum is not always seen, but it is practically constant in the human corpus luteum. Around the central blood-mass is the wrinkled yellow membrane which characterizes the corpus luteum by its unique color. There has been some question as to the origin of the cells that make up the yellow membrane, but it is now generally accepted that they represent the hypertrophied epithehal cells of the membrana granulosa. They are large and polymorphous, with a large nucleus, and resemble somewhat decidual cells. The cell-body contains drops of fat and yellow pigment granules that give the characteristic color. PHYSIOLOGY OF THE UTERUS AND OVARIES 39 These are the so-called lutein cells. Into this lutein layer sprout blood-vessels and connective-tissue radial projections, which vascularize and support the corpus luteum. The resultant picture of large epithehal cells, with pale stain- ing nuclei lying in contact with small thin-walled blood-vessels, corresponds to the structural appearance commonly regarded as characteristic of organs of internal secretion. As will be seen, this is one of the arguments for the belief that the seat of the internal secretion of the ovary is in the corpus luteum. -»:^ >^^«i!|> Fig. 16. — Graafian Follicle as it Appears in the Surrounding Ovarian Tissue. Just below the follicle is a corpus albicans. After the corpus luteum reaches the height of its development it gradually shrinks. The yellow coloring matter is absorbed and the lutein cells degen- erate in hyalin masses, held together by strands of connective tissue. The hyalin colorless masses then roll together in cloud-like convolutions and form the corpus albicans. This process of regression occupies about four weeks. The corpus albicans may remain a long time, but the hyahn material is event- ually entirely absorbed and all trace of the former corpus luteum disappears, excepting the scarred indentation on the surface of the ovary. The size of the corpus luteum varies considerably, reaching sometimes even 40 GYNECOLOGY in non-pregnant women a diameter of 2 cm. If pregnancy occurs its develop- ment is more pronounced, reaching its height about the second month. From the third month its regression is very slow, so that it is sometimes demon- strable at the end of pregnancy. If pregnancy is not present, the corpus luteum regresses rapidly and is usually shrunken by the end of a month. Follicle Atresia. — In the thirty to thirty-five j'-ears of menstrual hfe about fourteen to eighteen folhcles reach full maturity each year, making a total of Fig. 17. — Graafian Follicle, Well Advanced. 400 to 600 during a life time. Inasmuch as there is an original endowment of about 30,000 follicles at birth, only a small percentage of them develop com- pletely, the remainder becoming aborted during some stage of their develop- ment, a process that is called atresia of the follicle. This process must be re- garded as a physiologic one, beginning as it does in the newborn and probably in the mature fetus and lasting until the menopause. The cause of atresia is thought to be some insufficiency of the local blood- PHYSIOLOGY OF THE UTERUS AND OVARIES 41 supply, or a too deep embedding, which may be unfavorable for the bursting of the follicle. Follicle atresia takes place in the follo\ving way: The egg slowly undergoes a fatty degeneration and becomes liquefied. The granulosa cells also degenerate by the process of Vacuolization and fall into the central cavity of the follicle. The entire follicle collapses and assumes an irregular contour. At this stage the cells of the tunica interna begin to grow Fig. 18. — Graafian Follicle. Low power. This shows the edge of a fully developed follicle. The upper left part of the draw- ing is the cavity in the follicle. At the lower right edge projecting into this cavity is the cumulus proligerus, consisting of cells from the membrana granulosa, which lines the cavity, in the center of which is the ovum. At the bottom of the drawing can be seen a small section of ovarian stroma. Between this and the follicle is the connective tissue of the theca folliculi. and assume an epithelioid type, resembling closely the lutein cells of the mem- brana granulosa. This theca membrane may become quite thick and wavy, like that of the granulosa. As in the true corpus luteum there is a vascu- larization and connective-tissue formation, so that the resulting picture is the same as that of the corpus luteum, the essential difference being that the lutein cells are of connective-tissue origin, and not epithelial. FolUcle atresia is especially marked during pregnancy. During this period there is no actual ovulation, so that most of the more mature follicles become atretic. 42 GYNECOLOGY It is said that during pregnancy there takes place in the theca lutein cells of the atretic follicles not only hypertrophy but hyperplasia, and that the cells acquire more fat and lutein than is seen in the non-pregnant state. In chorio-epithelioma and tubal gestation they sometimes form definite cysts which later disappear. In some species of animals the collections of theca lutein cells embedded in the stroma form a constant picture. These masses of cells have been called TvA^'^" Fig. 19.— Corpus Luteum. Low power. At the top is the center of the corpus luteum, the edge seen being the edge of the blood-clot. Extending into this blood-clot are seen the pyramids formed of lutein cells, giving the edge of a corpus luteum its characteristic ruflSed appearance. Between these two layers is a thin layer of connective tissue. Below the layer of lutein cells — that is, around the outside of the corpus luteum — is the theca externa, which contains many blood-vessels. the interstitial gland, and correspond, as said above, to the lutein cells of the atretic folhcles. They are thought by some to play a part in the manufacture of the internal secretion of the ovary. Two forms of follicle atresia are distinguished — the obliterating and the cystic. Cystic formation in the ovaries is, therefore, physiologic. The cysts, however, may grow to an abnormal size and become of pathologic significance. (See Retention Cysts.) Fig. 19(1. — Corpus Luteum. Very low power. Around the edge is the pUcated envelope of lutein cells. The center is occu- pied by coagulated blood, around the edge of which the lutein cells are proliferating. Organization of the blood-clot is going on. Fig. 20. — Wall of Corpus Luteum. High power. This shows the pigment found in the lutein cells, which gives them their distinctive yellow color. It is derived from the blood extravasated during rupture of the follicle. 43 Relationship of gynecology to the General organism relationship of gynecology to the glands of internal secretion The study of the internal secretory organs has assumed so great an impor- tance that a famiharity with the subject is essential in the study of every branch of medical science. This is eminently true of the department of gynecology, for the female organism is peculiarly susceptible to physiologic and pathologic changes in the general endocrine system. Much of our knowledge gleaned from the vast store of experimental and clinical observation in this new line of research is so contradictory and confusing that space will not permit a comprehensive review of the subject. It will be necessary, therefore, to devote our attention chiefly to those facts that are most convincing and most generally accepted, with especial reference to the phases of the subject wliich relate particularly to the generative system. The essential glands of internal secretion may be defined as ductless struc- tures which by the agency of certain cellular elements manufacture chemical substances, called hormones, that are absorbed directly into the blood-circulation and by this means are enabled to influence the functions of other organs. The term internal secretion is necessarily used in a somewhat restricted sense. Broadly speaking, each tissue of the body by means of its specific chemical secretions is capable of affecting through the blood-stream other parts of the body. . In this sense the entire organism may be regarded as forming a complex internal secretory system. The subject, however, is confined to the considera- tion of a series of organs which produce hormones with especially powerful and important physiologic characteristics. This series of organs constitutes the ductless glandular system . and comprises the thyroid apparatus, the thymus gland, the suprarenal system, the hypophysis cerebri or pituitary body, the epiphysis or pineal body, the generative glands, the pancreas, and a few other organs, such as the kidneys, the intestinal and gastric mucosa. To this list the placenta has recently been added. Although by the internal secretory theory the influence of distant organs on each other is based on a chemical reaction instead of, as was formerly believed, on a direct nervous relationship, the nervous system nevertheless plays an impor- tant part, for many of the phenomena produced by the internal secretions are brought about by chemical action on the sympathetic or vegetative system of nerves. The glands of internal secretion are themselves supplied by sympathetic nerves and their function is, therefore, in large part regulated by the nervous system. The intimate relationship between the ductless glands and the sym- pathetic nerves is especially significant from a gynecologic standpoint on account 44 RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 45 of the peculiarly sensitive and labile character of the female nervous organiza- tion. It is known, for example, that the generative organs exercise a particular influence on the tone of the vegetative organs {i. e., organs that are supphed by sympathetic nerves), an influence which is more marked in women than in men. This is most noticeable at the so-called critical periods of a woman's life. At the menstrual period and during pregnancy there takes place an increased ex- citability of all the vegetative functions, which may be manifested either by an accentuated vitality or by various deviations from the normal. During the climacteric, when the generative glands cease then- function, the influence of the internal secretions on the vegetative system makes itself apparent by temporary vasomotor disturbances of a most varied character. At the time of puberty there takes place a most important increase in the vegetative functions, the change being more marked in girls than in boys. In all these instances the in- fluence on the sympathetic system is due not alone to the internal secretion of the generative glands, but in part to the correlated action of the other ductless organs. The theory of a correlation between the glands that constitute the endocrine system though only vaguely understood is, nevertheless, essentially well estab- hshed. It may be stated in general that the ductless glands are normally so correlated as to form a perfect physiologic balance which is preserved by a proper distribution of harmony and antagonism between the functions of the various glands. If one of the glands is diseased or injured or extirpated the normal balance is upset and the organism of the individual may be affected by the ab- normal action of one or more distant glands of the group. The reciprocal dis- turbance created in a given gland by the abnormality of another member of the system is often referred to as dysfunction. Such dysfunction probably does not constitute an alteration in the chemical composition of the secretion of the gland in question, but rather imphes a change in the amount, that is to say, a diminu- tion or an accentuation of the secreted substance. Changes in glandular activity of this kind are also referred to as hypo- and /njperfunctional. The reciprocal action of the different ductless glands and of their various secreting parts during a given upset of balance is of an exceedingly complex nature, and in our present state of knowledge is only partially understood. It was first thought that an internal secretion could only be elaborated by epithelial elements. The histologic type of internal secretory structure was described as consisting of relatively large, pale, not sharply defined epithelial tissue containing a rich network of capillary blood-vessels which carry off into the circulation products of the cell activity. This description is appUcable.to certain of the internal secretory tissues, but it has been discovered that structures of connective-tissue origin are also capable of manufacturing an internal secretion, and that in one and the same organ epithelial and connective-tissue elements may be working side by side, each elaborating secretions destined for separate purposes. Examples of this are seen in the hypophysis, the suprarenals, and, the ovaries. 46 GYNECOLOGY OVARY 1 That the ovary is a true organ of internal secretion is proved by very sub- stantial evidence gained from observations made after removal, and from transplantation of ovarian tissue, and by the effects of the injection into the tissues of ovarian substance. Castration before sexual maturity causes a failure of genital development, while in adult life it produces immediate regressive changes in the uterus, vagina, and external genitals, manifested by well-marked atrophy of the parts. It has been shown by animal experimenta- tion (Halban) that this genital atrophy can be inhibited after castration by transplanting the extirpated ovary in distant parts of the body, and if this operation is done on young animals the other genitals may develop normally. It has also been shown in animals that castration prevents rut, but that later implantation of ovarian tissue may reproduce the manifestations of rut (Halban) . An observation of much practical importance (as we shall see later) shows that the injection of ovarin in virgin animals creates changes of hyperemia and secretion in the internal and external genitals similar to those which occur during rut. These are only a few examples of numerous experiments that prove the existence of an ovarian internal secretion. The exact nature of the ovarian secretion has not been determined, nor is it conclusively known in what part of the ovarian tissue the substance is manu- factured. It seems probable that different portions of the ovary elaborate substances which have specific functions. There are two anatomic structures which may most reasonably be expected to be sources of hormones — the corpus luteum and the follicle apparatus. Inasmuch as ovarian secretion is known to exist before puberty, as proved by the changes in development after castration before maturity, it seems likely that the follicle apparatus must be the seat of manufacture, for the corpus luteum does not appear normally until sexual maturity. It is probable, therefore, that the follicle apparatus presides over the growth and nutrition of the genitals and that it influences directly or indirectly the general bodily development of the individual. The true nature and extent of the influence of the growing follicles are not known. Theories as to the internal secretory power of the atretic follicles are given below. In addition to the follicle apparatus, the corpus luteum has been shown to be the probable seat of manufacture of important ovarian secretion. As has been described in detail (see page 38), the corpus luteum forms within the follicle cavity after the discharge of the ovum, and is derived from the epithelial (granulosa) cells Hning the follicle. In its full development the corpus luteum presents the characteristic picture of an internal secretory gland, with large pale cells lying in close proximity to thin-walled blood-vessels, an appearance 1 Some of the material in this section is taken from articles by the author published in the Amer- ican Journal of Obstetrics, 1913, and in the Journal of the American Medical Association, 1917. RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 47 much like that of the adrenals. The corpus luteum does not develop until the age of puberty, and coincident with its appearance come the cyclical changes of menstruation and the possibility of fecundation, phenomena which disappear after the cessation of corpus luteum formation at the climateric. That the corpus luteum is an organ of internal secretion was first suggested by Gustav Born, who, after studying the corpus luteum verum of pregnancy, expressed the opinion that in histologic structure it corresponds to an internal secretory organ, and that it probably presides over the implantation and develop- ment of the fertilized egg in the uterus. Fraenkel supported the theory of Born by experimental work and attributed new physiologic functions to the corpus luteum; namely, the increase of the uterus at the time of puberty as well as its cyclical hyperemic changes of menstruation. Fraenkel concluded that the effect of the internal secretions of the corpus luteum is a preparation of the uterus for the insertion and development of the fertilized egg, menstruation taking place in case of failure of impregnation. Notwithstanding considerable opposition to many of Fraenkel's views, it is at present almost universally accepted that the corpus luteum is an organ of internal secretion, though the knowledge of its specific action is incomplete. Recent work by Leo Loeb has added valuable information regarding the corpus luteum as an organ of internal secretion. He has confirmed by experi- ments the theory that the corpus luteum inhibits ovulation, and has shown experimentally that ovulation may be accelerated by the removal of the corpus luteum. The absence of ovulation during pregnancy is thus thought to be due to the continued presence of the corpus luteum. Loeb's niost important con- tribution has been to demonstrate by animal experimentation the power of growth which the corpus luteum has over the uterus. He has shown that the corpus luteum elaborates a substance which has a sensitizing action on the uterus. In the non-pregnant animal a sHght decidual reaction is produced in the uterine mucosa which recedes in a short time as the corpus luteum retro- gresses. In the pregnant animal the decidual reaction is much more marked and remains permanent during pregnancy in the form of the so-called maternal placenta (i. e., decidua). This continued reaction is the result of the persistence of the corpus luteum and to the irritation of the growing ovum, as is proved by Loeb's experiments. If the uterus of a non-pregnant animal is incised or the mucosa mechanically irritated at the time during which the corpus luteum is elaborating its ''growth substance" a very marked decidual reaction is produced in the uterine mucosa, forming what Loeb terms a deciduoma or maternal placenta. Such deciduomata are short hved in the non-pregnant animal. Decidual reaction (q. v.) is therefore undoubtedly dependent on the internal secretion manufactured by the corpus luteum. In guinea-pigs and in rabbits this reaction is producible only in the stroma of the uterine mucosa. In these animals extra-uterine pregnancy experimentally created does not cause a decidual reaction in the stroma of surrounding tissues as is seen in the human female 48 GYNECOLOGY (see Ectopic Pregnancy). Loeb suggests, with good reason, ''that the difference in the readiness with which extra-uterine pregnancy develops in different species depends in part at least upon the readiness with which the stroma of the host responds with the production of a decidua favorable for the development of the embryo." That the corpus luteum is not the sole source, or even the most important source, of the internal secretion of the ovary is sufficiently evident from the fact that during the period of life of sexual immaturity in which the internal secretion is performing its most important function of body formation, the corpus luteum is wanting. It is necessary, therefore, to seek in some place in the ovary other than the corpus luteum for the primary source of the internal secretion. There are found in the ovary certain connective-tissue cellular elements, termed "interstitial cells," corresponding morphologically to the cells of Ley dig, which are generally behoved to constitute the source of the internal secretion in the testicle. These interstitial cells of the ovary occur in different form in dif- ferent species of mammals. They correspond in histologic structure to the cor- pus luteum cells, being large and polyhedral in form, with granular protoplasm in which fat-like granules are embedded. The nucleus is relatively small, usually acentric, and is poor in chromatin. The cells have, like lutein cells, a yellow tint, and in this way resemble the interstitial cells of the testicle of many species. Just as in lutein cells and in the cells of Leydig, mitotic figures are not seen (Tandler and Gross). The existence of the interstitial cells has long been recognized, having first been discovered by Pfiliger in 1863, who demonstrated them in the ovaries of cats and dogs. Successive investigators found the cells in numerous species and finally in apes and in human beings. It was found that they occur with great inconstancy, in some species appearing in separate gland-like masses, in others as scattered cells. They also exhibit marked variations in the same species. Thus, in the embryo of the horse the interstitial cells are strongly developed, while toward the period of birth they become gradually less well defined (Born) . In some species they increase at the time of sexual maturity and then diminish with age. In other animals they are most prominent during the spring of the year or during the season of rut. In still others they are affected by environ- mental changes, such as long-continued isolation. More recent investigation has shown that the interstitial cells become more highly developed after roent- genization of the ovaries, while in the male the homologous cells of Leydig undergo a like development as a result of vasectomy. These observations have paved the way for valuable experiments which have added much to our knowledge of the nature and morphology of the interstitial cells. Equally interesting have been the speculations regarding the origin of these cells. Schroen in 1863 regarded them as fragments of disintegrating corpora lutea. His and Waldeyer considered them wandering cells. Tourneaux recognized the homology between them and the cells of Leydig, and ascribed RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 49 their origin to the pre-existing connective tissue, a theory which we shall see harmonizes with views of the present time. Schuhn described them as epithelial structures; Harz, as offshoots of the glomeruli of the kidney; Chiarugi saw in them rests of the Wolffian body. Limon was the first to recognize their origin from the lutein cells of the theca interna of the atretic folHcles. Limon's views have been adopted by the best investigators, and it is now generally accepted that the interstitial cells of the ovary either are identical with the lutein cells of the atretic follicles or at least are derived from them (TancUer and Gross) . The inconstancy of the appearance of "the interstitial cells is explained by the fact that in some species or under certain conditions during the process of follicle atresia the theca lutein cells become "disaggregated," that is to say, separated from the surrounding envelope of the follicle (theca externa) and deposited in gland-like masses, or scattered indis- criminately through the ovarian stroma. Thus, in the rabbit, disaggregation takes place and the theca lutein cells are found in gland-like masses to which the term "interstitial gland" has been given. ^ In the human ovary, on the other hand, disaggregation takes place only rarely, and the theca lutein cells remain confined by the external envelope of the follicle. Hence an interstitial gland is not seen in the human ovary. It is quite conceivable that the function of the interstitial cells as producers of an internal secretion might be performed equally well whether limited by a theca externa or scattered in the stroma. If we accept the theory of the identity of the interstitial cells and the follicle lutein cells, we must conclude that the production of the interstitial cells is, in reality, a function of folHcle atresia. If, now, it can be shown by animal experimentation and otherwise that the interstitial cells are producers of an internal secretion, then we must conclude that follicle atresia is not a pathologic but a physiologic process, the object of which is the elaboration of an internal secretion. The detailed proof of the internal secretory power of the interstitial cells cannot be included in the scope of this section. We can only allude to the in- fluence of the ovary on the growth of the individual before puberty as shown by early castration; to the experiments with roentgenization, showing the influence of the interstitial cells on secondary sexual characteristics; to the homology of the interstitial ceUs and the cells of Leydig, and to the effects of ovarian transplanta- tion and ovarian therapy, in which the influence of the corpus luteum is excluded. Thus we have sufficiently convincing evidence that the internal secretion of ^ The interstitial gland is most pronounced in rodents, insectivora, chiroptera, and animals of prey. It is most apparent in early youth. With the appearance of the first corpus luteum the inter- stitial gland decreases, so that there seems to be a certain reciprocity between the corpus luteum and interstitial gland, which, as stated above, is derived from the theca interna cells of the atretic follicle. Good development of the interstitial gland in these animals is apparently associated with good fertility. In animals that bear many young at the same time the interstitial gland is found highly organ- ized at the age of sexual maturity, whereas in animals, like man, monkeys, and the hoofed animals, the gland is found poorly developed. In the latter case the gland is rudimentary at its best, and dis- appears completely after the appearance of the first corpus luteum (Aschner). 50 GYNECOLOGY the ovary is manufactured both by the corpus luteum and by the atretic folKcles. It is now necessary to point out the relationship between these two mechanisms from a physiologic standpoint. The exact nature of the lutein cells of the corpus luteum has been a matter of much discussion. Some have regarded them as epithelial in origin, others as derivatives of connective tissue. According to Pfannenstiel, the lutein cells are partly epithehal and partly connective tissue in structure. By this theory the innermost layers of cells toward the center of the corpus luteum represent a luteal reaction of the granulosa cells which develop from the original epithehal hning of the Graafian follicle; wliile the outer or theca layers represent a like reaction of prohferating cells springing from the connective-tissue envelope, or theca interna. These last named elements of the corpus luteum were termed by Pfannenstiel ''theca lutein" cells. They corre- spond in the matured corpus luteum to the lutein, or interstitial cells of the atretic follicle. The function of the theca lutein cells is probably twofold. The presence of fat in the protoplasm and the rich network of blood-vessels with which they are invested early suggested that they supply nutritive material for the development of the egg. The theory that they elaborate an internal secretion is of compara- tively recent date. To them was first ascribed hypothetically a specific in- fluence on the sexual impulse and the development of the secondary sexual characters, the latter theory being now well estabhshed by experimental proof. Between the corpus luteum and the interstitial gland {i. e., disaggregated interstitial cells in gland-like mass) an interesting reciprocal relationship has been pointed out by Bouin and Ancel, who have divided animals into two groups according to their methods of ovulation. To the first group belong those species in which ovulation occurs only after coitus, as in the rabbit, guinea-pig, mouse, and cat. Representatives of the first group exhibit a periodic corpus luteum and a corpus luteum of pregnancy, but not a well-defined interstitial gland; while those of the second group have a corpus luteum of pregnancy, but in place of a periodic corpus luteum an interstitial gland (Tandler and Gross). It has been objected that the interstitial cells, being of connective-tissue origin, are not of the true endosecretory type, which is usually epithehal in character. This objection is met by the fact that certain other connective-tissue elements are known to possess endosecretory power, notably the suprarenal cortex and the cehs of Leydig. It has been demonstrated that the endosecretory elements exhibit characteristic staining properties, and among these elements has been included a list of cehs of connective-tissue origin, such as the cells of the serosa, the stellate cells of the liver, the reticulum of the blood and lymph apparatus, and the bone-marrow (Goldmann). Another point of interest is the manner of growth of the interstitial cells. It is quite evident that they develop from the pre-existing connective-tissue cells of the ovarian stroma, which at a given moment "become activated" and take on the morphologic character and functional properties of interstitial cells (Tandler and Gross). It is conceivable, therefore, that the undifferentiated RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 51 stroma cells of the ovary have endosecretory powers which may be of value in the manufacture of ovarian extracts for therapeutic purposes. An important phase in the study of the- ovarian internal secretion is the ques- tion of the selective action of certain of the secretory elements. This part of the subject is at present very much in the dark. Fraenkel's assertion that the corpus luteum regulates the nidation and early growth of the egg is by no means uni- versally accepted. The early theory that the corpus luteum presides over menstruation is no longer tenable, some even holding that menstruation is deter- mined by the elimination of the corpus luteum. Loeb's view that the corpus luteum inhibits ovulation and that it is responsible for the growth of the maternal placenta is well established. Quite definite is the evidence that the interstitial gland presides over the development of the secondary sex development, experi- ments having shown that the sex characters remain if the purely generative portions of the ovaries are excluded by the Roentgen ray, whereas these charac- ters undergo wide variation after early castration (Tandler and Gross). There is much to show, on the other hand, that the action of the ovarian secretion is neither direct nor selective, but that it exerts only a balancing influence on other correlated and more powerful glands, the activity of which the ovarian secretion discharges or suppresses, as the case may be. Clinical manifestations of disturbances of the glands of internal secretion are caused either by deficient activity (hypofunctioii) or by an abnormal in- crease of activity (hyperfunction) of the glandular secreting substance. Under hypofunction must be considered not only the effects of diminished secretory power, but also the results of complete destruction or extirpation of the organ. In studying the effects of the removal or destruction of a given ductless gland one must take into account not only the influence of the loss of its specific secre- tion on the organism, but also the changes wrought in the other members of the group, the balance of whose function has thus been disturbed. Hypofunction of the Ovary. — Castration Before Maturity.— We have seen that early castration prevents normal development of the genital system. It also produces changes in some of the other ductless glands, the most notable being that of the hypophysis, in which there takes place an increase in the size . of the anterior lobe. It is generally though not universally conceded that this hypertrophy of the hypophysis is the cause of the skeletal deviations and accumulation of fat that characterize the individual of the eunuchoid type. Nearly all generalizations on this subject have been from observations of castrated males. In human beings information on this subject is gained chiefly from a study of the eunuchs of the Turkish harems and from a religious sect in Russia called the Skopts. It may be said that the body length of individuals who have been castrated early in general exceeds that of the non-castrated, an observation which is familiar in animals also, as in the case of oxen, geldings, and capons. Tandler and Gross and others ascribe this fact to a delayed ossifica- 52 GYNECOLOGY tion of the epiphyseal joints, which produces not only an increase in growth, but a deviation from the normal body proportions. The result is that the individual produced by early castration is not, in general, of the infantile type, but, on the contrary, far removed from it. While we find in children a relatively long trunk and short extremities, and a proportionately large skull, with small face, we find in the castrated a marked increase in the length of the extremities and a skull relatively small in comparison with the face. These gross physical changes are constantly observed both in man and in animals, and it is not surprising, therefore, to find that there also usually exists an enlargement of the sella turcica due to hypertrophy of the hypophysis. It is, therefore, seen that the genital glands may bear an antagonistic relationship to the hypophysis, and that the early removal of the inhibitory influence of the testis or ovary, allows for an overdevelopment of the hypophysis with corresponding skeletal changes (Novak). Another characteristic of the eunuch possibly referable to the increase of the hypophysis is the accumulation of adipose tissue which is usually though not always present. The muscles become permeated with fat. The distribution of fat over the body corresponds to that of the condition of dystro'phia adiposo- genitalis, i. e., in the hypogastric region, on the mons veneris, on the nates, hips and thighs, and on the mammary glands. There is also a characteristic deposit on the upper eyelids which may cause them to hang down like bags. There is a deficiency in the growth of hair. The distribution of fat, especially over the hips and nates of the male castrate, produces a suggestively feminine appearance, which taken together with the absence of hair and the persistence of a high-pitched voice has led to the general belief that castration imparts to the individual characteristics of the opposite sex. This is emphatically not the case. The deposition of fat and the meager growth of hair are purely the result of internal secretory reaction. The high- pitched voice is not caused by a larynx of female type. The organ resembles rather that of a child, in that there is no prominentia laryngea and ossification has not taken place. "For this reason the voice retains its childish character and in no way resembles a woman's voice; it is a childish soprano which late in life undergoes the changes in timbre and tone characteristic of mutation" (Biedl). Apart from the high voice, deficient hair, and the general deposition of fat the eunuch does not approach the feminine type. The character of men castrated early in life has been variously estimated. They are said, in general, to be de- ficient in the courage, passions, and aspirations of normal men, but there is no diminution in intellectual capabilities. Some eunuchs have attained high positions. Temperamentally the castrated man is quiet and phlegmatic, a characteristic that could hardly be generally ascribed to woman. It is important to emphasize the fact that early castration does not trans- form the individual into the heterosexual type, for it has a twofold significance. Not only does it have an important bearing on the subject of sex determination (q. v.), but it contradicts certain popular conceptions as to the after-results of late castration — a matter of considerable moment to the gynecologist. RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 53 Information regarding the results of castration before puberty in women is exceedingly meager. From the few observations made in the human race and from animal experimentation it may be assumed that early castration in women is followed by lack of development of secondary sexual characters including the breasts, and that the skeletal changes resemble those of the male castrate. Castration After Maturity. — Whereas the effects of castration before puberty have been studied chiefly in men, the opportunity for observing the results of late castration is best afforded in women, in whom the operation for removal of the internal genital organs is frequently required. From a physiologico-chemical standpoint the influence of castration after maturity has been extensively studied, but at the present time no very important results have been gained. Schickele has observed an increase in the arterial tension at the natural menopause and regards the effect as due to the loss of the depressor influence of the ovarian secretion. His observations have not been confirmed. Variations in sugar assimilation, coagulation time of the blood, blood-picture, chemical composition of the blood, reaction to drugs, etc., have been described, but cannot be detailed here, as in our present state of knowledge they are of minor importance to the practical gynecologist. It is probable that many of these changes are the result of disturbing the balance of the other ductless glands, and that the abnormalities are produced by the internal secretion of organs whose influence on the general metabolism is more powerful than that of the ovary. From clinical observations it may be said that late castration in women has comparatively little effect and that it does not entail the profound mental and physical change in the organism of the individual that was formerly supposed. Concerning this subject much will be said throughout this vv'ork (see especially section on Neurology) . One of the popular misconceptions regarding the results of oophorectomy is that certain features of the male type may be acquired, such as a deepening of the voice, increase of facial hair, coarsening of the skin, and a general assumption of the masculine character. Such ideas have doubtless been derived by reasoning from a reverse analogy to eunuchs. It has been pointed out above that even after castration before maturity there is not the slightest evidence of a transformation to the type of the opposite sex. This is seen not only in human beings, but in animals, and it may be definitely stated that after early castration the males of no species become feminine in type, nor do the females become masculine. If this fact is true after early castration it must certainly hold good after late castration when the organism has been permanently established both constitutionally and by habit. Another exaggerated idea regarding late castration relates to the accumula- tion of fat. There is no doubt that there exists a certain relationship between adiposity and genital deficiency. This is seen in the results of early castration and in certain internal glandular diseases which are attended with lack of development or atrophy of the reproductive organs. In some instances where 54 GYNECOLOGY functional amenorrhea appears in a previously normal woman there ensues an abnormal accumulation of fat, though in these cases there is usually a pluri- ^ glandular involvement. A noticeably large percentage of sterile women are fat. Much is said of the increase of fat in women who have reached the menopause, but this statement has undoubtedly been much exaggerated. Women who are destined to become fat usually begin to increase in weight long before the meno- pause, and often reach theu' maximum before menstruation ceases. Often the increase after the menopause is only apparent, for at that time the external tissues lose their firm contour and the fat settles into irregular and baggy folds, giving the impression of increase in size, though there may be no increase ui weight. In like manner the increase of fat after removal of the ovaries in adult women has been very greatly overstated, as any experienced gynecologic surgeon will testify. As a result of our personal experience we are able confidently to assert that castration of matured women is not ordinarily followed by a greater tendency X to adiposity than is any other operation, though it may happen in rare cases. The abnormal accumulation of fat that follow^s early castration is undoubtedly due to resultant changes in some other part of the internal glandular system, . . probably in the hypophj^sis. When castration takes place during full matmity the other glands of internal secretion are little affected, so that symptoms of dis- _• turbance are usually slight and transitory and often do not occur at all. A similar difference between earty and late castration is seen in the matter of the sexual impulse. In males who have been castrated before puberty sexual ' instinct is absent. When castration is performed after maturitj' libido is re- tained for a long time and copulation is possible, with ejaculation of the prostatic fluid. In females early removal of the ovaries would undoubtedly be followed by complete absence of the sexual instinct. After oophorectomy in matured women who have experienced intercourse and in whom the hbido has been normally awakened the sexual impulse in the majorty of cases is retained for a number of years, though its duration is probably not as long as in normal women. It is not infrequently noted that late castration may produce for a time at least an actual increase of the libido. In our own record of cases a number of women have reported that the sexual impulse became somewhat less constant, but, on the other hand, more spasmodic and intense. In the section on the relation of gynecology to sex it will be seen that in many normal women the libido is not awakened before sexual experience occurs, and J then only gradually. It would be interesting and in many instances important to know if after the castration of a matured woman this awakening of the sexual impulse would take place as under normal conditions. So far as we can discover no observations on this point have been recorded. From the foregoing the conclusion must be drawn that the sexual impulse after maturity is by no means exclusively dependent on the presence of the genital RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 55 glands. This dependence must be sought undoubtedly in the influence of other glands of internal secretion, a subject of the deepest significance which has not yet been elaborated. It has already been suggested (Gushing, Falta, and others) that the Freudian theory, which postulates an enormous influence of the libido in subconscious human motivation, may be explained on the basis of the internal secretions. It is entirely probable that many if not all the endocrine glands, in addition to their other physiologic properties, possess dii-ectly or indirectly sex-impelhng attributes. The most definite results of late castration in women are manifested by atrophy of the genital system and by certain temporary vasomotor disturbances. The subject of postoperative atrophy is mentioned below, and is again fully dis- cussed in the special section on Genital Atrophy {q. v.). The subject of the vaso- motor symptoms following oophorectomy is elaborated in the section on the Relationship of Gynecology to Neurology. Infantilism. — The relationship between early hypofunction of the ovaries and hypoplasia or infantilism is a subject about which there is much doubt. It is probable that most cases of infantilism are the result of some other cause than primary ovarian deficiency. (See also section on Infantilism and Sterility.) Infantilism relates to arrested development of various parts of the body, and may manifest itself universally in all parts of the body (infantilismus universalis) or it may appear only locally (infantilismus partiaUs). The manifestations of the condition in which we are par- ticularly interested are those that are seen in connection with the abdominal and pelvic organs and with the external female genitals, for some of them are of great clinical importance to the surgeon. Some of the familiar stigmata of the infantile or hypoplastic condition in the abdo- men are enteroptosis, abnormal mobihty of cecum and sigmoid, prolapse of the kidney, pelvic , kidney, short appendiculo-ovarian hgament, funnel-shaped appendix, etc. In the pelvis there are the congenital or developmental uterine malpositions of retroflexion, acute anteflexion, ante- flexion with retrocession, and procidentia, all of which may cause chnical symptoms. In addition to this are the anomahes due to the failure of complete union of the Miillerian ducts, causing the various forms of uterus didelphys and atresia, some of which may result in serious surgical comphcations. It was formerly supposed that these manifestations of infantilism were due to a deficient development of the ovary from the fact that the ovary is sometimes found hjq^oplastic. The present theory is that the local stigmata of infantilism, such as are seen in the genitalia, are merely manifestations of a general "hypoplastic constitution," and that hypo- plasia of the ovary, when it occurs, is only an incident and not a cause of the general condition. In the great majority of these cases the uterus is distinctly infantile, but the ovaries are either normal or actually larger than normal (excluding the occm'rence of cystic degeneration or thickened albuginea) . It is sufficiently evident, therefore, that infantilism is not necessarily due to ovarian deficiency. On the other hand, full development of the secondary characters may occur even in the complete absence of the ovaries. This is most commonly observed in cases of deficient union of the Miillerian ducts in which, according to Burrage, the ovaries are completely absent in 18 per cent. In cases of absence of the vagina the ovaries are sometimes either absent or only rudimentary. Many of these women are in every other way fully developed sexually and are sought in mar- riage; hence, the not infrequent necessity of the operation for making an artificial vagina. Atrophy. — Although up to the time of puberty the ovaries seem to have but moderate local or constitutional effect, we find definite evidence to show J 56 GYNECOLOGY that during the child-bearing and menstrual period of life the ovaries not only- exercise a distinct trophic influence over the uterus and external genitals, but they seem to play a certain more or less important part in the general chem- istry of the organism. This is best seen in the atrophy of the uterus and ex- ternal genitals, which takes place when the ovaries become atrophied or are removed after attaining the period of full maturity. When atrophy of the ovary takes place the organ becomes shrunken in size, the follicles cease to ripen, and degenerative changes appear in the follicle apparatus. The condi- tion when complete is manifested by amenorrhea. The uterus becomes small and flaccid, the cervix is shrunken and flattened. The labia become less full and rounded, the minora are slender and less prominent, and, flnally, disappear entirely. The vaginal and vulvar mucous membrane is pale, inelastic, and contracted, and may give rise to most distressing symptoms. Physiologically, ovarian deficiency appears at the menopause and during lactation. According to Thorn, lactation-atrophy of the ovaries with secondary atrophy of the uterus is a constant phenomenon in nursing women. Frankel describes it as appearing during the third month after childbirth, and as disappearing in the seventh month even if the mother continues to nurse. Foges has shown that this atrophy is due to a cessation of the function of the ovaries and not to the nursing of the mother. Pathologic ovarian cleficiencj^, as indicated by secondary atrophj- of the other genitals, is said to follow local pelvic conditions of inflammation and tumor formation, but this is rare, for in most cases the ovarian tissue con- tinues to functionate even though only a very small portion is left by the dis- ease. Ovarian atrophy sometimes follows infectious and constitutional dis- eases, such as scarlet fever, articular rheumatism, diseases of the thjToid, anemias, paralyses, etc. (See section on Genital Atrophy.) Fimctional Amenorrhea. — The amenorrhea, or oligomenorrhea, that is seen in fully developed women, who have previously menstruated normally, is accounted for as a result of functional ovarian deficiencj^, a theory that finds strong confirmation in the almost immediate beneficial effect which ovarian extract usually has on these cases. Burnam describes an ovarian deficiency which manifests itself in women of the fourth decade of life by lassitude, depression, and general ineffectiveness, a condition which he has been able greatly to benefit by the adixdnistration of large doses of corpus luteum extract. How far sterihty and dysmenorrhea are caused by hj-pofunction of the ovaries has not been determined. Ovarian extract occasionally influences these conditions, as shown b}" the most recent observations of the author. Hyperfunction of the Ovary. — Our present knowledge of the influence of hypersecretion of the ovary is very theoretic and not sufficiently well founded on scientific facts. Abnormal activity of the gland is supposed to be mani- fested by menorrhagias and possibly by premature sexual development and RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 57 overfertility. From a clinical standpoint, the most important phase of the question is that which applies to those cases of uterine bleeding which cannot be satisfactorily explained on an anatomic basis. This includes cases even when certain demonstrable anatomic changes are associated with the bleed- ing, such as myomata, chronic endometritis, glandular hypertrophy, chronic metritis (increase of connective tissue), chronic oophoritis, small cystic de- generation of the ovaries, etc.^ It also includes those baffling cases of so-called uterine insufficiency in which there is severe menorrhagia without macroscopic or microscopic change in the tissues of uterus or adnexa. 1 Schickele and Keller, in an article (Arch. f. Gyn., 1912, Bd. 95, Heft .3) entitled "On So-called Chronic Metritis and Small Cystic Degeneration of the Ovaries; Their Relation to Uterine Bleeding," have supplemented their work on the relationship of the glandular changes of the endometrium to uterine bleeding. These investigators undertook to verify the theory of Theilhaber that the bleeding from cases of uterine insufficiency is due to an abnormal disproportion between the connective tissue and muscle-fibers of the uterine wall. In a verj^ laborious piece of work they took sections from the myometrium of a considerable number of extirpated uteri. The sections were stained by the Van Gieson method and projected on millimeter paper, on which drawings were made of the connective tissue. In this way a fairly accurate calculation was made of the amount of connective tissue rela- tive to the muscular fibers. Their calculations led them to conclude that uterine hemorrhages had nothing to do with the amount of connective tissue in the myometrium. Hemorrhages may occur with an associated hypertrophy of the connective tissue, or they may occur -with, a perfectly normal amount of connective tissue. On the other hand, abnormal bleeding may be entirely absent in association vnth great overgrowth of the connective tissue. The same two investigators studied the ovaries of 7 cases of uterine insufficiency in which the uterus and adnexa had been extirpated, and found no characteristic anatomic changes in the follicles, connective tissue, blood-vessels, or albuginea, to which abnormal uterine bleeding could be assigned as a cause. The careful studies of Schickele and Keller of the relationship between endometrium, myome- trium, and ovaries, with abnormal uterine bleeding, are worthy of especial attention. Their general conclusions may be summed up as follows: The idea that bleeding and leukorrhea are cardinal symptoms of so-called endometritis (gland hj'pertrophy) must in the future be modified. It is well established that severe hemorrhages may take place both during and outside of menstruation without the slightest change in the endometrial glands; on the other hand, marked conditions of gland hyperplasia may exist without any abnormal bleeding. There can, therefore, be no essential connection between abnormal uterine bleeding and changes in the endometrial glands. Although uterine bleeding and gland hyperplasia may exist at the same time, there is no reason for declaring that the bleeding is caused bj' the glandular condition. There is no anatomic characteristic change in the mucous membrane, which, as such, calls forth hemorrhage or leukorrhea. The same thing may be said with regard to so-called chronic metritis (increase of connective tissue). There is, as a matter of fact, a true metritis, which depends for its origin on bacterial infec- tion, and which on healing develops certain anatomic changes, but we have no proof how often this form occurs, what its anatomic characteristics are, and whether there exists any connection between it and uterine bleeding. Hyperplasia of the connective tissue cannot be looked on as an expression of such a chronic metritis any more than can the dilatation of the blood-vessels, which is also present. It is certain that a hj-perplasia of the uterine connective tissue does not necessarily produce abnormal bleeding. If there were any such connection between the two, we should have abnormal bleeding with every case of connective-tissue hyperplasia, and the greater the hyperplasia, the more intense would be the bleeding. This is not the case. Those cases in which, in spite of a normal amount of connective tissue, and, therefore, well-developed musculature, intense hemorrhages occur, make it still clearer that the real etiologic factor is something different and more important. Everything forces us to the conclusion that the causes of abnormal uterine bleeding must be sought elsewhere than in the anatomic changes of the uterus. We naturally turn next to the ovary as the organ which would be most likely to influence the uterus. In the ovary anatomic changes can be demonstrated which may occur simultaneouslj^ with atypic uterine bleeding. However, it is an established fact that these same atypic bleedings may take place without any demonstrable anatomic change in the ovaries. This fact leaves the significance of the above-mentioned changes of the ovaries in a very uncertain light. We do not even know whether the functional processes in the ovary express themselves in its anatomic structure : whether any anatomic changes of the ovaries signify the outer sign of functional disturbances. Under such conditions the reputed significance of chronic oophoritis or of small cystic degeneration falls to the ground. We have at present no clue by which we can judge the function of the ovary by its anatomic appearance. 58 GYNECOLOGY The belief that most uterine bleeding is the result of a hypersecretion of the ovary is based on the theory of interrelationship between ovarian secretion and menstruation, the course of reasoning being as follows: The functions of the uterus are under the control of the ovaries, for without the ovaries there is no true menstruation. During menstruation the blood-vessels of the uterus, and especially of the endometrium, are always dilated and the normal menstrual blood is uncoagu- lable. It is supposed, therefore, that there is manufactured in the ovaries as an internal secretion a substance which passes over into the uterus in the blood, and which, when enough of it has accumulated, produces the phenomenon of menstruation by dilating the capillaries of the endometrium and reducing the coagulabiUty of the blood. The substance (probably by chemical influence) acts on the walls of the small blood-vessels of the endometrium, causing a hyaline change which makes them more permeable for the passage of the blood. The menstrual bleeding stops when the active substance which causes dilatation of the blood-vessels and non-coagulabihty of the blood is eliminated by the flow. The ovaries continue to manufacture the substance, which in turn continues to flow over into the uterus until enough is accumulated to produce again the menstrual discharge. By this theory, therefore, abnormal uterine bleeding is easily explained by the storage in the uterus of an excessive amount of ovarian secretion. This theory is not without scientific substantiation. Of very great interest are the experi- ments of Schickele on the influence of uterine and ovarian extracts on the time coagulability of the blood. He made extracts of the uterus, endometrium, and ovaries that had been removed for various causes at surgical operations, and, adding them to combinations of animal blood- serum and plasma, observed the changes in the time of coagulation as compared with normal controls. From these investigations he proved that extracts of the uterus and ovaries delay the coagulation. In those cases where the extracts were made from organs in which abnormal bleeding had not existed he found that the ovarian extract caused a greater delay than, did that from the uterus. In those cases where there had been severe menorrhagia or other hemor- rhages, the effect of the uterine extract was more powerful than that of the ovaries. More- over, he showed in these cases that the extract from the endometrium was more powerful than that from the myometrium. The general conclusion was that extracts from organs in which the menstruation had been unduly prolonged caused a greater delay in blood coagulation than did the extracts from organs where menstruation had been normal. The conclusion from the foregoing is that in the ovaries is produced a sub- stance that is passed over to and stored in the uterus and endometrium, which has the power of local dilatation of the blood-vessels and of delaying or pre- venting the coagulation of the blood. Hyperf unction of the ovary causes an oversupply of secretion, and thus brings about increased or prolonged men- strual flow. Ovulation and Menstruation. — It has long been a mooted question as to whether a definite relationship exists between the time of ovulation and men- struation. Observations on this point vary considerably in the study of the human ovary chiefly on account of the difficulty in determining the exact age of the corpus luteum. In order to facihtate the accumulation of evidence on this subject Frank has epitomized his own work and that of others in an excellent description of the macroscopic and microscopic appearance of the corpus luteum in its various stages. The reader is referred to this article for the microscopic details (Surgery, G3rnecology, and Obstetrics, Nov., 1914). In this RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 59 review the life of the corpus luteum is divided into four stages, the macroscopic appearances of which are herewith given verbatim in order to aid the operator who wishes to make a series of observations of his own: (a) Proliferative Period. — Macroscopically, immediately after ovulation the ruptured follicle appears as a small, flaccid, collapsed vesicle. This lack of prominence accounts for the fact that numerous investigators have overlooked the earliest stage. Confusion has also arisen from the gross and also microscopic resemblance of the atretic follicles to early corpora lutea. (b) Vascularization. — Macroscopically, the corpus luteum appears as a typical bluish-red prominence on the surface of the ovary. It is indistinguishable from the later stages. On cross-section more often than at a later period the central coagulum is fluid or jelly-like in consistence and its center may be freed from blood, but no absolute diagnostic value can be accorded to these differences. (c) Period of Ripeness. ^Macroscopically, the external appearance does not differ from that of the just vascularized corpus luteum. On cross-section, especially toward the end of this stage, the central coagulum may be firmer, and a well-defined yellowish-brown crenated margin (the lutein edge) may surround the clot. Not infrequently the center of the corpus luteum is cystic. (d) Period of Regression. — Macroscopically, the corpus luteum looks paler. On cross-sec- tion the centrum is more solid and colorless; instead of this, the center may remain cystic. The crenated margin is of brighter yeUow color, broad, and well defined. (e) Corpus Luteum of Pregnancy. — Macroscopically, it is often larger than the corpus luteum of menstruation; but it cannot be differentiated from it with any degree of certainty. Though a definite time relation between ovulation and menstruation is no longer disputed, the exact period of the relationship has not yet been deter- mined. Various estimates have been made, but, according to Frank, we are justified in the present state of our knowledge in "concluding merely that ovu- lation follows menstruation and that the fertilized ovum (impregnation) dates from before the missed period." There is evidence to show that impregnation usually dates from within the first week following menstruation, and that the optimum time for fertilization is immediately after the menstrual period. Meyer and Ruge have described the relationship between ovulation and menstruation as follows: "In the 28-day cycle of menstruation the ripening of the follicle probably comes after menstruation on about the eighth day from its beginning, if not during the time of menstrua- tion itself. The beginning of lutein formation is the second week; then the hemorrhage fol- lows in the second haK of the third and in the fourth week. The height of the hemorrhage fol- lows in the second half of the third and in the fourth week. The height of the hemorrhage is immediately preceding menstruation. During the latter regression begins and lasts about fourteen days. The normal sequence is then as follows: first, the hyperemic stage of the corpus luteum during the interval; the stage of vascularization of the corpus luteum at the beginning of the premenstrual phase; hemorrhage of the corpus luteum in the advanced premenstrual phase; the high point of hemorrhage of the mucosa and of the corpus luteum shortly before menstruation; and the regression during and after the same. During pregnancy the corpus luteum remains at the high point of its hemorrhagic state." The prevailing theory that there exists a definite time relationship between ovulation and menstruation has been upset somewhat by the investigations of Leopold and Ravano. Their conclusions may best be presented in the following quotation from Biedl: 60 GYNECOLOGY "Menstruation, that is, the periodic emission of blood by the uterine mucous membranes, depends upon the presence of the ovaries and the development of the uterine mucosa, and not solely upon the bursting of a Graafian vesicle. In the greater number of instances there is, both before and during the bursting of the vesicle, a determination of blood to the ovary. This is, in all probability, the reason why ovulation and menstruation are frequently coincident. Ovulation may take place in accordance with a specific periodic cyclic process, or its occurrence may be irregular; as a general rule, however, its periodicity coincides with that of menstruation. "In more than a third of instances ovulation and menstruation are not simultaneous. Ovulation may take place at any time, and is not necessarily accompanied by uterine bleeding. This fact snakes it appear extremely probable that conception also can occur at any time. " Menstruation may take place without ovulation. At the period when the ovaries undergo senile involution they sometimes contain normal Graafian folUcles and corpora lutea, which seems to show that the process of ovulation may outlast that of menstruation. "It is evident from the above statements that Frankel's theory of the dependence of men- struation upon ovulation and upon the internal secretory function of the corpus luteum is untenable." In view of the foregoing contradictory opinions on the part of the highest authorities definite conclusions on this important subject must for the present be held in abeyance. Ovarian Transplantation. — Perhaps the most striking evidence that the ovary is an organ of internal secretion is seen in the effects produced by implantation and transplantation of ovarian tissue. By these experiments the, ovarian in- fluence by direct nerve connection is excluded, and it is clearly estabhshed that the ovary secretes a substance that acts chemically on distant organs through the agency of the blood-stream. Experimentation has shown that in young castrated animals the genitalia may be made to develop normally at the time of maturity if ovarian tissue is implanted under the skin. In female baboons, a species which exhibits a men- strual function similar to that of the human female, menstruation may be pre- served after extirpation of the ovaries by transplanting the glands to various parts of the body. Experiments such as these are conclusive proof of the chemical influence of the ovarian secretion. Much work has been done in the transplant- ing of ovaries, and reports vary considerably as to the anatomic fate of the trans- planted tissue. Conclusions from the reports of others and from our own observations show that an ovarian graft, if it "takes" successfully, continues to live and functionate for a time and then gradually becomes converted into func- tionless fibrous tissue. The life of a graft depends on numerous factors. Auto- plastic grafts that have been removed and reimplanted in the same individual take better and live longer than do homoplastic grafts in which the gland is transferred from one subject to another of the same species. This is due to the physiologic antagonism of blood and tissue that exists between different indi- viduals. Homoplastic transplantation is more successful when there is a blood relationship between the two individuals than when they are entirely unrelated, for in the former case the physiologic antagonism is less intense. The success of an ovarian graft depends to a certain extent on the length of time between extirpation and transplantation. Thus, a graft that is made immediately is RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 61 Fig. 21. — Ovarian Transplant in Horn of Uterus after Six Years. 1, New vessels that have formed between the uterine and ovarian tissues. 2, Junction of uterine and ovarian tissues. 3, Corpus albicans. 4, Atretic follicle. Note that the surface of the ovarian graft did not become adherent to the surrounding tissues. History of the case: Operation May 3, 1910. Double salpingectomy, with transplantation of ovarian tissue in each horn of the uterus. Both ovaries preserved. Four years later patient re- ported that she had a miscarriage at three months. Statement corroborated by attending phys- ician, but no fetal tissue preserved for confirmation. Operation June 6, 1916. Hystero-oophorectomy for ovarian cyst and pelvic adhesions. Both operations performed by the author at the Free Hospital for Women, Brookline. 62 ■ GYNECOLOGY more favorable than one where the gland is preserved for a time in cold storage or where it has been treated with some chemical, such as iodin, or heated for the purpose of bacterial sterilization. The location of the graft is also important for the maintenance of the life and function of the gland, it being necessary that the tissue in which it is embedded should be sufficiently vascular to insure the establishment of a new blood-supply to the gland. The life of an ovarian graft even when successfully planted is quite inconstant and varies from two or three months to a year. In some well authenticated cases it has extended to two or even three years. The histologic changes that occur in a human ovarian graft may be seen by referring to the drawing (Fig. 21). In the case here depicted the ovarian tissue was removed six years after autotransplantation into the horn of the uterus. It will be seen that active follicular development has practically ceased. There ar^ the remnants of an old corpus luteum and in one place can be seen a small atretio follicle. No primordial follicles are visible. This was evidently an unusually successful graft, as is demonstrated by the well-marked vascular connection estab- lished between the ovarian tissue and its new host. In this case, as always happens, there took place a considerable diminution in the bulk of the transplanted tissue. Enlargements frequently noted in grafted ovaries are from our personal observations due to cystic degeneration of the follicles, and not, as some claim, to a regeneration of the ovarian parenchyma. To the gynecologist ovarian transplantation has been a subject of peculiar interest, in that it seemed to promise a solution of many difficult pelvic problems. Practical results have, however, up to the present time been disappointing, but it is quite possible that with improved technic and with a greater knowledge of the physiology of the ovarian functions some of the, hopes for its usefulness may in time be realized. In the treatment of sterility ovarian transplantation in the human female has been especially disappointing. A number of successful operations in animals of heteroplastic transplantation have been reported; as in the following experi- ment cited by Martin : "W. E. Castle and John C. Phillips (70) reported in Science, 1909 that ovaries were re- moved from an albino guinea-pig about five months old, and in their stead were introduced the ovaries of a black guinea-pig about one month old. The albino upon which the operation had been performed was then placed with an albino male guinea-pig and six months later bore two black-pigmented young. In many hundreds of matings of albino guinea-pigs observed by the authors only albino young were produced ; so there seems no room for doubt that in the case described the black-pigmented young derived their color from the black animal that fur- nished the ovaries." A similar result in the human female was reported by HalHday-Crom in 1905, who claimed to have brought about pregnancy and a full term child by engrafting in the uterus of a castrated woman ovarian tissue from another woman. Morris reported a similar case in 1906. Numerous reports of pregnancy following auto- RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 63 plastic grafting of ovarian tissue in the uterine horns after complete bilateral salpingectomy have appeared in the journals. In most of these cases there has been a history of abortion. Most of them, like that of the author (page 61), lack irrefutable evidence. We have performed this operation many times with- out success as regards the maintaining of fertility. Ovarian transplantation has been used in the treatment of women who have by surgical operation suffered the loss of their ovaries, but with the retention of , the uterus. The operation of double oophorectomy without removal of the uterus j is to be deplored, in that it is usually followed by discomforting pelvic and vaso- j motor sjTnptoms, often of extreme severity and long duration. Several such cases have been reported in which transplantation of ovarian tissue from another woman has been done followed by temporary reappearance of menstruation and remission of ablation symptoms. The results of such an operation are extremely inconstant, owing to the difficulty of successful grafting in heteroplastic transplantation. It was stated above that in unmatured animals normal development of the other genitalia follows castration if the ovarian tissue be transplanted in some part of the animal's body. In a similar manner, after castration of the adult hmnan female, genital atrophy may, for a time at least, be prevented -arid the menses continued if ovarian tissue is reimplanted. Such a result ensues onty if the uterus is left in situ. Menstruation in these cases is re- established usually after three or four months following the operation. A Hke result may be obtained less constantly by transplantation of ovarian tissue from another woman. Here again the procedure of grafting has only a limited field of usefulness, for it does not ultimateh^ do away with the disadvantages of remo\'ing both ovaries and leaving the uterus. It may be said also that ovaries that are so diseased as to recjuire removal from the pelvis are not usually suitable for implantation in some other part of the body. The most promising field for ovarian transplantation would seem to be in cases where hysterectomy with removal of non-diseased ovaries is required, in which it might be expected that the engrafted organ would supply an internal secretion sufficient to prevent ablation sjTiiptoms of hot flushes and other vaso- motor disturbances. The operation has been performed many times by different surgeons whose opinions as to its efficacy vary considerably. Some beheve that ablation sjonptoms are definitely and favorably influenced by the transplanted ovary; others have found it of little benefit. We have carried out the procedure in many cases and have carefully followed up and tabulated the results. In our series of cases as compared with hysterectomy cases with total ablation of the ovaries we have found practically no difi'erence in the incidence or intensity of the surgical menopause symptoms. It was our custom in the earher operations to transplant ovarian tissue after hystero-oophorectomy in the leaves of the broad ligament. In this situation the ovarian graft in several cases became cystic and painful, and in one instance apparently produced distressing moLimina with vicarious epistaxis. In the later operations the graft was inserted in a pocket 64 GYNECOLOGY made between the abdominal rectus muscle and its aponeurosis. In a few instances the section of gland became more or less periodically enlarged and tender, due undoubtedly to cystic degeneration of the follicles. In one case the gland grew rapidly to nearly the size of a fist and then suddenly collapsed. Some recommend planting the ovary in the subcutaneous fat. In a case in which this method had been used and which later came under our observation the ovarian tissue became extensively cystic, spreading through the fat and re- quiring several operations for its complete removal. From the foregoing experiences our conclusion has been that the operation of transplantation after hystero-oophorectomy is of little or no practical value. When the graft has been made in some easily accessible place the operation cannot be followed by any serious harm, and in certain cases, chiefly for sentimental reasons, it may be advisable. Our observations regarding the feasibihty of ovarian transplantation after hysterectomy are substantiated by Tuffier, who remarks that "where the uterus is absent ovarian transplantation is of no value." There is a possible field for ovarian transplantation in the treatment of the functional amenorrheas of young women. So far as we can chscover there has been practically no work done along tliis fine. The following experiment, per- formed by the author, is presented not as conclusive proof of the value of the procedure, but as an interesting suggestion that a remedy may be found for a difficult gynecologic problem: Two amenorrheic women came to the hospital at the same time. One of them, twenty-six years of age, had menstruated only a few times in her life. She had been married five j^ears, without children. She was perfectly developed both as to her primary and secondary- sexual characters. The second was a young woman of twenty-one who had menstruated onlj^ two or three times in her life, the last time four months previous to her coming to the hospital. It happened that there was at the hospital at the same time a woman who had had menorrhagia and metrorrhagia for five years as a result of uterine insuflficiency. Repeated cirretings had been of no benefit. The uterus was anatomically normal. The Wassermann test was negative. Inasmuch as a hj^sterectonw seemed advisable, it was determined to graft ovarian tissue from the menorrheic woman into the two amenorrhoic patients. Accordingly, during the hysterec- tomy on the last named patient, sections were taken from the ovar\' in which there was no corpus luteum. These sections were immediately transplanted into the anterior cer\dcal hp of the amenorrheic patients. The first patient a few days after the operation had a perfectly normal menstruation for the first time in three years. The second patient menstruated nor- mally in about twelve daj^s and has menstruated regularh^ since for about five months. In these two cases the action of the ovarian internal secretion was apparently exerted by a portion of ovarian tissue from which the influence of the corpus luteum was excluded. Organotherapy. — The therapeutic value of extracts of ovarian substance has passed beyond the stage of theory and speculation and is now an estab- hshed fact beyond all doubt. With regard to the nature of the active sub- stance, the exact location in the ovary of its manufacture, and many other questions we are still considerably in the dark. The earher reports of the use of ovarian extracts were, for the most part, discouraging, but in recent years RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 65 better preparations, a more definite knowledge of the physiology of the ovary, and a more intelHgent selection of cases for treatment have yielded results that are not only satisfactory, but often astonishing. The value of ovarian therapy is seen in the treatment of patients who are suffering from functional deficiency or absence of the ovarian internal secretion. The most conspicuous examples of this are those who experience the vaso- motor disturbances of the natural or artificial menopause, the symptoms of ' which consist chiefly of hot flushes, vertigo, etc. By the administration of a properly prepared extract these symptoms are, with some exceptions, greatly benefited or made to disappear entirety. The extract is, therefore, of the greatest help in the routine postoperative treatment of patients who have under- gone hysterectonw, at least 80 per cent, of whom suffer from vasomotor changes. Next to its importance in menopause cases is its value in treating j^oung women with functional amenorrhea and oligomenorrhea. Its results with-- these patients are not as constant as in the first class of cases, but its use is here successful, either partially or completely, in the majority of instances. A third type of cases in which ovarian therapy is surprisingly efficacious is represented by patients suffering from deficient circulation of the external genitaha. As is elsewhere stated (see page 46), animal experimentation has proved that the ovarian internal secretion has a specific hyperemic effect on the external genitalia. Substantiation of these experiments on animals is seen in the beneficial effect which ovarian extracts have on the conditions of pruritus, kraurosis, furunculosis, and other affections of the vulva in elderly women where vy' the local disturbance of the parts is due to inadequate circulation. Aschner has been able to produce hemorrhage and even hematometra in guinea-pigs by the injection of ovarian extract. He finds in animals thus treated that the ovaries-eontain an un- usual number of ripening foUicles, and ascribes to this phenomenon the hemorrhagic congestion of the uterine mucosa and the hj^peremia of the external genitals. Aschner has also found that placental extracts work still more strongly than ovarian extract, and suggests that they be used in amenorrhea, sterility, and climacteric disturbances. In the treatment of the foregoing classes of cases the e\ddence of the value of ovarian organotherapy is beyond dispute, and is entirely substantiated by a large experience in its use by the author. In addition to these three types, various other gynecologic affections are reported to be greatly benefited by ovarian extract. Burnam has had marked success in treating neurasthenic under-par women in the preclimacteric decade. " Dannreuther reports success in bringing a patient to term after repeated abor- tions, and finds the treatment helpful in the hyperemesis of pregnancy. A few cases have been reported of the cure of sterihty, but its efficac}^ in this respect is extremely doubtful. In conditions presumablj- due to hypersecretion of the ovaries and menor- rhagia, as one would expect, organotherapy is of httle assistance. There is at present much discussion and experimentation in the matter of 66 GYNECOLOGY the form of the extract. On the ahiiost universally accepted theory that mternal secretion of the ovary is manufactured by the corpus luteum, most extracts nowadays are made from the yellow body of either pigs or cows. On the ground that the corpus luteum of pregnancy is more stable than that of ovulation, it is considered by some (Dannreuther) of the greatest importance that the preparation be made from pregnant animals. On the other hand, the author, whose results compare favorably with those of the most enthusiastic users of the corpus luteum, has employed an extract from the entire fresh ovary which he has found equal in effect to the lutein extracts. The use of ovarian extracts is not dangerous, there being no toxic effects excepting a slight disturbance of the stomach. Dannreuther lays consider- able-stress on the depressing effect of continued doses on the blood-pressure. This is probably more noticeable in the case of corpus luteum extract than in that of the whole ovary. The dosage is the same whether corpus luteum or ovarian extract is given, 5 gr. three or four times daily. In most of the preparations now used 1 gr. of the extract represents 6 or 7 gr. of the fresh ovarian substance. It is of absolute importance that the preparation be fresh, the use of stale extracts probably accounting for many of the unsatisfactory results reported. It is quite probable that with a better chemical knowledge of the ovarian substance, and with improved methods of preparing and administering the extracts, there will in time be a notable advance in the use of this already in- valuable remedy. There is no doubt that in the change from the ovaries to the commercial extract important ingredients of the ovarian secretion are dis- turbed. That only a part of the full effect of the secretion is reproduced is shown by the fact that whereas ovarian therapy is eminently successful in treating disturbances of the menopause, it has no effect on stopping uterine atrophy. Moreover, it must be remembered that while in the body the ovarian secretion passes directly into the circulation, ovarian therapy requires that the substance pass through the digestive apparatus, so that a chemical disturbance in the secretion is more than probable (Bab). It has been justly asserted that most of the work thus far done on ovarian organotherapy^ has been unscientific in character, and that the chnical results from its use which have been reported are, therefore, in large part untrustworthy. The lack of greater progress in this important subject is due to certain impeding factors which serve as a serious handicap to proper scientific investigation. Foremost among these factors is the vagueness of our knowledge of the physiologic processes of the pelvic organs. We are secure in oxir belief that the ovary is an organ of internal secretion, but it has not yet been proved conclusively in what part of the organ the secretion is manufactured. Moreover, we are quite at a loss to know whether the secretion of the ovary acts directly on the organism or whether it serves only as a balance to the products of more powerful glands in other parts of the body. In addition to our ignorance of pelvic physiology we are greatly hindered in the study of ovarian extracts by the fact that it is impossible to make standard tests for most of 1 The material of this section is for the most part taken from an article by the author entitled "Ovarian Organotherapy. A Preliminary Report," Jour. Amer. Med. Assoc, vol. Ixix, No. 9. EELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 67 the clinical reactions for which administration of the extract is chiefl^^ indicated, animal ex- perimentation being inadequate on account of the exclusive^ human character of the reactions. The admirable experiments of Frank and others, showing the effect of ovarian extracts on the uterine tissue of castrated animals, are valuable in proving the actual existance of an active internal secretion in the ovary, but they do not lead us to definite information as to the effect of the ovarian secretion on such complicated hmnan phenomena as menstruation and the vaso- motor symptoms of ablation. A serious handicap in the study of ovarian therapy is the fact that the nature of the secre- tion is not 3'et kno\\Ti. On account of this doubt as to the nature of the potent substance there has been no effective standardization in preparing the various extracts used clinically and experimentally. As a result of our deficient knowledge of the physiology of the pehnc organs and the con- sequent hmitation to more scientific methods of research, most of our information bearing on the subject of ovarian organotherapy has been derived from observations made in a somewhat haphazard way in connection with the cUnical administration of the numerous commercial preparations put on the market by various drug firms. Thus it happens that there is a very wide divergence of opinion among clinicians in the matter of ovarian therapy. Many assert that the administration of ovarian substance is entirely valueless in any condition. Such testimony may, however, in the hght of recent ex- perience be disregarded. The chief controversy hes in the question as to which part of the ovary is most efficacious therapeutically, some advocating the corpus luteum alone, others the entire ovary, while, as will be seen, the author recommends the ovarian substance from which the corpus luteum has been excluded. Experience shows that all these three prepara- tions have essentially similar physiologic effects when used in certain conditions, variations occurring onl}^ in the intensiveness of the results. It may be said that in all preparations the most striking results are obtained in the treatment of the vasomotor symptoms of the meno- pause. All of them will benefit a certain number of cases of amenorrhea and oligomenorrhea and of circulatory disturbances of the external genitals. It seems probable, therefore, that the active substance is the same, whether the extract be made from the corpus luteum or from the rest of the ovary. Therefore in selecting a part of the ovary for the extraction of the secretory substance, it is a matter of choosing that tissue which shall yield the substance in greatest abimdance, and with the least toxic effect on the patient. Present knowledge indicates that there exist both in the corpus luteum and in the atretic follicles cellular elements identical in their origin from a specific connective-tissue structiu-e (the theca interna) and capable of producing an internal secretion which is important to the growth and normal functioning of the organism. If this is true, we have a basis on which to found a rationale for ovarian therapy. If an internal secretion is manufactured from both the corpus luteum and the atretic follicles by cells of identical structure, extracts made from the corpus luteum alone lack that valuable part of the secretion w^hich is derived from the atretic follicles. Moreover, it is im- possible to tell bj' inspection whether a given corpus luteimi is in the process of maturation or at the height of its development, or in a stage of involution and disintegration. It must happen that in the preparation of many corpora lutea for therapeutic purposes a varying number are included in which the essential cells are no longer active as organs of internal secretion, and are actually in a condition of dissolution. We should expect, therefore, that commercial prep- arations of corpus luteum would present a wide variation in their therapeutic effects, and, owing to their readiness to decompose, would have a special tendency to become toxic. On the other hand, if the preparation be made from the whole ovary, including corpus luteum, stroma, and follicles, the important follicular secretion is not lost. Preparations of this kind would be expected to be more stable in their composition and more constant in their effect than those of the corpus luteum alone. These conclusions have been amply borne out by our clinical experience. Reports regarding the results of ovarian therapj' are, for the most part, inadequate and contradictory. We shall, therefore, in discussing the subject confine ourselves to observations made from personal experience. In estimating the comparative merits of preparations of the whole ovary and those of the 68 GYNECOLOGY corpus luteum alone, most of our observations have been made in treating the vasomotor symptoms following hysterectomy. In this type of case the corpus luteum showed a great variation in effectiveness, often being entirely valueless and occasionally producing digestive disturbances. On the other hand, the whole ovary, used in a large number of cases, showed great constancy in therapeutic effect, so that we have come to regard it as almost a specific in the treatment of ablation symptoms, both of the artificial and natural menopause. Striking results have also been obtained in the treatment of functional amenorrhea and in the circulatory disturbances of the external genitals, such as kraurosis and the discomforts of senile atrophy. In order to test further the effect of luteal preparations compared with those of the whole ovary a series of clinical observations was undertaken with desiccated corpora lutea of preg- nant animals. Numerous cases were treated, representing hot flushes from the menopause, oligomenorrhea, dysmenorrhea, and amenorrhea. In all but two of the cases toxic symptoms of a digestive nature were produced. Preparations from both the cow and the pig reacted in the same way. The symptoms were invariably those of nausea and vomiting following one or two doses. In one case the ingestion of one 5-grain capsule resulted in continuous nausea and occasional vomiting for a period of ten days. The result of these clinical experiments cannot easily be explained. It was at first thought that the effects might be due to decomposi- tion of the extract, but fresh preparations produced the same symptoms. They could hardly be due to anaphylaxis on account of the high percentage of patients affected. These observations suggest the possibility that the nausea and vomiting of pregnancy may be determined by the toxic effect of the internal secretion of the gestative corpus luteum. In view of the favorable results obtained from the whole ovary compared with the corpus luteum alone, and of the positively bad results from the corpus luteum of pregnancy, we next determined to try the effect of the ovarian substance alone minus the corpus luteum. In this experiment the ovaries of pregnant animals were chosen partly as a check to the experiment with the gestative corpus luteum and partly to test the therapeutic effect of the internal secretion of the atretic folhcles. It was thought that pregnant ovaries would be par- ticularly favorable for studying the follicle internal secretion, owing to the well-known fact that during pregnancy the process of follicle atresia is especially active. The results with this substance were interesting. The toxic effect created by the corpus luteum of pregnant animals was entirely absent, thus showing that its poisonous reaction could not have been anaphylactic in character. The new substance produced results similar to those of the non-pregnant ovary, but, in general, more striking. This was especially true in the treatment of vasomotor symptoms following hysterectomy. The preparation proved generally successful in the treatment of hot flushes, and in some cases of amenorrhea, dysmenor- rhea, intermenstrual pain, catamenial nausea, headache, and the genital discomforts of senile atrophy. From observations made with this substance, incomplete as they are, we have at least suggestive evidence that an internal secretion is elaborated from the follicles which in thera- peutic value is equal to and probably greater than that produced by the corpus luteum. Determination of Sex. — An important problem in the study of the internal secretions is involved in the question of the determination of sex and the differ- entiation of secondary sexual characteristics. The stigmata of sex have always been regarded as dependent on the organs of generation. Primitive peoples even to the present day have considered the differences in sex as due to the influence of the external genitals, the breasts in women being also regarded as of especial importance. The ancient students of medical science held the uterus responsible for the peculiar characteristics of woman, and the word hysteria (tjoT£,oo9, uterus) was employed to express the unstable nervous manifestations to which the female sex is susceptible. In more recent times the seat of femininity was transferred from the uterus to RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 69 the ovaries, and the old saying of Helmont, "Propter solum uterum mulier est quod est," was changed by the Cheran to "Propter solum ovarium mulier est quod est." The modern knowledge of the ductless glands and their influence on growth has greatly modified the old ideas, and we now know that the question of sex differentiation is not as simple as the ancient dicta implied. Virchow believed that all the peculiarities of mind and body that differentiate man and woman are dependent on the generative glands, but offered no explanation of the fact that individuals possessing the glands of one sex frequently exhibit the bodily and psychic characteristics of the other sex. Modern science has succeeded only imperfectly in solving the riddle of sex development, but enough facts are known to show that the subject is exceedingly complex and that full normal sex growth is dependent on many factors in which probably all the glands of internal secretion play an important role. Theories regarding the origin of sex may be grouped under three headings: (1) That sex distinction is predetermined in the ovum or spermatozoon. (2) That sex is determined at or immediately after fertihzation. (3) That the sexual cells (ovum and spermatozoon) are undifferentiated at the time of fertilization and that the sex is not determined until some time during embryonic life. Biologic investigations reveal that sex distinction may take place in all three ways. Thus in certain lower forms of life the sex of the eggs laid by the female is influenced by external conditions, such as heat, cold, and humidity. In other forms the female lays eggs of two different sizes, the larger of which produces females and the smaller males. In each of these cases it is evident that the sex is determined in the ovum. In some forms of insects sex is determined by two kinds of spermatozoa, being dependent upon the number of chromosomes contained in the nucleus of the sperm cell. In this case the cells which contain an accessory chromosome produce females; the others, males. Biedl quotes authorities who claim to have discovered that in mammals and in man there exist two varieties of spermatozoa which have distinct staining reactions and which may possibly represent the two sexes. In bees, ants, and wasps, to quote Biedl, "the conditions are different, there being only one kind of egg and one kind of spermatozoon. Males are produced by parthenogenesis, females proceed from fertilized ova. The queen bee is impregnated once only, the semen being retained in the receptaculum seminis. From the eggs into which the sperm cells penetrate, females — that is, queens and workers— are hatched, while from the unfertihzed eggs, males^that is, drones- proceed. Lenhossek thinks it possible that the sperm cells find access only to those eggs which possess female characteristics and that they do not penetrate the male eggs. 70 GYNECOLOGY These observations show that, in the lower forms of hfe, sex differentiation may.aheady exist in the unfertihzed egg, or it may be determined in the course of, or immediately after, fertilization. In the higher order of mammals the factors that determine the time and nature of sex differentiation cannot be accurately noted. There is, however, evidence to show that in them the process corresponds to the third method mentioned above, by which differentiation takes place at a considerable time after f ertihza- tion during embryonic life. In man the so-called primitive genital trace remains undifferentiated until the fifth week, when it develops into a definite unisexual gland, either ovary or testis. During this prehminary period it is assumed that the primitive genital trace is potentially bisexual, or hermaphroditic, from the fact that in rare instances true hermaphroditism may occur in man; that is to say, elements of both sexes may appear in the gland of one or both sides, or even a male gland on one side and a female gland on the other. The factor which deter- mines the development of the primitive trace into ovary or testicle is, as Biedl remarks, absolutely unknown. The two sexes differ in other respects than in the generative glands. Most important are the excretory ducts of the glands and the genital apparatus, in- cluding the external genitals and breasts. These are rightly termed by Biedl the ''secondary sexual organs," for, as we shall see, their distinctive development is dependent upon the nature of the primary genital gland. In addition to these there are other less striking though marked differences in practically aU of the tissues of the body, such as skeletal details, distribution of fat and hair, formation of the larynx, consistence of the skin, muscular development, etc. The nervous and mental equipment of men and women shows a decided divergence. All those differences between the male and female exclusive of the glands of genera- tion (ovary and testes) may be regarded as "secondary sexual characteristics." Between the tissues of the primary and secondary characters there exists an important cellular difference. The organs of generation contain the germ cells or gametes (ovum, spermatozoon), the function of which is reproduction, that is to say, each cell is capable of reproducing a complete individual. The germ cells, therefore, possess the potential of immortahty. All the cells of the body other than the germ cells are called "somatic" cells. These make up the various organs and structures of the body, and are mortal, in that they die with the individual. It is quite probable that all the somatic tissues of the body possess in males and females secondary sexual differences. To those structures in which the differ- ences are apparent is applied the term "secondary sexual characters." We have already seen that the sex differentiation of the primary generative cells may take place in several ways, in human beings the process occurring some time after fertihzation and manifested by the development in the fifth week of a distinctive gland (ovary or testes) from the primitive genital tract. The question then arises, Is the sex of the somatic cells predetermined in the ovum or is it determined later by the nature of the generative gland through the influence of RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 71 an internal secretion? There are conflicting views on this point. According to Biedl and others the somatic tissue is primarily indifferent and does not begin to show differentiation until after the development of the generative gland. A number of facts support this view. In the early embryo there is no sexual distinction in the secondary genital organs. The primitive Wolffian and Miillerian apparatus lie side by side communicating by a common opening. (See section on Embryology.) At the end of the third month one of these two systems begins to develop at the expense of the other, according to the nature of the (now differentiated) generative gland; the Wolffian developing if the gland is male, and the Miillerian if it is female. Whichever system gains the ascendency, there always remain rudiments of the other even in full maturity. Thus it may be said that in the earliest beginning the individual, as far as the secondary genital organs are concerned, is completely bisexual and that the ultimate sex is determined after the develop- ment and under the influence of the genital gland. The same process doubtless characterizes all the other somatic tissues besides the genital organs, for in the newborn there are numerous well-defined differences of organization in the two sexes. These secondary sex characteristics are in many ways firmly estabHshed before birth, for even after the earliest castration the male always remains distinctively a male and the female a female throughout life. The prevailing theory at present is that the sex differentiation of the secondary genital organs and of the general secondary somatic characteristics is due to an internal secretion from the generative gland. It is also believed (chiefly as a result of the researches of Tandler and Gross) that this specific internal secretion is elaborated by the interstitial cells of the generative gland, that is, by the cells of Leydig in the testicle and by the analogous interstitial tissue in the ovary. An apparent contradiction to this theory is the fact that frequent incon- gruities occur between the nature of the sex gland and that of the secondary characteristics. Thus it often happens that both the Wolffian and Miillerian systems develop more or less equally in the presence of an apparently unisexual generative gland. In other cases the secondary sex apparatus may be pre- dominantly of the sex opposite to that of the gland. These represent the various forms of pseudohermaphroditism. In still other cases individuals with normal primary and secondary genitals may exhibit marked characteristics of the other sex. There are the masculine, hairy, deep- voiced women, and the soft, effeminate, beardless men. There are also curious cases reported in which there may take place during the life of the individual an almost complete alteration of the sexual characteristics, a result usually of some injury or disease of the genital glands. According to Biedl, the various manifestations of hermaphroditism give evidence that the primitive genital trace from which the ovary or testes develops at the fifth week is in its primordial beginning bisexual, and the genital gland in its development may retain both the male and female tissue elements that elab- 72 GYNECOLOGY orate the respective internal secretions. This condition Biedl names glandular hermaphroditisjn, and calls attention to itg frequency in animals even of the higher orders. Several cases of so-called "ovotestis" have been demonstrated in man. Hence hermaphroditism is, according to this theory, the result of a bisexual internal secretory mechanism in the generative gland, and the irregular secondary sex characteristics are determined b}^ the special activities of the two secretory tissues. We may sum up the theory of sex differentiation as expounded by Biedl as follows : (1) Sex differentiation may be determined in the ovum at the time of fertiHzation, or at a considerable time after fertihzation during embryonic hfe. In -the human race it takes place according to the last named method, (2) The generative gland (ovary or testis) is developed from the primitive genital trace. The primitive genital trace is at &st bisexual, as is shown by glandular hermaphroditism (ovitestis). The influence which directs the primi- tive genital trace into ovary or testis is absolutely not known. (3) The secondary sexual characteristics including the secondarj^ genital organs are the result of the influence of an internal secretion created by the generative gland. (4) Incongruities between the sex of the gland and that of the secondary characters, as seen in the various forms of hermaphroditism, are presumably due to the presence in the gland of both male and female organs of internal secretion (glandular hermaphroditism). The foregoing is interesting chiefly in demonstrating the bisexual character of the human organism in its earliest embryonic state. It does not, however, settle the question as to the predetermination of sex in the ovum or sperm ceU, for it does not even suggest an explanation of the cause of the differentiation that takes place in the primitive genital trace in the fifth week, an influence which may conceivably date back to the germ cell before or at the time of fer- tihzation. It is quite doubtful if the determination of the secondary sexual character- istics is as simple as Biedl would have us believe, referring them as he does entirely to the influence of the internal secretion of the genital glands. Most of the duct- less glands have, as we have seen, a powerful influence on growth and sexual devel- opment. The effect of tumors of the suprarenal cortex in evoking male secondary- characteristics in female patients is an example suggesting that other ductless glands than the gonads may have powers of sex differentiation and that her- maphroditism may be due to irregularities in the general internal secretory system. If the ductless organs are to a greater or less extent sex glands, are they themselves sexually differentiated, and if so, is their sexuality primary or secondary in relationship to the gonads? Such questions cannot at present be answered. RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 73 THE HYPOPHYSIS There has been demonst rated a most intimate functional relationship between the hypophysis and the sex glands; hence the subject is of especial interest to the gynecologist. In order to understand the various phenomena produced bj^ the internal secretions of the hypophysis a familiarity with its anatomic structure is essential. The hj'pophysis or pituitary body is situated within the craniimi at the base of the brain, being surrounded by a bony encasement called the sella turcica. It is connected with the brain by the infundibulum, which passes through an open- ing in the dura mater lining of the sella turcica. The organ, taken as a whole is flattened anteroposteriorly and almost completely fills the ca^dty of the sella turcica. Its weight is approximately the same in men and in nulliparous women, but is appreciably increased in women under the influence of pregnancy. The hypophysis consists of two parts, termed the anterior and posterior lobes, which exhibit important differences both in histologic structm'e and in physiologic properties. The anterior lobe, which constitutes the greater part of the organ, is kidney shaped, concave posteriori^', firm in consistency, and has a character- istic pinkish-gray color in the fresh state. It is epithehal and glandular in struc- ture. The posterior lobe lying in the concavity of the anterior is smaller in size, rounded in contour, of a soft consistency, and white in appearance. Its structure is composed of nervous elements. Thus the two lobes are often spoken of as the glandular and nervous parts of the hj^pophysis. Encasing the posterior lobe is an epithelial lining which extends upward along the infundibulum. This structure is designated the 'pars intermedia and probabty belongs essentially to the posterior lobe, with which it forms an impor- tant physiologic association in the elaboration of a specific secretion. Histologically the anterior lobe is composed of two fundamentally distinct types of epithelial cells, characterized bj^ then- difference in affinity for certain stains. These cells in consequence of their staining reaction are termed chromo- phils and chromophobes. The chromophils have a definite outline with a homogeneous protoplasm which is full of fine secretion granules. These cells staiii intensely with acid or basic stains, hence their name. The chromophobes, on the other hand, are ill-defined in outline; they do not contain secretion granules, and have no special affinity for acid or basic stains. The chromophobes are also termed the chief cells (Hauptzellen) . The posterior lobe, or nervous part of the hypophysis, consists of a loose stroma made up of connective-tissue elements and neurogha in which the latter is in excess. It is invested with the epithelial j^ars intermedia, with which, ac- cording to recent theories, it is structurally connected. Clinically, changes in the anterior lobe produce characteristic reactions in the general organism, as is exemplified by such diseases as giantism and acro- megaly. The functional acti^dty of the anterior lobe is closely interrelated with 74 GYNECOLOGY that of the sex glands. Extracts of the anterior lobe exercise a definite influence on the sexual apparatus. Extracts of the posterior lobe have a specific action on certain unstriped muscular systems, including the uterus. The interrelationship between the hypophysis and the genitalia has been clearly estabhshed by both experimental and clinical evidence. The earher experiments, carried out notably by Gushing, Biedl, and Aschner, demonstrated that deficiency of the anterior lobe secretion created artificially by partial removal of the organ produced genital atrophy in adult animals, while in unmatured animals it brought about a condition of permanent genital infantihsm. Gushing found in animals from whom the anterior lobe ot the hypophysis had been removed a characteristic picture. The animals grew very fat, the genital organs of adult animals becoming atrophied, and those of young animals remaining undeveloped and infantile in type. In time there ensued polyuria and glycosuria, falling out of the hair, subnormal temperature, and lessened resistance to infectious diseases. Aschner's experiments consisted of total and partial extirpations of the gland in dogs before and after sexual maturity, with the purpose of noting the anatomic changes in the reproductive organs. The operations on the hypophysis were made by the oral route, through the soft palate and cuneiform bone. The dogs which had been operated on before sexual maturity were al- lowed to live until several months after the time of normal maturity, and were then compared with normal control dogs of the same litter. The experimental animals showed the character- istic outward disturbances of development described by Gushing, manifested by retarded skel- etal growth, accumulation of fat, and general infantilism of the various organs, the internal gen- ital apparatus being small and underdeveloped. Histologic examination of the ovaries showed retarded and incomplete ripening of the follicles and a special tendency to cystic degeneration. The uterus remained hypoplastic and infantile in character. Heat appeared later in these dogs than in the normal, and only in rudimentary degree, with slight appearances of hyperemia and uterine secretion. There was invariably sterility and only faint manifestation of sexual impulse. Extirpation of the hypophysis in mature animals showed less marked changes in the genital organs. A moderate amount of degeneration was observed in the ovaries, while the uterus showed very much less atrophic change than is seen after castration. Heat was not entirely destroyed, but was considerably weakened. The effect of removal of the hypophysis on pregnancy was carefully studied. In order to remove the element of operative shock the operations on gravid animals were performed in two stages, the first consisting of opening through the bone and baring the dura, while in the second the gland was extirpated. Abortion invariably followed the second stage of the operation. Aschner finds less marked changes in the genital organs after his operations of extirpation than did Gushing and Biedl after partial removal. Aschner claims that the difference is due to the fact that by his special technic less injury is done to the brain substance than by Gushing' s intracranial method, and calls attention to the fact that lesions of various portions of the brain, cerebellum, and spinal cord may produce results in the genital system similar to those caused by "extirpation of the hypophysis. Further experimental evidence of the relationship between the hypophysis and the genital system has been afforded by the physiologic effects of various extracts of the hypophysis. Most of the earlier experiments were made with extracts of the posterior lobe. It was successively discovered that these extracts exercise a stimulating action on the musculature of the uterus, the bladder, and the intestines. Later they were found to possess a definite galactagogue influence, RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 75 acting either as a specific stimulant to the secreting mammary cells or as a con- strictor of the smooth muscle-fibers surrounding the milk ducts. The most interesting experiments bearing on the subject have been recently published by Goetsch, who studied the effects of overstimulation with anterior lobe pituitary extracts on the development and activity of the sex glands. In view of the retardation of genital growth produced by partial extirpation of the anterior lobe Goetsch reasoned that it might be possible to create premature sexual development by the prolonged daily feeding of anterior lobe extracts to young animals. The following quotation from Goetsch's article summarizes the results of his experiments : ''In comparison with the development in control animals the ovaries, tubes, and cornua of the uterus of animals fed with whole gland extract (in which the anterior lobe is the respon- sible factor) are larger, more vascular, and edematous in appearance, indicating increased development and activity. Even at the early age of two and two-fifths months, from one to two months before normal sexual maturity, the ovary is matured, and shows active ovulation and Graafian follicle formation, relatively few primordial follicles, and some increase in the amount of interstitial tissue. This striking appearance in so young an animal gives the im- pression that an early ovarian maturity has been produced by the feeding of the pituitary extract. The fimbriated end of the tube is more branched and the lining columnar cells are more ciHated, an indication of greater activity. There is marked hyperplasia of the uterine mucosa, the fining cells of which are more uniformly ciliated and active, and there is abundant gland formation in the endometrium. The appearance presented by the latter strikingly resembles in microscopic appearance the hyperplastic endometrium of early pregnancy. There is generaUy increased vascularity produced in the whole sexual system. The overdevelopment is apparent even in the muscle coat of the uterus, which is considerably thickened and is also more vascular. A somewhat similar change is produced by the feeding of corpus luteum to the female, but not to the same degree as after anterior lobe administration. "And, again, the feeding of pituitary anterior lobe extract to rats over prolonged periods was studied with the following results: After prolonged feeding of anterior lobe extract, over a period of eight or nine months, the sexual instincts are early awakened, along with the early maturity of the sex glands. As a result of this, a pair of rats, after anterior lobe feeding over a number of months, bred earlier and oftener, the female of this pair having two pregnancies in seven months as compared with none in the female of the control pair. The effect of the ante- rior lobe feeding lasts through the adult life of the animals. The control rat never reaches the degree of development and activity shown by the animal receiving the anterior lobe extract. For even at the age of ten months, after eight and a half months of anterior lobe feeding, the latter still shows a greater, more active, and mature sexual development than the control. "The feeding of pituitary anterior lobe to parent rats exerts its stimulating influence upon the offspring in intra-uterine life and during lactation, and, when the experiment is carried fur- ther and the feeding to the young is continued after weaning, it has an even greater stimulating effect upon growth, weight and development, and causes earlier and more frequent breeding, and an increased number of offspring in the litters. The stimulating effect upon the sex gland is greater, the longer the influence of anterior lobe administration is exerted. "The extract of pituitary posterior lobe, even after prolonged administration, does not stimulate growth in general, nor the development of the sex glands, as does anterior lobe even after a very short period. Thus, for example, there is a much less marked development of the , sex glands after administration for two and a half months. The posterior lobe element in the whole gland extract has an undoubted retarding influence upon the development of the sex glands, an effect very similar to that of ovarian extract upon the testes. This is shown by the relatively incomplete development of the testes, for example, after eight and a half months of posterior lobe feeding. If given in too large doses the extract causes in the rats loss of weight, a mild enteritis, and increased intestinal peristalsis." 76 GYNECOLOGY Clinically the reciprocal action between hypophysis and sex glands is mani- fested in numerous ways. Very striking is the influence of pregnancy on the size and weight of the hypophysis. Erdheim and Stumme made a systematic study of the hypophyses of women who had died during pregnancy, and proved that the gland always becomes hypertrophied during the pregnant state. They showed that the hypertrophy takes place only in the anterior lobe and that the posterior lobe not only does not share in the overgrowth, but actually suffers a certain amount of compression. On section the gland is lighter in color, is softer, and on pressure exudes a milky juice. This change in consistency is the result of a surprising change in the cellular elements of the anterior lobe. It is found that the chromophobe or principal cells have been transformed into an entirely new cellular type called pregnancy cells, large in size and accumulated in enormous numbers. They are arranged in broad columns and alveoli and at the height of pregnancy may assume the appearance of adenomatous hyperplasia. Cases have occurred in which the hypertrophy of the gland has been so great as to exert pressure on "the optic chiasm with resultant bitemporal hemianopsia (Goetsch). The acromegaly-like changes in the face and extremities that occasionally appear in pregnant women are thought to be due to hypertrophy of the anterior lobe of the hypophysis. After birth of the child the gland undergoes involution in a few months, though the number of chief cells or chromophobes remains per- mantly increased. At succeeding pregnancies the reaction is intensified and after repeated pregnancies there may take place a form of strumous degeneration with symptoms of hypophyseal deficiency. The author recalls two cases in which apparently changes in the hypophysis became patho- logic. In the first case a young woman after her first and only child became permanently amenorrheic. Though previously thin, she began soon after the birth of her child to accumu- late fat enormouslj^, so that in time she had the appearance characteristic of dystrophia adiposo- genitalis, the result doubtless of pressure on the posterior lobe of the hypophysis. The breasts became completely and permanently atrophied. At the age of about thirty-five she developed a cancer of the body of the uterus, a disease which commonly does not appear until after the menopause. The second case was one of a woman who after bearing several children ceased to men- struate at about the age of thirty-five. There ensued an increase of fat and partial atrophy of the genitals. Attention was called to a probable pituitary change by the typical acromega- loid appearance of the hands, which the patient said had assimied this character after the birth of her last child. The removal of the sex glands produces definite changes in the hypophysis. Fichera first described an enlargement and hyperfunction of the organ after the castration of numerous species of animals, and called attention to an increase of chromophils in the cells of the anterior lobe. Tandler and Gross demon- strated the same reaction in human beings. It was shown that eunuchs usually possess an enlarged sella turcica due to hypertrophy of the hypophysis, and it was pointed out that the skeletal peculiarities of the early castrate resemble in general RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 77 those seen in the disease giantism. The distrophic deposition of fat and the anomahes of skin and hair seen in eunuchs recall appearances characteristic of certain forms of pituitary disease. Tandler has demonstrated an enlargement of the hypophysis in castrated women. It has already been suggested that the hypophysis is, to a certain extent, a sexual organ. It is readily conceivable that after the removal of the sex glands in maturity the internal secretory function of stimulating the libido is carried on by the hypophysis. It is quite possible that the compensatory hypertrophy of ' the anterior lobe is nature's provision for carrying out this purpose. Support is lent to this idea by the increase of the sexual impulse that often follows late castration, a fact that may be explained by overstimulation from the hyper- trophied sex elements of the anterior lobe. The relation of the ovaries to the hypophysis is well illustrated by the case reported by Goldstein of a woman who in her youth had shown some tendency to giantism. At the age of thirty-eight she was subjected to a panhysterectomy for myomatous uterus. Soon after the operation she developed a very marked case of acromegaly. In this instance the influence of the ovaries had held in check the strong tendencies of the hypophyseal secretion. When the neutrahzing effect of the ovaries was removed the abnormal tendency of the hypophysis was manifested by the development of acromegaly. The influence exerted on the sexual glands by changes in the hypophysis is manifested through the effects of increased or diminished function of the gland. Hyperf unction, technically termed hyperpituitarism, is due to increased activity of the anterior lobe consequent upon adenomatous enlargement or hyperplasia of that portion of the gland. The increased secretory activity is referable to the chromophil cells which may be regarded as primarily the sexual elements of the pituitary organ. If under the influence of a diseased condition hyperplasia of the anterior lobe occurs before puberty, the ultimate result is gigantism. If i the hyperplasia takes place after maturity, acromegaly ensues. ^ During the early hyperactive stage of these diseases there takes place an | active stimulation of certain of the other organs of internal secretion, notably the sex glands. Thus in giants there may be a precocious acquisition of sexual power and secondary sex characters, attended with abnormal muscular strength. Acromegalics during the early stages may exhibit a great accentuation not only of sexual vigor, but of all their intellectual and physical powers. In the course of time, however, in both gigantism and acromegaly the overactive tissue of the anterior lobe of the hypophysis undergoes a regressive change in the form of strumous tumor, with tendency to cystic degeneration. Under these conditions the once hyperfunctionating organ is transformed into one in which the function becomes deficient. A corresponding hypofunction occurs in the rest of the organ- ism, especially in the sex glands. Men lose their libido sexualis and become impotent, while women become amenorrheic and sterile. Genital atrophy eventually occurs. The ovaries of acromegalic women show atrophic changes 78 GYNECOLOGY on the part of the Graafian folHcles and interstitial tissue with absence of corpora lutea. Hypofunction of the hypophysis, or hypopituitarism, as it is called, may occur secondarily as in gigantism and acromegaly after a period of increased activity or it may be primary. Primary hypopituitarism may be the result of certain inherent degenerative processes or more commonly the outcome of pressure either of the hypophysis itself or of a neighboiing organ. If it occurs before puberty there is a retardation in skeletal growth in the form of true dwarfism in contradistinction to the condition of gigantism which follows pre- pubertal hyperf unction of the hypophysis. Individuals of this kind possess typical characteristics. In addition to the undersized stature there is an aplasia of both the genital and interstitial elements of the genital glands, deficient growth of hair, and the pecuHar distribution of fat referred to before in conditions of dystrophia adiposo-genitalis. The reproductive organs and secondary sex characters are infantile and there is a general sluggishness of metaboMsm as indicated by polyuria. There may be symptoms of pressure on the optic nerve. In other words, these dwarfish individuals correspond in every physical respect to the experimental dogs of Gushing and others, in which the anterior lobe of the hypophysis has been partially extirpated. When the condition develops after maturity similar though less marked changes appear, i. e., adiposity, hypotrichosis, retrogression in the sex organs with irregularities of function and various abnormalities of metabolism. In addition to the well-defined cases of hyper- and hypopituitarism there are cases in which the symptoms are confused as a result of a state of increased and diminished activity occurring in the same gland at the same time. To such a condition has been given the term dyspituitarism. Organotherapy. — From a therapeutic standpoint extract of the posterior lobe (pituitrin) has proved of the greatest value, particularly in obstetrics. Although the extract has a stimulating influence on unstriped muscle generally, it seems to exert a specific action on the parturient uterus. Pituitrin acts as a powerful stimulant to uterine contractions and is, therefore, of use in accelerating labor and in preventing postpartum hemorrhages. It is rarely toxic, but it is attended with certain dangers when used in labor. It is, in general, contraindicated during the first stage of labor, the dangers being excessive pains on account of the powerful uterine contraction and rupture of the uterine wall if there is weakness of the musculature or obstruction to the labor. Another danger is asphyxiation of the child in cases where subsequent rapid delivery cannot be carried out. Pituitrin produces a sudden and somewhat prolonged rise in blood-pressure and in some cases this may prove dangerous to the patient. The extract, is most useful during the second stage of labor, in cases in which normal progress of labor has stopped. By its use many low forceps operations are avoided, while in many cases in which high forceps would ordinarily be necessary, delivery is brought about by a simple low forceps operation. RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 79 In the postpartum hemorrhage pituitrin has not taken the place of ergot. Williams recommends its use in conjunction with ergot. It acts more rapidly than ergot, but its effects are more transient; hence the best effects may be pro- cured by administering pituitrin first and following it later with ergot. Williams also recommends pituitrin as a prophjdactic against hemorrhage in cesarean section. It is important not to administer the drug before dehvery of the child on account of the danger of asphj'xiation. Immediate^ after de- livery 1 c.c. of the pituitrin is injected directly into the posterior wall of the uterus. The uterus undergoes a rapid and powerful contraction. Pituitrin has become a useful adjunct in the treatment of intestinal paresis and distention foUowing abdominal operations. Some even go so far as to employ it as a routine. The first dose is given from four to six hours after operation, and may be repeated a number of times at intervals of four to six hours according to indications (Goetsch). We have found it useful in a number of cases of severe distention, and in two cases it was apparently a life-saving measure. Pituitrin is said to be valuable for stimulating the bladder in postoperative retention. In our experience it has proved disappointing when administered for this purpose. Pituitrin is usually given hypodermically in doses of 1 c.c. from sealed ampules. The injection should be intramuscular. In our experi- ence we have never noted any toxic effects in its use for postoperative distention. Pituitrin has been frequently advocated for the treatment of functional menorrhagias, especially in those that occur in young women. We have found it of httle or no value. Extracts of the hypophysis have been used successfully in the treatment of patients suffering from pituitary deficiency. As Gushing has pointed out, in most of these cases both lobes are affected. The loss of libido and potentia in the male and amenorrhea and sterility m the female, which are chai'acteristic of hypophyseal disease, are, as we have seen, referable to disturbances of the ante- rior lobe, while the accumulation of fat and metabohc ^regularities are the result of defects in the posterior lobe. Gushing and his school, therefore, recommend for the treatment of these cases extracts made from both lobes of the gland. In gynecologic practice extracts of the whole gland are indicated in menstrual disorders that are essentially the result of pituitary deficiency, in which cases ovarian therapy may be used in combination. Goetsch calls attention in hypo- physeal therapy to the importance of constant and long-continued treatment with increasing dosage for successful result. He recommends beginning with 5 grains of the dried extract of the whole gland thi-ee times daily and increasing this dosage until improvement is noted. THE THYROID The variations in size of the thyroid gland during certain phases of the female sexual life has been observed since the earhest times, but only recently has the subject been put on a scientific basis by exact clinical observations and animal experimentation. 80 GYNECOLOGY It has been observed that at puberty the thyroid at times takes on a marked enlargement, which is much more intensive and much more common in girls than in boys, and it has been suggested that many of the puberty symptoms in girls, such as tendency to heart palpitation and the evidences of vasomotor disturbances, may be due to a hypersecretion of the gland at this period. Experiments have shown a certain antagonism between the ovaries and the thyroid gland. Animals that have been castrated early exhibit an abnormal length of certain bones, especially the tibia, while in animals from which the thyroid has been extirpated these same bones are excessively short. The early extirpation of the thyroid produces a certain amount of degenerative change in the ovaries or testicles, delays the time of puberty, and greatly limits the productivity of the individual. It has been well estabhshed that the thyroid swells during menstruation, a phenomenon that has long been observed, and as proof that this is not due to hyperemia is adduced the fact that sometimes these menstrual swellings are the starting-point of permanent goiters. Women with diseased thyroids usually have menstrual disorders. Kocher has observed that patients on whom a too radical goiter extirpation has been performed suffer from menorrhagia, and has treated such cases successfully with thyroid extract. He terms this condition menorrhagia tMjreopriva. That the relationship between thyroid and genitals is not understood is shown by the fact that in some cases of hypothyroidism, or myxedema, there is amenor- rhea, and that thyroid extract works beneficially for the conditions both of menorrhagia and amenorrhea when the gland is diseased. Interesting clinical observations have been made which seem to show some definite con- nection between th>Toidism and menstruation. Klokow reports the case of a seventeen-year- old girl who, whenever her menses were delayed, always developed a goiter, which immediately vanished as soon as the period appeared. Steinberger reports the case of a girl of sixteen who suddenly ceased flowing during one of her periods and at the same time developed a goiter. Treatment with iodin caused the goiter to disappear, whereupon the menstrual flow was re- sumed. The swelhng of the thyroid gland is most noticeable during pregnancy, H. W. Freund having demonstrated it in 45 out of 50 cases. Lange regards the process as a physiologic one, and considers it due to hypertrophy rather than to hyperemia of the organ, because of its amenability to iodin treatment. Lange also made the interesting observation that women in whom the thyroid does not swell exhibit a renal albuminuria, and expressed the beHef that the swelhng of the thyroid acts as a protection against certain poisons which are set free as a result of pregnancy, and which, without the protection of the secretion from th'e hypertrophied thyroid, are injurious to the kidneys. As a rule, the enlargement of the thyroid gland gradually disappears after the end of pregnancy, but not a few cases have been reported in which a perma- nently increasing goiter dated from a pregnancy. EELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 81 The thyroid swelling of pregnancy is ordinarily only very moderate, but several cases are cited in the literature by Novak where the goiter became so large as to threaten the patient's life, necessitating either a tracheotomy or artificial interruption of the pregnancy. During labor the thyroid is said to take on a still greater enlargement, which in a few cases has resulted in extreme dyspnea and death. The swelhng of the gland gradually recedes after labor, though it has been observed to be maintained to some extent through the lactation period. The influence of the climacteric on the thyroid gland is little known, and the subject is largely a matter of speculation. Several instances of Graves' disease have occurred at the climacteric, and have led to the suggestion that the neuropathic and vasomotor symptoms of the change of life are the result of hyperactivity of the thyroid gland. The relationship between myomatous uteri and thyroid diseases was first remarked by W. Freund in a paper written in 1891. Many interesting observa- tions have been made on this subject, but the relationship cannot be very con- stant, as a coincidence of the two conditions is certainly not particularly com- mon. Glaessner reports the case of a woman suffering from myoma and Graves' disease in whom both diseases disappeared at the chmacteric, while Frankel cured a myoma and a goiter at the same time by the use of the x-rays. Frankel explains both these cases on the theory that both cures were due to the injury to the ovaries. The most recent theory connecting uterine myomata with the thyroid gland is that of Neu, who attempts to account for the heart lesions so often found in long-standing fibroid cases, a condition which he styles the ''myom- herz." This myoma heart he regards as due to the effect on the heart of the thyroid disturbance with which myomata are sometimes associated. Hjrperthyroidism. — Basedow's disease is about eight times as common in women as it is in men, and occurs chiefly during the sexual period of life. It is usually associated with a certain amount of atrophy of the genital organs, which is often manifested by amenorrhea and a tendency to steriUty. Sterility, however, is by no means constant, and when impregnation does occur it usually has a deleterious effect on the diseased thyroid. A few cases have been re- ported in which an intercurrent pregnancy has exerted a favorable influence on the disease, but the general experience is to the contrary. Exophthalmic goiter is frequently seen associated with gynecologic dis- ease, such as misplacements, pelvic inflammation, etc., and the question of operation is a most important one. It may be said that the disease is some- times made worse by the shock of a surgical operation, and that, therefore, operative measures should only be undertaken in cases of necessity, or when it is obvious that the thyroid disease is being distinctly aggravated by the pelvic lesion. 6 82 GYNECOLOGY In one case in the author's experience in which there had been severe dysmenorrhea both the patient's general condition and the thyroid disease were distinctly improved by the opera- tion; in another case Graves' disease was not discovered untU after the operation, which un- questionably aggravated the disease to such an extent as to make it definitely noticeable. To persons suffering from exophthalmic goiter the question of marriage and reproduction is an important one. It is necessary to take into considera- tion the undoubted fact that either the tendency to the disease or ahied neurotic conditions may be transmitted by heredity, while the danger of aggravating the disease by pregnancy is a matter of moment. H3rpoth5n:oidism (Mjrxedema, Cretinism [Novak]). — Our knowledge of the resulting conditions of hypothyroidism is gained from animal experimen- tation, operations on human beings for goiter, and the clinical effects of absence or destructive disease of the thyroid gland. Removal of the thyroid of young animals produces constant and charac- teristic appearances, consisting of an immediate limitation of growth, especi- ally of the long bones, changes in the growth of the hair, lowering of the tem- perature, thickening of the skin, atheromatous changes of the aorta, genital hypoplasia, sterility, and idiocy (v. Eiselsberg). In older animals the changes are somewhat less marked and are charac- terized b}^ apathy, disturbances of the skin and digestion, emaciation, anemia, and lowered resistance to disease. The genital functions are diminished, but not always entirely destroyed. These experimental results in animals correspond very closely to the effects of thyroid removal in man, when all the gland structure (excluding the para- thyroid) has been extirpated. The condition has been termed "cachexia strumi- priva" (Kocher) and "postoperative myxedema." In the young complete re- moval brings about changes similar to those described in animals, sexual devel- opment being either entirely prevented or much delayed. Congenital myxedema or thyreaplasia relates to a condition where there is entire absence of the gland. The picture is characteristic and familiar — dwarf- ism, cretinic facies, peculiar thick, dry skin, broad nose, wide nostrils, and thick lips. There is very marked hypoplasia of the genital organs and mental defectiveness. This condition is said to be hereditary, being influenced by blood relationship or alcoholism of the parents. The disease does not make its appearance until the second half of the first year, it being supposed that in uterine life and during the lactation period the child receives thyroid secretion from its mother. Infantile myxedema is the result of an early atrophy of the thyroid gland in children who are born normal, and remain so until the fifth or sixth year, when they acquire the myxedematous condition. The disease is far more common among girls than boys. The genital system at puberty remains in the infantile stage. The other appearances of hypothyroidism are like those of congenital myxedema, only not as severe. RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 83 Myxedema of adults is more common than the infantile type and is seen especially in certain countries. It is the result of atrophy of the thyroid gland from either a simple or inflammatory process. The disease is characterized by dryness, thickness, and coolness of the skin, which shows swellings, especially of the face, neck, and extremities. The hands look plump and short, the eye- Hds hang down, and the upper hp is thick and protruding. The patient be- comes apathetic and indolent. The speech is slow and expressionless. Sweat secretion entirely ceases. The blood is reduced in red corpuscles and hemo- globin (Novak). The etiology of adult myxedema is not definitely known. Heredity seems to play a certain role, as shown by examples where it has appeared in several members of the same family. The disease is found chiefly in women, the proportion being estimated as high as 80 per cent. In a very large number of cases there are found pelvic disturbances, which, however, are probably rather the result than the cause of the disease. Severe intrapartum bleeding and too frequent chilclbearing have been assigned as etiologic factors. Sometimes myxedema develops during pregnancy. The special genital symptoms that occur with myxedema are usually in the form of menstrual disturbance, either as amenorrhea or menorrhagia, for both of which conditions thyroid extract works beneficially. The disease does not always alter the genitaha, but may cause marked atrophy. Another form of hypothyroidism is seen in the condition of endemic cretin- ism, in which the disease is associated with goiter and is confined to certain localities. The etiology of this affection, usually referred to drinking-water, cannot be discussed here. Hereditary influences unquestionably play some part in its transmission. The disease manifests itself by myxedema and disturbance of genital develop- ment. As a rule, the genitals preserve the infantile type, and there is partial or complete lack of development of the secondary sexual characters, especially apparent in the breasts and pubic hair. Sometimes the genitals mature nor- mally and the individual may procreate, but is hable to dystocia on account of narrow pelvis. THE PARATHYROIDS The influence of the parathyroids on the organism has been studied experi- mentally in animals. It has been found that in all animals where all four para- thjToids are removed death follows from acute tetany, while a partial removal of the parathyroids may or may not produce a condition of chronic tetany. The subject is of interest here in relation to the tetany of maternity, which is thought to be the result of parathyroid insufficiency. Following in fine with animal experiments in which, by many investigations, successful results on tetanized animals were obtained by the implantation of parathyroid tissue, von Eisels- berg has succeeded in effecting a permanent cure of recurring tetany in a woman g4 GYNECOLOGY by transplanting a parathyroid gland from a patient who was undergoing a goiter operation. The results of parathyroid extract administration in cases of tetany have so far not been particularly encouraging. An attempt has been made to show a relationship between the parathyroids and the conditions of eclampsia and osteomalacia. Favorable results have been reported of the use of parathyroid in cases of eclampsia, but the relation- ship has not been scientifically proved and is a matter of doubt. The same may be said of osteomalacia. THE SUPRARENAL SYSTEM A knowledge of the histology and comparative anatomy of the suprarenal system is essential for an understanding of the present theories regarding its internal secretory functions. Comparatively recent studies have shown that the suprarenal bodies, formerly regarded as homogeneous organs, in reahty represent the union of two different and independent organic systems. This knowledge was gained first by the frequent discovery of small bodies isolated from the main glands which from their histologic structure could only be regarded as accessory parts of the suprarenals. Secondly, comparative anatomy showed that in the lower vertebrates the two tissues which constitute the cortex and medulla of the suprarenal glands exist as two anatomically separate systems. Furthermore, comparative embryologic studies revealed the fact that two independent systems are evolved from two separate primordial beginnings, which in the higher vertebrates become topographically united in the form of a single gland. The cortex of the suprarenal body is originally derived from the mesoderm and is, therefore, a connective-tissue structure, a point which is of importance in considering its relationship with the glands of sex. The cells of the cortex are arranged in rows and columns. Their protoplasm is filled with fat or Hpoid granules. The cortical cells resemble closely the interstitial and luteal cells of the ovary both in their general arrangement and in their possession of lipoid granules. The medulla, on the other handj is derived from the ectoderm and is, therefore, an epithelial structure. It has a common origin with the sympathetic nervous system from which it separates in the process of embryonic evolution. The cells of the medulla, richly supplied with nerves and vessels, are arranged in spheroid or cord-like masses. They have an affinity for chromic acid from which they receive a brownish stain; hence they are called chromaffin cells. Thus the cells of the cortex are distinguished by their hpoid contents and the cells of the medulla by their chromaffinity. Besides the two suprarenal capsules there are to be found isolated cell aggrega- tions in certain parts of the body, some of which contain cortical and others medullary tissue. Rarely cell bodies are found containing both cortical and medullary tissue, thus constituting true accessory suprarenals. The accessory cortical cell collections are found in the neighborhood of the suprarenals; in the RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 85 renal substance itself; along the suprarenal veins; throughout the retroperitoneal space extending down into the pelvis; in the broad ligaments, and in the sex glands (ovary and testes). It will thus be seen that the cortical accessory- bodies He in general along the path traveled by the sex glands. The accessory medullary cell accumulations have a definite independent distribution. Inasmuch as the medulla of the suprarenals had a common em- bryonic origin with the sjTiipathetic nervous system, the accessory portions are found distributed along the sympathetic nerves and ganglia partly as isolated cells, partly as small cell bodies, and partly as glandular structures. The last named are invariably found at the bifurcation of the carotid artery and at the abdominal division of the aorta, and have received special names (carotid gland, accessory organs of Zuckerkandl) . All these accumulations are made up of chromaffin cells like those of the suprarenal medulla. Hence the meduUa with all its accessory elements is termed the chromaffin system. Thus it will be seen that the cortical portions of the suprarenal system is anatomically closely as- sociated with the urogenital organs, while the medullary or chromaffin portions are intimately connected with the sympathetic nervous system. "With this brief description of the anatomy of the suprarenal apparatus it wall be easier to understand its otherwise confusing physiology. The two systems of the suprarenal apparatus, cortical and medullary, have each an independent internal secretory function. Most of our present knowledge of the specific secretions of the two parts of the suprarenals relates to the medul- lary or chromafiin system, which elaborates the hormone, called adrenalin (or adrenin or epinephrin). Before the discovery of the independence of the two parts that constitute the suprarenal organs the whole glands were called the adrenals, from which the word "adrenalin" was derived. In the modern scientific treatises the medulla and its accessory tissue are generally referred to as the adrenal system. This nomenclature is apt to create confusion in the mind of the student. In contradistinction to the adrenal system, the cortex and its subsidiary tissue is termed the "interrenal systent" In order to prevent confusion we have purposely avoided using these terms. The physiologic functions and chemistrj^ of adrenalin are better known than those of any other hormone of the body. It is probably necessary to the Hfe of the organism. Experimental extirpation of the medulla does not always cause death, but in these experiments only part of the chromaffin substance is removed, for the adrenal function is carried on by the accessory tissue which is scattered throughout the body in association with the sjTnpathetic nerves and gangHa. These free portions of the system actually comprise collectively a mass of active functioning tissue considerably greater and more important than that part which is enclosed in the suprarenal capsules, namely, the medulla (Biedl). Adrenalin, owing to the origin and distribution of the chromaffin tissue, has a specific affinity for the sjTnpathetic nervous system and exclusively influences those parts of the body which are ennervated by the sjnnpathetic system. The 86 GYNECOLOGY results of its action correspond identically with those produced by electric stimula- tion of the sympathetic nerves supplying those organs (Biedl). Space does not permit a full discussion of the physiologic significance of the chromaffin tissue. The following brief summary of its action is taken from Falta : "The physiologic significance of the chromaffin tissue may be adduced from what has just been said with regard to adrenalin's intensive and manifold actions. We may assume that it maintains the normal excitabihty of the sympathetic nerves and that by means of graduation of the secretion it is concerned in the regulation of the blood-pressure, the distribution of blood, and the tonus of all other organs innervated by the symphatetic; further, that it maintains constant the amount of sugar in the blood and enters in a regulatory manner into other factors of the metaboUsm ; further, that it influences muscular power (whether directly or through carbo- hydrate metabolism is questionable) ; and finally it exercises an influence on the production of neutrophilic leukocytes and on the plasma contents of the circulating blood." Of especial interest is the fact that the hormone of the chromaffin system is greatly influenced by conditions of emotional disturbance. Cannon has shown experimentally how such emotions as fear, anger, desire, etc., may powerfully affect the output of adrenalin, either by suppression or accentuation, with cor- responding changes in the organs innervated by the sympathetic system. In view of the emotional lability that characterizes woman's nature especially at such critical periods as puberty, menstruation, pregnancy and the menopause, and the organic disturbances that occur at such times, there undoubtedly exists through the medium of the emotions an important relationship between the organs of generation and the internal secretion of the chromaffin system. The following quotation from Cannon gives an excellent idea of some of the interesting work he has done on the relationship of the secretion of adrenalin to the emotions: "When a cat becomes infuriated the pupils are dilated and the hair is erect from the neck to the end of the tail. But besides these surface manifestations there are internal changes; for example, the heart beats rapidly and the activities of the stomach and intestines are stopped. Both the internal and the external changes are due to the passage of nerve impulses to viscera along the neurons of the sympathetic division of the autonomic system. The relation of the fibers connecting the central nervous system with these neurons is such as to provide for diffuse action on all the viscera that are innervated by this division. "The suprarenal glands are supplied with nerves from the sympathetic division; and also the secretion of the suprarenal medulla affects all structures innervated by the sympathetic division precisely as if they were being stimulated by its impulses. We have found that the suprarenal glands secrete epinephrin in times of great excitement, that there is an increased Uberation of sugar from the fiver so that glycosuria may result, that there is an abolition or prompt lessening of muscular fatigue, and that there is a very much more rapid clotting of blood. It is known also that epinephrin causes a redistribution of blood in the body so that it is sent away from the alimentary canal, whose activities are inhibited, to the heart, the lungs, the central nervous system, and active skeletal muscles. It is known, also, that epi- nephrin causes dilation of the bronchioles, and it is known that it increases the number of red blood-corpuscles per cubic miUimeter — an increase which Lamson has shown occurs also to a marked degree in case of emotional excitement. "These changes, as true of man as of the lower animals in times of great emotional stress, are significant when the conditions which would give rise to the emotions are considered. Fear RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 87 is associated with the instinct to flee; rage, with the instinct to fight These are the emotions and instincts underlying the struggle for existence. They are also the emotions and instincts into which all other instincts may be readily turned when they are thwarted. The internal changes are all directed toward increasing the efficacy of the organism for physical struggle. The increased blood-sugar provides a source of muscular energy. The altered distribution of blood and the increased number of red blood-corpuscles arrange for carrying an abundance of oxygen to the active structures. The dilated bronchioles allow ready ventilation of the lungs when oxjrgen is greatly needed and carbon dioxid is being produced in large amounts. The provision for lessening muscular fatigue is directly useful in muscles likely to be employed in continued action. The rapid coagulation of blood tends to preserve that precious fluid in case of injury to blood-vessels. The organism in which these changes most promptly occur has the greatest reinforcement of its abilities and is most likely to be favored in physical struggle. These arrangements for reinforcement account for the great power and endurance which are exhibited in times of intense excitement." Of the cortical (or interreiml) part of the suprarenal system unfortunately comparatively little is known at present, although what few facts are at hand lend sufficient evidence that it bears a relationship to the sexual apparatus of considerably greater significance than does the chromaffin system. Experiments testing the physiologic action of extracts of cortical substance have not up to the present time produced very significant results : " R. G. and A. D. Hoskins have carried out a series of experiments on white rats in which certain of the young animals were fed with desiccated adrenal gland (Parke, Davis & Co.), while certain others were kept as controls. Forty-five rats were fed with adrenal body for varying periods of from nine to twelve weeks. Twenty-six animals from the same litters were kept as controls. The rate of growth and the weights of various glands were determined in each series. No differences between the two series could be detected in the case of the kidneys, heart, pituitary body, thyroid, thymus, or adrenal bodies. The spleens of the experimental series were somewhat smaller than those of the controls, but highly va- riable in size. The ovaries in the few cases studied were larger in the experimental series. The testes (26 experimental, 13 control) showed hypertrophy. These results indicate that the adrenal bodies exercise a stimulating effect on the growth of the testes in young ani- mals." (Quoted from Vincent.) A functional relationship between the sex glands and the suprarenals was first announced by Meckel, who observed that animals endowed with the strongest sexual powers are also possessed of markedly developed suprarenals. He also found macroscopic changes in both glands in birds and amphibia during the rutting period. Meckel's observations, made over one hundred years ago, have to a certain extent been confirmed by more recent researches. Defective development of both glands is often found associated, a result, doubtless, of their original proximity in embryonal life. Negroes are distin- guished by a greater development both of sex and suprarenal glands than is seen in white races, a fact which confirms in the human race the observations made by Meckel in animals. Further evidence of the correlation between the two glands is the occasional appearance in the realm of the genitals of accessory suprarenals consisting of cortical and even chromaffin tissue. One observer has demonstrated chro- 88 GYNECOLOGY maffin tissue in the ovary itself. In hypoplastic individuals with underdevel- oped sex glands a diminution of the suprarenals has also been noted, though this is now thought to be not a specific result of sexual deficiency, but a part of the general hypoplastic constitution. In the condition of status thymico- lymphaticus there is also associated hypoplasia of both glandular elements. Marine emphasizes the similarity between the cells of the cortex and the interstitial cells of the ovary both as to structure and their high hpoid content, and it is now generally believed that the interstitial cells of the sex gland play an important part in the development and main- tenance of the secondary sexual characters. If the two tissues are identical it is probable that the cortex also influences bodily growth. Strength is lent to this theory by the fact that both tissues reciprocate in their physiologic hyperplasias. Still further evidence that the supra- renal cortex influences growth is seen in the occurrence of cortical hyperplasia in acromegaly. As an expression of hyperfunction of the suprarenals a number of cases of female pseudohermaphroditism have been reported combined with the pres- ence of hypernephromata, and it is thought that there is a probable causal relationship between the two conditions. Numerous cases of this kind have been reported. To this list is added the following, for which the author is indebted to Dr. E. A. Codman, in whose prac- tice the case occurred: The patient, a woman of thirty-four, had been married five years and had no children. As a girl she had always appeared more masculine than her sister. She had a hairy condition about the nipples, under the arms, and in the middle of the chest like a man. The breasts were atrophic. She had also had hair on the chin sufficient to require shaving. The genitals were hypertrophied, the clitoris looking like the penis of a boy four or five years of age. There was no abnormality of the vagina and later at operation the uterus, ovaries, and tubes were found to be normal. Her catamenia had always been peculiar. She had had a profuse watery kind of discharge as a rule, but in 1909 following a severe shock her catamenia became normal for three months. In 1915 it stopped altogether and had not appeared since. In September, 1916, she noticed an enlargement just below the right costal border in the region of the liver. She was seen by Dr. Codman on December 19, 1916. At this time she had a very large tumor extending from the crest of the ilium upward to the right vault of the diaphragm from which it had pushed the liver over to the left side of her abdomen. The tumor had also pushed all the abdominal contents to the left side and extended a couple of inches beyond the median line and downward well below the umbilicus. It was painless, cystic in feeling, and not tender. She had no symptoms except a shght feeling of distention after meals and some loss of weight. An operation was performed by Dr. Codman. The operation was of great magnitude, but was successful and the patient made an excellent recovery. Microscopic examination showed the tumor to be made up of cells similar to the cortical tissue of the suprarenal body. The character of the tumor was malignant. The after-history of this case is extremely interesting in that it shows a beneficial effect on the secondary sex characters after the removal of the tumor. The following is an excerpt from a report by Dr. Codman: "The result of the case of Mrs. W. with the adrenal tumor was extraordinarily interesting. She returned to my hospital on September 2, 1917, with local recurrence in the scar and around the vena cava and kidnejr, but she had been wonderfully well since the first operation. Greatly to my surprise, I found that the secondary sexual changes had been very much improved. The hairy condition on the chest and even on the chin had been greatly reduced. Since the RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 89 operation she had menstruated regularly with a normal flow for the first time in her hfe. The breasts, instead of being perfectly flat like a male, had developed to a moderate size, and in the upper half of the left breast was a tumor which I took to be a chronic mastitis. It was like the caked condition one sees during menstrual period in some cas^s. She gained 30 pounds and felt well. The hypertrophy of the genitals was much less. She stated that she had never been so well and happy in her life." On account of the extensive recurrence a second operation was undertaken, but the disease had involved the great vessels of the abdomen to such an extent that the attempt to remove it eventuated in the death of the patient. Hypernephromata in children produce precocious sexual development, most of the cases being in female individuals. These children show a special form of precocity, in that there is an abnormally early development of certain primary and secondary characters, such as the external genitals, pubic hair, and general bodily form without symptoms that bespeak a true function of the sexual glands, namely, menstruation or ejaculation. In general it may be stated that clinical evidence favors the view that when cortical tumors occur in the female an accentuation of male secondary sexual characteristics develops, and simultaneously a hypoplastic condition of the inter- nal generative organs supervenes (Vincent). It is well established that castration is followed by a hypertrophy of the suprarenal gland, but whether this represents a compensatory process for the loss of the ovarian secretion is not definitely known. Attention has been called in this connection to the close similarity between the corpus luteum cells and those of the suprarenal cortex. There is considerable evidence that- the adrenal tissue, both that of the cortex and medulla, is hypertrophied during pregnancy and probably at menstruation, a result doubtless of increase of function. Individuals with Addison's disease frequently have a deficient genital endowment, which is regarded as a part of a general constitutional hypoplasia that predisposes to the acquisition of the disease. There are also variations in the secondary sexual characters. Addison's disease in female children, as a rule, prevents the appearance of the menses, and if it appears in adults it manifests itself by amenorrhea as one of the earliest symptoms, a matter of considerable diagnostic importance. Dysmenorrhea and menorrhagia are very rare symptoms. Individuals with Addison's disease rarely get pregnant, but if they do, abortion or premature labor are apt to occur. The effect of pregnancy on the disease is a deleterious one. Pigmentation of Addison's disease appears most markedly on the parts about the external genitals, and may be confined to this locality. Of diag- nostic interest is the fact that pelvic tumors, especially fibroids, sometimes cause pigmentation of the skin quite similar to that of Addison's disease. 90 GYNECOLOGY PINEAL GLAND (EPIPHYSIS) The pineal gland, which in some animals, notably reptiles, constitutes a well-developed organ, is in man comparatively insignificant in size (1 cm. and 0.5 cm. broad). Histologically it is composed of a few glandular cell elements held together by connective tissue. At about the seventh year the organ begins a process of involution which is completed at about the age of puberty, though a small amount of glandular tissue persists throughout life. The importance of the epiphysis to the human organism is variously estimated. It is of historic interest that Rene Descartes regarded the structures as the seat of the soul. It is thought by some that it is only a "functionless vestige of what was once in earlier evolutional stages a functioning eye." That it is an organ of internal secretion has been determined chiefly from clinical evidence and it is now gen- erally accepted that the organ exercises a greater or less influence on the bodily and mental development of the individual and upon certain nutritional tissues. To the clinical evidence that the epiphysis is an endocrine gland has been re- cently added confirmative proof from observations on the growth of young animals under the infiuence of pineal feeding, the experiments of McCord being of chief importance. Earlier deductions regarding the action of pineal secretion were made from the bodily changes created by tumors of the pineal gland in children. These growths are rare, only a few having been reported. They comprise cj^st formations, gummata, and tumors of various kinds, including teratomata. They occur chiefiy in males. The symptoms are both local and constitutional, the local symptoms being due to intracranial pressure and to encroachment of the tumor growth on neighboring brain structures. The con- stitutional symptoms are those that may be referable to disturbances in the func- tional activity of the pineal internal secretion. These consist in children of an abnormal increase in bodily size and of a precocious development of the sex organs. The sexual precocity is characterized by acquisition of pubic and general body hair, and in boys by a change in voice. The genitalia and secondary characters of a boy of five and a half years may correspond to those of puberty, as in a case of von Frankl-Hochwart. There is also usually a precocious psychic development evidenced by prematurity of thought. As the disease progresses and the gland becomes completely destroyed cachexia, decubitus, etc., ensue. When the disease occurs late in childhood or during adolescence or after maturity it is characterized by excessive obesity. According to Marburg, hypopineahsm leads to sexual precocity, hyperpineahsm to general obesity, and apinealism to cachexia. Biedl calls attention to the fact that there must exist an antagonism between the pituitary and pineal glands, for, as we have seen, pituitary insufficiency inhibits sexual development. Falta emphasizes the similarity in sexual precocity that exists between the constitutional effects of tumors of the pineal gland and hyperplasias of the suprarenal cortex. He thinks it possible that the trophic disturbances of the pineal glandular tumors infiuence the cortical system and cites a case in which hyperplasia of the cortex was found at autopsy. RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 91 Experimental evidence regarding the internal secretory action of the epiphysis is meager and somewhat contradictory. Conclusions from extirpation of the gland are at variance. Dandy's experiments led to the inference that the pineal gland is not essential to life and that it has no active endocrine function of im- portance to the animal's well-being. His conclusions coincide with those of earlier investigators. The more recent investigations of Horrax, however, developed that pinealectomized male guinea-pigs exhibit a premature sexual development, while females show a tendency to earher breeding. Horrax's results are in keeping with those of C. Foa, who found after extirpation of the epiphysis in young fowls a very marked precocious development of the testes and some of the secondary sexual characteristics. The clinical and experimental observations thus far described lead to the inference that the pineal gland secretes a substance which in early hfe before involution of the organ inhibits sexual development, and that such development is encouraged by conditions of hypopinealism. It would, therefore, be expected that the administration of pineal extracts would act as a deterrent to sexual maturity. Such, however, is not the case, as is shown by the experiments of McCord, which furnish one of the curious incongruences frequently seen in the study of the endocrine glands. In a recently published article McCord reports an extraorchnary premature increase in the testes of young male guinea-pigs and an earher sexual maturity in the females after pineal feeding. Administration of pineal substance to tadpoles produced accelerated growth. In unicellular organisms (paramecia) it increased the rate of production to more than double the normal, and in larval forms (ranidse) it hastened both growth and the differentiation of specific organs. THYMUS A relationship between the genital system and the thymus has long been observed in the involution of the thymus that normally takes place at puberty. Animal experimentation has shown that castration of young animals prolongs the time of thymus involution. Other observations reveal that in individuals with hypoplastic genitals involution takes place later than normal. Status thymicus is, therefore, associated with genital deficiency. Further researches have shown that castration in the young produces no observable change in the structure of the thymus, but that castration after sexual maturity causes a definite enlargement of the parenchyma. Extirpation of the thymus has failed to prove any reciprocal functional correlation between the thymus and the genital glands. UTERUS It has been suggested that the uterus produces a toxic inner secretion, the harmful influence of which is neutrahzed by the presence of the ovaries. Such a theory would account for the deleterious after-effects of double oophorectomy 92 GYNECOLOGY operations where the uterus has been left in. The theory, however, has no scientific, basis, there being no evidence nor probabihty of a uterine internal secretion. PLACENTA In the first few days of birth are noted certain appearances that have been referred to a reaction following the loss of placental secretion, and described as analogous to the involution processes of the mother. These changes in the newborn include the swelling of the breasts, from which comes a colostrum- like secretion, and in females a hyperemia and enlargement of the uterus, which in some cases may result in a discharge very hke that of menstruation (see page 18).i It is thought that the placenta exercises a very important influence on the mother during pregnancy, and that after the primary decidual reaction and nidation of the ovum the various pregnancy changes are largely under pla- cental control. We have already seen how the corpus luteum probably prepares and sensitizes the endometrium for nidation, and that in the first few weeks the life and growth of the ovum is, to a certain extent, dependent on the integrity of the corpus luteum. This duty, it is supposed, is then assumed by the pla- centa. That the ovaries after a certain period are of little moment in the progress of the pregnancy is shown by its uninterrupted continuance after double oophorectomy. That the involution process after labor is due to the removal of the placenta and not the fetus is evidenced by the persistence of pregnancy symptoms in cases of dead fetus and hydatidiform mole. The most important recent work on the placenta as an organ of internal secretion has been done by R. T. Frank. To the above deductions, which were first expressed by Halban and later confirmed by other investigators, Frank gives his endorsement and contributes additional evidence of placental internal secretory action. In order to exclude a possible ovarian influence Frank ex- perimented on castrated animals. He found that subcutaneous injections of emulsions or solutions of placental substance cause an enormous and rapid hyperplasia of the uterus, the weight of the uterine body sometimes reaching five to nine times that of the normal control animal. The increase takes place within six to eight days after the injection. Both the uterine musculature and mucosa share in this hyperplasia. The same reaction may be evoked in trans- planted portions of the uterus. Furthermore, the action is not changed by the removal of the suprarenals, pancreas, or thyroid, or by the combined removal of the suprarenals and thyroid. A similarly rapid and pronounced hyperplasia is produced in the breasts of rabbits after placental injection, and if the stimulus is prolonged colostrum can be expressed. 1 This last phenomenon may be the result of maternal ovarian secretion exerted through the medium of the placenta. RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 93 Frank found, in agreement with Herrmann, that "the active principles ob- tained from the corpus luteum and from the placenta can be extracted by identical methods, chemically have identical properties, and biologically produce identical results upon the uterus and breasts." Frank believes in the actual complete identity of the two substances and suggests that ''the placenta may act merely as a storage reservoir for the active principle elaborated by the corpus luteum during the earlier part of pregnancy," calling attention to the fact that the corpus luteum during the latter half of pregnancy is an involuting functionless organ. RELATIONSHIP OF GYNECOLOGY TO THE MAMMARY GLANDS The relationship between the breasts and the genital organs is very definite, but little understood. The female breasts develop rapidly at the time of puberty. In many cases they become enlarged at the menstrual periods, while during pregnancy the hypertrophy is of a marked degree. At the menopause the breasts atrophy. In what way does the cycle of development and function of the breasts depend on the function of the genital organs? The old theory that there exists between the mammary glands and the genital organs a specific nerve connection has been exploded as a result of more recent experiments. Galtz and Ewald were able to remove a large part of the spinal cord of a bitch without interfering with normal birth and secretion of milk in the breasts with ability to suckle the young. Similar observations have been made in women who, notwithstanding a complete fracture of the back, have been able to continue nursing their children. Pfister and Eckhardt suc- ceeded in dividing all the afferent nerves to the mammary gland in animals without disturbing the secretion of milk, while Basch reached a similar result after extirpating the celiac ganglion of the sympathetic system. The most spectacular experiment, showing that the function of the breasts is entirely independent of any nerve connection, was performed by Ribbert, who transplanted the breast of a pregnant rabbit on one of its ears. After the rabbit was delivered of its young the transplanted breast secreted milk. It has further been shown that the hypoplasia of the mammary glands which usually results from the castration of young animals may be prevented by the transplantation of ovarian tissue. From these and other experiments there seems to be no doubt that the changes in the mammary gland are due to the circulation in the blood of some chemical substance which represents a true hormone. An almost positive proof of this was demonstrated by Schauta in the case of the Siamese twins Blazek, one of whom became pregnant and bore a normal child. After the birth of the child both sisters secreted milk from their breasts. The same phenomenon has been observed by Christea in parabiotic rats and rabbits. 94 GYNECOLOGY Although it seems to be well established that the development and func- tion of the mammary glands is presided over by some chemical hormone, the problem of the source of this secretion has not yet been solved. The amount of experimentation and speculation has been very extensive, but the results have been conflicting and unconvincing. There is little doubt that the gro-^lh of the breasts at puberty, the swelling at the menstrual periods, and the atrophy at the climacteric are influenced chiefly by an ovarian secretion, since these phenomena do not appear after early cas- tration. The hypertrophy during pregnancy and the secretion of milk after delivery seem to be due to some other factor, since both these processes con- tinue after the removal of both ovaries during pregnancy, and, in fact, thej'' have been shown to be dependent in some way on the suppression of the ovarian function. (The milk period is said to last longer after castration, while in normal women the return of the menses is accompanied by disturbances of the milk secretion.) The uterus has also been ruled out as a dominating agent in the functions of the breast during pregnane}^ and childbirth. The present line of investigation is with reference to the influence of the fetus and the placenta. The experiments along this line are of great interest, but the results are inconclusive. It may be said, however, that there is evi- dence to show that the chemical influence of the placenta plaj^s some unex- plained part in the process, as is shown bj^ the following experiments: Basch injected placenta extract into virgin bitches, and found that it produced no changes in the beasts. He then implanted the ovary of a pregnant bitch in the abdominal wall of a virgin animal, and produced a hj'pertrophy of the breast. He next injected placental extract into this animal, and produced such an intensive secretion of milk that she was able to suckle a litter of young dogs. This experiment suggests that the complete cycle of mammary hypertrophy and milk secretion is dependent for its full expression on both the ovary and the placenta. There has been adduced no evidence to show that the mammae possess an internal secretion. Extract of mammary (mammin) has been used to some extent for the con- trol of uterine bleeding. There seems to be no doubt that the extract does exert some specific influence on the uterus, but it is not sufficiently effective to make the extract of much practical use. Aschner reports success in 16 out of 23 cases treated for functional menorrhagia and menorrhagia due to adnexal disease, fibroids, and uterine insufficienc3^ RELATIONSHIP OF GYNECOLOGY TO THE SKIN^ There is an important connection between certain skin lesions and the physiologic and pathologic processes of the genital organs. The changes in the skin are seen most markedly in those periods during which the genital organs ^ Principal authorities, Troph, Walthard, McCarthy. RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 95 undergo special activity, namely, the age of puberty, menstruation, pregnancy, the puerperium, and the menopause. (The skin manifestations accompanying pregnane}^ and the puerperium, though important, will be necessarily omitted in the following discussion.) Certain pelvic diseases are also associated with skin changes, while the external genitaha are subject to well-defined dermatologic affections. Menstrual Changes in the Skin. — Menstruation is preceded for several days bj^ an increased hyperemia that is most apparent in the skin of the cheeks, the chest, and thighs. This can be seen best in individuals who are naturally pale. The hyperemia recedes during the period and is succeeded for a few days by an unusual pallor. In individuals with high color the menstrual hyperemia is less apparent, but can be recognized by observing the changes in those parts which are normally pale — around the eyes, mouth, and chin. There are numerous skin eruptions related to the catamenial period which are classified under the term "menstrual exanthemata." The cause of these changes is not definitely known; some refer it to the influence of the ovarian secretion circulating through the system; others see a reflex or trophic disturb- ance in the innervation of the skin. The chnical picture of menstrual exanthemata is extremely varied. They may be discreet or diffuse, localized or general, urticarial, vesicular, macular, papular, resembling closely the appearance of erji:hema exudativum multiforme, or even of erji:hema nodosum. The location of the eruptions is usually on the thighs, abdomen, and breasts, but they may occur on other parts of the bod}^ They make their appearance several days before the onset of the period, and either disappear at the cessation of the flow or last for several days after. Occasionall}'' they break out only in the intermenstrual periods. The commonest form of these eruptions is the so-called herpes sexualis or menstruation herpes. This appears chiefly about the lips and nostrils, sometimes around the ears or eyes, occasionally on the breasts, fingers, and palms of the hands. It may also affect the mucous membrane of the mouth or the vagina and vulva,, and has been described as invohing the cornea of the eye. Menstrual herpes may be accompanied by other exanthemata and even by bleeding of the skin. Polland describes a well-defined eruption that he terms dermatosis dysmenorrJwica sym- metrica. This is a disease which appears only in women who suffer from menstrual disturb- ances, chiefly dysmenorrhea. The eruption begins -ndth hjTJeremia of the perifoUicular vessels, followed by serous or bloody exudation and the formation of vesicles on the epidermis. Ordi- narily the process extends over only a few days, but in some cases there is necrosis and ulcera- tion, eventuating in a scar. The eruption may be abnost universal over the body, but it is always sjonmetric. It often appears at puberty. Polland finds that the disease is benefited by ovarian extract (ovaraden triferrin) and beUeves that it is due to a disturbance of theanternal secretion of the ovary. 96 GYNECOLOGY Genital herpes is seen frequently in prostitutes and in individuals with great sexual irritability. Its occurrence is, however, usually closely related to the menstrual function. A purpuric type of erythema is sometimes seen in the form of ecchymoses or petechise which appear several days before menstrua- tion, and are often swollen and painful. Another form of hemorrhagic skin lesion is that due to vicarious menstrua- tion which may take place from the intact skin, from various mucous mem- branes, and from scars, wounds, and ulcers. Acute edema is sometimes seen associated with menstruation and the climac- teric, the edema occurring chiefly about the eyes, in the lower extremities, or in the external genitals. Pemphigus may occur in young girls in whom menstrua- tion has not been regularly established or who suffer from dysmenorrhea. Eczema is sometimes seen with various pelvic diseases, and it is thought by some that there may be a neurotic relationship between the two affections. Eczema at the time after the menopause, usually appearing on the scalp and behind the ears, occurs sufficiently often to be regarded as a specific disease under the term "climacteric eczema." Eczema of the external genitals and surrounding parts is very frequently seen in connection with pruritus and various pelvic diseases which produce an irritating discharge. In this case the eczema is the result of chemical changes in the skin wrought by the contact of the harmful secretions. Acne is a very common manifestation at puberty, though less frequent in girls than in boys. In matured women who are affected with acne there is usually a distinct relationship between menstruation and the appearance of the pustules. Acne of this type is localized chiefly about the chin. Individuals suffering from various pelvic disturbances, especially those that lead to scanty and irregular menses or to leukorrhea, seem to have a pre- disposition to acne. Women at the climacteric also frequently suffer from acne eruptions. Furunculosis of the external genitaha is sometimes seen as a chronic disease, and may be a source of great distress to the patient. The chronic or constantly recurring type is apparently a manifestation of deficiency in the function of the ovaries, by which the local resistance of the external genitals is lowered toward pyogenic organisms. That this theory is probably correct is shown by the curative effect of treatment with ovarian extract. A certain relationship between erysipelas and the menstrual function has been estabhshed, cases having been cited in which there have been periodic attacks of erysipelas coincident with the menses. There is a very close and well-known relationship between pigment hyper- trophy and the functions of the pelvic organs. At the time of puberty there is a physiologic increase of pigment, seen especially in the skin of the external genitals, about the nipples, and along the Hnea alba. During pregnancy the RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 97 pigment of these areas is markedly hypertrophied, while irregular spots of brown pigmentation appear on the face (chloasma gravidarum). Increase of pigmentation is often seen in individuals suffering from menstrual disturbances, chiefly amenorrhea and dysmenorrhea. With pelvic tumors, especially the large ovarian cysts, there is. often a noticeable increase of pigmentation. Vitihgo is not infrequently seen in association with abdominal tumors, and is thought to be the result of soiue toxic influence issuing from the tumor. This seems a reasonable theory, as the removal of the tumor often causes a marked improvement in the appearance of the skin lesion. Postoperative Eruptions. — One of the commonest -skin affections encoun- tered in gynecologic practice is the postoperative eruption popularly known by the somewhat misleading designation of "ether rash." This does not refer to the temporary erythema frequently seen during the administration of ether, which usually disappears by the time the patient recovers consciousness, but represents a well-defined disease that appears from a few hours to several days after the operation and runs a short but characteristic course. Observations of this disease are scanty and the etiology obscure. McCarthy, who has most recently studied the affection, found that in a series, of 1000 consecutive opera- tive cases at the Free Hospital for Women postoperative eruptions occurred 43 times. He divides the cases into two types-, those which appear within twenty-four to forty-eight hours after the operation, and those with a later onset, the latter following a more definite course. He describes the cases with early onset as exhibiting an eruption on the upper half of the body, beginning either on the face, chest, or arms and rapidly involving the abdomen and legs. The face is affected in almost every instance. The eruption varies in charac- ter from an erythema of brief duration to a papular type lasting for several days. Itching is the most marked symptom. There is little systemic disturbance beyond a mild elevation of temperature. In the second class of cases, which have a later onset of three to s.even daj^s after operation, the appearance of the eruption is sudden without prodromata, excepting that the temperature chart has usually continued higher than is seen in the ordinary uncomplicated post- operative convalescence. The condition varies in severity, from that in which only a localized part of the body is affected to one in which almost the entire body surface is involved. The eruption begins as a fine papular efflorescence on the inner surfaces of the forearms and thighs and extending over the body, rarely including th© face and never the palms and -soles. There is intense troublesome itching, which persists until the eruption has disappeared. The papules are at firet pink, but may later assume a dark reddish hue. The course of the disease reaches its height in twenty-four to thirty-six hours, and then rather rapidly subsides, the average duration being four days. McCarthy notes that those cases which begin on the third or fourth day after operation are of the longest duration and of greatest severity. The temperature remains slightly elevated, with little change in the pulse. There is also a moderate leuko- 7 98 GYNECOLOGY cytosis which is almost constant, and shown by control observations to be greater and more persistent than that frequently seen in uncomplicated con- valescence after surgical operation. Numerous etiologic factors have been suggested to account for postopera- tive eruptions, the disturbance being referred to the effect of ether, calomel, magnesium sulphate, morphin, and various substances used in enemata. Some have attributed the rash to chemicals used in laundering hospital linen. Some have ascribed it to climatic conditions. Others regard the disturbance as a manifestation of mild undetected sepsis, or to the absorption of tissue destruction at the site of the wound. McCarthy has analyzed all the causes usually given, and finds that no one of them is applicable to all cases. He concludes that the affection represents a vasomotor disturbance which may be evoked from the sympathetic nervous system by a variety of exciting causes. On this theory he accounts for the greater frequency of these eruptions in women, whose nervous organism is more easily disturbed than in men. The theory also explains the greater frequency of the eruptions in a gynecologic clinic than in one devoted to general surgery, in view of the rich supply of sympathetic nerves with which the female pelvic organs are endowed. RELATIONSHIP OF GYNECOLOGY TO THE ORGANS OF SENSE There exists between the organs of sense and the genitalia a relationship of considerable definiteness, the most marked manifestations being connected with the function of menstruation. The eye may undergo various functional and pathologic changes as a result of genital influences. Vicarious menstruation following suppression of the normal function may appear in the eyes, with extravasations of blood in the conjunctiva, eye muscles, lens, choroid, retina, or even in the optic nerve. The corresponding disturbances of vision disappear with the absorption of the extravasated blood if it is small in amount. If, however, the bleeding has been profuse the condition may be followed by chronic inflammatory or degenerative processes. Even in the presence of normal menstruation from the genitalia, hemorrhages may take place in various parts of the eye and cause more or less serious disturbance. Other pathologic processes sometimes seen in the eye induced by the in- fluence of menstruation are eczematous changes in the lids, herpes, hordeola, inflammations of the conjunctiva and cornea, or the aggravation of already existing inflammatory conditions. Increase of the pressure in the eye may occur, even to the extent of glaucoma. Even with normal menstruation numerous functional disturbances may take place, such as a narrowing of the field of vision, dulness of vision, weakness of accommodation, photophobia, oculomotor paralysis, lessening of color sense, etc., disturbances which may be much more marked if the menses are ab- RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 99 normal. Such functional aberrations may sometimes be regarded as mani- festations of psychoneuroses in nervous individuals during a period when the organism is peculiarly sensitive. Secondary anemia from severe lo-ss of blood from the genitals may be fol- lowed by anomalies in the eye, chiefly in the form of edema and thrombosis, which may produce permanent degenerative processes in the retina and optic nerve. In this way bleeding tumors may affect the eye. INIalignant growths of tjie pelvis sometimes metastasize in the eye. Infectious diseases of the pehdc organs may affect the eye either by direct contact with the infectious material or by embolic processes through the cir- culation. Of the former method, infection from gonorrheal discharges is the most familiar example. Diphtheria may also be transmitted in the same way. ISIetastatic infection of the eye is extremely rare excepting in connection with puerperal fever, in which it occasionally, though rarely, occurs. The embolic focus may have its seat in almost any part of the eye, but most commonly in the .retina, w^hence it may extend to a general panophthalmia. Puerperal sepsis sometimes causes a hemorrhage in the eye a's a result of toxic changes in the blood composition and a greater permeability of the endo- thehal walls of the capillaries (Mayer) . The Ear.^ — What has been said regarding functional disturbance of the eye during menstruation is also applicable to the ear, i. e., certain aberrations .from the normal cases may be referred to the general influence on the organism of the menstrual wave, and in others to manifestations of psychoneurotic impulses which become more active during the monthly period of greater sensitiveness. Existing chronic diseases of the ear have been observed to become per- manently aggravated by pregnancy and childbirth. The Nose. — Between the nose and the genital organs there exists a curious interrelationship which in some cases is quite inexplicable. The .sense of smell is one of the most powerful sexual excitants. Marked changes in the nose are often seen during the menstrual period. Vicarious menstruation is more often manifested by bleeding from the nose than from any other part of the body. Individuals who menstruate normally are often prone to epistaxis dur- ing the period. During the time of puberty nose-bleeds are very common. Anomahes of secretion are often seen at the time of catamenia, and may consist either of acute nasal catarrh with profuse secretion or of abnormal dryness of the nasal mucous membrane. Disturbances in the sense of smell are some- times observed during menstruation, e\'inced usually bj^ an increase of sensitive- ness or by perversions. Nasal affections during the catamenial period are much more common in those whose menstrual function is not normal, appearing with especial fre- quency in w^omen who suffer from dysmenorrhea. They are also more frequent in neurotic individuals. What was said, therefore, regarding the functional -disturbances of the eye and ear applies also to the nose. 100 GYNECOLOGY Cohabitation is ■sometimes attended with acute swelUng and discharge from the nasal mucous membrane; sometimes with unnatural dryness of the nose and throat. Kermauner has observed an abnormal lack of nasal secretion in those who habitually masturbate, and in the young who are addicted to this habit he recog- nizes a characteristic expression caused by a thickening and coarsening of the nose and lips similar to that produced by certain diseases of the hypophysis. The most striking example of the relationship between the nose and the genital organs is the influence on dysmenorrhea that can sometimes be ex- erted by cocainizing the nasal mucous membrane. A few drops of 20 per cent, cocain solution applied to the anterior end of the lower turbinate and the tuberculum septi (genital spot) will often, according to the best authorities, cure severe dysmenorrhea and prevent its recurrence for a considerable period of time (Fleisch, Brettauer, Meyer). Finally, at the time of the chmacteric one sometimes sees a severe intractable nasal catarrh associated with hyperesthesia of the fifth nerve. Other abnor- malitie's mentioned by Kermauner, as occurring at the change of life, are dry- ness and stoppage of the nose, adenoid and polypoid growths, and eczema ex- tending from the outer skin of the nostrils to the mucous membrane lining. BiELATIONSHIP OF GYNECOLOGY TO THE DIGESTIVE TRACT The relationship existing between the genital organs and the digestive tract is evident chiefly at the time of menstruation. Increased activity of the parotid glands has been repeatedly observed, so that in some cases one may speak of the condition as menstrual salivation. This phenomenon was noticed by the earlier writers, one of whom described a "vicarious salivation," which he said might take the place of the normal uterine flow. Habran described a case of periodic swelling of the parotid gland which ceased during the months of preg- nancy, to be resumed again after delivery of the child. Disturbances of the mouth during menstruation have been cited, such as herpes of the lips, periodic toothache, and the vicarious bleeding from the gums. Of especial importance is the relationship between menstruation and dis- turbances of the stomach, evidence of which is seen both in functional dis- turbances and in connection with organic disease. The functional symptoms appear usually in the premenstrual stage and last into the menstrual period, though sometimes they cease with the onset of the bleeding. The most common symptoms of a subjective character are loss of appetite, flatulency, nausea, vomiting, taste paresthesias, aversion to certain foods, especially meat, bad breath, pains in the stomach, sensations of hunger, etc. Symptoms of this kind are much more common in the neurotic and in those who suffer from abnormalities of menstruation, especially dysmenorrhea. RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 101 Besides these minor anomalies of the stomach, more serious disturbances may occur. Menstrual and vicarious bleeding from the gastric mucous mem- brane may occur, and may on some occasions constitute alarming and depleting hemorrhages. In some cases there may be severe cardialgia and symptoms simulating gastric ulcer, the differential diagnosis being very difficult. In a case of this kind seen by the author the patient had five abdominal scars, repre- senting as many operations performed, with the diagnosis of some serious intestinal lesion. The influence of menstruation is definitely shown in the aggravation of organic lesions of the stomach during the monthly period. This effect is especi- ally seen in ulcer of the stomach, which has a special disposition to bleed during the premenstrual and menstrual periods. Thus, it may be impossible to state whether monthly bleeding from the stomach is vicarious menstruation without actual stomach lesion, or whether the bleeding is from an ulcer which bleeds only when influenced by menstruation. The cause of the influence of menstruation on the functions and conditions of the digestive tract is as little known in this connection as it is in relation to other parts of the body. Wagner sums up a discussion of the matter by say- ing, "Whatever the cause of the disturbances may be, two facts are indubitably established : first, the secretory and motor activity of the stomach undergoes a premenstrual and menstrual alteration; and, secondly, that this leads to symp- toms according to the special disposition of the individual." Subjective gastric symptoms are not seen in all women at the time of menstruation, but they appear in a considerable percentage of them. Those specially disposed to the condition are the neurasthenic and hysteric. Some regard the dyspeptic symp- toms of these patients as purely nervous reflexes, while those who accept the internal secretion theory regard neurotic patients as peculiarly susceptible to the influences of altered secretion at the menstrual period. If the condition is due to secretory changes the nature of the process is not understood. Accord- ing to some, it is the direct result of an ovarian hormone circulating in the body. It would seem somewhat more reasonable and in accordance with present physiologic knowledge to suppose that the stomach changes are rather due to a disturbance of balance in the relationship of the glands of internal secretion during menstruation, and that the direct influence exerted either on the nerves of the stomach or on the stomach tissues themselves comes from some other gland than the ovary, probably the adrenals. Or, still further, it might be assumed that the gastric symptoms of menstruation may be the result of in- creased general nervous and emotional irritability, and that this condition produces hyperactivity of the adrenal glands with consequent influences on the secretory and motor apparatus of the stomach. This theory is in line with the well-known experiments of Cannon, who has demonstrated the effect of the emotions on the processes of digestion through stimulation of the adrenal glands. 102 GYNECOLOGY In addition to the neurasthenic and hysteric, a predisposition to menstrual gastric disturbances is seen in the chlorotic and anemic, and still more com- monly in those who suffer from congenital or acquired malpositions of the stomach. In the latter class of cases belong chiefly individuals of the hypo- plastic type, with the long narrow chest walls, splanchnoptosis, pelvic mis- placements, etc. Patients with organic lesions of the stomach undergo exacerbations of their symptoms during the menstrual period in 83 per cent, of cases, according to Plonies. » A form of menstrual bleeding from the intestinal tract is that sometimes seen in patients suffering from typhoid fever. Still another instance, and one quite frequently seen, is the increased tendency of hemorrhoids to bleed at the time of menstruation. Diarrhea is not infrequently^ an attendant discomfort of menstruation, one observer having found it in 49 per cent, of cases in a study of 758 women, though this figure seems rather high. Obstipation is another not uncommon symptom. StiU another class of patients frequently seen suffer from chronic constipation between the periods, while during menstruation the bowels are regular or even diarrheic. Certain digestive disturbances often characterize the menopause, such as pains in the pharynx and esophagus, nervous dyspepsia with flatulence, heart- burn, vomiting, etc. (Wagner). Diarrhea of a peculiarly obstinate nature sometimes signalizes the begin- ning of the change of life (Singer), and has the character of a secretion neurosis, without sign of catarrhal or inflammatory disease (Wagner). Somewhat more common is the occurrence at the chmacteric of intractable obstipation, with great tendency to gas formation. Wagner states that the constipation of the chmacteric is peculiarly resistant to the usual methods of treatment. In two cases he has had good results with ovarian therapy. Hemorrhages from the bowels are sometimes seen at the change of life. Most of the bleedings are from hemorrhoids, which at that time have a special tendency to become worse. In other cases where malignant disease has been excluded there has been demonstrated a true chmacteric intestinal bleeding from the mucous membrane. It is possible that this may be analogous to the bleeding frequently seen from the vaginal mucous membrane as a result of senile atrophy. The relationship between the genital system and the neighboring organs of the digestive tract is treated in another section. (See page 141.) The connection between pregnancy and the organs of digestion is a subject of much importance, but does not come within the sphere of this book. The subjects of enteroptosis, intestinal bands, and diverticulitis are treated elsewhere. RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 103 RELATIONSHIP O^F GYNECOLOGY TO ORGANS OF RESPIRATION Lung complications following gynecologic operations are comparatively frequent. Pulmonary embolism is discussed in the section on the Relationship of Gynecology to the Circulatory Apparatus. The subject of postoperative infections of the lungs forms a very important chapter in surgical convalescence. These infections most commonly take the form of pleurisy, bronchitis, and bronchopneumonia. Typic lobar pneumonia is rare. As in other local infections following operation, such as phlebitis and pyeh- tis, etc., the causation of pulmonary inflammations is not well understood, many reasons having been suggested. Patients who develop pneumonia soon after a surgical operation are commonly said to be suffering from ''ether pneumonia." It is probable, as we shall see, that ether may in some cases be an exciting factor; nevertheless, that it is not the sole cause, is shown by the fact that in- fections of the lungs may follow operations performed under spinal anesthesia or after the gas and oxygen sequence. There are many predisposing conditions which undoubtedly have some in- fluence in producing the disease. Thus, surgical shock may so lower the patient's resistance as to encourage a local inflammatory process. Old age is very distinctly favorable for lung infections. In our own series of cases the incidence of serious pneumonia was particularly noticeable in elderly women. The physical characteristics of the patient are supposed to have some influence, fat, short-necked individuals being thought to be es- pecially prone to pulmonary complications. In our series this theory has not been borne out. Bad behavior under ether — i. e., choking, vomiting, straining, etc. — plays a certain role, as it is probable that such patients sometimes inhale mucus, sahva, or particles of food that may later act as foci for infection. It is probable, too, that when patients act badly under ether the necessity of forcing the 'ether in an irregular manner serves to irritate the lungs, and thus favors either the development of a latent infection or the active growth of newly inhaled bac- teria. That a certain number of postoperative lung infections are proi3erly called "ether pneumonias" is evidenced by the fact that they are much more common when the anesthesia is inexpertly administered. Exposure to -cold while the patient is under anesthesia undoubtedly favors lung infections. The figures of all writers on the subject show a greater incidence of the disease in the winter months. There is no question that the inhalation of ether tends to stimulate latent foci of infection into activity, as is seen sometimes in the aggra- vation of a dormant tuberculosis into an acute form. Administering ether to a patient with a beginning bronchial cold is very dangerous. Undoubtedly, many cases of postoperative pneumonia are the result of stimulating a beginning process of infection which was not detected in the preliminary physical examination. 104 GYNECOLOGY The nature of the operation bears some relation to pulmonary complications. Pelvic operations are less commonly followed by infections of the lungs than are operations performed in the regions near the diaphragm, and such infections when they do occur are apt to be less serious. Hernia operations and those which require much handhng of the gut are more prone to lung infection, as are cases in which there is active pus or septic comphcations after operation. In gynecologic practice laparotomies are ten times more Hable to lung comphcations than are plastic operations (author's figures). This is due to the fact that the reflex respiratory irritation from ether is much greater dur- ing laparotomies than in operations on the body when the abdomen is not opened, excluding, of course, operations involving the respiratory tract or nerve-centers. Some of the pneumonias after operation, especially in old people, are of the hypostatic type. Still another important class are those which result from the lodging of minute septic emboh in the capillaries of the lungs, the emboli usually starting from a local sepsis in the wound, which may or may not be evident. Doubt- less some of the cases which begin late in the convalescence are caused in this way. Most postoperative lung infections do not get beyond the stage of a tem- porary pleurisy or bronchitis. In the more serious cases the disease becomes one of bronchopneumonia. Rarely pulmonary abscess or empyema may develop. In gynecologic practice the mortality from postoperative pneumonia is not very great. In a series of 4000 consecutive gynecologic operations performed at the Brookline Free Hospital, reported by the author in 1910, there were 2 deaths from pneumonia. During menstruation the vocal cords undergo a physiologic change which results in slight alterations of the voice. This is a matter of considerable im- portance to professional singers, some of whom are obhged to refrain from using the voice at the time of menstruation. Chronic diseases of the lungs, especially of tuberculous nature, are, as a rule, made worse by menstruation and pregnancy. Menstruation also exerts an unfavorable influence on the course of the more acute pulmonary infections of bronchitis, pneumonia, and pleurisy. In tuberculosis of the lungs there is at the time of menstruation a special tendency to sweating, catarrh, and headache. The temperature is apt to be more elevated and hemorrhages from the lungs are more likely to occur. Hemoptysis at this time is often erroneously regarded as vicarious menstruation. On the other hand, chronic lung tuberculosis is often attended with amenor- rhea, which, as Walthard has pointed out, is not necessarily accompanied with atrophy of the uterus. In amenorrhea with hypoplastic or atrophic genitalia true vicarious men- struation from the lungs is sometimes seen. Acute infections of the lungs may metastasize in the genital organs through RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 105 the circulation. Of the various infective organisms that attack the lungs, the pneumococcus is the most prone to cause secondary infections in the pelvis. It has been demonstrated in the purulent contents of ovarian cysts in para- and perimetritic exudates and in the contents of pus-tubes (Wait-hard, Scudder). It is an especially common excitant of peritonitis in children. Genital and peritoneal tuberculosis is probably, in the majority of cases, derived primarily from old or latent foci in the lungs. Septic processes and malignant growths of the pelvic organs may by entrance into the large veins metastasize in the lungs, as is seen, for example, in the early involvement of the lungs of chorio-epithelioma. Dyspnea, by interference with the diaphragm, is the frequent result of the large pelvic tumors, especially those which have metastasized in the peritoneum and those which are associated with ascites. RELATIONSHIP OF GYNECOLOGY TO THE BLOOD^ Menstruation. — The non-coagulability of menstrual blood has long been a subject of study and speculation, but has not yet been fully explained. Present evidence tends to show that the phenomenon is not a part of a general phj'-sio- logic change in the blood, for the most recent experiments have proved that the blood in the general circulation exhibits no difference in the time of clotting at the menstrual period (Hartmann, Cristea, Denk, et at). It is now accepted that the chemical influence which prevents coagulation of menstrual blood is localized in the uterus, but just what the active substance is is not known. The experiments of Schickele seem to indicate that it is manufactured in the endometrium under the stimulation of the ovarian secretions. (See also page 57.) Studies of the blood from the general circulation in menstruating women have shown certain characteristic changes. During the premenstrual period there is an increase in the red corpuscular elements of 1,000,000 or 1,500,000, which usually, just before the onset of the period, sinks to the normal leve) and even below it. The hemoglobin content exhibits a periodic rise and fall, though not entirely parallel with the variations of the red elements. At the beginning of menstruation can usually be demonstrated a moderate leuko- cytosis which undergoes a marked fall during the bleeding. In the premen- strual period there is diminished alkalescence of the blood and a lower specific gravity. More recent investigations (Neumann and Herrmann, et al) have shown periodic variations in the lipoid content of the blood. Alh these changes are not to be accounted for by the physiologic loss of blood, which under normal conditions is too shght to create so definite an alteration. They bespeak rather a periodic toxemia, which is evidenced not only by the blood-picture, but by marked general effect on the physical and nervous organism (Adolf Payer). ^ Chief authorities, Adolf Payer, M. Walthard. 106 GYNECOLOGY The nature of the circulating toxin, as is elsewhere frequently mentioned, is to be sought either in an ovarian hormone or in the products of one or more other internal secretory glands, the balance of whose activity is disturbed by the monthly change in the function of the ovaries. Chlorosis is a disease of young girlhood occurring at or soon after the period of puberty, and having a tendency to recur later in life. Although there is no pathognomonic blood-picture, the typical case is characterized by a marked decrease in the hemoglobin content without corresponding diminution in the red blood-corpuscles. Thus, in a case of average severity, the hemoglobin may register 50 to 60 per cent., while the red count remains normal. If, however, the hemoglobin becomes much reduced, as it may, to 30, 20, or even 10 per cent., the red count also falls very low. A special characteristic of the blood is its increased coagulability and its tendency to thrombosis (Payer). The relationship between chlorosis and the genital system is one which has attracted considerable attention. Virchow distinguished a monorrhagic and an amenorrheic form of the disease, of which the latter is by far the more com- mon. He and others after him attempted to trace a causal relationship be- tween chlorosis and hypoplasia of the genitals, Virchow regarding the retarded genital development as secondary to hypoplasia of the circulatory apparatus. It is apparent, however, that the occurrence of genital hypoplasia in connection with chlorosis is not as common as formerly supposed, as is shown by the fol- lowing figures of Often (quoted from Opitz-Menge) : In a study by Otten of 448 chlorotic patients, 186 cases, which included the majority of the severest cases with hemoglobin under 50 per cent., there was found not the slightest dis- turbance of the genital functions. Among the remaining 262 chlorotic girls and women were found sjrmptoms of delayed menarche, oHgomenorrhea, amenorrhea, and in a few instances menorrhagia. Dysmenorrhea was seen chiefly among those hving in wretched surroundings. Some cases of hypoplasia were seen, but in such small numbers that Otten could draw no con- clusions as to an etiologic relationship between chlorosis and lack of genital development. It is evident that dysmenorrhea is a common symptom in connection with chlorosis. A number of authors regard chlorosis not as a primary disease, but as secondary to a beginning or latent tuberculosis, and ascribe many of the symp- toms' ^characteristic of chlorosis, such as headache, dizziness, palpitation, sleep- lessness, indigestion, languor, etc., to the result of a tubercular toxin (Payer). It is probable that latent tuberculosis, though not being the sole cause of chlorosis, should be regarded as an important element in its etiology. Hemophilia was until recent times beheved to be transmitted by inheritance to males only, though, it might be inherited through an intermecUate female ancestor who herself did not suffer from the disease. It is now known that women may be subject to the affection, but not as commonly as men. Two forms, called the familial and the sporadic, have been distinguished. In the famihal type of hemophiha the blood is viscous, flows slowly. There is a con- RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 107 stant diapedesis of leukocytes, with a diminished number of polynuclear and a predominance of mononuclear forms. Clotting is very slow, lasting from two and one-half to nine or even twelve hours. In the sporadic form the blood is thin and watery. The blood-picture is normal. The coagulation time is delayed thirty to fifty minutes. The disease is of gynecologic interest chiefly because of the danger that attends puberty. It is probable that many of the severe menorrhagias and metrorrhagias that occur at puberty have a hemophiUc source. The condition is not always easy to distinguish from that of menorrhagic chlorosis. An acquired hemophiha has been described as occurring later in life, but in many of these cases there has been a history of purpura and morbus macu- losus, which many authors regard as related to hemophiha (Payer). In the hemophilic there is no retardation of the menarche, but the menstrual flow when established is most profuse and very resistant to treatment, and may sometimes cause the death of the patient. Payer quotes the figures of Foeuckel and Bohn, who found 10 deaths in 121 reported cases. No specific anatomic abnormahties have been found in the pelvic organs. Several cases of serious or fatal hemorrhages at childbirth have been re- ported. The treatment consists in trying to alter the chemical composition of the blood so as to favor its clotting or to apply styptic solutions to the uterine cavity. Of the last named, calcium chlorate (3 to 8 per cent.) solution and adrenalin have been used. Success has been gained by the injection into the blood of 10 per cent, gelatin solution. These methods have in the latest times given way to transfusions of human blood or to the injection of animal serums, especially those prepared from the horse and rabbit. If all other methods fail, hj'sterectomy can be employed as a last resort. Leukocytosis. — The study of the white corpuscles of the blood is of great importance to the gynecologist in the detection and treatment of acute infectious processes. What constitutes a hyperleukocytosis that may be regarded as indicative of infection is a matter of wide difference of opinion, estimates vary- ing from 10,000 to 30,000. In our experience we are accustomed to consider a white count of 15,000 as almost conclusive evidence of infection, while one of 11,000 or 12,000 creates a disturbing suspicion. In detecting local hidden infections following gynecologic operations the leukocyte count is most useful, while in observing the course of an inflammatory process with special reference to surgical intervention the frequent examination of the blood and charting of the leukocytosis is an invaluable guide, and one comparable in importance to the curve of pulse and temperature. With regard to the relationship between inflammations and hyperleuko- cytosis infections may be divided into three classes: (1) Those which are so mild as to cause practically no leukocyte reaction; (2) those which are so severe 108 GYNECOLOGY as to overwhelm the organism so that a leukocyte reaction is prevented; and (3) a long hst of infections between these two extremes, in which the reaction is present and proportionate to the severity of the disease. In the first class are included tubercular processes that are not complicated with mixed infections of other organisms; slight inflammations such as are seen in mild catgut infections are also counted in this list. The second class com- prises such conditions as the sudden overwhelming streptococcus peritonitis and septicemia that on rare occasions follow abdominal operations. In the third class are included most of the septic conditions seen in gynecologic surgery, such as appendicitis, pyosalpinx, wound infections, parametritis, phlebitis, postoperative pneumonia, etc. In the first part of an acute infection there is a marked increase in the polynuclear cells, which represent the active agents of the body for combatting the invasion of organisms. The nmnber of these cells is ordinarily proportionate to the severity of the disease, the number of mononuclears and eosinophils being comparatively small. In order to follow the course of the infection it is necessary to chart the leukocyte count every twelve or twenty-four hours. A sudden drop in the number of polynuclears indicates a loss of reactive power in the patient and entails an unfavorable prognosis. A drop in the absolute number of the neutrophils, with a high percentage relative to the mononuclears and eosinophils, also indicates an unfavor- able condition, for it shows that the reactive powers of the body are not keeping pace with the need for its combatting agents, the polynuclears. A cessation of the leukocytosis during an acute inflammatory process, followed by a stationary or gradually diminishing count, usually indicates a walling-off and locahzation of the infection. If the contest against the invading organisms is successful the need for the phagocytic polynuclears is passed, and they give way to the mononuclear Ijonphocytes, whose duty is that of reparation. An increase of Ijonphocytes, both relatively and absolutely, is, therefore, characteristic of convalescence. In the same way the eosinophils, which in the height of the conflict are absent or insig- nificant, appear during the healing process, "their increase indicating victory over the infec- tion." Posthemorrhagic Blood-picture. — After an acute hemorrhage there begins an immediate absorption of the body fluid to make up the loss in volume of the blood which normally constitutes about one-thirteenth of the body weight. This process is greatly hastened by the introduction of physiologic fluids into the body by mouth or rectum, subcutaneously or by intravenous infusion. The increase in fluid volume is more rapid than the regeneration of the red blood-corpuscles so that there is next a diminution in the red cells, each one of which possesses its normal hemoglobin content. Then the increase in the number of red corpuscles advances more rapidly than the hemoglobin content, so that the next phase is a relative deficiency of hemoglobin in the presence of a normal red count such as is seen in chlorosis (Walthard). The viscosity of the blood is accentuated after acute hemorrhage, and there is seen a hyperleukocytosis and an increase in the number of blood-plates. The regeneration of the blood after severe loss is surprisingly rapid if the hemorrhage is not repeated, as is frequently seen after bloody operations or RELATIONSHIP OP GYNECOLOGY TO THE GENERAL ORGANISM 109 after patients have had severe uterine hemorrhages, such as sometimes occur suddenly from polyps, cancer, etc. Too great loss of blood is by far the most common cause of surgical shock. In the present day of improved operative technic only the most difficult of gynecologic operations should be attended with shock as a result of loss of blood. By the prevention of the loss of blood patients with low hemoglobin .can be operated on with comparative safety. After chronic loss of blood from the genitalia (menorrhagia and metrorrhagia) , the appearance of the blood is that of any secondaiy anemia, namely, diminu- tion of red corpuscles and decrease of the hemoglobin content, poikilocytosis, and absence of leukoc}i:osis. Extravasation of Blood. — Large extravasations of blood, such as are most typically seen in extra-uterine pregnancy, are followed at first by the char- acteristic posthemorrhagic blood-picture, described above — i. e., diminution in the number of red corpuscles and hyperleukoc>i:osis. If the hemorrhage is not repeated the red cells soon regenerate, but absorption of the products of degenerative changes in the blood cause a continuation of the leukoc\i:osis which may reach a considerable height without the invasion of bacterial organisms. If the hematocele undergoes thick, fibrinous encapsulation as the long-stancUng non-infected cases often do, the leukocytosis cUsappears. If the hematocele becomes infected, hyperleukocytosis returns and follows the course seen in other purulent processes (Walthard). The presence of leukocytosis after blood extravasation, or as the result of absorption from a degenerating hematocele, creates sometimes an element of confusion in making a differential diagnosis between ectopic pregnancy and inflammatory adnexal disease, being one of numerous other signs and sjonptoms which the two diseases have in common. Necrotic Tissue. — The absorption of products of degeneration in necrotic tissue is attended with an increase in the leukocytes to 15,000 and over (Walt- hard). This is a matter of importance, chiefly in cases of torsion of ovarian cysts and necrotic myomas. If infection takes place, as it often does as a result of adhesions to the intestines, the leukocytosis follows the usual course of inflammatory processes. Postoperative Leukocjrtosis. — Numerous observers have described a hyper- leukocytosis following surgical operations, especially after those that involve the abdominal cavity. The highest point (about 16,000 and sometimes over) is said to be reached on the second morning, from which time it graduallj^ recedes and disappears in about three and one-half daj^s. The amount of the leukocytosis is dependent to some extent on the position, length, and severity of the operation. Many causes have been announced to account for the phe- nomenon, such as the loss of blood, anesthesia, opening the abdomen, injuries from instrumentation, etc. Some regard it as always an indication of sepsis (Zangemeister), while others consider that ''it represents the measure of the 110 GYNECOLOGY reaction of the organism against infection." Apparently, it bears some rela- tionship to the postoperative increase in temperature which it parallels rather closely. Jochmann considers it an indication of the process of healing. According to his theory, the leukocytes wander to the seat of the wound, where, upon their disintegration, a proteolytic ferment is set free. This ferment is in part absorbed, but a part is used for the digestion of the tissue fragments resulting from the traiima of the operation. By this digestive process there are set free in the circulation albumoses, which of themselves are capable of raising the body temperature. In this way is very ingeniously and plausibly explained the parallelism of fever and leukocytosis after abdominal operations. (Abstracted from Adolf Payer.) SERODIAGNOSIS Abderhalden's Test for Pregnancy and Cancer. — A serodiagnostic test for the presence of pregnancy and cancer has been cUscovered by Emil Abderhal- den, which, though at present in the experimental stage, bids fair with improve- ment and simplification of technic to be of very great clinical importance. The test is based on the assumption that when a foreign protein is intro- duced into the blood certain protective ferments are manufactured in the blood that are capable of splitting up the foreign protein into peptone or amino- acids. This constitutes a form of digestion which is termed "parenteric diges- tion," and is a physiologic process of great value in the bodily economy. The protective ferments may be produced in the blood in various ways. Thus, in the ordinary process of intestinal digestion the intestinal tract may be so over- loaded that food in complex form may. pass into the circulation and call forth digestive ferments in the blood, which splits up the invading proteins into substances that are not harmful to the organism. The protective ferments may be artificially created in the blood by intravenous or intra-abdominal injec- tions of foreign protein material. The protective ferments are also manu- factured in the blood of an individual who harbors certain tissues in the body from which unchanged protein material may be absorbed in the circulation. Specific examples of tissues of this kind are the placenta and cancer. This makes the subject of peculiar interest to the gynecologist. The principle involved in this reaction of the blood to foreign protein material is of vast importance in modern scientific medicine. To quote McCord: "The formation of protective enzymes then is sensitization, and all the phenomena of anaphylaxis and immunity are closely alhed. In this phenomenon is the basis for all prophylactic vaccination and the foundation for the creative activity of such substances as tuberculin. Although physiologic in its nature, the disintegrating of stable proteins is not without its deleterious action, as is evidenced by auto-intoxications. Such an enzyme cleavage of proteins underUes the various cutaneous reactions, such as leprodiagnosis, tuberculin reaction, and the cutaneous reaction of syphilis. These phenomena come as a result of introduction and cleavage of substances of a kind like unto that with which the organism is sensitized. Not only will this cleavage take place within the body, as in the instances cited, but the drawn blood contains the active enzymes, and when placed in contact with substances against which they are generated structural disrupting occurs extracorporeally with a breaking down into simple forms similar to that occurring intracorporeaUy . " RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 111 Abderhalden began his work in the study of pregnancy. It has been known for some time, as demonstrated by Veit, Schmorl, and Weichard, that chorionic vilh are discharged into the maternal circulation during the period of placental development. Abderhalden showed that this material, circulating in the form of a foreign protein, creates specific digestive ferments in the blood, and that when the mother's blood is drawn these ferments will still continue to act in vitro on placental tissue taken from some other human source. In this way, therefore, he discovered a means of diagnosing pregnancy. The method of determining the presence of the specific protective ferment is to bring a small amount of serum from the individual to be tested in con- tact with a preparation of placental tissue, and to observe whether or not the serum has the power of digesting the placenta. This can be done either with a polariscope or by the method of dialysis, by which the simple products (peptone or amino-acids) into which the placental protein has been split by the serum ferments may be detected by certain color reactions. The technic of carrying out the test is somewhat complicated and must be learned from writers who are experimenting with it. The descriptions given by Ball are recommended by the author as being especially clear in detail. Among other writers on the subject are Williams and Pearce, McCord and Boldt. The German literature of the last two or three years is replete with the subject. It may be said, in general, that the placental tissue to be used in the test is first prepared by boiling and coagulation, and then placed in a mixture of chloroform and toluol, in which it can be kept indefinitely. The serum from the individual to be tested is obtained by venous puncture and must be absolutely free from hemoglobin. The dialysis tubes usually recommended are the diffusion membranes of Schleicher and Schull, which should be first tested for their permeability to peptones. Small quantities of the prepared placenta and the serum from the individual to be tested are placed together in the diffusion tube, which is then placed in a small beaker of water. The apparatus is then put in the incubator for twelve to twenty-four hours at 37° C. If the patient to be tested is pregnant the ferments contained in the serum split up the protein of the placental tissue into peptone or amino-acids, which permeate the clialysing membrane into the surrounding water. The presence of peptone in the water is detected by adding a watery solution of triketo- hydrinenhydrat (ninhydrin), which gives a deep-blue color reaction. If the reaction is negative, the solution remains colorless or turns a slight yellow. According to Williams and Pearce, "results as satisfactory as those by dialysis are obtained by mixing tissue and serum in tubes, and, after incubating for twenty-four hours, testing the filtrate on coagulation by heat and acetic acid with ninhydrin." Opinions differ as to the present value of the Abderhalden test for pregnancy, 112 GYNECOLOGY some regarding it as too inaccurate to be of much clinical value, while others consider it reliable and practical (McCord). The test requires much skill and care, there being numerous chances for error. For that reason it has not yet come into general practical use. Since Abderhalden has given out his pregnancy test it has been demon- strated that cancer produces in the blood a protective ferment very similar in action to that evoked by the condition of pregnancy. By this it is to be assumed that, as in pregnancy, certain protein material from the cancerous growth is discharged into the circulation, and causes a reactionary manufacture in the blood of the protective ferment. As Ball has pointed out, "one would expect that a ferment, if produced at all, would be elaborated more vigorously in a pathologic process than would be necessary in a purely physiologic one. It would also appear that a person in apparently good health possessing a can- cerous growth might elaborate a stronger ferment than a person far advanced with disease." These conclusions have been shown to be true, for Ball has observed an increase in the density of the color reactions in his cancer cases as compared with that in his pregnancy tests, while Brockman finds that healthy cancer patients give a denser reaction than do patients well advanced with the disease. The principle and technic in making the test for cancer are the same as for pregnancy, excepting, of course, that the tissue to be tested is taken from fresh cancerous material instead of from placenta. The value of serodiagnosis for cancer is at present in a somewhat problematic state, but it is probable that with improvement in technic, and with increased knowledge of the principles of the reaction, the test will in time prove to be of great general benefit. RELATIONSHIP OF GYNECOLOGY TO THE ORGANS OF CIRCULATION Certain differences in the organs of circulation between the sexes are to be noted. The heart and blood-vessels of woman are both relatively and absolutely smaller and weaker than in man. The heart is smaller and weighs less at a given age. Thus, according to the figures of Miiller, the average of weight of the female heart between the ages of thirty and forty is 234.7 gm., as against 297.4 gm. for the male. It has been demonstrated (Kani) that the (lifference in the blood-vessels between the sexes is due to a greater thickness of the media in the vessel wall in man, a point which Jaschke thinks may be shown to have important clinical significance. In woman there is a more frequent high bifurcation of the aorta, while the apex of the heart is relatively higher, due to the shorter thorax and to the smaller size of the heart. Physiologically, the pulse-rate in woman averages higher and the fluctuations are greater. RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 113 A special female characteristic is marked vasomotor excitability resulting from the emotions, which may be so great as to produce uterine bleeding, a phenomenon of familiar occurrence. This vasomotor sensitiveness has an im- portant bearing in a vast number of ways, both in the physiologic and patho- logic sphere of woman. The blood-pressure in woman is relatively lower than in man, and is sub- ject to greater fluctuations, as a result of the greater lability of the pulse and of variations referable to vasomotor and psychic excitability. THE HEART At puberty the heart becomes markedly increased in size. With the estab- Ushment of the menses are often seen in girls functional irregularities of the heart, which may in some cases be of a more or less serious nature. Most commonly they consist of palpitation and vasomotor manifestations, such as blushing, blanching, faintness, fluttering of the eyelids, etc. In severe cases the frequency of the pulse may be very marked and attended with pain in the region of the heart, shortness of breath, feeling of oppression and rapid breath- ing, symptoms which disappear after the onset of the blood, to reappear at the following periods with diminished severity. In these cases heart lesions or changes in the size or tone of the heart cannot be detected. Circulatory disturbances at puberty are seen most frequently in individuals who have a neurotic inheritance and in those whose early environment has predisposed them to an unstable nervous equihbrium. In some, indications of enlarged thyroid and hyperthyroidism can be seen. Chlorosis, anemia, and the various hypoplasias are conditions especially apt to be attended with heart symptoms at puberty. Sometimes the above-mentioned symptoms continue to recur at the men- strual periods, especially if there is dysmenorrhea. Jaschke describes a type of case in which the heart symptoms alternate with those of menstrual pain, and applies the term "vicarious dysmenorrhea" to the condition. Other conditions that predispose to functional cardiac anomalies at the menses are hyperthyroidism and pelvic diseases, especially those attended with menorrhagia. In young women with amenorrhea, heart murmurs can often be demonstrated periodically, only to disappear after the return of the menses (Jaschke). During cohabitation subjective heart symptoms may appear, and if organic lesions be present the symptoms may be alarming. Kirsch calls attention to the injury to the functions of the heart resulting from long-continued incomplete orgasm, such as is caused by impotence of the husband, precocious ejaculation, coitus interruptus, and the use of condoms and vaginal preventives to concep- tion. The heart symptoms from this cause (tachycardia, heart weakness, dizziness, etc.) are only partial evidences of a general nervous weakness, which 8 114 GYNECOLOGY is manifested elsewhere by backache, pelvic pressure pains in the legs, and numerous other symptoms, all due to the same cause. Increased functional irritability of the heart is observed at the chmacteric. At this period of life appear also special characteristic vasomotor symptoms, the well-known "Ausfallserscheinungen." These consist chiefly of hot flushes or sensations of heat which appear momentarily. They are dealt with more fully elsewhere. (See Climacteric.) Schickele believes that the vasomotor disturbances of the change of hfe are due to a rise in blood-pressure consequent upon the absence of the ovarian secretion which normally acts as a blood depressant. This theory has not been entirely substantiated. It should be said that functional cardiac manifestations seen in relation to pelvic changes, especially those of the critical periods (menarche, menstrua- tion, pregnancy, and the menopause), are by no means constant, but are princi- pally seen in individuals of a neurasthenic or hysteric temperament. Long-continued bleeding from pelvic disease may cause anatomic changes in the heart muscle, a condition sometimes referred to as "the anemic heart" (Walthard). There is seen a fat deposit in the protoplasm of the cells of the heart muscle, an appearance not to be distinguished from true fatty degenera- tion. The condition has been shown experimentally to be the result of incom- plete oxidation. At the same time there takes place a dilatation of the heart, which, however, is not permanent, disappearing as it does after cessation of the uterine bleeding and restoration of the blood to its normal constituency. The therapy of the anemic heart resulting from pelvic disease is, therefore, identical with that of the pelvic disease. Pelvic diseases that are attended with long-continued disturbances of nutrition and respiration, like large ovarian cysts, myomata, and tumors associated with ascites, lead to brown atrophy of the cells of the heart muscles, a condition seen at autopsy in cases where there has been cachexia and marasmus. The relationship between the genitalia and organic lesions of the heart is not a particularly definite one, there being very little causal connection between diseases of the two systems. In uncompensated valvular heart disease with edema and ascites the labia majora may become swollen and edematous. It is observed also that long-standing uncompensation may be attended with edema and hypertrophy of the uterine mucosa, leading to menorrhagia and metrorrhagia, though in the hght of recent research this explanation of the bleeding must be accepted with reserve. A rare result of heart disease, mentioned by Jaschke, is an excessive bleeding from a corpus luteum from which it is claimed there may ensue an adhesive peritonitis. There is no doubt that under normal conditions considerable blood is not infrequently shed from the corpus luteum. Under the influence of the chronic passive congestion of heart disease it is reasonable to believe that such RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 115 a hemorrhage may be much greater than that which takes place under physio- logic conditions. The secondary anemia from bleeding fibroids and other tumors, which is manifested by a temporary compensatory enlargement of the heart, leads also to changes in the walls of the veins which predispose to thrombus formation. Infection of the thrombus may take place, with the sending off of septic emboh into the circulation. Myoma Heart. — Of particular interest to the gynecologist is the so-called "myoma heart." The frequency with which functional and sometimes organic changes in the heart are associated with uterine fibroids has in times "past led to the belief that there exists a definite immediate causal relationship between the two conditions. Just how the heart lesions are produced was not clearly explained. Some have believed that fibroid tumors manufacture a toxin which in circulating through the blood exerts a deleterious influence on the heart. Neu advanced the interesting theory that the changes in the heart are secondary to hypertrophy of the thyroid gland, which of itself is in some way induced by the myomatous growth. Thus the cardiac symptoms by this theory are in reality manifestations of hyperthyroidism. The general tendency at present is to ignore any causal relationship between the heart disturbance and fibroid growth, excepting in cases of long-continued bleeding in which compensatory changes are seen in the heart, such as are mentioned above in describing the anemic heart — changes that would appear in a secondary anemia from bleed- ing in any other part of the body. Certain vasomotor symptoms are sometimes observed in women who have fibroids, such as tremors, hot flushes, dizziness, tachycardia, etc., which have seemed to substantiate the claim of the toxic influence of fibroid tumors. These symptoms, however, are frequent in women without fibroids, and occasionally appear for the first time after hysterectomy for fibroids, so that they are not valuable evidence in support of the claim. Notwithstanding the present trend to disassociate myomata from heart lesions and to discard the toxic theory of uncomphcated fibroids, it is well to reserve judgment until the facts are "better established. The profound effect which fibroids without local symptoms often have on the general organism of woman, and especially on her nervous system, certainly suggest that the older theories may not be without basis. THE BLOOD-VESSELS Arteriosclerosis as the result of infectious diseases, especially of syphiHs, may occur in young women and be the exciting cause of menorrhagia and metrorrhagia. Non-infectious arteriosclerosis has in times past been supposed to play a very important role in the causation of uterine hemorrhages. In its general aspects arteriosclerosis is less common in women than it is in men, but it has been shown that the vessels of the female genital organs, and especially 116 GYNECOLOGY of the uterus, possess a special predisposition to become sclerotic. This has been demonstrated both in those who have had frequently repeated pregnancies, a long-recognized cause for arteriosclerosis, but also in the nulliparous. Pankow states that he can distinguish special forms of local sclerosis, due to child-bearing and to menstruation in virgins, and speaks of pregnancy-sclerosis and men- struation-sclerosis. A special preclimacteric arteriosclerosis has been shown to be a not uncommon cause of premature thickening of the vessels, especially if there be added the effect of frequent child-bearing. In the unmanageable uterine bleeding, so often seen in women near the menopause without demonstrable anatomic abnormality, arteriosclerosis has been widely accepted as a most important cause, but more recent investiga- tions tend to prove that its influence in this condition has been very greatly exaggerated. The present trend is in favor of irregularities in the function of the ovaries as the chief etiologic factor. Thrombophlebitis. — Phlebitis is a matter of interest to the gynecologist, in that it constitutes a somewhat frequent and troublesome complication in the convalescence of pelvic operations. The form of phlebitis most commonly seen in the practice of gynecologic surgery is of the so-called septic non-pyogenic type, and is the result of attenu- ated or non-virulent organisms circulating in the blood and lodging in the inner coat of a vein, usually of the lower extremity. The introduction of the organism into the circulation can probably take place at the time of the opera- tion, or it may be the result of a mild unrecognizable sepsis at the seat of opera- tion. The offending germ after lodging in the intima of the vein causes a lesion of the membrane which results in a thrombus and a local inflammatory process, though just how this process comes about is not definitely known. McLean regards as an important cause of thrombosis the necrosis of tissue remnants at the seat of operation, which harbor a low grade of infection and send off toxins into the circulation favorable for the development of a thrombus. This theory seems a very reasonable one, for thrombosis is especially apt to follow operations where there is much tying of pedicles and leaving of ragged shreds of tissue. Extension of the thrombus, lymphangitis, and edema cause a swelling of the leg which varies greatly in amount in different cases. There is always pain, and if the swelling is considerable the surface becomes white and shining, a condi- tion to which the name "phlegmasia alba dolens" was given in ancient times. In by far the greater number of cases the disease starts in the veins of the lower leg, the first evidence of trouble being a sharp cramp-like pain in the calf. In most cases it extends upward along the internal saphenous vein, causing pain and tenderness along the inner side of the thigh. In more serious but less fre- quent cases the inflammatory process of the vein may extend past the femoral ring into the veins of the pelvis, or it may originate in the femoral or iliac veins. Postoperative phlebitis usually appears between the eighth and twenty-first RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 117 day of convalescence, though it sometimes does not make itself evident until several weeks later. The course of the disease varies within wide limits, the mildest cases lasting only a few days, with no after-effects, and the more severe cases lasting weeks, and often resulting in permanent enlargement and partial disability of the leg. Thayer found, in an examination of a number of cases of postoperative thrombosis several years after the operation, that when the iliac and femoral veins were involved there was usually a permanent enlargement of the leg. Schenck estimated that about 65 per cent, of patients with postoperative phlebitis never completely recover, and that if recovery is to take place it will come within the first year. Phlebitis is practically always attended with moderate rise of temperature, which often appears several days before the onset of subjective symptoms. Postoperative phlebitis of the non-pyogenic type should always be regarded as a serious affection, the chief danger being the possibility of a separation of an embolic clot from the thrombus. This danger is present in cases of the mildest forms, and is to be considered for several weeks after the patient's apparent recovery. Numerous cases of pulmonary embolism have been re- ported in consequence of the apphcation of massage to relieve the pain of phlebitis. Nurses should always be given strict instructions concerning the nature and position of pain in phlebitis. This is particularly important be- cause the initial symptoms are usually regarded by the patient as those of muscular cramp. Another danger to which a patient with phlebitis is subject is the possibility of the disease changing from non-pyogenic to the pyogenic type. Pyogenic phlebitis usually starts as such, and represents the infection of a more virulent organism than does the preceding form. Whereas non-pyogenic phlebitis often follows what may be called "clean" operations, the pyogenic type, as a rule, is preceded either by an operation for some purulent condition or by postoperative active sepsis at the seat of the operation, such as stitch- abscess of the wound, septic parametritis, etc. The course of pyogenic phlebitis is a severe and alarming local sepsis about the affected part of the vein with marked constitutional reaction. Pyogenic phlebitis following gynecologic opera- tions usually appears in the leg and tends to remain localized. It may, how- ever, become diffuse, enter the circulation, and cause a fatal septicemia, or it may send septic emboli to distant parts of the body, causing pyemic abscesses. Treatment. — The preventive treatment of postoperative phlebitis is un- remitting attention to surgical asepsis, but, even with the greatest precautions and with apparently perfect healing of wounds, phlebitis occasionally appears. If we accept the theory of McLean, that thrombophlebitis is the result of necrotic tissue remnants, it is evident that clean, skilful surgical technic with considerate handling of tissues is of the greatest importance in preventing the complication. 118 GYNECOLOGY Treatment of the non-pyogenic cases consists in complete rest in bed with elevation and immobility of the leg. Comfort is given by applying an im- mense cotton swathing to the leg, surrounded by hot-water bags. Local medical applications to the leg are of no great curative value, but relief to the pain is sometimes afforded by painting the leg with ichthyol or by applying com- presses soaked in a weak lead-and-opium lotion. Matas recommends kaoUn poultices. The treatment of purulent phlebitis is usually surgical, and consists either in incision and drainage or, in some cases, if the disease is sufficiently localized, in excision of the infected area with ligation of the vein above. Embolism. — The subject of embolism is also of particular interest to the gynecologist in view of the fact that fatal embolism is peculiarly common after pelvic operations, especially those which implicate the hemorrhoidal and pampiniform plexus of veins and those which involve the appendix. In opera- tions for strangulated hernia there is said to be especial danger of emboHsm, due, according to Gussenbauer, to the fact that the thrombi are formed in the veins of the strangulated loop and set free in the circulation when the obstruc- tion is released. In nearly all statistics fatal embolism after hysterectomy for fibroids plays a somewhat conspicuous part. In our experience the accident has happened most frequently after minor pelvic operations during which the appendix was removed as a routine procedure. Postoperative emboli occur most frequently in the lungs, other less com- mon places being the kidney, spleen, brain, and pleura. The cause of surgical embolism cannot always be traced. Thrombophle- bitis, especiallj^ of the pelvic veins, with release of a small blood-clot into the circulation, is probably often the underlying cause, especially in those cases in which the embolism takes place at a considerable time after the operation. Undoubtedly, the manner of ligaturing the pelvic veins is of very great importance, a clean, skilful, and bloodless technic probably being the best pro- phylactic against the accident. Pulmonary embolism may occur during the operation, a short time after it, or at any time during the convalescence, often not until the patient is up and about. If the embolus is a large one, death may be instantaneous. Usually the patient does not die until several minutes after the first symptoms, which consist of sudden pain in the chest, difficulty of breathing, rapid pulse, deep livid color of the face, faintness and premonition of death, with rapid loss of consciousness. Pulmonary emboli are not always fatal. A small aseptic em- bolus may cause only a sharp pain, with a temporary distress in breathing and fleeting cyanosis, all symptoms disappearing in a few moments not to return, with the possible exception of slight lingering pain in the chest. Small non-fatal emboU may result in a hemorrhagic infarct of the lungs. RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 119 causing a moderate elevation of temperature for several days, with signs in the chest of localized consolidation and serofibrinous pleurisy. The infarct may be sufficient to cause hemoptysis. If the embolus is discharged from a septic thrombus, the lodgment in the lung may result in a serious pulmonary abscess. Varicose Veins (Varices, Phlebectasis) . — Varicose veins relate to a condition of permanent dilatation due to changes in the vessel walls. The term "varicose veins" is most commonly applied to the varices which occur in the lower limbs. These are far more common in women than in men, a result of the special obstructing influence exerted by the pregnant uterus on the veins. The venous enlargement usually takes place in the superficial veins, sometimes in the deeper vessels. In a third of the cases due to pregnancy the affection is bilateral, according to Jaschke, and when unilateral or more marked on one side than the other the veins of the right leg suffer more, probably on account of the tendency of the gravid uterus to rest in the right side of the pelvis. As a rule, the varices of pregnancy disappear after delivery of the child, but the stretching of the veins predisposes them to greater danger of thrombosis, phlebitis, and, later, permanent varicosities (Jaschke). Varicose veins of the leg of long duration are on account of their exposed position especially subject to trauma, with consequent rupture or septic throm- bophlebitis. On account of the incompetent circulation, lesions of the veins do not heal readily and indolent ulcers very frequently result. If the ulcers are neglected the surrounding tissues undergo a change, due chiefly to involve- ment of the lymphatics, and become thickened, brawny, and insensible, a con- dition resembling elephantiasis. Varicose veins of the legs, with their various complications, are so common in women that the affection may well be included in the hst of gynecologic diseases. Varicosities of the veins of the vagina and vulva, though less common than those of the lower extremities, are by no means infrequent as a complication of pregnancy, and are a source of serious clanger from rupture as a result of trauma, especially that from coitus or childbirth. Fatal hemorrhages from this cause have been reported. The condition is discussed in greater detail on page 293. Varicosities in the vaginal plexus of veins lead at delivery to separation of the vaginal mucous membrane from the paravaginal tissue, and hence predis- pose to later prolapse (Jaschke). A most important phase of varix formation is that which takes place in the pampiniform plexus of veins in the broad ligament in conditions of chronic pelvic congestion, especially when due to malpositions of the uterus. Accord- ing to Opitz, and in this our own experience coincides, many of the pelvic pains that attend uterine displacements are due to varicose veins in the broad liga- ments. These varicosities are often so tender as to cause a mistaken diagnosis of inflammatory adnexal disease. Restoration of the uterus to its normal posi- 120 GYNECOLOGY tion will often, though not always, cause the venous engorgement to disappear with complete relief of symptoms. The pelvic veins may become varicose from pregnancy or from large tumors, and Jaschke has reported fatal intra-abdominal hemorrhages as a result of this condition. Other phlebectases occurring as the result of pregnancy are seen in rare instances in relation to the uterine cervix and body, to the bladder, rectum, and stomach (Kaufmann, Halban, Bachrach, Ewald, Preiss). RELATIONSHIP OF GYNECOLOGY TO THE NERVOUS SYSTEM^ Influence of Menstruation on the Nervous System. — In considering the relationship between the genital and nervous systems one naturally regards first the important influence which the function of menstruation has on the general organism of a woman. John Goodman, in 1878, in an essay entitled "The Cyclical Theory of Men- struation," was one of the first to call attention to the fact that the function of menstruation is not a purely local process, but the expression of a profound change in the general circulatory system. This periodic change in the circula- tion Goodman regarded as under the direction of the nervous system and as following a regular law of rhythmic rest and activity, such as is represented by the heart action. Mary Putnam Jacobi, in the Boylston prize essay of Harvard University for 1876, presented, under the title of "The Question of Rest for Women during Menstruation," a most valuable contribution to the physiology of the pelvic organs, by expounding for the first time the ivave theory of menstruation. According to this theory, menstrual blood represents the overflow of superfluous nourishment material which has been stored up as a provision for impregnation, but which when impregnation does not take place is discharged in the form of a catamenial flow. Jacobi saw in this a rhythmic wave in the metabohc processes of woman which reaches its maximum immediately before and its minimum immediately after menstruation. In order to prove her theory, Jacobi made monthly obser- vations on several women and estabhshed that just before the menstrual period there is an increase in the body temperature, in the blood-pressure, in muscle strength, and in the pulse-beat, all of which gradually diminish during the menstrual period and are at their lowest ebb at its close. These observations were confirmed by other investigators. In 1890 von Ott and his pupil Schicharell studied in 57 normal women through 68 menstrual periods the temperature, pulse, blood-pressure, muscle strength, hmg capacity, inspiration and expiration strength, and the ocular reflexes, and from these studies concluded that the energy of the functions of the female organism is at its ^ Some of the material in this section is taken from an article by the author, published in the Boston Medical and Surgical Journal, 1913. RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 121 height immediately before menstruation and that it diminishes from the time of the beginning of the flow of blood. Von Ott constructed a curve which represents graphically the monthly wave of the life processes of normal woman (Fig. 22). The discussion as to the physiologic cause of this menstrual wave of depres- sion, whether it is the result of an ovarian internal secretion, whether it is from a rhythmic change in the central nervous system, or what not, is not at present conclusively established. The curve of Ott shows plainly that there is in the organism of the healthiest woman a monthly period of depression in her vital processes which finds definite expression in all her activities. This fact is of the very greatest importance in our understanding of a woman, either as an indi- vidual or as a patient. As Havelock Ellis has pointed out, the chart of von Ott would probably be paralleled, if it were possible to make accurate observations, in all the senses, emotions, and intellectual activities of women. 100 Menstructtx-OTL Fig. 22. — Curve of von Ott. In the preceding sections on the relationship of gynecology to the general organism we have seen that during menstruation the most varied disturbances take place in nearly every part of the body — i. e., in the organs of sense, in the digestive tract, in the skin, in the circulatory apparatus, etc. In the psychic and nervous organization of perfectly healthy women the menstrual curve is very plainly manifested. There is at that time a greater sensitiveness and im- pressionability. The individual is far more irritable and subject to outbursts of ill-temper and to unreasonable caprices. There is markedly less self-control and an invariable tendency to depression. The nervous refiexes are impaired and women are less skilful and dextrous during the menstrual period. What we have said so far relates to women in perfect health. Under patho- 122 GYNECOLOGY logic conditions the same upward and downward curve occurs, but the changes may be much more marked. In considering the pathologic aspects of the relationship between menstrua- tion and nervous disorders we must view the subject in two aspects. First, neuroses that are dependent entirely on an abnormal menstrual func- tion. In this case cure of the menstrual difficulty results in cure of the neuroses. Second, abnormalities of the nervous system which are made worse by the menstrual function. In this case, cure of a menstrual irregularity or arresting of menstruation is a source of relief, though not necessarily a cure, to the nervous abnormality. (1) Neuroses as a Result of Menstrual Irregularities.— Oi the menstrual irregularities, that may produce neuroses, dysmenorrhea is by far the most im- portant. By the term "dysmenorrhea" is meant the so-called essential dys- menorrhea, which consists of cramp-like pains of the uterus, felt usually in the front of the lower abdomen, occasionally in the sacral region. The pains of pelvic inflammation, chronic appendicitis, or other abdominal disease that are exaggerated during menstruation are not included under the term "essential dysmenorrhea" {q. v.). Essential dysmenorrhea is undoubtedly a purely physical sign, and, in the majority of cases, has some definite anatomic basis. The condi- tion commonly associated with true dysmenorrhea is a local hypoplasia of the genital organs, in which there usually exists a malposition of the uterus, in the form of a retrocessed anteflexion or a retroversion-flexion of developmental origin, or there may be malposition without hypoplasia. In a great number of these cases the individual is otherwise perfectly normal and there is often no predisposition to lack of nervous equilibrium. The painful periods at first often have little effect on the patient; but gradually, as she grows from girlhood into womanhood, permanent nervous manifestations of irritability, exhaustion, and depression make their appearance. The curve of menstrual depression becomes deeper and deeper, .and the return to the normal becomes later and later, during the intermenstrual period. Such patients no sooner recover from the effects of one period than they begin to dread the effects of the next one. The condi- tion is, therefore, one of continual hammering at the patient's nervous system and eventuates gradually in seriously affecting it. It is no wonder, therefore, that patients with dysmenorrhea nearly always in time become neurotic. The mistake, however, must not be made in supposing that the dysmenorrhea is in these cases the result of the neurotic condition. It is held by some that psychic and nervous conditions frequently induce chronic dysmenorrhea. This may possibly be true in some instances, but it is certainly uncommon. Such cases are, therefore, primarily for the gynecologist, who must do what he can to reueve the underlying pelvic condition. Unfortunately, essential dysmenor- rhea is difficult to treat successfully, but a certain percentage (50 to 75) yield to surgical treatment with immediate improvement of the nervous condi- tion. It sometimes happens that the dysmenorrhea cannot be cured by any RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 123 knowTi means and the patient develops into a hopeless invalid, a burden to her- self and her friends. In these extreme cases castration with hysterectomy is justifiable and indicated. In properly selected cases the cure of the mental and nervous condition may be complete. Other irregularities of menstruation besides dysmenorrhea may be the underlying cause of psychoneurotic conditions. Menorrhagia, for example, may so deplete the patient's general health and resisting power as to produce neurasthenic states, especially if there be coupled with it the fear of cancer. Continued amenorrhea may be; the cause of mental depression; but where it is associated with grave mental disorders, such, for example, as dementia prsecox, it must be regarded only as a sjmiptom of the disease. It should be noted that disturbed psychic states may exert a certain amount of temporary influence over the function of menstruation. It is extremely common for gjmecologic patients who are being prepared for operation to menstruate much out of their regular time. Sudden nervous or physical shocks often bring on the menstrual flow. It is doubtful if ordinary nervous shocks cause permanent irregularity, though this claim is frequently heard. Fear or nervous shock may also cause temporary amenorrhea, as is often seen in women who fear impregnation, the menstrual period sometimes being delayed as much as ten days or two weeks under the influence of such apprehension. (2) Influence of Menstruation on Pathologic Mental and Nervous Conditions. — ■ In this class of cases the primary seat of trouble is in the nervous system itself, and it includes everji:hing from hereditarj^ functional disorders to serious organic mental disease. There is no doubt that all of these conditions may be aggra- vated during the menstrual period. If, in addition, the menses are also ab- normal, the reaction on the nervous system is greatly increased. The nervous disturbance may be expressed only by severe periodic head- aches. Hysteria, hystero-epilepsy, epilepsy, erotomania, dipsomania, klepto- mania, and melancholia frequenth^ appear chiefly or solely at the menstrual period. Women with criminal or suicidal tendencies often show their inchna- tions at that time. To quote Havelock Ellis: ■'Lombroso found that out of 80 women arrested for opposition to the poUce, or for assault, only 9 were not at the menstrual period. Legi'and du SauUe foxmd that out of 56 women de- tected in theft at shops in Paris, 35 were menstruating. There is no doubt, whatever, that suicide in women is specially hable to take place at this period; I&ugelstein stated that in all cases (107) of suicide in women he had met wnth, the act was conmiitted during this period, and, although this cannot be accepted as a general rule (especially when we bear in mind the frequency of suicide in old age), Esquirol, Brierre, de Boismont, Coste, Moreau de Tours, R. Barnes, and many others have noted the frequency of the suicidal tendency at this period. In England WjTin Westcott has stated that, in his experience as a coroner, of 200 women who committed suicide, the majority were either at the change of Ufe or menstruating; and in Ger- many HeUer ascertained by postmortem examination of 70 women who had committed suicide that 25 (or in the proportion of .35 per cent.) were menstruating, a considerable proportion of the remainder being pregnant or in the puerperal condition. 124 GYNECOLOGY "Among the insane, finally, the fact is universally recognized that during the monthly period the insane impulse becomes more marked, if, indeed, it may not appear only at that period. 'The melancholies are more depressed,' as Clouston puts it, 'the maniacal more rest- less, the delusional more under the influence of their delusions in their conduct; those subject to hallucinations have them more intensely, the impulsive cases are more uncontrollable, the cases of stupor more stupid, and the demented tend to be excited.' These facts of morbid psychology are very significant; they emphasize the fact that even in the healthiest woman a worm, however harmless and unperceived, gnaws periodically at the roots of life." The preceding cases are primarily for the neurologist and the psychiatrist, yet there are certain of them whom the gynecologist may relieve. Cases of dysmenorrhea or menorrhagia should be submitted to the gynecologist, for if these symptoms can be cured the patient is relieved of an important nervous irritant. A limited number of cases of this class where the manifestations appear solely at the catamenial period are subjects for castration. Genital Psychoneuroses. — The term ''genital psychoneurosis" relates to a condition of mind which continually reverts to real or imaginary ills residing in the pelvic organs. In the strictest sense the designation "genital psychoneu- rosis" should be applied only to those cases in which the genital organs are actually sound and where the subjective symptoms are purely the result of imagination. In our experience, however, the pure genital neurosis is a com- paratively rare condition, at least in gynecologic practice, the principal type being that of the individual who, having some physical basis for pain or discom- fort in the pelvic region, exaggerates or overvalues both the pain and its sig- nificance. We may thus distinguish two types, one of which we will designate ''the genital neurosis of imagination" and the other the "genital neurosis of overvaluation." In the former the pelvic organs are entirely normal, while in the latter there exists some pathologic or functional abnormahty. This distinction is one of much clinical importance for on it depends the proper treatment of the case. Genital neurotics of the purely imaginative type belong to that class of indi- viduals who become consciously sensible of functions which normally belong to the realm of the subconscious, such as movements of the intestines, heart, and stomach, the attention having been directed to them accidentally or by the pain of some temporary aberration of function. The neurosis consists in the fixation or constant recurrence of the attention to the new sensations, even though the anatomic seat of the sensation is entirely normal. It is a general belief that neurotics of this kind are extremely common, a belief that has come down to us from the earhest times, it being supposed that 'there is some very specific relationship between the female pelvic organs and the nervous system Improvement in the study and diagnosis of both neurologic and gynecologic patients tends to show that the number of pure psychoneurotics is much less than was formerly supposed, and many cases, at one time con- demned as hopeless neurasthenics, are now found to be really sufferers from physical conditions that often can be alleviated. This applies not only to RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 125 gynecologic diseases, but to the affections of all departments of medicine and surgery. The manner in which sensations that under normal conditions are sub- conscious, or that to the nervously sound are little heeded, come into the realm of consciousness and acquire exaggerated significance is graphically told by Austen F. Riggs, from whose "Talks to Patients" the following is taken. Dr. Riggs pictures the field of consciousness as a great sea of immeasurable breadth and hmitless depth. The surface of this sheet of water is covered with waves. Each impression made upon our consciousness from the time of birth to the present moment is represented by a wave, and the waves are arranged in groups and systems according to the laws of association. "Now assume that the whole sheet is in total darkness, save that at or near the middle portion there is a light suspended from above which illuminates a very small area. It is a mere pencil of hght, capable of illuminating but one wave at a time, but it has the faculty of very rapid motion, and is thus capable of illuminating a good many waves in such quick succession that it produces the effect of having illuminated them almost simultaneously. This light repre- sents the attention. To carry out the figure, we must imagine ourselves suspended above it and as being able to control its direction by our will. Just as the searchlight of a battleship has a definite range beyond which the light does not reach, so the light of our attention can be pro- jected over only a hmited area of the sea of consciousness. All that lies outside this area, at any given moment, is, for that moment, subconscious, so that we speak of that portion of con- sciousness outside the range of the attention as the subconsciousness and that portion which lies within the illuminated area as the consciousness, or more accurately, the former is called the unaware consciousness and the latter the aware consciousness" ("Talks to Patients," Elementary Mental Mechanics). "Most of the time the vast majority of these waves stay quietly in the subconscious region, while only a small minority pass in and out of the aware region ; but under certain circumstances a great many may obtrude themselves into the illuminated area, and when this happens, trouble promptly ensues. "Each family of waves may be said to be made up of two subgroups; one of which, com- prising the waves representing the sensations of position, of vibration, and the deep muscle and tendon sensations, is a stable, stay-at-home cluster which normally always remains in the sub- consciousness. The other subgroup, which includes the sensations of touch, pain, and tempera- ture, is more mobile, more loosely held together, and thus many of its members are easily drawn from the family circle into the aware region. Any of these mobile sensations become very easily accentuated by the ordinary physical stimuli of the environment and are thus constantly flashing in and out of the attentive region. Even without physical accentuation, one or more of them may be drawn to the attention if one simply thinks of this or that part of one's body, and, consequently, at once becomes superconscious of it. "Bearing this mechanism in mind, it is easy to see that sensations of this class, after being repeatedly picked out and dwelt upon by an otherwise idle attention, will form a most unwel- come habit of finding their way with greater and greater ease into the aware consciousness and that consequently they will become exaggerated through repetition and over attention. This process, in fact, plays an important part in the genesis of hypochondriasis, where the sufferer becomes abnormally aware of many, one might almost say of all of his sensations; and it also plays no smallrole in numerous other sorts of 'nervousness.' "There is another accident which may occur in the mental field which produces a similar result. Not only may the mobile sensations of the 'touch' class, of which we normally may or may not be aware, become accentuated and exaggerated, but even those sensations of which 126 GYNECOLOGY . we are normally never aware, namely those belonging, to the stable, subconscious group, may, imder certain circumstances, reach the light of our attention. This they do by virtue of a proc- ess of disassociation — that is, by a breaking up of the normal arrangement of sensations in sub- groups and famihes. Thus when a family of sensory waves becomes accentuated (although usually only the more mobile subgroup of the touch and pain class is aif ected) , provided that the mental constitution be liable to disassociation, the hghtly balanced associative values of a whole family may be upset. The result is that one or more sensations of the stay-at-home group, which should have remained quietly at home in the subconsciousness, now disassociate them- selves from this their normal cluster and promptly join the other subgroup of the family. They then assimie the habits of their new companions and wander with them into the illumi- nated area. Thus not only does the 'touch' sensation become prominent, but it drags with it into the aware field one or more of its normally subconscious brothers. Here, of course, the latter hteraUy 'make a sensation.' They wear the uniform, let us say, of the knee family and are, therefore, recognized as hailing from the knee country; but this is the only famihar charac- teristic they possess, and they are above everything fascinating to the attention because of the utter strangeness of all their other qualities. They are out of place — as startingly out of place as fish out of water. The sensations are perfectly normal in themselves, but they are distinctly and markedly abnormal in their relative position in consciousness. Like deep-sea creatures suddenly hauled gasping to the surface, they are out of their natural element, the quiet sub- conscious regions, and are showing themselves in the utterly strange environment of the intensely active and brightly illuminated aware region. Of course they seem unnatural, un- desirable, and, furthermore, we treat them with fearful attention and respect, because they seem to signify that there is something very strange going on in the bodily region from which they emanate. The sufferer little realizes that their abnormality consists chiefly in malposi- tion and not in intrinsic quality or significance. "Once having gained the entre, the dislocated sensations in question very soon acquire the habit of caUing with always greater frequency and famiUarity. Naturally the attention dwells with greater and greater intensity upon its strange guests, and the latter consequently swell to an enormous importance. Before long the secondary physical results make their appearance. The function over which the sensations in question formerly presided without let or hindrance now suffers overstimulation or overinhibition as the case may be. The sensation, because of its abnormal activity and also because of its malposition in consciousness, has attracted more than its share of the attention, and the latter consequently interferes with the nervous control of the function" ("Talks to Patients," II, Nervousness). Cases of pure psychoneurosis with normal pelvic organs belong to the neurologist and psychiatrist. The duty of the gynecologist is to isolate these cases from those whose symptoms result from actual pelvic disease. Obviously, patients whose symptoms are imaginary are always of a neurotic constitution, but patients whose nervous symptoms are due to the irritation of pelvic disease may or may not have had a neurotic predisposition. Those whose nervous equilibrium is naturally unstable succumb more readily to pelvic irritants, but even those of the soundest constitution may become the victims of serious neuroses if the irritation be sufficiently protracted or combined with other elements of physical or mental strain. In treating a neurotic patient who complains of pelvic pain or discomfort it is the safest plan to assume that the ills complained of are actual and not im- aginary, though allowance may be made for a certain degree of exaggeration or overvaluation. By not observing this rule the gravest mistakes are often made. The conditions which produce genital neuroses are more apt to be the minor RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 127 pelvic affections which, without causing severe symptoms, maintain a nagging discomfort and keep the searchhght of the attention constantly turned upon them. The most common and most important source of such neuroses is that which comes from the adhesions of chronic pelvic inflammation. The discom- fort may be caused by peritoneal irritation or by the immobilization of organs which normally enjoy free motion in the pelvis. Of these, the adnexa suffer most, and more commonly those of the left side, the pain usually being referred to the ovary. The fact that even extensive adhesions may exist without detection by the most expert digital examination leads frequently to the diagnosis of psycho- neurosis without physical basis, such terms as "ovarian neuralgia" being used to explain the sensations of pain. Another most prohfic cause of neuroses is prolapse of the pelvic organs. This causes a sense of pressure and weight. The patient becomes actively aware of her uterus, and finds it difficult to turn her attention from it. The exhaustion that attends work and physical effort deplete the strength and stimulate the nervous irritabihty. Patients of the strongest nervous constitu- tion are subject to this form of genital neurosis. Reconstructive surgical opera- tions in this type of case are among the most satisfactory in gynecologic practice. Tumors which are attended with symptoms of adhesions or pressure, or that cause irregular menstruation or mental anxiety, produce neuroses. Unob- served, non-painful tumors, on the other hand, may reach large dimensions without producing the least effect on the nervous system. The effects of irregular menses have already been dwelt upon. Affections of the external genitals are often the cause of severe nervous troubles. Leukor- rhea, functional incontinence of urine, pruritus are of great chnical importance in this respect, as is pointed out in the sections devoted to those subjects. Senile atrophy and shrinking of the perineum deserve special mention. Vaginismus is the result either of a pure neurosis or may be due to some painful lesion. Many neuroses have a sexual origin and may result from sexual disharmony between husband and wife, disappointment at not bearing children, fear of im- pregnation, masturbation, shame, etc. The subject may be summed up by the statement that chronic pelvic condi- tions that cause constant or frequently repeated painful or disquieting sensa- tions produce functional neuroses and psychoneuroses, the extent of which depend partly on the duration and severity of the symptoms and partly on the inborn lack of resistance to nervous stimuli on the part of the patient. The genital neuroses, however, do not differ in character from those originating in other parts of the body, and do not represent a mysterious specific nerve con- nection between genitaha and brain, as was formerly supposed. The fre- quency of genital neuroses, as compared with others, is due to the comphcated nature of the genital organs and the ease with which they are thrown out of a normal equilibrium. The treatment of genital neuroses is directed toward the local cause of irri- 128 GYNECOLOGY tation, and requires exact diagnosis and tactful judgment, for if cases of this kind are improperly treated the effects are serious. The success in treatment depends on relieving the irritating local symptoms. If pelvic disease can be definitely excluded the patient should be treated neurologically, for in this case all forms of gynecologic treatment are usually harmful. Effects of Castration. — The subject of postoperative neuroses following hysterectomy and castration is of special interest to the gynecologist because of the frequency with which this operation must be performed, and because of the popular belief that ablation of the uterus and ovaries is followed by serious nervous disturbances that may even amount to insanity. That this notion is very greatly exaggerated is proved by the experience of present-day surgeons. It has been our observation that the artificial menopause causes no more dis- turbance than does a normal change of life. The nervous symptoms of the menopause may be divided into two distinct groups, the vasomotor and the psychoneurotic. Vasomotor symptoms are represented chiefly by hot flushes, though there may be other manifestations of dizziness, cold extremities, etc. In our series of cases vasomotor disturbances appeared in 80 per cent, after castration. The average duration of these symp- toms is from two to three months, though they may last longer. Painful or irritating complications after operation, such as hernia, postoperative adhesions, wound infections, and, especially prolapse of the cervical stump and vaginal wall, tend to make the symptoms more severe and to prolong them over a greater period of time. Ovarian extract acts as a specific for the vasomotor changes, almost invariably relieving them. The cause of hot flushes is in some way related to the removal of the ovaries, but in just what way the change takes place is not definitely known. Schickele ascribes them to a heightened blood-pressure, due to the removal of the vaso- depressor influence of the ovarian internal secretion. Observations made at the Free Hospital for Women in a series of about 50 cases have failed to reveal a single instance of increased blood-pressure following castration. That hot flushes are influenced by some other factor or factors is shown by their frequent appearance in women who possess functionating ovaries. In one of our cases, a patient with uterine insufficiency who had suffered severely from hot flushes for several years, the symptoms completely disappeared after hysterectomy and castration. Vasomotor disturbances do not usually produce nervous symptoms unless they are very severe or frequent, in which case they sometimes react seriously on the nervous system in the same way as any other physical irritant. Psychoneuroses, as distinguished from vasomotor disturbances, are by no means definitely consequent on the loss of the ovaries. On the contrary, psychoneurotic conditions are again and again relieved or completely cured by a hysterectomy operation which has relieved the patient of some painful irritant hke that, for example, of a pelvic infiammation. RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 129 Severe psychoneuroses may follow hysterectomy, but they are brought about in the following ways: The operation may have been misdirected and not indicated in the first place, or it may have been improperly performed, or surgical complications may have ensued which have left the patient in a painful, uncomfortable state. As proof of this is the fact that postoperative neuroses following hysterectomy were formerly far more common not many years ago than they are now. This can only be explained on the ground that the technic of the operation has in the last few years been very greatly improved, so that now if it is properly done there is no shock, no postoperative prolapse of the vagina, no pelvic adhesions and 'other unfortunate complications, which, if present, cause nagging discomforts that are sure to disarrange the nervous mechanism. Another important cause of the psychoneuroses of the artificial meno- pause is that resulting from mental suggestion. Under normal conditions a woman does not instinctively suffer a sense of physical degradation from the loss of her pelvic organs, especially if such a loss is attended with a relief of pain. This sense of degradation may, however, be very powerfully induced by the criti- cism of an unfeeling husband or the suggestions of unwise friends, by which the patient is led to contemplate her inabiUty to bear children or to fear the loss of youth and the premature onset of old age. Under such conditions the mental distress may result in severe psychoneuroses. Such a state, however, must be regarded as due to psychic irritation, and not, in any sense, as a specific consequence of the loss of ovarian secretion. What has been said concerning the nervous disturbances of the artificial menopause is also true of the physiologic menopause, in which vasomotor and psychoneurotic symptoms may appear. Dubois, after studying many cases for a period of more than thirty years, has come to the conclusion that the neurotic manifestations are largely due to mental suggestion as a result of the cares and worries and apprehensions that are usually incident at the period of the climacteric. RELATIONSHIP OF GYNECOLOGY TO THE SEX IMPULSE A study of the sexual impulse in woman includes a consideration of every period of life from earliest infancy to extreme old age. Until comparatively recent times normal sexual activity was supposed to begin only at the time of puberty and the appearance of menstruation. Before that period manifestations of a sexual character were for the most part regarded as abnormal and as evidence of disease or of some hereditary degenerative taint. Kisch, in his monumental work on the sexual life of woman, begins at what he terms the menarche (puberty), entirely disregarding childhood. Lowenfeld remarks "that the manifestations of the sexual impulse are not normally present in the days of childhood," and that when the impulse does appear it is either the 9 130 GYNECOLOGY result of pathologic conditions that affect the genital organs or of chance impres- sions or bad example. To Freud must be given the full credit of first recognizing the normality of the sex impulse in childhood and of calling attention to the enormous influence which infantile and adolescent sexuality has on the mental and physical character of the adult. The theories of Freud have not been received without intense opposition, but they have finally come to be so widely accepted, both by the medical profession and by psychologists, that they cannot be disregarded in a work of this kind. Freud attributes the little value that has in the past been ascribed to the childhood period of sexual development to the universal infantile amnesia which "causes the individual to look upon his childhood as if it were a prehistoric time and conceals from him the beginning of his own sexual life." Freud, how- ever, has been able to show that during the forgotten period of childhood the most important and lasting impressions are made on the childish mind, which, though lying latent and forgotten in the subconscious, actually continue to exert a powerful influence on the qualities and reactions of the individual throughout his lifetime. In considering Freud's views on infantile sexuality it must be remembered that we are studying the impulse in its various stages of development; that is to say, the sex manifestations of the young child are essentially rudimentary and are in no way equivalent to the physico-psychic sex reactions of the matured indi- vidual. Failure to appreciate this fact has led many to regard the Freudian theories with abhorrence. As Trotter puts it, it is like the embryology of the body, which to persons with no biologic training is far from being a gratifying subject of contemplation. INFANTILE SEXUALITY According to Freud the newborn child brings with it rudimentary sexual impulses which normally make their appearance at certain stages of the child's life with intervening periods of latency. These early rudimentary impulses are very complex and, as will be explained later, include perverse as well as so-called natural instincts. The first instinct that the child exhibits is that for nourish- ment, which is obtained by sucking its mother's breast. The act of sucking, first employed for appeasing hunger, is soon found to be soothing and pleasurable, and the child resorts to it often when not hungry, thereby inducing sleep. The act of nursing, notwithstanding its primary object, is to be regarded as the earliest manifestation of the sexual impulse, a fact not to be wondered at in view of the close association of the hunger and sex instincts that later in life are sufficiently obvious. The pleasurable sensation excited by the act of nursing leads the infant to seek other objects for sucking more accessible than the mother's nipple. This practice, which to a certain extent is universal among babies and is, within limits, physiologic, disappears in time and is harmless. It may, however, become excessive and be the starting-point of serious later developments. The objects RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 131 most frequently chosen for sucking are parts of the infant's own body, especially the thumb, the tongue, a part of the lip itself, or the great toe. Associated with the act of sucking there is often a rhythmic pulling of the lobe of the ear, or the rubbing of certain sensitive parts of the body. This habit completely occupies the attention of the child and leads to sleep and sometimes to a reaction resem- bling an orgasm. That thumb-sucking is a sexual manifestation is often recog- nized by parents who are vaguely aware that the child is doing something wrong and who strive to break the habit. Such a habit often persists for years, some- times for a lifetime, and probably in the majority of cases leads directly to masturbation. Freud finds among men a definite relationship between energetic ^ infantile thumb-sucking and a later tendency to excessive drinking and smoking, while among women he shows that it may lead in adult life to certain Hp perver- sions, or, if repressed, to hysteric symptoms connected with eating, such as globus hystericus, choking sensations, and vomiting. Thumb-sucking, which is only one of several examples of infantile sexual activity, illustrates the theory of erogenous zones, a term adopted by Freud from von Kraft-Ebing and defined by the latter as ' 'portions of the skin or mucous membrane in which stimuli produce a feeling of pleasure of definite quahty." Examples of these sensitive areas are the lips and mucous membrane of the mouth, the nipples, the anus, the neck o: the bladder, the buttocks, and the external genitals. As will be seen later, undue early excitation of any one of these zones may produce an abnormal sensibility of that particular part of the body and evoke in after years certain sexual aber- rations from habitual gratification, or neuroses from repression of the unnatural impulse. In habitual thumb-sucking we have an illustration of abnormal stimula- tion of the lip-and-mouth erogenous zone. The sexual impulse of the child is essentially auto erotic, that is to say, the sexual aim is directed to some portion of the child's own body, usually one of the erogenous zones. At birth the various zones are-each susceptible of develop- ing into predominant sexual areas if subjected to special excitation, a point which will be seen to be of importace in determining some of the perversions. Nature, however, provides that under normal conditions certain zones only shall be stimulated for future sexual activity. Thus the act of nursing prepares the lip zone, so that it plays a prominent part sexually during life. Freud sees in the irritation from uncleanliness, cleansing, chafing, etc., nature's provision for the early excitation of the genital zone. The infant soon recognizes the pleasurable sensibility of this area and learns to repeat the experience by onanism, even during the nursing age. In girls this is accomplished either with the hand or by pressure of the thighs. So nearly universal is this phenomenon that Freud regards it as a physiologic reaction which serves to estabHsh the future primacy of the genital zone. The first phase of infantile onanism is usually of brief dura- tion, though it may continue indefinitely and provide a permanent deviation from normal sexual development. At about the fourth year in most children there is a second reawakening 132 GYNECOLOGY of the sexual impulse, and again there is a period of onanistic activity which is also normally of short duration. Both the incidence and duration of this period varies considerably in different individuals. Girls do not escape this experience and there is some ground for belief that both this and the infantile period of masturbation are more common in them than in boys. In the second period the sexual demand in girls is apparently not necessarily determined by local irritation, but may be of central origin. It is characterized by a sudden itching or prurient sensation, often of a disagreeable nature, which is commonly reUeved by the hand or by pressure of the body against some projecting object or by bodily movements with the thighs closed. The sensation and its reHef may be induced by such exercises as riding a bicycle, swinging, rocking, riding in rail- road trains, etc. In its physiologic phase the onanism of childhood is not asso- ciated with psychic sexual phantasies. Freud rightly emphasizes the great importance of the influence of the second stage of childhood masturbation on the future character of the individual. At this period there begins to develop in the child's mind forces which inhibit the sexual impulse and which find their expression in a sense of shame and loathing. This sexual barrier, as it is termed, is not essentially the outcome of parental ,'liscipline and education, but, as Trotter has pointed out, is a true instinct. In a normally or, one might say, ideally developing and properly protected child the psychic barrier completely overcomes the masturbatic tendency and there ensues a latent period until the next stage of sexual awakening. During the latent period not only does the psychic inhibition prevent sexual practices on the part of the child, but it inspires loathing at the appearance of such inclina- tions in other children or in older persons. The normal child is, therefore, to a certain extent automatically protected from the dangers of seduction and enters on the age of puberty well prepared for the serious problems of life. For .many children, however, the latent period is a critical age. If the psychic barrier is weak either from hereditary predisposition or from unfavorable en- vhonment, or from both causes working together, the sexual activity of mid- cliildhood may continue and become intensified. Under such conditions the child is an easy prey to the influences of seduction or evil impressions and the sexual stream may flow readily into some perverted channel. In other cases the psychic barrier, though it may succeed in repressing the sexual impulse, appears too late and brings about a conflict so severe that it leaves in the childish mind a profound traumatic impression which may reappear in later years in the form of some serious neurosis. It is in cases of this kind that Freud has car- ried out his deepest researches and made his most important discoveries. Up to the time of puberty the sexes do not differ greatly in regard to their sexual activity, though it may be said that the inhibitive instinct seems to appear earUer and more effectively in girls than in boys. At iSie beginning of puberty, however, a marked divergence between the two sexes takes place. In the boy very definite and consistent sexual changes take place concomitant with the RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 133 rapid development of the genital apparatus. These may be summed up in the appearance of the libido, powerful attraction toward the opposite sex, and a more or less periodic discharge of the sexual products. In normal boys the sexual experience is constant, showing comparatively little variation in different indi- viduals. In girls, on the other hand, the sexuahty of puberty is not as well de- fined. In them the libido is not regularly awakened as a result of the physiologic and anatomic changes of puberty, but depends for its excitation on an external stimulus, such as seduction, love, onanism, suggestion from books, etc. Hence in guis puberty and the awakening of the hbido are not necessarily contemporaneous. The way in which full sexual sensibihty is developed may be best understood by the following quotation from Freud : "In respect to the auto-erotic and masturbatic sexual manifestations it may be asserted that the sexuahty of the httle girl has entirely a male character. Indeed, if one could give a more definite content to the terms 'masculine' and 'feminine,' one might advance the opinion that the libido is regularly and lawfully of a masculine nature, whether in the man or in the woman ; and if we consider its object, this may he either the man or the woman. "The chief erogenous zone in the female child is the clitoris, which is homologous to the male penis. All I have been able to discover concerning masturbation in httle girls concerned the clitoris and not those other external genitals which are so important for the later sexual functions. With few exceptions I myself doubt whether the female child can be seduced to anything but chtoris masturbation. The frequent spontaneous discharges of sexual ex- citement in Mttle girls manifest themselves in a twitching of the chtoris, and its frequent erections enable the girl to understand correctly even without any instruction the sexual manifestations of the other sex; they simply transfer to the boys the sensations of their own sexual processes. "If one wishes to understand how the little girl becomes a woman he must follow up the further destinies of this chtoris excitation. Puberty, which brings to the boy a great advance of libido, distinguishes itself in the girl by a new wave of repression which especially concerns the chtoris sexuality. It is a part of the male sexual life that sinks into repression. The re- inforcement of the sexual inhibitions produced in the woman by the repression of puberty causes a stimulus in the libido of the man and forces it to increase its capacity; with the height of the libido there is a rise in the overestiniation of the sexual, which can be present in its fuU force only when the woman refuses ajid denies her sexuality. If the sexual act is finally sub- mitted to and the clitoris becomes excited its r61e is then to conduct the excitement to the adjacent female parts, and in this it acts hke a chip of pine v/ood which is utilized to set fire to the harder wood. It often takes sorne time for this transference to be accomplished, during which the young wife remains anesthetic.'^ The sexual life of the first part of normal womanhood may be thus reca- pitulated : The first sexual activity appears in earliest infancy and results from the pleasurable sensations of nursing. It is manifested often by thumb-sucking, masturbation, and other equally significant acts associated with certain areas of the body termed erogenous zones. A second period of sexuality appears at about the age of four to six and is characterized chiefly by masturbation of the chtoris. This period is under normal conditions, of comparatively short duration and is terminated bj^ the develop- ment of the psychic barrier, which, supplemented by parental discipHne, causes the child to repress the masturbatic practice. After the termination of the onan- istic period of childhood the little girl's life is apparently asexual. At puberty 134 GYNECOLOGY there takes place a fresh wave of repression in contrast to the flood of libido which occurs in boys. The repressive inhibition lasts through maidenhood and may be regarded as a provision of nature in that it furnishes the resistance neces- sary for the highest effectiveness of the male libido. At the first coitus the normal woman is often anesthetic and may remain so until the clitoris is able to conduct its excitability to the adjacent parts and especially to the vagina. This period of sexual anesthesia may continue for several weeks or months. Occasionally it lasts until after the birth of the first child. This temporary anesthesia of the newly married woman is not to be regarded as pathologic, although it sometimes is the exciting cause of an anxiety neurosis. When full sexual sensibility has been e^r'iabKshed the libido of woman becomes mascuHne in type, though between man and woman the component parts of the libido may exhibit variations in intensity. Thus in woman the psychic element is often more powerful than the somatic, as compared with man, though in some in- stances the conditions may be reversed. The asexual period of maidenhood described above may be regarded as the ideally normal, and is undoubtedly the best preparation for the later duties of wife and motherhood, in that it makes for greater mental and social stability. The adolescent period is, however, pecuHarly liable to sexual interruptions such as may result from multiple ^love affairs, lax social environment, onanism, evil suggestion, etc. Women who during their maidenhood period experience such interruptions are especially subject to neuroses and are prone later to be- come irritable and discontented in married life. During the first part of married life the participation of woman in the con- jugal relation is more that of passive acquiescence. After the birth of children and as physical attraction wanes it frequently happens that the role of sexual initiative between the partners is reversed. The sexual libido of woman does not cease at the menopause, but may continue indefinitely afterward. During the period of the climacteric there is often an increase in intensity which under pathologic conditions may amount to n3miphomania. After the menopause the libido gradually diminishes, more, in all probability, from disuse and repres sion than from a physiologic disappearance of the emotion. Libido and sexual sensibility are not, as a rule, destroyed by castration in adult life. SEXUAL DEVIATIONS Masturbation. — Of the various sexual deviations to which woman is subject the most important is masturbation, a fact that is not fully appreciated. Not only is its frequency underestimated, but its influence on character and health has received too little attention. The subject of masturbation is not as well understood in woman as it is in man. Much of the evidence in the literature is vague and contradictory.. , It therefore becomes necessary to weigh judicially the evidence that is available and with the aid of clinical observations to draw such conclusions as seem most RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 135 reasonable. Freud's theories on infant sexuality, cited above, throw a new light on the masturbation of childhood. If these theories be accepted, we must re- gard as physiologic the brief onanistic periods of the nursing stage and of mid- childhood. These two manifestations of sex activity are practically alike in the two sexes and in no sense indicate degenerative hereditary tendencies. On the contrary, they are a provision of nature to prepare the genital zone for its ulti- mate sexual primacy, and their failure to appear may even denote an inborn sexual deficiency. If, however, they are not duly checked by the inhibitions which nature also -provides, then masturbation becomes pathologic. The per- sistence of the practice beyond its physiologic limits may indicate an hereditary predisposition or it may be the result of an unfavorable environment. There is no doubt that during the latent period of childhood an occasional infrequent recurrence of the prurient sensation of the clitoris demanding gratification may take place in entirely normal individuals, especially in those who in mature life develop strong sexual impulses. When, however, the recurrence is so fre- quent as to form an established habit, it must be regarded with concern. Al- though it is frequently asserted, and probably with truth, that onanism in the adult woman is less harmful than it is in man, the same assertion cannot be made of onanism of the latent period of childhood, for girls are peculiarly sus- ceptible to the abnormal psychic reactions to which the practice leads. When onanism becomes excessive in a child the condition is a difficult one to combat. In extreme cases the craving is incessant and insatiable. Preven- tion by tying the hands or by other mechanical means is, for the most part, futile, for orgasm can be accomplished by simple movements of the body. Excepting in cases where onanism is a syndrome of mental degeneracy the onanistic child is frequently prematurely bright and intelligent. When t*e psychic barrier is entirely inactive the child exhibits no sense of shame and is frank, cheerful, and care free. In this type of case there are often no signs of physical detriment. Such cases, however, must be kept from contact with other children, for in addi- tion to the auto-erotic impulse which leads them to constant masturbation there exists almost invariably a tendency to communicate their experiences to com- panions either male or female. They become, therefore, a dangerous source of seduction. The future of the childish victim of uninhibited onanism is not easy to prog- nosticate. Where hereditary degenerative influences play a part the masturba- tive tendency may be a prodrome to some later serious psychosis. In other cases the onanistic impulse which during childhood is auto-erotic may become frankly altruistic, that is, directed to others of the same sex. In this way the child may develop sooner or later into an invert or homosexualist. Such individuals may be entirely normal in every other way and often show great intellectual power and productiveness in mature life. In still other cases the normal repressive reaction of female puberty may check the onanistic tendency, and under proper environmental influences the 136 GYNECOLOGY sexual stream may eventually be directed into normal channels, though neurotic stigmata are comparatively certain to appear. So far we have discussed what we have chosen to term the "uninhibited masturbator," that is to say, the child in whom the psychic barrier of shame and self-reproach has failed to act. There is another important type, where the psychic barrier, though strong, only incompletely overcomes the sexual impulse. The result is a continual men- tal conflict which, as Freud has shown, may lay the foundation of a later neurosis. Individuals of this type often suffer more physical detriment than do those of the uninhibited class. They are frequently meager and sallow in appearance, subject to digestive disturbances, non-resistant to disease, mentally sluggish and apathetic, secretive, and antisocial. Between the two extremes of type there are all gradations. From the time of puberty to the time of female maturity, usually estimated at nineteen, masturbation is not physiologic, as to a certain extent it may be regarded in boys. If habitual masturbation occurs in the adolescent girl it is either a continuation of abnormal childhood onanism, or if it appears for the first time, it is the result of a prematurely stimulated but ungratified sexual activity. What has been said of masturbation of the latent period of childhood may be applied for the most part to the period of adolescence with some modifications. When the habit is excessive it is usually associated with some mental disorder. Patients of this kind often suffer from severe and extensive vulvitis as a result of manipulative irritation (see Vulvitis). Newly acquired masturbation at this age usually does not lead to serious results. Early masturbation is a poor preparation for married life, for those addicted to the habit are apt to be anesthetic in normal coitus. This is explained by the fact that continued excitation of the clitoris causes a fixation of sexual sensibility to that particular zone. When, therefore, normal coitus takes place the clitoris permanently refuses to give up its excitability to the zones of the vulva and vagina, which play an absolutely essential part in complete natural orgasm. Thus masturbation continued from childhood is rightly classed as an infantile fixation, and is comparable from a neurologic standpoint, though not necessarily concomitant, with those anatomic fixations which are so common in the female pelvic organs. Early continued onanism has an important influence on the character of woman, for in addition to the neuroses which it induces it is extremely apt to be instrumental in fixing certain traits of disposition that belong essentially to childhood. The infant is not only sexually auto-erotic, but is also otherwise psychically egocentric. We have seen that the auto-erotic tendency of mid- childhood is soon checked by the development of the psychic barrier which creates feelings of shame and self-reproach. This psychic barrier is, in reality, the herd instinct which by antagonizing selfish impulses adapts the individual to social surroundings. If the psychic barrier is incapable of checking the auto- erotic tendency as is manifested by continued masturbation it may fail also to RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 137 check other egocentric impulses not essentially sexual, such as jealousy, cruelty, dependence, and self-will, which are characteristic of the infant's nature. Thus, traits of this kind may become fixed, and individuals who exhibit them in mature life are said to be subjects of 'psychic, infantilism. Psychic infantilisms of char- acter are not necessarily conditioned on early masturbation, though it is probable that when they are well marked they are usually the stigma of some early sexual irregularity. The prevalence of masturbation in matured women is problematic, but it is undoubtedly far more common than is generally supposed. Gutceit is of the opinion that after the age of nineteen or twenty "sexual self -gratification is almost universally practised by women, even if it be not always practised to excess," but the statement probably is an exaggeration. It is impossible to secure exact data concerning the onanism of maturity, as women are habitually secretive and deceptive on this subject. From what evidence we have we are led to believe that women who have indulged in the habit in earlier life beyond the physiologic limit, either continue or resume it to a greater or less extent after the age of maturity. This must be especially true in women who do not achieve normal sexual gratification or in those in whom the early practice has by fixation prevented the extension of sexual sensibility from the clitoris to the neighboring erogenous zones (vulva and vagina). How often masturbation is acquired for the first time after maturity it is impossible to say, but it may be conjectured that in cases where gratification is lacking from impotence or indifference on the part of the husband, it is frequently resorted to as a means of relief. Hence we are brought to the conclusion that after maturity onanism is more common in women than in men, for in the latter it is a comparatively rare habit after the age of twenty-five. It is a matter of significance that the adult woman rarely consults a physician for advice in this matter. From this fact it must be concluded that if onanism is common in the middle period of life it is not at this time especially productive of obvious harm, certainly not in comparison with the onanism of youth. There is the best authority for the statement that the onanism of adult woman is much less detrimental both psychically and somatically than in adult man, Hitsch- mann states that "there is a special sexual constitution which causes certain people to become ill as a result of masturbation, while others bear their onanism without noticeable injury." It is important not to depreciate the possible harm that excessive masturbation may do even in matured Kfe. The evil results are seen mostly in psychoneurotic reactions and are more famihar to the neurologist than to the gynecologist. The onanism of woman, as a rule, produces no observable somatic changes, yet in some cases objective signs are definite. Of these, the most common is a lengthening and attenuation of the labia minora. The change is usually asym- metric. Sometimes only one labium minus is affected. This deformity we are incHned to think is the result of some special onanistic technic by which the 138 GYNECOLOGY labia become gradually stretched. It may, however, be analogous to the length- ening and relaxation of the scrotum characteristic of the male masturbator. The severe vulvitis from excessive onanism is described elsewhere. Other so- matic changes are the result of continued pelvic congestion. There is no doubt that some of the cases of severe menorrhagia in young girls after puberty have their origin in masturbation, though on this point we have had difficulty in our personal experience in securing reliable data. In a typical extreme case the uterus is much enlarged and usually retro verted. There is a marked permanent gland hypertrophy. Menorrhagia is severe and prolonged. In an extreme case observed by us of a girl of ten, marked dilatation of the superficial venous capillaries of the thighs and lower abdomen were noted. How common this is we do not know, as we have not seen it mentioned elsewhere. It is quite probable that masturbation may in some cases be the primary or contributing cause of the frequent condition of varicocele of the broad ligament in the same way as in the male it often leads to scrotal varicocele. Dyspareunia. — Like masturbation, dyspareunia is a subject the importance and frequency of which has not been adequately estimated in the study of the physical and mental welfare of woman. The word dyspar€U7iia is commonly misused as a synonym for painful coitus. In its strict sense it denotes a condition in which, though the libido sexuaHs is present, normal orgasm is not produced by intercourse. Dyspareunia may be the result of pain, but pain is not a neces- sary accompaniment and, except in a certain class of cases, is absent. Sexual anesthesia, frigidity, and anaphrodism are terms sometimes used equivalent to dyspareunia. Sexual anesthesia is used differently by different authors. Freud employs the term as we have used it above as synonymous with dyspareunia, i. e., local inexcitability, libido sexu- ahs being present. Von Kraft-Ebing, on the other hand, uses the term to denote complete asexuality, with entire absence of libido. Such a definition imphes an organic affection of the nerve centers, such as may arise from disease of the brain or spinal cord, diseases of the endocrine glands, marasmus, diabetes, morphinism, alcoholism, and sexual abuses. We prefer to use the expression in the Freudian sense. A complete understanding of the causes of dyspareunia would imply a knowl- edge of the mechanism of sexual excitability. Such knowledge we unfortunately do not possess and we must rely for guidance only on certain vague theories. The nerve theory may be briefly stated as follows : coitus stimulates the sensory nerves of the clitoris, the vulva, the vestibule, and the vagina; this stimulus is communicated to the cerebral cortex where it gives rise to pleasurable sensations; from the cerebral cortex is produced a reflex stimulation of the genitospinal center, which in turn excites a series of reflex discharges in the genital oj-gans, the most notable of which are the erection of the clitoris and the ejaculation of the secretions of various glands. Such an explanation is incomplete, for it does not take into account the in- fluence of the internal secretions of the body which undoubtedly play an impor- tant part in the reactions of ah psychic emotions. A deflnite connection between sexuahty and the endocrine glands is extremely probable, but not as yet under- RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 139 stood. The ovaries, at one time thought to be the very seat of sexuahty, are now known to occupy a secondary position, while the sexual influence of the other glands of internal secretion is entirely problematic. Freud emphasizes the importance of the chemical theory of sexuality and furnishes the following hypothesis : "Through the appropriate excitement of erogenous zones as well as through other condi- tions under which sexual excitement originates a material which is universally distributed in the organism becomes disintegrated, the decomposing products of which supply a specific stimuKis to the organs of reproduction or to the spinal center connected with them. Such a transformation of a toxic stimulus to a particular organic stimulus we are already familiar with from other toxic products introduced into the body from without." Acknowledging the inadequacy of both the nervous and chemical theories of the mechanism of sexuality we s^iall for the sake of convenience adopt the fol- lowing classification of Kisch of the fundamental causes of dyspareunia : 1. Insufficient or completely wanting peripheral stimulation of the sensory nerve terminals in the female reproductive canal. This implies a failure of conduction of the stimulus to the nerve centers. 2. Inhibitory influences proceeding from the cerebral cortex whereby pleasur- able sensations and perceptions are checked. 3. Diminution or cessation of the excitability of the reflex center in the spine (genitospinal center). This leads to failure of the sense of ejaculation. This forms a workable, though from the viewpoint of the chemical theory perhaps not a truly scientific, classification. It may be summed up by saying that dyspareunia may be the result of (1) failure of local sensibihty, (2) failure of a central pleasure sensation, and (3) failure of discharge. Although we have adopted the essential classification of Kisch, we shall not follow his grouping of specific conditions. Under the first heading, i. e., lack of local sexual sensibility, we must include primarily that condition mentioned above and suggested by Freud in which the clitoris refuses to give up its excitability to the surrounding erogenous zones of the vulva and vagina. Freud, we have seen, believes that this failure when temporary is physiologic and usually ensues for a variable period of time after defloration. If the anesthesia of the vagina and vulva remains permanent Freud believes that it is frequently the result of early masturbation by which the clitoris as a consequence of overstimulation becomes incapable of sharing its power of excitation with the neighboring areas. It is not unlikely that the anesthesia may persist in many cases where there has been no masturbatic agency and even no clitoris excitability. In such a case it might be impossible to judge whether the anesthesia were due to a congenital sensory deficiency of the peripheral nerves or to some psychic inhibition dating from early childhood except by a skilful and searching psycho-analysis. The diagnosis of such a case would be important, for if the condition were due to congenital nerve deficiency it would be incurable, whereas if it were the result of psychic repression it might under proper treatment be cured. 140 GYNECOLOGY Under heading 2 (t. e., failure of a central perception of pleasure) there are numerous specific causes for dyspareunia. Important among these are the cases in which local pain plays a part. Kisch groups these cases under heading 1, but it seems more reasonable to us to classify them with cases of psychic inhibition, for the sensation of pain arrives first at the cerebral cortex and checks the pleasure sensation which without the pain would have been perceived. The anesthesia accompanying defloration may be entirely due to the pain of breaking the hymen, for undoubtedly full sexual sensibility sometimes occurs as soon as the lacerated part is entirely healed, though this is probably not the rule. Any anatomic condition of the genital tract which produces painful coitus may be a cause of dyspareunia. The most frequent of these causes are pelvic inflammatory proc- esses of all kinds, acute or chronic, various inflammations of the vagina, cicatrices of the vaginal wall, tumors of the pelvis or vagina, inflammation of any part of the vulva, especiall}^ Barthohn's glands, urethral caruncle, cicatrices of the perineum, vesicovaginal and rectovaginal fistula, etc. The frequency with which pain is associated with dyspareunia has led to the misuse of the term as equivalent to painful coitus. Closely connected with pain as a cause of dyspareunia is the fear of pain. This is a purely psychic inhibition. The anesthesia which normally follows de- floration may be of this nature. There is no doubt that some of the permanent cases of dyspareunia are the result of the physical and mental shock induced by an inconsiderate partner at the first coition. Thus dyspareunia is alhed to vagin- ismus. Other very important causes of dyspareunia are the psychic repressions in the strict Freudian use of the term. These are the result of early childhood fixa- tions which may be brought about in various ways. Thus some accidental sexual experience of childhood, the so-called sexual trauma, may engender a sense of disgust for things sexual so profound and lasting as to act as a psychic barrier through life.^ Or the fixation may be the result of an early psychic conflict with sexual impulses by which the psychic censor becomes permanently dominant. Freud emphasizes as an important factor in dyspareunia the prolonged at- tachment of a daughter to her father. In these cases sexual sensibiHty becomes permanently repressed, and when marriage takes place normal sexuality cannot be awakened nor can the psychic affection be transferred from father to husband. More or less serious neuroses are apt to ensue. A similar result often follows long-continued interdependence of a mother and daughter. Dyspareunia may be the temporary result purely of emotional inhibitions, such as grief, worry, fear, indifference to or hatred of partner, etc. Such a condi- tion may be called relative dyspareunia. In woman local sexual sensibility is much more dependent on psychic affection than in man. It sometimes happens that a woman who in the first years of marriage is normal sexually, later acquires partial or complete anesthesia. In the absence of some organic disease or fiinc- ^The effect of such a sexual trauma is well told in the popular story "The Dop Doctor." EELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 141 tional changes in the endocrine glands this is in most cases due to a growing lack of sympathy between the partners. Psychic inhibitory dyspareunia is occasionally the result of inversion in cases where the homosexual inclination is so strong that normal coition is distasteful. Under the third division of the causes of dyspareunia we group those cases in which local sensibility and psychic perception of pleasure are present, but where from lack of irritability of the genitospinal center the final orgastic discharge is not completed. This is an extremely common complaint among women, and one which frequently leads to neurotic disturbance. In some cases there is an undoubted inherent deficiency in the excitability of the reflex spinal center. In a large percentage of cases, however, it is the result of incomplete coition, such as is represented by coitus interruptus, impotence and premature ejaculation of the male, various methods of preventing conception, etc. There are certain pathologic conditions in which the local and psychic ir- ritability is intense, without the possibility of complete gratification. Patients suffering from this trouble are in a continuous state of unsatiated erethism. They constitute the class of nymphomaniacs and incessant masturbators and are subjects usually for the psychiatrist. Dyspareunia most commonly comes to the notice of the gynecologist as a complaint of women who seek relief from sterility. There is no doubt that there is some etiologic connection between the two conditions. Kisch found that in 69 sterile women 38 per cent, were dyspareunic, though he does not state whether other causes of sterility were present. Although impregnation may take place in frigid women, or even in those who have been narcotized, nevertheless it is probable that for normal fertihty full sexual sensibility is necessary. Some of the mechanisms incidental to impregnation are purely sexual reactions, such as the activity of Bartholin's glands, the secretion of the cervical mucous crypts, the aspirating movements of the cervix, and the reflexes of the vaginal canal by which the semen is retained. These mechanisms, though not absolutely essential to impregnation, certainly favor conception. They are for the most part inactive in the dyspareunic woman. RELATIONSHIP OF GYNECOLOGY TO THE NEIGHBORING ORGANS The genitalia bear a close relationship to the neighboring pelvic organs, both physiologically and pathologically, as would be expected from their intimate anatomic proximity. Under normal conditions the bladder possesses a firm attachment to the anterior wall of the uterus, and the uterus rests directly on the vertex of the bladder, so that the movements of each organ have an important influence on the position of the other. The filling and emptying of the bladder may cause a difference of as much as 90 degrees in the direc- tion of the axis of the uterus, while changes in the plane of the uterus from abdominal pressure produce a corresponding change in the upper pole of the bladder. 142 GYNECOLOGY The ureters pass through the parametrial tissue close to the sides of the cervix and immediately underneath the uterine vessels, so that they are readily influenced by pathologic disturbances of the parametrium, or by uterine and intraligamentary tumors, the effect of the interference being transmitted directly to the kidneys with significant results. The proximity of the ureters to the uterus constitutes one of the most important clangers in the performance of deep pelvic surgery. Behind the uterus lies the rectum, which when filled with fecal matter may alter to a considerable extent the position of the uterus, while retrodis- placements and tumors pressing on the rectal wall may infiuence in an important manner the rectal function. The rectum and intestines play a serious role in the pathology and symptomatology of pelvic inflammatory disease, as does also the peritoneum. The appendix is another neighboring organ which must be reckoned with in numerous gynecologic conditions. The Bladder. — In association with pathologic changes of the position of the uterus the bladder may undergo marked dislocations or alterations of form. In upward displacement due to pressure of a tumor below, the vertex of the bladder is also carried upward, but such a change does not always produce vesical symptoms. Backward cHsplacement of the uterus (retroversion, retro- flexion) does not greatly change the position of the bladder, though there may be a slight drag at the point of the uterovesical attachment. This, however,, is not sufficient to produce vesical irritation, at least to the extent formerly supposed. Downward displacement or descensus of the uterus, on the other hand, has a very important effect on the bladder, for this is the chief factor in the production of cystocele. Cystocele not only causes symptoms of pelvic pressure, but, as it represents a pouch or diverticulum of the bladder which cannot easily be evacuated, the stagnant urine predisposes the bladder mucosa to infection and cystitis. When pressed upon by pelvic tumors the bladder displays a remarkable^ mobility and adaptability to new positions. Overlying tumors may press it deep in the pelvis, and underlying tumors may force it far up on the abdominal wall or to one side, while the pregnant uterus may compress it in the center and' cause bilateral dilatations of the walls. In the presence of great retroperitoneal! tumors the bladder may be distorted into the most bizarre shapes. In many of these cases, even of marked pressure or displacement, the bladder shows sur- prisingly little evidence of irritabifity. Conditions of displacement, however,, predispose the bladder to infection and irritation, the effects of which may be clinically very important. During pregnancy the uterus, if in the forward position, may produce frequency of micturition by pressure of the overlying fundus, while, if the fundus is retroflexed, the cervix may press on the neck of the bladder and cause interference with urination or incontinence. Impacted retroflexion may so obstruct the vesical neck as to result in complete retention (ischuria paradoxa) . At childbirth the general congestion of the pelvis in which, RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 143 the bladder wall takes part predisposes to cystitis, which is frequently excited by the necessity of catheterization. Injuries of the bladder are often caused by labor, as a result of crushing pressure against the pubes or of rough instrumen- tation, by which the vesicovaginal septum is either torn or suffers necrosis with consequent fistula. The injury which the bladder undergoes during labor often results in damage to the vesical sphincter, so that it becomes incompetent and the patient suffers functional incontinence. In inflammatory processes of the genitalia the bladder is often imphcated. Gonorrheal pelveoperitonitis, as is mentioned several times elsewhere, is usually confined to the posterior segment of the pelvis, but it may be so extensive as to involve the anterior half and the bladder. Septic processes of the different pelvic organs sometimes form adhesions to and rupture into the bladder, ex- amples of which are tubal, and ovarian abscesses, necrotic tubal pregnancies, ovarian dermoids, and purulent diverticula of the sigmoid. Parametritis fol- lowing supravaginal hysterectomy or a septic puerperium usually involves the bladder in a temporary cystitis, and, conversely, extensive deep-seated cystitis sometimes involves the parametrium. Cancer of the vagina does not implicate the bladder until late in the dis- ease, chiefly because it usually originates on the posterior wall. Cancer of the uterine cervix, however, frequently extends to the bladder, though it also in- vades the wall comparatively late. Vesical and genital tuberculosis are curiously independent of each other, an affection of either tract having no tendency to extend to the other. There is a vague relationship between genital psychoneuroses and the func- tion of the bladder, but it is not specific, and probably does not differ from nervous disturbances from other causes. Ureters. — The influence of the genitalia on the ureters is exerted by dis- turbances which mechanically compress or dislocate them so as to interfere with the normal flow of urine from the kidneys. Partial obstruction with hydro-ureter is sometimes seen in autopsies on pregnant women. This, according to Opitz, is not the result of direct pressure, but is thought to be due to hyperemia and edema of the ureteral mucous mem- brane. Rarely parametrial exudates result in scars about the ureters, which become constricted by the shrinking process of the tissue, with consequent hydro-ureter or hydronephrosis. The ureters are affected chiefly by the retroperitoneal tumors, such as intra- ligamentory fibroids and ovarian cysts, which, if they reach any considerable size, invariably dislocate the ureters from their normal position, a fact that must be borne constantly in mind while operating on these tumors. Cancer of the cervix ultimately invades the parametrium and surrounds the ureters, sometimes constricting or occluding them, but not often invading the ureteral wall itself. This implication of the ureters constitutes one of the chief dangers and difficulties in the radical operation for cervical cancer. 1.44 GYNECOLOGY The ureters are often injured during deep pelvic operations, with resultant fistulas. Affections of the ureter, •especially stone, often give symptoms of pain, which are referred to the peMc organs, causing incorrect diagnoses and iJl- judged operations. The relationship between the genital organs and inflammatory conditions of the peritoneum and intestines is dealt with at length in a special section (see page 153). Rectum and Sigmoid.- — The rectum must be taken into account in a great many gynecologic conditions. Most common of these is the rectocele which follows lacerations of the perineum, and which usually accompanies prolapse of the uterus and cystocele. Rectocele often interferes with proper defecation, and is an annoyance to the patient on account of the sense of protrusion from the vagina. Rectocele of itself, however, as a rule, causes few subjective symp- toms if the uterus and bladder are not prolapsed. The repair of rectovaginal fistula and complete laceration of the sphincter is an important department in the reconstructive surgery of injuries due to childbirth. Hemorrhoids bear a very significant relationship to pregnancy and labor. The pressure and stretching to which the sphincter is subjected at labor often causes hemorrhoids or aggravates small ones already existing, leaving the veins in a permanently enlarged and sometimes fissured condition. Laceration of the perineum relaxes the tissues about the sphincter, so that the hemorrhoidal veins cease to have proper support and become permanently dilated. Repair of the perineum usually cures the hemorrhoids. Severe puerperal parametritis may involve the rectum in a manner to constrict its lumen, even to complete occlusion, as has been reported in a few cases. The effect on the rectum of the retroverted uterus is a subject of some con- troversy. It is often stated that the retroflexed uterus in the course of time becomes adherent to the rectum. It is not likely that simple contact with the peritoneum covering the rectum causes adhesions. It is probable, however, that a heavy uterus, especially one containing a fibroid in its posterior wall, can interfere with the normal rectal peristalsis, and that the stasis thus pro- duced may cause an inflammation in the rectal wall which is communicated to the peritoneum. This process may take place as a result of constipation even when the uterus is not retroverted, a painful and intractable condition, termed "posterior parametritis." It is not unlikely that in some cases the parametritis is primary and 'causes a retroflexion by the traction of adhesions on the poste- rior wall of the uterus. Posterior parametritis, with adhesions between the uterus and posterior uterine wafl, is not infrequently caused by the ill-judged use of pessaries. The relationship of the rectum to acute inflammatory conditions of the pelvis is detailed elsewhere. Suffice it to say here that tubal and ovarian abscesses not infrequently rupture into the rectum, causing fistulas that some- RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 145 times heal spontaneously and sometimes remain permanent. It should also be repeated that many qf the pelvic abscesses of the gonorrheal and tubercular type owe their severity to a mixed infection caused by adhesions to the rectum and migration through the rectal wall of intestinal micro-organisms into the abscess cavity. Carcinoma of the cervix in its late manifestations invades the rectum and often causes fistulous openings. Cancer of the vagina also invades the rectum, but only when in advanced stage. On the other hand, low cancer of the rectum involves the vaginal wall comparatively early. In severe pelvic operations, especially where there are extensive adhesions, the rectum figures prominently, for it is very readity injured. Actual tears in the rectal wall can usually be sewed up with little difficult}^, and, if care is taken, do not often result in fistulas. Most fistulas occur after injuries which damage the rectal wall only partially and which escape the notice of the surgeon. If gauze drainage is placed in contact with one of these lesions a fistula is inevit- able. For this reason gauze should never be used for drainage in the abdominal cavity. Postoperative fistulas of the rectum, whether thej^ lead to the abdo- men or vagina, usually heal spontaneously in time, though not always. The symptomatology of affections of the rectum gives the false idea that the lesions have their seat in the genitaha and thus leads to wrong diagnosis. This is especially true of acute diverticulitis of the lower sigmoid or upper rectum, which may present a picture very like that of a tubal abscess. The pains of chronic colitis are often referred to the tubes and ovaries, and patients^ sometimes undergo needless operations from this mistake. Appendix. — The anatomic position of the appendix peculiarly predisposes it to complication in affections of the pelvic organs, especially those of an in- flammatory nature. Under normal conditions, the tip of the appendix usually lies in the pelvis, near the right tube and ovary, while in cases of ptosis or cecum mobile the appendix may lie completely in the pelvis, even so low as the floor of Douglas' pouch. Between the base of the appendix and the hilum of the ovary there runs a fold of peritoneum, called the "appendiculo-ovarian liga- ment," that is usually only rudimentary or not demonstrable, but often quite definite, in which it has been claimed run connecting lymph-channels between the appendix and the adnexa. This lymph connection has been denied. Sympathetic relationships between the appendix and the pelvic organs are based chiefly on inflammatory processes. Tumors of the ovaries may push the cecum and appendix to abnormal positions, and occasionally, though rarely, cause disturbance. Severe inflammations of the tubes do not exhibit a special tendency to im- plicate the appendix, the result, doubtless, of gravity, which is effective in keep- ing the inflammatory products in the posterior and lower part of the true pelvis. The appendix, however, is sometimes involved in the adhesions of a salpingitis. In this case the inflammation imparted to the appendix is external and shows 10 146 GYNECOLOGY microscopically as a peri-appendicitis, but there is little danger from this com- plication of causing an acute dangerous appendicitis. The adhesions which form about the appendix immobilize it and predispose it to later attacks of acute appendicitis, at the same time causing symptoms of chronic inflammation. On the other hand, acute appendicitis with purulent exudate is very prone to involve the right tube and even the whole pelvis, for gravity carries the products of inflammation to the pouch of Douglas and is thus instrumental in the infection of the adnexa. . In this way acute purulent appendicitis in young girls often causes very serious damage to the genital organs in the adhesions and closure of the tubes, adhesion and retroversion of the uterus, and chronic thickening of the cortex of the ovaries. If the attack occurs before puberty or in young girlhood it may prevent full genital development and result in infan- tilism, with its symptoms of amenorrhea or dysmenorrhea, neuroses, and sterility. Acute appendicitis occurring after maturity may, by its damaging influence on the genitalia, cause sterility, extra-uterine pregnancy, and dis- placements of the uterus. Very frequently chronic appendicitis and chronic salpingitis are found associated together, where the two conditions have originated entirely inde- pendently of each other. Chronic appendicitis is extraordinarily common in women, though it often exists without any appreciable symptoms. At least 60 per cent, of appendices seen at autopsies, and removed as a routine procedure during abdominal operations, show either gross or microscopic evidences of inflammation. Some even regard a certain amount of chronic inflammation of the appendix as physiologic. Such a theory, however, should not be harbored, and the appendix must be regarded as a dangerous and useless organ to be removed as a routine during those abdominal operations in which the expendi- ture of the few extra minutes required for its removal cannot be considered detri- mental to the patient. There is a very definite relationship between chronic appendicitis and menstruation. The premenstrual and menstrual hyperemia aggravates in- flammatory conditions of the appendix region as it does those of the pelvis, so that patients with chronic appendicitis almost invariably feel the pain more at the menstrual period, while many experience it then and at no other time. Moreover, attacks of acute appendicitis often have their starting-point at the time of menstruation. The course of appendicitis during pregnancy and childbirth is a subject of considerable moment. It is not probable that pregnancy predisposes to an initial infection of the appendix, but there is no doubt that in the presence of a latent appendicitis pregnancy predisposes to recurrent attacks or to lighting up the infection into one of acute activity. Numerous factors naturally con- tribute to this effect. Stretching and pulling of a spiral or kinked appendix and tearing of old adhesions may be caused by the growing uterus (Wagner). Moreover, the increased constipation during pregnancy, and the venous con- RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 147 gestion of the pelvis and abdominal organs, constitute conditions favorable to inflammation of the appendix. In the mild types of appendicitis the course during pregnancy does not differ essentially from that seen in non-pregnant women, but, if perforation or suppuration takes place, the danger of fatal peritonitis is very much greater in pregnancy. The explanation of this is that the cecum and appendix are forced from the protected recess in which they normally lie, forward and upward into the free abdominal cavity. The omen- tum is prevented from performing its usual walling-o£f service by the interven- tion of the gravid uterus, which tends to keep it in the left side of the abdomen. The collection and isolation of the inflammatory products in the pelvis, which is usual in the ordinary case of acute appendicitis, is impossible during preg- nancy because the pelvis is filled with the gravid uterus. Hence it will be seen that the peritoneum during pregnancy is especially exposed to general infection from a suppurating process of the appendix. Still more dangerous is an acute suppurative appendicitis that occurs at the time of labor, or an appendical abscess that by its attachment to the uterine wall, precipitates a premature delivery. Here the sudden diminution in size of the uterus and the general change that takes place in the position of the ab- dominal organs rends the protecting adhesions, and causes a discharge of pus into the free peritoneal cavity, a disaster which surgical operation seldom remedies. In sum, it may be said that a chronic or subacute appendicitis has during pregnancy a predisposition to become acute, and that if suppuration and abscess formation or perforation take place the danger of general peritonitis is consider- ably increased by pregnancy and very much increased by labor, whether it be at term or premature. Immediate removal of the appendix on suspicion of inflammation is, therefore, always advisable during pregnancy. It may be said that the operation is only rarely followed by abortion if the appendix is in the catarrhal or chronic stage of inflammation. RELATIONSHIP OF GYNECOLOGY TO THE GALL-BLADDER Between diseases of the pelvis and those of the gall-bladder there exists no direct or indirect causal relationship, excepting in the possible metastasis from one region to the other of malignant growths. There are, however, numerous ways in which disturbances of the gall-bladder require very serious considera- tion on the part, of the gynecologist. In every routine abdominal examination the gall-bladder must never be overlooked, especially when there is any com- plaint of right-sided pain or of vague symptoms in the upper abdomen. During an active attack of adnexal or gall-bladder disease a differential diagnosis is a simple matter, but if active pain is not present at the time of examination, and the examiner must rely to a great extent on the story of the patient, the dis- eases are not infrequently confounded, notwithstanding the comparative remote- 148 GYNECOLOGY ness from each other of the two regions. The difficulty often encountered, even by the most experienced, in the differentiation of chronic disease of the gall- bladder and that of the appendix is familiar to every practitioner. Even more difficult to distinguish from chronic affections of the gall-bladder are the con- ditions arising from the obstructing adhesions to which the ascending colon is so frequently prone. The presence of gall-bladder changes associated with pelvic disease is very often manifested by vague feelings of distress of the upper abdomen of the diges- tive character, which, _ as Clark emphatically states, must not in an}^ sense be regarded as reflex symptoms originating in the pelvic lesion. Concomitant symptoms of this kind in gynecologic cases must be given much weight, a large percentage of them when properly interpreted indicating the presence of gall- bladder disease, in contrast to affections of the duodenum and pylorus which in gynecologic practice are comparatively uncommon (Clark). Patients suffering from symptoms in the gall-bladder region alone are not, in the strictest sense, within the sphere of gynecology, nevertheless they very frequently consult the gynecologist, who is required to make an accurate ab- dominal diagnosis. Of chief importance to the pelvic surgeon is the discovery of gall-stones during the routine intra-abdominal examination which should be made, when feasible, in the course of every pelvic operation. Cases of this kind may be divided into two classes, those in which the history of the patient gives more or less evidence that the gall-stones have caused symp- toms, and those in which the presence of the stones is entirely unexpected. In the first class of cases the treatment is obvious, namely, appropriate surgical treatment of the gall-bladder at the time of the pelvic operation, if the conditions permit without undue danger, and if such is not the case, recommendation to the patient of a second operation at some later date. In the second class of cases in which the gall-stones are incidentally found without previously recognized symptoms the question of treatment is less simple to decide, and numerous considerations must be taken into account, most important of which is the pathologic significance of so-called symptomless cholelithiasis. The fallacy once held that a large percentage of gall-stones are entirely innocuous has of late years been exposed, especially by the work of J. G. Clark, who in writing on the subject has repeatedly called attention to the fact that "in the majority of cases of cholelithiasis micro-organisms of a more or less pathogenic nature are found, and that under these circumstances many vague symptoms, usually attributed to gastro-intestinal or general consti- tutional disturbance, may arise as the result of toxins elaborated about these foreign bodies (stones) in the gall-bladder." In considering the patient's history, therefore, with a view to the treatment of incidentally discovered gall-stones, the absence of the classical symptoms of gall-stone attacks does not by any means indicate that the presence of the RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 149 stones has been symptomless. Our present knowledge of cholelithiasis indi- cates that the affection should always be regarded in a serious light, and that the removal of the stones is at least desirable. The question of immediate surgical interference during the course of a pelvic operation must be decided by certain individual considerations. The extra operation involves no very great hazard, as Clark estimates the mortality of cholelithotomy in a large series of cases at 2 per cent. On the other hand, in the type of pelvic opera- tions in which an incidental cholelithotomy could be considered, namely, those excluding cancer of the uterus and severe pelvic inflammation, the mortality would be less than 1 per cent. The extra operation on the gall-bladder, there- fore, at least doubles the risk of the primary operation to which the patient has submitted herself. This added risk to the life of the patient, small though it is, must not be disregarded by the surgeon, especially if the primary opera- tion has been a severe one, or if the patient has expressly stated that she wishes to undergo no extra risk. Gall-bladder surgery entails a greater danger, both of postoperative pneumonia and of sepsis, than do the pelvic operations in conjunction with which the gall-bladder operations may be performed; more- over, there can be no doubt that even a simple cholecystotomy must be more dangerous when done conjointly with another abdominal operation than when performed alone. In addition to the added risk to life of cholecystotomy, one must also take into account the inconvenience and possible loAg persistence of drainage from a gall-bladder wound, which some patients resent who have sub- mitted themselves to a minor pelvic operation. It must be remembered, too, that gall-stones, though usually harmful to the patient's health, are, neverthe- less, in the majority of cases, not fatal. In view of all these considerations, we are rather conservative in the matter of operating at once on gall-stones found during a pelvic operation unless con- ditions are simple, and prefer in the greater number of cases to state the con- dition to the patient during her convalescence, and to operate with her con- sent at a later date when she has fully recovered from the primary operation. The problem is greatly simplified by making it a routine practice to explain to the patient before a pelvic operation certain complicating conditions that may be encountered unexpectedly, and to gain consent to do that which, in the mind of the surgeon, will be of greatest benefit to future health. With nervous or ignorant patients this must be done with tact in order not to give them un- necessary alarm. With a certain class of patients it is advisable to have the consent in writing. The gall-bladder should always be examined as a routine measure during pelvic operations, excepting when it is important to make an incision so small as not to admit the hand, or when there is sepsis present. In the latter case the danger of spreading infection to the upper portions of the peritoneal cavity is obvious. Palpation of the gall-bladder from a low median incision requires accurate anatomic knowledge of the upper abdominal region and expertness of 150 GYNECOLOGY touch, for it is often difficult to differentiate a collapsed gall-bladder from a loop of small intestine. If gall-stones are found, and it is decided to remove them at once, it is a temptation to perform the operation with the left hand in the abdomen to guide the incision and to hold the gall-bladder up into the wound from below, from which position the gall-stones can be pressed out with the greatest ease. This simple and rapid method of doing the operation is, however, fraught with danger, for it is almost impossible to avoid soiling the fingers with bile, so that when the hand is withdrawn from the lower wound there is danger of infecting the intervening peritoneum. The safest method is to complete the pelvic operation and to apply an efficient protective dressing to the abdominal wound. The operation for gall-stones is then performed with every preparation as if it were the initial operation, especially with regard to the position of the patient, which is important, for it is not possible to foretell the extent of the operation until the gall-bladder is exposed. The type of operation must be determined by the surgical judgment of the operator. In the simplest cases the so-called "ideal operation" of removing the stones and closing both the wound in the gall-bladder and that of the abdomen involves some risks. A safer method of treating the very simple cases is to close the gall-bladder, but to leave through the abdominal wound a small cigarette drain. The classic and safe method in the average uncomplicated case is to drain the gall-bladder, the wound from which should, under right conditions, close in two or three weeks, but unfor- tunately the period of closure is frequently considerably longer than this. When complications are present, cholecystectomy is the operation of choice, indications for which are changes in the wall of the gall-bladder, by which it has become thick and indurated, or thin and distended, or by which the mucosa has under- gone ulcerative and inflammatory processes. Chronic inflammation of the mucous membrane is manifested by the well-known "strawberry mottling" appearance. Adhesions about the gall-bladder and stricture of the cystic duct are other indications for cholecystectomy. A discussion of the more serious complications of the hepatic and common ducts does not properly come within the sphere of this book. RELATIONSHIP OF GYNECOLOGY TO THE PERITONEUM AND OMENTUM! A knowledge of the physiology and pathology of the peritoneum is of ex- treme importance, for not only is a large part of the symptomatology of pelvic disease referable to affections of the peritoneum, but it is on its natural plastic properties that the surgeon depends for some of his reconstructive operations. The free surface of the peritoneum consists of a single layer of flat polj^gonal epithelial cells, filled with a fine granular protoplasm. These cells are held ^ Chief authority, Fromme. RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 151 together by delicate fibrils, which, by their elasticity, allow the peritoneal layer to adapt itself continually to the changes in size of the hollow organs which it encompasses. Between the epithelial cells are numerous small openings or stomata through which t»he lymph-vessels empty into the periton.eal cavity. Each small open- ing is surrounded by epithelial cells arranged in a somewhat concentric order, the power of contraction of which probably controls the size of the stoma. Under the surface epithelium hes the subserosa, which consists of bundles of connective tissue, elastic fibers, and fat. In this tissue runs a rich network of communicating lymph-vessels, besides blood-vessels and nerves. The lymph- vessels of the peritoneal and pleural cavities communicate by perforating the diaphragm. The nerves of the peritoneum he in the subserous layer and are not particu- larly numerous. It has been shown that the parietal peritoneum is much more sensitive than that covering the viscera, due to the communication which its serosa has with the intercostal, lumbar, and sacral nerves. Between the muscu- lar layers of the intestines there runs a rich network of sympathetic nerves, with many microscopic gangha, the so-called "Auerbach's plexus," which plays a very important part in the intestinal paralysis of peritonitis, ileus, etc. Under normal conditions the production and absorption of fluid is so regulated that the peritoneal surface is kept sufficiently moist to provide for perfect lubrication for the movements of the various organs, but under pathologic conditions the power of the peritoneum, both for production of fluid and its absorption, is enormous. The surface of the peritoneum is very great and is said to equal that of the outside of the body. This great extent of absorbing surface is of advantage in taking care of the products of mild infections, such as frequently ensue after operation, but is a source of danger when the infection spreads over a large part of the area, in which case so much toxic material is absorbed that the resisting power of the individual is overcome. To counteract the tendency of infec- tions to spread over the entire abdominal cavity is the anatomic arrangement by which the cavity is divided into numerous sacs, which, though communi- cating with each other normally, are, when infected, readily isolated by adhe- sions. The isolation and exclusion of these various sacs or pockets of which the true pelvis is the most notable example is greatly facilitated by the great omentum and the movable portions of the colon, especially by the sigmoid flexure, less often by coils of the small intestine. The omentum is of inestimable benefit in the walling off and localization of infection. On account of its length and mobility it is able ordinarily to reach any portion of the abdominal cavity, and in most cases of locahzed peritoneal infection the omentum will be found doing a large share of protective duty. Its adhesive power is enhanced by its endowment with four peritoneal layers- two on the outer surfaces and two toward the omental bursa. The omentum 152 GYNECOLOGY is, therefore, exceedingly well supplied with blood- and lymph-vessels, and can furnish a greater amount of serum and phagocytes than can the rest of the peritoneum. Thus it is an important protective organ against infection, as has been proved by experimentation, in which it has been shown that animals from whom the omentum has been radically removed are much less resistant to peritoneal infection than are normal control animals. The omentum besides its protective power also has a corresponding absorb- ing power, greater than that of the rest of the peritoneal cavity. In addition to this, it has the astonishing ability to fasten itself to organs that have been bereft of their circulation, establish a new communication of blood-vessels, and thus nourish the organ or prevent its being infected. A good example of this is the way in which parasitic fibroids that become detached from the wall of the uterus are nourished and kept ahve by the protecting care of the omentum. The omentum is also of great use in surgical operations for the plastic cover- ing up of defects in tissues, such as extensive denudations after the removal of adhesions. It has been shown by experimentation that when a piece of omentum is transplanted to a denuded surface a communication of blood-vessels between the two takes place on the second day. Another very important service that the omentum performs is its capacity to shp into defects of the abdominal wall and thus prevent the entrance of the intestine. In most ventral hernias it is most effective in preventing involve- ment and injury of the bowel. In inguinal hernias the same is true whenever the omentum is long enough to reach the opening. In penetrating wounds of the peritoneum the omentum by its extraordinary mobility and lability often enters the wound first and prevents the prolapse of the intestine. The peritoneum has a special protective characteristic in that it is not easily penetrated by external infection. Subperitoneal abscesses, such as occur in abdominal wounds or in the parametrium, do not often extend into the peritoneal cavity. This is partly due to the fact that it possesses a remark- able power of elasticity and offers little resistance to the pressure of the abscess. The peritoneum also has an unusual reparative power of its epithelium, denuded surfaces being rapidly covered by newly grown cells. Transudation and Resorption. — As has been said, there exists between the contiguous peritoneal surfaces only a capillary layer of free fluid which is just enough to keep the surfaces well lubricated. This fluid is continually being renewed and absorbed by the subserous circulatory apparatus already described. When, however, there is any irritation of the peritoneum an increased amount of the fluid issues in the form of a serous exudate. The epithelial cells become swollen and cloudy. A fatty granular degeneration takes place in the proto- plasm, and there follows in places a destruction and denudation of the epithelium. After the partial destruction of the surface epithelium the same irritat- ing influence also injures the walls of the underlying capillaries, thereby creat- ing a greater permeability for the passage of the exudate and a chemical change RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 153 in the constituents of the blood. Together with the exudate, there takes place an outward wandering of leukocytes by diapedis. Fibrin coagulation takes place in the exudate. The exudate probably has httle bactericidal action, but its function is probably to dilute the injurious toxins of the irritant, and, still more important, to pour into the peritoneal cavity a rich supply of leukocytes. Absorption of fluid material in the peritoneal cavity is carried out by the subserous blood and lymph capillaries. If the absorbed material is toxic, its influence then is met by the general resisting power of the body, which is suffi- cient to neutralize a moderate amount of absorption. If, however, the toxins absorbed are too great in amount or too virulent for the general resistance to withstand, the individual succumbs. The combat against bacterial infection is also carried on by the phagocj^tic power of the leukocytes contained in the exudate. Adhesions. — From the standpoint of the gynecologist the most important reaction that takes place from peritoneal irritation from whatever cause is the formation of protective adhesions. Adhesions are the result primarily of injury to and destruction of the epithelial layer of two contiguous surfaces. When the serous surfaces are denuded the connective-tissue subserous layers become united by fine strands of fibrin into which stream wandering cells (fibroblasts), so that eventually a true connective-tissue union is created. Adhesions com- petent to withstand the pressure of fluid and prevent the spread of infection may form within a few hours. In the early stages adhesions are filmy and easily broken up by the hand, but as time goes on they become more organized and denser and gradually contract in the manner of scar tissue. The eventual character and fate of adhesions depends somewhat on the nature of the cause which originally produced them. Thus, we see that whatever produces a destruction of the peritoneal epi- thelium causes also the formation of adhesions. The surface epithelium of the peritoneum may be destroyed (1) by bac- terial infection; (2) by chemical injury; (3) by mechanical insults, and (4) by surface necrosis due to local interference of the blood supply. These may, therefore, be regarded as the four chief causes of peritoneal adhesions. (1) Bacterial Peritonitis. — From the standpoint of gynecology we are inter- ested principally in those forms of peritonitis which are confined chiefly to the pelvis, and of these the most important is that which results from gonorrhea. Gonorrheal peritonitis ascends from a primary infection of the external genitals and extends through the tubes to the pelvic peritoneum. In the great majority of cases the inflammatory process is confined to the posterior half of the pelvis, and it is in this region, therefore, that we find the principal adhesions. The surface of the tubes and ovaries is the first to be affected, so that the earliest adhesions form between them and the posterior aspect of the broad ligament against which they naturally rest. If the disease progresses adhesions form, uniting the posterior surfaces of the adnexa and uterus with the rectum and 154 GYNECOLOGY sigmoid or other portion of bowel that may have prolapsed into the true pelvis. The contraction of the adhesions draws the pelvic organs backward and down- ward deep into the posterior and lateral culdesacs. The disease is locahzed in the pelvis partly by gravity and partly by the protecting services of the great omentum and the sigmoid flexure, which, as a rule, prevent the infection from spreading above the brim of the pelvis. Adhesions from gonorrheal peri- tonitis have little tendency to become absorbed, but rather grow denser and tougher with time. They are also notable for their contractile power and result in serious displacements of organs. Infection of the pelvic organs by puerperal sepsis results in fewer adhe- sions than does that from gonorrhea, and for that reason it is less hkely to be confined to the pelvis, and much more frequently extends to the general ab- dominal cavity, causing a diffuse peritonitis and death. Such cases are usually due to the streptococcus, the virulence of which is so great that time is not given to the plastic apparatus of the peritoneum to form protective adhesions before a fatal dose of toxins is absorbed. Other organisms than the streptococcus may infect the pelvic organs from puerperal sepsis, chief among these being the staphylococcus group. A third common form of adhesions from bacterial peritonitis is that which is produced by tuberculosis, the invasion of which takes place .either by con- tinuation from a general abdominal peritonitis or through the blood-current from some distant focus, usually in the lungs or lymph-glands. The adhesions resulting from tuberculosis are often extremely dense and vascular, so that it may be impossible to separate them without causing serious damage to the organs which they involve. Tubercular adhesions, even the most resistant, have the peculiarity of often being completely absorbed, a characteristic which is not seen in adhesions due to gonorrhea. (2) Adhesions due to chemical injury are comparatively uncommon. The irritation and adhesions from bile spilled in the peritoneal cavity is an example of this, as proved by the results of injecting sterile bile into the abdomens of animals. Another example is the adhesive peritoneal irritation seen in pesudo- myxoma peritonei. Doubtless the adhesions from uninfected blood-clots in the pelvis, such as sometimes result from tubal abortion, have their origin in the chemical irritation of the disintegrating blood. An excellent example of chemical injury is the peritoneal adhesions, which occur after oil has been left in the abdomen under the mistaken idea that oil will prevent adhesions. (3) Adhesio7is due to mechanical injury are the result of a mechanical de- struction of the peritoneal epithehum, by which two damaged contiguous sur- faces become united in the manner described above. As a pathologic lesion this is most commonly seen in some of the adhesions that form on large tumors, where the destruction of the peritoneal epithelium is due to pressure necrosis. Traumatic adhesions resulting from injuries to the peritoneum during surgi- cal operations are included in this group, though it is not always possible to RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 155 state whether certain postoperative adhesions result from trauma or from mild sepsis. There is no doubt that the leaving of raw surfaces or ragged wound edges. is usually followed by adhesions. Clumsy protruding catgut knots may also be followed by the same result. Other traumatic causes of adhesions are rough handling of the intestines, improper use of dry gauze and abdominal retractors, too long exposure to the drying influence of the air, etc. One of the most important matters in the consideration of traumatic adhe- sions is the artificial creation of them for the purpose of making new ligamentous supports for prolapsed organs. Here the knowledge of the physiologic process of adhesion formation is of great practical value to the surgeon, for without an appreciation of this process many of his reconstructive operations are sure to result in failure. We know that the approximation of two- epithehal surfaces will not result in adherence unless the surfaces are first denuded or destroyed. This is as true of the peritoneum as it is of the skin or of mucous membrane. If, therefore, it is desired to create a permanent hgamentous attachment between two peri- toneal surfaces, one must be sure to destroy the epithehum of both surfaces over the area of desired adhesion. The contiguous serous surfaces may be denuded or scarified or destroyed by the pressure of a very tight knot. , The most common practical appHcation of this principle is in performing the operation for ventral fixation or suspension. The old-fashioned method of doing this operation was to place several stitches through the posterior wall of the uterus and the abdominal wall, and to scarify or denude the opposing peritoneal surfaces. This resulted in an extensive adhesion, which bound the uterus so closely to the abdominal wall as to immobihze it completely and lead to serious danger in later childbirth. The so-called "ventrosuspension operation" was done by uniting the peritoneal surfaces by a hght tie. A frequent result of this operation was a complete healing of the peritoneum without the formation of an adhesion, or the adhesion might be very slight, so that the drag of the uterus drew the abdominal peritoneum out into a long filament, causing danger of entanghng the bowel in an obstruction. The success of the Gilham type of operation depends eventually on the adhe- sions which form between the round ligaments and the peritoneum at the point of penetration. The success of Olshausen's operation is dependent on tying the suture attaching the round hgament to the abdominal wall so tightly that the peritoneal epithehum included in the knot will be destroyed. If the tie is too loosely made, as is done by the use of catgut or animal tendon, there is danger of not creating a permanent connective-tissue ligamentous adhesion. (4) Adhesions Due to Surface Necrosis.— This form of adhesions is best illustrated by the adherence of tumors with twisted pedicles to the peritoneal surface of surrounding organs. In this case interference of the blood-supply to the serous surface of the tumor is caused by torsion of the pedicle, with conse- 156 GYNECOLOGY quent destruction and necrosis ot the endothelial cells. The same result may follow interference of the circulation of the peritoneum from any other cause. The possibility of adhesion formation from transmigration of micro-organ- isms through the intestinal wall as a result of stasis is discussed in the section on Intestinal Adhesive Bands {q. v.). RELATIONSHIP OF GYNECOLOGY TO THE BONES AND JOINTS Between the pelvic organs and diseases of the bones and joints there is from the gynecologic standpoint no frequent direct relationship, if we exclude the influence of deformed pelves on childbirth, a subject which does not come within the sphere of this book. It seems to be well established that osteomalacia is to a certain extent dependent on abnormal ovarian secretion, as is shown by the marked improve- ment in the disease following the operation of castration. Fehling, who dis- covered the relationship of osteomalacia to the ovaries, noted that women with osteomalacia exhibit a fertility that is double the normal. This disease is also shown to be much more common in woman than in man. The effect of the ovarian secretion in the development of the skeleton has already been described on page 51 in discussing the effect of early castration. If enteroptosis and nephroptosis be included in gynecology, the causal rela- tionship between these conditions and the body form is of immense importance, as is pointed out in the sections devoted to those subjects. The gynecologist is continually being consulted by patients who refer their bodily pains to disturbances of their pelvic organs, whereas, in reality, they are due to some orthopedic affection. This is pre-eminently true of patients who suffer with backache. The backache resulting from sacro-iliac strain is some- times very like that from retroflexion, both in character and position, and can with difficulty be differentiated from it. The same is true of muscular strains in- volving the sacral and lower lumbar region. Backache above the lower lumbar and sacral region is never pelvic in origin, yet the idea that uterine displace- ments cause all forms of backache is so prevalent that patients are very prone to ascribe pain at any segment of the spinal column to pelvic trouble. The same is true of patients with foot strain, whose chief symptoms are felt in the back or thighs. The gynecologist must, therefore, be continually on the lookout for these cases, and to avoid needless treatment and operations where the sym- toms are in reality from some orthopedic origin. The postoperative treatment of gynecologic patients often requires an appreciation of orthopedic principles, especially in providing proper abdominal supports. Patients with incorrect body-form require the "remodeling" of the orthopedist, especially after operations for ptosis and abdominal hernia. RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 157 RELATIONSHIP OF GYNECOLOGY TO ACUTE INFECTIOUS DISEASES Acute infectious diseases, outside of pregnancy and the puerperium, affect the genital system only occasionally. The most common complication follow- ing these diseases is an acute septic vaginitis, which may extend to the cervix and uterine mucosa. This occurs mostly in children and may follow typhoid, cholera, pneumonia, variola, measles, scarlatina, and influenza. The vagini- tis is often very severe, and may terminate in gangrene and sloughing of the entire canal. These severe inflammations may result in plastic adhesions of the vaginal surfaces, causing a partial or complete atresia. The vaginitis and plastic union of the walls may take place without attracting attention to the local dis- ease, so that nothing may be known of its existence until delayed puberty with symptoms of obstructed menses make the condition evident. Many cases of atresia formerly thought to be congenital or the probable result of accidental gonorrheal infection are doubtless traceable to one of the acute infectious dis- eases contracted in childhood. The cause of infection of the vagina is not always clear, as the specific organisms of the primary constitutional disease cannot usually be demon- strated in the vaginal secretions. It is probable that the resistance of the individual is so reduced that the vagina no longer exerts its normal bactericidal action, and the flora of the vulva find in the vagina a favorable seat for ascend- ing infection. The organisms found in the vaginal discharge are usually of the streptococcus, staphylococcus, and colon bacillus varieties. Occasionally, though not often, the tubes may be infected by the specific organisms of acute infectious disease, notably typhoid, pneumonia, and in- fluenza. It is probable that the organisms in such cases reach the tubes through the circulation. Disturbances of menstruation are very common during the attack of infec- tious disease, the irregularitj^ consisting of too frequent and profuse flow. After typhoid there is apt to be a period of amenorrhea and atrophy for a few months. During typhoid fever there may be a selective destruction of the primordial and Graafian follicles of the ovary, a process which may be so extensive as to result in the death of all the follicles, with consequent atrophy of the ovaries, amenorrhea, and sterility (Stolz). Whether this effect on the parenchyma of the ovary is the result of the typhoid bacillus circulating in the blood, or whether it is accomplished by a toxin, is not known. Diphtheria may occur secondarily or primarih^ in the vagina. It produces ulceration and possible gangrenous sloughing, with ultimate atresia. Influenza affects the genital organs in a considerable percentage of cases, chiefly in the way of causing irregular menses. Menstruation is often brought on at the beginning of the attack, even in individuals who have had long-stand- ing amenorrhea. The menstrual disturbance may appear as a menorrhagia, but very frequently as a metrorrhagia. The uterus in these cases is found to be 158 GYNECOLOGY large and boggy. It is characteristic that the metrorrhagia caused by in- fluenza may last a long time after the influenza has disappeared and be exceed- ingly intractable. Influenza may also cause certain acute infections of the pelvic organs, among which there have been described cases of salpingitis, parametritis, urethritis, and cystitis. Gonorrheal infections of the pelvic organs are often hghted up into new activity by an attack of influenza. It has been shown also that pelvic tumors, such as cancers, uterine fibroids, and ovarian cystomata, sometimes undergo a rapid enlargement during an infection of influenza. Malaria may also cause a metrorrhagia, and it has been observed that the metrorrhagia may share in the periodicity of the disease appearing at a certain time each day. It may be said, in general, that as a consequence of any acute general infection there may ensue a period of amenorrhea, with atrophy of the ovaries, uterus, external genitals, and breasts. This, however, is usually a temporary manifestation unless there has been some specific destruction of the ovarian follicles, and disappears when the patient has regained her normal health and strength. ENTEROPTOSIS Although there is no very definite relationship between diseases of the pelvic organs and enteroptosis, nevertheless the latter condition is so common in women and so often associated with asthenic relaxation of the genital apparatus that it comes almost constantly to the notice of the gynecologist. Enteroptosis relates to a dovv^nward displacement of certain portions of the digestive tract owing to an inadequacy of the natural supports, while other portions remain fixed. In this way the intestine becomes kinked at the points of firmer attachment, with consequent partial obstruction to the normal flow of intestinal contents. The retardation of the intestinal function is termed "intestinal stasis," and results in certain characteristic digestive and constitu- tional symptoms. The etiology of enteroptosis is at present beheved to be referable primarily to congenital defects in certain attachments of the alimentary canal which are normally supplied by nature in man alone to support the abdominal organs on account of his erect posture. In addition to the primary cause of congenital deficiency of supporting attachments are other predisposing causes, namely, those resulting from inborn or acquired changes in the body-form of the indi- vidual, from the loss of subperitoneal fat, and from a deficiency in the muscular force of the abdominal musculature. The supporting attachments of the viscera with which man is endowed in contradistinction to quadrupeds represent the fusion of certain peritoneal surfaces that takes place during the prenatal de- velopment of the intestinal tract, and, as Coffey remarks, are undoubtedly RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 159 "for the purpose of holding the organs in their places, thus to prevent them from piling up in the bottom of the abdominal cavity by gravity," To quote Coffey further: "In studying the abdominal cavity from the standpoint of comparative anatomy we find that in rnan the hver has fused with the diaphragm, while in the quadruped it is suspended by a mesentery the same as other organs. In man the duodenum is firmly fixed to the right abdomi- nal wall, while in the quadruped it is freely movable. In man the ascending colon and descend- ing colon and the two flexures are normally fixed to the posterior abdominal wall without the intervention of mesentery, while in quadrupeds the large intestine has a long mesentery and is, therefore, freely movable. In man the great omentum grows down over the transverse colon and adheres to it. This does not occur in the quadruped. In man the omental bursa is usually obUterated by adhesions of its layers together. Obhteration does not take place in the quad- ruped. "In man the pancreas has been rotated behind the peritonetma and fixed to the abdominal wall. In quadrupeds the pancreas Ues between the layers of the mesentery. "In the monkey, which is a quadruped with a tendency to stand erect, the pancreas becomes adherent, and the duodenum is more firmly fixed than in the original quadruped. "The solid organs of the upper abdomen which are fixed in man and movable in the quad- ruped are the kidneys, liver, spleen, and the pancreas. "The parts of the intestinal tube left movable in man are the middle part of the stomach, the transverse colon, and the small intestine down to a point near the ileocecal valve and the sigmoid colon. "The transverse colon is attached by fusion to the posterior leaf of the omentum, which, in turn, is attached to the anterior leaf by the same process for the purpose of preventing the middle of the transverse colon from sagging and pulling on the two flexures." With this excellent description of the anatomy of visceral support the pathology of ptosis can be easily understood. The most common defect in the supporting attachment is represented by a lack of fusion of the cecum and ascending colon to the parietal peritoneum, so that this portion of the large intestine instead of being normally fixed is sus- pended by a mesentery as in quadrupeds. The ascending colon, therefore, with its great weight of feces and water, drags heavily on the fixed point at the hepatic flexure, produces a sharp kink in the canal, with consequent retardation of the flow of intestinal contents. If the fixation at the hepatic flexure is suffi- ciently strong to resist the drag of the colon and cecum, the cecum gradually becomes stretched out and dilated, often reposing deep in the true pelvis. This constitutes the so-called "cecum mobile" of Wilms, There exists between the ascending and descending colons membranous attachments to the lower poles of the kidneys. Downward displacement of the ascending colon, therefore, exerts a drag on the right kidney and is thought by some to be the chief cause of renal prolapse. Displacement of the descending colon is much less common than on the right, because of the more powerful attachment at the splenic flexure, which is the last point to give way in extreme cases of visceroptosis. In this way the infrequency of prolapse of the left kidney is accounted for. 160 GYNECOLOGY Ptosis of the transverse colon may take place entirely independently of the ascending colon, and is termed "mid-line ptosis" by Coffey, who advances the following theory for its occurrence. Between the hepatic and splenic attachments the colon has no parietal support. Nature has attempted to make up for this by fusion of the inner surfaces of the leaves of the omental bursa. As a result of this fusion the gastrocolic omentum is formed, which acts to suspend the colon from the lower border of the stomach. If the omental bursa fails to fuse this support is want- ing, and the transverse colon is susceptible to prolapse as a result. Ptosis of the transverse colon causes sharp kinking of the two flexures, especially at its splenic attachment, with consequent tendency to severe constipation. Prolapse of the stomach represents also a mid-line ptosis, the displacement occurring between the firm esophageal attachment on the left side and the attachment situated at the second portion of the duodenum on the right. In this form of prolapse a kink is established at the point of duodenal attachment, with consequent distention of the duodenum, pylorus, and stomach. According to Coffey, Goldthwait, and others, in practically all cases of enteroptosis can be demonstrated anatomic defects of embryologic fusion and abnormal mobility of the intestine. Of the predisposing causes for ptosis the most important are congenital or acquired errors in body form, and it may be said that in a normally formed body, which during life is maintained in correct posture, even if there be con- genital defect in rotation and fusion of the intestine, ptosis probably does not take place. When a normal individual stands in the proper erect position the upper part of the abdomen in which the heay^^ organs he is expanded by the widen- ing of the ribs and the raising of the diaphragm, while the lower abdomen is compressed and flattened by the firm contraction of the abdominal muscles. If a sagittal section be made through the body in this position, it will be found that the outline of the abdominal cavity is shaped Uke a pear, with the large end uppermost and inchned backward at an angle of 51 degrees (Coffey) (Fig. 23). The lower curve of the pear-shaped contour corresponds to an inchned shelf formed by the psoas muscle and a firm retroperitoneal pad of fat (Fig. 23). This padded shelf helps very efficiently to sustain the weight of all the heavy organs of the upper abdomen, excepting the pyloric end of the stomach and the transverse colon, which He in front of the shelf and which, as has been shown, depend for their support on their rather meager suspensory- ligaments. If, therefore, structural abnormahties of the body, either congenital or acquired, change the incHnation of the padded shelf, making it steeper, the heavy organs lose their most important support and tend to slide downward, unless their attachments to the parietes are sufficiently firm to counteract the influence of gravity and abdominal pressure. This is the fundamental prin- EELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 161 ciple which underHes the orthopedic treatment of visceroptosis, which, as we shall see, plays a most important role in the management of these cases. Goldthwait, R. C. Smith, Swaim, and others have rightly divided enterop- totic patients into two types, the acquired and congenital, with reference to changes in bodily structure. The condition may be acquired by faulty posture in childhood, early lack of nourishment, habitual constipation, long-continued errors of posture from occupational exigencies, neglect of muscular exercise, Fig. 23. — Section of a Normal Abdominal Cavity Showing the Pear-shaped Contour and the Inclination Backward of 51 Degrees. Note the position of the kidney under the last two ribs, and the supporting shelf of fat and muscle. relaxation due to child-bearing, the loss of bodily fat, etc. The victim of acquired ptosis exhibits a general drooping of the body. The shoulders drag forward and downward, lowering and compressing the chest wall. The contraction of the ribs diminishes the upper area of the abdominal cavity, which, as we have seen, should be large and roomy. Compensatory changes in the bony framework alter the inchnation of the pelvis, with consequent strain on the muscles of the back and the articulation of the sacro-ihac joints. The muscles of the abdomen 11 162 GYNECOLOGY are relaxed and allow the abdominal contents to sag downward and forward. These structural changes cause an alteration in the contour of the abdominal cavity, as shown in Fig. 24. The outline, formerly represented by a pear inclined backward at an angle of 51 degrees, assumes a new shape. The outline of the upper part becomes contracted and the lower part enlarged, the whole assuming more of an oval shape, while the long axis, losing its inclination, approaches the perpendicular. In this way the protecting shelf formed by the psoas muscle and the overlying pad of fat is partially obliterated, thus allowing the downward drag of gravity on the heavy organs of the upper abdomen. The congenital type of the enterop- totic is much more common than the acquired. In fact, it is probable that even in most cases of acquired ptosis physical errors in bodily structure of a congenital nature can be traced. The following description, quoted from Swaim, pictures this type: "As children they began Ufe 'frail'; they could not attend school regularly; they grew up delicate of stomach, nervous, subject to attacks of indigestion, incapable of doing all the things they wished to do or that were expected of them. They seldom had had serious illness; sooner or later an inflamed appendix has been removed or the pelvic organs 'hitched up' be- cause of menstrual disorders. At work they were clever, but incapable of sustained efforts without the inevitable results. Most of the patients beyond the age of twenty-one had had one or two nervous breakdowns. The physical characteristics in such cases are al- most typical. Their standing posture is very bad; their shoulders are stooped; scapulae prominent; the sacral and lumbar curves ex- aggerated; the abdomen prominent, especially in its lower half and with the chest flat; the muscles of the abdomen are lax; the erector spinse muscles are thin and tense, account- ing largely for the ache between the shoulders and the tired feeling at the base of the sku^' The circulation is sluggish, the hands and feet are habitually cold and clammy, and especially so when the patient is under nervous strain. The blood shows secondary anemia, and in this type the blood-pressure is usually subnormal while the temperature is always subnormal in the morning. Examination of the abdomen generally shows it to be of the scaphoid variety with a very acute sternocostal angle. The ribs are long and reach nearly to the crest of the ileum. There is often some tenderness with spasm in the epigastrium or a httle to the right of it. The cecal region is tympanitic and the 'corded sigmoid' is usually present. Pressure over the epigastrium causes a characteristic feeling of nausea and distress similar to the habitual discomfort experienced by the patients. Their loins are thin and the right kidney is either pal- pable or actually movable. Not seldom the edge of the hver can be felt and the aorta is pal- FiG. 24. — Enteroptosis with Changes in THE Body Contour. RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 163 pable in its whole length. With the patient on his face there is a distinct hollowing in the costo- vertebral angle, showing an absence of retroperitoneal fat. About 10 per cent, of such cases have slight lateral curvatures. The urine usually is normal. The gastric analysis may show normal findings, or hyperacidity or anacidity, and this varies from time to time. The stool shows, as a rule, considerable undigested material. The .x-rays show the long, tubular 'drain- trap' stomach, some stasis with lack of peristalsis. The smaU intestines are rarely visible be- cause of hypermotihty, as demonstrated by the early filling of the cecima. In this type the small intestines have a tendency to be short. The radiograms of the colon show stasis at the cecmn or at the transverse sag. It seems probable that a mechanical obstruction of the bowel takes place, producing malnutrition, which, in turn, makes the position of the intestines more potent. Veils and bands are, of course, to be found. Let us study the patient more closely. Normally, abdominal fat covers all the abdominal organs and nerve plexuses. Where the abdominal fat is lacking they are exposed. It is generally believed that fat supports the kid- neys, plus the more obvious supports. "In these patients there is almost always a lack of fat tissue. The drag downward of the stomach and intestines must come on their attachments, especially the mesentery, which carries aU the nerves and the blood-vessels of the small intestines and transverse colon." In a very considerable percentage of cases of congenital enteroptosis there exists some pelvic abnormality with corresponding symptoms, and it is for this reason that the gynecologist shares an equal interest in the subject with the internist, general surgeon, and orthopedist. As was stated above, there is no very definite causal relationship between enteroptosis and pelvic disease, excepting in cases where pelvic adhesions may cause a forcible dragging down or fixation of the intestines. The pelvic abnor- mality so frequently accompanying enteroptosis is to be regarded rather as an associated condition, and usually represents some form of genital hypoplasia. It is, of course, possible that early ill nourishment of the congenital ptotic may interfere with the full development at puberty of the genital organs, but this is probably not an important element, in view of the fact that a very large number of patients are seen with genital hypoplasia who are otherwise com- pletely developed and without the slightest tendency to enteroptosis. In individuals who manifest a lack of development elsewhere it is to be expected that the generative system should share in the general physical deficiency, at least in a considerable percentage of cases, and this is true of the ptotic patient. The independence of development that the genitals often exhibit with reference to the rest of the body is not infrequently shown in the congenital enteroptotic by an entirely normal pelvic apparatus. The abnormalities of the pelvis most often associated with enteroptosis are malpositions, usually either anteflexion with retrocession or retroflexion. Occa- sionally one encounters a procidentia in a nuUiparous woman. Deficiency of ovarian function with amenorrhea or ohgomenorrhea is frequent. Dysmenor- rhea and sterility are extremely common. The symptomatology of enteroptosis is a subject so extensive that it can be touched on only superficially here. The symptoms are due to the retardation in the bowel of the fecal contents, a condition aptly termed by Lane "intestinal stasis," and are evoked by the absorption into the circulation of toxic products 164 GYNECOLOGY from the stagnating and decomposing material. The typical sjmiptoms consist of frequent nausea and vomiting, often severe and sometimes accompanied with blood, loss of appetite, diminution in body weight, sometimes rapid, circula- ■ tory disturbances, such as coldness of hands and feet, constipation with much gas formation of the bowels and discomforting distention, mental apathy, and a great variety of muscular and joint pains. Many of the patients exhibit char- acteristic skin changes, especially acne and sallowness of the complexion. Ner- vous symptoms of all kinds and severity, amounting sometimes to mental derangement, are practically always present. Swaim has called attention to the possibiUty that much of the symptomatology may be referable to pressure and stimulation of nerves of the sympathetic ganglia, with consequent influence on the organs of internal secretion. If pelvic abnormalities are present, and sometimes even when they are not demonstrable, there may be severe disturbances of menstruation, usually dysmenorrhea, and various forms of genital psychoneuroses. As a result of the studies of Metchnikoff and Lane, many diseases are thought to be the direct resultant from the auto-intoxication of intestinal stasis, such as arteriosclerosis, nephritis, diabetes melhtus, rheumatism, various arthritides, ulcer of the stomach, cholehthiasis, cystic, and malignant degeneration of the breast, etc. Undoubtedly, the lov\^ering of general resistance caused by enterop- tosis makes the individual more susceptible to these diseases, even if the rela- tionship is not more direct. Metchnikoff has succeeded in producing cal- careous deposits in the arterial walls of animals in whom an artificial intestinal stasis has been created. The diagnosis of enteroptosis and stasis, though frequently obvious, is in all cases ultimately made by a;-ray pictures of the intestine, the details and significance of which should be interpreted only by an expert rontgenologist. The treatment of enteroptosis calls for the cooperation of more specialties than almost any other disease, and may require medical, orthopedic, surgical, gynecologic, and neurologic measures. Medical treatment is necessary in all cases, and consists primarily in pre- scribing a simple digestible diet and a proper course of hygiene. At first the lubrication of the intestine must be gained, and for this the better preparations of liquid paraffin (Russian oil) are at present in the greatest favor. Hydro- therapy when available is unquestionably of much benefit. Orthopedic treatment is in all cases of the greatest importance, even when drastic surgical measures are undertaken. It consists in the appHcation of braces and supports which correct the posture and support the prolapsed viscera. In addition, the patient is taught to assume various positions which reheve the drag of the viscera and to perform numerous exercises to strengthen the weakened muscles of the trunk. The problem of the orthopedic treatment has been worked out pre-eminently by Goldthwait, to whose writings the reader is especially referred. Inasmuch as the body form is faulty in all cases of RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 165 enteroptosis, orthopedic treatment must supplement all other measures. This is not sufficiently recognized in the cases which are treated surgically. Gold- thwait has emphasized this point in the following (shghtly modified) quotation: "Special attention may be given to a particular organ, but the importance of the influence of the other organs or other structures upon the special organ must not be lost sight of. Opera- tions may be performed, but before it is attempted to sew a stomach in what is supposed to be its normal position, it must be seen that the body is so remodeled that the proper amount of subdiaphragmatic space exists for the organs. A hole must be prepared before a peg can be put into it. To suture a stomach or Uver to the upper abdominal region, when the ribs and dia- phragm are so low that when the body is used they continually crowd the attached organs do\\Ti- ward, must frequently result in gi-eater discomfort than existed before. A movable organ under such conditions is better than a fixed one, because it may have periods of ease or acquire new positions in which reasonable function is possible. In the fixed position this mechanical inter- ference may be constant. When such operations are required, if the body is considered with reference to all its parts and the mechanistic significance of the relationship of the many organs each to the other is kept in constant memory, care must be taken to see that the body is pre- pared by a period of remodeling, or special exercises are given, or postures assumed, so that the organ when put in place can have the best chance to do its work." The surgical treatment of enteroptosis is also too broad a subject to be treated here more than superficially, and is at the the same time in such an experimental stage that definite conclusions are as j-et unjustifiable. In speak- ing of the surgery of enteroptosis it is to be noted that we do not include opera- tions for the frequently associated membranous adhesions, a subject which is dealt with later (see page 176). Some of the operations that have been emploj'-ed with greater or less suc- cess are as follows. Rovsing, a pioneer in this branch of surgery, has sutured the stomach wall directly to the peritoneum of the anterior abdomen, and has from time to time reported astonishingly good results. His method, however, has not been general^ adopted. Beyea shortened the gastrohepatic ligament, but this method, though sounder in surgical principle than that of Rovsing, proved inadequate on account of the natural weakness of the hgament. Lane, to whom belongs the chief credit of demonstrating to the profession the possibihties of surgery in the treatment of ptosis, applied heroic measures by either removing the colon entire or short- circuiting it by cutting off the ileum and planting it in the lower bowel. These radical operations have been widely tried, but with rather disappointing results. Wilms, recognizing the importance of the stretched-out movable cecum in the condition of stasis, fixed the cecum to the lateral parietal wall with con- siderable success. Coffey, appreciating the principle of suspension without fixation, devised an operation which has proved very efficient. The steps of the operation are as follows: First, shortening by plication the falciform peritoneum, thus sustaining the liver; second, shortening the gastrohepatic omentum by plication (Beyea's method), thus giving a greater support to the stomach; third, suturmg the 166 GYNECOLOGY greater omentum along a line just below the transverse colon to the parietal peritoneum, thus affording a strong support both for the colon and indirectly the stomach. In addition to the operations of suspending the viscera, an attempt is made to restore the contour of the abdominal cavity by enlarging the space of the upper abdomen and compressing that of the lower abdomen. This is accomphshed by sphtting the anterior sheaths of each rectus muscle and by leaving unsutured the wound of the aponeurosis made by the original incision. The pendulous lower abdomen is strengthened by a special plastic operation of overlapping the aponeurosis. Coffey's operation, on account of its simplicity and logicalness, has been very extensively employed, with varying results. In giving a general estimate of the surgery of enteroptosis in the hght of present experience it may be said that notwithstanding the numerous failures that have been recorded against it, the brilliant results of Lane, Coffey, and others have demonstrated that certain cases of enteroptosis are surgical and that failures are often due to lack of judgment in selection of cases, inadequate experience in performing the operations, and, above all, to inappreciation of the orthopedic requirements of practically all cases. As to the various operations that have been employed it may be said that the complete resection of the colon is, in our present state of knowledge and experience, too radical a procedure, excepting in extreme cases, though in the light of the continued verification of Metchnikoff's theories one cannot help believing that at some future period the operation may become one of immense benefit to the human race. Short-circuiting of the colon is also looked on with disfavor by many surgeons, whp have tried it enthusiastically, only to be disap- pointed in its results. In certain cases, however, there is no doubt of its value. The conservative operation of Coffey is also at the time of writing looked upon unfavorably by numerous surgeons, who have not found in it the universal panacea that they had anticipated. We have personally found it extremely useful, and ascribed the failures that we have met with to inexperience in the technic and to a neglect of the orthopedic requirements. The gynecologic treatment of enteroptotic patients is the same as that of pelvic disease under other conditions. It must, however, be borne in mind by the surgeon and explained to the patient that surgical treatment of the pelvic organs is directed toward the local symptoms only, and that relief of them does not involve a disappearance of the train of symptoms caused by stasis of the intestines. For this reason it is of the greatest importance that the gynecol- ogist should be familiar with the pathology and clinical picture of enteroptosis. Fortunately the idea is passing — though it has not yet entirely passed — that all kinds of digestive disturbances, muscular pains, and nervous derangements may be ''reflexes" resulting from a misplaced uterus or cystic ovary. If the pelvic organs are giving the enteroptotic definite symptoms for which a pelvic operation offers a reasonable hope of relief, the operation is indicated. If the ptotic condition is also one for surgery, the two operations may be done KELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 167 at the same time, with proper regard also for the necessity of orthopedic remodel- ing of the faulty body structure. Of much importance in the performance of the pelvic operation is a con- sideration of the abdominal wall, which in most cases is in a state of relaxation. The operation recommended by the author (see page 771) may be used with much advantage to strengthen the wall and compress the lower part of the ab- dominal cavity. It is of especial value in cases of acquired ptosis where there is usually a diastasis of the recti muscles. Neurologic treatment of the enteroptotic is less prominent than it was be- fore the chnical significance of the condition was generally recognized, and when these patients were regarded as hopeless neurasthenics. In some cases, however, modern neurologic treatment is of prime importance in securing a complete recovery. These are the cases in whom the neurotic habits of introspection and overvaluation of symptoms have become so estab- lished that they do not entirely disappear after rehef of the physical disability. These habit-neuroses are best treated by the methods of reasoning and sugges- tion with which the expert neurologists of today are acquiring such brilliant results. MOVABLE KIDNEY The term "movable kidney" is a general one, relating to conditions of abnormal mobility of the kidney. Nephroptosis means falling or prolapse of the kidney, . and is practically synonymous with movable kidney. Floating kidney, when properly used, relates to the more extreme cases of movable kidneys such as when the organ becomes completely invested by a covering of peritoneum and hangs loose in the abdominal cavity, or when it descends to the pelvis, or when it lies close to the anterior abdominal wall. Under these conditions the stretched out supporting tissues constitute a sort- of mesentery from which the kidney swings. Movable kidney is so common in women that it is included in the category of gynecologic diseases. Formerly supposed to be rare, it is now under im- proved methods of diagnosis estimated to occur in one out of every five women, in contrast to men, in whom the occurrence is only 2 per cent. In the vast majority of cases only the right kidney is affected. In a comparatively small percentage both kidneys are involved, while prolapse of the left kidney .alone is extremely rare. Kelly's figures show f?iat symptoms of movable kidney appear most fre- quently between the ages of twenty and thirty, and that the condition is very rare in the young. Kelly thinks that the development of symptoms so fre- quently seen during the third decade may possibly be due to the fact that this is usually the most active period of a woman's life as regards bodily effort and child-bearing. The etiology of movable kidney has been a subject of much theory and 168 GYNECOLOGY speculation. In by far the great majority of cases the condition is acquired, a congenital origin having been established in only a few cases. Of the pre- disposing causes some, which, in the earlier studies of the disease were regarded as important, may be excluded as having little or at least only secondary in- fluence. Of these may be mentioned tight lacing. The corsets in vogue at one period, which constricted the upper portion of the abdomen and a part of the chest wall, may have acted in conjunction with more fundamental influences in forcing the kidney downward. Pregnancy and labor, once thought to be a frequent primary factor, probably act only secondarily in relaxing the lower ab- dominal wall, thus favoring a tendency to visceroptosis in which the kidney may have a share. The frequency with which movable kidney is found in the nuUiparous and the old-maid type is evidence that pregnancy is not to be regarded as of primary importance. Traumatism in the form of sudden falls and jars, once regarded as a fre- quent cause of acute prolapse of the kidney, can probably be excluded. As in cases of retroversion and prolapse of the uterus, or other forms of relaxed tissues, the pathologic condition is the result of gradual stretching, either from con- stant strain or often-repeated traumatism. Congestion of the kidney, asso- ciated with menstruation or pregnancy or malposition of the uterus, is of very minor significance as an etiologic factor in nephroptosis, though it may often act to exaggerate the symptoms if such a condition already exists. The fundamental etiology of movable kidney in the light of present knowl- edge is probably contained in the following conditions: (1) Physiologic defi- ciency of supporting structures; (2) errors in bodily structure; (3) drag on the kidney of the cecum and ascending colon; (4) loss of supporting fat. In most cases of relaxed organs it is self-evident that there exists in the individual some inborn deficiency in the supporting tissue structure, rendering it unable to resist adequately the ordinary exigencies of physical life. This tissue deficiency may be general, as in cases of general visceroptosis, or localized, as in the case of a movable kidney or a retroverted uterus that exists in an individual otherwise perfectly sound. Of chief importance in the etiology of movable kidney is the body form, to which it bears the same relationship as does enteroptosis. As has been shown in the discussion of enteroptosis, the heavy organs of the abdomen, including the kidneys, are contained in the upper portion of the abdominal cavity, the contour of which in the normal individual is shaped like a pear, inclining back- ward at an angle of 51 degrees. This inclination provides a sort of shelf which, with the aid of abdominal pressure and the padding of postperitoneal fat, sup- ports all the heavy organs excepting the transverse colon and the pyloric half of the stomach. On this padded shelf the kidney is .especially dependent for its support. The inclination of the shelf, and consequently its supporting power, is altered by changes in the body form caused by relaxation and droop- ing. The upper roomy portion becomes constricted by collapse of the chest wall RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 169 and the contents are forced downward. The lower abdomen becomes larger, the long axis of the cavity more vertical, and the pear-shaped outline of the abdominal cavity more cylindric. Hence the frequency with which nephrop- tosis is found in individuals who, either by inheritance or by improper posture, or by occupational requirements or other cause, are bodily malformed. There is . an undoubted influence between movable kidney and movable cecum. During the process of rotation of the intestine during embryonal life and its adaptation to the erect posture of man, the ascending colon, as has been stated on page 159, becomes fused with the posterior parietal wall and the anterior aspect of the kidney. It has been shown by anatomists that in 20 per cent, of subjects coming to the autopsy talkie there has been an incom- plete fusion of the lower part of the ascending colon, so that instead of being supported by an attachment to the parietal wall it swings free on a mesentery, constituting the so-called cecum mobile of Wilms. The weight of the cecum, therefore, bears heavily on its attachment to the kidney, which, if its natural supports are congenitally inadequate, or if the angle of the padded shelf is less- ened b}^ incorrect body form, is dragged from its bed. Longyear, who has writ- ten a book on the subject, believes this to be the sole cause of movable kidney. The presence of fat in the shelf on which the kidney rests is of considerable importance. The shelf, as has been seen, is composed of the psoas muscle and a pad of fat. If this pad of fat is lost by absorption, the shelf loses its supporting angle. Just how far this acts as a primary cause is problematic. Kelly has shown in. his statistics that the rapid absorption of bodily fat is by no means con- stantly followed by nephroptosis, while on the other hand a very considerable number of his cases were either fat or moderately well nourished. It is not unlikely that the absence of the supporting fat pad, often noted in connection with movable kidney, is due to pressure which, as is well known, is a potent factor in causing the rapid disappearance of fat. S5rmptoms. — In the great majority of cases movable kidney causes no symptoms whatever, and, considering the very great frequency of the condition, only exceptionally requires treatment. As is the case with the relaxation of other organs, the severity of the symptomiS does not correspond to the degree of prolapse, some of the most troublesome symptoms occurring with only slight descent of the kidney. Of the symptoms which make treatment of nephroptosis necessary is local- ized pain in the kidney region. This may be of a constant dull dragging charac- ter, or it may consist of sharp attacks resembling renal colic, sometimes at- tended with vomiting and prostration. The dull dragging pain is felt in the back, the loin, and in the region in front of the kidney. It is sometimes associated with a sensation of something being loose in the right abdomen. It is frequently exaggerated by menstruation, and is always worse during pregnancy. The pain can be reproduced in character by filling and slightly distending the kidney pelvis with fluid. According to 170 GYNECOLOGY Kelly, there is very little tendency of the pain to radiate downward, as in the case of pain from stone. Sharp attacks of pain are less common than the dull dragging variety. They represent sometimes the result of twisting or kinking the ureter with temporary hydronephrosis; sometimes a twisting of the renal pedicle without urinary obstruction. The attacks of pain when due to urinary obstruction may be followed by passing a large quantity of urine. In many cases of nephroptosis there are marked gastro-intestinal disturb- ances. These take the form of gastric indigestion, severe constipation, mucous colitis, etc. These symptoms must not be regarded as ''reflexes" resulting from descent of the kidney. They are probably, as a rule, manifestations of gastro-intestinal stasis from associated enteroptosis. The fact that such symp- toms are sometimes cured by fixation of the kidney may be explained by the mechanical relief which the operation may afford to the drag on various parts of the intestinal tract which the prolapse of the kidney accentuated. Patients with nephroptosis are frequently nervous, but the nervous mani- festations are in no sense reflexes in the common acceptance of the term. They bear a causal relation to the kidney only when the nephroptosis is causing symp- toms which by constant repetition irritate the nervous system. The effect on the nerves, therefore, follows the law emphatically laid down in the discus- sion of genital neuroses in the section devoted to Neurology. Rare symptoms of movable kidney are jaundice and attacks of pain in the gall-bladder region, clue probably to an obstruction of the gall-bladder from the drag which a movable kidney exerts on the duodenal attachment of the intes- tine to the posterior parietal wall. Besides these, other unusual symptoms are headaches, albuminuria, hematuria, irritation of the bladder, intercostal neural- gia, palpitation of the heart, edema of the legs. Edebohls has demonstrated the frequency with which movable right kidney and appendicitis are associated. He ascribes the inflammation of the appendix to the effect of congestion of the appendical veins caused by the pressure of the kidney on the mesenteric veins against the head of the pancreas. The diagnosis of movable kidney is a comparatively simple matter, but the decision as to whether in a given case the symptoms are clue to the malposition of the kidney or to disturbance of some other organ may be very difficult. Diseases of the ureter, appendix, cecum, ascending colon, and the gall-bladder region must all be carefully excluded. The anatomic position of the kidney can usually be determined by palpa- tion. The patient is fiat upon her back with the knees drawn up. The left hand is placed flat under the left flank, the ends of the fingers reaching the costovertebral angle of the last rib. This hand is held firmly, while the fingers of the right hand are pressed in front, just below the costal margin. The patient is requested to draw in a deep breath and then breathe out quickly. The movable kidney can be felt as a smooth body slipping between the fingers. A normally placed kidney cannot be felt except in very thin individuals. RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 171 The amount of descent is divided by Glenard into three degrees. By his classification the kidney is in the first degree of prolapse when the lower pole can just be felt on deep inspiration; it is in the second degree when the body of the kidney can be caught and held near its center and prevented from receding when the patient breathes out; it is in the third degree when on deep inspira- tion the entire kidney can be grasped and prevented from receding on expira- tion by holding the anterior and posterior walls together above the prolapsed organ. In doubtful cases the pelvis of the kidney may be injected through a cysto- scope and ureteral catheter. By this means the capacity of the kidney pelvis is tested and the presence or absence of hydronephrosis noted. The average capacity of the pelvis is 5 to 10 or 12 cm. Kelly estimates that in 1 out of every 7 cases of nephroptosis that give symptoms there is a beginning hydronephrosis. The plan of injecting the pelvis has been shown by Kelly to be of advantage in determining the diagnosis, in that when the pelvis is filled to distention the pain, which the patient has been suffering as a result of prolapse of the kidney, is exactly reproduced. If the pelves of both kidneys are filled with a metal salt, like collargol, an :c-ray picture can be taken with the patient standing, from which very important information can be gained as to the comparative size and position of the kidney. This method of examining the pelvis of the kidney is termed "pyelography," and is very extensively used in diagnosis. The method, however, is not without danger. Buerger has recently reported cases in which both collargol and argyrol, used for the purposes of pyelography, penetrated into the renal paren- chyma as far as the surface of the kidney and produced areas of necrosis and suppuration. Treatment of movable kidney is to be employed only when the displace- ment is causing definite symptoms. When there are no symptoms present it is important to avoid informing the patient that she has a movable kidney, for knowledge of this kind in nervous wom,en may create psychoneuroses and fixed ideas that become seriously troublesome. When a movable kidney is giving symptoms it may be treated by either orthopedic or surgical measures, or by both. Orthopedic measures consist primarily in correcting and remodeling the body when errors in structure are present. This is done by braces, postural and muscular exercises, as described in the section on Enteroptosis. In addition to this, the application of a properly fitting abdominal support, sometimes supplied with a pad, is most efficient in relieving and often entirely curing the sjonptoms of movable kidney. Whether in such cases an anatomic cure of the position of the kidney is completely secured is doubtful, but this is not necessary if the patient is relieved of her pain and discomfort. Operative measures seek to attach the loose kiclnej' to the muscles which lie behind it, so that it is prevented from descending. The operation when 172 GYNECOLOGY properly performed and applied to the right ease is usually successful. Many operations have been devised for the condition, one of which is described in detail on page 800. INTESTINAL BANDS The subject of intra-abdominal bands is closely allied to that of enterop- tosis, in that the two conditions are quite constantly associated. Xevertheless, they may appear independent 1}^ of each other, and for that reason it seems best to treat the subjects separately. Science is at the present time in a quandary as to the true etiology of these membranous bands, but the discovery of their existence and recognition of their clinical significance constitute an important step in medical progress. Numer- ous types of these structures have been described, and to them have been given picturesque names, a familiarity with which is necessary for the understanding of the literature on the subject. Some of the descriptions relate to bands that are found in the fetus, while others represent structures encountered during adult life. (1) The Bloodless Fold of Treves. — This is a prenatal fold of peritoneum covering the head of the cecum and appendix, and, according to Eastman, found in more than 20 per cent, of fetuses. Eastman's description of this fold as he finds it is as follows: "It passes from the lateral posterior peritoneum to the terminal part of the ileum and the caput coli, fusing with the peritoneum covering the intestine. It is always more or less fan shaped, the broad attachment being to the mural peritoneum. The intestinal end is always the more narrow. It forms a pocket in which the vermiform appendix and more or less of the caput coH and cecum are ensconced." Every surgeon will recognize having met with apparently non-inflammatory folds similar to this during the removal of the appendix, and having called the condition one of "retroperitoneal appendix." (2) The Parietocolic Fold of Jonnesco and Juvara. — This is another mem- branous fold discovered in the study of fetuses. In the majority of the cases the fetal fold arises from the peritoneum at the left or inner side of the ascending colon, passing over the anterior aspect of the ascending colon in an upward slant- ing direction. It is attached to the parietal peritoneum at the right of the ascending colon. It may adhere to the anterior and lateral aspects of the colon (Bainbridge) . The similarity between this fetal structure and Jackson's membrane is to be noted. (3) Jackson's membrane is a peritoneal fold frequently observed during abdominal operations and described by Jackson, who considered it the result of an inflammatory process. His description of the structure is as follows: "From a point iust at the hepatic flexure to three inches above the caput coU there spreads from the parietal margin over the external lateral margin to the internal longitudinal muscle RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 173 band a thin vascular veil in which long straight unbranching blood-vessels course, most of which are parallel with each other, and take a slightly spiral direction over the colon from the upper peritoneal attachment to the inner lower portion of the gut, ending just above the caput. The appendix is not imphcated in any way. Coursing with the blood-vessels are numbers of shining narrow bands of connective tissue, which gradually broaden as they go and end in a shght fan-shaped attachment at various points on the anterior and inner surfaces of the colon. At these points of attachment the gut is held in rigid pUcation. At the beginning of the hepatic flexure the drawn membrane particularly angulates the contained colon." (4) The Genitoynesenteric Fold of Douglas Reid. — This is a fold of peritoneum frequently found in the fetus, which extends from the mesentery of the terminal segment of the ileum do^vn into the pelvis, being attached in the fetus to the genital gland below. It has also been termed by other observers the "appendic- ulo-ovarian ligament" (see page 145). It is occasionally seen during abdominal operations, and, aside from its possible connection with Lane's kink, sometimes is of clinical interest by causing a retroversion of the uterus. Reid ascribes to this connection between the appendix and aclnexal regions the frequent associa- tion of inflammatory processes between the two. We have looked for the per- sistence of this fold in the course of abdominal operations extending over about twelve years and have occasionally observed it. Eastman has found it in a very considerable percentage of cases in fetuses after the seventh month and has also observed it in the adult. (5) Attic Adhesions. — Adhesions about the gall-bladder and pyloric region are found with very great frequency, as any surgeon who makes a routine practice of examining this part of the peritoneal cavity during pelvic or other abdominal operations can testify. Alorris has given the name of "attic adhe- sions" to these structures. Lane's kink, or ileopelvic hand, relates to a membranous attachment pass- ing from the ileum to the parietal wall at a point near the ileocecal junction, frequently causing a sharp angulation. This is a structure noted in the adult. Eastman calls attention to its similarity to the genitomesenteric fold of Douglas Reid, and suggests that it may be a persistence of this fetal membrane. Numerous other bands are described in various parts of the abdominal cavity, involving the appendix, pancreas, liver, stomach, and descending colon. The clinical significance of all these various intra-abdominal bands Hes in their tendency to obstruct the alimentary canal and cause s\Tnptoms and conditions of stasis. The theories advanced to explain their existence may be divided into three classes: (1) That which assigns a fetal origin to them; (2) that which explains them as a result of a postnatal inflammatory reaction; and (3) that which asserts that they represent a non-inflammatory reaction on the part of nature to resist the ptosis of the abdominal viscera resulting from man's erect posture. Those who believe in the prenatal origin of these bands point to the close similarity that exists between certain well-defined fetal structures and the mem- branes discovered in adult life, as is seen, for example, in the resemblance of the lU GYNECOLOGY parietocolic fold of Jonnesco to Jackson's membrane. The origin of the fetal merabra,nes has not been satisfactorily explained, but it is known that at an Fig. 25. — Abdominal Bands. The drawing shows Lane's kink, Jackson's membrane, adhesions of the hepatic flexure, adhe-' sions about the gall-bladder and pylorus, adhesions of the splenic and sigmoid flexures, and adhe- sions of the sigmoid to the left broad ligament. The small intestine and omentum have been omitted from the drawing for the sake of illustration. early stage of fetal life the entire abdomen is filled with bands similar to those seen after an attack of peritonitis, and that toward the close of fetal life they RELATIONSHIP OF GYNECOLOGY TO THE GENERAL ORGANISM 175 usually melt away (Bainbridge, Keith). It is urged by the supporters of the congenital theory of intra-abdominal bands that these bands represent the per- sistence after birth of certain of the fetal adhesions above described. The adherents of the inflammatory theory of the origin of intra-abdominal bands base their assumption on an .inflammatory reaction of the peritoneum covering the bowel induced by mild chronic infections of the mucosa, from which the process is transmitted through the wall (Pitcher, Gerster). Others (notabl}^ Martin) ascribe the -adhesions to- a traumatic reaction of the peri- toneum resulting from overriding of comparatively fixed portions of the gut by abnormally movable viscera. Jackson regarded the membrane which he described as the outcome of a chronic pericolitis. Coffey is also an exponent of the inflammation theory. The third theory, which assumes that the intra-abdominal bands represent an evolutionary provision of nature to resist the tendency of the viscera to prolapse, belongs peculiarly to Lane. He maintains that the efforts of nature to counteract the drag of the bowel results in a hypertrophy of its membranous supports, constituting, as Bainbridge well puts it, a ''physiologic response to a mechanical demand." The bands or folds resulting from this process are termed by Lane "crystallizations of resistance" or "crystallizations of force." They are designed, first, in their physiologic role to facilitate the drainage of the bowel. Later they may come to defeat the very object for which they were created, and become material factors in obstruction and stasis. The points where these bands may form are described by Lane as follows: (1) In the third part of the duodenum and at the commencement of the jejunum; (2) at different points along the terminal coil of the ileum; (3) in the.ileocecal region, including the appendix; (4) in the region of the hepatic flexure and the first part of the transverse colon; (5) at the splenic flexure;, (6) at the sigmoid loop; (7) in the rectum. . No one of the causes which serve as a basis for the three preceding theories can explain satisfactorily all of the intra-abdominal bands, but it is probable that each one, either independently or in association with one or both of the other two, plays a part in the formation of a certain number of these struc- tures. Sjrmptoms. — Intra-abdominal bands may cause no symptoms whatever, and they may act, as has been mentioned above, to prevent sagging of the bowel and maintain proper drainage. If, however, in association with enterop- tosis they cause a retardation of the fecal contents the symptoms are those of stasis, as described in the section on Enteroptosis. When intra-abdominal bands unassociated with enteroptosis constrict the bowel and cause symptoms, the clinical picture is somewhat different. Pa- tients of this type may be well formed, often well-nourished in appearance. Symptoms of stasis may be in evidence, especially those of constipation, mus- cular pains, and lack of nervous equilibrium. 176 GYNECOLOGY In these patients localized pain plays an important part in the symptom- atology and may cause much difficulty in diagnosis. On the right side the affection may simulate adnexal disease, appendicitis, and affections of the kidney, or, if the pain is higher up, gall-bladder disease, ulceration of the duode- num or stomach. On the left side it may be confused with adnexal disease, with cancer, or diverticulitis of the sigmoid. The diagnosis is made by excluding other diseases, but pre-eminently by the ic-ray. In our experience the expert rontgenologist describes with astonishing accuracy conditions that are later verified by operation. The treatment of constricting intra-abdominal bands that cause symptoms is essentially surgical. When enteroptosis is also present it should be treated according to the suggestions made in the section relating to that subject. The bands should be released by careful dissection. Many of these bands reach a marked degree of hypertrophy and constitute powerful structures. This is especially true of those which develop across the upper part of the ascending colon, by which the cecum and sometimes the duodenum may become very much distended. Not only must the main constricting bands be severed and dissected away, but frequently adhesions between loops of intestines' must be released. If raw surfaces are created by this procedure, an effort should be made to cover them with peritoneum if any is available for this purpose. Some- times it is advantageous to graft over the raw area a piece of fat removed from the omentum. While performing an operation of this kind it is common to hear the remark that the operation is futile because the adhesions will re-form rapidly. This is a mistake, as we have on several occasions been able to testify when the abdomen had to be reopened for some other cause at a later date, the formerly adherent area being surprisingly clear of adhesions. If in cases of enteroptosis the release of constricting bands makes the condition of ptosis worse, provision for the support of the intestine can be made by attaching it to the parietes by the methods suggested by Coffey. When intra-abdominal bands are encountered incidentally during the course of an abdominal operation they should be treated conservatively, for many times it will be found that they act as an efficient means of preventing ptosis. This is especially true of the veil-like forms of Jackson's membrane. If it is evident that the bands are constricting the bowel, they should be dissected. PART I.l GYNECOLOGIC DISEASES Inflammations gonorrhea Considering its prevalence, the intractability of its local processes, and its far-reaching influence on the health and bodily resistance of the individual, gonorrhea in woman must be regarded as one of the most important of gyneco- logic diseases. Because of the greater complexity of the female genital tract the disease in woman is far more varied and more dangerous, both to life and health, than in man. Gonorrhea has a unique standing among infectious diseases not only in its chnical manifestations, but in the fact that its specific organism, the gono- coccus, has certain special characteristics that differentiate it conspicuously from all the pathogenic bacteria. The microscopic appearance and the morphology of the gonococcus cannot be dealt with in this work; we are here chiefly interested in its clinical pecu- liarities. There exists to the gonococcus no immunity whatever, either from previous attacks, or by individual resistance, or by hereditary racial quahties, such as belongs in some form to most other microbic organisms. In some married people there appears at times to be a mutual immunity to an existing gonor- rhea, yet this is only apparent, for, under favorable circumstances, the infection may hght up into activity in either of the pair, and is always capable of imparting an acute contagion when transferred to a third person. The gonococcus finds its most congenial habitat on mucous surfaces, where it resides for the most part superficially between the interstices of the epithelial cells. It has little tendency to invade the lumina of deep-lying glands, such as those of the cervix and the vulva, but confines its activities to the glandular ducts. Nor does it have a disposition to penetrate into the subcutaneous con- nective tissue nor to invade the lymph- and blood-channels, although rarely it may do all of these things. Thus, it is sometimes found attacking the joints, or the tendons, or the valves of the heart, while a few cases of a general gono- coccus septicemia have been reported. The organism has a special predilection for certain human mucous surfaces, and when deposited on these grows immediately in the same manner as do other 12 177 178 GYNECOLOGY bacteria on their favorite culture-media. No abrasion or injury of the tissue surface is necessary, the normal uninjured epithelium being sufficient for its life and reproduction. When confined in occluded spaces like that of a sactosalpinx, the gono- coccus soon dies, whereas in unrestrained secretions it retains an extraordinary longevity and virulence. The gonococcus is exclusively a human parasite. It is not found outside of the human body, nor can it readily be inoculated on other than human tis- sues. Moreover, it can be easily cultivated only on media made from human secretions. Thus, it will not grow on pure agar, but may be cultivated on agar combined with human blood. It will grow in hydrocele fluid, ascitic fluid, the contents of ovarian cystomata, and even in urine; but not in bouillon, animal blood-serum, and the other commonly used culture-media. Another characteristic of the gonococcus is that it is infectious only in the moist state and that it grows only on moist surfaces. Under dry conditions it soon dies. Gonorrhea is, therefore, an almost purely contagious disease, and is rarely transferred indirectly except in the case of young children. With this last exception, gonorrhea of the genitals is transmitted almost exclusively by sexual contact. Acute gonorrhea in a woman may be contracted from an acute or chronic gonorrhea of the man, and vice versa. From a clinical standpoint one of the most important characteristics of the gonococcus is its power of latency. This does not correspond biologically to the spore stage of some other bacteria. It means that the organism remains hving in the human tissue, but is temporarily inactive. It means that the patient has gonorrhea without symptoms. The gonococcus, lurking as it does in the interstices between the epithelial cells, is comparatively safe from in- juries which do not destroy the cells, so that it may remain dormant for long periods of time until stimulated into activity by changes in the circulation of the surrounding tissue. The limit of the period of latency which the gono- coccus may possess is a matter of conjecture and is placed by different authori- ties from two to ten or more years. Probably three or four years is the average limit in man and a somewhat longer period in woman. Reports of cases of latency of twenty-five and twenty years are to be received with doubt. The favorite lurking places for the latent gonococcus are in the secluded and well-protected folds of certain tissues for which it has a predilection. Exam- ples of these are the prostate gland in the male, and in the female the ducts of the cervical and vestibular glands, and the rugae of the fining membrane of the Fallopian tubes. The latent germ may light up into acute activity in two ways: it may either produce a fresh gonorrheal attack in the individual in whom it has been residing as a latent parasite, or it may be transferred to an- other individual, and, finding there a fresh soil more congenial to its growth, incite an acute process. The condition that favors an awakening of a latent gonorrhea is the bringing of fresh nourishment to the tissue in which it exists as INFLAMMATIONS 179 a result of hyperemia, such as may be ehcitecl, for example, by excessive venery, menstruation, childbirth, and ill-advised pelvic operations. It is tills power of latency which makes the gonococcus so treacherous an organism, and which renders so futile the efforts to prevent the extensive ravages that the disease makes on the health of the human race. According to Amann, it is probable that the gonococcus does not pass through a true incubation time, but rather begins to grow and multiply in a very short time after being deposited. The reaction in the tissues appears within from twelve hours to two days, and, according to Amann, never more than three days. Norris, on the other hand, gives an incubation period aver- aging three days to a week. The various phases of gonorrheal disease in woman are determined by the predilection which, as we have seen, the gonococcus has for certain surface tis- sues of the body. To meet the requirements for the active development of the gonococcus the tissue must be soft and delicate, continually moist, and well supplied with blood. The surface may be modified epithelium, like that of the urethra or the delicate squamous epithelium -of the vagina, -or it may be cylindric mucous epithelium, like that of the endocervix, or it may be the endothehum of the pelvic peritoneum or the delicate epithelium of the conjunctiva. The surface epithelium of the various parts of the female genital system offers favorable soil for the growth of the gonococcus, and the infection of each one of these parts constitutes a special disease, which may either exist as an affec- tion by itself or be associated with infections of other areas of the genital system. The parts of the genital tract which may be infected to a greater or a less extent are: (1) the vulva and vagina (of children); (2) the urethra; (3) Skene's or para-urethral glands; (4) Bartholin's glands; (5) the endocervix; (6) the endo- metrium; (7) the endosalpinx; (8) the ovaries, and (9) the pelvic peritoneum. An understanding of gonorrhea in women may best be gained by a succes- sive study of the infections of these parts, and we will, therefore, proceed to consider the subject under the following topics: (1) Vulvovaginitis; (2) ure- thritis; (3) inflammation of Skene's glands; (4) Bartholinitis; (5) endocervicitis; (6) endometritis; (7) salpingitis; (8) ovaritis, and (9) pelvic peritonitis. Extragenitally the gonococcus may infect the anus, the mucous membrane of the rectum, the conjunctiva of the eye, and the mucous membrane of the mouth and nose of the newborn. These infections, however, constitute diseases which do not come within the scope of this book, and are, therefore, only to be mentioned in passing. It should also be noted that the gonococcus has no tendency in women to ascend into the bladder and kidneys, and that, there- fore, the urinary tract, with the exception of the urethra, ordinarily takes no part in a gonor- rheal attack, no matter how extensive the disease may be in the genital system. Gonorrhea in Children Vulvovaginitis. — Primary gonorrheal infection of the vulva and vagina is a disease which affects children or young girls almost exclusively. This is due to 180 GYNECOLOGY the fact that the modified squamous epithelium of the vulva and vagina in children and early youth is soft and delicate. It is extraordinarily susceptible to gonorrheal infection. As the child develops into adult life the surface epithelium of the vulva and vagina becomes somewhat cornified and more resistant, so that in adult life a primary infection of the vulva or vagina is rare. In very severe or badly neglected cases these parts may become secondarily involved in the adult, but when this occurs there is usually a mixed infection of organisms other than the gonococcus. The mode of infection of vulvovaginitis in children is -often difficult to deter- mine. A few cases in the lower strata of humanity can be traced to depraved sexual practices. The children of gonorrheal patients are exposed to infection by contaminated towels, sponges, and bed-hnen. The iochial discharge of a puerperal woman in whom childbirth has lighted up a latent gonorrhea is a fre- quent means of infecting the child, for the lochia is an extremely favorable medium for the growth of the gonococcus. Such sources of infection as these just enumerated are sufficiently obvious, but when gonorrhea makes its appear- ance and extends from child to child in carefully regulated institutions, such as hospitals and schools, the mode of infection is often puzzling and difficult to trace. In searching for the cause of such epidemics it is useful to remember that the disease can be transmitted only in the moist state. The clinical picture of a child with gonorrheal vulvovaginitis shows much swelling and redness of the external genitals, associated with pain and extreme tenderness. The parts are continually bathed with a profuse discharge of pus. The disease, like all forms of gonorrhea, is apt to last for weeks and months if not promptly treated at its onset. The disease has little tendency to ascend above the vagina into the uterus and tubes, but much damage may be done in the vagina as a result of the tendency to ulceration of the vaginal membrane with consequent plastic adhesions between opposing surfaces. This is one of the commonest causes of acquired gynatresia (see page 535). Various complica- tions may arise. In a certain percentage of cases the urethra is infected, while in a still greater number the cervix becomes involved. Other somewhat infre- quent complications are inguinal adenitis, cystitis. Bartholinitis, condylomata acuminata, arthritis, ophthalmia, and proctitis. General peritonitis is occa- sionally seen, rarely the result of upward extension through the uterus and tubes, more commonly the outcome of a gonorrheal septicemia (Norris) . Gonor- rheal peritonitis is peculiarly favorable in its prognosis, and, if a diagnosis can be made, should be treated conservatively. The treatment of gonorrheal vulvovaginitis in children is very difficult and requires great care and patience. During the acute stage there is often so much pain and tenderness that it is impossible to do more than keep the ex- ternal genitals clean. Even this treatment, if properly carried out, requires much constant attention and can best be done in a hospital, where care must be exercised that other children be not contaminated. When the more acute INFLAMMATIONS 181 process has subsided somewhat it is often possible to inject protargol, 2.5 to 5 per cent., or argyrol, 25 per cent., into the vagina and to give cleansing douches. If this can be done in conjunction with rest and strict cleanliness the disease can usually be quickly controlled, though it may be long before it is completely cured. It is needless to say that most of these cases are badly neglected if they do not receive hospital treatment. When the disease appears in young girls just past the age of puberty in whom local treatment is more feasible, it is also best when possible to put the patient to bed in a hospital under the care of a competent special nurse. From faur to six hot cleansing douches should be given daily, while every day or every other day an injection of protargol (5 to 10 per cent.) may be adminis- tered. The discharge under this treatment is quickly controlled, but the treatment should be kept up for from ten days to three weeks or more. The patient on returning home should keep up the daily douches under the super- vision of her mother or a nurse. If the disease becomes recrudescent, the patient should receive again the hospital treatment. It is impossible to tell at a given time whether or not one of these patients is completely cured, as the microscopic examination of the vaginal secretion is quite misleading if the report is negative. Excellent results have been reported from the use of gonococcal vaccines, which seem to be more efficacious in the treatment of the vulvovaginitis of children than in any other acute form of gonorrheal disease. Gonorrhea in the Adult urethritis In gonorrhea of the adult the primary infection takes place in the majority of cases in the urethra. Just how often this occurs is somewhat difficult to determine, and the estimates of primary urethritis vary from 60 to 90 per cent. This uncertainty is due to the fact that the disease in the urethra is often very slight and attracts little attention on the part of the patient. As the more serious symptoms of ascending gonorrhea often do not appear for several weeks or months after the primary urethritis, the association between the two phases of the disease may be lost. This probably occurs in the majority of cases in adults. Next to the urethra as a point for primary infection, the endocervix holds second place, while the vagina is primarily infected rarely except in the young. That the urethra should be usually first attacked is logically to be ex- pected, for the epithelium of the meatus being, in the female as in the male, an extremely favorable medium for the growth of the gonococcus, is the first of the susceptible points of the external genitals to be exposed to infection during coition. It often happens, of course, that more than one point may be infected at the same time. The urethra may also be infected secondarily from a primary focus in the cervix, and it is probable that this is often the case, for the meatus 182 GYNECOLOGY is SO situated in the vestibule that leukorrheal discharge from the vagina almost inevitably becomes lodged to some extent between the folds of tissue which envelop the urinary orifice. The disease is usually confined to the lower third of the urethra. There is no doubt that the transmission of an acute gonorrhea from the man is more apt to cause a primary infection in the urethra, or in the urethra and cervix at the same time, while a chronic gonorrhea of the man might be expected fii'st to attack the cervix. In the young, or where the external orifice is proportionately small, the urethra is primarily infected, while in those who have borne children or who have a relaxed vaginal outlet the cervix is more apt to be first affected. The picture of a well-defined gonorrheal urethritis is very characteristic and almost pathognomonic. The vestibule is reddened and tender and bathed in pus. The meatus is pouting and swollen, while from the urethra can be ex- pressed a thick creamy pus, a smear from which shows the gonorrheal diplococci in greater or less abundance. In making a diagnosis of urethritis it must be remembered that the reddening of the vestibule and the eversion of the meatus may persist after the urethritis has healed, especially if there has been an as- sociated infection of Skene's glands. Then, too, a vaginitis or endocervicitis may cause a leukorrhea which bathes the vestibule, a part of the secretion being deposited in the opening of the meatus. This leukorrheal deposit often looks like the pus from a urethritis. In testing, therefore, for a urethritis it is always best to wipe the vestibule and meatus thoroughly before attempting to express pus from the urethra. Urethritis may be caused by the colon bacillus and other organisms, but many cases of urethritis from this cause are the result of previous damage done by a gonorrheal infection. Symptoms. — As has been noted, urethritis in a woman may come and go without producing any noticeable s^^mptoms. Sometimes there may be a mild temporary discomfort in urinating which is no more severe than the irri- tation which most women occasionally experience from a concentrated urine. A typical case of urethritis in the female is quite similar in its initial sj^mptoms to that in the male. There is first a sense of discomfort and then a burning from urination, followed by a purulent discharge, which may or may not be ob- served by the patient. This pain on urination is sometimes extremely severe, and may be accompanied by ulceration and bleeding from the urethral mucous membrane. The swelling of the external genitals often gives a sense of pelvic pressure, so that the patient not infrequently consults her physician, thinking that she has a prolapse of the womb. The course of the disease, as compared with that in the male, is less severe and less definite. The duration of the aver- age case is from three to six weeks, but the acute symptoms usually last only a few days. The disease has little tendency to ascend in the urinary tract unless carried up by improper local treatment. Occasionally gonorrheal urethritis persists and becomes chronic, but when this happens there is usually an associ- ated inflammation of Skene's glands, which has an influence in maintaining the INFLAMMATIONS ' 183 persistence of the urethritis. Such a case of chronic urethritis may last indefi- nitely and be very difficult to cure. The infection in time becomes mixed, and may persist long after gonococci cease to appear in the discharge. Discomfort on urination continues to a greater or less extent. Acute gonorrheal urethritis, as we have seen, often heals spontaneously. Many cases when under observation do not require local treatment of the urethra, chief attention being directed toward preventing the disease from ascending and attacking other parts of the genital system. The local treatment of urethritis is best carried out by injecting protargol (2 to 10 per cent.) into the urethra, care being taken not to force the solution into the bladder. The solu- tion should be held in the urethra for several minutes by pressing a pledget of cotton against the meatus. The patient should urinate just before the injec- tion and should abstain from urinating for an hour afterward. The solution should be used only in such strength as the patient can tolerate without pain. If the case is taken in time, ascending infection can usually be prevented by un- remitting cleanliness, chiefly in the form of frequent vaginal douches. The treatment of chronic urethritis is, for the most part, devoted to the inflammation of Skene's glands, which usually accompanies and maintains the condition. Stricture of the urethra as a result of gonorrhea is not common in women because of the comparative mildness of the disease and the slight permanent damage usually done to the urethral mucous membrane. The symptoms of stricture are like those in man — i. e., frequent and difficult micturition and sometimes incontinence. Strictures usually yield readily to treatment, which consists either in slow dilatation without anesthesia or in forcible dilatation under an anesthetic. INFLAMMATION OF SKENE'S GLANDS Skene's glands are small secretory structures situated on each side of the meatus, their function being probably that of lubrication, though this has not been clearly established. The ducts of these glands have minute exits near the meatus which simulate the duct-openings of Bartholin's glands at the introitus of the vagina. There is also a third gland, described by Schuller, which lies anteriorly, half-way between the other two. It is probable that Skene's glands may be primarily attacked by gonorrhea, but their infection is usually second- ary to a urethritis. An inflammation of them is one of the stigmata of gonor- rhea, for they are rarely infected specifically by any other organism. Skene's glands when inflamed cause the meatus to look swollen and red. The ducts, which are normally hardly discernible, become widened and exude characteristic gonorrheal pus. The disease of the glands usually ceases with the healing of the associated urethritis, but the process may become chronic and exist as an independent disease for a long time. As in other chronic gonorrheal 184 GYNECOLOGY processes, the infection in time becomes mixed and the gonococcus crowded out by other organisms. The glands then remain as small pus-pockets which main- tain a constant irritation of the meatus and urethra. This condition is a source of worry and mental distress to patients, especialty if they are awarp of the original cause of the trouble. Sometimes the process burrows more deeply into the tissue and creates a chronic peri-urethral abscess, with an opening into the urethra through which it discharges pus either continuously or periodically. Chronic inflammation of Skene's glands may produce granulation, caruncles, or eversion of the urethral lining membrane. Sometimes the process causes permanent destruction of the meatus, so that the opening of the urethra is abnormally wide, a condition which may result in partial incontinence. Inflamed Skene's glands w^hich do not subside under treatment of the urethra may be injected with protargol or iodin by means of a blunt-pointed hypodermic needle. The long-standing cases, especially those in which permanent pus- pockets are established, require careful dissection and excision. INFLAMMATION OF BARTHOLIN'S GLANDS Bartholin's glands are two racemose glands, situated one on each side of the posterior commissure of the vaginal orifice, their physiologic function being that of lubrication. In the virgin the openings are close together, but in the relaxed vagina they are more widely separated. The minute openings of the ducts are usually discernible on inspection and can be marked by the two caruncular remains of the hymen, which lie one on each side of the vaginal opening and which persist till the membrane becomes smoothed out by the atrophy of later age. These two ducts form useful landmarks in operations for repair of the re- laxed vaginal outlet. Bartholin's glands may be infected primarily, but the infection is usually secondary to an infection elsewhere, especially in the urethra. They are rarely infected by any other organism than the gonococcus, so that an inflammation of them constitutes an almost unmistakable stigma of gonorrhea. The initial infection takes place in the short duct of the gland. Other pyogenic organisms in time take part in the inflammatory process and crowd out the gonococcus. The infection may then extend to the main part of the gland, and an abscess be estabhshed which may become acute at once or lie dormant to light up at some later period. The initial infection may pass unnoticed and no evidence of disease in the gland appear till long after other manifestations of gonorrhea have disappeared. As a rule only one gland is affected, but both glands may become inflamed, either simultaneously or at different periods. Inflammation of Bartholin's glands is almost sure to recur if the gland is not entirely excised. This recurrence may take place at any time after the first infection, often appearing years later. The nature of the recurring inflammation may vary from a slight thickening and tenderness of the gland up to an enor- INFLAMIVIATIONS 185 mous abscess. The clinical picture of an abscess of Bartholin's gland is very characteristic. The swelling of the gland causes a deviation to one side of the usually straight line of the introitus, and, on inspection, can readily be recog- nized at a glance. There is exquisite pain and tenderness in the acute stages. On separating the labia the parts appear red and inflamed and bathed in pus if the abscess occurs during the primary gonorrheal attack. The recurrent ab- scesses are often milder in their course. Fig. 26. — Bartholin's Gland. Low power. General ^-iew of the structure consisting of glands of the racemose type cut across, lying close together, and in some places dilated. At the top is seen a duct. The treatment of Bartholinitis is complete excision of the gland whenever it is possible. In the very acute cases it is necessary first to incise the abscess and evacuate the pus, and then dissect out the gland as soon as the wound becomes clean and granulating.. In the recurrent tj-pe, where the inflammatory process is milder, the gland can be excised entire without spilling the pus until the last cut is made across the duct. This is preferable to evacuating the abscess first, because the gland after being emptied collapses and the dissection of the sac is rendered more difficult. A description of the operation for Bartholinitis is given on page 588. 186 GYNECOLOGY Between the recurrences of inflammation the gland usually regresses in size to such an extent that it can hardly be felt on palpation. It is better not to operate during this stage, as it is difficult to find the gland during dissection and differentiate it from surrounding tissues. An operation at this time is apt to result in considerable mutilation, with the possibility of leaving some of the gland structure behind. It sometimes happens that the inflammatory process in the gland entirely subsides, leaving the duct occluded. Secretions of the glandular cells may Fig. 27. — Bartholin's Gland. High power. From top of same section as previoiis drawing, showing the duct which is Uned by low cuboidal epithehum and the glands which are Hned by a single layer of high cells which secrete mucus. then cause a retention cyst. This is a late phase of Bartholinitis and does not appear until long after the active process has ceased, sometimes many years after. These cysts may regress and then recur after considerable lapse of time, or they may become permanent and slowly grow into quite large tumors. They do not give much pain, but they often interfere with coitus and sometimes cause urinary symptoms. Cysts of Bartholin's glands are nearly always consequent upon an old gonorrheal infection and, therefore, are to be regarded as fairly reliable stigmata of the disease. INFLAMMATIONS 187 The treatment of Bartholin's cysts is always total extirpation on account of their tendency to recurrence. In operating, the incision should be made through the skin and not through the soft modified membrane of the introitus near the r^ Fig. 28. — Cyst of Bartholin's Gland. It shows the characteristic swelling on one side of the introitus. Abscess of Bartholin's gland gives the same outward appearance. duct. By careful dissection the cyst may be removed entire. If it is punc- tured, the cyst collapses and the dissection then becomes ragged and mutilating. It is to be remembered that the clean removal of a Bartholin's gland or cyst is not ^ .particularly easy operation. The dissection must be carried deeply into the 188 GYNECOLOGY paravaginal tissues, and there is often troublesome bleeding. The operation should, therefore, not be attempted under local anesthesia. (See page 589.) Another phase of recurrent Bartholinitis is an inflammatory thickening of the gland, which gives considerable discomfort or pain. The gland may not be Fig. 29. — Large Cyst of Babtholin's Gland. Drawn from an elderly woman who had carried the tumor for many years. The vulva was distorted and the cyst pressed on the urethra so as to interfere with urination. The cyst was dissected out entire without rupturing it. There was no connection with the inguinal canal. large enough to be discernible on inspection, but can be felt between the thumb and forefinger placed just inside the introitus. No matter how small the gland may feel, if it is giving symptoms it should be excised, for nagging discomfort INFLAMMATIONS 189 of the perineal region, from whatever cause, is hable to be a source of nervous irritation, which may develop serious consequences out of all proportion to the gravity of the original lesion, ENDOCERVICITIS Before taking up the gonorrheal infections of the endocervix and endometrium it is advis- able to review briefly several important facts about the structure of the cervix and body of the uterus which are not always sufficiently emphasized. It is a good plan to regard the fundus and Fig. 30. — Glands of the Cervix. Low power. The glands are shown in cross-section. They are lined by cylindric cells, the nuclei of which lie at the base, leaving a large amount of clear protoplasm. These glands lie in the connective and muscular tissue of the cervix, not having a cytogenous connective tissue around them as do the glands of the endometrium. cervLx of the uterus as two very distinct organs, which difTer from each other more or less essentially in their histologic structure, physiologic functions, and in the pathologic processes that affect them. We shall have occasion often to refer to this fact as we proceed m the study of uterine conditions. The mucous membrane of the cervix is very different from that of the fundus. In the endocervix the membrane is composed of compUcated racemose glands, with small ducts empty- ing into the cervical canal. The epithelium hning the cervical glands is of the high cyUndric 190 GYNECOLOGY . goblet-cell type. These glands secrete a true mucus, which, as we shall see later, is of great importance in many ways. The endocervical mucosa is thrown into definite rugae, radiating from a central line, an arrangement commonly called the arbor vitae. These folds are of clinical significance in inflammatory processes of the endocervix. Toward the internal os the mucous membrane becomes modified, the glands become less arborescent, and the high cylindric epithelium becomes lower in type. At the internal os the mucous membrane of the cervix merges into the mucosa of the body or the endometriimi. The endometrial mucous membrane consists of simple tubular glands lined with a low cu- boidal epithelium. The surface epithelium of the canal is of the same type, but cihated. The endometrium produces a thin secretion which is not true mucus. We thus see that the endo- cervix and endometrium are tmhke both histologically and in their physiologic functions. They also differ in the manner in which the same infection may affect them. Normally the internal os acts as an efficient barrier to all organisms excepting the gonococ- cus, the tubercle bacillus, and the spermatozoon. If, however, the os be artificially dilated, or if it become patent as a result of parturition, infection is possible from any pathogenic germ. Thus it is that in the non-impregnated uterus ascending infection in the endometrium and tubes rarely occurs excepting from gonorrhea. The endocervix, however, is more suscep- tible to infection, as the external os affords less protection and the mucous folds of the cervical mucosa constitute a favorable soil for various organisms. Especially is this true of the gono- coccus. Gonorrheal infection of the endocervix may be primary or secondary. How frequently it is primary is a matter of conjecture, and opinions vary consid- erably, some placing the figure as low as 10 per cent, and others as high as 40 per cent. It is possible that many of those cases whose first noticeable symp- toms are from a salpingitis have been primarily infected in the cervix. This is a reasonable conclusion, because the cervix is one of the most insensitive parts of the body, and diseases of the organ, inflammatory or otherwise, give little or no pain. The discharge resulting from the first infection may readily be over- looked by the patient. It is likely that the endocervix is involved primarily or secondarily in most cases of gonorrhea. Acute gonorrheal endocervicitis in its primary stage is not often a matter of special treatment, excepting as it occurs as a part of a general complex infection. When seen the cervix is red and angry looking, with ever- sion and prominence of the mucous membrane. It causes some pain to the touch, and is said in some cases to be associated with tenderness of the in- guinal lymph-glands. There is always present a profuse gonorrheal discharge mixed with mucous secretions from the cervical glands. Menstrual disturb- ances, usually in the form of menorrhagia, are common. Chronic gonorrheal endocervicitis, on the*i6ther hand, is a special disease which is of great clinical importance and one that is very difficult to treat. The process of gonorrheal infection of the endocervical mucous membrane simulates that of Skene's and Bartholin's glands in that the infection occurs in the ducts of the glands. Later, a mixed infection of other organisms takes place gradually to the exclusion of the gonococcus, and the infection is then carried into the complicated lumina of the racemose glands. The irritation of the infection stimulates the mucous cells to a hypersecretion, so that a stream of mucopurulent material is continually poured out into the cervical canal. INFLAMMATIONS 191 thus producing the constant leukorrhea which is so characteristic of the disease. In some glands the inflammatory process may cause a closure of the duct. The gland continuing to secrete without an outlet becomes a retention cyst. This process also takes place in all chronic inflammations of the cervix, wdth formation of retention cysts. They are commonly designated as Nabothian cysts from the name of Naboth, who first described the cervical glands. Na- bothian cysts are filled either with clear mucus or with a cloudy mucopus, if the gland is infected. Endocervicitis, unHke BarthoHnitis, is not a stigma of gonorrhea, for it may occur as a result of the lacerations of childbirth or it may even appear in virgins. The endocervix is a favorite and treacherous place for the latent gonococcus to lurk, either in the folds of the lining membrane or in the ducts of the glands, ready to fight up into later infectious activity under the hyperemic influence of coitus, menstruation, or childbirth. When a chronic gonorrheal endocervicitis has been established the condition resembles somewhat that of gleet in the male. There is a persistent irritating leukorrheal discharge which the patient has difficulty in controlling, even with numerous douches. Douches have no curative effect on the disease, as they do not reach the seat of infection. They merely cleanse the vagina of the accumu- lated secretions and prevent to some extent the irritation which results from the contact of the discharge with the external genitals. The influence of this con- stant leukorrheal discharge often has a disastrous effect on the nervous system of the patient, especially if she is aware of the original cause of her trouble. She feels herself degraded by her condition and, as her efforts for controlling the disease are usually unavailing, her health becomes impaired far out of propor- tion to the seriousness of the local infection. Endocervicitis must be regarded as one of the most important factors in the genital neuroses which play such a prominent part in gynecologic disease. The treatment of endocervicitis should be applied directly to the endocer\'ix itself. AppHcations of tampons and painting the vagina and vaginal portion of the cervix, like douches, do not reach the seat of the disease, but serve only to keep the vagina clean. It is sometimes possible to cure the infection by repeated local applications to the cervical canal. A quicker but not infallible method is to curet and cauterize the endocervix. If all other methods fail, the rather diffi- cult Schroder's operation of removing the entire endocervix may be performed. (See page 604.) It is necessary to emphasize at this point the fact that most leukorrheal dis- charges from the uterus are not from the endometrium, but from the endocervix. This is of great practical importance in the use of the curet, which is so often improperly applied to the endometrium instead of to the endocervix, wiiere the real trouble lies. In this way very frequently serious infection is carried to the endometrium, and thence spread to the tubes and pelvic peritoneum. 192 GYNECOLOGY ENDOMETRITIS The endometrium seems to be peculiarly immune to what may be called a permanent infection of gonorrhea. It must be that during the process of ascend- ing from the endocervix to the tubes the gonococcus resides in activity on the mucous membrane of the endometrium for a time, but a true acute gonorrheal endometritis is rarely seen. The conclusion is that the endometrium serves as an efficient bridge for the passage of the gonococcus to the tubes, but that it is not a congenial soil for the organism to make a permanent abiding place. This fact is shown in the microscopic examination of uteri removed for acute adnexal disease, in which usually the endometrium presents no sign of active inflamma- tion. Gonorrheal endometritis is not, therefore, often a disease for direct local treatment. If it does occur, and can be demonstrated, it should either be let alone or treated with great care. The curet is a dangerous instrument to use in such a case on account of its ability to extend the infection to the pelvic cavity or of lighting up pre-existing adnexal disease. Moreover, intra-uterine applica- tions and douches are also fraught with danger. In cases of long-standing pelvic inflammatory disease the endometrium is sometimes found by microscopic examination to be in a condition of so-called chronic endometritis. (See page 247.) This is probably more often the end- result of puerperal sepsis than it is of acute gonorrheal endometritis. It may cause abnormal uterine bleeding during the recrudescence of pelvic inflammation. This makes the conduct of the case somewhat confusing, for it often leads to an ill-advised cureting, which may awaken the pelvic process into dangerous activ- ity. Persistent leukorrhea is a constant symptom of chronic endometritis. Dysmenorrhea, sterility, and abortion are probably sometimes caused by it. The treatment of chronic endometritis is rarely directed to the endometrium alone, as a diagnosis is made with such difficulty. The disease is, for the most part, treated in connection with chronic adnexal disease, with which it is usually associated. GONORRHEA OF THE TUBES It is seldom that an infection of the tubes follows immediately a primary gonorrheal urethritis or endocervicitis. The internal os, an obstructive barrier to most microorganisms, is less effective against the gonococcus, and, though delaying its invasion for a time, may eventually allow it to pass through and attack the tubes. This may not occur for months or even years after the initial infection, and represents the awakening of a chronic latent endocervicitis. The gonococcus, on passing the barrier of the internal os, proceeds to the tubes, doing very little damage to the intervening endometrium, which it uses more as a bridge than as a soil for permanent propagation. The tubal isthmus, though small in caliber, is an open portal for all fluids and organisms that pass the internal os, so that the gonococcus finds ready access to the tubal mucosa, INFL^^JVIMATIONS 193 the delicate folds of which are especially well adapted for its implantation and growth. Psithology. ^Endosalpingitis. — In the earliest stages of the disease the folds of the mucosa become swollen and reddened, while the lumen is bathed with an exudate which is more or less purulent, according to the severity or the duration of the infection. The tube itself becomes elongated and thickened; the fimbri- '-••-/ ~-'^'''<'' ', V, >■-'• :.vv ';:/-■,, ••..»''■, T-*,,- -"V'.; -,"-•■, jv. \,'. 'o^"* ; ' /f' n ^■>- !*'■';•; jr :■ ■ 1^^ 0(1. <>f .. ', . I Fig. 31. — Normal Tube. Middle Portion. Low power showing lumen. The lumen of the tube is very nearly filled by folds of mucous membrane called villi. These lie free in the lumen and consist of a connective-tissue stroma carrying blood-vessels. They are covered with ciliated, cylindric epithelium. ated extremities are thickened, red, and angry looking. Up to this point the disease is a simple endosalpingitis (also called catarrhal salpingitis) , and may rep- resent the preliminary stage of a later and more severe inflammation, or it may be the limit of the disease. Both tubes may heal completely, or one tube may proceed no further in the process, while the other may go on to destructive changes. There is no doubt that both tubes are always originally infected. In some cases the endosalpingitis stage of the disease seems hardly to be noticed 13 194 GYNECOLOGY by the patient, while in others the pain and tenderness and constitutional reac- tion appear out of proportion to the amount of anatomic changes in the tube. Pyosalpinx. — As the disease progresses it becomes more purulent in type. The epithelium of the mucosa, shorn of its cilia and rugse or folds, becomes ulcerated and glued together. The wall of the tube becomes thicker as the inflammatory process extends into the muscularis and subserosa. The tubal ostium becomes closed, due probably to retraction and agglutination of the Fig. 32. — Chronic Salpingitis. Low power. To illustrate the fusing together of the villi of the tube during an acute endosal- pingitis. As can be seen by their fusion, they form spaces lined by tubal epithelium, which are crlled follicles. The process is now quiescent, the villi are not much swollen, though thickened in places due to the formation of connective tissue, and the wall of the tube is apparently normal. fimbrise, while a closure also takes place at the tubal isthmus. In this way a pus-sac is formed which may grow to very considerable proportions. The pus- tube is usually bent upon itself and becomes adherent to the posterior surface of the broad ligaments, though it may adhere higher up in the pelvis to portions of the large intestine and to the abdominal wall, or to the bladder. With the formation of a pyosalpinx there is always present an associated inflammation of the pelvic peritoneum, of the germinal epithelium of the ovaries, and of the INFLAMMATIONS 195 subperitoneal cellular tissue,' especially that between the leaves of the broad Hgament. Pyosalpinx occasionally becomes healed spontaneously, but, as a rule, it results in permanent damage to the pelvic organs and peritoneum. Tuho-ovaritis. — The tubal extremity may become closed in another way than that described above. The exudate from the tube naturally flows over the surface of the ovary and the fimbrige readily become attached to the ovary, thus closing the tubal exit. This is a common way for the tube to become occluded, ■'.^: -""^i^iSv^^ii-^ Fig. 33. — Chronic Follicular Salpingitis. Low power. This shows well the end-result following acute inflammation of the tubal mucous membrane. The villi become adherent to each other, fuse, and form the gland-like spaces, called follicles, which are seen. They are lined by the epithelium of the tube and do not extend into the wall. The process at this stage is quiescent, so that no infiltration with round cells is seen. and the result is especially disastrous because the inflammatory process may include the entire ovary. In the first method the ovary usually escapes with, at most, only a superficial infection, but when the end of the tube is intimately attached to the ovary the purulent process may enter the substance of the ovary itself and destroy a considerable part of its tissue. Ordinarily, the albuginea layer of the ovary, which has rather a dense structure, is resistant to infectious organisms, but when a corpus luteum forms and bursts, the ovarian tissue over the area is temporarily a thin, non-resistant, practically necrotic structure, con- 196 GYNECOLOGY taining a rent through which the ovum has been expelled. Moreover, the cavity of the corpus luteum, with its rich lining of luteal cells and its blood con- tents, forms an excellent bed for the implantation of the invading gonococci. If now the tube becomes engrafted on the surface of a regressive corpus luteum, the cavity of the corpus nisiy easily become involved with the tubal abscess. As the abscess grows the containing sac is composed of the tubal wall and stretched- out ovarian tissue. This is called a tuho-ovarian abscess. The ovarian tissue by this process is never completely destroyed, for even if both ovaries are im- FiG. 34. — Chroxic Salpingitis. Low power of a part of the villi. The follicles, gland-like spaces formed by fusion of the villi, are well shown. There is edema of the stroma and a marked infiltration with round cells. plicated in an inflammation of this kind, no matter how extensive, ovulation and menstruation do not cease. The ovary, however, is permanently^ damaged and cannot be restored to its former condition. The progress of a tubo-ovarian abscess is the same as that of a sactosalpinx, excepting that its course is apt to be 'more severe. Hydrosalpinx. — One of the manifestations of gonorrheal salpingitis is a cystic condition of the tube due to closure of the ostium, the wall being thinned out into a translucent membrane, and the contents consisting of a clear serous fluid. This is termed "hydrosalpinx" or "sactosalpinx serosa." It was formerly believed INFLAMMATIONS ^ 197 that the condition is an end-result of a tubal abscess in which the activity of the pyogenic organisms has ceased, and the pus elements contained in the sac have been gradually converted into a clear fluid. This theory is no longer held, and it is now thought that the process is serous from the start. Norris states that "most gonorrheal hydrosalpinges result from an inflammation which seals both ends of the tube and allows fluid to collect within the lumen. The mechanism, under these circumstances, is very similar to that which produces a pyosalpinx, V- -''-iff. ^il'>.@f ? bZ4\,v- jis-lt^vi. #/<-:.? i/.sv Fig. 35 — Chronic Salpingitis. High power. This section is stained to show the plasma ceUs. These are derived from lympho- cytes (Mallory) by a large increase in the amount of cytoplasm which has basophilic properties. They are also characterized by the excentric position of the nucleus, and may contain several nuclei. Their importance is that they are present in chronic inflammation. differing only in the fact that the inflammation does not progress to the stage of pus formation." In other words, it represents a mild and quickly aborted gonorrheal infection. It is also supposed that a hydrosalpinx may be formed after the active pus-forming stage of the disease as a result of a late sealing of the tube when the secretion has become serous. The change from the old belief that hydrosalpinx is a converted pyosalpinx is due to the investigations of Menge, who was unable ever to demonstrate bacteria in the fluid, and in the great majority of specimens examined could find no evidences of inflammation 198 GYNECOLOGY in the tissue of the wall. This he found always greatly thinned, with a lining mucous membrane which, though atrophied by pressure, was nearly always intact. Hydrosalpinx may also be caused bj^ a pelvic inflammatorj- process whose origin is outside of the tube, the closure of the ostium being the result of a peri- salpingitis. In this way tuberculosis, puerperal infection, and appendicitis are, doubtless, accountable for a certain number of cases. Pelvic tumors which cause pressure adhesions, especially uterine myomata, are also included among the causes of hydrosalpinx. Tvho-ovarian cysts may, theoretically, be converted tubo-ovarian abscesses. It is probable, however, that most of them indicate the adhesion of a tube to an Fig. 36. — Acute Purulent Salpingitis. The tubes are greatly swollen and pus is seen exuding from one of the tubal ends. The fimbrlEe are swollen and have not reached the stage of adhesion and closure. ovarian cyst, with the later estabhshment of a communication between the lumen of the cyst and that of the tube. Hematosalpinx, denoting a confined hemorrhage into the tubal lumen, is, in the great majority of cases, the result of an extra-uterine pregnancy or gynatresia. There is, however, no doubt that in both pyosalpinx and hydrosalpinx blood- vessels in the wall may be ruptured either by pressure or torsion, with consequent hemorrhage into the lumen. Gonorrhcea Isthmica Nodosa. — The isthmus of the tube may be the seat of gonorrheal infection, which may be localized at this point or be part of a general tubal infection. The disease when seen is usually chronic, but may be acute, INFLAMMATIONS 199 luxneu YxxribnoAc^ Enb'- Ju\i\cum Fig. 37. — Tubo-ovaritis. Diagram showing how an inflamed tube may become attached to the ovary and communicate its infection to the ovary through the opening of a corpus luteum. "i-eft TviV)0-o\)(xravxv MbSiWUS f'- L "^ Y'G^^Cs.vKiJS Fig. 38.- — Right Tubal Abscess, Left Tubo-ovarian Abscess. On the right is a tubal abscess distinct from the ovary which is seen buried in adhesions. On the left the tube and ovary are involved in a common abscess, the ovarian portion of the sac being represented with a slightly scarred surface. and is characterized by a hard nodule in one or both horns of the uterus, with occlusion of the tubal canal. This form of tubal infection is termed chronic interstitial salpingitis. A more scientific and descriptive name is salpingitis 200 GYNECOLOGY Fig. 39. — Chronic Tubo-ovaeitis. In this case the tubo-ovarian masses became adherent to the fundus of the uterus. The mass on the left has been unfolded in the manner that should be employed during an operation for pelvic inflammation. INFLAMMATIONS 201 isthmica nodosa. The importance of this form of salpingitis is often overlooked by surgeons in performing a salpingectomy for gonorrheal disease when they simply amputate the tube at or near the uterine cornu. The isthmus of a tube removed in this way may later give trouble as a chronic interstitial salpingitis, or it may even light up into an active abscess of considerable size. When a salpingectomy is to be performed for gonorrhea the tube should, therefore, be removed, isthmus and all, by a wedge-shaped incision into the cornu of the uterus. Fig. 40. — Hydrosalpinx. Low power. The lumen of the tube is seen to be dilated. The villi have been inflamed, have formed follicles by fusion, and are seen as a gland-like layer around the inside of the tube. The wall of the tube is thickened, as is the mesosalpinx, which extends down toward the left lower corner. This is an early stage, so that the mucous membrane of the tube is not compressed and the wall of the tube is not thinned out. Pelvic Peritonitis. — All cases of gonorrheal salpingitis are accompanied by a greater or less degree of pelvic peritonitis. This is necessarily so because the serous or purulent exudate from the tube inevitably flows from the fimbriated extremity and infects the peritoneal surface with which it comes in contact. The inflammation of the peritoneum produces a destruction of the epithehum of the peritoneum, with consequent gluing together of contiguous surfaces by ad- hesions. These adhesions are at first light and filmy and are easily broken up, but in the course of weeks, months, or years they gradually become more and more firm, until at last they are exceedingly tough and unyielding. They 202 GYNECOLOGY also contract and produce serious dislocations of the pelvic organs. Pelvic adhesions resulting from gonorrheal salpingitis are of immense clinical impor- tance, and patients suffering from this complication constitute a very large per- centage of the cases met with in a gynecologic clinic. The condition of adhesions following salpingitis is commonty termed chronic pelvic inflammation, or chronic pelvic inflammatory disease. In order to under- stand fully the clinical and surgical aspects of chronic pelvic inflammatory dis- ease it is necessary at this point to consider the antomic changes which adhesions usually make in the pelvis. When one first operates on a severe case the pelvic organs seem to be in a hopelessly confused tangle, and an in- experienced operator is apt to get into serious trouble in trying to extricate them. As a matter of fact, the adhesions form in rather a definite manner, and if this is kept clearly in mind, cases which on first appearance seem utterly discouraging, may be disentangled with ease without injury to the patient. The key- note to the situation is that the posterior culde- sac, or pouch of Douglas, is the lowest point of the abdominal cavity, whether the subject be standing, sitting, or lying, and as a consequence the fluid exudates of a pelvic peritonitis tend to gravitate to this point. The anterior pouch of the pelvis (utero vesical space), being at a higher level than the posterior, and out of range of the discharging ends of the tubes, remains com- paratively free from infection except in very extensive cases. It is to be remembered, then, that the infective process is chiefly in the pos- terior half of the pelvis. When the adhesions form and become organized, the tubes and ovaries are folded backward and become ad- herent to the posterior leaves of the broad liga- ments and the posterior wall of the uterus and vagina. They are also drawn downward deep in the pelvis. The intestines adhere to the surfaces of the organs, and the whole pelvis may thus become filled with a conglomerate mass, consisting of uterus, adnexa, and bowels, which it sometimes at first seems hopeless to extricate. These cases are, however, almost never inoperable if the dissection of the adhesions is carried out systematically. • A practical point to consider in the pathology of pelvic inflammatory dis- ease is its relation to retroversion and retroflexion of the uterus. Inasmuch as Fig. 41. — An Unusual Form of Hydrosalpinx. As a rule, hydrosalpinx has more the form of a retort. INFLAMMATIONS 203 the disease is usually confined to the posterior half of the pelvis, it is natural that the contraction of the adhesions should exert a backward pull on the uterus. In this way the uterus becomes firmly adherent to the bowel and adnexa in the position of retroversion. This consitutes the second most common cause for backward displacement of the uterus. The uterus may be folded back on itself into various degrees of retroflexion. It is possible that the center of the uterus may be drawn backward by adhesions without retroverting or retroflexing the uterine body, thus producing the position of anteflexion. Adhesions of the adnexa, acting unequally on the sides of the uterus, may produce a lateral version. Symptomatology of Acute Salpingitis. — The symptomatology of acute sal- pingitis is very varied. We see many cases with severe symptoms, but with very little anatomic change in the tubes, while, on the other hand, we frequently en- counter extensively destructive changes in the adnexa in patients who have only mild symptoms. In many cases of salpingitis, especially in mature women, symptoms of the initial infection of the external genitals may be entirely lacking, so that it is often impossible to tell the duration of the disease. In young women gonorrhea pursues a more typical course than it does in mature women on account of the greater dehcacy and susceptibility of the tissues. Such a course would be some- what as follows : Two or three days after exposure by coitus the patient notices a burning on micturition. This burning usually lasts only a few days, but may last much longer. A purulent discharge is soon noticed, and the patient passes through an attack of urethritis of greater or less severity. If the attack of urethritis is a mild one, as is more often the case, the patient will remember only that she had a period of smarting urination associated with a leukorrheal dis- charge. If Skene's glands are involved, the urethritis symptoms will be more marked. After the subsidence of the urethral symptoms the patient is troubled with a leukorrheal discharge the severity of which depends on the care which she receives. In the course of two or three weeks or more (sometimes less) one of the vulvovaginal glands may become involved and an abscess develop which is very painful and brings the patient under a doctor's care. The doctor treats the abscess by poultices or incision and the abscess subsides for the time being, only to appear again at some indefinite period in the future. The leukor- rheal discharge continues, but changes somewhat in character. It loses its creamy purulent appearance and becomes more stringy and mucous, represent- ing now the discharge from an infected endocervix. The change in character is due to the mixture of mucus which pours forth from the overstimulated endo- cervical glands. Gonococci become more difficult to find in the discharge, and many successive examinations, even when taken from the endocervix, may be negative, a point to be remembered when one is trying to determine whether or not a patient is still capable of transmitting the disease. In the course of an indefinite period of time (days, weeks, months, or years) the patient' is seized with an attack of acute abdominal pain, with great tenderness across the lower 204 GYNECOLOGY part of the abdomen. There is moderate fever, usually vomiting and constipa- tion. The pain is usually general across the lower abdomen, but it may be localized on one side. The patient is compelled to go to bed and summon medical help. At the present day the general practitioner recognizes and prop- erly diagnoses these cases better than was done a comparatively few years ago. If the pain was localized chiefly on the right the patient was frequently hurried to a hospital, where her appendix was removed through a McBurney incision, the true cause of the disease not being even then discovered. These attacks are commonly called by the laity "inflammation of the bowels." The duration of an attack of acute salpingitis is usually from one to six weeks, and is longer than the average attack of appendicitis. This fact is valu- able as a guide in interpreting the history of a patient who describes a past abdominal attack. If she had a right-sided attack, from which she was confined to her bed less than a week, she may have had either appendicitis or salpingitis, the evidence being rather in favor of the former. If, however, she was confined to her bed for several weeks the preponderant evidence is very much in favor of a salpingitis. Acute salpingitis is not often fatal, especially if it is the first attack and tends gradually to subside. It may even heal spontaneously and completely, but this does not happen often. The usual course is that after the cessation of the acute symptoms the disease becomes chronic, lighting up at occasional intervals into an acute activity of greater or less severity. Rupture of a pyosalpinx is a rare accident. LamoureiLx, in 1912, was able to collect only 27 authentic cases in the hterature. The onset of symptoms is sudden. It is said that some- times the patient is conscious of the rupture of the sac. Pain ensues, at first locahzed to the pelvis and then spreading to the entire abdomen. AH the symptoms and signs of general peritonitis follow. Diagnosis is difficult, the condition usually being regarded as a peritonitis from an appendicitis, unless the attending physician has been famiUar with the case preceding the rupture. Prognosis in these cases is fairly good as compared with general peritonitis from other causes, the mortality being about 50 per cent, in cases that receive early operative treatment. Probably the most common form of acute gonorrheal salpingitis is that which represents an acute exacerbation of a chronic process. It does not neces- sarily mean that there has been a previous acute attack, because, as we shall see later, salpingitis may start and continue for some time without acute symp- toms. Acute secondary salpingitis is apt to be more severe and more destructive than a primary attack. This is due to the fact that the preceding chronic proc- ess has been causing slow damage to the pelvic organs, which have become permanently dislocated and distorted by adhesions. Thus, a tube which has become adherent to an ovary is more likely to impart a destroying inflammation to the ovary than in a fresh case where the organs are normally separated. Or, again, if the bowel be attached to the tube an acute salpingitis is liable to cause such damage to the wall of the gut as to allow organisms to pass through from INFLAMMATIONS 205 the intestinal canal and take part as a mixed infection in the pelvic inflammatory- process. This mixed infection increases very much the danger of a fatal peri- tonitis. On account of the confining adhesions in secondary salpingitis it may readily be seen that there is a greater tendency to the formation of large abscess than in the first type. In the latter case the active period of the disease is apt to subside before the tubal ends become sealed. In the secondary type the pus becomes confined at once by unyielding adhesions already formed, and thus is produced more commonly the large tubal or tubo-ovarian abscesses. The symptoms and course of a secondarj^ acute salpingitis are very similar to those in a fresh case. There is usually to be had in the secondary form a history of previous similar attacks or of a chronic pelvic inflammation. In this type of salpingitis, as in the first, the tendency of the disease is to subside under proper treatment, but the abscesses often become so threatening that operative measures have to be taken early. Diagnosis of Acute Salpingitis. — There are two distinguishing features which characterize all cases of acute salpingitis, and if these be borne in mind the diagnosis is comparatively simple. One is the condition of the abdomen, as shown by palpation, and one is the condition of the sides of the pelvis, revealed by bimanual examination. The abdomen is very characteristic. The area just above the pubes, such as can be covered by the whole hand laid transversely, is uniformly tender and rigid, while the abdomen above the umbilicus, except in extreme cases, is markedly less tender and less rigid. The area of tenderness and rigidity in the lower abdomen of course corresponds to the well-defined limits of local peritonitis which characterizes the disease. Vaginal examination usu- ally reveals tender masses in the sides and back of the pelvis, in which case the diagnosis is practically obvious. Sometimes, however, definite masses cannot be felt, and then one makes a diagnosis from a. well-defined tenderness of the adnexa which is almost pathognomonic. Real tenderness must be carefully differentiated from that caused by inexpert or ungentle vaginal touch. In making a diagnosis the patient's history, general appearance, and social condition are of importance, but often misleading. Careful inspection of the external genitals is of great value. The presence of an intact hymen in a doubt- ful case makes salpingitis improbable, but does not entirely rule it out, in young women. Gonorrheal stigmata, such as a urethritis, inflammation of Skene's and Bartholin's glands, throw the weight of evidence in favor of salpingitis, as does also the presence of gonococci in a vaginal discharge. If evidence of exter- nal gonorrhea is absent, it must be remembered that in a first salpingitis attack the external infection may have been very mild or quite temporary, or the pri- mary seat of infection may have been in the endocervix. In secondary salpin- gitis the external signs of gonorrhea have usualty disappeared long before. In making a diagnosis of salpingitis the complement fixation test is sometimes useful. It is very similar in principle to the Wassermann reaction for syphilis. By those thoroughly familiar with the test it is regarded as a valuable adjunct in 206 GYNECOLOGY the diagnosis of gonorrhea. The test cannot be used in early acute cases, for it is negative until the third or fourth week after the disease is contracted. Ac- cording to Norris, in subacute or chronic gonorrheas the percentage of positive results is about as high as those afforded by the Wassermann test for syphilis. Differential Diagnosis of Acute Salpingitis. — The conditions most hkely to be confused with acute salpingitis are appendicitis, extra-uterine pregnancy, twisted pedicle cyst, infected or twisted fibroids, and diverticulitis of the sig- moid. Appendicitis can usually be readily distinguished from salpingitis by the location of the pain and the area of abdominal tenderness, which in the adult is approximately 3 inches higher than the site in which tubal symptoms usually appear. The pain of appendicitis is apt to start in the epigastrium before be- coming localized in the right side, while that of salpingitis usually begins in the pelvic region. This difference is, however, not entirely reliable, for the pain of salpingitis is frequently felt first in the midabdominal region. If the inflamma- tion of the appendix extends to and includes the tube, as it often does in young girls, the location of the initial pain causes confusion. In salpingitis the local symptoms are usually on both sides of the abdomen, though they raay be more intense on either side. If they are confined to the left side, appendicitis is un- likely, but is not necessarily ruled out. Palpation of the abdomen in most cases gives definite information. In localized appendicitis the right rectus muscle shows involuntary rigidity, which is either absent or less marked in the left muscle, and the rigidity is most evident at McBurney's point, especially if there is present also an inflammatory exudate. On the other hand, localized sal- pingitis causes an even symmetric rigidity of the lower portions of both muscles below the umbilicus, though one side may be more tender than the other. Bimanual examination gives by far the most important information in the differential diagnosis, and should never be omitted as a routine, even if the case seems to be unquestionably one of appendicitis. In uncomplicated appendi- citis the vaginal finger elicits no pelvic tenderness, while in acute salpingitis pelvic tenderness is always present and is very characteristic. In the majority of cases distinctive masses may be felt in the adnexa. If the hymen is un- ruptured the evidence is against salpingitis, but does not exclude it, for the gonococcus can gain access to the tubes from the vulva. Gonorrheal stigmata, such as pus from the urethra, inflammation of Skene's and Bartholin's glands, favor the diagnosis of salpingitis. An intact hymen often necessitates a biman- ual examination per rectum. In making a rectal examination it must always be borne in mind that the uterus and cervix feel much larger than when examined through the vagina. If appendicitis has implicated the right tube, the diagnosis is more difficult, but even in this case the pelvic tenderness is much higher up than in a typical case of uncomplicated salpingitis. The onset of the attack and its course for the first few days is quite similar INFLAMMATIONS 207 in the two diseases, but appendicitis tends either to become rapidly worse, with symptoms of peritoneal extension, or it subsides in a few days. Salpingitis, on the other hand, has little tendency to general peritonitis, but local symptoms of an acute attack extend over a considerably longer period. If general peritonitis is present the diagnosis is very much in favor of ap- pendicitis. A salpingitis severe enough to cause general peritonitis would almost invariably show unmistakable evidence of adnexal enlargement. Between acute salpingitis and extra-uterine pregnancy there should, as a rule, be no great difficulty in diagnosis. The pain of extra-uterine is sharper and more lancinating than that of salpingitis and is less constant. Abdominal rigidity and tenderness is less marked than in salpingitis and may be absent al- together. By vaginal examination the pelvis may feel the same in the two conditions as regards adnexal enlargement, but in salpingitis there is much greater tenderness as a rule. A purulent vaginal discharge or the stigmata of gonorrhea favor salpingitis. In salpingitis the constitutional symptoms are more severe and the leukocy- tosis is. much more significant. In ectopic the usual history of a delayed period is a very important, though not absolutely reliable, sign. Between chronic salpingitis and a pelvic hematocele from ectopic the diag- nosis is very difficult, as is pointed out in the chapter on Extra-uterine Preg- nancy. The symptoms of a twisted pedicle cyst may be very like those of a sal- pingitis, and, as there is often an acute inflammatory process added to the con- dition of torsion, the differential diagnosis may be very baffling. The diagnosis is of vital importance because torsion of a cyst demands immediate operation, while in acute salpingitis operation is usually to be deferred. The history of the case is very valuable, though in both diseases there may be an account of recurring attacks. Bimanual examination in the early stages of torsion shows tenderness and a mass only on one side unless there happen to be bilateral cysts. At this stage, too, the cyst is movable and distinguishable from the immobile mass of a salpingitis. If torsion has I'esulted in infection and . peritonitis, a differential diagnosis may be impossible, but patients who have reached this stage are very sick and operative interference is palpably urgent. In case of doubt it is always best to operate, for, if torsion is present, the life of the patient may be saved, while, if the disease is salpingitis, operation ordinarily does no harm and may even hasten the convalescence. What has been said of torsion and infection of cysts may be said also of pe- dunculated fibroids. Diverticulitis of the sigmoid may cause symptoms and present signs very like acute salpingitis. It may more closely resemble tubal inflammation than appendicitis, for, on account of the mobility and length of the sigmoid, the inflammatory mass in which the diverticulum is involved may lie deep in the 208 GYNEGOLOGY pelvis, so that it cannot be distinguished by touch from an adnexal enlargement. Diverticulitis is confined to the left side and occurs usually in- women beyond the age in which a salpingitis is liable to be contracted. The first case of diver- ticuhtis seen by the writer was diagnosed by him as a pyosalpinx. Treatment of Acute Salpingitis. — This is usually expectant if there is no doubt about the diagnosis. It consists in complete rest in bed, with frequent hot vaginal douches and hot apphcations to the abdomen for the rehef of pain. As the peritonitis is hmited to the pelvis and has little tendency to become general, it is best to keep the bowels open by catharsis and enemata. The leuko- cyte count of the blood, taken every two or three days, is an excellent guide to the progress or subsidence of the disease. Most cases of acute salpingitis sub- side partially or completely under proper care and nursing. The decision as to later operative methods is determined by various factors. If the attack of salpingitis is the first one, and subsides, leaving little evidence of the disease by bimanual examination, it is best not to operate, but to keep the patient under observation, for the disease may possibly heal spontaneously. Patients whose abdomens are opened under these conditions often show nothing abnormal in the appearance of their pelvic organs, even though later they may start up a destructive pelvic inflammation. It is best, therefore, to wait and see whether other acute attacks ensue, or whether the organs are to undergo a slow process of chronic adherent inflammatory disease, or whether, perchance, the patient may not get well spontaneously. If a first attack of salpingitis simulates closely an appendicitis or a twisted pedicle cyst or an extra-uterine pregnancy, and there is much doubt in the mind of the attending surgeon, it is better to operate at once, for with the last-named conditions an operation is usually impera- tive, while if the case does turn out to be one of salpingitis a properly performed operation does little harm and may hasten the convalescence. If the attack of salpingitis leaves permanently damaged organs, the case comes under the head- ing of chronic pelvic inflammation, to be discussed later. If a secondary acute salpingitis appears, the treatment is still expectant, but somewhat less conservative than in the case of a primary salpingitis. Here the damage to the organs is usually more obvious, and, as a rule, operation is de- ferred only until the more acute symptoms subside. In the average case this requires from ten days to three weeks. Sometimes the symptoms do not sub- side and an operation must be done to save the patient's life. This is eminently so when there is a large pelvic abscess whose course suggests a mixed infection. These abscesses may occur in the primary attacks, but are more apt to appear in the secondary cases, as described above. Inasmuch as the tubes are drawn downward and backward by the inflammatory adhesions, the abscesses are con- sequently found, as a rule, deep in the posterior culdesac. As they increase they tend to point downward into the vagina, and may be readily puncturisd from an incision through the posterior wall of the vagina. This operation should not be used as a routine^ but may be resorted to in extreme cases. As a rule, INFLAMMATIONS 209 the operation of vaginal puncture is not necessary. The patient may be kept under treatment of rest and hot douches until the temperature and leukocytosis become normal. The patient is then ready for operation, the nature of which depends on the extent of damage to the pelvic organs. In the severely destruc- tive cases it is necessary to remove the adnexa and uterus by a supravaginal hysterectomy with drainage through the vagina. (See page 713.) Chronic Pelvic Inflammation as a Result of Gonorrheal Salpingitis Chronic peMc inflammation is a disease which is of the greatest chnical importance, both to the speciahst in gjTiecology and to the general practitioner, for not only is it of very wide occurrence, but its general constitutional results are varied and far reaching. We have seen in the remarks on the pathology of salpingitis that the chronic stage consists in a gradual process of pelvic adhesions which dislocate and immobihze the genital organs. The symptoms of chronic pelvic inflammation are due directly or indirectly to this adhesive process. The chronic form of the disease may ensue after an acute attack, or it may de- velop gradual^ mthout a definite initial onset. This is due to the fact that the first infection may run a very mild course, so as to attract little attention on the part of the patient. The resulting adhesive process may, however, be consider- able and quite incommensurate with the mildness of the beginning of the dis- ease. It is even possible for a patient to have an extensive chronic pelvic inflam- mation without any subjective S3rmptoms at all, the condition being found incidentally during an operation for some other cause. UsuaUy, however, the s^Tiiptoms are fairly definite and quite characteristic. The most constant is pain in the lower abdomen on one or both sides. This pain is either continu- ous or frequent, with short intermissions. It is made worse by exertion. The pain is usually not very severe in character, but is described as dull and drag- ging. Sometimes it is little more than a continuous pelvic discomfort which the patient has difficulty in describing. The seat of the pain is always low in the abdomen; on the right it is 2 or 3 inches below McBurney's point. Alhed symptoms are very numerous and represent disturbances of most of the func- tions of the body. Patients Tvith chronic pelvic inflammation look worn and dragged. Girls lose the bloom of youth and appear prematurely old. The continuous nagging pain of the pelvis acts as a severe irritant to the nervous sj^'stem, so that these patients usually become neurotic, irritable, introspective, melancholy, often hysteric. Digestive disturbances are common. On account of the adhesions of the large intestine constipation and mucous colitis are frequent. The dis- turbance of the nervous and digestive functions leads to headaches. Adherent masses in the posterior culdesac, or the backward dislocation of the uterus, may cause sacral backache. Most women with this disease are sterile, and this may be a source of mental worry. Leukorrhea from an associated endocer\dci- 14 210 GYI^ECQLOGY tis is usually present and aggravates the nervous and mental distress. Bladder symptoms are sometimes present, but are not common, because the disease does not usually extend to the anterior half of the pelvis. Disturbances of menstruation are common and are of importance. Some of the menstrual abnormalities of chronic pelvic inflammation cannot easily be explained. Some think them due to a disturbance in the ovarian secretion, which is believed to preside over the function of menstruation. This, however, is not proved. There is usually dysmenorrhea, in the sense that the pelvic pains are exaggerated during catamenia. As will be seen (see page 516), this must be — r5 ,' » rri , ^T Fig. 42. — Chronic Salpingitis. Both tubes are closed and implicated in adhesions. Salpingitis isthmica nodosa is seen at the bases of both tubes. regarded not as an essential, but as a secondary, dysmenorrhea. It is doubtless due to the increased congestion of adherent and immobilized organs. It occasionally happens that there is a temporary amenorrhea. Patients in this condition sometimes think themselves pregnant and attempt abortion, with very disastrous results. Menorrhagia and metrorrhagia are not uncommon, and may lead to much confusion in diagnosis. For example, a period of menorrhagia may follow a period of amenorrhea. This sequence, in connection with pelvic pain and a palpable mass, may cause a very excusable diagnosis of extra-uterine pregnancy. INFLAMMATIONS 211 The abnormal uterine bleeding sometimes leads the attending physician to curet the uterus, a dangerous procedure, which too often results in lighting up the chronic process into dangerous activity. A rare appearance in this disease, but one which causes great apprehension on the part of the patient, is a sudden gush of a large amount of water or pus from the vagina. This may occur periodically, and is due to the sudden empty- Fig. 43. — Pelvic Adhesions from Salpingitis. Seen through an incision with the patient in the Trendelenburg position. Bladder, uterus, tubes, and intestines are all involved and matted together in a mass of adhesions. ing backward of a tubal cyst or a tubal abscess. This condition is called hydro- salpinx or pyosalpinx profluens. As we have seen, the isthmus of the tube ordinarily prevents any backward flow of fluids, but it appears that occasionally its valve-like action is incompetent, and the pent-up serum of a hj^drosalpinx or the pus of a pyosalpinx may discharge into the uterine canal and vagina. If this occurs only when the fluid contents exert a certain pressure the discharge may act automatically and become periodic. 212 GYNECOLOGY Treatment of Chronic Pelvic Inflammation. — The treatment of chronic pelvic inflammation is either medical or surgical. Medical treatment consists in local applications to the vagina designed to allay the inflammatory process, while surgical treatment consists in the removal of organs or parts of organs that are permanently damaged. The time-honored medical treatment is the use of hot vaginal douches and the apphcation of iodin and tampons to the vault of the vagina. We have already seen that hot douches are valuable in helping to reduce inflammation in the more active stages of the disease. They are also valuable for relieving the pain and congestion when the disease is chronic. Iodin acts as a counterirri- tant and vaginal antiseptic, while the effect of tampons soaked in glycerin and ichthyol is somewhat similar to that of a poultice. By these means patients can often be temporarily relieved of their symptoms, but apphcations to the vagina have no permanent effect on the pelvic adhesions, so that local treatment cannot be regarded as a curative measure. In some cases, however, douches and tampons relieve the patient to such an extent that more radical treatment is lumecessary. The majority of these patients come sooner or later to operation. Chronic pelvic inflammation with adhesions is sometimes treated by the electric applica- tion of heat, the treatment being known as diathermy. It is contraindicated in the presence of pus or hemorrhage. Direct-high frequency electric currents are apphed to the pelvic organs by placing large electrodes one on the abdomen and the other either on the lumbosacral region or in the vagina. The heat is developed slowly and progressively and is continued thirty to forty minutes. It is claimed that by this method pain is relieved and the organs become freely movable, due to an "absorption of the adhesions." Excellent results have been reported by Kowarschik, Keitler, and Recasens. Considering the relief given in chronic pelvic inflammation from the time-honored use of hot douches the treatment seems logical, but it is doubtful if an actual absorption of adhesions takes place. The surgical treatment of chronic pelvic inflammation is either conservative or radical, depending on various factors, such as the amount of destruction of the tissues, the age of the patient, her social condition, etc. Conservative surgery of chronic pelvic inflammatory disease consists in saving as much of the pelvic organs as possible. This is often feasible because there may, for example, be irreparable damage to one tube, while the other may have healed completely, or one ovary may be extensively involved in an adhesive or cystic process, while the other may have escaped serious injurj^, or one portion of a tube may be comparative^ sound, while the rest of it is beyond repair. Thus, various problems present themselves which must be solved by the ingenuity and experience of the operator. The various combinations and devices for conserv- ative operations on the adnexa are described in detail on pages 757-765. When the organs are damaged to such an extent that conservatism offers no hope for a cure, it becomes necessary to do a radical operation, which consists in the removal of the uterus and appendages by a supravaginal hysterectomy. The decision as to conservatism or radicalism requires on the part of the surgeon INFLAMMATIONS 213 a wise judgment based on experience, a knowledge of pathology, and correct information of the patient's clinical history, social condition, and personal wishes regarding the disposition of her pelvic organs. Surgeons differ consider- ably in their ideas as to when to be conservative and when not to be. More- over, each case must be decided on its individual merits. Hence, it is impossible to lay down an entirely satisfactory code of rules that will meet the require- ments of every case. There are certain general principles which may serv^e as valuable guides in the conduct of these cases, but the final decision must rest chiefly on the judgment of the operator. In the first place, it must be recognized that the final clinical and pathologic results of conservative operations are not as good in the percentage of cures as are those of properly performed radical operations. This is due to the fact that postoperative adhesions are much more apt to form after conservatism. It is impossible in most cases to perform such operations as salpingectomy, salpingo- oophorectomy, salpingostomy, resection of the ovary, etc., without leaving surfaces which are more than likely to become adherent. The peritoneal wounds, even with the greatest care, are somewhat ragged, and it is inevitable that a considerable number of catgut knots and sutures must be left exposed to act as irritants to the peritoneum. In addition to this, much of the pelvic peri- toneum w^hich has been damaged by the breaking up of adhesions is necessarily left in a condition favorable to the re-formation of adhesions. This is especially true of the posterior w^all of the uterus and the posterior leaves of the broad ligaments. The same is true of the damaged surface epithehum of the ovaries. In the radical operation of supravaginal hysterectomy, on the other hand, if it is performed as described on page 713, there is no exposure of damaged peri- toneal surfaces except in the deepest parts of the pouch of Douglas, where it does practically no harm. The pelvic peritoneum which comes in contact with the overlying intestines and omentum after the operation is only that of the anterior half of the pelvis, in which, we have seen, adhesive peritonitis does not usually take place, and the peritoneum is, therefore, left smooth and uninjured. In addition to this, only one catgut knot is exposed, and that is in a position where it does little harm. There is, therefore, a great difference in the results of the two operations as far as the formation of postoperative adhesions is concerned, and, in consequence, there is necessarily a difference in the clinical results. A conservative operation nearly always relieves the patient partially or completely for a time, but many of the patients in the course of a period of time varying from, a few months to one or two years begin to experience again the old nagging pains, and a certain number of cases come again to operation. The recurrence of the symptoms is due to the slow re-formation and contraction of pelvic adhesions and a repeti- tion of dislocating and immobilizing of the organs. However, many patients get entirely well, and the percentage of cures is sufficient^ greater than that of failures to make the operation advisable under certain conditions. 214 GYNECOLOGY Although the radical operation when properly done has a higher rate of symptomatic cures than has the conservative, there are objections to the re- moval of the pelvic organs which must be carefully considered. First, there is the prevalent idea that such an operation is usually followed by certain serious and definite nervous symptoms. This subject is discussed in the section on Neurology, and we see there that this wide-spread belief dates from the time when hysterectomies were perform.ed in such a way as to result in pelvic ad- hesions and prolapse, two conditions which are the chief causes of genital neuroses. The objection is not a serious one at the present day. In young women, whether married or unmarried, it is obvious that the radical operation should not be performed unless the organs are so irreparably damaged that conservatism is no longer feasible. The reasons for conservatism in young women are partly sentimental and social, but these are so powerful that conservative operations must be performed even when there is a considerable prospect of a later operation. In addition to this is the moderate percentage of possibility of making the patient fecund. (See section on Sterihty.) The question of the change of sexual feelings after castration is discussed on page 128. The personal environment of the patient is a factor of the greatest impor- tance, and one with which the surgeon should be thoroughly famihar before undertaking an operation for pelvic inflammation. For example, in the case of a poor widow who has living children depending on her for care and support a radical operation, with its greater likehhood of a permanent cure, might be advisable, whereas in a recently married woman of the same age it might be unjustifiable. In women approaching or past the menopause the radical opera- tion is preferable unless the destructive process is comparatively shght. When one or more conservative operations have been performed without relief to the patient the radical operation is obviously indicated. In a large number of cases the problem is solved at once by the fact that the organs are beyond reasonable hope of repair. A radical operation is then im- perative, irrespective of age or condition. Sometimes this condition presents itself unexpectedly, as the preliminary bimanual examination may fail to reveal the real extent of the pathologic process. In such a case the surgeon may be in an embarrassing predicament if he has failed to gain the consent of the patient for the removal of organs. It is, therefore, of the greatest importance that before every pelvic operation where inflammation is suspected the situation be explained to the patient, and her consent, and, if she be married, that of her husband, be secured for the performance of whatever operation the surgeon considers for her best health and welfare. SERUM AND VACCINES IN GONORRHEA The treatment of gonorrheal conditions by serum and vaccines has been only partially successful. In gynecologic practice it may be said that with our INFLAMMATIONS 215 present knowledge neither of these forms of treatment are of use in cases of acute urethritis or in pelvic inflammatory conditions, whether acute or chronic. The best results have been obtained in gonorrheal arthritis and in the vulvo- vaginitis of children. In the latter disease the benefits from the use of vaccines is so well established that it should alwaj^'s be adopted as a specific part of the treatment. Antigonococcic serum is usually prepared from health}^ rams that have been treated with gradually increasing doses of dead and live cultures of gonococci. The dosage is 2 c.c. of the serum, administered subcutaneously for from two to five doses, with intervals of one to five days, according to the reaction produced in the patient and the behavior of the disease. The reaction in the patient shows a slight elevation of temperature and a feeling of malaise. There is some redness and swelling about the point of injection. A slight increase in the dis- charge from the genital tract is produced for the first few days following treat- ment (Norris). Vaccines are preparations of dead gonococci suspended in normal salt solu- tion and standardized, so that the number of gonococci to a cubic centimeter of the salt solution is known. Autogenous and stock vaccines are used; autog- enous vaccines are preparations of dead gonococci that have been obtained from the patient and grown on culture-media. Stock vaccines are obtained from several cultures that have been taken from as many different individuals, usually about eight or ten different strains being used. The autogenous are regarded as somewhat more efficacious than the stock preparations. The stock vaccines are put up in sealed containers, each container holding a known number of dead bacteria. The vaccines are administered subcutaneously, four or five doses being the average treatment. The dosage begins with about 5,000,000 bacteria, and is increased up to 20,000,000 or more. The reaction is similar to that from the serum. The opsonic index is a valuable guide to the dosage, but is rarely available (Norris). The reaction induced by the injection of dead gonococci has been used as a sign of the presence of gonorrheal disease. Its value in practical diagnosis has not yet been established. Wolff has reported excellent results in the use of vaccines in 40 cases of vulvovaginitis. He strongly urges the advantage of autogenous vaccines, and recommends that no other treat- ment be given except that of ordinary cleanliness. The vaccine is injected hj'podermically, the initial dose being 25,000,000 to 50,000,000. The injections are given at intervals of five to seven days over a period of about thirty-five days. GENITAL TUBERCULOSIS : Tuberculosis of the female genital organs is confined chieflj^ to the tubes and endometrium. It may, however, appear exceptionally as an affection of the vulva, vagina, or cervix. In the study of this subject there have been es- tablished certain facts with which it is important to be familiar : 216 GYNECOLOGY (1) It has been shown by experiments on susceptible animals that pure cultures of tubercle bacilli when deposited on the surface of the vagina will rarely grow unless there has been a previous lesion of the epithehum. If, how- ever, the cultures be deposited in the horn of the uterus the result is practically always positive. (2) Although tubercle bacilh have been demonstrated by experimentation in the semen of males affected by pulmonary tuberculosis, it is doubtful if the disease is ever transmitted by coitus. (3) The question of heredity is an important one. It has been shown that the mother may infect the fetus from a distant focus through the blood circula- tion. It has also been shown that the fetus and placenta may be infected by coitus. Infections of this kind must be regarded as incidental and unusual. The inheritance from tubercular parents is more commonly a predisposition to the disease, in the form of a weakness on the part of certain epithehal structures in resisting the invasion of the tubercle bacillus. (4) Genital tuberculosis in women is quite independent of the urinary tract and does not tend to ascend from the former to the latter. (5) It is thought that genital tuberculosis may ascend in the genital tract — e. g., from the cervix to the endometrium, and thence to the tubes — but this must be very rare. There is, however, a decided tendency of the disease to descend from the tubes to the endometrium. TUBERCULAR SALPINGITIS Tuberculosis attacks both the mucous membrane lining of the tube (endo- salpinx) and the peritoneal covering (perisalpinx) . The tube is an especially favorable location for the growth of the tubercle bacillus as well as for the gonococcus, on account of its convoluted form and its succulent lining mem- brane. Tuberculosis of the tubes, whether of the endosalpinx or the perisalpinx, is always bilateral. It is doubtful if the infection ever takes place primarily in the tubes, the mode of infection being either ascending or descending, or by the hematogenous route from some distant focus. Ascending infection from a tuberculosis of some part of the external genitals is exceedingly rare, and there is reasonable doubt if it ever occurs. In this respect the progress of the disease is in marked contrast to that of gonorrhea. . Descending infection originates from a tuberculosis of the peritoneum or in- testines above the tubes. The descending disease may affect either the peri- salpinx or the endosalpinx, or both. When only the perisalpinx is involved, the surface of the tube merely takes part in a general tubercular salpingitis. When the endosalpinx is involved the disease becomes specialized. The hejnatogenous mode of infection in the tubes implies a metastatic growth of tubercle bacilli which have come by the blood circulation from some distant INFLAMMATIONS 217 focus, usually in the lungs. In this case the original focus may become entirely healed, while the new growth of bacteria may continue to flourish. The infec- tion may, therefore, appear to be primary in the tubes, whereas it is, in reality, secondary. Except when the tubes take part in an acute general miliary tuberculosis, tubercular salpingitis is always chronic. As we have seen, the disease may be either an endosalpingitis or a perisalpingitis, or both. Fig. 44. — Tubercular Salpingitis. High power to show giant-cells. The gland-like spaces are follicles formed by fusion of the villi. In the center of the drawing are four giant-cells which are characteristic of tuberculosis. The tissue around them has become necrotic and is infiltrated with round cells, mostly of the mononuclear variety. Tubercular endosalpingitis somewhat resembles in its processes a gonorrheal infection. The first stage is catarrhal, in that it involves only a superficial inflam- mation of the mucous Hning. The tubal ostium tends to close early and the dis- ease may progress to a tubercular pyosalpinx. The contents of a tubercular pus- tube consist of a white, mushy, cheesy material if the infection is exclusively tubercular, but a mixed infection in these tubes is common. If the latter takes place the pus-tube is then exactly like that originating from gonorrhea. In fact, 218 GYNECOLOGY tuberculosis and gonorrhea may exist together. In pus tubes of this kind the presence of the tubercle bacillus may sometimes be detected by miliary tubercles on the surface of the tubes. Often it is only discovered by microscopic examina- tion of tt^ walls of the infected tube. This similarity that exists between large tubercular and gonorrheal pus-tubes may in some circumstances be of serious domestic or medicolegal importance. The later pathologic processes of a tubercular tube are quite different from those of gonorrhea. An old tubercular tube, in which the more active process has ceased, is usually either caseous or fibrous, each of which conditions is entirely characteristic. In the former case the enlarged tube contains a white homogeneous cheesy mass which is unmis- takable, while in the second case a fibrosis takes place which completely occludes the lumen and leaves the tube a solid fibrous cy finder. A third form of end-result is a hydrosalpinx, though this is not common. There is no doubt that genital tuberculosis may exist in fetal life. It is thought that the rare cases of so-called congenital hydrosalpinx are the outcome of a fetal tubercular salpingitis (Ans- pach). Tubercular perisalpingitis is manifested by the appearance of miliary tuber- cles on the peritoneal surface of the tubes. This may exist by itself,' or as a part of a tubercular peritonitis. It is evident that a tuberculosis of the perisalpinx may extend through the ostium of the tubes to the endosalpinx, and, conversely, tuberculosis of the endosalpinx may extend to the perisalpinx, either through the ostium or by direct extension through the tubal wall. Tubercular salpingitis is nearly always associated with pelvic adhesions, which in a severe case may be of extraordinary density and strength, so that the adherent mass is absolutely inextricable. This is in contrast to gonorrheal adhesions of the pelvis, which are rarely inoperable. The symptoms of tubercular salpingitis unassociatecl with a tubercular peri- tonitis are the same as those of chronic gonorrheal salpingitis. The condition found by pelvic examination is also exactly the same, so that, unless there is an intact hymen, it is almost impossible to make a definite diagnosis of tubercular salpingitis. The presence of a tubercular focus elsewhere in the body may serve as a guide to the diagnosis, but it is as often misleading. If genital tuberculosis is associated with a general tubercular peritonitis the diagnosis may then be very obvious. The progress of tubercular salpingitis is very slow and insidious. If it comes on early in life it may cause a local or general hypoplasia or under- development of the individual. Amenorrhea is sometimes a result of the dis- ease, especially if it has extended to the endometrium, while sterility is almost inevitable. The treatment of tubercular salpingitis is practically the same as that of chronic pelvic inflammation from gonorrhea, except that in young women the operation should tend more to the radical operation of hysterectomy. This is due partly to the fact that conservative operations are apt to be followed by a INFLAMMATIONS 219 recurrence of symptoms, and partly to the fact that the endometrium is second- arily involved in a large percentage of cases. Some cases, where the pelvis is filled with a densely adherent mass involving the intestines, are entirely inoperable, but these inoperable cases may make extraordinary cures under proper hygienic treatment, due to the fact that chronic adhesions, unlike those from gonorrhea, often become completely absorbed and disappear spontaneously. As has been shown, the diagnosis of tubercular salpingitis is nearly always made after the abdomen has been opened. Old shrivelled up fibrous tubercular tubes found incidentally during pelvic operations may be removed without disturbing other organs. TUBERCULOSIS OF THE UTERUS Tuberculosis of the uterus is usually confined to the endometrium, and this, in turn, is usually associated with and secondary to tuberculosis of the tubes. Fig. 45, — Tubercular Endometritis. Low power. Around the edges are dilated glands lying in an edematous stroma. The center contains a tubercle consisting of necrotic tissue infiltrated with round cells and coataining several giant-cells. The infection takes place by descending extension in the manner mentioned above. It is difficult to say how frequently tubercular endometritis comphcates tuber- 220 GYNECOLOGY culosis of the tubes, but good authority estimates it as occurring in about one- half of the cases (Kiistner) . This is a matter of considerable practical impor- tance in deciding the question of a conservative or radical procedure when operat- ing on the tubes. Tuberculosis of the endometrium, as a rule, usually affects only the mucous membrane, and usually appears microscopically only as scattered tubercles in the stroma. It may, however, become more extensive and ulcerate the surface. Rarely the process invades the myometrium, and may even go so far as to convert the uterus into a cheesy, necrotic mass. Tubercular endometritis is not a well-defined disease by itself, and is usually discovered only incidentally during a microscopic examination of uterine curet- ings. When symptoms occur, the most common is persistent leukorrhea. If ulceration of the endometrium occurs, there may be bleeding. Sometimes there is long-continued amenorrhea. Inasmuch as tubercular endometritis is nearly always secondary to tuber- cular salpingitis, local treatment, such as cureting and antiseptic apphcations, is futile. TUBERCULOSIS OF THE OVARY The ovaries are not infrequently infected secondarily from a tubercular salpingitis. A few instances of isolated tuberculosis of the ovaries have been reported in which unquestionably the infection must have reached the ovary by the hematogenous route from a distant tubercular focus. Primary tubercu- losis of the ovaries, like that of the tubes, is extremely doubtful. TUBERCULOSIS OF THE CERVIX The cervix is rarely infected by tuberculosis. When this does occur the infection is usually primary. The appearance is that of an irregular ulceration, and it can be distinguished from syphihs or cancer or simple erosion only by microscopic examination of an. excised specimen. VAGINA Isolated tuberculosis of the vagina is a rare cUsease. When it does occur it is usually found in children. It manifests itself by irregular ulcerations of the vaginal surface, VULVA Tuberculosis of the vulva is the same as lupus. It appears as extensive ul- cerations, combined with polypoid hypertrophy of the tissues. The disease may extend over the perineum to the anus and rectum and may also spread into the vagina. The ulcerations are irregular and covered with a shmy debris. They are sufficiently destructive to cause fistulse in the labia. Tuberculosis of the vulva may simulate closely elephantiasis, syphihs, esthi- INFLAMMATIONS 221 omene, and cancer, and the diagnosis can only be made definitely by microscopic examination of an excised piece of tissue. The treatment of tuberculosis of the vulva is like that for lupus elsewhere in the bodJ^ If the disease has not extended too far into the surrounding tissues a vulvectomy is often advisable. TUBERCULAR PERITONITIS Tubercular peritonitis is not classified strictly as a gynecologic disease, but it is so closely associated with genital tuberculosis, and cases are so frequently seen in gynecologic chnics, that it must be considered here. Three forms of tubercular peritonitis are to be distinguished: In the first form mihary tubercles are disseminated over the peritoneum of the abdominal cavity, either generally or partially. There is always ascites, which is usually tinged with blood. Adhesions may or may not be present. This type of the disease is termed tubercular peritonitis with ascites. The second form is characterized by extensive adhesions without ascites. The intestines, omentum, and mesentery are matted together in a conglomerate indistinguishable mass. If the pelvis is involved the pelvic organs are imphcated in the process. The adhesions are dense and inextricable. It is usually im- possible to free intestines bound together in these masses without injuring their walls. Nevertheless, the adhesions seen in this disease, hopeless as they may appear, sometimes entirely disappear at a later stage. This type is called dry adhesive tubercular peritonitis. It may be general or it may be locahzed in certain parts of the abdomen. The first and second form may occur together in different parts of the same abdomen. In fact, the second type may represent a later stage of the first. The third form of the disease occurs as tuberculous nodes agglutinated in masses. These masses tend to become necrotic and may cause fistulse. The tubercular nodes may form circmnscribed annular masses around the intestines, with corresponding enlargement of the mesenteric glands, a condition some- times so closely simulating cancer that it may be impossible to make a diagnosis excepting by the microscopic examination of the tissue. This type is called nodidar tubercular peritonitis. The symptoms of tubercular peritonitis vary somewhat, according to the type of the disease. In the first form there may be no well-defined sjmiptoms until sufficient fluid has collected in the abdomen to call attention to the location of the disease. This is the type that is most often seen in the young. General constitutional symptoms are first noticed, such as general weakness, night-sweats, loss of weight and sleep, and various digestive disturbances. Girls are apt to be amenorrheic and to show retarded development. Attention is called to the ascites by enlargement of the abdomen or by dyspnea. In the second form of the disease the constitutional symptoms are Hke those in the first. There is apt to be more definite abdominal pain. The adherent 222 GYNECOLOGY masses may be felt by palpation of the abdomen and resemble various tumor formations. On this account cases of adhesive tubercular peritonitis are fre- quently encountered during exploratory abdominal operations. Nodular tubercular peritonitis is clinically a much more serious disease than the other two types. In this form there is greater destruction of tissue; hence, abdominal symptoms may be very severe. Blood and pus may appear in the stools, and the symptomatology, like the gross pathology, may closely resemble cancer of the intestine. The diagnosis of tubercular peritonitis with ascites is usually comparatively easy to make. Ascites in a young person unassociated ^vith heart or kidney dis- ease or edema elsewhere in the body usually means tuberculosis of the perito- neum. If the patient is in the cancerous age it may be difficult to differentiate between tuberculosis and malignant disease. The tubercuhn test is useful when there is great doubt. The diagnosis of adhesive tubercular peritonitis is usually difficult to make with exactness, especially if the conglomerate mass involves the pelvis. These masses are so dense that they are often mistaken for adherent ovarian or fibroid tumors. The condition is especially hke the cancerous peritonitis that results from a mahgnant ovarian cyst. Even after the abdomen is opened it may be impossible to make a diagnosis from gross inspection. Nodular tubercular peritonitis, as has been mentioned above, is especially hke mahgnant disease, both from external examination and after the abdomen is opened. The diagnosis of tubercular disease from inspection during opera- tion is, of course, simple if miliary tubercles are present, but in the severe cases there is often no sign of them. The treatment of tubercular peritonitis is a subject of interest and specu- lation. In the ascitic cases the question of operation arises. It was discovered that many of these cases recovered after an operation of opening the abdomen and evacuating the fluid. It was supposed that these cures were due to the effect of letting hght and air into the peritoneal cavity. For that reason many surgeons made long incisions and exposed the peritoneum as much as possible. The custom of operating on these cases became general. It was then discovered that many cases got well without operation, and at the present time opinion as to the advisability of surgical interference is somewhat divided. The light and air theory is not now generally held. One theory as to the benefit of opening the abdomen and evacuating the fluid is that the disease is converted by this means into the dry adhesive form, which is a more favorable stage for spontaneous heahng. There seems to be no doubt that operation is sometimes advantageous, while the chances of doing harm are almost nil. When the fluid coUects to such an extent as to cause dyspnea and other discomforts, evacuation of the fluid may be imperative. This is best done by a laparotomy incision rather than by paracentesis on account of the possibility of adhesions of the intestine to the anterior abdominal wafl. If operation is performed the general con- INFLAMMATIONS 223 stitutional measures for treating tubercular patients must, of course, also be carried out. The dry adhesive form of tubercular peritonitis comes to light usually during an exploratory laparotomy following a doubtful or mistaken diagnosis. If the disease is confined mostly to the pelvis, the case may be operable, and the pro- cedure is that described under Tubercular Salpingitis. If there is considerable involvement of the intestines the case is usually inoperable, as the adhesions can- not be separated without too much bleeding and injury to the intestinal walls. These cases, hopeless as they look, are by no means incurable. Under proper hygienic treatment patients sometimes make the most astonishing recoveries. We have observed 2 cases which came to laparotomy many years after explora- tory incisions, when the presence of conglomerate adhesions made further operation out of the question. At the time of the second laparotomy, one of which was for a fibroid and the other for postoperative hernia, the tubercular adhesions had almost completely disappeared. Prognosis. — Opinions as to the ultimate prognosis of ascitic and adhesive tubercular peritonitis differ much. Many regard the outcome of the disease as favorable in a considerable percentage of cases, while others believe the final prognosis extremely bad. All agree that the disease is rarely of itself fatal, but those who take a dark view of the subject consider that most of the patients ultimatel}^ die of some other form of tuberculosis. Our experience has been favorable. It should be mentioned incidentally as a warning that when the abdomen is opened and tubercular peritonitis of the first two types is found, the wound should never be drained, for if this is done a persistent sinus is almost sure to follow. Nodular tubercular peritonitis cannot easily be treated by surgery. The condition is usually discovered on opening the abdomen for expected intestinal cancer, appendicitis, or diverticulitis, etc. If the condition is such as does not absolutely require interference, like that of intestinal obstruction or abscess formation, it is best to leave the lesions alone. Attempts to remove the disease by intestinal resections are apt to be followed by permanent fecal fistulas. Even the nodular form of tubercular peritonitis may get well spontaneously. To summarize the treatment of the disease, it may be said that general hygienic measures, such as are employed for tuberculosis elsewhere, are the most important. If a considerable amount of ascites is present, evacuation of the peritoneal cavity by a laparotomy incision probabty hastens a cure. Most cases of adhesive and nodular tubercular peritonitis come to operation on account of the doubt in diagnosis. When peritoneal tuberculosis is found the abdominal wound is to be closed without drainage, without further operation, except when the disease is confined to the pelvic organs without serious in- volvement of the intestines, or when some condition is found which demands immediate surgical intervention. General Inflammatory Processes inflammations of the vulva The vulva is relatively immune to infections on account of the firm epithelial covering with which it is protected. It is, however, exposed to all sorts of inflam- matory irritants, so that the absolute number of affections to which it is subject is sufficiently great. Acute primary vulvitis is a rare occurrence except in children, in whom the gonococcus is the most important exciting organism. In the adult, vulvitis is usually secondary to inflammatory lesions elsewhere in the genital tract, such as may exist in the endometrium, endocervix, or vagina; or it may be the result of chemical irritation from the discharges of malignant or necrotic new growths above, or from diabetic urine or from vesical or rectal fistulas, where there is maceration and destruction of the superficial epitheUum, so as to allow the invasion of pathogenic organisms. Vulvitis may also be caused by trauma and infection from masturbation or indiscreet coition, from scratching, or from uncleanliness and chafing during menstruation. The symptoms of vulvitis are reddening and swelling of the parts, with pain and increased secretion. Edema of the labia minora is especiafly marked and may reach an alarming extent. A special form of vulvitis, due usually to excessive scratching from pruritus, is a great swelhng of the clitoris and prepuce, causing a condition hke that of acute phimosis in man. The secretion which bathes the vulva in vulvitis differs according to the nature of the infection, the most profuse type appearing in gonorrhea. As the secretion dries, adhesions and ulcerations may form. The pain in the acute forms is severe and distressing, consisting of great heat and pressure, coupled with burning on micturition. As the process becomes less acute the pain often gives way to intolerable itching. Gonorrheal vulvitis, including the vulvovaginitis of children, Bartholinitis, the infection of Skene's glands, and the forms of external gynatresia, has been treated under the subject of Gonorrhea, to which the reader is referred. SOFT CHANCRE Soft chancre, or ulcus molle, occurs most commonly near the frenulum, but may appear in numerous small ulcers over the entire external genital apparatus and out on the thighs and buttocks. These ulcers are characterized by their multiplicity and their great tendency to cause suppurating inguinal buboes. 224 GENERAL INFLAMMATORY PROCESSES 225 The ulcers are usually small, with well-defined edges and covered with a thick purulent secretion. They are shallow, and are distinguished from syphilitic chancre by the absence of basal induration. Soft chancres are venereal in origin. They are usually painful, and are associated with a greater or less amount of vulvitis, which increases the dis- comfort. The buboes which are so apt to follow are extremely painful and usually suppurate. The chancres are, as a rule, easily controlled by applying to each ulcer some caustic solution like crude carboHc or chromic acid, followed by alcohol. The apphcation of the acid is momentarily painful, but patients are usually entirely willing to submit to it. The buboes can sometimes be made to subside and absorb by rest and the apphcation of moist heat. If they suppurate it is necessary to incise and evacu- ate them, after which the wound goes through a process of slow healing. Patients with buboes should be kept in bed, as walking about greatly aggravates the condition. SKIN LESIONS The most common skin affection of the vulva is that due to chafing, eczema intertrigo. This is seen especially in the sulcus, between the greater and lesser lips, and in the furrows between the vulva and the thighs. The skin is reddened' or brownish red and may take on a permanent discoloration. The c6ndition is usually due to uncleanliness, coupled with some irritating discharge froi^n the upper genital or urinary tract, and is especially common in fat women and during hot weather. Other skin lesions seen are acne, herpes, psoriasis, molluscum contagiosum, etc. Lichen sclerosis is sometimes seen. It closely resembles kraurosis in appearance. Seborrhea is quite frequent, and is characterized by a white secretion, mostly on the labia minora. The glands may form cysts which sometimes become in- fected and suppurate. The presence of these small sebaceous cysts, usually seen on the labia majora, may be a source of mental apprehension on the part of the patient. They often disappear spontaneously. If the cysts are giving pain or causing anxiety, they may be dissected out under local anesthesia. Otherwise they need no special treatment. Furunculosis is a disease that may be the result of uncleanliness, but it some- times occurs periodically with menstruation. It may also appear as a specific disease, usually near the time of the menopause, in which case it seems to be the result of a local circulatory disturbance, possibly connected with deficiency of the ovarian function. This latter type may be much benefited by the use of ovarian extract. Syphilis.— The primary syphilitic lesion of the vulva may have exactly the same appearance as that seen in man, characterized as it is by a smooth, sharply defined ulcer, with hard indurated base, and a livid coloration of the surrounding tissue. In woman, however, there is a much greater tendency to the formation of 15 226 GYNECOLOGY multiple primary ulcers, due chiefly to the fact that the labia minora lie in close proximity to each other, so that the infection is transmitted from one lip to the other. For this reason multiple syphilitic ulcers are often seen symmetrically Fig. 4tJ. — Condylomata Acumixata. In this case the excrescences are collected into discrete masses. Usually the condylomata are more widely scattered over the vulva and surrounding parts. located on both labia. The initial lesion may be situated on any part of the external genitals, but it is found most commonly near the frenulum, the clitoris, and the inner surfaces of the labia minora. The lesions are apt to be associated with hard edema of the surroimding parts GENERAL INFLAMMATORY PROCESSES 227 and extensive erosions. Indolent buboes are felt in both groins, while later secondary efflorescent manifestations follow. Owing to the local edema, multiple ulcerations, and erosion of the primary affection syphilis may be confounded with elephantiasis, tuberculosis, and esthiomene. The diagnosis may be made absolute by finding the Spirochseta palUda and by a positive Wassermann reaction. Fig. 47. — Condylomata Acuminata Vulv^. Low power. Section of a complete condsdoma showing how the papillse of the corium hyper- trophy, growing outward, carrying the epitheUum with them, giving the whole a wart-like appear- ance. The stroma beneath contains many dilated blood- and lymph-vessels. Condylomata Acuminata.— These are warty or papillary excrescences that appear on the labia and surrounding parts of the external genitals. Their origin is usually venereal and nearly always the result of gonorrhea. They have the form of pointed papillse, and are termed "acuminata" to distinguish them from the broad condylomata that result from syphilis. These warty growths appear in clusters mostly on the major and minor lips of the vulva. Other warts, either .singly or in clusters, are sown about over the neighboring parts of the buttocks -and thighs. They may even invade the vagina for a short distance. Sometimes the clusters become very large. The condition is frequently mistaken for cancer, 228 GYNECOLOGY though to the experienced there is no difficulty in making a diagnosis. The condylomata of themselves do not give much trouble to the patient, but there is usually an associated leukorrheal discharge with consequent maceration and soreness of the parts. The appearance of the excrescences may cause great apprehension on the part of the patient. Fig. 48. — Condylomata Acuminata Vulvae. Higher power drawing of a papilla from the previous section. The epithelium is thickened, but the cells show no atypical growth and no signs of invading the stroma, as they do in carcinoma of the vulva. The stroma of the papilla contains several dilated blood-vessels and is infiltrated with leuko- cytes. The growth of the papillse is entirely superficial, there being no tendency to grow down into the subcutaneous tissue. For this reason the treatment is very simple. It consists merely in scraping off the papillary growths with a sharp curet. The superficial excoriation of the skin may be painted with iodin and the healing process is very rapid. If the condylomata extend to the softer parts of the vestibule and vaginal orifice their removal may be attended by GENERAL INFLAMMATORY PROCESSES 229 troublesome bleeding, especially if the patient happens to be pregnant. If the condylomata are at all extensive it is best to remove them under general anes- thesia. ESTHIOMENE This is a disease about which we have very little definite knowledge. The name is adapted from the Greek word meaning to gnaw out, so that it corre- sponds practically to the term "rodent ulcer." The disease consists of an exten- FlG. 49. ESTHIOMENE. The labia are hypertrophied, resembling somewhat elephantiasis. There is extensive ulceration of all the parts. The ulcerated areas have a tendency to be symmetric on the two sides. sive inflammation and ulceration of the vulva. The parts are greatly swollen and covered with superficial sloughing areas. These areas are apt to be at the points of contact of the swollen labia, so that there is a certain symmetry in the ulcerations. The parts are bathed with a foul purulent discharge. The origin of this disease is obscure. It is seen mostly in prostitutes, and, though it is thought to have some possible relationship to syphilis, it does not yield at all to syphilitic treatment. It is regarded by some to be the result of a 230 GYNECOLOGY lymph-stasis in the external genitals, as it sometimes follows the excision of inguinal buboes. It is often associated with stricture of the rectum. Esthiomene simulates in its appearance cancer and lupus, from which it should always be distinguished by a microscopic examination of a section of tissue. There are inflammations of the vulva, especially in neglected gonorrhea cases, where there is much swelling of the vulva with contact erosions which resemble esthiomene rather closely. These conditions, however, yield to local treatment and can in this way be distinguished. The symptoms of esthiomene are great burning sensation and pain in the external genitals. The patient's plight is distressing in the extreme. Local treatment of a true esthiomene ig almost hopeless, and the only means of relief is by a complete vulvectomy. ELEPHANTIASIS VULV^ Elephantiasis relates to a coarse enlargement of the vulva involving the labia minora or majora, or both. The outer appearance of these growths varies con- siderably, special names being given to describe the differences in surface struc- ture. Thus, elephantiasis glabra relates to a form which has a smooth surface; elephantiasis tuberosa, to a form which is covered with irregular nodules; ele- phantiasis condylomatosa, to one covered with warty excrescences (Gebhard). The hypertrophy may become very great, and the enlarging mass pedunculated, tumors having been observed weighing as much as 30 pounds. In the course of time severe ulcerations may form, giving, an appearance similar to that of esthiomene. Histologically, the process consists of a chronic indurative hypertrophy of the subepithelial connective tissue, excepting in the condylomatous type, in which, both microscopically and macroscopically, the excrescences are almost exactly like those of condylomata acuminata. The etiology of elephantiasis is. quite obscure. The disease appears during the age of sexual maturity.. It is much more common in the Orient than with us, and for that reason it is supposed that it may be due to some parasite, possibly bilharzia (Jaschke). Among some tribes of" the Hottentots is seen with considerable regularity an enormous lengthening of the labia minora. The term /'elephantiasis" is also applied to this condition. Elephantiasis in many cases does not at first give symptoms. The growth may become exceedingly edematous, causing lymphorrhea. If the surface be- comes ulcerated the condition may be very painful, resembling esthiomene. With the larger tumors coitus is entirely interfered with. The treatment of elephantiasis is removal by a partial or complete vulvec- tomy, according to the extent of the enlargement. A special form of elephantiasis is seen among the Southern negroes who live GENERAL INFLAMMATORY PROCESSES 231 in the damp, sv/ampy regions about the plantations. The disease has been shown to represent a condition of lymph-stasis, usually brought about by the Filaria sanguinis hominis, sometimes by syphilis and other eruptive diseases. The fibrous growth of the tissues is not due primarily to the lymph-stasis, but to recurrent erysipelatous infections of the affected part, each attack of which "~^: ^^r c\\i e s ■ \ 9 < ST' Fig. 50. — Elephantiasis Vulvae. There is great hypertrophy of the labia majora with a tendency to papillary outgrowth. On the left thigh can be seen several metastatic papillary excrescences and a scar where some of them had been removed at a previous operation. The treatment of this case was a complete vulvectomy.^ leaves the tissues more hypertrophied (Hill). The disease is more common in men, affecting the scrotum or lower extremities. In women it is apt to involve the external genitals. It is quite likely that this form of the disease is identical with that described among the Orientals. * Operation by Dr. F. A. Pemberton, Free Hospital for Women. 232 GYNECOLOGY ,,-^_*« .;.'. i\>' 'n ■ .> °- " r, -^ 5 '', { . r •%.-:, . K i ,^ > 1 , , . - « • , . / rS);^ «'. ? '• ',! /," Fig. 51. — Elephantiasis of the Vulva. Low power. Microscopically, this shows the characteristics of a fibroma. The thin layer of stratified squamous epithelium in which there are few, poorly developed, or no papillae, lying on a loose connective-tissue stroma, with a few small round cells scattered through the tissue. Near the center are two dilated lymph-spaces. KRAUROSIS The term "kraurosis" is derived from a Greek word meaning to shrink. In this disease there is a sclerotic change in the cutis of the vulva. The epidermis be-' comes thin and flattened, and there is an increase of connective tissue in the subcutis, together with a disappearance of elastic fibers and pigment. The result of this is that the surface of the vulva becomes white and parchment-like and is easily fissured. In the advanced stages the various parts of the vulva become obliterated and shrink to the consistency of leather. The process may extend to the anus. There is usually a fairly well-marked line of demarcation between the diseased and healthy skin. The etiology of kraurosis is not always clear. There is no doubt that it is usually the result of a long-continued irritation caused by discharges which, by their chemical action, gradually alter the structure of the vulval cutis. A pruritus of the vulva from any cause soon produces a white parchment-hke ap- pearance, which, if the irritating cause continues, in time develops into a per- manent change. Some, however, regard the pathologic process of kraurosis as an inherent primary disease. This theory has not been proved. GENEEAL INFLAMMATORY PROCESSES 23^ Kraurosis of the vulva is related to senile atrophy, and reference should be made to that subject. It not infrequently serves as a starting-point for cancer of the vulva. The symptoms of kraurosis consist chiefly of intolerable itching. Patients with this disease suffer pitifully and are often driven to acts of desperation. V.jl^rcvMec; r-v <^,v'? 'i ■ / t Fig. 52; — Kraurosis Vui.v^. The clitoris and labia minora have disappeared. The vulva is white and creased. The vagina is atrophied and stiff at the introitus. This was an extreme case and was inoperable on account of the extension of the disease into the orifices of the vagina and urethra. The treatment of advanced cases is \'Tilvectom3^, if the process has not in- volved too much vestibule and vaginal introitus. Several cures from ovarian extract have been reported, one of them by the author. In this condition ovarian extract theoreticall}^ works benefit by its power to cause hj^peremia of the external genitals and thus improve the circula- tion. Results seem to bear out the theory. t 234 GYNECOLOGY , v of which tincture of iodin is by far the most valuable. In some cases tampons soaked in glycerin and ichthyol are useful if employed in connection with douches and iodin. Vaginal suppositories of ichthyol may be used in the same way, but are not very efficacious. Senile vaginitis, if not the result of obstruc- GENERAL INFLAMMATORY PROCESSES 239 tion of secretions is best controlled by painting the vagina with iodin without the use of tampons. The progress of vaginitis, as far as complete cure is concerned, is often un- favorable. It is best to treat the intractable cases in a hospital, where com- petent nursing and systematic treatment will often accomphsh in a short time results that weeks of office or out-patient treatment fail to secure. Vaginitis Emphysematosa. — This is a special disease that occurs ahnost exclusively during pregnancy and disappears after delivery. There is little or no discharge resultant from it, and few synaptoms, so that it often passes un- noticed. It is characterized by small blebs of the vaginal surface, which some- FiG. 54. — Chronic Endocervicitis. Low power. Near the top are five cervical glands in cross-section, lined by the typical cylindric epithelium. The tissue around them is infiltrated with leukocytes. To the right of these glands and in the lower part of the section are areas of squamous epithelium which has grown down into the glands, filling them. These areas are typical stratified squamous epithelium and must be differenti- ated from carcinoma. times reach the dimensions of small cysts. Upon incising them a small amount of gas escapes. The etiology of this condition has not been clearly proved, but it is sup- posed, on fairly good evidence, that it is the result of some gas-forming bacillus. The clinical importance of this disease is insignificant > 240 GYNECOLOGY Garrulitas Vaginae. — ^^This is a condition which is characterized by the audible escape of gas from the vagina following certain quick changes of bodily position, and which has been thought to be the result of gas-forming bacteria in the vagina. It is more likely entirely mechanical in origin, the result of incomplete valvular closure of the introitus (Jaschke). Paravaginitis (paracolpitis) relates to an acute phlegmonous inflammation of the tissue surrounding the vagina. It is the result of deep infection following some serious lesion of the vagina, such as may occur from instrumentation at (& m\ Fig. 55. — Chronic Endocervicitis. High power. On the left is a cervical gland the epithelium of which is being invaded by lympho- cytes. The rest of the drawing shows the stroma of the cervix infiltrated with leukocytes, mostly of the mononuclear variety. This infiltration occurs around the glands, as would be expected, because bacteria gain entrance through them. childbirth, violent coition, attempts at criminal abortion, etc. Such an inflam- mation may become of the gravest import by extending to the pelvis and causing a fatal septic peritonitis. The infection may remain localized and has, during healing, an especial tendency to cause atresia of the vagina. Treatment is carried out by hot or cold antiseptic douches, with application of rubber or glass plugs during convalescence to prevent the formation of vaginal adhesions. Localized abscesses require incision and drainage. GENERAL INFLAMMATORY PROCESSES 241 CERVICITIS AND ENDOCERVICITIS Non-specific infections of the cervix and cervical mucous membrane are, in the majority of cases, due to lacerations that result in erosion or ectropion. This subject is treated in the section on Lacerations from Childbirth. Erosion of the cervix is occasionally seen in virgins, and is accountable for the persistent leukorrhea from which they sometimes suffer. The cause of these Fig. 56. — Chronic Endocervicitis. High Power of the Cervical Glands. The glands are dilated and were filled with mucus containing desquamated epithelial cells, round cells, and bacteria, but have become emptied in preparing the section. At places, as in the upper left corner, the epithelium is absent. The stroma between the glands is edematous and infil- trated with round cells. erosions is not definitely known. It is probable, however, that it is due to ab- normal mechanical irritation, for the condition is most frequently seen when there is a malposition of the cervix, so that it impinges on the anterior vaginal wall, or when the cervix is disproportionately long, so that it is in too close con- tact with the posterior wall. In cases of genital atrophy and vaginitis the cervix may take part in the 16 242 GYNECOLOGY inflammation and result in plastic adhesions, causing atresia with hydro- or pyo- metra (g. v.). The symptoms of endocervicitis and cervicitis consist of leukorrheal dis- charges. The treatment is either local apphcation of iodin or an operation 5f #^ Viif\ ^^'-' ^ / a / ^\^^^s'm ^4-^ Fig. 57. — Chronic Cervicitis. Pseudohealing of an Erosion. High power. The left half of the picture shows the duct of a gland occluded by the stratified squamous epithelium of the cervix which has grown over and down into it. On the right is a duct down into which the squamous epithelium is growing along the wall, but which has not become oc- cluded. Below the squamous epithelium is seen the normal cylindric epithelium which lines the glands of the cervix. which will restore the cervix to its normal contour and position. Very intrac- table cases can be cured by Schroder's operation of complete removal of the cervical mucosa (g. v.). ENDOMETRITIS The mucous membrane of the body of the uterus, or endometrium, is a tissue which has been greatly misunderstood. It is, in reality, a comparatively GENERAL INFLAMMATORY PROCESSES 243 inoffensive tissue, and very little responsible for the many ills formerly ascribed to it. The destiny of the endometrium is primarily to be the soil for the implanta- tion of the impregnated ovum. It is doubtless for this reason that nature pro- vided that it be comparatively immune to the infections and malignant growths common to other membranes. Thus, we have seen that, except in the puer- peral state, it is protected against practically all infectious organisms except the tubercle bacillus and the gonococcus. Even tuberculosis of the endometrium is quite uncommon, while the gonococcus, in its passage from the endocervix to the tubes, resides only for a short period on the endometrial surface and rarely leaves any permanent trace of its sojourn. During the puerperium, however, when a part of its surface is lacerated and denuded by the separation of the placenta, the remaining part swollen to a vulnerable decidua, and the protective barrier of the internal os stretched widely open, the endometrium is exposed and susceptible to the attack of infectious organisms. It is at this time that the more serious inflammations of the endo- metrium occur, and from these attacks the chronic inflammatory changes more commonly date their origin. . The subject of endometritis is at present in a considerable state of confusion due to the fact that the terminology which is in common use has been handed down from a time when the pathology of the endometrium was little understood. In some of the older books no clear distinction was made between the mucous membrane of the body and that of the cervix, so that diseases were ascribed to the endometrium which, in reality, are locahzed in the endocervix. In fact, the endometrium was supposed to be affected in most forms of pelvic disease, and this led to a great deal of local treatment and cureting -that was not only not necessary, but often harmful. Thus, patients with pelvic inflammation, misplacements, leukorrhea, and irregular menses were apt to receive vigorous treatment of the endometrium as a routine measure. The term ''endometritis" was loosely applied to all the changes in the uterine canal, and it was supposed that the effects arising from this disease were serious and far reaching. More recent studies have entirely changed this erroneous conception of the endome- trium, and it is now known that this membrane plays only a comparatively small part in gynecologic disease. In the first place, we must limit the word ''endometritis" only to such condi- tions as imply a true inflammatory process in the endometrium. This relates to infections by pathogenic organisms and to chronic changes that result from these infections. The circulatory changes, both physiologic and pathologic, must be given appropriate names, and not be included as formerly under the misleading title of "endometritis." No entirely satisfactory classification of the diseases of the endometrium has yet been made, and we must be content to try and simplify the subject as much as possible. 244 GYNECOLOGY The changes of the endometrium, formerly included under the general term "endometritis," may be divided into three types: (1) Infectious endometritis, the result of microbic invasion; (2) chronic interstitial endometritis, resulting from a previous infectious attack, and (3) gland hypertrophy, resulting from circulatory changes. INFECTIOUS ENDOMETRITIS Serious infections of the endometrium occur most commonly as a result of puerperal sepsis. The endometrium is at this time in a peculiarly exposed con- FiG. 58. — Acute Endometritis. High power. Parts of two glands are seen. The stroma between them is edematous, the cells are swollen, the nuclei large, and it is infiltrated with leukocytes. In the upper part of the drawing is a mass of exudate in the lumen of glands consisting of leukocytes, epithelial cells, and mucus. dition owing to the denudation resulting from the separation of the placenta, the patency of the cervix, and the general vascularity of the parts. The organ- isms which most commonly attack the endometrium at this time are the strepto- coccus, the staphylococcus, and the latent gonococcus. The inflammatory proc- ess may remain localized in the endometrium or it may extend deeply into the GENERAL INFLAMMATORY PROCESSES 245 muscular wall of the uterus. It may spread to the pelvic cavity and cause a peritonitis either by extension through the tubes or through the l>Tnph-spaces of the uterine wall to the parametrium. Infectious endometritis may result from gonorrhea. The most serious forms of gonorrheal endometritis are caused by the lighting up by the puerperium of a latent gonorrhea. Under these circumstances the endometrium does not possess its normal immunity to the gonococcus, and the infection may be severe and dangerous. This invasion of the gonococcus accounts for many cases of Fig. 59 — Chronic Interstitial Endometritis. High power. This section is stained to show the plasma cells which are found in chronic in- flammatory conditions, and are important in this special disease because their presence in large numbers makes the diagnosis more certain. They are characterized by their large size and the excentrically placed nucleus. puerperal sepsis, the later results of which are manifested by chronic inflam- mation and one-child sterility. Outside of the puerperal state infectious endometritis is astonishingh' un- common. Routine curetings, removed for diagnosis in vaginal operations, and the cases of pehdc inflammation requiring hysterectomy supply ample material for the microscopic study of the endometrium. The percentage of true infectious endometritis is very small, while evidences of acute purulent inflammation are rare. 246 GYNECOLOGY Treatment. — Acute infectious endometritis, outside of puerperal sepsis, is not a disease requiring specific treatment except in unusual instances. It must be always remembered that the use of the curet in any septic condition of the endometrium is dangerous, for it opens new avenues for the spread of the inflammatory process to the pelvic peritoneum. The endometrium may be infected by the passage, of unclean instruments past the internal os. It is also Fig. 60. — Interstitial Endometritis. High power. This illustrates the diffuse infiltration of the stroma with small round cells which can be seen scattered throughout the section. The stroma cells are swollen and there is some edema. possible to cause infection during a cureting operation by carrying organisms from an infected endocervix and implanting them on the endometrium. This is another of the dangers in using the curet. Tuberculosis of the endometrium comes under the heading of Infectious Endometritis. It is discussed on page 244. Senile atrophy sometimes predisposes the endocervix and endometrium to GENERAL INFLAMMATORY PROCESSES 247 infection which produces plastic adhesions and partial or complete atresia. The result may be the backing up of pus in the uterine canal, so-called pyometra (q. v.). CHRONIC INTERSTITIAL ENDOMETRITIS This is a condition the pathology and symptomatology of which are not sufficiently understood. It consists in a structural change in the endometrium which is evidently the result of some previous active infectious process. In our ^> *,>Sf ^V^^^ <»n Fig. 61. — Chronic Interstitial Endometritis. Low power. This section shows the dilatation of the glands Which is sometimes found in this condition. The epithelial cells are low and inactive, the glands are usually circular, while in pre- menstrual dilatation they are irregular in outline. The stroma is denser than normal and collections of small round cells can be seen. series of cases there is a noticeably large percentage of abortions in the patients' histories, while many of the cases had associated pelvic inflammatory disease. The endometrium is thickened to a greater or less extent. Under the micro- scope the thickening is seen to be due to an increase of the stroma, in which there is a marked infiltration of small round cells. This condition is probably one of the factors which sometimes cause abnormal bleeding in association with pelvic inflammation. Chronic endometritis cannot be easily diagnosed, nor can it 248 GYNECOLOGY often be satisfactorily treated as a disease by itself, for local applications to the endometrium are not feasible, while a cureting may light up into dangerous ac- tivity a latent pelvic inflammation. There are various grades of chronic inflammation of the endometrium which are of interest microscopically, but which cannot be distinguished by clinical symptoms. Driessen has described a special form of endometritis which he calls "postmenstrual necro- biotic endometritis," the cUnical symptom of which is profuse and protracted menorrhagia. Fig. 62. — Chronic Interstitial Endometritis. High power. Parts of two glands are seen, the epithelium of which is infiltrated with round cells. The stroma is edematous, infiltrated with round cells, and has an increased amount of fibrous tissue. The endometrium in these cases is found to show necrosis, hyahne degeneration, infiltration with multinuclear leukocytes, dilatation of the vessels, cystic dilatation of the glands, proliferation of the epithelium, and deficient glycogen. He also finds signs of incomplete regeneration of the uterine mucosa, such as is seen in endometritis following abortion. Driessen explains this condition on the ground that on account of some irregularity in ovula- tion and menstruation the mucosa is not cast off as it should be normally, and that the portions of the mucous membrane remaining and disintegrating in the canal prevent a normal regenera- tion of the endometrium with consequent bleeding, as do the remnants of an abortion or the decidua. Cureting may cure or only temporarily relieve the condition. GENERAL INFLAMMATORY PROCESSES 249 «>>. O ^O'^ ^^<© ^' g 43 <3S2> Cl- eg) ^ o 'CJ, °»-S Fig. 63. — Chronic Interstitial Endometritis. High power. The stroma cells and nuclei are swollen, there is some edema, and the tissue is infiltrated with small round cells. On the left, gland epithelium is seen, the cells are somewhat of the goblet shape, and are secreting mucus. GLAND HYPERTROPHY Various forms of hypertrophy of the endometrium, formerly thought to be the result of inflammation and called endometritis, are now known to be the result of circulatory changes. Until recent years all hypertrophied endometrium was generally supposed to be a pathologic process. Scientific study has shown that the endometrium undergoes a definite physiologic cycle of hypertrophy each month corresponding to the menstrual congestion. This change is characterized by a general thickening of the membrane. The stroma is swollen by a congestion of the blood-vessels and by an edematous exudate in the spaces between the cells, while the glandular acini are longer and arranged in spiral forms. This process begins shortly before the menstrual flow, reaches its height during the flow, and then gradually subsides, to be repeated at the next catamenial period. The premenstrual and postmenstrual hypertrophy is, therefore, physiologic and common to a greater or less degree to all menstruating endometria. (See also page 24.) The hypertrophy may, under certain conditions, be permanent or excessive, and it must then be regarded as pathologic, though it does not neces- sarily cause symptoms. When the hypertrophy becomes extreme the mucous 250 GYNECOLOGY membrane is thrown into folds of .varying size. This process is called polypoid gland hypertrophy. An extreme form of the process shows great thickening of the endometrium, and the glands, besides being long and spiral, branch out and exhibit a true hyperplasia. This type, when pronounced, is called adenoma of the endometrium, and is sometimes difficult to distinguish from adenocarcinoma. The glands, however, preserve their type and do not tend to dip into the mus- cular tissue of the uterus. It may be said in general that the endometrium becomes thickened under conditions of prolonged hyperemia or passive congestion of the genital organs. Fig. 64.'— Gland Hypertrophy of the Endometrium. High power. The glands he close together, the stroma cells between them being compressed. The epithelium is high, the cells active. This drawing shows especially the tuft-like invagination of the epithelium of the glands into the lumen, forming a connective-tissue papilla covered with epithelium. These conditions are furnished physiologically by the menstrual flux, as we have seen. Pathologically, the hypertrophy may be the result of misplacements, pelvic inflammation, ah decidual processes, repeated abortions, extra-uterine pregnancy, masturbation, excessive venery, etc. Sometimes extreme forms of gland hypertrophy of the polypoid and adenomatous type exist apparently as an independent disease, the etiology of which is obscure. Gland hypertrophy, as a condition secondary to pelvic congestion in a large GENERAL INFLAMMATORY PROCESSES 251 percentage of cases, gives no symptoms. It may cause a moderate leukorrhea from the oversecretion of the endometrial glands, but this leukorrhea is not distinctive. Uterine pain and tenderness are often given as symptoms of gland hypertrophy, but these symptoms are more likely due to the pelvic condition to which the hypertrophy is secondary. The most important manifestation of gland hypertrophy is menorrhagia. Here, however, we meet with difficulty be- cause of our defective knowledge of the causes of menorrhagia, and we cannot be sure that the hypertrophy is not the result rather than the cause of the abnor- mal bleecUng. In the polypoid and adenomatous types of hypertrophy, leukorrhea, menor- rhagia, uterine pain and tenderness, and dysmenorrhea may appear as well-de- fined symptoms. Treatment. — Since it has been learned that the hypertrophy of the endo- metrium is usually either physiologic or a secondary manifestation which does not of itself often give symptoms, there is not much to say concerning special treatment of the endometrium. Attention is rather directed to the primary pel- vic abnormalities. When the extreme forms of polypoid or adenomatous hypertrophy occur the object of treatment is to control the menorrhagia, which may be very severe and depleting. Drugs, such as ergot, hydrastin, and hamamelis, are practically useless. Pituitrin is said by some recent writers to be of much benefit, especially in the treatment of young girls. Cureting may diminish the bleeding temporar- ilj', but in many cases the hypertrophied membrane re-forms rapidly and the cureting has to be repeated. Sometimes palliative treatment is of little avail, and in order to prevent the continued loss of blood a supravaginal hysterectomy must be resorted to. Radiation is coming to be of great value in these cases, but in young women it must be employed with caution and by expert hands to avoid destruction of the ovarian follicles, with consequent sterility. METRITIS The term "metritis," like endometritis, is somewhat loosely used to designate various inflammatory and circulatory changes in the body of the uterus. Strictly speaking, it should be applied only to such inflammatory conditions as result from microbic infection. True metritis, when it does occur, is most commonly the result of severe puerperal infection, extending from the endometrium into the tissues of the uterine body. In the present days of improved obstetric technic puerperal metritis is not often met with. Outside of the puerperium, infections of the metrium are rare. A few cases have been reported of gonorrheal metritis, while tuberculosis sometimes extends from the endometrium to the deeper layers of the uterine body. The treatment of infectious metritis belongs, for the most part, to the realm, of obstetrics. It is primarily conservative and expectant. If the uterus con- .252 GYNECOLOGY tains infected and decomposing material, it is removed, but deep curetage is dangerous. Extreme cases sometimes require rapid total hysterectomy with drainage of the pelvis. INFLAMMATIONS OF THE OVARY The subject of oophoritis (or ovaritis) is at present in a state of some confusion, there being no unanimity among writers as to the classification of the various inflammatory processes of the ovary or to the clinical interpretation of many of the anatomic changes that take place in the ovarian tissue. We are obliged, therefore, to be somewhat arbitrary in treating the subject, and shall classify inflammations of the ovary simply under the headings of infectious oophoritis and interstitial oophoritis. By "infectious oophoritis" is meant those conditions of the ovary which result from the invasion of pathogenic microorganisms. It includes both the acute and chronic stages of the infectious process. By the term "interstitial oophoritis" is included a considerable number of somewhat vaguely understood degenerative conditions, manifested both in the stroma and epithelial structure of the ovaries, and resulting from constitutional disturbances, old inflammatory processes, or circulatory changes. Interstitial oophoritis is, therefore, not a true inflammation in the sense of being an infection of microbic organisms. INFECTIOUS OOPHORITIS Of the direct infections of the ovaries, that from puerperal sepsis is the most common, the streptococcus being the most frequent invading organism. The way by which the ovaries are attacked is usually from a pelvic peritonitis. In this way the ovarian surface is first implicated by contact with the inflamed peritoneum. In most cases the albuginea acts as an efficient barrier to prevent the organisms from breaking through into the parenchymatous tissue of the ovary, so that the process remains one of perioophoritis. In severe cases, how- ever, the infection may enter the ovary and cause an acute suppurative oophori- tis. Cases of this severity are usually fatal, but if the patient recovers the ovaries become involved in dense adhesions, often harboring chronic abscesses, until the infectious process gradually dies out or surgical operation intervenes. In such cases the ovaries are in a condition of true chronic oophoritis. Infection from puerperal sepsis may enter the ovaries by other ways than through the surface epithehum and albuginea. Sometimes the invasion may be by the route of the cellular tissue, from the parametrium through the hilus of the ovary into the ovarian stroma. According to Gebhard, the infection may reach the ovaries from a septic puerperium by the way of the parametrial blood-ves- sels as a result of septic thrombosis. Outside of the puerperium the greater number of infections of the ovary are GENERAL INFLAMMATORY PROCESSES ^253 the result of gonorrhea. As has been pointed out in the section on that subject, the surface of the ovary may become involved in the general peritonitic process accompanying gonorrheal salpingitis, or the inner structure of the ovary may become involved in suppuration by the passage of infection from the ostium of the tube through the ruptured opening of a corpus luteum or even of an atretic follicle. In this way, as was shown, are formed the tubo-ovarian abscesses. These compound abscesses harbor the invading organisms longer than does a simple pyosalpinx, so that the disease is more severe, longer in duration, and requires more radical surgical treatment. Tuberculosis may infect and include the ovary in a general suppurative proc- ess, extending from the tube in the same manner as gonorrhea. Miliary peri- toneal tuberculosis may affect the surface of the ovary, but rarely, if ever, in- vades the ovarian stroma through the epithelial covering and the protective albuginea layer, though occasionally it may enter the opening of a ruptured follicle. Isolated tuberculosis of the ovary, of which a few cases have been reported, is the result of hematogenous infection from a distant focus, as has been shown in the section on Tuberculosis (g. v.). The ovary in the form of an ovarian tumor may become infected as a result of torsion and adhesion to the intestine, from which, as a result of necrosis, organisms, usually the colon bacillus or some member of the staphylococcus group, convert the cyst into an abscess. The surface of the right ovary some- times becomes infected secondarly to acute appendicitis, especially in young girls. Infectious oophoritis sometimes results in intra-ovarian hemorrhages with the formation of blood-cysts, a subject which is discussed more fully in the section on Ovarian Tumors. Chronic infectious oophoritis represents the part taken by the ovaries in a general pelvic inflammation, and can hardly be regarded as a disease by itself. The symptoms from this condition are due to immobilizing peritoneal adhesions, and the special effect on the ovaries cannot be clinically distinguished. Chronic infectious oophoritis may be associated with or be converted into the interstitial type. INTERSTITIAL OOPHORITIS Interstitial oophoritis is a subject which we must treat somewhat apologet- ically, including as it does a number of conditions the pathogenesis of which we have only an incomplete knowledge. As stated above, interstitial oophoritis does not represent an infectious process, but rather one of tissue degeneration. In the earlier stages there is a general increase in the size of the organ. The interstitial elements are hypertrophied. There is a hyperplasia of the stroma cells without loss of their distinctive structure and also a well-marked thicken- ing of the albuginea. An acute stage has been described in which are seen 254 ' GYNECOLOGY clusters of small round cells near the blood-vessels, and sometimes an edema pervading the lymph-spaces between the stroma cells. In association with the changes in the interstitial tissue are practically always seen signs of degeneration in the parenchyma. There is marked diminution in the number of primordial follicles and an abnormal tendency to atresia and cyst formation of the riper follicles ("small cystic degeneration"). In addition to the above findings there can usually be seen a thickening of the vessels in the medullary zone of these ovaries, so that they appear as hyaline masses, indicat- ing a tendency to obliterating arteritis. Later stages of the process may exhibit an excessive cyst formation, in which usually one cyst develops at the expense of the others, and converts the ovary into a cystoma of greater or less size. (See Tumors of Ovary.) The cyst formation, according to Gebhard, is the result of an inability of the follicles to burst on account of the resistance of the dense albuginea layer, and represents a thwarted physiologic function. In other cases the interstitial elements undergo a sclerotic change, the parenchy- matous portions disappear, and the ovary shrinks into a small fibrous, atrophied structure resembhng that of old age. The etiology in some cases is quite clear, while in others it is entirely obscure. Ovaries that have long been buried in adhesions often exhibit interstitial oophori- tis. This process, though the secondary outcome of a previous infection, must, nevertheless, be regarded not as inflammatory, but as an indication of degenera- tion resulting from interference with the circulation and normal function of the ovary. Degeneration of the ovaries sometimes occurs after acute infectious dis- ease like typhoid, septicemia, small-pox, cholera, scarlet fever, and severe intoxications, such as are caused by phosphorus, arsenic, etc. The degenera- tion may be so complete as entirely to destroy the function of the ovaries, with consequent amenorrhea and sterility. Here the process is one which the ovaries share with certain other organs of the body after such maladies, and is not an infection, but a form of local degeneration. In lactation atrophy and premature senility a like change occurs in the ovaries. Other etiologic factors commonly supposed to produce ovarian degeneration have their basis in circu- latory disturbances. Of these may be mentioned chlorosis, harmful influences during menstruation, such as exposure to cold or violent physical exertion, in- complete involution of the uterus after childbirth, circulatory changes from chronic heart disease, sexual irritation from masturbation or imperfect coitus, extra-uterine pregnancy, and, finally, the influence of pelvic tumors, especially of uterine fibroids. Undoubtedly, oophoritis is sometimes found associated with ah of these conditions, but in our present state of knowledge a definite causal relationship between the two must be accepted with reservation. The symptomatology of infectious oophoritis is identical with that of pelvic inflammation, to which the reader is referred in the chapter on Gonorrhea. With regard to the symptomatology of interstitial oophoritis ideas have within recent years undergone a considerable change. We now know that GENEEAL INFLAMMATORY PROCESSES 255 atresia of the follicles is physiologic, and that a certain degree of small cystic formation is to be found in practically all normal ovaries during the menstruat- ing period of life, and that the process does not cause pain. Nor is pain in the ovary itself caused by an abnormal degree of cystic degeneration, even to the formation of a retention cystoma. If, however, adhesions are present, or there is torsion of the enlarged ovary or engorgement of the broad ligament veins, pain is in evidence. Moreover, sclerosis of the ovaries does not of itself cause pain. Old women have sclerotic ovaries, but do not suffer pain from them. It is probable that most cases of so-called ovarian pain result from peritoneal adhesions, varicosities in the broad ligaments, torsion of the ovarian vessels, possibly the drag of a heavy organ on the ovarian ligaments. Of these causes peritoneal adhesions is the most frequent. They cannot always be detected even by the most expert examination, and this leads frequently to such diagnoses as ''ovarian neuralgia." Another common fallacy is that cystic degeneration causes "reflex" nervous symptoms, such as hysteria, genital psychoneuroses, etc. This subject is dis- cussed in the section on Neurology. Interstitial oophoritis is a not infrequent cause of sterility, as would be ex- pected from the pathology of the affection. The treatment of infectious oophoritis is that of pelvic inflammation. The treatment of interstitial oophoritis depends on the associated condi- tion which causes the symptoms. It cannot be diagnosed except in the case of abnormal cyst formation when surgical interference is indicated, the opera- tion being conservative (resection) or radical (oophorectomy), according to the size of the cyst. The resection of ovaries which show moderate cystic de- generation is a useless and often harmful procedure. For cases of premature sclerosis and atrophy, ovarian extract is indicated. PARAMETRITIS AND PELVIC CELLULITIS Anatomy of the Pelvic Cellular Tissue. — Lying beneath the pelvic perito- neum is a complicated intercommunicating space filled with a somewhat loose connective tissue, which is termed the ''pelvic cellular tissue." This tissue partly surrounds all the organs of the pelvis. In it are embedded the ureters and the large vessels of the pelvis. In some places the cellular tissue is loose and filmy, a characteristic which originally gave the structure its name. In other places it is denser and contains smooth muscle-fibers. These thickened portions con- stitute the so-called ligaments of the uterus. The presence of muscular fiber is especially well marked along the uterine vessels near their entrance into the uterus, and gives the tissues at these points such firm supporting strength that they are designated the cardinal ligaments of the uterus. Certain parts of the pelvic cellular tissue are characterized by special names from their relationship, to various organs. Thus, that which is in contact with 256 GYNECOLOGY the uterus is called parametrial; that near the bladder, paracystic, and that near the rectum, paraproctal. Inflammations of these portions have the correspond- ing names of parametritis, paracystitis, paraproctitis, etc., while a general term including any form of inflammation of the tissue is "pelvic cellulitis." The parametrial cellular tissue surrounds that portion of the uterus and cervix that is included in the pelvic diaphragm. The most important part of it lies at the bases of the two broad ligaments. It is enclosed by the leaves of the broad ligaments above and merges into the wall of the vagina below. In front there is a certain amount of dehcate parametrial tissue between the bladder and its reflection on the anterior wall of the uterus. Behind, the peri- toneum is bound closely to the posterior wall of the uterus, cervix, and vagina, so that there is little parametrial tissue in evidence. In close connection with the parametrium is the cellular tissue about the bladder. It communicates in front of the bladder with the very loose fibers which occupy the so-called prevesical space or space of Retzius. Behind, the parametrium is less directly connected with the paraproctal ceUular tissue in relation with the rectum. Between the rectum and vagina is found a layer of the tissue which communicates behind with a layer between rectum and sacrum. The subperitoneal cellular space reaches out laterally to the abdominal wall and posteriorly to the lumbar vertebrae. Besides these comparatively direct communications, the tissue ramifies to other areas by narrow channels. Thus, it connects with the fat of the ischio- rectal fossa by a smafl opening between the ischiococcygeus and the levator ani muscles. With the interstitial connective tissue of the lower extremities a com- munication exists through the crural arch along the crural vessels. A similar connection with the gluteal region is found through the greater ischiadic open- ing; also one with the inguinal region along the round ligament. The area occupied by the pelvic cellular tissue must be regarded as a space through which infection may spread along lines of least resistance, or which' extravasations of blood may permeate, or which tumors may readily dissect in the process of growth. The pathology of the cellular tissue is, therefore, classified into three phases — inflammation, hematoma, and tumor formation. The first two phases will be discussed in this section, the third is treated in the section on Tumors. INFLAMMATIONS OF THE PELVIC CELLULAR TISSUE Infection of the cellular tissue occurs as a microbic invasion through lymph- channels, the most common seat of infection being the parametrium. The inflammatory process may remain localized or it may spread to other parts of the cellular space. It usually affects the overlying peritoneum, the inflam- mation of which may be confined to the local area or spread in the form of a general peritonitis. The infectious process may reach no further than the GENERAL INFLAMMATORY PROCESSES 257 stage of infiltration, or it may progress to suppuration of the most extensive character. Just as there is a wide range in the pathologic aspects of cellulitis, so, in the chnical picture, the disease may vary from one of mild insignificance to one of rapid fatal termination. Pelvic cellulitis practically always implies a thrombosis of the veins which pass through the tissue involved. In a parametritis the thrombosis may be confined to the branches of the hypogastric and internal spermatic veins, but it may extend to the internal iliac, common ihac and crural veins, and even to the vena cava. The relationship between the inflammatory process and the formation of thrombi is not a constant one. Extensive thrombosis is frequently seen in con- nection with slight evidence of parametrial infiltration and vice versa. The most important secondary results of thrombosis are pulmonary emboHsm and the edema of the lower extremity in cases where the crural vein is involved (phlegmasia alba dolens — milk leg). If the inflammatory process of the cellular tissue progresses to local suppura- tion the abscess may break through into neighboring organs, most commonly the vagina, rectum, or bladder, occasionally into the cervical canal. The healing of celluhtis results in dense scar formation, which may cause serious dislocation and immobihzation of the pelvic organs. The interest in ceflular inflammation centers chiefly in that of the para- metrium. Parametritis is most commonly an obstetric disease, infection result- ing from some trauma of the cervix by which pathogenic organisms are intro- duced, or from a puerperal septic condition of the endometrium through the lymph-channels of the uterine wall. The obstetric aspects of parametritis can- not be treated here. From the standpoint of gynecology, parametritis is most commonly seen as a compfication of pelvic operations. The operation most frequently followed by this affection is that of hysterectomy for pelvic inflammation, in which there exists some active infectious process in the subperitoneal ceflular tissue. Just as cellulitis may involve the overlying peritoneum, so a pelvic peritonitis may also implicate the underlying cellular tissue. Removal of the pelvic organs sometimes lights up the infection of the ceflular tissue, and local sepsis, usuafly in the parametrium, results, which if not well provided for by competent drain- age may cause the backing up of a pelvic abscess. Postoperative cellulitis or parametritis may follow any pelvic operation in which the ceflular tissue is infected during the operation; for example, the parametrium may be infected from a septic endometrium by careless handflng of the uterus during a hyster- ectomy operation. A parametritis may also result from a parametrial hematoma that later becomes infected. Minor operations, such as dilatation and curetment, the use of the sound, and operations on the cervix, if performed without aseptic precautions have been known to cause parametritis. Even foreign bodies in the vagina, which cause 17 258. GYNECOLOGY ulceration and local infection, may transmit the inflammatory process to the parametrium through the lymph-channels. Inflammation of the parametrium from these latter causes are, however, rare. An important factor in the causation of gynecologic parametritis is the in- fection from necrotic tumors of the uterus and cervix, such as sloughing fibroids and cancer. Cancer of the cervix is especially prone to infect the parametrium, harboring, as it always does, the most virulent organisms. This point is of special clinical importance, because it is often difficult to determine by palpation whether a parametrial infiltration is due to the extension of inflammation or of cancer, and on this point often rests the decision as to whether or not the case is operable. It is possible for the parametritis foUowing the infection of cancer of the uterus to extend to the pelvic peritoneum and cause a local or even a general peritonitis. Rare causes of parametritis are the spreading of infection from appendicitis and the invasion of actinomycosis. Wertheim gives as an unusual cause of parametrial inflammation the deep invasion of the gonococcus through the peritoneum. An actual gonococcal parametritis is probably rare, nevertheless the cellular subperitoneal tissue is very frequentty found edematous and inflamed during operations for pelvic inflammation of gonorrheal origin. Doubtless the invasion of the cellular tissue is the result of other organisms which so often complicate all gonorrheal infec- tions. Extensive tuberculosis of the pelvis is sometimes attended with deep infil- tration of the cellular tissue. Symptoms. — The chief symptom of postoperative parametritis is pelvic pain, usually more on one side than the other. On account of the proximity which the process has to the bladder, and the usual extension to the paracystic cellular tissue, there are, as a rule, symptoms of irritable bladder with the pres- ence of a mild cystitis. There is always some elevation of temperature, and if suppuration occurs there is a marked rise in the leukocytosis and an increase of local symptoms. Postoperative parametritis, though it may progress to a fatal termination, is usually not a particularly dangerous comphcation, though it may prolong the convalescence for many weeks. If there is suppuration, and evacuation of the pus is brought about either spontaneously or by secondary operation, a rapid cure usually results. Cases in which the parametrial infection is of the infiltrat- ing, non-suppurative type, though milder in their course, have a tendency to recurrence one or more times weeks or months after subsidence of the first attack. . A very chronic form of parametritis, compHcating pelvic inflammation re- sulting from salpingitis and adhesions in the posterior culdesac, is often met with during pelvic operations. The cicatricial tissue caused by this comphca- tion is exceedingly dense, and greatly increases the difficulty and danger of the GENERAL INFLAMMATORY PROCESSES 259 operation. This condition is almost invariably met with when a previous posterior colpotomy has been performed for the evacuation of a tubal abscess, and it is for this reason that the latter operation is to be avoided excepting as a life-saving measure. The chronic form of parametritis is also frequently encountered during the extended operation for cervical cancer, a complication which makes the isola- tion of the ureters and uterine vessels extremely difficult. Patients who have had radium treatment usually show the cicatricial form of parametritis to a greater or less extent. The cicatricial type of chronic parametritis is termed ''parametritis atrophi- cans" (Freund) and "parametritis posterior" (Schultze). Postoperative parametritis is, as a rule, easily detected by digital examina- tion. The cervix is entirely immobilized, and there is a hard board-like feel to the surrounding tissues which is entirely characteristic, and simulated only by the infiltration of malignant disease or by a parametrial hematoma. The indurated area is situated on one or both sides of the cervix, reaching to the pelvic wall, very often extending around to the front if the paracystic tissue is involved. It is usually tender. Suppuration is indicated by increased swelling and softness of the mass, associated with rise in the leukocyte count and aggra- vation of the constitutional symptoms. A differential diagnosis between infectious parametritis and postoperative parametrial hematoma cannot always be made. Hematoma is, as a rule, les^ tender, constitutional reaction is less marked, and the leukocyte count is lower or absent. Parametritis associated with cancer of the cervix, if of the chronic exuda- tive type, cannot well be differentiated from infiltration of the malignant dis- ease. If the process is more acute the patient has well-defined symptoms of pelvic inflammation. Such patients should not be operated on, nor should they receive radium treatment, which not only tends to aggravate the inflammatory process, but also intensifies the malignity of the cancerous disease. The use of radium not infrequently of itself produces an inflammatory reaction in the parametrium, which makes radical operation immediately following radium treatment exceedingly dangerous as regards postoperative sepsis (see also Radium Treatment of Cancer). The treatment of postoperative parametritis is usually palliative because in most cases the process tends to absorption rather than to suppuration. The best treatment is rest in bed with frequent hot vaginal douches. Absorption under treatment may take place in a few days, but may require several weeks, sometimes months. If suppuration occurs the abscess must be opened and evacuated, usually by a vaginal incision. Sometimes a postoperative para- metrial abscess may be evacuated by careful dilatation of the canal of the cervi- cal stump. If there has been vaginal drainage, enlarging the drainage opening may be all that is necessary. 260 GYNECOLOGY Extensive dissecting abscesses may require more than vaginal drainage. In some cases they may best be opened by an incision near the groin, through which the peritoneum is stripped back without entering the abdominal cavity, so that the abscess may be evacuated extraperitoneally. It may even be neces- sary to attack the disease by incision in the gluteal, perineal, or ischiorectal regions. Septic cellulitis may follow pelvic operations and originate in other parts of the cellular space than the parametrium. We have seen two cases of exten- sive cellulitis in the lateral wall of the abdomen and pelvis follow shortening of the round ligaments by the Mayo method. Suprapubic operations on the bladder may result in sepsis of the cellular tissue and cause a dissecting abscess reaching to the lumbar region. Other instances might be enumerated. The treatment of these abscesses can sometimes be carried out successfully by con- servative measures, but in general it is best to open them by the most advan- tageous route. PARAMETRIAL HEMATOMA Parametrial hematoma, though not an inflammatory disease, is treated here because of its close association with parametritis. The hematoma results from some trauma which has caused a hemorrhage into the parametrial tissue. Being partially confined, the extravasated blood soon clots and forms a dense tumor. The tumor may be restricted to the parametrial region, or it may dissect its way through the cellular space upward as far as the region of the kidney, forming an immense tumor. Severe parametrial hematomata are most frequently seen as an obstetric complication, following laceration of the cervix into the broad ligament, with rupture of veins in the parametrial tissue. In gynecologic practice extensive hemorrhages into the cellular tissue may occur during the enucleation of intrahgamentous or postperitoneal growths. The accident is discovered by the appearance of a rapidly increasing tumor in the flank, with evidences of shock on the part of the patient. Such a hemor- rhage may be fatal, or the blood may soon clot and the patient be little the worse for the accident. Postoperative parametrial hematoma is by no means uncommon, especially after supravaginal hysterectomy. The comphcation is due to incomplete hemo- stasis and postoperative oozing of blood into the parametrial space. Fre- quently it entirely passes notice unless the patient receives a vaginal examina- tion before leaving the hospital. In other instances the convalescence lacks smoothness. The temperature continues to be slightly elevated and the pa- tient experiences some pelvic discomfort. Sometimes the patient within a few hours after operation passes through a temporary period of shock with very rapid pulse, for which the attendants are unable to account. Vaginal examination of a patient with parametrial hematoma reveals a hard board-like induration adjacent to the cervical stump and complet-ely im- GENERAL INFLAjVI^L^TORY PROCESSES 261 mobilizing it. The induration may extend forward into the paracj'stic region; sometimes it extends to the pelvic wall. The hematoma is usually slow in absorbing, and maj^ remain weeks or months in the pehds before its disappearance. Sometimes it becomes infected and converted into a parametrial abscess. The treatment of parametrial hematoma is primarily prophylactic, and consists in taking extreme care in hgating all bleeding points during the opera- tion of hysterectomy, or, better still, to perform the operation in such a way that there will be no bleeding. The maneuver shown on page 722, of closing the peritoneum over the cervical stump in such a way that there will be oppor- tunity for drainage back into the peritoneal ca\'ity of slight oozing, is a good l^reventive, for blood is much more readily absorbed from a peritoneal surface than from the parametrial tissue. When a hematoma has been formed surgical interference is practicalh^ always contraindicated. The treatment should be conservative, as in the exudative form of parametritis, and consists in rest and the frequent application of hot douches. If the hematoma becomes infected the treatment then becomes that of suppurating parametritis. URETHRITIS Acute urethritis is almost exclusively the result of gonorrheal infection, and has been described in the chapter on Gonorrhea {q. v.). The infection is usually primary and appears after a short incubation period. There is at first discomfort, then intense burning, on micturition. The meatus becomes swollen and hyperemic, while the entrances to the ducts of Skene's glands become red and sw^ollen. A thick j^ellow pus appears, and occasionally there is bleeding from ulceration or fissure of the urethral membrane. The acute stage of the disease passes quickly. The pus becomes thinner and more scanty, and the disease either heals spontaneously or passes on into the chronic stage, which maj^ last for months or years. Gonorrheal urethritis may come and go without producing noticeable s^nnptoms. (See also section on Gonorrhea.) Chronic urethritis may be the end-result of an acute gonorrheal attack, or the gonorrheal infection may be of the chronic type from the first. Chronic urethritis maj^ also be primarih^ the result of infection from other organisms than the gonococcus, those most commonly found being the colon bacillus and the staphylococcus. It is, however, very difficult to say in a given case whether the original infection was or was not gonococcal, for in a chronic urethritis which remains from an acute gonorrheal attack various pathogenic organisms may be found without the presence of the gonococcus. Primary colon bacillus urethritis doubtless occurs, but its frequency is problematic. Chronic urethritis is localized in certain portions of the urethra, not often involving the entire canal. The principal symptom of chronic urethritis is burning on micturition. 262 GYNECOLOGY Its long and intractable persistence usually has a deleterious effect on the general nervous system, especially if the patient thinks herself infected with a venereal disease. Treatment is by the local apphcation of 5 per cent, silver nitrate to the urethra, and requires time and patience. Periurethral abscess is usually secondary to inflammation of Skene's glands, and occupies the anterior vaginal wall in its lower third. It communicates by a small opening with the urethral canal, into which it intermittently discharges. The abscess contents may change in time to a thin or serous character and the condition become painless, so that the swelhng may be mistaken for a vaginal cyst. The diagnosis can be made by the ability to evacuate the tumor into the urethral canal. The treatment is removal of the abscess or cyst sac by careful cHssection. The opening into the urethra must be treated by the methods used for vesical and urethral fistula. Stricture of the urethra is not a common affection among women. It is usually the result of gonorrhea, but may be due to the injuries of childbirth. Urethral stricture is not infrequently seen in women with marked genital atrophy, the process simulating that which takes place in the cervix with con- sequent atresia. The symptoms are difficulty and discomfort in urination. The treatment is usually simple, and consists either in gradual dilatation under cocain or rapid dilatation under full anesthesia. The severe cicatricial form of stricture, which is rare, may require annular dissection of the scar tissue. Kelly recommends electrolysis, by the method of Newman, as a routine method of treating intractable stricture. CYSTITIS Cystitis, in its strictest sense, relates to an infection of the bladder wall by pathogenic organisms. The existence of a cystitis is demonstrated by the presence of infectious bacteria and the products of inHammation in the urine. The mere presence of bacteria in the urine does not constitute a cystitis, for it has been shown that quantities of germs may be introduced into the bladder without harmful effect, while it is a common occurrence that patients with septic processes in the kidneys for long periods of time pass urine that is loaded with bacteria without infecting the bladder. In order to create a cystitis, bacteria must find a point of entry into the tissues of the bladder wall through the lining epithehum. This entrance may be gained either by a lesion of the bladder wall or by some condition in which there is a lessened resistance on the part of the mucous membrane. Injuries of the bladder mucosa may be caused by traumatism during operations, or in- GENERAL INFLAMMATORY PROCESSES 263 strumentation, or by unskilful catheterization. The lesion itself does not con- stitute a cystitis, but prepares the way for infectious organisms. Invasion of the bladder by bacteria may result from the trauma of vesical stones, or from inflammatory processes of neighboring organs, which, by contact and adhesions, involve the bladder wall. The resistance of the bladder mucosa may be lowered by the irritation of chemical substances excreted in the urine, such as results from the ingestion of cantharides, asparagus, fermented hquors, etc., or it may be caused by the long retention of urine from cystocele or stricture from pelvic tumors. Severe colds and physical exhaustion also lower the resistance of the bladder to infection. Conditions of lowered resistance do not necessarily lead to cystitis, but they merely predispose the organ to infection. They are prob- ably an infrequent etiologic factor in the disease. The irritation of ammoniacal urine is a very definite cause for bacterial infec- tions, the chemical change being usually brought about by bacterial action. A very great number of bacteria have been named as excitants of cystitis, the most important being the Coh communis, proteus Hauser, streptococcus, staphjdo- coccus, pyocyaneus, tubercle bacillus, typhoid bacillus, and rarely the gono- coccus. There may be combined or mixed infections, especially in the presence of the tubercle bacillus. The reaction differs also with various exciting organ- isms, the urine, for example, being alkahne with the proteus Hauser and acid with the staphylococcus or colon bacillus infections. Routes of Infection. — The chief route of invasion by infectious organisms is through the urethra. It has been a matter of considerable debate as to whether spontaneous ascending infection takes place through the urethra. This has been generally denied in the male, but thought to be possible in the female on account of the shorter and less comphcated urethral canal. It has been pointed out, however (Stoeckel), that the entrance of bacteria to the bladder is conditioned on the integrity of the sphincter vesicae muscle, which under normal conditions is as efficacious in women as it is in men. In women, on the other hand, there is far greater opportunity for injury to the muscle, such as results from childbearing, cystocele, and general conditions of prolapse, so tkat it much more frequently becomes relaxed and affords an avenue of entrance for bacteria from the urethra and vestibule. The most common means of infecting the bladder through the urethra is by catheterization. This may be accomplished by carrjdng organisms into the bladder on an unclean catheter, or it may be done by transferring bacteria from the vestibule and meatus on a catheter that has been properly sterihzed. Postoperative cystitis following catheterization and introduction of organisms depends, to a. great extent, on the amount of trauma done to the bladder during operation. Aside from the actual accidental tearing or cutting, the bladder wall may be injured in a variety of ways not always appreciated by the surgeon during a difficult pelvic operation. Kelly calls attention to the furrowing and infiltration of blood seen in the mucosa of the posterior wall fol- 264 GYNECOLOGY lowing the method sometimes used of stripping the bladder by gauze dissection from the cervix and. vagina during a hysterectomy operation. The careless clamping and tying of vessels in the bladder wall may cause local injuries or congestions, which sometimes develop minute ulcerations or desquamations of the lining epithelium resulting from extravasations of blood (Stoeckel). These may serve as ports of entry for bacteria introduced by catheterization. Cystitis is especially common after labor because of the frequency of injury to the bladder by the passage of the head and the necessity for catheteriza- tion. It is noticeable that patients who have suffered from postpartum cystitis are especially prone to develop the condition after later labors or pelvic opera- tions which involve the bladder, such as hysterectomy or anterior colpoplasty. It has been shown that the hyperemic state of the bladder wall during childbirth is especially favorable to the growth of invading organisms, as are all conditions of pelvic congestion, such as may result from menstruation, large pelvic tumors, adnexal disease, masturbation, and too frequent coitus. Another means of infection of the bladder is by the descending route from the kidneys, though, as has been stated, pus in the urine from infected kidneys may exist for a long time without causing cystitis. There seems to be no doubt that infection may be carried to the bladder wall by the route of the blood circulation — so-called hematogenous infection. Undoubtedly, some of the cases of colon cystitis have thus been contracted from congestion and stasis of the intestines. The cystitis that sometimes fol- lows acute infectious diseases, like tj^phoid, malaria, and influenza, in which the specific organism can be demonstrated in the urine, undoubtedly results from a hematogenous infection. There seems to be no question also that micro-organisms may reach the bladder through the lymph-channels, either from the large intestine or from infections of the pelvic genital organs. Cystitis may also be caused directly by the rupture into the bladder cavity of a tubal abscess or dermoid cyst or purulent diverticulitis. A somewhat frequent secondary inflammation of the bladder is that which results from a parametritis, the organisms probably entering the bladder wall through the lymph-channels. This is seen both in puerperal sepsis and in the postoperative parametritis that occasionally follows hysterectomy operations, especially those for extensive purulent pelvic inflammation. The spontaneous infection of an ascending gonorrheal urethritis is probably rare. The organism has been demonstrated in acute cystitis by Wertheim and Young, so that gonorrheal cystitis unquestionably exists. It is probable, how- ever, that in most cases the disease is transferred to the bladder by ill-considered instrumentation or treatment of the urethral canal. Pathology. — The mucosa of acute cystitis has a characteristic appearance of general reddening, injected branching blood-vessels, and edematous thickening of the membrane, with ecchymoses and erosions, seen most commonly at the GENERAL INFLAMIV^ATORY PROCESSES 265 trigonum. The inflammatory process, as a rule, does not affect the entire bladder wall equally, the floor, including trigonum and fundus, being the chief seat of the infection. According to Kelly, in the acute stages there is com- paratively little loss of epithehum. Severe inflammatory processes may, how- ever, take place, with very general necrosis of the cpithehal layers, forming so- called croupous or diphtheritic membranes, or even reaching the muscularis and causing gangrene of the bladder. Gangrene results in sloughing of the inner lining of the bladder, with consequent thinning of the wall and possible rupture or extension of the inflammation to the peritoneum (Kiistner). Heahng of this condition results in great shrinking of the organ. A special appellation, used by Kelly for conditions of sloughing of the bladder waU, is exfoliative cystitis. In the chronic stages of cystitis the changes are very numerous. Certain proliferations of the epithehum may take place, producing granular, warty, or polypoid elevations of the surface, to which special names, as cystitis vegetans, verrucosa, and polyposa, have been given. Metaplastic conditions of the epithehum characteristic of leukoplakia and xerosis are seen which are said to lead to cancer of the bladder (Albarran). The proliferating papillomatous forms of cystitis can sometimes be differentiated with difficulty from true new-growth papillomata, the transition from one condition to the other being gradual. In some cases there occurs a dipping down or infolding of the mucous membrane, with the ultimate creation of gland-hke inclusions. The epithehum hning these pseudoglands becomes modified, and resembles the mucosa of the intestinal tract. The inclusions may form cysts, which in the female bladder often break down, ulcerate, and become incrusted with calcium salts (Kelly). The gland inclusions are doubtless the original seat of adenocarcinoma of the bladder. It has been pointed out (Zuckerkandl) that isolated cysts may occur in nor- mal bladders, but that the condition is pathologic when they become multiple or diffuse. The affection has been termed cystic cystitis and herpes vesicw. Simple or solitary ulcer of the bladder occurs usuafly on the posterior waff, and resembles somewhat tubercular ulceration. The cause of simple ulcer is thought to be from local trophic injury to the bladder wall by thrombosis of a ■vein. Stoeckel has observed them after pelvic operations where vessels had been tied in the wall. These ulcers are sometimes made by inexpert cystoscopy. The capacity of the bladder may, as a result of chronic inflammation, be- come greatly diminished by a cicatricial change in the bladder waU, with con- sequent shrinking of the organ, or by a concentric hypertrophy of the tissues of the wall. The shrunken bladder is most commonly the result of neglected vesical tuberculosis, secondary, as a rule, to tuberculosis of the kidneys. The waff is stiff and unyielding, neither dilatable to its full extent nor able to con- tract to its normal limits. Paracystitis relates to an inflammation of the connective tissue about the bladder, the infection of which may have come from a cystitis or from a para- 266 GYNECOLOGY metritis. Purulent paracystitis may extend for a long distance in the sub- peritoneal cellular tissue and may result fatally. Pericystitis is an inflammation of the peritoneum covering the pelvic portion of the bladder. It may result from cystitis or from a general pelvic inflamma- tory disease, by which the adnexa or anterior wall of the uterus or intestines become attached to the bladder. As a rule, however, the anterior half of the pelvis is peculiarly free from infection in adnexal disease, so that the bladder is only occasionally involved. Symptoms and Course. — The characteristic symptoms of acute cystitis are pain, dysuria, frequency of urination, and pus in the urine. The bladder is tender and sensitive to abdominal and vaginal palpation and to the passage of the catheter. The dysuria in cystitis is usually distinctive, in that the pain is severe just before micturition and is relieved by the act, that of urethritis being most severe during urination. The completion of urination is attended with tenesmus. If the affection is severe and there is great frequency, the condition of the patient may be one of almost constant strangury. The pain often radiates into the vagina, rectum, and legs. The symptoms are most distressing at night on account of disturbance of rest and sleep by the incessant need of mic- turition. In the acute stages there is usually fever which may reach a considerable height. The fever recedes with the subsidence of the acute disease, but if after careful treatment it still remains elevated, one must search for other causes, especially an ascending infection to the kidney pelvis. Acute cystitis under rest and proper treatment, as a rule, heals after vari- ous exacerbations, but it may exceptionall}^ develop into the chronic form (Stoeckel). Symptoms of chronic cystitis are, in general, the same as those described for the acute form, though less intensive, except in the cases of contracted blad- der, when distressing symptoms may continue for long periods of time. Bleed- ing is comparatively rare in cystitis unless it is associated with stone or tumor formation. A possible complication of cystitis is an ascending infection resulting in pyelitis or pyelonephritis. Occasionally the inflammation may extend to the peritoneum or paracystic tissue, or may send embolic thrombi into the circu- lation with the production of a pyemia. The duration of chronic cystitis may be indefinite, resisting all forms of treatment and lasting for years. The diagnosis of acute cystitis is not a difficult one, as the clinical picture is very characteristic, consisting of severe pain and frequent necessity of micturi- tion, with distressing tenesmus, a sense of fulness and pressure in the pelvis, tenderness of the bladder region, rise of temperature, and presence of pus in the urine which is usually neutral or alkaline. A very similar picture is presented in acute gonorrheal urethritis which can, as a rule, be differentiated from GENERAL INFLAMMATORY PROCESSES 267 cystitis by the appearance of gonorrheal pus exuding from the urethra and by the two-glass urine test, the second urine being clear in urethritis. • The diagnosis of chronic cystitis is a much less simple matter. The subjec- tive symptoms are less characteristic and cannot always be distinguished from those that result from pressure or traction from affections of neighboring organs. The examination of the urine affords only incomplete evidence. The cloudy appearance of a urine that has not been freshly voided is misleading on account Fig 65.^-Unusual Result of an Exfoliative Cystitis, which has Caused Plastic Adhesions OF THE Bladder Wall, with Great Contraction of the Bladder. The adhesions are being severed in order to give greater capacity to the bladder. Through the cystoscope the appearance was that of multiple diverticula. (Operation by Dr. F. A. Pemberton at Free Hospital for Women.) of the possibility of urates or phospates or bacteria causing the cloudiness. If the freshly passed or catheterized urine is cloudy the condition is pathologic. If pus is found by microscopic examination an inflammation is evidently present, but its location is not indicated, as it may come from an infection higher up. Washing out the bladder gives some information as to whether the condition is one of cystitis or pyelitis. In cystitis the wash-water soon returns clear, and will remain clear for some time, while in pyelitis there is an early reappearance of pus. 268 GYNECOLOGY Though cHnical observations give a more or less valuable clue to the nature and location of the disease, a definite diagnosis can only be made with the cysto- scope. In acute cystitis cystoscopy is entirely contraindicated on account of the danger of aggravating the inflammation, but in chronic cystitis it is essen- tial for diagnosis and often for treatment. The cystoscope will reveal the presence or absence of an inflammation of the urethra, while a simple pyehtis may usually be determined by exudation of pus from the ureteral oriflce, associated with a normal bladder wall. The changes of the bladder wall are numerous, as has already been stated, and consist chiefly of various grades of vascularization, from intensive infection of the blood-vessels to diffuse bright or dark red coloring of the tissues, in which the distinct outlining of the blood-vessels entirely disappears. The glistening appearance of the normal mucous membrane is lost and the surface appears dull. The mucosa from edema often has a puffy and granular character. The purulent secretion is either attached to the wall in shreds or floats freely in the fluid con- tained in the bladder. In advanced cases defects of the epithehum take place, with consequent ulcers with irregular flat edges. These ulcers on healing cause sharp cicatricial ridges which interfere with the elasticity and contractility of the bladder wall. The lesions of cystitis rarely occupy the whole of the bladder wall, but are, for the most part, confined to the floor of the bladder, trigonum, and fundus, the vertex being comparatively free from infection. As a rule, also, the inflamma- tory areas occur in scattered irregular patches, sometimes in spots or petechise. Prophylaxis. — In the postoperative conduct of gynecologic cases cystitis may, to a great extent, be prevented by proper regard to catheterization. The use of the catheter should always be avoided if possible, but the fact remains that the majority of patients recovering from pelvic or plastic operations require one or more catheterizations. This must usually be done by the nurse, but if she is properly trained or instructed infections from the use of the catheter may be reduced almost to nil. The following is the technic employed at the Free Hospital for Women: Under aseptic precautions the vestibule and meatus are thoroughly wiped with 1 : 1000 corrosive solution on sterile gauze. A glass female catheter with slight curve at the end is attached to a sterile foimtain syringe containing 2 per cent, boric solution or sterile water, the receptacle containing the fluid being held a short distance above the level of the patient. When the catheter is about to be introduced into the meatus the solution is allowed to flow until the end of the catheter reaches the bladder, when it is turned off and the rubber tube of the syringe is detached from the catheter. When the urine has been completely drained from the bladder the catheter is drawn gently out, with the thumb over the open end to prevent the dropping of urine as it is extracted. Every motion in introducing and withdrawing the catheter must be made with extreme gentle- ness so as not to injure the bladder mucous membrane. The glass catheter is the best form. The surface is smooth and non-irritating and it can most easily be sterilized and kept sterile. Its special advantage over a rubber catheter is that it can be introduced by grasping it well away from the end, while a rubber catheter on account of its lack of stiffness must be taken in the fingers near the end of entrance, thus adding an GENERAL INFLAMMATORY PROCESSES 269 f^lement of danger of infection. Metal catheters have sharp edges at the openings and easily- become rusted, so that there is greater danger of injuring the dehcate mucous membrane of the urethra and bladder. The treatment of acute cystitis is pre-eminently heat and warmth. The patient should be kept strictly in bed and applications of moist or dry heat kept over the bladder region. Moist heat is the most effective, and can best be applied with pads of wool soaked in hot normal salt solution, by which method the frequent changes are not likely to cause maceration of the skin, as is the case with cotton pads and plain water. In order to relieve pain, codein or opium rectal suppositories are indicated, subcutaneous injections of morphin being avoided excepting in extreme cases. Kelly calls attention to the importance of determining as soon as possible the exciting or- ganism, showing that the treatment should be varied according to the kind of bacterium found. To quote Dr. Kelly: "We are able here to distinguish five different forms of treatment, according as they are apphed to one or other of these groups of infecting organisms : for example, when tubercle baciUi are found, the general practitioner may safely conclude at once that the trouble is quite cer- tainly renal in its origin and surgical in its treatment. Gonococcal cystitis will disappear under the use of oil of copaiba or the oil of sandalwood. The colon bacillus and the typhoid bacillus are more affected by urotropin taken in doses of 3 to 15 or 20 grains four times a day, according to the toleration — big doses, if they do not ii'ritate the bladder, are, as a rule, most efficient. The diphtheria bacillus (rarely found) calls for the administration of antitoxin. If the proteus is found and the urine is alkaline, give benzoic acid in doses of 10 to 15 grains to make it acid, and then follow this with urotropin. Staphylococci and streptococci also call for the use of urotropin." A bland diet must be imposed in which alcoholic drinks and highly seasoned food is strictly prohibited. The patient is encouraged to drink large quantities of water, the numerous mild alkaline waters being especially recommended. When the more acute sjnxiptoms have subsided the best method of medication is the use of urotropin, cystogen, or helmitol, the efficiency of which depends on the liberation of formaldehyd in the urine. In order that the fomaldehyd be freed it is necessary that the urine be strongly acid. It is, therefore, important to change the reaction of neutral or alkaline urines by the use of benzoate of soda (doses of 10 to 15 grains), or by combining with the urotropin acid sodium phosphate in 10-grain doses. In the acute stage of cystitis all forms of local treatment of the bladder are strongly contraindicated. When, however, the more severe symptoms have passed, bladder lavage is of much assistance. The treatment of chronic cystitis is extremely varied, and depends on the character and duration of the disease. The treatment is one that requires experience and judgment, for if not intelhgently carried out the disease may drag on indefinitely, becoming progressively worse. The first step is to rule out the possibility of infection from disease higher 270 GYNECOLOGY up in the urinary tract. This can only be done by expert cystoscopy, cathe- terization of ureters, and a:;-ray photographs of the kidney, pelvis, and ureters. It will, of course, be found that in a large percentage of cases the origin of the trouble is from above, and that the essential treatment must be aimed in that direction. If the diagnosis of chronic cystitis is established the treatment is carried out according to the indications discovered by the cystoscope. For cases of general diffuse inflammation not tubercular, bladder douches are indicated, together with the medication mentioned above. The solutions most commonly used for bladder lavage are 2 per cent, boric acid, silver nitrate (1 : 10,000 to 5000), and a pale-pink solution of permanganate of potash. Of these, the boric acid is the least irritating and the safest to use,, though not as effective as silver nitrate. In giving lavage of the bladder care must be taken not to distend the bladder too much at first, for this not only causes pain, but may open up new avenues of infection. After washing out the bladder it is best to leave in some of the solution, to be voided by the patient about one-half hour later. Another method of treating the bladder is by instillations, which consists of injecting small amounts of some solution into the bladder and leaving it there for a certain period of time. The solutions most commonly used for this pur- pose are silver nitrate (1 : 1000), protargol. (5 per cent.), and argyrol (30 per cent.) . Kelly recommends, gradual distention of the bladder for certain cases when the capacity has become very limited. The treatment is carried out by a series of irrigations by which the amount of fluid injected into the bladder is progress- ively increased until the bladder, at first capable of holding only 30 or 50 c.c.,, is made to contain 200 or 300 or even 500 c.c. of fluid. The treatment requires great care and patience. A chart is kept to show the daily increase of bladder capacity (see Kelly and Burnam, Vol. II, p. 464). The treatment of localized areas of inflammation or ulceration is best car- ried out by the local application of silver nitrate through an open-air cystoscope, with the patient in the knee-chest position. Curetage for small ulcerated conditions can be carried out through a large cystoscope, care being taken not to injure the ureteral orifices, or it may be done through a suprapubic opening into the bladder. In severe long-standing cases of chronic cystitis it may be necessary to give the bladder a complete rest. This may be done either by constant drainage or by creating an artificial fistula. Constant drainage is carried out in the ordinary way, it being advisable to use a glass catheter, preferably that recommended by Skene. The relief produced by permanent drainage is in some cases remark- able. The bladder should be irrigated once or twice each day. Still more marked is the result of an artificial vesicovaginal fistula. This is done by mak- GENERAL INFLAMMATORY PROCESSES 271 ing an incision through the vesicovaginal septum posterior to the internal ure- thral orifice. The drainage can be maintained in two ways — either an opening is made large enough for the introduction of a self-retaining glass catheter which is sewed in place, or, preferably, an incision about f inch long is made and the mucous membrane of the bladder and vagina sewed to prevent too rapid closure (see page 815). By the latter method the urine drains out con- tinually, as in a case of traumatic fistula. It is best to keep these patients in a hospital until the disease has subsided in its severity, when they may be allowed to go home and be more or less active. If the perineum is tight it is necessary to enlarge it so that the vaginal introitus is funnel shaped, otherwise the urine is damned back in the vagina and bladder with injurious results. The final results of vaginal drainage are excellent. There need be no fear of making the opening into the bladder on the ground of a possible irremediable fistula, for it will be found that there is usually some trouble in keeping the fistula from closing spontaneously. If it does not close of itself, the operation of closure is practically always successful, for there is not, as in traumatic fistula, a loss of tissue, formation of cicatrices, and difficulty in approximating wound edges without tension. When cases of ulceration of the bladder have resisted all treatment, a radical excision can be performed through a suprapubic incision. TUBERCULOSIS OF THE BLADDER Tuberculosis of the bladder is practically always secondary to some other primary focus in the body. In women the infection is, with few exceptions, secondary to .renal tuberculosis, the disease never passing from the genital to the urinary tract, as it does in men. Renal tuberculosis may exist for years, even in a destructive form, before the bladder becomes chronically affected. On the other hand, the cystitis may assume an early and acute type, causing the most distressing and intractable symptoms, such as have been described above. The pathologic changes in the bladder wall range from disseminated tubercles of the mucous membrane, through various stages of ulceration involving the bladder wall more or less deeply, to rare cases of extensive destruction of the wall and invasion of the paravesical tissues. The diagnosis of a suspected case of tuberculosis of the bladder is directed to a search for the primary disease in the offending kidney, and this can at the present time usually be accomplished successfully by catheterization of the ureters, x-ray photographs, and renal functional tests. The treatment of vesical tuberculosis consists in the removal of the diseased kidney if the other kidney is not affected, information of which can be definitely established by the above-named methods of examination. If the disease in the bladder is not too severe, extirpation of the kidney suf- 272 GYNECOLOGY fices for a complete cure. Without removal of the kidney a cure is practically out of the question. If, after nephrectomy, the disease still persists, the various methods described above for treating chronic cystitis are available, especially that of drainage through a vesicovaginal opening. If only a locahzed residuum remains, it can be exsected through a suprapubic incision. In the most ex- treme cases the bladder has been completely extirpated and the ureters im- planted in the bowel. Kelly recommends the simpler method of cutting off the ureters and implanting them in bowel or skin, preferably the latter. When the disease is far advanced and relief from surgical measures is out of the question, the patient is to be treated like an inoperable cancer case, with doses of morphin sufficiently large to prevent suffering. SYPHILIS OF THE BLADDER Syphihs of the bladder is a very rare affection, having been recognized definitely only a comparatively few times. The manifestations are of the ter- tiary type, and appear as papillomatous elevations or as ulcerations without distinctive characteristics. The diagnosis is made by a positive Wassermann test, the improvement of the condition under salvarsan, or by finding the Spiro- chaeta palhda in a piece of the gummatous growth excised for microscopic exam- ination. CYSTITIS VETULARUM (OLD WOMEN) Inflammation of the bladder is common in old women, and is a result of general local atrophy which causes so many other disturbances. The shrinking of the tissues about the vaginal introitus affects the meatus, which is gradually drawn inward toward the vagina, often resulting, as we have seen elsewhere, in a partial prolapse of the urethral mucous membrane. The protecting labia minora shrink up and disappear, and the vaginal orifice, losing its former elas- ticity, remains stiffly open. Thus, the urethra is by its position exposed to in- fections from a senile vaginitis or from fecal contamination. The cystitis that ensues is a result of direct transmission of pathogenic bacteria through the urethra to the bladder mucous membrane. The resistance of the bladder to infection is greatly lessened in old women as a consequence of the atrophied anemic condition of the mucosa and the diminished elasticity and capacity of the bladder wall. ^ These aged patients suffer greatly from the frequent necessity of urination, often from actual incontinence, by which their rest is incessantly disturbed. Patients of the better class are much distressed by the constant odor of decomposing urine that pervades the room in which they live. Many of these patients are sufferers from other affections, such as rheumatism or bronchial catarrh, and dread afl local manipulation, so that treatment is very difficult. Hot bladder douches give the most relief if they can be given. GENERAL INFLAIVIjVIATORY PROCESSES 273 Occasionally the incontinence can be reKeved by the skilful application of a pessary. Bladder irritation usually occurs in old women, in the absence of bacterial infection, as a result of the senile changes in the bladder wall, which reduce its capacity and contractility. The symptoms are increased micturition and cloudy urine, the appearance in the urine being due to desquamation of the lining epithelium. These patients are often remarkably relieved by an occa- sional bladder douche given in amount sufficient to distend moderately the contracting bladder wall. PYELITIS Pyehtis relates to a bacterial infection of the mucous membrane of the pelvis of the kidney. It represents a milder form or preliminary stage of the more extensive inflammations of the kidney that pass under the names of pyelonephritis, suppurating kidnej^, and kidney abscess. The distinction be- tween pyehtis and the more severe forms of kidney inflammation is, therefore, one of clinical convenience rather than of any essential pathologic difference. Pyelitis bears an important relationship to gynecology in many ways, chief of which are the comparative frequency of the disease as a complication in the convalescence from gynecologic operations, and in the course of preg- nancy or the puerperium; its connection with gonorrhea; and the role that it plays in certain phases of gynecologic diagnosis. The knowledge of pyelitis has been greatly increased by the use of" the cystoscope, and it has been found that the disease is much more common than was formerly supposed, many cases that were before thought to be cystitis now being shown, by more exact methods of diagnosis, to be, in reality, inflammations of the pelvis of the kidney. The mode of entrj'- of bacteria to the kidney has been a subject of much dis- cussion and experimental work, and it is now known that infection may take place either through the agency of the blood circulation, the hematogenous route, or from the bladder upward through the ureteral canals — the urogenous route. Infection by the hematogenous or descending route is by far the more common, as has been proved both by clinical and experimental evidence. In- fection by the ascending route of cases is evidenced by clinical observations, but has not yet been established by scientific experimentation. The pathogenic bacteria responsible for pyelitis are pre-eminently the Coli communis, and of secondary frequency the staphylococcus, streptococcus, pro- teus, and probably the gonococcus. In addition to these, numerous other special organisms have been described that are either very rare or are possibly modified forms of the more common bacteria. In acute cases the staphylo- 18 274 GYNECOLOGY COCCUS, streptococcus, and proteus are more frequently present, while in chronic cases it is usual to find the colon bacillus in pure culture (Kelly). The presence of bacteria in the blood and their excretion in the urine does not necessarily betoken an infection of the kidney or its pelvis, for pathogenic organisms may pass through the kidneys for long periods of time without doing local damage. Infection is consequent on some condition that lowers the resistance of the organ, such as might result from a systemic disease or some local interference with the excretory function. Contributory to pyehtis and the other kidney infections are pyemia, septicemia, ulcerative endocarditis, pneu- monia, and the acute infectious diseases. Local causes are stone and hydro- nephrosis resulting from external pressure on the ureters, such as is exerted by tumors. Pregnancy and postoperative sepsis are especially important factors in causation. Ascending infections of the kidney pelvis are apt to follow condi- tions of urinary retention in the bladder, or inflammatory bladder lesions that affect the tissue at the openings of the ureters. The etiology of the pyelitis that complicates pregnancy and the puerperium has not been definitely determined. It is supposed that the resistance of the kidney is lowered by retention from pressure of the gravid uterus on the ureters or bladder, and that the infection, which nearly always is the colon bacillus, takes place through the blood route from the intestines, which are apt to be in a con- dition of stasis favorable for the absorption of bacteria. Pyelitis, complicating gynecologic operations can be explained in no other way than by a hematogenous infection from a septic focus at the seat of the operation. The primary focus is not always- apparent, for it not infrequently happens that pyelitis follows operations the wounds of which heal without appreciable sepsis. It is a matter of observation that surgical operations may light up an old pyelitis conjbracted during pregnanpy'.. Investigators are divided as to whether the gonococcus ever causes pyehtis. An ascending infection seems improbable. If the cases of so-called gonorrheal pyelitis are authentic, it seems more likely that the gonococci reached the kidney by the hematogenous route, the localiza- tion of the disease in the kidney being analogous to gonorrheal infections of the joints. Symptoms. — Acute pyelitis is ushered in with chills and high fever. The urine contains pus and albumin. The acute attack may end in death, or the fever may recede and become remittent, or the disease may develop into the chronic type. Repetition of chills and exacerbations of temperature signify usually involvement of the kidney parenchyma with abscess formation. Pain and tenderness of the kidney is usually, but not always, present. Chronic pyelitis may be the end-result of an acute attack, but more com- monly starts as the chronic form from the beginning. • The symptomatology of pyelitis is not always clearly defined. The essential GENERAL INFLAMMATORY PROCESSES 275 symptoms are pus in the urine, sensitiveness of the kidney region, moderate swelhng of the involved kidney, leukocytosis, irritability of the bladder, and disturbances of the general health. None of these symptoms are, however, to be relied upon. A pyelitis may exist many years without alteration in the health, constitutional changes being due rather to the gradual involvement of the kidney, which evokes the symptoms characteristic of diffuse hematogenous nephritis. Sensitiveness of the kidney, as shown by pain or tenderness, is present in only about half of the cases, while an appreciable enlargement of the kidney, such as can be felt by manual examination, appears in only about one-quarter of the cases. Dilatation of the pelvis, when present, is due to some obstruction or dislocation of the ureter, which may in some cases produce an intermittent enlargement of the pelvis like that seen in hydronephrosis. Cystitis is not always present, as the infected urine may pass through the bladder for a long time without exciting inflammation. Frequency of urination is, however, practically always present, due partly to chemical irritation of the bladder and partly to the fact that in most cases of chronic pyelitis there is an excretion of large quantities of urine (Kelly). As far as the examination of the urine goes, the presence of pus is the only constant sign. The reaction is usually acid, but may be alkaline. The caudate epithelial cells, formerly regarded as of important diagnostic value, are now known to be simulated by cells from the deeper layers of the epithelium lining the lower urinary tract. In a case of simple pyelitis the amount of albumin in the urine corresponds only to the pus contents. If the albumin is increased it bespeaks an involvement of the parenchyma of the kidney — pyelonephritis. Renal casts are not found in simple pyelitis, and their appearance signifies a pyelonephritis, though their absence does not necessarily rule out a nephritis extension. Leukocytosis is usually present, but there are exceptions to the rule. As pus in the urine is the only constant sign, the final diagnosis of pyelitis must be made with the cystoscope. In a pronounced case the diagnosis can be made by observing cloudy urine spurting from the urethral orifice. The ureters are then catheterized, and the diagnosis made by examination of the two specimens of urine. In a case of simple pyelitis the functional test of the kidneys shows little or no difference between the two sides. If, however, the kidney itself is impli- cated, the diseased side will always show retarded function. Postoperative Pyelitis. — The clinical course of the postoperative pyelitis which frequently occurs as a comphcation during the convalescence from gyne- cologic operations is so characteristic that it deserves special mention. It ap- pears more frequently after abdominal operations than after simple plastic or external operations, although it may occur after the latter. It is rather more common in women who have borne children. This is due to the fact that pye- 276 GYNECOLOGY litis is a frequent complication in the puerperium and, as has been stated, a patient who has once passed through an attack is extremely liable to a later recurrence either from another childbirth or from a surgical operation, even though it be years after the initial attack. A close examination of the histories of all patients who develop a postoperative pyelitis, whether they have borne children or not, will reveal a surprisingly large percentage of previous attacks. The time of onset of pyelitis following surgical operation seems to character- ize two types of the disease. In one the initial symptoms appear within two or three days following the operation. In the other the symptoms are not evident for one or two or even three weeks after operation. It has been a matter of personal observation that when the disease appears late the symptoms are more severe and last somewhat longer than when it develops early. As a rule, postoperative pyelitis comes unexpectedly in a patient who is making an otherwise satisfactory convalescence. The onset may be mild or severe. In the mild form the first evidence is a burning on micturition with a moderate rise of temperature and a general sense of malaise. The urine shows an increase of leukocytes. The symptoms increase for a few days and then subside. Even in the mild form the temperature may rise to 103° F. If the attack is early the time of surgical convalescence may not be prolonged and the patient may be little inconvenienced. Such a patient, however, is more susceptible to another attack if she undergoes a surgical operation at some later date. There is also possibility of recurrence during the convalescence. In the severer forms the attack may be acute and often alarming. There may be sudden intense pain on micturition. The temperature runs a characteris- tically high course for one or two days, frequently reaching 104° and 105° F. In these cases the kidneys usually show evident signs of the disease. One or both kidneys may be palpably enlarged, tender, and painful. Often these signs appear first in one kidney and then in the other as the first subsides. The average course in the severe form is about a week, though pus in the urine persists con- siderably longer. Patients are subject to one or more recurrences with inter- vals of a few days to several weeks. The great majority of postoperative pyelitis cases get well without leaving serious injury except a greater susceptibility to the disease. The prognosis of pyelitis is variable. A simple pyelitis may last years with- out encroaching on the kidney, but it may extend to the renal parenchyma and cause pyelonephritis. A quiescent pyelitis is very apt to be lighted up by preg- nancy and labor or by surgical, especially gynecologic, operations. The prognosis of unilateral affections is better than that of bilateral disease, in which uremic conditions may ensue. The treatment of acute pyelitis consists of rest in bed, hot applications, abundant ingestion of water, and urotropin. The treatment of chronic pyelitis is practically the same. Cases which GENEEAL INFLAMMATORY PROCESSES 277 do not yield to general medical measures can often be cured by lavage of the renal pelvis with solutions of silver nitrate (1 : 1000), bichlorid of mercury (1 : 10,000), and formahn (1 : 3000) (Kelly), the solutions being made some- what stronger as the treatment progresses. Vaccine therapy has been recom- mended, but most observers have found it of little value. Surgical procedures for the relief of pyelitis must be directed toward the removal of such causative conditions as pelvic tumors or constriction of the ureters, stones of the renal pelvis, etc. Surgical operations on the kidney for simple pyelitis are not commonly indicated. Nephrotomy, or splitting the kidney and leaving it open for drainage, is recommended, especially by Casper, but it is not an operation in general favor. Nephrectomy is indicated in those cases where an intractable cystitis is maintained by a pyelitis, and which does not yield to non-surgical treatment. INFLAMMATION OF THE COLON DIVERTICULITIS An important affection of the large intestine which the pelvic surgeon must bear in mind in the diagnosis of acute abdominal conditions, and which he must be prepared to treat when unexpectedly encountered, is diverticulitis of the colon. Diverticulitis is a disease the clinical and surgical significance of which has been only quite recently recognized, though anatomic knowledge of acciuired intestinal diverticula has existed for many years. Sommering, as far back as 1794, described a case of acquired diverticula of the small intes- tine. In 1845 Gross demonstrated and pictured diverticula in the large intestine. The con- dition was also described by Klebs, Alibert, Schroder, Sydney Jones, Astley Cooper, and others. In 1896 Hanseman found, at autopsy of a man of eighty-five, four hundred diverticula occurring throughout the entire length of the intestines. These historic cases were all from autopsies and were regarded merely as anatomic curiosities. In the translation of Noth- nagel's Encyclopedia, pubhshed as recently as 1904, the following statement is made: "As these lesions (acquired diverticula) are chiefly of anatomic interest and have very httle chnical significance, only a few general remarks will be made on this question." The general recognition of the surgical importance of the subject may be said to date back only a few years. In 1906 Sampson and Gogornier published their case of obstruction from diverticuUtis of the small intestine, and called attention to the fact that acquired diverticula not only occurred more frequently than is supposed by pathologists, but that they are the unrecog- nized etiologic factors in many inflammatory processes of the intestine, especially those occur- ring in the region of the sigmoid. In 1907 W. J. Mayo pubUshed 5 cases of diverticuUtis of the sigmoid and at that time was able to collect only 18 other authentic cases from the hterature. Since then surgeons and pathologists have given closer attention to the subject, and the record of cases is rapidly increasing both in the operating room and in the laboratory. Acquired diverticula are to be distinguished from so-called congenital di- verticula, of which Meckel's diverticulum and the vermiform appendix are 278 GYNECOLOGY the most familiar examples. It was formerly supposed that the acquired variety results from an actual hernia of the mucous coat through the fibers of the mus- cles of the intestines, and the term "false diverticula" was applied to them by Cruveilhier and Rokitansky, to distinguish them from the so-called "true diverticula," the name applied to the congenital form in which all the coats of the intestines are present. It has since been learned, however, that in the early stages of an acquired diverticulum all the coats are present, but that, as it de- velops, the muscle-fibers become atrophied by pressure and disappear partially or completely. The terms "true" and "false" are, therefore, no longer to be used synonomously with "congenital" and "acquired." Acquired diverticula may appear at any point in the entire length of the intestines, though more commonly in the sigmoidal region. They are rarely if ever seen in the rectum. Their occurrence in the appendix itself has been noted by Kelynak, Ribbert, Edel, Fischer, Mortens, Kelly, and others. The diverticula are practically always multiple, and range in number from two or three up to several hundred. In size they rarely occur larger than a hazel nut, and many of them are microscopic. Frequently they are difficult to find, since externally they may be completely hidden in masses of fat, and when searched for from the inner side of the bowel their openings may be so small as to escape notice. The diverticula are at first semiglobular in shape, but as they become larger and more distended they assume a more elongated form, usuallj'' with a constricted neck, a point which is of considerable importance in the matter of later pathologic changes. Most of the diverticula of the large intestine contain feces which are retained on account of the constricted nature of the neck. The diverticula of the small intestine, on the other hand, are, for the most part, empty, due partly to the more fluid nature of the intestinal contents and partly to the fact that the openings are less apt to be constricted. In the small intes- tine the diverticula are almost invariably along the mesenteric attachment, either between the leaves of the mesentery or just to one side. In the large intestine they may occur anywhere, but more commonly they appear on some part of the free border. They are very apt to protrude into the appendices epiploicge, and this is their commonest situation in the large intestine. Those which enter the epiploic appendages are characterized more than any others by having constricted openings. The walls of most of the more advanced speci- mens contain only the mucous membrane and serous coat. Some of the diver- ticula in the same specimen of gut may contain all the coats in their walls; others may be covered with only the longitudinal layers of muscle-fibers, while others may have only the mucous and serous coats. The etiology of these lesions has never been satisfactorily elucidated. It seems fairly evident, though not incontestably proved, that the fully developed condition is acquired and not congenital, from the fact that it has never been discovered in a child, and that it occurs in the great majority of cases after the GENERAL INFLAMMATORY PROCESSES 279 age of fifty. Most of the cases appear in individuals who have passed middle age and who have a tendency to obesity. In a considerable percentage of the cases constipation is an associated symptom. Anatomic study of the diver- ticula shows that they take place either at the point of entrance into the gut of blood-vessels or, more commonly, at the point of attachment of an appendix epiploica, both being sites of lessened resistance. The early investigators differed as to whether diverticula were formed by traction from without or by pulsion from within. Certain forms of diverticula are caused obviously by the traction of tumors or adhesions. It is conceivable that the diverticula of the small intestine may be caused by traction. The tremendous tractile force which the mesentery of the small intestine exerts on the gut during great distention is sufficiently familiar to surgeons. The diver- ticula in the free border in the large gut, on the other hand, can be formed in no other way than by pulsion. Apparently the amount of pulsion necessary to produce diveritula does not need to be extraordinary. Given the predisposing factor of innate local muscular deficiency, the ordinary pulsion that normally exists in the bowel is sufficient to bring about the result. An analogous instance is the gradual development of femoral or inguinal hernias in individuals who have never been subjected to strains, and who, on account of an inborn local tissue deficiency, are subject to the formation of hernias from ordinary intra- abdominal pressure. A sufficient number of cases has been collected from the operating-room and from the pathologic laboratory to show evidence that probably most people having diverticula suffer no harm from them. Diverticula of the small intes- tine appear to be almost without danger. In nearly all cases where symptoms have arisen the diverticula have been situated in the large intestine and usually in the region of the sigmoid. The reason for this is that the diverticula of the small intestine, unlike those of the large intestine, do not harbor feces. The mode of infection of diverticula is similar to that of appendicitis. The diverticulum, at first microscopic, becomes gradually pushed out into a pouch with a constricted opening. This pouch becomes a receptacle for feces which are not evacuated on account of the constriction. The fecal contents, decom- posing and hardened, become a nidus for various bacterial flora, and the con- cretion thus formed, irritating and ulcerating the mucous lining of the diver- ticulum, spreads infection by the lymphatics to the neighboring wall of the gut and to the peritoneum, or else actually perforates the wall of the diverticulum and causes a local abscess. Such an abscess may develop into a general peri- tonitis, or it may adhere to some hollow organ, more often the bladder, and discharge into it and cause a fistula; or the abscess mass may absorb spon- taneously. Heine has collected 8 cases of enterovesical fistulse which were proved to result from the adhesion of a suppurating diverticulitis to the bladder. Numerous other cases have been reported since. Undoubtedly many of the 280 GYNECOLOGY cases of gas and feces in the bladder have a similar origin. Hochenegge and Grifiin have described cases where carcinomata have developed from diverticula. The symptoms of acute diverticulitis are pain in the left side, with the forma- tion of an inflammatory mass which can sometimes be felt through the left flank, often in the left pelvis, by vaginal examination. Diverticulitis is of special interest to the gynecologist on account of the location of the inflammatory process in or near the left pelvis. When the dis- ease occurs low down in the bowel the symptoms and objective findings from bimanual examination may simulate closely a pelvic abscess of tubal or ovarian origin. If the disease is located higher up in the flank it may be confounded with a left-sided appendicitis, or with certain other inflammatory processes of the sigmoid, or with cancer. The diagnosis is important, for diverticuhtis is as dangerous as acute appendicitis, and requires prompt surgical interference. The treatment should always be surgical, and is complicated by the fact that the diverticula are practically always multiple, though the inflammatory process may be confined to only one or two of the pouches. In very severe cases the process may be so extensive that nothing more can be done than to open and drain the abscess, from which a persistent fecal fistula nearly always results. When possible, the best treatment is to resect the bowel and to reunite the canal, either by a lateral or end-to-end anastomosis. Sometimes the diverticula are so grouped that they may all be included in the resected segment of bowel. Frequently, however, diverticula must be left behind, which may possibly be- come inflamed at some later date and cause a repetition of the acute conditions. The author has had one such case. ISCfflORECTAL ABSCESS Ischiorectal abscess is an acute suppurative process located in the peri- rectal tissue about the lower end of the rectum and anus. Patients with pulmonary tuberculosis, and those who have had gonorrhea of the external genitals, are prone to this affection, though it often appears in individuals otherwise sound. The course of the disease is characterized by prehminary malaise and discomfort on defecation, followed by a chill, rather high fever, and great local pain and tenderness. A characteristic bulging tumor can be seen situated usually at one side of the anus and occupying the ischiorectal space. The abscess may break spontaneously and gradually subside, or, if not incised and drained, it may spread through the cellular and fat tissue in the ischiorectal fossa, and even extend to the opposite side. Such an abscess, if neglected, may cause the death of the patient by general sepsis. On account of the tendency of these infections to extend upward through the cellular and fat tissues, treatment should consist in early free incision and drainage. Ischiorectal abscesses are especially apt to result in fistulas. GENERAL INFLAMMATORY PROCESSES 281 FISTULA IN ANO Anal fistulas may be the outcome of previous ischiorectal or perirectal abscesses. The origin is commonly from an infected hemorrhoid. Neglected abscesses and those that rupture spon \A(.?t^ ^ taneously are usually followed by a per- manent fistula, and even those that re- ceive early surgical treatment are apt to suffer the same fate. The fistulous opening may assume one of several different forms, according to the position of its outlet. The fistula is said to be complete when it opens both inward toward the bowel and outward on the skin; it is said to be incomplete where there is only one opening, and this opening may lead either inward or outward, the other end of the fistula being blind. The outer opening is usually within one or two inches of the anus, but it may be further away, sometimes even appearing at or inside the perineal outlet. The inside opening is in most cases just within the anal margin between the upper and lower borders of the sphincter muscle. It may, however, be situated above the upper border of the muscle and com- municate directly with the lumen of the bowel. There may be a single internal opening which leads by communicating channels to several outlets on the skin. In the severe forms, especially those due to tuberculosis, the tissue may be greatly undermined with numerous openings fined with gray sluggish granula- tions, the surrounding skin being of a deep purple, unhealthy appearance. Usually the simple fistulas show externally only a small red papule situated near the anus and containing a minute opening through which a fine probe can be passed (Fig. 66). The internal opening may be microscopic, and is in most cases situated between the internal and external sphincter. Anal fistulse are extremely persistent and do not often heal spontaneously. "Under ordinary circumstances they do not give much pain, but keep the patient in a state of annoyance on account of the continued shght purulent discharge. Fig. 66. — Fistula in Ano. The opening of the fistulous tract usually appears as a small pimple near the anus. 282 GYNECOLOGY In many cases the external opening closes more or less periodically and causes a recurrence of the ischiorectal abscess. The treatment of fistula in ano is, as a rule, surgical, though some cases are so extensive as to be practicably inoperable. The use of pastes and wax preparations is not recommended except as a last resort, where surgery has failed. Surgical procedures are usually represented by one of two methods, one by which the fistulous tract is laid open and allowed to heal by granulation, and the other by which the tract is entirely extirpated by careful dissection. These methods are described on page 824. Dissection of the fistula is recommended, as it is usually followed by a shorter convalescence, and because it involves less danger to the sphincter muscle. The first method of open incision usually necessitates cutting a por- tion of the sphincter muscle. If the internal opening Hes between the upper and lower border of the sphincter, no harm is ordinarily done by dividing the lower external half, especially if the incision be made in a radial direction. If, how- ever, the internal opening is situated above the internal border of the sphincter, division of the muscle may result in permanent fecal incontinence, and may necessitate a later plastic operation for repair. By the dissection method it is usually necessary to do only slight damage to the fibers of the sphincter muscle, and whatever damage is done in the removal of the fistulous tract can readily be repaired by subcutaneous suture at the time of operation. A third method is one devised by Elting, who removes the lower end of the bowel containing the fistulous opening in the manner of a Whitehead opera- tion for hemorrhoids (see page 819). If the opening is below the internal sphincter and near the external orifice this method is probably superior to those mentioned. If, however, the opening is situated high, the dissection method is preferable. FISSURE IN ANO Anal fissures originate as small cracks in the surface tissue lining the folds of the anal margins. These cracks are usually made by the passage of hard, constipated fecal matter, which produces the lesion either by scratching the membrane or by overstretching the anus. Fissures made in this way usually heal spontaneously, but occasionally they become the seats of chronic ulcers which persist for months or years. The cause of the persistence of these ulcers is not definitely known, but it is thought that it may be due to the fact that the base of the ulcer becomes involved in the fibers of the sphincter muscle and is thus prevented from proper healing. The fissure bleeds easily and causes exquisite pain on defecation. For this reason the patient shrinks from having bowel movements and falls into a condition of chronic constipation, which, in turn, serves to aggravate the disease. GENERAL INFLAMMATORY PROCESSES 283 Long-continued suffering from anal fissure may result in serious depletion of the patient's general health. The treatment of fissure is best carried out under full anesthesia, when one of two methods can be used — that of stretching the sphincter or that of excis- ion. By the first method the fissure is forcibly and deeply opened, so that it is practically converted into a fresh wound, while theoretically (and possibly practically) the fibers of the sphincter muscle are rendered temporarily less active, so that the fissure is given an opportunity to heal. A better and more surgical procedure is to make a clean dissection of the fissure, approximating the wound edges carefully with fine catgut. It is possible to cure a fissure by patient office treatment. This consists in first cocainizing the fissure and then applying to the ulcer silver nitrate, either in solution or in pencil form. The treatment should be repeated several times each week. It is not always easy to expose an anal fissure to view. If such difficulty is encountered, the best method of examination is to put the patient in Sims' position. The forefinger inserted in the vagina can then easily evert the anal canal. If appHcations are to be made to the ulcer it is advantageous to place the patient in the right Sims' position, as in this way the left forefinger can be used to evert the anus, leaving the right hand free for making the neces- sary manipulations. INFLAMMATORY STRICTURE OF THE RECTUM One of the most important inflammatory conditions of the rectum seen in gynecologic chnics is stricture. The lumen of the rectum may be constricted in a number of ways, such as by pressure from large impacted tumors of the pelvis, or from retroperitoneal growths, or from polyps and malignant growths of the rectal tissue itself. Extensive parametrial infections may in rare in- stances obstruct the bowel. The term stricture of the rectum is, however, com- monly used to designate a special condition of fibrous, cicatricial stenosis of the lumen, usually occurring within 2| to 3 inches from the anal outlet. The stricture may be annular in form, occupying only a short segment of the bowel wall, or it may be tubular, and extend for a considerable distance toward the sigmoid. The etiology of the disease is somewhat obscure. It was formerly sup- posed that the majority of these strictures were the result of tertiary syphilitic changes. Modern diagnostic methods have shown that many of these pa- tients do have syphihs, though not all of them. There is evidence that some of the cases are the result of the annular form of intestinal tuberculosis, such as occurs elsewhere in the intestinal tract. Some observers are of the opinion that gonorrheal proctitis with ulceration and subsequent cicatricial heahng is im- portant in the causation. Other writers practically rule out gonorrhea as a 284 GYNECOLOGY factor in the disease. Vulvovaginal abscesses are said to open an avenue of infection to the perirectal tissue and prepare the way for chronic inflammation. Lynch calls attention to the occurrence of cicatricial stenoses following pelvic operations, especially vaginal hysterectomies and end-to-end anastomoses of the rectum, and assigns the result to interference with the circulation of the rectal wall. It is probable that severe rectal ulceration and infection of the peri- rectal tissue from almost any cause, occurring in the lower part of the rectum, is capable of producing a stricture. In our own series of cases syphihs seems to have been the leading cause, though only in a few cases has it been possible to mate a definite diagnosis. Rectal stricture develops very slowly, patients becoming aware of trouble by gradually increasing difficulty in evacuating the bowel. Frequent painful defecations evoke small masses of thin ribbon-like stools without giving the patient the sensation of having emptied the rectum. Mucus and not infre- quently blood are passed. On rectal examination the stricture is usually found within easy reach of the finger. As patients do not seek advice until symptoms of occlusion ensue, the opening of the stricture is always found very small, scarcely admitting the tip of the finger. The rectal wall is densely fibrous and there is to be felt a firm infiltration in the pararectal tissue. The cicatrix about the opening is slightly elastic, and in the annular type can sometimes be stretched sufficiently to allow the finger to slip through. In passing the finger through, one receives the impression that the tissue would easily rupture on forcible pressure. This is entirely true, for even a gentle attempt at dilatation is occasionally fol- lowed by a smart hemorrhage. The tubular type of stricture is firmer and less dilatable than the annular. Some of the strictures occur higher up in the rectum or in the lower sigmoid region, but they are much less common than those that form near the anus. Many strictures, especially those of the syphilitic type, exhibit about the anus numerous irregular tabs of skin, with fissures and rents, commonly called rhagades. They are not pathognomonic of stricture, though they probably are, for the most part, significant of syphihs. The diagnosis of inflammatory stric- ture is usually a simple matter, but it may be very difficult to distinguish it from cancer or sarcoma. Stricture, as a rule, is attended with little loss of weight or impairment of health, and the symptoms are usually of long duration, in contradistinction to mafignant disease, in which there is a comparatively short history of local trouble, together with noticeable cachexia and wasting. The presence of blood and pus in the stools is characteristic of both diseases. In stricture the occluding mass is smoother, more fibrous, sfightly elastic, and rather evenly distributed around the rectum. In malignant disease, especially cancer, the mass is irregular and nodular, and apt to be more localized on one side, though this is not always the case. In doubtful cases a Wassermann test should be made. If it is positive, the balance of evidence is in favor of stric- ture, yet this is not entirely reliable, as was seen in one of our cases, in which a GENERAL INFLAMMATORY PROCESSES 285 positive Wassermann was found in a patient who was discovered at autopsy to have rectal cancer. Sometimes a positive diagnosis can be made readily by removing a piece of tissue for microscopic examination when there is exuberant tissue in the rectal canal. Often, however, tissue of diagnostic value is not easily accessible, and in order to secure a proper specimen it is necessary to cut through the mucous membrane deep into the offending mass. Such a procedure is not always ad- visable, but, if cancer is suspected and the mass is operable, the most radical measures for securing an immediate diagnosis are justifiable. Inflammatory stricture is sometimes confused with intussusception of the sigmoid. The treatment of inflammatory stricture is either mechanical or surgical, for, even if the disease is proved to be syphilitic in origin, specific treatment is of no local value. The simplest treatment, and one that may be employed in the great majority of cases, is gradual dilatation. In the annular type, situated ver}^ low, occasional repeated stret-ching with the finger gives complete relief. If the cicatrix is very dense or tubular, or situated beyond the reach of the finger, it is necessary to use graduated rectal bougies. These require skilful care, partly on account of the danger of hemorrhage in stretching the tissue, and partly because of the ease with which one of these instruments may be forced through the rectal wall into the peritoneal cavity, from a bhnd pouch below the stricture. It is best, there- fore, to use the instrument through a proctoscope unless the stricture is very low. Surgical measures for the relief of stricture are various. The simplest and safest method for the narrow constriction is the use of Lynch's thyrotome, by which the constricting tissue is first seared by a special apparatus and then divided. Much more radical and dangerous is the posterior proctotomy, by which the posterior rectal wall, including both sphincters, is boldly divided, packed, and allowed to granulate. In complete obstruction a colostomy may always be resorted to with perfect safety to the patient. Occasionally it is advisable to perform a radical opera- tion, in which case the surgical procedure is the same as that for cancer of the rectum. It should be repeated that, in the great majority of instances, gradual dila- tation is all that is necessary, and that the dangerous surgical measures are to be adopted only as a last resort. New Growths tumors of the vulva FIBROMA AND FEBROMYOMA True fibromata of the vulva are comparatively rare tumors, occurring almost exclusively in the labia majora. They do not often reach a size greater than that of a hen's egg, but tumors of large dimensions have been reported. They have Fig. 67. — Fibroma of the Vulva. Low power. On the surface is a thin layer of stratified squamous epithelium showing small, poorly developed papillae. The stroma consists of fibrous tissue infiltrated with small round cells. their origin in the connective tissue of the greater hps, and are usually hard discrete tumors that can readily be shelled out. Some of them sink down by their weight, drawing the skin out in the form of a pedicle, the consistency of 286 NEW GROWTHS 287 the tumor becoming softer and more flaccid. This tj^pe is termed ''fibroma molluscum pendulum." In some of the tumors can be found smooth muscle-fibers, while in others are seen small glandular or cj-stic openings that have the appearance of adeno- myomatous tissue. A slender stalk is sometimes found connecting the tumor with the inguinal canal. This connection, taken with the histologic appearance of the tumors, suggests that the myomatous and adenomyomatous tumors are probably derived from the round ligament, the tumors of which they closely resemble. The symptoms of fibromata of the vulva depend on the size and position of the tumor, and consist chiefly of discomfort on walking, interference with coitus, and a sense of dragging and weight if the growth is large or pendulous. Thej^ are apt to undergo marked swelling, with increase of symptoms before and during menstruation. The diagnosis is usualh^ simple, though there may be some confusion in differentiating the condition from labial hernia, lipoma, or cyst of Bartholin's gland. The flbromata may undergo sarcomatous change. The treatment of flbromata of the vulva is surgical removal. They are easily shelled out as a rule. The pendulous form of tumor may often be removed by simple amputation of the skin pedicle. Operation is always indicated, even when the tumor is giving no symptoms, on account of the possibility of sarco- matous degeneration. LIPOMA Fatty tumors of the vulva are rare. They appear either in the labia majora or in the mons veneris. They are composed of fat in which is mingled a small amount of fibrous tissue. Occasionally m^rxomatous tissue is found, in which case the growth should be characterized as a mixed tumor. It is said that the hpomata increase during pregnancy and diminish during the puerperium. They also swell during menstruation. The consistency of lipomata of the labium is soft and almost fluctuant, so that it is sometimes with difficulty differentiated from a cyst. The treatment is surgical removal. A rare tumor of the vulva is called "adenoma hidradenoides vulvae" ; the tumor is benign and shows a growth of glandular tubes lying close together with sUght connective-tissue stroma. The glands are Hned with regular cyUndric epithelium. The structure shows the histologic characteristics of the sweat-glands; hence the name (Stern). CARCINOMA OF VULVA Cancer of the vulva is comparatively uncommon, and does not usually appear until after middle life. It takes its origin chiefly from the urethral orifice, from the clitoris, and from the sulcus between the greater and lesser lips, rarely from Bartholin's glands. In advanced cases the origin cannot usually be distinguished. 288 GYNECOLOGY The great majority of cancers of the vulva are of the squamous epithelial type, but growths from Bartholin's glands are adenocarcinomatous, while a rare form of melanotic carcinoma has been described. It is possible for cancer of the uterus to become secondarily implanted on the vulva, in which case the growth has the histologic structure of the primary tumor. As a rule, the growth CaT:\CtP -' V\(.f?GrA\)es- FiG. 68. —Early Cancer of the Vulva, with Ixfiltr-'^.tion of the Tissues at the Posterior Commissure and Beginning Ulceration. appears on one side, and is at first irregular and nodular, without ulceration, and is surrounded by a more or less krau^otic tissue, from which it seems to spring. On account of the rich lymphatic circulation of the vulva, cancer in this location is extremely malignant, and metastasizes early to the inguinal tym'ph- glands, and thence to the glands of the iliac system. The disease in the early stages is not painful, and does not at this time often come to the notice of the physician, symptoms ensuing when the tumor becomes NEW GROWTHS 289 ulcerated or when the inguinal glands become infected. Locally the disease gives rise to itching and burning and a bloody foul secretion bathing the external parts. The involvement of the inguinal glands may be very extensive and exceed in severity the processes of the primary growth. The pain in the later stages of the disease is excruciating, enhanced as it often is by thrombotic ex- tension into the veins of the leg. y^/f '^T-s 1< i-' t ■CJ »«.«■*. •qt' -t- ^ 3_ ^ "^ ^ *j> :^ ^'^ ^ -„-^*^ „^ i. "^ -=> — ^ J. *=• "^^ w t -• -^ - — *• I-} * ■* *. •* "" *r \ ^ ^i? ^ " ^ 3 Lj t- ^ @ ^ *" " - u -^ r- "^ c i ' > ■^ i:> . c (> -/ "^T-.^a 0,0 *^<- ^ Q, "^ ^ - ^ * ^^ ^ 2- ■S" » <- i~~ S "^^ s ^ "* "^ « ^ & *• i Z ^'^' 3 -* » a. <» \. " '^ .:-i '=■ ^ h f " J" '' ? - ^ , ' - V. 1 , \. . - T, J a f '' ^ "^ I ' o S ^ f f ^ ^ ->, v*" 1 V 6' '- -" ^ i ^ I ^ ^ e o ^ fc7 ¥ ^ ^ <1 ^ Fig. 69. — Epithelioma of the Vulva. High power. This section shows the surface epithelium, which is not ulcerated, and the finger- like projections of the growth extending into the deeper parts of the stroma of the ^'ulva. There is no basement-membrane between the cells of the growth and those of the stroma. The carcinoma cells are irregular in shape and vary in size. Very few mitotic figures are seen in this section. The diagnosis of cancer of the vulva is not always easy to make by inspec- tion. In the early nodular stage, with beginning ulceration, it maj^ closely resemble a primary syphilitic lesion, while in the later ulcerative stages it may be impossible to distinguish it from esthiomene. The latter diagnosis is especi- ally difficult, for cancer of one side of the vulva is often in time communicated to the other side by contact infection, so that sj^mmetric ulcerations exactly simulating esthiomene are frequently seen. Elephantiasis, tuberculosis, and 19 290 GYNECOLOGY even condylomata acuminata are sometimes mistaken for cancer. In all cases where there is the slightest doubt of the diagnosis a specimen should be removed from the growth for microscopic examination. The treatment of cancer of the vulva is immediate and radical operation if the case when seen is operable. The operation consists in an extensive vulvec- tomy and dissection of the inguinal lymph-glands of both sides. Most of these cases come to operation late, and on account of the tendency to early metastases the prognosis is, consequently, unfavorable as a rule. If the case is inoperable the best hope of relief is from radium. The most valuable recent work on the subject of cancer of the vulva is that embodied in a report by Taussig of 15 cases personally observed. The following are the conclusions reached by Taussig: Cancer of the vulva is very definitely a disease of old age, the majority of cases occurring after the age of sixty. The question of age depends, however, on the etiologic factor-s in the Fig. 70. — Extensive Cancer of the Vulva Originating in Condylomata Acuminata (after Taussig). case and under certain conditions the disease may appear in young women. Taussig's obsetva- tions regarding the etiology are especially valuable. Thus in his series of cases he found defi- nite proof that the cancerous growth may originate from the following conditions: trauma, syphihs, condylomata acuminata, kraurosis, leukoplakia, and Paget's disease. The most com- mon predisposing cause is found in the atrophic kraurotic processes that characterize the vulva NEW GROWTHS 291 in old age. Hence the greater incidence of the disease at that time. On the other hand, it may develop from syphilis or condylomata acuminata, so that it may appear early. Taussig's youngest cases were twenty-seven and thirty-three. The disease is unusually malignant when it occurs in younger women. Taussig suggests that the cessation of the. ovarian secretion after the menopause may be a predisposing element in the development of vulvar cancer, for in two of his comparatively young cases (i. e., under forty-five) a previous operation involving the removal of the ovaries had been performed. Previous pregnancies are not a factor in the etiology, for the disease appears with about equal frequency in those who have not borne children. FiG. 71. — Cancer of Clitoris with Metastasis in Groin (after Taussig). Cancers that originate from a kraurotic vulva are somewhat more benign in their course. They have a tendency to eversion rather than inversion, suggesting that the tissues in the kraurotic cases possess a greater imperviousness to the progress of the disease. The lymph-glands are involved even in the earliest stages of the disease. "Even after radical removal of the lymph-glands with the vulvar mass the chance for a reappearance of the cancer in the glandular system is three times greater than in the local recurrence." The site of the original tumor was in order of frequency as follows: labial fold, clitoris, Bartholin's gland, peri-urethral region. When the disease is locally far advanced it may be impossible to distinguish the point of origin. The cancers that developed from the labial folds were more scirrhous in type and slower in growth. Those that sprang from the clitoris or vestibule were of a softer and much more malignant nature. Taussig has adopted a special technic in operating on cancer of the vulva which will be found explained in detail in Part III of this book. In general his method comprises first a complete dissection of the inguinal regions by the Basset technic. At the end of about two 292 GYNECOLOGY Fig. 72. — Cancer of Vulva Originating from Kraurotic Labium. weeks the tumor mass is removed by cautery, no attempt being made to cover in the wound by plastic maneuvers. SARCOMA OF VULVA Sarcoma of the vulva is even less common than carcinoma. It presents no definite characterizing features clinically, appearing at first as a circumscribed hard oval tumor, not to be distinguished from fibroma excepting by its more rapid growth. Later it may infiltrate the surrounding tissues and, becoming ulcerated, resemble carcinoma or esthiomene. An absolute diagnosis can only be made by the microscope, which reveals various malignant types in -different tumors, such as spindle- and round-cell forms, myxosarcoma, and perithehoma. Many of the reported sarcomata of the vulva are melanotic, and doubtless orig- inate in pigmented nevi. The treatment of sarcoma of the vulva is, like that of carcinoma, radical surgery. Rare Tumors of the Vulva. — A few cases have been reported in the literature of neuroma, enchondroma, myxoma, osteoma, teratoma, and echinococcus cyst of the vulva. Cysts of Bartholin's gland have been described on page 186. A few cases of carcinoma developing from this gland have been reported. Hydrocele muUebris is a cyst which sometimes extends from the inguinal canal into one of the labia majora. It represents a cystic condition of the canal of Nuck. NEW GROWTHS 293 VARICOCELE Varicocele of the vulva occurs almost exclusively as a result of pregnancy. The veins may become greatly dilated and form an irregular tumor, usually on one side of the vulva. After delivery the distention either subsides completely or leaves a few isolated veins permanently dilated. These are usually seen in the neighborhood of the clitoris. Varicocele of the vulva, if extensive, may cause discomforting pain and be a source of danger on account of the possibility of rupture. Surgical treatment is rarely indicated except when permanent varices of considerable size are left after childbirth. The best treatment is rest in bed, with the use of the knee-chest position two or three times daily. Rupture may occur spontaneously or after some violent effort, or from trauma. Rupture may result in a large hematoma, or if the skin is broken, in a serious or even fatal hemorrhage. URETHRAL CARUNCLE ■ The urethral caruncle (sometimes termed "papillary angioma") is essentially a mucous polyp of the vestibule. In its most common form it appears as a small polypoid growth, either with a broad base or with a fine slender pedicle growing from the meatus. It is intensely red in color and often exquisitely tender. In exceptional cases the polypoid growth is multiple, extending over a considerable area of the vestibule, so that it has a papillary appearance often suggesting car- cinoma. Microscopically, the true caruncle is clothed with a squamous epithelium. The underlying connective tissue is usually infiltrated with round cells. The epithelial covering sends down off-shoots into the deeper tissues which, on cross- section, present an appearance closely resembling squamous cell carcinoma. Gebhard describes tubular glands that pervade these polyps, the lining epithelium of which exhibits extraordinary changes that range from squamous epithelium, like that of the vestibule, to a high cylindric type with basal membrane. Clinically, the urethral caruncles may be very troublesome affairs. They are especially apt to occur in elderly women, though not confined to that age. Their importance hes chiefly in the intense pain which they often cause during urina- tion or coitus. The diagnosis is usually simple, though they are sometimes not easily dis- tinguished from a prolapsed urethral mucous membrane except by micro- scopic examination of the tissue. The true caruncle is covered with squamous epithelium like that of the vestibule, while prolapse of the urethral mucous mem- brane is covered with the modified epithelium characteristic ofthe urinary tract. The extensive caruncular growths that spread out over the vestibule may easily be regarded as cancerous growths. The diagnosis should be made by microscopic examination of an excised specimen. The microscopic resemblance to cancer should be borne in mind. The treatment of simple urethral caruncle is removal under cocain, if possible. Sometimes, however, the growth is so tender that the patient will not even allow 294 GYNECOLOGY the application of cocain, so that complete anesthesia is necessitated. The caruncle may also be removed by fulguration. It is advisable not to attempt the removal of the extensive multiple caruncles by surgical dissection, for they usually recur. The best treatment is by repeated applications of the high-frequency current, by which means they are more easily kept under control, though not alwaj^s permanently cured. URETHRA Prolapse of the urethral mucous membrane is most commonly an affection of old age, though it may appear in infants or in girls before the age of puberty. Prolapse of the urethra in the adult is usually a result of senile atrophy, and is apparently due to traction of the shrinking skin of the vestibule on the loose mucous membrane of the urethra. In its simplest and most common form it Fig. 73. — Prolapsed Urethr.\l Mucous Membrane. Low power. The crypts in the mucous membrane are seen in cross-section. The epithelium is like that of the urethra. This distinguishes the condition from the true urethral caruncle, which is covered with simple squamous epithelium. The stroma contains manj' blood-vessels filled with cor- puscles and is infiltrated with leukocytes. appears as an eversion or ectropion of the urethral mucous membrane, which either in part or in its entire circumference rolls out into view. The affection NEW GROWTHS 295 is often mistaken for caruncle. In the simple form it ordinarily gives no dis- comfort, but under certain conditions it may be the source of serious trouble. Congestion and constriction of the blood-vessels may produce a change similar to that seen in hemorrhoids, with thrombosis, swelling, and bleeding. In extreme cases there may be gangrene and sloughing of the protruding membrane. Prolapse of the urethra in which thrombosis has occurred may simulate cancer somewhat in appearance. Treatment of urethral prolapse depends on the severity of the case. Mild conditions which give no symptoms need no special treatment. If congestion, thrombosis, or gangrene appear, the best treatment is surgical removal, the prolapsed and swollen portion of the membrane being removed in the manner of Whitehead's operation for hemorrhoids and the wound edges sewed with fine catgut. Prolapse of the urethra in children, according to Kelly, may- date back to the nursing period of life, and may involve either a part or most of the urethral mucous membrane. There is pain on urination, reddening and swelling, and often bleeding. Kelly states that the disease either comes on slowly or may develop suddenly from traumatic causes like rape, violent coughing, long-stand- ing diarrhea, local injuries, etc. The treatment is surgical removal. TUMORS OF THE CLITORIS Tumors of the clitoris are comparatively infrequent. In cases of pseudo- hermaphroditism the clitoris is often very much enlarged, resembling a small \ Fig. 74. — Hypertrophy of the Clitoris. Low power. Cross-section of the clitoris. Around the edge is the stratified squamous epithe- lium. Beneath this and scattered through the stroma are dilated blood- and lymph-spaces. The hypertrophy in the stroma consists of an increase in connective tissue and the corpora cavernosa cannot be made out distinctly. penis, but not perforated by a urethra. It is sometimes advisable to excise the organ in such cases, expecially if it is a source of irritation. An acquired hyper- 296 GYNECOLOGY trophy of the chtoris is occasionally seen, which is thought to be caused by mas- turbation. There is doubt, however, whether masturbation produces hyper- trophy or whether the hypertrophy is not rather the primary condition, causing masturbation by irritative influence. Certain it is that masturbation sometimes results in atrophy of- the chtoris (Kiistner). Hypertrophy, if it becomes trouble- some, requires a clitoridectomy. Removal of a normal clitoris for masturbation is of questionable value. Fig. 75. — Hypertrophy of the Clitoris. High power. Along the edge of the section is the squamous epithehum. Many blood-vessels full of corpuscles are seen throughout the stroma, and to the right are several dilated lymph-spaces. The darker areas are small bundles and muscle-fibers scattered through the stroma. Carcinoma of the clitoris is occasionally met with. It follows the course and demands the surgical treatment of any cancer of the vulva, namely, com- plete vulvectomy and dissection of the inguinal regions. TUMORS OF THE VAGINA SARCOMA OF THE VAGINA Sarcomata of the vagina are comparatively rare tumors. Two forms are to be distinguished: (1) Those which occur in children and (2) those which appear in adult life. NEW GROWTHS 297 The sarcomata of children are usually congenital, and are thought (Wilms) to have their origin in off-shoots of the mesoderm which become detached during the early growth of the Wolffian duct. Histologically, these tumors are primarily composed of myxomatous tissue, connective tissue, and both smooth and stri- ated muscle-fibers, with sarcomatous metaplasia. They are, therefore, not true sarcomata in the strictest sense of the word, but are mixed tumors related to the teratoid group. They usually spring from the anterior wall of the vagina, occasionally from the posterior, and have a characteristic polypoid or grape-like form protruding from the lips of the vulva. The sarcomatous polyps soon be- come necrotic and the vagina is filled with a septic, sloughing mass. The disease infiltrates the deeper layers of the vagina, soon involves the cervix and bladder, extends to the uterus and vulva, infiltrates the pelvic connective tissue, and metastasizes in the regional lymph-glands. When the growth begins on the posterior wall of the vagina it has little tendency to involve the rectum. The disease is nearly always fatal, only a very small number of cases having been cured. The only hope of a cure is from a very early diagnosis and a radical extirpation of the uterus and vagina. Sarcoma of the vagina in the adult follows the usual form of sarcoma found in the rest of the body. Cases of melanotic, myxomatous, telangiectatic, and giant-cell type have all been reported. These tumors appear either as nodular or infiltrating growths from any part of the vagina, and involve the entire vaginal canal in a hard, resisting mass. The disease is usually hopeless. If an early diagnosis can be made, the treatment is complete removal of the uterus and vagina. CARCINOMA OF VAGINA Primary cancer of the vagina is somewhat uncommon. These growths usu- alty originate in the squamous epithelium of the vagina, but occasionally are adenocarcinomatous in type, in which case it is supposed that they spring from congenital cysts or gland inclusions of the vaginal mucous membrane. Cancer of the vagina secondary to cancer of the uterus is frequent, and doubt- less many of the cases reported as primary are, in reality, of this kind. Primary cancer of the vagina usually springs from the posterior wall. On account of this location it has been claimed that the disease is the result of trauma such as would result from the use of pessaries. It is doubtful if pessaries do more than encourage the development of a tissue already predisposed to cancer. The growth has at first a circular circumscribed appearance with somewhat raised indurated periphery. The original area gradually spreads, infiltrating the paravaginal connective tissue, until it involves the entire vaginal canal. Ulceration and bleeding take place early, and the symptoms are the same as those of cancer of the cervix. The diagnosis of primary cancer of the vagina is usually not difficult unless 298 GYNECOLOGY the disease has so involved the cervix that the original seat of the disease cannot be distinguished. The prognosis of vaginal cancer is very bad, but extirpation is possible if an early diagnosis can be made. The method of operation depends on the original seat of the disease. If it is located high in the vagina the best operation is abdominal extirpation of the uterus and vagina by the Wertheim extended method. If the cancer is situated near the introitus the operation should be Fig. 76. — Squamous Carcinoma of the Vaginal Wall. Low power. The growth is seen invading the stroma of the vaginal wall. At its upper end it has lost the typical layer of basal cells and the basement-membrane. The cells are large, the nuclei vary greatly in size. The stroma above the growth is infiltrated with leukocytes, an inflammatory reaction often found with carcinoma. from below, and be completed either from below or be combined with abdominal extirpation. In inoperable cases radium sometimes proves to be valuable as a palliative measure. When the disease has extended into the rectum the only hope of a cure is a total extirpation of the uterus, vagina, and rectum. This necessitates the estab- lishment of an artificial anus. NEW GROWTHS 299 Secondary cancer of the vagina is very common, especially as a manifesta- tion of advanced cancer of the cervix. Both everting and inverting carcinoma of the cervix tend in time to involve the paravaginal connective tissue, especi- ally in the anterior wall between the vagina and bladder. It is for this reason that it is important, in performing a radical operation for cancer of the cervix, to remove as much of the vagina as possible. -'^ \ fee. •«»♦« 4^ ■<*.,. -^& " ^ a h^^»J''^i Fig. 77. — Squamous Carcinoma of the Vaginal Wall. High power. Near the center is a giant carcinoma cell containing many nuclei. Just above it to the left is a mitotic figure. This is taken from the small area in the left side of Fig. 70. Cancer of the body of the uterus does not directly involve the vagina, but may infect it by metastatic seed implantation. The vagina may also be the seat of chorio-epithelioma. Rarely the tumor is primary in the vagina; it usually represents a metastasis from a primary growth in the uterus. VAGINAL CYSTS Small cysts of the vaginal wall are comparatively common. They vary in size from that of a hazelnut to an Enghsh walnut, though rarely they may become very large, extending upward into the broad hgament. They usually appear on 300 GYNECOLOGY the anterior wall and may be single or multiple. They occur at any age, even in childhood, and first make themselves evident by protruding from the introitus. The etiology of these cysts is somewhat varied. Undoubtedly many of them arise from gland-inclusions formed by infoldings of the mucous membrane in fetal life. This accounts for the smaller cysts. Some of the larger ones probably have their origin in Gartner's duct. In cases of narrow or unilateral vagina it is thought that cysts may arise from glandular structures representing the undeveloped Miiller's duct of the other side. Multiple cysts of the vagina are Fig. 78. — Normal Vaginal Wall. Low power. On the surface is a covering of well-developed stratified squamous epithelium. This lies on connective tissue through which are scattered bundles of smooth muscle-fibers and many blood-vessels. . less common than the single cysts. If they occur in a line they are supposed to originate from Gartner's duct, while if they are irregularly placed they prob- ably develop from vaginal gland inclusions. The small vaginal cysts do not ordinarily give subjective symptoms, but in married women they often interfere with coitus and sometimes with childbirth. The diagnosis of vaginal cysts is extremely easy, there being little else with which they could be confused. The cysts have a thin wall lined with a single layer of epithelium and contain a clear serous fluid. NEW GROWTHS 301 The treatment is operative. The smaller cysts can usually be shelled out with comparative ease, though care must be exercised not to injure the bladder. The larger cysts, especially those that extend inward and upward between the leaves of the broad hgament, may present serious technical difficulties. The methods of removal must be determined by the exigencies of the individual case. Cysts of the anterior wall sometimes communicate with the urethra, in which case they are not true cysts, but are rather diverticula of the urethral canal- It is probable that most cysts of this type originate as periurethral abscesses. Fig. 79 — Wall of a Vaginal Cyst. Low power. At the bottom is the layer of squamous epithelium which lines the vagina. Above this is the connective- and muscle-tissue wall of the vagina and at the top a layer of cuboidal epithe- lium which lines the cyst. This is characteristic of a cyst of Gartner's duct. In the lower part of the vagina, near the introitus, cysts may arise from the inclusion of small areas of epithehum following healing from lacerations or opera- tions for repair of the perineum where there has been an incomplete denudation of the mucous membrane. These cysts might properly be included under the term "perineal cysts," but, as they often result from a high denudation, they may be situated well up in the vaginal canal, usually on one side. The contents of these cysts is a yellowish, semifluid, sebaceous material, and represents the activity of the included epithehum with retention of the secretion. 302 GYNECOLOGY They are usually about the size of a pea, though they may attain that of a hazel- nut. As a rule they are not painful, but sometimes cause a disagreeable irrita- tion at the introitus, which may be so severe as to cause dyspareunia or even serious vaginismus. The treatment is removal by dissection if they give symp- toms. A special form of vaginal cyst and one which may cause serious surgical compHcations is that which results from a bhnd secondary vagina. There are two types of defective development which may cause vaginal cysts of this kind. In one there exists a rudimentary uterus and a rudimentary blind vagina, the Fig. 80. — Vaginal Cyst Due to Blind Supernumerary Vagina. In this case both horns and cervices are fully developed. There are two vaginas, but one has no outlet. The blind vagina is converted into a cyst which becomes filled with products of men- struation from the corresponding uterine horn. canals of which do not communicate (Fig. 80). In these cases the cervix of the rudimentary uterus becomes fused with that of the well-developed organ. Secre- tions accumulate in the blind vaginal sac and produce a cyst, as shown in the drawing. In another type there exists a double uterus, double cervLx, and double vagina, but the vagina of one side' is without an external opening. In this case the blind vagina becomes filled with menstrual products in the form of a charac- teristic chocolate colored fluid. Sometimes the pressure may be so great as to break an opening through into the normal vagina. When this occurs the con- tents of the sac become infected and the blind vagina is converted into a reser- voir of foul pus which discharges constantly or periodically into the normal vagina. NEW GROWTHS 303 Fig. 81. — Vaginal Cyst Due to Blind Superntjmerary Vagina. On one side there is a fully developed uterine horn, cervix, and vagina. On the other is a rudi- mentary uterine horn, the cer-\-ix being fused and without a canal. Corresponding to the rudimen- tarj^ horn is an undeveloped vagina -nithout an outlet. Secretions have converted the vagina into a cyst. Fig. 82. — Vaginal Cyst Due to Blind Supernumerahy Vagina. Drawing illustrates author's case described in the text. One uterine horn had been amputated by a previous operator. A cj'st which had formed in a blind vagina had forced an opening into the cervical canal. The contents of the vaginal sac had become infected so that the sac fed by the uterine secretions became a reservoir of foul pus. 304 GYNECOLOGY In a case seen by the writer one of the horns of a double uterus had been removed several years before by another operator. When the patient presented herself for examination there was found an immense pus sac which was discharging through the cervix of the remaining uterus. After an unsuccessful attempt to rectify the trouble by draining the abscess through the vagina the patient was finally cured by performing a complete hysterectomy and establishing full drainage for the abscess sac through both vagina and abdominal wall. After a time the vaginal sac dried up, the walls evidently healed together by plastic adhesions, and the patient got well. In this case the septum between the two vaginae had become the seat of a great plexus of vaginal veins, so that an attempt to remove the septum and to convert the two vagina into a single canal could not be carried out. Otherwise this procedure would theoret- ically have been preferable to the operation of hysterectomy, as the patient was a young woman. Fibromyomata and myomata of the vagina are "very rare tumors, less than 200 having been reported. They arise from the smooth muscle-tissue of the vaginal wall. They do not attain a large size, and are usually polypoid in their develop- FiG. 83. — Vaginal Cyst Wall. High power. At the top is the lining of the cyst, consisting of a single layer of low cells. The rest of the tissue consists of the loose connective tissue of the vaginal wall with several veins in it. This is a cyst of Gartner's duct. ment. They have a predilection for the posterior wall of the vagina. They are especially prone to necrosis, infection, and sloughing, and occasionally undergo sarcomatous metaplasia. As a rule, they are well defined from the surrounding NEW GROWTHS 305 tissue and can be shelled out like uterine myomata. Sometimes they grow diffusely and cannot be removed except by dissection, in which case they are found to be adenomyomata, probably originating in Gartner's duct. The treatment of vaginal myomata is operative removal. Adenomyomas of the rectovaginal septum are comparatively rare tumors, though it is probable that they are more common than has generally been supposed, many cases having been overlooked from mistaken diagnosis. These tumors have for some time been recognized and a few cases reported. Cullen has recently called attention to their importance and has described them more accurately than has been done heretofore. As we have not had an opportunity to observe a case we shall abstract freely from Cullen's articles on the subject. Cullen classifies adenomyomas of the rectovaginal septum as follows: 1. Small adenomyomas lying relatively free in the rectovaginal septum. 2. Adenomyomas adherent to the posterior surface of the cervix and at the same time to the anterior surface of the rectum. 3. Adenomyomas gluing the cervix and rectum together and spreading out into one or both broad ligaments. 4. Adenomyomas involving the posterior surface of the cervix, the rec- tum and broad ligaments, and forming a dense pelvic mass that cannot be liberated. In the majority of cases the growth is felt as a diffuse thickening behind the cervix in which the cervix and rectum are involved. Sometimes the mass is nodular, giving the impression of an adherent myoma. If the tumor has grown extensively the whole pelvis floor and vaginal vault may be hard and indurated. In the early stages the tumor may be discrete and movable, usually attached to the posterior wall of the cervix. By rectal examination the tumors may usually be more definitely outlined. The rectal mucosa is, as a rule, not impaired, but the 'tumor mass projects in the lumen of the bowel, occasionally constricting it. The rectal mucosa over the tumor mass may become polypoid. Histologically, adenomyomas of the septum present the same picture as seen m the uterine adenomyomas. The structure consists of unstriped muscle and connective-tissue fibers in which are scattered singly or in groups glandular ele- ments of the type seen in the uterine mucosa. The glands invariably lie in a bed of cellular tissue like the stroma that surrounds the glands of the endometrium. Sometimes the glands become dilated and may form cysts of considerable size. The histogenesis of the adenomyomas is somewhat vague, but on account of their characteristic structure is referred unquestionably either to the uterine mucosa or to rests of the Miillerian duct. The most pronounced symptom of these tumors is menorrhagia, all the cases reported by Cullen having occurred during the menstruating era and ranging 20 306 GYNECOLOGY in age from twenty-five to fifty-three. Pain with menstruation is not a constant symptom, but may be present and is sometimes very severe. As would be ex- pected, rectal pain is often a prominent symptom. If the lumen of the bowel is obstructed the rectal discomfort may be great, with frequent discharges and tenesmus. When the disease has spread out into the broad ligaments and throughout the floor of the pelvis general pelvic discomfort is to be expected, with pains shooting into the legs as the result of the involvement of nerves by the encroaching fibrous tissue of the tumor. The diagnosis of the adenomyomas may be difficult. The condition most likely to be confounded with them is inoperable cancer involving vagina and rectum. It should be remembered that in the adenomyomatous growths the mucosa of the rectum is always intact except for a possible polypoid hyper- trophy. Conditions of low-growing uterine or of cervical fibroids combined with chronic pelvic and parametrial inflammation may cause difficulty in exact differ- ential diagnosis. In the latter cases, however, lack of involvement of the rectal wall can usually be demonstrated. The surgical treatment of adenomyomas of the rectovaginal septum may best be presented by the following quotation from CuUen: "Some might argue that simple removal of the appendages would cause atrophy of the uterine mucosa contained in the adenomyomas of the rectovaginal septum. My Case 2 is a sufficient answer. Although a supravaginal hysterectomy had been performed two years before for a myomatous uterus, the pelvic condition had grown steadily worse. "l. Where small discrete nodules exist in the posterior vaginal vault, these may be readily removed through a vaginal incision, as was so successfully done by Stevens. "2. Where the growth occupiesthe posterior surface of the cervix and extends laterally, after the ureters have been dissected out carefully, a complete abdominal hysterectomy should be performed. "3. 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 then be hfted farther out of the pelvis, thus facilitating the removal of the necessary wedge of the anterior rectal wall. The uterus really acts as a handle, and the necessary rectal tissue and the uterus are removed as one piece. "4. Where the lumen of the bowel is greatly narrowed, a complete segment of the rectum should be removed with the uterus, and an anastomosis should be made. "5. In desperate cases, where everything in the pelvis is glued together, an ideal operation is out of the question. The patient will not stand a long operation, and, if she could, a satis- factory result could not be obtained. In such a case it would be better to cut across the sig- moid, invert the lower end, close it, and bring the upper end out through the abdominal wall of the left ihac 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 hgament 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." NEW GROWTHS 307 NEW GROWTHS OF THE UTERUS MYOMA OF THE UTERUS Uterine fibroids are discrete fibrous growths that develop in the wall of the uterus. These tumors are properly termed "fibroids," "myomata," "fibromy- omata," or ''leiomyomata" (Mallorj^) . They are constituted of smooth muscle and connective-tissue fibers, their histologic composition being similar to that of the uterine wall. The relative proportion of muscle and connective tissue varies greatly in different tumors. In general, the connective-tissue element tends to increase at the expense of the muscle tissue, as the tumor grows older, a process similar to that which takes place in the uterine wall after the child-bearing period. /^Jt^ Fig. 84. — Subserous Myomata. The histogenesis of uterine fibroids is not definitely known. Theories vari- ously ascribe their origin to the muscle cell of the uterus, to the connective-tissue cells of the uterus, to the walls of the blood-vessels, and to misplaced germ cells. The etiology is also vague. Numerous examples have been reported which seem to show that heredity may play some part in their causation. The relative frequency of fibroids in negroes suggests the influence of race as an etiologic factor. The theory of abnormal ovarian hormones as a cause has been pre- sented, but not substantiated. There is no doubt that the function of menstrua- tion is the most important definite factor in the causation of fibroids, for they develop only during the menstrual era. There seems also to be some relationship 308 GYNECOLOGY between fibroids and the child-bearing function, in that those who have not borne children are undoubtedly somewhat more susceptible to myomatous growth than are those who have been fertile. Uterine fibroids develop chiefly in the wall of the uterus above the internal OS, true cervical fibroids being rare. The particular location of the tumor in the uterine wall is a matter of considerable chnical importance, and fibroids are, therefore, defined by their position of growth. They are divided into three N/v.v?^.np X\c^i Koonbli'.o .3.iy n' Fig. 95.- — Fibromyoma with Necrosis. Low power. Much of the tissue has become necrotic, leaving material of a thick fluid consistency which has no definite structure microscopically, infiltrated with a few leukocytes. The myomatous tissue is preserved along the blood-vessels, as is well shown to the right of the drawing. Sarcomatous Change. — The so-called malignant degeneration of fibroids occurs most commonly in long-existing tumors after the menopause. The change starts usually at some localized point near the center of the growth. The entire tumor may become involved and be the starting-point of distant metastases. There is a wide variation in the estimates of the frequency with which sarcoma- tous change takes place. This is most generally put at 5 per cent. More recent investigations with improved staining methods have demonstrated that many of the diagnoses are erroneous, and that the actual proportion is nearer 1 per cent. (See also Sarcoma of Uterus.) 318 GYNECOLOGY In order to make an exact diagnosis between a myoma rich in cells and a myosarcoma Raab recommends the following points for consideration: (1) Structure of the muscular tissue and its richness in cells; (2) changes in the nuclei; (3) division of the nuclei; (4) content of intercellular fibrils (hyaline) ; (5) giant-ceUs; (6) boundaries of the tumor. Other important points are that : 1. Rich cell content and limited development of connective tissue cannot settle the diagno- sis of myosarcoma, since ordinary myomata, rich in cells, may show the same condition. 2. The nucleus in myosarcoma does not show any decided change in form in contrast to that of ordinary myoma. Fig. 96. — Fibromyoma with Calcification. Low power. The darker areas scattered through the tissue are areas of beginning calcification. Their irregular outlines and deep staining properties are characteristic. The tissue on the right is poor in nuclei and consists largely of connective tissue. 3. The mere presence of division of nuclei cannot be taken as decisive. It is decisive only if abundant, and examination should be directed chiefly to the youngest parts of the tumor that have not yet undergone regressive metamorphosis. 4. Hyaline degeneration is more likely to take place in myomata and is perhaps to be regarded as a cicatricial process. 5. Giant-cells have a special value in the diagnosis of malignancy. They may appear very rarely in benign myomata, but if found, they are isolated. They appear in great numbers in myosarcoma and with especial abundance in the boundaries of the hyaline masses. 6. Benign tumors show sharply circumscribed boundaries. Myosarcomata do not show a real infiltrating proliferation, but a penetration into the lymph- vessels (Kohler). NEW GROWTHS 319 Adenocarcinoma of the endometrium is not infrequently associated with myomata. This combination occurs more commonly in the large, long-existing tumors. It, of course, is not in any sense a carcinomatous degeneration of the fibroid, as the two processes are histologically entirely distinct. It is probable that the myomatous growth, acting mechanically as an irritant to the endo- metrium, encourages the mahgnant process. Fig. 97. — Fibromyoma with Carcinoma. Low power. Most of the section consists of fibromyomatous tissue in process of necrosis, with an infiltration of leukocytes. Four areas of carcinomatous tissue are seen, the centers of two of which are necrotic. This area was found in the center of a polyp. The case is extremely rare. In very rare instances a myomatous polyp of the uterus may become permeated with a carcinomatous growth. In a case operated on by the author a necrotic myoma was removed from the cervical canal in an elderly woman. The polyp, both macroscopically and microscop- ically, was that of a pedunculated fibroid about the size of an English walnut. Through portions of the tumor were found areas of squamous cell carcinoma, though there was no apparent trace of mahgnant disease in the cervical tissue. The disease later recurred in the parametrimn. Von Winewater reported a very similar case (Arch. f. Gyn., 1912) in which there was an adeno- carcinomatous invasion of a pedunculated myoma. In his case the uterus was removed. Al- though adenocarcinoma was found throughout the myoma, the uterine wall was entirely free from malignant invasion. He thinks that the disease originated in the pedicle of the myoma and spread into the tumor rather than into the uterine wall, following the lines of least resistance. 320 GYNECOLOGY Infection. — Uterine myomata may become infected in several ways. Super- ficially they may take part in a pelvic peritonitis that results from a gonorrheal or puerperal infection. The inflammation in this case is confined to the peri- toneal covering of the tumor and is manifested by adhesions. Necrotic myomata become adherent as a result of a damaged peritoneal covering. The injury to the peritoneum is caused by obstruction of the peripheral blood-supply. Fibroids may also become adherent to peritoneal surfaces if the pressure is great enough or is exerted against hard surfaces so as to traumatize the serous membrane. A necrotic fibroid adherent to the intestines may result in serious infection and peritonitis, the path of infection being through the wall of the intestines. This is one of the special dangers that threaten fibroids associated with pregnancy. Another form of infection is that which reaches the myoma through the general circulation. This has been proved by the finding of pathogenic germs in the tissues of fibroids and explains the elevated temperature which some myomatous women show. It must also explain many cases of acute pelvic inflammation which complicate uterine fibroids where gonorrheal and puerperal infection can be positively ruled out. These inflammations are sometimes very extensive, involving the adnexa and resulting in large pelvic abscesses. Polypoid submucous myomata frequently become infected and gangrenous. Occasionally during the puerperium subserous myomata suppurate. Frequency. — Uterine myomata occur with extraordinary frequency. At least 40 per cent, of all women have fibroids, while nearly all single women of middle age have them. Only a certain percentage of the tumors, however, give trouble, many of them remaining entirely insignificant. It is rare to see fibroids in women under twenty-five years of age. Most tumors begin their growth between the ages of twenty-five and forty, and if they cause symptoms they become subject to treatment, most commonly between the ages of forty and fifty. After the menopause it is doubtful if new tumors ever develop. Thus, it will be seen that the origin of growth of fibroids parallels somewhat closely the child-bearing era. The rate of growth varies widely. Usually it is very slow, and it may take several years for a myoma to become large enough to attract attention. Occasionally one takes on a very rapid development, and it is tumors of this kind that have been frequently mistaken for sarcomata. The microscopic appearance of rapidly growing myomatous cells is very like sarcoma and can only be distinguished by expert examination. In manj^ in- stances the apparent rapid enlargement of a fibroid is not due to an actual multiplication of the myomatous elements, but to edema or some form of de- generation or inflammation. "^ Fibroids associated with pregnancy usualty enlarge, though they may diminish, in size. Sometimes there is a temporary enlargement, followed by a cessation of growth or even an atrophy. The enlargement of a fibroid after the menopause is always due to some form of degeneration. NEW GROWTHS 321 Symptoms. — The symptomatology of uterine fibroids depends to a great extent on the location of the tumor. If favorably placed, a myomatous tumor may grow to a large size without giving the patient the slightest discomfort. A subserous fibroid growing toward the abdominal cavity may be sup- ported by the brim of the pelvis. By drawing the uterus with it, the fibroid, instead of causing pelvic pressure, acts in exactly the opposite direction, so that patients may carry one of these tumors for years without noticing it. In fact, many patients, feeling the hard lump in the abdomen, regard it as a normal part of their anatomy. If, however, the tumor is so located as to cause pelvic pressure, symptoms ensue. Thus, a fibroid growing in the lower posterior wall of the uterus is more likely to exert downward pressure on the pelvic supports than one that is grow- ing in the fundus. This downward pelvic pressure, in whatever way it is caused, represents one of the most important phases of all gynecologic symptomatology. The patient is almost continually conscious of a bearing-down discomfort, which, without giving actual pain, serves in time to become a serious drain on the general health. Patients with this symptom cannot be on their feet long with- out becoming tired. Working women become worn and exhausted, while the well-to-do are prevented from taking part in the various activities to which they are accustomed. The ill effect of pelvic pressure on the general nervous system is of great clinical importance, and must be borne in mind in considering the treatment of uterine fibroids. Besides producing the effect of weight and general pelvic pressure, fibroids may cause other pressure symptoms. A tumor encroaching on the rectum may cause constipation. It does this partly by obstructing the lumen of the bowel and partly by interfering with the muscular peristalsis of the rectal wall. Occasionally an impacted myoma may entirely obstruct the bowel. Fibroids on the anterior wall . of the uterus may cause symptoms of irritation of the bladder, though this occurs less commonly than one might suppose. They have been known to cause by pressure complete suppression of the urine. Tumors that obstruct the bladder usually develop from the cervix. It is possible for a myoma to grow in such a way as to press on the sciatic nerve and cause pain in the leg. Large tumors are often attended with cyanosis and palpitation as a result of their size and weight. Uncomplicated fibroids are not tender and ordinarily do not give pain, except occasionally in connection with menstruation. Pelvic pain and tenderness usually signify an inflammatory process. If the process is active, the course is that of any pelvic inflammation. Painful and tender fibroid tumors, where there is no active inflammation, as a rule, indicate adhesions. A sudden acute abdominal attack is sometimes the result of torsion and demands immediate operation. Interstitial fibroids are very apt to cause dysmenorrhea, while intermenstrual pain is a very frequent sign of interstitial growth. 21 322 GYNECOLOGY The most important effect of fibroids is uterine bleeding in the form of menor- rhagia. The catamenia is characterized bj^ a more profuse flow, the appearance of clots in the menstrual blood, and a prolongation of the period beyond its normal limits. There is usually a shortening also of the intermenstrual period. All three forms of these tumors may cause abnormal uterine bleeding, but it more commonly comes from the submucous or centripetally growing type. Centrifugal tumors may grow to an enormous size without producing menor- rhagia. The continued menorrhagia of bleeding fibroids results in serious detriment to the patient's health. A secondary anemia always ensues and the hemoglobin may be reduced as low as 25 per cent, or even 10 per cent. Besides the constitutional symptoms resultant on the frequent losses of blood, bleeding fibroids produce a very deleterious effect on the nervous sys- tem, espeeialty if there be a neurotic predisposition. Polypoid submucous fibroids, besides causing menorrhagia, may. also cause metrorrhagia. This is due to the fact that these tumors usually become necrotic and the intermenstrual blood comes from the macerated surface. Hemorrhages from this source may be ver\' alarming. It should be remembered, however, that the bleeding from fibroid tumors is always venous, and, therefore, almost never fatal. Necrotic polypoid submucous fibroids cause a foul leukorrheal discharge which in odor and consistency closely resembles that from cancer of the cervix. There are certain changes that appear in other organs of the body with sufficient frequency in connection with fibroid tumors to have led to the belief that the growths bear some causal relationship to the associated condition. The principal secondary conditions in this connection are heart lesions, hyper- thyroidism, and diabetes. Of these, heart lesions occur most frequently, and appear sufficiently often to have earned the appellation of "myoma heart." Disturbances of the heart are usually seen, either in connection with large long-standing myomata in women past middle life or where there has been long-continued menorrhagia and secondary anemia. The fundamental condi- tion of the heart is that of compensatory dilatation, which usually rights itself after the removal of the tumor. If, how^ever, the case is neglected the heart may lose its compensation (see also page 115 j. Fibroids and Pregnancy. — The relationship between pregnancy and uterine myomata is a subject of much importance, for not only does pregnancy affect the growth of the tumors in various ways, but the tumors exert a dangerous influence over the course of pregnancy. Fibroids, as we have seen, may take on a very rapid growth during preg- nancy. In this process the myomatous elements seem to share in the phj^siologic hypertrophy of the uterine wall. The enlargement of the myoma may Ije per- manent or the tumor may become regressive after the birth of the child. Some- times fibroids atrophy during pregnancy, but this is not the rule. The blood- supply of fibroids during pregnancy is usually diminished, especially if they are NEW GROWTHS 323 subserous or pedunculated, and this constitutes a very serious danger, for it may result in necrosis of the tumor and subsequent infection. Fatty degenera- tion of the tumors is one of the changes that take place during pregnancy. Of the influences that fibroids exert on the course of pregnancy, abortion is one of the most common. It is probable that interstitial tumors disturb the muscular tension of the uterine wall, so that abnormal contractions occur suffi- cient to dislodge the ovum. Submucous fibroids produce abnormal changes in the endometrium. It is thinned and flattened over the surface of the tumor, while the remainder becomes permanently hypertrophiecl. The endometrium may, therefore, become poor soil for the continued gro'^i;h of the ovum. Undoubtedly, fibroids to some extent prevent impregnation. This is denied by some, but authentic figures seem to show that the percentage of sterility in myomatous women is higher than in normal women. The average proportion of sterility in all women is between 12 and 15 per cent., while that in myomatous women is about 30 per cent. Just why a myomatous predisposition causes sterihty is not known. On the other hand, it has been claimed that fibroids, by prolonging the menstrual era, sometimes favor fertilit3\ Myomata that are large or so placed as to obstruct the uterine canal may act as a serious interference to childbirth. The relationship between .myomata and the function of menstruation is a matter of interest. Women who develop fibroids are apt to give a history of having begun to menstruate at an especially early age. Thej^ also continue to menstruate to a later age than the average, the menopause coming at fifty or over. Myomatous women usually menstruate profusely from the time the catamenia is estabhshed, and clotting of the menstrual blood often occurs long before evi- dences of fibroid growth appear. The diagnosis of uterine fibroids is, in the majority of cases, attended with little difficulty. The characteristic hard, nodular, asymmetric feel of the uterus is usually unmistakable; nevertheless, there are many chances for error. In palpating the abdomen the most important sign is the ability to feel the fundus of the uterus just back of the pubes. In the absence of pregnancy this incficates a fibroid uterus in the vast majority of cases, though it must be remem- bered that it may result from a tumor of the adnexa in the posterior culdesac, which is pushing the uterus forward toward the anterior abdominal wall. An adherent tumor of this kind, whether of "the ovary or of the Fallopian tube, creates with the uterus a mass which is often mistaken for a fibroid uterus, a mistake in diagnosis that may be made by the most expert. The error, however, is not serious, for if there are symptoms, either condition indicates an abdominal ope- ration. A well-advanced cancer of the body of the uterus is often difficult to dis- tinguish from a symmetric edematous fibroid. If there has been metrorrhagia, suspicion of cancer should be aroused, and it is advisable to make a prehminary 324 GYNECOLOGY intra-uterine exaixdnation, with removal of a specimen for microscopic diagnosis. This is important, since even after the abdomen is opened it may not be possible to distinguish between the two conditions. A correct diagnosis is essential, be- cause if the tumor is a fibroid, supravaginal hysterectomy is indicated, while if it is cancer of the body, a complete hysterectomy, preferably by Wertheim's method, should be performed. The diagnosis between pregnancy and a myomatous uterus is sometimes ex- ceedingly difficult and may lead to disastrous procedures. A symmetric edema- tous myoma may resemble a pregnant uterus very closely indeed. When there is doubt between these two conditions, the most rehable help is from the history of menstruation. Pregnancy causes amenorrhea and fibroids tend to cause menorrhagia, yet it must be borne in mind that pregnant women sometimes bleed periodically, while fibroids occasionally are associated with temporary amenorrhea. Other incidental signs are helpful. Of these, the consistency of the cervix is most valuable. The cervix of a myomatous uterus does not exhibit the softness characteristic of pregnancy. If, however, there is a severe laceration with eversion of the fips, the sign may be doubtful. The condition of the breasts, the presence or absence of blueness of the vaginal mucous membrane, are inci- dentally valuable. If on opening the abdomen doubt still exists, something can be told from the color of the uterus. A myomatous uterus has rather a pmk- ish hue, while that of the pregnant one is a deep purple. If doubt still exists, it is best to incise the uterine wall in a longitudinal chrection, by which a certain diagnosis can be made at once. The corpus luteum sometimes indicates the real condition, but is not entirely rehable. If it is very large, it throws ad- ditional e^-idence in favor of pregnancy. The use of the uterine sound, formerly so commonly used in the diagnosis of uterine myomata, is not recommended under any concUtion. The information gained from it is of httle value, while the dangers in its use are considerable. The Abderhalden test for pregnancy is especially valuable in differentiating fibroids from pregnant uteri. The treatment of uterine myomata depends on their size, rapidity of gro"^i:h, and the production of sjonptoms. ]\Iany fibroids require no treatment at all. Small subserous tumors that are either stationarj^ or growing very slowly, and which are causing no symptoms, may be let alone, but should be kept under periodic observation, especially if the patient is hkely to become pregnant. Atrophied fibroids of moderate size after the menopause do not need treatment if they are giving no symptoms, but should be carefully watched for evidences of degeneration. Large fibroids, when discovered, should, as a rule, be removed even if thej^ are causing no discomfort, for they are practically sure to give trouble sooner or later, and their removal is safer and easier if it is done before serious symptoms or com- pHcations take place. Fibroids that cause symptoms should in most cases be treated surgically. NEW GROWTHS 325 The symptoms that, require surgical intervention are those that result from bleeding, pressure, infection, and degeneration. It is obvious that symp- toms from the last three conditions named can only be treated by surgical operation. Bleeding, however, when not due to degenerative processes in the tumor, may be subject sometimes to other forms of treatment than surgery. As we have seen, the bleeding from a submucous myoma comes from the hypertrophied endometrium not covering the tumor. It is, therefore, possible sometimes to reheve the menorrhagia by curetment. The relief is, however, usually only temporary. The procedure is especially useful in tiding a patient over the menopause, with the hope of a future atrophy of the tumor. This form of treat- ment is to be used only in small or moderately sized fibroids. There are various drugs that are in common use for treating menorrhagia due to fibroids, most prominent of which are ergot, hydrastis, and hamamelis. The results of their use are, however, very unsatisfactory. Recently pituitrin has come into favor, and encouraging reports have been made in its administra- tion for the control of non-puerperal uterine bleeding. In some cases the bleeding from fibroids may be controlled by the use of radium or the a;-rays. The effect of radiation results in the destruction of the folli- cles of the ovaries, which, according to our present knowledge, preside over men- struation. Whether radiation affects the bleeding, in addition, bj^ direct effect on the uterine tissues is a matter of conjecture. This form of treatment undoubt- edly has a valuable place in the therapy of fibroids in certain cases, especially in patients who are near the menopause or who are constitutionally unfit for surgi- cal operation. The treatment has certain disadvantages which, for the present at least, greatly restrict its field of usefulness. Besides the ordinary danger of burns in the application of radiation there is very serious danger, in treating cases where there is any form of degeneration, infection, or malignant disease, of greatly aggravating the complicating process. Radiation when apphed im- properly to fibroid tumors may cause degeneration, necrosis, and inflammation,, so that it must be used only by the most experienced. After the menopause bleeding always means some form of degeneration or malignancy, so that radiation should not be used at that period of life. The work of Kelly with radium in treating myomata has been especially noteworthy. His method of treatment is to introduce large amounts of radium into the uterine canal with com- paratively short exposure. He is able to produce amenorrhea in every case, and in many instances a great reduction and even disappearance of the tumor. In the case of yoimg women, by proper regulation of the dosage he can relieve menorrhagia without causing com- plete amenorrhea. Kelly beheves that with improved technic it will be possible to reheve every patient of hemorrhage and in 9 cases out of 10 to do away with the tumor. Myomectomy and Hysterectomy. — The surgical treatment of uterine myo- mata consists either in the enucleation of the tumor, myomectomy, so-called, or in the removal of the uterine body by a supravaginal hysterectomy. 326 GYNECOLOGY Small tumors that are met with incidentally during a pelvic operation should always be removed by myomectomy as a routine, unless they are so numerous or deep-seated that this operation is not feasible. It is often possible to enucleate symptom-giving tumors of considerable size, and the question not infrequently arises as to which operation is advisable. This question must be decided very much as is the question of conservatism or radical- ism in chronic pelvic inflammation. One must first weigh the comparative merits of the two operations. If the myoma is of considerable size and not well pedunculated, a myomectomy is a bloodier and more difficult operation than hys- terectomy. The immediate convalescence from extensive myomectomy opera- tions is apt to be very stormy, while that from hysterectomy is unusually good. Moreover, the removal of one or more fibroids from the wall of the uterus does not insure against the development of others at some later date. In young .women the chances of recurrence are very considerable. Myomectomy opera- tions, owing to the exposure of wound edges and suture knots, are more often followed by postoperative adhesions than are hysterectomy operations. Thus, it will be seen that myomectomy has certain disadvantages which often make the procedure inadvisable. There are, however, circmnstances under which the operation must be performed if it is surgically possible to do so. The most im- portant indications for its use are in young women who wish to bear children, and in those who for sentimental reasons prefer the ill chances of a myomectomy to the loss of pelvic organs. Women in the child-bearing period who have had a myomectomy performed should be periodically examined until after the meno- pause. Most fibroids that require operation are best treated by a supravaginal hys- terectomy by the abdominal route. The abdominal route has so many advantages over the vaginal that the question hardly needs discussion. It may be said, how- ever, that the chief advantage of the former is that it is possible to secure a much more efficient postoperative pelvic support, a point that far outweighs all other considerations. A supravaginal operation is preferable to a complete hysterectomy, partly because it is a simpler and safer operation, and partly because by leaving the cervix better pelvic support can be secured. The only advantage that a complete hysterectomy has over supravaginal amputation is the avoidance of a possible future carcinoma of the remaining cervical stump. This complication does occur, but it is extremely rare. It is safe to say that if a complete hysterectomy were performed in every case as a routine the increased operative mortality would be considerably greater than the incidence of cancer following supravaginal amputation. The technic of supravaginal hysterectomy is described in detail on page 7,13. The chief points to aim for in performing the operation are to secure permanent pelvic support and to avoid the possibility of postoperative adhesions. If these two objects are attained the after-results of hysterectomy for fibroids are excel- NEW GROWTHS 327 lent, and are especially remarkable in those cases where there have been associ- ated nervous disturbances. The question of leaving in one or both ovaries when possible is one about which there is considerable disagreement. It is doubtful if leaving in ovarian tissue does very much good. Polypoid myomata are removed per vaginam. If they have a firm pedicle they can be removed with blunt-tipped scissors, preferably under an anesthetic, as the bleeding is sometimes troublesome. Some of the necrotic myomata can be removed by the finger without anesthesia, a point that is useful to remember in treating elderly women, in whom these necrotic fibroids very frequently appear. ADENOMYOMA Adenomyomata constitute a special type of uterine fibroids. They are distinguished from the ordinary myomata by the diffuse manner in which they grow in the uterine wall, and by their containing embedded in the myo- matous tissue numerous gland-like structures. These glands are lined by epi- thelium very similar to, and probably, for the most part, identical with, that of the endometrium, while immediately surrounding the glands is a cytogenous connective tissue like that of the endometrial stroma. The origin of the adenomyomata is a matter of much scientific interest. As a result of the investigations of von Recklinghausen, it was believed for a time that they all develop from rests of the Wolffian body, von Recklinghausen demonstrated structures in some of his specimens resembling the convoluted tubules and glomeruli of the kidney. Later researches, especially by R. Meyer, Cullen, and Opitz, have shown that in most instances the glandular elements are developed from and connected with the glands of the mucosa. Meyer has also shown that in some of the small subserous tumors the epithelial structures are derived from the peritoneal epithelium of the surface of the uterus. It is conceded that only one form of adenomyoma, that which grows in the parame- trium, is probably derived from embryonal rests. The adenomyomata, for the most part, develop in the posterior wall of the uterus, more commonly near the uterine horns. They may, however, grow in any part of the uterus and even rarely in the cervix. Occasionally they form polypoid tumors in the uterine canal. They do not attain large dimensions, rarely reaching a size greater than that of an orange. On account of the diffuse nature of their growth it is often difficult to distinguish the boundary line be- tween tumor and uterine wall, especially if the tumor is located near glandular tissue, as in the case of adenomyomata at the uterine horns. In fact, many of the so-called tumors of this region are pronounced by Meyer not true tumors at all, but inflammatory hypertrophy of the uterus, a condition to which he gives the name of "adenomyositis." It has also been shown that adenomyo- mata are frequently associated with, and probably caused by, chronic pelvic inflammatory processes, in which tuberculosis plays an important part. 328 GYNECOLOGY The adenomyomata are not, as a rule, of great clinical importance. They do not often grow to a size large enough to produce serious symptoms unless the tumor is a polypoid growth into the uterine canal. The symptoms of adenomyomata are menorrhagia and menstrual pain referred to the uterus. Cullen, who has made an exhaustive study of these tumors, regards the clinical diagnosis of the condition as not difficult. Fig. 98. — Adenomyoma. High power. Sections of four glands are seen, lined by a single layer of epithelial cells. These lie in a connective-tissue stroma like that of the endometrium. The whole is surrounded by myo- matous tissue in which are a few mononuclear leukocytes. The adenomyomata have no special disposition to carcinomatous change, though this does occur in rare instances. SARCOMA OF THE UTERUS Sarcoma of the uterus is far less common than uterine cancer, the rela- tive proportion of frequency being about 1 to 40. These tumors always arise from the connective tissue of the uterus, and may have their origin either in the connective tissue of the myometrium or in that of the mucous membrane. They are divided into two important classes, according to these two points of NEW GROWTHS 329 origin. Those that develop in the myometrium almost invariably represent a malignant change in a pre-existing fibromyoma — so-called malignant degenera- tion of fibroids. This type, termed myosarcoma, is stated by Meyer to be far more common than that which arises from the mucous membrane. Myosarcoma of the uterus, for the most part, is an affection of middle age, the highest incidence occurring at about fifty. Sarcoma from the mucous membrane appears relatively earlier, the youngest case reported by Doderlein being five years, while the youngest case of myosarcoma reported was twenty. The etiology of sarcoma of the uterus is quite obscure. Sarcoma of the Mucous Membrane. — Macroscopically, sarcoma of the mucous membrane may be diffuse or polypoid. In the polypoid form masses of peduncu- lated tumors become extruded through the cervical canal, and either slough off spontaneously or are removed by opera- tion, only to appear again. These con- stantly recurring tumors are sometimes called recurrent fibroids until a micro- scopic examination reveals the true nature of the growth (Fig. 99). Where this type of sarcoma springs from the mucosa of the cervix the vagina be- comes filled with a mass of grape-like polyps, which eventually protrude through the introitus into the outer world. The tumor under these condi- tions is commonly called a grape-mole or sarcoma botryoides. Diffuse sarcoma of the endometrium spreads into the wall of the uterus peripherally in the same manner as an inverting adenocarcinoma of the body. Myosarcoma. — Sarcomatous degeneration of fibroid tumors — myosarcoma — usually starts near the center of the growth. It may appear as a sharp 1}^ defined nodule or it may spread diffusely in the surrounding tissue. Various forms of degeneration are apt to take place, so that, macroscopically, the sarcomatous portion of the tumor is sometimes distinguished from the normal tissue by dis- colored appearances, necrosis, or accumulation of fluid. Histology. — The cells of which the uterine sarcomata are made up are con- siderably varied. Meyer divides the growths into muscle-cell sarcoma (in Fig. 99. — Grape Sarcoma, or Sarcoma Bot- ryoides. The vagina is seen crowded with grape- like masses of the growth. (Copied from a drawing in Kiistner's Handbuch.) 330 GYNECOLOGY which muscle cells and sarcoma, cells are mixed), spindle-cell sarcoma, and round- cell sarcoma. The cells may be of all kinds and sizes. Sarcomata of the endo- metrium are chiefly characterized by round cells. The latter type of sarcoma (especially the diffuse kind) is sometimes differen- tiated with difficulty from adenocarcinoma of the body, which in the advanced stages loses its glandular characteristics, the appearance and arrangement of the cells appearing quite similar to round-cell sarcoma. On the other hand, the cells of diffuse sarcoma of the endometrium may assume an alveolar Fig. 100. — Sarcoma of the Cervix. Low power. This drawing shows the sharp line of demarcation between the growth on the left and the cervical stroma on the right. The latter consists of connective tissue with a few bundles of muscle scattered through it. The former consists of a homogeneous mass of cells very nearly the same size, having circular vesicular nuclei. There is very little stroma between the masses, and they are traversed by a fine network of capillaries, as can be seen in the drawing. In the center is a blood-vessel running into the tumor tissue from the cervical stroma. arrangement which closely resembles an adenocarcinoma. This is sometimes called "adenosarcoma." In some cases there is a rich development of blood- vessels or lymph elements, and the tumors are termed "angiosarcoma" or ''lymphosarcoma." Melanosarcoma of the uterus has been described. Cystic degeneration of the tumors has led to the designation "cystic sarcoma." It is possible for sarcoma and carcinoma to coexist in the same uterus. Diagnosis. — An accurate clinical diagnosis of sarcoma of the uterus is, in the majority of cases, very difficult to make. In the polypoid type, where the NEW GROWTHS 331 tumors present in the vagina, the removal of a section for microscopic examina- tion can easily be done. The so-called recurrent fibroids are almost pathog- nomonic of sarcoma, but the specimens removed or expelled should receive microscopic examination. In the less obvious forms of sarcoma the diagnosis is very blind, and is usually not definitely made except by the microscope, after operation or autopsy. There are, however, certain symptoms which msiy lead to suspicion of sarcoma, and of these uterine bleeding is the most important. In children before puberty, bleeding from the vagina, if precocious menstruation is excluded, must be regarded with grave concern, for it is apt to indicate the presence of uterine or vaginal sarcoma. In later life all bleeding and sloughing myomatous polyps should receive searching microscopic examination. Diffuse sarcoma of the uterine mucosa occurring during menstrual life presents practi- cally the same symptoms as adenocarcinoma of the body, chiefly metrorrhagia and foul discharge. The diagnosis should be made in the same way, namely, by removal of a specimen for microscopic study, preferably under an anesthetic, and preliminary to operation. Where the sarcoma represents a malignant degeneration of a mj^oma the diagnosis can rarely be made positively. ]Many times these sarcomata are discovered only during the routine examination to which all fibroids should be subjected. During menstrual life menorrhagia and rapid increase of a myoma- tous uterus give warning of mahgnant degeneration, but these sj^mptoms are, of course, not pathognomonic, as fibroids often take on sudden and rapid in- crease without the stimulus of malignant change. After the menopause the appearance of blood and sudden enlargement of a long-existing myoma are very suggestive signs of sarcomatous change, but thej- may also be caused bj' other forms of degeneration. The appearance of ascites, together with rapid growth of a fibroid tumor, is a warning of sarcomatous change, for it rarely occurs in connection with non- malignant fibroids. Loss of weight and cachexia are also important symptoms suggestive of sarcoma. Estimates of the frequency with which sarcomatous degeneration takes place in fibroids varj" from less than 1 per cent, to over 10 per cent. This wide difference is due to errors in microscopic diagnosis, for in many instances rapidh^ growing myomatous tissue resembles sarcoma so closelj^ that a correct differen- tial diagnosis can be made only by the most expert. The true incidence of sarco- matous degeneration of uterine fibroids is probably between 1 and 2 per cent. Sarcoma of the uterus has a much greater tendency to metastasize to distant ■parts of the body than does cancer, either of the body or of the cervix, and for this reason it must be regarded as especially malignant. The tendency to metastadze varies somewhat according to the special type of sarcoma. The most dangerous form is the diffuse sarcoma of the endometrium which metas- tasizes ver^' early. Somewhat less mahgnant is the polypoid type, while the most favorable is the sarcoma of uterine myomata. 332 GYNECOLOGY This last-named group is apt to be very treacherous, however, for some- times a small and inoffensive localized area within a myoma may be followed after removal by extensive metastases and death. The treatment of sarcoma of the uterus consists, if the case is operable, in a total extirpation of the uterus, preferably by the Wertheim method. In inoperable cases there is not much that can be done. Radium and x-ray treatment is, for the most part, ineffectual, and is positively contraindicated in degenerated myomata, for by this means the malignant disease may often be stimulated to new activity. CERVICAL POLYPS Cervical mucous polyps occur with extraordinary^ frequency. They are seen most commonly in women after forty, though they may appear earlier. They are very frequent after the menopause. ..^;^~-„ /f^i-#3^,;»«a^^^ /j--::^c : : ~ ' '~^^ = ' '■ ,- ■ "'■■ ' i^^ /'/' ~ ~-" , ' ~ V .-■"'" - •„ \ <~: - \ ., -^ ^ - 1' ~"-- - - •' ■ -■. ' ,_ ^ ■■^ ^..C^^^, -"' ^f.C.^M-V:::F. Fig. 101. — Ceevical Polyp. Cross-section of a polyp. The epithelium covering the polyp is of the stratified squamous va- riety, showing that this part of the polyp lay in the vagina. The spaces are dilated glands lined by a single layer of cylindric epithelium similar to that of the cervical canal, where the polyp originated. The stroma consists of connective tissue with a few muscle bundles in it. The cervical polyp represents a hypertrophy of the mucous membrane of the endocervix and contains all the elements of that structure. It usually has a slender pedicle, so that the polyp can easily be plucked off. Sometimes the NEW GROWTHS 333 polyp is sessile, with a broad base. These growths never reach a large size and are more often multi'ple than single. They are of a bright red or purple color, and can usually be felt by the examining finger as soft movable bodies at the ring of the external os. They may grow in any portion of the cervical canal. When one is seen extruding at the external os there are usually others higher up in the canal. They are composed of hypertrophied cervical mucous membrane, the glands being dilated and cystic, filled with a clear mucus. When grasped with an instrument they easily rupture and collapse. These small tumors have no Fig. 102.- — Mucous Polyp of the Endometrium. tendency to become mahgnant. They are, however, by no means harmless and are sometimes of considerable clinical importance. Symptoms. — The chief symptom is bleeding. Polyps may evidently exist for long periods of time without making themselves known. As a rule, the bleeding is rather mild in character. There is apt to be an increase of menstrual flow with slight signs of blood between the periods. If the menopause is past, the bleeding usually shows as a slight staining on the underclothing. Some- times, however, even a small polyp may be the cause of profuse and exhausting hemorrhages. Patients not infrequently acquire a pronounced secondary anemia from their presence. Mucous polyps often set up a very persistent leukorrheal discharge. They 334 GYNECOLOGY easily become eroded and infected and maintain an inflammation of the endo- cervical mucous membrane. Often leukorrhea is the only symptom of their presence. The diagnosis of cervical polyps is very important, for they produce symp- toms very like those of mahgnant disease. In most cases they can be felt and seen, even if they are growing part way up the cervical canal, for they usually cause the external os to be more patulous than normal. In fact, in the presence of the above-named symptoms an abnormally patulous os leads one to suspect polyps, even if they are not at first apparent. The macroscopic appearance of a pedunculated polyp is quite characteristic and could rarely be confused with anything else. The sessile variety which grow well up in the cervix might suggest cancer. Microscopically, the picture is invariably that of hyper- trophied endocervical mucous membrane. The larger polyps may sometimes be mistaken for degenerated polypoid myomata and should be carefully differ- entiated from them by the microscope, because the latter may sometimes be ma- hgnant (adenomyomata, ''recurrent" fibroid). The diagnosis of cervical polyp cannot always be made by digital examination and inspection, but may require anesthesia and an intra-uterine examination. With symptoms of irregular bleeding the possibility of cervical polyps must not be overlooked, for it is very easy to miss them during an intra-uterine examination if the upper part of the cervical canal is not carefully investigated with curet and polyp forceps. The treatment of cervical polyps is always removal. The pedunculated polyps at the external os can easily be removed through a speculum by snipping them off with scissors, and it is a temptation to do this in the office. It is always better to advise anesthesia and a complete intra-uterine examination, for in the majority of cases one or more small, beginning polyps can be found higher up in the cervix in addition to the one that is apparent. It is also im- portant to curet thoroughly the canal of the cervix, for in most cases there is an associated endocervicitis which is very apt to persist after the removal of the polyp. As a rule, cutting off these growths causes very little bleeding. The sessile variety sometimes needs dissection and the placing of two or three fine catgut sutures in the wound. Well-defined mucous -polyps of the endometrium are less common than those from the cervical mucosa. Their formation, symptomatology, and treatment are the same. It is an easy matter to miss them during an exploratory curetage of the uterine canal, and for that reason it is always advisable in this operation to search the canal with placenta forceps. CANCER OF THE CERVIX Cancer- starting in the cervix of the uterus must be studiously differentiated from that which originates in the body' The two forms are quite distinct, both histologically and chnically, a fact which serves still further to emphasize NEW GROWTHS 335 that the cervix and body of the uterus are to be regarded as two independent organs that differ widely from each other in their pathologic and physiologic processes. Pathology, — Cancer of the cervix when it comes under observation usually appears as a squamous-cell carcinoma. In its incipiency, however, the growth presents certain differences, according to the particular part of the cervix in which the disease has its origin. It is necessary to remember that the epi- thelium of the cervix is divided into two parts, that which covers the vaginal portion and that which extends from the external to the internal os, the so-called ;cxv\cer-\- :j Vc\<^vr\cv. Nv:^.< Fig. 103. — Everting Cancer of the Cervix. In this case the disease has originated in the posterior lip of the portio and is growing in cauli- flower-like masses toward the vagina. There is only moderate invasion of the cervical wall. It can readily be seen that this form is less treacherous than the inverting type. endocervix. The epithelium covering the vaginal portion is really modified epidermis, and consists of layers of squamous cells like those of the skin, but without hair-follicles, sebaceous or sweat glands. The squamous epithelial cells just above the external os merge into true mucous cells, which hne the surface both of the endocervix and the arborescent glands that branch from the endocervix. In a nulliparous woman under normal conditions the endocervix is entirely concealed and well protected by the contour of the vaginal portion. When the cervix has been lacerated the endocervix tends to evert, and appears redder and more roughened than the squamous epithelium of the vaginal por- 336 GYNECOLOGY tion. This appearance has led to its being called an erosion or ulceration. Although true erosion may occur, the condition usually is one of eversion or ectropion. Cervical cancer may originate in the squamous epithelium of the vaginal portion, or in the transition epithelium of the everted area, or in the fully developed cylinder mucous epithelium higher up in the endocervix. If the cancer starts from the epithelium of the vaginal portion it begins as a typical squamous cell carcinoma or epithelioma with large polyhedral cells and forma- tion of cancroid pearls. If the cancerous process starts in the everted mucous ,\J\c€ratvow JriG. 104.- — Inverting Cancer of the Cervix. In this case the growth is invading the walls of the cervix with little tendency to extend outward into the vagina. In this type there is an earlier invasion of the parametrium. It can be seen from the drawing that the disease might escape detection by the examining finger. This form of the disease is especially treacherous. membrane or in the endocervical canal, the structure of the epithelial growth is at first adenoid, but this characteristic is usually soon lost and the cells grow in solid masses, approaching the squamous cell type. As most cases of cancer of the cervix are well advanced before they come to examination, it is usually difficult to tell from the microscopic appearance where the disease started. For this reason nearly all cancers of the cervix are diagnosed as squamous cell carcinomata or epitheliomata. Occasionally, but not often, the adenoid type persists in a growth originat- ing from the endocervix and the growth remains as a true adenocarcinoma. NEW GROWTHS 337 It is important to bear in mind the points from which cervical cancer may start, as the course of the disease varies somewhat according to the place of \ A Fig. 105. — Adenocarcinoma of the Cervix. Very low power. Section of the whole uterus. At the bottom on each side is the A-aginal wall. The outside of the cervix appears normal. On the left, extending the whole length of the cervical canal, is the growth, invading the stroma of the cervix. More of it can be seen at the internal os on the right. This illustrates especially the importance of curetage for diagnosis, as this growth could not be seen on inspection of the cervix. origin. Thus, cancer beginning in the epithehum of the vaginal portion grows outward in papillary excrescences until a characteristic cauliflower mass is formed. 338 GYNECOLOGY It has little tendency to extend toward the body of the uterus, and invades the parametrium and regional lymph-glands relatively later than does cancer of the endocervix. On the other hand, it has a greater tendency to invade the vaginal wall and extend to the bladder. Cancer of the endocervix may grow outward in a papillary form like that from the portio, especially if it originates in the everted mucous membrane of a lacerated cervix. It has, however, a special tendency to become what is called "invertent"; that is to say, it grows inward toward the cervical wall and para- metrium. The process may continue for a considerable time without giving external evidence of its presence. It reaches the parametrium earher than does v.on Fig. 106. — -Advanced Cancer of the Cervix. In this case the disease has invaded the whole of the cervical walls and is extending into the walls of the vagina and bladder. The crater represents the condition after curetment and cauterization. cancer of the portio, and has a relatively greater tendency to metastasize to the regional lymph-glands. It may also invade the vaginal wall by extension in the subepithehal connective tissue, causing a thickening and induration of the wall without disturbing the epithelial covering. It will be seen, therefore, that this form of cervical cancer is especially treacherous, in that it may progress to an advanced stage without giving warning of its presence. In the majority of cases the disease has so far advanced before the patient appears for examination that it is impossible to tell, either from gross inspection or microscopic examination, the location in the cervix from which the growth NEW GROWTHS 339 originally started. In the following discussion the various types will not be distinguished, but will be included together under the term "cervical cancer." Incidence. — Cancer of the cervix appears most commonly between the ages of forty and fifty. In a series of 6071 cases collected by one investigator (Kob- lanck) 33.7 per cent, occurred between thirty and forty, and 24 per cent, between thirty and sixty. Occasionally cases are seen later than sixty and earlier than thirty. In our own experience the youngest case has been twenty-five. Craigin has reported a case of cancer of the cervix in a girl of eighteen. \Jt«.t>.YveVesSe)<; V(.ip.G»' ',','<.., 'f*^ .« .^ ' -.^ Fig. 111. — Adenocarcinoma of the Body of the Uterus. The disease is beginning in the upper part of the canal and is extending both inward into the mus- cular wall and outward toward the canal. In this case the growth has a papillary appearance. \s _ Vvinb\jS "Vcvoxwo.--' ^^ V:C=.-c(XV5t&,iqv^ Fig. 112 — Adenocarcinoma Beginning. Near the Internal Os. This tumor has metastasized in the ovaries. 364 GYNECOLOGY muscular wall glandular offshoots are seen invading the muscle below the normal line of demarcation, between muscle and endometrium. Macroscopic- ally, upon opening the uterine cavity the growth appears as an irregular eleva- tion of the endometrium, the surface of which in some places may be smooth and wavy, in others papillomatous. The cut surface is usually somewhat lighter in color than that of the normal uterine tissue, and a rather distinct outline can be made out between cancer and muscle tissue. The disease gradually en- croaches on the uterine wall until in advanced cases the musculature may be little in evidence. In the course of time it may break through the outer wall Fig. 113. — Hydhometra. In this case the patient, aged sixty- two at the time of operation, had never menstruated, though in earlier life she had had periodic molimina. The tumor seen in the cavity is a papillary adeno- carcinoma, probably of recent developmcDt. The contents of the uterine cavity were of a serous character with brownish tinge. The outline of the cervix has been sketched in to show the absence of a complete canal. The operation consisted of a supravaginal hysterectomy, the cystic nature of the uterus not being discovered until the specimen was opened. and become disseminated to neighboring parts. Unlike cancer of the cervix, it usually does not invade the parametrium excepting by direct extension, a process which indicates a late stage of the disease. Metastasis to the regional lymph-glands is later than in cancer of the cervix. Occasionally cancer of the body metastasizes to the tube and ovary in a comparatively early stage of its growth, an extension rarely seen in cancer of the cervix. Cancer of the body has its principal incidence later in life than cancer of the cervix, the figures of Koblanck showing that in 50 per cent, of cases it occurs between the ages of fifty and sixty. It is quite rare to find it in patients under Fig. 114. — Pedunculated Adenocarcinoma of Body of Uterus. Fig. 115. — Adenocarcinoma of the Endometrium. High power. The distinctive feature is the glands, the epithelium of which has proliferated until the lumens are obhterated. The epithelial cells are large, vary in size, and on the right especially appear like squamous epithelial carcinoma. Well-formed glands, however, are seen in other places with thin trabeculse of stroma between them. 365 366 GYNECOLOGY forty. It is seen only about one-eighth as often as cancer of the cervix, accord- ing to statistics. Nulliparous women seem to have a special predisposition to this form of cancer, a fact that still further differentiates it from cervical cancer. Cancer of the body is quite often found in association with uterine fibroids, whereas the combination of fibroids with cancer of the cervix is comparatively rare. As the process frequently originates in the mucous membrane covering the myoma, it is thought that the cancerous growth is stimulated by trauma exerted by the fibroid on the overlying endometrium. ^$^- .^ / V ^ ,%o.C' ^* /^^®^;^« ^^r f ^ ■C'^ */-a«#i «t%:^ ^^^'% ^^ s ... ^«*:. .'-,\>, "^t .J4 ji fj- 4..^ .JA"'*> z '* '^?^£&- 7Put.fl O Hui^i,-r(5A'i.^^^ Fig. 116. — Adenocarcinoma of the Endometrium. "-^ High power. To illustrate the growth of the epithelial cells outward from the gland, as is seen in the upper left two-thirds of the drawing. The gland seen has lost its basement-membrane and lies in a mass of carcinoma tissue. To the lower right is a strand of stroma which has become separated from the tumor in cutting the section. Cancer of the body is especially favorable from a surgical standpoint be- cause not only is its progress slow, but it usually gives early warning of its pres- ence. It makes its appearance first by increased uterine secretion and then by bleeding. This bleeding, coming as it frequently does after the menopause, attracts the immediate attention of the patient, so that she is apt to seek medical advice in time for successful surgical treatment. When the disease occurs before the menopause its detection from clinical symptoms is more diffi- cult. The bleeding at this time is apt to appear only as a profuse menstrual NEW GROWTHS 367 period, and the mistake is often made, both by the patient and her doctor, of regarding the menstrual disturbance merely as an indication of the change of life. The progress of the disease, however, is usually so slow that the persistent hemorrhages finally excite suspicion in time for surgical cure. When a cancer of the body is associated with a uterine fibroid the bleeding has no definite diagnostic characteristic which would differentiate it from that seen in an 9> ^ ,( t ■> ■•^qM ^•^^ ..\, qy L* >»; ef^' 4k % "'te'^Quog ^: ^v '&^r. fi& I J' jaSe • 1 .'^^- ^c '-^ $&'■■, «f «* '^\ '""'so ^ » ^ ""c " ^: t r> ''-» ij ^ ^ ■* ;'v J /* <'' "° ^ ■0- '» ' > «'' i wi? J 1 e 1 " ^ » "^ > \ . ^^ •S" *♦ /,• ^ '-'. • 4'' Ji * , "'"^ y> ? " * s oae i, ? ->.*' .« / # J ' "3 ^% • ». * "s Jrw/^ CS .//(/£ T "^a ~ I"' / Fig. 120. — Adenocarcinoma of the Endometrium. Low power to show a papillary outgrowth. We see a branching, connective-tissue stroma carry- ing blood-vessels, covered with epithelium lying in one to several layers. This is characteristic of the advanced adenocarcinoma growing out into the uterine cavity. The marked change can be understood if this is compared with the normal endometrium. 24 370 GYNECOLOGY When the diagnosis of cancer is established the treatment is immediate radical operation. The operation for cancer of the body is similar to that for cancer of the cervix, except that it need not be so extensive. Removal of lymph-glands is rarely necessary, while a wide dissection of the parametrium is not required in most cases. Moreover, as cancer of the body has little tendency to extend downward, there is not the need. of removing the upper part of the vagina as there is in operating for cancer of the cervix. The operation for cancer of the body, therefore, is very much less difficult than that for cervix cancer, and the primary mortality is correspondingly. lower. The prognosis as to recurrence is very good, and permanent cures should be obtained in at least 80 per cent, of cases operated on. CHORIO-EPITHELIOMA MALIGNUM This term is applied to a malignant tumor that develops from the epithelial elements of placental tissue. It most commonly follows the expulsion of a hydatidiform mole, but may date its origin from an abortion or a tubal preg- nancy, or even a normal pregnancy. The tumor usually appears first as a nodu- lar excrescence growing from the surface of the uterine canal or from the lumen of the tube. The growth is very vascular, often having the appearance of a hematoma, and tends to bleeding and necrosis. Metastases soon appear on the wall of the vagina or in the neighboring pelvic organs, and spread rapidty by the blood circulation to distant parts of the body, especially to the lungs. The disease, if not checked by surgical interference, is usually very fatal, destroy- ing the patient with extraordinary rapidity, but sometimes abruptly ceases in its progress even after the appearance of distant metastases. Its onset may follow the abortion or mole from which it takes its origin almost immediately, or it may not appear for days, months, or even years later. The history of our present knowledge of chorio-epithelioma is one of unusual interest. The disease was first described by Saenger less than twenty-five years ago. He thought that these tumors developed from the decidual cells of the endometrium, and gave the name deciduoma to the disease, supposing it to be a sarcoma. Later, Marchand described the histology more exactty, and showed that the tumor-growth develops from the epithelial cells surrounding the chorionic viUi, and is, therefore, a carcinoma. This view is universally held at present, and all terms formerly used at different times to designate the disease have given way to the name suggested by Marchand, "chorio-epithelioma," which best describes its histogenesis. There -has also been a complete change in our knowledge of the clinical course of these tumors quite as remarkable as that of our ideas as to their histology. Saenger's first 5 cases died with general metastases within seven months after abortion, and he regarded the disease as absolute^ hopeless. In 1896 Apfel- NEW GROWTHS 371 staedt stated that all therapy against these most malignant of all known neo- plasms was madness. Nevertheless, six years later Polano reported 50 per cent. and Teacher reported 63.3 per cent, of cures. Although these percentages are today regarded as unduly high, 3'et the number of operative cures is very large, while numerous instances have been reported where tumor masses which had been left behind during incomplete operations have eventually healed spontaneously. We see, therefore, the great- ■:'.'■'.. 'S •^ .■;> .,1,'r ! ■'■ •' >-;rsc^,v:(^. .•V":,- :kv?^'- ■: -^/; f ••;^v^;^'js*l y^ . r .',•!• .'• . • /• IV, ;'/■••' ••. • (.. •' iff' -••-•,-- r y-l Fig. 121. — Retained Placenta, Infected. Low power. The section consists mostly of coagulated blood. The strands of fibrin show especially. Infiltrating it are large numbers of leukocytes, mostly of the polynuclear variety. Near the top and in the center are several chorionic villi. est contrasts in the clinical picture of different cases, ranging from the stormiest and most malignant course to spontaneous and permanent retrogression. The first instances of spontaneous cure were reported by Pick and Schlagen- haufer, the former describing a case of vaginal metastasis following abortion. Schlagenhaufer concluded, from the observations of his case, that there are two clinical forms of the disease. The first is extraordinarily malignant and quickly overwhelms the organism with metastases, while the second form is benign from 372 GYNECOLOGY the outset. He further stated that the histologic appearance of the two forms is ahke. In order to understand the microscopic appearance of chorio-epitheHoma it is necessary to review the histology of the chorionic villus, from the epithelial elements of which the chorio-epithehoma has its origin. The chorionic villus is clothed with two layers of epithelium, the outer being termed the "syncytium," and the inner the "layer of Langhans." The term "syncytium," from its deriva- FiG. 122. — Placental Polyp. Low power. The light areas are chorionic villi, cut in various planes, which have become hyaline in places and still show their connective-tissue structure in others. They have lost their epithelial covering of Langhans' cells and syncytium. They lie in fibrous tissue formed by the organi- zation of blood. tion, denotes a fusing together of cells, and describes the outer layer, in that it consists of a continuous mass of darkly staining protoplasm in which are more or less regularly placed nuclei. There are, therefore, no definite cell boundaries. The continuous cell mass is occasionally interrupted by open spaces or vacuoles. The underlying layer (cells of Langhans) is composed of a single column of large bright epithelial cells with well-marked boundaries and weakly staining nuclei. They look like squamous epithelium, and are, in fact, derived from the fetal ectoderm. The outer layer (syncytium) is derived from the inner layer (Lang- NEW GROWTHS 373 bans), so that both layers are fetal in origin. Both layers in the normal placenta have a tendency to proliferate and grow outward into the space between the chorionic villi. The syncytial covering heaps up and pushes out into poty- poid processes that may become broken off. Hence, isolated irregular syncytial masses may often be found in the intervillous spaces. In this way syncytial 1^/ r.-..^- J>* 'Sf' .^ -^ v'y, , •? 'V : , Fig. 123. — Placenta at Full Term. Low power. On the right is an area of decidua consisting of greatly enlarged cells derived from the stroma of the endometrium. The enlargement takes place mostly in the protoplasm of the cell, the nucleus enlarging proportionately little. On the left are chorionic villi cut in various planes. They consist of a loose connective tissue containing comparatively large blood-vessels, covered by a layer of Langhans' cells and syncytium. The intervillous space is normally filled with blood. The small, dark areas are fragments of syncytium. elements are sometimes taken up by the blood-current and transported to distant organs, especially the lungs. The layer of Langhans is also prone to proliferate, and may break through the surrounding syncytial covering and grow in irregular masses of cells that include fragments of the syncytium (see Fig. 125). The pro- liferation of these two epithelial elements may be considerable and yet be within physiologic bounds. 374 GYNECOLOGY In chorio-epithelioma exactly the same overgrowth takes place without change in the appearance of the cells, excepting that it progresses to a malignant growth. When the fact became known that the disease might be either benign or malignant, every effort was made by pathologists to discover some distinguishing histologic mark by which the two forms might be differentiated. These efforts have been unsuccessful. Marchand, Aschoff, Zagorianski, Kissel, v. Franque, Albrecht, Hormann, and others agree that we have absolutely no histologic criterion for determining the malignancy of these tumors. Fig. 124. — Hydatid Mole. Low power. Parts of two chorionic villi are seen running across the field. They are tremen- dously swollen, as may be seen if this is compared with the drawing of the placenta at full term. The layer of Langhans' cells covered with syncytium are well shown on the surface of the villi. On the space between the villi in the center are several fragments of syncytium. This space is normally filled with blood in which these fragments lie. Moreover, a further difficulty in diagnosis exists in the fact that the tumors exactly resemble the normal fetal tissue. Hitschmann and Cristofoletti came to the following conclusion: "As a matter of fact, we are convinced that a histologic difference is entirely improbable. We know of absolutely no morphologic and biologic difference between the physiologic fetal tissue and the pathologic. The more carefully we study the earliest phases of placenta formation and compare them with chorio- NEW GROWTHS 375 epithelioma, the more we feel justified in the statement that between trophohlast (fetal tissue) and chorio-e'pithelioma there is no difference." ;tPW, Fig. 125. — Chorionic Villus, Showing Growth of Langhans' Cells Breaking Through the Syncytium into the Intervillous Space. Fragments of syncytium are seen in the sprouting mass of Langhans' cells. On the right is a collection of Langhans' cells, more highly magnified, surrounding syncytial fragments. (After Winter.) The same writers call attention to the biologic resemblance that exists between the tropho-~ blast, or fetal tissue, and chorio-epithelioma. "All the characteristics of the tumor cells are to be found in the normally functioning trophoblast. The enormous capacity for growth of the Fig. 126. ^Syncytium and Langhans' Cells. ' Two chorionic villi are seen, showing the outer syncytial envelope and the inner layer of Lang- hans' cells. In the center is a mass of proliferating Langhan's cells in which are scattered fragments of syncytium. (After Winter.) fetal ceUs, the destruction of maternal blood-vessels are apparent in both, excepting that in the physiologic tissue there is a, local and time hmitation. The relation of the fetal cells to the maternal tissue is just the same. The tnost important function of the trophoblast is the destructio7i 376 GYNECOLOGY of the maternal tissue, especially the erosion of the blood-vessels. In this way does the young egg come into relationship with the mother's blood, the intervillous circulation become established, . and the nourishment of the egg remain assured. The entire egg rests within the maternal blood- vessels and is bathed in maternal blood. "These same .characteristics v/e find in the chorio-epithelioma. There is the same destruc- tive faculty, the same elective behavior toward the maternal blood, and, therefore, the almost exclusive extension by way "of the blood-stream. Both tissues have no supporting tissue struc- ture, no individual blood-vessels, and both are dependent for their nourishment on the circulat- ing blood of the mother. The fetal cells of the trophoblast are, therefore, morphologically and °f«^' " ." X.'--^' Fig. 127. — Syncytium in the Decidua. Low power. This illustrates the wandering of fragments of syncytium in the decidua. The dark masses consist of syncytium which were found in the decidua. Several glands are seen, as this is endometrium. biologically identical with the cells of the malignant chorio-epithelioma. Therefore, in diag- nosing a chorio-epithelioma no safe conclusion may be drawn from the destruction of the mater- nal tissue as to its malignancy, because destruction of the maternal tissue is the most important function of the trophoblast." (Translation.) Symptoms. — Chorio-epithelioma usually makes itself known by repeated uterine hemorrhages following an abortion or a mole. Bleeding is always the characteristic symptom, no matter where the tumor is located, and is due to the corrosive action of the tissue on the walls of blood-vessels with which it comes NEW GROWTHS 377 in contact. Cureting brings about only a temporary cessation of the bleeding, which is apt to be severe and depleting. The patient becomes rapidly anemic and cachectic. Albuminuria is a very frequent accompaniment. A second cureting reveals a new mass of tissue in the canal of the uterus. A diagnosis by microscopic examination of the curetings is very difhcult to make, as is explained above, and patients are often lost as a result of a negative report from the pathologist. It is extremely necessary, therefore, to take into account the clin- Fig. 128. — Chorio-epithelioma. Low power. At the bottom is the edge of a chorionic villus covered with a regular layer of Lang- hans' cells. In the middle, lying on this, is syncytium. To the left of this and above it are masses of Langhans' cells. Near the top and near the right edge are large fragments of syncytium haA-ing the larger, deeper staining nuclei and deeper staining protoplasm, the whole floating in blood. ical course of the disease, without relying too much on the findings of the micro- scope. After metastases occur the diagnosis is simple, but it is then usually too late for treatment, though cases of spontaneous cure even at this stage have been reported. Metastases frequently occur in the vagina, and sometimes the first evidence qf the disease is seen here, the chief symptom being bleeding. On account of the corrosive action of the tumor and the friability of its tissue, metastatic emboli 378 GYNECOLOGY slip very readily into the blood-stream and are carried to distant parts of the body. The embolic masses when lodged grow and corrode the neighboring blood-vessels, causing local hemorrhages. Sometimes symptoms from the metastatic growths give the first warning of the disease without uterine mani- festations. Metastases to the lungs are especially common, and cause pulmonary hemorrhages, or they may be localized in the brain, liver, or kidneys, etc. In making a diagnosis of chorio-epithelioma, and coming to a decision as to the treatment, the surgeon often find& himself in a serious predicament. The situation which presents itself in a suspected case is somewhat as follows: Fig. 129. — Chorio-epithelioma. High power. This tissue consists of Langhans' cells. The nuclei and cell protoplasm do not stain as deeply as they do in syncytium, the nuclei are not as large, and the cell boundaries can be seen. No cell walls are found in syncytium, it being held together by fine protoplasmic threads. A patient, some time after deliverj^ of a hydatidif orm mole or after an abortion, begins to bleed profusely. A cureting is done, and a considerable amount of tissue is removed from the uterine canal, which, on microscopic examination, shows numerous fetal elements. Many Langhans' cells are seen in groups, and in different places may be seen great syncytial masses with large, variously formed protoplasm. Such a picture may correspond either to a placental rest or to a benign form of chorio-epitheUoma, or to an early stage of a malignant chorio-epithehoma. If radical operation is done there is a chance that the NEW GROWTHS 379 patient will be subjected to needless danger, with the loss of her pelvic organs, for there is no wa.y of telling that the condition in the uterus is not perfectly harmless. If one does not operate, and waits for later symptoms to develop, metastases may take place and it will be too late to save the patient. More- over, one is confronted by the fact that a curetment sometimes turns a benign form of* the disease into immediate and overwhelming malignancy, as is em- phatically pointed out by Hitschmann and Cristofoletti. Cases have been reported where the initial curetings have been examined and pronounced by competent pathologists as malignant, and the extirpated uteri have later been Fig. 130. — Chorio-epithelioma. High power. Most of the tissue consists of Langhans' cells the nuclei of which do not stain as deeply as those of the syncytium, and the cell outlines of which can usually be seen. Near the center are two syncytial nuclei which are larger, irregular in shape, and stain deeply. Near the right upper edge is a mitotic figure in a syncytial nucleus. found to be perfectly normal. Whichever course the surgeon adopts, he is running a risk, and he must depend to a certain extent on his surgical instinct to make the right decision. If the initial curetings show large or overwhelming numbers of grouped Langhans' and syncytial cells, immediate radical operation is advisable, especi- ally if a hydatidiform mole has preceded. If the initial curetings show con- spicuous, though not numerous, characteristic cell collections, the case is re- garded with grave suspicion, and, if the symptoms have been preceded by a mole, radical operation is seriously considered. If, however, the symptoms 380 GYNECOLOGY have followed abortion, it is justifiable to wait to see if further bleeding ensues, which, according to Meyer, will usually take place in two or three weeks if the disease recurs, though the patient should be kept under strict observation for several months, even if her catamenia is normal. If after the careful cureting of a suspicious case, bleeding recurs, and the curetings again show the same findings, radical operation is indicated. The surprising way in which some seeminglj- very malignant chorio-epi- theliomata heal spontaneously, even after incomplete operations, is inter- FiG. 131. — Chobio-epithelioma. High power. At the bottom is the edge of a chorionic villus. The first layer of cells covering it consists of Langhans' cells. Covering this is syncytiiim and throughout the rest of the drawing are masses of syncytium lying in coagulated blood. In the lower center is seen the vacuolated appear- ance which syncytium has. estingly explained by Hitschmann and Cristofoletti. These writers observed in their own and reported cases the very common occurrence of parametrial infiltration. From the study of autopsies and surgical cases they found that this infiltration does not consist in an invasion of the parametrial connective tissue by the cancerous elements, but that the thickening is due to a thrombosis of the parametrial and spermatic veins. This thrombosis of the large pelvic veins may act in two ways : either it may become a new focus for metastasis and send off embohc mahgnant masses to NEW GROWTHS 381 the lungs, where they may erode the puhiionary arteries and spread rapidly over the whole body, or the thrombosis, by interfering with the uterine circula- tion, may cause a necrosis of the tumor cells, which are very dependent for hfe on the maternal blood-stream, and by this necrosis cause a further thrombosis of the veins. In this way the thrombosis may become a protective barrier to metastases, and serve, at the same time, to produce disintegration and death of the entire growth. The writers present cases which convincingly substantiate this theory. If the idea is correct, it is of very great practical value. It shows that the route of metastasis is through the pelvic veins, so that great care must be exer- cised in cureting or operating on these cases to avoid sending emboli artificially into the circulation by insulting the diseased tissue, which, being without supporting structure, is extremely friable and susceptible to embolism. For this reason it is inadvisable to perform the radical operation by the vaginal route. When the operation is done abdominally the first step must be to tie the hypogastric and spermatic veins in order to block the avenues for emboli. If the case is inoperable as far as the uterus and parametrium are concerned, the large veins should be tied, in the hope of interfering with the circulation of the tumor and preventing metastasis. If the case is operable a total extirpation should be performed by the Wert- heim method. TUMORS OF THE OVARY No organ of the body has so great a disposition to tumor, especially cyst formation, as has the ovary, as would be expected from the natural charac- teristics of its tissues. The enormous proliferating power of germinal epi- thelium, the physiologic process of atresia and cyst formation, the monthly congestion, and the secretory power of the epithelial structures are all normal forces which it may well be imagined are readily transformed from physiologic functions to pathologic processes. Tumors of the ovary are divided into two main groups — (1) non-proliferating tumors and (2) proliferating tumors. (1) Non-proliferating Tumors The tumors of this group represent errors in the development and regres- sion of the Graafian follicles which result in retention cysts. These cysts are of two kinds — those which are produced by abnormal secretion of an atretic follicle, follicle cysts, and those which are consequent on incomplete involution of a corpus luteum. Follicle Cysts. — We have seen in the section on Physiology that only a com- paratively few of the primary folhcles with which the ovary is originally endowed 382 GYNECOLOGY come to full maturity. Most of the follicles during some stage of their develop- ment become aborted; the ovulum dies; the epithelium of the membranosa Fig. 132. — Cystic Degeneration of the Ovary. Macroscopic drawing of a section of a whole ovary. In the cortex are several small cysts which microscopically proved to be cysts of Graafian follicles. On the left are cysts with only thin parti- tions between them, suggesting how, as they become larger, the partition thins out, ruptures, and allows two cysts to coalesce into one. MMo»TCT<< Fig. 133. — Cyst of a Graafian Follicle. Low power. At the top is the lining of the cyst consisting of one to several layers of cells derived from the membrana granulosa of the follicle. This lies on the connective-tissue stroma of the ovary. Through the center of the section are several Graafian follicles, the cells of which have fallen out in cutting the section. The lower part of the section is the cortex of the ovary, the epithelial covering being absent. degenerates and disappears. This process is termed atresia oj" the follicle, and is, in a certain sense, physiologic. Atresia of a follicle is attended with a certain amount of secretion, especially when the lining epithelium (granulosa) persists, NEW GROWTHS 383 SO that many of the folhcles become visible cysts of greater or less dimensions. This cyst formation is, within certain limits, to be regarded as a physiologic process. Under certain conditions, however, the production of these cysts becomes abnormally great, and the ovary is then said to be in a state of cystic degeneration, though the line between the. normal and abnormal state is not clearly defined. Just what causes cystic degeneration is a matter of some doubt. Increased density of the connective-tissue stroma (interstitial oophori- tis), which prevents proper resorption of the atretic follicle elements, probably Fig. 134. — Cyst of a Graafian Follicle. High power. At the top is the lining of the cyst wall, consisting of layers of cells derived from the membrana granulosa of the follicle. Below this is the loose connective tissue that surrounds the follicle, and below this the dense connective tissue of the cortex of the ovary. acts as a cause in a certain number of cases. In other instances it is likely that disturbances of circulation, such as repeated or continuous hyperemia, may cause a too rapid development of the primordial follicles and hence an over- production of atretic follicles. Cystic degeneration causes a general enlargement of the ovary, but it does not reach the dignity of a tumor until one of the cysts grows at the expense of tlie other cysts and the rest of the ovarian tissue. The growth of an atretic follicle cyst may be due to persistence of the lining 384 GYNECOLOGY epithelium which continues to secrete a clear amber fluid (v. Franque). Usually, however, the membrana granulosa disintegrates and disappears. The growth of the cyst is then conditioned on a transudation from the blood-vessels of the theca interna, which may persist for a long time. As a rule, only one cyst takes on this abnormal growth, though sometimes there may be two and even three. As the cyst continues slowly to enlarge, the rest of the ovarian tissue, including the other folhcle cysts, becomes compressed, so that finally it becomes stretched out and incorporated in the thin wall of the usurping cyst, appearing only as a whitish, opaque thickening of the wall. Fig. 135. — Corpus Luteum Cyst of Ovary. Macroscopic drawing, enlarged, of section of whole ovary. On the right is a corpus luteum show- ing well the plicated envelope of lutein cells. The cavity was filled with cloudy fluid, as in this case the blood did not organize and we have an early stage of corpus luteum cyst. On the left are several corpora lutea which have gone on to the stage of corpus albicans, and at the top one small corpus luteum still in process of organization. The great majority of folHcle retention cysts reach a fairly uniform size, about that of the fist. They have a thin translucent wall, usually with no sign of epithelial hning. Most of them are monolocular. Some of the folhcle cysts grow to a much larger size, even to that of a man's head. The larger cysts are lined with epithehum, and the greater size of the cyst is due to active secretion on the part of the Hning epithelium. Follicle cysts of this type cannot, therefore, be regarded properly as retention cysts. There is also a question whether they should be included as non-proliferating NEW GROWTHS 385 tumors. Von Franque does not consider the persistence and increase of the epithehal Uning structure sufficient cause to include them in the new-growth tumors, and points to a similar growth of tubal epithelium in the large hydro- salpinges. Follicle cysts are essentially benign and have almost no tendency to papil- lary outgrowth. Occasionally wart-like excrescences are found on the inner ''S, i'' />'^' °- -> '^ >■' ^'' .°' ^^, ^^ Fig. 136. — Corpus Luteum Cyst. Low power. The space in the center is the cavity of the cyst. Lining it is a thin layer of con- nective tissue which lies on a layer of dense fibrous tissue which formally was made up of lutein cells, the whole being surrounded by vascular connective tissue, in which is a slight infiltration of round cells. surface, but these, as a rule, represent only local hyperplasia of the connective tissue rather than an overgrowth of epithelium. Corpus luteum cysts differ from folhcle cysts in that they represent a cystic formation that takes place in a more advanced stage of development of the folhcle. They attain about the same dimensions as the follicle cysts. They are recognizable in the earher stages by the wavy, characteristically yellow lutein- cell lining. The cyst content is usually of a reddish, turbid character, in dis- tinction from the clear amber fluid of the folhcle cysts. In the large corpus 25 386 GYNECOLOGY luteum cysts epithelial elements may be entirely wanting, so that they cannot be identified from follicle cysts even by microscopic examination. Blood-cysts of the ovary may result from the internal bleeding of follicle or corpus luteum cysts. According to von Franque, hemorrhages may occur in the ovarian stroma in cases of chronic oophoritis which causes a special frangibility of the blood-vessels. Such hemorrhages take place at the men- strual periods, and repeated hemorrhages at consecutive menstruations may cause Fig. 137. — Corpus Luteum Cyst. High power. To the right is the cavity of the cyst. Lining this is seen a thin layer of con- nective tissue. A line of demarcation can be seen between this layer and the next which consists of fibrous tissue rather more dense, which has taken the place of the layers of lutein cells. On the left is the connective-tissue stroma of the ovary with a few round cells in it. blood-cysts of considerable size. The fresh outflow of blood may produce severe pain and serious symptoms, even death. As a rule, however, the condition is not a serious one, and the discharged blood is gradually resorbed. Doubtless some of the puzzling cases in which an ovarian cyst is unmistakably felt by vaginal examination, only to disappear completely in a comparatively short time, are instances of blood-cysts. True cysts, unless they rupture, do not disappear in this way. To the non-proliferating cysts of the ovary is given the NEW GROWTHS 387 name cystoma, or cj^stoma simplex. This term implies a simple cystic enlarge- ment of the ovary, and must be distinguished from the word ajstadenojjia, which is applied to the true proliferating cysts. In addition to the corpus luteum cysts are other cysts, called theca-lutein cysts. The theca-lutein cysts develop from atretic follicles, but the cells of the theca interna (connective tissue) become hypertrophied and form a layer on the inside of the follicle which looks much like the lutein layer of the true corpus luteum The layer, however, is not as wavy and folded, nor are the cells as large and well marked, as the true lutein cells. To distinguish them they are called theca-lutein cells. Isolated remnants of these theca-lutein cells found in the ovaries constitute the so-called interstitial gland, which it is thought may play some part in the production of the ovarian internal secretion. It is not always possible to distinguish between a corpus luteum cyst and a theca-lutein cyst unless the yellow layer hning the cyst is markedly folded and the cells large and unmistakable. The theca-lutein cysts may contain hematomata, and thc}^ may become infected from the tube in the same ways as the corpus luteum cysts. The theca-lutein cysts are especially in evidence in association with hydatid mole or a chorio-epithelioma. It is estimated that in more than 50 per cent. of cases of mole the ovary undergoes a cystic degeneration, which disappears after the removal of the mole. These cystic ovaries have been shown to con- tain theca-lutein cysts. They are about the size of an apple and usually multiple. They are hned with a lutein layer, which, however, is flatter and thinner than that of a true corpus luteum. They do not have much clinical significance, as they usually regress if the patient does not die from the disease of the placenta. There has been some debate as to whether the cystic condition of the ovary is the result or the cause of the degenerative processes of the chorion seen in hydatid mole and chorio-epithelioma. It seems likely that the cysts represent an excess in the process of atresia of the follicles that normally takes place during pregnancy. It is important to bear in mind the possibihty of the occurrence of these cysts with mole or chorio-epithelioma, for otherwise their discovery might lead to the diagnosis of metastases from the original disease. (2) Proliferating Tumors of the Ovary The proliferating tumors represent neoplastic growths from the ovarian tissue, and are divided into two classes, according to whether they develop from the epithelial (parenchymatous) elements or whether they arise from the connective-tissue (stromatogenous) structure. Parench3rmatous Tumors. — About 80 per cent, of all new growths of the ovary have a glandular or adenomatous character, of which b}^ far the greater number exhibit secretory activity on the part of the epithelial cells that line the glandular structures. The term cystadenoma is, therefore, given to these tumors 388 GYNECOLOGY to indicate the pathologic process that underlies their growth. The glandular proliferation takes place from the epithelial cells that line the original cyst, and is represented by the formation of daughter cysts, which in turn reproduce themselves in the same waj^ until innumerable cysts are formed. In this waj^ the main tumor is made up of many cystic chambers, and is, therefore, called multilocular. All cystadenomata are essentially multilocular. Fig. 138. — Pseudomucinous Ctstadenoma of the Ovary. High power. This drawing shows the glands characteristic of this tumor. They are lined by a single layer of high cells having small nuclei lying at the bases of the cells. The glands lie in connec- tive tissue derived from the stroma of the ovary. It may, however, happen that one or a few cysts grow at the expense of the others which become compressed into the surrounding wall, or many small cysts may rupture and become confluent into one larger cyst, so that the tumor may have the appearance of a single cyst (monolocular) or there may be only a few chambers apparent (parvilocular) . Microscopic examination of the walls of such tumors reveals their true multilocular nature. The epithelium of cyst adenomata, in addition to its power of producing daughter cysts, is prone to NEW GROWTHS 389 sprout forth into papillary branches. This usually takes place toward the lumen of the cyst, in which case the growth is said to be ''inverting." The papillae may also grow outwardly and appear as excrescences on the outer sur- face of the main tumor, in which case they are termed "everting." The epi- thehurn from these tmnors, when broken off from the papillary excrescences of the outer wall, or when it escapes from the cyst lumen through a rupture of the wall, has the power of becoming implanted in the tissue on which it falls and of reproducing both the glandular cystic and the papillary processes that it -de- FiG. 139. — Pseudomucinous Cystadenoma of the Ovary. Low power. The lining epithelium of the cyst cavity is seen at the top and consists of a single layer of cylindric epithelium having small nuclei that lie at the bases of the cells. These cells have the power of secreting pseudomucin in large amounts. velops in the main tumor. These extraneous growths are called seed or implan- tation metastases. They are most commonly seen on the peritoneum of the abdominal viscera and parietes. The cystadenomata of the ovary are of two types which differ markedly from each other in their contents, histologic structure, and tendency to papillary and malignant proliferation. They are named, from the character of their contents, ''cystadenoma pseudomucinosum" and "cystadenoma serosum." The -pseudomucinous cystadenomata are said to constitute the commonest form 390 GYNECOLOGY of ovarian tumors, though in our own series of cases they have been found less frequently than have the serous cystadenomata. They are usually unilateral, and rarely develop- between the leaves of the broad ligament, tending rather to have well-formed pedicles. These cysts are oval in shape, with a smooth sur- face. They are always multilocular, and are distinctly glandular in tjrpe. The single chambers of the tumor vary greatly in size, usually a few of them growing to considerable proportions at the expense of the others. The fluid contents consist of a thick mucoid substance, which resembles closely true Fig. 140. — Pseudomucinous Cystadenoma of the Ovaby. High power. From the specimen seen in Fig. 139. mucus in appearance, but differs from it in that it does not present the char- acteristic mucin reaction with acetic acid; hence its name, "pseudomucin." The color of the pseudomucin, which in its pure state is of a clear glassy transparency, may be considerably altered by transudations from the blood- vessels and by necrotic changes in the cyst wall, from torsion, so that it may present numerous tints, from yellowish or greenish-gray tones to dirty brown or even black. Often a characteristic greenish, shimmering hue is seen, due to the presence of cholesterin plates, which represent a product of regressive changes in the cellular elements (von Franque). The reaction is alkahne. NEW GROWTHS 391 The cysts are lined with a high, non-cihated, cyhndric epithelium with a basal nucleus. During activity these epithelial cells assume the characteristic appearance of beaker cells, and secrete pseudomucin in the same way as the lining cells of the stomach or gall-bladder secrete true mucus. The cells are beautifully arranged in regular order in a single layer. As distinguished from the serous cystadenomata, papillary outgrowth of the Hning epithelium is comparatively rare. From a clinical standpoint, the pseudomucinous cysts belong to the class of benign neoplasms. They grow very slowly and may reach enormous dimen- sions. The famous classical ovarian tumors of great size that were frequently described before the days of modern surgery were of this type. They rarely Fig. 141. — Contour of Abdomen Containing a Large Ovarian Cyst. (Reproduced from a photograph.) develop carcinomatous degeneration, in which they are again distinguished from the serous variety, which has an especial tendency to malignanc3^ From an operative standpoint, the pseudomucinous cysts are particularly favorable. The operation itself is usually attended with little difficulty, be- cause, having no inclination to grow between the leaves of the broad ligament, they usually lie free in the abdomen, with an easily accessible pedicle. Adhe- sions to the intestines are not present unless the tumor is complicated by some inflammatory process, such as might ensue from salpingitis or from torsion of the pedicle. Inasmuch as the disease is usually confined to one side, and as there is little tendency to later recurrence in the unaffected ovary, a simple extirpation of the tumor, without removal of the other organs of the pelvis, is all that is necessarv. It should be remembered, however, that carcinomatous 392 GYNECOLOGY degeneration, though rare, is still possible, and the rule of making a careful gross examination of the growth before closing the abdomen should always be carried out, as in the removal of all ovarian neoplasms. If carcinoma is discov- ered, the uterus and other ovary should be removed. According to Pfannenstiel, carcinomatous recurrences have taken place in the scar of the stump from which the tumor has been removed. This complication, however, must be so rare that it need not be taken into very serious consideration. Fig. 142. — Papillary Cystadenoma of the Ovary. Low power. The papillary projections from the wall of the cyst can be seen cut in various planes. They consist of a connective-tissue stroma containing blood-vessels, covered with a single layer of cylindric epithelium. The spilling of the cyst contents in the abdominal cavity is attended with less risk than in the case of serous cystadenomata, as the epithelial elements have less tendency to implant themselves on the peritoneum. This, however, is not universally true, for it occasionally happens that cell elements that have escaped from the cyst into the peritoneal cavity, either spontaneously or from accidental rupture during operation, form implantation metastases, which, by the peristaltic movements of the intestine, may become disseminated through- out the abdomen. The cells continue to secrete pseudomucin, so that as a NEW GROWTHS 393 result the entire peritoneal cavity becomes filled with extensive gelatinous masses that cannot easily be removed. This condition has been described by Werth, and named by him pseudomyxoma peritonei. The process, though essentially benign, has, nevertheless, a bad prognosis, for the gelatinous masses, acting on the peritoneum as a foreign body, cause a form of chronic peritonitis which usually eventuates in the death of the patient. Life may be prolonged by repeated laparotomies and removal of as much of the growth as possible. On the other hand, it occasionally happens that after the removal of the greater part of the masses the remainder disappear spontaneously. Fig. 14.3. — Papillary Cystadenoma of the Ovary. High power to show an early stage in the papillary formation. In the gland on the left can be seen tufts of epithelium growing out into the cavity of the cyst. Cystadenoma Serosum. — The serous cystadenomata, like those of the pseudo- mucinous variety, are usually multilocular, though the number of chambers is much less than in the former. Many times they appear macroscopically monolocular, but microscopic evidence of daughter cysts may be found in the wall. These tumors are characterized by being filled with a clear, yellowish, serous fluid, entirely free from pseudomucin and extremely rich in albumin. The cysts are lined with a low cylinder epithelium, which is usually ciliated, and which closely resembles in size and form the epithelium of the uterine and tubal mucosa. Most of the serous cystadenomata show a papillary proliferation of the lining epithelium. 394 GYNECOLOGY -':rJ)'-:'''?i^'??i/OAf,';i;!.':^. fe^'.'V ^ Fig. 144. — Epithelial Inclusion in the Ovary. Low power. This drawing illustrates one method of the formation of a cj'stadenoma. A deep siilcus is seen in the cortex of the ovary, which is lined by the epithelium peculiar to the ovary. At the bottom to the right are seen several gland-like formations, the epithelium of which is higher and in process of proliferation. These glands may be formed by the end of such a sulcus being pinched off. Then if proliferation takes place a cystadenoma may be formed. To the left the line of demarca- tion between the cortex and the rest of the ovarian stroma is well shown. The papillary process may appear both in the inner hning of the cj^st and on the outer surface. In both cases the histologic appearance of the epithelial NEW GROWTHS 395 cells is the same, namely, that of a low, cylinder ciliated epithelium, though the ciha are apt to be wanting in exposed portions of the outer papillary growths and if they become carcinomatous. The serous cystadenomata, in contrast to the pseudomucinous, have a tend- ency to grow in both ovaries, although the process may not he contemporaneous in the tioo, a fact that must always be borne in mind by the surgeon. Another unfavorable characteristic which the serous cystadenomata possess in com- imrison with the pseudomucinous is that they are apt not to be supplied with good pedicles, but have a tendency to develop through the hilus of the ovary Fig. 145. — Epithelial Inclusion in the Ovary. High power. A gland-like formation found in the cortex of ah ovary which may be the beginning of a cystadenoma of the ovary. between the leaves of the broad ligament. In this confined position they not only cause more symptoms of pain and pressure, but are more difficult and dangerous to remove. The serous cystadenomata grow more slowly than the pseudomucinous type and do not reach as large a size. The clinical significance of serous cysts depends very much on whether or not they are papillomatous. The non-papillary variety is usualty benign and does not recur after operation, but it is possible that an apparently non-papillary cystoma may recur rapidly in cancerous form, the papillary growth having ex- isted microscopically in the wall of the original tumor. 396 GYNECOLOGY The papillary tumors are of more serious clinical importance because of their greater tendency to malignant degeneration, and because of the possibility of implantation papillomata on the peritoneum. This results always in an ascites that may become prodigious. It sometimes happens that after removal of the main cyst the seed papillo- mata of the peritoneum spontaneously disappear. In other cases they remain and the ascites rapidly reappears. The origin of the ovarian cystadenomata is a subject of much interest. It was formerly thought that these tumors are derived from isolated rests of i^/« d u ■ u.» **'\*': %y'} u^ ^ •^.c ■U^ i / 'fi, .^1 ■;ii;>r,';:^i./..ni'U%,.. '^< ^ ;>^#^^'^^^^^'^'^^ ^ Fig. 146. — Epithelial Inclusion in the Ovary. High power from the previous drawing. The cells lining the cavity have become higher and have larger nuclei than the normal ovarian epithelium. the Wolffian or Mliller's ducts which are sometimes found in the ovary. This theory seems unhkely, because the above-named rests do not produce like tumors in locations other than the ovary. It has been estabhshed beyond doubt that the serous papillary cystadeno- mata spring from the germinal epithelium covering the ovary. They may develop from papillary outgrowths from the ovarian surface, or from glarid- hke inclusions that result from a dipping-in of the epithelium into the substance of the ovary. NEW GROWTHS 397 It has been the fortune of the author to secure from an operation performed for pelvic inflammation a specimen of very early papillary serous cystadenoma involving both ovaries, in which it is clearly evident that the growth in both ovaries is developing from the germinal epithelium, both from the surface and from inclusions in the stroma. (See Figs. 148, 149.) The origin of the pseudomucinous cysts is not as well estabhshed as that of the serous type, but there is good evidence to show that these tumors also spring from the germinal epithelium. Fig. 147. — Epithelial Inclusion in the Ovary. Low power. This illustrates a possible beginning of a cystadenoma. In this case an adhesion to the ovary caused the formation of the cavities seen. The epithelial cells have already lost the low cuboidal shape of the normal ovarian epithehum and are proliferating, as is seen in the next drawing. The exciting cause of tumor formation in the ovaries is not known. Inflam- matory processes seem to have no particular relation to their development. They may appear at any period of life, even in fetal hfe. It seems probable that the anlage from which the cystadenomata are derived dates back to ab- normal embryonal development, by which cefl inclusions of the germinal epi- thelium are left in the ovary that are capable of lighting up into activity at any period of life. There is a question as to whether inflammatory processes predis- pose to cyst formation of the ovary. Pfannenstiel believes that the influence 398 GYNECOLOGY of inflammation is important, especially in malignant papillary tumors, von Franque, on the other hand, regards inflammation as a neghgible factor. Carcinoma of the Ovaries.— Gebhard divides carcinoma of the ovary into two classes — (a) Genuine, idiopathic carcinoma, which develops directly from previously unchanged ovarian tissue, and (6) cystic carcinoma, which either develops from a benign ovarian cyst (carcinomatous degeneration) or starts as a cancerous cyst from the first. (a) The solid, or genuine, carcinomata of the ovary are very rare, and are usually of the medullary type. They do not grow to a very large size. The consistency of these tumors is soft, white, and brain-hke, and they have an NmI*, G-x-ovses Pig. 148. — Bilateral Papillary Cystadenoma of the Ovaky. Drawing from a specimen removed at operation by the author. On the left is seen a papillary cauliflower-like growth springing from a small multUocular cyst of the ovary which can be seen just below and to the right of the cauliflower mass. Some of the excrescences show cystic formation. On the right is seen a tube and ovary united by inflammatory adhesions. The ovary has the appearance of ordinary cystic degeneration. It was found bj' microscopic examination that this ovarj- is a verj- early papillary cystadenoma, the growth of which is entirely inverting instead of everting, as on the opposite side. As will be seen bj' reference to the microscopic dra-\vings (Figs. 149 and 150), this specimen shows extraordinarily well the way in which the papillarj^ cystadenoma develop from the germinal epithelium covering the ovary. especial tendency to various kinds of degeneration, so that cj^st formation is often found. Microscopically, the medullary cancers often show a tendency to adenomatous growth. These cancers become dangerous when they have broken through the outer capsule, in which case the disease is disseminated throughout the abdominal cavity. (6) Cystic Carcinoma. — The cystic carcinomata may start as malignant tumors, or they may represent a carcinomatous degeneration of a benign papil- lary cystadenoma. The appearance of a mahgnant papillary cyst so closely resembles that of the benign cystomata that often they can hardly be differ- entiated macroscopically. The contents of a cancerous cyst are apt to be opaque or bloody, due to desquamation and breaking ofi" of the papillarj^ excrescences. NEW GROWTHS 399 Microscopicallj% the anatomic appearance resembles closely that of cancer of the body of the uterus. Serous cystadenomata are much more prone to undergo carcinomatous de- generation than is the pseudomucinous variety, especially if they show tendency to papillary growth. According to Pfannenstiel, at least one-half of the papil- lary cysts of the ovarj^ are malignant, and, as they cannot always be distin- guished from the benign form, all papillary cystadenomata of the ovaries should be surgically treated as if they were malignant. Clinically, the cystic carcinomata Fig. 149. — Serous CYSTADENOM-i of the Ovary. Low power of a papilla. The top of the papilla, at the right, is very edematous as compared with its base, at the left. The tips of the papillEe may become so edematous as to appear cystic. The epithelial covering maj- consist of one to se^•eral layers of cells which, in the inverting type, where the papUla lies in a cyst, may show cilia. Dilated Ijoiiph-spaces are seen in the tip near the center, and a gland to the right. Above is a further branch of the papilla. are extremelj^ malignant, and tend to recurrence even when thej^ are apparently entirely removed by operation. (c) Metastatic Carcinoma of Ovary. — It should be remembered that many cancers of the ovarj^ are secondary to cancers of other organs, such as the stom- ach, gall-bladder, intestines, breast, uterus, and tubes, and have the anatomic characteristics of the original tumor. It is a matter of debate as to how the ovary becomes secondarily involved by malignant growths starting so far away as the stomach or gall-bladder without infection of intervening organs. There 400 GYNECOLOGY are two theories to explain this: one that the disease travels by a retrograde transportation through the lymph-channels, and the other that the cancer cells of the original tumor escape into the peritoneal cavity and are carried by gravity and the peristaltic movements of the intestines to the surface of the ovaries, where they become implanted in the ovarian stroma by passing between the cells of the outer layer of germinal epithehum. Kraus has shown by experi- ments on animals that inorganic particles (carbon, etc.) injected into the upper .'.i.^^-. Fig. 150. — Serous Cystadenoma of the Ovary. Low power. To show inclusions of germinal epithelium in the stroma of the ovary. Two of these are seen. If the epithelium lining the inclusion is compared with the surface epithelium seen above, the activity of the former is understood. The cells are higher, the nuclei larger and stained deeper. These inclusions at first are circular or oval in shape. The one on the right shows the begin- ning oi the inversion of the wall into the stroma of the ovary, with also a beginning papilla in the center of the lower edge. peritoneal cavity may be found later actually invading the ovarian tissue through the interstices of the germinal epithelium. When cancer of the "Svary occurs in association with malignant disease of neighboring organs, hke the uterus or tubes, it is often difficult to determine in just which organ the disease was primary. This is due to the fact that adeno- carcinoma of the uterine and tubal mucosa may exactly resemble adenocar- cinoma originating from the gland inclusions of the germinal epithehum of the ovary, the fundamental tissue being in all three cases embryologically identical. NEW GROWTHS 401 Pfannenstiel makes the following statement: "It seems probable that when ovarian cancer is associated with cancer of a similar type in distant organs the disease of the ovary is usually secondanj, while it is more commonly primary when the associated cancer is in neighboring organs like the tubes or uterus." Ovigenous Tumors of the Ovaries. — There are two forms of ovarian tumors, the dermoids and teratomata, that can be classified neither as parenchymatous nor as stromatogenous, in that they develop from germ-cell elements and con- tain in their structure tissues of all three germinal layers. They are, therefore, very appropriately called ovigenous or ovulogenous. Fig. 151. — 'Serous Cystadenoma op the Ovary. High power of an inclusion of germinal epithelium. The epithelial cells are cylindric, crowded together, irregularly placed, and contain large nuclei. The basement-membrane is absent. Several of the cells are 'swollen; their nuclei are large, contain definite nucleoli, and appear like germ cells. Dermoid cysts constitute from 5 to 10 per cent, of all ovarian tumors. They may occur only in one ovary or bilaterally. Rarely they are multiple, as many as eleven having been seen in one ovary and twenty-one in both ovaries (von Franque). They are practically always monolocular, and ordinarily do not grow much larger than a man's fist, though occasionally they develop into very large tumors. The cysts always contain sebaceous material, which is fluid at the body temperature, but thick and doughy when cooled. In one or more parts of the 26 402 GYNECOLOGY wall can be found thickened areas, the so-called "dermoid plugs," which, on microscopic examination, exhibit the various structures of the skin and corium. From these epidermal areas stream masses of hair which may or may not be of the same color as that of the patient who harbors the tumor. Hair is present in nearly all of the tumors. Next to hair, irregularly formed bony structures are most commonly encountered. Section of the dermoid plug often shows rudi- mentary and ill-assorted but easily recognizable tissues from entoderm, ecto- derm, and mesoderm, such as nerve-ganglia, nerve-fibers, glandular elements . A^^-.-: ^^. Fig. 152. — Serous Cystadexoma of the Ovaet. Low power. This section is taken from the surface of an ovary which contained a serous cyst- adenoma and shows the activity of the epitheUuni covering the ovary. The cells are becoming cylindric in shape, the nuclei are larger and stain stronger. At one point the beginning of a papilla is seen, the stroma is growing out, pushing the epithelium with it. The stroma is edematous and contains many dilated blood-vessels. from the respiratory and alimentary tracts, breast tissue, etc., in addition to the hair and bone above mentioned. The stage of development of the various tissues corresponds roughly to the age of the patient. The most completely formed structures are usuallj^ of ectodermal origin, from the cranial parts, such as hair, parts of the jaw, teeth, parts of the skull and brain, the eyes, the glottis, and trachea. A crudely rudimentary fetus maj^ be seen. No sign of fetal membranes has ever been observed. The part of the inner cyst wall not occupied by the dermoid plug is lined with a low epithelium, like that of a simple NEW GROWTHS 403 follicle cyst, or the epithelial elements may be absent. The inner wall may show a form of granulation tissue resulting from irritation of the hair or of rough bony parts. Dermoid cysts grow very slowl}^ and, in contrast to teratomata, have only a slight tendency to become mahgnant. Mahgnant change may, however, take place in some part of the included tissue, most conmionly of the epidermoid type, and next frequently from included thyroid tissue. Dermoids are not infrequently found in connection with pseudomucinous cysts. On account of this association it has been suggested that the pseudomucinous cyst is, in reality, Fig. 153. — Papillary Adenocarcinoma of the Ovary. Low power. This section shows the glands with the thin trabeculse of stroma between them. These glands are lined by a single layer of cells, but often several layers are found and sometimes the lumen is filled. In the upper part the papillary formation is shown. an embryonic tumor, the similarity of its secreting cells to those of the intestinal tract indicating an origin from the entoderm. Dermoid cysts are apt to have long pedicles, doubtless the result of their slow growth. They are, therefore, particularly prone to torsion, especially when associated with pregnancy. On account of their tendency to torsion, they frequently become inflamed and adherent to neighboring organs. Necrosis of the cyst wall, especially when adherent to bladder or rectum, is apt to occur, with consequent fistulous openings into these organs. 404 GYNECOLOGY The cyst content is proteolytic and corrosive, and when discharged into the abdomen by rupture of the cyst wall is conducive to peritonitis. The teratomata are rare tumors allied in their structures to the dermoids in that all three germinal layers are represented. Unlike the dermoids, however, they are essentially malignant. The tissue elements are mingled indiscrimi- nately, and for the most part represent an embryonal stage of development. The tumors grow rapidly and metastasize freely. They reach a large size, are irregular in contour and solid in consistency, with occasional great cystic cavi- \« "Saa Fig. 154. — Caecinoma of the Ovaey. Low power. This illustrates the solid carcinoma of the ovary consisting of alveolar masses of cells growing in the stroma of the ovary. ties. Microscopically, all tissues of the body are found mingled in a lawless growth. Less than 50 cases of teratoma of the ovary are found in the hterature. Struma ovarii is a term apphed to tumors of the ovary, which in their histo- logic appearance and by the iodin test are proved to be thj^roidal in character. These tumors are often mahgnant, produce ascites, and tend to metastasize. There has been much speculation as to their origin, it being at first supposed that they represent a metastasis from the thyroid gland tissue. It is now NEW GROWTHS 405 believed that the}' constitute a special form of teratoma (Pf annenstiel) , or that thej' represent malignant degeneration of thjToid tissue included in a dermoid e3'st (von Franciue). It was formerly thought that dermoid cysts and teratomata represent a form of incomplete parthenogenesis, but this idea has been somewhat modified. It is now supposed that the dermoid does not develop from a true germ-cell or ovum, but from a blastomere, which at an early time had been separated from Fig. 155. — Colloid Carcixoil^ of the Ovary. Low power. Scattered through the section are glands, Hned by a single layer of high cells. Many of the glands are filled -n-ith mucus. The rest of the tissue consists of ovarian stroma. This growth was metastatic from a carcinoma of the sigmoid and the glands are characteristic of that. the original germ-cell bundle. The isolation of such a blastomere if transported awaj' from its original location accounts also for the dermoid and teratoid tumors found in other parts of the bodj". This theory may be better understood from the following abstract from Opitz and Menge : A number of facts seem to contradict the theory that the dermoid and teratoid tiunors spring parthenogenetically from an unfertilized ovimi. Chief among these are the appearance of these tumors in parts of the body far distant from the ovary, and also their development in men not only in the testis, but in other parts of the bodj'. Further, the structure of the tissues 406 GYNECOLOGY of a dermoid corresponds in a general way to the age of the patient who carries it. Also the absence of fetal membranes, which normally are developed before any of the other tissues found in dermoids, contradicts the theory of origin from an unfertilized egg. Finally, if it were possible for a dermoid to spring from an unimpregnated egg one would expect a much greater frequency of these tumors, considering the enormous number of unfertil- ized eggs that pass the tube. Nevertheless, only 5 authentic cases of dermoids in the tubes have been reported. Since the dermoids and teratomata contain constituents from all three germinal layers (entoderm, ectoderm, mesoderm), it must be that they spring from cells that "stand close to" Fig. 156. — Colloid Carcinoma of the Ovary. High power of the section shown in the previous drawing. This shows the typical cylindric epithelium associated with the large intestine, lea^dng spaces. The epithelium has fallen out of many of the glands, the fertihzed ovum. This requirement is met by the so-called blastomeres, which are the products of the first cell division of the impregnated egg, and which experimentation on the lower animals has shown have, when isolated, the power of producing rudimentary embryos. It is readily conceivable that in the complicated processes of growth of the earliest embryonal time some of these cells may be displaced to the most diversified parts of the developing organ- ism. It has been proved by animal experimentation that the earhest segmentation divides the ovum into two kinds of blastomeres, those which become the later germ-cells (ova or spermato- NEW GROWTHS 407 zoa) and those which enter into the construction of the bodj^ (somatic cells). It is conceivable that from some irregularity of development and arrangement of the primary cells a somatic blastomere ma}' become displaced and included, for example, in the ovary, where it may either be destroj-ed undeveloped or, imder the irritating influence of some chemical change in the blood or sm-rounding tissue substance, be awakened later from its dormant state into produc- tive acti%'ity, and create a dermoid cyst or a teratoma. (Free translation.) Stromatogenous Tumors of the Ovary. — The stromatogenous tumor.s spring from the connective-tissue stroma with which the ovary is richly supplied. Fig. 157.— Colloid Carcinoma of the Ovary. (Metastatic.) High power. This shows the large cells with the eccentrically placed nucleus characteristic of Krukenberg's tumor. When cut in the right plane, as in the lower right and middle parts of the drawing, they have the appearance of a seal ring. The benign tumors are represented by tlie fibromata, which appear either as small circumscribed growths or as diffuse neoplasms forming large solid tumors. The circumscribed fibromata represent a local Iwperplasia of the ovarian stroma, which in some cases can with difficulty be differentiated from the fibrous changes of an interstitial oophoritis. In other cases the fibromatous K^,. ""w^fr^ Fig. 158. — Dermoid Cyst. Very low power. Section of the whole ovary. On the right is a white, well-defined area which is a small dermoid cyst. Its contents consist of yellowish, greasy material containing hair. The three cavities below are small follicular cysts and the one above to the left is a corpus luteum. nmrKfta couciEL Fig. 159.— Dermoid Cyst. Very low power. Section of the small dermoid cyst shown in the last drawing. This shows the so-called plug of the dermoid cyst extending into the cavity. It is covered with stratified squamous epithelium under which are sebaceous glands and hair-follicle. A hair-follicle can be seen to the left of the middle of the plug near its surface. This is a very early stage in the development of a dermoid cyst. They are seldom found so small. 408 NEW GROWTHS 409 growth is near the surface, and appears as a tuberous or papillary wart-like excrescence. Another form of circumscribed fibroma has its origin in a corpus luteum. These tumors have a definite capsule. They have a dense fibrous central structure surrounded bj" a cortex of yellow or reddish-j-ellow color, in which lutein cells can be demonstrated. The circumscribed fibromata have very little clinical significance. Diffuse fibromata represent a general hyperplasia of the ovarian stroma, which pro- FiG. 160. — Dermoid Cyst. High power. Showang the edge of the plug which is covered with stratified squamous epithelium. At the middle is the entrance to a hair-follicle, the continuation of which is seen below in the center of the drawing. The stroma consists of connective tissue infiltrated with a few leukocytes. duces a large solid tumor that always preserves an ovarian contour. Cross- section shows a whitish dense homogeneous connective-tissue substance. Often the tissue is softened by edematous infiltration of the lymph-spaces, which, microscopically, gives the appearance of myxomatous tissue. The edematous infiltration may be so extensive as to form cystic cavities filled with clear colorless fluid. Occasionally hemorrhagic areas are seen. 410 GYNECOLOGY Muscle-fibers have been demonstrated by good authorities in these tumors, but their presence is rare. Diffuse fibromata may grow to a very large size. They are characterized even when of moderate size by causing ascites; though in what way this is brought about is not known. Pfannenstiel ascribes the ascites to a chemical Fig. 161. — Round-cell Sarcoma of the Ovahy. Low power. The upper part of the dramng shows the tumor, characterized by its round cells lying close together. There are many blood-vessels scattered through it. The light band is part of a corpus albicans and at the bottom is a small area of normal ovarian stroma. irritation of the peritoneum. Schauta considers it to be due to pressure and stasis of the blood-vessels of the parametrium. The diffuse fibromata may undergo sarcomatous degeneration. Sarcoma. — Sarcomata of the ovary are rare tumors. They may originate as a mahgnant growth, or they may represent a degeneration of a fibroma. In about one-fourth of the cases reported they occur bilaterally. They closely resemble ovarian fibromata, and can often be distinguished from them only by the microscope. Ascites is always present, but this is not a special mark NEW GROWTHS 411 of malignity, because it is usually associated with all solid tumors of the ovary. The sarcomata have an early tendency to metastasis, which takes place into the retroperitoneal lymph-glands, and finally on the visceral and parietal peritoneum. Anatomically, these tumors ma}'- be of the spindle-cell or round- cell variety of sarcoma. The former, according to Gebhard, are smaller, have less tendency to metastasize, and occur at a more advanced age than the latter, '© & ^t^t ^^ ^ ,?5J «S, ©.« t^ • i ^ ^ I (5) Dermoid cvsts. II. New growths which arise from embryonal elements in the < broad hgaments. ' (a) Parovarial cysts. (b) Cysts and sohd tumors of Gartner's duct. (c) Dislocated adrenal tissue. (d) Cysts from rests of the primary kidney (Wolffian body). ^Principal authority, Freund (in Veit, Vol. I). 424 GYNECOLOGY III. New growths which develop in . , , . 1 I (a) Uterus (subserous intrahgamentary fibroids), neighboring organs and ex- ^ . tj + n ^ , ■ X XI 1 IT . I (o) Ovaries (cysts or solid tuniors). tend into the broad ligaments. T^r AT _xT- 1 • 1 X 1 ( Carcinoma of uterus. IV. New growths which extend or i ^ . „ ^ , , . ■ , XI 1 • J Carcinoma oi rectum, metastasize into the pelvic S ^ . i- 1 i 1 1 ^. j^. I Carcinoma ot bladder. connective tissue. \ ^ ■ r \^ Carcinoma oi ovaries. We are at present interested only in the first group of the classification, the other groups having already been discussed in their proper places. The primary retroperitoneal tumors may be located anywhere in the sub- serous cellular space that reaches from deep in the pelvis up to the region of the kidneys. Those that originate between the free leaves of the broad ligament, near the round ligaments, occupy a position in the pelvis similar to the tumors of the internal genitalia, from which they cannot readily be distinguished by bimanual examination. Tumors that develop deep in the pelvic connective tissue usually grow downward in the paravaginal and pararectal space, and may even extend through the ischiadic foramen into the gluteal region. If they have their origin in the tissue posterior to the cecum or sigmoid flexure, they tend to grow upward toward the kidney region. These neoplasms often attain an enormous size, and when they develop in certain situations in the pelvis cause extraordinary dislocations of the pelvic organs, especially of the bladder, the vertex of which may be forced high up on the abdominal wall or far to one side. In one case of retroperitoneal sarcoma that came to the notice of the author the bladder was drawn out into a spiral tube of such length that the vertex could not be reached by the end of a male rubber catheter inserted in the m-ethra. Most of these tumors grow slowly at first, and do not cause sjTuptoms until they are large enough to produce pressure on important organs. Interference with the function of the bladder is apt to be the first sign of trouble, with reten- tion or incontinence of urine. Pressure on the ureters maj^ cause hydronephrosis. Freund describes a form of "chronic uremia" with general bodily disturbances consequent on the long and slowly increasing pressure interference of the ureters. Large tumors situated deep in the pelvis, especially those of the solid type, in the course of time compress the rectum and may completelj^ prevent the passage of fecal matter. Interference with the pelvic circulation causes enormous dilatation of the veins and constitutes a serious danger to be reckoned with in enucleating the tumors. Pressure on the nerve plexuses of the pelvis sufficient to cause symptoms is a comparatively late development and may produce pain of the severest t>"pe. Fibromyomata originate in the smooth muscle-fibers with which the broad and round ligaments are abundantly supplied. These tumors, developing as NEW GROWTHS 425 thej^ do between the leaves of the broad hgament, are to be distinguished from the intrahgamentary fibroids of uterine origin by the absence of myomatous tissue connection between them and the uterus. Uterine fibroids that grow into the broad hgament never separate from the uterine wah, as do certain free pedunculated fibroids (parasitic myoma), so that if there is no myomatous con- nection between the hgamentary fibroid and the uterus it must be regarded as having an independent origin. The intrahgamentary fibromyomata grow very slowly, as a rule, unless they undergo some form of degeneration, when they may take on a sudden and rapid development. If they originate high in the broad hgament they may become pedunculated. If they start deeper in the pelvis they may either extend upward toward the region of the cecum or sigmoid, or downward toward the ischiadic foramen. Fibromata of the round ligament may develop intra- or extraperitoneally or within the inguinal canal (Kelly). The infundibulopelvic hgament may also be the seat of fibromatous growi:h. Fibroid tumors of the pehnc connective tissue are subject to the same regres- sive and degenerative changes characteristic of uterine myomas, including com- phcations from infection, suppuration, and necrosis. Sarcoma of the pelvic connective tissue may start as an essentially mahgnant tumor, but more commonly it represents the degeneration of a fibroma or fibro- myoma. The sarcomatous change in a fibroma is signified by rapid growi^h of the tumor or by the sudden onset of pressure sjanptoms. The prognosis is bad, for not only is the removal of the tumor difficult and dangerous, but there is great probability of early recurrence. Lipoma.— Retroperitoneal lipomata starting in the connective tissue of the pelvis are very rare. More common are those that originate in the mesocolic region, though these tumors may extend into the pelvic subserous tissue. The growi:hs have the form either of pure hpomatous or mjrxomatous tissue. They grow diffusely in the subserous ceUular tissue and may reach enormous dimen- sions, reaching from the pelvis to the kidneys. Some of them undergo sarcoma- tous degeneration and recur after removal. Recurrences also sometimes take place after extirpation of tumors that are microscopically entirely benign. Dermoids.— The most interesting of the retroperitoneal tumors are the dermoids. These originate in the subserous cellular tissue and are entirely independent of the ovaries, though they possess the same characteristics of structure as do the ovarian dermoids. The histogenesis of extragenital dermoids is at present a matter of speculation, numerous theories having been suggested. By the so-called blastomere theory it is thought that at the earhest divisions of the impregnated egg one of the original cell elements (blastomere) becomes isolated and exists as a fetal inclusion, or as a fetus ^dthin a fetus. Some regard the tumors as springing from misplaced germ-cells which develop partheno- genetically, while others believe that they grow from accessory ovarian tissue. 426 GYNECOLOGY on the ground that supernumerary ovaries with germ-cells have been found within the leaves of the broad ligament; (See also Dermoids of the Ovary.) Another theory is that the extragenital dermoids represent defective twin development. These cysts have a tendency to grow downward toward the perineum, pushing the vagina, uterus, and rectum to one side, and may eventually emerge from the ischiadic fossa in the gluteal region and appear under the skin of the buttocks. The size of the tumors described varies from that of a pigeon's egg up to a baby's head (Freund). The cysts are usually oval in shape, though they are so^mewhat flaccid and adapt themselves to the compressed quarters in which they lie. The structure of the retroperitoneal dermoids is, in general, like that of the dermoids that originate in the ovaries, except that those which develop helow the pelvic diaphragm usually exhibit the elements of only one germinal layer. The con- tents usually consist of characteristic sebaceous or atheromatous material with hair and bone, but these may be absent and the fluid may be of a non-distinctive nature. The growth of retroperitoneal dermoids is extraordinarily slow, and they give no symptoms unless they become infected or until they become large enough to cause pressure disturbances. The prognosis is good if they can be removed before they become too large or too adherent. The treatment of retroperitoneal pelvic tumors is always surgical removal if possible, because of the danger of malignant degeneration and the inevitable pressure disturbances that are sure to ensue sooner or later even in the benign growths. If the tumors are large, their removal tests the skill of the surgeon to the utmost. If the tumor is attacked by the abdominal route an incision is made through the broad ligament, and then, at some point that is free of blood- vessels, the outer capsule of the tumor is divided and the plane of cleavage is found. When this plane has been properly located the tumor can be enu- cleated gradually by blunt dissection with the fingers. By this method of de- cortication serious bleeding can be avoided, and there is less danger of injuring the rectum and bladder. In removing dermoid cysts it is advisable to extir- pate them if possible without rupturing the wall, for the contents are very proteolytic and predispose the surrounding tissues to infection. The point of attack for the cysts must be determined by the location of the tumor, and the incision may be abdominal, prevesical, perineal, retro-anal, or parasacral. TUMORS OF THE BLADDER The most frequent and the most important tumor of the bladder is the papilloma. The majority of these tumors are well pedunculated and have a NEW GROWTHS 427 characteristic villous surface. Some, however, possess broad sessile bases, while the papillary nature of the surface may be disguised by a gluing together of the villi from inflammatory processes. The papillomata vary in size from that less than a pea to that of a man's fist. They may be either solitary or multiple, or even disseminated over the entire surface of the bladder mucous membrane. They occur most commonly on the floor of the bladder, but are not infrequently seen suspended from the vertex. The microscopic appearance is that of characteristic papillary growth — villous processes with a vascular connective-tissue stalk covered with numerous layers of epithelium, bespeaking the origin of the process from the bladder epithelium. Some of the tumors are solid and fibrous, while others have long delicate papillse like water plants. Incrustations of urinary salts sometimes cover the tumor as a result of necrosis. It is often difficult to tell, even from microscopic examination of these tumors, whether they are benign or mahgnant. There seems to be no doubt that some of the growths are malignant from the beginning, and also that some of the papillomata, though originating as benign tumors, later degenerate into carcinomatous activity. It is the part of wisdom to regard all papillomata of the bladder as suspicious, and to remove them as quickly and completely as possible. CARCINOMA OF BLADDER Carcinoma of the bladder occurs in the forms of scirrhous, medullary, and cancroid squamous epithelial growths. The scirrhous variety is relatively more favorable than the others. The squamous form is said to develop from the leukoplactic changes of a chronic cystitis. Carcinoma of the bladder, though sometimes at first papillary in form, tends to spread out irregularly through the wall, with ultimate ulceration and infiltration of the paracystic tissue. Metas- tases are comparatively late and take place in the regional pelvic lymph-glands. Secondary carcinoma of the bladder comes as a direct extension from cancer of the cervix or vagina, but occurs later than one would expect from the close proximity of the primarily diseased organs. Invasion of the bladder wall bespeaks an advanced stage of cancer of the cervix or vagina, usually beyond the point of operability. As the disease progresses the vesicovaginal septum may be eaten away, with consequent fistula formation. Other tumors of the bladder are of relative infrequency. A form of adenoma with infiltrating tendencies has been described. Cases of sarcoma have been reported, mostly in children. There have been a few cases of dermoid cysts developing in the wall of the bladder. These are to be distinguished from the ovarian dermoids that occasionally become attached to and rupture into the bladder. Other rare tumors of the bladder are myxoma, fibromyxoma, and fibroma. Small cysts of the mucosa are the result of chronic inflammatory changes. 428 GYNECOLOGY Symptoms. — The first sign of a bladder tumor is usually bleeding without previous symptoms, which may suddenly cease and not appear again until long after. The bleeding may be shght or profuse, and may appear sponta- neously or as the result of some trauma. It is at first intermittent, but in the course of time, as the tumor grows, the hemorrhages are more constant and often result in severe secondary anemia. The tumors are at first uncomplicated with cystitis, but when ulceration has occurred, cystitis, often of a severe grade, ensues. The treatment of vesical tumors is immediate removal. For small single or multiple papillomata the high-frequency current is extremely efficacious. For the larger tumors, and those that from their appearance suggest malignancy, extirpation by the suprapubic route is the best course. For the more extensive growths, where greater exposure of the bladder is required, the transperitoneal route is available and comparatively safe. Total extirpation of the bladder, with implantation of the ureters in the bowel, is an operation of last resort. The mortality of this operation is high, while an ascending infection of the ureters and kidneys is almost inevitable. VESICAL CALCULUS Stone in the bladder is far less common in women than in men partly be- cause the exciting causes, so far as they relate to cystitis, are more easily healed in women, and partly because the female urethra more readily allows the pass- age of small vesical or renal concretions before they have a chance to reach a size of clinical importance. Vesical calculi form by the crystallization of different urinary salts, and may originate in the bladder itself or be passed into the bladder from the kidney. They are composed chiefly of ammonium urates, phosphates, uric acid, oxalates, carbonates, cystin, and xanthin, the larger stones having usually a mixed com- position, which gives them a distinct lamellated structure. The primary etiologic factor in the formation of urinary calculi is thought to be some obstruction or stagnation of the urine. Cystitis and ammoniacal conditions are especially favorable. Concretions always form about foreign bodies which are not infrequently found in the bladder of women. These consist of small objects, such as hair-pins, pencils, nails, etc., which, being used for purposes of abortion or masturbation, accidentally slip through the urethra into the bladder. Other foreign bodies that- are found in the bladder as nuclei of calcuH are pieces of cotton, broken bits of catheter, or other instru- ments used by physicians in treatment. One of the commonest starting-points for a concretion is the so-called "wandering" stitch or unabsorbable hgature that has been placed in the bladder wall during a previous pelvic operation. The real vesical calculi move freely in the bladder unless they are impacted in diverticula, a favorite location, or are fixed in the urethral canal. They NEW GROWTHS 429 may exist for a considerable period without causing symptoms, but erosion of the wall, with bleeding and subsequent infection, are sure to take place in time. The symptoms, then, are of a severe cystitis with hematuria. The diagnosis is not usually difficult. Many times the stone can be felt by bimanual examination, while a sound will give the characteristic metalhc click unless the stone is so embedded that the instrument cannot come in contact with it. The diagnosis is established by the cystoscope and by the a;-ray. Treatment. — Small stones and foreign bodies can be drawn out through the urethra with the help of the cystoscope, but great care should be taken not to injure the vesical sphincter or lacerate the urethral mucous membrane. By means of the lithotrite, a powerful crushing instrument, many stones can be broken and removed piece by piece, or crushed, and the small bits washed out of the bladder by an irrigating and evacuating apparatus. If the stone is so large or hard that these means are not feasible, it can be removed through a vesicovaginal opening, the wound being left open for drainage if there is present a severe cystitis. A large stone may also be removed through a suprapubic extraperitoneal incision. TUMORS OF THE RECTUM CANCER OF THE RECTUM Of the malignant growths of the rectum, carcinoma is by far the most com- mon. The tj^pe of cancer most frequently found is the adenocarcinoma, which repeats in its structure the rectal mucous membrane from which it is sometimes difficult to distinguish it, excepting by its tendency to penetrate into the deeper layers of the rectal wall. Colloid carcinomata, and occasionally the medullary and scirrhous types, may also occur. They grow most commonly at the lower end of the gut, just within the anus or at the junction of the rectum with the sigmoid, though they may originate at any point of the rectal canal. Consti- tuting as they do pelvic tumors which can be palpated by vagina, they come, to a certain extent, within the sphere of gynecology. They may occupy only limited portions of the rectal wall or they may extend around the entire circumference of the tube in the manner of the inflammatory strictures (g. v.). They metas- tasize to the regional lymph-glands, and may spread by direct extension to various parts of the pelvis involving the pelvic connective tissue. Extension into the vaginal mucous membrane sometimes takes place. In the later stages distant metastases are sent to the liver and lungs. Sjmiptoms. — The chief symptom of cancer of the rectum is bleeding, due to the tendency which the tumor has of superficial necrosis and ulceration. Rec- tal pain is a comparatively early symptom. There is also a marked tendency to constrict the bowel, especially in the annular form, with dilatation of the 430 GYNECOLOGY bowel above and retention of feces and the products of necrosis of the tumor. This results in severe auto-intoxication and cachexia. The diagnosis of cancer of the rectum is not difficult. In most cases the tumor mass can be felt both by vaginal and rectal examination and can be seen, through the proctoscope. With the aid of a proctoscope, if the tumor is not situated too high, a specimen can be removed for microscopic examination. A differential diagnosis between inflammatory stricture and the annular form of carcinoma may be quite difficult. In this the general constitutional symptoms are often of assistance, for, as a rule, the general effect, of inflammatory stricture on the health of the patient is much less severe than that from cancer. The prognosis of cancer of the rectum is, in general, rather bad, but it is- much better in women than in man, due to the fact that the rectum is less adher- ent in the female pelvis, and hence offers a better chance for surgical removal of the disease. The treatment of cancer of the rectum is radical removal if the disease is not too far advanced. Eadium seems to be less efficacious, in this disease than in cancer of the cervix. The nature of the operation depends on the location of the tumor mass. An early cancer situated just above the anus, which has not penetrated the deeper layers, can sometimes be removed through a dilated sphincter by resecting the gut in the manner of Whitehead's operation and suturing the upper end to the anal membrane. Cases as favorable as this are- not often seen. Low cancer of the rectum may sometimes be removed through; an incision starting from the vagina through the perineum and into the sphincter muscle. If necessary the sphincter may be cut both anteriorly and poste- riorly, and the incision carried back to the coccyx (Abbe). The rectum can then be dissected out, including, if necessary, some of the vaginal wall. In this way several inches of the gut may be resected and the upper end brought down and sutured to the anus. The cut ends of the sphincter are sutured and the wound of the perineum and vagina closed by the usual plastic methods. In this way control of the bowels is maintained. Abbe recommeneds an inguinal- colostomy as a preliminary to this operation. Only a few cases are seen which are early enough for a cure by this method. Occasionally a cancer of the rectum near the junction of the sigmoid can be resected and the bowel ends united by end-to-end anastomosis. The author has one such case well at the end of five years. For the extensive cases more radical measures are necessary. These include the establishment of an artificial anus and a dissection of the rec- tum either by the abdominal or perineal route, or by a combination of both, or by the removal of the sacrum according to the method recommended b}^ Kraske. Other malignant tumors of the rectum are epitheliomata which grow inward from the anal region, sarcomata, and endotheliomata, all of which, are rare tumors. The treatment of these tumors is the same as that for cancer. NEW GROWTHS 431 ADENOMA Adenomata of the rectum are benign new growths springing from the rectal mucous membrane. They may be sessile or pedunculated, in which latter case they constitute the familiar rectal polypi, the most common of benign tumors of the rectum. These pol^^pi may be single or multiple, and sometimes occur in such numbers and are so closely grouped that the term "polyposis" has been applied to the condition. The rectal polyp repeats histologically the rectal mucous membrane from which it originates, except that there is usually a marked hyperplasia of the glandular structure which occasionally becomes cystic. Rectal polypi vary in size from that of a pea to a walnut, and tend, as a rule, to remain benign in character. They are, however, sometimes the start- ing-point for adenocarcinoma. Some of the rectal polypi are fibrous in structure and represent probably a growth from the rectal submucosa. The polypoid growths of the rectum cause bleeding and sometimes tenes- mus. They are diagnosed without difficulty and are best treated by surgical removal. The rare condition of polyposis is a grave disease, the treatment of which must be determined by the exigencies of the case. PROLAPSE OF THE RECTUM Prolapse of the rectum is a disease that occurs most frequently in child- hood, but is sometimes seen in the adult. True prolapse of the rectum must be distinguished from prolapse of the mucous membrane, which is a common accom- paniment of hemorrhoids. In the latter case, the mucous membrane slips away from its loose attachment to the muscular layer of the rectal wall and protrudes from the anal orifice. The extent of prolapse of this kind is necessarily limited, seldom more than 1 inch of the rectal mucosa coming down. This form of pro- lapse has been termed "incomplete prolapse" and "prolapsus ani." It may sometimes be the preliminary stage of a later true prolapse of the rectum. Prolapse of the rectum, in its strictest sense, relates to a turning inside out of the entire rectum, including all the layers of the wall. The descent of the rectum is due to a loss of the somewhat loose connective-tissue attachment which it has to the hollow of the sacrum. In children, the curve of the sacrum being flatter than in the adult and the sacral attachment being more delicate, prolapse after prolonged straining or depleting diseases is comparatively com- mon. In the adult, on the other hand, the more pronounced curve of the pelvic outlet and the greater development of the protecting levator ani muscles makes the disease uncommon. In gynecologic practice the condition may be seen at any age, but it is said to be more common in elderly women in whom there is much perineal and sphincteric relaxation. Most of the cases we have aeen have been in comparatively young women. 432 GYNECOLOGY The characteristic appearance of prolapse of the rectum is that of a rosette which extrudes with the act of defecation. The size of the extruded mass is, as a rule, surprisingly large. It is usually not painful at first, but, as the pro- lapse recurs more and more frequently and drying and ulceration of the mucous membrane takes place, the condition may become very distressing. In the more advanced cases there is frequently a hernia of Douglas' pouch, contain- ing intestines situated in the anterior part of the prolapsed mass. This, as Mos- chowitz has pointed out, represents the type of "sliding hernia." The treatment should always at first be palliative and supportive. Opera- tion is rarely necessary in children, a cure being usually possible by so strapping the buttocks as to prevent extrusion and at the same time allow for defeca- tion. In the adult the same procedure can be carried out unless there is great relaxation of the parts surrounding the anus. Some advocate the use of a vulcanite plug held in place by a T-bandage and pad, and claim by this method that in time the natural tonicity of the support- ing structures asserts itself sufficiently to maintain the rectum in position. Cold and mildly astringent enemas may be tried at first. If the case is intractable, one must resort to surgical methods, which consist either of linear cauterization or of various cutting operations. Linear cauteriza- tion, performed under anesthesia, is done by drawing several times a blunt- pointed PaqueHn cautery at dull red heat along the mucous membrane in the longitudinal axis. The cautery should sere only the mucous membrane and not be allowed to burn deeply into the muscular tissue. Five or six lines should be made. This procedure sets up an inflammatory reaction, which after healing serves to prevent the descensus of the bowel. This method can also be used for prolapse of the rectal mucous membrane. The surgical operations best adapted to the cure of prolapse are described in detail in the section on Operative Technic. They consist of amputation of the prolapsed rectum, fixation of the rectum to the sacrum, and intra-abdominal suspension. HEMORRHOIDS Hemorrhoids constitute a varicose condition of the hemorrhoidal veins. They have been classified as to form, location, and consistency in numerous different ways, but the description by Pennington is especially practical. He calls attention to the fact that hemorrhoids are formed on the inner side of the two cones that coalesce in embryonal fife to form the anal canal. The upper cone represents the end of the hindgut (rectum), and is lined with intestinal mucous membrane and nourished by the superior hemorrhoidal vessels. The lower cone is the proctodeum and corresponds to the anal dimple (Fig. 166). It is lined with squamous epithelium and is supplied by the inferior hemorrhoidal vessels. In embryonal life the apices of these two cones unite at the pectinate line, failure of union being the cause of imperforate anus. Pennington dis- NEW GROWTHS 433 tinguishes hemorrhoids according to their location in relation to the point of coalescence of the two cones. Internal hemorrhoids represent a dilatation of the superior hemorrhoidal veins in the upper cone, while external hemor- rhoids result from distention of the inferior hemorrhoidal veins of the lower cone. Interno-external hemorrhoids are located partly within both cones, and are the result of a varicose condition of both superior and inferior sets of veins. Internal hemorrhoids always contain fluid blood, the interno-external type contain both fluid and clotted blood, while the external hemorrhoid either con- tains a clot (thrombotic pile) or is a mere tab of skin which represents the rem- nant of an old hemorrhoid. XcmotrVvoib txVemcu Me.>rY\ovr\vo\b Fig. 166. — Hemorrhoids. The three types of hemorrhoids are shown — internal, external, and interno-external. Pennington.) (After The causes of piles are extraordinarily numerous. Some individuals in- herit a predisposition to piles in a congenital deficiency in the supporting power of their tissues. Very important are those conditions which cause stasis or ob- struction of the portal system, in which a long column of blood is unsupported by valves. The pregnant uterus and tumors that exert pressure on the mesen- teric vessels or some part of the portal system are examples. Abdominal pressure exerts an obstructing influence on the portal circulation, and, therefore, the labors of childbirth constitute a frequent cause of hemorrhoids which, how- ever, may exist only temporarily. Chronic diseases of the heart, lungs, and liver are frequently associated with hemorrhoids. Chronic constipation and 28 434 GYNECOLOGY enteroptosis are other factors. Retroversion of the uterus and pressure on the rectum by pelvic tumors are usually mentioned in the etiology, but probably do not play a very important role. A very frequent cause of hemorrhoids, not always sufficiently appreciated, is the lacerated or relaxed perineum. Here the support of the levator ani muscles, which is of importance to the proper circulation of the anal region, is lost or made incomplete by the separation and retraction of the two muscles. The importance of the relaxed perineum in the causation of hemorrhoids is evi- denced by the regularity with which hemorrhoidal symptoms are relieved following perineoplastic operations. External hemorrhoids become inflamed easily, in which case they are swollen and edematous and are very painful. Itching is sometimes a distressing sjnnp- tom. In individuals with little resistance the inflammation may be extensive and even involve the veins of the leg. Skin-tabs do not ordinarily give much discomfort, but they are liable to recurrences of thrombosis or inflammation. Internal hemorrhoids are liable to fissure and especially to bleeding. The bleeding may be only slight in amount and give little trouble, or it may be serious enough to cause grave anemia or even fatal hemorrhages. The diagnosis of external hemorrhoids is a simple matter. For internal hemorrhoids a digital examination should always be made, to I'ule out the possibility of stricture, cancer, or ulceration of the rectum. Internal hemor- rhoids cannot easily be felt by the examining finger and should be subjected to inspection. This can best be done by placing the patient in the Sims position. With the right forefinger hooked into the perineum, and pressing strongly on the rectal wall toward the anus, the entire anal canal is easily rolled out and com- pletely exposed to view. The maneuver is more successful if the patient at the same time exerts abdominal pressure as in the act of defecation. The treatment of hemorrhoids comprises palliative and operative measures. Palliative treatment does not effect a cure, but serves to alleviate distressing symptoms during an "attack." A restricted diet and the use of cathartics that produce soft unirritating stools are of first importance. Local applications in the form of ointments (Ung. gallse et opii, hamamelis, etc.) are useful if the ointment is applied so that it comes in contact with the mucous surface inside the sphincter. Hamamelis suppositories are excellent for the average case. Inflamed piles are best treated by rest and hot fomentations, frequently changed and held snugly against the anus by a T-bandage. Morphin suppositories may be necessary for the pain in severe cases. Strangulated piles must be reduced, if necessary under an anes- thetic. In considering radical treatment for hemorrhoids it must be remembered that operations for this disease are not without their drawbacks. Dangerous hemorrhage, sepsis, even fatal embolism have been known to occur. If the operation is done coincidently with an abdominal section the convalescence NEW GROWTHS 435 may be greatly complicated by the inability to use the rectum for enemata if there is stasis of the bowels. The mere existence of hemorrhoids does not indicate an operation. Con- tinued symptoms do. In the case of hemorrhoids dependent on perineal relaxa- tion the plastic operation usually cures the hemorrhoids. The methods of operating on hemorrhoids are numerous, and may be divided in two classes: (1) Those that depend for their efficacy on the creation of a slough and heahng by granulation, and (2) those that depend on clean removal. In the first class are included such procedures as crushing, apphcation of strong nitric acid, injections of carbohc acid, and the classical clamp and cautery. Operations of the second class include dissection, hgature, and the annular excision commonly known as Whitehead's operation. Operations of the first class are rarely used now, as they have fittle to recom- mend them. They are apt to be followed by bleeding, swelling, and fissures. Operations of the second class are described in the section on Operative Technic (see page 819), and are the procedures of choice. Defects of development Embryologic Development of the Genital Organs. — A knowledge of the main processes that take place in the fetal development of the pelvic organs is neces- sary for an understanding of certain malformations and tumor groT\i:hs. At about the end of the fourth week of embryonal hfe in the human the Wolffian bodies are formed along the sides in the lower third of the body, reach- ing upward as far as the point where later the diaphragm develops and extend- ing downward in the form of a duct (Wolffian duct) to the cloaca. In the fifth to the sixth week of embryonal hfe there appear, just inside of the Wolffian bodies, the elements of the genital glands, covered with a special epithehal layer, the so-called "germinal epithehum," which contains here and there cells rich in protoplasm, the primary eggs. Coincidently with the development of the genital glands there are seen, situated externally to the Wolffian bodies, two ducts which extend to the uro- genital sinus (Fig. 167). These are the ]\Iullerian ducts. From the primary genital glands are developed the ovaries in woman, while from the Miillerian ducts is developed the entire genital tract to the vaginal introitus. The Mullerian ducts are at first sohd, and extend to the urogenital sinus as separate, unfused structures. Malformations of the genital tract always imply some disturbance in the proper development of these two ducts, and involve either an atresia of one or both ducts or a lack of fusion. If the development of Miiller's ducts proceeds normally they run close together in their lower half, eventual^ becoming merged into one structure. The upper parts of this structure (the future uterus) first acquire lumens lined with a single laj^er of cyhnder epithelium, while the lower section of the fused portion (the future vagina) remains solid for a somewhat longer period, being composed of large cells rich in protoplasm. Gradually, however, this lower part also acquires a lumen and becomes the vagina. The fusion of the lower half of Miifier's ducts is completed in the ninth fetal week. At this period the vagina is merged into a single structure, but is still solid. The uterus, on the other hand, is separated into two hollow comipartments, this double construction remaining until the fourth or fifth month, when the uterus and vagina acquire a single communi- cating lumen, which shows no signs of the former double formation, except a slight depression at the fundus where the partition ended. It is important to keep clearly in mind tliis particular part of the embr3"olog5'' of the genital tract in order to comprehend the various types of maldevelopment of the uterus. At about the beginning of the fifth month the uterus becomes differentiated from the vagina by the formation of the vaginal portion (cervix). At the end 436 DEFECTS OF DEVELOPMENT 437 of the fifth month the fundus of the uterus rounds out, so that all appearance of the former double character of the uterine body disappears. The wall of the uterus acquires muscle-fibers at about the fifth month, at which time also the hymen appears as a special differentiation of the lower vaginal segment. At birth the uterine body is small, thin walled, and insignificant in comparison with the cervix. oC Houtt N<><:?.c^ Fig. 167. — Diagram Showing the Relationship of the Mullerian and Wolffian Ducts and THEIR Openings into the Urogenital Sinus. Even in the earliest periods can be noted a difference in the character of the epithelium in different segments of the Mtillerian ducts. The upper portions from which the tubes and uterus are formed first become hollow, and are lined with a simple cylinder epithelium, while the vaginal part, as was stated above, remains until a later period a solid structure, filled with large cuboidal epithelial cells. The layer of epithelium which lines the upper parts does not become ciliated until extra-uterine life. The mucous membrane of the uterine body is in the embryo very little 438 GYNECOLOGY differentiated from that of the cervix, while the branching folds, which charac- terize the cervix in the adult (arbor vitse), are, in the embryo and child, con- tinued to the fundus of the uterus (Fig. 168). The establishment of secreting glands in the mucosa of the uterus is a late development, there being no definite period for their appearance. It is said that in some instances there is a full equipment of glands at birth, while in others they do not appear until the child is ten or twelve years old. The glands of the cervix develop first. ^r^iyy i 4 Fig. 168. — Development of the Utebus.' 1. Uterus of newborn child. The cervix shows much greater development than the body. The folds of the arbor vitae reach from the cervix to the top of the uterine canal. 2. Uterus of a seven- year-old child. The body is equal in development to that of the cervix. The folds of the arbor vitae reach just beyond the internal os. 3. Uterus of a mature virgin. The development of the body excels that of the cervix. The folds of the arbor vitse reach only to the internal os. 4. Uterus of a woman who has borne children. The body shows a still greater development. The folds of the arbor vitse occupy only about two-thirds of the cervical canal. The external os of the cer\Tx is dilated, (vyter Kiistner.) As the Miillerian ducts develop in the female there is a corresponding retro- gression of the Wolffian ducts, remnants of which may later play a part in the formation of certain pelvic tumors. Retrogression of the Wolffian body and ducts begins at the seventh or eighth week and is completed about the fifteenth to the sixteenth week of fetal life. Rests of these structures persist in the broad hgament under the name of the DEFECTS OF DEVELOPMENT 439 ''parovarium," which appears in the form of a comb, with the back running parallel with the tube, and the teeth extending in a somewhat radiating direc- tion toward the ovary. The parovarium is divided into two parts, the outer (or, more exactly, the upper) part, near the tubal extremity, being termed the epoophoron, and the inner (or lower) part, near the round ligament, the paro- ophoron. The thread-like strands of the parovarium are, in reality, minute canals lined with a low cuboidal epithelium and surrounded with a firm con- nective tissue (Schuler). In the paroophoron portion are sometimes found rudimentary glomei-uli. The small pedunculated hydatid cj^sts of JNIorgagni, often seen dangling from the edge of the broad ligament near the fimbriae, are regarded as remnants of this Wolffian body. The back of the comb-like figure, by which we have described the paro- varium, represents the remains of the Wolffian duct. This duct may persist in a part or the whole of its course. Thus, there is sometimes a communicating tubule between the epoophoron and the edge of the broad ligament in the fimbriae. That part below the parovarium is sometimes also found to persist, and to it has been given the name "Gartner's duct." As a rule, only short segments of this duct persist, but in a few instances it has been traced from the parovarium to the uterus, through the uterine musculature to the vaginal por- tion, and through the vaginal wall to an opening at the hymen. The course in the vagina is along the lateral or dorsal part of the wall. The persisting rests of Gartner's duct maj^ be the seat of retention cysts or of epithelial new growths. Ovaries. — To the median side of Aliiller's ducts and the Wolffian body appear at about the sixth week the rudiments of the genital glands, which in the male develop into testicles and in the female into ovaries. These structures are at first alike in both sexes, and consist of a connective-tissue ridge covered with cylinder epithelium. Differentiation into the male or female organ takes place in the next three months. The development of the ovary is characterized by a rich proliferation of cells from the epithelial covering (germinal epithelium), together with an ingrowth of connective-tissue cells and blood-vessels from the neighboring Wolffian ]x)dy. The epithelial cells which permeate the structure become cut off and confined in balls or compartments (Eifacher of Nagel, Eibal- len of Waldej^er), and form the basis for the primordial follicles. The folHcles first formed retreat toward the center of the organ, while new folficles are formed from the surrounding germinal epithelium which has a tendency to dip inward into the stroma (Fig. 8). A remnant of this process can be seen in the newborn in the form of in- grow^ths of germinal epithelium into the stroma. This tendency of the epi- thelium surrounding the ovary to inversion often persists, and the cutting off in the stroma of such cell-inclusions undoubted^ is the basis of many ovarian new-growth tumors. The ova, or germ-cells, are distinguished from the other cells by their greater 440 GYNECOLOGY size. They are found included in the cell masses above described and scattered through the investing layer of germinal epithelium. After birth there is no further generation of new follicles. During the first year many of the primordial follicles already created disappear. Descent of the Ovaries. — At about the third month of embryonal life the descent of the ovaries takes place. The gubernacul"um of Hunter, which at first represents an abdominal fold, later becoming endowed with connective tissue and muscle-fibers, connects the Wolffian body with the inguinal canal at \\)\y(V r ^ _^ ^ FiG. 169. — Diagram Showing Descent of Ovaries and Fusion of Mtjller's Ducts into Uterus AND Vagina. The way in which the gubernaculum of Hunter becomes the round and ovarian ligaments is shown. an early period. At the time when the Wolffian body is in the process of retro- gression this ligament fails to keep pace with the growth of the rest of the body, and exerts such traction on the genital gland that it is drawn dow^nward into the pelvis. The gubernaculum of each side fuses in its upper third with the Mtiller's ducts at their point of union (fundus of the uterus), so that finally it is divided into two unequal portions, one that extends from the fundus to the inguinal canal, the round ligament, and one that runs from the fundus to the ovary, the suspensory ligament of the ovary. DEFECTS OF DEVELOPMENT 441 Before full sexual development the ovaries remain relatively high, their complete descent into the depth of the pelvis being consummated after maturitj'-, due possibly to the gradual increase in weight of the organ. (Adapted from Otto Klistner, in Kiistner's Lehrbuch.) The Wolffian and Miiller's ducts primarily open below into the lower part of the allantois, which at this time represents an anterior extrusion of the end- gut from the body cavity. Later the walls of the abdomen join in the mid-line up to the umbilicus, and the portion of the allantois between the umbilicus and the openings of the Wolffian and Miiller's ducts becomes the bladder and urethra. Below this level the descending part of the canal is termed the "urogenital sinus," while the ascending part is the rectum. The part into which these two canals empty in common is called the '^cloaca." CONGENITAL DEFECTS OF THE UTERUS Defects of the uterus occur chiefly as a result either of complete or partial failure of union of the two Mlillerian ducts. An entire absence of uterine tissue does not occur, for even in the cases of congenital absence of the vagina there is FiG. 170. — Uterus Duplex Bicornis cum Vagina Duplici. Double Vagina. Normal in the opossum. Double Bicornuate Uterus with always a rudimentary development of the uterus, which som.etimes exists only as a small retroperitoneal sohd strand of tissue scarcely appreciable by rectal examination. Failure of union of the Mlillerian ducts may result in the following abnormal formations : (1) Uterus didelphj^s, or uterus duplex separatus. This signifies a com- plete separation of the two halves of the uterus with double vagina. This form 442 GYNECOLOGY is rarely seen in living human individuals, being usually associated with other malformations of the pelvis that are incompatible with life. -\\i p Fig. 171. — Uterus Duplex Bicornhs. Double Uterus. Normal in the squirrel, hare, and beaver. (2) Uterus duplex bicornis cum vagina duphci. In this case there is a separa- tion of the two bodies, but the two cervices are fused. The vagina is double (Fig. 170). Fig. 172. — Uterus Bicornis Unicollis. Bicornuate Uterus. Normal in the hyena, dog, goat, and sheep. (3) Uterus duplex bicornis. Here the formation is like the preceding- ex- cept that there is a single vagina. (4) Uterus bicornis unicolhs. In this type the body of the uterus is double, DEFECTS OF DEVELOPMENT 443 but the cervix is fused into one. The two bodies may, however, not be widely separated, but lie closely together so that the fundus has a saddle shape. (5) Uterus septus duplex. The external form of the uterus is entirely norinal, but the entire canal is divided by a septum reaching from the fundus to the external os. (6) Uterus subseptus uniforis. The external contour is normal, but there exists a partial septum extending from the fundus. Fig. 173.- -Uterus Subseptus Uniforis. Partial Septum of the Uterine Cavity. Normal in the horse and the ass. Fig. 174. — Uterus Biforis. The uterine cavity is single, the cervical canal is double. Normal in the ant-eater. Fig. 175. — Uterus Unicornis. The adnexa of one side are wanting. Normal in birds. (7) Uterus biforis. The canal of the body is normal, but a septum divides the cervix completely so that there is a double orifice (Fig. 174). (8) Uterus unicornis. In this form there is complete absence of one-half of the uterus (Fig. 175). The foregoing are the essential malformations, but they may assume various forms as a result of unequal development in the two sides. If both halves of a double uterus develop equally, both may functionate perfectly — i. e., menstruate and conceive. Usually in double uterus one-half is better developed than the other, and if repeated pregnancies take place they occur in the same half. One- 444 GYNECOLOGY half may be diseased with cancer or bacterial infection, while the other remains entirely unaffected. The opening of one-half of a double uterus may become closed, with resulting hematometra. When one horn of a double uterus is in- completely developed there may be a congenital atresia of its canal, and this may also eventuate in a hematometra. The symptoms of these two conditions are the same as those described under the subject of Gynatresia. Pregnancy may occur in a rudimentary horn. If there is a communication between the rudi- mentary horn and the main uterine canal an abortion may take place through the opening. Sometimes, however, a rudimentary horn which has no com- munication with the uterine canal may become impregnated by a wandering fertilized ovum from the opposite side. The clinical picture is then one of tubal pregnancy. Double formation of the uterus, as a rule, has no special chnical significance unless there is atresia and hematometra. The diagnosis is usually difficult to make. If sepsis is not present, and one-half of the uterus is normal, the atretic half may be amputated. Where pregnancy takes place in a rudimentary horn the treatment is the same as that of extra-uterine pregnancy, with amputation of the rudimentary horn if the other uterine body and adnexa are normal. DEVELOPMENTAL DEFECTS OF THE VAGINA Most cases of defective vagina that produce symptoms are the result of inflammatory processes acquired after birth, as described in detail under the heading of Gynatresia (g. v.). The developmental defects have chiefly to do with entire absence of the vagina or to septum formation, or to the union of two abnormally narrow Miil- lerian ducts. In most cases of congenitally absent or defective vagina, except where there is septum formation, the uterus is functionless, so that no symptoms of retained secretions ensue at puberty, as in the case of acquired gynatresia. It often happens, however, that individuals, even with complete absence of the vagina and with rudimentary internal genital organs, may be otherwise fully developed both as to external genitals and the secondarj^ bodily sexual characteristics. These women may have normal sexual instincts, and are often so attractive as to be sought in marriage. In such cases it sometimes be- comes necessary to create an artificial vaginal pouch for the purpose of co- habitation. In performing this operation it is first necessary to separate the bladder from the rectum, which are united along the area normally occupied by the vagina. A space is made by blunt dissection corresponding to the size of the normal vagina. The next step is to line this newly made pouch with an epithelial sur- face, as otherwise the raw surfaces cannot be kept from readhering. This may DEFECTS OF DEVELOPMENT 445 be accomplished by turning in flaps from the labia minora and from the skin of the buttocks. A better, though more dangerous operation, is to bring down through an opening into the peritoneal cavity a resected loop of the intestine, to which is attached its corresponding section of mesentery. The pouch can thus be lined with a true mucous membrane, which is kept alive by its mesenteric circulation. An abdominal operation is necessary for the resection of the bowel and the union of the bowel-ends. The details of both methods of operation are described in Part III. A third method is also described by which an artificial vagina is formed from a section of the rectum. DEVELOPMENTAL DEFECTS OF OVAREES AND TUBES Absence of both ovaries occurs only in non-viable fetuses in which there is complete absence of genital elements. The failure of one ovary is seen in uterus unicornis or where one horn is extremely rudimentary. On the other hand, an accessory ovary is sometimes, though rarely, seen. Whether the third ovary represents an independent separate growth from the start, or whether it was accidentally cut off from the normal ovary during early embryonal life, is a matter of doubt. Absence of the tubes, like absence of the ovaries, occurs only on one side in the case of uterus unicornis. Imperfect or hypoplastic development is discussed under the subject of Infantilism. DEFECTS OF THE URETHRA AND BLADDER Hypospadias in the female differs essentially from that seen in the male. In the latter it relates to an opening of the urethra on the under side of the penis, at any point from the glans to the colliculus seminalis. This part is wanting in the female, in whom the urethra corresponds to that portion of the male canal which extends from the colliculus to the bladder. Female hypospadias may represent various grades of deficiency, from mod- erate defects of development to complete absence of the urethral canal. When the urethra is entirely wanting there is a funnel-shaped opening into the bladder, so that there appears to be a communication between the bladder and vagina. It should be remembered, however, that in embryonal life the urinary system at no time communicates with the Miillerian ducts, so that in complete hypospadias the urethral opening is really into the vestibule. When the defect of the urethra is complete, there is also an absence of the sphincter vesicae with full incontinence of urine. When the urethra is incompletely developed the incontinence may be only partial. The treatment of hypospadias is operative, and is directed to the control of 446 GYNECOLOGY the urine. If the hypospadias is complete the success of the operation is always in doubt. If, however, the defect is partial and the vesical sphincter muscle is present, a skilfully performed plastic operation should cure the patient. The operative technic must be determined somewhat by the exigencies of the case, but may be carried out on the general principles recommended for Incontinence (see page 614). VXreWfo^ Fig. 176. ^Epispadias. Exstrophy and epispadias are comparatively rare conditions in the female. Both these malformations are different grades of the same embryonic defect. In the early stages of development the cloacal membrane reaches to the primitive belly-stalk or forerunner of the umbihcal cord. As the embryo grows the upper portion of this membrane disappears as the sides of the abdominal wall and pelvis join, while the lower part corresponds to the opening of the uro- genital sinus and the rectum. DEFECTS OF DEVELOPMENT 447 Under abnormal conditions the cloacal membrane may partially or entirely persist, due to the incomplete merging in the middle line of the sides of the muscular abdominal wall or of the pelvis. The thin epithelial cloacal membrane 3k\\ CXYvWiS .^ i"l'(\test\Yie- - 1* ^^JjcvCtr CVoaecA. m grpomtot- 3^e.-m\>raxvs^ ^ bucks' ^^ ^loo^co. W Fig. 177. — Common cloaca into which the gut and the allantois empty. The cloacal mem- brane reaches to the region of the later bladder and urethra. Knowledge of this membrane is important in understanding exstrophy of the bladder (Pankow). 3iUvb6t<- Got iVTuUev" Fig. 178. — The cloaca separates into a ven- tral and dorsal part. The Wolffian ducts open into the ventral part. Miiller's ducts at this stage are not established. The dotted line shows the position of their later development. The beginning of the bladder can be seen as a dilata- tion in the duct of the allantois (Pankow) . thus exposed soon breaks and allows the urinary contents of the bladder to escape through the opening of the belly wall. If the opening is extensive the — = ~-= .)v("u!lfc«^ ^^&W,t[(. ^=^,,^\)Vetetr C\onco>V^Si^;^*.^ _,-^ / \ ■ ■ . = r Fig. 179. — ^The sinus urogenitalis is formed. The ureter is seen sprouting from the Wolffian duct. The Miiller's ducts have at this stage not yet reached the sinus, urogenitalis, their future position being shown by the dotted lines (Pankow). condition is called exstrophy of the bladder. The extrusion of the bladder is due to abdominal pressure which forces the posterior bladder wall out through the abdominal opening. 448 GYNECOLOGY Fig. 180. — The urogenital sinus has broken through the cloacal membrane. The intestine is still closed. The Miillerian ducts have reached the urogenital sinus to the median side of the Wolffian ducts, but have not yet acquired an open lumen. The site of the future hymen is indicated. The ureter has separated from the Wolffian duct. The part between the ureter and Miiller's ducts becomes the lower part of the bladder and the urethra. Douglas' pouch is in- dicated between the gut and the urogenital sinus. The shaded portion protruding to the left of the drawing represents the genital tubercle, the future clitoris (Pankow). Fig. 181. — The urethra and vagina open into the common urogenital sinus, which gradually gets shorter and shorter, eventually becoming the vestibule. The perineum is developed. The rectum has established an opening through the anal dimple. The lumen of vagina and uterus has been formed (Pankow). If the defect takes place so that only the upper part of the bladder is ex- posed the condition is called a superior vesical fissure; if the defect is in the DEFECTS OF DEVELOPMENT 449 lower part of the bladder it is called inferior vesical fissure. If the separation is confined to the urethra and the vulva the condition is termed epispadias. Inferior vesical fissure and epispadias may be combined. In exstrophy and fissure of the bladder the urine usually" passes completely through the abdominal opening. In epispadias incontinence may be complete or partial, or even absent in mild grades of the deformity. Treatment is directed toward control of incontinence, and can be accom- plished onl}^ by plastic surgery. Operations for exstrophy are difficult, and must usualh^ be repeated several times before success can be attained. For moderate degrees of epispadias operations may be successful, but patients should always be told that it may require several or even many operations before a cure can be effected. ATRESIA OF THE ANUS This term is applied to a condition in which the normal communication between the rectum and the outside world was not established during the process of development. In viable children two types of atresia are to be CUlons--- Aac\bvuvv\)\lV Svnus UfoofctaTcxUs Fig. 182. — Section of Normal Infant's Pelvis. distinguished: (1) where the lowest portion of the rectum is deficient and the bowel ends in a bhnd pouch, and (2) where the embryonal communication be- tween the rectum and urogenital sinus persists. In the latter case, in the full- term child, the rectum opens into the vestibule. True atresia of the rectum is properly applied only to the first tj^'pe. This condition is discovered soon after birth by the absence of defecation, and re- quires immediate operative interference. Occasionally the atresia is due to 29 450 GYNECOLOGY a simple gluing together of the superficial epithelium, in which case an open- ing is easily made by blunt puncture. If there is more than a thin membrane FiG. 1S3. — Imperforate Antts. between the rectal pouch and the external anal dimple the operation is a serious one and accompanied by a high eventual mortality. The operation consists Fig. 184. — Vestibular A?gx^s. in making an anteroposterior incision through the anal dimple, dissection of the intervening tissue, and bringing the rectum down to the incision, to which it is DEFECTS OF DEVELOPMENT 451 sutured. In all cases the sphincter muscle is present, so that, if the operation is skilfully performed, complete control of the bowels is secured. Manj^ suc- cessful cases have been reported. Anus vestibularis is the term applied to the second type of anal atresia. In this condition there is no opening through the anal dimple, but the former embryonal opening into the urogenital sinus persists (Fig. 184). As the vestibule in such cases is often deeply placed, the rectal communication appears to be in the vagina, and for this reason the condition is sometimes spoken of as a vaginal anus. This is incorrect, as a connection between the rectum and Miiller's duct is embryologically impossible. The defect should always be termed "vestibular anus" (Pankow). If the opening into the vestibule is very small, there may be obstruction to defecation and the newborn child may require surgical operation. Usually, however, the opening is large enough to permit the passage of feces, and patients with this defect often grow to adult life without knowledge of their condition. Some even conceive and bear children. Operation is, however, sometimes indicated if there is incontinence and uncleanHness, especially in women who contemplate marriage. The operation is not difficult, and usually results in perfect success. The rectal pouch is brought down to an opening through the anal dimple and sutured there, and a new anus estabhshed. The old vestibular anus is denuded and closed by suture. HERMAPHRODITISM The sex of an individual is determined only by the nature of the genital glands (i. e., as to whether they are ovaries or testes), and not by the appearance of the external genitals, nor by the development of the secondary sexual char- acters of the body. True hermaphroditism implies the presence in the same individual of both ovarian and testicular tissue, fully developed and functionating. There are numerous instances of true hermaphroditism in some of the lower species of animal life, but in man it has never been demonstrated and probably does not exist, though several cases have been reported in which there has been found in the genital glands both ovarian and testicular tissue, the so-called ovitestes. In all of these cases only the elements of one sex were fully developed and capable of function. Such individuals could, therefore, not be termed true hermaph- rodites. The sexual intermediates that appear in the human species are always essen- tially male or female, though they may have the outward characteristics of the opposite sex. They are, therefore, properly designated as "pseudohermaphro- dites." Pseudohermaphrodites are divided into two classes — feminine and mascu- line. In individuals of the former class the structure of the genital glands is 452 GYNECOLOGY ovarian, but external genitalia and the secondary sexual characteristics are of the male type. This class is comparatively rare. Most pseudohermaphrodites possess the male genital gland, but are out- wardly more of the feminine type. In these individuals the penis is rudi- mentary and is not perforated by the urethral canal. The meatus urinarius lies at the base of the rudimentary penis and often cannot be seen, especially in children, as it opens into a blind depression which closely resembles a vagina. The testes are either undescended or lie high up in separated scrotal sacs, which may have the exact appearance of labia majora. Individuals of this kind are usually regarded in childhood as girls, are given feminine names, and grow up as females. Sometimes male characteristics may develop as the child comes to maturity and call attention to the real sex. It is sometimes impossible to make a diagnosis of the correct sex except by microscopic examination of the sexual gland, a procedure which under ordinary circumstances is not feasible. There may be great variations in the type of pseudohermaphroditism just described, depending on the development of the genital organs. The elements representing Miiller's ducts are, as a rule, rudimentary, but, on the other hand, they may develop into nearly full-sized uterus, tubes, and vagina. At least one case has been reported of an individual who lived and cohabited both as a man and as a woman. The testes of the pseudohermaphrodite possess a special predisposition to malignant degeneration. Malpositions of the Uterus When a woman is standing the uterus lies normally in approximately a horizontal position. The anterior wall is in contact with the bladder, while on the posterior wall and in the recto-uterine pouch rest the intestines. This position of the uterus is not a fixed one, for, owing to the requirements of child- birth, the organ is necessarily mobile. Thus, by manipulation it can be rotated backward through an angle of 180 degrees, while laterally it can be turned through an angle of 45 degrees to each side. Pressing as it does on the wall of the bladder, its position is continually changing in an anteroposterior plane, accommodating itself automatically to the varying changes in the size of the bladder. Nor is its level in the pelvis a fixed one, for under the influence of forced abdominal pressure, such as results from straining, the elastic supports of the uterus allow a certain amount of descent in the direction of the pubic outlet. The uterus, notwithstanding its remark- able mobihty, nevertheless under normal conditions returns to its proper position after temporary displacement, such as may result from forcible manipulation, pregnancy, severe strains, rapidly growing tumors, or any influence that does not cause a fundamental change in the elasticity of its supports or its inherent muscular structure. The axis of the uterus is not normally straight, for there exists between the body and cervix a moderate permanent angulation or anteflexion which has a considerable variation within normal limits. After the menopause the normal angulation disappears and the axis of the uterus becomes straight. The nomenclature of uterine displacements has not been standardized. The following terms and definition's, though not in all particulars universally employed, have received the sanction of good usage: Retroversion of the uterus means a turning backward of the entire organ on an axis situated approximately at the internal os. In an uncomplicated retro- version the cervix and body retain their normal relationship to each other, so that as the body turns backward the cervix points forward. For the sake of convenience, retroversion is divided into three degrees: The first degree in- 453 Fig. 185. — Normal Position of Uterus. 454 GYNECOLOGY eludes deviations from the normal position to a point where the long axis of the uterus coincides with the long axis of the vagina. At this point the uterus is Pig. 186. — Retroversion. First Degree. Fig. 187. — Retroversion. Second Degree. said to be in the second degree of retroversion, and the cervix points in the direction of the vaginal orifice. Deviations beyond the second degree are said Fig. 188. — Retroversion. Third Degree, with Retroflexion. to be in the third degree, and the cervix tends to point correspondingly further forward. MALPOSITIONS OF THE UTERUS 455 Anteversion means a turning forward of the uterus. As a matter of fact, the uterus in its normal position is turned forward as far as it can go, resting as it does on the bladder. The term "anteversion," therefore, describes the normal position of the uterus and does not denote a displacement, as it was formerly- supposed. The term is rarely used at present. Lateral version means a turning of the uterus to the right, or left. Retroflexion of the uterus means a bending backward of the body on the cervix, causing an angulation of the posterior wall. The flexion takes place at the internal os. It is usually a more advanced manifestation of retroversion, and does not occur until the uterus has reached the third degree of retroversion. When retroversion and retroflexion are combined it is customary to say that the uterus is in a position of retroversion-flexion. Fig. 189. — Lateral Version. Fig. 190. — Lateral Flexion. Lateral flexion means a bending of the uterine body on the cervix to the right or left. If there has been also a version involving the cervix, one speaks of right or left version-flexion. Anteflexion relates to forward angulation between the body and cervix. The uterus is normally anteflexed to a certain degree. The term "anteflexion" is used to denote an abnormal amount of angulation. The condition is de- scribed more exactly by hyperanteflexion, a word that is not in common use. Retrocession is a specialized term that relates to a condition in which the uterus has receded to a position nearer the sacrum than normal, but in which the fundus continues to point forward. In the majority of anteflexion cases the whole uterus is abnormally far back, and is said, therefore, to be retro- cessed. Conversely, retrocession, when properly used, implies an anteflexion of the body. 456 GYNECOLOGY Anteposition denotes that the uterus, as a whole, is in a position abnormally near the pubes or anterior abdominal wall. This position is created by the .^orrnoV Jtx\s jVx\s oC Fig. 191. — Anteflexion with Retrocession. The whole uterus sags back toward the sacrum. pressure from behind of a tumor situated in the posterior culdesac, or by ab- normal attachment of the fundus to the anterior abdominal wall. Fig. 192. — Retroversion and Prolapse (Descensus) of the Uterus. Retroposition and retrolocation are terms vaguely used, and may include retroversion, retroflexion, and retrocession. MALPOSITIONS OF THE UTERUS 457 Prolapse of the uterus denotes a permanent descent of the uterus from its physiologic level in the direction of the vaginal introitus. The word descensus describes the condition more accurately, but is not as commonly used. The term "prolapse" relates to all degrees of descent of the uterus until the cervix reaches the vaginal introitus. Procidentia denotes extreme prolapse, and includes all conditions in which the cervix extrudes from the vaginal introitus (Fig. 193). Uterus uii\k£ionpate^ a-rib V osYevvor \\lcM Fig. 193. — Procidentia Showing Elongation and Hypertrophy of the Cervix. Complete procidentia is used to designate the extrusion of the entire organ from the vaginal orifice (Fig. 194). The word "prolapse" is sometimes applied to the vaginal wall. When used in this sense, prolapse of the anterior vaginal wall corresponds to a cystocele, while prolapse of the posterior wall is identical with a rectocele. Torsion of the uterus means a twisting of the body on the cervix in the ver- tical axis. 458 GYNECOLOGY \iaQvT\oA VicxW- NaomolWall Fig. 194. — Complete Procidentia. The entire uterus is outside of the body. Elongation of the uterus means a lengthening of the organ by pressure, tension, or hypertrophy. The elongation may occur in the body, in the cervix, or in both. Inversion of the uterus means a turning inside out of the entire organ. RETROVERSION AND RETROFLEXION Etiology. — We have seen that the uterus during the erect posture lies in a horizontal plane, with the anterior surface resting on the fundus of the bladder, while abdominal pressure is exerted on the posterior uterine surface through the medium of the intestines. In general, the uterus is maintained in its normal forward position by three factors: first, by the proper tone of its anatomic supports; second, by the elas- ticity of its musculature; third, by the abdominal pressure which serves to keep the anterior uterine wall in contact with the bladder. Backward rota- tion of the uterus occurs when these factors cease to exert their proper influence, and this may happen in the following ways: (1) The supporting tissues of the uterus or its own musculature may be- MALPOSITIONS OF THE UTERUS 459 come permanently weakened, so that the fundus sags back from the bladder. This allows the intestines to enter the vesico-uterine space, so that abdominal pressure is now exerted on the anterior surface of the uterus, and serves gradually to force it backward into the posterior culdesac. The weakened supports of the uterus cannot cope with the force of the abdominal pressure and the retroversion becomes permanent. (2) The fundus of the uterus may be forcibly and permanently dragged back by the formation and shrinking of adhesions that form between its poste- rior surface and the rectum and pelvic wall, or by tumors attached to the poste- rior wall. (3) The uterus may be pushed back by various tumor growths. A special fourth type comprises cases where the uterus has developed in the posterior posi- tion. This type, however, would properly be included in the first-mentioned class, as the con- dition is undoubtedly due to a congenital deficiency in the uterine supports or musculature. Each one of these types presents special clinical features, and we shall, therefore, consider them separately. RETROVERSION DUE TO RELAXATION Lax pelvic supports may be acquired by pregnancy and childbirth, or they may be due to a phj^siologic insufficiency of tissue in the suspensory apparatus, or they may result from a combination of both causes. By far the greatest number of retroversions follow child-bearing. The tissues of the uterus and of all its supporting structures are enormously hyper- trophied and stretched during pregnancy. These tissues by normal involution return nearly but not quite to their original form and tonicity. Permanent laxness of these tissues results from an incomplete involution of the parts after the puerperium. This may be brought about by various factors. The impor- tant cause is a congenital insufficiency inherent in the tissues themselves. Indi- viduals differ greatly in respect to the tone, elasticity, and recuperative power of their supporting tissues, as is shown by the fact that some women who have borne many children often show astonishingly little damage to their pelvic supports, while in others only one childbirth may result in the most extreme displacements. In the latter case the patients often present other evidence of deficient tissue-supporting strength, such as enteroptosis, diastasis of the abdominal recti, etc. Rapid and frequent pregnancies may result in permanent laxity of pelvic support even in those naturally endowed with good tissues. The early getting up from child-bed is an occasional factor in the causation of retroversion, but its frequency is probably exaggerated. The social condition of the patient undoubtedly plays an important part. It has been our experience to find displacements following child-bearing far more .frequent among the working class than among the well-to-do. This is only partly explained by the better physical inheritance that the well-to-do in 460 GYNECOLOGY general possess. Other causes are more important. Poor women work hard and continuously during the period of pregnane}^, most of them without efficient abdominal support. The strain of constant severe abdominal pressure neces- sitated by physical work, and unrelieved by proper rest or support, must produce a greater stretching of the pelvic tissues, and therefore results in a more incom- plete involution than is the case in the more fortunate woman who can regulate her life to her condition. Heavy work soon after the puerperium, entailing as it does forcible abdominal pressure, is also a factor. It is possible that lack of nourishment and inter- current disease may have a deleterious effect on the supporting tissues during pregnancy and the puerperium, though it is probable that they do not in the non-pregnant state. Long lactation periods, such as poor women are prone to subject themselves to, maj^ weaken the pelvic structures bj^ means of the local atrophy which overlactation produces in the genital system. Besides the damage that may be done to the uterine supports, we must con- sider also the influence which pregnancy exerts on the musculature of the uterus. It has been shown (Theilhaber) that when the uterus develops into maturity the proportion of muscular tissue to connective tissue in the uterine wall becomes as 3 to 2 instead of 2 to 3. It has also been shown that each pregnancy diminishes the relative amount of muscular fiber. At the menopause the uterus becomes atrophied, chiefly at the expense of the musculature, so that the connective-tissue element again predominates. Repeated pregnancies may by their influence on the musculature cause the uterus to lose its proper tone so that it becomes flaccid. This flaccidity is most apparent at the level of the internal os, so that the body may turn on the cervix as if on a hinge. Such a uterus tends to sag backward away from the bladder in certain positions of the individual, so that the intestines have an opportunity to fall into the utero vesical space, and, by exerting pressure on the anterior wall, gradually to cause a retroflexion. After the menopause the uterus is always in the second degree of retro- version if the physiologic process of atrophj^ takes place normally. This is due to the change in the musculature of the uterine wall. The uterus loses its form of angulation and the body becomes smaller, lighter, and more flaccid. It sags away from the bladder and the intestines enter the uterovesical space. The body of the uterus, however, being small and hght, and the uterine supports being somewhat shrunken, complete retroversion does not take place. The uterus remains straight, with its long axis pointing in the direction of the vagina and Ijdng among the intestines, which act as a cushion both in front and be- hind. It is important to remember, therefore, that retroversion of the senile uterus is physiologic and not pathologic. In nulliparous women lax uterine supports that allow an acquired retro- version are usually the manifestation of a congenital lack of tone in the support- ing tissues. This tendency may be confined to the pelvis, or the pelvic condi- MALPOSITIONS OF THE UTERUS 461 tion may be part of a general lack. of tone seen elsewhere. Women who have ptoses of the various abdominal organs are very apt to have an associated retroversion. On the other hand, some women show the tissue weakness only in relation to the pelvic organs. In the latter case the condition may be one of local infantilism. The mechanism of retroversion in women with congenitally lax tissues is the same as that in women whose supports have been damaged by childbirth, namely, a sagging backward of the uterine body so as to allow the intestines to exert pressure on the anterior surface. Congenital insufficiencj" may, of course, act in combination with pregnancy to produce displacements of the pelvic organs, as we have already seen. The uterus maj' at puberty develop in the position of retroversion, and when this occurs we speak of the condition as congenital retroversion. In infancy and childhood the uterus is always retrocessed and it may be retroverted. Congenital retroversion is, therefore, a phase of infantilism. There are usually other manifestations of infantiUsm in association with retroversion, such as a short anterior wall of the vagina and short uterosacral ligaments. One cause of congenital retroversion is an incomplete descent of the ovary. In these cases the infundibulopelvic ligament is short, and by dragging back- ward on the uterus prevents a normal anteversion. Retrocession may be the result of lax pelvic supports'. We have limited the term "retrocession" to the condition where there is a backward position of the uterus toward the hollow of the sacrum, but where the uterine body retains its anteflexed relation to the cervix. Retrocession may be the result of the injury of childbirth to the supporting tissues, but it is more commonly a manifestation of infantilism, and, as there is nearly always associated with it abnormal ante- flexion, the subject will be discussed under that heading. It should be noted that the relaxation of pelvic supports with consequent permanent retroversion is not the result of ordinary- falls and jars. In a woman with normal pelvic organs nature has provided for accidents of this kind. Un- less a woman has a very full bladder, the sudden increase of abdominal pressure serves only to force the uterus into its normal position. If the bladder is full it is conceivable that the uterus might be forced backward from the bladder by the entrance of the intestines in the uterovesical space. Unless the force is great enough to cause actual destruction of the tissues, the natural elasticity of the uterus and its supports cause it to return immediately to its normal position. It was formerly thought that various forms of acquired displacement, such as retroversion, prolapse, and procidentia, are frequently caused by falls and inju- ries, but it is now known that these conditions are due to the gradual stretching of supports either congenitally weak or damaged by child-bearing. Pathologic Conditions. — The retroverted uterus following child-bearing is usually large, heavy, and congested as a result of obstruction of the circulation. The uterine vessels enter the uterus on the sides at a right angle. Backward 462 GYNECOLOGY rotation of the organ, therefore, causes a torsion in 'these vessels so as partially to obstruct the veins. The circulation from the ovarian vessels is also interfered with by the downward drag of the ovaries and broad ligaments. The enlarge- ment of the uterus is at first due to engorgement, but the chronic state of con- gestion may result in a permanent hypertrophj^ of the uterine wall. The contour of the congested retrofiexed uterus is often somewhat uneven, receiving as it does impressions from the surrounding surfaces in which it is ' embedded, and has a deep purple mottled color. The consistency is softer and less elastic than normal. On restoring a retrofiexed uterus to its proper position during an abdominal operation it is often possible to observe a very marked change take place in a few minutes. The uterine body becomes smaller and firmer, somewhat erectile in consistency, while the surface becomes smooth and of a normal pink color. The endometrium of a retroverted uterus usually shows a permanent hypertrophy which is like that of the phj^siologic phases, but some- what more marked. This is doubtless due to the circulatory disturbance. The circulatory change caused by a retrofiexed uterus is shown also by a dilatation and often a varicosity of the pampiniform plexus of veins in the broad ligament. This condition of the veins is an important factor in the symptomatology of retroversion-fiexion. The ovaries, suspended as they are from the posterior wall of the uterus, share in the retrodisplacement and lie in the lateral culdesacs of the pelvis in a position of so-called prolapse. They are also apt to be affected by the obstructed circulation. The physiologic cystic degeneration of the follicles tends sometimes, though not always, to become exaggerated beyond the normal limits. This change is much more likely to occur if the ovary is immobilized by adhesions. The surfaces of ovaries that have been long prolapsed sometimes become sclerotic, owing to a thickening of the albuginea. The tubes of a retrofiexed uterus often appear swollen and congested, but permanent changes probably do not occur in them unless they become adherent. The question as to whether a long-standing retrofiexion of the uterus may result in traumatic adhesions is one about which there has been a considerable difference of opinion. The earlier writers accepted the possibility and fre- quency of such adhesions almost universally, but at the present time the belief of tjie best authorities is that under ordinary conditions they rarely occur ex- cept as a result of infection. There is no doubt, however, that pressure adhesions on the posterior surface of the uterus may result from improperlj^ fitting pessaries. The question of traumatic adhesions from retroversion is sometimes a matter of considerable importance, especially in the argument of medicolegal cases. In this connection it might be remarked that it is difficult to see why the poste- rior surface of the uterus, lying in contact with the rectum, should become adherent any more readily than does the anterior surface of the uterus in its= normal contact with the bladder. MALPOSITIONS OF THE UTERUS 463 Retroversion of the uterus, as will be emphasized later, is usually the first stage of descensus or prolapse. In fact, it may be said that a retroverted uterus from relaxed supports is always in a greater or less degree of prolapse, a fact which, we shall see later, is of the very greatest importance in relation to the symptomatology and treatment. Sjnnptoms of Retroversion Due to Relaxation. — Some women with even marked degrees of retroversion exhibit no symptoms whatever. This fact has led some to infer that the backward displacement of the uterus is physiologic (Cabot). Such observations are erroneous, for there can be no doubt that the great majority of women with retroversion suffer in some way from the condi- tion. The two most common symptoms directly caused by retroversion are backache and the sense of pelvic pressure. In the analysis of a series of 500 cases of retroversion from all causes the writer found that sacral backache was a definite symptom in 76 per cent. The cause of backache as a result of backward rotation of the uterus has not been satisfactorily explained, and for that reason its existence as a definite symptom of retroversion has been denied (Cabot) . The confusion that has arisen in this subject is partly due to the supposition that retrodisplacements may cause backaches at any level of the spine. It should be remembered that backache from retroversion occurs only in the sacral or very low lumbar region and is always central. Of the fact that retroversion of the uterus does cause backache in this location there is no doubt whatever. The nature of the pain is not entirely characteristic. It is often worse, on exertion or standing. Sometimes it is worse at night. It is often difficult to differentiate it from sacro-iliac or muscular strain. The sense of pelvic pressure may be combined with a sacral backache or it may exist as a sjmaptom by itself. This symptom is the result partly of the increased weight of the uterus, but is chiefly due to its condition of prolapse. It may appear as a definite bearing-down feeling which is increased or brought on by standing, or it may manifest itself as an early state of tire on exertion. The physical exhaustion resulting from retroversion and prolapse has a very important influence on the general health of the patient, and especially on the nervous system. It is the commonest occurrence to see active, athletic, good- tempered women after several childbirths become nervous, irritable, unreason- able, discontented, easily exhausted, and apparently completely changed, both nervously and physically, as a result of the constant pelvic discomfort and weak- ness from retroversion and prolapse. There may be numerous secondary symp- toms that develop from the general nervous disturbance, such as headaches, muscle pains, indigestion, constipation, etc., which are to be regarded as indi- rectly caused by retroversion of the uterus. Patients with retrodisplacement frequently complain of pain in one or both sides. When pelvic inflammation is not present these pains are commonly assigned to the ovaries. Some even speak of an ovarian neuralgia, others ascribe 464 GYNECOLOGY the pain to the cystic degeneration of the ovaries. The pain is probably due usually to the varicose condition of the veins of the broad ligament. Patients with retroversion in about 56 per cent, of cases suffer some dis- turbance of the menstrual function (author's figures). A secondary dysmenor- rhea is often present, manifested by an exaggeration of the symptoms that occur during the intermenstrual period. Thus, backache, pelvic pressure, pain, in the side are increased during catamenia, as are all the nervous and general and constitutional symptoms. Patients with congenital retroflexion usually suffer from essential dysmenor- rhea, the pain often being located in the back instead of in the abdomen. True dysmenorrhea is more common in backward displacements when there is also flexion. Abnormalities in the menstrual flow are not infrequent, though not constant. Owing to the obstruction of the circulation and the permanent hypertrophy of the endometrium that are common in the retroverted uterus, various degrees of menorrhagia are encountered. Irregularity in the time of the intermenstrual periods is apt to exist, the irregularity consisting usually in a too frequent incidence of the menses. Leukorrhea is often present as a result of a hypersecretion of the congested endometrium. Constipation is present in about 51 per cent, of cases (author's figures). This may possibly be due to partial obstruction of the rectal lumen, but it is more probable that the pressure of the uterine body on the wall of the rectum interferes with the normal muscular movements of the gut, thus diminishing its expulsive force. Retroversion is said to cause symptoms of irritable bladder by a backward pull on the bladder wall. This is probably not true. The bladder is an extra- ordinarily adaptable organ, and when one considers abnormal positions in which it can be placed without symptoms during various reconstructive operations it is difficult to believe that the slight traction exerted by a retroposed uterus could cause definite symptoms of irritability. Irritable bladder is frequently caused by childbirth, and may thus be associated later with a retroversion, without causal relation between the two conditions. Retroversion is a not uncommon cause of abortion. This may be due to the permanent hypertrophy of the endometrium, which offers a poor soil for the growth of the ovum, or it may possibly be referred to the imperfect circulation of the maternal blood through the uterus. Impaction of the pregnant uterus in the pelvis may cause abortion as a result of interference with the growth of the uterine musculature. Women with retroversion are apt to be sterile, especially those in whom the retroversion is due to congenitally weak supports. In women with retroversion acquired from childbirth the sterility, if present, is probably the result of the displacement of the cervix which no longer dips into the receptaculum seminis. In women with naturally insufficie^ supporting MALPOSITIONS OF THE UTERUS 465 tissue the same cause may act, but there are also apt to be other manifestations of infantiUsm which may combine to prevent fertility. (See Sterility.) The diagnosis of retroversion and retroversion-flexion is usually a simple matter, and skill can be acquired with comparatively short experience. If the touch is gentle, so as not to cause pain and resistance on the part of the patient, it is rarely necessary to use an anesthetic. The method of using a uterine sound or probe is obsolete, unsurgical, and dangerous. Examination is much more accurate with the patient on a table than on a bed. It is very important that the bladder should be emptied immediately before the examination, as a full bladder may cause a considerable degree of backward rotation. The position of the uterus can be diagnosed entirely by bimanual examination, inspection of the cervix giving no additional evidence of value. Retroversion of the first degree is determined by the external hand on the abdomen, which feels the fundus pointing away from the bladder. In retroversion of the second degree the fundus of the uterus cannot be felt either by the abdominal hand or b}' the internal vaginal finger. The cervix is found pointing in the direction of the long axis of the vagina. In retroversion of the third degree the posterior wall of the uterus can be felt by the vaginal finger dipping backward into the culdesac of Douglas. If there is retroflexion the angle between body and cervix is readily felt. In third degree retroversion and flexion the cervix points either in the direction of the axis of the vagina or forward toward the anterior vaginal wall. One of the commonest errors in diagnosis is to mistake an anteflexion with retrocession for retroversion. The cervix of anteflexion points in the same direction as that of a retroversion, and as the posterior wall of the cervix in these cases is often abnormally long it may be mistaken for the posterior wall of the uterus. The error is still further facihtated by the fact that when ante- flexion and retrocession are present the fundus, though pointing forward in its relation to the cervix, cannot always be felt by the external abdominal hand. The anterior angle between the fundus and cervix, however, can always be made out by the vaginal finger feeling along the anterior cervical wall. If this pre- caution be taken the mistake need never be made. If the hymen is very tight it is sometimes necessary to make a bimanual rectal examination. This requires more skill than.dops a vaginal examination. With the finger in the rectum the cervix feels very much larger than it does per vaginam, and it is frequently diagnosed as a pelvic tumor by the inexpert. With the finger in the rectum the uterus can be perfectly well felt bimanualh^, but, on account of the indistinctness with which the cervix is felt, it is sometimes difficult to tell which is the fundus and which is the cervix. One is, therefore, sometimes in doubt after rectal examination whether the uterus is in the normal position of anteversion or in the third degree of retroversion-flexion. The fundus of a large uterus sharply retroflexed is often mistaken for a myoma growing centrally on the posterior wall, and vice versa. 30 466 GYNECOLOGY Treatment. — When a retroverted uterus causes no symptoms there is no need of treating it. When a retroverted uterus gives no symptoms, but there is an associated sterihty or tendency to abortion, treatment is indicated. When retroversion definitely causes symptoms, treatment is advisable. The treatment of retroversion due to relaxation consists in restoring the uterus to its normal position, and this can be done by orthopedic or surgical measures. Orthopedic measures comprise the various forms of rings and pes- saries apphed in the vagina to support the uterus from below, while surgical treatment includes numerous operative procedures for suspending the uterus from above. Pessaries are of considerable value in the treatment of retrodisplacements with prolapse, but for uncomplicated retroversion they have only a Hmited field of usefulness, excepting as a temporary palhative measure. Occasionally women wear pessaries for years without discomfort, but, as a rule, they become a source of annoyance in a comparatively short time. They require constant attention in order to keep them clean, and even when properly cared for cause a mild vaginal irritation. If they are neglected or if they fit improperly, they may cause severe ulceration and vaginitis. The long-continued wearing of a pessary acts as a nervous irritant, and patients with a tendency to pelvic neuroses are made worse by their use. Pessaries keep the uterus forward by pressure on the posterior wall of the cervix near the internal os. If the tone of the musculature has been damaged, so that the uterus is retroflexed, the pessary exerts its force directly at the point of flexion, and consequently aggravates the condition. Pessaries should never be used, therefore, when retroflexion is present. Pessaries are most valuable in treating retroversion during the early months of pregnancy and immediately after the puerperium. A lax retroverted uterus that becomes pregnant is in serious danger of aborting. Such a position produces pelvic pressure and is a frequent cause of so-cafled reflex vomiting. The apphca- tion of a pessary which holds the uterus in its normal position until the fourth month, when it rides above the pelvis, will often avert the danger of abortion and relieve the symptoms of pressure and nausea. If after the puerperium it is found that the uterus is subinvoluted and tends to sag backward, a permanent retroversion may often be prevented by the use of a pessary until the uterus attains a normal size and consistency. For most cases of retroversion that give symptoms surgical treatment is the most satisfactory. At the present day this usually involves opening the abdomen and employing one of the many methods devised for maintaining the uterus in its forward position.. The technical details of the best of these operations are described in the section on Surgery. We shall discuss here some of the principles underlying those operations. In the days when opening the abdominal cavity was a dangerous procedure the Alexander operation was MALPOSITIONS OF THE UTERUS 467 devised. This consists in exposing the inguinal canals by two incisions and drawing on the round ligaments until the uterus is brought to a forward position. The slack of the round ligaments is either removed or sewed in the inguinal wounds. By this operation the abdominal cavity need not be opened and the danger of peritonitis is avoided. It is also a safe procedure with reference to future childbirth. The operation at present is comparatively httle used in this country, as it has numerous disadvantages. It is often difficult to find the ligaments in the inguinal canals; small undeveloped ligaments break off easily during the process of drawing them out of the abdomen; if undetected pelvic adhesions exist, the operation is entirely nullified; it is impossible adequately to inspect the pelvic organs, and, most important of all, the percentage of recurrence is very high as compared with that of other operations. Abdominal operations consist of various surgical devices by which either the uterus is attached to the anterior abdominal wall or its hgaments are em- ployed so as to provide a new and artificial support. Operations for attaching the uterus bodily to the anterior abdominal wall are called ventral suspension and ventral fixation. These two terms are some- what vaguely used, but at the time when the operations were popular ventral suspension implied that the uterus was sewed to the peritoneum only, while fixation meant that the supporting sutures passed through peritoneum, muscle, and fascia. The first of these operations often resulted in drawing the perito- neum out into long filiform bands, and has been entirely discarded. The second operation of fixation, when thoroughly done, resulted in too firm an adhesion of the uterus to the abdominal wall, causing symptoms of local discomfort and occasional dystocia. This operation has also been given up except in some cases of prolapse in women beyond the child-bearing period. Another type of operation comprises the principle, introduced by Gilliam, of drawing a loop of each broad hgament through the abdominal wall at some point. The number of modifications of this operation is very great, as will be seen by referring to the section on Surgery, where the details of the most im- portant are described. Operations performed by the Gilliam method are very efficient in maintaining the position of the uterus, the percentage of recurrences being almost negligible even after childbirth. There are some objections to the operation. It is not always possible to control exactly the position of the uterus on account of the variation in the site of the natural attachment of the round ligaments to the uterus. If the attachment is low, drawing the liga- ments tightly through the abdominal wall faces the uterus too much toward th'e abdominal wall, and causes a retrofiexion of the body at the same time. This position is too far from the normal and sometimes gives trouble. If the uterus is drawn up too tightty, as it is liable to be by this operation, the ovaries and tubes are brought to too high a level, and may become involved in postoperative adhesions near the abdominal wall. The operation is also liable to result in 468 GYNECOLOGY creating a diaphragm across the pelvis consisting of uterus and broad ligaments. This has been known to result in serious dystocia. Another type of operation has for its principle the reduplication of the sup- porting ligaments without making artificial suspensory attachments. The earliest of these operations consisted in a simple reduplication of the round ligaments. The principle of this operation is hke that of Alexander's, except that the shortening of the ligaments is done intra-abdominally. This method of support is extremely inefficient, and is followed by a large percentage of recurrences. A more efficient operation of this type is the so-called "Webster- Baldy operation," by which the round ligaments are drawn backward through an artificial opening in the broad ligaments and attached to each other on the posterior wall of the uterus. This brings the uterus into a more nearly normal position than does any other operation yet devised, and is indicated in many cases of uncomplicated retroversion. If, however, there is much prolapse or the uterus is heavy, or there is liability of postoperative adhesions, the results of this operation are not uniformly good. Another operation of the reduplicating type is that devised by Coffey, by which the broad ligaments are folded in together in front of the uterus. The results of this operation are not entirely satisfactory and it has a limited field of usefulness. The operation, suggested many years ago bj^ Olshausen, is one of 'the simplest and most efficacious of all the various procedures, and is applicable to all forms of retrodisplacement. By this operation a single ligature is passed around each round ligament, near the uterus and through the peritoneum, rectus muscle, and fascia. The ligatures are tied very tightly, so as to create a small ligamentous adhesion between the round ligament and the abdominal wall. By varying the distance of the ligature from the uterine body and the point of attachment on the abdominaFwall the desired position of the uterus can be exactly determined. The results of this operation if properly done- are almost constant, and the dis- advantages mentioned in reference to the other operations are practically ob- viated. The operation is also applicable to conditions of prolapse excepting severe procidentia. The results as regards child-bearing are most satisfactory. In all operations in which the uterus is suspended from the abdominal wall, except in Sim.pson's and Mayo's modification of the Gilliam method, the possibility of intestinal obstruction cannot be absolutely ruled out. If the opera- tions are properly performed the possibility is exceedingly remote, except in the now obsolete ventral suspension, with its resultant filiform band. Some prefer reposition of the uterus by the vaginal route. A method for vaginal fixation is described in Part III. RETROVERSION DUE TO ADHESIONS Adherent retroversion is a result of pelvic peritonitis, the most common causes of which are gonorrhea, puerperal infection, and tuberculosis. An addi- tional cause is the pelvic extension from an acute appendicitis, especially when MALPOSITIONS OF THE UTERUS 469 the attack occurs in young girls. Retracting adhesions may also be due to improperly fitting pessaries. As has already been explained, the exudate of a pelvic peritonitis settles by gravity in the posterior culdesac, and the drying and organization of the exudate results in adhesions of the posterior surfaces of the uterus and adnexa. The shrinking of these adhesions draws the uterus back- ward into the position of retroversion or flexion. Adherent retroversion differs from the retroversion of relaxation in that there is, as a rule, no descensus or prolapse. In fact, the uterus is held more or less rigidly at its normal level by the pelvic adhesions. This fact, as we shall see later, is a matter of clinical importance. The pathologic anatomy of adherent retroversion is that of pelvic inflam- mation, and has already been described in the section devoted to that subject. The diagnosis of adherent retroversion is not always an easy matter. When an obvious inflammation of the adnexa is present, it is known that the retro- verted uterus must share in the general inflammatory process, and is, therefore, probably adherent. It may be that the inflammation of the adnexa has sub- sided to such an extent that they cannot be palpated. In this case it is diffi- cult to differentiate an adherent retroversion from an impacted non-adherent retroversion. Sometimes the uterus becomes attached to the rectum in such a way as to allow considerable mobility, even to the extent that the displacement may be partially reduced by bimanual examination. Under these circumstances an error in diagnosis may readily be made, and such an error might be more or less serious if Alexander's operation or the application of a pessary were being contemplated. When no evidence of adnexal disease is made out, the presence of adhesions can usually be detected by the pain that is elicited when the uterus is drawn away from the rectum by the examining finger placed behind the cervix. The symptomatology of adherent retroversion is identical with that of pelvic inflammation. Backache and pelvic pressure symptoms are less pro- nounced than in retroversion from relaxation, because, as a rule, there is little or no descensus of the uterus. The treatment of adherent retroversion is included in that of pelvic inflam- mation. In choosing the best method of replacing the uterus one must consider the possible effect of postoperative adhesions. Operations of the reduplicating type, such as Coffey's and Baldy's, do not lift the uterus sufficiently away from the posterior culdesac, so that adhesions more readily form. Moreover, these operations do not give sufficient supporting power to insure resistance against the contraction of new adhesions. Experience has shown that operations of the GilHam type, performed for adherent retroversion, are sometimes followed by very extensive adhesions. The most satisfactory operation for the avoidance of troublesome postopera- tive adhesions is Olshausen's anterior fixation of the round ligaments. 470 GYNECOLOGY RETROVERSION DUE TO DISPLACEMENT BY TUMORS The uterus is less commonly displaced backward by tumors, for the majority of pelvic tumors lie in the posterior culdesac and tend to force the uterus up- ward and forward. Pedunculated fibroids growing from the anterior uterine wall may cause retroversion, as may ovarian tumors with long pedicles which occasionally rest in the uterovesical space. On rare occasions pus-tubes become adherent to the anterior wall and force the uterus backward as they develop. A uterus that has been forced back by a tumor will sometimes spring back spontaneously to its normal position after removal of the tumor, even when the displacement has been maintained for a considerable length of time. As a rule, however, the retroversion is permanent, and the removal of tumors that dislocate the uterus should always be followed by a proper supporting opera- tion. PROLAPSE AND PROCIDENTIA PROLAPSE Prolapse of the uterus is usually a second phase of retroversion as a result of relaxation, and its causes are the same, namely, child-bearing and physiologic insufficiency of tissues. Occasionally prolapse is the result of downward pres- sure from an abdominal tumor or from ascites. In the very great majority of cases, however, prolapse is the result of child-bearing, and is far more frequent than is commonly supposed. It is almost constantly associated to a greater or less degree with vaginal relaxation, and is a factor to be reckoned with in all reconstructive surgery for the repair of injuries due to childbirth. As has been stated in the definition, prolapse relates to all forms of descensus from the normal level of the uterus to a point where the cervix reaches the vaginal introitus. Under normal conditions the uterus possesses some mobility in the direction of the pelvic outlet, and under the influence of forced abdominal pressure there is a certain amount of physiologic descensus. The uterus, how- ever, should return immediately to its normal position after release of the ab- dominal pressure. The normal excursion of the uterus varies somewhat in individuals. Descensus is pathologic when it exceeds the normal Hmits, or where, after the continued abdominal pressure of standing, walking, working, etc., the uterus does not return to its physiologic level. Prolapse is in most cases associated with retroversion, to which it is a second- ary stage in the process of pelvic relaxation. It may, however, exist with the body of the uterus in the forward position. The entire uterus may sag downward toward the pelvic outlet without changing the direction of its craniocaudal axis, or the fundus may remain in normal position while the cervix swings forward toward the bladder. The latter condition is due to abnormally lax uterosacral MALPOSITIONS OF THE UTERUS 471 ligaments. This form of prolapse may occur after an anterior suspension of the uterus. Prolapse is associated with most cases of relaxation of the vaginal walls, especially with the anterior wall, for, on account, of the intimate attachment of the bladder to the cervix, prolapse naturally drags the bladder down with it and favors the formation of a cystocele. Per contra, the presence of a cystocele usually indicates an associated prolapse. However, the two conditions do not Cvv^ocele. lbfc<,)[vv-\uinQ'' ^^^.Sxcx\j«:s vxvcv wx- FiG. 195. — Retroversion and Descensus of the Uterus Toward the Vaginal Orifice. The vaginal walls are relaxed, with prolapse of bladder and rectum (cystocele and rectocele). necessarily go hand in hand, for cystocele is occasionally found without pro- lapse, especially when it occurs in nulliparous women. Prolapse may be present with anteflexion in those cases in which the ante- flexion exists in combination with retrocession. In fact, retrocession implies a certain degree of prolapse. This subject will be discussed under the heading of Anteflexion. Diagnosis. — The existence of a prolapse is often sufficiently evident from a history of pelvic pressure, especially if the symptoms date from childbirth, , The diagnosis is made in the dorsal position by placing the examining finger on 472 GYNECOLOGY the cervix and requesting the patient to bear down, as in the act of defecation, when the downward excursion of the uterus may be noted. It is sometimes difficult to get a patient to exert abdominal pressure in this way, and it is then necessary to make the examination with the patient in the standing position. In both tests there may be an error, for the amount of prolapse in the same patient is not always constant. After fatigue from long standing the uterus may be several degrees lower than after rest in bed. It is important to know the lowest point to which the uterus may descend. Another error is sometimes made in examining a patient from whom a pessary has just been removed, for the prolapse may not become evident until the patient has been about on her feet for some time. Very often the full extent of the prolapse is not apparent until the patient is anesthetized and the cervix is drawn downward toward the vaginal outlet. In determining the degree of prolapse with the patient under anesthesia it is important to be familiar with the amount of downward traction that the normal uterus will undergo. This varies in different women and is sometimes con- siderable.. Symptoms. — The symptomatology of prolapse has already been described under Retroversion, for it is the descensus which almost necessarily accompanies retroversion that causes the most important symptom, pelvic pressure, with its train of nervous and constitutional complaints. The severity of the pressure symptoms does not necessarily correspond to the amount of prolapse, for some women with very marked descensus, even to the degree of procidentia, suffer little or no discomfort, while in others very moderate prolapse may cause distressing results. These, how^ever, are the ex- ceptions, and, as a rule, the relationship between the symptomatology and the anatomic position of the uterus is fairly constant. It is important to remember that in patients suffering from the lacerations of childbirth the symptoms of pelvic pressure and weakness are due chieflj^ to the descent of the uterus and not to the tears of the cervix and perineum. This significant fact is referred to again under the subject of Lacerations. Treatment. — Prolapse of the uterus may be treated palliatively ^dth vaginal supports or radically by surgical operation. The application of vaginal tampons gives temporary relief, but the long- continued use of tampons is undesirable. In prolapse pessaries have a wider field of usefulness than in uncomplicated retroversion. They are of especial advantage in treating elderly women with uterine atrophy, in whom there is some contra-indication to surgical operation. In prolapse of the pregnant uterus pessaries are an absolute necessity. In women of the child-bearing period who wish more children before going through a radical reconstructive operation they are also valuable. Pessaries relieve prolapse by sustaining the vault of the vagina and by stretching out the vaginal walls so as to take up the slack caused by their relaxa- MALPOSITIONS OF THE UTERUS 473 tion. The counter-support of the pessary is against the two columns of the arch of the pubes. If the pessary causes a retroflexion of the uterus this form of treatment is contra-indicated. In women after the menopause with genital atrophy the uterus gives no trouble, for it is not large or heavy enough to become retro- flexed over the upper pole of the support. Pessaries are, therefore, much more appUcable to elderly women than during the child-bearing period. In using pessaries after the menopause it is important to pay special attention to cleanhness by douching and occasionally removing and scrubbing the pessary. The senile vaginal membrane is thin, easily excoriated, and prone to plastic inflammation, and pessaries are apt to become covered with irritating incrusta- tions deposited from the vaginal secretions. It is best when possible to use hard-rubber pessaries, especially in elderly women, as the soft-rubber varieties become very foul even with careful attention. Moderate degrees of prolapse are sometimes spontaneously cured by atrophy and shrinking of the parts after the menopause. This spontaneous cure is, however, not to be rehed upon, for more often the symptoms of prolapse are increased after the menopause is estabUshed. Surgical Treatment.— When surgery is feasible, operative measures for pro- lapse are usually to be recommended, for in this way alone can the patient be radically cured. As prolapse is usually one of several manifestations of damage done by child-bearing, its treatment is in most cases only one of several proced- ures, each one of which is necessary for the complete cure of the patient. One or more of the foUoAving conditions may be present : lacerated cervix, cystocele, lacerated perineum, and diastasis of the abdominal recti muscles. Of all these, prolapse is the most important, for it is conducive of the most serious symptoms. The methods of treating the other injuries of childbirth are referred to else- where. Surgical measures for treating the prolapsed uterus are extremely numerous. They may be divided into vaginal operations which seek to build up a support from below, and abdominal operations by which the uterus is restored to position by some form of artificial suspension. Vaginal operations, in general, are less efficacious than those of the abdominal type. The abdominal operations for prolapse are, for the most part, identical with those for retroversion. It should be remembered, however, in operating for prolapse that the operation must not only serve to keep the uterus forward in anteversion, but that the suspension must take the place of the lost strength of the pelvic diaphragm, and must, therefore, be capable of sustaining the weight of the pelvic organs and resisting abdominal pressure. Some of the operations recommended for retroversion are not always to be rehed upon for prolapse. The operations of the reduplicating type (Wjdie's, Coffey's, Baldy's) have not sufficient sustaining power, and are unreliable if the uterus is heavy or if the prolapse is marked. The operations of the Gilliam type are efficacious in suspensory power, but 474 GYNECOLOGY do not control sufficiently well the position of the uterus, for by these operations the uterine body is apt to be faced toward the abdominal wall and the cervix tilted forward toward the pubes. The best operation in our experience is that of the Olshausen type. The suspensory effect of the artificial adhesions created by this operation can be very accurately regulated. If the uterus is large and heavy or there is marked prolapse, a more powerful attachment is gained by passing the ligatures through the bases of the round ligaments, even including the uterine tissue itself. The size and streng-th of the artificial adhesions may be governed by the amount of contiguous peritoneal surfaces included in the hgatures, while the amount of reduction of the prolapse can be regulated by the point of attachment on the anterior abdominal wall. By attaching the uterus sufficiently high on the abdominal wall the tendency of the cervix to s^ving forward is usually overcome, especially if the operation for cystocele, described on page 608, is performed at the same time. It is occa- sionally necessary to shorten the uterosacral Hgaments to prevent the forward sag of the cervix. In some cases of prolapse suspension of the uterus to the abdominal wall is not symptomatically successful. These are the cases of large permanently hypertrophied uteri, associated with thin, flabby abdominal wall and diastasis of the recti muscles. The weight of such a uterus from its new attachment causes symptoms even more troublesome than did the preceding prolapse. In this type of case the interposition operation of Watkins and others is applic- able. We, however, would prefer to remove the uterus, employing the technic recommended for operations for procidentia (see page 696). Patients with this type of prolapse are usually multiparous worn-out women, to whom the removal of the uterus is a blessing. The question of operating on women with prolapse who are hkely to have more children is one which the surgeon has frequently to meet. This must be decided chiefly on the ground of the severity of the sjmiptoms. Where there is much disability or great nervous disturbance it is best to advise operation, even at the risk of a later pregnancy and the possible chance of another operation for lacerations. If the operation for prolapse is done properly the patient can be assured the chances of dystocia, or recurrence of the prolapse after childbirth, are exceedingly small. She should, however, be told that there can be no guarantee against new lacerations of the cervix or perineum. If symptoms are not too severe, and there is reasonable expectation of an early pregnancy, the patient should be treated palliatively and operation deferred. The question of operation sometimes arises where there is considerable pro- lapse, but no symptoms. If it is apparent that the condition is hkely to get worse, operation is advisable. If the prolapse seems to have reached its hmit, the deci- sion must be conservative. Judgment as to the future outcome of a given case is only gained by experience. MALPOSITIONS OF THE UTERUS 475 PROCIDENTIA Procidentia, as we have defined it, relates to an extreme degree of prolapse, and is applied to the condition in which the cervix extrudes from the vaginal introitus. It may seem somewhat arbitrary to make a sharp distinction between partial prolapse and procidentia, as they are different stages of the same process. The distinction, however, is convenient, as there are definite clinical differences between the two conditions. Fig. 196. — Procidentia. Elongated cervix ulcerated. (Drawn after an illustration by Watkins.) Procidentia, though it may occur at any age from twenty-five on, is more commonly an affliction of middle or later life. It is, as a rule, very gradually developed, the condition being accelerated by the physiologic weakening of the pelvic supports that occurs at and after the menopause. Rarely it may be seen in young women a few months after labor. The change from prolapse to procidentia — i. e., the protrusion of the cervical orifice beyond the vaginal introitus — sometimes gives the patient the impression 476 GYNECOLOGY that the condition has developed suddenly, especially if the prolapse has not been noticed or if the perineum has been sufficiently small to obstruct tempo- rarily the onward progress of the down-coming cervix. It should be remem- bered, however, that the presence of a procidentia indicates a gradual and usually slow progress. It is not brought on suddenly from a normal condition by falls, jars, and other forms of traumatism. The existence and extent of procidentia are not necessarily dependent on the number of labors through which the patient has passed, but rather on the individual character of the pelvic supporting tissues. It is a noticeable fact that Fig. 197. — Procidentia. Typical Case. the mothers of very large famihes often suffer very little damage from their repeated labors, while other women, with a very limited number of childbirths, may exhibit extreme relaxation. Congenital procidentia is a term somewhat improperly applied to nulhparous women who develop the condition. It is implied that there exists a congenital- tissue deficiency in the pelvic supports, but not that the procidentia appears in infancy. It may come to notice in comparatively young women, often not until the approach of or even after the menopause. In the congenital type the descent represents chiefly a continued elongation of the cervix. As there have MALPOSITIONS OF THE UTERUS 477 been no previous lacerations, cystocele, rectocele, and hypertrophy of the cervix are less marked than in the ordinary procidentia that results from childbirth. The extrusion of the cervix in procidentia is in most cases primarily due to its elongation. This lengthening process of the cervix occurs in nearly all cases of marked prolapse, and is probably brought about by the effect of abdominal pressure on the bladder, which, by its attachment to the cervix, gradually draws the cervix out into an attenuated cord. The cervix may reach the length of 4 or 5 inches, and can be felt by rolling the extruding mass between the thumb and forefinger. The external end of the cervix usually becomes hypertrophied, some- times to a great extent. The lower extremity of the bladder averages from I to 1 inch from the border of the anterior lip of the cervix and represents a large diverticular pouch. Behind the cervix is another pouch, which is the prolapsed culdesac of Douglas. Rectocele may or may not be present, but usually is to some extent. The levator ani muscles are always widely separated, and usually atrophied as a result of the wedge-like pressure of the extruding mass. The vaginal membrane covering the extruded parts attains a characteristic dry, cornified surface. On the cervical lips and sometimes on other portions of the mass are often seen decubitus ulcers with sharply defined edges and granulating surfaces covered with yellowish sloughs. To one unaccustomed to the appearance of procidentia a severe case with ulcerations is an alarming sight, and many times the diagnosis of malignant disease is made. It should be remembered, however, that notwithstanding the traumatism the cervix receives, procidentia rarely results in carcinoma. As a rule, the fundus of the uterus does not extrude from the vaginal outlet, the increase in the length of the procidentia being due to the gradual elongation of the cervix. Occasionally the entire body of the uterus with its appendages may be included in the mass (Fig. 194). An important feature of the pathologic anatomy of procidentia is the separa- tion 'Of the vaginal wall from its attachments to the rami of the pubes. Tjiese attachments are a very important element in the snp'po.rt of the uterus, and the amount oi descensus of the uterus depends chiefly on the degree of their separa- tion. In extreme form's of procidentia the vagina is cojnpletely detached from the pubic rami, a point of significance in the matter of treatment. A special form of procidentia is that which results from an improperly performed hysterectomy, by which the vault of the vagina is not adequately suspended. This may follow either a supravaginal or complete hysterectomy, but is more frequently seen after the latter. In this form of procidentia the vagina is turned inside out, the bladder coming down with the anterior wall. The diagnosis of procidentia is usually perfectly obvious. It should rarely be confused with cancer, but if the ulcerations are at all suspicious a specimen should always be removed and examined microscopically. It is of the utmost importance to reduce the procidentia and make a bimanual examination, as the condition may be caused either by pregnancy or a pelvic tumor or by ascites. 478 GYNECOLOGY Symptoms. — As has been stated before, the symptomatology of prolapse of the uterus is not always proportionate to the amount of descensus of the uterus, and this is noticeable in procidentia, for some women with very marked falling of the womb have astonishingly little disturbance beyond the discomfort of the prolapsed mass between the thighs. Many women will endure a procidentia for years without complaint. Just why some patients with moderate grades of prolapse often suffer greater sense of pressure and more serious nervous reaction than do some with extreme descensus has not been entirety explained. No doubt the personal -equation is an important element, for it is a matter of common observation that 'women who go for years with a procidentia without impairment of their normal activities- are of the strong self-reliant type, while those in whom moderate prolapse pro- duces serious symptoms can usually be shown to be naturally of unstable phys- ical and nervous equilibrium. On the other hand, the suffering from procidentia may be extreme, and patients are sometimes entirely incapacitated, even from walking. Nervous manifestations may be severe, even to the point of insanity, especially in cases of procidentia following hysterectomy. In the latter class the psychic element result- ing from disappointment at the failure of the operation plays a significant part. Urinary symptoms are common owing to inability completely to evacuate the bladder. Constipation is also frequently present, especially if there is a rectocele. Sometimes neither the act of urination nor -of defecation can be accomplished without manual reduction of the prolapsed parts. Bleeding and a foul -discharge may result from the ulceration of the 'surface, and are signs which often lead to the diagnosis of cancer. The treatment of procidentia is either palliative or surgical. As procidentia often occurs in elderly or aged women in whom a surgical operation might be dangerous, palliative treatment is not infrequ-ently indicated. This consists chiefly in the use of various form^ of pessaries and uterine stipports. Hard- rubber pessaries are the best to use if they can be fitted properly. The particu- lar form of pessary can only be determined by trial. The -soft-rubber doughnut pessaries become foul very quickly, but sometimes it is necessary to use them. Many cases of procidentia cannot be kept reduced by any of the pessaries in common use. This is particularly true ivhen the vaginal walls roll out in voluminous folds, carrying the pessary with them; so that there is no oppor- tunity for it to engage behind the pubic arcK. The only support which can hold up such a uterus is the cup-pessary, fitted with a stem and harness. This type is uncomfortable and almost sure to cause ulceration, and should rarely be employed. Some women are able to keep fairly comfortable by wearing a very tight perineal bandage with a supporting pad. At the present day surgical treatment is much more successful than formerly. Most cases can be completely cured by operative methods, while all cases can be assured of rehef. The results of surgery are so satisfactory that operation. MALPOSITIONS OF THE UTERUS 479 should always be advised except when there is some strong contra-indication in the patient's general health. There are numerous excellent operations for procidentia. Every gjTie- cologic surgeon of experience has his individual technic, and it would be impos- sible in this w^ork to include all the various methods that give good results. Several of the operations in common use are described in detail in the section on Surgical Technic. It may be said, in general, that the best operations now used can be divided into two classes — those that emploj^ the interposition prin- ciple, and those that depend on artificial suspension from the abdomen. B}^ "interposition" is meant the separation of the uterus from the bladder, rotating the fundus far forward, and stitching the bladder on the posterior surface of the uterus. The uterus thus acts as a support to the bladder, reducing the cystocele. The operation is described in detail on page 699. To Dr. Watkins, of Chicago, is due the chief credit of this operation. The principle is extensively used in the European clinics and it has many adherents in this country. Those who use the operation report excellent results. The principle of suspension is also widely used in this countrj'-, though in its use there is a great variety of technic. The author favors this principle, and a detailed description of the operation used by him is given on page 696. This operation involves, first, an amputation of the elongated cervix, plastic repair of the cystocele, and repair of the relaxed perineum. The second part of the operation consists in performing a supravaginal hysterectomy, attaching the remaining cervical stump to the broad ligaments, interposing the cervical stump under the bladder, and then attaching it to the anterior abdominal waU. Other operations described in the section on Technic are those recommended, by Goffe, Baldy, Crile, Mayo, etc. The operative methods thus far referred to practically preclude a later pregnancy, though some cases of successful childbirth have been reported fol- lowing the interposition operation. Procidentia may occur in comparative!}^ young women who wish more children. These patients can be greatly relieved by the performance of an operation similar to that recommended for partial prolapse, and yet be left in a condition in which the danger of serious dystocia is practically absent. The operation, as already noted, consists of plastic repair of the cervix, anterior wall, and perineum, together with a suspension of the uterus, preferably by the Olshausen method. The cervix is not so apt to be elongated in younger women, but it may be. If it is necessary to amputate it, the operation of Hegar (described on page 599) is the best to emplo}', as by this method exact approximation can be attained with first-intention healing. It is of great importance to avoid the formation of scar-tissue, which may serve either to prevent impregnation or, if conception does take place, to interfere seriously' with childbirth. 480 GYNECOLOGY ANTEFLEXION The uterus is normally anteflexed at the junction of the cervix and fundus. The term "anteflexion," however, is commonly used to denote an abnormally sharp angulation. It is difficult to state precisely the limit of normal ante- flexion, for what may be normal in one individual might be abnormal in another. It is usually stated that if the angle between cervix and body is less than 90 degrees it is pathologic. The angle may be so acute that the fundus and cervix are nearly parallel. The cervix is usually abnormally long, and may equal or even exceed the length of the fundus. The uterus may acquire anteflexion by the pressure of overlying tumors, by contracting adhesions, or by relaxed supports. The first of these causes is not common. Contracting adhesions may produce anteflexion bj^ forming on the anterior wall and drawing the fundus forward, or they may form on the posterior wall and draw the center of the uterus backward, while the fundus is held forward by its ligaments. Adhesions are a rare cause. Eelaxation of the uterine supports sometimes acts in such a way as to allow the uterus to sag back in i-tetrocession, the fundus, however, being held forward by the round hgaments. This is quite common. In the greatest number of cases anteflexion is the result of a faulty development, and is usually associated with other defects in the uterus. The typical anteflexed uterus is hypoplastic and the cervix is long and conical. The uterus, as a whole, in most cases lies abnormally far back in the hollow of the sacrum, in the position already described as that of retroces- sion. The cervix points either in the direction of the vaginal axis, or forward toward the. anterior vaginal wall. This form and position of the uterus is that which is normally found before puberty. The condition is, therefore, one of infantilism. Other evidences of hypoplasia are also frequently found, as a short anterior or posterio-r vaginal wall, short uterosacral ligaments, infantile type of ovaries, etc. Besides the local hypoplasia of the pelvic organs the individual may exhibit evidences of infantihsm in many parts of her physical make-up. On the other hand, the deficient development may appear only in the pelvic organs of an individual otherwise fulh' matured. In the severe cases of anteflexion there is usually to be found at the internal OS a cicatricial thickening which produces a certain amount of stenosis of the canal. This occurs more often on the posterior wall, but may be on the anterior, or it may involve the entire circumference as an annular constricting band. The signiflcance of this process is discussed elsewhere. The small anteflexed uterus feels, on examination, to be rather firm and unyielding, but when the patient is anesthetized it is found to be softer and more flaccid and with less erectile power than the normal uterus under like conditions. This would indicate a deficiency in the musculature. This is another evidence MALPOSITIONS OF THE UTERUS 481 of infantilism, for it is known that in the uterus before puberty the connective tissue predominates over the muscular tissue, whereas in the properly developed uterus the reverse is true. Symptoms. — Anteflexion may exist without symptoms, but it is usually associated with either dysmenorrhea or sterility, or both. There seems to be no doubt that these symptoms are in some way the mechanical result of the angulation and constriction of the uterine canal, but just how they are pro- duced has not yet been satisfactorily explained. The relationship of ante- flexion to dysmenorrhea and sterility is dwelt on in the sections on those sub- jects. The retrocession of the uterus commonly met with in anteflexion often produces symptoms identical with those from retroversion, and for the same reason. In fact, the cervix, both in retroversion and retroflexion, is practically in the same position. Hence it is that patients with anteflexion often complain of backache and pain in the sides of the pelvis, the latter symptom being due to stasis of the vems in the broad ligament. It has been our experience that patients with anteflexion are especially prone to chronic appendicitis, but no adequate explanation of this can be given. Women in whom anteflexion produces dysmenorrhea nearly always have an unstable nervous equilibrium. (See Dysmenorrhea and section on Neurology.) The diagnosis of anteflexion is readily made by passing the examining finger along the anterior wall of the cervix and pressing deeply into the anterior vault of the vagina, when the angle between cervix and body of the uterus can always be felt. Mistakes are, however, frequently made on account of the retroces- sion of the uterus and the forward direction of the cervix, which on hasty ex- amination give the impression of a retroversion. A myoma centrally placed on the anterior wall of the fundus may simulate closely an acute anteflexion. The treatment of anteflexion of the uterus is mentioned in detail in Part III. It comprises four methods: the use of stem-pessaries, instrumental dilatation, plastic operations on the cervix, and suspension of the uterus from the anterior abdominal wall. By the orthopedic or pessary method a straight or shghtly bent canahzed stem, usually made of hard rubber, is inserted in the uterine canal, where it is kept for six weeks or two months. Dysmenorrhea and sterility are sometimes entirely cured by this measure, but it is to be remembered that it may cause infection of the tubes. The use of stem-pessaries sometimes perma- nently reduces the anteflexion, but frequently the uterus returns to its former position. The recurrence of the anteflexion is not always accompanied by a return of the symptoms. Dilatation of the cervical canal should be done under an anesthetic, and is best performed with Hank's graduated dilators. If a cicatricial band is present at the internal os the dilatation may be diffi- cult. It is sometimes necessary to incise this obstruction with a bistoury. Simple dilatation is successful in a limited number of cases. Si 482 GYNECOLOGY ' Plastic operations on the cervix are numerous, but, though occasionally- successful, are rather unsatisfactory in their results. The operations most used are: the removal of a transverse wedge from the posterior wall of the cervix, the posterior discission, and the bilateral artificial laceration. These operations are described in the section on Technic. Suspension. — It has been stated above that the musculature of the typical anteflexed uterus is lax and flaccid. The characteristic sagging back in the posi- tion of retrocession is, in reality, a condition of relaxation, differing only from congenital or developmental retroflexion in that the fundus points forward in relation to the cervix instead of backward. There may even be a limited amount of descensus. When the abdomen is opened the anteflexion may be com- pletely reduced by drawing the fundus upward toward the wound in the ab- dominal wall. By suspending the uterus the angulation can be permanently reduced. This is best accomphshed either by the Gilliam type of operation or by the Olshausen method, preferably the latter. In other words, anteflexion may be treated exactly as congenital retroflexion, and this is reasonable because the two conditions, from a pathologic standpoint, are nearly the same. The results of the suspension operation for anteflexion are not always suc- cessful either for dysmenorrhea or for sterility, but in the experience of the writer they are considerably more satisfactory than those secured by the other methods mentioned above. In all cases, of anteflexion the presence of a cicatricial band at the internal OS makes the prognosis worse as regards curing the symptoms. If the suspen- sion operation is employed it should always be preceded by a thorough dilatation of the cervix. INVERSION OF THE UTERUS Inversion of the uterus is due primarily to a relaxation of the uterine wall and most frequently occurs as a comphcation of childbirth. It may also result gradually from the traction of a submucous or pedunculated fibroid or from cancer, so-called onkogenetic inversion. That the condition even after chfld- birth is a rare one is shown by Jones' collected figures, which show an average of 1 case in 128,767 labors. Inversion of the uterus is either acute or chronic, those cases which last a month or less being called acute, those seen at a period longer than this being regarded as chronic. Inversions from gynecologic causes — i. e., the traction of tumors — are always of the chronic type. The inversion is called "incomplete" when the fundus does not pass the cervix, and "complete" when it extends beyond this point. In very rare instances the inversion includes the cervix, so that the entire organ is inside out. Usually, however, the cervix remains as a sort of coflar about the inverted fundus. In all chronic cases the cervix is firmly contracted, while in the acute cases following labor it becomes contracted very quickly, from a few minutes to a MALPOSITIONS OF THE UTERUS 483 few hours (W. C. Jones). In acute cases the inverted fundus is large, but in the chronic form it may become markedly involuted (Hoover). Some cases of gangrene have been reported where the circulation has been cut off. If there is an associated prolapse or a pedunculated myoma the mass may extrude from the vulva. The symptoms of acute inversion are shock and hemorrhage, cases of this kind being entirely within the sphere of obstetrics. The symptoms of chronic inversion are similar to those of prolapse. The diagnosis in acute cases is usually unmistakable, but in the chronic variety it maj^ offer considerable difficulty. The condition with which inversion is most apt to be confounded is that of a pedunculated fibroid. When the fibroid Fig. 198. — Myomatous Polyp. Distinguished from inversion by a deepening of the uterine canal. lV\vio\-n.cx Fig. 199. — Myoma Causing Inversion by Traction. Distinguished from simple polyp by shortening the uterine canal. and inversion occur simultaneously the diagnosis is still more puzzling. W. C. Jones has offered an excellent means of differentiation in pointing out that the key to the situation is the length of the uterine canal, a fibroid always producing elongation; inversion always shortening it. The accompanying diagrams illus- trating this point are adapted from Jones' article. If the patient's abdomen is not too thick, the depression from the abdominal side caused by the inversion can be felt by bimanual examination. The treatment of acute inversion is immediate manual reposition. If this is difficult, it is better, according to Kiistner, to resort at once to the conservative method of operation described in Part III. Surgical treatment of chronic inversion is either radical or conservative, the choice of which course is determined as in other uterine conditions.' Thus, if 484 GYNECOLOGY the uterus be studded with fibroids, or if there is suggestion of malignancy, or if the patient is past the menopause, extirpation of the uterus is indicated. This can be done by the abdominal or the vaginal route, the former being recom- mended because of the better opportunity of preventing a future prolapse of the vagina. Of the conservative operations, that devised by Kiistner and termed "colpo- hysterotomy" is the classical method, though it has been modified to some extent by others. Two forms of operation are described in the section on Operative Surgery. Vaginal amputation of the extruded fundus is sometimes done, but is an operation not to be highly recommended. The same may be said of reposition of the inverted uterus by the abdominal route. Injuries due to Childbirth laceration of cervix Lacerations of the cervix usually result from childbirth, especially when there has been instrumental delivery. They are also caused by dilatation operations and instrumental abortions. Tears of the cervix, as a rule, occur on one or both sides. Occasionally the posterior and, more rarely, the anterior lips are torn. If the laceration takes place in more than two places it is called stellate. The surface of a cervical tear may heal over completely, leaving only a smooth cleft without further change in the cervix. Usually, however, lacerations pro- duce certain pathologic conditions, the most important of which are eversion of the mucous membrane (ectropion) , hypertrophy of the lips, erosion, and cyst formation of the Nabothian glands. Eversion or ectropion results from a pouting of the cervical lips after lacera- tion, by which the mucous membrane is allowed to roll outward toward the vagina. This condition of the mucosa is greatly aggravated by the various chronic inflammatory changes in the cervical tissues that are apt to ensue after laceration. Hypertrophy of the cervix following laceration relates to an enlargement of the cervical lips, which sometimes is very great. This increase in size is due partly to an actual hyperplasia of the cervical connective-tissue stroma, partly to a chronic inflammatory infiltration, and partly to a general edema of the tissues. A further important factor in the enlargement of the cervix is depend- ent on the change in the endocervical glands. These glands, it will be remem- bered, are of a complicated racemose type, with small single ducts opening into the cervical canal. The ducts easily become obstructed with resultant cyst formation of the main portion of the gland. If a number of the glands become cystic the cervix may be enormously enlarged. The contents of the cysts con- sist primarily of true mucus from the secreting lining cells of the glands, but there is apt to be a mixed infection which adds products of inflammation and detritus to the mucous material. The mucous membrane of an everted cervix is practically 'always infected, and frequently shows microscopically a necrosis and desquama- tion of the superficial epithelium. If this condition becomes sufficiently exten- sive to be recognized by inspection it is termed "erosion." Erosion and ulcera- tion of the cervix, as a result of a laceration and its attendant cervicitis, is not as common as is supposed. The everted mucous membrane has a deep red appear- ance, which, to the inexperienced eye, gives the impression of a loss of surface 485 486 GYNECOLOGY tissue. The diagnosis of "ulceration of the cervix" is, therefore, verj^ often erroneousl}^ made. True ulceration where observed must always be regarded with concern, as it is hkety to indicate some form of disease more serious than simple cervicitis. Its appearance demands a removal of tissue for microscopic examination. The spontaneous heaUng of cervical tears is often attended with dense scar-formation most marked in the angles of the lacerations. This scar- formation may extend out on the lateral walls of the vagina or upward into the parametrium. The contraction of the scar-tissue may immobihze the uterus to some extent, or cause version of the body to one side or backward. Symptoms.^ — Lacerations of the cervix do not cause definite local pain, as the cervix is a peculiarly insensitive organ. The hypertrophy of the hps in- creases the weight of the uterus, and as there is usuall}^ some prolapse asso- ciated with severe lacerations, the sense of weight and pelvic pressure is often present. Backache is a somewhat inconstant symptom. If the uterus is immobihzed by scar-tissue in the parametrium there is increased pelvic discomfort. Ectropion always produces leukorrhea and sometimes irregular bleeding. Numerous so-called "reflex" disturbances from cervical tears have been described, such as headaches, pains in the spine, and various hysteric neuroses. These are undoubtedly secondary nervous manifestations of depleted health caused by the damage to the pelvic organs in which the lacerated cervix is only one factor. Laceration of the cervix sometimes causes sterihty, probably as a result of the chemically changed secretions from the everted and inflamed mucous membrane which may be inimic to the life of the spermatozoa. Women with deep tears extending to the internal os are very apt to have multiple miscarriages, probably due to interruption of the normal function of the uterine musculature. The diagnosis of lacerated cervix is usually obvious both to touch and sight. The erosion and eversion of the mucous membrane may simulate the ulcerations of tuberculosis and sj^philis, but these latter are very rare. It is of the greatest importance to distinguish between severe laceration and cancer of the cer%dx. It is sometimes very difficult to make a diagnosis without the removal of a section for microscopic examination. To the touch the hard hj^pertrophied lips of cervicitis, made irregular and nodular by the Nabothian retention cysts, may be almost indistinguishable from cancer. Bleeding from contact of the examining finger which is so characteristic in cancer is sometimes met with in cases of laceration with erosion. On inspection the Nabothian cysts can usually be readily seen. The presence of these cysts, as a rule, is evidence against cancer, but this is by no means always the case. It should be remembered that cancer usually originates in one of these lacer- ated everted cervices, so that on the least suspicion a specimen must be removed INJTJRIES DUE TO CHILDBIRTH 487 for microscopic examination. In an early cancer of the cervix the point of origin is not always distinguishable. In a doubtful case, therefore, it is best to remove several pieces. Parametrial cicatrices sometimes obscure the diagnosis, for it immobilizes the uterus and gives to the examining finger a sense of indefinite resistance in the adnexa closely resembling a chronic salpingitis with adhesions. Treatment of Lacerated Cervix. — Nearly every woman who bears a child has some laceration of the cervix. Only those require treatment that give definite symptoms, or that by their appearance threaten the development of a cancer. Unless the tears are small, it is advisable always to repair the cervix as a routine during plastic operations of the vagina, and to examine micro- scopically the tissue removed. Eroded and inflamed cervices may be temporarily improved by local apphca- tions such as iodin, ichthyol, and glycerin tampons, etc., but they cannot in this way be permanently cured. Surgical treatment is based usually on the operation devised by Emmet many years ago and never improved upon. This consists in denuding the edges of the clefts caused by the laceration, and sewing the denuded surfaces together (see page 593). If there is great hypertrophy of the hps or extensive scar- tissue formation it may be necessary to resort to other measures, as the removal of transverse wedges from the Hps (see page 598) or to amputation of the entire cervix. Unless the cervix is elongated, as in prolapse and procidentia cases, it is best to perform a tracheloplasty rather than amputation if there is hkelihood of later child-bearing. If amputation of the cervix is necessary, Hegar's method gives the best results (see page 599), as it secures a more accurate approximation of the wound edges than does any other form of operation. CYSTOCELEi Cystocele is a descent of the bladder toward the introitus caused by relaxation of the anterior vaginal wall. In the great majority of cases cystocele is one of the results of child-bearing, though it may occur in nulliparous and even in virgin women. When not the result of the injuries of childbirth it is due to congenital tissue weakness. Cystocele is nearly always associated -with a greater or less degree of prolapse. In general, the two conditions are roughly proportionate to each other. This is due to the intimate attachment which the bladder has to the anterior wall of the cervix uteri, so that neither organ can prolapse without a tendency to drag the other with it. Cystocele, especially of the congenital type, is occasionally seen with little or no prolapse of the uterus, but this is uncommon, and may be ^ For mechanism, see that of Prolapse. 488 GYNECOLOGY regarded as a true hernia of the bladder. We do not, however, see prolapse of the uterus without some descent of the bladder. This is a fact of great practical importance in the matter of treatment, both of cystocele and prolapse of the uterus. Cystocele usually begins in the upper anterior part of the vagina near the attachment of the bladder and cervical wall. Where the vaginal wall has once lost its integrity the cystocele is gradually increased by abdominal pressure, and in time appears at the introitus. The exertion of abdominal pressure by strain- ing or standing causes the anterior wall, with the bladder behind it, to protrude into the world. The constant application of the force of abdominal pressure acts as a drag on the cervix of the uterus, which becomes lengthened and attenu- ated, until it may reach the stage of procidentia. The force of abdominal pres- sure serves more and more to drag the vagina away from its attachments to the rami of the pubes. As this attachment is one of the most important supports of the uterus, the uterus itself prolapses increasingly. The descent of the bladder may include the urethra, and when this takes place the condition is termed "urethrocele." Urethrocele is usually only an incidental part of the process of cystocele, but it may occur alone. If the cystocele extrudes constantly from the vagina the surface epithelium becomes dry and cornified, and if there is also procidentia it may become ulcer- ated. The symptoms of cystocele are closely associated with those of prolapse of the uterus, the chief one being that of general bearing-down or pelvic pressure with tendency to fatigue. This might more properly be spoken of as an asso- ciated symptom, being due principally to the prolapse of the uterus. If the cystocele is advanced the patient is conscious of its protrusion, often regarding it as the womb. This annoyance may have a deleterious influence on the nervous system if the patient's mind becomes riveted on the local condition. The involvement of the neck of the bladder causes symptoms of urinary irri- tability and frequency, while the sacculated condition of the bladder walls prevents complete voiding, and thus produces stagnation and chemical changes in the urine. Relaxation of the urethra and neck of the bladder may cause partial incontinence, especially in old people. Incomplete voiding of the urine sometimes encourages a cystitis, though it is surprisingly uncommon. The diagnosis of advanced cystocele is entirely obvious. The milder forms are diagnosed by feeling the anterior wall near the cervical reflexion, and requesting the patient to bear down as in the act of defecation. There is a normal amount of bulging of the anterior wall, just as there is a normal amount of descent of the uterus, and this must be learned by experience. Under ether the amount of cystocele present is demonstrated by grasping the anterior vaginal wall with two pairs of thumb forceps and drawing it forward toward the opening. The difference between the normal and pathologic amount of slack is easily learned. INJURIES DUE TO CHILDBIRTH 489 The diagnosis of urethrocele is determined by passing a sound into the urethra. It should be remembered that there is apt to be a considerable hyper- trophy of the anterior vaginal wall at the level of the urethra. This hyper- trophied protrusion is sometimes taken for a cystocele or for urethrocele. Treatment. — The following remarks on the treatment of cystocele relate to the method of treating genital prolapse by suspension, and are not entirely applicable to the interposition method, which involves a different mechanical principle. A description of the latter technic is given on page 608. In treating cystocele, one should always remember its close relationship to prolapse of the uterus, and regard the two conditions as phases of the same process. Failure to appreciate this fact led some of the older operators to regard cystocele as incurable. This is because the simple performance of a plastic operation on the anterior wall of the vagina, without permanently cor- recting the associated prolapse of the uterus, will almost certainly be followed by a recurrence of the cystocele. On the other hand, however, the reduction of the prolapse of the uterus will, at the same time, reduce milder grades of cystocele without plastic operation on the cystocele. In treating cystocele, therefore, it is a fundamental principle that the most essential part of the operation is the elevation of the cervix, for it is to its cer- vical attachment that the bladder chiefly owes its position in the pelvis. The elevated cervix does not take up all the slack of the relaxed anterior wall, and this must usually be corrected by a plastic operation. If the operation is done in this way the reduction of the cystocele will remain permanent. Plastic operations for folding in the redundant anterior wall are numerous. A useful operation for this purpose is described on page 608. This opera- tion, to be successful, must in most cases be supplemented by some form of sus- pension which will elevate the cervical attachment of the bladder. This is accomplished by the methods described under Prolapse and Procidentia of the Uterus. A special point to be noted in the operation described for cystocele is the method of treating the upper portion of the cystocele near the cervical reflexion. The denudation is carried out more widely than at the lower portion, so that when the vaginal flaps are approximated a firm bridge is made across the front of the cervix, carrjdng it backward toward the sacrum. This serves to correct the tendency of the cervix in partial prolapse to swing toward the pubes. The treatment of cystocele by the interposition method involves a separation of the bladder from the uterus, and then transposition of the bladder to the posterior surface of the uterus. In this way the uterus is brought under the bladder and supports it from below. 490 GYNECOLOGY LACERATED PERINEUM In order to understand the mechanism of perineal lacerations it is important to have a clear idea of the essential points in the anatomy and function of the perineal muscles. Unfortunately, the subject is not an easy one, for the parts are very difficult of dissection and the descriptions of them are, for the most part, vague and misleading. The most practical demonstration of the functional anatomy of the pelvic diaphragm which we have seen is that by Studdiford, pubHshed in Johnson's Surgical Therapeutics. His statement is so clearly expressed that we caimot do better than to quote it verbatim : "The levator ani muscle, together with the strong fascia covering its internal and external surfaces, is conceded to be the essential part of the pelvic diaphragm, but there is no uniformity of opinion as to the relative value of the two elements, the mechanism of their action in giving support, and how they are affected by injury. The levator ani is a paired muscle which has its origin from the tendin- ous arch which extends from the lower margin of the pubes to the spine of the ischiimi, from the inner surface of the superior ramus of the pubes, and from the pubes parallel to the symphysis. The fibers coming from the pubes form a dis- tinct muscular band, the pubococcygeus muscle, and are the most important part of the levator. The fibers from the tendinous arch, the ileococcygeal muscle, are slender fascicuh separated by small interspaces. The majority of the fibers from the tendinous arch are inserted into the lateral margins of the coccyx, some are joined with the muscles from the opposite side, and others are inserted into the anococcygeal hgament. The fibers of the pubococcygeus arising from the pubes pass directly backward, some of the fibers uniting with the fibers of the external sphincter. Others pass directly to the anococcygeal hgament, while still others join with the fibers from the opposite side posterior to the rectum, some of the fibers minghng with the longitudinal fibers of the rectum. The muscle is in close relation with the side walls of the lower end of the vagina, its fibers mingling with the longitudinal fibers of the vaginal wall. The relation of the muscle to the external sphincter is of the utmost importance and is so intimate that separation by dissection is impossible. Functionally the two mus- cles must be considered together as forming a strong muscular band extending from the pubis to the coccyx, controlling and embracing the lower end of the rectum and attached to the side walls of the vagina. It is usual to describe the levator ani as a sling or horseshoe-shaped muscle. It would give a more correct idea of the structure were it described as V shaped, the angle of the V being much wider posteriorly where the muscles are attached to the ischial spines and narrowing as the anterior fibers (pubococcygeus) attached to the pubic bone are approached. The sides of the V have a slight convexity toward the median line, the apex of the V being the attachment to the coccjtc. The open part of the V between the anterior portion of the pubococcygeus muscles is INJURIES DUE TO CHILDBIRTH 491 protected by the urogenital trigone made up of two strong layers of fascia, in- closing between them the deep transversus perinei muscles together with some involuntary muscle-fibers. The urogenital trigone is attached to the inner margins of the inferior rami of the pubes anterior to the tuberosities of the ischii, its sharp posterior border marking the anterior boundary of the ischiorectal fossae. It is perforated by the vagina and urethra and fuses with the fascia covering these organs. The posterior surface of the trigone is in relation with the fascia covering both surfaces of the levator ani and gives support to the fibers of the pubococcygeus. The deep transversus perinei, rising from the inner surface of the tuberosity of the ischium between the layers of fascia and forming part of the posterior half of the urogenital trigone, is attached along with the anterior fibers of the external sphincter to the so-called central tendon of the perineum. It is this part of the perineum that I beheve has been im- properly described. 'Tn an article of mine in 1909 the importance of the involuntary muscle-fibers contained in the pelvic floor was emphasized. The study of these fibers was based not only on gross dissection, but on frozen sections and microscopic ex- amination of the tissues from the cadaver and microscopic examination of tissue removed from the Hving subjects during operative procedure. These observa- tions have been confirmed by study of dissections since that time. These in- vestigations showed that the tissue lying between the halves of the levator ani and at the points of attachment of the anterior end of the external sphincter and to the deep transversus perinei muscles in the perineal body was made up largely of involuntary muscle-fibers. These fibers running in both a transverse and longitudinal direction are in close relation to all the muscles. So far as I have been able to determine, no fibers from the two halves of the levator ani muscle pass between the vagina and rectum. These involuntary muscle-fibers we consider important in the mechanism of the pelvic floor, their contraction tending to draw the two halves of the levator ani and the deep transversus peri- nei muscles toward the median Hne, thus placing these muscles in the most advan- tageous position for action, and by drawing the anterior end of the sphincter forward aid the supporting power of the levator. These fibers undoubtedly increase in size and strength during the pregnancy, and account for the increased projection and thickening of the pelvic floor at that time. They also permit the dilatation of the pelvic floor at the time of labor and undergo involuntary changes after labor. "The force of the contractions of the levator ani are directed by the course of its fibers. In the upright position the fibers of the pubococcygeus run almost horizontal from the pubes to a line drawn between the tuberosities of the ischii which marks the posterior border of the urogenital trigone, to the posterior sur- . face of which the fascia covering the muscle is attached. Posterior to this line the fibers interminghng with the fibers of the external sphincter pass upward and backward to the coccyx. So that when contraction of the muscles takes place 492 GYNECOLOGY the involuntary fibers approximate the two halves of the muscles toward the median line, the urogenital trigone is pulled upward and forward, closing the vaginal slit. The exaggerated action of these involuntary fibers can be seen in cases of vaginismus. The lower end of the rectum is also drawn upward and forward, and the portion of the muscles posterior to the ischial tuberosities is Fig. 200. — Semidiageam Showing the Relatioxship of the Perineal MrscLES. On the left is seen the fascial investment called the urogenital trigone. Behind the lower edge of the trigone lies the transversus perinei muscle not seen in the drawing. On the right the trigone and transversus perinei have been removed. The bundle of muscle-fibers which constitute the anterior part of the levator ani muscle and which are called the pubococcj^geus muscle can be seen. The intersecting involuntary muscle-fibers which cross between the two pubococcygeus muscles are indicated in the drawing. Note the relationship of the pubococcygeus to the vagina and the sohincter ani. supported by the upward and forward pressure of the obturator and gluteal muscles on the tissues filling the ischiorectal fossae. Bearing in mind this rela- tion of the structures of the pelvic diaphragm which is so essential to its proper action, it will be readily seen that the way in which such action could be most easily disturbed would be by injury to the tissues marking the junction of the INJUEIES DUE TO CHILDBIRTH 493 involuntary muscle-fibers, the urogenital trigone, and the fascia covering the pubococcygeus. It is at this point that lacerations of the pelvic floor usually occur, and the effect of such injuries is measured by the extent to which the relations of the various structures to each other are disturbed. Figures 200-203 give a diagrammatic representation of the effect of such injuries. A laceration in the median line through A that does not extend below the upper margin of the external sphincter involves some of the involuntary muscle-fibers and causes little disturbance of function and is easily repaired at the time of injury. Injury on one side allows the pubococcygeus on that side to sag away from the median line by the detachment of the involuntary muscle-fibers. If the tear extends through the skin, as it usuallj^ does, the relations of the pubococcygeus on that side to the external sphincter are disturbed and the sphincter is drawn Fig. 201. — Diagram Showing the PrBococcTGEirs Portion of the Levator Ani Muscles, THE Urogenital Trigone, and the External Sphincter. B, B, junction of involuntary muscle-fibers, pubococcygeus, and urogenital trigone. toward the uninjured side. The deep transversus perinei and the urogenital trigone on the injured side retract, pulling the pubococcygeus fibers outward, such retraction increasing in force if the fascia of the levator ani and the trigone are separated from each other. If the tissues on both sides are injured, the re- sulting disturbance of function of the pelvic diaphragm is more marked, the involuntary fibers are torn from the two halves of the pubococcygeus, and the muscles sag away from the median line (Fig. 203). The retraction of the trigone occurs on both sides and the external sphincter drops downward and backward and is usually drawn toward the half of the pubococcygeus from which there is the least separation of the involuntary fibers. The posterior vaginal wall drops downward and backward posterior to a line drawn between the iscliial tuberosities. 494 GYNECOLOGY When these injuries occur during labor they allow the two halves of the pubococcygeus to separate as the birth of the presenting part takes place. I I iG. 202. — Laceration Through Right Vaginal Sulcus. On the left the relation of invgluntary fibers, pubococcygeus, and trigone is intact. Note that on the right the pubococcygeus sags away toward the pubic bone. The sphincter is drawn toward the unaffected side. Fig. 203. — Laceration Through Both Sulci A and B. Both pubococcygeus muscles together with the urogenital trigone sag outward and retract toward the pubic bones. The external sphincter drops backward and toward the least injured side. have never been able to demonstrate in either recent or old lacerations of the pelvic floor the rupture of the fibers of the pubococcygeus that is so graphically INJURIES DUE TO CHILDBIRTH 495 pictured in many text-books, and do not believe that it takes place except in badly executed forceps operations. I have seen cases in which the fibers of the pubococcygeus were torn close to their attachment to the symphysis during the withdrawal of the forceps blades. In two cases where brutal attempts at deUvery by forceps had been made the fibers of the pubococcygeus were torn above the sphincter so that the ischiorectal fossa was opened. I believe that this opening into the fossa will occur whenever the fibers of the pubococcygeus near the perineum are actually ruptured. "The effect of such injuries increases in direct proportion to the length of time during which they are allowed to remain unrepaired and the amount of intra-abdominal pressure to which they are subjected. The muscles atrophy from impairment of function. The fascia becomes stretched and the unsup- FiG. 204. — Laceration Through Sphincter. In this case there is little damage to the pubococcygeus and trigone, so that there is less sagging and retraction than when the laceration has taken place in one or both sulci. It is also possible to have a laceration both through the sphincter and into one or both sulci. ported action of the sphincter allows the posterior vaginal wall and the rectal wall beneath it to prolapse. The gluteal muscles give some support for a time by pushing upward on the tissues of the ischiorectal fossae, but sooner or later the fascia of the levator bounding the inner walls of the fossae gives way under the strain and the upper angles of the fossae become flattened and the support of the gluteal muscles is lessened or withdrawn. Where the tear extends through the external sphincter and its function is eliminated (Fig. 204) the sagging of the pubococcygeus is less in evidence because these muscles are reHeved of the strain necessary for the maintenance of the action of the sphincter. The relaxa- tion of the pelvic floor occurring in nulliparae, or after labor in which there has been no visible tear of the vaginal waU, is, in my opinion, due to stretching or rupture of some of the involuntary fibers. In nulKparae this may result from poor 496 GYNECOLOGY development of these fibers, as it often occurs where the genital organs are also developed, or it may be caused by overstrain from excessive muscular action causing badly directed intra-abdominal pressure." Symptoms. — The symptomatology of lacerated perineum is closely inter- related with that of cystocele and prolapse, with which it is usually associated as a part of a general process of relaxation. The role played by the lacerated perineum in the symptoms caused by this chain of lesions is less important than that of cystocele and prolapse. NM.V. Sxuve%. -CivisTocfcVe — Conn. lissTB° -X Fig. 208, — Decidual Cast. Low power. The stroma cells of the endometrium become enlarged, most of the enlargement being in the protoplasmic part of the cell, and they become flattened instead of round and oval, due to pressure against each other. The intercellular connective tissue disappears. The epithelium of the glands is lost or consists of a single layer of low inactive cells. There is a slight infiltration with leukocytes. Decidual casts are found in extra-uterine pregnancy. of a patient with tubal abortion discloses a pelvic mass. If the bleeding is con- fined to the tube it can at first be felt as a sausage-shaped tumor, extending at right angles to the uterus. If the tubal mole becomes large and heavy it sinks into the posterior culdesac, where it can be felt as a rounded, well-defined mass, pushing the uterus forward toward the pubes. If there is gradual bleeding into the peritoneal cavity a hematocele forms, usually in the posterior culdesac, which at first is felt per vaginam as a soft doughy mass, and if successive examinations are made its increase in size may be recognized. 512 GYNECOLOGY If the hematocele remains for a long time in the cavity without absorption a semi-organized capsule forms about it, which gives the examining finger the sensation of a cyst or soft myoma. The hematocele may become so large as to be easily felt through the abdomen, sometimes extending to the level of the umbilicus. Tubal abortions, even when the hematocele is of large size, sometimes heal spontaneously by absorption of the blood-clot. This process is occasionally astonishingly rapid. More often the symptoms continue for several weeks until surgical aid is sought. During this period the patient continues to have frequent pain and irregular uterine bleeding. The protein decomposition of the clotted blood often, though not always, produces a form of auto-intoxication, which may be of a serious character. Patients with absorbing heinatoceles are apt to run a moderate elevation of temperature and suffer from various intes- tinal disturbances. Sometimes they acquire a peculiar greenish, waxy pallor of the facies and occasionally exhibit mental aberrations. A moderate leuko- cytosis is usually present. If the hematocele becomes infected, symptoms of acute pelvic inflammatory disease ensue, usually of a very serious nature. Diagnosis. — One seldom sees an extra-uterine pregnancy in the first stage before rupture. In this stage the tube is soft and not easily palpable. The delay of menses and the enlargement of the uterus make an exact differentia- tion from a normal pregnancy very difficult. In the second stage, or that of rupture, the cases of severe bleeding are very characteristic and easily recognizable. The sudden terrific abdominal pain and the tragic collapse of a woman in full health is unmistakable. In the chronic stage the diagnosis is often confused and difficult to make. The history is of the greatest importance, the chief factors of which are the age and social condition of the patient, the question of delayed menses, the charac- ter and location of the initial and succeeding pains, and the time and nature of uterine bleeding. Most patients with ectopic pregnancy give a history of passed or delayed menses, but occasionally cases are seen in which there has been no appreciable irregularity, and when this happens the diagnosis is especially misleading. The nature of the pain in ectopic cases is usually rather characteristic. It is felt in one side of the pelvis, and is peculiarly sharp and lancinating and often accompanied by fainting spells. In contradistinction to this the pain of an abortion is less sharp and usually referred to the uterine region, while the pain of pelvic inflammation is dull and more constant. It is often very hard to dis- tinguish between a tubal abortion and a threatened or incompleted uterine abortion. In both cases history of delayed menses, pain, and onset of bleeding correspond to either condition. The pelvic examination may also be equivocal, for the uterus is enlarged and soft in both conditions, while a large corpus luteum or cystic ovary of a normal pregnancy may present to SPECIAL GYNECOLOGIC DISEASES 513 the examining finger a feeling no different from that of a small tubal sac of an ectopic pregnancy. Microscopic examination of curetings give some information, for if chori- onic villi are present ectopic may be ruled out. Sometimes, however, the fetal remains of a uterine abortion disappear rapidly, while the decidual reaction may be seen for a considerable time. Under these conditions the microscopic examination would be of no value. An interstitial pregnancy is essentially ectopic, and its symptoms and course are practically the same as those of tubal pregnancy. The diagnosis by bi- manual examination is very difficult and requires a most expert touch; when there is doubt, examination under ether should be urged. Sometimes a normal pregnancy at two or three months, in which there is some asymmetry of the uterus, may simulate closely an extra-uterine pregnancy at first examination. Under anesthesia the doubt is usually expelled at once. On account of the ease by which errors can be made in the diagnosis be- tween extra-uterine and normal pregnancy it is important always to make a preliminary vaginal examination under ether before performing an abdominal operation for ectopic pregnancy. If this is made a routine procedure, unneces- sary surgery will not infrequently be avoided. The expulsion of decidual shreds or a uterine cast is very useful evidence in cases of suspected ectopic pregnancy, but even this may be misleading, especially in women who have a history of exfoliative dysmenorrhea. The doughy, irregular feel of a soft pelvic hematocele is quite recognizable, especially if the uterus can be well defined as being pressed forward in ante- position. If the hematocele acquires a semi-organized capsule the mass becomes smoother and firmer to the touch and may be quite deceptive. Such a tumor may simulate closely an ovarian cyst, a soft myoma, or a pus-tube. It may, if symmetrically placed in the posterior culdesac, feel exactly like a retroflexed fundus of a pregnant uterus. The differential diagnosis between a long-standing tubal abortion and pelvic inflammation is sometimes very baffling. The tubal mass, the intermitting pain, and the irregularity of the menses maj^ sometimes apply to either condition, and a mistaken diagnosis is often made. Little harm is done, however, by the mistake, as an operation is usually indi- cated in both cases. As a rule, extra-uterine pregnancy is unaccompanied by temperature, but if there is a disintegrating hematocele a moderate fever may be present. Marked elevation of temperature would indicate an inflammatory process. Treatment. — If an ectopic pregnancy is discovered in the first stage — i e., before rupture- — immediate removal of the tube is indicated. In case of tubal rupture, with sudden collapse and alarming symptoms, it is undoubtedly best to operate immediately if proper surgical facilities are at hand. The operation can be done very rapidly, with little additional shock to 33 514 GYNECOLOGY the patient. From the observation that patients often survive the first attack it was at one time the custom of many surgeons to wait for this possible outcome before attempting operation. In hospital practice, at the present time, ex- pectant treatment is not to be advised, for in this way some patients will be lost who might have been saved by prompt intervention. The modern simpli- fied methods of blood transfusion constitute a valuable hfe-saving measure in these cases when used in connection with a surgical operation. In the third stage of tubal pregnancy, namely, that of regression of the hema- tocele after tubal abortion, surgical intervention is not as urgent, and time may usually be taken for establishing a correct diagnosis. When a diagnosis is made of probable aborted extra-uterine pregnane}^ the question of operation or ex- pectant treatment arises. It is known that many cases get entirely well spon- taneously and even have later normal pregnancies. Is it best, therefore, to keep the patient under observation and wait for this possible outcome? Unless the hematocele is far advanced in its process of absorption and other signs point to an early spontaneous cure the expectant treatment is not to be advised. It sometimes happens that a secondary rupture occurs which may be fatal to the patient, and this may take place at any time during the so-called termination period. This catastrophe is not very common, yet it occurs sufficiently fre- quently to act as a menace. It is difficult at any one time to tell whether the oozing and accumulation of the hematocele has ceased. Even if imminent danger has passed, most patients with hematoceles are destined to weeks and months of invalidism before a complete absorption of the blood can be accomphshed. During this time there is risk of infection, formation of pelvic adhesions, and the toxic effects of the absorbing blood-clot. It is better to operate, remove such organs as are necessarj^, and completely empty the abdominal cavity of blood. It may be said, therefore, in general, that ectopic pregnancy in all three stages is very definitely a surgical disease, and that usually prompt intervention is indicated. The technic of operating is a matter of considerable moment and of some difference of opinion. Unquestionably, the abdominal route is the most ad- vantageous in all stages of the disease. Among other reasons for using the abdominal route is the importance of removing the blood completelj^ from the abdominal cavity, a procedure that cannot be as thoroughly accomplished per vaginam. It was at one time thought that the absorption of blood from the peritoneal cavity was in some way useful to the patient, and some surgeons went so far as to leave as much blood as possible in the abdomen. The error of this has already been pointed out, and it is necessary to remove all the blood possible unless the patient is in such extreme condition that the time and manip- ulation required for sponging out the blood would be dangerous to life. In operating for ectopic pregnancy judgment as to what tissues to remove is a matter of moment. If only the offending tube is removed, it must be SPECIAL GYNECOLOGIC DISEASES 515 remembered that the same process that caused the abnormal nidation of the ovum may act again in the opposite tube. The figures of Richard R. Smith, who has collected valuable statistics on this subject, show that only about 33 per cent, have normal uterine pregnancies later, while about 15 per cent, have a repeated ectopic pregnancy. The question, therefore, of preserving or remov- ing the other tube is often an important one. This must be answered, as in other questions of conservatism or radicalism in pelvic surgery, on the ground of the age of the patient, her desire for children, and sentimental considerations as to the loss of genital organs. The decision of removal or preservation of the uterus must be based on the same grounds as those in the treatment of pelvic inflammatory disease {q. v.). DYSMENORRHEA The word dysmenorrhea is used in two somewhat different senses. In one sense it is simply descriptive of the symptom pain occurring at menstruation; in the other it is the name of an actual disease. When it is used to denote a disease it is best to employ the term essential dysmenorrhea, suggested by Schaeffer. ESSENTIAL DYSMENORRHEA Essential dysmenorrhea is a disturbance that is characterized at the time of menstruation by severe cramp-like pains of the lower abdomen, from which the patient is entirely free during the intermenstrual period. This form of dysmen- orrhea is very distinctive, and must not be confused with the kind of menstrual pain which represents an aggravation during the menstrual congestion of the more or less continued pain from various pelvic disorders, like salpingitis, pelvic inflammation, appendicitis, etc. This latter form of dysmenorrhea might more exactly be termed ''secondary" or "acquired dysmenorrhea." Essential dysmenorrhea, though one of the commonest of gynecologic dis- eases, is one about which little is known. Etiology. — A satisfactory interpretation of the etiology of true dysmenor- rhea has not yet been made, but the various theories are iiiteresting and are of some practical value. The older authors regarded the cause of dysmenorrhea as due entirely to mechanical obstruction. Others divided the disease into three classes — an organic form, depending on obstruction, a congestive, and a neuralgic form. Others divided dysmenorrhea into uterine and ovarian varie- ties. The theory of mechanical obstruction is based on the idea that the flow of blood is interfered with by a congenital stenosis of the internal os, so that, being dammed back in the uterine cavity, it becomes clotted and acts as a foreign body, setting up contractions of the uterine body. The cramp-like pains are caused by the passage of the clotted blood as it is forced through the internal os. This stenosis may be due to a misplacement, of which anteflexion is the more 516 GYNECOLOGY common and retroflexion the less common tj^pe. Inasmuch as these two forms of uterine flexion are due to deficient development, dysmenorrhea has long been regarded as the result of genital hypoplasia. In the obstructive theory the swelling of the endometrium, whether it be the premenstrual edema or a true, permanent, pathologic hypertrophy, plays a considerable part, as it is supposed to increase the obstructive narrowing of the internal os. Gebhard describes an endometritis dysmenorrhoica, in which the mucosa is greatly thickened at the time of menstruation and filled with fine particles of clotted exudate. He thinks that this exudate exerts a pressure on the uterine nerves which is expressed by dysmenorrheic pain. It should be said in passing that these views regarding endometritis and clotting of the blood do not harmonize with the more recent ideas of hyper- trophic endometrium as a phase of a physiologic menstrual cycle, and of the clotting of the blood as a result of the abnormal chemical influence of the ovarian inner secretion. Moreover, the hypertrophied endometrium does not seem to be as constant an accompaniment of anteflexion and retroflexion as the older writers supposed. Theilhaber denies that the misplacement of the uterus, or stenosis of the internal os, or hypertrophy of the endometrium, have anything to do with dys- menorrhea as etiologic factors, but sees the cause in a spastic contraction of the circular muscular fibers around the internal os, called forth by a predisposition to abnormal nervous irritability. Menge refers the trouble to the physiologic menstrual contraction waves of the uterus, which in women who are bodily and mentally sound are unnoticed, but which in women who have lesions of the genital organs, or who are of a neurotic constitution, are felt as labor-pains. In other words, Menge regards the disease as a psychoneurosis. Kronig, though admitting the possibility of mechanical causes, considers most dysmenorrheas as psj'choneuroses. An interesting theory' is proposed by "S^ictor Schultz, who starts with the fact that the transformation of the infantile uterus into mature development is gradual and often delayed. During this change the connective tissue in the outer laj^er of the uterine waU, which is in excess in the infantile organ, gives way normally to muscle tissue. If this change is delayed or does not take place, the uterine contractions at the menstrual period cause a "stretching pain" in the insufficient uterine wall. This theory is thought by Schultz to account for the fact that dysmenorrhea is so often seen in persons with hypoplastic genital organs. The spontaneous cure often seen after childbirth he considers as due to structural changes in the uterine wall. Stolper considers that dysmenorrheic pains are due to uterine contractions in the presence of congested circulation. He thinks that the real cause of the trouble lies in the abnormal venous congestion of the uterus that might result from sexual or bodily overexertion, constipation, sedentary life, onanism, etc. SPECIAL GYNECOLOGIC DISEASES ^^"^ Olshausen describes an ovarian dysmenorrhea which is independent of any form of pelvic inflammatory process, and which he regards in the light of an ovarian neuralgia. A so-called "nasal dysmenorrhea" has been described by Fhess and elaborated by Schaeffer. It is shown that in some cases the pains of a dysmenorrhea may be cured by the application of cocain to the tuberculum septi, which is desig- nated the "genital spot." With this array of conflicting theories, the problem of etiology seems far from a solution. Leaving theory aside, there are certain facts which occur with sufficient constancy to give some basis for working out a method of treatment. There is no question that a malposition of the uterus occurs so frequently with symptoms of dysmenorrhea that there m.ust be some etiologic relation- ship between the two conditions. This idea is substantiated by the fact that many cases of dysmenorrhea are completely cured by correcting the malposition. The most common malposition seen in dysmenorrhea cases is anteflexion, while developmental retroflexion is not infrequently met with. If a large num- ber of anteflexion cases are studied it will be found that in the great majority of them the uterus, besides being anteflexed, is retrocessed, or sagging back toward the sacro-ihac fossa. When the abdomen is opened and such a uterus is brought up toward the abdominal wound, it will be found that the organ is lax, and that the angulation is due not to an anterior spastic contraction, but to a sagging back or a squatting down due to relaxation. The condition is, there- fore, actually one of retroposition, and differs only from retroversion in that the fundus is kept pointing in a forward direction, either by the round ligaments or by the structure of the musculature. The cervix in anteflexion cases lies in the same position relative to the vagina as it does when the uterus is retroflexed. All plastic operations on the cervix, therefore, do not in any way alter the essential position of the uterus relative to its normal level in the pelvis. Another anatomic condition frequently but not always present in these cases is a distinct cicatricial band at the internal os, which can be distinctly felt while dilating the cervix, and which often makes the dilatation of the in- ternal OS diflacult. As to the canal itself, an actual obstructing stenosis is never demonstrable in these cases. Hypertrophy of the endometrium is by no means constant. In our experience it has not appeared more frequently than in parous women without dysmenor- rhea. It is more common in the retroflexion than in the anteflexion cases. Most of the cases show a moderate degree of hypoplasia, as indicated usually by a long conical cervix. When, however, the uterus and adnexa are seen withm the abdomen and the uterus brought up into position, the condition of hypoplasia often is not noticeable. We find, therefore, in most cases of true dysmenorrhea certain anatomic -changes, which occur with sufficient regularity to assign a definite relationship between them and the menstrual pain: 518 GYNECOLOGY (1) Malposition of the uterus nearly always present; usually a retrocession with anteflexion; less commonly a retroflexion; occasionally anteflexion without retrocession. (2) Moderate hypoplasia, chiefly apparent in the form of the cervix, nearly always present. (3) Cicatricial band at the internal os, not constant. (4) Hypertrophy of the endometrium, not constant. The important factors are malposition and hypoplasia of the uterus. We have seen that the malposition of the uterus is usually due to a relaxation and sagging of the uterus on itself, rather than to a spastic contraction of the uterine muscles. The condition is frequently seen in conjunction with ptosis of the kid- ney or of the colon, so that fundamentally it would seem as if the lesion were due uo a physiologic deficiency in the supporting tissues. The so-called "con- genital" misplacements of the uterus probably occur at the time of puberty, when the organ takes on a very rapid development, and it is conceivable that a ■uterus which develops in an improper position may be retarded in its full growth by partial interference with its blood-supply. This would account for the moderate hypoplasia that is usually present, and, in this sense, the hypoplasia might be regarded as secondary to malposition of the organ. This would also explain the fact that the condition is frequently seen in women who are in every other respect fully developed. We have shown in the enumeration of the various theories as to the etiology of dysmenorrhea that by some the symptoms are regarded purely as a mani- festation of a psychoneurosis. It must be admitted that these patients are usually very nervous and often extremely neurotic. The question is raised, therefore, Which is primary, the dysmenorrhea or the neurotic condition? Vede- ler, Kronig, and others believe the neurosis to be primary. We have here the same problem that is discussed under the title of Postoperative Psychoneuroses, in which it is attempted to show that the nervous condition is secondary and due to constant nagging pain and discomfort. In dysmenorrhea the pain is periodic, to be sure, and is completely absent during the intervening period. Nevertheless, the pain is so severe that in time patients become nervously ex- hausted during the menstruum. The effect of this lasts longer and longer into the intermenstrual period, until there comes a time when the patient hardly recovers from one period before the next one is upon her, and in this way the nervous irritant is constantly maintained. The pathologic mental habit then becomes fixed and the patient develops into a confirmed neurotic. This course of symptoms may frequently be followed in the history given by mothers of school girls who are brought for consultation, in many of whom the increase of nervous symptoms is the chief cause for seeking medical advice. There is no doubt that when this condition of pathologic mental habit is reached there is much "overvaluation" and exaggeration of symptoms, and that such patients may be greatly relieved by suggestion and mental therapy. SPECIAL GYNECOLOGIC DISEASES 519 Symptoms. — The patient with essential dj^snienorrhea usually feels per- fectly well between her periods, as far as any local condition is concerned. At the menstrual period, however, either just before or at the time of the appear- ance of blood, the patient is seized with severe, often agonizing, cramp-hke pains in the lower abdomen, which extend into the back or down the legs, last- ing with a few intermissions from a few hours to one or two daj^s. During this time the patient is more or less incapacitated from normal activities and is usuall}^ confined to bed. Severe headache and general malaise are -often pres- ent, while vomiting is not uncommon. The disease usually appears early in menstrual hfe, often at the first menstrual period, and gradually increases in severit}'. It is frequenth^ relieved by married hfe, but is sometimes aggra- vated by it. Patients with essential dysmenorrhea are ver^^ apt to be sterile, the two conditions evidently being referable to the same causal factor. If, however, pregnancy and childbirth take place the ctysmenorrhea is often cured. The treatment of dj'smenorrhea is difficult and unsatisfactor3^ The methods of treatment, both medical and surgical, are exceedingly numerous. All the methods used are sometimes successful, but all of them fail frequently. Medical treatment is less satisfactory than surgical. Some of the drugs used are hy- drastis, cottonroot, viburnum, aspirin, antipjTin, acetanilid compounds, hj^- oscyamus, dionin, salipyrin, salcodein. bromids, ovarian extract,^ atropin, morphin, cocain, alcohol, and many others. .\mong the nmnerous drugs used for dysmenorrhea, atropin is at present receiving much attention. It has been emploj'ed with much success by Drenkhaber, who injects the drug directly into the cervical canal. The dose is 1 mg. in 1 c.cm. of water. Many writers report good results by oral administration. The drug is administered two days before menstruation is expected to appear and continued until the second or third day of menstruation, depending on the duration of pain. The average dose is t^o grain three times daily. E. Novak recom- mends gi\ang aspirin in combination -n-ith the atropin in some cases. In cases in which atropin does not prove effective Spitzig recommends the use of sodimn citrate, 20 grains three times a day, during the week or two preceding the expected period. The administration of citric salts is supposed to diminish the viscidity of the uterine blood that is produced by the menstrual congestion. Klein divides dysmenorrhea into two tj'pes, one in which there is h\'peractivity of the ovarian secretions and one in which the fimctioh is defective. In the first case there is exces- sive edema of the uterine mucosa. He regards the uterine coUc under these conditions as caused by the sweUing of the mucous membrane. In the second type of dj'smenorrhea there is atrophy of the mucous membrane and a flabby undeveloped musculature of the uterus. In this tj'pe Klein thinks that the uterus is unable to expel the blood properl}', so that it stagnates, becomes clotted, and thus causes pain when finally expelled. On the theory' that the ovarian and adrenal secretions are antagonistic Klein recommends the use of adrenaUn in cases of dys- menorrhea due to oversecretion of the ovary and reports only two failures in the treatment of 35 patients. In the second tj-pe of case where the ovarian secretion is deficient he recommends gi\dng pituitrin -^-ith the adrenalin, on the groimd that it causes contractions of the uterus and thus promotes early discharge of the blood before it becomes clotted. ^ The author has recenth' had striking success in a number of dysmenorrhea cases ■with a prepara- tion of desiccated ovaries of pregnant animals minus the corpus luteum. TheilP.bxCvUV5 Fig. 213.- — Vulvectomy. Closure of the wound. A second circular incision is then made about the vaginal orifice and meatus urinarius, special care being taken to leave as wide a margin about the meatus as the exigencies of the case will permit. The structures hdng between these two incisions are dissected away in one piece, the depth of the incision depend- ing on the nature of the disease for which the operation is being done. There is always considerable hemorrhage, especially in the region about the clitoris. As the vessels are apt to retract to a position troublesome to reach, it is advisable to control each spurting vessel as soon as it appears. The wound is closed in the form of a racquet, the upper edges of the outer wound being approximated 584 GYNECOLOGY from side to side down to the point of the wound just above the meatus. At this point the edges of the outer and inner wound are approximated. Sometimes the excision of the vulva is necessarily so extensive that various plastic maneuvers must be resorted to. If the vaginal mucous membrane cannot easily be approximated to the edge of the skin wound, the vagina can be freed for a short distance and thus be brought down more easily. In operating for cancer of the vulva it is often necessary to make so wide a dissection out on the skin that the method of approximation above described is not feasible. The classical plastic device for overcoming this difficulty is to make a wide triangular incision with the apex toward the thighs. The tri- angular area of skin included within the lines of incision is somewhat loosely attached and can easily be slid inward toward the vagina. The wound edges can then be approximated. Fig. 214. — Basset's Opeeation for Cancee op the Vttlva. The Incision. Hasset performs the complete operation at one sitting. We recommend Taussig's method of dissecting the inguinal regions first and performing a vulvectomy at a later operation. SPECIAL OPERATION FOR CANCER OF VULVA The best method for operating on cancer of the vulva is that recommended by Taussig. He divides the operation into two stages, the first being a dissection of the two inguinal regions, and the second, performed sometime later, a removal OPERATIONS ON THE VULVA 585 of the primary cancer mass. The two-stage operation is especially advisable be- cause it is impossible to secure first intention healing from the vulvectomy wound, and if the inguinal regions have been dissected at the same time they are almost sure to be infected from the vulvar area. This results in an enormous gaping wound which requires weeks of granulation and slow healing. The dissection of the inguinal regions is carried out by the Basset method. A long inguinal incision is made as in an operation for inguinal hernia, the inci- sion being carried somewhat further toward the vulva so as to allow for wide retraction of the skin. The aponeurosis of the external obHque is divided as in a hernia operation and the round ligament exposed from the external to the Fig. 215. — Dissection of the Inguinal Region for Cancer of the Vulva. The round ligament is being freed, with glandular and fatty tissue attached. internal ring. The ligament is lifted out of its bed, care being taken that as much of the surrounding fatty and cellular tissue shall adhere to it as possible, for in this are contained the lymphatics of the so-called "upper pedicle." When the ligament has been freed to the internal ring one sees at this point the epigastric artery and vein. The small peritoneal culdesac which surrounds the round Hgament at its entrance into the peritoneal cavity is now shown. Without opening the peritoneum a retractor is inserted into this culdesac and drawn strongly upward, as in Fig. 215. This exposes the anterior part of the internal iliac fossa. All the glandular and cellular fatty tissue is then dissected away from the iliac vessels. Returning now to the inner end of the round liga- 586 GYNECOLOGY ment (i. e., at the external inguinal ring) the cellular tissue about it is carefully dissected away well down into the upper part of the labium majus. This com- pletes the dissection of the ''upper pedicle" or chain of lymphatics. The next step is to free the lower chain. This consists in removing the cel- lular fatty tissue around the saphenous and femoral vessels. The lower hp of the inguinal incision is retracted downward to the upper part of Scarpa's tri- angle. If more room is necessary a perpendicular incision may be made extend- FiG. 216. — Dissection of the I^TGTTINAL Region for Cancee of the Vulva. Removal of the upper chain of lymphatics. ing from the inguinal incision over Scarpa's triangle. One dissects then all the cellular tissue from the outer part of the triangle to the labium majus, completely denuding the attachments of adductor longus and pectineus muscles and the femoral vessels. If the tissues have been invaded and are voluminous it is sometimes necessary to tie and divide the saphenous vein. The next step and one of importance is to remove the glandular tissue be- neath the femoral ring. This is accompUshed by cutting across Poupart's OPERATIONS ON THE VULVA 587 ligament (Fig. 217) and through the femoral ring just inside the femoral vein. It may even be necessary to incise the bony attachment of Gimbernat's Hgament. When the cellular tissue of this region has been thoroughly cleaned out the round ligament is then tied and cut at its point of entrance into the peritoneal cavit}^ and the ligament removed with the entire glandular fatty mass attached. In order to make a clean dissection it is necessary to tie the deep epigastric vessels close to their point of origin. Fig. 217. — Dissection of the Ing^tinal Region for Cancer of the Vulva. Exposure of the lower chain of lymphatics by lifting up Poupart's ligament. The red line indicates the direction of the incision which is to divide Poupart's ligament. Exposure of the vessels. The final step is to restore the inguinal canal. The femoral ring is closed by suturing the internal oblique to the femoral fascia. Over this the severed ends of Poupart's ligament are sutured together. Basset recommends leaving in a small drain leading from the deep subperi- toneal space. Both inguinal regions should be dissected in the same radical manner. The second stage of the operation as described by Taussig is as follows : ''Two weeks later the inguinal wounds have healed, usually by first intention. We- now proceed to an excision of the vulva, using neither scalpel nor scissors, but only the cautery-knife. No attempt is made afterward to close the entire 588 GYNECOLOGY ' wound by a dissection of flaps. A half-dozen silkworm-gut sutures are used merely to approximate the skin edges. Thus a considerable surface is left de- nuded. No dressing is kept on the wound after the patient is back in bed. Under the open-air treatment with the occasional assistance of dry heat and the frequent irrigation of the vulvar wound with Dakin's solution, rapid granulation Fig. 218. — DibSECxiox of the Inguinal Region for Cancer of the Vvlva. Poupart's ligament has been divided. The upper and lower chains of glands are being removed en masse. is obtained and hone of the necrosis and infection that otherwise is usually as- sociated with extensive vulvar excisions appears." OPERATIONS ON BARTHOLIN'S GLANDS Very acute abscesses of Barthohn's glands sometimes require incision and evacuation of the pus. The incision in this case should always be made through the skin on the outer aspect of the enlarged gland rather than through the modified membrane on the vaginal side. After subsidence of the inflammatory process the gland should always be removed by a radical dissection, as other- wise it is almost sure to give trouble later, either as a recurrent abscess or in the form of a cyst. Many of the abscesses of Bartholin's glands when the in- OPERATIONS ON THE VULVA 589 flammatory process is not violently acute can be excised without preliminary incision, the decision as to this point being determined by the amount of infiltra- tion or involvement of the surrounding tissues. Cj^sts of Bartholin's glands, even when small, should always be radically excised, otherwise they are sure to recur. |M\ 'Jk(K.V^ N>^ v?6Ya\> Fig. 219. — Dissection of Bartholin's Gland for Cyst or Abscess. The incision is made through the skin outside of the labium minus. The cystic gland is dissected out entire with blunt-pointed scissors. In order to avoid rupturing the cyst the dissection is carried out on the outer side first, the region of the duct being dissected last. Fig. 220. — Excison of Bartholin's Gland. The wound external to the labium minus is closed with deep silkworm-gut sutures. A small rubber drain is placed through a stab-wound, to be removed in thirty-six to forty-eight hours, or later if an abscess has been exsected. The complete operations for both abscess and cyst are practically identical. The patient should be fully anesthetized, for the dissection must alwaj^s be carried deeply into the tissues, and there is, as a rule, troublesome bleeding. The incision is made on the outer surface of the swelling through the skin. An attempt is then made to dissect out the capsule of the abscess or cyst, the outer portion embedded beneath the skin being treated first. The dissection is gradually brought around toward the inner side, where it becomes more diffi- 590 GYNECOLOGY cult on account of the adherence of the thin membrane of the inner side of the labium minus. The area of the duct is approached last, and as the dissection is carried across this portion the tumor usually collapses and discharges its con- tents. It is not always possible to enucleate the entire tumor without ruptur- ing the capsule before crossing the duct; nevertheless, if this can be done, the results of the operation are much more satisfactory. If the capsule has col- lapsed it must be removed from the depth of the wound in ragged shreds, rem- nants of which if left behind are liable to be the source of a future recurrence. In dissecting out a fresh gonorrheal abscess it should be remembered that the pus is often under considerable tension. If the abscess is accidentally rup- tured the eyes of the operator, which are necessarily in a position near the field of operation, are in much danger of infection from the spurting pus. Before closing the wound great care should be taken to stop all the hemor- jhage with ligatures of fine catgut. If the bleeding cannot be controlled in this way, deep sutures may be taken in the bleeding tissues. The dead space left by removal of the tumor is closed for the most part by buried deep sutures. A small drain of folded rubber tissue is left in the bed of the wound leading to a small stab-wound to one side of and below the original incision. The main wound is closed with silkworm-gut sutures deeply placed, the ends of which are shotted. OPERATIONS ON THE CERVIX DILATATION OF THE CERVIX Dilatation of the cervical canal is performed as a therapeutic measure for sterility and dysmenorrhea, and as a preliminary step to curetage of the body of the uterus and repair of the cervix. With the patient in the perineal position, the anterior Hp of the cervix is grasped in the middle by a pair of double hooks (or bullet forceps). Enough tissue should be included in the double hooks to prevent their tearing out and causing a laceration. The best instrument is that devised by Cullen, the hooks of which are mouse- toothed, and by their firmer hold on the tissues cause less tearing than do the ordinary so-called bullet forceps. The cervix is drawn gently down toward the vaginal introitus. Strong traction should be avoided. Dilatation of the non-pregnant uterus is most safely carried out with Hanks' graduated dilators. It is best if possible to secure a set of old-fashioned dilators which have a short thrust with only a shght angle. (The dilators usually sold are too long and too sharply bent.) The first dilator should be passed with extreme care in all cases, for deviations or angulations of the canal, or obstructions from stenosis or growths, may deflect the point of the instrument into and through the uterine tissue. In certain conchtions of atony of the uterus, more especially such as exist after the menopause or during gestation, an instrument may perforate the uterine wall with almost inappreciable resistance. If the first dilator does not discover the direction of the canal at once, a fine probe should be used. When the direction of the canal has been estab- hshed the successive sizes of the dilators are used until the last has been passed. If greater or more prolonged dilatation is desired, as in the treatment of dys- menorrhea and steriHty or of retained products of conception, Goodell dilators may then be used. These must be handled with care, as it is an easy matter to split the side of the cervix with them and cause a dangerous hemorrhage. If the dilatation is being done for exploration or curetage of the endometrium, it need not be carried beyond the passage of the largest Hanks' dilator. The next step is to ascertain the depth of the uterus, and this is done with a measured uterine sound. This is also a dangerous instrument, and one which most often is responsible for perforation of the uterine wall. In order to avoid this accident the sound before being passed should be bent to the same angle as the dilators. In passing it no more pressure should be exerted than is made by the friction of resting it on the forefinger. 591 592 GYNECOLOGY Sometimes a cervix is difficult to dilate, as occurs, for example, in the hypo- plastic anteflexed type of uterus, where there is a dense band of connective tissue at the internal os. The difficulty of passing the sound must be met by strong countertraction on the double hooks in the anterior lip of the cervix, and may result in lacerating the tissue. If such a laceration occurs it should be repaired with fine catgut, for if neglected the wound may become infected and cause a long-standing and intractable cervicitis. In order to avoid the accident of lacerating the cervical lip when it is found that the dilatation is going to be difficult, two pairs of double hooks may be used inserted each on one side of the cervix. If laceration takes places less injury is done, as the wound does not communicate with the mucous membrane. CURETAGE Since our knowledge of the physiologic and pathologic processes of the uterine mucosa has been put on a new scientific basis the use of the curet is much less frequent than formerly. As a curative agent, its principal function is for the removal of products of conception that cannot be extracted in any other way, and occasionally in some cases of hypertrophy or chronic inflammation of the endometrium and for chronic endocervicitis. Its chief use is for the removal of endometrial tissue for the purpose of microscopic examination. After dilatation of the cervix and passage of the sound to determine the depth of the uterus, it is best to explore the uterine canal next with a pair of placenta forceps. These can now be used safely because the direction and depth of the canal is known. The object of the placenta forceps is to discover and remove polypoid growths which may escape detection with the curet. The curet is passed into the canal in the same manner as that described for the sound. It should not be bent at an angle sharper than that of the dilators unless it is being used to remove some resistant material like that of adherent placental tissue. If the object of the curetage is the removal of hypertrophic mucosa the entire uterine canal is thoroughly scraped with a sharp curet until everywhere the sharp scratch of the submucosa, the so-called cri uterine, can be heard. Each time the curet is carried into the uterine canal it should be passed lightly on the finger, but it may be drawn out vigorously. If the object of the curetment is the removal of fetal tissue, it is best to use a blunt wire curet, especially if the retained tissues are infected. The deep scarification of the uterine canal, under such circumstances, may carry the in- fection into fresh lymph-channels and encourage or set up a dangerous puer- peral infection. If in the case of retained products of conception it is difficult to remove all the contents of the uterus, it is better not to err on the side of being too thorough, for the danger of perforating the uterus or of spreading infection OPERATIONS ON THE CERVIX 593 is greater than that of leaving in portions of fetal tissue, which are usually ex- pelled spontaneously. This may occasionally require a later curetment, when the uterus is less liable to infection or perforation. When the curetage is being employed for diagnosis a small sharp curet is used, which explores every part of the uterine canal. If the tissue removed is suggestive of malignancy, the curet is purposelj^ carried deep into the uterine wall in order to be able to tell by microscopic examination whether or not the disease has invaded the myometrium. In cureting for diagnosis the placenta forceps must always be used in order not to miss any polypoid growths. Curetage of the cervix for endocervicitis should be done with a small, very sharp curet, and the cureting should be confined to the cervical canal, for if the fundus is included there is danger of spreading the infection of the endocervical glands. After cureting the endometrium no further treatment is usually necessary, it being important to avoid intra-uterine douches and chemical applications. If there is severe bleeding, it may, under rare circumstances, be necessary to pack the uterus with sterile gauze, though such bleeding can usually be con- trolled by packing the vagina tightly against the uterine vessels. If it seems likely that bits of tissue have been left in the uterine cavity, these may be wiped out with a strip of gauze carried, preferably, on a Burrage tampon extractor. It should be remembered, however, that the uterus is frequently perforated by this wiping-out process. Curetment for cancer of the cervix is best done with a large, comparatively sharp curet, which, however, must be used with great care when in proximity to the bladder or posterior culdesac, or the uterine vessels. Cases for curetage should always be subjected to a thorough surgical prepara- tion, and should, with few exceptions, be anesthetized. If patients are properly prepared, and the operation done under antiseptic precautions, simple puncture of the uterus ordinarily does no harm, and it is usually not necessary to sew up the wound through a laparatomy incision. The patient should, however, be watched carefully for possible hemorrhage. Larger wounds, such as are made b}' the curet or placenta forceps, especially in removing fetal tissue, may allow the gut to prolapse into the uterine canal. Perforation of the posterior culdesac made while cureting cancer of the cervix is almost inevitably followed bj^ fatal peritonitis. TRACHELOPLASTY Repair of the cervix is indicated in conditions of erosion, eversion, and inflammation, and is intended to restore the organ as nearly as possible to its normal appearance and tissue condition. Most operations for repair of the cervix are based on the operation originally suggested by Einmet. The technic of the operation is as follows : 38 594 GYNECOLOGY With the patient in the perineal position, dilatation of the cervix is first per- formed in order to make the tissue softer and more pliable and to give more room for the passage of ligatures. The anterior and posterior lips of the cervix are grasped each with double hooks placed exactly in the middle line, as indi- cated by the central raphe, from which radiate the branching folds of the cervical mucosa (arbor vitse). The double hooks are then brought closely together so as to approximate the two cervical lips. In cases of laceration this gives an accurate idea as to whether the cervix has been torn on one or both sides. .It is somewhat more common to find that the tear is unilateral, and that the repair need be carried out only on one side. This point is emphasized because the beginner is apt to place the traction forceps midway between the ends of the tear and denude on each side of the forceps, instead of placing the forceps in the midline of the cervix and denuding only where the tear indicates. If the latter method of technic is not carried out the operation will result in a crooked canal which is apt later to cause either an atresia of the lumen or a fistulous opening in one end of the wound. Fig. 221. — Tracheloplasty. Unilateral Tear. Heart-shaped outline of the area to be denuded. When the location of the tear or tears has been definitely made, the limit of the denudation at the os is marked with the scalpel on one or both sides of the traction forceps. In marking these points it must be borne in mind that the exit of the new canal must be funnel shaped, so that it is better to err on the side of getting it too wide than too narrow, otherwise there is danger of atresia in later life when the cervix becomes atrophied. These important landmarks having been made, the lips of the cervix are drawn widely apart and the area of denudation outlined with the scalpel. This area simply includes the sides and angle of the laceration (Fig. 221). The OPERATIONS ON THE CERVIX 595 outside edge is a continuous line from the mark on che anterior lip to that of the posterior hp in the smooth vaginal portion of the cervical membrane; the inside edge constitutes a hne between points in the rough endocervical mucous membrane. The width of the denudation area is usually about f inch, corre- sponding to the natural thickness of the cervical wall. It is important that the figure of denudation be symmetrically drawn on the two lips, so that when they are approximated for suture there will be perfect coaptation of the wound edges. The denudation of the marked-out area is made with a small scalpel, SvjtovcUo.i Fig. 222. — Tracheloplasty. Unilateral denudation of cervix and placing of stitches. beginning from the mucous membrane, and should be carried out so that the tissue to be removed from both lips and the angle between them is taken off in one piece. If there is a great deal of scar-tissue beneath the denuded surface it may be dissected out in small wedge-shaped pieces. When the laceration is deep, denudation of the angle usually causes some bleeding from the cervical artery. This should be controlled by a • ligature passed into the tissue with a needle before the stitches are placed, for if this bleeding is neglected it may give trouble during the convalescence, sometimes 596 GYNECOLOGY requiring a secondary operation. If there are several lacerations, they should be denuded before putting in the stitches. The placing of the sutures may cause considerable embarrassment on the part of the operator if the laceration is a deep one, or if the cervix cannot be drawn well down to the introitus. This difficulty may, however, always be avoided by the proper use of special needles. The best needle is that originally devised by Emmet. It has a slight curve, and can be forced through the tough fibrous tissue of the cervix without danger of breaking, an accident which may be very troublesome. ^ The placing of the first suture is the most important. If the angle is diffi- cult to reach, it is best to use a ''double header" suture — i. e., one with a needle on each end. The first needle is passed from within outward on one lip, so that it will issue well beyond the angle of denudation (Fig. 222). The other needle Fig. 223. — Unilateral Teacheloplasty Fig. 224. — Lacerated Cervix with One Lip Completed. Longer than the Other. is then passed in a similar way in the other fip, and the two ends are fastened in a clamp. By passing the suture in this way no difficulty is encountered, and it is placed so high beyond the angle that when tied it serves to control any cervical vessels that might otherwise bleed later. The other sutures are then placed in like manner, the ''double header" no longer being necessary after the first one or two stitches. It is best to clamp the ends of the sutures without tying until they have all been placed. Sutures are then placed on the denuded area of the other side if a double laceration is present. When all the sutures are in place the traction forceps are removed and the sutures tied. The best suture material is No. 1 chromicized catgut. Not infrequently one fip, usually the anterior, is longer than the other, so that the denuded areas do not match when approximated (Fig. 224). If the difference in length is only sfight, the difficulty may be obviated by placing a tenaculum in the side of the longer fip, a short distance from the angle of denudation, and drawing it sharply outward. This creates a new angle and makes the two lips of equal length. One lip, however, may be so much longer than the other that this maneuver will not suffice to make their length OPERATIONS ON THE CERVIX 597 equal. In this case the end of the longer lip may be amputated by a wedge- shaped incision and the edges sewed with catgut. In this way the lips are easily made of equal length. Fig. 225. — Tbacheloplasty. Method of creating a new angle when one Up is longer than the other. If this cannot be done on account of the stiffness of the tissues, a wedge-shaped piece may be removed from the end of the longer lip. Fig. 226 — Tracheloplastt. Creating a new angle when one lip is longer than the other. When the hypertrophy and elongation of one lip is very marked the preceding operation is not sufficient to equalize the two lips. It is then necessary to ampu- tate the elongated lip. This is done by removing it by a wedge-shaped incision (Fig. 227). The edges of the wound may then be easily approximated by a few 598 GYNECOLOGY interrupted catgut sutures (Fig. 228). When the amputation wound has been closed the two hps are equal in length and the operation for the laceration is carried out as in the ordinary case. Sometimes the hypertrophy of the submucous connective tissue along the center of the canal is so great that the denuded areas of the sides cannot be approximated without too great tension on the stitches (Fig. 230). To obviate Fig. 227. — Tkacheloplasty. Amputation of an elongated lip. Fig. 228. — Tkacheloplasty. Amputation of an elongated lip. Closure of wound. Fig. 229. — Tkacheloplasty. Amputation of an elongated lip. Closure of wound. this a transverse wedge may be removed from one or both lips, and the edges of the mucous membrane sewed with catgut (Figs. 231, 232). When this is done it will be found that the denuded areas can be approximated without difficulty. When the tear is stellate there are more than two lacerations and the repair looks somewhat complicated. By sewing up each tear as above no great difficulty is encountered, a smooth result depending on the ingenuity of the operator. OPERATIONS ON THE CERVIX 599 Fig. 230 Ectropion of the Cervical Mucous Membrane After a Severe Bilateral Laceration. J)^nu6e6 J/rea "ff'^.r/i ov to o . ope.t\mo<;, Fig. 231. — Tracheloplasty. Removal of wedge-shaped piece from the everted mucous membrane. (Baker's method.) Fig. 232. — Tracheloplasty. Baker's method of reducing redund- ant and everted mucous membrane by the removal of wedges. AMPUTATION OF THE CERVIX The chief indication for amputation of the cervix is in procidentia, where the cervix is usually elongated and attenuated. The operation of amputation should not be preceded by dilatation, a pro- cedure which so stretches and thins out the canal that it is difficult to avoid tearing into it in the process of stripping out the cervix. A sound is first passed to determine the depth of the uterus and cervix and to ascertain approximately the 1-vel of the internal os. A sound is then passed through the urethra into the bladder fold, where it is reflected from the cervix. This fold is usually found on the anterior wall of the cervix very near the external os, and a knowledge of its exact position is very important. 600 GYNECOLOGY Traction hooks are then placed one at each corner of the tear and one in the middle of the cervix, including both lips and sealing the opening, so as to avoid the expulsion of any endocervical discharge during the operation. With the cervix held out in strong traction a circular incision is made just beyond the reflection of the bladder fold. The assistant exercises counter- traction on the vaginal mucous membrane, and the circular dissection is carried out with a knife until the small tubular core of the cervix is reached, great care Fig. 233. — Amputation of the Cervix. The cervix has been drawn well out from the vagina. The cervix is being circumcised at^' (the junction of the bladder with the portio vaginalis. being taken not to injure the bladder fold. The fold of Douglas' pouch on the posterior wall of the cervix is usually not in danger in this dissection, as it is attached higher up than the bladder. After the core of cervix is reached it will be found that the tissue of the uterine wall can easily be stripped back from it by gauze dissection (Fig. 233), the knife being occasionally necessary to sever OPERATIONS ON THE CERVIX 601 especially resistant connective-tissue fibers. This dissection is carried to within a short distance of the internal os, as determined by the length of the 'cervix pre- viously ascertained. The two traction forceps, are then inserted in the sides of the cervical tube close to the limit of the dissection, and held by the assistants. The cervix is drawn strongly outward by the remaining traction forceps and the Fig. 234. — Amputation of the Cervix. The elongated cone-like cervix has been stripped out of its bed and is now ready for amputation. tubular core is amputated by a wedge-shaped incision, so that the uterine por- tion will be convex. This is an important maneuver, because it leaves a con- venient stump for the insertion of stitches through the cervical mucous mem- brane — the stump being held forward by the two traction forceps. If this precaution is not taken, the cervical mucous membrane will retract sharply 602 GYNECOLOGY back, and be so hidden from view that it is difficult to place sutures in it. During the dissection the bleeding may be little or great, depending on the amount of congestion in the individual case. The bleeding points are now tied, preferably with No. catgut. The placing of the sutures should be carried out with great precision, for it is to the exact approximation of the wound edges that the operation owes its ifo.S JTo.l %>.z ^vCort ot Ce-cvix. Vl^CS.SCNiCi. c^ Fig. 235. — Amputation of the Cebvix. The cervix has been amputated so that the stump juts from the surrounding tissue in the form of a wedge. Three sutures have been introduced into the anterior lip of the cervical stump and contin- ued to the vaginal mucous membrane, taking in a little of the intervening tissue. Three other corre- sponding sutures are next passed through the posterior cervical wall in the same way. By the tying of these six sutures the mucous membrane of the cervical canal and that of the vagina are exactly approximated. (See Fig. .?37.) success. Inaccurate coaptation almost invariably results in local sepsis, with sometimes a very marked constitutional reaction. The cervical stump is held in the middle line by the traction forceps. Three sutures are placed through the anterior lip of the cervical stump including the mucous membrane, and carried to the anterior edge of the vaginal flap (Fig. 235). OPERATIONS ON THE CERVIX 603 Three sutures are then passed through the posterior hp of the cervical hp to the posterior edge of the vaginal flap. Next a suture is passed from the anterior vaginal flap across, including the left cervical angle, and issuing from the posterior flap at a point directly opposite to that from which it started. The ends of the suture are clamped and drawn strongly to the right, the traction forceps being removed (Fig. 236). A long-pointed tenaculum is then inserted in the edge of the vaginal flap at a point exactly between the entrance and exit of the last placed cross-suture and drawn strongly outward. Cross-sutures are V/.'PGKo.^/e,*^ . Fig. 236. — Amputation of the Cervix. Manner of introducing the lateral sutures so as to secure exact approximation. The first suture is drawn sharply to the opposite side and a tenaculum placed in the angle of the vaginal wound. The sutures can then be accurately introduced, so as to avoid any puckering or clumsy coaptation of the wound edges. The sutures uniting the mucous membrane of the cervix and that of the vagina (as in Fig. 235), though applied first, are omitted in this drawing for the sake of clearer illustration. now placed from the anterior to the posterior flap, each one including some of the loose paracervical tissue to avoid leaving a dead space. The same pro- cedure is then carried out on the other side of the cervical stump. When the stitches are tied it will be found that exact coaptation has been secured. By employing this technic sepsis will rarely occur and scar formation or atresia of the canal need not be feared. The operation just described is a high amputation of the cervix. Low am- putation is done in the same way for removal of the cervix when not elongated, the dissection being carried up only a short distance. 604 GYNECOLOGY Fig. 237. — Amputation of the Cervix. Hegar's method, showing the manner in which the approximation sutures are introduced. The sutures on each side are passed deeply into the paracervical tissue so as to assist in controlling hemor- rhage, the most important blood-vessels lying in these areas. Fig. 238. — Amputation of the Cervix. Sutures tied and operation finished. SCHRODER'S OPERATION Schroder's operation is used for intractable endocervicitis, and is designed ■for the complete removal of the endocervical mucous membrane. The cervix is first seized with two pairs of double hooks or traction forceps, one on each lip of the cervix, and drawn down to the vaginal introitus. The cervix is then split on each side with the scalpel, the incision being carried well up toward the internal os, in a manner simulating a deep bilateral laceration. Bleeding points are clamped and tied. The lips are then held widely apart by the traction forceps. From each lip a transverse wedge-shaped piece is taken, including all the mucous membrane excepting a narrow margin near the internal OS, into which sutures can be placed. The shape of the wedge of tissue to be OPERATIONS ON THE CERVIX 605 Fig. 239. — Cervicitis and E^^)ocERVICITIS, with Formation of Naeothian Cysts. Fig. 240.^ — Schroder's Operation for Extir- Fig. 241. — Schroder's Operation for Extir- pation OF THE EndOCERVIX. First step. The cervix is being cut bilaterally to the level of the internal os. PATION of THE EndOCERVIX. The bilateral incision has been made. The mucous membrane of the posterior lip has been removed and the mucous membrane of the an- terior lip is being dissected in the same manner. removed will be understood by reference to Fig, 241. The cervical mucous membrane of the vaginal portion of each lip is approximated to the margin of 603 GYNECOLOGY' endocervical mucous membrane by two catgut sutures. In approxirriating these edges the hps are folded in on themselves, so that the cervical canal is now Fig. 242. — Schroder's Operation for Extir- pation OF THE ENDOCERVIX. The mucosa has been removed from both lips. On the anterior lip the mucous membrane of the cervical canal has been united to that of the portio by three sutures. The same process is being repeated on the posterior lip, the middle suture having been passed. Fig. 243. — Schroder's Operation for Extir- pation OF THE EndOCERVIX. The mucosa has been removed and the ap- proximation of the cut edge of the cervical mucous membrane to that of the portio has been secured by the sutures on each lip. The angles are being denuded, the rest of the opera- tion being carried out exactly as an Emmet's tracheloplasty. lined with the epithelial surface of the vaginal portion. Before tying the sutures the traction forceps must be removed, but the cervix may be still held Fig. 244. — Schroder's Operation. Angles ready for suture. Fig. 245. — Schroder's Operation pleted. COM- down by applying one of them to the anterior wall of the cervix sufficiently high to avoid exerting any tension on the stitches. When the anterior and posterior walls have been folded in and the stitches tied it will be found that OPERATIONS ON THE CERVIX 607 the cut surfaces on the sides of the cervix now present the appearance seen when a bilateral laceration has been denuded and ready for the placing of the sutures. The sutures are then placed in the manner described for a tracheloplasty. In passing the sutures which fold in the cervical Hps a small full-curved needle should be employed, and great care should be exercised to avoid tearing through the endocervical mucous membrane, for if this happens it is difficult afterward to place the stitch so that it wih hold securely. The success of the operation depends very largely on the skilful placing of these mucous membrane sutures, for if they give way the result is a long and cicatricial process of healing. Schroder's operation is a radical but almost certain cure for endocervicitis, but it is difficult of performance and should not be attempted except by those experienced in plastic surgery, for if improperly done the result is a troublesome mutilation of the cervix. OPERATIONS ON THE VAGINA ANTERIOR COLPOPLASTY. (AUTHOR'S METHOD.) The description of this operation can be understood only by reference to the accompanying cuts and cUagrams. ViVGccvw«.S- FiG. 246. — Operation for Ctstocele. (Author's method.) In order to expose the cystocele before beginning the denudation, tenacula are placed in the upper angles of the introitus and drawn upward and outward. This brings the cystocele into a convenient position for operation. The field of operation is exposed by inserting tenacula in the upper angles of the introitus made by the anterior fold of the vestibule with the lateral walls of the vagina (Fig. 246). By drawing the tenacula outward the whole cysto- 608 OPERATIONS ON THE VAGINA 609 cele is brought into full view. The first step is to map out the area for denuda- tion by selecting and marking the angles of the figure. The points F and D (Fig. 247) are first chosen by picking up the mucous membrane with two pairs of thumb forceps and drawing them together in the middle line. The points should be selected so that when approximated in front of the cervix the cysto- cele is entirely reduced and the tension is suflScient to form a sort of bridge in front of the cervix, forcing it backward. By pinching the forceps together the Fig. 247. — Anterior Colpoplasty. points are marked in the mucous membrane. The points G and C are next selected. These are also chosen so that when approximated in the middle line the anterior part of the cystocele will be approximated. These points, G and C, are always closer together than F and D, because the vagina should not be drawn too tightly near the introitus. The point E is in the central fine, just at the reflection of the vaginal mucous membrane from the portio of the cervix. When the points have been carefully marked, the area included between E, D, C, G, and F is denuded with Emmet's scissors. Experience has shown 39 610 GYNECOLOGY that this method of denudation is safer, more rapid, and more satisfactory than removal of the mucous membrane by the sphtting of a flap. When the area has been denuded a suture is first placed, entering the mucous membrane at D^ Fig. 248. — Operation for Cystocele. Anterior Colpoplastt. (Author's method.) The amount of cystocele is determined by folding the redundant wall in the manner here depicted. By pressing the thumb forceps four landmarks are made in the mucous membrane which serve as a guide to the denudation. These four marks correspond to the points A, B, C, and D in the diagram (Fig. 247). passing across the cystocele, and issuing at F. The ends of the suture are clamped and drawn sharply upward by the assistant. This approximates and brings into easy reach the edges E-F and E-D, which are then united by several inter- rupted sutures. OPERATIONS ON THE VAGINA 611 The first stage of the operation is now completed, and should result in reduc- ing the posterior part of the cystocele and drawing a tight bar of tissue across the front of the cervix. The second stage of the operation is directed to the anterior part of the cystocele which includes the urethra. This portion is usually protuberant, though the prominence of the tissue is often due rather to hypertrophy of the vaginal wall than to hernia of the urethra. A point A is selected several centimeters from the urethra, which will, without too great tension, meet the points G and C when brought together in Fig. 249. — Operation for Cystocele. (Author's method.) Stitches placed and readj- for tjing. the middle line. The points H and B are determined by the insertion of the tenacula. The area included between G, H, A, B, and C is then denuded. A crown suture entering near the angle C, including the angle A in the manner of a mattress suture and issuing at G, is then passed and the ends clamped. By draT\dng this suture sharply to the left the edges H-G and H-A are ap- proximated and sewed with interrupted sutures, and by drawing the suture sharply to the right the edges A-B and B-C are united in a like manner. The 612 GYNECOLOGY Fig. 250. — Operation for Ctstocele (Ai^thor's Method). Buried running stitch, implicating the bladder wall, to be used in cases of marked cystocele. The stitch should be passed so as to include the fascial investment which lies between the bladder and vaginal walls. OPERATIONS ON THE VAGINA 613 crown suture is then tied, two or three stitches placed between G and F, and the operation is completed. By carrjdng out this technic the cystocele is reduced throughout and the wound edges are all accurately approximated. Fig. 251. — Oper.\tiox for Cystocele. (Author's method.) Sutures tied, operation completed. The anterior vaginal wall should at the finish of the operation have a concave contour. If the c3^stocele is very marked it is a good plan to enfold the bladder by a row of buried No. 00 catgut sutures before placing the main sutures. It should be remembered that this operation, Hke all plastic operations on the anterior wall, cannot be depended on of itself to maintain a permanent reduction of the cystocele if there is present at the same time a prolapse of the uterus. As prolapse and cystocele usually go hand in hand, the operation for cystocele is valuable chiefly when used in combination with an appropriate suspensory operation for rehef of the prolapse. 614 GYNECOLOGY OPERATION FOR FUNCTIONAL INCONTINENCE OF URINE Numerous operations have been devised in times past for functional incon- tinence. One type of operation is based on the principle of narrowing the ex- ternal orifice, another of reduplicating and folding in the urethra along its entire d ."Bent Soonbi y- viounb "V^^GrcvOeS- FiG. 252. — Kelly's Operation for Functional Incontinence of Urine, Combined with the Author's Anterior Colpoplasty. The anterior vaginal wall has been denuded as for a cystocele, except that the corners of the flaps have been dissected up in the region of the neck of the bladder and of the urethra. The drawing shows the method of determining the position of the neck of the bladder. A uterine sound is slightly bent at the end and introduced into the bladder. The neck of the bladder can easily be perceived as the end of the sound passes it. course (Pawlik, Duret). Gersuny advocated dissecting out the urethra and twisting it so as to narrow the canal. In still another form of operation the urethra is transplanted so that the meatus is brought near the clitoris (Albarran, OPERATIONS ON THE VAGINA 615 Dudley). In this way the urethra is made to describe a sharp bend around the symphysis. The author has tried all of these methods, and finds that, though temporarily successful, they usually result in recurrence after a few months. The operation de\dsed by Kelly, however, produces a high percentage of per- manent cures. This operation depends for its success' on suturing together the lacerated or relaxed tissues of the sphincter at the neck of the bladder. Inasmuch as a considerable proportion of women with functional incontinence also have a cystocele, we have successful!}' combined Kelly's operation with the f^l.^Oxayes — Fig. 253. — Operation for Fuxctioxal Ixcontinence of Urine. Kelly's Method Combined "mTH THE Author's Operation of Anterior Colpoplastt. Sutures have been placed and tied, narro^-ing the internal orifice of the urethra. Two linen sutures are shown placed in the unjdelding tissue at the sides of the urethra. When these sutures are tied a firm supporting bridge is created, guarding the first line of sutures. author's anterior colpoplasty. The operation is as. follows : The anterior vaginal wall is denuded in exactly the same way as in the operation for c^^stocele de- scribed on page 609. When the denudation has been completed, the urethra is then dissected out with blunt curved dissecting scissors. This leaves the flaps at the upper part of the operative field free. Tenacula are then inserted in the three converging angles and the flaps drawn sharplj' outward. In this way the 616 GYNECOLOGY urethra at its entrance into the bladder and the surrounding tissue are widely exposed to view (Fig. 253). A uterine sound, with its point slightly bent, is now introduced into the bladder. As the point of the sound passes the internal orifice of the urethra it gives a slight but very perceptible jump. This point is readily marked by feeling the end of the sound from the side of the vaginal wound. By pressing backward on the handle of the sound the exact location of the bladder neck can be kept constantly in view. Several interrupted sutures ?! Gravies- Fig. 254. — Kelly's Operation for Incontinence Combined with the Author's Anterior Col- POPLASTY. Operation Completed. of fine linen are then passed, picking up ragged tissues on each side of the urethra at the level of its entrance into the bladder. These sutures are tied in the middle line, and serve to compress the internal orifice, as can be plainly tested by drawing out and again inserting the bent sound. The sutures thus placed are reinforced by two or three other sutures of linen, which pick up firm unyield- ing fibrous tissue well up on the sides of the urethra. The operation for cystocele is then continued in the usual manner, provision being made to give a little extra tightness at the point corresponding to the neck of the bladder. When finished the appearance is like that seen in Fig. 254. OPERATIONS ON THE VAGINA ANTERIOR COLPOPLASTY (CLARK'S TECHNIC) 617 In the operation of anterior colpoplasty just described the operative field is exposed by simple denudation of the vaginal mucous membrane. Another type of operation for cystocele consists in separating completely the vaginal membrane from the bladder wall. Of these two methods we prefer the former, as it is more rapid and involves less danger from bleeding or injury to the bladder NVlP.trr- Fig. 255. — Antehior Colpoplasty. Initial incision of vaginal mucous membrane. Fig. 256. — Anterior Colpoplasty. The mucous membrane of the vagina has been incised and the vaginal and bladder walls freely separated by blunt dissection. wall, while the ultimate results are equally as good as those from the second more radical method. Many surgeons, however, prefer the flap-splitting procedure. The anterior vaginal wall is first seized with tenacula at the most prominent part of the cystocele. The tenacula are drawn sharply out, leaving a ridge of tissue which is incised for a short distance between the tenacula, as in Fig. 255. With the aid of the knife and with blunt dissection the incision is carried into the tissues until the plane of cleavage between bladder and vagina is reached. The 618 GYNECOLOGY two surfaces are then separated by blunt dissection so as be extended in both directions. Anteriorly the incision is meatus so as to include the prominence usually described riorly the incision is carried to the junction of cervix and the incision are seized with tenacula. The next step is to as possible the anterior vaginal wall from the bladder. to allow the incision to carried well toward the as urethrocele. Poste- bladder. The ends of separate as completely This is done mostly Fig. 257. — Anteeior Colpoplastt (Clark's Technic). Two or three mattress sutures are placed well out on the sides and in relation to the neck of the bladder. In the drawing they are repre- sented somewhat nearer the meatus than they should be. These sutures are placed for the purpose of relieving functional incontinence. W.p.Q, Fig. 258. — Anterior Colpoplastt (Clark's Technic). The mattress sutures have been placed. The hernial protrusion of the bladder has been infolded by a buried Gushing stitch, which is passed so as to include the investing fascia which lies between the vaginal and bladder walls. by blunt dissection with the finger, though occasional tissue fibers require cutting with scissors. Gauze should not be employed as it increases the danger of in- juring the bladder. All bleeding points should be controlled at once and tied. The separation is carried out well down on the sides of the cystocele. The urethra in its upper third at the base of the bladder should be thoroughly exposed. In stripping the vagina from the bladder care should be taken to leave the thin OPERATIONS ON THE VAGINA 619 aponeurotic membrane which will be found investing the bladder. This will be seen to be slender and attenuated at the center of the cystocele, but strong and well marked on the sides. The next step is a technical maneuver introduced by J. G. Clark, which is designed to control the functional incontinence from which many patients with cystocele suffer to a greater or less extent. Two mattress sutures of No. 1 catgut are placed well up into the angles on the sides of the urethra \vl MyOrr—- Fig. 259. — Anterior Colpcplasty (Clark's Technic). The mattress sutures have been tied. The excess of vaginal mucous membrane is being trimmed away. \ / Fig. 260. — Anterior Colpoplasty (Clark's Technic). The vaginal wound is closed with interrupted catgut sutures. and crossing the urethra near its junction with the bladder (Fig. 257). The ends of the sutures are clamped and not tied until all the external sutures are placed. The next step in the operation is to implicate the hernial protrusion of the bladder by a continuous No. 1 catgut suture. Clark's method of employing the Cushing stitch is an excellent one. In applying the implicating stitch it should be carried well out on the sides of the protruding bladder and include the aponeu- rotic investiture mentioned above, for it is on this fascial support that the final 620 GYNECOLOGY success of the operation largety depends. When the imphcating stitch has been apphed it will be found that there usually exists a greater or less excess of vaginal membrane. This excess of membrane is then trimmed off. The amount of membrane to be removed requires good judgment. Care must be taken not to cut away too much, for if the edges of the wound are approxunated under too great tension it may favor the later formation of obstructmg and pauiful scars in the vagina. The wound is closed with interrupted sutures of No. 1 chromic gut. COMBINED AMPUTATION OF CERVIX AND ANTERIOR COLPOPLASTY The f oho wing operation entails a more extensive anatomic dissection than does the Hegar's amputation combined with a simple anterior colpoplasty, and Fig. 261. — Amputation of Cervix and Anterior Colpoplasty (Studdiford). The vaginal mucous membrane over the cystocele has been incised and the vagina and bladder walls freely separated bj^ blunt dissection. The cervix is being circumcised. should not be attempted by an inexperienced operator. The technic here de- scribed is in general that recommended by W. E. Studdiford. OPERATIONS ON THE VAGINA 621 The cervix is grasped with double hooks and drawn strongly outward and downward so as to expose the entire cystocele. A median incision is made through the vaginal mucous membrane from a point | or f inch below the meatus to the junction of the vagina with the portio vaginalis of the cervix. The plane of cleavage is found between the vaginal and bladder walls >/\<.^-(cXCvMtS Fig. 262. — Amputation of Cervix and Anterior Colpoplasty (Studdiford). The bladder has been exposed and stripped back from the cervix. In the case from which this drawing was made the cardinal ligaments were exposed on the right. On the left they had been torn away during the process that led to the condition of prolapse. and the vagina stripped away widely on each side of the central incision. It is of importance to carry this sphtting of the two walls far out on the sides of the cystocele, and it should be especially thorough at the level of the neck of the blad- der. The cleavage of the two walls is accomplished by the gloved finger and with bknt dissection. Many use gauze to hasten the dissection, but this technic adds much to the danger of rupturing the bladder wall. 622 GYNECOLOGY When the dissection of the surfaces has been completed the cervix is cir- cumcised at the point of junction of the vagina and portio. The vaginal flaps are seized in tenacula and drawn outward and the dissection of the flaps con- tinued behind the cervix. This gives a very free exposure to the bladder, which is now stripped back until the level of the internal os is reached. The extent of this part of the dissection depends on the length of the cervix, which in marked Pig. 263. — Amputation of Cervix and Axterior Colpoplasty (Studdiford). The hernial protrusion of the bladder has been infolded by a Gushing stitch. cases of procidentia is usually considerable. The cervix is still further freed laterally and posteriorly. As the elongated cervix is developed the fibers of the important cardinal ligaments are brought into view, unless they have been torn or stretched away during the process of the uterine prolapse. When the cervix has been fully developed attention is directed to the bladder. A Gushing stitch is applied well out on the sides of the cystocele so as to infold the central part of the protruding cystocele. Care should be taken that the OPERATIONS ON THE VAGINA 623 suture. includes at each bite a firm hold of the fascia which invests the bladder. In passing the stitch at the level of the neck of the bladder the needle is carried deeply into the firm tissue which Hes at the sides of the urethra. This serves to rectify the functional incontinence with which many of these patients are troubled. It is a good plan at this stage to introduce the retention mattress stitch depicted on page 618. When the protruding cystocele has been implicated the amputation of the cervix follows as the next step. V/.PGr^ Fi6. 264. — Amputation of the Cervix and Anterior Colpoplasty (Studdiford). The cervix has been bisected and the two lips are to be amputated by wedge-shaped incisions. The cervix is first bisected by a lateral incision up to the point selected for the amputation. The lips are drawn apart as in Fig. 264. Each lip is separately amputated by a wedge-shaped incision as depicted in the drawing, so as to leave two pouting projections on each Hp (Fig. 264). The object of this is to secure an everting tube-shaped opening for the uterine canal. Two catgut sutures are placed first through the posterior cervical lip-stump 624 GYNECOLOGY and into the vaginal wall of corresponding points (Fig. 265) and tied. Two sutures are then placed through the anterior stump and including the angles of the vaginal flaps at each side of the original longitudinal incision. Sutures are placed at the angles of the cervical stump and into the edges of the mucous mem- brane on each side (Fig. 266). The final step is to complete the cystocele opera- fduc memb Fig. 265. — Amputation of Ceevix and An- terior COLPOPLASTY (StUDDIFORd). The cervix has been amputated. The mucous membrane of the endocervix is being united to the vaginal mucous membrane. Note the manner in which the lips of the cervical stump are included in the sutures. \\l,P.&r-N Fig. 266. — ^Amputation of Cervix and An- terior Colpoplasty (Studdiford). The stitches in the cervical stump have been tied. The edges of the vaginal mucous membrane are being coaptated by a subcutic- ular stitch. tion by uniting the two flaps of vaginal wall. In most cases the tissue is redun- dant and should be judiciously trimmed off. The edges may be united by a subcuticular running Gushing stitch or by interrupted sutures, preferably the latter. OPERATIONS ON THE VAGINA 625 EMMET'S PERINEOPLASTY. (AUTHOR'S TECHNIC.) First Step. — The posterior wall of the vagina is grasped with a pair of Cullen hooks at a point which when approximated to the anterior vaginal wall wiU touch it at the junction of the anterior and middle thirds of the urethra. If a cystocele has been performed by the method described on page 608 the point will correspond to the crown stitch on the anterior wall. A tenaculum is then placed just inside the opening of the left Bartholin's gland and drawn sharply outward, \\t.^t^- |%C\V>C*^ Fig. 267. — Operation for Laceration- of the Perineum. (Emmet's method.) Exposure of the lateral sulci and external perineum. Tenacula are placed at the orifices of the ducts to Bartholin's glands and drawn outward. A tenaculum or bullet forceps seizes a point on the posterior vaginal wall which when approximated to the anterior vaginal wall will touch it at the point of junction of the middle and outer thirds of the urethra. In denuding the lateral sulcus a tenaculum is placed at the natural angle formed by exposing the sulcus. (See Fig. 268.) while the traction forceps attached to- the posterior wall is drawn in the opposite direction. This exposes a triangular depressed area or sulcus with the apex inside the vagina. The size of this area represents the amount of separation of the anterior fibers of the levator ani muscles (puborectalis) from the sides of the rectum. In the normal perineum, or one in which there has been no separation of the puborectalis, the triangular sulcus is either absent or insignificant. A tenaculum is placed in the apex of the triangle. The instruments attached to the three angles are drawn strongly in divergent directions, so that the 40 626 GYNECOLOGY triangle is mapped out by the tense folds of mucous membrane between them. Denudation of the triangle is best performed with Emmet's scissors, which first cut smoothly along the tense lines of mucous membrane and then remove the intervening tissue. The denudation can be done very rapidlj^ by this method. The tenaculum forceps on the posterior w^all are then drawn in the opposite direc- tion and a tenaculum placed at the opening of the right Bartholin's gland. The instruments are drawn apart and the triangular sulcus of the right side exposed. The two triangles are rarely alike, as the separation of the puborectalis muscle is nearly always greater on one side than on the other. "When this area is denuded "T^ec<;oce\(L-' Fig. 268. — Operation for Laceratiox of the Perijjeum. (Emmet's method.) The left lateral sulcus has been exposed and denuded. in the same mariner as that of the other side, the traction forceps is drawn upward toward the pubes in the middle line, while the tenacula in Bartholin's ducts continue to exert traction outward in opposite directions (Fig. 269). By this maneuver a third triangle is exposed corresponding to the so-called external perineum. This area is denuded, the first strip of membrane being removed b}^ cutting smoothly from one tenaculum to the other. All important bleeding points of the exposed surface should be tied with fine catgut. Beginning now on the patient's left the inside stitches are placed with the purpose of closing up the sulcus caused by the rupture of the puborectalis muscles, and restoring the former lateral vaginal support of the rectum. The OPERATIONS ON THE VAGINA 627 proper placing of these sutures is of supreme importance when there is any considerable amount of rectocele present. The triangular denuded area is now exposed by traction on the forceps and tenaculum. A catgut suture is then introduced, beginning at the outer side of the apex of the triangle. It is carried directly toward the operator, dipping well into the levator ani muscle, and is brought out in the external perineum. It is then reintroduced in the side Fig. 269. — Operation for Lacerated Perineum. (Emmet's method.) The two lateral triangles have been denuded and the third triangle of the external perineum is being exposed for denudation. The first cut with the scissors is in an even curving direction from tenaculum to tenaculum — the intervening tissue is then removed. of the rectal portion, quilted superficially in the tissue, and carried directly backward toward the apex, where it emerges in the mucous membrane opposite the point from which it started. It is thus seen that the suture takes a V-shaped course, with the apex of the V in the external perineum, one leg of the V in the levator ani muscle, and the other in the side of the rectum (Fig. 270). It therefore reproduces quite faithfully, when tied, the attachment of the pubo- rectalis muscle. Two or three more stitches are then introduced in like manner. 628 GYNECOLOGY If there is a rectocele present, the suture, which is quilted into the rectal portion, is curved around more and more toward the front, so that the last suture reaches the middle hne (Fig. 271). The suture ends are clamped and the triangular sulcus of the other side is treated in the same manner. When all the sutures have been tied it will be found that the rectocele has entirely disappeared. By employing this method it is possible completely to reduce a rectocele of any size, with only a rare recurrence, and it is this part of the Emmet operation Fig. 270. — Operation for Laceration of the Perineum. (Emmet's method.) The denudation is complete. Sutures have been introduced in the left lateral sulcus. They are brought outward toward the external perineum, and then inward, making a V shape with the apex in the external perineal region. which makes it superior to others for the treatment of rectocele and extensive relaxation of the perineum. Second Step. — Having disposed of the rectocele, and restored the lateral vaginal attachments of the rectum, attention is now directed to bringing together the separated levator ani and transversus perinei muscles. In order to expose the field of operation and to indicate the final position of the perineal body, the last two internal sutures are not cut, but clamped together, and drawn strongly upward by the assistant until the posterior wall of the introitus touches the anterior, and held in this position until the end of the operation (Fig. 273). OPERATIONS ON THE VAGINA 629 The tissue of the external perineum is now dissected so as to give access to the separated levator ani muscles. This is quite important, especially when there is a considerable amount of scar-tissue present. No attempt is made to develop the muscular fibers of the levator muscles, for in this way fascial tissue is removed which is valuable for the purpose of union in healing. The fascial covering of the muscles should, however, be cleared of intervening scar and Fig. 271. — Opj:ration for Rectocele. The denudation is carried out as in the usual Emmet's perineoplasty. The reduction of the rectocele is accomplished entirely during the suturing of the lateral sulci. The stitches are carried deeply into the levator muscles on the sides. They are quilted into the rectal portion in the manner here shown, each one being carried further around toward the front until the last (fourth) stitch reaches the median line of the rectocele. When the stitches on both sides are drawn taut the rec- tocele is made to disappear. fatty tissue. In order to facilitate the isolation and clearing of the muscles long-pointed tenacula are carried deep into the lower portion of the levators to the sides of .the sphincter ani,' and the muscle bellies brought prominently into view in the manner depicted in Figs. 273, 274. After removing all intervening tissue that may interfere with the union of the muscles, a figure-of-8 catgut stitch is introduced so as to create a broad surface of approximation of the two muscte 630 GYNECOLOGY Fig. 272. — Operation fob Rectocele. Running buried catgut stitch implicating the rectal wall. This stitch is useful when there is marked hernial protrusion of the rectum. When the stitch has been placed the lateral sulci are closed in the usual way. Fig. 273. — Operation for Lacerated Peri- neum. The stitches of the internal part have been tied and cut with the exception of the last two sutures, the ends of which are left long to serve as tractors. The wound edge of the external perineum is trimmed so that the denuded fig- ure is exactly symmetric. The drawing shows the levator muscles being freed, so that they can be easily approximated without tension. OPERATIONS ON THE VAGINA 631 bellies (Fig. 274). This suture is ultimately to be buried. It is drawn taut and clamped. The sutures of the external perineum are next applied, beginning at the top. The first stitch is merely for superficial approximation. It passes Vi.v Lacerated Peri- Fig. 275. — Operation for NUEM. The deep figure-of-8 catgut stitch has been tied and cut, thus approximating the levator ani muscles. Deep silkworm-gut sutures have been placed and are ready to be tied and shotted. Fig. 274. — Operation for Lacerated Perineum. The internal part of the operation has been finished and the last two stitches left long, so that they may be used as retractors. The skin has been freed up from the levator muscles. A buried figure-of-8 approximation stitch of chromic- ized catgut No. has been introduced. The ends are not tied until the external stitches have been placed. from side to side, including the small tongue of vaginal mucous membrane be- tween the two last internal sutures. This tongue should first be trimmed so that when the suture is tied there will be perfect coaptation of the wound edges. Other sutures are now introduced, each one dipping deeply into 632 GYNECOLOGY the bellies of the levator ani muscle, thus reinforcing the buried figure-of-8 stitch. The upward tension on the two internal stitches that are being held by the assistant should not be released until every suture is tied. The tying of the external sutures is, therefore, best begun at the anal end of the external Fig. 276. — Operation for Lacer.\ted Perineum. In this operation a central denudation has been made and the sutures introduced from side to side, including the levator ani muscles from the point where they can be approximated. The inside sutures are of catgut and outside sutures of silkworm-gut. This operation is not as serviceable as the Emmet operation when there is much relaxation of the outlet. (Adapted from Holden's operation.) wound. When all the stitches have been tied, the posterior surface of the in- troitus should impinge on the anterior. Most operators at the present day use catgut for the external perineal stitches instead of silkworm-gut. Extensive experience with both sutures has convinced us that silkworm-gut sutures, individually shotted, conduce in the long run to cleaner wounds, shorter convalescences, and better end-results. The necessity of removing them on the ninth day is a disadvantage which is more than counterbalanced by the superiority of the local results. OPERATIONS ON THE VAGINA 633 CLARK'S PERINEOPLASTY^ As has been previously stated, the distinctive principle of the Emmet opera- tion consists in reducing the rectocele by drawing up the rectum on each side in the direction of the attachments of the levator ani muscles to the pubic rami. In another type of operation the rectal hernia is reduced by drawing the tissues together in the middle line. The cardinal principle of this method depends for its success on employing the support of the aponeurotic pelvic fascia which in- vests the rectocele in the plane between the vaginal and rectal walls. Hence this method resembles in principle the various operations for hernias involving the abdominal wall. There are numerous modifications of the central type of perine- /A Fig. 277. — Clark's Pertneopi^sty. Outline of area of denudation. The line from the lateral tenacula to the central tenaculum is not straight, but forms an angle into the sulcus on each side. oplasty. Of these, we have found the technic used by Dr. J. G. Clark especially practical. The Operation. — The field of operation is exposed by grasping the sides of the introitus at the Bartholin openings with Teale's tenacula. A tenaculum is then inserted in the posterior wall of the vagina at a central point two -thirds the distance from the introitus to the cervix. When traction is made on the three tenacula thus placed the field of operation is thoroughly exposed and the outline of the area to be denuded is marked out with a scalpel as in Fig. 277. A distinctive and important feature of the denudation is the creation of the two angular flaps of vaginal tissue which may be seen in the illustration to have 1 The drawings illustrating Dr. Clark's method of performing anterior colpoplasty and peri- neoplasty do not strictly accord in a few minor details with Dr. Clark's technic. Owing to the haste in pubUcation there was no opportunity to make the necessary changes in the drawings. 634 GYNECOLOGY their apices in the lateral sulci at the sides of the rectocele. By leaving these angular flaps the vaginal mucous membrane may be coaptated in the median line without undue tension, and hence with httle danger of causing the formation of obstructing vaginal bands. When the area thus outhned has been thoroughly and deeply denuded the two angular flaps are dissected free as in Fig. 278 in order to give greater opportunity for carrying out the next step of turning in the hernial protrusion of the rectocele. In imphcating the rectocele a running Gushing stitch of No. chromicized catgut is carried from the upper angle of the denuded area and continued outward Fig. 278. — Clark's Perineopl.isty. Denudation of the area and freeing; of the anuglar flaps. toward the operator sufficiently far to include the whole of the hernial protrusion. In placing the Gushing stitch it is of great importance to include the aponeurotic fascia which is found to be of definite strength and thickness on the sides of the protruding mass. When this buried running stitch has been placed and tied the mucous membrane of the vagina is coaptated by interrupted sutures of No. 1 chromicized catgut beginning at the upper central angle of the denuded area. These stitches are placed as firmly in the tissues as possible so as to reinforce the buried stitch, but not deeply enough to injure the rectal wafl. When the apices of the angular flaps- are reached the remaining stitches are placed very deeply OPERATIONS ON THE VAGINA 635 and well out on the sides in order to include the separated bellies of the levator ani muscles. The interrupted sutures are consecutively introduced until the points of entrance of the Bartholin glands are reached. All the interrupted stitches are then tied. The last step of the operation consists in uniting the muscles of the external perineum by a return buried catgut stitch of No. catgut placed in the following manner: A tenaculum seizes the edge of the external wound at a point equidistant from the two lateral retraction tenacula. By drawing the middle tenaculum sharply downward the denuded surface of the external perineal wound is exposed in the ^"^. { Fig. 279. — Clark's Perineoplasty. The area has been denuded and the angu- lar flaps in the sulci freed. The central part of the rectal hernia is being infolded by a buried Gushing stitch. This stitch is passed into the fascial tissue which invests the rectal wall be- tween vagina and rectum. Fig. 280. — Clark's Perineoplasty. Insertion of central stitches. The last four stitches are placed deeply in the bellies of the levator (pubococcygeus) muscles. form of a triangle with the apex toward the sphincter. A catgut suture is intro- duced near the duct of the left Bartholin gland and carried deeply into the tissues, including the muscular masses of the levator ani and transversus perinei muscles. It is passed from side to side in the same' manner as a Gushing stitch and continued to the lower angle of the exposed area. Having reached this point it is then returned in the reverse, direction, more superficially but still placed 636 GYNECOLOGY sufficiently deep to secure not only an exact coaptation of the skin edges, but also a firm union of the subcutaneous tissues. Having reached on its return journey the level of the introitus, the stitch is carried outward through the vaginal mucous membrane near the duct of the right Bartholin gland. When the two free ends (Fig. 282) are snugly tied the external perineum will be found to be neatly closed without the exposure of a knot. Fig. 281. — Clark's Perineoplasty. The central stitches have been tied and cut. A buried Gushing stitch has been started at the upper end of the external wound and carried deeply on each side to the lower end of the wound. It is now continued as a subcuticular stitch to the point whence it started. Fig. 282. — Clark's Perineoplasty. The subcuticular stitch is just being fin- ished. When tied the external wound is com- pletely closed without exposure of the knot. Operation for Complete Tear. — When the perineal tear involves the sphincter ani muscle the first part of the operation is carried out in every way as above up to the point where the buried stitch of the external perineum reaches the limit of its outward journey. At this point the stitch is tied and cut. The denudation of the skin of the external perineum is then extended as in Fig. 283 so as to expose the ends of the torn sphincter. A new buried catgut suture is next placed at the point where the first was tied, and cut and continued downward, being placed deeply on each side close to but not including the rectal mucous membrane. OPERATIONS ON THE VAGINA 637 By drawing the stitch tight when it reaches the external skin of the anus the ruptured mucous membrane of the rectum will be approximated without exposure of the stitch. The buried stitch is now clamped while the next step is carried out. This consists in securing with tenacula the ends of the torn sphincter and draw- ing them prominently out to view. The sphincter ends should be dissected clean Fig. 283. — Clark's Perineoplasty for Com- plete Tear. The first part of the operation is performed as for a simple tear. The area for exposing the ruptured ends of the sphincter is outHned and denuded. In the above drawing the buried cat- gut Gushing suture approximating the levator muscles is represented as having been already introduced. It is better not to introduce this suture until the ends of the sphincter have been secured, as in Fig. 284. W.P^Gr ■ Fig. 284. — Clark's Perineoplasty for Com- plete Tear. The ends of the sphincter have been secured by tenacula. The buried Cushing stitch has been applied. It is best to tie the buried suture at this point and to continue later with a new stitch as will be seen in Fig. 285. of scar tissue so that they may be approximated freely and without tension. Three interrupted catgut sutures No. are placed so as to unite the ends fii-mly together (Fig. 285). The buried catgut suture is then continued as in the operation for simple tear, and when tied with the free end at the introitus (Fig. 286) completes the operation. 638 GYNECOLOGY Fig. 285. — Ci^^rk's Pkrineoplasty for Com- plete Tear. The first buried stitch has been placed and tied. A second buried stitch is then introduced and continued so as to approximate the torn edges of the rectal wall. The end of this stitch is seen in the drawdng extruding beneath the sphincter muscle and is to be used as a .sub- cuticular stitch to close the wound. After the buried suture has been placed the ends of the sphincter are brought together and united by three interrupted catgut, sutures as shown in the drawing. Fig. 2S6. — Clark's Perineoplasty for com- plete Tear. The buried suture seen mth its end free in the lower part of the pre^^ous drawing has been continued as a subcuticular stitch and is about to be tied to the free end of the first buried .suture. When these ends are tied the wound of the external perineum is closed without the ex- posure of a. knot. STUDDIFORD'S PERINEOPLASTY ^ The operation elaborated by Studdif ord fox the repair of the lacerated peri- neum is studiously based on the exact anatomy of the parts. Before attempting to follow the steps of the operation the reader should refer to Studdiford's description of the anatomy and function of the perineum quoted in detail in Part II of this book. Tenacula are applied at the caruncles which mark the openings of BarthoHn's glands. Strong outward traction on the tenacula brings into prominence the mucocutaneous border of the posterior vaginal wall. A Kocher forceps or tenac- ulum is then inserted at the apex of the tab of mucous membrane which is always outlined between the two lateral sulci of the vagina. This point is often marked by an isolated caruncle. The mucocutaneous border is incised from tenaculum 1 The illustrations of this operation were made from sketches drawn while watching Dr. Stud- dif ord 'operate. Owing to the necessity of haste in pubUcation there was no opportunity to submit the finished drawings to Dr. Studdiford for inspection. OPERATIONS ON THE VAGINA 639 to tenaculum and the tissues freed by blunt dissection with scissors. Scar tissue will be found on each side corresponding to the two lateral sulci. These scars are fhst nicked with scissors and an opportunity given to insert the finger into each sulcus beneath the vaginal mucous membrane. With the forefinger in the sulcus the scar may be readily brought into view by upward pressure- on the vaginal mucous membrane (Fig. 287). The scar tissue of each sulcus is excised in the manner shown in Fig. 288. The denuded area is now similar in outline to that Fig. 287. — Sttjddiford's Perineoplasty. Initial incision. Tenacula have been applied at the caruncles and drawn outward. The mucocuta- neous border has been incised. The tissues are being separated by blunt dissection with scissors. of the Emmet operation except that the two wings of the area are asymmetric on account of the difference that usually exists in the extent of the two lateral scars. The perineal muscles and trigone are next developed, obstructing scar tissue being dissected away. The muscles are not bared to their muscle-fibers, but are brought to view in their fascial investments. The deep sutures are now placed. A suture with needle at each end is started at the rectal protrusion surmounted by the central vaginal tab. The needle is then passed very deeply into the pubo- 640 GYNECOLOGY coccygeus muscle of the one side behind and not including the trigone. The needle of the other end of the suture is then carried into the belly of the other pubo- coccygeus muscle. The final course of the suture is to include the anterior end Vv^.v^ Gjx-c^^it-?, Fig. 288. — Studdifoed's Perineoplasty. Exposure of the lateral sulci. The vaginal mucous membrane is freed in the two sulci by for- cibly inserting the forefinger beneath the scars. The scar tissue is cut away as in the drawing. The mucous membrane of the left sulcus has been removed. That on -the right is about to be incised. The final appearance is similar to that of the denudation of Emmet's perineoplasty. of the sphincter muscle, that end of the suture being applied which will best draw the sphincter toward the side on which the laceration was deeper. A second deep suture is applied in the same manner. The next step is to close the lateral sulci which have been thus exposed. OPERATIONS ON THE VAGINA 641 This is done with a running subcuticular Gushing stitch starting from the apex and extending to the base of each lateral triangle, care being taken to secure as far as possible the investing fascia. (In the drawings this step precedes the placing of the deep stitches.) When the subcuticular sutures have been tied the stitch of the left side is passed through the upper end of the right trigone and the stitch of the right side is passed through the upper end of the left trigone Fig. 289. — -Studdifoed's Perineoplasty. Approximation of the pubococcygeus muscles. The two lateral sulci have been closed by buried Gushing sutures, the ends of which are left long. The bellies of the levator ani muscles are being united by two buried sutures. One suture has already been placed and tied. The second suture is being placed. The suture is equipped with a needle at each end. A bit of tissue is first included in the median line under the central tongue of mucous membrane. It is passed on each side deeply into the levator pubococcygeus muscles behind the trigone. The upper fibers of the sphincter ani muscle are included in the suture. (Fig. 290). The two sutures are tied and kept long. This unites what may be termed the crown of the perineum. The two ends of the united suture are then used to close the external wound. One end unites the edges of the trigone, and is returned as a subcuticular stitch to approximate the skin edges. The two ends are then tied in such a way as to bury the knot. If there is marked rectocele present special measures must be taken. In 41 642 GYNECOLOGY case of high rectocele Studdiford advocates a central incision through the mucous membrane of the posterior vaginal wall. The vagina and rectum are separated widely on each side of the central incision. When the rectum has been well mobilized the hernial protrusion is implicated by a running stitch, as in Clark's operation. The excess of vaginal mucous membrane is trimmed, if necessary, and coaptated, preferably by interrupted catgut sutures. The rest of the operation is then carried out as described above. Studdiford, like Clark and others, recommends in addition to the plastic operation for rectocele the prin- FiG. 290. — Studdifokd's Perineoplasty, Approximation of the trigone. The pubococcygeus muscles have been united by two buried sutures which have been tied and cut. The long ends of the Gushing sutures wliich have closed the lateral sulci are now employed to unite the trigone. Each suture is crossed over and inserted in the upper end of the trigone. The ends are then firmly tied, thus bringing the upper ends of the trigone together and in relation to the central tongue of mucous membrane. ciple of closing the posterior culdesac through an abdominal incision. This may be accomplished either by the Moschowitz technic for rectal prolapse or by the author's modification described on page 644. If the rectocele is low, the levator ani muscles (pubococcygei) are brought together in the median line as high up as possible, so as to interpose them between the rectum and vagina. This is the principle employed in the so-called central operations of which Holden's operation {q. v.) is a type. OPEKATIONS ON THE VAGINA 643 A Vno^oae Fig. 291. — Studdiford's Perineoplasty. Closure of the external perineum. The sutures which were inserted in the upper ends of the trigone have been tied and the ends still left long. One suture is then continued downward so as to approximate the sides of the trigone. After reaching the lower limit of the wound it is then returned as a subcuticular stitch to the point whence it started. It is then tied to the other suture. In this way the wound is closed subcutaneously and without the exposure of a knot. OBLITERATION OF DOUGLAS' POUCH FOR RECTOCELE (AUTHOR'S METHOD) In severe cases of rectocele the most painstaking and apparently effective perineoplasty is sometimes followed by a recurrence. This is due to a deepening of the pouch of Douglas caused by the expanded rectum, so that even when the perineal muscles remain intact the surgeon may find in the course of time that a hernial protrusion is beginning to roll out over the perineal dam under the influence of abdominal pressure. Such recurrences usually do not become severe nor do they often cause serious subjective symptoms. Nevertheless, the reap- pearance of a lump in the vagina is disconcerting and annoying to the patient and a source of chagrin to the surgeon. Several operators, notably D. F. Jones and J. G. Clark, have successfully obviated this difficulty by the use of the Moschowitz operation originally designed for prolapse of the rectum. We have also employed this operation for the prevention of recurrent rectocele and found it of practical value. In a complicated reconstructive operation, however, we have found the Moschowitz technic somewhat long and tedious, and we have. 644 GYNECOLOGY therefore, devised the following rapid method of obliterating the pouch of Douglas and have had results equally as good as with the Moschowitz operation. We recommend it only for cases of redocele and not for rectal prolapse. The operation is to be used in connection with some form of suspension of the uterus or with the method of operating for procidentia in which, following supravaginal hysterec- tomy, the cervical stump is attached to the anterior abdominal wall. Fig. 292. — Closube of Douglas' Pouch (Author's Method). The uterus is drawn upward and forward as far as possible. The sides of the rectum are seized wth AlHs' clamps at the points where the uterosacral ligaments join the sides of the rectum. The clamps are inserted into the pararectal tissue rather than into the rectal wall itself. The clamps are then brought up to the posterior wall of the cer\ax just above the origins of the utero- sacral ligaments. Sutures passed into the uterus and through the pararectal tissue suspend the rectum to the posterior wall of the cervix at these two points. The patient is placed in a steep Trendelenburg position. The intestines are packed back with gauze sponges, leaving only the rectum to be seen in the pelvis. The uterus is drawn upward and forward as far as possible so as to give a good view of the pouch of Douglas. In cases of marked rectocele the pouch will be OPERATIONS ON THE VAGINA 645 found abnormally deep. The course of the uterosacral ligaments is then observed, and at the points where they join the rectal wall Allis' clamps are apphed. It will be found that the clamps may be set firmly into the pararectal tissue without including the rectal wall, and that when traction is exerted on the clamps the rec- tum may be lifted under considerable tension without danger of tearing the Fig. 293. — Closure of Douglas' Pouch (Author's Method). The openings made by the loops of the uterosacral ligaments are being closed by running sutures. The closure on the left has been completed; that on the right is being completed. Interrupted sutures attach the wall of the rectum to the posterior wall of the cervix. rectal wall. By drawing upward on the two Allis clamps the anterior wall of the rectum is then lifted to as high a point as possible on the back of the uterus. This point is usually at about the level of the uterine attachments of the utero- sacral ligaments. Two sutures are then placed through the pararectal tissues included in the clamps and into the uterine wall. The sutures are tied and the ends left long to serve as tractors. Thus at this stage it will be seen that the 646 GYNECOLOGY rectum is drawn tightly up and suspended by two sutures to the back of the uterus. On the sides it will be observed that each uterosacral ligament forms a loop making a corresponding opening into the posterior culdesac. The two openings are closed by running catgut sutures. So far no sutures have entered the wall of the rectum. It is now necessary to attach the rectum to the uterus by placing interrupted sutures from rectum to uterus between the two traction stitches. In placing these stitches it is necessary to enter the muscularis and submucosa of the rectal wall in order to secure a firm attachment of adhesions to the uterine surface. AVhen the stitches have all been placed it will be found that the posterior culdesac is completely shut off. The uterus or cervical stump is then attached to the anterior abdominal wall, an attachment which serves to support the rectum. There is no danger of obstructing the lumen of the bowel. ENLARGING A TIGHT PERINEUM In enlargmg a perineum that has been sewed too tightly, or that has shrunken from senile atrophy, it must be remem- bered that the stricture is due to a cica- tricial contraction of the superficial parts of the perineum, and. not to a too close union of the muscles, which we have seen is impossible. Usually a sharp unyielding band of tissue is felt at the introitus, distention of which causes pain or discomfort. The operation aims to do away with this obstructing band and to create a funnel- shaped elastic introitus. This may be done as follows: A transverse incision is made through the scar (Fig. 294). All the unyielding cicatricial bands are then dissected out subcutaneously through the initial incision (Fig. 295). The wound is sewed in a direction at right angles to the way in which it was incised (Fig. 296). If other separate cicatricial bands or cords are found inside the vagina they are to be treated in the same way. It is a significant fact that the peri- neal wounds following this operation heal with some difficulty, owing to the de- ficient blood-supply to the wound. The after-care is, therefore, very important. It is inadvisable to undertake this operation, simple as it seems, without full anesthesia. ^j4v.& ^^^ Fig. 294. — Enlarging a Tight Perineum. A transverse incision is made through the sharp cicatricial posterior fold of tissue. OPERATIONS ON THE VAGINA 647 \xl3?.G^ Fig. 295. — Enlarging a Tight Perineum. Cutting out the scar-tissue by subcutaneous dis- section with scissors. Fig. 296. — Enlarging a Tight Pehineitm. Wound closed, leaving funnel-shaped introitus. OPERATION FOR COMPLETE LACERATION OF THE PERINEUM In operating for perineal tears through the sphincter the principles of the Emmet method are recommended, with modifications to suit, the circumstances and the individual technic of the operator. The following is the technic em- ployed by the writer: The patient is given a very thorough bowel preparation, beginning the second day before the operation. Before beginning the operation it is well to pack the rectum with a narrow strip of gauze to prevent the escape of feces. The first part- of the operation is performed exactly like the first step in the ordinary perineoplasty — ?'. e., the lateral sulci are denuded and sutures placed, unitmg the anterior portion of the levator ani muscles (puborectales) to^the sides of the rectum. This in some cases is unnecessary, for it often happens that the perineal separation is entirely in the median line along the raphe uniting the lower bellies of the levators, and not at all along the sides of the rectum. This is usually the case when the rectovaginal septum is ruptured for any consider- able distance. When there is no separation in the lateral sulci and no extensive tear of the septum a simple median denudation is used with catgut approxuna- 648 GYNECOLOGY tion from side to side, care being taken not to make the introitus too tight. If there is extensive rupture. of the rectovaginal septum a special technic is required (see below) : The type of case most commonly seen is depicted in Fig. 297. When the internal vaginal part of the operation is finished, the two last catgut sutures vl-V-Oxuvies — ■ Fig. 297. — Operation for Complete Lacer-^tiox of the Perixeum. The internal part of the perineum operation has been completed. The red line indicates the outline of the area to be denuded from the external perineum. It is carried below the dimples that mark the position of the sphincter ends. This denuded area should not be made so wdde that the skin edges cannot be approximated without too much tension. which close the lateral sulci are left long, clamped together, and held firmly upward by an assistant .for the remainder of the operation. The area of denuda- tion of the external perineum is now outlined. Beginning at the Bartholin duct of the left side, a light mark is made in the skin with the scalpel down to the dimple which indicates the retracted end of the sphmcter muscle. This line should be curved slightly inward. On reaching the dimple the line is carried around it, and across to the dimple that represents the other end of the torn sphincter. Tliis transverse incision skirts along the edge of the connective- OPERATIONS ON THE VAGINA 649 tissue bridge which usually forms between the sphincter ends, and should be made at the junction of the skin and mucous membrane of the bowel (Fig. 297). V.?.^ \cv\cvcuUiTrv ^'^® xt^ S^Wncttx- Fig. 298. — Operation for Complete Laceration of the Perineum. (Author's teehnic.) The field of operation has been exposed by the denudation outlined in Fig. 297. The levator muscles are then transfixed with tenacula and broiight to view. A figure-of-8 catgut suture (No. 0) is placed as in the drawing. The ends of the sphincter muscle are transfixed and exposed in the same way. An approximating buried catgut figure-of-8 stitch is also placed in the ends of the sphincter muscle. Deeply placed silkworm-gut sutures are then introduced from side to side beginning at the top, as in the Emmet operation. The two buried catgut sutures are not tied until all the silkworm- gut sutures are placed. On reaching the dimple of the right side the line of demarcation is carried around the dimple and up to the Bartholin duct of that side. It is of very great im- portance that the figure thus outlined should be exactly symmetric, for if it is not, the edges of the wound when brought together from side to side will not match. Care should be exercised also in making the vertical lines not to draw them too far apart, otherwise the wound edges when brought together will be under too great tension. 650 GYNECOLOGY When the figure has been satisfactorily marked out, the intervening skin is removed with Emmet's scissors. All scar-tissue is dissected away until all the parts involved in the operative field are soft and plastic. Tenacula are now introduced deeply into the bellies of the separated levators, and held so as to bring the muscles boldly into view. Two other tenacula seize the ends of the sphincter muscle and expose them in the same manner (Fig. 298). Figure-of- 8 sutures of No. chromicized catgut are then placed in both the levator and N^.*?^ Gr — Fig. 299. — Operation for Complete Laceration of the Perineum. (Author's technic.) The two buried figure-of-8 catgut sutures have been tied, one approximating the levator ani muscles and the other uniting the ends of the sphincter muscle. The silkworm-gut sutures have been placed and are ready to be tied. sphincter muscles, the suture ends being left long and not yet drawn taut. Beginning then at the top of the wound wilk worm-gut stitches are placed deeply into the fibers both of the levator and sphincter muscles. In crossing from one side to the other over the chasm made by the laceration the silkworm-gut stitches issue from and enter at the very edge of the rectal mucous membrane, but not including it. When all the stitches have been properly placed the two figure-of-8 stitches which are to be buried are tied firmly, but not too tightly, and the ends OPEKATIONS ON THE VAGINA 651 cut short. The silkworm-gut sutures are then tied, beginning at the anal end, the ends cut and shotted (Fig. 300). The success of the operation depends chiefly on an exact approximation of the sides of the wound without undue tension, for if this is not attained, non-union, sepsis, and greater or less destruc- tion of the wound are almost sure to ensue. / '<*«««,>• Fig. 300 — Operation for Complete Tear of the Perineum. The silkworm-gut sutures have been tied, cut, and shotted. During convalescence the wound requires unremitting attention with ex- pert nursing, under the utmost antiseptic precautions. The bowels are kept closed for from nine to twelve days and then moved with oil catharsis. The external stitches are removed on the ninth day. If a stitch shows signs of infec- tion before that, it is best to remove it. Catgut for the external stitches is inter- dicted. When the tear extends far up the rectovaginal septum, the denudation of the vaginal portion is central and not in the lateral sulci. The denudation 652 GYNECOLOGY begins above the upper angle of the wound, and is carried down on either side to the Barthohn ducts. Only a small amount of vaginal tissue should be removed in the region of the introitus, for if this precaution is not observed there is much danger of closing the .perineum too tightly.. Fig. 301. — Operation for Complete Laceration of the Perineum. (Warren's " apron" method.^) The sphincter muscles are exposed by turning down a flap which, when sewed up, is supposed to prevent the wound from contamination by the bowel. The operation is not applicable when the rectovaginal septum has been torn. The surest results are gained by using silkworm-gut to close the vaginal part of the wound, notwithstanding the annoyance of having to i^emove them later, catgut not being dependable in these cases. Buried rows of catgut sutures, clQsing the wound in layers, seem at the time of operation to unite the wound with great strength, but the catgut is treacherous, and in the long run the results from its use are inferior to those where the hard, non-absorbable suture has been employed. Rectovaginal fistula is usually associated with a tear through the sphincter ^ The principle involved m the apron operation was devised by Dr. J. Collins Warren of Boston- whose paper on the subject, entitled "New Operation for Rupture of the Perineum through the Sphincter," was published in the Transactions of the American Gynecological Society for 1883, OPERATIONS ON THE VAGINA 653 muscle, and is due, as a rule, to the healing over of the intervening tissue. It is often seen in cases in which the attending obstetrician, having repaired the tear immediately after delivery, has secured only partial healing of the wound. Thus, sometimes one sees a rectovaginal fistula where the sphincter has healed completely. In operating on rectovaginal fistulas, if the sphincter is competent, it is best to attempt the closure of the fistula by itself, though it is more difficult to cure a single fistula than a lacerated sphincter. If the sphincter is incompetent, it is advisable to cut through the anus to the fistula, making a fresh complete tear. The fistula operation may be done in layers with one or two rows of buried catgut, or it may be closed with a single row of interrupted non-absorbable sutures, silver wire or silkworm-gut. We have found the latter method more successfuk The opertion is practi- cally identical with that for vesicovaginal fistula. A wide denudation is made in an oval shape about the fistula, the direction of the oval being made longi- tudinal or transverse, so that the tissues may be brought together from side to side with as little tension as possible. If the wound is to be sewed in layers the rectal mucous membrane is separated from the vaginal membrane for a short distance about the fistulous opening. The membranes are then sewed separately with catgut. The other and better method is to close the entire wound with silver wire, the sutures being placed well out from the margin of the wound, so that they may act as a sort of splint. (See Operations for Vesicovaginal Fistulse.) OPERATIONS FOR VESICAL FISTULA For vesicovaginal fistula several operations have been devised. For small fistulse, where there is plenty of healthy tissue about the opening, the classical V/-?' to- Fig. 302. — Vesicovaginal Fistula. Dissection of mucous membrane around the fistulous opening. operation of Marion Sims is entirely satisfactory. It is-performed in the follow- ing way: 654 GYNECOLOGY The patient is either in the lithotomy or in the Sims position. The latter is sometimes preferable where the fistula is high up toward the vault of the vagina, as is frequently the case when the injury has been done in the process of a hys- terectomy. An oval denudation is made with fine scissors about the opening down to the vesical mucous membrane, special care being taken to trim off the cicatricial edge of the bladder opening. The denuded margin about the orifice should be as wide as possible without causing too much tension when the edges Fig. 303.- — Vesicovaginal Fistula. Wound being sutured longitudinally by the classical method of closure. are approximated, usually from J to | inch. The ends of the oval are carried out still further from the opening. The direction of the denuded oval is deter- mined by the individual case, and is made longitudinal, transverse, or even obhque in relation to the vaginal axis, according to which way the tissues can be brought together with the least tension. As a rule, the transverse denuda- tion is the most favorable. When the denudation has been cleanly and s>aii- metrically made, interrupted sutures are introduced from side to side, being carried well into the vaginal tissues and down to the edge of the bladder mucosa, OPERATIONS ON THE VAGINA 655 but not including it (Fig. 303). The suture material is, preferably, fine silver wire, carried by silk guides, which are threaded on fine full-curved needles. It is advisable to begin at the center of the wound and work each way, so that there will be no error in approximating the vaginal mucous membrane that covers the fistula. The stitches should be fairly close together and carried for a considerable cUstance to each side of the opening, so that even when the fistula is small eight or ten sutures are usually required. The silver-wire ^V^^feJBi \Ni.?6 Fig. 304. — Vesicovaginal Fistula. Wound being sewed transversely by the classical method of closure. sutures are twisted, bent to one side, and cut off about h inch long. They are removed in fifteen to seventeen days. During convalescence for the first week or ten days the patient should not be allowed to accumulate more than 4 ounces in her bladder. Two or three catheterizations may at first be necessary, after which the patient is usually able to urinate voluntarily. Strict watch of the urinations should be kept and the patient wakened at regular intervals during the night. If catheterization is necessary, it should be done only by experienced 656 GYNECOLOGY hands. If the patient is conscientiously tended in this manner the results are far better than those attained by the use of self -retaining catheters, which should be avoided if possible. A second method for treating vesicovaginal fistula is that of dissection and cleavage of the vaginal and bladder walls, and sewing the wound in separate layers. This method is especially applicable to cases in which there has been a considerable loss of tissue, so that the approximation of the wound edges by N^.T.Coxcv»es.--«- Fig. 305. — Operation for Vesicovaginal Fistula. Incision for the method of closing by layers. the Sims method cannot be accomplished without too great tension. An incis- ion' is made with a sharp knife (Fig. 305) and the bladder and vaginal walls separated about the fistulous opening. This dissection is carried out until the edges of the vesical wound can be approximated with forceps without tension. The edges of the bladder wound are freshened by trimming them with scissors. The vesical layer is closed by a continuous fine catgut suture introduced by the Lembert method. The vaginal plane is closed by interrupted non- OPERATIONS ON THE VAGINA 657 absorbable sutures, preferably of silver wire, applied as in the Sims operation. It is often advantageous to sew the two layers so that the two wounds will not coincide, but cross each other in direction. Sometimes the vesical plane can be closed, but the vaginal flaps cannot be coaptated without too great strain. Kelly's method in this emergency is to sew the vesical mucous membrane of one side of the wound to the combined edges of the bladder and vagina of the \l.?.C^-a\i«.s--- FiG. 306. — Oper.'\.tion fob Vesicovaginal Fistula. Sewing up by layers. The first line of sutures inverts the vesical mucous membrane. A con- tinuous Lembert stitch of fine chromic gut is employed for the bladder wall. Interrupted silver wire or silkworm-gut sutures close the vaginal wound. other side of the wound. This leaves a raw area which, Kelly states, is soon covered with epithelium. A third method of treating vesicovaginal fistula, and one especially recom- mended by Albarran, is the operation of Braquehaye. An incision is made as in Fig. 305, leaving a margin of vaginal mucous membrane about the fistulous orifice. If the fistula is in a position difficult of access, much more room can be gained by making a paravaginal incision, such as is described on page 728 in performing a vaginal hysterectomy for cancer. 42 658 GYNECOLOGY The walls of the vagina and bladder are then separated, as in the preceding operation. The small area of mucous membrane left about the fistulous opening is dissected up so as to form a collarette, which is inverted into the bladder. In this way denuded surfaces are in contact with each other at the -opening, a con- dition favorable for closure. The inverted orifice is closed in by a reduphcating continuous Lembert stitch, as shown in Fig. 309. The vaginal mucous mem- brane is closed by interrupted sutures, as in the two preceding operations, it being advantageous to have the two suture lines cross at an angle. Fig. 307.: — Operation for Vesicovaginal Fistula Closure by Layers. The bladder wall has been sewed with a continuous Lembert stitch of fine chromic gut. The vaginal wall is being closed with silver wire. In extreme cases, where there has been a profound destruction of the tissues, such as the almost complete disappearance of the vesicovaginal septum, the condition may be treated by closing up the vagina below the opening (colpo- cleisis). By this method the upper part of the vagina becomes an integral part of the bladder, so that if the patient has not reached the menopause the menstrual blood passes into the bladder. The disadvantages of the operation are obvious. OPERATIONS ON THE VAGINA 659 Vesicocervico vaginal (or juxtacervical) fistula (Fig. 310) cannot be satis- factorily denuded in the manner of vesicovaginal fistulse described above. In these cases the orifice of the fistula is usually embedded in an immovable mesh of cicatricial tissue, making plastic operations well nigh impossible. The best plan here is to make a transverse incision, and separate the vaginal vault and bladder from the cervix. This exposes the opening in the bladder wall, which may then be closed by a continuous Lembert suture. The method is illustrated in Fig. 314 (adapted from Kelly). Fig. 308. — Braquehaye's Operation for Vesicovaginal Fistula, Modified by Albarran- Turning in the cuff around the fistula (adapted from Albarran) . In vesico-uterine (intracervical) fistula the opening is into the cervical canal aiid cannot be seen. The position of the fistula can be determined by intro- ducing one probe into the opening from the bladder and one into the cervical canal, the height of the opening being detected by the chcking of the two metal instruments. If the opening is low, the fistula may be reached by a transverse vaginal 660 GYNECOLOGY Fig. 309. — Braquehate's Operation for Vesicovaginal Fistula. Method of closure. The lines of suture of the two layers will be at right angles. Fig. 310. — Vesicocervicovaginal (or Juxtacervical) Fistula. The fistulous opening is near the cervix. incision, with separation of the bladder from the cervix, as in the operation for juxtacervical fistula described above. If the communication between uterus OPEIL'^TIONS ON THE VAGINA 661 Fig. 311. — Repair of Juxtacervical Fistula. The bladder has been separated from the cervix. The bladder wall has been closed by a Lembert running stitch, which inverts the mucous membrane toward the lumen of the bladder. The vaginal membrane has not yet been sutured. Fig. 312. — Repair of Juxtacervical Fistul.\. Both the bladder wall and the vaginal wall have been closed by separate layers of sutures. 662 GYXECOLOGY and bladder is well up in the cen-ix the conchtion is best approached by the abdominal route, the details of the operation being as follows : Median abdominal incision, with the patient in the Trendelenburg petition. The uterus is held well back by traction forceps and a transverse incision made through the utero vesical reflection of peritoneum. The bladder is then separated from the cervTX until the vesical opening is completely isolated -uith plenty of free bladder tissue about it to aUow for suturing. The wound is closed by one or, if possible, two rows of Lembert sutures. Fig. 313. — JuxTACEKVicAii Fisttjxa. The Ixcisiox. The opening into the uterine canal may be sutured or not. If the edges are freshened, it vnW heal spontaneously, and if not closed too tightly acts as a channel for drainage in case the bladder wound does not heal properly. Vesico-uterine fistulse may be closed indirectly by denuding and suturing the cer\ucal hps (hysterostomatocleisis), by which procedure the uterus is made to drain into the bladder. The operation is not recommended unless other methods are not feasible. OPERATIONS ON THE VAGINA 663 . _ v^/RGx axle's. ttfe' 'ti /mT 11 iia^l^i' Fig. 314. — Juxtacervical Fistula. The bladder has been freed from the cervix. The opening in the bladder is being closed in by a running Lembert suture. Fig. 315. — Uterovbsical Fistula. There is a fistulous communication between the bladder and the canal of the cerAox. 664 GYNECOLOGY Fig. 316. — Repair of Uterovesical Fistul.^ by the Abdominal Route. An opening has been made through the peritoneal reflection, exposing the fistulous tract. Fig. 317. — Acquired Atresia of the Vagina. The later effect of simple incision without complete removal of the occluding membrane. The incision closes down to a pinhole opening which affords very incomplete drainage of the uterus and vagina. Foul decomposing material collects in the vagina and discharges continuously or periodically through the small opening in the membrane. OPERATIONS ON THE VAGINA 665 OPERATIONS FOR ATRESIA OF THE VAGINA The operation for atresia in girls, where there is partial or complete retention of menstrual blood, is attended with considerable danger of fatal sepsis, and every precaution should be taken to prevent infection. When hematocolpos and hematometra are present the occluding membrane is first freely incised, the cavities of the vagina and uterus evacuated and carefully irrigated. This does not complete the operation, for the opening made by such an incision sometimes closes up entirely, but more often results in one or more pinhole FiG. 318.— Acquired Atresia of the Vagina. Dissecting out the occluding membrane mth scissors. apertures through which the menstrual.blood may partially flow (Fig. 317). A certain amount of mucus and blood is dammed back into the vagina, becomes foully infected, and produces dire results. In order to leave the vagina in a permanently normal condition the occluding membrane should be completely dissected out and the wound edges approximated with great care. Such a wound will heal by first intention, even in the face of a badly septic discharge. The details of the operation for dissecting out an occluding membrane are as fol- lows: 666 GYNECOLOGY After the septum has been incised and the contents of the space beyond have been removed, there should be a thorough cleansing of the parts, as stated above. The edges of the septum should then be trimmed flush with the walls of the vagina (Fig. 318). All scar-tissue should be removed so as to prevent a future contraction. When the septum has been completely cleared away it will be found that there remains a denuded area which extends like a ring around the inner circumference of the vagina. The mucous membrane of the upper Fig. 319.— Acquired Atresia of the Vagina. The transverse septum has been dissected out and the upper portion of the mucous membrane of the vagina united to the lower by interrupted catgut sutures. portion of the vagina is then drawn down and approximated to that of the lower portion by interrupted catgut sutures (Fig. 319). Such an operation should restore perfectly the normal cahber of the vagina, and is not followed by a tendency to the development of a stricture. The use of antiseptic douches twice or three times daily is begun the day after the operation, and should, be kept up until the discharge completely disappears. OPERATIONS ON THE VAGINA 667 OPERATIONS FOR ABSENCE OF VAGINA The creation of an artificial vagina may be done either by the method of employing a loop of gut or by the turning in of skin-flaps from the surrounding parts. A technic devised and employed successfully by the author in one case is as follows : The patient is placed in the perineal position. A superficial transverse incis- ion is made just below the urethra. Through this transverse slit the bladder and rectum are slowly dissected apart with the finger. The forefinger of the left hand should be kept in the rectum, and some blunt instrument, like a Fig. 320. — Congenital Absence of Vagina. urethral dilator, should be held in the bladder by an assistant. The dissection is carried out by the right forefinger, the left forefinger behind and the blunt instrument in front acting as guides to prevent tearing into the wall of the rectum or bladder. In this way an artificial opening can be made of the exact proportions of the normal vagina. Care should be exercised not to enter the abdominal cavity. The next step is to line this cavity with a pouch of skin made up of flaps turned in. from the surrounding parts. To accomplish this, the two labia minora are dissected off, from above downward, in such a manner as to leave a pedicle sufficiently large to furnish good circulation. The two sur- faces are then split apart so that two paddle-shaped fiaps remain. There should then be dissected from the inner side of the thigh two similar flaps which have their bases at the two lower corners of the artificial opening. All four flaps 668 GYNECOLOGY ^^;__4- V/.p.GcrtxMes. Fig. 321. ■ — An Operation for Absence of the Vagina (Author's Method). An artificial opening has been made between bladder and rectum, corresponding to the size of a normal vagina. Four skin-flaps have been sewed together over an old-fashioned glass speculum in- verted. The two upper flaps are the two labia minora partially amputated and spread out flat. The two lower flaps are turned in from the th'gh. The sewing of the seams is not completed until after the glass form has been removed and supporting stitches placed in the vault of the new vaginal opening. OPERATIONS ON THE VAGINA 669 Tk;. :■;_'_'.— Operation' foe Congenital Absence of Vagina. The glass form has been removed and the seams of the pouch completely sewed. The untied sutures seen issuing from the pouch were p^e^-iousiy passed through the vault of the artificial opemng made between the bladder and rectum. The pouch is inverted into the artificial opening and the stitches tied so as to prevent any prolapse of the pouch before it heals to the raw surface of the opemng. are then sewed together over a glass form, as shown in the cut (Fig. 321). Before the flaps are sewed together several catgut sutures, with the ends left long, 670 GYNECOLOGY should be placed in the vault of the artificial cavity. When the skin pouch has been nearly completed, the glass form is removed and the catgut sutures are brought out through the skin pouch. The pouch is then inverted, and the sutures are tied in such a manner that the pouch fits snugly into the artificial cavity. SCHUBERT'S Operation for Absence of Vagina Schubert has devised a method of creating an artificial vagina from the rectum. He performs his operation as follows: The patient is placed in the right Sims position. The hymen is first com- pletely dissected away, leaving a circular denuded area of tissue where the introitus is usually situated. The sphincter is then dilated and a circular incis- ion made about the anus. Through this incision the rectum is dissected from the sphincter muscle for the distance of about 3 cm. without injuring the muscle. Beginning then at a point 5 cm. above the anus a 10 cm. incision is made over the coccyx, which is extirpated. The pelvic fascia is divided by a longi- tudinal incision. Through this opening the rectum is drawn out after first being freed from its connective-tissue attachments. The rectum must be suffi- ciently freed so that the upper segment of the loop can be drawn clown to the anus. The loop of rectum drawn out through the opening at the coccjoi is now pinched with intestinal clamps and divided. The cut end of the lower segment is firmly closed by sutures. The culdesac of gut thus formed is attached as high as possible to the sacrospinal ligament. The finger is then pushed through the opening in the vulva made by dis- secting off the hymen, and an opening in the tissue made toward the coccygeal wound. The canal thus made is widened so that it will easily admit two fingers. The anal end of the rectum which was first dissected away from the sphincter is drawn up through the newly made orifice and attached there by interrupted sutures through the margin of the skin. The new vagina thus constructed, therefore, consists of the lower end of the rectum, which now extends from the new opening in the vulva to the blind culdesac attached to the sacrospinal ligament. The operation is concluded by drawing the upper cut end of the rectum down through the sphincter and suturing it there to the skin margin. The advantages of this operation over the Baldwin method are that it is less dangerous to life, and that the secretions from the bowel mucosa are less irritating. BALDWIN'S Operation for Absence of Vagina First Step. — A transverse incision is made at the hymen (Fig. 323). The plane of cleavage between the rectum and bladder is sought, and the two organs separated by blunt dissection until the peritoneum is reached. A cavity is thus made corresponding in width and depth to a roomy vagina (Fig. 324). OPERATIONS ON THE VAGINA 671 An iodoform gauze tampon is inserted in this artificial opening and the patient put in the Trendelenburg position for laparotomy. Second Step. — Laparotomy. — A median incision is made and the pelvis in- spected. Rudimentary internal genitalia will be found, usually in the form of a double uterus. The two uteri should be separated by incision, and if one contains a lumen, it should be amputated. The junction of the ileum with the cecum is then sought. At the distance of about 12 inches from the cecum the Fig. 323.' — Operation for Congenital Absence of the Vagina. The red line shows the transverse inciBion made preliminary to separating the bladder from the rectum. mesentery of the ileum is found to be especially long. Beginning at this point, about 10 inches of the ileum is resected and the ends of the resected portion closed by a purse-string suture. The two ends of the ileum are now united by a lateral anastomosis in front of the mesentery of the detached segment (Fig. 326). A silk hgature is passed around the detached portion of bowel at its middle point, to be used as a tractor (Fig. 326). An assistant removes the gauze tampon from the opening previously made between rectum and bladder and inserts a long clamp, which he pushes against the layer of peritoneum interven- 672 GYNECOLOGY Fig. 324.-^Operation for Artificial Vagina. An opening has been made between the bladder and rectum as far as the peritoneum. Fig. 325. — Operation for Artificial Vagina (Baldwin's Method). A portion of the small intestine has been resected, leaving the mesentery attached. OPERATIONS ON THE VAGINA 673 ing between the opening and the peritoneal cavity. With this clamp as a guide an opening is made by the operator through the peritoneum, great care being exercised not to injure the bladder or rectum. The traction Hgature is now grasped by the clamp, which by this means draws the detached segment of Fig. 326. — Operation for Artificial. Vagina. Lateral anastomosis uniting the ends of the resected gut. The free loop of intestine with mesentery attached is being drawn down by a guide ligature. bowel down into the artificial opening in the form of a loop. The peritoneum is sewed with fine catgut sutures around the ends of the loop. The abdominal wound is closed. Third Step. — The loop of bowel is drawn down until it extrudes from the new 43 674 GYNECOLOGY Fig. 327. — Operation for Artificial Vagina (Baldwin's Method), A loop of intestine has been resected, leaving the mesentery attached. Lateral anastomosis has been performed, uniting the ends of the resected gut. The free loop of intestine has been drawn down through the opening made between bladder and rectum (after Stoeckel). XevMMciQi.na Fig. 328. — Operation for Artificial Vagina. The free loop of intestine has been drawn down into the opening made between bladder and rectum. It has been stitched in place and an opening made in the wall. The septum made by the loop may be incised later. OPERATIONS ON THE VAGINA 675 introitus. The outer wall of the gut is incised and the edges stitched to the skin around the hjaneneal opening. The two legs of the loop are twisted so that the left lies anterior and the right posterior. In this way a double vagina is formed (Fig. 327). The walls of the gut which form the -septum between the two vaginal canals become adherent in. the course of time. This septum may- be incised later, so that a simple vagina is created. It should be remembered that the mucous membrane of the new vagina continues to secrete, and that it constitutes an absorbing surface, to which certain kinds of vaginal douches, like corrosive sublimate, may be a dangerous poison. The secretion is influenced by diet, being greatly increased by albuminous food. VAGINAL CELIOTOMY Anterior and Posterior Colpotomy The vaginal route for the surgical treatment of such conditions as uterine fibroids, ovarian tumors, pelvic adhesions, extra-uterine pregnancy, etc., is now Fig. 329. —Anterior Colpotomy for Pelvic Operations by the Vaginal Route. comparatively little used, and is for the most part confined to operations for prolapse, like those of Watkins and Goffe, and occasionally to vaginal hysterec- tomies. 676 GYNECOLOGY The pelvis may be entered either by opening the anterior or posterior wall of the vagina. Anterior colpotomy is performed in the following way: The anterior lip of the cervix is seized with traction forceps, and the uterus drawn strongly down toward the introitus. The peritoneal cavity may be entered either through a transverse incision made at the junction of the bladder and cervix or, pre- ferably, by a J.-shaped opening. By the latter method an incision is made from a short distance below the urethra to the cervix. The vaginal wall on each side is then loosened from the bladder and a cross incision made at right Fig. 330. — Posterior Colpotomy. Crucial incision through the posterior vaginal wall into the culdesac of Douglas. angles to the first, at the level of the junction of the bladder with the cervix. The two flaps are further separated from the bladder wall by blunt dissection and drawn outward by traction hooks. The bladder is then stripped back from the cervix, care being taken not to injure its wall. When the peritoneal reflection is reached it is seized with tissue forceps and incised, the incision being carried to each side into the broad ligaments as far as possible. The peritoneum of the bladder reflection is lifted up and cut in the median line as far as the fundus of the bladder (Fig. 329). Into the opening thus made is inserted a speculum which draws the bladder up to the symphysis. The next step is the •delivery of the uterus and adnexa through this opening. The traction OPERATIONS ON THE VAGINA -.677 forceps on the anterior cervical lip is forced back toward the posterior wall of the vagina so as to ant evert the uterus. The anterior wall of the uterus is seized with double hooks and the fundus drawn out of the. wound. As the uterus is dehvered, the tubes and ovaries come into view and shp out of the wound unless restrained by adhesions. The desired operation can then be performed. Posterior Colpotomy. — The technic of posterior colpotomy is somewhat simpler than the anterior operation, but according to those who employ the vaginal route, notably Goffe, it is much less useful for the average case. The posterior hp of the cervix is grasped mth traction forceps and drawn forward toward the symphysis. The posterior vaginal wall is thus put on the stretch. A longitudinal incision about 5 cm. long is made, beginning at the portio and running back in the median hne. The incision is carried through the vaginal wall, the loose cellular tissue, and into the peritoneal Cavity. In order to enlarge the opening thus made, two lateral cuts may be made at right angles to the original incision (Fig. 330). To deliver the uterus and adnexa the poste- rior wall of the uterus is seized with double hooks and drawn backward out of the vaginal wound. OPERATIONS FOR UTERINE MALPOSITION Operations for retroversion olshausen's operation for suspension of the uterus (author's TECHNIC) A SHORT median suprapubic incision is made. The appendix is inspected and removed as a routine measure. The edges of the peritoneum and fascia on each side of the wound are clamped in order to facihtate the passage of stitches. Each round hgament is grasped near the uterus with a half-length clamp, which is pressed tightly enough to raise the ligament, but not to lacerate it. A hga- :;^,^.Cae.2>T Fig. 3.35. — Simpson's Operation for Retroversion. An opening has been made in the fascia and a specially curved clamp passed through it be- tween fascia and muscle. The point of the curved clamp is about to enter the internal inguinal ring. uterus, and, therefore, has greater supporting power. On the other hand, it leaves two openings on the sides through which the intestines may prolapse, and it also leaves two weak points in the fascia through which the loops are drawn. Simpson's Operation.— Of the various modifications of the Gilliam round ligament operation, that of Simpson is, in the opinion of the author, the best. 682 GYNECOLOGY This operation has the advantage of securing permanent anterior position of the uterus without danger of intestinal comphcations. It has excellent supporting power. There is, however, danger of adhesions forming between the uterus and the abdominal wall, causing an occluding diaphragm across the pelvis, with possible subjective symptoms and danger of dystocia. This latter danger which the operation shares with all the Gilliam operations, according to Simpson, is obviated if his technic be properly followed. The technical steps of the operation are as follows: Through a median incision the round hgament is caught in pressure forceps about 1^ inches from \k!5^&tCvV>(LS>- FiG. 3.36. — Simpson's Operation for Retroversion. The curved clamp has been passed through the internal ring, beneath the peritoneum. It has pierced the peritoneum and is in the act of grasping the round ligament preparatory to drawing it back through the internal ring (adapted from Simpson). the uterus. A second clamp grasps the parietal peritoneum at the point of the internal ring. The skin is retracted from the wound and the fascia punctured about 1| inches to the side of the lower angle of the incision. A specially curved clamp is passed through the puncture and obliquely through the rectus muscle, entering the space between the leaves of the broad hgament through the internal ring. It is forced along in the subperitoneal space until it reaches the clamp first placed on the round ligament 1^ inches ffom the uterus. The curved clamp is forced through the peritoneum and made to grasp the round hgament. It is then drawn out, bringing the loop of round OPERATIONS FOR UTERINE MALPOSITION 683 ligament with it through the channel forced by its entrance into the abdominal cavity. The loop of the round ligament is fastened beneath the rent in the fascia by a linen thread, which closes the rent and attaches the hgament at the same time. The procedure is repeated on the other side. In choosing the point of the ligament which is to be drawn through the opening it is important not to take it too close to the uterus, for by this means the uterus is drawn too snugly against the anterior abdominal wall, causing the danger of occluding adhesions mentioned above. Fig. 337. — -Simpson's Operation for Retroversion. The loop of round ligament is brought up to the opening in the fascia where it is being anchored by a figure-of-8 stitch. The insert shows how the stitch both fastens the ligament and closes the wound in the fascia. In order to perform the Simpson operation easily it is of very great moment that the perforating clamp have a proper curve. The blades are somewhat longer and more fully curved than those of the ordinary half-length clamp. Without this curve the passage of the clamp into the abdominal cavity is some- times extremely difficult. Mayo's Modification of Gilliam's Operation (Internal Alexander).— In this operation the perforating clamp does not pierce the fascia, but passes between the fascia and the outer surface of the rectus. It then enters the internal ring and grasps the round ligament in exactly the same way as in the Simpson opera- tion. After the ligaments are drawn out through the abdominal wall they are crossed over in front of the recti muscle and sewed together in the middle 684, GYNECOLOGY c\\e~& beneoJrtv Fig. 338. — Simpson's Operation for Retroversion. The round ligament has been drawn through the internal ring and attached beneath the fascia (adapted from Simpson) . Nsll^cS Fig. 339. ■ — Simpson's Oi'miiation for Retroveksion. The operation completed and viewed by imagination from inside the abdomen (adapted from Simpson) . OPERATIONS FOR UTERINE MALPOSITION 685 line (Fig. 340). This operation has no advantages over the Simpson method, and involves the objectionable feature of joining the two loops, which incurs the danger of drawing the uterus up too tightly, with consequent adherence to the abdominal wall. Kelly's Modification of Gilliam's Operation. — In this operation the per- forating clamp passes directly through the rectus muscle and peritoneum, but not through the fascia, as in the original Gilliam's. The round ligament is Fig. 340. — Mayo's Internal Alexander. The red lines indicate the course of the round ligaments. They are drawn through the inguinal rings over the muscle but underneath the fascia, the loops being united in the middle line. drawn straight out, giving the same direct pull as in the Gilliam operation, and is joined across the rectus muscles with its fellow in the manner used by Mayo. The operation gives many excellent results, but has the same, objections as Mayo's operation. BALDY'S OPERATION (Also Called the Baldy-Webster Operation) This operation is useful for cases of simple retroversion and for retroversion with moderate prolapse, where no great supporting power is required. It has the advantage of securing a position of the uterus more nearly normal than does any other operation. It is also devoid of danger from childbirth or from com- plications of intestinal obstruction. ■ The operation is performed in the Trendelenburg, position. The broad liga- ment of the right side is pierced by a half-length clamp "at" a point close to the uterus and directly under the ovarian ligament. The round ligament is then grasped by thumb forceps at a point about one-third of the length of the ligiament 686 GYNECOLOGY from the uterine end. The ligament is carried by means of thumb forceps into the bite of the perforating clamp, which thus seizes the ligament and draws it through the perforated opening to the posterior wall of the uterus. The round ligament of the left side is then drawn through an opening in the left broad liga- ment in exactly the same manner. The loops of the two round hgaments are next sutured together, several stitches being also placed to unite them to the posterior wall of the uterus. Care must be taken to attach the ligaments at Fig. 341. — Baldy-Webster Operation for Retroversion. An opening is made through the broad Hgament just under the suspensory ligament of the ovary. A half-length forceps passed through the opening grasps the round ligament and draws it backward. just the right level on the back of the uterus, for if the attachment is too low the uterus may become retroflexed over the ligaments, and if the attachment is made too high there, is danger of causing an anteflexion of the uterus. The perforation of the broad ligaments and the suture of the round ligaments must be done with as little damage to the peritoneum as possible, for otherwise there is liability of adhesions of the ovaries, a complication for which the operation has been criticized. OPERATIONS FOR UTERINE MALPOSITION 687 Fig. 342. — Baldy-Webstbr Operation for Retroversion. The round ligament of the right side is being drawn through the opening in the broad ligament. Tig. 343. — ^Baldy-Webster Operation for Retroversion. The round ligaments of the two sides are being drawn backward through the openings in the broad ligaments. 688 GYNECOLOGY Fig. 344. — Baldy-Webster Operation for Retroversion. The two round ligaments are attached together and to the posterior wall of the uterus. ALEXANDER'S OPERATION As originally performed the Alexander operation was based on the prin- ciple of restoring, the retro verted uterus to a forward position by drawing the round ligaments through the inguinal rings, where they were anchored by su- tures, the slack of the ligaments being either cut or redupHcated. In the earher days it had the great advantage of avoiding the necessity of opening the ab- dominal cavity, which at that time constituted a dangerous major operation. There were, however, serious drawbacks to the success of the operation, so that when asepsis and improved surgery made exposure of the peritoneum com- paratively safe, it was generally discarded in favor of the newer procedures for replacing the uterus. Among the disadvantages attending the operation may be mentioned, first, the frequent difficulty of finding the ligament. It was usually sought for at the external ring, where its muscular elements blend in connective- tissue fibers running down into the labium majus. If it could not be found here, it was sought in the inguinal canal, where it is often vague and difficult to distinguish from the surrounding .parts. Not infrequently wounds were closed without either ligament being discovered. Another difficulty was the frequency with which the ligaments broke when tension was exerted on them. Still another disadvantage was the inability to determine whether or not the retroverted uterus- was adherent, in which case the operation was valueless. Inguinal hernias and wound sepsis were common complications. In the study of a series of Alexander operations performed in the old way the author found 15 per cent, of recurrences in cases personally examined. OPERATIONS FOR UTERINE MALPOSITION 689 Though the operation is little used at the present day in this country, it has been revived abroad under the name of the Alexander-Adams operation, but with an improved technic which does away with many of the former objec- tionable features. By the newer method the peritoneal cavity is opened at the inguinal ring, so that if the ligament has not been found in the inguinal canal it can be traced from within the abdomen outward. By securing the ligaments within the abdomen they may be drawn out without 'danger of rupturing them. Moreover, the opening of the abdomen enables the surgeon to palpate the uterus, determine its position after traction of the ligaments, ascertain the presence or absence of adhesions, and perform minor operations on the appendages. ^^•^S-- Fig. 345.^ — Alexander-Adams Operation for Retroversion. The round ligaments have been cut and freed, and are being drawn upward by traction clamps. The peritoneum has been opened on both sides. The position and condition of the uterus is being explored by the two forefingers. In closing the wound the danger of postoperative hernia is lessened by treating the canal in the manner of a Bassini operation for inguinal hernia — i. e., sewing the conjoined tendon to Poupart's ligament. The technic of the operation, as used abroad and described by Doderlein- Kronig, is as follows: A 3-inch incision is made parallel to Poupart's ligament as in the operation for inguinal hernia. The incision through skin, fat, and superficial fascia is carried down to the white glistening fascia of the external oblique muscle. The external inguinal ring is exposed, easily recognizable by the divergence of the fascial fibers and by its relation to the pubic spine. The fibers of the external 44 690 GYNECOLOGY oblique are split above the external ring in a direction parallel with Poupart's ligament. In ordinary cases the round ligament may easily be seen lying in the bed of the inguinal canal, but if it cannot be distinctly defined, an opening is made through the peritoneum at the internal ring, when the ligament can be followed from within outward. The ligament is drawn up with two clamps at its distal end and severed between the clamps. It is then freed from its bed and drawn firmly outward until the cone-shaped reflection of the peritoneum surrounding the proximal end of the hgament is brought into view. JV'poueucusiS- -J'Xi^ \ V4A?Gra{tfcr"l\-yC Fig. 346. — Alexandee-Adams Operatio^t for Retroversion. Opening the peritoneum. By traction on the round ligament the peritoneum is drawn up in a funnel- shaped fold (after Doderlein-Kronig) . The peritoneal reflection is now opened (Fig. 346), and the operation up to this point repeated on the other side. The forefingers of the two hands are now introduced into the peritoneal cavity, as in Fig. 345, and the pelvis explored. By this maneuver the position of the uterus is controlled. When the desired position is attained the ligaments are sewed to the under side of the outer flap of fascia and the redundant portion cut off. In order to guard against possible postoperative hernia the edge of the OPERATIONS FOR UTERINE MALPOSITION 691 Fig. 347. — Alexander-Adams Operation for Retroversion. Closure of peritoneal opening and suture of the round ligament to tHe under side of the fascia (after Doderlein-Kronig) . conjoined tendon is attached by a few stitches to Poupart's ligament, wound is closed by overlapping the fascia layer. The Operations for Anteflexion pessaries for anteflexion of the cervix 'As has been stated (see page 466), the use of intra-uterine pessaries is un- surgical in principle, and may be followed by inflammatory processes in the tubes, of which we have observed two instances. Nevertheless, even with this risk the procedure is regarded as justifiable and is very widely employed. If apphed to the proper cases the results gained by pessaries, both for dysmenor- rhea and sterility, are comparatively good. Numerous forms of pessaries are in use, some of which require sutures in the cervix to keep them in place, others being self -retaining in principle. We greatly prefer the latter type, as the sutures used for sewing in the instrument inevitably cause a greater or less inflammatory reaction in the cervix that some- times continues in the form of a chronic cervicitis or endocervicits after the removal of the pessary. ■ In using the other type of intra-uterine pessary it is important to insert also a vaginal pessary, which not only prevents the intra-uterine instrument GYNECOLOGY Fig. 348. — Uterine Stem-pessary Contain- ing Groove for Drainage. CJ G^ Fig. 350. — Applicator Used for Intro- Fig. 349. — Chamberlain's Intra-uterine ducing the Uterine Stem-pessart Pictured ' Stem-pessart. in Fig. 349. OPERATIONS FOE UTERINE MALPOSITION 693 from slipping out, but also maintains a good position of the uterus, which in most cases of anteflexion is retrocessed. The forms of pessary recommended by the author are shown in Figs. 348 and 349- In the first one there is a groove that provides for proper drainage. The second pessary shown is an excellent one, ingeniously devised by Chamber- lain. It is conveniently introduced by the apphcator shown in Fig. 350. In applying an intra-uterine pessary the patient should be under complete anesthesia in order that the cervix may be thoroughly dilated. It is usually not necessary to curet the endometrium. In fact, it is desirable to leave this intact, for the dangers of sepsis are increased if a foreign body in the form of a pessary is left in contact with an abraded mucous surface. The pessary is left in from six weeks to two or three months. It must be very carefully watched by the attending physician, and should be removed at once if undue leukorrheal discharge or pelvic pain appear. The self-retaining pessaries can be extracted without trouble. Those, however, that have been sewed into the cervix sometimes cause considerable embarrassment in their removal. OPERATIONS ON THE CERVIX FOR ANTEFLEXION Several operations on the cervix for straightening the uterine canal have been devised. Baker's operation consists in removing a transverse wedge from the posterior wall of the cervix. The operation is a difficult one, and can best be performed with the patient in the Sims position. An oval incision is made, the width of which includes most of the posterior vaginal portion of the cervix, the ends of the oval being carried around to the sides of the cervix. In excising the wedge it is usually necessary to enter the cervical canal, which, however, does no harm. Severe bleeding may be encountered as the wound reaches to the sides of the cervix. The bleeding vessels should be tied with hgatures sewed into the cervical tissue. The wound is closed with interrupted catgut stitches. This operation, if properly done, straightens out the angulation of the cervix and does not mutilate it. Symptomatic results are, however, only moderately satisfactory. Pozzi's operation consists in creating an artificial bilateral laceration of the cervix. With the patient in the perineal position, the anterior and posterior hps of the cervix are incised deeply to the level of the internal os, in the form of a bilateral laceration. Wedge-shaped pieces of cervical tissue are removed from the two wounds thus made in order to allow for the approximation of the vaginal and cervical mucous membranes. The wounds are closed with interrupted catgut sutures. This operation is a mutilating one, and is apt to be followed by the same compfications that result from laceration by childbirth — i. e., ectropion, €ndocervicitis, and cervicitis. Our short experience with the operation has been unsatisfactory, and we have discarded it in our chnic. 694 GYNECOLOGY Dudley's Operation.- — Another principle, used for many years for ante- flexion, is that of posterior discission of the cervix, including the internal os. This does away with the lower leg of the angle and theoretically relieves obstruc- tion. The technic devised by Dudley is the best one to employ in performing this operation. With the patient either in the Sims or perineal position, the cervix is first thoroughly dilated. The posterior wall of the cervix is then divided exactly in the median line back as far as the junction of cervix and vagina. The next step is to sever the constriction at the internal os. This is done with a narrow scalpel, which, under guidance of the finger, cuts the fibers of the internal os until the opening is sufficiently wide to admit the finger into the Vv(^@^ Fig. 351. — Dudley's Operation fob Ante- flexion. Removal of wedges from the sides of the incision and placing of the approximating stitch. Fig. 352. — Dudley's Operation for Ante- flexion. Closure of the wound. uterine canal. Care must be exercised in performing this part of the operation not to enter the peritoneal cavity in the pouch of Douglas, an accident that, however, does no special harm. The next maneuver is to approximate the ends of the wound at the external OS to the upper angle of the wound. In order to accomplish this without tension, wedge-shaped pieces of tissue are removed from the middle portion of each side of the wound, as shown in the drawing (Fig. 351). A stitch is then introduced in the manner shown in Fig. 351, which when taut draws the posterior part of the external os up to the angle of the wound at the internal os. Stitches are placed in the lateral parts of the wound to control hemorrhage and secure good coaptation of the wound edges. OPERATIONS FOR UTERINE MALPOSITION 695 This operation is frequently followed bj' good results as regards the rehef of dysmenorrhea and the cure of sterihty. It is, however, mutilating to the cervix, and is often foUowed by ectropion and endocervicitis with annoying leukorrheal discharge. We have on a number of occasions been obhged to per- form a tracheoplasty to reheve the symptoms caused by the operation. ABDOMINAL OPERATION FOR ANTEFLEXION (AUTHOR'S METHOD) As has been pointed out on page 482, the only way permanently to straighten out an anteflexed uterus without mutilating it is by means of suspending it \i.^.GTa««3--i9'3 / Fig. 353. — Positiox of Uterus ix Axteflexion. The uterus is sharply bent on itself and the whole organ sags back toward the sacruna in the position of retrocession. The cenix is disproportionately long. from above. We have employed this principle for several years, and have secured much better results, especially for dysmenorrhea, than by any other method. The mechanical principle involved is ihustrated in Figs. 353 and 354, in which it is seen that the anteflexed retrocessed uterus may be brought into a practically normal position by suspension from the abdominal wall. Several operations maj^ be used for the reduction of anteflexion — e. g., the 696 GYNECOLOGY Alexander- Adams, Gilliam's, Mayo's, Simpson's, and Olshausen's. The Baldy- Webster and Coffey operations are inapplicable to this condition. Ni.^.\a^6 ^v Via L^ttWJl„ Vl.^.6««.wa,9. Fig. 356. — Operation for Procidentia (Author's Method). Sagittal section showing completed operation. The cervix and body of the uterus have been amputated, leaving only a disk of uterine tissue. The bladder has been drawn up over this disk and attached by its flap to the posterior wall of the vagina. The whole mass, including the disk, the at- tached broad ligament, and the upper wall of the bladder, has been fixed to the anterior abdominal wall. The manner in which the cystocele is reduced by this maneuver is shown in the drawing. The auxiliary operation on the anterior and posterior walls of the vagina is not represented. of the two artificial hgaments made between the stump -of the cervix and the anterior abdominal wall. The secondary defense consists of the broad hga- ments brought together by their attachment to the cervical stump, on which a portion of the bladder rests as on a shelf. The results of this operation are excellent, there being httle danger of recurring prolapse of the cervix or anterior wall of the vagina. Recurrence of the rectocele has in a few instances been seen requiring re-operation on the OPERATIONS FOR UTERINE MALPOSITION 699 perineum. The recurrence of rectocele may be avoided by applying several stitches in Douglas' fossa in the manner used in the Moschowitz operation for rectal proJapse (g. v.). If the patient is desirous of having children, the operation for moderate pro- cidentia may be done satisfactorily without removing the uterus. The initial steps of the operation are the same as in that already described — i. e., high amputation of the cervix, anterior colpoplasty, and perineoplasty. Instead of performing a supra-vaginal hysterectomy with abdominal fixation of the cervical stump, it is possible to secure an excellent- result by suspending the uterus by Fig. 357. — Operation for Procidentia (Author's Method). This is an imaginary view of the completed operation seen from within the abdominal cavity. The bladder flap has been drawn over and attached by one- catgut suture behind the cervix. If there is great relaxation of the bladder the flap may be attached much deeper in the culdesac than is shown in the drawing. The two silk sutures shown in Fig. 355 have been introduced into the abdominal wall through peritoneum, muscle, and fascia and tied on the inside, as in the Olshausen operation (Fig. 332 The abdominal wound has been closed. If by an unusual chance this fixation attach- ment should give way, it may be. seen that the broad ligaments form an efficient ' ' secondary defense ' ' to prevent prolapse of the cer\dx and the vaginal vault. the Olshausen method sufficiently high up on the abdominal wall to reduce the prolapse. The dangers as to childbirth, if the patient becomes pregnant, are no greater than after any of the suspensory round figament operations. THE WATKINS INTERPOSITION OPERATION FOR PROLAPSE AND PROCIDENTIA The principle of the Watkins operation is based on a separation of the bladder from the anterior wall of the uterus and transposing its attachment to the posterior wall, so that the uterus is left in a position to support the entire bladder. Watkins performed his first operation in 1898. Several modifica- tions, notably that of Wertheim, have appeared since. 700 GYNECOLOGY Fig. 358.— Watkins' Opebatiox for Procidentia. Separating the vaginal wall from the bladder by blunt dissection wdth scissors. OPERATIONS FOR UTERINE MALPOSITION 701 Fig. 359.— Watkins' Operation for Procidentia. Separating the bladder from the cervix by blunt dissection ^-ith scissors. 702 GYNECOLOGY The technic of the Watkins operation is as follows : The anterior hp of the cervix is grasped with traction forceps and drawn forcibly down to or out of the introitus. A transverse incision is made at the junction of the bladder and the portio. The ends of the incision are grasped with pressure-forceps and held taut. The end of a pair of scissors, closed, is then inserted in the wound and forced upward toward the meatus, in the plane Crown "'-Suture tf.SxrcvociS;. Fig. 360. — Watkins' Operation for Procidentia. The fundus has been delivered beneath the bladder. The crown stitch has been applied. of cleavage between the bladder and anterior vaginal wall (Fig. 358). When the level of the urethra is reached the scissors are opened and withdrawn, thus creating an area of separation of bladder and vagina, the amount of which varies according to the size of the cystocele and the amount of adherence be- tween the two layers of tissue. In performing this part of the operation there is considerable danger of injuring the bladder. This must be guarded against OPERATIONS FOR UTERINE MALPOSITION 703 by gentle manipulation of the tissues. When the bladder and vagina have been separated, the anterior vaginal wall is incised along the median line and the edges of the flaps caught with pressure forceps. The flaps are then stripped further back by blunt dissection. The amount of stripping of these flaps should be only enough to cover the anterior wall of the uterus in its new position. In case of an extensive cystocele, where it is desirable later to cut away redundant parts of the wall, the stripping of the flaps is, of course, carried further. ~~^^,<=>xrcv.\iCS> Fig. 36L — Watkixs' Operatiox for Procidentia. The crown suture. The next step is to separate the bladder from the cervix. This is done by inserting the scissors in the line of cleavage for a short distance and then opening them (Fig. 359). This process is repeated carefully, and with the points of the scissors pressing against the cervix until the movable plica of the peritoneal reflection from bladder to uterus is reached. The separation of the bladder is not always easy. In cases of difliculty Watkins recommends separating the 704 GYNECOLOGY lateral portions first, as the adherence of the tissues is less there than along the median line. Where the peritoneal fold comes into view it is picked up with tissue forceps and cut. The opening thus made is enlarged either by cutting or by forcing it open with the finger. The next step is the delivery of the uterus through the wound. A narrow retractor is inserted, drawing the bladder well up to the symphysis. The ante- rior wall of the uterus is first seized with traction forceps and drawn downward and forward, carrying the cervix up and back. By this maneuver one can grasp N\L '^.&-. (x^tcx ViatKvns Fig. 362. — Watkins' Operation for Procidentia. Diagram showing position of organs when the operation is finished. the fundus of the uterus with traction forceps and deliver it through the wound. Watkins cautions against the attempt of dehvering the uterus by the anterior wall because its diameters are greater than those of the fundus. With the uterus held forward out of the wound, sutures are now placed as in Fig. 360, connecting the upper end of the vaginal wound with the fundus of the uterus. In attaching these sutures one must keep in mind that it is im- portant to superimpose the entire bladder on the uterus, but not to fix the uterus so firmly against the urethra as to interfere with urination. The vaginal wound is now closed over the anterior surface of the uterus by a OPERATIONS FOR UTERINE MALPOSITION 705 continuous catgut suture, which occasionally catches the peritoneum of the uterus. The transverse incision may be sewed up transversely or longitudinally. If the operation is done during the reproductive period, the uterine ends of the tubes should be ligated and severed, and peritoneum sewed over the exposed surfaces in order to prevent possible impregnation. If the cervix is much elongated and hypertrophied, the operation should be preceded by amputation of the cervix. In all cases a careful perineoplasty should be performed. Fig. 363. — Watkins' OpERATioisr for Procidentia. Closure of wound. Wertheim described an operation in 1899 similar to that of Watkins and based on the same mechanical principles. In the Wertheim operation the bladder is stitched to the posterior wall of the uterus at the level of the internal OS (Fig. 364). In closing the vaginal wound a portion of anterior wall of the, uterus is left exposed in the vagina (Fig. 365). From a surgical standpoint, Watkins' technic is obviously superior, .• 45 706 GYNECOLOGY GOFFE'S OPERATION FOR PROLAPSE A vaginal operation for moderate prolapse and cystocele somewhat similar in mechanical principle to that of Watkins, though not as radical, has been devised by Goffe. The uterovesical pouch is opened as in the Watkins operation, or as described for Anterior Colpotomy (see page 676). "titb anb tut [nM^.Gt^ Fig. 364. — Wertheim's Oper.'\.tiox for Prolapse and Procidentia. Showing how the edge of the peritoneal reflection is stitched to the posterior wall of the uterus (adapted from Doderlein-Kronig) . The uterus is then delivered, and a shortening of the round ligaments by reduphcation performed through the vaginal opening. The principle involved in this operation is to shift the bladder around on the uterus so as to form a new attachment not only in the median line, but also at the two cornua of the bladder. A description of the steps of the operation from this point is quoted from Goffe: OPERATIONS FOR UTERINE MALPOSITION 707 "The object of the next procedure is to carry up into the pelvis and to fix the firm immovable base of the bladder. To accomphsh this a point is se- lected in the middle of the base of the bladder wall which, when carried up to the torn edge of the peritoneum on the anterior face of the uterus, middle point, will take up all the slack in the base of the bladder, making a comparatively straight line from the urethra to the uterus. Through this point a suture is passed and carried also through the selected point on the anterior face of the — V)ttruS V.T^^^n Fig. 366 — Wertheim's Operation for Prolapse and Procidentia. In this operation the peritoneum of a portion of the fundus of the uterus is left exposed in the vagina. Compare this with Fig. 363, wliich shows the Watkins method of vaginal closure. uterus, catching up in its course the corresponding torn edge of the peritoneum on the bladder. This suture is left long and is not tied until all the sutures are passed. Two points are then selected in the base of the bladder on either side on a transverse line with the first selected point and equally distant. These two points indicate the cornua of the bladder. Through them similar sutures are passed and carried through the round ligaments or points on the torn-off edges of peritoneum on the surface of either broad ligament sufficiently distant from the middle point to take up all the slack in the base of the bladder, from 708 GYNECOLOGY side to side; these sutures are also left long. The three sutures are then tied successively, beginning with the middle one. The effect of this is to stretch the base of the bladder taut and smooth in every direction. This restores the support of the bladder which is derived from the uterus. In addition to this, it is necessary to overcome the condition of hernia, and secure to the bladder the support which it receives from the fascia lata. This is accomphshed in the Fig. 366. — The Matos' Vaginal Operation for Procidentia. The broad ligaments are being united by a running mattress suture (adapted from the Mayos). following manner: The fascia along the middle hne of the vaginal incision and the mucous membrane as well are then trimmed off at either side sufficiently to remove the overstretched and ruptured part of the fascia and secure for support the strong uninjured portion of the fascia lata. The freshened edges of the fascia lata and vaginal mucous membrane are then stitched together through- out the whole length of the vagina, thus bringing it up snugly against the base OPERATIONS FOR UTERINE MALPOSITION 709 of the bladder. The uterine end of the vaginal incision is then stitched to the uterus directly under the attachment of the bladder." For complete procidentia Goffe applies the same principle in a more radical way: The uterus is first removed by vaginal hysterectomy (see page 728). The two broad ligaments are then stitched together across the pelvis. Upon this newly constructed plane the bladder wall is spread out and stitched, in practically the same manner used in the prolapse operation, in which the bladder _,i.V^ Dx-ocvbLup Fig. 367. — The Mayos' Operation for Procidentia. The broad ligaments have been united in the middle line. The vaginal mucous membrane is being approximated by a running stitch (adapted from the Mayos). was attached to the anterior uterine wall. To this plane is also attached the upper end of the vagina. THE MAYOS' OPERATION FOR PROCIDENTIA An operation for procidentia combining the principles of the Watkins and Goffe operations is that devised by the Mayos. A vaginal hysterectomy is performed as described on page 728, except that clamps are used on the broad hgaments instead of ligatures. The edges of the broad ligaments are then approximated laterally, and a running mattress suture of chromicized catgut passed through both ligaments, along a line suffi- 710 GYNECOLOGY ciently far back of the clamps so that when drawn taut the broad hgaments are tightened (Fig. 366). This mattress stitch runs at a distance of 1 to 1| inches from the edges of the ligaments, and is designed also to secure the vessels without possibility of shpping. The upper border of the united broad ligaments is then stitched to the vaginal wall at the level of the upper angle of the vaginal wound. This compels the bladder to rest on the broad ligaments as on a kind of shelf. The loose Fig. 368. — Spinelli'.s Oplr\tiox for Inversion. The initial incision. edges of the broad ligament are now stitched smoothly together, and the vaginal flaps closed by a running suture (Fig., 367). CONSERVATIVE OPERATION FOR INVERSION OF THE UTERUS The technic of the operation devised by Kiistner for inversion is as follows: A wide transverse incision is made opening the pouch of Douglas. The forefinger of the left hand is introduced through this incision into the cup- shaped depression caused by the inversion of the fundus. If the uterus can be OPERATIONS FOR UTERINE MALPOSITION 711 brought outside of the vulva, the inverted fundus will appear uppermost, the posterior aspect of the uterus and cervix being toward the operator. A longi- tudinal incision is then made exactly in the middle line, dividing the posterior wall of the cervix and a part of the posterior wall of the fundus. With the fore- finger in the cup-shaped depression on the abdominal side, and the thumb on the fundus of the exposed side, the uterus can now be reinverted to its original con- dition. The reinverted fundus is retroflexed and drawn out through the poste- Fig. 369. — Spinelli's OpER.iTioN for Ix\'ersion. The anterior wall of the uterus has been opened preparatory to reinverting it. rior colpotomy opening, and the wound of the posterior wall and cer\dx closed wdth deep catgut sutures. The posterior colpotomy wound is sewed. This operation has been modified by other operators, who recommend making an anterior vaginal incision. SPINELLI'S OPERATION FOR INVERSION OF THE UTERUS Spinelli's modification of Kiistner's principle of vaginal operation for inversion is the method most commonly in use at present. 712 GYNECOLOGY A transverse anterior vaginal incision (Fig. 368) i& first made and the bladder separated from the uterus, as described for Anterior Colpotomy (see page 676). A median incision is then made through the cervix, dividing completely the constricting ring. This incision should be carried toward the fundus, through the anterior uterine wall, until a point is reached which will allow the reinver- sion of the uterus. It is, as a rule, necessary to continue the incision as far as the fundus. W,T^G-^ Fig. 370. — Spinelli's Operation for Inver- sion. The uterus has been reinverted. In order to secure approximation of the edges of the wound in the uterine wall it has been necessary to remove wedges of tissue on each side, as is shown in the drawing. \N •Pt^ Fig. 371. — Spinelli's Operation for Inver- sion. Closure of the incision of the cervix and anterior wall. The uterus is reinverted by placing the forefingers at the cervix for coun- terpressure, and forcing the fundus upward by the thumbs in the manner that one would naturally use in turning a tennis ball inside out through a cut in its side. When the uterus has been restored to its original form, the next step is to close the incision in its wall. It will, however, be found that, owing to the shrinking which the peritoneum has undergone in its inverted position, it can- OPERATIONS FOR UTERINE MALPOSITION 713 not be approximated, the tissue of the uterine wall pouting out in the manner of an ectropion. The excessive tissue must be trimmed away in the form of longitudinal wedges, as seen in Fig. 370, when the peritoneal edges may be coaptated without difficulty. The wound of the uterine wall is closed with two rows of continuous catgut sutures. The first suture includes and firmly unites the muscular wall, while the second is superficial and approximates the peritoneal surfaces. The wound of the cervix is closed wdth interrupted catgut sutures. A cigarette-wick is left in for drainage, as there is always danger of Fig. 372. — Spixelli's Oper.\tion for Inversion. The vaginal incision has been sutured and a small rubber drain inserted at one angle. sepsis. Crossen recommends drainage both from the anterior and posterior culdesac. The vaginal wound is sutured except for the portion occupied by the drain. HYSTERECTOMY OPERATIONS SUPRAVAGINAL HYSTERECTOMY The patient is in a pronounced Trendelenburg position. The length of the median abdominal incision depends upon the size of the mass to be removed from the pelvis. If there is no enlargement of the pelvic organs the incision need not be greater than 3| inches unless the patient is fat. In all cases the 714 GYNECOLOGY incision through the aponeurosis should be carried down as far as possible to the pubes, for it is at the lower end of the wound that most room is needed. The intestines, which should be carefully prepared, are walled- off with gauze. The fundus of the uterus is then seized with volsella, unless there is question of infection or necrosis of the tissue, in which case they should not be used. The uterus is first drawn sharply to the left, thus exerting tension on the broad ligament and bringing the round and infundibulopelvic ligaments into prominence. A single half-length clamp is apphed near the ovary, includ- ing the round ligament close to the uterus and the infundibulopelvic ligament, in which run the ovarian vessels. The clamp should be so applied that the two \voun6-)-i\o . \l\.^ vaxvawyes .Ve Fig. 374. — Supravaginal Hysterectomy. Dissection of the uterovesical fold of peritoneum. The blades of the scissors are pushed under the peritoneum before cutting it, thus avoiding unnecessary bleeding. the bladder. The uterovesical reflection of peritoneum is picked up with thumb forceps close to the bladder, where it is loosely attached, and opened sufficiently to admit the end of a pair of blunt curved scissors, which are pushed under the peritoneum to the cut surfaces on each side of the uterus (Fig. 374). This chssects up the peritoneum so that it is easily cut, with the complete avoid- ance of bleeding. It is not riecessary to dissect a flap of peritoneum on the posterior wall of the uterus. The uterus is now ready for amputation. A half-length clamp is applied to the left uterine vessels, where they ascend the uterus at the level of the 716 GYNECOLOGY internal os. A second, toothed, clamp is applied to the same vessels f inch higher on the uterine wall, and the vessels are severed close to the second clamp so as to leave" the proximal stump as long as possible. The traction forceps on the fundus of the uterus is then seized in the left hand of the operator and drawn as sharply to the right as possible in order to expose the cervix and give room for the amputation. A wedge-shaped incision is made across the cervix uinn_^ Fig. 375. — Supravaginal Hysterectomy. First Step of Amputation. The uterine vessels, having been exposed, are grasped with two clamps and are being severed. Care must be taken to leave the ends of the vessels sufficiently long above the lower clamp so that they may easily be seized by the "secondary defense" clamp seen in Fig. 379. until the cervical tissue is entirely severed. The uterus is now held only by the right uterine vessels (Fig. 377). They are clamped and cut so as to leave a long pedicle beyond the clamp. With the removal of the uterus and appendages only two clamps remain in the pelvis controlhng the uterine vessels. A third, toothed, clamp is now attached to the posterior lip of the cervical stump for the purpose of traction. K there is any question about the possibility of infection from HYSTERECTOMY OPERATIONS 717 the cervical canal, it may be cauterized or treated with crude carbolic acid or alcohol or iodin. The lips of the cervical stump are united with two or three interrupted sutures and then the uterine vessels are tied. The technic of tying these vessels is im- portant. While amputating the uterus pains were taken to leave the pedicles of the vessels extending beyond the clamps as long as possible. Beginning now on the right, the redundant pedicle of the vessels is included in another pair of Fig. 376. — Supr.\ vaginal Hysterectomy. Second Step of Amputation. The vessels of the left side have been severed and the uterus is being amputated by a wedge-shaped incision. clamps to act as a sort of secondary defense. A ligature is introduced with a full-curved needle first into the tissue of the cervix inside- the vessels, then around the vessels and' tied. As the knot is tied the first or lower clamp is released. The ligature is then passed again in the same manner, and when tied the secondary clamp is removed. In this manner the uterine vessels are tied twice. By using the secondary clamp no blood is lost. The same procedure is carried out on the left. 718 GYNECOLOGY The next step, and a most important one, is the suspension of the cervical stump by the broad hgaments in order to avoid a later prolapse, a comphcation Fig. 377. — Supravaginal Hysterectomy. The left uterines have been clamped and cut. The uterus has been amputated by a wedge- shaped incision. The uterines of the right side have been reached and exposed by lifting the uterus. A clamp now grasps the vessels, which are severed with as long a pedicle as possible. which, as we have emphasized (see page 129), is the most common cause for the physical and nervous symptoms following hysterectomy. HYSTERECTOMY OPERATIONS 719 Fig. 378. — Supravaginal Hysterectomy. The uterus has been amputated by a wedge-shaped incision. Two or three interrupted sutures close the walls of the cervical stump. The first suture is being placed. ~TiVsl Tie-' \vIP.G--^ Fig. 379. — Supra vagixal HYSTERECTOivrY. The uterines of the right side are about to be tied. The "secondary defense" clamp has been appHed to the ends of the vessels. When the Ugature has been tied the lower clamp is removed. A second tie is then made for extra safety. 720 GYNECOLOGY Beginning on the right, the round and infundibulopelvic ligaments, which have been tied so as to meet each other at an angle, are grasped with clamps. Fig. 380. — Supravaginal Hysterectomy. The uterine body has been amputated. The lips of the cervical stump have been closed by two interrupted sutures. The right uterine vessels have been tied once and the ligature is being intro- duced for a second tie. The stump of the uterine vessels is controlled by the "secondary defense" clamp. -^TeTxl'OYve-U'cn "^OUX-^bXlQ,. Vv/.TtG.. 3^Q\)Q\as \ CatuiccxX btuvA'^ Fig. 381. — Supravaginal Hysterectomy. The stumps of the broad ligam,ent have been sewed to the stump of the cervix. The bladder flap of peritoneum is being lifted up preparatory to stitcliing it to the posterior wall of the cervical stump. A strong catgut hgature is applied on a needle which first passes through the tissue of the cervical stump, then through the round hgament near the tied end, and including a little of the peritoneum covering the infundibulopelvic HYSTERECTOMY OPERATIONS f21 Vr:pGr- ^'""^^ °^ l3ou|>\a?. Fig. 382. — Supra. vagixal Hxstehectomt. Operation completed. The bladder flap of peritonexim has been attached with one suture to the Dosterior wall of the cer^■ical stump. ^\a^ber vlovinb li'^p • ""^V^ecxrvb Ooaru Fig. 383. — Supravaginal Htsteeectomt. Method of lea^dng in the adnexa of both sides. ligament. The cendcal stump and the ends of the two Hgaments are approxi- mated and the ligature is tied. The needle-end of the hgature is left long, and 46 722 GYNECOLOGY again passed through the cervix and around the ends of the ligaments of the left side, which are also tied to the cervical stump in the same way. The final step of the operation is to grasp the loose flap of peritoneum which is reflected over the bladder, and draw it up toward the wound. This gives a chance, by the translucency of the peritoneum, to determine just where the edge of the bladder lies. A suture is passed through the margin of the per- itoneum, across the posterior wall of the cervix, and out again through the margin. When tied t>he peritoneal flap covers the united cervical and liga- FiG. 384. — Vaginal Drainage After Supra-vaginal Amputation. The stump of the cervix is drawn upward and forward by a toothed clamp inserted in the pos- terior wall. A long clamp has been introduced into the vagina, pressed against the posterior wall, and unclasped. An incision is being made through the vaginal wall between the opened ends of the clamp. mentary stumps and is attached to the posterior surface of the cervix (Fig. 382) . This completes the operation. By this technic very little blood is lost, and the cervix and vagina are permanently held in a high position in the pelvis. An additional point of value in the technic is that only one catgut knot is left exposed and is in a position where it can do little harm. This is an im- portant factor in the avoidance of postoperative adhesions. In sewing up the abdominal wound after an operation in the Trendelenburg position the patient should be returned to the horizontal position before the skin and fat are sutured. It will be found in most cases when this is done that HYSTERECTOMY OPERATIONS 723 on account of the change in position a httle bleeding takes place from the subcutaneous vessels which require tying. If this precaution is not taken it will happen occasionally that the skin sutures will not control this adventitious bleeding, and a blood-clot will form in the wound which may cause delay in the convalescence. Vaginal Drainage. — Whenever drainage of the pelvis is necessary it should be made, if possible, through the vagina. Abdominal drainage should be resorted to only in the most severe inflammatory cases, or when the posterior culdesac IBiab^er ^' W.P.Grawes- Fig. 385. — Vaginal Drainage After Supravaginal Htsterectomt. The tips of the clamp in the vagina are seen just emerging through the opening in the posterior vaginal wall. is SO occluded with adhesions that opening the vagina would entail too great risk of injuring the rectum. The method of instituting vaginal drainage during the operation of supra- vaginal hysterectomy is as follows: After the cervical stump has been closed and the uterine vessels have been tied, an assistant introduces into the vagina a long curved clamp with the tip turned toward the abdominal wound (Fig. 384). As the introduction of the clamp must be made under the operating sheet covering the patient, th,e assist- 724 GYNECOLOGY ant must be careful not to enter the urethra instead of the vagina. The stump of the cervix is drawn strongly upward and the ends of the clamps are pressed against the posterior vaginal wall near the cervix. The clamp is then unclasped and the surgeon makes an incision between the ends of the clamp through the vaginal wall (Fig. 384). The assistant closes the clamp, forces it through the vaginal opening into the posterior culdesac and receives a cigarette-drain, which he draws down into the vagina (Fig. 386). The rest of the operation is then completed and the abdominal wound closed. In most cases the drain is removed Tlidtavcuon C\a\np on SVomoofCiiroix. . Fig. 3bD. — Vaginal Drainage After Supravaginal Hysterectomy. A cigarette drain is being passed by the surgeon to a clamp, which has penetrated an opening made in the posterior vaginal wall. in two or three days and does not have to be replaced. By this method of drain- ing the pelvis the time of convalescence of the patient is not lengthened beyond that of cases where drainage is not required. COMPLETE HYSTERECTOMY Except for malignant disease, complete hysterectomy, which implies an extirpation of the cervix together with the uterine body, is seldom necessary. There are, however, certain conditions which make the removal of the cervix desirable, conditions that sometimes cannot be foreseen before the abdomen is HYSTERECTOMY OPERATIONS 725 opened for operation. On account of the possibility of indication for complete hysterectomy, and consequent exposure of the vaginal mucous membrane, the vagina should always be thoroughly prepared before a pelvic operation which by any chance may involve a hysterectomy. One of the conditions that make a removal of the cervix advisable is a chronic endocervicitis associated with pelvic inflammatory disease. In most Vite-rvne. "Vessels Fig. 387. — Hysterectomy with Removal op the Cervical Canal. The uterine vessels have been tied (or clamped) and cut. The cervical canal is being "coned" out with a knife. cases such an endocervicitis heals spontaneously after a supravaginal hyster- ectomy, but occasionally the inflammation persists and the patient continues after the operation to suffer from an irritating leukorrhea. This unpleasant consequence may be avoided by a removal during the operation of the cervical mucous membrane, which can be accomphshed either by performing a complete hysterectomy, as described below, or, better and more simply, by "coning" 726 GYNECOLOGY out the cervical mucosa, as depicted in Fig. 387. This latter maneuver is espec- ially valuable in pelvic inflammatory cases in which there has been parametritic infiltration, making the complete removal of the cervix a difficult and dangerous procedure. Fig. 388; — CoMPiiETE Hysterectomy. The vessels have been tied and cut and the bladder dissected from the anterior cervical wall. The paranietrium is grasped on each side with pressure forceps and di-\aded close to the cervix and vagina. A small longitudinal incision has been made exposing the vaginal portion of the cervix. The vagina is divided in a circular direction, starting from the small incision. The operation of coning the cervical mucosa is performed in the follow- ing way: All the preliminary steps of a supravaginal amputation are carried out as described above. Then, instead of amputating the uterine body in the usual way, it is dissected away by s, deep circular incision in the tissues of the cervix extending to the portio, so that most of the cervix is removed with the HYSTERECTOMY OPERATIONS 727 uterus in the form of a cone-shaped wedge, including all of the cer\acal mucous membrane. By this method very httle bleeding is encountered and there is absolutely no danger of injuring the ureters. As onty a minimum of vaginal surface is exposed, the wound in the cervix may usually be closed as in an ordinary supravaginal hysterectomy without drainage, pro\'ided, of course, there has been proper preliminary preparation of the vagina. If it seems de- FiG. 389. — CoiiPLETE Hysterectomy. The cervix has been grasped by the anterior wall and delivered through the opening in the vagina. The posterior wall of the vagina is about to be severed with scissors. sirable to drain, it may be done as in the operation for complete hysterectomy described below. Complete hysterectomy is indicated in certain cases, of myoma invohing the cervix, or when a severe laceration of the cer\ax is present, or when the gross appearance of the fundus suggests the presence of adenocarcinoma. Some cases of malignant disease of the ovaries or of extensively adherent intra- ligamentary cj^sts require complete hysterectomy. 728 GYNECOLOGY The Steps of the Operation. — The adnexa and uterine vessels are secured and ligated as in the operation of supravaginal hj^sterectomy. The utero- vesical plica of peritoneum is divided, and the bladder stripped away from the cervix and upper vagina by blunt scissors dissection. The parametria! tissue is then clamped very close to the cervix, extreme care being taken not to include the ureters, which should, if possible, be definitely located before applying the clamps. The parametrial tissue is divided on each side. The end of the cervix is determined by palpation with the thumb and forefinger, the vaginal canal opened close to the portio, and the uterus removed by circular incision of the vaginal wall. Crossen's technic of this part of the operation is shown in Fig. 388. If the vagina has been carefully prepared beforehand, and there is no exuda- tion from the uterine canal during the operation, it is sometimes safe enough to close the vaginal wound without drainage. As a rule, however, it is advisable to place a drain subperitoneally as follows : The edges of the vaginal wound are carefully wiped with alcohol. If by some error there has been no previous vaginal preparation, the upper exposed part of the vagina should be treated with iodin after first thoroughly protecting with gauze the surrounding parts of the pelvis. The corners of the vaginal wound are closed with interrupted catgut sutures, leaving a central aperture through which a cigarette-drain is placed. The broad ligaments are then sewed to the angles of the vaginal stump, wliile the uterovesical flap of peritoneum is drawn over the whole and stitched to the back of the vagina in the pouch of Douglas. In this way protective drainage is secured, while the vagina is suspended by the broad ligaments for the preven- tion of a later prolapse. The vaginal drain may usually be removed in thirty- six to forty-eight hours unless there is special danger of sepsis, in which case it is left in according to the exigencies of the case. After finishing the portion of the operation involving the closure of the vaginal wound it is advisable for the surgeon to change gloves and instruments after removing the gauze placed for protection of the pelvis. VAGINAL HYSTERECTOMY As compared with a properly executed abdominal hysterectomy, the extir- pation of the uterus per vaginam has no advantages. It cannot be done more rapidly, and there is no less shock or loss of blood, though claims to the contrary are sometimes made. Vaginal hysterectomy is useful in some types of operation for procidentia. Steps of the Operation. — The cervix is grasped by a traction forceps and drawn firmly down toward the introitus. A cross-incision is made at the line of junction of the bladder and anterior cervical wall. The bladder is then stripped from the cervix and the uterovesical pouch opened. The traction for- ceps is removed from the cervix, and the cervix is itself pushed back in the HYSTERECTOMY OPERATIONS 729 vagina, so as to antevert the uterus. The fundus is thus -brought into view, seized with volsella, and brought out through the opening in the uterovesical Fig. 390.' — ^Vaginal- Hysterectomy. Transverse incision of the vaginal wall at the junction of bladder and cervix. Stripping back the bladder (adapted from Doderlein-Kronig) . pouch. Mass ligatures are now placed on the broad ligament, including the round hgament tube and suspensory ligament of the ovary, which are severed near the uterus. The parametrium is -divided on the sides of the 730 GYNECOLOGY uterus, thus exposing the uterine vessels, which are tied and cut. Several stitches are placed in the stump of the parametrium on each side, attaching it to the sides of the vaginal wound. The uterus is now drawn strongly forward and the pouch of Douglas exposed. With the uterus in this position the pos- terior wall of the vagina is easily divided. During this incision there is Fig. 301. — Vaginal Hysterectomy. Opening the utero vesical space (after Doderlein-Kronig). some bleeding from the vaginal vessels, which should be controlled as the uterus is removed. The round ligaments are then sewed into the corners of the vaginal wound. This is an important step, for it prevents to some extent a later prolapse of the vaginal wall. The anterior and posterior vaginal walls are approximated by interrupted catgut sutures. HYSTERECTOMY OPERATIONS 731 WERTHEIM'S EXTENDED OPERATION FOR CANCER OF THE UTERUS The Wertheim operation is used both for cancer of the cervix and cancer of the body of the uterus. Its chief object is to remove with the uterus as much of the parametria! tissue as possible and to include a wide margin of the vagina. The description of the operation given below applies to cancer of the cervix. For cancer of the body the same technic may be applied, but the dissection of the parametrium and the vaginal margin need not be so extensive. Fig. 302. — Vacunal Hysterectomy. Tying off the adnexa. Before operating on a case of cancer of the cervix, especially of the everting type, it is usually necessary to remove the necrotic excrescent growth from the vagina. By the original Wertheim method this is done without anesthesia immediately before the performance of the radical operation. Some curet the cervix just before, with the patient under anesthesia. It is our custom to do the prehminary cureting under light narcosis about a week or ten days before attempting the main operation. In performing the preliminary operation the chief object is to remove merely the main bulk of the cancerous mass in order to facilitate the later opera- tion, and to leave the cancerous field so that it can be made as clean as possible 732 GYNECOLOGY / /■ Fig. 393. — Vaginal Hysterectomy. The broad ligament and the upper part of the parametrium have been divided. The under part of the parametrium and posterior vaginal waU are about to be divided (adapted from Doderlem- Kronig) . HYSTERECTOMY OPERATIONS 733 during the days intervening before the radical operation. The cancerous masses are removed with a large curet, but the curet is not carried too deeply ^(M:?.G^. a^Wv Fig. 394. — Vaginal Hysterectomy. Division of the posterior vaginal wall (adapted from Doderlein-Kronig) into the surrounding tissue wall, for if this is made too thin it is liable to be rup- tured by the tension on the uterus necessary in the course of the later operation. Another important reason for a not too thorough cureting is the possible danger 734 GYNECOLOGY of penetrating the peritoneal cavity, an accident which, on account of the viru- lent organisms always contained in the cancerous mass, is almost inevitably followed by a fatal peritonitis. - '- The preliminary operation should be regarded also as a cureting and not as a cauterization, for if the latter is done a slough is produced, which during its separation produces an unclean discharge, that acts as a source of danger during the later operation. After cureting away the cancerous masses the Fig. 395. — Vaginal Hysterectomy. Sewing the peritoneum to the vaginal stump. The broad ligaments have been stitched to the -vagina on each side (adapted from Doderlein-Kronig) . crater is packed with iodoform gauze to prevent unnecessary loss of blood. If the bleeding is considerable the vagina should also be packed. In about twenty- four hours the packing is removed. During the interval before the main opera- tion formalin douches (1 to 2 per cent.) are given daily. The patient is kept out of doors as much as possible and supporting treatment given for about a week or ten days. The Operation. — A thorough bowel preparation is very necessary, so that the intestines may be well collapsed at the time of operation. The catharsis HYSTERECTOMY OPERATIONS 735 should be given the second night before the operation^ so that the patient may have an undisturbed night preceding the operation. The usual abdominal and vaginal preparation is carried out. When the patient has been anesthetized the vagina is wiped dry and then thoroughly painted with iodin. It is not necessary to leave a gauze packing in the vagina if the iodin application is properly done. In performing the operation it is important to carry out a very systematic line of procedure in order to save as much time as possible. Nj^'^-Cr—, Fig. 396. — Vaginal Hystkkectomy. Final Step. Suturing thie anterior and posterior walls of the vagina. (1) Opening the Abdominal Cavity. — It is advantageous to have the patient in a steep Trendelenburg position, which in our experience does not possess the dangers very commonly attributed to it. It is important that the weight of the patient should be partly supported by well-padded shoulder-braces. The abdomen niay be opened by a very long median incision reaching from the pubes to the umbilicus. This is the incision usually employed in this country, and, as a rule, gives plenty of room. The transverse incision carried directly across the abdominal muscles, as depicted in Fig. 397, exposes the field of opera- tion more completely than does the longitudinal opening. We have not found 736 GYNECOLOGY V^Grck\)es.iC)v5' \ % KJ~/. v^ u/^ /ri I I X. \ V ""''^*, < \ Fig. 397.— Transverse -Incision for Cancer of the Cervix. The abdominal muscles have been severed from spine to spine. T^e peritoneum has been split from the abdominal wall and stitched down so as to protect the intestines from the field of operation. it necessary to resort to this method. In our work we have had no trouble with necrosis and sloughing of the abdominal wound from prolonged retraction pressure during the operations. This complication, however, is mentioned HYSTERECTOMY OPERATIONS 737 by numerous operators, and various means of protecting the wound are em- ployed, red sheet-rubber being especially recommended. .Wertheim avoids the difficulty by not using metal retractors, the sides of the wound being held back by the hands of his assistant. liiG. 3y». — Wertheim's Operation for Cancer of the Cervix. Stripping the bladder from the anterior wall of the cervix and vagina. This should be done by blunt dissection with scissors, never with gauze. Some protect the intestines by turning down a wide flap of peritoneum from the anterior abdominal wall and stitching it to the peritoneum of the posterior pelvic wall, as is seen in Fig. 397. This we have not found necessary. (2) Ligature of the Broad Ligaments. — The broad ligaments are tied in the same manner as that described for supravaginal hysterectomy, except that if the operation is for cancer of the cervix the ligatures around the inf undibulo- 47 738 GYNECOLOGY pelvic atid round ligaments are placed at a greater distance from the uterus. This is done in order to remove a large amount of parametrial tissue. If the operation is for cancer of the body, where the 'dissection does not need to be so wide, the two ligaments may be tied and severed near the uterus, as in supra- vaginal hysterectomy. They can then be used to sew into the angles of the vaginal stump in order to prevent a future prolapse of the vagina. In cancer of the cervix operations, however, it is necessary to cut the liga- ments so wide that they are not available for suspending the vagina. (3) Separating the Bladder. — After the broad hgaments have been tied and cut, the bladder is separated from the anterior wall of the cervix and vagina. The uterovesical peritoneal reflection is first picked up with thumb forceps in the middle line at a point where it can be easily lifted away from the underlying tissues; a nick is made in the peritoneum, and the blunt end of a pair of scissors introduced beneath the peritoneum, stripping it up toward each round Hgament. The peritoneum is cut across, exposing the fold of bladder that is attached to the cervix and vagina. The bladder is then dissected away from its uterine and vaginal attachments and not stripped off with gauze. The dissection is best carried out with blunt scissors, partly by blunt dissection and partly by cutting the firmer strands of tissue. This manner of freeing the bladder we regard as of great importance in the technic, for the use of gauze dissection is a source of much danger to the bladder, not only in the way of actually rupturing the bladder wall, but in 'so traumatizing the sfnall vessels of the wall as to result in later cystitis or ulceration (see also page 262). The separation of the bladder should be carried down as far as possible; small bleechng vessels should be tied at once with fine catgut. A complete separation of the bladder cannot be made at this stage. (4) Identification of Ureters and Ligation of Uterine Vessels. — When the bladder has been dissected away as far as possible, the uterus is held forward and to the left, exposing the right side of the pelvis. The next step is to identify clearly the right ureter. The two layers of the broad ligament are separated and the cellular tissue between them gently cleared with the blunt end of the scissors. In favorable cases the ureter is plainly seen lying at the base of the sulcus between the two layers of the broad hgament. Usually, however, it is not at first easily visible, and requires some search. It may best be found by picking up the posterior layer of the broad ligament and rolling the tissue between the thumb and forefinger, when it can usually be felt as a soft, non- pulsating cord. Some operators, after identifying the ureter, free it and lift it from its bed by passing under it a strip of gauze or a ligature or some curved instrument. We are accustomed to strip the ureter as Httle as possible, as inter- ference with its blood-supply predisposes to necrosis and ureteral fistula. When the ureter has been isolated, the next step is to tie the uterine vessels. With the ureter as a guide, the forefinger is passed beneath the uterine vessels in the HYSTERECTOMY OPERATIONS 739 direction of the bladder, and then pushed forward until it emerges through the cellular connective tissue lying between the uterine vessels and bladder (Fig. 400). The first part of this maneuver is comparatively easy, but the final protru- sion of the finger through the last layer of tissue is attended with considerable difl&culty, and in cases of chronic parametritic inflammation, or especially after radium treatment, it is almost impossible. If the forefinger cannot be pushed Fig. 399. — Wertheim's Operation for Cancer of Cervix. Exposure of the right ureter. The two leaves of the broad ligament are separated and the ureter brought into view by blunt dissection. It always lies in the posterior leaf and can easily be palpated by the thumb and forefinger. tnrough in the classic way the opening may be made by a blunt ligature-carrier or by a clamp devised by the author for this purpose and depicted in Fig. 402) When the finger has been properly looped about the vessels the pulsation of the uterine artery can easily be felt. The vessels are then lifted away from the ureter and freed as far as possible toward the pelvic wall. A double ligature is passed and tied and the vessels cut between the two hgatures. The ureter and its point of entrance into the bladder are now freely exposed, and an oppor- f40 GYNECOLOGY tunity given for separating by blunt dissection the ureter and angle of the bladder from the lateral wall of the vagina. This procedure helps to carry out still further step No. 3 — i. e., the separation of the bladder from the vagina, which it was said was necessarily left incomplete. The isolation of the ureter, hgation of the uterine vessels, and separation of the ureter and bladder from the side of the vagina are repeated on the left side. "U-Xvtc "IB\abber IftrRoun'bla.^ ' Ctxnter ^-CRounb J-ii0 "RvQht LRe,nne - ^' Vessels ^'^.'PCB X csA) es , Fig. 400. — Webtheim's Operation for Cancer of the Cervix. The broad ligaments have been tied and cut. The bladder has been dissected from the cervix. The right ureter is exposed. The forefinger is being introduced between the ureter and uterine ves- sels. The point of the forefinger is forced through the cellular tissue in front of the vessels. (5) Separation of the Rectum and Final Dissection of the Parametrial and Paravaginal Tissue. — The uterus is now drawn strongly forward, exposing as well as possible the pouch of Douglas. The peritoneum at the bottom of this pouch is picked up and cut, and the blunt-pointed scissors inserted beneath the peritoneum, as in separating the utero vesical reflection. The peritoneum is in the same way cut across from broad ligament to broad ligament, exposing the HYSTERECTOMY OPERATIONS 741 uterosacral ligaments. Clamps are placed on the ligaments and the tissue severed. On cutting these ligaments the uterus is noticeably released. The rectum is, as a rule, easily separated from the vagina, as there exists between them only a loose cellular tissue connection. After freeing the rectum, the remaining parametrial and paravaginal- attach- ments on the sides and back of the vagina are successively clamped and cut. ^^i-TvaubuS \jte.X\ 1VvQV;t UteviYieS. CuV- \i^\. Ufeter ^ 'Urete "!Doug\a9. "^ooCtVvj cxo in C\V iisSufc ^* WT?fera\je<^ — Fig. 401. — Wertheim's Operation for Cancer of the Cervix. The uterine vessels of both sides have been ligated and tied and the ureters exposed. The recto-uterine reflection of peritoneum has been divided. The uterosacral ligaments have been clamped and are being severed. The paravaginal tissue is exposed. the uterine mass being more and more released at each cut. At this stage, before finally clamping and removing the mass, the bladder, especially at the points of entrance' of the ureters, can be still further separated from the vagina. (6) Clamping and Amputation of the Vagina.— When the dissection has been carried down the vagina as far as possible, always to a considerable distance below the site of the cancer, the vagina is to be amputated. It is an excellent 742 GYNECOLOGY safeguard at this point to insert on each side of the vagina, just below the level of the proposed line of amputation, strong catgut hgatures, the ends of which are left long and clamped. These ligatures serve as tractors to prevent the I / .^\i^^ ~?)\abber Sulufe W.'P'orcvve Fig. 402. — Wertheim's Opbr.\tion for Cancer of the Cervix. The uterus and vagina have been freed. Traction sutures have been applied to the vaginal wall to hold it into view after amputation. The author's special clamp has been applied to the vagina below the seat of the growth. Wertheim clamps have been applied below. These latter may be omitted if there is deficient vaginal margin. Amputation is made between the clamps with knife or cautery. retraction of the vaginal stump after amputation, and also to control the bleed- ing which is apt to come from the vaginal angles. In order to prevent the escape from the cancerous field of possible infectious HYSTERECTOMY OPERATIONS 743 material the vagina must be effectively shut off for its entire width. To accom- phsh this numerous clamps have been devised, notably the right-angled clamps of Wertheim. Berkeley and Bonney use a large T-clamp, which appears to be an excellent device. In the drawing (Fig. 402) the vagina is clamped above and below, the amputation being made between the clamps. This has been the author's technic, but with a thorough vaginal preparation, such as is described above, it is probably better to dispense with the lower set of clamps, as without them more of the vagina can be removed. Their presence, however, insures for vi V \:U two ^W'bbvir Vl.'^G.>f(x\ie'=^ "^(LcXuvn- Fig. 403. — Wertheim's Operation for Cancer of the Cervix. Two cigarette -^\acks have been placed in the opening of the vagina. The vaginal walls, held up into view by traction ligatures, have been sutured on each side of the wicks. The peritoneal edges are to be stitched together over the wicks, thus shutting them off from the peritoneal cavity. safety both in controlling hemorrhage from the vaginal veins and in preventing possible infectious material escaping from the lower vaginal section into the ab- dominal cavity. If the lower clamps are not used, gauze should be stuffed into the vagina as soon as it is opened. After amputation of the vagina Hgatures are passed around the masses of paravaginal tissue included in the clamps. The vagina is partially closed by interrupted sutures, a small opening being left in the middle. (7) Drainage and Closure of the Peritoneum— -li is the safest plan to drain the paravaginal space. This is done by passmg into the vaginal opening a loop 744 GYNECOLOGY of Penrose drainage-tubing, which is caught and drawn down by an assistant, who seizes it with a long forceps inserted in the vagina from below. This leaves the two ends of the drainage-tube free in.the abdominal ca^dty. The peritoneum is united over the drain, so that it is excluded from the peritoneal ca\dt3\ (8) Removal of Glands. — If infected Ijmiph-giands are found to be present, it is our custom to finish the main operation up to the point of closing in the peritoneum before dissecting out the glands, in order to be readj^ to finish the operation quickly if the patient begins to show signs of shock or if serious diffi- culty is encountered in dissecting out the glands. The removal of the glands requires patience and skill on the part of the operator. ~^\cx^^er Fig. 404. — Wertheim's Operatiox for Ca.nxeu of the Cervix. Final Step. The peritoneum has been completely sutured over the rubber drains. Note that the four middle sutures are interrupted. Shock depends almost exclusively on the loss of blood. In the average case where the hemorrhage has not been severe, there is no shock and the convalescence is rapid. Comphcations that may be met with during the operation are injury to the bladder, ureter, or rectum, and dangerous uncontrolled hemorrhages. The last are most apt to be encountered in cases where there has been a long-standing pelvic inflammatory disease with peritoneal adhesions. In these cases the land- marks become confused and the usual planes of cleavage between tissues are lost. The same is true in operating on cases that have been treated by radium. EXTENDED VAGINAL HYSTERECTOMY FOR CANCER OF THE CERVIX The operation developed by Schauta is a very difficult one, and should be attempted only by those familiar with the vaginal route for performing pelvic surgery. The illustrations of this operation are adapted from Schauta. HYSTERECTOMY OPERATIONS 745 The cancerous area is first thoroughly cureted and cauterized. The opera- tion is then performed by the following steps: (1) Circumcision of the Lower End of the Vagina. — A circular incision is made around the circumference of the vagina at the introitus, and the vaginal wall dissected away for the distance of about 2 inches. In this way a cuff is formed the open end of which is closely sewed with interrupted sutures, the ends of which are left long and included in a clamp. The vaginal cuff is now Fig. 405.- — Schauta's Operation for Cancer OF THE Cervix. Initial circumcision of the vagina. Fig. 406. — Schauta's Operation for Cancer OF the Cervix. The vaginal cuff is being dissected. held forward by the sutures, and the separation of the vagina continued along its lateral and posterior wall, care being taken not to injure the rectum. The dissection of the vagina from the rectum should be carried out wdth blunt scis- sors rather than by stripping with gauze. (2) Paravaginal Section. — When the vagina has been well freed from the rectum a deep incision is made in the left lower angle of the vaginal bed, extend- ing first laterally to the lower end of the left labium minus, then turning down- ward parallel to the rectum and to the left of it, separating the fibers of the 746 GYNECOLOGY M\i.^.^^iXVifcS- FiG. 407. — Schauta's Operation for Cancer op the Cervix. The vaginal cuff has been dissected out and closed with traction sutures. The bladder is exposed. The deep paravaginal incision has been made through the perineum. HYSTERECTOMY OPERATIONS 747 levator ani muscle, curving around the anus, and terminating posterior to it, near the median line. Deeper in, the incision splits the paravaginal and para- rectal tissues, the coccygeal muscles, and the cellular tissue of the ischiorectal fossa. Much bleeding is encountered, which can be controlled by ligature and gauze packing. By this incision a surprisingly large amount of room is afforded for carrying out the other steps of the operation. The tissue corresponding to Fig. 408. — Schauta's Operation for Cancer of the Cervix. The bladder has been separated from its vaginal and cervical attachments and held up by the upper retractor. The uterine artery, ureter, and parametrium of the left side are exposed. Douglas' fossa is now picked up and cut and the recto-uterine pouch opened. A large strip of gauze is inserted into the pouch to prevent the prolapse of the bowels. (3) Separation of the Bladder and Identification of the Ureters. — The vaginal wound is now held well back by the tension on the attached sutures, and the bladder dissected away from the vagina with blunt scissors. The dissection 748 GYNECOLOGY Fig. 409. — Schauta's Operation for Cancer of the Cervix. The left uterines have been tied and cut. The ureter becomes freed. With the guidance of the left forefinger the parametrium is being divided. should be carried well out on the sides of the vagina until the ureters are exposed. The bladder is now retracted upward and an opening made into the uterovesical Douch. HYSTERECTOMY OPERATIONS 749 (4) Ligature of the Uterines. — The vagina is held sharply over to the right side, while the operator identifies the uterine artery with his left forefinger. A hgature-carrier is passed through the base of the broad hgament around the uterine vessels. The Hgature is tied and the uterus cut from the part of the ligament secured by the tie. The vessels of the opposite side are tied in the same way. Fig. 410. — Schauta's Operation for Cancer of the Cervix. The fundus of the uterus has been delivered. The broad ligament of the left side is about to be tied and cut. The parametrial tissue is excised as far away from the uterus as possible, there being some bleeding from the hemorrhoidal vessels that run to the uterosacral ligaments. (5) Removal of Uterus and Adnexa. — The fundus of the uterus is delivered through the opening into the uterovesical pouch. This is accomplished by passing the forefinger of the left hand into the pouch of Douglas and anteflexing the fundus by pressure from behind. The fundus is seized with strong volsella and drawn sharply forward. In this way the broad Hgaments 750 GYNECOLOGY are brought into view. The uterus is then drawn to the right, and with the left forefinger as a guide a double ligature is applied on a ligature-carrier to the broad ligament. The round and infundibulopelvic ligaments are tied and the uterus severed from the broad ligament. The same procedure is carried out on the opposite side and the uterine mass removed. Fig. 411. — Schauta's Operation For Cancer of the Cervix. Closing the peritoneal layer by a continuous stitch. The paravaginal wound is closed with deep sutures-. The peritoneum is closed and a gauze packing left in the opening above the vaginal wound. The convalescence is a long one owing to the time taken for healing of the vaginal wound. MYOMECTOMY OPERATIONS ABDOMINAL MYOMECTOMY In performing the operation for enucleation of uterine myomata the ab- dominal incision must be made sufficiently large to admit of convenient handling of the pelvic organs. The fundus of the uterus is seized with double hooks MYOMECTOMY OPERATIONS 751 and drawn toward the abdominal wound into such a position as will expose best the myoma to be removed. It is often advantageous to insert a second pair of double hooks into the uterine wall immediately below the lower pole of the tumor, traction on which lifts the uterus so that the field of operation is more in a horizontal plane. An incision through the wall of the uterus is made parallel with the axis of the uterus over the most prominent part of the tumor. The incision is carried down to the surface of the myoma, which can usually be >N?P.(ix'(x\>e-S Fig. 412. — Abdominal' Myomectomy. Incision for a myoma in the posterior uterine wall. recognized by the difference in direction of its fibers from those of the uterine wall. When the surface of the myoma has been exposed the tumor is grasped with a pair of double hooks carried deeply into the tissue. With firm traction on the double hooks the tumor can then be readily shelled out by means of some blunt dissecting instrument, a pair of blunt-tipped curved scissors being especially useful. The enucleation is done carefully to prevent too great lacera- tion of the tissue of the uterine wall and to avoid, if possible, opening the uterine cavity. 752 GYNECOLOGY If the tumor happens to be an adenomyoma it cannot be shelled out in this way, growing as it does diffusely in the wall of the uterus. Under these circum- stances the tumor must be dissected away from the uterine tissue, from which it cannot always be clearly differentiated. When the myoma has been removed, there is, except in the case of small trnnors, considerable bleeding from the bed in which it lay. The careful con- trol of this hemorrhage is of supreme importance, for it is to the lack of this precaution that the notoriously bad after-results of myomectomy are chiefly due. Bleeding points should be isolated and ligatured as far as possible, and bteif'i.'nQ:, \y(."^Gr Fig. 416. — Omental Graft. The triangular piece of omentum has been attached to the posterior wail of the uterus by several catgut sutures. dominal wound and inspected as in Fig. 415. A portion having been selected which contains a good blood-supply, a wedge-shaped piece is exsected of a size MYOMECTOMY OPERATIONS 755 sufficient to cover the area on the surface of the uterus requiring protection. The cut edges of the omentum are sewed together after. ligature of the bleeding Jvl\iomtV Fig. 417. — Vaginal Myomectomy. Clamping the pedicle. vessels. The omental graft is then applied to the uterus and stitched in place by a few interrupted sutures of fine catgut as in Fig. 416. 756 GYNECOLOGY VAGINAL MYOMECTOMY By vaginal myomectomy is meant the removal of pedunculated submucous myomata through the vagina, and not, as it is used in some books, the enuclea- tion of intramm'al and subperitoneal tumors by vaginal section, a procedure which is not recommended by the present writer. Pedunculated submucous mj^omata first make themselves e\ddent by bleed- ing or by a foul discharge, or by both. They are usually necrotic and septic. If they are associated with intramural and subserous fibroids, as they commonly are, it is best to remove the submucous tumor first, and to perform the radical operation for extirpation of the uterus at a later date. Otherwise there is much danger of sepsis. In removing a polypoid myoma the patient is in the perineal position and, preferably, under full anesthesia. Unless there is some constitutional contra- indication, full anesthesia is advisable because of the possibiUty of a smart hem- orrhage. In performing the operation the pedicle of the tumor is first sought with the finger. If the attachment is high up in the uterus it must be found with a blunt instrument like a pair of uterine scissors. When the pedicle is found, it is enclosed and crushed in the end of a uterine clamp. If the tumor is thoroughly necrotic the clamping will often cause it to fall away from the attachment, and the clamp can be removed T\'ithout bleeding. If the tumor is not attached too far up in the canal it may often, if necrotic, be easily detached by the end of the finger without serious bleeding. If, however, the pedicle is firm, it must be cut with scissors, which are guided in their direction by the clamp attached to the pedicle. Removal of the clamp does not often cause more than moderate bleeding. Sometimes, however, the hemorrhage is sufficient to require packing the uterine canah with gauze. The packing is removed on the following day. Patients from whom a necrotic myomatous polj^p has been removed usually run a septic temperature for several days after the operation, with a moderate leukocjrtosis. It is this condition which serves as a warning not to perform a radical operation on the uterus in the presence of one of these sloughing tumors. OPERATIONS ON THE TUBES SALPINGO-OOPHORECTOMY When the tube and ovary are to be removed together it is essential to determine first whether there has been an ' inflammatory process in the tube. If there are no signs of previous infection, the tube may be amputated near the uterus, with a short pedicle, without danger of future trouble. If, however, there are indications of salpingitis, whether recent or long standing, the entire tube should be exsected from the cornu of the uterus. In dealing with an ovarian cyst with a free pedicle a convenient technic is as follows: The torsion, if present, is first reduced, so that the broad hgament pedicle, which was twisted into a rope form, is smoothed out and flat. Two Fig. 418. — ^Salpingo-oophorectomy. Showing method of clamping and cutting the broad-ligament pedicle of an ovarian cyst. clamps are then applied, meeting each other at an angle near the base of the broad ligament. One clamp near the uterus includes the tube and ovarian ligament, while the other includes the infundibulopelvic ligament, which con- tains the ovarian vessels. The tumor mass over which the tube is usually spread is then removed by cutting the broad ligament pedicle in a V shape, and in such a manner as to leave a margin of tissue beyond the clamps. If the tumor possesses a large blood-supply, the spilhng of reflux blood from the tumor can be avoided by placing distal clamps and cutting between the two sets of clamps. This prevents soiling the field of operation. When the tumor has been removed the two clamps on the stump of the broad ligament are shifted to the corners, an assistant clamping the ends of the three 757 758 GYNECOLOGY or four vessels that bleed from the cut edge. The tube and vessels are then tied separately, two ligatures being applied to the ovarian vessels. The two clamps which are attached to the ends of the V-shaped pedicle are approxi- mated, and the wound edges very carefully united with a continuous No. catgut stitch beginning at the apex of the V. It is possible in this way to close the wound with a minimmii exposure of raw edge, a matter of very great importance in the avoidance of future pelvic adhesions. Special care must be taken when completing the suture in uniting the stump of the tube to the stump of the infundibulopelvic ligament not to leave a clumsy mass of tissue and knots. If for any reason this is unavoidable, the round ligament can be drawn over the mass and stitched so as to prevent its exposure and possible adherence to the intestines. } i.n"S\jn?)\\)u\oPe\\)\o Lii.oax\-\ex\ Fig. 419. — Salpingo-oophokectomt. Closure of the wound in the broad ligament by approximating the stump of the infundibulopelvic ligament to the stump of the tube. After performing a salpingo-oophorectomy the uterus should always be suspended by a round hgament operation, even if its position at the time of operation is perfectly good, for if this is not done a later retroversion is almost inevitable. SALPINGECTOMY Exsection of the tube without removal of the ovarj^ is an operation used in the conservative surgery of pelvic inflammation. Where this operation is done it is not enough to amputate the tube at the uterine cornu; it must include a resection of the interstitial portion of the tube to prevent the possibility of a later exacerbation of the disease in the tubal isthmus. In order to hold the tube in position for easy dissection the edge of the meso- salpinx between the fimbriated extremity and the ovary is seized by a clamp or pressure forceps. Another clamp, preferably with teeth, is apphed to the OPERATIONS ON THE TUBES 759 tissue of the uterine fundus beyond the tubal isthmus. The tube is then re- moved b}" cutting through the mesosalpinx, avoiding as much as possible the veins of the broad ligament. A few bleeding points require hgature. When the dissection has reached the uterus the remaining portion of the tube is re- moved with a knife by cutting a deep wedge-shaped piece of uterine tissue from the cornu. In this way the entire tube, including its isthmus, is exsected. When the incision is made into the uterus a spurting vessel is alwaj^s encountered. It is important to tie this vessel in such a way as not to distort the tissue or expose too much catgut. / "7 . '/f Fig. 420. — SALPixGECTOinr. Sho^-ing the method of completeh- removing the tube, including the isthmus, which is apt to be im- plicated in the infiammatorj' process (salpingitis isthmica nodosa). The success of the operation depends to a great extent on the manner of sewing up the wound, which must be done so as to leave as smooth a peritoneal surface as possible and to avoid the exposure of catgut knots. A convenient method of closing the wound is to begin at the uterine end and first place deep into the uterine wall a figure-of-8 stitch of No. 1 catgut. This closes the wedge-shaped opening in the cornu. It can be made to include the spurting vessel alluded to above. The peritoneal edges of the mesosalpinx are now united with a continuous fine catgut stitch. By using the Lembert method of applying the stitch the eversion of raw edges may be avoided, and the catgut knots on the vessels can be covered in. If, however, as is often the case, there have been manj' adhesions, the mesosalpinx wound is ragged and the 760 GYNECOLOGY peritoneal surfaces damaged. In such a case it is impossible, even with the most painstaking care, to leave a wound which can be insured against the for- I ^M/^ Fig. 421.— Salpingectomy. The tube of the left side has been exsected, including the isthmus, and the wound in the peritoneum closed by a running suture. mation of postoperative adhesions. It is for this reason chiefly that conserva- tive surger}^ for pelvic inflammatory disease so often results in failure. SALPINGOSTOMY fSTOMATOPLASTIC) As stated above, when it is necessary to remove a tube that has been dam- aged by infection, it is not good surgery to leave any part of it, on account of the danger of a later recurrent inflammatory process in the remaining stump. It is necessary, however, sometimes to take this risk when the desire for children surmounts all other considerations. The chances of impregnation through a damaged and resected tube are, to be sure, not very promising, yet the possi- bility is present, and, according to the author's figures, is somewhat greater than is ordinarily supposed. In deciding on a stomatoplastic operation on the tube the pelvic organs must first be thoroughly freed of adhesions and the tubes and ovaries carefully in- spected. Only those organs are chosen for preservation which offer a reasonable chance of regaining proper function. Thus, a tube which shows a salpingitis nodosa at the cornu is entirely hopeless and should be removed completely. OPERATIONS ON THE TUBES 761 A tubo-ovarian mass in which there is much destruction of the ovarian tissue, such as results from combined abscess or cyst of the two organs, must also be removed entire. A tube which is closed and adherent at the fimbriated extremity, but without thickening of the wall or occlusion of the proximal part of the canal, even if it is somewhat distended (hydrosalpinx), is suitable for resection. The presence of one good ovary is, of course, essential, but the ovary may be on the opposite side from the tube to be repaired, for it has been shown that impregnation can take place as the result of migration of the ovum across the pelvis. In case one or both ovaries are good, but both tubes are impossible, the only chance for pregnancy is by transplantation of ovarian tissue in the uterine cornua. To perform the operation of salpingostomy the tube is held up to view by attaching a clamp to the edge of the mesosalpinx. The tube is then trimmed Fig. 422.^ — Salpingostomy. Showang the method of creating a new ostium for a tube closed by, inflammation. This operation is performed only for the purpose of restoring fertility. away from the ovary up to a point where the tubal wall begins to have a normal look, usually about a third to a half of the length of the tube from its extremity. Bleeding points are tied with fine catgut. The mesosalpinx is grasped with fine pressure forceps close to the tube at the point where it is to be amputated. It is important not to crush the tube at any time with clamps or forceps. The tube is then cleanly amputated, and a probe passed gently into the canal to determine whether or not it is patent. This can be done for only a short distance, for it is impossible to determine the patency of the tube near the uterus even under normal conditions, it being too small to admit a fine probe without danger of injuring the tubal mucous membrane. The question of patency in this part of the tube must, therefore, be guessed at from its generak appearance. ' The tube is then slit up a short distance in order to make the new ostium 762 GYNECOLOGY wider. The mucous membrane of the tube is next united to the peritoneal covering with sutures of No. 00 catgut passed in a very fine needle. It is im- portant to accomplish this with as few stitches as possible, for the catgut knots are especially Hable to promote adhesions. It is usually necessary to use only three sutures, as seen in Fig. 422. Another method for performing a stomatoplastic operation on the tube is that proposed by Bell and illustrated by Fig. 423. This operation is applicable where there has been a closure of the fimbriated end without serious damage to Fig. 423. — Bell's Salpingostomy. A longitudinal incision is made in the closed and dilated end of the tube. The perineum and mucous membrane of the tube are united with a hemstitch suture. the tubal wall or closure of its lumen. A long longitudinal incision is made near the end of the tube. The edges of the wound are whipped over with a hemstitch of fine catgut. OPERATION FOR TUBAL STERILIZATION It is occasionally important to sterilize a patient without the removal of any of the organs. Simple tying of the tubes is quite inadequate, as the lumen of the tube becomes readily re-estabhshed. The same is true of section of the tube and hgature of the cut ends. Among the numerous methods recom- mended for tubal sterihzation we have adopted that of Taussig, who describes his operation as follows: "The abdomen is opened by a small median incision in the usual manner, and the uterine end of one Fallopian tube seized with forceps. The uterus is thus pulled into view, so that a suture can be passed through the uterine horn at the tubal insertion. Before tying this suture the interstitial portion of OPERATIONS ON THE TUBES 763 the tube is cut away by a V-shaped incision. Next, the tube is freed from its peritoneal attachment for a -chstance of about 1 inch, and, a hgature having been thrown around the distal end, this free portion of the tube is resected, "With an arterj^ forceps or Mayo dissecting scissors the laj-ers of the broad ligament are separated from each other at the point where it has been opened up. Catching the end of the tube with an extra suture, to prevent it from slipping, the threaded needle is now passed through the open space in the broad hgament, and emerges just anterior to the round ligament, near the attachment of the vesical peritoneum to the uterus. An extra suture is passed through the peri- toneum at this point so as to completely burj^ this end of the Fallopian tube in the broad ligament. "The third step in the operation consists of sewing the round ligament by one or more sutures to the upper posterior surface of the uterus, thus closing over the point of the tubal insertion and the small open space in the peritoneum of the broad ligament. 'The same technieis observed in resecting the tube of the other side, and the abdomen closed in the usual manner." OPERATIONS ON THE OVARIES RESECTION OF THE OVARY This operation does not at present hold the prominent place in gynecologic surgery that it did in the days before it was learned that the so-called cystic degeneration of the ovaries is, for the most part, a physiologic process. There are times, however, when the process passes the physiologic bounds and the operation of resection must be resorted to. This is especially true when one follicle seems to be growing at the expense of the rest of the ovarian tissue, and gives pro iTiise of becoming a large retention cyst. The necessity of performing J''i(;. 424. — Resection of Ovary. A follicle cyst is being exsected. The clamps which hold the ovary into view are lightly placed so as not to crush the tissues which they include. a resection of the ovary in the course of a pelvic operation must, however, always be regarded as a regretable incident, for the likelihood of the ovary's becoming adherent is very great. The ovary is exposed to view by placing one clamp on the edge of the meso- salpinx and the other on the ovarian suspensory ligament, the clamps being locked just tight enough to hold the ovary in place, but not so as to crush the tissue or shut off the blood-supply. An oval incision is then made around the cyst, exposing the translucent capsule of the cyst, which can easily be shelled out of its bed in the ovarian tissue. If the supporting clarrips have not been apphed too tightly there is some bleeding from the hilum of the ovary. 764 OPERATIONS ON THE OVARIES 765 All the bleeding should be very carefullj^ stopped by fine catgut ligation. When the bleeding seems to be stopped the clamps should be unlocked, to be sure that they are not accidentally controlling other small vessels. The wound in the ovary is then sewed with fine catgut on a small curved, needle. The ovarian tissue is very friable, especially if the operation is near a corpus luteum. The edges should be trimmed until firm tissue is reached, care being taken that the Fig. 42o, — Resection of Ovary. The cyst has been dissected out of its bed and the wound of the ovary sewed with a fine catgut running stitch. edges when approximated will give good coaptation without tension and without presenting ragged edges. The greatest care should be taken in sewing the wound so as to leave it as smooth as possible, in order to safeguard against adhesions. TRANSPLANTATION OF OVARIAN TISSUE Transplantation of ovarian tissue is principally employed either for restora- tion of fertility after a pelvic inflammation, or for the purpose of relieving the vasomotor symptoms of the artificial menopause following hysterectomy. In the first instance the operation is indicated when it is necessary to remove both tubes, one or both ovaries being normal. The steps of the operation are as follows : The tube of one side is completely exsected in the manner described for sal- pingectomy. The wound of the mesosalpinx is carefully closed with the ex- ception of the wedge-shaped opening made in the cornu of the uterus in dis- secting out the isthmus of the tube. This small cavity is now examined to make sure that all scar- and inflammatory tissue have been removed. A probe determines whether there is free communication with the uterine canal, though the opening should be small. A slice of tissue about \ inch thick and the size 766 GYNECOLOGY of the thumb-nail is taken from the ovary, including epithelial covering, cor- tex, and medullary layer, and placed in the opening in the uterine cornu, the wound being closed with a figure-of-8 stitch. The wound in the ovary is sewed by a running stitch of fine catgut. The same process is repeated on the other side. If only one ovary has been left, enough tissue must be taken to supply both cornua. The operation of transplantation after hysterectomy is as follows: A small receptacle containing warm sterile salt solution is ready at hand. When the uterus and adnexa are removed from the pelvis the surgeon immediately cuts off one of the ovaries and places it in the warm salt solution, where it is kept Fig. 426.- — Transplantation of Ovarian Tissue in the Horns of the Uterus. The tubes have been exsected. Wedges have been removed from the ovaries and the wounds closed. A section of ovarian tissue is being introduced in the right cornu. The same procedure has been carried out and completed on the left side. until the operator is ready to implant it. Numerous locations are used for the implantation, most commonly between the leaves of the broad ligament and in the abdominal wall. Of these two sites, the latter is far preferable, partly because the blood-supply is more favorable for the graft and partly because it is more accessible if by chance the tissue later becomes cystic or gives trouble otherwise. If the abdominal wall has been chosen as the site of implantation the opera- tion is completed as far as the closure of the abdominal fascia. A place is then chosen where the sheath surrounds the edge of one of the recti muscles. A small slit is made in the sheath at the muscle border. The ovary is taken from the salt solution and a slice removed from the healthiest part, including, if possible, OPERATIONS ON THE OVARIES 7Q7 epithelium, cortex, and medullary tissue. The piece of, ovary is now slipped into the small opening in the muscle sheath (Fig. 427), and placed so that it lies between muscle and fascia. The opening in the fascia is closed with one suture of fine catgut. Fig. 427. — Implantation of Ovarian Tissue in Abdominal Wall. A slice from the ovary is being inserted between the fascia and right rectus muscle. It is important to remember that the whole organ should not be implanted in the abdominal wall, for it is almost sure to give later trouble by cystic degenera- tion. By using a sHce of the ovary the establishment of a new circulation in the graft is more surely accomplished than if the intact ovary is implanted. OPERATIONS ON THE ABDOMINAL WALL BAKDENHEUER'S INCISION An extended transverse incision for difficult pelvic operations is used fre- quently abroad, but very little in this country. This incision is carried with a moderate downward curve from one anterior superior spine to the other. The incision is made transversely through the entire wall, including skin, fascia, muscle, and peritoneum. As a rule, only the recti are divided, but if the opera- tion demands it the lateral muscles of the abdomen may also be cut. Fig. 428. — Transverse Incisioxs for Pelvic Operations. The shorter of the two red lines indicates the Pfannenstiel incision. The longer red line shows the Bardenheuer incision, sometimes used for extensive pelvic operations. The Pfannenstiel incision cuts only the skin and fascia transversely. The Bardenheuer incision cuts transversely all the layers of the abdominal wall from spine to spine. This incision gives a great amount of room for manipulations in the pelvis (Fig. 428). Bardenheuer, who first advocated it, recommends also turning down the upper flap of peritoneum and suturing it to the posterior pelvic perito- neum in order to protect the intestines from the field of operation. This incision is somewhat too radical except for extraordinary cases. 768 OPERATIONS ON THE ABDOMINAL WALL 769 THE PFANNENSTIEL INCISION The transverse, or Pfannenstiel, incision for pelvic operations has many adherents, especially abroad, its chief value being based on cosmetic considera- tions. The use of this incision, the scar of which is entirely concealed by the pubic hair, obviates the ugly appearances so frequently seen after the median longitudinal cut, such as keloid formation, pigmentation, depression, and spreading of the scar. The technic of the operation is as follows: Fig. 429. — The Pfannenstiel Incision. The skin and fat hav« been incised just within the boundary of the pubic hair. The fascia is cut transversely as in the drawing (after D oderlein-Kronig).. , A straight or slightly curved transverse incision 3j inches in length is made above the pubes just within the line of pubic hair. The incision is carried down through skin, fat, and fascia to the rectus muscles. The adhesion of the fascia to the linea alba is then cut away with scissors from the upper and lower fascial flaps (Fig. 430). The recti muscles are separated by blunt dissection, as in the median incision, and the peritoneum is cut longitudinally. The simple incision does not give as good exposure of the pelvis as does the median incision, nor can the appendix and other portions of the abdomen be as easily reached and ex- plored. If, however, the ends of the skin and fascia wound are curved upward, the recti muscles may be drawn more widely apart and a much better exposure 49 770 GYNECOLOGY is afforded. This extension of the wound is quite necessary in the performance of the more difficult pelvic operations, such as for myoma, pelvic inflammation, etc. It is also often necessary in the routine removal of the appendix, if it happens to be placed rather high. If the appendix is high and adherent its removal through the Pfannenstiel incision may be attended with much tech- nical difficulty. The wound is sewed up in layers, and provision must be made to attach the fascia to the rectus muscle to obliterate the dead space consequent on the extensive stripping back of the fascial flaps. Fig. 430. — The Pfannenstiel Incision. The fascia has been cut transversely and is being stripped back from the rectus muscles. The attach- ment at the linea alba is trimmed away with scissors (after Doderlein-Kronig). In addition to the cosmetic value of the incision, other advantages are claimed for it. Postoperative hernia is supposed to be less common following it. Patients are able to get up earlier during convalescence and do not require abdominal binders. On the other hand, it has the important disadvantage of having considerably greater tendency than the longitudinal wound to become infected. It also requires more time during the operation, both in making and in closing it. • OPERATIONS ON THE ABDOMINAL WALL 771 ^?- ^^{.P.&- cNi;te<-X> Fig. 431 — The Pfannenstiel Incision. The fascia has been stripped back from the rectus muscles above and below. The rectus muscles have been separated in the middle Une and the peritoneum is being opened longitudinally (after Doderlein-Kronig) . DIASTASIS OF THE RECTUS MUSCLES In order to determine the extent of the diastasis of the rectus muscles during a pelvic operation the left hand is placed in the wound, palm up, with the middle finger at the umbilicus. By lifting up the abdominal wall with the hand in this position the thinned-out central portion of the wall becomes apparent, while the edges of the separated rectus muscles can be readily felt. In most cases of abdominal relaxation the abnormal separation of the muscles extends above the umbilicus. When the pelvic operation has been finished the skin incision is enlarged to about 2 inches above the umbilicus. The incision is not carried deeper than the fat. The skin and fat layer is then dissected wddely away from the aponeurosis (the attachment of the umbiHcus being severed) until the edges of the rectus muscles are reached. It is important that the aponeurosis should be well cleaned of fat. When all vessels have been tied, sutures are placed in such a way as to infold the abdominal wall and bring the divergent muscles into close union. This can best be done by employing the 772 GYNECOLOGY ''pulley stitch" (Fig. 433). Beginning at the upper end of the field, a suture of some strong material is carried first deeply into the aponeurosis of the right side near the edge of the muscle; it is then introduced superficially into the apon- eurosis of the other side; again, it is brought back and passed superficially in Fig. 432. — Operation for Diastasis of the Rectus Muscles. The fat has been pushed far back from the fascia, the umbilicus cut across. The thin layer of tissue intervening between the separated recti is demonstrated by inserting the hand as in the drawing. The edges of the rectus muscles can be seen or felt. the right side; and, finally, deeply into the left side (Fig. 434). When the ends of the suture are drawn away from each other the intervening aponeurosis is infolded and the edges of the muscles are firmly approximated. When the suture is tied the approximation is greatly reinforced. The suture material to be used depends upon the extent of the diastasis and the amount of tension OPERATIONS ON THE ABDOMINAL WALL 773 Fig. 433. — Pulley Stitch. Used for reduplicating the fascia and approximating the beUies of the muscles in operations for hernia and diastasis of the recti. VI^Gtcvmcs — ■ Fig. 434. — Operation for Diastasis of the Rectus Muscles (Author's Method). Introduction of the pulley stitches through the fascia at the borders of the rectus muscles. Two fingers of the left hand are inserted in the abdominal wound to guide the direction of the sutures and to avoid injuring underlying intestine. The sutures should not be carried through the entire wall. They include only the fascia and part of the muscular tissue. requisite to unite the muscles. If the tension is very great, it is best to use a No. 7 braided silk doubled or strong linen. If the tension is moderate, No. 2 774 GYNECOLOGY chromicized catgut doubled may suffice. The object in doubling the suture is to avoid cutting through the tissues. The approximation pulley stitches are placed about | or | inch apart, down to the upper end of the primary incision, or, if the incision is a very long one, to about 2| inches below the umbilicus. V^.l^Svovvee., Fig. 435. — Operation for Diastasis of the Rectus Muscles (Author's Method). Pulley stitches have been introduced through the fascia at the borders of the separated recti. The lower part of the wound where the incision into the abdominal cavity has been made is closed in layers in the usual way, the rectus muscles lying in close approximation after the pulley stitches have been drawn and tied. The use of the pulley stitch is the most powerful method of approximating tissues that we possess and can be used in most cases where great tension must be overcome. OPERATIONS ON THE ABDOMINAL WALL 775 OPERATION FOR UMBILICAL HERNLA. (AUTHOR'S METHOD) The basic principle involved in this operation is that in order to secure adequate support for the new wound and to insure against a recurrent hernia of the scar, the rectus muscles, which in all cases of umbilical hernia are separated, must be reunited not only at the site of the hernia, but for a considerable dis- tance above and below. A long incision is therefore made, as in Fig. 437, in the median hne above and below, but encirchng the protruding mass. The first step is to dissect out the sac, cutting deeply in the surrounding fat until the white, firm tissue of the aponeurosis over the rectus muscles is reached. The dissection is then carried on until the hernial ring is clearly developed. When the sac is very large it is often found lying far over on the side of the abdomen, more or less adherent to the aponeurosis (Fig. 436). To one unfamiliar with this condition the develop- ment of the ring is at first confusing. \jmba Fig. 436. — Umbilical Herota. Transverse section of abdomen showing diastasis of recti, hernial sac, and adhesion of intestines and omentum to the sac wall. The waj- in which the hernial sac folds over on the fascia and becomes one-sided is shown. Also the disappearance of fat immediately over the hernia. "WTien the sac and ring have been clearly exposed an attempt is made to empty the sac of its contents, which cannot be done if there are adhesions inside the sac or along the edge of the ring. If there are no adhesions the sac is opened and trimmed off at the ring. If adhesions are present the sac must be opened with great care, so as not to injure a possible loop of intestine. The adhesions of the omentum or intestines to the inner surface of the sac and the ring are freed and the contents dropped back into the abdominal cavity. The freeing of the adhesions may be attended with much difficulty. In our experience the best and safest technic in this tedious task is the use of the Mixter curved dissecting scissors. The temptation to use gauze dissection should in all cases be resisted, for no other method is so prolific of trauma to the intestines. An 776 GYNECOLOGY important maneuver in the dissection of adhesions involving the bowel is to loop the left forefinger under the adhesion and hft it firmly up. By this means a resisting surface is given for the dissection, and, at the same time, a better opportunity for differentiating the tissues. In freeing the adhesions from the edge of the ring it will usually be found that they involve a considerable margin of the peritoneal surface around the ring. All the adhesions should conscientiously be freed — not only those attach- ing omentum and intestine to the peritoneum of the sac and abdominal wall, but also those uniting loops of intestines together. If injury is done to the 'V(P.GrB>v«u's- FiG. 437. — Umbilical Hernia (Author's Method). The incision is indicated by the red line. seromuscular coat of the intestinal wall, it must be repaired with fine catgut. In some cases it is advantageous to graft a piece of omental fat over raw surfaces that cannot otherwise be protected. When all adhesions have been released the omentum is pulled clown under the wound and a flat gauze ^ handkerchief inserted. The skin wound is then greatly enlarged by extending the median incision toward the pubes and toward the ensiform cartilage. The fascia on each side of the wound is widely exposed by dissecting back the fat. At this point, in the case of a large hernia, the skin wound extends nearly the whole length of the abdomen. OPERATIONS ON THE ABDOMINAL WALL 777 The ragged remnants of the hernial sac are now trimmed away and the wound through the abdominal wall extended downward, but not upward. Next the layers of the abdominal wall are cleanly dissected out and isolated in the lower half of the wound, but not in the upper half. This will be under- stood by referring to Fig. 435. In order to expose the bellies of the rectus muscles W.^.GrtwjcS-: Fig. 438. — Umbilical Hernia. The hernial sac has been dissected away from the surrounding abdominal fat and lifted up from the fascia. The sac is being cut away at the hernial ring. If the sac contains adherent omentum and loops of gut the opening must be made in the most convenient place, and all adhesions of the sac and ring removed before the sac is trimmed off. it is necessary to run the scissors along the inner edge of the sheath which encloses them. The next step is the application of sutures so as to approximate the rectus muscles along their entire length, and in doing so the plan is to bring them together by reduplication of the fascia in the upper half and by union of the 778 GYNECOLOGY layers in the lower half. The reason for this is, that if the layers of the upper half are dissected out and an attempt made to approximate them, it will be found that they are unable to stand the tension. The muscles, however, can be brought together by reduphcation of the uninjured fascia, which is very power- FiG. 439. — Abdominal Hernia (Author's Method). Stitches tied. The stitches of the upper single row are all pulley stitches. If there is much tension, they should be of strong silk or linen. If the tension is only moderate, strong catgut (No 2 chromicized) is sufficient. The fascia of the lower part of the wound is overlapped and sewed with two rows of interrupted chromic catgut sutures. ful. It will be found that when the upper half of the recti are reunited in this way the beUies of the lower half lie closely together, requiring no further tension to approximate them. In placing the sutures the peritoneum is first sewed for a few inches, the OPERATIONS ON THE ABDOMINAL WALL 779 end of the suture being left long. The left hand is then inserted beneath the layer of tissue that intervenes between the separated recti muscle and a series of pulley stitches apphed, beginning at the top of the wound (Fig. 434). If no very great tension is required, they may be of No. 2 chromicized catgut doubled. If great tension is necessary to approximate the edges of the muscles, it is neces- FiG. 440. — Abdominal HER>nA (Author's Method). The fat of one side is stitched down over the row of sutures in the fascia. This is to protect them in case of -n-ound sepsis and is especially important when silk or linen has been used. A cigarette drain is placed in the wound through a lateral stab-wound. It is a good plan to leave the end of the drain long enough so that it can be withdrawn without disturbing the dressing and binder. sary to use a non-absorbable stitch, either No. 7 braided silk or strong Pagen- stecher hnen. The suture should usually be doubled to insure against cutting through the tissues. The pulley stitches are apphed as pictured in Fig. 434, the left hand guarding against possible puncture of the abdominal wall and injury to the bowel. They 780 GYNECOLOGY should not be carried through the peritoneum, but may dip deeply into the muscle. After placing the pulley stitches they are drawn tight and tied. The suture of the peritoneum is then completed and several interrupted catgut stitches inserted in the rectus muscles, which now lie in close union. The fascia of the lower half of the wound is overlapped as depicted in Fig. 439. We now have a very long wound, usually with much fat, and numerous bulky knots in the fascia, all factors favorable for sepsis. In order to provide against Fig. 441. — The Mayos' Operation for Umbilical Hernia. Showing the position of the initial incision and the hernial ring after dissection of the sac. this, the fat of one side of the wound is stitched with fine catgut to the fascia so as to cover and protect the line of sutures. In order to prevent the accumula- tion of serum and dissolved fat in the wound it is drained by a Penrose tube passed through a stab-wound. The end is left long enough so that it may be extracted in two or three days without disturbing the dressing. In applying the dressing a continuous strapping with, surgeon's plaster should be used. The most effective swathe is the three-tailed binder devised by Rockey. The patient should be kept in bed three weeks. OPERATIONS ON THE ABDOMINAL WALL 781 THE MAYOS' OPERATION FOR UMBILICAL HERNLA A simple and popular method of operating on umbilical hernia, and one from which excellent results are reported, has been devised by the Mayos. It consists in making a large transverse elliptic incision including the hernia and a considerable amount of adjacent fat. The hernial mass is removed as in the preceding operation, the sac opened, and all adhesions freed. The wound in the fascia is enlarged transversely until the edges of the rectus muscles Fig. 442. — The Mayos' Operation for Umbilical Heristia. The hernial sac has been removed. The fascia is being overlapped and secured by mattress sutures. are reached. The upper flap of fascia, together with its peritoneal lining, is then lapped over the under flap, and attached in this position by a row of mat- tress sutures passed from the edge of the lower flap. The edge of the upper flap is stitched down on the underlying fascia. Numerous other excellent operations have been devised. Graser performs an operation which combines the principles of the two operations described above. He makes a transverse incision, dissects out and approximates the rectus muscles, and sews up the fascia transversely. Blake and Webster have developed operations similar in principle to the first operation described. 782 GYNECOLOGY OPERATION FOR POSTOPERATIVE HERNIA The operation for postoperative hernia used by the author is in principle like that for umbilical hernia, though for hernias that occur in scars of low- pelvic operations the wound need not be so long. The principle to be observed is to unite the rectus muscles at a considerable distance above the hernia, so that at the site of the hernia there is no lateral tension in approximating the edges of the various layers of the abdominal wall. The method of re- FiG. 443. — The Mayos' Operation for Umbilical Hernia. Final step of overlapping and securing the fascia. duphcating the fascia at the point where there is greatest tension instead of dissecting out the layers is to be observed in these hernias, as in the umbiUcal type. TRANSPLANTATION OF FASCIA FOR POSTOPERATIVE HERNIA In some cases of abdominal hernia neither the operation of approximating the rectus muscles nor the overlapping of flaps of fascia is feasible on account of causing too great tension on the tissues of the abdominal wall. In order to meet this contingency various devices have been employed, such as the insertion of OPERATIONS ON THE ABDOMINAL WALL 783 metal plates, wire gauze, etc. These methods, though occasionally successful, are imsatisfactory and in principle unsurgical. A more rational method that bids fair to become of great importance in the treatment has recently been introduced, and consists in the transplantation to the abdominal wall of fascia taken from the thigh. The technic employed by WiUard Bartlett and depicted in Figs. 444-446 is as follows: A free incision is made over the hernial area and the skin and fat widely dissected away from the margin of the sac or thinned out portion of the ab- Fig. 444 TRANSPLuiXTATioN of Fascia Lata for Postoperatr-e Herxia (Bartlett's Method). The letter H incision on the outside of the thigh. dominal wall, as in the other operations for hernia. If it is seen that the edges of the ring cannot be brought together without too great tension, the incision is carried no further and the wound is covered with a sterile dressing. With the patient still on her back, the right leg is exposed and flexed in the position shown in Fig. 444, After a thorough skin preparation, preferably with iodin, a long H incision is made in the middle of the lateral aspect of the thigh. The length of the incision depends on the amount of fascia that it is desired to re- move. As a rule, a generous flap is necessary, and the incision will occupy the middle three-quarters of the hne extending from the great trochanter to the 784 GYNECOLOGY external condyle of the leg. The cross-incisions at the ends of the longitudinal cut, forming a letter H, enable the .surgeon to expose a very wide area of fascia without impairing too much the circulation of the skin-flaps, thus avoiding any possible danger of later necrosis and sloughing. The skin and fat of the thigh are dissected from the fascia lata from the edge of the sartorius in front of the thigh to the edge of the semimembranosus behind. The fascial flap is removed Fig. 445. — Transplantation of Fascia Lata for Postoperative Herota (Bartlett's Method). Showing method of dissecting fascia from thigh. in the form -of a parallelogram and placed in warm normal salt solution until needed. The wound of the leg is closed. The abdominal wound is then uncovered. Without making any incision in the fascia the hernial protrusion is inverted and the edges of the turned-in portion sutured with catgut, care being exercised not to pierce the fascia so deeply as to injure a loop of intestine that may be closely adherent beneath. OPERATIONS ON THE ABDOMINAL WALL 785 The flap of fascia lata is removed from the saHne solution and cut in the center, the two pieces being sewed together so that the fibers of both pieces in the new parallelogram thus formed will run transversely instead of longitudinally, as in the first piece. A glance at Fig. 446 will explain this point. This maneuver ^ Fig. 446. — Transplan'tation of Fascia Lata Fobj Abdominal Hernia (Bartlett's Method). The piece of fascia lata removed from the thigh has been cut in two and the pieces laid side- wise so that the direction of the fibers will be at right angles to those of the abdominal fascia. The layer of fascia covering the hernia has been reduplicated by a running suture, the ends of which can be seen above and below the transplanted fascia. is carried out- so that the fibers of the transplanted flap will not coincide in direction with those of the abdominal fascia covering the hernia. The layer of fascia lata is then stitched to the abdominal wall over the inverted hernia (Fig. 446). The wound is closed with a stab-wound drain placed as in Fig. 440, The denuded muscles of the leg become rapidly invested in a new sheath. 50 786 GYNECOLOGY Valuable work in fascial transplantation has been done by H. A. Shaw, who epitomizes the essential principles of technic in the following concrete form : "Essentials of Fascial Transplantation. — In selecting a transplant it has been repeatedly demonstrated that tissue which normally is poorly vascularized is much better adapted than highly vascularized tissue. For the first few days the transplant must obtain its chief nom-ish- ment from the lymph exudate, supphed by the tissues surrounding, and eventually from the ordinary source due to the vascular connections formed in the new home. Therefore, the less ■vascular the transplant and the more vascular the soil, the greater assurance of success. "In the selection of tissue for the purpose of transplantation, from a histologic standpoint it seems to be more of a question of vascularization than of any peculiarity or arragement of its cellular constituents, although 'the higher the development of the cell, as ganghon-cell, nerve- cell, muscle-cell, etc., the less likely js it to sxurvive.' "Therefore in order of their importance would be, first, low normal vascularity, second, simple cellular structure. Fascia to an admirable extent answers both requirements and, in addition, has great tensile strength, which adds materially to its value in a great number of indications. 'It can be transplanted with almost uniform success and is much more sure of success than the ordinary skin graft.' "Fascial transplants m common wdth all tissue transplants may be (1) autoplastic (same subject), (2) homoplastic (same species), (3) heteroplastic (another species). "(1) Autoplastic transplants of fascia lata, when fresh and transplanted under careful technic, are almost as sure to take as normal fascia is to unite after suturing. It is a material that is always available with a minimum amount of injury to the part from which it is obtained and, therefore, either homo- or heteroplasty would have no great advantage even if of equal success. Autoplastic fascial transplants undergo practically no histologic metamorphosis. "(2) Homoplastic transplants of fascia lata usually take, but undergo histologic change, wherein the elastic tissue is replaced by fibrous, thereby losing one of its most valuable proper- ties under certain conditions, and in this respect preserved autoplastic tissue acts the same as homoplastic. Success of homoplastic flaps probably depends more or less upon the similarity of the blood-serum of the donor and recipient. " (3) Heteroplastic transplants only act as support for the new formed cells, while the old cells are being resorbed, fibrous tissue usually being substituted for the transplant. There- fore, if the formation of new cells be at least as rapid as the absorption of the old, we obtain a result that would be a clinical success but a histologic failure. Herein enters a great element of chance. Fascia is so easily obtainable in such liberal amounts that heteroplasty should not be resorted to and is mentioned simply to condemn. " Technic. — To insm-e success in fascial transplantation we should adhere strictlj^ to the following rules: " (1) Handle Gently. — In this respect we should keep constantly in mind the fact the more mechanical injury, the less the vitality of oiu- transplant, andJhere I would suggest sharp dis- section of our transplant at those points where it is intimate with intramuscular septa, thus minimizing trauma. " (2) Keep Transplant Moist and Warm. — 1 would suggest where practical to prepare your field completel}' for the reception of the transplant and suture in situ immediately. Some- times this will be impractical, if so, keep transplant in physiologic salt solution at normal temperature. The advantage of immediate suture is the fact that our fascia loses none of its contained lymph by osmosis with salt solution and does not become dry or cold. "(3) Keep Free from Antiseptics. — The same principle appHes here as in skin grafting. Therefore do not prepare patient by dry (benzin-iodin) method; do not use iodized gut; allow no possible contact with antiseptics. " (4) Transplant Must Come in Close Contact with Tissue and be Maintained in that Position. — This is important in establishing the future circulation of the transplant, as we can readily see how impossible it would be for our delicately budding embryologic vessels to bridge over any amount of dead space, and how imperfectly maintained contact would disintegrate our OPERATIONS ON THE ABDOMINAL WALL 787 granulating vascular loops. A firmly applied equal pressure bandage is of great service in this respect. "(5) Minute Attention to Every Aseptic Detail. — While infection does not absolutely spell failure, or failure may involve only a limited area of the transplant, yet an aseptic conscience is the first essential of successful fascial transplantation. We fully realize that under normal circumstances the tissues will care for a certain number of micro-organisms, but here we have tissue completely cut oS from its normal blood-supply and whose resistance is practically nil; tissue that must derive its im^mediate nourishment from the surrounding lymph exudate which, if d'luted with an infiamm.atGry transudate, would furnish poor nourishment and pre- vent the intimate contact between the transplant and its new home. " (6) Perfect Hemostasis. — Here again we deal with an interference with proper nutrition and a creator of dead space. "(7) Transplant Must be Kept on a Stretch. — Otherwise it will become shortened and possibly be replaced by fibrous tissue. In other words, it must be placed in as near its physio- logic environment as possible. The elastic fibers in fascia lata normally keep it in intimate contact with the muscle, allowing for contraction and expansion. When removed there is a primary contraction due chiefly to the elastic fibers that is com.plete in a fev/ moments. This is practically overcome by tacking in place immediately upon removal or, better still, by the aid of forceps as recommended by Dr. Guleka." OPERATION FOR FEMORAL HERNIA Femoral hernia is so rare in men and so common in women that it must be classified as a gynecologic disease. The operation for femoral hernia is usually regarded as a simple procedure, and so it is in many cases. The operation in common use consists in cutting down to the hernial mass, either from an inguinal hernia incision or by a longi- tudinal incision immediately over the protrusion. The hernial sac is found en- cased in a mass of fat which often renders the isolation and opening of the sac extremely difficult, especially if, as is frequently the case, the sac is small. When the sac has been found it is freed from the surrounding fat, emptied of its con- tents, and tied off as high as possible. No attempt is made to close in the ring, as there is no anatomic exposure of the tissues and a blind placing of deep stitches would be ineffectual and dangerous. In the average case the hernial opening is very small, so that recurrence is not common. In many instances, however, the opening is stretched and relaxed, so that the simple tying of the sac without closure of the femoral ring is quite inadequate and may result in recurrence. An ingenious and effective radical operation for femoral hernia has been pre- sented by Moschowitz and later emphasized and illustrated by Seilig andTuhol- ske. The principle of the operation involves an approach to the hernia through the inguinal canal. The femoral ring is exposed from behind, the sac emptied of its contents, drawn backward, and tied. The ring is closed by suturing Pou- part's hgament to a powerful tendinous band, the so-called Cooper's hgament, which hes posterior to the femoral ring. The details of the operation are as follows : The incision usually employed for repair of inguinal hernia is made. In order to secure greater exposure this incision may be carried further down toward the pubes, or, if necessity require, it may be extended by a right-angle incision 788 GYNECOLOGY toward the thigh. The aponeurosis of the external obHque is then divided and the conjoined tendon exposed. The round hgament is isolated and hfted out of the way by a loop of tape. The thin layer of transversahs fascia is incised and the peritoneum brought to view. If the parts be now retracted as in Fig. 447, the neck of the sac as it passes through the femoral ring comes into view. At this point in the operation a knowledge of the anatomy is essential. The crural ring is bounded externally by the external ihac vein, anteriorly by Poupart's ligament, internally by Gimbernat's ligament, and posteriorly by Cooper's liga- ment. Just beyond the external ihac vein is the deep epigastric artery which may Tas-cvcx- FiG. 447. — Opebation fob. Femoral Heekia (Moschowitz). An inguinal incision has been made and the peritoneum exposed, bringing to view the neck of the hernial sac as it enters the femoral ring. be encountered in opening the transversahs fascia. It should be remembered that near the edge of Gimbernat's ligament there may run an anomalous obtu- rator artery, the so-called corona mortis, the cutting of which is likely to cause serious trouble. The next step of the operation is to incise the peritoneum near the neck of the sac and to pull the contents of the sac (intestine or omentum) back into the ab- dominal cavity. Usually the contents are not adherent to the sac. If they are adherent traction on the contents will pull the entire hernial mass through the ring and convert it into an inguinal hernia. If the mass is adherent to the OPERATIONS ON THE, ABDOMINAL WALL 789 thigh it may be necessary to extend the incision and dissect out the sac in the usual way. In case of a strangulated hernia the opening is enlarged by incising Gimber- nat's ligament, care being taken not to cut an aberrant obturator artery. If the contents of the sac are readily drawn back a dressing forceps is then passed through the ring, applied to the wall of the sac and drawn backward, thus bringing the sac into view. The sac is tied off in the usual way as high as possible. Fig. 44S. — Operation for Femoral Hernia (Moschowitz). The peritoneal sac has been opened and the contents of the hernia drawn backward through the femoral ring into the abdominal cavity. The sac has been drawn out, tied, and cut. Cooper's ligament and Poupart's ligament are being united, thus closing the femoral ring. The next step, which is the most important part of the operation, is the closure of the ring. The parts are fully retracted. Along the horizontal ramus of the pubes and projecting from it is a dense, tough, white, glistening membrane, which is Cooper's hgament. Two or three sutures of chromic catgut are then so placed as to unite Cooper's and Poupart's Hgament. The first suture passes deeply through Cooper's hgament just internal -to the external iliac vein. It then includes the cut edge of the transversalis fascia and Poupart's ligament (Fig. 448). The other sutures are similarly placed, the innermost one including a bite in Gimbernat's ligament. 790 GYNECOLOGY The final step of the operation is like that for inguinal hernia. The con- joined tendon is sutured to Poupart's hgament and the aponeurosis of the ex- ternal oblique, united by an mibricating stitch. THE PERCY CAUTERY FOR CANCER OF THE CERVIX In applying the principles of the Percy cauterization it is necessary to have a special equipment. This consists chiefly of several electric heating irons with an assortment of tips and a water-cooled vaginal speculum (Figs. 449, 450). >v \ Fig. 461. — Suspension of Kidney. The latissimus dorsi has been cut transversely. The retroperitoneal fat has been opened and the perirenal fat grasped with forceps. Traction of the perirenal fat has brought the upper pole of the kidney into view (adapted £rom Kelly and Burnam). the movable kidney is forced upward under the ribs, so that in bringing it into view it must be drawn downward rather than upward. The kidney is brought OPERATIONS ON THE KIDNEY 801 into view by attaching several clamps to the fatty capsule and exerting careful traction so as not to tear the fat. In order to expose a space for the insertion of stitches the capsule is stripped from the posterior surface and upper pole of the kidney. The kidney, without being delivered, is then thoroughly palpated to discover any incidental abnormality. Fig. 462. — Suspension of Kidney. Introduction of the Brodel suture (adapted from Kelly and Burnam). In placing the stitches for suspension the object in view is to create an arti- ficial adhesion between the capsule of the kidney and the muscle with which it i& to lie in contact. This can best be accomplished with a non-absorbable stitch, either of linen or silk, preferably the latter. As to the level at which the kidney should be suspended, Kelly advocates 51 802 GYNECOLOGY attaching it as high as possible, and our experience substantiates this advice. If the kidney can be made to recede above the twelfth rib the external obhque muscle is strongly retracted or, if necessary, cut, and the tissues dissected back until the twelfth rib is exposed. Three stitches of fine silk are to be used for suspending the kidney. They are placed in a line along the outer border of the kidney, the upper one at the Fig. 463. — Suspension or Kidney. Placing of the Brodel stitches (adapted from Kelly and Burnam). junction of the upper and middle thirds, the lower one at the lower pole, and the third halfway between these two. The upper stitch is applied first, and is de- signed to anchor the upper pole of the kidney to the twelfth rib. The suture is first threaded on a large curved needle, which carries the suture from a point just above the twelfth rib through the wall, emerging in the wound close to the kidney. The needle is then changed to a fine full-curved needle, and the suture in the kidney taken at the junction of the upper and middle thirds. The OPERATIONS ON THE KIDNEY 803 manner of applying the stitch was devised by M. Brodel, and consists in plaiting it into the kidney substance at three points of a small triangle, so that a maximum of tensile strength is achieved without danger of lacerating the capsule. The stitch is completed by again threading it on the large needle and carrying it back to a point above the twelfth rib, near that from which it started. The second stitch is passed in a similar manner through the quadratus muscle at the lower pole of the kidney, care being taken not to injure or include the first lumbar nerve which runs just under the lower edge of the muscle. It should always be identified before placing the stitch. The third suture is applied in the quadratus muscle between the two already placed. In using the Brodel stitch it should not be carried deeply into the kidney substance. Before tying the suspensory sutures care should be taken that any of the fatty capsule intervening between the kidney capsule and the muscle be cleaned away, for its presence prevents the formation of an adequate suspensory adhesion. The redundant fat of the capsule may be removed or stitched to the quadratus muscle. The wound is closed in layers without drainage. If the latissimus dorsi has been cut, its fibers are sewed together. INCISION FOR MAJOR OPERATIONS ON THE KIDNEY When the proposed operation is to involve delivery and removal of the kidney it is of great importance to have a generous opening to avoid embar- Fig. 464. — Nephrectomy. The Incision. passing difficulties and dangerous accidents. For this purpose a long incision is necessary. As in making the incision for suspension, one must first determine the location of the twelfth rib, the outer border of the sacrospinalis muscles, and the curve of the iliac crest as far as the anterior superior spine. Within the 804 GYNECOLOGY angle made by the twelfth rib and the muscle border is an area which is softer to the feel than the surrounding parts, and it is in this area that the incision starts. It is then carried in a curving sweep toward the anterior superior spine, the length of the incision being determined by the magnitude of the opera- tion. The muscular structures covering the kidney may be opened in a variety of ways. The superior lumbar triangle may be first exposed and a blunt opening of the lumbar fascia made in the manner described for minor operations. This \vi\*.Gvcv\ies Fig. 465. — Nephrectomy. The fibers of the external oblique muscle are being divided preparatory to making the "frying pan" incision. wound may then be greatly enlarged by cutting downward in the direction of the anterior superior spine across the abdominal muscles (external oblique, internal oblique, trans versalis) and by cutting upward across the latissimus dorsi and the inferior serratus posticus muscles. Or the muscular structures may be cut before opening the lumbar fascia (Fig. 467). Still another method is the "frying pan" incision of Kelly. A long skin in- cision is made. The abdominal muscles are first opened by splitting the fibers, as in McBurney's operation for appendicitis. The wound is stretched with the fingers as in Fig. 460). An incision from this opening is then made OPERATIONS ON THE KIDNEY 805 upward through the muscles in the direction of the upper angle of the wound (Fig. 466). When the lumbar fascia is opened the retroperitoneal fat leaps into view, while at the posterior angle can be seen the border of the quadratus lumborum with the first lumbar nerve (ileohypogastric) skirting along beneath its lower edge. Division of this fat brings one to the thin fascial layer of Gerota's capsule, division ^^e>xayes Fig. 466 — Kelly's "Frying Pan" Incision for Nephrectomy. The fibers of the external oblique nluscle have been separated. The incision is carried across the muscles to the upper angle of the wound. The underlying layers of muscle are treated in the same way. of which reveals the lemon-yellow fat of the true fatty capsule of the kidney. It is not always easy to distinguish the two layers of fat and Gerota's capsule. Care should be taken in making the opening through the surrounding layers to avoid entering the peritoneal cavity or injuring the cecum which lies imme- diately in front of and intimately associated with the outside fat layer. This can be done by keeping well back toward the quadratus muscle. 806 GYNECOLOGY VI ^.G-. a^-ttvlM<. Fig. 467. — Nephrectomy. Diagram showing the muscles that are divided before opening the lumbar fascia: a, Serratus posticus inferior; h, latissimus dorsi; c, external oblique; d, internal oblique; e, sacrolumbalis; /, lumbar fascia; g, transversalis. ln\.OU \umb X 0\d\. 3-Uo-Ui.ai.Xev-u'i ^vav> s- Fig. 488. — Mayo's Operation for Varicose Veins. Showing the manner of making the incisions. incision of Schede; multiple incision and ligation; Trendelenburg's resection of a portion of the internal saphenous vein in the upper thigh; complete dissection of the vein by long incision, and Mayo's subcutaneous enucleation with a specially devised instrument. Of these, the Trendelenburg operation is the simplest, and can be used in OPERATIONS ON THE RECTUM '829 many cases, especially in those which are complicated with a varicose ulcer. The Schede operation, once popular, is at present comparatively little used. Multiple incision and ligation is a long and tedious operation, but in some cases must be resorted to. Complete dissection of the vein is a long operation and entails too great a risk in the event of sepsis, which, in view of the extremely long wound, constitutes a grave danger. In the majority of cases the subcutaneous enuclea- tion by Mayo's method is, in our experience, the most desirable. When the vein walls are very thin and frangible the operation does not work out as smoothlj^ as one would wish, but in this case the principle of enucleation may be com- bined with a large number of incisions, and satisfactory results obtained, though the operation may be long and laborious. The technic of the operation is as fol- lows: The leg is held in an elevated position either by an assistant, who holds the patient's heel in the palm of the hand, or, as Mayo recommends, slinging the foot to an upright at the end of the operating table. A small transverse incision is made on the inner side of the thigh just below the saphenous opening. The vein, as a rule, is easily found. In very fat patients, in whom the landmarks are less easy to determine, it may be necessary to enlarge the incision one way or the other in order to encounter the vein. When the vein has been found, it is severed, the proximal end being ligated and the distal end seized with a clamp. J Fig. 4S9. — Instrument Used for Stripping^ the Vein in Mayo's Operation for Varicose Veins. The distal end is freed and drawn out a short distance into the wound and threaded into the loop at the end of the enucleator. This is a special instrument devised for this operation by the Mayos, and is constructed like a very long blunt curet, with the end bent at an angle (Fig. 489). When the vein has been threaded into the loop, its end is held with moderate tension by a clamp. The enucleator is forced gently but firmly through the subcutaneous tissues toward the knee in the direction of the vein. An assistant steadies the tissues with his hands placed one on each side of the end of the instrument. As the enucleator is forced through the tissues the lateral branches of the vein are torn off. In a favorable case the point of the instrument may be carried to a few inches above the knee before it becomes impossible to push it further without exerting too great tension on the vein. The point is then forced up against the skin and a small transverse incision made over it. The vein thus brought into view is drawn out of the opening and also from the loop of the instrument, which is extracted from the first wound. The vein is again threaded into the loop, and the enucleator forced through the tissues to a point below the knee. This section of the vein is the most important to remove, and also the most difficult, for it contains branches that anastomose both with the external saphenous vein and with the deep venous circulation of 830 GYNECOLOGY the leg. If (as in our experience it usually does) the vein breaks during the stripping of this section, an incision is made below the knee, the vein isolated, and the enucleator worked upward in the reverse direction toward the point of rupture. Below the knee the vein is somewhat more adherent than above, so that the incisions must be made more frequently. If the external saphenous is vari- cose, the same procedure is carried out on the back and outer part of the leg. Bleeding from the lacerated branches of the vein is rarely troublesome and can easily be controlled by pressure. The small wounds are sewed up and the leg kept in moderate elevation during convalescence. It is best for the patient to wear an elastic stocking for a few weeks after operation. If a varicose ulcer is present with the usual brawny induration it is advisable to treat the patient first for a period in a hospital. The patient is kept in bed with the leg elevated. The best treatment for ulcer is Crede's ointment or scarlet ointment. The effect of the Crede preparation, which is made from silver salts, is sometimes very rapid. If the ulceration is not cured in a reasonable time the operation consists of a resection of the vein either by the Trendelenburg or Mayo operation, preferably the latter, with a removal of the section extending from 8 inches above the knee to 4 inches below it. The ulcerated area is then dissected out and the surface thus exposed skin-grafted. The entire leg is bandaged, leaving a window of celluloid or fine gauze elevated from the wound through which the condition of the graft may be daily watched. TECHNIC Author's Note. — In writing the following section the author realizes the wide divergence of opinion that exists among gynecologists in regard to many matters of technical detail. The methods here described are those in use at the present time at the Brookline Free Hospital for Women and are the result of many years of trial and comparison with other methods. To the experienced gynecologist who has worked out his own technic the section may be of little interest. To the beginner it is offered either for imitation or as a groundwork from which an individual technic may be developed. Many of the instructions contained in this section have already been mentioned throughout the book in discussing the treatment of the various gynecologic diseases. EXAMINATION OF THE PATIENT Pelvic examination in the office should be made only in the presence of an attending nurse or a female friend of the patient, preferably a relative. The patient is first instructed to empty her bladder, and then to- loosen her clothing about the waist and to remove her corsets. The nurse arranges the patient on the table with a sheet draped over the knees, the abdomen being exposed so that it may be inspected and palpated. It is inadvisable to cover the face, as pain and tenderness can best be detected by watching the facial expression. In the examination of a gynecologic patient the attention should first be directed to the abdomen. Its contour will give evidence of large tumors, abnormal fat, hernia formation, ascites, accumulation of gas, etc. Undue laxity of the abdominal muscles with diastasis is frequently noticeable at the first glance. Palpation of the abdomen must be undertaken with the utmost gentleness and delicacy of touch. The first point for examination should alwaj^s be the uterine region immediately above the pubes. If the fundus of the uterus can be felt it may be assumed that some abnormality is present, the conditions which produce this sign being most commonly pregnancy, myoma, or a tumor in the posterior culdesac which presses the uterus forward into anteposition. The ovarian regions are then palpated, at first gently, then firmly and deeply, for the discovery of possible adnexal tumors, and to elicit tenderness if pelvic inflammation is present. Attention is next directed to the abdominal rectus muscles, with special reference to undue rigidity or laxness. If rigidity and tenderness are present, it must be determined whether the muscular spasm is general, or whether it is confined to or more marked in one muscle, or whether it is localized in a cer- tain area, as in the pelvis, the appendix region, the epigastrium, etc. In deter- mining muscular spasm of the abdominal recti it is of the very greatest im- portance to distinguish between voluntary and involuntarj^ muscle contrac- tions. Many patients from fear, resentment, or lack of nervous control will 831 832 GYNECOLOGY hold the abdominal muscles in a continuous state of rigid contraction, which makes the abdominal examination difficult and confusing. Relaxation of the abdominal wall with diastasis is usually quite apparent from inspection and palpation. It is made more evident by asking the patient to cough, or still better by raising the patient's shoulders a few inches from the table, when the recti are brought into firm contraction. Umbilical and post- operative hernias are brought into prominent view in this way. Every abdominal examination should include as a routine careful palpa- tion of the regions of the appendix, gall-bladder, liver, stomach, kidneys, and colon, even if the symptoms do not call particular attention to these organs. If abdominal enlargement is discovered, one must first determine whether or not it is due to fat, to intestinal distention, or to ascites. If a pelvic tumor is definitely made out the final diagnosis of its nature must usually be deferred until the vaginal examination is made. When all possible information has been gained from palpation of the abdo- men, the vaginal examination is undertaken. The external genitals and anus are first inspected under a good light. Ab- normal conditions made evident by inspection are genital atrophy, abnormal secretions, urethral caruncle, enlargement of Skene's and Bartholin's glands, skin lesions of the vulva, procidentia, relaxation of the vaginal outlet, hemor- rhoids, etc. If the outlet is relaxed the amount of prolapse of the vaginal wall is best determined by placing the forefingers of the two hands in the two lateral sulci of the torn perineum and pressing firmly downward toward the buttocks. When the patient is requested to strain as in the act of defecation the anterior and posterior walls of the vagina roll outward and show distinctly the amount of cystocele and rectocele present. Digital examination by vagina is first made with the left forefinger, which should be well lubricated. The best lubricants are made from glycerin and sea-moss. If one of these preparations cannot be had, soap and warm water is entirely satisfactory. Vaselin preparations are disagreeable, and if gloves are used are injurious to the rubber. The left forefinger is introduced through the introitus with the hand in the position of pronation, pressure being exerted on the perineum, in order to avoid as much as possible contact with the urethra and chtoris. Passage through the introitus must be made with extreme gentleness and deliberation, for any quick or rough movement will cause the patient to contract the muscles of the abdomen and thighs. . When the first phalanx of the forefinger has passed the introitus the hand is turned into the position of supination, which gives a spiral motion to the entering finger. The patient is now requested to relax as much as possible, and this is best accomphshed by separating the legs widely. If the preliminary part of the examination has been ungentle or inconsiderate it is impossible to secure proper relaxation on account of the patient's fear of being hurt. TECHNIC 833 When the forefinger has reached the cervix, the external os is palpated and such conditions noted as the direction of the cervix, laceration, eversion, hyper- trophy, cystic nodules, malignant infiltration, etc. Next, the finger feels along the anterior wall of the vagina, noting -the anterior wall of the uterus, if it is in the forward position, and distinguishing the amount of angulation between cervix and body. The lateral and posterior fornices of the vagina are explored for the discovery of such abnormalities as vaginal scars, cysts, hypoplastic shortening, parametrial infiltration, or the protrusion toward the vagina from above of a tumor or pelvic abscess. The right hand is now placed on the abdomen above the pUbes and a bi- manual examination made of the internal pelvic organs. The position of the uterus is first determined. This is best accomplished by placing the forefinger under the cervix and lifting the uterus toward the abdominal wall until the right hand can palpate the fundus, and note its size, consistency, and contour. If by hfting the uterus toward the anterior abdominal wall the fundus can- not be felt by the right hand the uterus must be in some form of retroposition, the degree of which is then determined by forcing the left forefinger deeply into the posterior fornix of the vagina and palpating the posterior wall of the uterus. If the vagina is deep or the patient very fat, this last maneuver may be greatly facilitated if the examiner places his left elbow against his hip, by which firm and powerful pressure may be exerted without causing the patient pain. Prolapse of the uterus is measured by placing the left forefinger on the cervix and requesting the patient to strain as in the act of defecation, when the amount of descensus may be noted. A more accurate method is by examination in the standing position. When the position, size, and consistency of the uterus have been investigated, the sides of the pelvis are explored. The examining finger passes into the left posterior fornix of the vagina, pressing in deeply, while the right hand is shifted to the lower left quadrant of the patient's abdomen and pressed inward as if to meet the forefinger of the examining hand. In this way the adnexa are forced downward toward the left forefinger, which is thus enabled to palpate the lower hemisphere of the ovary. In a normal pelvis the adnexa cannot be felt by the external hand, while the finger in the vagina feels only one pole of the ovary unless the patient is very thin. A normal tube cannot ordinarily be palpated. Bimanual examination of the adnexa reveals such pathologic conditions as prolapsed and cystic ovaries, ovarian tumors, tubal pregnancy, salpingitis, chronic pelvic inflammation with immobilizing adhesions, etc. Of great im- portance in examining the adnexa is the detection and proper interpretation of pain, and here again must be emphasized the necessity of distinguishing pain from some pathologic process and that which may be elicited by rough manipu- lation. When the adnexa of the left side have been investigated attention is directed to the right side. When the examiner stands between the patient's knees he is 53 834 GYNECOLOGY liot in an advantageous position to explore the right side with the left forefinger. The left forefinger is, therefore, withdrawn from the vagina and the right fore- finger inserted, the left hand now being used on the abdomen. A very satisfactory method of exploring the right side without withdrawing the left forefinger is for the examiner to step to the left side of the patient, in which position it is easy to reach deeply into the right fornix of the vagina with the left forefinger. When it is necessary to inspect the cervix and upper part of the vagina and to make local applications, a speculum must be used. This may be done with the patient on the back, in which case a bivalve speculum is usually employed. A much more efficacious and convenient method is the classic one by which the patient is first placed in the Sims position, the success of the procedure depending chiefly on securing a proper position. It is necessary that the examining table be fitted with a Sims shelf extending from the left lower corner. The patient is made to lie on her left side with feet and legs supported by the shelf. The left hip should correspond as closely as possible to the lower right corner of the table. The right shoulder should be in contact with the right edge of the table, while the left arm rests along the other edge. In this way the patient is made to lie upon her breast. The nurse stands at the patient's back, separating the lips of the vulva with the tips of the fingers, while the Sims speculum is being introduced by the ex- aminer. When the speculum has been properly placed the nurse seizes it firmly with her right hand, still retracting the buttocks with the fingers of her left hand. In order to secure a good exposure of the cervix and vault of the vagina it is necessary for the examiner to depress the anterior vaginal wall with a cotton stick or other convenient instrument. The Sims position is of especial advantage in inspecting the cervix, for removing specimens of tissue for microscopic ex- aminations, for probing the cervical canal, and for the apphcation of tampons and medicinal substances to the vaginal canal. Occasionally the knee-chest position is useful for vaginal examinations. In this position two Sims' speculums may be employed, applied one to the poste- rior and one to the anterior wall of the vagina. The knee-chest position is un- comfortable and disagreeable to the patient, and as it has httle advantage over the Sims position it need rarely be used. PELVIC EXAMINATION IN A PRIVATE HOUSE Whenever possible gynecologic patients should be examined at the office, on a proper table with good hght. When, however, it is necessary to make the examination at the patient's home the patient is instructed to be in bed. The abdominal part of the examination is made with the' patient lying near the edge of the bed. For the bimanual part of the , examination it is advantageous for : TECHNIC 833 the patient to lie across the bed. In order to bring the pehds into a good position for palpation of the organs the buttocks should extend over the edge of the bed, the feet being supported on two chairs or on the knees of the examiner, who is seated in a chair in front of the patient. If in this position the examination is unsatisfactory, it may be facilitated by having an assistant sit on the bed beside the patient and raise the thighs until they are in contact with the abdomen. ABDOMINAL OPERATIONS Preparation. — In the performance of pelvic operations by the abdominal route the preparation of the bowels is of very great importance, for if they are distended and cannot easily be kept away from the surgical field the technical difficulties of the operation are greatly increased. Moreover, a thorough prepara- tion of the bowels insures to a certain extent against troublesome postoperative gas formation. Surgeons differ considerably in the matter of catharsis, castor oil and calomel being the drugs most commonly used. Our method is as follows: Unless the case is one of emergency the patient is required to enter the hospital on the second afternoon before the day set for the operation. This is done chiefly in order that the patient may pass through the somewhat deplet- ing experience of catharsis at least twenty-four hours before the operation and have a night of unbroken rest umiiediately prececUng her ordeal. Accordingly, on the afternoon of entrance into the hospital calomel in ^-grain doses is given every half-hour until 4 grains have been administered. Calomel given in doses of this size passes rapidly through the intestinal tract, and only very rarely causes any of the disagreeable digestive and constitutional symptoms com- monly ascribed to its use. If only a short time is available for the preparation of the bowels it is better to use castor oil. Early the following morning the patient receives | ounce of Epsom salts and in about one hour is given a high enema of soapsuds (1 pint). By this form of catharsis the patient undergoes a thorough cleansing of the bowel, but is not drastically purged. After the enema the patient receives the preliminary skin preparation, which is carried out in the following way : Hospital patients are first given a warm tub bath. The abdomen and vulva are shaved and scrubbed with soap and water and alcohol. A vaginal douche of sterile water is given. Dry sterile pads are then applied. The patient is allowed to be up and about the rest of the day. Private patients are permitted to leave the hospital during the day and return at 5 o'clock. At that time the abdomen is washed with 70 per cent, alcohol, and then painted with tincture of iodin diluted with 70 per cent, alcohol (1 to 3). A fresh sterile pad is applied. Early on the morning of the operation a cleansing suds enema and another vaginal douche of sterile water are given. When the patient has been anes- thetized the abdomen is again painted with tincture of iodin (1 to 3). 836 GYNECOLOGY The above preparation of the vulva and vagina is carried out as a routine measure in conjunction with the preparation for all gynecologic abdominal operations to provide for possible vaginal examination or drainage that may unexpectedly be required during the course of the operation. If the abdominal operation is preceded by a vaginal operation the vulva and vagina receive an extra cleansing after the patient is anesthetized and im- mediately preceding the operation in the manner described below for the prepara- tion of vaginal operations. Technical Detail in the Conduct of Abdominal Pelvic Operations The patient should empty her bladder just before taking the anesthetic. It is advisable to anesthetize the patient on the operating table in a room ad- joining the operating room. When the patient is fully anesthetized whatever vaginal preparation is necessary should be carried out before wheeling the patient into the operating room. If the operation is to be for a pelvic tumor it is best to catheterize the bladder in order to determine the position of the bladder, and to draw off any possible residual urine, the presence of which might inter- fere with the performance of the operation. The patient is then placed in the Trendelenburg position and the table wheeled into the operating room, where a coat of iodin is applied to the ab- domen and the patient properly draped with sterile coverings. If the incision is to be a median one care should be exercised to make it ex- actly in the middle line, and not longer than is necessary for the proper per- formance of the intended operation. All small vessels in the abdominal fat should be caught at once with curved half-length clamps which fall out of the way when in place. If the aponeurosis is exposed without staining it with blood the linea alba is usually visible at once. The fascia is opened along this line, the scalpel entering the fatty space between the bellies of the rectus muscles. The muscles are separated with a few touches of the knife and the subperitoneal fat brought to view. The surgeon then places the forefingers of both hands in the wound and strips back the fat from the peritoneum, at the same time releasing the peritoneum from the under sheath of the rectus muscles for a short distance from the wound. The peritoneal layer thus thinned out is picked up with thumb forceps by the surgeon and the assistant and the peritoneum opened between the forceps by one delicate stroke of the knife. The opening thus made is enlarged by scissors until it will admit the hand of the operator, unless for some reason it is important that the wound be very small. The first step is always to investigate the pelvis. If the pelvic condition, is a serious one, such, as a tumor or pelvic inflammation, attention is at once directed to that without further exploration of the abdominal cavity, this procedure being deferred until the end of the operation, and then carried out only if the TECHNIC 837 patient's condition warrants it or if sepsis has not been encountered during the pelvic operation. If the pelvic condition is simple, requiring only a few minutes for its cor- rection, as in the case of an uncomplicated retroversion, the appendix is sought for and removed. The left hand is then introduced into the abdominal cavity and all parts rapidly explored, especial attention being paid to the palpation of the gall-bladder and to abnormal adhesions in any part of the intestinal tract. If the pelvic condition demands a serious operation the abdominal wound is enlarged according to the requirements of the case, a hysterectomy demand- ing an incision of the fascia well down to the symphysis. When the incision has been properly enlarged retractors are placed in the wound and the intestines packed away from the field of operation. This may be accomplished in the following way: The anesthetist has been previously instructed to have the patient deeply narcotized at this point of the operation, for if this is not done the manipulation of the intestines and the irritation of the gauze packing coming in contact with the peritoneum will stimulate contractions of the abdominal muscles with consequent delay of the operation. In order to remove the in- testines from the operative field the surgeon first lifts with his left hand the coils of bowel which He in the pelvis and pushes them toward the upper ab- domen. With his right hand he pulls down the omentum so as to cover the intestines as much as possible. A "Western strip" wrung out in warm salt solution is then placed against the omentum and folded back and forth, forcing the intestinal contents into the upper abdominal cavity. A second strip is applied in like manner to tuck back any loops of intestine that may tend to escape. A dry gauze handkerchief is applied in front of the two strips. In this way the bowel is completely walled off from the field of operation in the pelvis. By first bringing down the omentum and then using moist gauze a minimum of trauma is done to the peritoneal surface of the intestines. If the bowel is involved in extensive pelvic adhesions these must be released before the walling-off gauze is apphed. A strict count of the sponges used during the operation must be made by two persons and a written record kept by the operat- ing room nurse. Various devices are employed to prevent the possible leaving in of a sponge in the abdominal cavity. One of these consists of strips of braid sewed to the gauze sponges with leaden weights attached. Wakefield uses a very long strip of gauze which is fed from a pocket in the sterile abdominal sheet, in which it is . folded and fastened. Some operators protect the edges of the wound with napkins fastened to the skin with small towel clips. We have not found this necessary. In the performance of pelvic operations it is important that the surgeon adopt a definite line of procedure for each operation, and follow the same technic step by step each time he does the operation. In this way he is enabled not only greatly to increase the speed with which he works, but to receive much 838 GYNECOLOGY more efficient help from his assistants, who in a short time learn to anticipate his every want. Success in pelvic surgery depends largely on the avoidance of loss of blood. Bleeding confuses the operation, causes delay, and is almost exclusively the cause of postoperative shock. It can best be prevented by rehgiously following the rule always to clamp or hgate a vessel before cutting it. The important vessels of the pelvis should be tied twice and a generous stump left beyond the tie to avoid later retraction. The suture material used in pelvic surgery in our practice is, for the most part, chromicized catgut of various sizes. The ovarian and uterine vessels should be tied with No. 2 chromic gut. The ties are made twice with triple knots. Other vessels may be tied with No. 1 or No. 0, depending on their size and location. Small vessels in the bladder and intestinal walls are tied with No. 00 gut. Peritoneal surfaces are stitched with No. or No. 00. In the pelvis it should be kept in mind that knots and sutures are a prolific cause of postoperative adhesions. The surgeon must, therefore, continually exercise his ingenuity in avoiding as much as possible the exposure of the suture material to peritoneal surfaces. The difficulties of pelvic surgery depend to a great extent on the inaccessi- bility of the field of operation. Thus, operations which under favorable condi- tions are comparatively simple, may present the most serious technical diffi- culties if the abdominal wah is very fat, or if the incision is too small, or if the abdominal muscles are in contraction from incomplete narcosis, or if the intes- tines are distended with gas. One way in which operators often make trouble for themselves is by the collection of a great number of clamps, which obstruct the surgeon's view, pre- vent easy manipulation, and cause repeated tangles in the attempts to place hgatures. In a difficult pelvic operation, like that for cancer of the cervix, for example, it saves time to tie the vessels as they are caught and to keep the field free from clamps. In releasing pelvic adhesions the surgeon must exercise precision and de- hberation, most of the accidents that happen during this process being the result of haste or impatience. On the other hand, he must be sure that steady progress is being made, for time passes very rapidly when one is timidly puttering over some difficult adhesion. When the pelvic operation has been finished the condition of the patient is noted, and if it is satisfactory and the operation has not already consumed too much time, the appendix is sought for and removed. If no pus or other infecting condition has been encountered during the pelvic operation the walhng-off gauze is extracted and the abdominal cavity explored, special search being made for possible gall-stones. The great omen- tum, if it is sufficiently ample, is now drawn down over the field of operation and the wound closed. TECHNIC 839 If pus has been encountered the patient is lowered into the horizontal posi- tion and the dry handkerchief gauze removed. The surgeon then changes his gloves and extracts the remaining strips. The intestines are not handled at all and no attempt is made to explore the abdominal cavity. Suture of Abdominal Wound. — In sewing up the abdominal wound there are many methods, that employed by the author being as follows: The ends of the wound in the peritoneum are seized with half-length clamps which draw the peritoneal folds well up from the rest of the wound. The edges of the peritoneum are sewed by a running suture of No. 1 chromic gut, beginning at the upper end. When the stitch has reached the lower end and is about to be tied tension on the peritoneum is released, and as much air as possible is allowed to escape from the abdominal cavity through the small opening in the perito- neum. Three or four sutures of No. 1 chromic gut are then introduced into the bellies of the recti muscles and tied sufficiently tight to approximate the muscles, but not tight enough to cause a paralysis or necrosis of the muscle-fibers. If the muscles are so separated that they cannot be approximated without due tension the skin wound is extended, and the operation for diastasis described on page 771 is performed. When the sutures in the muscle bellies have been tied the corners of the fascia are caught by toothed half-length clamps. If the wound is a short one, without lateral tension, the fascia is closed by a single running suture of No. 1 chromic gut. If the wound is a long one or if there is considerable lateral tension, such as exists in fat abdominal walls, the upper half of the wound is closed with a No. 2 chromic gut suture which is tied at the center of the wound. A second suture of the same size is then introduced at the lower corner and the lower half of the wound is closed in like manner. All the small vessels of the fat previously caught in clamps are tied with No. 00 chromic gut. The patient is now let down into the horizontal position. By this change it frequently happens that other small vessels in the fat or just under the skin begin to bleed. These are observed carefully, clamped, and tied. This maneuver is a rather important precaution against the postoperative bleeding and conse- quent hematoma of the wound. The skin and fat are approximated by several deeply placed sutures of silkworm gut. In order to secure exact coaptation of the skin edges a running stitch is used of No. 00 chromic gut and introduced with a very long Glover's needle held in the hand. The method of using a subcutaneous stitch for the skin coaptation we have discarded. A sterile dressing is then applied to the wound and fastened with a few adhesive straps. If the wound is very extensive, like that from a hernia operation, broad adhesive straps are applied overlapping each other and covering the lower part of the abdomen. Outside of this dressing is placed a many-tailed binder. The deep silkworm-gut sutures are removed on the fifth or sixth day. The coaptation stitch of fine catgut absorbs for the most part during the final days of 840 GYNECOLOGY convalescence, but it is usually necessary to pick from the wound a few remaining bits of the suture before the patient leaves the hospital. Postoperative Treatment of Abdominal Cases In our hospital practice no morphin or other narcotic is given either before or after operation in the routine case. This rule we have not been able to carry out consistently in our private practice, in which many of the patients receive one or more doses of morphin during the first thirty-six hours following opera- tion. It is a very significant fact, however, that the hospital patients are, on an average, at least a day ahead of the private patients during the first part of convalescence. This difference in favor of the hospital cases is, in considerable measure, undoubtedly due to the fact that drug narcosis is not employed. The personal element must in all surgical work be kept constantly in mind, and it cannot be denied that women in comfortable circumstances, whose training in life has been less rigorous than that of the less fortunate classes, are physically more sensitive to the first postoperative discomforts and more frequently require the relief afforded by drugs, which are given, as a rule, rather to prevent nervous exhaustion than as an alleviation of actual pain. When in the average case morphin is indicated it is our practice to administer | grain subcutaneously several hours after the operation if the patient is beginning to get restless. During the first night, if it seems evident that the patient is becoming tired out either from pain or nervous from loss of sleep, another I grain of morphin is allowed, combined with y^-o- of hyoscin. Usually no further narcosis is necessary, except with very nervous or excitable patients. The question of moving the bowels after an abdominal operation is an important and sometimes troublesome one. In the treatment of routine cases three methods may be employed, each one of which has its adherents. Either catharsis may be begun as soon as possible after the operation, or it may be started two or three days after, or the bowels may be left entirely alone until they move spontaneously. In our experience the first method brings the best results as regards rapid and comfortable convalescence, and we have employed it almost universally in our hospital practice and in the majority of our private cases. In detail the method is as follows : About fifteen to eighteen hours after operation the pa- tient is given 3 grains of calomel in ^-grain doses at half-hour intervals. One hour after the last dose | ounce of magnesium sulphate is administered. Four hours later a high soapsuds enema (1 pint) is given. In the great majority of cases the enema is followed by expulsion of gas and a colored watery movement of the bowels containing flakes of feces. If the enema is unsuccessful, it may be repeated in two or three hours with 1 dram of turpentine added to the soap- suds. . With this treatment it is only rarely that the patient does not have a fairly comfortable second day. On the second night a cathartic is given, prefer- TECHNIC 841 ably in the form of a compound rhubarb pill (gr. v). On the following morning the patient receives another suds enema. This sequence is repeated during the rest of the convalescence — i. e., cathartic pill at night and an enema the follow- ing morning — even if the bowels move spontaneously. This method of early postoperative catharsis is less successful if it has been necessary to give morphin. When properly carried out the convalescence is remarkably rapid and only very exceptionally attended with the prolonged dis- comforts of gas, nausea, etc. By its use also the problem of nourishment is greatly simplified. During the first day after the operation sips of hot water are given at frequent intervals until 4 ounces can be retained. Dram doses of cold milk and hme-water in equal parts are then given. On the second day the patient has a cereal for breakfast, egg and toast at noon, and milk-toast at night. On the third day the diet is the same as on the second, while on the fourth day the patient is given the regular house diet. The second method, that of delaying the catharsis until the second or third night, must in some cases be resorted to, but its results are far less satisfactory than those of the first method. If there is severe reaction from the operation, or if there is prolonged nausea from the anesthetic, or if the patient's stomach is extremely dehcate, it is best not to attempt early catharsis. As a rule, patients of this kind begin to be troubled with gas on the second day. If it is accom- panied by distention, various enemas must be tried to relieve the patient's dis- tress. The formation of gas is likely to continue until satisfactory catharsis has been estabhshed, and it is, therefore, advisable to institute it as soon as the patient's stomach has become settled. The choice of a cathartic is then a diffi- cult one, for under these circumstances the stomach is in very unstable equihb- rium. In our experience calomel is useful only when used soon after the operation, and is, therefore, not available in these cases. Castor oil is most efficacious, but is not always tolerated by the patient. Other cathartics, such as rhubarb, cascara, phenolphthalein, German powder, may be chosen. Pluto water in 2- and 3-ounce doses on the morning of the third day usually works well. It should be followed by an enema in a few hours if the bowels do not move spon- taneously. Fabery's salts used in the same way we have found excellent. The third method of treating the bowels in postoperative abdominal cases is to leave them alone until they move of themselves. We have not found this a particularly useful method for treating routine cases, for although it frequently works out successfully, in many instances gas formation takes place, and the patient falls into the second class described above, where catharsis and enemata become imperative. We are accustomed to adopt the method only in those cases in which active peristalsis might be dangerous, as after resection of the bowels, or when there is possibility of a general peritonitis. We also employ the method when the operation has been attended with profound shock. In these cases salt solution in small quantities (4 ounces) is introduced into the rectum 842 GYNECOLOGY at frequent intervals until the patient's condition becomes satisfactory. Such patients usually have a spontaneous movement of the bowels in a few days. Length of Stay in Bed of Abdominal Cases. — Patients who have undergone such routine gynecologic abdominal operations as uterine suspension, myo- mectomy, supravaginal hysterectomy, oophorectomy, appendectomy, etc=, and whose convalescence has been normal, remain in bed from seven to nine days, and can leave the hospital in from twelve to sixteen days. Patients on whom operations for hernia or diastasis of the abdominal muscles have been performed should remain in bed from two to three weeks, according to the magnitude of the operation and the condition of the abdominal wall. Fat patients usually remain longer than thin because of the greater danger of postoperative hernia. The provision for adequate abdominal support following all abdominal cases is of great importance, and should in no instance be neglected. For the average woman a well-fitting modern corset, reaching below the abdominal wound and exerting firm pressure over the lower abdominal region, is the best form of sup- port. Very fat women require specially made corsets or abdominal belts. The best form of belt is made of webbing. The belt should be so constructed as to support and elevate the lower pendulous part of the abdomen. It should be worn continuously except at night. TECHNIC OF PLASTIC SURGERY Preparation. — Twenty-four hours before the proposed operation the patient is given | ounce of Epsom salts. The vulva is shaved and scrubbed with soap and water. The vagina is thoroughly cleansed with green soap and sterile water. The vulva is dried and a dry sterile pad applied. Four or five hours later the patient is given a high soapsuds enema. The sterile water vaginal douche is repeated, the vulva cleansed, and the dry sterile pad reapphed. If the patient is obhged to urinate or have a movement of the bowels, the external parts are irrigated and a fresh pad apphed. Early on the morning of the operation enemas are given until the water returns from the bowel clear. This is an important part of the preparation, for only by this means can the bowels be surely prevented from moving on the operating table and soihng the field of operation. Again the vagina is douched and a sterile pad reapplied. When the- operation is to be for complete tear of the perineum the prepara- tion is the same except that castor oil is given as a cathartic instead of salts, the idea being that the movements from the oil are less irritating. The diet of these cases should be restricted on the day preceding the operation, especially as regards milk. TECHNIC 843 Technical Details in the Performance of Plastic Operations When the patient is fully anesthetized the lower leaf of the operating table is dropped and the patient placed with the buttocks just projecting over the edge of the table. The legs are drawn up with knees bent until the thighs rest on the patient's body. The legs are held in this position by a nurse assistant. (>4~('n Fig. 490. — Directions for Making Ewin Perineal Sheet. The sheet for vaginal operations performed in the dorsal position is made 84 inches long by 64 inches wide. One end is folded so that the corners marked c join c on each side, and the seams are closed, thus forming a pocket. The opening for the vxilva should be 6 inches long, 2\ inches wide at the bottom, If inches wide at the top. The lower facing, from a to h, is made double, to give a thicker covering over the anus. The edges of the opening are finished with a narrow bind- ing. From the top of the opening, on the under side, fasten a strap, 10 inches long by 2 inches wide, in the manner indicated by the dotted line on the diagram. To cover the patient, gather the top edge of the pocket in one hand, and cover the feet so that the toes of each foot come into the corner of the pocket, care being taken to locate the open- ing directly over the vulva. The strap on the under side must be pinned securely to the patient's night-dress. The sheet is tucked well under the buttocks, the long end being left to cover the pad. This method of holding the perineal position is maintained throughout the operation, and is in our experience superior to the use of the posts and stirrups with which operating tables are usually equipped. With the patient in the perineal position, an assistant scrubs the vulva, vagina, anus, and adjacent parts of the thighs and buttocks with sterile soap and water, rinsing off the external parts with sterile water and alcohol. A specially constructed perineal sheet is draped over the legs of the patient. g44 GYNECOLOGY Numerous forms of sheets for this purpose have been devised. One of these which we have found very convenient is depicted in Fig. 490. The surgeon's assistant stands at the patient's left, maintaining the position of the left leg by holding the knee under his right axilla. In this way the assist- ant has both his hands free for helping the surgeon. In like manner a nurse stands, at the right of the patient, holding the right leg in the same way and acting as second assistant to the surgeon. At the surgeon's right is the suture and instrument table presided over by a nurse whose sole duty it is to place the necessary suture or instrument in the hand of the surgeon. This rather elaborate system of assistance is provided in order to secure as much speed as possible for operations which at best are rather tedious and time-consuming. Inasmuch as plastic operations must in the majority of cases be combined with a laparotomy, every effort should be made to shorten the time taken in their performance. This is best accomphshed by carrying out the steps of a given operation in the same way each time, and by having a team of assistants who are thoroughly famihar with the technic of the surgeon. Suture Material. — In most cases where sutures are required inside the vaginal canal catgut is employed. There is divided opinion among operators as to the comparative merits of plain or chromicized gut. Our experience has led us to discard the plain gut and to use the chromicized form exclusively. For ap- proximating vaginal surfaces No. 1 is the most useful size and is emploj^ed in the operations of tracheloplasty, amputation of the cervix, anterior colpoplasty, and perineoplasty. In closing vaginal wounds the stitches should always he inter- rupted. Running stitches are used only in closing the deep layers in operations for fistula in which the tissues are split into separate planes, stitches of this kind being always buried. Sutures that are to be buried should not be larger than No. or No. 00. In fistula cases, both those of the bladder and rectum, it is best to unite the vaginal mucous membrane with interrupted silver wire, even in those cases in which the wounds are closed in different planes. In sewing up wounds external to the vaginal orifice experience has taught us that silkworm gut is the best suture material, though many operators have discarded it in favor of catgut, on account of the necessity of removing the stitches. When silkworm gut is used the best method of protecting the ends is to clamp them in perforated shot, for by this means the stitches can be kept very clean and are prevented from causing discomfort by pricking the skin of the patient. Denudation. — All plastic operations involve a certain amount of denuda- tion of the epithehal surfaces. Denudation of the cervical mucous membrane in the operation of tracheloplasty is most easily done with a sharp scalpel. In the operations of anterior colpoplasty and perineoplasty the vaginal mucous mem- brane may be removed either by the ''splitting" of a flap of membrane from the underlying tissue, or by removal of the membrane in narrow strips with Emmet's TECHNIC 845 scissors. We greatly prefer the latter technic. The flap-splitting method causes more bleeding, entails a greater loss of tissue, and even in the hands of an expert operator is associated with the danger of perforating the wall of the bladder or rectum. In some cases the plane of cleavage between vaginal mucous mem- brane and the underlying bladder or rectum is found easily enough and the layers can be rapidly and safely separated, but if the tissues are thinned out by tension or atrophy the separation may be difficult, bloody, and dangerous to the hollow organ beneath. We therefore recommend to the beginner the adoption of the classic technic of Emmet-^'. e., denudation of the tissues with scissors. With a httle practice the membrane can be removed rapidly and entirely without danger. In making a denudation it is important that the edges of the area should be smoothly cut. In order to accomphsh this it is a good plan to pick up with tenacula the ends of the hne to be cut. By drawing the tenacula in opposite directions the membrane is brought up into a sharp fold or ridge, which may be smoothly trimmed off with scissors (see Operation for Perineoplasty). Coaptation —The success of plastic surgery of the vagina depends to a great extent on the ability of the operator to secure accurate coaptation of the wound edges without undue tension. In order to accomplish this the greatest care should be taken in making the denudation, that the wound edges when coap- tated shall fit perfectly without wrinkling and puckering of the tissues. This requires a good eye for symmetry and proportion on the part of the operator. Wounds in which the edges have been skilfully approximated heal rapidly by first intention, whereas wounds in which the coaptation is clumsy and ragged invariably heal by granulation and the formation of permanent scar tissue. As has been emphasized in the section on Plastic Surgery, m.any of the unpleasant after-results from operations on the vagina are the result of the contraction of old cicatrices. After-care of Plastic Cases The patient is encouraged to urinate within a few hours after operation. When an operation for cystocele has been performed it is important that the bladder should not become distended. For the first two days it should not be allowed to accumulate over 5 ounces of urine. Fortunately, most patients who have had cystocele operations are soon able to urinate voluntarily. They should be made to empty the bladder every four hours for the first two days and at night should be wakened for this purpose. If the patient is unable to pass her water voluntarily she must be catheterized at regular intervals. If the cathe- terization is carried out in the following manner (described also on page 268) there is practically no danger of causing a cystitis: A sterile glass catheter is attached to a fountain syringe suppUed with sterile water. The sterile water at low tension is allowed to flow through the catheter and cleanse the vestibule and surrounding parts of the vulva. The catheter is then introduced into the 846 GYNECOLOGY meatus while the water is still flowing. When the end of the catheter reaches the middle of the urethra the water from the fountain syringe is shut off and the rubber tube of the syringe detached from the catheter. The catheter is then passed into the bladder and the urine withdrawn. When a patient has had an operation for vesicovaginal fistula it is of still greater moment that the bladder be not distended with urine. These patients for the first four days should void every four hours, or if voluntary urination is impossible they should be catheterized. After the second day the intervals between voiding may be somewhat longer. Most patients who have had opera- tions for vesical fistulas are able soon to urinate voluntarily. It is a good plan,, however, to catheterize such patients at least once a day, for many of them' retain a certain amount of residual urine. In none of our cases, either for cystocele or for vesical fistula, do we employ constant drainage. Catharsis. — On the morning following a plastic operation the patient is given I ounce of Epsom salts, and in the course of three or four hours a low soap- suds enema, except after operations involving the sphincter or rectum. At night the patient receives a compound rhubarb pill (gr. v) and on the follow- ing morning an enema, whether she has a voluntary movement or not. The cathartic pill at night and enema in the morning are repeated daily as a routine during the rest of the patient's stay in the hospital. In some cases, especially in private practice where there is great objection to the taking of enemas, this treatment must be modified somewhat by adding other cathar- tics. The results, however, are not as satisfactory as when the above routine- procedure is carried out. After operations for complete tear we are not accustomed to move the bowels for nine days. Patients who have had this operation require the most unremit- ting care and expert nursing. Every effort is made to prevent a movement of the bowels, and for this reason the patient is kept on a restricted liquid diet without milk, though oysters, eggs, and jellies of various kinds are occasionally permitted. If there is active peristalsis the patient may be given 15 drops of tincture of opium. The bowels are moved on the ninth day by giving 1 ounce of castor oil fol- lowed in a few hours by a low oil enema (cottonseed oil, 4 ounces). After the first movement the bowels are treated in the same manner as in other plastic cases. Care of the Stitches.- — Much of the success of a plastic operation depends on^ the care of the stitches, for any neglect of them is sure to be followed by sepsis. The first duty of the nurse is to irrigate the stitches after each urination or defecation with sterile water and to apply each time a fresh sterile pad to the parts. In the treatment of the vaginal stitches two methods are in vogue : one by which the stitches are let alone and the other by which they receive frequent TECHNIC 847 cleansing douches. These may be called the dry and wet methods. We are very much in favor of the wet method, which is as follows : On the day following the operation vaginal douches of sterile water are given, two each day. This is continued throughout the convalescence. If at the time of leaving the hospital there is any leukorrheal discharge present, as there sometimes is as a result of irritation from stitches not yet absorbed, the patient is advised to take a douche each day or every other day for a week or two after reaching home. If silkworm-gut stitches have been used in sewing up the ex- ternal part of the perineum, they should be removed on the ninth day, after which the patient is allowed to sit up. Her usual stay in the hospital is from twelve to fifteen days. By treating the wounds in the above way sepsis is very unusual in the ordinary plastic cases. Operations for complete tear, involving as they do the anus and rectum, are more frequently comphcated by sepsis on account of the impossibility of keeping the wounds perfectly clean. The sepsis usually takes the form of a small locahzed stitch abscess which discharges and then heals rapidty, occa- sionally causing a ixiinute temporary fistula. It rarely affects the ultimate func- tional result of the operation. Stitch abscesses during the first stage are best treated by hot applications of sterile salt solution, changed very frequently. Treated in this way the in- fections remain localized and often disappear without suppuration. If suppu- ration occurs the hot apphcations are continued until the pu^ discharges spon- taneously. Once or twice each day the small abscess is forcibly evacuated through the small opening by pressure with the fingers. With careful attention and cleanliness the wound soon heals without injuring the result of the operation. Silver wire stitches used in operations for fistula are treated as other vaginal stitches. They are not removed for two or three weeks. NDEX Abbe's operation for carcinoma of rectum, 430 Abderhalden's test for pregnancy and cancer, 110 in differential diagnosis of uterine my- oma and pregnancy, 324 Abdomen, fatty, ovarian cyst and, differen- tiation, 416 lateral wall, cellulitis in, 260 operations on, length of stay in bed, 842 preparation for, 835 support after, 842 suture material, 838 technical detail, 836 treatment after, 840 palpation of, 831 Abdominal bands, 172. See also Intestinal bands. cavity, sponge in, 837 hernia, 500 operation for, 775 myomectomy, 750, 751 operation for anteflexion of uterus, 695 ptosis, 158. See also Enter optosis. support after abdominal operations, 842 tumors, vitiligo associated with, 97 wall, operations on, 768 wound, suture of, 839 Abortion, tubal, 508 treatment, 514 Abscess, ischiorectal, 280 of Bartholin's gland, 185 treatment, operative, 588 of kidney, 273 perim-ethral, 262 stitch, in plastic operations, treatment, 847 tubo-ovarian, 196, 253 Absence of Fallopian tubes, 445 of ovaries, 445 of uterus, 441 of vagina, 444, 535 Baldwin's operation for, 670 Graves' operation for, 667 operations for, 667 ovaries and, 55 Schubert's operation for, 670 54 Absence of vagina, treatment, 540 Accessory organs of Zuckerkandl, 85 ovary, 445 Acetone in carcinoma of cervix, 362 Acid, benzoic, in cystitis, 269 boric, in cystitis, 270 trichloracetic, in dysmenorrhea, 520 Acne and menstruation, relation between, 96 at puberty, 96 Acromegaly from hyperfunction of hypoph- ysis, 77 influence of suprarenal cortex in, 88 Adams- Alexander operation for retroversion of uterus, 689 Addison's disease and genitalia, relation be- tween, 89 Adenocarcinoma of cervix, 336, 337 of endometrium, 362 of uterus, 362 sarcoma and, differentiation, 331 Adenocarcinomatous degeneration of uterine myoma, 319 Adenoma hidradenoides vulviE, 287 of endometrium, 250 of rectum, 431 Adenomyoma of Fallopian tubes, 421 of parovarium, 419 of rectovaginal septum, 305 of round ligament, 423 of uterus, 327 of vagina, 305 Adenomyositis of uterus, 327 Adenosarcoma of parovarium, 419 of uterus, 330 Adhesions, attic, 173 pelvic, after gonorrheal salpingitis, 202. See also Pelvic inflammation, chronic. peritoneal, 153 from bacterial peritonitis, 153 from chemical injury, 154 from mechanical injury, 154 from surface necrosis, 155 from tuberculosis, 154 traumatic, 154 traumatic, from retroversion of uterus, 462 Adiposity after remoA'al of ovaries, 52, 53, 54 849 850 INDEX Adiposity as cause of sterility, 533 Adrenalin, 85 function of, 85, 86 in dysmenorrhea, 519 in hemophilia, 107 secretion of, effect of emotions upon, 86 Adrenin, 85 Albarran's modification of Braquehaye's op- eration for vesicovaginal fistula, 657, 659 Albuginea of ovary, 32 Alexander-Adams operation for retroversion of uterus, 689 Alexander's operation for retroversion of uterus, 466, 688 internal, for retroversion of uterus, 683 Allingham's operation for hemorrhoids, 819 Alpha ray, 349 Amenorrhea, 571 castration as cause, 571 disturbances of glands of internal secretion as cause, 572 etiology, 571, 572 functional, 572 ovarian deficiency and, 56 extract in, 65 in constitutional diseases, 572 neuroses from, 123 of young women, transplantation of ova- rian tissue in, 64 of youth, 523 placental extracts in, 65 tuberculosis and, relationship, 572 Amoeba urogenitalis, 238 Amphimixis, 24 Amputation of cervix, 599 and anterior colpoplasty combined, 620 Hegar's operation, 599, 604 of uterus, 713. See also Hysterectomy. Anal fissure, 282 treatment, 283 fistula, 281 Elting's operation, 827 Graves' operation, 824-827 operations for, 824 treatment, 282 Anaphrodism, 138 Anastomosis, ureteral, 810, 811, 812 Anemic heart, 114 Anesthesia, sexual, 134, 136, 138 Angioma, papillary, of vestibule, 293 Angiomatous degeneration of uterine myoma, 315 Angiosarcoma of uterus, 330 Anteflexion of cervix, pessaries for, 691 of uterus, 455, 480 abdominal operation, 695 Anteflexion of uterus, Baker's operation, 693 diagnosis, 481 Dudley's operation, 694 etiology, 481 Graves' operation, 695 operations for, 691 pessaries for, 481, 691 Pozzi's operation, 693 suspension operation, 482 symptoms, 481 treatment, 481 Anteposition of uterus, 456 Anteversion of uterus, 455 Antigonococcic serum, 215 vaccines, 215 Antitoxin, diphtheria, in cystitis, 269 Anus, atresia of, 449 imperforate, 449 prolapse of, 431 vaginal, 451 vestibular, 451 Appendicitis, acute gonorrheal salpingitis and, differentiation, 206 and movable kidney, association, 170 chronic, and menstruation, relation be- tween, 146 during labor, 147 pregnancy, 146, 147 relation of genitalia to, 145-147 Appendiculo-ovarian ligament, 145, 173 Appendix, retroperitoneal, 172 vermiform, relation of genitalia to, 145 Apron incision in fistula in ano, 825 Arbor vitse, 438 Argyrol in cystitis, 270 Arteriosclerosis, 115 as cause of uterine hemorrhage, 116, 117 Artificial impregnation in sterility, 566 vagina, Baldwin's method of making, 670 Graves' method of making, 667 method of making, 444, 667 Schubert's method of making, 670 Ascites after operation for ovarian cysts, treatment, 417 associated with cancerous cysts of ovary, 415 with fibroma of ovary, 410 with ovarian tumors, 412 cysts of ovary and, differentiation, 415 txibercular peritonitis with, 221 Aspermatism, 556 Atresia of anus, 449 of cervical canal, 543 of follicle, 40, 382 cystic, 42 during pregnancy, 41 INDEX 851 Atresia of follicle, manner of taking place, 41 obliterating, 42 of hymen, 536 treatment, 539 of rectmn, 449 of uterus, 444 of vagina, 535. See also Gynatresia. Atroph}', genital, 540 cancer and, differentiation, 546 complications, 543 diagnosis, 546 due to castration, 543 to constitutional diseases, 543 etiology, 543 treatment, 546 lactation, 543 of ovaries, 56 of bladder, 545 of cer\'ix, 541 of Fallopian tube, 541 of labia majora, 542 minora, 542 of ovary, 56, 542 as cause of changes during menopause, 23 pathologic, 56 of urethra, 545 of uterine fibroids, 316, 317 of uterus, 541 of vagina, 542 Atropin in dysmenorrhea, 519 Attic adhesions, 173 Auerbach's plexus, 151 Ausf aUserscheinimgen ,114 Azoospermia, 556 Backache, 156 in carcinoma of cervix, 579 in malposition of uterus, 579 in retroflexion of uterus, 577 in retroversion of uterus, 463 due to adhesions, 469 Bacteria as cause of cystitis, 262, 263 routes of infection, 263 of pyeUtis, 273 mode of entrance, into bladder, 262, 263 to kidney, 273 Bacterial peritonitis, 153 Baker's operation for anteflexion of uterus, 693 Baldwin's operation for absence of vagina, 670 Baldy's operation for retroversion of uterus, 685 Baldy-Webster operation for retroversion of uterus, 468, 685 Ball myoma of uterus, 310 Bands, ileopehac, 173 intestinal, 172. See also Intestinal bands. Bardenheuer's incision, 768 Bartholinitis, gonorrheal, 184 treatment, 185 Barthohn's glands, abscess of, 185 treatment, operative, 588 carcinoma of, 292 cysts of, 186, 292 treatment, 187 operative, 588 gonorrheal inflammation, 184 treatment, 185 operations on, 588 Bartlett's method of transplantation of fascia for postoperative hernia;, 783 Basedow's disease. See Exophthalmic goiter. Basset's method of dissection of inguinal re- gions in carcinoma of vulva, 584, 585 Bearing-dowTi feehngs, 579 Bed, length of stay in, in abdominal opera- tions, 842 BeU's method of stomatoplastic salpingos- tomy, 762 Benzoate of soda in cystitis, 269 Benzoic acid in cystitis, 269 Beta ray, 349 Beyea's operation for enteroptosis, 165 Bichlorid of mercury in pyelitis, 277 Bicornuate uterus, 442 double, with double vagina, 441 Bilharzia hEematobia of vulva, 238 Bladder, atrophy of, 545 calculus of, 428 diagnosis, 429 treatment, 429 capacity of, diminished, 265 carcinoma of, 427. See also Carcinoma of bladder. cysts of, 265 defects of, 445 drainage, in cj^stitis, 270 exstrophy of, 446, 447 treatment, 449 fissure of, inferior, 449 superior, 448 fistula of, 498. See also Fistula, vesical. gangrene of, 265 gradual dilatation, for limited capacity, 270 implantation of ureter in, 812 inflammation of, 262. See also Cystitis. irritable, in retroversion of uterus, 464 mode of entrance of bacteria into, 262, 263 operations on, 815 pelvic cellulitis after, 260 papilloma of, 426 i 852 INDEX Bladder, papilloma of, treatment, 428 relation of genitalia to, 141, 142 stone in, 428 syphilis of, 272 tuberculosis of, 271 diagnosis, 271 treatment, 271 tumors of, 426 symptoms, 428 treatment, 428 ulcer of, 265 wall, sloughing, 265 Blastomeres, 406 Blood, appearance of, after menorrhagia, 109 after metrorrhagia, 109 coagulability of, influence of uterine and ovarian extracts on, 58 extravasation of, leukocytosis after, 109 regeneration of blood after, 109 in chlorosis, 106 menstrual, 105 amount lost, 20 non-coagulabilitjr of, 20, 105 regeneration of, after hemorrhage, 108, 109 relation of genitalia to, 105 serum in menorrhagia of youth, 525 transfusion in hemophilia, 107 in menorrhagia of youth, 525 Blood-cysts of ovary, 386 Bloodless fold of Treves, 172 Blood-pressure, 113 Blood-vessels, pelvic, congestion of, during menstruation, 20 relation of genitalia to, 115 Bones and joints, relation of genitalia to, 156 Boric acid in cystitis, 270 Bowels, postoperative treatment, 840, 841 Braquehaye's operation for. vesicovaginal fistula, 657 Albarran's modification, 657, 659 Breasts and ovaries, relation between, 94 condition of, during menstruation, 20 development of, at puberty, 18 enlargement of, at birth, 18 during menstruation, 18 influence of placenta on, 94 relation of genitalia to, 93 Broad ligament, fibromyoma of, 424 varicose veins in, 119 Brodel stitch, 803 Buboes after soft chancre of vulva, 225 Byrne's treatment of carcinoma of cervix, 360 Cachexia in carcinoma of cervix, 344 strumipriva, 82 Calcification of uterine myoma, 316 Calcium chlorid in hemophilia, 107 in menorrhagia of youth, 525 Calculus, vesical, 428 diagnosis, 429 treatment, 429 Callous stenosis of cervix, 555 Canal of Nuck, cyst of, 292 Cancer. See Carcinoma. Capsule, Gerota's, 799 Carcinoma, Abderhalden's test for, 110 as cause of sterility, 558 of Barthohn's gland, 292 of bladder, 427 secondary, 427 of cervix, 334 age incidence, 339 backache in, 579 bleeding in, 342 cachexia in, 344 curetage for, 593 diagnosis, 344 elevation of temperature in, 343 etiology, 339 heat treatment, 360 in poor and ill-nourished, 342 incidence, 339 infection of lymph-glands, 345 invertent, 336, 338 Kronig's operation, 361 lacerated cervix and, differentiation, 486 leukorrhea in, 342, 570 mesothorium in, 348 metastasis, 343 metrorrhagia in, 576 operability, 346 operative treatment, 347 pain in, 343 palliative treatment, 361 parametritis and, differentiation, 259 pathology, 335 Percy's treatment, 360, 790 prognosis, 344 radium in, 348, 362 details of treatment, 355 Graves' technic, 792 selection of cases for, 353 removal of specimen for diagnosis, 345, 346 Schauta's operation, 744-750 squamous-cell, 335 starting points, 337 symptoms, 342 treatment, medical, 348 operative, 347 palliative, 361 vaginal discharge in, 342 INDEX 853 Carcinoma of cervix, vaginal hysterectomy for, 744-750 Wertheim's operation, 731-744 x-rays in, 348 of clitoris, 296 of Fallopian tubes, 420 diagnosis, 421 etiology, 420 prognosis, 421 treatment, 421 of ovary, 398, 404 classification, 398 colloid, 405, 406, 407 cystic, 398 metastatic, 399 secondary, 399 solid, 398 of parovarium, 419 of rectum, 429 diagnosis, 430 prognosis, 430 symptoms, 429 treatment, 430 of uterus, 362 age incidence, 364 associated with fibroids, 366, 367 bleeding in, 366, 367 diagnosis, 368 fibroid and, differentiation, 323 genital atrophy and, differentiation, 546 gland hyperplasia of endometrium and, differentiation, 368 in well-to-do, 342 increase, 339 metastasis, 364 metrorrhagia in, 576 treatment, 370 Wertheim's operation, 731-744 of vagina, 297 diagnosis, 297 prognosis, 298 treatment, 298 of vulva, 287 diagnosis, 289 Taussig's operation for, 291, 584 treatment, 290 operative, 584 Carcinomatous degeneration of ovarian cysts, 398 of uterine myoma, 319 Carotid gland, 85 Caruncle, urethral, 293 Castration. See Ovariectomy. Catamenia. See Menstruation. Catarrh, nasal, at menopause, 100 Catarrhal salpingitis, 193 Catharsis, postoperative, in abdominal cases, 840, 841 in plastic cases, 846 Catheterization as cause of cystitis, 263 Cautery in rectal prolapse, 432 Percy's, for carcinoma of cervix, 361, 790 Cecum mobile of Wilms, 159, 169 movable, and movable kidney, influence be- tween, 169 Cells, germ-, 439 interstitial, 48-51 Langhans', 372 lutein, 39 of Leydig, 48 somatic, 407 theca-lutein, 387 function of, 50 Cellular tissue, paracystic, 256 parametrial, 256 paraproctal, 256 pelvic, anatomy of, 255 inflammations of, 256. See also Para- metritis. Cellulitis, pelvic, 255 after operations on bladder, 260 in lateral wall of abdomen, 260 Cervical canal, atresia of, 543 Cervicitis, 241 symptoms, 242 treatment, 242 Cervix, adenocarcinoma of, 336, 337 amputation of, 599 and anterior colpoplasty combined, 620 Hegar's operation, 599, 604 anteflexion of, pessaries for, 691 atrophy of, 541 callous stenosis, 555 carcinoma of, 334. See also Cardnovia of cervix. curetage of, 592 dilatation of, 591 ectropion of, 336, 341 elongation of, in procidentia of uterus, 477 epithelioma of, 335, 336 erosion of, 241, 336, 341, 485 operative treatment, 593 eversion of, 336 operative treatment, 593 fibroids of, 310, 311 , , glands of, 189 hypertrophy of, after lacerated cervix, 485 laceration of, 485. See also Laceration of cervix. plastic surgery, 593 polyps of, 332. See also Polyps, cervical. tuberculosis of, 220 854 INDEX Cervix, ulceration of, 336, 485, 486 Chamberlain's pessary, 692 Chancre, soft, of vulva, 224 Character, influence of masturbation on, 132, 136 Child-bearing, influence of, on size and weight of uterus, 17 Childbirth, injuries due to, 485 Chloasma gravidarum, 97 Chlorosis, 106 and genital system, relation between, 106 blood-picture in, 106 CholeUthiasis, 148. See also Gall-stones. Chorio-epithehoma malignum, 370 and trophoblast, biologic resemblance, 375 bleeding in, 376 histology, 372 metastasis, 377 metrorrhagia in, 575 parametrial infiltration in, 380 spontaneous healing, 380 symptoms, 376 theca-lutein cysts associated with, 387 treatment, 378 of Fallopian tube, 421 of vagina, 299 Chromaffin system, 85, 86 Chromophils, 73 Chromophobes, 73 Circulation, deficient, of genitalia, ovarian extract in, 65 organs of, relation of genitaha to, 112 Circulatory system, condition of, during menstruation, 21 Clamp and cautery operation for hemor- rhoids, 822 Clark's perineoplasty, 633 for complete tear, 636 technic of anterior colpoplasty, 617 Climacteric, 22. See also Menopause. Climate, effect of, on menopause, 19 on occurrence of menstruation, 18, 19 Clitoris, carcinoma of, 296 hypertrophy of, 295, 296 tumors of, 295 Cloaca, 441 Coagulability of blood, influence of uterine and ovarian extracts on, 58 Coagulation of menstrual blood, prevention, 20, 105 Coaptation of wound edges in plastic surgery, 845 Cocain in dysmenorrhea, 520 Cocainizing nasal mucous membrane, in- fluence of, on dysmenorrhea, 100 Coccygodynia, 580 Coccyx, pain in, 580 Coffeys' operation for enteroptosis, 165 for retroversion of uterus, 468 Coitus, heart symptoms during, 113 painful, 138, 140 unpleasant, 534, 535 Cohc, uterine, 577 Colloid carcinoma of ovary, 405, 406, 407 Colon, diverticulitis of, 277. See also Diver- ticulitis of colon. implantation of ureter in, 814 inflammation of, 277 Colpitis, 236. See also Vaginitis. Colpoplasty, anterior, and amputation of cer- vix combined, 620 Clark's technic, 617 Graves' method, 608 Colpotomy, vaginal, 675 anterior, 676 posterior, 677 Compact layer of uterine mucosa, 26 Complement-fixation test in diagnosis of gonorrheal salpingitis, 205 Conception, physiology of, 23 Condyloma acuminata of vulva, 227 treatment, 228 Congestion, premenstrual, of uterine mucosa, 24 Connective tissue, pelvic, tumors of, 423 Consanguinity as cause of sterility, 561 Consciousness, 125 aware, 125 unaware, 125 Constipation at menopause, 102 in procidentia of uterus, 478 in retroversion of uterus, 464 Constitution, hypoplastic, 55 Constitutional changes during menopause, 22 diseases, amenorrhea in, 572 as cause of sterility, 560 genital atrophy due to, 543 Copaiba, oil of, in gonococcal cystitis, 269 Corpus albicans, 39 luteum, 38 and interstitial gland, reciprocal relation- ship between, 50 as organ of internal secretion, 46 cysts, 385 formation of, 38 macroscopic appearance, in various stages, 59 of pregnancy, macroscopic appearance, 59 period of regression, macroscopic appear- ance, 59 INDEX 855 Corpus luteum, period of ripeness, macro- scopic appearance, 59 persistence of, pregnancy and, 47 proliferative period, macroscopic appear- ance, 59 size of, 39 vascularization period, macroscopic ap- pearance, 59 Crede's ointment in varicose ulcer, 830 Cretinism, 82 endemic, 83 Cri uterine, 592 Critical period of woman's life, 23 Crystallizations of resistance, 175 Cumulus oophorus, 34 Curetage of cervix, 592 of uterus, 592 Curve of Ott, 121 Cystadenoma of ovary, 387 origin, 396 pseudomucinous, 389 origin of, 397 treatment, 391 serous, 393 origin of, 396 of parovarium, 419 Cystic carcinoma of ovary, 398 cystitis, 265 degeneration of ovaries as cause of sterility, 558 of ovary, 383 of uterine myoma, 314 follicle atresia, 42 sarcoma of uterus, 330 Cystitis, 262 bacteria as cause, 262, 263 routes of infection, 263 catheterization as cause, 263 course, 266 cystic, 265 diagnosis, 266 diphtheric, treatment, 269 etiology, 262-264 exfoliative, 265 gonorrheal, 264, 274 treatment, 269 urethritis and, differentiation, 266 hematogenous, 264 in old women, 272 operation in, 815 pathology, 264 polyposa, 265 prophylaxis, 268 symptoms, 266, 274 syphilitic, 272 treatment, 269 Cystitis, tubercular, 271 treatment, 269 vegetans, 265 verrucosa, 265 vetularum, 272 Cystocele, 457, 471, 487 diagnosis, 488 Graves' operation for, 608 symptoms, 488 treatment, 489 Cystogen in cystitis, 269 Cystoma of ovary, 387 Cystostomy, vaginal, 815 Dudley's method, 815 Kelly's method, 816 Cystotomy, suprapubic, 815 Kelly's method, 815 Cysts, blood-, of ovary, 386 dermoid, of Fallopian tubes, 421, 423 of ovary, 401, 408, 409 mahgnant changes, 403' parthenogenesis, 405 of parovarium, 419 of pelvic connective tissue, 425 treatment, 426 echinococcus, of vulva, 292 nabothian, 191 of Bartholin's glands, 186, 292 treatment, 187 operative, 588 of bladder, 265 of canal of Nuck, 292 of corpus luteum, 385 of Fallopian tubes, 421 of Graafian follicle, 381- of ovary, 254, 381 ascites after operation for, treatment, 417 and, differentiation, 415 blood-, 386 carcinomatous degeneration, 398 dermoid, 401, 408, 409 malignant changes, 403 parthenogenesis, 405 diagnosis, 415 diastasis of recti muscles and, differen- tiation, 416 everting, 389 fatty abdomen and, differentiation, 416 follicular, 381 implantation metastasis, 389 inverting, 389 monolocular, 388 multilocular, 388 operation for, 757 parvilocular, 388 856 INDEX Cysts of ovary, prognosis, 417 pseudomucinous, 388 origin of, 397 treatment, 391 rupture, 412 seed metastasis, 389 serous, 393 origin of, 396 symptoms, 412 torsion, 413 acute gonorrheal salpingitis and, dif- ferentiation, 207 treatment, 416 of parovarium, 418 treatment, 419 of vagina, 299 diagnosis, 300 etiology, 300 treatment, 301 of vulva, sebaceous, 225 parovarian, 418 treatment, 419 perineal, 301 sebaceous, of vulva, 225 theca-lutein, 387 tubo-ovarian, 198 Davenport's .treatment of dysmenorrhea, 521 Decidua, 47 ectopic, 509 Deciduoma maUgnum, 370 Defecation, pain on, 581 Defects, congenital, of uterus, 441 developmental, 436 of ovaries and tubes, 445 of vagina, 444 of bladder, 445 of development, 436 of urethra, 445 Degeneration, carcinomatous, of ovarian cysts, 398 of ovary, 254 cystic, 254, 383 as cause of sterility, 558 small, 254 of uterine myoma, 311. See also Myoma of uterus. race, as cause of sterility, 561 Denudation in plastic operations, 844 Dermatosis dysmenorrhoica symmetrica, 95 Dermoid cysts of Fallopian tubes, 421, 423 of ovary, 401, 408, 409 malignant changes, 403 parthenogenesis, 405 of parovarium, 419 Dermoid cysts of pelvic connective tissue, 425 treatment, 426 plugs, 402 Descent of ovaries, 440 of uterus, 457 Determination of sex, 68-72 Development, defects of, 436 Diarrhea at menopause, 102 during menstruation, 102 Diastasis of recti muscles, 500 operation for, 771-774 ovarian cyst and, differentiation, 416 treatment, 501 Diathermy in chronic pelvic inflammation with adhesions, 212 Diet in cystitis, 269 Digestion, parenteric, 110 Digestive disturbances at menopause, 102 system, condition of, during menstruation, 20 tract, relation of genitalia to, 100 Digital examination by vagina, 832 Dilatation of cervix, 591 Dionin in carcinoma of cervix, 361 Diphtheria and genitaha, relation between, 157 antitoxin in cystitis, 269 Diphtheric cystitis, treatment, 269 Discus proligerus, 34, 36 Dissection and ligation for hemorrhoids, 819 of ingmnal regions for carcinoma of cervix. Basset's method, 584, 585 Distoma haematobium of vulva, 238 Diverticula, intestinal, 277 acquired, 277, 278 congenital, 278 false, 278 true, 278 of urethral canal, 301 Diverticuhtis of colon, 277 etiology, 278 symptoms, 280 treatment, 280 of sigmoid, acute gonorrheal salpingitis and; differentiation, 207 Double bicornuate uterus with double vagina; 441 uterus, 442, 443, 444 Douglas' pouch, closure of, for rectocele. Graves' operation, 643 Drainage of bladder in cystitis, 270 vaginal, after supravaginal hysterectomy 723 Dudley's method of vaginal cystostomy 815 operation for anteflexion of \iterus, 694 INDEX 857 Dudley's operation for dysmenorrhea, 520, 521, 694 Dwarf uterus, 554 Dwarfism from hyperfunction of hypophysis, 78 Dysfunction of glands of internal secretion, 45 Dysmenorrhea, 515 acquired, 515 essential, 122, 515 Davenport's treatment, 521 Dudley's operation, 520, 694 etiology, 515 malposition of uterus and, relation, 517 nasal treatment, 520 Pfannenstiel's operation, 521 Pozzi's operation, 521, 693 symptoms, 519 treatment, 519 nasal, 520 orthopedic, 521 surgical, 520 in retroversion of uterus, 464 influence of cocainizing nasal mucous mem- brane on, 100 membranous, 522 diagnosis, 523 etiology, 523 prognosis, 523 symptoms, 523 treatment, 523 nasal, 517 neuroses from, 122 ovarian, 517 extract in, 519 secondary, 515 vicarious, 113 Dyspareunia, 534 causes, 138-140 Dyspitmtarism, 78 Dyspnea as result of large pelvic tumors, 135 Ear, relation of genitaha to, 99 Echinococcus cyst of vulva, 292 Eclampsia and parathyroids, relation be- tween, 84 Ectopic decidua, 509 pregnancy, 506 acute gonorrheal salpingitis and, diiTer- entiation, 207 diagnosis, 512 etiology, 506 hematocele in, 508, 511, 512 hematoma in, 508 hematosalpinx in, 508 metrorrhagia in, 576 pain in, 510, 511, 512, 577 Ectopic pregnancy, pelvic hematocele in, 508 rupture in, 508 treatment, 513 symptoms, 510 treatment, 513 uterine bleeding in, 508, 509, 511 Ectropion of cervix, 336, 341 of urethral mucous membrane, 545 treatment, 547 Eczema associated with pelvic diseases, 96 climacteric, 96 intertrigo of vulva, 225 Edema of skin associated with menstruation and climacteric, 96 Edematous degeneration of uterine myoma, 311 Effluvium seminis as cause of sterility, 555 Ekehorn's operation for rectal prolapse, Tuttle's modification, 817 Electricity in chronic pelvic inflammation with adhesions, 212 in dyspareunia, 535 in papilloma of bladder, 428 in stricture of urethra, 262 in urethral caruncle, 294 Elephantiasis in Southern negroes, 230 of vulva, 230 Elongation of cervix in procidentia of uterus, 477 of uterus, 458 Elting's operation for anal fistula, 282, 827 EmboHsm, postoperative, 118 Embryologic development of genital organs, 436 of ovaries, 439 of uterus, 436 of vagina, 436 Emmet's denudation of tissues with scissors, 845 operation for complete laceration of peri- neum. Graves' modification, 647 for laceration of perineum, 497 Graves' modification, 625 for rectocele, Graves' modification, 625 . of tracheoplasty, 487, 593 perineoplasty. Graves' modification, 625 Emphysematous vaginitis, 239 Enchondroma of vulva, 292 Endemic cretinism, 83 Endocervicitis, 241 as cause of sterility, 557 treatment, 564 curetage of cervix for, 593 gonorrheal, 189 chronic, 190 treatment, 191 858 INDEX Endocervicitis, Schroder's operation, 604 symptoms, 242 treatment, 242 Endocervix, gonorrheal inflammation, 189 leukorrhea from, 191 Endometritis, 242 as cause of steriHty, 557 chronic interstitial, 247 dysmenorrhoica, 516 exfoliative, 522 fibrinous, 523 gonorrheal, 192, 245 infectious, 244 treatment, 246 interstitial, chronic, 247 radium in, 528 postmenstrual necrobiotic, 248 radiiim in, 531 tubercular, 219 Endometrium, adenocarcinoma of, 362 adenoma of, 250 gland hyperplasia, cancer of uterus and, differentiation, 368 gland hypertrophy, 249 treatment, 251 gonorrheal inflammation, 192 hj^ertrophy, 249 treatment, 251 infections of, 244 inflammation of, 242 menstruating, physiologic anatomy, 24 polypoid gland hypertrophy, 250, 574 polyps of, 333, 334 sarcoma of, 329 tuberculosis of, 219 Endosalpingitis, gonorrheal, 193 tubercular, 216, 217 EndotheUoma of FaUopian tubes, 421 of ovary, 411 of rectum, 430 Enteroptosis, 158 acquired, 161 Beyea's operation for, 165 Coffey's operation for, 165 congenital, 162 diagnosis, 164 etiology, 158 predisposing, 160 Graves' operation for, 167 Lane's operation for, 165 mid-line, 160 Rovsing's operation for, 165 symptoms, 163 treatment, 164 gynecologic, 166 me'dical, 164 Enteroptosis, treatment, neurologic, 167 orthopedic, 164 surgical, 165 Wihns' operation for, 165 Enterovesical fistula, 499 Epinephrin, 85, 86 Epiphysis, internal secretory action of, 90, 91 relation of, to genitalia, 90 Epispadias, 446, 449 treatment, 449 Epistaxis during menstruation, 21 Epithelial layer of primordial follicle, 33 Epithehoma of cervix, 335, 336 of rectimi, 430 of vulva, 289 Epithehum, germinal, 436 of ovary, 31 peritoneal, destruction of, 152, 153 bacterial infection as cause, 153 Epoophoron, 439 Ergot in menorrhagia due to uterine fibroids, 325 in postpartum hemorrhage, 79 Erosio virginis, 570 Erosion of cervix, 241, 336, 341, 485 operative treatment, 593 Erysipelas and menstruation, relation be- tween, 96 Essential dysmenorrhea, 122, 515. See also Dysmenorrhea, essential. symptoms, 568 Esthiomene of vulva, 229 treatment, 230 Ether pneumonia, 103 rash, 97 Eimuch, characteristics of, 52, 53, 76 Eversion of cervix, 336 operative treatment, 593 Ewin perineal sheet, directions for making, 843 Examination of patient, 831 in private house, 834 Exanthemata, menstrual, 95 ExfoUative cystitis, 265 endometritis, 522 Exophthalmic goiter, 81 at climacteric, 81 question of marriage and reproduction in, 82 Exstrophy of bladder, 446, 447 treatment, 449 Extirpation of kidney, 803 for injury of ureter, 813 Extra-uterine pregnancy, 506. See also Ectopic pregnancy. Extravasation of blood, leukocytosis after, 109 INDEX 859 Extravasation of blood, regeneration of blood after, 109 Eyes, condition of, during menstruation, 21 hemorrhage of, puerperal sepsis as cause, 99 relation of genitalia to, 98 Face, hair on, in middle age, 23 Facies, ovarian, 412 Fallopian tubes, absence, 445 adenomyoma, 421 atrophy, 541 carcinoma, 420. See also Carcinoma of Fallopian tubes. chorio-epithelioma, 421 condition of, during menstruation, 20 cysts, 421 defects, developmental, 445 dermoid cysts, 421, 423 endothelioma, 421 fibroma, 421 fibromyoma, 421 fibromyxoma cystosum, 421 gonorrheal inflammation, 192 in infantilism as cause of sterility, 553 isthmus of, gonorrheal infection, 198 lymphangioma, 421 mucous polyps, 421 myosarcoma, 423 operations on, 757 papilloma, 421 sarcoma, 421 Taussig's operation for sterilization of, 762 tuberculosis, 216 tumors, 420 False vaginismus, 533 Fascia, retrorenal, 799 transplantation of, for postoperative hernia, 782 Bartlett's method, 783 Shaw's principles of technic, 786 Fat, accumulation of, after removal of ovaries, 52, 53, 54 Fatty abdomen, ovarian cyst and, differen- tiation, 416 degeneration of uterine myoma, 315 tumors of vulva, 287 Femoral hernia, Moschowitz's operation for, 787 Fetalism as cause of sterihty, 560 Fibrinous endometritis, 523 Fibro-adenoma of parovarium, 419 Fibroids, menorrhagia of, radium in, 529 of uterus, 307. See also Myoma of uterus. Fibroma molluscum pendulum of vulva, 287 of Fallopian tubes, 421 Fibroma of ovary, 407 ascites from, 410 of pelvic connective tissue, 423, 424 of vulva, 286 treatment, 287 retroperitoneal, 424 Fibromyoma of broad ligament, 424 of Fallopian tubes, 421 of infundibulopelvic ligament, 425 of pelvic connective tissue, 423, 424 of round ligament, 424 of uterus, 307. See also Myoma of uterus. of vagina, 304 of vulva, 286 Fibromyxoma cystosum of Fallopian tubes, 421 Fibrosarcoma of ovary, 410 Fissure in ano, 282 treatment, 283 of bladder, inferior, 449 superior, 448 Fistula, enterovesical, 499 in ano, 281 Elting's operation for, 282, 827 Graves' operation for, 824-827 operations for, 824 treatment, 282 intracervical, 498 operation for, 659 juxtacervical, 498 operation for, 659 rectovaginal, operation for, 652, 653 ureteral, formation of, 814 urethrovaginal, 498 uterovesical, operation for, 659 vesical, 498 diagnosis, 499 operations for, 653 symptoms, 499 treatment, 499 vesicocervicovaginal, 498 operation for, 659 vesico-uterine, 498 operation for, 659 vesicovaginal, 498 Braquehaye's operation, 657 Albarran's modification, 657, 659 operations for, 653 Sims' operation, 653 Flatus vaginalis, 240 Flexion of uterus, lateral, 455 Floating kidney, 167 Fluid material, absorption of, in peritoneal cavity, 152, 153 Flushes, hot, after ovariectomy, 128 Fold, bloodless, of Treves, 172 860 INDEX Fold, genitomesenteric, of Reid, 173 parietocolic, of Jonnesco and Juvara, 172 Follicles, Graafian, 32, 37 apparatus as organ of internal secretion, 46 atresia of, 40, 382 cystic, 42 during pregnancy, 41 manner of taking place, 41 obliterating, 42 bursting of, internal force for, 37 cyst of, 381 developing and ripening of, by ovary, 32 ripening of, 33 primordial, 33 epithelial layer of, 33 Foot strain, 156 Formalin in pyelitis, 277 Freud's theory of infantile sexuaUty, 130-134 Frying pan incision, Kelly's, for nephrec- tomy, 804 Functional amenorrhea, 572 incontinence of urine, Kelly's operation, combined with Graves' anterior col- poplasty, 615 menorrhagia, 524 Fungus of vagina, 238 Furunculosis of external genitalia, 96 of vulva, 225 Gall-bladder, operation on, during pelvic operation, 149 relation of genitaha to, 147 strawberry mottling of, 150 GaU-stones, 148 operation for, during pelvic operation, 149, 150 symptomless, 148 treatment, 148-150 Gamma ray, 349 Gangrene of bladder, 265 Garruhtas vaginae, 240 Gartner's duct, 439 Gas, expulsion of, from vagina, 240 Gelatin solution in hemophiha, 107 Genital atrophy, 540. See also Atrophy, genital. herpes, 96 neurosis, 124 of imagination, 124 of overvaluation, 124 treatment, 127 psychoneuroses, 124 treatment, 127 spot, 100, 517 tuberculosis, 215 Genital tuberculosis as cause of sterihty, 558 Genitaha, deficient circulation of, ovarian ex- tract in, 65 eczema of, 96 effect of removal of, hypophysis on, 76 embryologic development, 436 external, condition of, during menstrua- tion, 20 furunculosis of, 96 Genitomesenteric fold of Reid, 173 Germ-cells, 439 Germinal epithehum, 436 of ovary, 31 Gerota's capsule, 799 Giantism from hyperfunction of hypophysis, 77 Gilliam's operation for retroversion of uterus, 467, 680 Kelly's modification, 685 Mayos' modification, 683 Simpson's modification, 681 Gland, carotid, 85 h>"perplasia of endometrium, cancer of uterus and, differentiation, 368 hypertrophy of endometrium, 249 treatment, 251 polj-poid, of endometrium, 250, 574 radium in, 527 interstitial, 387 Glands of internal secretion, dysfunction of, 45 hjTDerfunctional changes in, 45 hypofunctional changes in, 45 relationship of gynecology to, 44 of ovary to, 46 Glandular ducts of ovary, 32 Gl^nard's disease, 158. See also Entewp- tosis. Glycerin and ichthyol in chronic pelvic in- flammation, 212 in vaginitis, 238 Glycogen production from uterine mucosa, 30 Goffe's operation for prolapse of uterus, 706 Goiter during labor, 81 during menstruation, 80 during pregnancy, 80, 81 exophthalmic, 81, 82 at menopause, 81 question of marriage and reproduction in, 82 Gonococcus, 177 clinical peciiharities, 177 latent power, 178 Gonorrhea, 177, 181 in children, 179 serum treatment, 214 INDEX 861 Gonorrhea, vaccine treatment, 214 Gonorrheal barthoUnitis, 184 treatment, 185 cystitis, 264, 274 treatment, 269 endocervicitis, 189 chronic, 190 treatment, 191 endometritis, 192, 245 endosalpingitis, 193 hematosalpinx, 198 hydrosalpinx, 196 inflammation of Bartholin's glands, 184 treatment, 185 of endocervix, 189 chronic, 190 treatment, 191 of endometrimn, 192 of FaUopian tubes, 192 of Skene's glands, 183 metritis, 251 oophoritis, 253 parametritis, 258 peritonitis, 153 pyosalpinx, 194 salpingitis, 192. See also Salpingitis, gonorrheal. tubo-ovaritis, 195 urethritis, 181 cystitis and, differentiation, 266 stricture of urethra as result, 183 symptoms, 182 treatment, 183 vulvitis, 179 vulvovaginitis in children, 179 treatment, 180 Gonorrhoea isthmica nodosa, 198 Graafian follicle, 32, 37 apparatus as organ of internal secretion, 46 atresia of, 40, 382 cystic, 42 during pregnancy, 41 manner of taking place, 41 obhterating, 42 bursting of, internal force for, 37 cyst of, 381 developing and ripening of, by ovary, 32 ripening of, 33 Grafting, omental, after myomectomy, 753 Grape-mole sarcoma of uterus, 329 Graser's operation for umbilical hernia, 781 Graves' disease. See Exophthalmic goiter. method of anterior colpoplasty, 608 of making artificial vagina, 667 Graves' modification of Emmet's operation for laceration of perineum, 625 for rectocele, 625 of Olshausen's operation for retroversion of uterus, 678 operation for anteflexion of uterus, 695 for closure of Douglas' pouch in recto- cele, 643 for complete laceration of perineum, 647 for cystocele, 608 for diastasis of rectus muscles, 771 for enteroptosis, 167 for fistula in ano, 824-827 for postoperative hernia, 782 for procidentia of uterus, 696 for umbilical hernia, 775 technic in application of radium in carci- noma of cervix, 792 Gynatresia, 535 diagnosis, 539 etiology, 536 hematocolpos in, 538 hematometra in, 538 hematosalpinx in, 538 treatment, 539 operations for, 665 symptoms, 537 treatment, 539 Gynecologic diseases, non-maUgnant, radium in, 525-533 after-care, 532 details of treatment, 531 dosage, 531 selection of cases, 526 operations, lung compUcations after, 103 Hair on face in middle age, 23 Hamamelis in menorrhagia due to uterine fibroids, 325 suppositories in hemorrhoids, 434 Headache during menstruation, 20 Hearing during menstrviation, 21 Heart, anemic, 114 at menopause, 114 at puberty, 113 changes in, associated with uterine fibroids, 115 from hemorrhage from pelvic disease, 114 during cohabitation, 113 lesions associated with uterine myoma, 322 mj'^oma of, 115, 322 relation of genitalia to, 113 Heat in acute cystitis, 269 treatment of carcinoma of cervix, 360 Hegar's operation for amputation of cervix, 599, 604 862 INDEX Helmitol in cystitis, 269 Hematocele in ectopic pregnancy, 508, 511, 512 pelvic, in ectopic pregnancy, 508 Hematocolpos in gynatresia, 538 Hematogenous cystitis, 264 Hematoma in ectopic pregnancy, 508 parametrial, 260 parametritis and, differentiation, 259 treatment, 261 Hematometra, 444 in guinea-pigs, production of, by injection of ovarian extract, 65 in gynatresia, 538 Hematosalpinx, gonorrheal, 198 in ectopic pregnancy, 508 in gynatresia, 538 treatment, 539 Hemophilia, 106 familial type, 106 sporadic type, 107 treatment, 107 Hemorrhage from pelvic disease, changes in heart muscle from, 114 in carcinoma of cervix, 342 of rectum, 429 of uterus, 366, 367 in cervical polyp, 333 in chorio-epithelioma malignum, 376 in guinea-pigs, production of, by injection of ovarian extract, 65 in procidentia of uterus, 478 in tumors of bladder, 428 intestinal, at menopause, 102 of eye, puerperal sepsis as cause, 99 postpartum, pituitrin in, 79 regeneration of blood after, 103 uterine. See Metrorrhagia. Hemorrhagic metropathies, vaporization in, 548 Hemorrhoids, 432 Allingham's operation for, 819 bleeding, during menstruation, 102 clamp and cautery operation for, 822 diagnosis, 434 dissection and ligation for, 819 etiology, 433 external, 433 internal, 433 interno-external, 433 operations for, 819 relation of, to pregnancy and labor, 144 thrombotic, 433 treatment, 434 Whitehead's operation for, 819 Hermaphroditism, 71, 72, 451 Hermaphroditism, glandular, 72 Hernia, abdominal, 500 operation for, 775 femoral, Moschowitz's operation for, 787 - postoperative, 503 diagnosis, 504 Graves' operation for, 782 transplantation of fascia for, 782 Bartlett's method, 783 treatment, 504 shding, 432 umbihcal, 502 Graser's operation for, 781 Graves' operation for, 775 Mayos' operation for, 781 Herpes, genital, 96 menstrual, 95 sexualis, 95 vesicae, 265 Heterosexual type and early ovariectomy, 52 Hitschmann and Adler on cyclic changes in uterine mucosa, 24 Hormones, 44 Horn, rudimentary, of uterus, 444 Hot flushes after ovariectomy, 128 after radium treatment, 532 House, private, examination of patient in, 834 Hyaline degeneration of uterine myoma, 311 Hydatid mole, 374 theca-lutein cysts associated with, 387 Hydatids of Morgagni, 421 Hydrastis in monorrhagia due to uterine fibroids, 325 Hydrocele muliebris, 292 Hydrometra, 364 due to closure of cervical canal, 544 Hydrops tubse profluens, 569 Hydrosalpinx, 211 congenital, 218 gonorrheal, 196 Hydrotherapy in enteroptosis, 164 Hymen, atresia of, 536 treatment, 539 intra-uterine closure, 536 Hyperanteflexion of uterus, 455 Hjrperfunction of hypophysis, acromegaly from, 77 giantism from, 77 of ovary, 56 of suprarenals, 88 Hjrperfunctional changes in glands of internal secretion, 45 Hyperleukocytosis and infection, relation be- tween, 107 and inflammation, relation between, 107 INDEX 863 Hyperleukocytosis, postoperative, 109 Hypernephroma as cause of precocious sexual development, 89 Hyperpinealism, 90 Hyperpituitarism, 77, 78 Hyperplasia, gland, of endometrium, cancer of uterus and, differentiation, 368 Hypersecretion of ovary, 56 uterine bleeding from, 57, 58 Hyperthyroidism. See Exophthalmic goiter. Hypertrophic changes in uterus before and after birth, 17 Hypertrophy, gland, of endometrium, 249 treatment, 251 radium in, 527 of cervix after lacerated cervix, 485 of clitoris, 295, 296 of suprarenal gland after ovariectomy, 89 pigment, and functions of pelvic organs, rleation between, 96 polypoid gland, of endometrimn, 250, 574 Hypofunction of hj^Dophysis, 78 dwarfism from, 78 of ovary, 51 infantilism and, relation between, 55 Hypofunctional changes in glands of internal secretion, 45 Hypophysis, anatomic structure of, 73 changes in, due to castration, 51, 52 effect of, on genitalia, 77 in pregnancy, 76 diseases of, as cause of sterility, 560 effect of ovariectomy on, 76 extract of, value of, 74, 78, 79 hyperfunction of, acromegaly from, 77 giantism from, 77 hypofunction of, 78 dwarfism from, 78 relation of ovaries to, 77 to genitalia, 73, 74 removal of, effect of, 74 on genital organs, 76 on pregnancy, 76 Hypoplasia of ovary, infantiUsm and, rela- tion between, 55 Hypoplastic constitution, 55 Hypospadias, 445 Hypothyroidism, 82 Hysterectomy, 713 complete, 724 steps of operation, 728 for uterine myoma, 325 in hemophilia, 107 neuroses after, 128 ovarian extract after, 64 procidentia after, 477 Hysterectomy, psychoneuroses after, 128, 129 supravaginal, 713 vaginal drainage after, 723 transplantation of ovarian tissue after, 766 vaginal, 728 for carcinoma of cervix, 744-750 Hysterostomatocleisis, 662 Hysterotomy in uterine insufficiency, 549 IcHTHYOL in postoperative phlebitis, 118 in pruritus of vulva, 236 in vaginitis, 238 Ileopelvic band, 173 Imperforate anus, 449 Impregnation, artificial, in sterility, 566 Incision, apron, in fistula in ano, 825 Bardenheuer's, 768 for major operations on kidney, 803 for nephrectomy, 803 for suspension and minor operations on kidney, 796 Kelly's frying pan, for nephrectomy, 804 Pfannenstiel's, 769 transverse, in pelvic operations, 768 Incontinence of urine, functional, Kelly's operation, combined with Graves' anterior colpoplasty, 615 operation for, 614 Infantile myxedema, 82 ovaries, 551 sexuahty, 130 masturbation in, 132, 133 onanism in, 132, 133 second period of, 133, 134 thumb-sucking as manifestation, 131 uterus, 553 Infantihsm, 549, 550 as cause of sterility, ovaries in, 551 tubes in, 553 uterus in, 553 etiology, 550 hjrpofunction of ovary and, relation be- tween, 55 hypoplasia of ovary and, relation between, 55 of uterus, 480 psychic, 137 Infection and hyperleukocytosis, relation be- tween, 107 and leukocjrtosis, relation between, 107 external, resistance of peritoneum to, 152 of endometrium, 244 of metrium, 251 of ovary, 252 of uterine myoma, 320 of uterus, 251 864 INDEX Infection, value of omentum in walling off and localization of, 151 Infectious diseases, acute, acute septic vagi- nitis after, 157 relation of genitalia to, 157 endometritis, 244 treatment, 246 metritis, 251 oophoritis, 252 chronic, 253 etiology, 254 symptoms, 254 treatment, 255 Inflammation and hj^jerleukocytosis, relation between, 107 gonorrheal, of Barthohn's glands, 184 treatment, 185 of endocervix, 189 of endometrimn, 192 of Fallopian tubes, 192 . of Skene's glands, 183 of urethra, 181 of bladder, 262 in old women, 272 of colon, 277 of endometriima, 242 of large intestine, 277 of ovary, 252 of parametrium, 255 of pelvic cellular tissue, 256. See also Paravietritis. of pelvis of kidnej^, 273 of peritonemn, pain from, 578 of uterus, 251 gonorrheal, 251 infectious, 251 tubercular, 251 of vagina, 236 of vulva, 224 ■ pelvic, chronic, as result of gonorrheal sal- pingitis, 202, 209. See also Pelvic inflam77iation, chronic. relation of, to retroversion and retro- flexion of uterus, 283 menorrhagia of, radium in, 530 Inflammatory processes, general, 224 stricture of rectum, 283 treatment, 285 Influenza and genitalia, relation between, 157, 158 Infundibulopelvic ligament, fibromyoma, 425 Inguinal regions, dissection of, for carcinoma of vulva, Bassett's method, 584, 585 Injuries due to childbirth, 485 Insanity, influence of menstruation on, 124 Internal secretion, effect of nervous system upon, 44, 45 glands of, dysfunction of, 45 hyperfunctional changes in, 45 hypofunctional changes in, 45 relationship of gynecology to, 44 of ovary to, 46 secretory function of suprarenal system, 85 Interposition operation in prolapse and proci- dentia of uterus, 479, 699 Interstitial cells as producers of internal se- cretion, 49 existence of, 48 growth of, 50, 51 origin of, 48, 49 endometritis, radium in, 528 gland, 42, 387 and corpus luteum, reciprocal relation- ship between, 50 pregnancy, 506 symptoms and course, 513 Intestinal bands, 172 attic adhesions, 173 bloodless fold of Treves, 172 diagnosis, 176 genitomesenteric fold of Reid, 173 ileopelvic, 173 Jackson's membrane, 172 Lane's kink, 173 origin, 173 parietocohc fold of Jonnesco and Juvara, 172 points of formation, 175 s5T2iptoms, 175 treatment, 176 diverticula, 277. See also Diverticula, in- testinal. hemorrhage at menopause, 102 stasis, 158, 163 Intestine, large, inflammation of, 277 relation of genitalia to, 142, 144 Intra-abdominal bands, 172. See also Intes- tinal bands. Intracervical fistula, 498 operation for, 659 Intraligamentary fibroid, 310 Intra-uterine closure of hymen, 536 Inversion of uterus, 458, 482 complete, 482 conservative operation, 710 diagnosis, 483 incomplete, 482 Ktistner's operation, 710 myoma and, differentiation, 483 onkogenetic, 482 Spinelli's operation, 711 INDEX 865 Inversion of uterus, symptoms, 483 treatment, 483 Invertent carcinoma of cervix, 336, 338 lodin in carcinoma of cervix, 362 in cervicitis, 242 in chronic pelvic inflammation, 212 in condyloma acuminata of vulva, 228 in endocervicitis, 242 in gonorrheal inflammation of Skene's glands, 184 in membranous dysmenorrhea, 523 in pruritus of vulva, 236 in vaginitis, 238 Ischiorectal abscess, 280 Ischuria paradoxa, 142 Jackson's membrane, 172 Joints, relation of genitalia to, 156 Jonnesco and Juvara, parietocolic fold of, 172 Jux-tacervical fistula, 498 operation for, 659 Kaolix poultices in postoperative phlebitis, 118 Katz's theor}' of cause of ectopic pregnancy, 507 Kelly's frying pan incision for nephrectomy, 804 method of suprapubic c3^stotomy, 815 of vaginal cystostomy, 816 operation for functional incontinence of urine, combined with Graves' anterior colpoplasty, 615 for retroversion of uterus, 685 in uterine insufficiency, 549 technic of suspension of kidney, 800 Kidney, abscess of, 273 extirpation of, 803 for injury of ureter, 813 floating, 167 mode of entrance of bacteria to, 273 movable, 167 and appendicitis, association, 170 and movable cecum, influence between, 169 diagnosis of, 170 etiology of, 167 pyelography as aid in diagnosis, 171 symptoms, 169 treatment, 171 ■ operations on, 796 major, incision for, 803 minor, 796 incision for, 796 pelvis of, inflammation, 273 removal of, 803-809 55 Kidney, suppurating, 273 suspension of, 796 Kelly's technic, 800 tumors of, ovarian tumors and, differen- tiation, 415 Kink, Lane's, 173 Knee-chest position, 834 Kram-osis of vulva, 232 radium in, 531 treatment, 233 Kristeller, 565 Kronig's modification of Sampson's method of ureterovesical transplantation, 813 operation in carcinoma of cervix, 361 Krukenberg's tumor, 407 Klistner's operation for inversion of uterus, 710 Labia majora, atrophy, 542 minora, atrophy, 542 Labor, appendicitis during, 147 goiter during, 80 Laceration of cervix, 485 carcinoma and, differentiation, 486 diagnosis, 486 Emmet's operation, 487, 593 hypertrophy after, 485 metrorrhagia in, 516 operative treatment, 593 symptoms, 486 treatment, 487 of perineum, 490 Clark's operation for, 633 complete, Clark's operation for, 636 Emmet's operation. Graves' modifica- tion, 647 Graves' operation, 647 operation for, 647 Warren's operation, 652 diagnosis, 497 during labor, 494 effect of, 493-495 Emmet's operation, 497 Grave's modification, 625 Studdiford's operation, 638 symptoms, 496 treatment, 497 Lactation, condition of uterus during, 543 sterility, 560 Lactation-atrophy, 543 of ovaries, 56 Lane's kink, 173 operation for enteroptosis, 165 Langhans' cells, 372 layer, 372 Layer, compact, of uterine mucosa, 26 866 INDEX Layer, epithelial, of primordial follicle, 33 Langhans', 372 medullary, of ovary, 32 parenchymatous, of ovary, 32 spongy, of uterine mucosa, 26 Lead-and-opium lotion in postoperative phle- bitis, 118 Leg, milk-, 116, 257 Legs, pain in, 581 varicose veins of, 119 Mayos' operation for, 729 operations for, 728 Leiomyoma of uterus, 307. See also Myoma of uterus. Length of stay in bed in abdominal opera- tions, 842 Leukocytosis after blood extravasation, 109 and infection, relation between, 107 in absorption of products of degeneration in necrotic tissue, 109 postoperative, 109 Leukoplakia of vulva, 234 Leukorrhea, 568 following radium treatment, 532 from endocervix, 191 in carcinoma of cervix, 342, 570 following radium treatment, 359, 360 in cervical polj^ps, 333 in chronic endometritis, 192 gonorrheal endocervicitis, 191 pelvic inflammation, 209 in endocervicitis and cervicitis, 242 in erosion of cervix, 241 in gland hypertrophy of endometrium, 251 in retroversion of uterus, 464 in stenosis of vagina, 537 in tubercular endometritis, 220 in vaginitis, 237, 238 Levator ani muscle, 490 Leydig, cells of, 48 Ligament, appendiculo-ovarian, 145, 173 broad, fibromyoma of, 424 varicose veins in, 119 infundibulopelvic, fibroma of, 425 round, adenomyoma of, 423 fibromyoma of, 424 tumors of, 422 treatment, 423 Ligation of proximal end of ureter, 813 Lipoma of pelvic connective tissue, 425 of vulva, 287 retroperitoneal, 425 Liquor folHculi, 34 Loins, pain in, 580 Lumbar pain, 580 trigonum, superior, 798 Lung complications after gynecologic opera- tions, 103 tuberculosis of, influence of menstruation on, 104 Lupus of vulva, 220 Lutein cells, 39 Lymphangioma of Fallopian tubes, 421 Lymph-glands, infection of, in carcinoma of cervix, 346 of peritoneum, 151 Lymphosarcoma of uterus, 330 Ljoich's thyrotome in stricture of rectum, 285 Malaria and metrorrhagia, relation between, 158 Malignant chorio-epithelioma, 370 degeneration of uterine fibroids, 317, 329, 331 Malposition of uterus, 453 as cause of sterility, 558 treatment, 561 backache in, 579 dysmenorrhea and, relation, 517 operations for, 678 Malthusian doctrine, 560 Mammary extract in menorrhagia, 94 in uterine bleeding, 94 glands. See Breasts. Mammin in menorrhagia, 94 in uterine bleeding, 94 Marchant's operation for rectal prolapse, 817 Mascuhne type, reversion to, during meno- pause, 23, 134 Masturbation, 132, 134-138 early, influence of, on character, 136 excessive, in child, 135 in matured women, 137 second stage of childhood, influence of, on character, 132 uninhibited, 135 Maternal placenta, 47 Maturity, ovariectomy after, 53 before, 51 Mayos' operation for prolapse and prociden- tia of uterus, 709 for retroversion of uterus, 683 for umbilical hernia, 781 for varicose veins, 829 Medullary layer of ovary, 32 Melanosarcoma of uterus, 330 Membrana granulosa, 34 Membrane, Jackson's, 172 Membranous dysmenorrhea, 522. See also Dysmenorrhea, membranous. Menopause, age occurring, 19 INDEX 867 Menopause, atrophy of ovaries as cause of changes during, 23 constipation at, 102 constitutional changes during, 22 diarrhea at, 102 digestive disturbances at, 102 disturbances of, placental extracts in, 65 eczema of, 96 exophthalmic goiter at, 81 heart at, 114 influence of climate on, 19 on thyroid, 81 intestinal hemorrhage at, 102 loss of ovarian secretion as cause of changes during, 23 menorrhagia at, causes, 22 nasal catarrh at, 100 nervous symptoms of, 128, 129 nose during, 99 obesity during, 23 physical changes during, 22 psychic disturbances during, 22 psychoneuroses of, 129 reversion to masculine type during, 23, 134 sexual impulse just before, 23 vasomotor disturbances of, 114, 129 Menorrhagia, 572 appearance of blood after, 109 at menopause, causes, 22 causes, 574 from uterine fibroids, 322 treatment, 325 functional, 524 in gland hypertrophy of endometrium, 251 in retroversion of uterus, 464 mammary extract in, 94 neuroses from, 123 of fibroids, radium in, 529 of pelvic inflammation, radium in, 530 of youth, 524 radium in, 528 thyreopriva, 80 Menstrual blood, amount lost, 20 non-coagulability of, 20, 105 changes in skin, 95 exanthemata, 95 exfohation of uterine mucosa, 522 herpes, 95 salivation, 100 Menstruating endometrium, physiologic anat- omy, 24 Menstruation, abnormaUties of, 571 age occurring, 18 amount of blood lost during, 20 and acne, relation between, 96 Menstruation and chronic appendicitis, rela- tion between, 146 and erysipelas, relation between, 96 and ovulation, time relation between, 58, 59 bleeding hemorrhoids at, 102 blood during, 105 cessation of, 19, 22 condition of breasts during, 20 of circulatory system in, 21 of digestive system during, 20 of external genitals during, 20 of eyes during, 21 of Fallopian tubes during, 20 of nervous system during, 20 of ovaries during, 20 of skin during, 21 of uterus during, 20 congestion of pelvic blood-vessels during, 20 diarrhea during, 102 disturbances of, in chronic pelvic inflam- mation, 210 , in ovarian tumors, 414 in retroversion of uterus, 464 of mouth during, 100 of stomach and, relationship, 100, 101 duration of, 19, 20 effect of climate on occurrence of, 18, 19 of social conditions on occurrence of, 19 enlargement of breast during, 18 of thyroid gland in, 20 epistaxis during, 21 establishment of, 18 factors which influence, 18 goiter during, 80 headache during, 20 hearing during, 21 herpes, 95 increased activity of parotid glands during, 100 influence of disturbed psychic states on, 123 of nervous shock on, 123 of psychic excitement on, 21 on insanity, 124 on mental diseases, 123 on nervous diseases, 120, 123 on tuberculosis of lungs, 104 irregularity of, 19 neuroses from, 122 molimina of, 571 myoma of uterus and, relation, 323 non-coagulability of blood of, 105 nose during, 99 nose-bleed during, 21 Ott's curve, 121 INDEX Menstruation, pains of, 21, 580. See also Dysmenorrhea. pelvic discomfort during, 20 performing pelvic operations during, 22 phsyiology of, 18 precocious, 21 in infants, 18 sense of well-being during, 20 sexual impulse during, 21 suicide during, 123 tubal, 30 vasomotor disturbances during, 21 vicarious, 21 skin lesion from, 96 vocal cords during, 21, 104 voice during, 21, 104 wave theory, 120 Mental diseases, influence of menstruation on, 123 Mercury, bichlorid of, in pyelitis, 277 Mesothorium in carcinoma of cervix, 348 Metritis, 251 gonorrheal, 251 infectious, 251 tubercular, 251 Metropathies, hemorrhagic, vaporization in, 548 radium in, technic, 795 Metrorrhagia, 575 and malaria, relation between, 158 appearance of blood after, 109 from arteriosclerosis, 115, 116 from hypersecretion of ovary, 57, 58 from uterine fibroids, 322 treatment, 325 in carcinoma of cervix, 576 of uterus, 576 in cervical poljqjs, 576 in chorio-epithelioma malignum, 575 in extra-uterine pregnancy, 508, 509, 511, 576 in lacerations of cervix, 576 in sarcoma of uterus, 331 mammary extract in, 94 Micturition, painful, 581 Mid-line abdominal ptosis, 160 Milk-leg, 116, 257 Mole, hydatid, 374 theca-lutein cysts associated with, 387 tubal, 508, 511 Molimina of menstruation, 571 Morgagni, hydatids of, 421 Morphin in carcinoma of cervix, 361 suppositories in hemorrhoids, 434 Moschowitz's operation for femoral hernia, 787 Moschowitz's operation for rectal prolapse, 817, 818 Mouth, disturbances of, during menstrua- tion, 100 Movable cecum and movable kidney, in- fluence between, 169 kidney, 167 and appendicitis, association, 170 and movable cecum, influence between, 169 diagnosis, 170 etiology, 167 pyelography as aid in diagnosis, 171 symptoms, 169 treatment, 171 Mucosa, uterine, compact layer, 26 cyclic changes in, 24 glycogen production from, 30 menstrual flow and, 28 postmen strual involution of, 28 premenstrual congestion of, 24 spongy layer, 26 Mucous polyps of Fallopian tubes, 421 of vestibule, 293 Miifler's ducts, 436, 441 failure of union, results of, 441 Muscles, recti, diastasis of, 500 operation for, 771-774 treatment, 501 Myoma, ball, of uterus, 310 cervical, 310, 311 heart, 115, 322 of uterus, 307 adenocarcinomatous degeneration, 319 and menstruation, relation, 323 and pregnancy, relation, 322 and thyroid, relation between, 81 angiomatous degeneration, 315 as cause of sterility, 559 atrophy, 316, 317 ball, 310 calcification, 316 carcinoma and, differentiation, 323 associated with, 366, 367 • carcinomatous degeneration, 319 centrifugal, 308 centripetal, 308 changes in, due to passive congestion, 311 classification, 308 cystic degeneration, 314 degeneration, 311 diagnosis, 323 edematous degeneration, 311 etiology, 307 fatty degeneration, 315 frequency, 320 INDEX 869 Myoma of uterus, heart lesions associated with, 115, 322 . hyaline degeneration, 311 hysterectomy for, 325 in well-to-do, 342 infection, 320 interstitial, 309 intraligamentary, 310 intramural, 309 inversion and, differentiation, 483 malignant degeneration, 317, 329, 331 menorrhagia from, 322 treatment, 325 menstruation and, relation, 323 metrorrhagia from, 322 myomectomy for, 325 myxomatoid degeneration, 314 myxomatous degeneration, 313 necrosis of, 315 operations for, 750 pain from, 680 pregnancy and, differentiation, 324 relation, 322 red degeneration, 314, 316 regressive changes, 316 sarcomatous degeneration, 317, 329, 331 submucous, 310 subserous, 309 supravaginal hysterectomy for, 325 symptoms, 321 thrombotic degeneration, 314 treatment, 324 uterine hemorrhage from, 322 treatment, 325 vasomotor symptoms, 115 of vagina, 304 Myomectomy, abdominal, 750, 751 for uterine myoma, 325 omental grafting after, 753 operations, 750 vaginal, 756 Myomherz, 81 Myosarcoma of Fallopian tubes, 423 of uterus, 329 Myxedema, 82 congenital, 82 infantile, 82 postoperative, 82 Myxoma of vulva, 292 Myxomatoid degeneration of uterine myoma, 314 Myxomatous degeneration of uterine myoma, 313 Nabothian cysts, 191 Nasal catarrh at menopause, 100 Nasal dysmenorrhea, 517 mucous membrane, cocainizing, influence. of, on dysmenorrhea, 100 treatment of dysmenorrhea, 519 Necrosis of uterine fibroids, 315 Necrospermia, 556 Necrotic tissue, absorption of products of degeneration in, leukocytosis in, 109 Nephrectomy, 803-809 for injury of ureter, 813 in pyelitis, 277 in tuberculosis of bladder, 271 incision for, 803 Kelly's frying pan incision for, 804 Nephroptosis, 167. See also Movable kid- ney. Nephrotomy in pyelitis, 277 Nerves of peritoneum, 151 Nervous diseases, influence of menstruation on, 123 symptoms of menopause, 128, 129 system, condition of, during menstruation, 20 influence of menstruation on, 120 on internal secretion, 44, 45 relation of genitalia to, 120 Neuralgia, ovarian, 127, 255, 578 Neuroma of vulva, 292 Neurosis after hysterectomy and ovariec- tomy, 128 as result of masturbation, 136 of menstrual irregularities, 122 from amenorrhea, 123 from dysmenorrhea, 122 from menorrhagia, 123 genital, 124 of imagination, 124 of overvaluation, 124 treatment, 127 New growths. See Tumors. Newborn, atresia of hymen in, 536 sexual impulse in, 130 Nodular tubercular peritonitis, 221 Non-malignant gynecologic diseases, radium in, 525-533 after-care, 532 details of treatment, 531 dosage, 531 selection of cases, 526 Nose during menopause, 99 during menstruation, 99 relation of genitalia to, 99 vicarious menstruation from, 21 Nose-bleed during menstruation, 21 Nuck, canal of, cyst of, 292 870 INDEX Obesity as cause of sterility, 560 . during menopause, 23 Oil of copaiba in gonococcal cystitis, 269 of sandalwood in gonococcal cystitis, 269 Ointment, Crede's, in varicose ulcer, 830 scarlet, in varicose ulcer, 830 Oligomenorrhea, functional, ovarian defi- ciency and, 56 extract in, 65 of youth, 524 Olshausen's operation for prolapse of uterus, 474 for retroversion of uterus, 468 Graves' modification, 678 Omental grafting, 753 Omentum, absorbing power, 152 capacity of, to slip into defects of abdom- inal wall, 152 grafting of, after myomectomy, 753 physiology of, 150 protective power, 151 . relation of genitaUa to, 150 use of, in plastic operations, 152 value of, in walhng off and localization of infection, 151 Onanism, 131, 132. See also Masturbation. Onkogenetic inversion of uterus, 482 Oophorectomy. See Ovariectomy. Oophoritis, 252 gonorrheal, 253 infectious, 252 chronic, 253 etiology, 254 symptoms, 254 treatment, 255 interstitial, 252, 253 etiology, 254 symptoms, 254 treatment, 255 tubercular, 253 tubo-, chronic, 199, 200 Operations, abdominal, length of stay in bed, 842 preparation for, 835 support after, 842 suture materials, 838 technical detail, 836 treatment after, 840 on abdominal wall, 768 on bladder, 815 on cervix, 591 on Fallopian tubes, 757 on kidney, 796 major, incision for, 803 minor, 796 incision for, 796 Operations on ovaries, 764 on rectum, 817 on ureters, 810 on vagina, 608 on vulva, 582 plastic, after-care of, 845 ' care of stitches, 846 coaptation of wound edges, 845 denudation in, 844 preparation for, 842 stitch abscess in, treatment, 847 suture material, 844 technic of, 842 technical details, 843 Operative gynecology, 582 Osteoma of vulva, 292 Osteomalacia and ovaries, relation between, 156 and parathyroids, relation between, 84 Ott, curve of, 121 Ova, 439 Ovarian dysmenorrhea, 517 extract after hysterectomy, -65 dosage, 66 form used, 66 fresh, importance of, 66 in absence of ovarian secretion, 65 in amenorrhea of youth, 524 in deficient circulation of genitalia, 65 in dysmenorrhea, 519 in functional amenorrhea and oligo- menorrhea, 65 in kraurosis of vulva, 233 in pruritus of vulva, 236 in sclerosis and atrophy of ovary, 255 in sterility, 65, 566 in vasomotor changes after ovariectomy, 128 influence of, on time coagulability of blood, 58 production of hematometra in guinea- pigs by injection of, 65 of hemorrhage in guinea-pigs by injec- tion of, 65 value of, 64 facies, 412 neurahga, 127, 255, 578 pain, 577 secretion, 46 absence of, ovarian extract in, 65 loss of, as cause of changes during meno- pause, 23 tissue, transplantation of, 60, 765 after hysterectomy, 63, 766 in functional amenorrheas of young women, 64 INDEX 871 Ovarian tissue, transplantation of, in sterility, 62, 565 Ovariectomy, accumulation of fat after, 52, 53, 54 after maturity, 53, 134 as cause of amenorrhea, 571 before maturity, 51 puberty in women, 53 changes in hypophysis due to, 51, 52 early and late, differences in, 53, 54 heterosexual type in, 52 effect of, 46 on hypophysis, 76 genital atrophy due to, 543 hot flushes after, 128 hypertrophy of suprarenal gland after, 89 neuroses after, 128 psychoneuroses after, 128, 129 transplantation of ovarian tissue after, 63 vasomotor disturbances after, 55, 128 voice after, 52 Ovarin, 46 Ovaritis, 252. See also Oophoritis. Ovary, absence of, 445 absence of vagina and, 55 accessory, 445 albuginea of, 32 and breasts, relation between, 94 and osteomalacia, relation between, 156 atrophy of, 55, 542 as cause of changes during menopause, 23 pathologic, 56 blood-cysts of, 386 carcinoma of, 398. See also Carcinoma of ovary. colloid carcinoma, 405, 406, 407 condition of, during menstruation, 20 cystadenoma of, 387 origin, 396 pseudomucinous, 389 origin of, 397 treatment, 391 serous, 393 origin of, 396 cystic carcinoma, 398 degeneration, 383 as cause of sterility, 558 cystoma of, 387 cysts of, 254, 381. See also Cijsts of ovary. defects of, developmental, 445 degeneration of, 254 cystic, 254 dermoid cysts of, 401, 408, 409 malignant changes, 403 parthenogenesis, 405 descent of, 440 Ovary, developing and ripening of follicles by. 32 development of, 18 embryologic development, 439 endothelioma of, 411 fibroma of, 407 ascites from, 410 fibrosarcoma of, 410 function of, essential, 32 functional anatomy, 31 germinal epithelium of, 31 glandular ducts of, 32 hyperfunction of, 56 hypersecretion of, 56 uterine bleeding from, 57, 58 hypof unction of, 51 infantilism and, relation between, 55 hypoplasia of, infantilism and, relation between, 55 in infantiUsm as cause of sterility, 551 infantile, 551, 552 infections, 252 inflammations, 252 lactation-atrophy of, 56 medullary layer of, 32 operations on, 764 parenchymatous layer of, 32 perithelioma of, 411 physiologic anatomy, 31 pseudomucinous cystadenoma of, 389 origin, 397 treatment, 391 relation of, to glands of internal secretion, 46 to hypophysis, 77 to thyroid, 80 resection of, 764 sarcoma of, 410 metastasis, 411 secretion of, 46 serous cystadenoma of, 393 origin, 396 small cystic degeneration, 254 stigma on, 37 struma, 404 teratoma of, 404 parthenogenesis, 405 transplantation of, 60, 765 after hysterectomy, 766 in sterility, 565 tuberculosis of, 220, 253 tumors of, 381 ascites associated with, 412 diagnosis, 415 exciting cause of formation, 397 facial expression, 412 872 INDEX Ovary, tumors of, menstrual function in, 414 non-proliferating, 381 ovigenous, 401 ovulogenous, 401 parenchymatous, 387 pregnancy complicating, 414 pressure symptoms, 412 prognosis, 417 proliferating, 387 removal of both ovaries, 417 stromatogenous, 407 symptoms, 412 torsion, 413 treatment, 416 tumors of kidney and, differentiation, 415 m-eter sjTxiptoms, 412 ■Ovigenous tumors of ovary, 401 Ovitestes, 72, 451 Ovulation and menstruation, time relation be- tween, 58, 59 Ovulogenous tumors of ovary, 401 Ovum and spermatozoon, place of union, 24 Facet's disease of vulva, 234 Pain from inflammation of peritonevmi, 578 from pelvic pressure, 578 from uterine fibroids, 580 in carcinoma of cervix, 343 in coccyx, 580 in coitus, 138, 140 in dysmenorrhea, 518, 519 in ectopic pregnancy, 510, 511, 512 in legs, 581 in loins, 580 in retroversion of uterus, 463 in rupture of tubal pregnancy, 577 in side, 579 intermenstrual, 21 lumbar, 580 of menstruation, 580. See also Dysmenor- rhea. of micturition, 581 on defecation, 581 ovarian, 577 pelvic, 576 Palpation of abdomen, 831 Papillary angioma of vestibule, 293 excrescences of vulva, 227 Papilloma of bladder, 426 treatment, 428 of Fallopian tubes, 421 Paracolpitis, 240 Paracystic cellular tissue, 256 Paracystitis, 265 . Paraffin, liquid, in enteroptosis, 164 Parametrial cellular tissue, 256 hematoma, 260 parametritis and, differentiation, 259 treatment, 261 infiltration in chorio-epithelioma malig- num, 380 Parametritis, 255, 256 as complication of pelvic operations, 257 atrophicans, 259 cancer of cervix and, differentiation, 259 chronic, 258, 259 cystitis from, 264 diagnosis, 259 differential, 259 etiology, 257, 258 gonorrheal, 258 parametrial hematoma and, differentiation, 259 posterior, 144, 259 postoperative, 257 symptoms, 258 treatment, 259 Parametrium, hematoma of, 260 inflammation of, 255 Paraproctal ceUular tissue, 256 Parasites, vaginal, 238 Parathyroid extract in tetany, 83 Parathyroids and eclampsia, relation be- tween, 84 and osteomalacia, relation between, 84 relation of, to genitalia, 83 removal of, effect of, 83 Paravaginitis, 240 Parenchymatous layer of ovary, 32 Farenteric digestion, 110 Parietocolic fold of Jonnesco and Juvara, 172 Paroophoron, 439 Parotid glands, increased activity, during menstruation, 100 Parovarium, 418, 439 adenomyoma of, 419 adenosarcoma of, 419 carcinoma of, 419 cystadenoma of, 419 cysts of, 418 treatment, 419 dermoid cysts, 419 fibro-adenoma of, 419 tumors of, 419 Patient, examination of, 831. in private house, 834 Pedicle, upper, 585, 586 Pelvic adhesions after gonorrheal salpin- gitis, 202. See also Pelvic inflammation, chronic. INDEX 873 Pelvic blood-vessels, congestion of, during menstruation, 20 cellular tissue, anatomy, 255 inflammations, 256. See also Para- metritis. paracystic, 256 parametrial, 256 paraproctal, 256 cellulitis, 255 after operations on bladder, 260 in lateral wall of abdomen, 260 connective tissue, dermoid cysts, 425 treatment, 426 fibroma of, 423, 424 fibromyoma of, 423, 424 lipoma of, 425 sarcoma of, 425 tmnors of, 423 symptoms, 424 treatment, 426 discomfort during menstruation, 20 hematocele in ectopic pregnancy, 508 inflammation, chronic, as result of gonor- rheal salpingitis, 202, 209 disturbances of menstruation in, 210 symptoms, 209 treatment, 212 menorrhagia of, radium in, 530 . relation of, to retroversion and retro- flexion of uterus, 202 operations, Bardenheuer's incision, 768 operation for gall-stones during, 149, 150 on gall-bladder during, 149 parametrial hematoma as complication, 260 parametritis as complication, 257 performance of, during menstruation, 22 Pfannenstiel's incision, 769 transverse incisions in, 768 pain, 576 peritonitis as result of gonorrheal salpin- gitis, 201 Pelvis of kidney, inflammation, 273 retroperitoneal txunors, 423 subperitoneal tumors, 423 varicose veins of, 120 Percy's treatment of carcinoma of cervix, 360, 361, 790 Pericystitis, 266 Perineal body, 491 cysts, 301 muscles, functional anatomy of, 490, 491 sheet, Ewin, directions for making, 843 Perineoplasty, Clark's, 633, 636 Emmet's, Graves' modification, 625 Perineoplasty, Studdiford's, 638 Perineum, laceration of, 490. See also Lacera- tion of perineum. plastic surgery, 625 tight, operation for enlarging, 746 Perisalpingitis, tubercular, 216, 218 Perithehoma of ovary, 411 Peritoneal adhesions, 153 from bacterial peritonitis, 153 from chemical injury, 154 from mechanical injury, 154 from surface necrosis, 155 from tuberculosis, 154 tramnatic, 154 cavity, absorption of flmd material in, 152, 153 epithelium, destruction of, 152, 153 bacterial infection as cause, 153 fluid, transudation and resorption, 152 Peritonemn, inflammation of, pain from, 578 lymph-vessels of, 151 nerves of, 151 physiology of, 150 relation of genitaha to, 150 reparative power of epithehum, 152 resistance of, to external infection, 152 tuberculosis of, 221 Peritonitis, bacterial, 153 gonorrheal, 153 pelvic, as result of gonorrheal salpingitis, 201 tubercular, 221 diagnosis, 222 dry adhesive, 221 nodular, 221 prognosis, 223 symptoms, 221 treatment, 222 with ascites, 221 Periurethral abscess, 262 PeriviteUine space, 36 Pessaries for anteflexion of cervix, 691 of uterus, 691 in amenorrhea of youth, 524 in anteflexion of uterus, 481 in oligomenorrhea of youth, 524 in procidentia of uterus, 478 in prolapse of uterus, 472, 473 in retroversion of uterus, 466 Petit's triangle, 798 Pfannenstiel incision, 769 Pfannenstiel's operation in dysmenorrhea, 521 Phantom pregnancy, 572 Phlebectasis, 119 operations for, 828 Phlebitis, postoperative, 116, 117 874 INDEX Phlebitis, postoperative, pyogenic, 117 treatment, 117 Phlegmasia alba dolens, 116, 257 ' Physical changes during menopause, 22 Pigment hypertrophy and functions of pelvic organs, relation between, 96 Piles, 432. See also Hemorrhoids. Pineal gland, internal secretory action of, 90, 91 relation of, to genitaha, 90, 91 Pituitary body. See Hypophysis. Pituitrin in gland hypertrophy of endo- metrium, 251 in menorrhagia due to uterine fibroids, 325 of youth, 525 in postpartum hemorrhage, 79 in uterine insufficiency, 548 to stimulate uterine contractions, 78 value of, 78, 79 with adrenalin in dysmenorrhea, 519 Placenta, influence of, on breasts, 94 on mother during pregnancy, 92 maternal, 47 relation of, to genitalia, 92 Placental extracts in amenorrhea, 65 in climacteric disturbances, 65 in sterility, 65 polyp, 372 site, chorio-epithehoma maUgnum, 370 Plastic operations, after-care, 845 care of stitches, 846 coaptation of woiind edges, 845 denudation in, 844 on stump of Fallopian tube, 563 preparation for, 842 stitch abscess in, treatment, 847 suture material, 844 technic, 842 technical details, 843 Plexus, Auerbach's, 151 Plugs, dermoid, 402 Pneumococcus as cause of secondary infec- tions in pelvis, 105 Pneumonia, ether, 103 postoperative, 103 Polypoid gland hypertrophy of endometrium, 250, 574 Polyposis, rectal, 431 Polyps, cervical, 332 bleeding in, 333 diagnosis, 334 metrorrhagia in, 576 symptoms, 333 treatment, 334 . mucous, of Fallopian tubes, 421 Polyps, mucous, of vestibule, 293 of endometrium, 333, 334 placental, 372 rectal, 431 Position, knee-chest, 834 of uterus, 17 453 Sims', 834 Posthemorrhagic blood-picture, 108 Postmenstrual involution of uterine mucosa, 28 necrobiotic endometritis, 248 Postoperative catharsis in abdominal cases, 840, 841 in plastic cases, 846 embohsm, 118 hernia, 503 diagnosis, 504 Graves' operation for, 782 transplantation of fascia for, 782 Bartlett's method, 783 treatment, 504 hyperleukocytosis, 109 infections of lungs, 103 leukocjrtosis, 109 myxedema, 82 neuroses after hysterectomy and ovariec- tomy, 128 parametrial hematoma, 260 parametritis, 257 phlebitis, 116, 117 pyogenic, 117 treatment, 117 pneinnonia, 103 pyehtis, 275 skin eruptions, 97' thrombophlebitis, 116 thrombosis, 116, 117 treatment of abdominal cases, 840 of bowels of abdominal cases, 840, 841 of plastic cases, 846 of plastic cases, 845 Postpartum hemorrhage, pituitrin in, 79 Pozzi's operation for anteflexion of uterus, 693 in dysmenorrhea, 521, 693 Precocious menstruation, 21 in infants, 18 Pregnancy, Abderhalden's test for, 110 appendicitis during, 146, 147 atresia of folhcle during, 41 changes in hypophysis in, 76 complicating ovarian tumors, 414 corpus luteum of, macroscopic appearance, 59 ectopic, 506. See also Ectopic pregnancy. effect of removal of hypophysis on, 76 INDEX 875 Pregnancy, extra-uterine, 506. See also Ec- topic ■pregnancy. following ovarian tissue transplantation, 62, 63, 565 goiter during, SO, 81 in rudimentary horn of uterus, 444 influence of placenta on mother diu:ing, 92 interstitial, 506 symptoms and course, 513 myoma of uterus and, differentiation, 324 relation, 322 persistence of corpus luteimi and, 47 phantom, 572 tetany in, 83, 84 tubal, 506. See also Ectopic pregnancy. Premenstrual congestion of uterine mucosa, 24 Pressure, pelvic, pain from, 578 symptoms of ovarian tumors, 412 of tumors of pelvic connective tissue, 424 Prevesical space, 256 Primordial egg, 33 folhcle, 33 Private house, examination of patient in, 834 Procidentia of uterus, 457, 475 after hysterectomy, 477 congenital, 476 diagnosis, 477 elongation of cervix in, 477 Goffe's operation, 706 Graves' operation, 696 interposition operation, 479, 699 Mayos' operation, 709 operations for, 696 pessaries for, 478 suspension operation, 479 symptoms, 478 treatment, 478 Watkins' operation, 479, 699 "VYertheim's operation, 705 Prolapse of anus, 431 of rectum, 431 incomplete, 431 Marchant's operation, 817 Moschowitz's operation, 817, 818 operations for, 817 suspension operation, 817 treatment, 432 Tuttle's modification of Ekehorn's opera- tion, 817 of urethra, 294 in children, 295 of uterus, 457, 470 diagnosis, 471 Goffe's operation, 706 Prolapse of uterus, Graves' operation, 696 interposition operation, 479, 699 Mayos'' operation, 709 Olshausen's operation, 474 operations for, 696 symptoms, 472 treatment, 472 surgical, 473 Watkins' operation, 479, 699 Wertheim's operation, 705 of vaginal wall, 457 Protargol in cystitis, 270 in gonorrheal inflammation of Skene's glands, 184 urethritis, 183 vulvovaginitis in children, 181 Pruritus of vulva, 234 etiology, 235 radium in, 531 treatment, 235 Pseudohermaphroditism, 71, 451 Pseudomucin, 390 Pseudomucinous cystadenoma of ovary, 389 origin, 397 treatment, 391 Pseudomyxoma peritonei, 393 Pseudovaginismus, 533 treatment, 534 Psychic distiu-bances during menopause, 22 states, disturbed, influence of, on men- struation, 21, 123 Psychonem-oses after ovariectomy and hys- terectomy, 128, 129 genital, 124 treatment, 127 of menopause, 129 Ptosis, abdominal, 158. See also Enterop- tosis. Puberty, acne at, 96 age occurring, 18 development of breasts at, 18 effect of chmate on occurrence of, 18 heart at, 113 ovariectomy before, in women, 51, 52 sexuality of, 132, 133 thyroid at, 80 Pubescent uterus, 554 Pubococcygeus muscle, 490 Puerperal sepsis as cause of hemorrhage in eye, 99 of sterihty, 557 Pulley stitch, 772 PyeUtis, 273 etiology, 273, 274 postoperative, 275 prognosis, 276 876 INDEX Pyelitis, treatment, 276 Pyelography, 171 Pyelonephritis, 273, 275 Pyometra, 247 Pyosalpinx, gonorrheal, 194 profluens, 211, 569 rupture of, 204 Race degeneration as cause of sterility, 561 Radium, apphcation of, Graves' technic, 792 in bleeding from uterine fibroids, 325 in carcinoma of cervix, 348, 362 details of treatment, 355 Graves' technic, 792 selection of cases for, 353 of rectum, 430 of vagina, 298 in endometritis, 531 in gland hypertrophy of endometrium, 251, 527 in interstitial endometritis, 528 in kraurosis of vulva, 531 in menorrhagia of fibroids, 529 of pelvic inflammation, 530 of yoimg, 528 in non-malignant gjoiecologic diseases, 525- 533 after-care, 532 details of treatment, 531 dosage, 531 selection of cases, 526 ■ in myoma, 325 in parametritis, 259 in pruritus of vulva, 236, 531 in sarcoma of uterus, 332 in uterine insufficiency, 526, 549 physical properties, 348 Rash, ether, 97 Receptaculum seminis, 23, 554 Recti muscles, diastasis of, 500 operation for, 771-774 ovarian cyst and, differentiation, 416 treatment, 501 Rectocele, 144, 457, 471, 497 closure of Douglas' pouch for. Graves' operation, 643 Graves' modification of Emmet's opera- tion, 625 Rectovaginal fistula, operation for, 652, 653 septum, adenomyomas of, 305 Rectum, adenoma of, 431 atresia of, 449 carcinoma of, 429. See also Carcinoma of rectum. effect ,of retroverted uterus on, 144 endothelioma of, 430 Rectum, epithelioma of, 430 inflammatory stricture, 283 treatment, 285 operations on, 817 polyposis of, 431 polyps of, 431 prolapse of, 431. See also Prolapse of rectum. relation of genitalia to, 142, 144 sarcoma of, 430 stricture of, inflammatory, 283 treatment, 285 tumors of, 429 Red degeneration of uterine myoma, 314, 316 Regeneration of blood after hemorrhage, 108, 109 Regressive changes in uterine myoma, 316 Reid's genitomesenteric fold, 173 Relaxation of vaginal waUs as cause of steril- ity, 558 Resection of ovary. 764 Respiration, organs of, relation of genitalia to, 103 Retrocession of uterus, 455, 461 Retrodisplacement of uterus. See Retrover- sion of uterus. Retroflexion of uterus, 455, 458 relation of pelvic inflammatory disease to, 202 Retrolocation of uterus, 456 Retroperitoneal appendix, 172 dermoids, 425 lipoma, 425 sarcoma, 424, 425 tumors, 423 Retroposition of uterus, 456 Retrorenal fascia, 799 Retroversion of uterus, 453, 458 Alexander-Adams operation, 689 Alexander's operation, 466, 688 Baldy's operation, 685 Coffey's operation, 468 diagnosis, 465 due to adhesions, 468 diagnosis, 469 symptoms, 469 treatment, 469 due to displacement by tumors, 470 due to relaxation, 459 symptoms, 463 treatment, 466 effect of, on rectum, 144 etiology, 458 first degree, 453 Gilliam's operation, 467, 680 Kelly's modification, 685 INDEX 877 Retroversion of uterus, GUliam's operation, Mayos' modification, 683 Simpson's modification, 681 internal Alexander operation, 683 Kelly's operation, 685 Mayos' operation, 683 Olshausen's operation, 468 Graves' modification, 678 operations for, 678 pathologic conditions due to, 461 pessaries in, 466 relation of pelvic inflammatory disease to, 202 second degree, 454 Simpson's operation, 681 symptoms, 463 third degree, 454 traumatic adhesions from, 462 treatment, 466 ventral fixation, 467 suspension, 467 Webster-Baldy operation, 468, 685 Retroversion-flexion of uterus, 455 Retzius, space of, 256 Ripening follicle, 33 Rodent ulcer of vulva, 229 Rontgen rays. See x-Rays. Round ligament, adenomyoma of, 423 fibromyoma of, 424 tumors of, 422 treatment, 423 Rovsing's operation for enteroptosis, 166 Rudimentary horn of uterus, 444 uterus, 441 Rupture of ovarian cysts, 412 of pyosalpinx, 204 of tube in ectopic pregnancy, 508 pain of, 577 treatment, 513 Russian oil in enteroptosis, 164 Sactosalpinx serosa, 196 Salivation, menstrual, 100 vicarious, 100 Salpingectomy, 758 Salpingitis, catarrhal, 193 chronic interstitial, 199 gonorrheal, 192 acute, appendicitis and, differentiation, 206 diagnosis, 205 differential, 206 diverticulitis of sigmoid and, differen- tiation, 207 extra-uterine pregnancy and, differ- entiation, 207 Salpingitis, gonorrheal, acute, secondary, 204, 205 treatment, 208 symptoms, 203 treatment, 208 twisting of pedicle of ovarian cyst and, differentiation, 207 as cause of sterility, 556 treatment, 562 chronic pelvic inflammation as result, 202, 209. See also Pelvic inflammation, chronic. pathology, 193 pelvic peritonitis as result, 201 interstitial, chronic, 199 isthmica nodosa, 201 tubercular, 216 progress, 218 symptoms, 218 treatment, 218 Salpingo-oophorectomy, 757 Salpingostomy, stomatoplastic, 760 Bell's method, 762 Sampson's method of ureterovesical trans- plantation, 812 Sandalwood, oil of, in gonococcal cystitis, 269 Sarcoma botryoides, 329 cystic, of uterus, 330 grape-mole, of uterus, 329 of endometrium, 329 of Fallopian tubes, 421 of ovary, 410 metastasis, 411 of pelvic connective tissue, 425 of rectum, 430 of uterus, 328 adenocarcinoma and, differentiation, 331 bleeding from uterus in, 331 cystic, 330 diagnosis, 330 grape-mole, 329 histology, 329 metastasis, 331 treatment, 332 of vagina, 296 in children, 297 of vulva, 292 retroperitoneal, 424, 425 Sarcomatous degeneration of uterine fibroids, 317, 329, 331 Scarlet ointment in varicose ulcer, 830 Schauta's operation for carcinoma of cervix, 744-750 Schroder's operation for extirpation of endo- cervix, 604 for sterility, 564, 604 878 INDEX Schubert's operation for absence of vagina, 670 Schultz's theory of etiology of dysmenorrhea, 516 Seborrhea of vulva, 225 Secretion, abnormal, symptoms due to, 568 internal, effect of nervous system upon, 44, 45 glands of, dysfunction of, 45 hjHperfunctional changes in, 45 hypofunctional changes in, 45 relationship of g5Tiecology to, 44 of ovary to, 46 of uterus, 91 ovarian, 46 absence of, ovarian extract in, 65 loss of, as cause of changes during meno- pause, 23 Semen, escape of, from vagina, as cause of sterility, 555 Senile vaginitis, 544 Sense, organs of, relation of genitalia to, 98 Sepsis, puerperal, as cause of hemorrhage of eye, 99 of sterility, 557 Septum formation of vagina, 444 partial, of uterine cavity, 443 rectovaginal adenomyomas of, 305 Serodiagnosis of pregnancy and cancer, 110 Serous cystadenoma of ovary, 393 origin, 396 Serum, antigonococcic, 215 blood, in menorrhagia of youth, 525 treatment of gonorrhea, 214 of hemophilia, 107 Sex, determination of, 68-72 impulse, relation of genitalia to, 129 Sexual anesthesia, 134, 136, 138 deviations, 134 dyspareunia, 138 masturbation, 134 herpes, 95 impulse during menstruation, 21 just before menopause, 23 sensibility, local, lack of, 139 Sexuality, infantile, 130 masturbation in, 132, 133 onanism in, 131, 132 second period of, 133, 134 thumb-sucking as manifestation, 131 of puberty, 132, 133 Shaw's principles of technic in fascia trans- plantation, 786 Shock, nervous, influence of, on menstrua- tion, 123 Side, pain in, 579 Sigmoid, diverticulitis of, acute gonorrheal salpingitis and, differentiation, 207 relation of genitalia to, 144 Silver nitrate in anal fissure, 283 in chronic urethritis, 262 in cystitis, 270 in pyehtis, 277 Simpson's operation for retroversion of uterus, 681 Sims' operation for vesicovaginal fistula, 653 position, 834 Sinus, urogenital, 441 Sippel's theory of cause of ectopic pregnancy, 506 Skene's glands, gonorrheal inflammation of, 183 Skin, condition of, during menstruation, 21 edema of, associated with menstruation and chmacteric, 96 eruptions, postoperative, 97 lesion from vicarious menstruation, 96 of vulva, 225 menstrual changes in, 95 relation of genitaha to, 94 Shding hernia, 432 Social conditions, effect of, on occurrence of menstruation, 19 Sodium citrate in dysmenorrhea, 519 Somatic cells, 407 Space of Retzius, 256 perivitelline, 36 prevesical, 256 uterovesical, 202 Spasm of vagina, 533 Spermatozoon and ovary, place of union, 24 Spinelli's operation for inversion of uterus, 711 Splanchnoptosis, 158. See also Enteroptosis, Sponge in abdominal cavity, 837 Spongy layer of uterine mucosa, 26 Spot, genital, 100, 517 Squamous-cell carcinoma of cervix, 335 Stasis, intestinal, 158, 163 Status thymicus, 91 Steam in uterine insufficiency, 548 Stenosis, callous, of cervix, 555 of vagina, 536 treatment, 540 Sterility, 549 absolute, 549 acquired, 549 causes of, 556 adiposity as cause, 560 artificial impregnation in, 566 carcinoma as cause, 558 consanguinity as cause, 561 constitutional diseases as cause, 560 INDEX 879 Sterility, diseases of hypophysis as cause, 560 effluvium seminis as cause, 555 endocervicitis as cause, 557 treatment, 564 endometritis as cause, 557 escape of semen from vagina as cause, 555 etiology, 550 fetalism as cause, 550 genital tuberculosis as cause, 558 gonorrheal salpingitis as cause, 556 treatment, 562 in retroversion of uterus, 464 infantilism as cause, 550 ovaries in, 551 tubes in, 553 uterus in, 553 lactation, 560 malposition of uterus as cause, 558 treatment, 561 myoma of uterus as cause, 559 obesity as cause, 560 ovarian extract in, 65, 566 implantation and transplantation in, 62, 565 placental extracts in, 65 preventive measures as cause, 560 primary, 549 puerperal sepsis as cause, 557 race degeneration as cause, 561 relaxation of vaginal walls as cause, 558 Schroder's operation for, 564, 604 secondary, 549 treatment, 561 tumors as cause, 558 vaginismus as cause, 561 x-ray as cause, 559 Sterilization, tubal, Taussig's operation, 762 Stigma, ovarian, 37 Stitch. See Suture. Stomach, disturbances of, and menstruation, relationship, 100, 101 Stone. See Calculus. Strain, foot, 156 Strawberry mottling of gall-bladder, 150 Stricture, inflammatory, of rectum, 283 treatment, 285 of urethra, 262 as result of gonorrheal urethritis, 183 Stromatogenous tumors of ovary, 407 Struma ovarii, 404 Studdiford's method of combined amputation of cervix and anterior colpoplasty, 620 perineoplasty, 638 Subconsciousness, 125 Subperitoneal tumors, 423 Suicide during menstruation, 123 Superior lumbar trigonum, 798 Suppurating kidney, 273 Suprapubic cystotomy, 815 Kelly's method, 815 Suprarenal system, 84 anatomy, 84, 85 hyperfunction of, 88 hypertrophy of, after ovariectomy, 89 internal secretory function of, 85 relation of, to genitalia, 85, 87 Supravaginal hysterectomy, 713 vaginal drainage after, 723 Suspension of kidney, 796 Kelly's technic, 800 of uterus for anteflexion, 482 Graves' modification of Olshausen's operation, 678 in procidentia, 479 operation for rectal prolapse, 817 Suture abscess in plastic operations, treat- ment, 847 Brodel's, 803 care of, in plastic operations, 846 material in abdominal operations, 838 in plastic operations, 844 of abdominal wound, 839 pulley, 772 wandering, as cause of vesical calculus, 428 Symptomless cholelithiasis, 148 Symptoms, 568 due to abnormal secretions, 568 essential, 568 Syncytioma mahgnum, 370 Syncytium, 372 Syphilis of bladder, 272 of vulva, 225 Syphilitic cystitis, 272 Tampons, vaginal, in prolapse of uterus, 472 Taussig's operation for carcinoma of vulva, 291, 584 • for tubal sterilization, 762 Technic, 831 Temperament, change in, after fifty, 23 Temperature, elevation of, in carcinoma of cervix, 343 Teratoma of ovary, 404 parthenogenesis, 405 of vulva, 292 Test, Abderhalden's, for pregnancy and can- cer, 110 in differential diagnosis of uterine myoma and pregnancy, 324 complement-fixation, in diagnosis of gonor- rheal salpingitis, 205 Tetany in pregnancy, 83, 84 880 INDEX Tetany, parathyroid extract in, 83, 84 Theca externa, 34, 49 folliculi, 34 tunica externa of, 34 interna of, 34, 36 interna, 34, 36 Theca-luetin cells, 387 function of, 50 cysts, 3S7 Thread-worms, vulvovaginitis in children from, 238 Thrombophlebitis, postoperative, 116 Thrombosis, postoperative, 116, 117 Thrombotic degeneration of uterine myoma, 314 pile, 433 Thumb-sucking manifestation of sexual im- pulse, 131 Thymus, relation of, to genitalia, 91 Thjrreaplasia, 82 ThjToid and myoma of uterus, relation be- tween, 81 at puberty, 80 enlargement of, during menstruation, 20 extract and pituitrin in menorrhagia of youth, 525 influence of menopause on, 81 relation of ovary to, 80 to genitalia, 79, 80 Tight perineum, operation for enlarging, 646 Torsion of ovarian cysts, 413 acute gonorrheal salpingitis and, differ- entiation, 207 tumors, 413 of uterus, 457 Tracheloplasty, 593 Emnaet's operation, 593 Transfusion, blood, in hemophilia, 107 in menorrhagia of youth, 525 Transplantation of fascia for postoperative hernia, 782 Bartlett's method, 783 ' Shaw's principles of technic, 786 of ovarian tissue, 60, 765 after hysterectomy, 63, 763 in functional amenorrheas of young women, 64 in horn of uterus, 61, 62 in sterihty, 62, 565 ureterovesical, 812 Sampson's method, 812 Kronig's modification, 813 Transudation and resorption of peritoneal fluid, 152 Transverse incisions in pelvic operations, 768 Traumatic adhesions from retroversion of uterus, 462 peritoneal adhesions, 154 theory of etiology of cervical cancer, 339- 342 Treves' bloodless fold, 172 Triangle, Petit's, 798 Trichloracetic acid in dysmenorrhea, 520 Trichomonas vaginaUs, 238 Trophoblast and chorio-epithelioma malig- num, biologic resemblance, 375 function of, 375 Tubal abortion, 508 treatment, 514 menstruation, 30 mole, 508, 511 pregnancy, 506. See also Ectopic preg- nancy. rupture in ectopic pregnancy, 508 treatment, 513 Tubercular cystitis, 271 treatment, 269 endometritis, 219 endosalpingitis, 216, 217 metritis, 251 oophoritis, 253 perisalpingitis, 216, 218 peritonitis, 221 diagnosis, 222 dry adhesive, 221 nodular, 221 prognosis, 223 symptoms, 221 treatment, 222 with ascites, 221 salpingitis, 216 progress, 218 symptoms, 218 treatment, 218 Tuberculosis, amenorrhea and, relationship, 572 genital, 215 as cause of sterility, 558 of bladder, 271 diagnosis, 271 treatment, 271 of cervix, 220 of endometrium, 219 of Fallopian tubes, 216 of lungs, influence of menstruation on, 104 of metrium, 219, 251 of ovary, 220, 253 of peritoneum, 221 of uterus, 219, 251 of vagina, 220 of vulva, 220 INDEX 881 Tubo-ovarian abscess, 196, 253 cysts, 198 Tubo-ovaritis, chronic, 200 gonorrheal, 195 Tumors, abdominal, ^atiligo associated with, 97 as cause of sterility, 558 Krukenberg's, 407 of bladder, 426 s3'mptoms, 428 treatment, 428 of clitoris, 295 of Fallopian tubes, 420 of kidney, ovarian tumors and, differen- tiation, 415 of ovary, 381. See also Ovary, tumors of. of parovarium, 419 of pehac connective tissue, 423 symptoms, 424 treatment, 426 of rectum, 429 of round ligament, 422 treatment, 423 of uterus, 307 of vagina, 296 of \Tilva, 287 retroperitoneal, 423 subperitoneal, 423 Tunica externa of theca folliculi, 34 interna of theca folliculi, 34, 36 Tuttle's modification of Ekehorn's operation for rectal prolapse, 817 Typhoid fever and genitaha, relation between, 157 Ulcer of bladder, 265 rodent, of vulva, 229 varicose, Crede's ointment in, 830 operations for, 830 scarlet ointment in, 830 Ulceration of cervix, 336, 485, 486 of A^ilva, 229 Ulcus moUe of AOilva, 224 Umbilical hernia, 502 Graser's operation for, 781 Graves' operation for, 775 Mayos' operation for, 781 Upper pedicle, 585, 586 Uremia, chronic, from pressure of tumor of pelvic connective tissue, 424 Ureter, implantation of^ in bladder, 812 in colon, 814 operations on, 810 proximal end, hgation of, 813 relation of genitaha to, 142, 143 symptoms of ovarian tumors, 412 56 Ureteral anastomosis, 810, 811, 812 fistula, formation of, 814 Ureterocystanastomosis, 812 Ureterocystostomy, 810 Uretero-ureterostomy, 810 Ureterovesical transplantation, 812 Sampson's method, 812 Ivronig's modification, 813 Urethra, atrophy of, 545 defects of, 445 l^rolapse of, 294 in children, 295 stricture of, 262 as result of gonorrheal urethritis, 183 Urethral canal, diverticula, 301 caruncle, 293 mucous membrane, ectropion of, 545 treatment, 547 Urethritis, 261 acute, 261 chronic, 261 treatment, 262 gonorrheal, 181 cystitis and, differentiation, 266 stricture of urethra as result, 183 symptoms, 182 treatment, 183 Urethrocele, 488 diagnosis, 489 Urethrovaginal fistula, 498 Urine, incontinence of, functional, Kelly's operation, combined with Graves' anterior colpoplasty, 615 operation for, 614 leakage of, in vesicovaginal fistula, 499 Urogenital sinus, 441 Urotropin in cystitis, 269 Uterine canal, radiimi apphcation in, technic, 795 cavity, partial septum, 443 cohc, 577 contractions, pituitrin to stimulate, 78 extracts, influence of, on time coagula- bihty of blood, 58 hemorrhage. See Metrorrhagia. insufficiency, 547 diagnosis, 548 radium in, 526 symptoms, 548 treatment, 548 mucosa, compact layer, 26 cyclic changes in, 24 glycogen production from, 30 menstrual exfoUation, 522 flow and, 28 postmenstrual involution of, 28 882 INDEX Uterine mucosa, premenstrual congestion of, 24 spongy layer, 26 Uterovesical fistula, operation for, 659 • space, 202 Uterus, absence of, 441 adenocarcinoma of, 362 sarcoma and, differentiation, 331 adenomyoma of, 327 adenomyositis of, 327 adenosarcoma of, 330 amputation of, 713. See also Hysterectomy. angiosarcoma of, 330 anteflexion of, 455, 480. See also A?ite- flexion of uterus. anteposition of, 456 anteversion of, 455 atresia of, 444 atrophy of, 541 bicornis unicolUs, 442 bicornuate, 442 double, with double vagina, 441 biforis, 443 carcinoma of, 362. See also Carcinoma of uterus. condition of, during lactation, 543 during menstruation, 20 congenital defects, 441 curetage of, 592 cystic sarcoma, 330 defects of, congenital, 441 descent of, 457 didelphys, 441 double, 442, 443, 444 duplex bicornis, 442 cum vagina dupUci, 442 separatus, 441 dwarf, 554 elongation of, 458 embryologic development, 436 examination of, 833 fibroids of, 307. See also Myoma of uterus. fibromyoma of, 307. See also Myoma of uterus. flexion of, lateral, 455 hemorrhage from. See Metrorrhagia. hyperanteflexion of, 455 hjTDertrophic changes in, before and after birth, 17 in infantilism as cause of steriUty, 553 infantile, 553 infantiUsm of, 480 infections of, 251 inflammation of, 251 gonorrheal, 251 infectious, 251 Uterus, inflammation of, tubercular, 251 internal secretion of, 91 inversion of, 458, 482. See also Inversion of uterus. leiomyoma of, 307. See also Myoma of uterus. lymphosarcoma of, 330 malpositions of, 453 as cause of sterility, 558 treatment, 561 backache in, 579 dysmenorrhea and, relation, 517 operations for, 678 melanosarcoma of, 330 myoma of, 307. See also Myoma of uterus. myosarcoma of, 329 physiology of, 17 position of, 17, 453 procidentia of, 457, 475. See also Proci- deritia of uterus. prolapse of, 457, 470. See also Prolapse of uterus. pubescent, 554 removal of, 713. See also Hysterectomy. retrocession of, 455, 461 retrodisplacement of. See Retroversion of uterus. retroflexion of, 455, 458 relation of pelvic inflammatory disease to, 202 retrolocation of, 456 retroposition of, 456 retroversion of, 453, 458. See also Retro- version of uterus. retroversion-flexion, 455 rudimentary, 441 horn, 444 sarcoma of, 328. See also Sarcoma of uterus. septus duplex, 443 size and weight of, influence of child-bear- ing on, 17 subseptus uniforis, 443 suspension of, for anteflexion, 482 Graves' modification of Olshausen's op- eration, 678 in procidentia, 479 torsion of, 457 tuberculosis of, 219, 251 tumors of, 307 unicornis, 443 version of, lateral, ^55 version-flexion of, 455 Vaccine treatment of gonorrhea, 214 of gonorrheal vulvovaginitis in children, 181 INDEX 883 Vaccine treatment of pyelitis, 277 of vulvovaginitis in cliildren, 215 Vaccines, antigonococcic, 215 Vagina, absence of, 444, 536 Baldwin's operation for, 670 Graves' operation for, 667 operations for, 667 ovaries and, 55 Schubert's operation for, 670 treatment, 540 adenomyoma of, 305 artificial, Baldwin's method of making, 670 Graves' method of making, 667 method of making, 444, 667 Schubert's method of making, 670 atrophy of, 542 carcinoma of, 297 diagnosis, 297 prognosis, 298 treatment, 298 chorio-epitheUoma of, 299 cysts of, 299 diagnosis, 300 etiology, 300 treatment, 301 defects of, developmental, 444 digital examination by, 832 Distoma haematobium in, 238 embryologic development, 436 escape of semen from, as cause of sterility, 555 expulsion of gas from, 240 fibromyoma of, 304 fungus of, 238 inflammation of, 236 myoma of, 304 operations on, 608 parasites of, 238 plastic surgery on, 608 sarcoma of, 296 in children, 297 septum formation, 444 spasm of, 533 stenosis of, 536 treatment, 540 tuberculosis of, 220 tumors of, 296 varicose veins of, 119 Vaginal anus, 451 colpotomy, 675 anterior, 676 posterior, 677 cystostomy, 815 Dudley's method, 815 Kelly's method, 816 Vaginal drainage after supravaginal hyster- ectomy, 723 hysterectomy, 728 for carcinoma of cervix, 744-750 myomectomy, 756 tampons in prolapse of uterus, 472 wall, prolapse, 457 relaxation, as cause of sterility, 558 Vaginismus, 533 as cause of sterility, 561 false, 533 treatment, 534 Vaginitis, 236 acute septic, after acute infectious diseases, 157 emphysematosa, 239 etiology, 237 prognosis, 239 senile, 544 symptoms, 238 treatment, 238 Vaporization in uterine insufficiency, 548 Varices, 119 operations for, 828 Varicocele of vulva, 293 Varicose ulcer, Credo's ointment in, 830 operations for, 830 scarlet ointment in, 830 veins, 119 Mayos' operation for, 829 of vulva, 293 operations for, 828 Vasomotor disturbances after ovariectomy, 55, 128 during menstruation, 21 of menopause, 114, 129 sensitiveness, 113 symptoms in uterine fibroids, 115 Veins, varicose, 119 Mayos' operation for, 829 of vulva, 293 operations for, 728 Ventral fixation in retroversion of uterus, 467 suspension in retroversion of uterus, 467 Vermiform appendix, relation of genitaha to, 145 retroperitoneal, 172 Version of uterus, lateral, 455 Version-flexion of uterus, 455 Vesical. See Bladder. Vesicocervicovaginal fistula, 498 operation for, 659 Vesico-uterine fistula, 498 operation for, 659 Vesicovaginal fistula, 498 Braquehaye's operation, 657 INDEX Vesicovaginal fistula, Braquehaye's operation, Albarran's modification, 657, 659 operations for, 653 Sims' operation, 653 Vestibular anus, 451 Vestibule, caruncle of, 293 mucous polyp of, 293 papillary angioma of, 293 Vicarious dysmenorrhea, 113 menstruation, 21 skin lesion from, 96 salivation, 100 Visceroptosis, 158. See also Enteropiosis. Vitiligo associated with abdominal tumors, 97 Vocal cords during menstruation, 21, 104 Voice after ovariectomy, 52 during menstruation, 21, 104 Vulva, adenoma hidradenoides, 287 Bilharzia hsematobia, 238 carcinoma of, 287 Bassett's operation, 584, 585 diagnosis, 289 operative treatment, 584 Taussig's operation for, 291, 584 treatment, 290 chancre of, soft, 224 condyloma acuminata of, 227 treatment, 228 cysts of, sebaceous, 225 Distoma haematobium in, 238 echinococcus cyst, 292 eczema intertrigo, 225 elephantiasis of, 230 enchondroma of, 292 epithelioma of, 289 esthiomene of, 229 treatment, 230 fatty tumors, 287 fibroma of, 286 molluscum pendulum, 287 treatment, 287 fibromyoma of, 286 furunculosis of, 225 hydrocele muliebris, 292 inflammations of, 224 kraurosis of, 232 radium in, 531 treatment, 233 leukoplakia of, 234 lipoma of, 287 lupus of, 220 myxoma of, 292 _ neuroma of, 292 operations on, 582 osteoma of, 292 Paget's disease of, 234 Vulva, papillary excrescences, 227 pruritus of, 234 etiology, 235 radium in, 531 treatment, 235 renioval of, indications, 582 rodent ulcer, 229 sarcoma of, 292 sebaceous cysts, 225 seborrhea of, 225 skin lesions, 225 soft chancre, 224 syphilis of, 225 teratoma of, 292 tuberculosis of, 220 tumors of, 286 ulceration of, 229 ulcus molle, 224 varicocele of, 293 varicose veins of, 119, 293 warty excrescences, 227 Vulvectomy, 582 Vulvitis, 224 gonorrheal, 179 Vulvovaginitis, gonorrheal, in children, 179 treatment, 180 in children from thread-worms, 238 vaccine treatment, 215 Walthaed's method of examination in vaginismus, 534 Wandering stitch as cause of vesical calculus, 428 Warren's apron incision in fistula in ano, 825 operation for complete laceration of peri- neum, 652 Warty excrescences of vulva, 227 Watkins' operation for prolapse and proci- dentia of uterus, 479, 699 Wave theory of menstruation, 120 Webster-Baldy operation for retroversion of uterus, 468, 685 Wertheim's operation for carcinoma of cervix, 731-744 of uterus, 731-744 for prolapse and procidentia of uterus, 705 Whitehead's operation for carcinoma of rec- tum, 430 for hemorrhoids, 819 Wilms' cecum mobile, 159, 169 operation for enteroptosis, 165 Wolffian bodies, 436 retrogression, 438 INDEX 885 Wolffian ducts, 436, 441 retrogression, 438 Wounds, postoperative hernia, 503 Z-RAT as cause of sterility, 559 in bleeding from uterine fibroids, 325 in carcinoma of cervix, 348 in gland hypertrophy of endometrium, 251 X-ray in menorrhagia of youth, 533 in pruritus of vulva, 236 in sarcoma of uterus, 332 in uterine insufficiency, 549 Zinc chlorid in carcinoma of cervix, 362 Zona pellucida, 36 Zuckerkandl, accessory organs of, 85 COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below or at the expiration of a definite period after the date of borrowing, provided by the rules of the Library or by special ar- rangement with the Librarian in charge. 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