Columtjia fflnitiersiitp mtf)eCitpofi^eto|9orfe CoUese of l^\)^iitiani anb ^urgeonsf Br. Ctitoin P. Cragin 1859-1918 THE DISEASES OF WOMEN A HANDBOOK FOR STUDENTS AND PRACTITIONERS BY J. BLAND SUTTON, F. R. C S. Enc, Surgeon to the Chelsea Hospital for Women; Assistant Surgeon, Middlesex Hospital, London ; AND ARTHUR E. GILES, M. D., B. Sc. Lond., F. R. C. S. Edin., Assistant Surgeon, Chelsea Hospital for Women, London WITH ri5 ILLUSTRATIONS rTITLADELPTITA W. B. SAUNDERS 925 Walnut Street 1897 LONDON: RF.B^L^N PUBLISHING CO., Ltd., ii Adam St., Strand. Copyright, 1897, By\A/. B. SAUNDERS. PRESS or WtSTCOTT li THOMSON PHILAOA. ELECTHOTVPEO OV W. B SAUNDERS PHILAO* PREFACE. In writing this book it has been our earnest desire to relate facts and describe methods belonging to the science and art of Gynaecology in a way that may be useful to students for examination purposes, and which will also enable them to practise this important department of sur- gery with advantage to their patients and with satisfaction to themselves. J. BLAND SUTTON, ARTHUR E. GILES. London, June, 1897. Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/diseasesofwomenhOOblan CONTENTS. CHAPTER I. PAGB The Anatomy of the Reproductive Organs of Women 17 Ovaries, 17; Parovarium, 18; Fallopian Tubes, 18; Uterus, 19; Vagina, 20; Vulva, 21; Arteries, 23; Veins, 25; Lymphatics, 26; Nerves, 26; Pelvic Peritoneum, 26; Mesometrium, 26. CHAPTER II. Physiology of the Reproductive Organs of Women 30 Menstruation, 30; Anatomical and Physiological Changes, 31 ; Sig- nificance of Menstruation, 36 ; the Menopause, 37. CHAPTER III. Methods of Examination of the Female Pelvic Organs .... 38 Abdominal Examination, 38; Vaginal Examination, 39; Bi- manual Examination, 40 ; the Uterine Sound, 41 ; the Volsella, 44 ; the Speculum, 45 ; Examination under an Anaesthetic, 48. CHAPTER IV. Malformations of the Reproductive Organs of Women .... 49 Malformations of the Vulva ; Hermaphrodism and Pseudo-her- maphrudism, 49. CHAPTER V. Malformations of the Reproductive Organs of Women (Con- tinued) 59 Malformations of the Vagina, 59 ; Absence of the Vagina, 59 ; Atresia of the Vagina, 59 ; Stenosis of the Vagina, 59 ; Double Vagina, 60 ; Malformations of the Uterus, 61 ; Absence of the Uterus, 61 ; Rudimentary Uterus, 61 ; Infantile Uterus, 6l ; Single- horned Uterus, 62 ; Double Uterus, 63. 5 /' 6 CONTENTS. CIIArrER VI. rACB Retention of Menstrual TRODUcrs in Atresia 68 Atresia of the Vagina, 68 ; of the Os Externum, 68 ; kA the ( >^ Internum, 68; affecting One Half of a Double Uterus or Vagina, 68. CHAPTER VII. Diseases OF the Vulva : Age-changi;s ; Inflammations 77 Age-changes, 77 ; Injuries, 79 ; Varix, 79 ; Hafmatoma, 80 ; Vul- vitis, 80 ; CEdenia, %i ; Erysipelas, 83 ; Gangrene, 84 ; Abscess, 84. CHAPTER VIII. Diseases of the Vulva (Continued) : Cutaneous Diseases .... 85 Eczema, 85; Herpes, 85; Lupus, 86; Syphilis, 86; Elephanti- asis, 86 ; Pruritus, 87 ; Kraurosis, 88. CHAPTER IX. Diseases of the Vulva (Continued): Morbid Conditions of the Clitoris, Urethral Orifice, and Perineum 91 The Hymen, 91 ; Diseases of the Clitoris, 93 ; Urethral Caruncle, 93 ; Ruptured Perineum, 94. CHAPTER X. Diseases of the Vulva (Continued) : Tumors and Cysts 97 Li|K)mata, 97 ; Myxomata, 97 ; Sarcomata, 97 ; .'Vngeiomata, 97 ; Papillomata, 97 ; Epithelioma, 97 ; Carcinoma, 99 ; Mucous Cysts, 99 ; Sebaceous Cysts, 99 ; Cysts of Bartholin's Gland, 99. CHAPTER XI. Diseases of the Vagina : Age-changes; Displacements ; Iniurii-:s . 102 Age-changes, 102; Cystocele, 103; Rectocele, 103; Enterocele, 107; Injuries, 107; Foreign Bodies, 108; Fistuloc, 109. CHAPTER XII. D1SEASF.S OF THE Vagina (Continued) : Vaginal Infection and the Vaginal Secretions i" Normal Vaginal Secretion, III; Pathological Vaginal Secretion, 114; Varieties of Discharge found in the Vagina, 117. CONTENTS. 7 CIIMTKR XI I r. vscv. Diseases of the Vagina (Continued) : Inflammation, Tumoks, and Cysts ii8 Vaginitis, ii8; Saicoma, 124; Epilhelionia, 125; Mucous Cysts, 125; Gartncrian Cysts, 125 ; Peri-urelhral Cysts, 126 ; Echinococcus Colonics, 126. CHAPTER XIV. Diseases of the Uterus : Flexions and Displacements 127 Age-changes, 127 ; Uterine Measurements, 127; Anteflexion, 128; Retroflexion, 129; Retroversion, 131. CHAPTER XV. Diseases of the Uterus (Continued): Displacements; Hyper- trophy AND Atrophy 136 Prolapse and Procidentia, 136; Hypertrophy of the Supra-vaginal Portion, 141 ; Hypertrophy of the Vaginal Portion, 144; Atrophy of the Uterus, 146. CHAPTER XVI. Pessaries 147 Ring Pessary, 148 ; Hodge Pessary, 148 ; Vaginal Stem Pessary, 150; Contraindications to the Use of Pessaries, 150; Retained Pessary, 151. CHAPTER XVII. Diseases of the Uterus (Continued) : Inversion of the Uterus . 153 CHAPTER XVIII. Diseases of the Uterus (Continued) : Injuries ; Diseases result- ing from Gestation 160 Laceration of the Cervix, 160; Perforation of the Uterus, 163; Superinvolution, 163; Subinvolution, 164; Retained Products of Conception, 165. CHAPTER XIX. Diseases of the Uterus (Continued) : Diseases of the Endo- metrium i68 Acute Endometritis, 169; Chronic Endometritis, 172. CHAPTER XX. PAGB Diseases of the Uterus (Continued): The Endometrium (Con- tinued) 174 Adenomatous Disease of the Cervix (Erosion), 174; Adenomatous Disease of the Corporeal Endometrium, 17S; Tuberculosis, 179. CHAl'TEk XXI. Diseases ok the Uterus (Continulii) : Mycmata 181 ^ Intramural Myomata, 182; Submucous Myomala, 184; .Subserous Myomata, 186; Secondary Changes, 186; Impaction, 188; Myomata and Pregnancy, 189. CHAPTER XXII. Diseases of the Uterus (Continued) : Clinical Characters axd Treatment ok Myomata 192 Clinical Characters, 192 ; Diagnosis of Myomata and Pregnancy, 193; Normal Pregnancy, 194; Ilydramnion, 195; Retroversion of the (}ravid Uterus, 195; Cornual Pregnancy, 196; Treatment of Myomata, 198; Polypi, 201. CHAPTER XXni. Diseases ok the Uterus (Continued) : Sarcoma, Adenoma, and Car- cinoma 202 Sarcoma, 202; Epithelioma, 206; Adenoma. 207; Carcinoma of the Cervix, 208; Carcinoma of the Body of the Uterus, 212; Re- tention-cysts, 213. CHAPTER XXIV. Diseases of THE Fallopian Tubes 215 Salpingitis, 215; Pyosalpinx, 217 ; Hydrosalpinx, 218 ; Ilamato- salpinx, 219; Tubercular Salpingitis, 220; Tumors of the Fallopian Tube, 222. CHAPTER XXV. Diseased of the Fallopian Tubes (Continued) : Diagnosis and Treatment of Salpingitis 224 Acute Salpingitis, 224 ; Chronic Salpingitis, 225. CONTENTS. 9 CHAPTER XXVI. PAGE Diseases of the Fallopian Tubes (Continued) : Tubal Gestation . 229 Tubal Changes, 230 ; the Tubal Mole, 231 ; Tubal Abortion, 232 ; Rupture of the Gestation-sac, 234 ; Tubo-uterine Gestation, 239. CHAPTER XXVn. Diseases of the Fallopian Tubes (Continued) : Tubal Gestation (Continued) 241 Diagnosis, 241 ; Treatment, 245. CHAPTER XXVni. Diseases of the Ovaries 250 Age-changes, 250 ; Malformations, 251 ; Displacements, 251 ; Corpus Luteum, 255; Apoplexy of the Ovary, 256; Oophoritis, 257; Cirrhosis of the Ovaries, 259; Ovarian Neuralgia, 259. CHAPTER XXIX. Diseases of the Ovaries (Continited) : Tumors and Cysts .... 261 Fibromata, 261; Myomata, 261; Sarcomata, 262; Carcinoma, 263 ; Simple Cysts, 263 ; Adenomata, 265 ; Dermoids, 265 ; Papil- lomatous Cysts, 269 ; Parovarian Cysts, 270 ; Gartnerian Cysts, 271. CHAPTER XXX. Diseases of the Ovaries (Continued) : Secondary Changes in Ovarian Tumors 273 Septic Infection, 273 ; Axial Rotation, 275 ; Rupture, 276; Symp- toms and Diagnosis of Ovarian Tumors, 277. CHAPTER XXXI. Diseases of the Ovaries (Continued) : Differential Diagnosis and Treatment of Ovarian Tumors 2S1 Phantom Tumor, 282; Pregnancy, 282; Ascites, 283; Distended Bladder, 283; Kidney, Spleen, Liver, 284; Ovarian Tumors and Pregnancy, 2S5 ; Treatment of Ovarian Tumors, 286. CHAPTER XXXII. Diseases of the Pelvic Peritoneum and Cellular Tissue .... 2S8 Septic Infection, 288; Epithelial Infection, 289 ; Hydroperitoneum, 290 J Pelvic Cellulitis, 292; Pelvic Abscess, 293. lO CONJENJS. CHAPTER XXXIII. rxcB Diseases ok the Pelvic Peritoneum and Celli'lar Tissue (Con- tinued) : Tlmors 296 Lipomata, 296; Myomata, 296; Sarcomata, 297; Echinococcus Colonies of the Pelvis, 297. CHAITEK XXXIV. Disorders of Menstruation 301 Amenorrhcca, 301 ; CryptomenorrlnLa, 303 ; Menorrhagia and Metrorrhagia, 304; Dysmenorrhcea, 306; Membranous Dysmenor- rhoea, 310. CHAPTER XXXV. Vaginismus and Dyspareunia; Sterility 312 Vaginismus, 312; Dyspareunia, 313; Sterility, 314. CHAPTER XXXVI. Diagnosis 318 Family History and Previous Health, 318; Menstruation, 319; Confinements and Miscarriages, 319 ; Present Illness, 320; Present Symptoms, 321 ; Rectal and Vesical Symptoms, 322 ; General Symptoms, 323. CHAPTER XXXVH. Diagnosis (Continued) : The Physical Examination 325 General Health and Appearance, 325 ; Heart, Lungs, etc., 325 ; Abdominal Examination, 325 ; Vaginal Examination, 328. CHAPTER XXXVIII. GYNitCOLOGICAL OPERATIONS 2>ii General Considerations, 333 ; Operations during Menstruation, 335; Preparation of the Patient, 335; the Crutch, 336; the Sterilizer, 339. CHAPTER XXXIX. Vaginal Operations: Operations on the Perineum, Vulva, and Vagina 34' Perineorrhaphy, 341 ; Removal of Urethral Caruncle, 347 ; Re- moval of the Clitoris, 348 ; Bartholinian Cysts, 349 ; Coljxjrrhaphy, 350- CONTENTS. 1 1 CHAPTER XL. HAGS Vaginal Operations (Continued) : Vaginal Fistula; Atresia ok THE Genital Canal 352 Vesi CO- vaginal Fistula, 352 ; Uretero-vaginal Fistula, 354 ; Ulcro- vesical Fistula, 355 ; Recto-vaginal Fistula, 355 ; Colpocleisis, 355 ; Imperforate Hymen, 355 ; Cicatricial Union of the Labia, 356 ; Occlusion of the Vagina, 357 ; Atresia of the Cervix, 358. CHAPTER XLI. Vaginal Operations (Continued) : Operations on the Uterus . . 359 Dilatation of the Cervix, 359; Curetting, 360; Vaginal Myomec- tomy, 363. CHAPTER XLH. Vaginal Operations (Continued) : Operations on the Uterus (Continued) 368 Trachelorrhaphy, 368 ; Amputation of the Cervix, 370 ; Amputa- tion of the Hypertrophied Cervix, 372 ; Vaginal Hysterectomy, 373 ; Anterior Colpotomy, 376. CHAPTER XLIIL Abdominal Operations : General Considerations 379 Coeliotomy, 379 ; Preparation of the Patient, 379 ; Instruments, 380 ; Suture and Ligature Material, 380; Sponges, 381 ; the Table, 382 ; Anaesthesia, 3S2 ; Abdominal Incision, 382 ; Closure of the Wound, 383 ; Dressing, 384 ; In'igation, 384 ; Drainage, 384. CHAPTER XLIV. Abdominal Operations (Continued) : Ovariotomy and Oophorec- tomy 387 Ovariotomy, 387 ; Incomplete Ovariotomy, 394 ; Anomalous Ovari- otomy, 394; Repeated Ovariotomy, 395 ; Oophorectomy, 395. CHAPTER XLV. Abdominal Operations (Continued) : Ovariotomy (Continued) . 399 After-treatment, 399 ; Risks of Ovariotomy, 401 : Injury to \'is- cera, 402 ; Foreign Bodies Left in the Abdomen, 404; Sequelre of Ovariotomy, 405 ; Remote Effects of Ovariotomy on Primary and Secondary Sexual Characters, 407. 12 CO.V'/L.Vy^. CHAPTER XLVI. PACE Abdominal Oi-erations (Continued) : Operations for Tibal i'regnancy 408 At the Time of Priman- Rupture, 408; Subsequent to Primary Rupture, 409 ; Mesometric Rupture, 409 ; After the Fifth Month, 409. CHAPTER XLVH. Abdominal Operations (Continued) : Operations on the Uterus . 411 Supra-vaginal Hysterectomy, 411; Pan-hysterectomy, 414; Myo- mectomy, 415; Ccesarean Section, 416; Porro's Operation, 418: Hysteropexy, 419; Shortening the Round Ligaments, 421. LIST OF ILLUSTRATIONS. FIGURE PAGE 1. Sagittal section of the female pelvis 19 2. The vulva of an adult 22 3. Diagram of the uterine and ovarian arteries 23 4. Diagram of the hypogastric stem 24 5. Diagram of ovulation 32 6. Stages in the formation of a corpus luteum 34 7. The uterine sound •••.... 42 8. Volsellce 45 9. Fergusson's speculum 4° 10. The duck-bill speculum 46 11. Generative organs of the embr)o 5^ 12. Generative organs of the male 52 13. Generative organs of the female 54 14. The external organs of a bypospadiac male 5^ 15. Uterus in a boy 57 16. Exstrophy of the bladder in a girl 5^ 17. Rudimentary uterus 60 18. Conical cer\-ix 61 19. Normal nulliparous cei"vix 61 20. Multiparous cervix 61 21. Unicom uterus 63 22. Uterus bicomis ... 64 23. Uterus didelphys . , 65 24. Diagram illustrating the effects of atresia 69 25. Diagram illustrating the effects of atresia 7° 26. Vulva of a girl 77 27. The Hottentot apron 7^ 28. Variations in the shape of the hymeneal aperture 91 29. The vestibular bulb and Bartholin's glands 100 30. Cystocele and rectocele 104 31. Vaginal secretion containing the vagina bacillus 112 32. Cultivation of the vagina bacillus 1 13 33. Gonococci II5 34. The uterus in sagittal section 127 35. Diagram illustrating flexions of the uterus 130 13 14 LIST OF ILLUSTRATIONS. FIGl'KB FACR 36. Prolapse of the ulcrus 1 38 37. Hypertrophy of the supra- vaj;iiial Cervix 142 3S. Two dia'men and lie paral- lel with, but deeper in the vulvar cleft than, the nymphnj. ANATOMY OF REPRODUCTIVE ORGANS. 23 When the labia are separated certain spaces are exposed which receive special names. Of these the most conspicu- ous is the vestibule, an area limited in front by the glans of the clitoris, behind by the margin of the vulvar orifice ; laterally it is limited by the converging borders of the nymphae. The urethra terminates in this space. At the posterior part of the vulvar cleft there is a well-marked depression limited by the hymen and fourchette, known as the fossa navicularis. The opposed surfaces of the labia, great and small, are kept moist with the secretion furnished by the glands lodged in their cutaneous investment. In addition there are two special structures known as the glands of Bartholin, which measure i cm. in width, lodged one on each side near the outer aperture of the vagina. The orifice of each duct opens in the recess between the corresponding labium mi- nus and the fold of the hymen (Fig. 29). OVARIAN AR ROUND LIGAMENT UTERINE ART Fig. 3. — Diagram showing the uterine and ovarian arteries. The Arteries. — i. The Ovarian Arterj.—Thxs vessel arises on each side from the abdominal aorta below the renal arteries, and runs downward in the subserous tissue 24 DISEASES or WOMEN. to pass between the layers of llie niesomctrium at the brim of the i)elvis ; it tlieii makes its way to the side of tlie uterus near the fundus to inoscuhite with the uterine artery. In its mesometric course branches are distributed to tlie ovary, Fallopian tube, fundus of the uterus, and the meso- metric connective tissue (Fig. 3) ; an arterial twig also issues from it to anastomose with a small vessel derived from the deep epigastric arter)-, which is conducted along the round ligament of the uterus. 2. The Uterine Artery. — In a large proportion of cases this artery comes from the h}'pogastric trunk, a branch of Common iliac. Hypogastric stem. Superior vesical. Inferior vesical. Uterine. AfiJdle hamorrhoidal. Obturator. Internal pudic. Sciatic. Gluteal. Fig. 4. — Diagram to show the uterine artery arising from the hypogastric stem (Parsons and Keith). the anterior division of the internal iliac, which breaks up into superior vesical, inferior vesical, and uterine branches (Fig. 4). In other cases the uterine artery arises as a sepa- rate branch from the anterior division of the internal iliac. It runs under the peh'ic peritoneum toward the cer\i.\ : on ANAl'OMY OF RErRODUCTIVR ORGANS. 2$ entering the mesometrium it turns upward and pursues a tortuous course on the side of the uterus nearer the pos- terior than the anterior surface, and on approaching the fundus inoscuhites with the ovarian artery. In its course along the uterus it gives many branches which pass across the anterior and posterior wall of the organ to anastomose with corresponding twigs from the opposite artery. 3. 77u' Vaginal Ai-fcrics. — There are two or three vagi- nal arteries which arise from the anterior division of each internal iliac artery, or they may be derived from the uter- ine or middle ha^morrhoidal arteries. They traverse the pelvic connective tissue and ramify on the walls of the vagina, anastomosing with the vessels of the opposite side. 4. The Vulvar Arteries. — The greater and lesser labia are supplied by branches from the superficial and deep external pudics and the superficial and transverse perineal branches of the internal pudic. The clitoris derives its blood-supply from the terminal branches of the internal pudic arter}', which arises from the anterior division of the internal iliac. This vessel also gives branches to the skin and the deep tissues of the labia, including the bulbi vestibuli. The Veins. — i. Ovarian Veins. — These are situated mainly in the mesosalpinx, where they form the pampini- form plexus. Near the outer end of the mesosalpinx the veins coalesce and form a single vessel — the ovarian vein — which joins on the right side the inferior vena cava, and on the left side the renal vein. 2. The Uteritie Veins. — These form a large plexus in each mesometrium ; the individual branches are sometimes very large. From this plexus a single trunk issues to join the internal iliac vein. 3. The Vaginal J^eins. — These form a plexus around the vagina from which definite branches issue and accompany the arteries. 4. The Vulvar J^eins. — These also accomjian)' the cor- 26 DISEASES OE WOMEN. responding arteries. The superficial external pudic vein terminates in the great saphena vein. The internal pudic ends in the internal iliac vein. The veins from the bulbi vestibuli communicate with the vaginal, pudic, and obtura- tor veins. The Ivymphatics. — The lymphatics follow the course of the veins. Thus the lymphatics from the ovaries, the Fallopian tubes, and fundus of the uterus accompany the ovarian veins and terminate in the lumbar lymph glands. The lymphatics of the round ligament of the uterus join the inguinal glands ; whilst those of the lower segment of the body of the uterus and its cervix open into the glands lying alongside the iliac vessels. The vaginal lymphatics join the pelvic glands. The vulvar lymphatics open into the inguinal glands, but those from the clitoris accompany the internal pudic arteries to the pelvic glands. The Nerves. — The nerves of the ovaries. Fallopian tubes, and uterus are derived from the .sympathetic .system, and are conducted to them along the vessels : branches from the renal plexus are conveyed to the ovaries and tubes by the ovarian arteries, whilst the hypogastric plexus, inter- mingled with twigs from the third and fourth sacral nerves, supplies the uterus and vagina. The vulvar structures are supplied by the ilio-inguinal nerve and the long pudendal branch of the small sciatic nerve. A branch of the genito-crural accompanies the round ligament of the uterus into the labium majus. The clitoris is supplied by the internal pudic : this is a compara- tively large ner\'e, and its terminal twigs end in tactile cor- puscles. This nerve by its superficial perineal branches also supplies the labia. The Pelvic Peritoneum. — The pelvic peritoneum in women has a complex disposition which it is necessar}' to thoroughly appreciate in order to comprehend the various morbid conditions to which the pelvic organs are liable. The peritoneum as it descends from the posterior wall of ANATOMY OF REPRODUCTIVE ORGANS. 2/ the abdomen enters the cavity of tlie true pelvis and covers the anterior face of the sacrum, the ureters, sacral plexus of nerves, and iliac vessels ; it also invests the first part of the rectum and forms the meso-rectum. It gradually leaves the sides of the second part of the rectum and, passing on to the upper 2 cm. of the posterior vaginal wall, extends over the whole of the posterior aspect of the body of the uterus. Continuing, it invests the fundus and anterior sur- foce of the body of the uterus, and leaves it at the level of the internal os to cover the posterior surface of the bladder, and then ascends on the anterior abdominal wall. As the peritoneum invests the uterus a fold known as the meso- metrium (broad ligament) extends from each side of it, which becomes continuous with the peritoneum investing the iliac fossa. Thus the transverse fold formed by the uterus and its mesometria divides the pelvic cavity into two recesses, of which the posterior is the recto-vaginal fossa [pouch of Douglas) and the anterior the utero-vesical fossa. It will be necessary to study these fossae and the meso- metrium in detail. The Mesometrium. — This important fold is formed by the peritoneum as it is reflected over the uterus and Fallo- pian tubes ; it consists of two layers of serous membrane. The part in relation with the uterus and tubes has the fat of the subserous tissue replaced by unstriped muscle tissue, but as it approaches the floor of the pelvis fat again appears in relation with it. The mesometrium lodges between its layers, in addition to the Fallopian tube, the ovary with the parovarium, Gartner's duct, the ligament of the ovary, the round ligament of the uterus, the ureter, the uterine and ovarian arteries, the pampiniform plexus of veins, and the lymphatics of the uterus : these structures are embedded in loose connective tissue. Two strands of muscle tissue, the utero-sacral ligaments, pass from the lateral aspect of the cervix to the sides of the second sacral vertebra. The upper portion of the mesometrium is called the 28 DISEASES OE WOMEN. mesosalpinx ; it is included between the Fallopian tube, the tubo-ovarian li^ranieiit, the ovary and the ovarian ligament, and contains between its layers the parovarium and the associated sej^nient of Gartner's duct, the ovarian arterj' and veins, and the uterine end of the round ligament of the uterus. The Recto-vaginal Fossa {Poudi of Douglas). — This is a cul-de-sac of the peritoneum in relation with the floor of the pelvis, situated, as its name indicates, between the rec- tum and the upper 2 cm. of the posterior vai^nnal wall and the cervix uteri. Laterally the upper limits of this jxjuch are the utero-.sacral ligaments. The pouch is deeper on tlic left than the right side, the peritoneum being carried down- ward by the rectum. When the pouch is not occupied by intestine or omentum, its anterior and posterior walls are in apposition. The Utero-vesical Fossa. — This is a shallower cul- de-sac between the bladder and the body of the uterus. Its depth varies with the empty or distended condition of the bladder. The Ovarian Pouch. — This is a shallow recess in the posterior layer of the mesosalpinx. It varies in depth, being small and inconspicuous in many, whilst in others it is deep enough to accommodate the entire ovar)-. In the virgin the ampulla of the tube falls over the mouth of the pouch and conceals the ovary. Canal of Nuck. — In addition to the two fossae actually within the pelvic cavity, there is a peritoneal pouch directly connected with the anterior layer of each mesometrium which partially invests the round ligament of the uterus and accompanies it through the inguinal canal to the la- bium. This pouch, known as the canal of Nuck, normally becomes obliterated in the adult. In order that the student may thoroughly comprehend the relations of the pelvic peritoneum it will be useful to summarize briefl}' the manner in which it invests the parts : ANATOMY OF RE PRODUCT I VE ORGANS. 29 1. The Ovary. — This projects from the posterior layer of the mcsometrium and strictly has no peritoneal invest- ment. 2. The Fallopian Tube. — This is invested on two-thirds of its circumference. The tubal ostium communicates with the coelom (peritoneal cavity) on the posterior aspect of the mcsometrium, below the ovary and near the brim of the pelvis. 3. The Uterus. — The peritoneum covers, posteriorly, the whole of the surface of the body and fundus of the uterus and supravaginal portion of the cervix ; anteriorly, the fun- dus and -body to the junction of the body and cervix. The sides of the uterus are in relation with the connective tissue of the mcsometrium. TJie Round Ligament of the Uterus. — In the pelvis this structure is invested by the anterior layer of the mcsome- trium. As it traverses the inguinal canal it invaginates the peritoneum of the canal of Nuck. 4. The Vagina. — The only part of this tube in relation with the peritoneum is the posterior cul-de-sac. CHAPTER II. THE GENERAL PHYSIOLOGY OF THE REPRODUCTIVE ORGANS OF WOMEN. The development, maturity, and decline of the reproduc- tive powers in a healthy woman correspond to the men- strual life, the beginning of which is termed Puberty, while its termination is the Menopause. This period extends from the age of thirteen to that of forty-eight, with individ- ual variations. Warm climates, sedentary and luxurious habits, and emotional stimulation are associated with early puberty ; late puberty is commonly found in the opposite conditions. Puberty is sometimes defined as " reproductive maturity ;" but it must be remembered, first, that concep- tion sometimes occurs before menstruation has begun ; secondly, that the uterus continues to grow till about the eighteenth or twentieth year and the woman cannot usu- ally be considered as sexually mature till this time. The external indications of approaching puberty are : enlargement of the breasts (mammse), development of hair in the axillae and on the mons Veneris ; subjective sensa- tions such as fulness of the pelvis, backache and shooting pains in the thighs, and lastly some alteration in the dis- position, in the direction of shyness and reserve. The actual establishment of puberty is reckoned from the first menstruation. MENSTRUATION. I. Clinical Features. — After the first menstruation, which may be rather abundant, it is not unusual for a pe- so PHYSIOLOGY OF REPKODUCTIVE ORGANS. 3 1 riod of irregularity to succeed ; then after some months the process assumes its regular rhythmic form. The periodicity varies with individuals, and in the same individual at differ- ent times ; most frequently twenty-eight to thirty days elapse between the commencement of one period and the commencement of the next. The total quantity of blood lost at each monthly period varies from two to three ounces (60 to 90 c.cm.) and the flow lasts from two to seven days. Sometimes on the third or fourth day it ceases, to recommence in diminished quantity after twenty-four hours for another two or three days. A discharge of mucus commonly precedes and follows that of blood. The latter has all the characteristics of ordinary venous blood, except that it does not coagulate, owing to admixture with mucus from the cervical canal ; it also contains epithelium derived from the uterus and vagina. When abundant, it may be bright red, and clots may form. Under favorable condi- tions menstruation is painless, especially for the first few years. Later, and in some cases from the first, an aching pain in the sacrum precedes the flow, passing off as this becomes established. Suprapubic pain may either precede or accompany the flow — generally the latter. In London about 30 per cent, of women continue to menstruate pain- lessly. The intensity of the pain varies from slight discom- fort to intense agony preventing the woman from getting about or from attending to her ordinary pursuits. No hard-and-fast line can be drawn between normal menstrua- tion and dysmenorrhoea. Similarly, there is great varia- tion in the nature and amount of constitutional disturbance; headache, lassitude, sickness, obscure reflected pains are not infrequent, with mental depression or irritibility. Lastly, in a few cases the general health is better than during the intermenstrual periods. II. Anatomical and Physiological Changes. — A. Ovulation. — This signifies the ripening and escape of ova from the ovaries. When these glands (which are the 32 DISEASES OE WOMEN. dominant organs of reproduction in women) fail to develop, sterility results, and the woman generally retains the physi- cal characters of the child. Thus the breasts are small, the Dehiscence of a ripe ovum. Ovum. Uvttm:- \ ^Membrana gr,-.' Discus proUgerus. Fig. 5. — Diagram illustrating ovulation ; ovary of the rabbit (A. E. G.). pubic hair is scanty or absent, and the pelvis is narrower than usual, whilst menstruation does not occur or is much delayed. With the onset of puberty the ovaries, previously PHYSIOLOGY OF REPRODUCTn'E ORGANS. 33 small, enlarge and exhibit the periodic series of changes known as ovHlatio)i. Ovulation consists in the growth and shedding of an ovum, which first sinks more deeply into the stroma, and then approaches the surface of the ovary ; the follicle in which the ovum is contained bursts, and the ovum itself is discharged. Normally it finds its way into the Fallopian tube and is propelled along it to the uterus ; should the ovum be fertilized it develops into an embryo. Failing this, it passes out, probably with the menstrual discharges. The process of ovulation will be readily understood by a reference to the accompanying diagram (Fig. 5) repre- senting its successive stages. From this it will be seen that a given ovum first becomes surrounded by a layer of small cells, to form an ovarian (Graafian) follicle. At the same time the stroma bounding the follicle becomes denser. On one side of the ovum a line of cleavage occurs in the middle of the surrounding cells, and the space is found to contain fluid. The ovarian follicle now presents an appear- ance which has been compared to a signet ring ; the margi- nal cells receive the name of membrana granulosa, whilst those immediately surrounding the ovum are called the discus proligerus. As the follicle grows it approaches the surface of the ovary, and its envelope becomes vascu- lar from enlargement of vessels derived from the stroma. The ripe follicle bulges on the surface ; the most promi- nent point, which is non-vascular, gives way and the ovum escapes, surrounded by the discus proligerus. This consti- tutes the dehiscence of the ovum. The cavity of the fol- licle becomes filled with blood, derived from the vessels in its capsule, and the capsule itself contracts in folds. The blood-filled cavity with its convoluted walls is called, from its yellow appearance, the corpus luteum (Fig. 6). By degrees the liquid part of the blood is absorbed. The cor- pus luteum becomes paler and shrinks and is converted into cicatricial tissue whose only ultimate trace is a scar 3 34 DISEASES OE WOMEN. or cicatrix on tlit.' surface of the ovarj'. \\y the rejx-ti- tioii of this process, the smooth apj^earance of the )'ouii^r ovary is replaced by the ru^^ed aspect of the ovary of the adult. When pret^naucy occurs, the corpus luteum, instead of reachinj^ its fullest development in three weeks and disap- pearin<:j in three months, persists in a well-developed form for three or four months, after which it gradually diminishes, and commonly disappears in two or three months after delivery. Probably a certain number of ova fail, on their dehis- cence, to enter the Fallopian tube, and are lost in the cce- lom (peritoneal cavity). Maturation (ripening) of ova may Fig. 6. — Stages in the formation of a corpus luteum : A, recent blood ; B, ilic wrinkling of its walls ; C, contracting stage (A. E. G.). occur before puberty, and ripe ova have been detected in the ovaries at birth. The view formerly held, that an ovum ripens at each menstrual period, is now abandoned by most authorities. Nor is there any evidence that ovulation occurs alternately in the two ovaries ; there is apparently no con- stant relation in the activity of the two glands. B. CJiangcs in the Uterus. — The only part of the uterus which shows menstrual changes is that between the inner orifices of the Fallopian tubes and the internal os. The PHYSIOLOGY OF RErKODUCTrVE ORGANS. 35 Fallopian tubes themselves take no part therein (Sutton, Heape). The preeise nature of the chancres, which affect the mucosa alone, has been much disputed. The classical views have been as follows : {a) That the whole thickness of the mucosa, down to the muscular layer, is stripped off and shed at each monthly period (Pouchet, Williams). ib) That the surface epithelium only is cast off (Leopold, Kundrat and Engelmann). [c] That the mucous membrane remains quite intact (Coste, Moricke). The difficulty of obtaining specimens of the healthy menstruating uterus has led to this divergence of views. There is, however, reason to believe that in some of the higher apes the process closely resembles that which occurs in women ; and, basing our description partly on compara- tive observations (Sutton, Heape) and partly on researches on the human uterus, the changes are as follows : The mucosa of the non-menstruating uterus is composed of a stroma containing numerous glands and blood-vessels, and covered by a single layer of cubical epithelium. Shortly before menstruation begins the stroma-cells proliferate and the superficial vessels become dilated ; with increased con- gestion the dilated capillaries break down and blood is extravasated into the superficial parts of the stroma under the epithelium. Later the epithelium gives way, probably in part from a degenerative change, and is cast off, along with portions of the stroma and of the glandular epithelium. The debris passes out with the menstrual fluid. After a time, regeneration of the mucosal surface takes place, by re-formation of blood-vessels and by the reproduction of epithelium, partly from the torn edges of the glands and partly by the transformation of stroma elements (Heape). During menstruation there is a slight spontaneous dilata- tion of the cervical canal, attaining its maximum on the third and fourth days (Herman). 36 DISEASES OF WOMEN. 111. The Significance of Menstruation. — Wc need not refer here to old theories, which are merely of historic interest. The first attempt to explain menstruation from the facts of anatomy and physiology resulted in the Oi'ulaliou Theory, which supposes that regularly, every month, an ovum ripens and is set free, leading to uterine congestion and menstruation. This theory, which was widely held during the second quarter of this century, through the work of Lee, Negrier, Bischoff and Raciborsky, is now generally discarded ; for repeatedly instances have occurred where menstruation has recently happened and there has been no trace of the ripening of an ovum ; and, on the other hand, where ripe follicles and recent corpora lutea are present and menstruation has not been established, or has ceased, or is in abeyance. An explanation has therefore been sought in the periodic variations of nutrition, as shown by the pulse, temperature, blood-pressure, and the quantity of urea excreted. This is the Cyclical Theory (Jacobi, Goodman, Reinl, and others). The existence of the variations is established ; but that they are the cause of menstruation, is not. Probably the simplest way to regard the whole matter is as follows : The female organism presents a tendency to an alternation of nutritive -and reproductive activity. The alternation has a monthly rhythm ; but to inquire why, is as fruitful as to ask why the respiratory rhythm should be about four seconds or the cardiac cycle something under one second. Periodically, then, the body prepares itself to take on reproductive functions ; in this preparation the vaso-motor system acts as chief agent, as shown in variations of tem- perature, pulse, and nervous manifestations, as well as in ovarian and uterine changes. The latter are directed to the protection and nutrition of a developing ovum, for the changes preceding menstruation correspond closely to the early stages in the formation of the decidua of pregnancy. PHYSIOLOGY OF REPRODUCTIVE ORGANS. 37 If, however, no fertilized ovum be ready, a miniature abor- tion occurs, for the nidus of the early embryo must always be freshly prepared. After the menstrual discharge, the uterus begins its preparations anew. Menstruation, there- fore, is a missed pregnancy. The Menopause. — The onset of the menopause pre- sents very varied features. In some women there is no disturbance at all ; menstruation goes on normally and then simply ceases, without prodromata ; this occurs most often among unmarried women. In other cases menstruation becomes irregular in its periodicity, while the quantity becomes variable ; after an unusually long interval there is a final and rather profuse flow, and the menopause is estab- lished without any constitutional trouble. But in the majority of women the "change of life" is not so easily effected. Various nervous phenomena appear ; the patient is subject to hot flushes, attacks of giddiness, obscure pains in breasts, abdomen, and limbs. Digestion is disordered, with flatulence and constipation. There is a great tendency to deposits of fat, which, with the flatulence, may cause " spurious pregnancy," or a phantom tumor. Many women become depressed, and unstable minds may cross the border-line of insanity. It is, therefore, with many, really a " critical period," demanding careful supervision. The pelvic organs show corresponding anatomical changes. The ovaries become smaller and wrinkled ; the vagina contracts and assumes the shape of a cone, at the apex of which is a dimple representing the os uteri, — for all the vaginal portion of the cervix atrophies and disap- pears. The uterine body diminishes in size, and in extreme cases can hardly be felt. CHAPTER III. METHODS OF EXAMINATION UF THE FEMALE I'ELVIC ORGANS. Accurate diagnosis is not a matter of intuition. It de- pends on a scientific intcrjjictation of physical signs and of symptoms. The value of symptoms is threefold. They determine, first the necessity, and secondly the meth(jd of examina- tion ; thirdly, they influence the interpretation of signs. The value of physical signs is that they are of the nature of facts ; for their discovery, training and a systematic method are essential. This chapter is concerned with the exposition of a systematic method; whilst the student will obtain his training by the application of the method in the out-patient room and by the bedside. Abdominal Examination. — This should alwa)'s be made first, in the classical order : Inspection, Palpation, Percussion, Auscultation. Inspection. — This shows the size of the abdomen, and may reveal striae, pigmentations, prominence of superficial veins, irregularities of surface, as evidence of past or present distention or of intra-abdominal pressure. Palpation shows in the first place the resistance of the abdominal walls, and when carried deeper will give infor- mation as to the enlargement of particular organs or of certain parts of the abdomen. If there be any abdominal tenderness this is also revealed. It is often necessary to ascertain the condition and relations of the liver, stomach, spleen, and kidneys. Palpation is also most important in 38 exam/jVation of pelvic organs. 39 pregnancy. In the absence of a tumor occupying the pel- vic inlet, the sacral promontory can be easily reached. Parussion indicates the nature of local or generalized abnormalities discovered by palpation ; solid, liquid or gas- eous local conditions may thus be analyzed, and the size and distribution of tumors or of collections of fluid may be ascertained. A loaded colon, often of significance, will sometimes be discovered by this and the preceding method. Ausailtatioii has also its value, chiefly in pregnancy and in certain uterine tumors where a venous murmur may be heard. In conducting the above inquiries the position of the patient may require to be changed ; she may be turned to one or the other side, or the knees may be drawn up in order to relax the abdominal muscles. Inspection of the external genitals is often unnecessary, at least in the first instance, whilst in other cases it will be indicated by the nature of the symptoms complained of Vaginal Bxamination. — For this purpose the patient may lie on her back or side. The Dorsal Position. — We take this first because it is the best for a complete pelvic examination. It is often convenient to let the patient retain the position in which the abdominal examination was made, the knees being drawn up. The right hand is used for the vaginal exploration, and the left for abdominal palpation, the physician standing on the right side of the patient. Or, if more convenient, the patient is placed at the foot or side of the bed, with knees drawn up and everted, the physician standing or sitting opposite the perineum. In either case the examination is made in the same systematic manner. The index finger, well lubricated, is introduced into the vagina by gently feeling for the perineum, and passing forward till the posterior margin of the vaginal outlet is 40 D/SIiASF.S OF WOMEN. reached. In the vagina, the finder should press chiefly against the posterior wall. It must be remembered that the direction of the vay^ina is toward the body of the first sacral vertebra. After the character of the vaginal walls and of the cervix have been noted, the left hand is placed on the abdomen, to make the bimanual examination. The abdominal wall is depressed just above the pubes, the fingers being placed as flat as possible to avoid hurting the patient with the nails or finger tips. The position of the pelvic brim must be remembered; for exploration of the posterior regions of the pelvis the hand will have to be placed nearer the umbilicus ; similarly, it must be moved to one or other side in examining the lateral parts of the pel- vis. As the external hand is moved, the finger in the vagina is moved at the same time, passing into the anterior, posterior, or lateral vaginal fornices, in order to meet the external fingers ; and gentle pressure must be made till the inside and outside fingers meet, or till some definite struc- ture is felt between them. In women who have borne children it is generally better to use two fingers for the vaginal examination, because we can thus reach higher up, and a better idea is obtained of the position of the organs. Still using the dorsal. position, ^ rccto-abdonii)ial cxavii- nation may be required, either in the first instance in \irgins or to give additional information in others. Much may be made out by this method : the general size, position, and shape of the uterus can be determined, the posterior surface of the uterus exjilored, and the appendages often distinctl)' mapped out. In certain cases a rccto-vagi)ial-abdo]iii>ial cxavimatiou is resorted to ; this is especially useful in defining exudations or solid bodies in the recto-vaginal fossa, for vaginal touch alone might suggest that these were in the rectum, while rectal exploration alone might give the impression that they were in the vagina or connected with the uterus. EXAMINATION OF PELVIC ORGANS. 4 1 TJic Lateral Position. — The patient lies on the left side, with buttocks projecting over the edge of the bed, and with the knees drawn up. In this position the relation of parts is not so clear, and the beginner will more readily make mistakes. It is well, however, to accustom oneself to both methods, and in certain cases it is useful to employ- both in turn. But for some purposes the lateral position answers all requirements, especially when the bimanual examination is not necessary ; whilst for some manipula- tions, both for diagnosis and for treatment, it is preferable. The litlwtomy position, with pelvis raised and knees flexed on the abdomen, is seldom required for an examination, unless under an anaesthetic. The semi-prone position, or Sims', is useful when it is required to examine, with the speculum or otherwise, the anterior vaginal wall, and sometimes for purposes of treat- ment. The patient lies on her left side, and partly prone; both knees are drawn up, the right in front of the left. The patient's chest lies almost flat on the pillow, the left arm is placed behind her or hangs over the edge of the bed. The genii-pectoral position is occasionally required ; for instance, to replace a retroverted gravid uterus. The pa- tient rests on her chest, arms, and knees, the pelvis being raised and the thighs vertical. We have so far traced the methods to be adopted, and the information that may be obtained, in using the hands alone. We must now pass under review the various acces- sory procedures, with the aid of instruments. Of these the most important is the uterine sound. The Uterine Sound. — This is a rod of copper, silver- plated, rigid enough to retain any shape imparted to it, and flexible enough to admit of being bent with the fingers. It is set on a handle which is flattened, and rough on one surface (Fig. 7). The sound is straight in the portion next the handle ; the distal portion is curved, the concavity 42 DISEASES OE IfOMEX. being on the same .side as the rough surface of the handle. The curve is of such a nature that the last 2^ in. (6.2 cm.) form an angle of about 140° with the straight portion; and at the junc- tion of these two parts there is a well-marked knob or angle on the convex side, which can be readily distinguished by the finger, and which marks the distance to which the sound should enter a normal uterus. The instrument is gradu- ated by means of notches on the convex side. The first notch is i \ in. (3.7 cm.) from the tip ; the knob or angle forms the next mark, 2^ in. (6.2 cm.) from the tip, and the remaining notches are i in. (2.5 cm.) apart ; the first being 3I in. (8.7 cm.) from the tip. The length of the uterine canal is easily meas- ured by placing the finger on the point just outside the external os when the sound has passed as far as it will, and keeping the finger in its place while the sound is being withdrawn. The distance is read off by means of the graduation notches. The sound should not be used when the patient has missed a menstrual period, unless preg- nancy be certainly excluded ; when there is any pelvic inflam- FlG. 7. — I he utcriiic sound. mation, malignant disease of the uterus, or when the vagina or cervix is septic. All these EXAMINATION OF PELVIC ORGANS. 43 points can be determined by the preliminary digital ex- aminations. Hoiv to Use the Sound. — It is most important that the position and direction of the uterus should be first deter- mined, so that if, for instance, the uterus is strongly flexed, a little additional curve maybe first imparted to the sound ; if the organ be lying much ante- or retroverted, an idea can be gained beforehand of the general direction that the sound will take. This settled, the finger is placed so as to rest against the os, and the point of the sound is carried along the concavity of the finger and guided by it into the cervical canal. Once entered (a matter of little difficulty, as a rule), the handle of the sound is to be carried gently back to the perineum. In most cases this will suffice to cause the end of the sound to slip through the os internum. No pressure need be used. But if the uterus is retro- verted, the concavity of the sound should first be directed backward, and by moving the handle slightly forward the sound enters the cavity. In some cases, when there is lateral deviation of the uterus, or when the canal is tortuous (as when a myoma is present), a little patience and care will be needed. But always desist rather than use force. The introduction of the sound is sometimes facilitated by taking hold of the anterior lip of the cervix with a volsella, and drawing it gently down. Information Given by the Sound. — It is possible to intro- duce and withdraw a sound, and to realize little but the fact of its introduction ; but, used as an extended, sensitive finger, it will teach much. At the outset the degree of patency of the os will be noted, the smoothness or other- wise of the cervical canal, and the existence (if present) of muscular spasm at the os internum ; one gets also a general idea of the firmness or flabbiness of the tube, through which the sound is passing. The sound once introduced, the length of the ca\'it\' can be measured, and by gentle rota- tory movement its width may be gauged. Projections may 44 DISKASIS OF WOMEN. be met with, as sessile tumors, which at first obstruct the passage of the sound. Sometimes, also, two distinct direc- tions will be found in which the sound passes, as in a bipar- tite uterus. Meanwhile the patient will herself have given some indications ; at certain points she may complain of pain, as in passing through the internal os, or when touch- ing the fundus. If the bimanual examination has revealed a tumor it will now be noted whether the sound passes into it or not, and in the latter case whether movements of the sound are at once conveyed to the tumor or vice versa; in this way a uterine can often be distinguished from a non- uterine tumor. When the tumor is uterine, by placing one finger in the anterior and the other in the posterior fornix, or with one finger in each lateral fornix, it may be possible to determine whether the tumor is in the anterior, posterior, or side wall of the uterus. As the sound is withdrawn, it may be felt to be gripped, either by spasm or by mere narrowness of the passage ; we have here the test of stenosis. If, while the sound is intro- duced as far as possible, the finger be placed on it up against the cervix, and it be kept in this position when the sound is withdrawn, the length of the cavity can be exactly read ofif. Lastly, we look at the sound, to see if its introduction has caused bleeding. The Volsella. — This is principally an instrument for treatment, but may be required also for diagnosis. It is used to draw the cervix down, and is generally applied to the anterior lip. In most cases an antero-posterior grasp of the anterior lip is obtained ; but in nullipara; with a small cervi.x it is often more convenient to seize the lip trans- versely. When the uterine canal is bent, traction on the cervix tends to straighten it, and thus facilitates the intro- duction of the sound. The ordinary volsella (Fig. 8) is slender, with thin hooks ; for obtaining a firm hold, as when the uterine canal is being dilated, the bulldog volsella (Fen- ton's) is a very convenient instrument. EXAMINATION OF PELVIC ORGANS. 45 In removiiiL^ a volsella, care is required lest the vagina be caught and torn. Fig. 8. — Bulldog volsella ; slender volsella. The Speculutn. — Introduced as an instrument of diag- nosis, the specukim has now become an appHance for treatment. There is very little that a speculum shows that cannot be discovered by touch. It is convenient, however, 46 DISEASES OF WOMEN. to sec at times the condition of tlic vagina and the cerxix. The simplest is the cylindrical or Fcrgtisson's spcculnm (Fig. 9). This is a hollow cylinder of stout glass, silvered like a mirror and coated with vidcanite. Its extremity is bevelled and is very liable to chip. When this happens it will scratch the patient and cause j)ain. To introduce it, the instrument is warmed and lubricated with oil or \aseline and the perineum is held backward while the end o{ the speculum is pressed against it. The instrument is gently pushed in the direction of the vaginal axis. If care be taken to avoid pressure ante- FiG. 9. — Fcrgusson's speculum. Fig. 10. — The duckbill (Sims') speculum. riorly against the pubes, and if a suitable size be chosen the procedure causes no pain. As the speculum passes up, a general view is obtained of the vaginal walls, and finally the cervix comes into view. If the uterus is lying forward, the anterior lip of the cervix may alone be visible, until this is drawn down with a tenaculum or volsella. In other po- sitions of the uterus the inferior surface of the cer\'ix comes EXAMINATION OF PELVIC ORGANS. 47 fully into view. A small swab of cotton-wool should be at hand to clear away the mucus and blood (if any) from the surface of the cervix ; this can then be examined with ease. The duckbill (^SiJns') speculum (Fig. lo) can be used only in the semi-prone or the lithotomy position, and requires an assistant to hold it. By its means a good view can be ob- tained of the anterior vaginal wall and of the cervix. The bivalve [Cusco's) speculum is easy to introduce, and allows of considerable separation of the two free ends, whilst the part embraced by the vulvar outlet is not further distended. A good view of the vaginal walls may be ob- tained by slightly rotating the instrument. It has the dis- advantage of complexity of screw and hinges, making it a matter of difficulty to keep it perfectly clean. Neugebauers specuhim is one of the most generally con- venient. The larger posterior blade is first introduced, well lubricated ; the smaller blade lies within the larger, the two together forming a cylinder where they touch. Any degree of separation of the inner ends of the speculum can be ob- tained that may be desired ; a good view of the cervix can be obtained, and by using one blade alone the anterior or posterior vaginal wall can be explored. A very useful instrument is Auvard's specidum. It is on the principle of Sims' speculum, but is made " self-retain- ing " by means of a weight on the handle. The handle itself is grooved, so that it can be used as a conduit for fluids when the vagina is being douched. Its special value, however, is for purposes of operation ; it can only be used with the patient in the lithotomy position. It is sometimes necessary to include in one's examination the digital exploration of the interior of the uterus. Ex- cept immediately or soon after confinement or miscarriage, or when the cervix is dilated by a tumor (polypus), this can only be done under an anaesthetic, and the cervical canal must be dilated. Tents were formerly used for this purpose, but they are always tedious and often unsafe, and except in 48 DISEASES OF WOMEN. special circumstances it is better to carry out dilatation at one sitting. Examination under an Anaesthetic. — We would lay special stress on the importance of this as an aid to exact diagnosis. In the case of unmarried girls and nulli- parous women with narrow vagina it is especially indicated ; partly, in the former case, for ethical reasons. That it may be satisfactory, the rectum should be first emptied by means of an enema, and the urine drawn off, if necessar)', by catheter. The first advantage is the avoidance of pain ; as a con- sequence the examination can be much more thorough, and deep pressure exerted as required. In the second place the muscular relaxation allows of a much better bimanual examination. There should be no difficulty, in an ordinary case, in exactly mapping out the position of the uterus, ovaries, and tubes. The differential diagnosis of pelvic conditions from one another and from renal and other abdominal tumors is comparatively easy. Small pelvic swellings are often easily overlooked in an ordinary examination ; whilst an examination under an anaesthetic in the lithotomy position will generally dis- cover them without trouble. In addition, the bladder and rectum can, if necessary, be thoroughly explored. CHAPTER IV. MALFORMATIONS OF THE REPRODUCTIVE ORGANS OF WOMEN. MALFORMATIONS OF THE VULVA. Hermaphrodism and Pseudo-hermaphrodism. — Hermaphrodism implies the combination in an individual of functional male and female sexual organs. Men and women are distinguished from each other by- two sets of sexual characters, primary and secondary. Primary Sexual Characters. — These are directly associated with the function of reproduction. In a man they include the penis, the testes with the vasa deferentia, the prostate, and Cowper's glands. In a woman they consist of the vagina, the ovaries, the Fallopian tubes, and the uterus. Secondary Sexual CJiaracters. — These comprise those features which enable the male to be distinguished from the female irrespective of the organs of reproduction and those used for the nourishment or protection of the young. The characters belonging to this group, so far as the human family is concerned, are exclusively in possession of the male. Man is distinguished from woman not only in the possession of a beard and greater muscular develop- ment with its necessary accompaniment, greater physical strength, but he has a more powerful voice, and the skin of his trunk and limbs is thick and more abundantly supplied with coarse hair, which has a somewhat different disposition in women. In man the front of the chest is usually covered with hair, and that on the pubes passes upward to the um- 4 -19 50 D/SEAS/:S OF IVOA/E.y. bilicus, whereas in the female it is restricted to the mons Veneris. A less constant feature, but one which seems con- fined to men, is a luxuriant growth of hair on the promi- nence of the pinna known as the tragus. Secondary sexual characters are not present in the young, but become manifest at puberty, by which term we signify reproductive maturity. At this period the generative or- gans increase in size, and in the male become functionally active. In the female, puberty is more strikingly declared by the institution of menstruation. Until the advent of puberty the boy, so far as secondary characters are concerned, resembles the female as much as he does the male, but after that period he begins to assume those indicative of the male. It occasionally happens that children are born with mal- formed external genital organs which render it difficult to determine whether the child is male or female ; even when the individual attains puberty the secondary sexual charac- ters appear in such form as to increase rather than to diminish the doubts which were entertained at the child's nativity. When doubt exists as to the sex of a child it is often termed an hermaphrodite. This term is employed by natu- ralists to signify an animal possessing conjoined ovaries and testes (a combination occasionally occurring in vertebrata and known as an ovotestis), or an ovary on one side and a testis on the other. There is no example on record of such combinations in a human individual which survived its birth, but individuals to which the term hermaphrodite is usually applied are those in which there is defective devel- opment of the external genitals and the secondary' sexual characters resemble those of the female. So far as the human family is concerned individuals with malformed ex- ternal genitals should be called pseudo-hennaphrodites. Before proceeding to describe the leading features of this condition it will be necessary to briefly review the main MALFORMATIONS OF KKPRODUCI'lVE ORGANS. 5 I facts which have been ascertained in reijard to the develop- ment of the organs of reproduction. The early embryo possesses in a potential form the pri- mary sexual organs of both sexes, and at an early stage in its development it would be impossible to determine its sex (Fig. 11). In this undifferentiated stage the future reproduc- Genital gland. Mesonephros. Muller's duct. Round ligament. Ureter. Mesonephric duct. Conjoint Midler s ducts. Urethra. Orifice of Midler s duct. Uro-genital sinus. Penis ; clitoris. Fig. II. — Generative organs of the embryo before the differentiation of sex (Henle). tive organs are represented by two glandular masses which ultimately become the genital glands, and associated with them is a remarkable temporary organ known as the meso- nephros (Wolffian body), furnished with a series of tubules — the mesonephric (Wolffian) tubules, opening into a duct — the mesonephric (Wolffian) duct, which terminates in a recess, known as the uro-genital sinus, which opens to the 52 D/sEAS/:s or women. exterior. In ailtiilinn to the ducts just mentioned there is another pair, known as Mi'iller's ducts, which are jieculiar inasmuch as they open into the ctelom (pleuro-peritoneal cavity) ; they run parallel with the mcsoncphric ducts and open into the uro-<;enital sinus. The external opening of this sinus is surmounted anteriorly by a va.scular body and laterally is limited by two parallel folds of skin. In the male (Fig. 1 2) the genital masses become testicles, the mesonephric (Wolffian) tubules and ducts develop and Testis. -Epididymis. Vas deferens. Ureter, Vesicula. Sinus pocularis. Prostate. Urethra. Bulb. Scrotum Urachus. Corpus cavcrnosum. Corpus spongiosum. Glans penis. Fig. 12.— Generative organs of the male (Hcnlc). become vasa efferentia ; the main duct on each side is known as the vas deferens, which ultimately opens in the floor of the urethra, the adjacent parts of which become exces- MALFORMATIONS OF KE PRODUCTIVE ORGANS. 53 sivcly developed and form a musculo-glandular or^an, the prostate. Coincident with the growth of the mesonephric tubules and duct the glandular part of the mcsonephros atrophies, and its vestiges are incorporated with the testis and lie between the body of the testis and its globus major, closely associated with the vasa efferentia. Usually the Miilleriaii ducts atrophy except at their extremities, the lower of which fuse to form a sinus in relation with the prostatic urethra — the sinus pocularis ; the anterior ex- tremity being probably represented by a pedunculated body, the cyst of Morgagni. In the female (Fig. 13) the Miillerian ducts develop and fuse in their middle and posterior thirds to form a median muscular organ, the uterus and vagina ; the anterior thirds remain separate as the Fallopian tubes. The genital masses become ovaries ; the remains of the mesonephros and the associated tubules and duct persist as vestiges. The glandular elements of the mesonephros are known in the adult ovary as the paroophoron, its tubules form the vertical tubes of the parovarium, and the duct occasionally persists throughout its whole length as Gartner's duct. It has already been pointed out that the orifice of the uro-genital sinus is surmounted by a small eminence and is laterally limited by cutaneous folds. In early embryonic life this orifice is common to the terminations of the urethra, genital passages, and alimentary canal. Subsequently the orifice of the gut is separated from the uro-genital passage, the posterior orifice becomes the anus and the anterior be- comes the uro-genital opening, and the structures in its walls specialize into labia majora, labia minora, clitoris, and hymen, w'ith the various recesses which in the adult receive special names. In the male further fusion and development take place ; the parts which in the female persist as labia fuse together and form the scrotum, and at the same time the anterior prominence enlarges and becomes the penis; the lateral 54 DISEASES OJ- WOMEN. folds fuse in the median line to form a canal, known as the membranous and penile urethra, alon^ its lower border. P^inally the testicles descend from the lumbar region into the false pelvis, then, preceded by a pouch of peritoneum, Round Ui^amcul Crura Bulbi vestihuli Clitoris. Fig. 13. — Generative organs of the fcnialc (Henic). traverse the abdominal wall, and finally occupy perma- nently the scrotum. Thus a .study of the developmental histoiy of the genital organs enables us to prove that the female possesses ves- tiges of male organs, whilst the chief male organs are MALFORMATIONS OF REPRODUCTIVE ORGANS. 55 represented in the female, as set down in the subjoined table : Adult Male. Adult Female. Body of testis. Oophoron. Faradidyniis. Paroophoron. Vasa efi'erentia. Parovarium (epoophoron). Vas deferens. Duct of Gartner. Fallopian tube. Uterus. Sinus pocularis. Vagina. Corpora cavernosa (penis). Corpora cavernosa (cliloridis). Corpus spongiosum. Glans clitoridis and vestibular bulbs. Prostatic urethra. Urethra. Membranous urethra. Vestibule. Folds at the entrance to sinus Hymen. pocularis. Cowper's glands. Bartholin's glands. Scrotum. Labia majora. The embryology of the genitalia makes it clear so far as the external organs are concerned that the male organs are more highly specialized than those of the female, and if the fusion of the parts concerned in forming the penile urethra be arrested, a condition more or less resembling the female is the consequence. For example, the external genitals represented in Fig. 14 illustrate this very well. The erectile body is really an in- complete penis, the penile urethra is represented by a groove opening into a cul-de-sac which corresponds to an incom- plete vulva. The two halves of the scrotum have failed to unite across the median line, and thus resemble labia majora. The right one contains a testis ; the left testis was retained in the inguinal canal. This individual was a hypospadiac male, but to his misfortune was brought up as a girl. Imperfections of this kind in the external genital organs are associated with modifications of the secondary sexual characters. The distribution of hair on the pubes may resem- ble the female type ; often it corresponds to that of a male. Menstruation depends on the co-existence of a uterus ; of 56 DISEASES OE WOMEN. this more will be stated later on. The mamm.x' may be as lar^a' as those of a woman ; more often they are of the male type. The hair on the heatl is no guide, for if an indi- \itlual has been trained as a boy it is short ; if a girl it will usually be long. The presence or absence of hair on the face varies. A pseudo-hermaphrodite may have an abun- Fio. 14. — The external genitals of a hypospadiac male or pseudo-licrniaphrodite. dant beard and mustache. At puberty the voice changes to that of a man and sexual inclination is manifested for women. It is a significant fact that the condition of tiie external genitals in pseudo-hermaphrodites affords no reliable indica- tion of the nature of the internal ijcnital orcfans. An in- MALFORMATIONS OF KFTIWDUCTIVF ORGANS. 57 dividual with such imperfections as are presented in Fig. 15 may or may not have a uterus and Fallopian tubes. On the other hand a uterus may be associated with a perfect penis and testes. The presence of a uterus does not enable us to decide the sex in a doubtful case. In questionable cases of sex the only absolute test is the genital glands. The presence of ovaries is decisive proof of a female ; testes indicate the male; and, as accurate discrimination between Uterus. Fig. 15. — Sagittal section of the pelvic organs of a boy with a well-developed uterus (Mu- seum of Middlesex Hospital). a testis and an ovary is only possible on microscopic exam- ination, it is only in exceptional circumstances that such a test can be applied. It is impossible in an elementary work of this kind to describe the various defects of the reproductive organs which occur in pseudo-hermaphrodites, but in the majority of these unfortunate individuals the genital glands are testes, notwithstanding the fact that many of them have a uterus with Fallopian tubes. 5« DISEASES OF WOMEN. The majority of pscudo-hcrniapliroditcs arc brought up as girls ; this is a iiiisfortiinc, because at puberty (which may be j^reatly dehi)etl) the supposed girl suddenl}- assumes the voice of a man and begins to grow a beard. \\' hen there is doubt as to the sex of a child it should be named, trained, and educated as a boy. Exstrophy of the bladder has sometimes given rise to dif- ficulty in determining the sex of a child (Fig. i6). Careful Fig. i6. — Exstrophy of the bladder in a girl ^Museum of Middlesex Hospital). examination will dispel this difficulty, for on cleaning the pink vesical mucous membrane exposed at the pubes, urine will be seen to escape from the orifices of the ureters. CHAPTER V. MALFORMATIONS OF THE REPRODUCTIVE ORGANS OF WOMEN (Continued). MALFORMATIONS OF THE VAGINA AND UTERUS. Absence of the Vagina. — This may occur when the uterus also is absent ; but the uterus may be well developed and the vagina absent. Partial Absence of the Vagina. — This is more com- mon, and the middle part is most often deficient. There is then a short sinus opening externally, and admitting a probe for a distance of perhaps -g- to 2 in. (i to 5 cm.) ; the cervix opens into a closed pouch, the remains of the upper end of the vagina. A solid, cord-like band of connective tissue may connect the two portions ; less often the lower half of the vagina is absent. In some cases a very short external sinus is present and the rest of the vagina is absent. Atresia of the Vagina. — A transverse septum may exist at any part of the vagina, but it is most common at the vaginal orifice. This condition was formerly described as atresia of the hymen, but careful examination will always discover the hymen adherent to the under or external sur- face of the septum. This condition is due to the lower end of the fused Mullerian ducts having failed to open into the cloaca. The symptoms and treatment of these conditions will be described in Chapter VI. Narrowing (Stenosis) of the Vagina. — A very nar- row vagina may be due simply to partial arrest of develop- ment ; in other cases it would appear that one Mullerian duct has failed to develop; this may occur with a normal 69 6o DISEASES OF WOMEN. uterus or in association with a uterus of whicli only one half has developed (uterus unicornis). The trtitt))ic)il is dilatation with graduated bougies. Double Vagina. — This is always associated with double uterus. It may give rise to no symptoms, even after mar- riage ; but the longitudinal septum may be torn through during either coitus or childbirth. More often one half is enlarged by sexual intercourse, and pregnancy occurs in the corresponding half of the uterus. In other cases one half only is completely pervious, the lower portion of the other half ending blindly, either at the ROUND LIGAMENT UTERINE HORN \, Fig. 17. — Ritdimentary uterus (Schroeder). vulva or at some higher point. The symptoms may then be perplexing, as menstruation may seem to be free while the occluded portion is really the seat of ha,>matocolpos (Chap. VI.). As in the case of a single vagina, the middle portion only of one half may be obliterated ; its lower por- tion then appears as a sinus opening by the side of the larger vagina. Tn'at))ic)it. — If a double vagina be discovered, the sep- tum should be divided throughout its whole extent, or, better .still, a longitudinal .strip of it be removed, so as to throw the two cavities into one. This will minimize the risk of complications during delivery. The vagina must MALFORMATIONS OF REPRODUCTIVE ORGANS. 6 1 be packxd with gauze till heal- ing has taken place, to pre- vent the reunion of the cut edges. Malformations of the Uterus. — Absence of the ute- rus may occur with or without absence of the ovaries. Rudimentary Uterus. — The uterus may be present in the form of a very small body with rudimentary horns and Fallopian tubes (Fig. 17). From incomplete examination such cases have been erro- neously described as absence of the uterus. The ovaries are small. Important other malformations or general ar- rest of development usually co-exist. But, when this is the only malformation, the secondary sexual characters appear late, or not at all ; and menstruation is absent. Infantile Uterus. — The uterus preserves the type which it presents normally at birth ; that is to say, the whole organ is narrow in proportion to its length, and the cervix is long in proportion to the body. The external os is small (pinhole os) and the cervix conical (Fig. 18). Acute ante- flexion frequently co-exists. -The conical cervix as seen in a speculum (A. E. G.). -A normal nulliparous cervix (A. E. G.)- Fig. 20 cervix of a parous woman (A. E. G. 62 DISEASES OE WOMEN. This may be associated with general arrest of development of the genital organs ; or the otiier parts may be well formed. Figs. 19 and 20 are introduced for comparison with the conical cervix. Syinptoiiis niid Sii^iis. — The only indication of the condi- tion maybe absence of menstruation in youth, with sterility later. In other cases scanty and painful menstruation occurs. Bimanual examination shows the presence of a small uterus, probably anteflexed. If a sound can be introduced through the narrow external os, it will be found to enter for only i^ or 2 in. (3 to 5 cm.). Treatment. — In the absence of symptoms, no treatment should be attempted, as nothing,will avail to induce growth of the uterus to its proper size. If dysmenorrhcea be pres- ent, efforts may be made to straighten an anteflexed uterus and to render its canal more patulous by dilatation. The sterility is incurable. Atresia of tlie external os may be congenital or acquired. Both are rare. Menstruation may be entirely absent, and the symptoms and signs will then resemble those of the infantile uterus. If the ovaries and the body of the uterus be well developed, menstrual molimina will occur, with the accumulation of menstrual products within the cavity of the uterus. (See Haematometra.) Single-homed Uterus {Uterus unieornis). — If one half only of the uterus fail to develop, this condition results (Fig. 21). Both ovaries may be well developed, but as a rule the one associated with the rudimentaiy cornu retains its in- fantile shape. The vagina is often narrow and the uterine cavity small. Nevertheless, no symptoms may be present and the woman may menstruate, have sexual intercourse, and become pregnant, just as in the normal condition. On the other hand, if pregnancy occur in the rudimentary horn it practically takes the course of a tubal gestation, resulting in rupture. MALFORMATIONS OF KEPRODUCriVE ORGANS. 63 Double Uterus. — There are three types of the con- dition known as double uterus, viz. the uterus septus, the uterus bicornis, and the uterus didelphys. The primary feature, embryologically, is incomplete union of Muller's ducts. I. In the Uterus septus the ducts have fused exter- nally, but the septum formed by their approximation per- Tube. Uterine cornua. Tube. Fig. 21. — Uterus unicornis. sists ; consequently the uterus seen from the outside appears normal. On section it is found to contain two distinct cavi- ties. The septum may extend to the vulva, producing a vagina with the appearance of a double-barrelled gun ; or it may involve the uterus alone, the vagina being single ; or it may fail to reach the external os, in which case the cer- vix looks normal when seen through a speculum. This is the titcrns S7ibscptus. 2. In the uterus bicornis external union has occurred in the lower part of the uterine body, but is wanting in the upper part ; so that when such a case is bimanually ex- amined, the depression between the two halves of the fundus is plainly felt (Fig. 22). Here also the extent of the septum varies, reaching to the vulva, to the os exter- 64 DISEASES OE WOMEN. luiin. or to the os intcinuin only. The last kind gives the vaiict)- known as uterus hicornis unicollis. 3. In uterus didelphys (Fig. 23) the two halves of the uterus have remained externally distinct, and can be moved independently of one another. The vagina.- are invariably separate, though united by connective tissue, and a loose Fig. 22. — Uterus bicornis (Schroeder). bridge of connective tissue and peritoneum stretches be- tween the cervices. A well-marked fold of peritoneum usually stretches directly between the bladder and rectum, passing between the two halves of the uterus. Each uterus has its own Fallopian tube, whose point of junction with the uterine body is indicated by the origin of the round ligament ; it has also its own ovary. The two halves are often unequally developed, and one vagina may end blindly above the vulva, so that the corre- sponding uterus is quite shut off from the outside. Diagnosis. — The presence of tw^o vaginal canals is a cer- tain indication that the uterus is double. Where the vagina is single, the malformation of the uterus may be discovered in one of several \vays. Thus, when the division involves the cervix, two ora externa may be seen through the specu- lum ; on bimanual examination two separate uterine cornua MALFORMATIONS OF REPRODUCTfVE ORGANS. 65 may be felt, with a depression between. The condition may be suspected from the passage of the sound in two different directions; when one half has become occkided, with reten- tion of menstrual blood, the opening of tlie fluctuating Fig. 23. — Uterus didelphys. tumor may reveal the presence of the second canal ; lastly, some complication during delivery may lead to diagnosis. A careful examination is required to distinguish the variety of double uterus. If bimanually the fundus feels normal in shape, whilst two cervical openings are present, and two sounds can be simultaneously introduced without coming in contact inside the uterus, the case is one of uterus septus. If a well-marked central depressiDii exists, 5 66 DISEASES OE WOMEN. wc have to deal with uterus bicornis or uterus didelphys. If the cer\'ix be single, it is a two-horned uterus. If it be double, the following points will serve to distinguish the two. In the case of the uterus bicornis, the two halves are closely adherent, usually for some distance above the level of the internal os ; and they cannot be moved independently. In the case of the uterus didelphys, the twc; halves can be so moved ; indeed, one may be found lying in front of, or at some distance from the other; and further, the separation down to the level of the external os can be distinctly felt by recto-abdominal examination. In both cases the points of two sounds simultaneously introduced may diverge widely, pointing perhaps to the respective iliac crests, while the handles cross each other in the vagina at right angles. As a rule, each horn or each half-uterus can be felt to have attached to it its own Fallopian tube and ovary. Coiiip/ications. — One half of a double uterus may be oc- cluded at the cei"vix ; or there may be atresia of the cor- responding vagina ; in which case the symptoms of haemato- metra arise. Otherwise a double uterus may give rise to no symptoms at all, and several pregnancies may be passed without the condition being suspected. In other cases some complication arises during delivery, leading to discovery of the condition ; but considerable perplexity may be caused at first. Thus in some cases an obstetrician has on exam- ination found a wide vagina and dilating cervix ; a later examination, in which the finger has inadvertently entered the second vagina, has revealed a narrow vagina and a closed OS.* The following are the clinical complications to which a double uterus may give rise: 1. Unilateral atresia, with retained menstrual products. 2. Dyspareunia. ' For a summary of recorded cases of uterus didelphys the reader is referred to the Obstet. Traits., vol. xxxvii. MALFORMATIONS OF RFPRODUCTIVE ORGANS. 6j 3. Double vaginitis or endometritis, treated unsuccess- fully by applications to one side only. 4. Obstruction to delivery by a displaced empty half. 5. Obstruction due to the vaginal septum. 6. Retained and undiscovered products of conception in one half in cases of double pregnancy. The two halves of a double uterus may menstruate inde- pendently. When pregnancy occurs in one half, a decidua forms in the other half Trcat))ic)it. — A double uterus does not require treatment as a rule ; but if a double vagina exists, the septum should be removed. CHAPTER VI. RETENTION OF MENSTRUAL PRODUCTS IN CASES OF ATRESIA. According to the situation of the atresia and the duration of the symptoms, the following conditions maybe met with, shown diagrammatically in Figs. 24 and 25 : I. Atresia of the Vaginal Orifice. — At first the men- strual blood collects in the vagina, which becomes distended (A) and often bulges through the vulvar aperture — lucuiato- colpos. Later, the cervix distends and its walls are thinned, the body of the uterus not being at first affected (j5) — Jiceniatotracluion. By continued accumulation the body of the uterus is involved {C) — hcematomctra. Lastly, the Fal- lo})ian tubes may become distended {D) — lucuiatosalp'uix. II. Absence of the I/Ower or Middle Portion of the Vagina. — The distention occurs in the same order as above, first the vagina {R) and then the uterus {F^ being affected. The lower portion of the vagina, if present, is patulous. III. Atresia of the Os Externum. — The vagina re- mains normal, and htematotrachclos first occurs {G). It is probable that considerable distention may take place here without the body of the uterus sharing in it. Later, h;ematometra and ha:matosalpinx ma)' follow. IV. Atresia of the Os Internum. — The cervi.x, as well as the vagina, remains free, and a pure hajmatometra is found (//). As a congenital condition, this is rare. V. Atresia affecting One Half of a Double Uterus or Vagina. — Changes occur in the same order as in the 08 MENSTRUAL rRODUCTS IN ATRESIA. 69 case of the undivided organs ; when the atresia concerns the second vagina, hieniatocolpos is first found, the cystic swelling extending either down to the vulva (/) or only part of the way, by the side of the patent vagina (/). Haimatometra follows (A'), or it occurs alone if the atresia D E F Fig. 24. — Diagram illustrating the effects of atresia of the genital passages (A. E. G.). affects the os externum {L). In the diagram the various forms of atresia in cases of double uterus are represented as affecting the uterus bicornis ; but similar conditions are found in connection with uterus septus and uterus didelpln's. . Secondary Changes. — The dilated walls of the vagina, 70 DISEASES OE WOMEN. uterus, or r^illopian tubes become thinned out; the contrast between health)- and distended walls is well seen in the uterus itself, where the endometrium suffers considerable atrophy, and the muscular coat is thinned. This thinning / A- /- Fir.. 25. — Diagram illustrating the eflfccts of atresia of the genital passages (A. E. G.)- may be partly compensated, as in the case of an aneuiysm, by the deposition of blood-clot on the internal surface, and partial organization of the fibrin. Suppuration may take place, either spontancousl}- or through a temporary fistulous ajK-rture. When the atresia is secondar}', this result is more common. The vagina, uterus, or Fallopian tubes may then become bags of pus, MENSTRUAL rRODUCTS IN ATRESIA. 7 I and the terms pyocolpos, pyometra, and pyosalpinx are applied. Signs and Symptoms. — The first symptoms generally occur within the first year or two after puberty. The patient gives a history of having experienced periodical monthly molimina without external menstruation {crypto- mcnorrJuvii). Pain is sometimes felt from the first ; in other cases it occurs later, and increases in severity and duration as distention proceeds, till it becomes continuous. Symp- toms of pressure on surrounding organs may also be pres- ent. If suppuration takes place, febrile symptoms appear and the patient falls into a hectic condition. Physical Signs. — On abdominal palpation a tense fluctu- ating swelling may often be felt rising out of the pelvis ; and if the obstruction be at the vulva it may be seen bulging here also. Fluctuation may be obtained on pressing alter- nately on the abdominal and vulvar swellings. When the uterus itself is not involved, it may sometimes be felt through the abdomen as a solid projection at the summit of the cystic swelling. We will consider in succession the physical signs afforded by the different conditions above enumerated. Atresia of the Vaginal Orifice. — The finger at once meets the resistance of the cystic swelling at the vulva, and no passage exists by the side of it. By combined rectal and abdominal examination it can be felt that the mass fills the pelvis ; if seen early the fingers may meet above the swelling, or the undilated uterus can be made out. If hsematometra also exists, the swelling is larger; but the degree to which the uterus is involved cannot usually be determined till the retained fluid has been evacuated. An irregularity of the summit of the swelling can often be felt by the abdomen when the Fallopian tubes are distended ; but this is not always the case because the tubes are apt to be drawn into a position parallel with the uterus, just as when the uterus is enlarged by pregnancy or a myoma. 72 DISEASES OE WOMEN. Absence of the Lcncer or Middle Part of the Vagi>ia. — The short cul-dc-sac, wlicn it exists, is patent for 2 or 5 cm., but nothing further can be made out by the va- gina. On examining by the rectum, the finger will read- ily recognize a sound introduced through the urethra, there being but little tissue intervening. But, higher up, the finger meets the resistance of a cystic swelling, con- tinuous with a similar swelling felt by the abdomen when the distention is considerable. If the vaginal deficiency extends to near the uterus, it may not be possible to reach the hxMnatocolpos through the rectum ; and an ill-defined abdominal fulness may be the only thing felt. But this, taken in conjunction with the history and symptoms, may serve for diagnosis. Atresia of tlie Os Externum. — The cervix presents in the otherwise normal vagina, as a smooth fluctuating swell- ing in which no aperture can be discovered. Bimanu- ally the mass is felt to occupy the position of an enlarged uterus. The fundus may be felt as a smaller and harder projection at the summit of the elastic swelling. Atresia of the Os Liternnni. — The cervix feels and ap- pears normal ; the body of the uterus is uniformly en- larged, and feels almost exactly like a pregnant uterus. Atresia of One Half of a Double Uterus or ]\igi)ia. — The patent half of the vagina is narrow, but other- wise resembles the normal. The uterus appears to be pushed over to one side, and the sound passes in a lat- eral direction for a normal distance. On one side of the vagina is felt a fluctuating swelling, extending down to the vulva, or reaching only part of the way. It bulges toward the healthy side so as to further narrow the va- ginal passage. By bimanual examination the swelling is felt to extend up to the side of the uterus, with which it is closely connected. When the vagina is undivided, and the atresia is situated at the external os of the second uterus, the upper part of the vagina is very wide. At one MENSTRUAL PRODUCTS LV ATRESIA. 73 side is the cervix, through which a sound can be passed into the uterus, when it takes a lateral direction. The rest of the vaginal summit is occupied by a cystic swelling lying to the side of the uterus and cervix, which it has dis- placed beyond the median line. The depression between the distended and the empty half of the uterus may be felt by abdominal palpation or by the bimanual method. Diagnosis. — A hzematocolpos is usually readily diag- nosed by the signs and symptoms above mentioned. H?Ematometra must be diagnosed from pregnancy : the integrity of the hymen, the absence of vaginal pulsation and discoloration, and of the symptoms of pregnancy will serve as a guide, as will also the condition of the cervix, which is elastic and smooth in the case of haematotrachelos^ and which does not present the softness characteristic of pregnancy, when the obstruction is at the internal os. In cases of doubt the patient may be kept under observation for some time ; the swelling will increase, but not nearly so quickly as is the case in pregnancy. Haematotrachelos might be simulated also by a cyst in the upper part of the vagina ; careful examination will discover the cervix beyond the cyst in this case. Other conditions which superficially resemble haematometra, such as inversion of the uterus or a large cervical polypus lying in the vagina, do not occur at the age at which haematometra is met with ; and there should be no difficulty in the diagnosis. Retention of menses in a second vagina or uterus leads to much greater difficulty in diagnosis. Thus, haematocol- pos must be distinguished from abscess in the vaginal wall, pelvic abscess burrowing down by the side of the vagina, vaginal cysts, encysted collections of fluid bulging down in the recto-vaginal pouch, and, when the upper part of the vagina is principally involved, from ovarian or parovarian cysts and distended tubes. The latter would be recognized, principally by their shape, on recto-abdominal examination. The nature of lower vaginal swellings will probably not be 74 DISEASES OF WOMEN. made out till they arc incised ; whilst in the case of swellings lii^her up, the abdomen will most likely be opened, under the impression that the case is one of ovarian cyst. ll^ematometra in a second uterus is often diagnosed as ovarian or tubal cystic disease, or as a dermoid. The only clue, in the absence of all trace of a second cervix or of a double vagina, lies in the close connection of the swelling with the uterus ; but even this distinction may not be ap- parent, as the depression in the fundus in the case of uterus bicornis, or the almost complete separation of the two halves in the case of uterus didelphys, gives the impression that the swelling is extra-uterine. As a matter of fact, the nature of the case is rarely recognized until the abdomen has been opened in the operating theatre or the post- morteni room. Results. — If left untreated, the fluid gradually accumu- lates, the size of the swelling causing great discomfort as well as severe pain. Two grave complications threaten : suppuration may take place and a large abscess form, which opens into the rectum or the ccelom (peritoneal cavity) or points externally ; or rupture of some part of the sac occurs. The dilated tubes are most likely to give way, as in them the greatest thinning ,of the walls takes place. From either complication death may result. It is important to remember that a haematocolpos or hasmatotrachelos exer- cises injurious pressure on the ureters. Treatment. — A haematocolpos must be opened. The in- cision should be free, and the contents allowed to escape without any pressure. By too rapid evacuation, rupture of a ha^matosalpinx may be brought about ; but the danger of this has probably been exaggerated. A more serious risk is that of septiccTemia ; on this account the strictest asepsis should be adopted. When the greater jxirt of the fluid has been evacuated, gentle irrigation may be employed to clear out the residue and prevent decomiiosition changes from taking place. The principal difficulty in after-treatment lies MENSTRUAL PRODUCTS IN ATRESIA. 75 in the tendency of the orifice to contract ; for this reason the incision must be free, and, if necessary, a part of the wall should be dissected out. The passage of bougies may be subsequently required from time to time. The treatment of atresia with absence of a part of the vagina, is more difficult. An attempt should be made to dissect down to the deeper part of the vagina, so as to make a complete vagina ; this is especially necessary in cases of retention. The first difficulty is in the actual dis- section, which must be made between the urethra in front and the rectum behind : a distance of many centimetres may be traversed before the blind end of the vagina is reached. The second, and perhaps greater, difficulty is to maintain the patency of the vagina when formed. With this end in view various plastic operations have been devised, portions of skin being turned in. Repeated ope- rations, extending over many months, have sometimes been required ; but several ultimately successful cases have been reported. Haematometra also requires incision. Sometimes the obstructing membrane is so thin that a probe or sound can readily be pushed through it ; in other cases a knife is re- quired. After incision, forceps should be introduced to secure a free aperture, and after evacuation the cervical canal is loosely packed with iodoform gauze ; whilst later the tendency to contract must be met by the use of dilators. When, in case of haematometra with deficiency of the va- gina, it is found impossible to maintain the new channel in a sufficiently patulous condition, or when the formation of such a channel is not practicable, it will be necessary to carry out radical measures, such as o6phorectom\" or hysterectomy. Lateral lusmatocolpos must be treated on the same prin- ciples as the above, but the vaginal septum should be freel)' removed, so as to make only one vagina, otherwise the jG DISEASES OF WOMEN. oi)cnin<^f will almost certainly close again, and, having once been opened, septic organisms may find their way in, and a pyocolpos be found the next time instead of a ha.'niato- colpos. Of this there are several instances on record. In the case of lateral haimatometra, vaginal incision should be practised when possible, and part of the uterine septum may be removed, to prevent re-closure. If the con- dition be discovered after opening the abdomen, vaginal incision should still be perfocmed when the two halves of the uterus are closely connected ; although, if at the same time there be vaginal deficiency, hysterectomy will probably be called for. In cases of separation of the two halves of the uterus, as in marked instances of uterus bicornis or uterus didelphys, the occluded half may be removed by hysterectomy. There are several cases recorded in which this was done, Hajmatosalpinx calls for removal of the distended tube. Characters of Retained Menstrual Blood. — The evacuated fluid is a dark chocolate color, sometimes almost black. It is thick and flows slowly, like treacle or honey. It is mixed with mucus and seldom contains coagula. Microscopical examination shows the presence of epithelial debris, and blood-corpuscles in various stages of disintegra- tion. The viscidity is due to partial absorption of the liquid portion of the blood. CHAPTER VII. DISEASES OF THE VULVA. AGE-CHANGES; INJURIES; VARIX ; HJEMA- TOMA; INFLAMMATION. Age-changes. — Infancy. — At this period the mons Veneris is devoid of conspicuous hair and the labia majora Prepuce. Clitoris. Frcnum. Nympha. Urethra. Orifice of vagina. Hymen. Fig. 26. — The vulva of a girl (Henle) appear as two parallel cutaneous eminences ; the thin edges of the labia minora project between them and arc pink like mucous membrane (Fig. 26). Puberty. — At this stage the pubic hair becomes conspicu- 77 78 DISEASES OE WOMEN. ous and usually ^rows freely on the outer surfaces of the greater labia. The labia increase in size and usually con- ceal the nj'niphiu. Their opposed or internal surfaces remain pink, whilst the outer surfaces become pigmented, especially in brunettes. It occasionally happens that the nymplue grow after puberty, and instead of remaining concealed within the vul- v^ar cleft, protrude and ^ ' resemble a pair of elon- gated molluscan palps. When the nymphac l)rotrude in this way they undergo a curious change : those parts cov- ered by the labia ma- jora retain their pink- ness and possess as usual very large seba- ceous glands, but the palp-like portions be- come decph' pigmented, lose their sebaceous glands, and occasionally delicate hairs of two or more centimetres in length grow from them. Labia minora elongated in this way are some- times spoken of as " hypertrophied nympha; ; " some writers attribute the condition to masturbation. It reaches its maximum in Hottentot women, whose " apron " is really formed of greatly elongated nymphae (Fig. 27). Menopause. — After the forty-fifth year the hair on the mons and labia, like that on the rest of the bod}-, becomes white and is gradually shed. The greater labia shrink as the subcutaneous fat disappears and the n}'mph;e project bc- FlG. 27.- -The Hfittentot .ipron (Blancbard aiiJ Lcsutur). DISEASES OF THE VULVA. 79 yond them. The vulvar orifice is often greatly narrowed in consequence of the shrinking of the structures border- ing upon it. Injuries. — The vulva is liable to injury from falls upon pointed objects ; cuts from potsherds when chamber-pots break whilst women sit upon them ; kicks from brutal hus- bands ; and violence during rape. The labia are sometimes lacerated during the careless use of midwifery forceps. Deep wounds of the vulva are invariably attended with free bleeding. Treatment. — Turn out the clots, secure the bleeding points with forceps and ligature; oozing may require re- straint with firm pads and pressure. Varix. — The vulva is well supplied with veins, and con- tains especially a good deal of erectile tissue. Obstruction to the venous circulation in the pelvis, abdomen, or thorax consequently readily causes the veins to assume a varicose condition. This is found very often during the later months of pregnancy ; and in some cases the enlargement may be extreme, forming a swelling, on one or both sides, as large as a fist, involving principally the labia majora, and presenting to the touch the characteristic feeling of " worms in a bag," which is met with in varicocele of the scrotum. The left side is more often affected than the right. The dilated and tortuous veins can also be readily seen through the skin. The veins of the thigh are generally also involved ; and on inspecting the vagina, similar venous plexuses may be seen, extending up a considerable distance under the mucous membrane. There is a great risk of rupture of these veins during delivery; either the surface veins may give way, giving rise to serious bleeding, or subcutaneous rupture may occur, producing a hjematoma of the vulva. Treatment. — Rest in the horizontal position diminishes the swelling; but when associated with pregnancy, no cure can be hoped for till after delivery. In severe cases it may be advisable to induce premature delivery, to diminish its se- 8o DISEASES OF WOMEN. verity and duration, and, through the smaller size of the child's head, lessen the risk of rupture and thrombosis. When due to other varieties of backward pressure on the veins, the cause must be treated. Slight cases are often associated with chronic constipa- tion, and in these, as well as in severer cases, great im- provement results from attention to the bowels. Excision of the veins gives good results. Haematoma of the Vulva. — This is due to subcu- taneous rupture of veins in the labia majora, and is nearly always traumatic. A fall or blow may cause it, but it gen- erally follows delivery, especially when the child's head is large and has rested long on the perineum. The condition is usually easily recognized from the his- tory, and from the presence of a smooth, fluctuating swell- ing in the labium majus, which has formed quickly and is irreducible. These points serve to distinguish it from hernia, and from abscess and cyst of the labium. It may not be easy to distinguish it from simple oedema ; but this is unimportant, as the treatment is the same. Treatment. — On no account should a haematoma be opened, unless it is enlarging quickly, when there is prob- ably a large vessel ruptured ; in this case a free incision should be made, the clots turned out, and the bleeding- point secured. Otherwise the extravasated blood tends to absorb readily, and generally subsides in two or three weeks. Occasionally a hrcmatoma suppurates and requires free incision, drainage, and strict cleanliness. INFLAMMATION OF THE VULVA. Vulvitis. — This may arise from many causes. In girls it is often due to dirt, thread-worms, and tuberculosis of the uterus. The same causes may produce vulvitis in adult women. Other causes are vaginitis resulting from gonor- DISEASES OF THE VULVA. Si rlioea, and extension of inflaniniation from surroundini:^ struc- tures. Vulvitis is not uncommon in the newly married. Signs and Syjnptoms. — The patient complains of throb- bing pain and heat in the vulva, aggj'avated by walking and by long sitting ; generally also of discharge. When se- vere there are constitutional febrile symptoms. When the urethra is affected there is burning pain on micturition. The vulva is congested and consequently swollen. The swelling may affect individual parts, as the labia majora, nymphai, or clitoris ; or the whole vulva may be involved. It may be bathed in discharge from the vagina, which may be mucous, muco-purulent, or purulent ; in gonorrheal cases it is always purulent. As the result of these irri- tating discharges the skin is often excoriated, not only over the vulva, but also over the contiguous part of the thighs and round the anus. When due to injury, bruising and ecchymoses may be seen. On the other hand, when of gonorrhoea! origin, two rather characteristic signs are present: firstly, urethritis ; the meatus is red and swollen, and on pressing on the urethra through the vagina, from within outward, a drop of pus commonly escapes. Sec- ondly, affection of the ducts of the Bartholinian glands ; in this case the orifices of the ducts can be readily seen as red points situated laterally in the angle between the h)^men and labia minora ; on pressing the duct between the finger in the vagina and the thumb outside, a drop of pus may escape ; or a definite swelling, due to abscess, may be pres- ent in the situation of the duct (see Abscess of the Vulva). The lymphatics of the vulva pass to the horizontal set of inguinal glands ; these will therefore be enlarged and tender in cases of severe vulvitis. Diagnosis. — There is no difficulty in recognizing vulvitis, but the diagnosis of its nature is often as difficult as it is important. The question is whether, in a given case, the condition is gonorrhoeal or not. On the answer much often depends, such as questions of criminal assault and of 6 1 82 DISEASES OE WOMEN. uncliastity. If the ^onococcus be found in the pus, the ex- istence of gonorrhte.i is established ; its absence, however, is no proof to the contrary. If the inflammation be non- purulent, if the urethra be unaffected, and if the Bifttholin- ian ducts be not involved, the probability is strong tliat the case is not gonorrhceal ; in the opposite conditions the probability is in favor of <^onorrhcea. Some information may be derived from the existence of uretliritis in the hus- band ; if he have a marked purulent urethritis and the pus contains gonococci the ari^ument is in favor of t^onorrhcea in the woman. In children, want of cleanliness and tuber- culosis will serve as a clue; but it must be remembered that gonorrhoea is a possible condition even when there is no suspicion of criminal assault. Some epidemics of vulvo- vaginitis in little girls have been of this nature ; and the source of contagion has sometimes been traced to bad social conditions, such as the fact that a child, sleeping in the same bed as a father or mother suffering from gonor- rhoea, has become contaminated. Cojirsc and Coniplicatiivis. — A simple vulvitis runs a short course to recovery, under proper treatment. If neglected, or if septic from the first, the possible complications are urethritis, labial absces.^, cedema and gangrene of the labia, infection and abscess of Bartholin's glands, inguinal bubo, vaginitis, endometritis, salpingitis, and peritonitis. Treatment. — Tiie patient should be kept in bed if possible: if there be constitutional di.sturbance, this is essential. The parts must be kept thoroughly clean ; a warm sitz-bath, medicated with boracic acid, carbolic (i : 60), or biniodide of mercury (i : 2000), and repeated several times a day, will ensure cleanliness and relieve pain. After a bath or irrigation the vulva should be well dried and dusted with oxide of zinc, and a pad of cotton-wool applied. If there be suppuration on the surface, all discharge should be re- moved by irrigation, and the surface swabbed over with nitrate-of-silver solution (2 per cent.), chloride of zinc (5 per DISEASES OF THE VULVA. 83 cent.), or carbolic (10 per cent, in glycerin). Fomentations \vrun<^ out of boracic acid may then be applied. When the inflammation is severe, the patient should lie with the knees supported on a pillow and separated to prevent the contact of the tender surfaces. (Bdetna of the Vulva. — This may occur as the result of vulvitis, and is then commonly due to spreading of the inflammatory process to the deeper tissues, involving vessels and lymphatics. More often it depends upon pressure on the pelvic veins, by tumors, pelvic inflammation, or the pregnant uterus. It may also form part of a general anasarca the consequence of cardiac or renal disease. All parts of the vulva are affected, but the principal enlarge- ment is of the labia majora. The whole vulva may attain the size of a foetal head. The treatment consists in rest in bed, moderate purgation and warm fomentations, if due to phlebitis and lymphatic obstruction. When due to pressure, the cause must if pos- sible be dealt with — e. g. a tumor should be removed ; pel- vic inflammation should be treated as described under that heading ; pregnancy may occasionally require to be pre- maturely terminated. As a palliative measure, small punc- tures may be made with a narrow-bladed scalpel. Erysipelas of the Vulva. — This generally follows labor, and occasionally wounds of the vulva. It behaves in the same way as when affecting the skin elsewhere ; but owing to the laxity of the connective tissue of the labia there is much swelling. Since the use of antiseptics in midwifery it is less often seen, and should be regarded as a preventable disease, at any rate when occurring as a com- plication of childbed. It is seldom confined to the vulva, but spreads thence to the thighs, abdomen, and buttocks. The labia minora are apt to suffer severely, for their blood-supply is interfered with, and ulceration, perforation, or gangrene may follow. It is important that when this condition exists no internal 84 I^J^J- ■ I •"» ^•- ••> 0/'\ WOMEN. examination should be made; otherwise the internal organs may be infected and septicaemia supervene. The treatment is that of erysipelas in any other part of the body. Gangrene of the Vulva. — This occurs under the fol- lowing conditions : 1. As the result of injury, especially long-continued pressure of the head in the third stage of labor, or from the unskilful use of instruments. 2. Following cedema, cellulitis, or erysipelas of the vulva. 3. As a complication of some of the exanthemata, as small-pox, scarlet fever, measles, and typhus. 4. In underfed and dirty children, when it is analogous to noma or cancrum oris. 5. As a result of phagedenic ulceration. Except in the last case, when the clitoris is apt to be in- volved, the nympha: are most apt to suffer ; they ma)- be perforated, or the lower portion may slough off The treatment consists in supporting the patient's strength ; in keeping the parts as clean as possible with antiseptic applications ; and in relieving pain by hot fomentations, with opium internally, if necessary. Abscess of the Vtllva. — This is occasionally due to injury or to suppuration following on cellulitis, er}^sipelas, or hajmatoma. But in many cases it arises in the sebaceous glands of the labia and in the ducts of Bartholin's glands. As a rule, one side only is affected. As might be expected, gonorrhoea is the principal cause. The signs arc those of an abscess in other situations, local redness, swelling, heat, and pain, often accompanied with febrile symptoms. Treatment. — This consists in a free incision to evacuate the pus, warm bathing followed b}' fomentations, and strict cleanliness. CHAPTER VIII. DISEASES OF THE VULVA (Continued). CUTANEOUS AFFECTIONS, PRURITUS, AND KRAUROSIS. "E^czetna of the Vulva. — The mucous surface is not, as a rule, involved, but the cutaneous surface presents a number of papules which become vesicular and break, allowing of the escape of serous fluid ; the vesicles then dry up with the formation of small scales. The intervening skin is hot and erythematous. Successive crops of vesicles may ap- pear. Eczema is found associated with some constitutional conditions, as diabetes, rheumatism, and gout ; and some- times with local conditions in which irritating discharges are present — e. g. vesico-vaginal fistula and endometritis. It rhay run an acute or a chronic course. The most trouble- some symptom is irritation, which causes scratching and thereby aggravation of the disease. Menstrual disorders are frequent (Hebra). Treatment. — The vulva should be kept clean and dry. Frequent bathing with boracic lotion and dusting with oxide-of-zinc powder will suffice in mild cases. When ob- stinate, and when the skin has become white, thickened, and cracked, the vulva should be painted over, under an anaesthetic, with carbolic acid, one part to four of glycerin, and a simple dressing, such as a boracic ointment, applied. Constitutional causes must at the same time receive ap- propriate attention. Herpes of the Vulva. — This is also a vesicular condition, but the vesicles are arranged in small groups, and the inter- 85 86 DISEASES OF WOMEN. veiling erythema is less marked, or absent. The vesicles may run together, forming bulla,*. Herpes is not infrequently associated with the menstrual periods, especially when these are characterized by dysmenorrhea ; and with pregnancy. If a herpetic patch ulcerates, it may resemble a chancre, especially if the inguinal glands are affected. Great irrita- tion is the principal symptom. Treatment. — This is similar to that recommended for eczema. I/UpUS of the Vulva. — Probably many distinct condi- tions have been described under this name, such as various syphilides when ulceration has occurred, gummata, and elephantiasis. The condition found in kraurosis, when there are small reddened sensitive patches, has been called lupus, and indeed the latter term has been loosely applied to almost any ulceration of the pudenda. It is better to restrict the term " lupus " to tubefculous skin lesions ; and in this sense lupus of the vulva is ex- ceedingly rare. It then presents the characteristics of lupus as seen on the face, and may, like that, be mainly ulcerative or mainly hypertrophic and "tubercular" in form. It runs a chronic course. Syphilis. — This disease may manifest itself on the vulva as a primary sore (chancre), or as mucous plaques and tu- bercles. Tertiary lesions and gummata are uncommon. In the late stages the opposed surfaces of the labia are liable to a change similar to that often seen on the tongue, and known as leucoplakia. Vulvar, like lingual leucoplakia, may ulcerate and become a precursor of epithelioma. In infancy congenital .syphilis sometimes declares itself in the labia in characteristic coppery-red spots. Elephantiasis. — This affection is common in tropical countries, but is rare in Europe. It consists of hypertrophy of the subcutaneous connective tissues, accompanied by dilatation and thrombosis of lymphatic vessels and spaces. This chansfe is often associated with filaria in the blood. DISEASES OF THE VULVA. ^7 The skin is generally thickened and rugose, like the rind of an orange, and pale. The labia majora are its favorite seats ; more rarely it affects the clitoris, and still more rarely the labia minora. The legs may be affected at the same time. When the enlargement is great and much discomfort is caused by the heavy pendulous masses (which sometimes weigh many pounds), they should be removed with the scalpel or thermo-cautery. Pruritus. — Itching of the vulva may arise from a vari- ety of causes. They may be arranged in three groups : I. Irritating Discharges; II. Diseases of the Vulva; and III. Reflex Irritation. Group I. — This will include diabetes, cystitis, and leu- corrhoea. (a) Diabetes. — The margins of the urethra and the vesti- bule are congested. The examination of the urine and the history of the case will establish the diagnosis. The irrita- tion may be lessened by sedative applications to the vulva and urethra. Pruritus is often the first symptom which leads to the detection of diabetes. (b) Cystitis. — The pruritus is generally a minor feature, and is usually relieved by washing out the bladder. (c) Lcucorrluva. — In view of the number of instances in which leucorrhcea exists without pruritus, it seems doubt- ful whether this cause can act alone, without some predis- posing or accessory condition. Nevertheless, the cure of the vaginitis or endometritis, as the case may be, will generally be followed by disappearance of the pruritus. In many cases the inflammation has started with gonor- rhoea; and then the concurrent urethritis helps to keep up the irritation. Group II. — (a) Congestion of tlic Vnlva. — This may be due to varicose veins caused by pressure in the pelvis ; or to functional causes. In the former case the causal condi- tion must be dealt with ; the possible conditions are retro- version of the gravid uterus, simple pregnancy, a uterine or 88 DISEASES OE WOMEN. ovarian tumor blockint:^ up the pelvis, pelvic cellulitis, or intra-abdominal pressure on the vena cava. Functional congestion may be associated with the men- strual epochs, and the jjruritus will then be periodic ; or it may be due to masturbation. The latter is not infrequently associated with pruritus, but whether as cause or effect it would be difficult to decide. (b) llihitis. — The skin of the affected parts is at first red and hot ; later it becomes pale, thickened, and cracked, ap- pearing as if sodden ; often there are marks due to scratch- ing. It is always worse at night. Treatment may be begun in mild cases by sedative and cooling applications, such as evaporating lotions, glycerole of belladonna, or opium or cocaine ointment. In more obstinate cases the parts should be painted, under ether, with a solution of carbolic acid in glycerin (i : 5), and the resulting sore treated with non-irri- tating dressings. Other caustics also have been recom- mended ; but this is one of the most successful. Cure will follow in most cases, though several applications may be required. If this fails there is only one course left — viz. to excise the affected parts. (c) Pcdiailns Pubis. — This is readily recognized on in- spection. The pubes -should be shaved and thoroughly cleansed with a solution of perchloride of mercury (1:1000). Group III. — Reflex Causes. — (a) From the Reetum. — Thread-worms may be responsible, or some unhealthy con- dition of the rectal mucous membrane, such as anal fissure, or a rectal polypus. Pruritus ani is generally added to pru- ritus vulvre in these cases. (b) From the Bladder. — In cases of vesical irritability with frequent micturition pruritus may be present as a re- flected neurosis. Bladder sedatives, such as hyoscyamus and belladonna, are then indicated. (c) From the Uterus. — Pregnancy sometimes is associated with pruritus, even when there is not marked leucorrhea. Kraurosis Vulvae. — This disease to which Breisk}- in DISEASES OE THE VULVA. 89 1885 gave the name kraurosis (xpaopo^, dry, withered) was first accurately described by Lawson Tait, in 1875, as an atrophic change affecting the nyniph;u. Symptoms. — The patient complains of irritation referred to the vulva, excessive pain during sexual intercourse and on passing water, and of a yellowish discharge. The irri- tation is worse when the patient is warm in bed, and com- monly disturbs or prevents sleep. As a result, the general health is impaired, the appetite fails, and the face has a harassed look. Physical Sig)is. — In the early stage the skin of the labia minora, vestibule, and clitoris is smooth and shiny ; the urethral meatus presents a red, caruncular appearance, and along the margins of the carunculae myrtiformes there are small patches as of subcutaneous haemorrhage, which are often exceedingly tender to the touch. Later, the nymphae diminish and finally disappear, while the orifice of the vagina becomes so contracted that, even in a multipara, it will barely admit a finger. The pubic hair has a peculiar stub- bly aspect, and near the labia majora may be coarse and broken. In the final stages the vulva is very pale, with a look as if it had been ironed, all folds and creases having been smoothed out. The vagina, above the hymen, is not affected ; the labia majora also generally escape, but in many patients kraurosis of the vulva is associated with marked atrophy of the uterus. Pathology. — The disease occurs mostly after the age of forty ; its cause is unknown. It is best described as a pro- gressive atrophy of the vestibule and nymphae. Microscopically the affected parts show great increase of fibrous tissue, running principally in bands parallel to the surface. The vessels and nerves are compressed as they pass between these bands, and this accounts for the petechial hemorrhages and the great sensitiveness found in the early stages, and for the bloodlessness and comparative 90 DISEASES OF WOMEN. inscnsil)ility later on. Tlic papilhc arc small, the rete Mal- pit^iiii thin, ant! the sebaceous and sweat glands disappear. Course and Prognosis. — The disease, if left alone, runs a chronic course of five or six years ; durinj^ this time there is great suffering and discomfort, but ultimately, when the atrophy is complete, the pain disappears. The parts remain friable ; even coitus may cause troublesome lacerations, and these are considerable if pregnancy and labor supervene. TrcatDioit. — Palliative measures are unsatisfactory. Sed- ative lotions, cocaine ointment, etc. give only temporary relief The pruritus may be stopped for a time by painting over the affected parts, under ana,'sthesia, with a 20 per cent, solution of carbolic acid in glycerin. Failing such remedies the application of the thermo-cautery to the red and painful spots is very useful. Occasionally it is neces- sary to excise the affected parts. CHAPTER IX. DISEASES OF THE VULVA (Continued). MORBID CONDITIONS OF HYMEN, CLITORIS, URETHRAL ORIFICE, AND PERINEUM. The Hymen. — Normally, the hymen, when stretched, forms a diaphragm with a central perforation situated nearer the anterior than the posterior margin (Fig. 28). D E F Fig. 28. — Variations in the shape of the liytneneal aperture : A, normal ; B, crcs- ccntic ; C, fringed : /', tlivideU by transverse band; if, divided by antero-posterior band; F, cribriform (A. E. G.)- 91 92 DISEASES OE II OMEN. The variations are as follows : A small circular aperture, centrally situated (./) ; a crescentic fold posteriorly, the aperture bein<^ anterior (Zf) ; a fringed condition in which the margin is indented in several places (c) ; a double ori- fice with a transverse division {d) ; a double orifice with an antero-posterior division (Zf) — this resembles the external appearance of a double vagina, for which it must not be mistaken ; lastly, the cribriform h>'men (/), in which there are several perforations. Variations in Structure. — It may be very thin and easily torn ; or dense and unyielding, requiring division before coitus can take place ; or, thick and fleshy. It may be unusually distensible and yielding, so that a finger or small speculum may be introduced, or coitus occur, without rup- ture. When the legs are separated the hymen may be- come so tense that the finger cannot be introduced, whilst it may pass easily when the thighs are approximated (Brouardel). This small structure has therefore an important medico- legal bearing. A permeable hymen, or one of the shape shown in Fig. 28, D, must not be taken as a certain indi- cation that intercourse has taken place ; and secondly, an unruptured hymen is not positive proof of virginity. Treatment. — A rigid or contracted hymen may require dilatation or division, to allow of coitus taking place. Carunculse hymenales result from the rupture of the hymen caused by coitus ; they consist of the portions of the hymen which are left between the radiating tears, and touch one another so that in the undisturbed condition the hymen may still appear intact. When everted they resemble the petals of a daffodil. Carunculse myrtiformes are due to more extensive stretching of the hymen, as during childbirth. They ap- pear as isolated nodules round the hymeneal margin, and are produced by tearing through of the base of the hymen. Cysts. — Small cysts lined with ejiithelium sometimes form in the tissues of the hymen. DISEASES OE THE VULVA. 93 Painful caruncles of the hymen arc a frequent source of vaginismus and dyspareunia. They appear as a series of congested spots, resembling small recent bruises, and ex- ceedingly sensitive, situated at the hymeneal margin. They occur principally in cases of kraurosis vulvae, and are often found associated with urethral caruncle. For treatment see Kraurosis. Imperforate hymen is considered under the head of Atresia Vulvae (p. 6'6\ The rupture of the hymen is generally attended by pain of short duration and slight bleeding. The latter may occasionally be so profuse as to demand surgical intervention, and may even be fatal. MORBID CONDITIONS OF THE CLITORIS. Inflammation. — This may form part of a general vul- vitis, or it may be due to the development of a venereal sore or phagedenic ulcer. In other cases the prepuce becomes adherent to the glans of the clitoris, and the pent-up secre- tion (smegma) sets up irritation which may lead to ulcera- tion or a small abscess. The treatment of this condition consists in separating the adherent margins of the prepuce and keeping the parts clean and dry. Elephantiasis is usually associated with elephantiasis vulvae ; occasionally the clitoris is affected independently of the labia and forms a tumor hanging down as a large mass in front of the vulva. epithelioma. — This is a somewhat rare affection of the clitoris. The prognosis after removal is favorable, as the glands are affected very late and there is but little tendency to deep or extensive spreading. Treatment. — This consists in complete extirpation of the clitoris and its crura. Urethral Caruncle. — This is a small red fleshy growth situated on the posterior aspect of the urethral meatus. 94 DISEASES OE WOMEN. Pathology. — It occurs at or after middle life. It is often associated with kraurosis vulva;, and in these cases it is probably due to the atrophic changes which characterize that condition ; for there is often a strikinf,^ similarity be- tween some kinds of urethral caruncle and those red and tender spots round the hymeneal margin which occur so constantly in kraurosis. In other cases, however, there is no accompanying krau- rosis, and the caruncle is then usually larger and more prominent, and is due in all probability to changes taking place in Skene's ducts, two small recesses in the floor of the urethra. It is possible that these changes have an in- fective origin, but their pathology is not quite clear. In some cases the structure of the caruncle is suggestive of adenoma ; in others the principal feature consists in the increase of thin-wallcd vessels like those seen in piles, and has suggested the name urethral hemorrhoid. The view that a caruncle is always due to changes occurring in the urethral ducts receives strong support from the fact that the caruncle is invariably situated on the floor of the urethra in the situation of the ducts. Symptoms and Signs. — The patient complains as a rule of pain and tenderness" at the meatus, with a burning sensa- tion on passing water, and sometimes of frequency of micturition. Occasionally the caruncle gives rise to bleed- ing and pain on coitus. A caruncle is readily recognized on inspection, presenting the characters above described. It often extends from one to two centimetres up the urethra. Treatment. — The simplest plan is to remo\'e the small growth with scissors, or to destroy it with the thermo-cau- tery under an anaesthetic. THE PERINEUM. This term is applied to the cutaneous and subcutaneous tissues intervening between the fourchette and the anterior margin of the anus. Its centre corresponds to what is DISEASES OF THE VULVA. 95 known in the male as the central point of the perineum. On section (Fig. i) it is triangular and marks the meeting of the sphincter of the anus, the transverse perineal and the rudimentary bulbo-cavernosus muscles. It also contains a strong meshwork of connective tissue, and fibres of elastic tissue intermingle with the confluent attachments of the muscles mentioned above. Ruptured Perineum. — By this is meant a tear extend- ing through the lower part of the posterior vaginal wall and the perineum ; it may extend into the anus. Causes. — It is almost invariably due to parturition, but occasionally it is produced by surgical procedures, such as the extraction of large uterine polypi or foreign bodies from the vagina. When it occurs during labor the predisposing circum- stances are — 1. Disproportion between the size of the head and the genital passages. 2. Precipitate labor. 3. Want of care in the delivery of the head or shoulders. 4. Certain malpresentations, especially the unreduced occipito-posterior. 5. The use of instruments. The application of forceps does not, however, necessarily endanger the perineum ; on the contrary, properly used, it may lessen the risk of injury, by controlling and guiding the expulsion of the head. 6. Morbid conditions of the perineum : as undue softness and friability, which may be due to long-continued pressure of the child's head; undue rigidity; or diminution of elastic- ity as the result of chronic inflammation. 7. The risk is greater in primipara;, and increases with the age of the primipara. Varieties. — The following are met with : I. Partial. — Little more than the fourchette may be in- volved ; or the perineum may be divided to a greater or less extent, but the sphincter ani remains intact. W^ithiii g6 DISEASES OE WOMEN. tlic vagina, the tear nearly always occurs to one or other side of the posterior va^nnal column. The tliickness and firmness of this structure prevent a median split. 2. Complete. — The laceration is anteriorly the same as in the partial variety, but posteriorly it extends throuj^^h the sphincter ani, and may pass for some distance up the anterior wall of the rectum. 3. Central. — In this kind, which is uncommon, the ante- rior pari of the perineum remains intact, but a tear occurs at some place between the faurchette and the anus. It is due, as a rule, to long-continued pressure of the child's head, whereby the vitality of the thinned-out perineum is so impaired that it gives way at its most prominent point. Or perforation may occur later from gangrene, a vagino- perineal fistula thus resulting. Cases have also been re- corded in which the central tear was so large that the child was born through it, passing out behind the posterior com- missure of the vagina. Res7ilts of Ruptured Perine?aii. — When the rupture is partial, there is a tendency to prolapse of the vaginal walls, especially the posterior; this may be followed by a more complete hernia of the pelvic floor. There is also inability to retain a pessary when this is indicated on account of prolapse or retroversion. When the rupture is complete, in addition to the conse- quences mentioned above, there is diminution or loss of control over the rectum, causing incontinence of faeces or flatus. Treatment. — When a perineum becomes torn during par- turition, it should always be repaired at once. Two or three sutures will usually suffice, and union readily occurs. When not seen till some time after, secondary perineor- rhaphy is required. CHAPTER X. DISEASES OF THE VULVA (Continued). TUMORS AND CYSTS. The vulva is liable to lipomata, myxomata, sarcomata, angciomata, papillomata, epithelioma, and carcinoma. I/ipomata. — These may arise in the fatty tissue of the mons or in the deep connective tissue of the labia ; they usually form sessile tumors, but may be pedunculated. A sessile lipoma is apt to be mistaken for an omental hernia occupying the canal of Nuck, and vice versa. Myxomata. — These form irregular lobulated peduncu- lated tumors of the labium ; they are usually single and the skin covering them is deeply pigmented. Sarcomata. — These are very rare ; the commonest spe- cies is melanoma (melanotic sarcoma), arising in the pig- mented tissues of the greater labium. They are usually rapidly fatal from dissemination. Angeiomata. — Nsevi occur in the labia of children ; the more serious plexiform angeioma is very rare. Papillomata (JVarts). — These are very common on the vulva and surrounding cutaneous surface, and are often asso- ciated with irritating vaginal discharges, especially gonor- rhoeal. Kpithelioma. — This arises on any part of the vulva and occasionally occurs primarily on the clitoris. It is rare before middle life, but the liability increases with advancing years. The opposed surfaces of the labia are liable to those changes so often seen on the tongue and known as leucoplakia ; vulvar-likc lingual Icucoplakia may be the 7 'J7 98 DISEASES OE WOMEN. precursor of epithelioma. Epithelioma of the vulva runs much the same course as in other situations and quickly involves the inguinal lymph-glands. In the late stages foul ulcerating cavities form, and the depressions formed by the primary disease and those resulting from the necrosis of the infiltrated glands join to form a continuous bleeding and discharging cavity. Death comes about from exhaus- tion and distress induced by pain, frequent bleedings, and mental anguish. Sometimes a large vessel is opened by ulceration, and rapid death from bleeding ensues. Diagnosis. — This is usually easy ; the conditions most likely to be mistaken for it are — {a) Papillomata, especially if inflamed or ulcerating. {6) Hard chancre. This forms a single ulcer, with hard base, and no tendency to spread. The inguinal glands are small, separate, and amygdaloid. {c) Soft chancres are multiple ; there is no induration ; and they heal rapidly under proper treatment. {li) Lupus is distinguished by alternations of tubercular masses, ulcers with bluish undermined edges, and contract- ing cicatrices. There may also be tracts of healthy skin between the ulcers, whilst the cancerous ulcer is compact and shows no tendency to heal. {/) Sloughing phagedena appears as a breaking-down abscess with gangrenous walls and free secretion of pus. There is no induration, and the history of venereal infection points to its true character. Treatment. — If seen early enough, free excision is the proper treatment and the prognosis is generally good. When practicable, the cut edges of the vagina should be sutured to the skin at the margin of the wound ; the urethral mucous membrane should be similarly treated when the growth surrounds the urethral meatus. When the clitoris is alone affected, complete extirpation of this appendage is necessary. If the growth has extended deeply into the vagina, or DISEASES OF THE VULVA. 99 has spread extensively, palliative treatment is alone possible. The discomfort may be relieved by frequent antiseptic irri- gations and dressings smeared with eucalyptus and vase- line; anodynes, of which morphia subcutaneously admin- istered is the best, are usually required to relieve pain. Carcinoma. — This is a very rare affection of the vulva ; it arises in Bartholin's gl^id and involves the labial tissues, infects the lymph-glands, disseminates, and recurs after re- moval. Structurally it mimics the acini of the gland. Cysts of the Vulva. — These are of three species : mucous, sebaceous, and cysts of Bartholin's glands. Mucous Cysts. — These are found principally on the inner surface of the labia minora, and seldom attain a large size. They should be opened, and if they recur the cyst- wall should be dissected out. Sebaceous Cysts. — These resemble similar cysts in other regions. The small black spot marking the orifice of the duct will generally give the clue to their origin. They are liable to be infected by vaginal discharges and then usually suppurate. An abscess in a sebaceous gland requires free incision ; an enlarged gland requires excision. Cysts of Bartholin's Gland. — These usually arise in the duct, but in chronic cases the gland may enlarge. Sometimes the occlusion is not complete ; the duct may then become dilated for a day or two, and this is followed by a sudden discharge of mucous fluid. In the case of complete retention the fluid may be watery or viscid ; oc- casionally it resembles the contents of a ranula. Symptoms and Cmwsc. — The patient complains chiefly of discomfort, sometimes of pain. The inconvenience may be felt in walking or sitting, whilst the pain may be a constant aching due to distention, or take the form of dyspareunia. An inflammatory condition may be present from the first as a complication of gonorrhoea. Pus is then found e.xuding in small drops from the duct-orifice; later this tends to close up, and abscess results. lOO DISEASES OE WOMEN. A simple cyst is fairly well diftcrcutiated from the sur- rounding structures ; but if suppuration sets in, the cyst- walls become thickened and infiltrated, and the distinc- tion between them and surrounding tissues is obscure. When an intermitting cyst is examined during its stages of collapse, the gland itself may be felt, between the finger in Vestibular bulb. Bartholin' s gland. The duct. Fig. 29.— The right labium majus dissected to show Bartholin's gland and its duct (semi- diagrammatic). the vagina and the thumb outside, as a little mass the size of a pea or small bean. Diagnosis. — The cyst presents a characteristic pear-shaped swelling, occupying the most dependent part of the labium majus, the narrow end of the swelling being uppermost. DISEASES OE THE VULVA. lOI It is only when it gets large that it involves the upper part of the labium. In chronic cases the orifice is readily seen as a small pit in the angle between the hymen and the la- bium minus (Fig. 29). The lesser lip is not affected when the cyst is small ; when large, it is stretched and flattened over the swelling. Suppuration is readily recognized by the much greater pain, the redness of the skin and mucous membrane, and the heat of the part. Three conditions require to be differentiated from a Bartholinian cyst or abscess : (a) Hcematoma. — The swelling is more uniform through the labium majus ; it feels usually more doughy, and there is commonly a history of injury or recent parturition. A haimatoma may affect the lesser lip alone. (b) Ingidnal Hernia. — This appears at the upper end of the greater lip, and tends to disappear when the patient is lying down ; there is an impulse on coughing, and it may be resonant. In any case there is not a free flattened space between the swelling and the inguinal opening. (c) Hydrocele of the Canal of Niick. — In this case the swelling occupies the upper or middle part of the labium, the lower end being free. There is no impulse on straining or coughing, nor is the swelling affected by the position of the patient. Treatment. — The only satisfactory way of dealing with a Bartholinian cyst is to dissect it out. CHAPTER XI. DISEASES OF THE VAGINA. AGE-CHANGES, DISPLACEMENTS, INJURIES, FOREIGN BODIES, AND FISTUL/E. Age-changes in the Vagina. — In the child the vagina forms merely a transverse slit. The walls are thrown into numerous close folds, mainly transverse, and more marked at the side. After puberty the vai^ina becomes larger, the widening affecting especially the upper part. There are, however, considerable variations in individual cases ; in some the va- gina remains nearly the same width above as below ; in others, the capaciousness superiorly forms a marked con- trast to the narrow entrance. After marriage the folds become somewhat flattened out, and the whole vagina becomes dilated, owing to the ca- pacity of its walls for stretching. Childbirth accentuates the changes, and after repeated labors the folds become almost obliterated, and the orifice may remain gaping, owing to stretching or rupture of the sphincter vaginae. At the same time the walls become lax, and tend to protrude through the vulvar orifice. With the onset of the menopause, atrophic changes set in. The walls now become quite smooth on the surface ; and the lumen becomes contracted, especially at its upper portion ; with the result that the fornices are obliterated, and the whole vagina assumes a conical form, with its apex upward. At the summit of the cone the cervix forms a small projection ; or, this also becoming atrophied, the vag- 1U2 DISEASES OF T/IR VAGINA. IO3 inal vault becomes almost pointed, with a small depression at its apex representing the external os and barely admitting a sound or a probe. DISPLACEMENTS OF THE VAGINA. These are commonly associated with displacements of the uterus, the whole forming the typical " hernia of the pelvic floor ;" but as the vagina may be affected principally, or alone, we shall here describe the two chief types — viz. cystocele and rectocele. Cystocele. — This is really a hernia of part of the blad- der into the vagina, the vaginal mucous membrane form- ing its outer covering ; or it may be expressed as a deflec- tion of the vesico-vaginal septum toward the vagina. It forms a smooth, rounded swelling, which bulges through the vulvar aperture when the patient coughs or strains. If the lower part of the anterior vaginal wall is mainly af- fected, the swelling is more properly called a urctJirocclc ; in this case it is smaller, and the thickened urethra can be felt as a median projection through the vaginal wall. Rectocele. — This is a hernia of the rectum into the va- gina, covered by the mucous membrane of the posterior vaginal wall. It forms a swelling resembling that produced by a cystocele, except that it is on the posterior aspect of the vagina. If the finger be introduced into the rectum it can be passed into the pouch in the vagina ; and similarly a sound introduced into the bladder can be passed into a cystocele. A rectocele is nearly always associated with a deficient perineurh ; and further, cystocele and rectocele are often found together. When this is the case the vulvar outlet, when the patient strains, is occupied by two smooth swell- ings placed one in front of the other ; between them the finger can be passed up to the cervix (Fig. 30). Causes. — The direct cause of these conditions is a relaxa- tion of the tissues forming the vaginal walls. This, again, I04 DISEASES OF WOMEN. is brought about mainly by parturition. Women who have iDorne a great number of children are the principal sufferers, and most cases come under observation between the ages V-^' * Fig. 30. — Cystocelc and rectocele (A. E. G.). of thirty and forty-five. After the menopause the general tendency to atrophy of the genital passages counteracts in some measure the laxity of the vaginal walls. The mechanism of the displacement differs slightly in the production of a cystocele and a rectocele. Cystocelc. — It will be remembered that the anterior vagi- nal wall is attached more firmly below, opposite the pubes, than above ; now in the case of a tedious labor, when a large head presses for some time on the vaginal walls, the anterior wall is forced down, and its attachments to the DISEASES OF THE VAGINA. I05 pubes are loosened and may even be separated. After a first confinement the parts may regain more or less their normal fixity. But after repeated labors, especially if dif- ficult, the lower part of the anterior vaginal wall remains permanently loosened from its pubic attachment, and tends to prolapse whenever the intra-pelvic pressure is increased, as when the bladder is full ; when the patient strains at stool or coughs ; and in some cases when she simply stands erect. A cystocele may arise in another way. Owing to the fact that the principal attachment of the anterior vaginal wall is at its lower end, it follow's that if the uterine sup- ports be loosened, and the uterus comes to lie low in the pelvis, the upper and lower ends of the anterior vaginal walls are approximated ; the intervening part bulges back- w^ard, especially when the bladder is full ; and in this way also a cystocele is produced. Rectocelc. — The posterior vaginal wall is mainly attached above, being held in place by the utero-sacral folds. When these are lengthened and rendered lax, as by the dragging of a heavy uterus or as the result of repeated labors, the posterior vaginal wall hangs lower, and may bulge in the form of a rectocele. The tendency to this is greatly in- creased if the perineum be torn, as the inferior support is then lost. Indeed, a slight degree of rectocele is possible when the perineum is torn, even if the utero-sacral folds remain at a normal tension, and the uterus is in its proper position. But it is evident that, owing to the superior attachment of the posterior wall, there can be no great pro- lapse of that wall as long as those attachments remain firm. In accordance with the above considerations we find, first, that cystocele is more common, and usually more marked, than rectocele ; secondly, that prolapse of the uterus strongly predisposes to prolapse of the vaginal walls. Sy)iipto))is. — The patient complains principally of " bear- Io6 DISEASES OE WOMEN. iiig down." and of something protruding from the vulva. In out-patient practice the statement made is often that " the womb comes down." The feeling of weight and dragging is aggravated after long standing or walking, and during defecation. With cystocele and urethrocele there is often frequency of desire to pass water. On making an examination, the vaginal outlet is seen to be occupied by one or two swellings according as one or both conditions exist. In recent cases the mucous membrane retains its normal character; in those of long standing it may be thickened and hard, approaching the appearance of the skin. The swelling is distinguished from a protruding cervix by the absence of the os externum and by the fact that it has an anterior (cystocele) or a posterior (rectocele) attachment. A finger passed through the anus into the posterior swelling, or a sound passed through the urethra into the anterior one, will confirm the diagnosis. The cerv'ix uteri is generally met with low down in the vagina. Trcatuicnt is of two kinds, palliative and curative. (a) Palliative treatment consists in the employment of pessaries ; of these the most useful is the rubber ring. When the perineum is much torn, it is often found that no ring will remain in pcsltion, unless so large as to cause harmful pressure. An instrument of the cup-and-stem t)-pe may be used, such as a ring with a Y-shaped stem, the limbs of the Y being attached at the ends of a diameter of the ring. Perineal bands are fastened to the lower end of the stem. These plans are, at the best, faulty ; and when a simple ring cannot be retained it is much better to resort to operation unless contraindicated. (b) Curative or Radical Treatment. — Vox rectocele, a peri- neorrhaphy may be performed, either alone or associated with posterior colporrhaphy (colpo-perineorrhaplu')- This will often allow of the wearing of a ring, e\en if the opera- tion does not entirely cure the prolapse. For cystocele many varietes of anterior colporrhaphy DISEASES OF THE VAGINA. lO'J have been devised (see Colporrhaphy). In obstinate cases some more serious measure may be tried, such as vaginal or ventro-fixation (see Hysteropexy). For cystocele asso- ciated with retroversion of the uterus, vagino-fixation often answers well ; for the two opposing tendencies — of the ute- rus to fall back, and of the vaginal wall to fall down — coun- teract one another (Edge). Vaginal Hernia {Entcrocclc). — A rare form of hernia sometimes occurs in which the uterus and the lower part of the vagina retain their proper position, whilst the peri- toneal pouch in front of or behind the uterus bulges into the vagina and is occupied by coils of intestine. It is dis- tinguished from the conditions just described by the follow- ing points : i. The swelling is not continuous, anteriorly or posteriorly, with the margin of the vulva; 2. The finger can- not be passed into the pouch through the anus nor can a sound be passed into it through the urethra ; 3. The cervix uteri is found high up. A vaginal hernia has been mistaken for prolapse, polypus, and inversion of the uterus. Injuries. — Serious and even fatal injuries of the vagina have followed rape on adult women as well as children ; severe lacerations have been caused during willing coitus, due to unusual size of the penis, undue narrowness of the vagina, or even awkwardness on the part of the man. First coitus sometimes causes alarming and even perilous bleed- ing, especially when the laceration of the hymen extends to and involves the vulva or the vaginal wall. Fatal peritonitis has followed the forcible introduction of foreign bodies by brutal men. Women sometimes injure themselves fatally by introducing pointed instruments for the purpose of inducing abortion, or during fits of sexual frenzy. The upper part of the vagina may be lacerated by the careless use of instruments in operations on the uterus and during instrumental delivery, or by the child's head in a I08 DISEASES OE WOMEN. long second stage of labor. When free bleeding results, it may be erroneously thought to be derived from the cavity of the uterus. As a rule the bleeding stops readily under the influence of a hot vaginal douche (115° F.). If it persists, the lacerations may require to be repaired. A serious form of laceration sometimes occurs during labor, the recto-vaginal or the utcro-vesical pouch being opened up. This may occur from violent uterine contractions in cases where the pelvis is narrow or there is other obstruc- tion to delivery ; it has also been produced during the introduction of the forceps, perforator, or cephalotribe. Coils of intestine may protrude through the gap, and even hang out from the vulva. The accident is generally fatal. Foreign Bodies. — The vagina, like the other accessible cavities of the body, is liable to have foreign bodies intro- duced into it. Little girls from sheer curiosity insert hair- pins, pebbles, seeds, fruit-stones, pencils, etc. Older girls introduce sponges, cotton-wool, and the like, with the hope of preventing conception from illicit intercourse. Pomade-pots, pewter pots, cotton-reels or spools, candle- extinguishers, and small india-rubber balls have been re- moved from the vagina of matrons ; some of them were introduced to prevent pregnancy, others to act as supports to prolapsed wombs. Pessaries of extraordinary shape, size, and complexity have been introduced by obstetric physicians and forgotten till urinary fistulai or stinking dis- charges have led to examination. Brutal men when rioting with low drunken women have thrust into the vagina pipe- bowls, thimbles, clock-weights, or pieces of metal. The vagina has served as a repository for stolen prop- erty — c. g. gems, bank-notes, jewelry, and pocket-books. Among odd things the following deserve mention : A cockchafer beside a pomade-pot (Schroeder) ; a small bust of Napoleon the Great ; and cylinders of inverted pork-rind. A woman was admitted into the cancer ward of the Mid- dlesex Ho.spital with a certificate of " stone cancer " of the DISEASES OF THE VAGINA. IO9 uterus. Examination proved the alleged cancer to be a piece of brick. When a healthy young woman is found to be suffering from a stinking vaginal discharge, it is exceedingly prob- able that she has a foreign body in the vagina. Fistulse. — As the vagina is placed between two hollow viscera, the bladder and rectum, it is not surprising that fistulous passages are occasionally formed between them. Fistulae are caused by sloughing of the vagina during pro- tracted labor; injuries from obstetric implements; ulcera- tion due to pessaries and other foreign bodies. They also occur in the late stages of epithelioma of the vagina and carcinoma of the cervix uteri and the rectum. Occasion- ally they are due to ulceration of the bladder set up by ves- ical calculi formed around foreign bodies introduced into the bladder. Vaginal fistulae, vesical, ureteral, and rectal, occasionally follow vaginal hysterectomy ; usually, however, they are merely temporary. Vaginal fistulae are of four kinds: i. Vesico-vaginal ; 2. Urethro-vaginal; 3. Uretero-vaginal; 4. Recto-vaginal. The names are sufficient to indicate their positions. Utero-ves- ical fistulae may be also considered here. Symptoms. — In the case of a vesico-vaginal fistula the patient complains that she cannot hold her water. Some urine may collect in the bladder and be voided periodically if the fistula is small ; otherwise the urine escapes from the vagina as rapidly as it enters the bladder. The vulva and vagina are inflamed and excoriated by the constant wetting ; and sometimes a phosphatic incrustation forms. If the fistula be rectal, great discomfort and distress is caused by the passage of faeces and flatus by the vagina ; though, if the fistula be small, the faeces may be prevented by their semi-solid form from entering the vagina. The Methods for the Detection of Vaginal Fistuhu. — The persistent and involuntary escape of urine from the vagina is no diseasilS of women. sufficient indication of the existence of a urinary fistula, but it is not always a simple matter to localize its precise position. To determine this it is advisable to put the patient in the lithotomy position and expose the parts with a duck-bill speculum introduced into the vagina in a good light. A vesico-vaginal or a urethro-vaginal fistula rarely gives rise to difficulty, and the pink everted edges surrounding its vaginal orifice soon lead to its detection. When there is difficulty in finding it, the vaginal mucous membrane should be cleared of mucus, and warm milk injected into the blad- der through a catheter in the urethra ; it will then dribble through the fistula. Injections of milk arc very serviceable for the detection of uretero-vaginal fistulas. In this case when it is injected into the bladder none escapes into the vagina, yet during the course of the examination urine has continued to escape into the vagina. This test is necessary even when the ori- fice of the fistula is clearly visible. In this form of fistula, if the urine which escapes involuntarily from the vagina is collected, measured, and compared with that voided from the bladder, it will be found that the two quantities equal each other. In the case of a utero-vesical fistula the urine will be seen escaping from the cervical canal of the uterus ; when milk is injected into the bladder some of it escapes down the cervical canal ; this is conclusive. Treatment. — In recent injuries the blood-clot should be removed and deliberate search made for bleeding vessels, which should be secured with forceps and ligatured. Capil- lary oozing is best restrained by careful packing with gauze. The subsequent treatment is that adapted for wounds in general. In the case of foreign bodies, they should be re- moved as soon as discovered ; when long retained it is usually necessary to obtain the advantage of an ana."s- thetic. Persistent vaginal fistuUi.' of all kinds require ope- rative treatment. CHAPTER XII. DISEASES OF THE VAGINA (Continued). VAGINAL INFECTION AND THE VAGINAL SECRETIONS. GoNORRHCEA and sepsis play a very important part in the production of vaginitis. For the better appreciation of their influence we must make some prehminary observations on the bacteriology of the normal vaginal and uterine secre- tions. The Normal Vaginal Secretion. — In the following remarks the excellent account given by Doderlein will be followed. Origin. — The vagina contains no glands ; and some ob- servers have consequently inferred that the secretion found in the vagina is derived in every case either from the cer- vical or Bartholinian glands. This view is disproved by the following considerations : First, the cervical canal is nor- mally occupied by a tenacious plug of mucus, which shuts off the cervical from the vaginal canal; secondly, the Bar- tholinian glands usually secrete very little fluid, and the ducts open on the outside of the hymen ; thirdly, in closed vaginal cysts a typical vaginal secretion is found ; fourthly, the cervical and vaginal secretions present markedly dif- ferent characters. The vaginal secretion is derived from the shedding of squamous epithelium together with the exudation of some lymph-serum. Normally, it forms a thin coating on the surface of the vagina. Characters. — It is a rather thin opalescent fluid, devoid of 111 1 1 DJSEASES OI' WOMEN. visciclit)', .iiul soiuctiincs, when abundant, forming a wliite fliicciilcnt and curdy matter. It gives a strongly acid re- action, due to the presence of lactic acid. Estimated quan- titatively, the acidity is equivalent to 0.4 per cent, of sul- phuric acid or 0.9 per cent, lactic acid. In the new-born the action is neutral ; in the healthy virgin it is acid ; in normal pregnancy the acidity is greater ; whilst in patho- logical conditions the reaction is feebly acid, neutral, or even alkaline. The acidity disappears during and for some days after menstruation, and for five or six weeks after normal Fig. 31. ^Normal secretion from the vagina, showing ilie vagina-bacillus (Dodcrlcin). labor. Examined microscopically, the vaginal secretion in the new-born contains only squamous epithelium. In the virgin and in normal pregnancy there is constantly found, in addition, the vagina-bacillus (Figs. 31, 32); whilst in a certain percentage of cases a fungus is found, the Monilia cajidida. The vagina-bacillus and the fungus are invariably absent from pathological secretions. The vagiiia-bacilliis belongs to the anaerobic bacilli. It may be cultivated on agar or gelatin, or in bouillon, blood- DISEASES OF THE VAGINA. 113 serum, or milk. It requires moisture and warmth equiva- lent to the body-temperature. It occurs in the form of short straight rods. As the result of pure cultivations lactic acid is invariably produced, equivalent quantitatively Fig. 32. — Pure cultivation of vagina-bacillus (Doderlein). to 0.5 per cent, sulphuric acid, which corresponds to 1.125 per cent, lactic acid. Role of the Vagina-bacillus. — To this bacillus is due the presence of lactic acid in the vaginal secretion, as indicated by the fact that when the bacilH are absent, as in the new- born and during the puerperium, the reaction of the secre- tion is always neutral. In its presence saprophytes and pathogenic micrococci, such as the streptococcus and sta- phylococcus, are unable to develop, and before long perish. When the vagina-bacillus is absent, as in the lochial secre- tion, both saprophytes and staphylococci are able to flour- ish. The Monilia is a harmless organism which can only grow in the presence of the vagina-bacillus ; that is, in the healthy vaginal secretion. The antagonism between the vagina-bacillus and patho- 114 DISEASES OF WOMEN. genie organisms is illustrated by the following experiments described by Dodcrlein : (a) A pure cultivation of the vagina-bacillus on peptone- agar of three days' growth was inoculated with a cultivation of the staphylococcus pyogenes aureus. The staphylococci were soon destroyed. When, however, the two bacilli were inoculated on agar at the same time, the vagina-bacillus perished, showing that abundant products of the growth of the latter arc required to destroy the staphylococcus. (b) The vagina of a virgin was inoculated with a bouillon culture of staphylococcus pyogenes aureus. After six hours an abundant cultivation of staphylococci was ob- tained therefrom. After twenty-four hours only a few colonies were found; these further diminished on the sec- ond and third days, and by the fourth day the staphylo- cocci had been quite destroyed in the vaginal secretion. As a result of the protective influence of the vagina- bacillus it happens, as Winter has shown, that when patho- genic organisms are found in the normal vaginal secretion they are always in a condition of weakened virulence. The normal ccnncal secretion consists almost entirel}' of mucus, in which are found entangled a few columnar cells derived in part from the surface epithelium and in part from that lining the glands. It is in consequence viscid and tenacious, so that a plug of it filling up the external os is often very difficult to dislodge. Its reaction is alkaline or neutral, and it contains no micro-organisms. Pathological Vaginal Secretion. — This is thin, yel- lowish white, or, if pus be mixed therewith, greenish. It may be so abundant as to flow from the closed vagina, giv- ing all the symptoms characteristic of leucorrhoea. Its reaction varies from faintly acid, through neutral, to strongly alkaline. Examined microscopically, it is found to contain epithelial debris, and often pus-cells. Both in cover-glass preparations and by cultivation it is found to contain saprophytic bacilli and micrococci — -.viz. DISEASES OF TJJE VAGINA. 115 staphylococci and often streptococci. The vagina-bacillus and the monilia fungus are never present. A pathological vaginal secretion may be regarded as a favorable cultivation medium for pathogenic organisms. Doderlein performed eighteen inoculation experiments with pathological vaginal secretions on rabbits, and in every case septicaemia resulted. The transition from a normal to a pathological secretion may be brought about in two ways : First, by mere functional increase in the amount of secre- tion, such as arises from sexual excesses. Thus in thirty prostitutes examined by Doderlein the secretion was not once found to be normal, even when there was no specific gonorrhoeal infection. Masturbation, the wearing of rubber pessaries, frequent and purposeless vaginal irrigations, and the introduction of alkaline substances, such as soap, may have the same effect. Second, through pathological organic changes, such as Fig. 33. — Gonococci. are found in endometritis, adenomatous disease of the cer- vix, vaginitis, and cancer. Besides the organisms of sepsis there is sometimes found a specific micro-organism, the gonococcus of Neisser (Fig. I 1 6 DISEASES OE WOMEN. 2^^-^. It must be remembered, hcnvever, that, as Bumm has pointed out, the vagina often escapes gonorrha.'al infec- tion, owing to the resistance offered to the entrance of gonococci by the stratified squamous eiiithelium, whose superficial portion is hard and horny. But the disease readily attacks the urethra and the delicate columnar epi- thelium of the cervix. In cases of gonorrhoea the vaginal secretion is therefore usually altered indirectly by the admi.xture therewith of the unhealthy cervical secretion, which is abundant, alka- line, purulent, and consequently albuminous ; and the vaginal secretion accordingly acquires these characters. The vagina-bacillus perishes under these circumstances ; and a favorable soil is provided for the development of the pathogenic germs previously described. The actual inocu- lation of these pathogenic germs may occur during men- struation, sexual intercourse, gynaecological manipulations, and parturition ; in the latter case not only through vaginal examinations and operative procedures, but also through traumatism incident to labor. An important practical deduction to be drawn from these considerations is, that in cases in which the vaginal secre- tion departs from the normal type special care should be taken to disinfect the vagina before resorting to any intra- uterine manipulations, even the passage of the sound, lest the uterine cavity, previously unaffected, be inoculated with septic organisms. Having thus briefly reviewed the pathogenesis of vag- inal infection, we may enumerate the principal morbid conditions which may result therefrom — viz. : Vaginitis ; endometritis, of both cervix and body ; salpingitis, ca- tarrhal and purulent ; septic peritonitis ; pyocolpos and pyometra ; and pelvic cellulitis. These results may follow either from sepsis alone, or from sepsis complicated by gonorrhoea. In concluding these remarks on the secretions, the fol- DISEASES OF THE VAGINA. 11/ lowing resume of the different kinds of discharge found in the female genital passages may prove useful : 1. Normal vaginal discharge, of which the characters have been given above — viz. white, creamy or curdy, and so slight in quantity as not to attract the patient's attention. 2. A clear viscid discharge, composed principally of mucus. This is the normal cervical discharge, and is usu- ally not seen except on examining with the speculum ; but it may be mixed with the vaginal discharges at the begin- ning and end of menstruation, and occasionally, when abundant, at other times. 3. A muco-purulent or purulent discharge, yellowish or greenish according to the proportion of pus. This is seen characteristically in acute gonorrhoea, and commonly re- sults also from chronic endometritis. It is the variety most frequently spoken of as " the whites," when containing but little pus. It stains and stiffens the linen. 4. Watery discharges may result from simple hyperaemia of the genital passages, and occasionally from intermittent hydrosalpinx. They are also found in cases of cancer, but the discharge then assumes more often the characters of the next variety. 5. Foetid discharges occur as the result of ulceration, and the principal conditions which produce them are re- tained pessaries, sloughing fibro-myomata and polypi, de- composing products of conception, and, most frequently of all, cancer. 6. Bloody discharges, other than menstrual, may be due to cancer, endometritis, fibro-myomata, polypi, adenomatous disease of the cervix, and lacerations. The discharge is often pinkish in cancer ; but in any of the above con- ditions it may vary from a very slight rose tint to the red of almost pure blood. CHAPTER XIII. DISEASES OF THE VAGINA (Continued). INFLAMMATION; TUMORS AND CYSTS. Vaginitis. — The chief causes of inflammation of the vagina are — (a) Injuries, such as result from obstetric ope- rations, accident, foreign bodies, retained pessaries, immod- erate coitus, and careless application of caustics to the uterus ; (b) Infections, such as gonorrhcea, sepsis, and tuber- culosis ; and (c) Pregnancy. According to the age of the patient different t}'pes will be found. In children it may be simple, or due to thread- worms, gonorrh(ea, and exceptionally to uterine tubercu- losis. In adults it is nearly always gonorrhceal. Want of cleanliness and constitutional conditions are predisposing causes, as they favor the growth of pathogenic organisms (see preceding chapter). It is through a disturbance in the secretion, associated with congestion, that pregnancy may induce vaginitis. Pathology. — As in inflammation elsewhere, the first con- dition is congestion, causing heat and redness of the mu- cous membrane. The discharge which is produced is known clinically as leucorrhca, and consists at first of a wateiy fluid, with cast-off epithelial cells. If the latter are in great quantity, the discharge is no longer clear, but white and turbid (hence the name). If pus forms, it imparts a yellow or green color to the discharge. In simple cases the inflammation soon subsides, without further change than more or less desquamation of the epi- thelium. In senile vaginitis atrophic changes follow: the 118 DISEASES OE THE VAGINA. II9 epithelium is reduced in thickness, and fibrous changes ensue in the mucous membrane, which narrow the hmien of the passage. The same result may occur in places from the action of caustics ; but here the epithelium may be deeply destroyed, and the contraction is sometimes marked (see Complications). When the vaginitis is purulent, from sepsis or gonorrhoea, on microscopic examination the epi- thelium is seen to be at first swollen, due to infiltration of round cells in the papillae, which are very vascular. The interpapillary spaces are filled up by exudation of cells and serum, till the papillae cease to be distinct. The epi- thelium then becomes thin and presents the appearance of granulations, which bleed readily (Ruge). The gonococcus itself is not able to penetrate the stratified vaginal epithe- lium (Bumm) ; but the staphylococcus and streptococcus appear to be able to do so. Under proper treatment the granulations subside, and the epithelium gradually resumes its normal appearance. But when the inflammation has been very virulent, large patches of epitheUum may be detached, mixed with coagu- lated exudation ; and this condition has been described as diphtheritic, membranous, or desquamative vaginitis. Varieties. — Clinically it is useful to distinguish the fol- lowing varieties of vaginitis : (a) Vulvo-vaginitis of children ; (b) Vaginitis of pregnant women ; (c) Gonorrhoeal vaginitis of adults ; (d) Senile vaginitis ; (e) Membranous vaginitis. (a) Vulvo-vaginitis of children acquires some of its import- ance from its medico-legal bearings. The question of crim- inal assault sometimes arises, and the medical attendant should bear in mind the following points : First, vulvo- vaginitis of simple character may occur when there has been no violence nor external interference of any kind. It is then found mostly in weak and neglected children. Sec- I20 DISEASES OE WOMEN. ondly, vulvo- vaginitis may be produced by indecent vio- lence short of rape. Thirdly, gonorrhceal vulvo-vaginitis may occur, in epidemic form, in schools ; the starting-point may be an accidental contamination by the bed-clothes w hen children sleep with parents or elder brothers ; and infection may be spread with towels or other linen, or by the use of one bath for several children. Fourthly, the gonorrhoea may result from raj)e ; this is probably rare in proportion to the total number of cases. This form of vaginitis has been found at all ages from early infancy to puberty. The symptoms are sometimes slight ; with the exception of a mucous or purulent discharge they may be absent. But more often the child complains of pain, scalding mic- turition or itching ; and there may be some febrile dis- turbance. It has been shown that thread-worms may set up vaginitis in children by passing into the vagina, from the rectum. The smallness of the hymeneal orifice in children, while it is in some measure a safeguard against infection, tends to aggravate the disease when once established, and is a difficulty in the way of cure, because it favors the re- tention of discharges. (b) Vaginitis of Pregnant Women. — To what has been said about this we need only add that at times it may be due to latent gonorrhoea, allied to gleet in the male, taking on increased activity as the result of the congestion caused by pregnancy. Vaginitis may occur also during the puerperium, as part of a puerperal infection, and is then generally septic. The laceration or bruising of the vagina by the passage of a large head or by instruments favors inflammation ; and indeed, apart from infection, there is always some degree of traumatic inflammation in these cases. (c, d, e) GonorrJia'al vaginitis is the most conmion form of vaginitis in adults, and what is here said of vaginitis in general applies more especially to the gonorrheeal foiin. DISEASES OF THE VAGINA. 121 Senile and incnibranous vaginitis do not require special description. Symptoms. — The patient complains of pain and burning in the vulva; smarting pain on passing water; dyspareunia and discharge. On examination, the vaginal walls are hot, red and swollen, and acutely tender to the touch. The dis- charge, generally yellow or green, is found bathing the ex- ternal genitals as well as the vagina. The signs described under the complications of vulvitis may also be present. In senile vaginitis the discharge may be thin and sanious, leading one at first to suspect carcinoma of the cervix. Diagnosis. — As stated under Vulvitis, the matter of prin- cipal difficulty and importance is often to distinguish gonor- rhceal from non-gonorrhceal vaginitis. In the absence of pus, the probability is that the inflammation is of simple character ; but in cases of some standing this sign is of less importance. When there is pus it may be septic in origin, or it may come from the cervix uteri, and not primarily from the vagina. A careful examination must therefore be made with the speculum, when, if the vagina is at fault, it will be seen reddened and studded over with brighter red points. In all cases of doubt a careful search must be made for gonococci. Implication of the urethra and of the Bartholinian ducts affords strong presumptive evidence of gonorrhoea ; by some, either condition alone is regarded as certain proof Leucorrhoea due to endometritis or carci- noma is distinguished from that due to vaginitis, by the use of the speculum. Course and Complications. — If left untreated a simple vaginitis does not give much trouble ; but the results of gonorrhoea are far-reaching and serious. The most im- portant is the spreading of the disease up the genital pas- sages, producing successively endometritis, purulent salpin- gitis, and septic peritonitis. For this reason gonorrhoea is a much more serious condition in women than in men. Nor does the danger stop here. Under the influence of 122 DISEASES OE WOMEN. i)re<^nancy a latent fj^onorrhoL'a may reawaken to virulent activity, in the vagina, the uterus, or the tubes ; or the trouble may lie dormant till labor comes on, when a rapidly fatal form of puerperal septicemia may develop, for which the medical attendant may incur undeserved responsibility- In other and perhaps more frequent cases sterility results from the sealin<^ up of the fimbriated ends of the Fallopian tubes, which become converted into bags of pus. This is generally associated with a troublesome form of dysmenor- rhoea. It is evident, therefore, that no effort should be spared to treat energetically and thoroughly every case of acute gonorrhoeal vaginitis. The infection of the urethra seldom causes any complica- tions in women ; stricture is very rare, and consequently the bladder, ureters, and kidneys commonly escape. At times, however, cystitis may be set up. In addition to the complications mentioned under Vulvitis, the following have to be considered : Vcsico-vaginal and Recto-vaginal Fistiilcs. — These occur more often from other causes, but may result also from severe vaginitis attended with ulceration. Atresia Vagina. — This is especially apt to occur when there has been much destruction of the epithelium, and is therefore often well marked when the vagina has been much injured by caustics applied to the cervix uteri. In such cases, if examined at a later date, the finger discovers the vagina to be contracted, usually a little below the level of the external os. The contraction may be so great as barely to admit the finger-tip. But if this can be passed through the constriction, which is often annular, it enters an ex- panded part of the vagina, in which is found the cervix. The vagina may, in fact, be said to present an hour-glass contraction. The condition, if it occur in later midtile age, about the time of the menopause, causes but little trouble ; but in earlier adult life the contraction may go on to oblit- eration of the canal, and haematocolpos results. Similarly, DISEASES OF THE VAGINA. 1 23 but more rarely, the external os may become stenosed or occluded, giving rise at first to dysmenorrhoea, and later to haimatometra. Purulent oplithalinia is a frequent complication of vulvo- vaginitis in children, the infection being conveyed directly by the patient's fingers or indirectly through linen and clothing. Peritonitis ranks next in order of frequency to ophthalmia as a complication of gonorrhoea in young women. GonorrJixal rJieumatisni also occurs, but less frequently than among men. Prognosis. — From the above it will be seen that when treatment is not thoroughly carried out, the prognosis is grave as regards the subsequent health. With proper care, however, in the early stages, the outlook is very satisfactory. Treatment. — In the treatment of simple vaginitis, all that is required is to keep the patient in bed and to order vaginal douches of warm unirritating lotions, such as boracic acid (oj or 3ij to the pint) or subacetate of lead. For gonorrhoeal vaginitis, a more energetic treatment must be undertaken in order to abort the course of the disease and diminish the tendency to complications. The following will be found an effective method: The patient is anzESthetized and placed in the lithotomy position ; the vagina is then well irrigated with a solution of carbolic acid (i : 40); after which it is thoroughly swabbed out with a solution of carbolic acid in glycerin (i : 10), or with a solu- tion of chloride of zinc (10 grs. to sj) ; the cervix is simi- larly treated, and a uterine probe may be dipped into the solution and applied to the uterine cavity. The vagina is then again irrigated with carbolic lotion (i : 40) or a satu- rated solution of boracic acid ; iodoform tampons are placed in the vagina, and the patient sent back to bed. The after- treatment consists of douches, morning and evening, with warm saturated boracic lotion. If this thoroueh treatment under an ana.'sthetic cannot 124 DJSEASKS OJ- WOMEN. be applied, douches of carbolic acid (i : 40) should be ordered mornini^ and evening; it is not advisable that much force should be used, lest toxic discharges be forced up into the cervical canal. A milder method, often serviceable when there is much pain and tenderness, is a course of hot sitz-baths, twice daily. In children it is advised that, in the acute stage, care should be taken that the child's head be not immersed in the bath, lest the eyes become contaminated by the dis- charges. After bathing or syringing, iodoform bougies may be placed in the vagina, each vaginal bougie contain- ing 3 grs. of iodoform. For children smaller bougies are employed. Chronic vaginitis is not seen except in associa- tion with chronic endometritis, and its treatment is described with that of the latter condition. The treatment of complications must be carried out as may be required. An abscess in the vaginal xvall may be due to extension of pelvic cellulitis into the connective tissue of the vagina, and the abscess-cavity may remain connected with that from which it is derived or become cut off from it ; or it may be due to suppuration in a vaginal cyst. The febrile symptoms and the redness of the vaginal wall over the swelling will point to its true nature. The treatment con- sists in evacuating the pus by means of a free incision. TUMORS AND CYSTS OF THE VAGINA. The vagina is rarely the seat of tumors : they belong to four genera : lipomata, myomata, sarcomata, and epitheli- oma. Lipomata and myomata are v&xy rare. Sarcomata. — Examples of this genus occur in adults; it appears that they are rare before forty years of age. They are sessile, ulcerate early, and bleeding is the first sign which attracts attention (Gow). In children the)- have a tendency to be polypoid. They cause death by interfer- ing with the bladder or rectum (D'Arcy Power). DISEASES OF THE VAGINA. 125 Bpithelioma. — This disease may arise in any part of the vaginal mucous membrane, but it is more liable to begin at the junction of the vulva and vagina, or on that portion which is reflected over the cervix uteri. When epithelioma attacks the vulvar end of the vagina, it is very apt to begin near the urethral orifice. In such cases the inguinal lymph-glands are early infected; the ulceration quickly involves and perforates the vesico-vaginal septum and leads to a fistula. When the posterior wall is attacked, ulceration leads to a recto-vaginal fistula. It is very extraordinary that the early .stages of this fatal disease cause so very little inconvenience that patients rarely seek advice until the disease has long passed the limits of justifiable surgery. Cysts. — The vagina is liable to the following species : mucous, Gartnerian, and peri-urethral cysts, and echino- coccus colonies. Mucous Cysts. — These are small and resemble retention cysts, but their nature is doubtful. Some observers con- sider them as retention cysts of vaginal glands ; others deny the existence of such glands and explain these cysts as due to obliteration of the mouths of crypts in the vaginal wall. By others, again, they are regarded as due to dila- tation of lymphatic spaces, and are described as associated with gaseous bullae in the condition called emphysematous vaginitis. They occur not infrequently in cases of vaginitis and endometritis, resembling superficially the Nabothian fol- licles seen on the cervix. Gartnerian Cysts. — The pathology of these cysts is described in connection with the parovarium. Cysts arising in the terminal segment of this duct pro- ject as soft fluctuating swellings in the upper part of the vagina; sometimes two distinct cysts arise in connection with one duct. They vary greatly in size ; some do not measure more than two centimetres in diameter, others may 126 DISEASES Of WOMEN. exceed these dimensions three or four times. The inner wall of the cysts is lined either with cubical or stratified epithelium. Peri-urethral Cysts. — Small cysts are sometimes found in the anterior vaginal wall near the urethra : sometimes they bulge into the urethra. Skene is of opinion that these cysts arise in the ducts which he detected and described in the lloor of the urethra near the meatus. Bchinococcus Colonies {Hydatids). — These are very rare and are generally due to echinococcus colonics in the mesometrium burrowing in the recto-vaginal septum. Treatment. — This is the same as that employed for tu- mors and cysts in other regions of the body — namely, re- moval — but in the case of sarcomata and epithelioma it is rare for the disease to come under observation before it has so deeply involved the rectal and vesical walls that inter- ference with it only anticipates the complications which en- sue in the natural course of the disease, — rectal and vesical fistulae. Cysts when small are readily enucleated, and the pro- ceeding is safe if the operator keeps close to the cyst-wall. In the case of large Gartnerian cysts which burrow from the vagina into the mespmetrium, unless great care is exer- cised the ureter may be easily damaged and a troublesome fistula result. When there is difficulty or anxiety in enu- cleating vaginal cysts, the surgeon may freely incise them, evacuate the contents, and stuff the cavity with gauze ; the cyst is then slowly obliterated by granulation. This method, however, though safe, is rarely certain, for the rent in the wall may close and the cyst re-form. Enucleation of the whole of the cyst-wall is the only sure method of treat- ment. CHAPTER XIV DISEASES OF THE UTERUS. AGE-CHANGES; FLEXIONS AND DISPLACE- MENTS. Age-changes. — The uterus undergoes some important changes between birth and puberty. In the new-born in- fant the uterus has no fundus, its summit is often deeply notched, and the neck of the uterus is larger than its body. The arbor vitae is very distinct. The body of the uterus lies above the level of the brim of the true pelvis, and its anterior surface forms a well- marked curve where it rests on the urinary bladder. Toward pu- berty the fundus develops, and the organ assumes the pear-like shape so characteristic of the mature ute- rus (Fig. 34). After the meno- pause, it shares in the general atrophy of the reproductive organs. The cervix especially diminishes in size until it becomes merely a small button-like projection at the inner end of the vagina. Measurements. — The fully- developed virgin uterus has the following average dimensions:- length, 3 in. (7.5 cm.); breadth, 2 in. (5 cm.); thickness, i in. (2.5 cm.); length 127 Fig. 34. — Sagittal section through the uterus and the adjacent part of the v.Tgina of an adult ; J^ natural size (Henle). 128 DISEASES OE WOMEN. of cavity, 2\ in. (6.2 cm.); weight i^ ounces (42 grammes). After jDregnancy the uterus never regains its virgin propor- tions and remains, until the menopause, enlarged in all its measurements and increased in weight. FLEXIONS AND DISPLACEMENTS OF THE UTERUS. It has been customary to include anteversion among the displacements of the uterus ; as this is the normal position of the uterus, and never gives rise to symptoms, it will be omitted from the list of pathological conditions. We have then to consider the following : Anteflexion ; Retroflexion ; Retroversion ; Prolapse and Procidentia. Anteflexion of the Uterus. — This, when moderate, is normal ; it becomes abnormal when exaggerated. Causes. — It is most often congenital ; less often it is due to parametritis involving the utero-sacral ligaments. The subsequent cicatricial contraction may draw this portion of the uterus backward, causing anteflexion. Symptoms. — Even a considerable degree of anteflexion may exist without causing any trouble, especially in the young. When symptoms are present they are — (i) dys- menorrhoea ; (2) sterility ; (3) reflex nervous phenomena. The way in which dysmenorrhcea is produced is not quite plain. It has been attributed to obstruction to the outflow of blood by the projecting angle ; but this is improbable, for in the first place the menstrual flow in these cases is always moderate and even scanty, and the amount of blood passing at any one time is therefore small ; and in the second place obstruction would necessarily cause accumu- lation behind the obstruction, and this never occurs. More probably the pain is caused by the contraction of the muscle fibres at a disadvantage. The dysmenorrhcea generally comes on some years after the first establishment of men- struation. Sterility is due partly to the fact that congenital ante- DISEASES OF THE UTERUS. 1 29 flexion is generally associated with undcr-dcvelopmcnt of the uterus, and a pinhole os ; but it may also result from the tilting forward of the cervix ; for when the canal is straightened and the cervix points backward, conception sometimes follows. Reflex nervous phenomena are not uncommon ; one of the most frequent is bladder-disturbance. On examination the fundus is felt like a knob just in front of the cervix, and between the two the tip of the fin- ger rests in a well-defined angle. The sound is arrested at the internal os, and in order that it may pass to the fundus it may require to be sharply bent forward, for the canal of the cervix often makes a right angle with that of the body of the uterus. Two varieties of anteflexion are found : in one, the cervix is in its normal position, whilst the fundus is bent forward and downward (Fig. 35, III) ; in the other, the fundus is in normal position, while the cervix is bent for- ward and upward (Fig. 35, II). Treatvicnt. — Vaginal pessaries are absolutely useless. Two courses are open : first, dilatation of the cervical canal; secondly, a plastic operation. The dilatation should be carried up to 12 mm. It has the effect of straightening the canal. It may be necessary to repeat the dilatation after a few months, or to pass a few smaller dilators from time to time. In virgins these repeated manipulations are a disad- vantage. Plastic operations include the division of the cer- vix, by a single median incision or bilaterally. Retroflexion of the Uterus. — This occurs, rarely, as a congenital condition ; more often it is a complication of retroversion (Fig. 35, V). In the former condition, if the fundus of the uterus be brought forward, for instance by the sound, it springs back into the faulty position as soon as the sound is withdrawn. But when associated with ret- roversion there is at first free hinge-like movement at the internal os, and the fundus, if replaced, remains in the new position. If it remain long retroflexed this mobility be- 9 130 DISEASES OE WOMEN. comes impaircti. The uterus sometimes becomes fixed in a position of rctroflexiDii b)' pelvic cellulitis. II III \ n AY \ n VI (^ Fig. 35. — Diagrams illustrating flexions and displacements of the uterus : a, axis of the vagina; b, axis of the normal uterus : I, nurmal position : II, anteflexion, fundus in normal position; IH, anteflexion, cervix in normal position; IV, retroversion; V, retroversion with retroflexion; VI, anteversion with retroflexion (A. E. G.). Symptovis. — (i) Dysmenorrhcea, produced in a manner analogous to that resulting from anteflexion. (2) Pain on DISEASES OF THE UTERUS. I31 defecation, and constipation, due to the pressure of the fundus on the rectum. Sterility is not a prominent symptom of retroflexion. Treatment. — If the uterus be freely movable, as indicated above, the flexion should be first corrected by digital manipulation, or failing this by the sound, and a Hodge pessary introduced. Special care must be taken lest the uterus be brought into a position of anteversion while the flexion remains unreduced (Fig. 35, VI). The posi- tion of the cervix must accordingly not be taken as a guide, but the fundus must be felt bimanually in front of the cervix. If the uterus be rigid, a Hodge pessary will not correct the flexion ; dilatation of the cervix is then the proper treatment, and a Hodge pessary may be subsequently applied, or a plastic operation may be undertaken, such as hysteropexy. Retroversion of the Uterus. — Retroversion of a nor- mal-sized uterus is, under certain circumstances, physiologi- cal ; for instance, in a patient lying on her back with a full bladder. In such a case it is not an uncommon thing to find, on making a second examination a few days later, that the fundus is lying forward. The same thing may occur with a uterus that is slightly enlarged, as in early preg- nancy, and during the early weeks after labor. These con- ditions, therefore, require no treatment. In other cases retroversion is a pathological condition. Causes. — I. Relaxation of the uterine ligaments, as the effect of repeated pregnancy. The utero-sacral, round, and broad ligaments are all involved, for if any one pair of the three retained its normal tension, retroversion would be resisted. 2. Increased weight of the fundus, due to chronic con- gestion, subinvolution, pregnancy, or myomata. 3. Cicatricial contraction following pelvic inflammation ; such as shortenincf of the utero-sacral ligaments when the 132 DISEASES OF WOMEN. round ligaments are relaxed. If these remain tense, ante- flexion is produced instead. 4. Pressure on the front of the uterus, due to an ovarian or other tumor, or to a frequently over-distended bladder. A wandering spleen lodged in the pelvis has sometimes caused the same result. 5. Retroversion is in rare cases due to a fall or sudden strain ; it is a question whether this cause can operate with- out the predisposition indicated under paragraphs i and 2. Symptoms. — These vary according as the retroversion is simple or complicated by pelvic inflammation or fixation. Among the symptoms caused by a movable retroverted ute- rus, there may be sudden pain, if the displacement has been accidentally produced ; otherwise the patient complains of a feeling of ill-defined weight and fulness in the pelvis, due, probably, to congestion. From the position of the fundus there is often discomfort during action of the bowels, and con- stipation. Bladder disturbance is not common unless the uterus is enlarged; aud then there may be enough pressure of the tilted cervix against the base of the bladder to cause frequent desire for micturition with dysuria; followed by complete retention of urine. If the fundus remains for some time low in the recto-vaginal (Douglas's) pouch, the tubes and ovaries are dragged upon, and one or both of the latter may become " prolapsed ;" in that case dyspareunia is gen- erally complained of, as well as dysmenorrhcea, and ster- ility is usually present. When complicated with pelvic inflammation, the chief symptoms are — pain, often excessive and continuous; se- vere dysmenorrhcea ; irregular metrorrhagia, due to the fact that the uterus cannot contract properly ; abundant leucorrhoea, caused by the pelvic congestion ; general weakness, and secondaiy nervous disturbances. The reflex nervous disorders consequent on retroversion and retroflexion (for the two conditions are frequently com- bined) require some notice. A list of them would com- DISEASES OF THE UTERUS. 1 33 prise all known functional disorders ; and, while the associa- tion of some of these with displacement may be considered as a coincidence, tiiere are many which must be regarded as directly due to the uterine condition, as is shown by those cases in which reposition of the uterus is followed by immediate cessation of symptoms, whilst these come on again at once if the displacement recurs. The most fre- quent reflex neuroses are — digestive disorders, especially vomiting ; cardiac disturbances ; frequency of micturition and incontinence of urine ; headache and neuralgia. In some cases of long standing, the restoration of the uterus to its proper position is not followed by improvement of the reflex disorders ; although the first appearance of these may have coincided with the commencement of the uterine trouble. Complications. — Among these we might reckon the ner- vous disturbances just referred to. The local complications include pelvic inflammation, prolapse of the ovaries and tubes, and hernia of the pelvic floor, — namely, cystocele, rectocele, and prolapse of the uterus. As we shall point out in discussing prolapse, retroversion of the uterus is nearly always the first stage in the production of that condition. Treatment. — The first thing is to replace the uterus, with the fingers alone if possible ; with the sound if necessary. Digital Manipnlation. — Two fingers are introduced into the vagina and are made to press on the fundus, through the posterior vaginal fornix, in a direction forward and up- ward. If the uterus be fairly rigid the fundus can readily be tilted up by pressing backward on the front of the cer- vix. The fundus being raised by either method, the fingers of the other hand depress the abdominal wall above the uterus and bring the fundus forward, whilst the fingers in the vagina assist by pressing the cervix back. The manip- ulation may be assisted by placing the patient in the genu- pectoral position ; and in difficult cases, when the use of the sound is contraindicated, this should be done. 134 DISEASES OF WOMEN. Replaccuioit ivith the Sound. — The sound is passed with the concavity of the curve pointing backward. When the point is at the fundus, the handle is brought round to the front with a wide sweep, so that its intra-uterine portion rotates on its longitudinal axis, but does not otherwise move. On no account should the semicircle described by the revolving portion be made by the point of the sound. The handle is then gently and slowly drawn backward, in the middle line, toward the perineum, until the fundus can be felt with the hand on the abdomen. While the sound is being withdrawn, the finger in the vagina should be pressed against the cervix, to keep it in position. The uterus having been replaced, some form of Hodge pessary is then introduced, paying attention to several points. Thus the instrument must fit properly; it must be adapted to the width of the posterior fornix, and also to the length of the vagina. If too long, it is apt to press on the urethra, and cause difficulty in micturition ; or it may press on the rectum and produce a tendency to con- stipation. If the vaginal walls are lax and the fundus heavy, the instrument is likely to be tilted up anteriorly, and the retroversion is reproduced. If an ovary is lying in the recto-vaginal (Douglas's) pouch it may be pressed upon, and much pain will result. An instrument made of block tin answers well ; it is clean, and can be moulded to any desired shape. One or both of the posterior angles can be depressed to prevent pressure on the ovaries, and the an- terior bar may be indented so as to form an arch over the urethra. The relation of the breadth to the length of the instrument can also be adjusted. As a rule the posterior bar should be made to project well forward and upward. When adhesions are present, treatment must be different. Obviously, to put in a pessary is to add risk to ineffi- ciency. The one thing needful is to restore the mobility of the uterus. If time be no object, this may often be attained by a somewhat prolonged course of rest in bed, combined DISEASES OF THE UTERUS. 1 35 with a depletory treatment by means of vaginal irrigation and tampons of glycerin, with or without ichthyol (5 to 10 per cent.). During this treatment an occasional attempt must be made to raise up the uterus ; for this purpose the sound may be used, but it requires to be employed with great care. After some time it will often be found that the uterus can be moved a little, and by degrees the normal position can be restored. When this occurs a Hodge pessary is in- troduced and kept in for some time. If suppurative disease of the appendages be present, the above treatment will generally be futile ; and until the of- fending organs be removed no permanent cure can be hoped for. Sometimes the adhesions, by long neglect, have become so firm that they cannot be overcome by the above means. An operation then gives the only hope of cure — namely, opening the abdomen, freeing the adhesions, and suturing the fundus to the abdominal wall (hysteropexy). This should not be lightly undertaken, but the risk attending it should be carefully weighed with the alternative of not operating, which may mean a life of chronic invalidism and impaired usefulness, Even when there are no adhesions, pessaries may, after long trial, entirely fail to relieve the retroversion and the attendant symptoms ; and here also operative interference may be required. Hysteropexy and the operation for shortening the round ligaments are the two principal methods of dealing with this condition. CHAPTER XV. DISEASES OF THE UTERUS (Continued). PROLAPSE AND PROCIDENTIA; HYPERTRO- PHY AND ATROPHY OF THE UTERUS. The terms prolapse and procidentia arc applied to different degrees of the same condition : when the uterus, though low down, lies entirely in the va(;ina, it is spoken of as prolapse ; when it protrudes through the vulva, as procidentia. Causes. — All the causes of retroversion of the uterus, except cicatrical contraction due to pelvic inflammation, may be regarded as predisposing to prolapse, inasmuch as the former is the first stage of the latter. The exciting causes are — 1. Increased intra-abdominal pressure, either continuous, as in the case of ascites and abdominal tumors, or inter- mittent, as from frequent straining efforts or a chronic cough. 2. Weakening of the supporting structures of the pelvic floor, such as relaxation and hypertrophy of the v^aginal walls and laceration of the perineum. A very patulous con- dition of the vulva, such as is met with sometimes in mul- tiparas, may have the same effect as a damaged perineum. 3. Traction on the uterus from below, by the weight of a hypertrophied cervix, by a cervical tumor, or by repeated operative manipulations, whereby the uterus is drawn down. Pathology. — It occasionally happens, when the pelvis is large and the vaginal walls are very lax, that the uterus becomes prolapsed in a position of anteversion ; but this is 136 DISEASES OF THE UTERUS. 1 37 rare. The uterine canal is normally at risj^ht angles to the vagina, and in the great majority of cases the uterus must come to lie in the axis of the pelvic outlet before prolapse can occur to any extent. As long as it lies in the axis of the pelvic inlet, deficiency of the pelvic floor has no appre- ciable effect, and intra-abdominal pressure simply presses the whole uterus backward against the posterior vaginal wall and the sacrum. But, once retroversion takes place, the lack of perineal support is felt, and increased pressure leads to descent of the uterus toward the vaginal orifice. The mechanism presents a close parallel to the delivery of the head during parturition in the unreduced occipito-pos- terior position : the long axis of the head does not conform to that of the pelvic outlet, and delivery is delayed ; whilst as soon as rotation forward of the occiput places the long axis of the head in relation to that of the pelvic outlet, descent is easy. As the uterus descends, it draws down with it the upper part of the vaginal walls, whereby the vaginal fornices are deepened. If the initial causes remain at work, and the vaginal orifice be large, either from stretching or from deficiency of the perineum, the cervix protrudes from the vulva (Fig. 36), and eventually the greater portion or the whole of the uterus comes to lie outside, covered by the vaginal walls reflected over it. In this way a mass the size of the closed fist may be found outside the vulva. When the whole vaginal attachment is very lax, the lower portion of the vaginal walls may take part in the pro- trusion, in the form of a cystocele and rectocele ; whilst in exceptional cases the tubes and ovaries, the bladder, and a considerable portion of the intestines may come to lie in the hernial mass. There is another mode of production of prolapse in which descent of the whole uterus is not the principal feature ; but the first stage is hypertrophy of the supravaginal portion of the cervix — /. c. the part situated between the internal os 138 DISEASES OF WOMEN. aiul the wiL^inal portion. In the course of the hypertrophic elongation, either the fundus must be pushed upward or the vaginal portion downward. The latter is the course of least resistance, and is consequently followed. In these cases the cervix may be low down, while the fundus is nearly in its normal position and the uterine cavity is found to be greatly lengthened (Fig. 37). Later the whole uterus may assume a lower position as the result of the increasing Fig. 36. — Prolapse of uterus due to the pressure of two ovarian dermoids. weight of the cervix. Authors differ in the relative influ- ence which they ascribe to these two conditions, primary descent and hypertrophy, in the production of prolapse; the difference is no doubt partly due to the fact that in cases of primary descent a certain degree of secondary hypertrophy generally occurs. We believe that primary descent is the more frequent condition. Rcsiilis of Prolapse and Procidentia. — The continued re- DISEASES OF THE UTERUS. 1 39 troversion leads to chronic congestion and hyperplasia of the whole uterus ; but the effect is most marked in the cervix, which is less supported by surroundinij structures and more exposed to the influences leading to chronic in- flammation. We find, therefore, chronic cervical catarrh and cervical hypertrophy in the majority of cases, whilst adenomatous disease is frequent. In cases of procidentia the cervix is greatly thickened. By the rubbing of the clothes and exposure to the air the exposed surface of the vagina and cervix is hardened and thickened, so that it comes to resemble skin, and patches of ulceration are not uncommon. These may attain the size of a florin ; they have a clean, punched-out appearance ; the base and margins are smooth and the latter are neither raised nor undermined. When the protrusion has been re- duced and kept in position for some time, the hardened sur- face becomes moist and soft again, returning to its normal condition. Signs and Symptoms. — The patient complains of a feel- ing of "bearing down;" of trouble with micturition and defecation ; of pain and fatigue in walking ; and of " falling of the womb." When the uterus is low down, but still con- fined within the vagina, the symptoms are often more severe than in procidentia ; indeed, it is not uncommon to meet with patients who have been going about their work for a consid- erable time with a large mass protruding from the vulva. The signs are generally obvious. In the milder cases the cervix is felt to be low down in the vagina, the uterus being in a position of retroversion. The sound shows that the uterine cavity is lengthened, and the amount of lengthening will afford information as to the degree of hj'pertroph}' in the case. A rectal examination will complete the informa- tion ; for when there is not much hypertrophy the level of the fundus will be easily reached by the finger, whilst in cases of considerable hypertrophy the fundus may in this manner be felt to occu[))' nearly its normal position. 140 DISEASES OF WOMEN. Procidentia is evident on inspection. The external os will be found usually on the most prominent part of the mass, and occasionally in front of or beliind this point when the case is complicated by a large rectocele or cystocele. Diagnosis. — This is easy ; but procidentia may be sim- ulated by inversion of the uterus. Here the surface is redder and softer, and instead of the central orifice of the external os the two lateral orifices of the Fallopian tubes are seen. A large polypus may at first sight be mistaken for procidentia, but the absence of an orifice and the presence of a pedicle leading up to the cervix will establish the diagnosis. It is important to determine whether the case is one of simple descent or of hypertrophy of the supravaginal cervix, as the treatment is different ; this may be done as above mentioned under the head of physical signs. It should be ascertained also whether there is any cause for the prolapse beyond deficiency of the pelvic floor and relaxation of ligaments; so that, if found, this may be dealt with. Treatment. — A prolapsed uterus must first be placed in proper position, or a procidentia reduced. In many cases the introduction of a rubber ring pessary' will then suffice to prevent recurrence. But it will often be found necessary to repair a torn perineum, removing at the same time re- dundant portions of the vaginal walls, before the ring will remain in the vagina. When such an operation is contra- indicated, and the vaginal orifice is so wide that a ring can- not be kept in, some form of pessary with a vaginal stem and perineal bands will be required (see Chapter XVI.). In cases of procidentia where the exposed surface is much ulcerated, the patient should he kept in bed, emollient ajjplications made to the ulcers, and vaginal douches given. When the ulcers have healed a pessary may be introduced- The congestion usually requires no special treatment, as it subsides when the uterus is maintained in a normal position. Procidentia due to supravaginal li)'pertrophy of the cer- DISEASES OF THE UTERUS. 14I vix must be differently dealt with : here complete reduc- tion is not possible, as even when the fundus is in normal position the cervix is low down. Amputation of a por- tion of the cervix must therefore form the first step in the treatment; and it may be required also when the hypertrophy is secondary to descent. Cases of prolapse and procidentia which resist milder measures require further operative procedures, such as ventro-fixation of the uterus or the shortening of the round ligaments. It is in cases of this kind that hysteropexy has often given the most brilliant and satisfactory results. Alexander's operation succeeds, not by pulling up the uterus, but by maintaining the fundus in a position of ante- version. The first stage in prolapse, retroversion, being thus prevented, the prolapse itself is prevented. If the shorten- ing be not sufficient to cause anteversion, it is useless ; for the fundus is then able to move freely along an arc of a circle whose radius is determined by the length of the round ligaments, and whose centre is at the symphysis. The arc corresponds closely to the pelvic axis. Total extirpation of the uterus has been advised and practised for the treatment of procidentia. The operation is under the circumstances singularly easy, but the ques- tion of the justifiability of so radical a measure is an im- portant one. HYPERTROPHY OF THE CERVIX UTERI. This presents two varieties according as the supravaginal or vaginal portion of the cervix is affected. Hypertrophy of the Supravaginal Portion. — This may occur as a primary or secondary condition. When primary it may in some cases be inflammatory in its origin, and some authors have supposed it to be so in every case. But we think it doubtful whether metritis often has this effect, and prefer to regard the origin as unex- plained. Specimens examined after removal have some- 142 D/SE.ISES OF WOMEN. limes presented the appearances of parenchymatous metri- tis ; but this may have occurred as a secondary change. In other cases the structure has been that of the normal cervix. The effect of this hypertro[)hy lias been described in the section on Prolapse of the Uterus. The fundus remains in its normal j)osition, while the cervix is found low d(jwn in the \'ai;ina or protruding from the vulva. When secondary it is the result of prolapse (Fig. 37), and is most likel}' to occur when the latter is caused by 'Ric/um Uterus. Bladder. Fig. 37. — Ulenis. bladder, and rectum in .s.-»gittal section ; from a ca.se of hypertrophy of tlie supravaginal section (Museum R. C. Surgeons). traction from below while the fundus is partly anchored by adhesions ; but the congestion of a prolap.sed uterus no doubt plays a part in the production of hypertrojihy. Whether the hypertrophy be primary or secondary, the DISEASES OF THE UTERUS. I43 resulting condition is the same. The cervical portion of the uterine canal is elongated. The vaginal portion of the cervix retains its proper length, or may be slightly elon- gated ; but a false appearance of great lengthening is pro- duced by the dragging down of the vaginal fornices by the Fig. 38. — Two diagrams illustrating (A) hypertrophy of the supravaginal portion, and (B) hypertrophy of the vaginal portion of the cervix : a, bladder; 3, recto-vaginal pouch; c, vagina (A. E. G.). cervix as it descends (Fig. 38, a). For the same reason the vagina is always shortened. The symptoms and physical signs are those of prolapse. The proper treatment is amputation of the cervix. Owing to the close attachment of the bladder to the anterior surface of the uterus, it remains in front of the cer- vix as it lengthens ; and a sound introduced into the bladder may be felt to pass down apparently in the substance of the anterior part of the cervix. Similarly, the peritoneum is closely connected with the posterior surface, and the rectovaginal (Douglas's) fossa becomes deepened when the 144 DISEASES OF WOMEN. cervix lengthens, so that a process of peritoneum may be found under the vaginal reflection on the posterior surface of the cervix. These facts require to be borne in mind in amputation of the cervix, lest the bladder be injured. The opening of the coelom (peritoneal cavityj is less serious, and is perhaps in most cases unavoidable. A distinction is made by many Continental writers be- tween hypertrophy of the supravaginal portion proper, and the part which they describe as the intermediate portion (Fig. 39). The former is said to cause obliteration of both vaginal for- nices (Fig. 37), whilst in the lat- ter variety the posterior fornix is preserved (Schroeder). In the form which we are now about to describe both forniccs remain. Hypertrophy of the Vagi- nal Portion of the Cervix. — This is often spoken of as the i)ifravaginal portion ; the above term is more correct. A small degree of In-pertrophy often oc- curs, as previously stated, in connection with chronic cer- vical catarrh and erosion ; the enlargement is then more strictly speaking due to inflammatory infiltration, with thickening of the glandular tissues, and we need not dwell on it further. Hypertrophy proper is a developmental or congenital condition, but it is described here instead of in the chapter on Malformations for convenience and for the sake of com- parison with the previous condition. The growth takes place principally at the time of puberty, and nothing is known as to its causation. It is generally associated with stenosis of the external os, which presents the " pinhole " type. The elongation may be so great that the cervix Fig. 39. — Diagram of the three zones of the uterine neck (Schroeder) : a, infravaginal portion ; b, intermedi- ate portion ; c, supravaginal portion. DISEASES OF THE UTERUS. H5 protrudes through the hymen. The vaginal reflection is attached to the base instead of near the apex of the hyper- trophied portion, and consequently the length of the vagina is not diminished (Figs. 38, B, and 40). This serves as a striking distinguishing feature between this and the form of hypertrophy previously described. The bladder and recto-vaginal pouch retain their normal positions and thus Fig. 40. — A prolapsed uterus in sagittal section. diminish risk of either being wounded during the opera- tion of amputation. The symptoms to which it gives rise are a sense of dis- comfort and the feeling of a foreign body in the vagina ; sometimes it causes dysmenorrhcea, menorrhagia, and leu- corrhcea. But in some cases, if the cervix remains within the vagina, no symptoms may be complained of till after 10 146 DISEASES OF WOMEN. niarriaj:^c, when it <;ivcs rise to dysparcuiiia. The diagnosis is a matter of no difficulty when the len^^th of the vagina has been ascertained. The only possible treatment is am- putation of the cervix. ATROPHY OF THE UTERUS. Atrophy occurs normally after the menopause, and may proceed to such an extent that the cervix entirely disap- pears, leaving only a small aperture in the vaginal summit to represent the external os, while the fundus may shrink till it becomes a mere knob surmounting the vagina. The menopause may occur prematurely, but otherwise naturally, in women who have not borne children, and in whom con- sequently it cannot be ascribed to superinvolution ; and in these cases a similarly marked atrophy may take place. Atrophy may follow also an artificial menopause, pro- duced by the removal of the tubes and ovaries, or by a disease destroying their functions, such as pelvic inflamma- tion, salpingitis, and ovaritis. Certain constitutional con- ditions produce the same result, especially tuberculosis and chlorosis, less frequently diabetes, Bright's disease, chronic morphinism, insanity, and other central nervous disorders. Lastly, it occurs in the form of superinvolution after de- livery (see p. 163). CHAPTER XVI. PESSARIES. A PESSARY is an instrument used to support the pelvic organs in cases of hernia of the pelvic floor, or to maintain in a normal position a uterus which has a tendency to flex- ions or displacements. Pessaries must be regarded as a palliative method of treatment, though at times a radical cure may be effected by their means. In late years their use has been restricted by the introduction of operative measures ; but operations are in some cases contraindicated by the age or ill-health of the patient or by her unwillingness to submit to them, whilst in other cases they fail to reheve the condition for which they are undertaken. Pessaries remain, therefore, indispensable, though they should be used as seldom as possible. To be effectual, a pessary must answer the following requirements : 1. It must maintain the normal position of the uterus and vaginal walls, and relieve symptoms. 2. When it is in its place the patient should be uncon- scious of its presence. 3. It must be light, smooth, not acted upon by the uterine and vaginal secretions, and not irritating to the vaginal walls. The best materials for this purpose are alu- minum, vulcanite, block tin, celluloid, and hardened india- rubber. The last three have the advantage that they can be moulded to any required form ; in the case of celluloid and india-rubber this is done by innnersing them in boiling 147 148 DISEASES OF WOMEN. Fig. 41. — The ring pessary. water, when they become soft, refraining their rifjidity on coohng. Tlierc arc three types of pessary in general use. The Ring Pessary (Fig. 41). — This should be made of good hard rubber, with a central wire spring, so that it may be compressed to facilitate introduction and may regain its shape when released. It is used for cystocele, rec- tocele, and uterine prolapse— i. c. for hernia of the pelvic floor. It should not touch the bony parts of the pelvis, but should slightly stretch the lateral vaginal walls. It depends for its efficacy on the integrity of the posterior vaginal wall and the levator ani, and is useless when the perineum is much lacerated ; for then it comes out as soon as the patient strains, as during coughing, sneezing, and defecation. The same result fol- lows if the ring be too small, whilst if too large it interferes with the action of the bladder and rectum and may cause vaginal ulceration. A rubber ring should not be left /// situ longer than six months without being seen to ; for the rubber tends to become rough and corrugated, leading to irritation of the vaginal mucous membrane and profuse leucorrhcea. In some cases this effect follows in a shorter time, three or four months ; in others a pessary of the best rubber may be worn for a year without inconvenience. The Hodge Pessary. — This is, in surface a.spect, rec- tangular, with the upper angles rounded ; in profile it resembles an opened-out S (Fig. 42). It is used for back- ward displacements of the uterus, when the uterus is movable. It may be made of vulcanite, aluminum, cellu- loid, or block tin ; the two latter will be found most con- venient, as it is often necessary to slightly modif)- the shape PESSARIES. 149 to suit the requirements of the individual case. Various Fig. 42. — The Hodge pessary. modifications of the original Hodge pattern are found (Fig. 43), but the important element of success in treatment by Fig. 43. — A glycerin pessary, Hodge pattern. means of pessaries is that the instrument should fit. I50 DISEASES OE WOMEN. Modes of Action. — Like the rinj^, the Hodge pessary should not touch any bony points. The action is described as that of a lever, the middle portion of the pessary resting against the posterior vaginal wall and forming the fulcrum ; the intrapelvic pressure acts in a direction downward and backward, mainly against the lower portion of the pessary, and this tends to tilt the upper end forward and upward against the posterior surface of the body of the uterus. Another influence is exerted also : when the posterior vaginal fornix is pushed upward, the cervix is drawn back- ward, and if the uterus be fairly rigid, the fundus is in this way tilted forward. The backward pressure of a heavy uterine body is also resisted, through the lever action of the Hodge pessary, by the anterior vaginal wall, as long as this is not much relaxed. It is in harmony with this explana- tion that the crescent-shaped instrument is used, with the lower end pointing forward; but pressure on the urethra must here be specially guarded against. The Vaginal Stem Pessary. — This consists of a cup or ring mounted on a stem, the lower end of which projects from the vulva, and has attached to it perineal bands which pass forward and backward to be fastened to the waistband (Fig. 44). Such an instrument is sometimes used for pro- lapse of the uterus or vaginal walls when the perineum is so deficient that a ring cannot be retained and the age or other conditions of the patient do not allow of repair of the perineum. Zwanckc's pessary is on the same principle, but has the disadvantage of being difficult to keep clean. Contra-indications to the Use of Pessaries. — No pessary should be used when there is any inflammatoiy condition of the genital organs, — pain and irritation would be the result. In the unmarried pessaries are undesirable excej)t when .symptoms are severe and there is a strong probability of cure by their means. When the uterus is fi.xed, pessaries are harmful as well as useless; it is vain to hope that the}' will overcome adhesions. So, also, when PESSARIES. 151 the uterus is markedly retroflexed as well as retroverted it is useless to put in a Hodge pessary unless the flexion be first corrected ; for all that would result would be an ante- version with retroflexion. Whatever the position of the Fig. 44. — Vaginal stem pessary. uterus, a pessary should not be introduced unless the mal- position gives rise to symptoms. Retained Pessary. — The first effect of a pessary long retained is vaginitis ; if the vagina has not been kept clean by douching, the discharges become purulent ; the pessary hinders their exit, and comes to lie ultimately in what is practically an abscess-cavity. The bad effects are aggra- vated by the contraction of the vaginal orifice which occurs at the menopause. If the pessary be a ring or a Hodge, the vaginal wall in contact with it becomes ulcerated, so that there results a groove lined with granulations. These tend to grow up around the pessary, and may at length grow over and fuse, forming a bridge of tissue holding the pessary firmly imbedded in the vaginal wall. In the case of a flattened pessary with perforations the granulations may in like manner sprout and project through the perfora- 152 DISEASES OE WOMEN. tions, formin DISEASES OF WOMEN. (2) A myoma of moderate size in a woman between thirty and forty-five becomes impacted and causes reten- tion of urine at each menstrual period. Such a case is very suitable for oophorectomy. The following conditions demand hysterectomy : (i) A myoma rapidly increasing in size and extending high above the pelvic brim and pressing on the colon, so as to cause intestinal obstruction. (2) A myoma rapidly enlarging after the menopause. (3) A fibro-cystic myoma. (4) A myoma that has given little trouble suddenly be- gins to enlarge rapidly, accompanied by rapid pulse, high temperature, and signs of septicaemia. These signs indicate septic infection of the tumor. A gangrenous myoma should be removed without delay ; occasionally a gangrenous myo- ma is too large to be removed through the vagina, and re- quires abdominal hysterectomy. (5) The large pedunculated myomata, which simulate ovarian tumors, may be easily dealt with by transfi.xion and ligature of their pedicles (abdominal myomectomy). There are several methods of performing hysterectomy : the steps of each are given in detail in the chapter devoted to this operation. Myomata Complicating Pregnancy. — As uterine myomata and pregnancy sometimes coexist, it will be use- ful to briefly summarize the dangers which may occur with such a combination; they are — i. Abortion; 2. Mechanical impediment to deliveiy ; 3. Free bleeding on abortion or delivery at term; 4. A subserous myoma may inflame; 5. A submucous myoma may become infected and necrose ; 6. Septicaemia. The stages when some of the above troubles may arise and the appropriate treatment for each may be indicated thus : I. During Prcgnaticy. — It may be necessary to induce labor; to enucleate the tumor when it grows from the cervi.x ; to perform abdominal h)'stcrcctomy. DISEASES OF THE UTERUS. 20I 2. TIlc Dijficulty declares itself during Labor. — It may then demand hysterectomy. 3. Complications during the Pucrpcrinvi. — These may re- quire abdominal myomectomy or abdominal hysterectomy. Polypi. — All stalked or sessile tumors which hang from the internal wall of the uterine cavity or its cervical canal are termed polypi. The term is a very old one, and has merely a chnical significance. The microscope has taught us that polypoid tumors of the uterus belong to different genera. The hard ''fibroid polypi" are composed of unstriped muscle-fibre and fibrous tissue: they are niyoinata ox fibro- myoniata (Fig. 62). The soft ''mucous polypi" consist of oedematous con- nective tissue in which glands may be scanty or abundant. These are adenomata (Fig. 65). Many polypi are detached fragments of placenta, and used to be called placental polypi (Fig. 51). " Malignant polypi " are protruding or fungating processes of carcinoma (can- cer). „-,, . f • 1 /- . Fig. 65. — So-called mucous polypus of ihe There is one clmical feature cervical canai (a. e. g.). common to all varieties of polypi, except occasionally small pedunculated adenomata of the cervix, and this is irregular loss of blood. The small cervical polypus (Fig. 65), even when it does not cause bleeding, often produces muco-purulent discharge from the canal. C li A V T !•: R XXII I. DISEASES OF THE UTERUS (Continued). SARCOMA, ADENOMA, AND CARCINOMA. Sarcoma. — The tissue of the uterus, Hke striped and and unstriped muscle in other regions of the body, is occa- sionally the seat of sarcoma, sometimes of the round- and sometimes of the spindle-celled species. The uterus differs from a muscle in the important fact that it is occupied by a cavity lined by mucous membrane which, during sexual life, is very active. Until recently it was believed that sarcomata of the uterus were somewhat rare : this error may be attributed to the fact that in clinical work it is so customary to regard malig- nant disease of the uterus as the equivalent of carcinoma that no steps are taken to verify the nature of the disease by histologic methods. In 1893, Sanger and. Pfeiffer independently described a variety of uterine sarcoma which in its microscopic charac- ters so strongly resembled decidual tissue that it has be- come customary to speak of it as " deciduoma." However, the records of a large number of similar cases have been published, which make it clear that many examples of ma- lignant disease formerly classed as " uterine cancer " are really sarcomata which contain a large number of cells similar in size and character to the big cells found in the placenta and known as " decidual cells." Recent observations have brought to light the important fact that sarcoma of this variety is very liable to occur in the endometrium within a few weeks or months of abortion 202 DISEASES OE THE UTERUS. 203 or delivery at term. The course of the disease is marked by oft-recurrin' slow process, and probably six years is required for the conversion. The process is identi- cal with that which leads to stricture of the male urethra. It is not unusual to find a hydrosalpinx on one side of the uterus and a sclerosed Fallopian tube on the other. Sclerosed tubes are sometimes sources of danger, as small abscesses form in them, perforate the wall of the tube, and lead to adhesion of small intestine, and cause fatal in- testinal obstruction. Tubercular Salpingitis. — Most examples of this dis- ease are undoubtedly secondary to tuberculosis of the en- dometrium. The naked-eye features of a tubercular tube are often very characteristic, but it is sometimes impossible to distinguish it from a pyosalpinx. In man)' instances the abdominal ostium is occluded and the tube tightly stuffed with caseous material (Fig. 78). On removing this material the mucous membrane presents the usual velvet-like ap- pearance characteristic of the walls of a chronic abscess. In many patients tubercles are found in other parts of the body, so that it is difficult to decide which is the pri- mary seat of the disease. The bacilli are often difficult of detection ; however, when tubes are found distended with caseous pus and deposits containing tubercle-bacilli are DISEASES OF TIIK FALLOPIAN TUBES. 221 found in other organs, it may be used as evidence that the disease in the tubes is hkewise tubercular. The only abso- kite test of tubercular salpingitis is the detection of the tubercle-bacilli in the contents or the tissues of the Fallo- pian tube. It is an important clinical fact that many cases of tubercu- lar peritonitis in infants, girls, and young women are due to Fig. 78. — Tubercular salpingitis, from an infant. infection from tubercular tubes in consequence of the ostia remaining unoccluded. Exceptionally infection of the peri- toneum has resulted from perforation of a tubercular tube. It is also possible that the tubes may sometimes be infected secondarily to tubercular peritonitis, due to tuberculosis of the intestine. Non-inflattittiatory Stenosis of the Tubal Ostium. — There is a curious and somewhat rare variety of tubal 222 DISEASES OF WOMEN. distention which is sometimes, though erroneously, de- scribed as pyosalpinx ; it is not caused by septic changes in tlie uterus or by gonorrhoea. The patients arc usually virgins, or, if married, they are sterile. In well-marked specimens the tubes become converted into huge banana-like or legume-shaped cysts, which not only appear above the pelvic brim, but may reach as high as the navel. The abdominal ostium is usually completely occluded, but traces of the fimbriai may be observed even in extreme cases. The contents of these dilated tubes are viscid like old honey, and are occasionally of the con- sistence of putty. In some specimens the mucous mem- brane resembles wet chamois leather. This rare variety of tubal disease seldom causes inconvenience until the enlarge- ment of the tubes produces obvious swelling of the lower part of the belly. The change probably depends on non- inflammatory (possibly congenital) stenosis of the abdom- inal ostia of the Fallopian tubes. Tumors of the Fallopian Tube. — These are exces- sively rare, and belong to four genera: Myoma, adenoma, sarcoma, and carcinoma. Myoma. — Tumors composed of unstriped muscle tis- sue growing from the Fallopian tube are among the great- est rarities of oncology : this is extraordinary, considering the extreme frequency of myomata in the uterus. Even when growing from the tube they rarely attain such sizes as to be clinically important. Sarcoma. — At present this is so rare a tumor of the tube that it may be regarded as merely of pathological in- terest. Adenoma. — Tumors composed of glandular tissue have on several occasions been observed growing from the tubal mucous membrane. An adenoma of the Fallopian tube may assume the dendritic form of a large papilloma, or con- sist of a mass of cyst-like swellings and resemble a bunch of grapes. The stroma of the tumor consists of delicate DISEASES OE THE FALLOPIAN TUBES. 223 connective tissue in which glandular acini, lined with a single layer of colunniar epithelium, are imbedded. Some of the cysts present in these tumors contain intracystic pro- cesses. A curious feature connected with these tumors is the presence of free fluid in the belly — hydroperitoneum. This is due to the secretion from the adenoma escaping through the abdominal ostium of the tube and irritating the peritoneum. Although the peritoneal fluid may be evacuated, it accumulates as long as the adenoma is allowed to remain. Removal of the adenoma at once and perma- nently arrests the effusion. Carcinoma. — This disease as a primary affection is ex- cessively rare. The tubes are occasionally implicated by extension of cancer from the uterus. CHAPTER XXV. DISEASES OF THE EALLOPIAN TUBES (Continued). DIAGNOSIS AND TREATMENT OF SALPIN- GITIS. Acute Salpingitis. — The leading signs of this affection are not dependent on the tubes, but become manifest when the infection extends from the tubes to the pelvic perito- neum. When this disease is secondary to septic endome- tritis the signs often come on with great suddenness. The discharges from the uterus arc offensive ; the patient may have a temperature of ioo° F. Suddenly she is seized with a rigor; the temperature rises to 103° or 104°; the belly quickly swells ; and in twenty-four hours there is clear evi- dence of infective peritonitis. In some of these cases death follows in a few days ; in others the patients slowly recover. When these signs supervene on delivery or abortion, the condition is often called puerperal peritonitis. Similar attacks are sometimes seen after operations upon the uterus, and may complicate a gangrenous intra-utcrinc myoma (polypus). As a rule, slow accession of symptoms indicates gradual extension of infection from mucous and muscular to serous tissue. Sudden onset of the severe signs means actual leak- age from the tube into the coelom (general peritoneal cav- ity). In some cases acute infection of the peritoneum is in- dicated by profound collapse. The above signs may be interpreted thus : slow extension leads to chronic changes ; leakage, as a rule, leads to general infective peritonitis, and not infrequently to death. 224 DISEASES OF THE FALLOPIAN TUBES. 225 It should also be borne in mind that sudden infection of the pelvic peritoneum during labor may arise from the bursting of a pyosalpinx, or a suppurating ovarian cyst of small size. Acute pelvic peritonitis sufficiently severe to imperil life occasionally occurs in the early stage of gonorrhoea before the coelomic (abdominal) ostia become scaled. Treatment. — Acute salpingitis demands absolute rest in bed and the routine use of mild vaginal injections. The bowels should be kept regular with mild saline purgatives. When the pelvic pain is very great warm fomentations should be applied to the hypogastrium, and morphia or opium may be judiciously prescribed. When the signs indicate extensive fouling of the peri- toneum and the patient's life is imperilled, the surgeon may have to consider the advisability of performing cceliotomy. In all cases in discussing treatment the surgeon is bound to remember that his diagnosis is not infallible, and, though the signs may indicate leakage from an infected tube, it may be due to a rupture of an ovarian or a perityphlitic abscess. In such cases cceliotomy is the only hopeful course. Chronic Salpingitis. — This is a very common disease, and one that not infrequently imperils life ; even in cases when life is not endangered, the pain and inconvenience these women suffer are often such as to render them chronic invalids. The chief points are these : The patient is usually be- tween twenty and thirty-five years of age, and furnishes a history of difficult labor or abortion, followed by a pro- tracted illness, since which she has been sterile and suf- fered from excessive, prolonged, and often painful menstru- ation. Defecation and sexual congress are sources of pain ; some complain also of a vaginal discharge. Married women, and occasionally single women, furnish details of such a kind as lead us to believe that an attack of gonorrhoea marked the beginning of the trouble. 15 2 26 DISEASES OE WOMEN. The symptoms, briefly summarized, are menorrhagia, pain, and sterility. Tubercular salpingitis has wider age-limits, as it occurs in chiklreii from eighteen months onward (Fig. 79). In girls after puberty this variety of salpingitis is often accom- panied by amenorriuea. On examining the abdomen an irregular tender swelling may be sometimes detected in one or both flanks ; more frequently there is an indefinite swelling, and in some, on palpation, a sense of resistance can be made out, but in very many cases no swelling can be detected. On internal examination there will be found Ijing on each side of or behind the uterus an elongated swelling, Fig. 79. — Tubercular salpingitis, from a baby. which usually gives rise to great pain when pressed by the examining finger. Not infrequently the uterus is acutely retroflexed, and then the uterine fundus with the enlarged tubes and ovaries forms a rounded ridge running trans- versely across the pelvic floor. As a rule, a moderately distended tube can onl}' be felt through the vagina or by the bimanual method. Tactile judgment is a very important factor in the diag- nosis of pehic swellings. To estimate the size, consistence, fixity, or mobility of a tumor l}ing in close relationship with the uterus requires e.xperience. In a general way, it may be stated that it is impossible to DISEASES OF THE FALLOPIAN TUBES. 22/ accurately diagnose between the various forms of tubal and the followinij forms of ovarian disease : 1. Tubercular abscess of ovary; 2. Apoplexy of the ovary ; 3. Small ovarian cysts, tumors, or dermoids ; 4. Small parovarian cysts ; 5. Gravid tubes previous to rupture or abortion. The following conditions are very liable to be mistaken for tubal disease : Retroflexion of the uterus ; Pelvic cellulitis ; Fecal accumulation in the rectum ; A kidney in the hollow of the sacrum ; A small uterine myoma ; Cancer of the sigmoid flexure of the colon ; Abscess, due to inflammation of the vermiform appen- dix burrowing into the mesometrium ; Tumors of the sacrum or innominate bone ; Tumors of the mesometrium, including echinococcus colonies. When a Fallopian tube is so distended as to render it capable of being felt above the pelvic brim it is liable to be, and often is, mistaken for an ovarian cyst. On the other hand, when ovarian and parovarian cysts are not large enough to be felt above the pelvic brim they closely simu- late pelvic cellulitis or distended tubes. Trcatinoit. — When the tubal mucous membrane has be- come seriously damaged and the tubes fixed by adhesions to surrounding structures, then drugs are of little avail. When such persons are able to lead a life of ease they often become chronic invalids and try Continental health resorts, where they visit the springs and indulge in baths, especially the mud-baths of Bohemia. In poorer patients such treat- ment is out of the question, and in order to lead a useful life, as well as to escape from pain, they willingly submit to surcfical measures. 228 DISEASES OE WOMEN. The orciiiiary rules of surgery suggest that wlicii the physical signs iiulicate that the Fallopian tubes are occluded and distended with pus or other fluid, producing pain and inconvenience, so as to cause the patient to lead the life of a chronic invalid, it is justifiable to remove them. Removal of the Fallopian tubes and ovaries (oophorec- tomy) is justifiable and the only radical means of treatment in the following conditions : Pyosalj^inx and tubo-ovarian abscess ; hydrosalpinx ; ovarian abscess ; tubercular sal- pingitis. In tubercular salpingitis oophorectomy should only be undertaken when there is no evidence of tubercle in other organs, such as lungs, bladder, or kidneys. The method of performing oophorectomy is described in the section devoted to the description of operations. CHAPTER XXVI. DISEASES OF THE FALLOPIAN TUBES (Continued). TUBAL PREGNANCY. In order to reach the uterine cavity an ovum must traverse the Fallopian tube. When an oosperm (fertilized ovum) is retained in the tube it develops and gives rise to the condi- tion known as " tubal pregnancy." Concerning the cause or causes of tubal pregnancy noth- ing is known, and this uncertainty will continue until reliable evidence is forthcoming in regard to the situation in the genital passages where ovum and spermatozoon normally meet. It is reasonable to believe that fertilization normally happens in the uterus, but when it occurs in the tube it is accidental and tubal pregnancy is the consequence. It is probable that when an' ovum is converted into an oosperm the latter immediately engrafts itself on the adjacent mucous membrane, whether it be tubal or uterine. Tubal pregnancy may happen as a first pregnancy in women who have been married eight, ten, or even twenty years. A Fallopian tube may become gravid in the newly married or in the mother of a large family. Both tubes may, in very exceptional instances, be gravid concurrently, or one tube may become pregnant years after its fellow. Very rarely two oosperms are retained in the same Fallo- pian tube — twill tubal pregnancy. Tubal may complicate uterine pregnancy. An analysis of a large number of cases establishes the fact that tubal pregnancy is very apt to occur in women who have been sterile many years, and has given color to 229 230 DISEASES OF WOMEN. the suggestion that chronic saljjin^itis ami loss of tulial epithelium may predispose to this accident. A careful sc- ries of investigations on an abundant supply of material teaches us that a healthy Fallopian tithe is rnore likely to become gravid than one wJiieh has been injhnnetl. The events which follow the retention of an oosperm in a Fallopian tube vary according to its position, thus : Retention in the ampulla and isthmus is called tubal gestation. Retention in the portion traversing the uterine wall is known as tubo-uterine gestation. This variety requires separate consideration. The stages of tubal pregnancy will be described in sec- tions, as follows : Changes in the tube ; The tubal mole ; Tubal abortion ; Tubal rupture ; The decidua and placenta. The Changes in the Tube. — During the first month or six weeks following the lodgement of an oosperm, the tubal tissues are swollen and turgid ; occasionally at the site where the villi are implanted the tubal wall becomes very thin. In many cases, especially when the oosperm is lodged in the ampulla of the tube, the abdominal ostium gradually closes by a process very analogous to that de- scribed as resulting from salpingitis. Occlusion of the ab- dominal ostium is a slow process and requires probably eight weeks for its completion (Fig. 80). When the oosperm is retained in the isthmus or in the uterine section of the tube the abdominal ostium is rarely affected. In a fair pro- portion of cases the ostium dilates instead of contracting. There is as yet no good explanation forthcoming in re- gard to these two opposite conditions, but they exercise an important influence on the subsequent course of the preg- nancy. Microscopic investigation of the uterine end of the DISEASES OE THE EALLOPIAN TUBES. 231 tube serves to show that it is not obstructed when the tube is gravid. The Tubal Mole. — The changes which occur in the oosperm are the same whether it be lodged in a Fallopian tube or in the uterine cavity : in each situation it is liable to become converted into what is known as a " mole." Such a body is an early embryo and its membranes into which blood has been extravasated. Tubal moles vary greatly in size : some have been detected with a diameter of i cm. ; Fig. So. — Gravid Fallopian tube with completely occluded ostium. others measure 5 or even 8 cm. Small tubal moles are globular, but after they attain a diameter of 3 cm. they as- sume an ovoid shape. The amniotic cavity usually occu- pies an eccentric position ; occasionally the embryo is de- tected within it (Fig. 81). More often it escapes, or is de- stroyed by the original catastrophe which formed the mole. When no embryo, amniotic cavity, or chorionic villi can be detected by the naked eye, a microscopic examination of sections will lead to the detection of chorionic villi. They are very characteristic structures (see Fig. 52, page 166), 232 j>/s/:asi:.s oj- II omj-:\. and as certain evidence of tubal pregnancy as tlic embryo itself. It is an interesting fact that the blood in a tubal mole lies between the chorion and the amnion in a temporary' space known as the subchorionic chamber. This blood is derived from the circulation of the embryo, and a large proportion of the red corpuscles are nucleated. Tubal moles only arise in the first two months following fertilization. The laminated condition of the clot presented by some of these bodies indicates that a mole is sometimes formed by a succession of hemorrhages. Fig. 8i. — Tubal mole, whole and in section. Tubal Abortion. — It has already been pointed out that the lodgement of an oosperm in the outer third of the tube usually leads to occlusion of the abdominal ostium by the end of the eighth week. So long as this orifice remains open the oosperm is in constant jeopardy of being extruded through it into the ccelom (peritoneal cavity), especially when lodged in the ampulla of the tube ; the nearer it is situated to the ostium the greater the risk of its ejection from the tube. To this accident the term tidml alwvtion is ajipiicd, for it is parallel to tluxse earh' abortions occurring in uterine gestation before the end of the second month ; DISEASES OF THE FALLOPIAN TUBES. 233 and it further resembles them in the fact that the oosperm is nearly always converted into a mole. In tubal abortion the mole is occasionally discharc^cd through the ostium into the coelom (peritoneal cavity) with a copious hemorrhage, accompanied with the usual signs of internal bleeding, and death may occur early from the anaemia thus induced or from shock. In such instances I''iG. 82. — Fallopian tube immediately alter " complete tubal abortion, drawing represents the " mole." The lower the mole, being very small, may escape recognition when the clot is examined either at operation or post-Dwrtcui. The amount of blood discharged into the coelom under these conditions sometimes amounts to two, three, or even four litres. When the mole is extruded from the tube through the unclosed abdominal ostium it is described as " complete tubal abortion " (Fig. 82) ; very frequently the 234 D /SEAS IIS OF If'OMEAf. mole is retained in the tube ; it is then referred to as " in- complete tubal abortion." The retention of the mole leads to recurrent hemorrhat^'e. The loss of blood in both varie- ties of tubal pregnancy is often so ^reat as to imperil life. Tubal abortion is of ^reat interest, as the bleeding which accompanies it was formerly erroneously ascribed to metror- rhagia, reflux of menstrual blood from the uterus, or hem- orrhage from the tubal mucous membrane. Rupture of the Gestation Sac. — It is an undeniable fact that every gravid tube left to itself either aborts or bursts. When from any cause the pregnancy is disturbed before the abdominal ostium is occluded, the probability is in favor of abortion, but a gravid tube often ruptures in spite of a patent ostium. When the pregnancy advances until the ostium is closed, then the tube bursts at some period between the sixth and tenth week following impreg- nation ; this accident is rarel)'' deferred till the twelfth week. This is called primary rupture, and may be intraperitoneal or extraperitoneal. The determining causes of the rupture are of various kinds, such as jumping from a train, chair, or carriage; defecation; sexual congress; examination of the uterus, etc. Occasionally no such influence is demon- strable. Primary Intraperitoneal Rupture. — In this variety the rupture is so situated that the blood escapes into the ccelom and inundates the recto-vaginal fossa. The embryo or mole may escape through the rent or be detained in the tube. The blood effused may amount to two litres or even more. Extravasations of this kind were formerly called pelvic ha^matoceles. This term could, with advantage to the student, suffer obliteration. The dangers of primary intraperitoneal rupture of a gravid tube are rapid death from hemorrhage or death from repeated hemorrhages. Women occasionally survive a limited hemorrhage, and the effused blood slowly absorbs. DISEASES OF THE FALLOPIAN TUBES. 235 When the bleeding is not excessive the blood collects in the rectovaL,nnal fossa, and floats up the coils of intestines, and these, with the omentum, (gradually form a covering to the fossa by adhering together, thus isolating the blood in the pelvis from the general peritoneal cavity. Taylor has shown that the effused blood in these cases sometimes coagulates in layers and forms a spurious cyst. Primary Bxtraperitoneal Rupture. — In a fair pro- portion of cases the tube bursts in that portion of its cir- cumference lying between the folds of the mesosalpinx. When this happens the mole and a varying amount of blood are forced between the layers of the mesometrium. As a rule, the bleeding is arrested before it assumes dangerous proportions in consequence of the resistance which occurs when the mesometric tissues become dis- tended. This is fortunate, for the blood and mole are entombed in the mesometrium, and rarely cause subse- quent trouble. Rupture may take place, the embryo with its membranes remain uninjured, and the pregnancy continue; for, no longer confined within the narrow limits of the tube, it be- gins to avail itself of the additional space thus offered, and burrows, as it grows, between the layers of the mesomet- riufn. According to the manner in which this mode of rupture is sometimes described, it mis^ht be imagined that the tube splits and the products of gestation are suddenly discharged from the tube into the mesometrium. This is not the case, or the pregnancy would in every instance come to an end from the dissociation of the foetal from the maternal struc- tures. A careful study of the morbid anatomy of the acci- dent indicates that the slow and gradual distention of the tube causes it to thin and gradually yield in that part of its circumference uncovered by peritoneum, until an opening forms, accompanied by sudden hemorrhage, which produces collapse, the profundity and duration of which depend upon 236 DISEASES OF WOMEN. the amount of blood effused. Tliis artificial opening gradu- ally extends, while the growing embryo and placenta make their way into, and by degrees occupy, the new area of con- nective tissue opened up, unless the life of the embryo is terminated by renewed hemorrhage. When gestation continues in this way it is spoken of as " mesometric pregnancy," because the sac is formed in jiart by the expanded Fallopian tube and the layers of perito- neum forming the mesometrium. The Placenta and Decidua. — In tubal gestation the placenta is liable to many vicissitudes which influence very seriously the life of the foetus, and are such grave sources of danger to the mother that they demand great considera- tion from the surgeon. A uterine placenta consists of foetal and maternal ele- ments, but a tubal placenta possesses foetal elements only (chorionic villi), for in a tubal pregnancy a decidua forms in the uterus, not in the tube ; further, the tubal mucous mem- brane takes veiy little share in the formation of the placenta. It is the primitive character of the tubal placenta which helps to make the embryo's life so precarious. The Decidua. — In all varieties of tubal pregnancy a decidua forms in the uterine cavity ; it is rarely retained until term; when it is, the membrane is thrown off dui^ing the false labor characteristic of that period. More fre- quently the decidua is discharged in pieces during the early period of labor or is expelled whole with signs of miscar- riage. Decidual vary in thickness from 6 to 8 nmn. They may be described as bags resembling in outline an isosceles triangle (Fig. 83). The base corresponds to the fundus of the uterus, and the apex to the internal opening of the cer- vical canal. At each angle of the triangle there is an open- ing. Those at the basal angles correspond to the Fallo- pian tubes, and the apical orifice to the cervical canal. The outer aspect is shaggy, and the inner surface is dotted with the orifices of uterine glands. The angle corresponding to DISEASES OE THE FALLOPIAN TUBES. 237 the internal orifice of the cervical canal is often represented by a large opening. The histology of a decidua is best studied in sections cut parallel with the surface. In this way the epithelium lining the ducts of the uterine glands is well shown. The spaces not lined with epithelium are blood-vessels. Fig. 83.— Uterus with the decidua in situ (from a case of tubal pregnancy). It is useful, for clinical purposes, to be familiar with the microscopic characters of deciduse, because it happens that an early uterine abortion often simulates primary rupture of a gravid tube, and vice versa. On examining shreds which have escaped from the vagina one is able to decide by means of the microscope whether they are fragments of decidua or chorionic villi from a uterine conception. Displacement of the Placenta. — Up to the date of 238 DISEASES OE WOMEN. primary rupture the formation of the placenta has been procecdinf^ in relation with the mucous membrane of the tube, but after this occurrence, if the disturbance is not severe enoufjh to terminate the pregnancy, the course of events is modified in a remarkable manner, and the ultimate result is lar<;ely determined by the relative position of the fcetus and placenta. When the embryo is situated above the placenta, the latter gradually grows and insinuates itself between the layers of the mesomctrium (broad ligament) until it comes to rest upon the floor of the pelvis. Should the embryo he below the placenta, the foetus will ultimately come to rest on the pelvic floor, and the placenta will be pushed upward by the growing foetus. This gradual displacement leads to disastrous changes, such as repeated hemorrhages into the placenta, which im- pair its functions and lead to arrest of development and death of the fcetus. A tubal foetus, even when it survives to term, is always an unsatisfactory individual. When res- cued by the surgeon these foetuses rarely live more than a few weeks or months. Many are ill-formed and present hydrocephalus, club-foot, ectopia of the viscera, and the like. Should the fcetus die early, the placenta gradually atro- phies, and in cases of lithopaedion there is no trace of it. Secondary Rupture of the Sac. — The constant ten- sion to which the gestation sac is exposed may, if increased by a sudden hemorrhage, lead to rupture and death. This is known as " secondar}^ intraperitoneal rupture." Occa- sionally the gestation continues to term ; then symptoms of labor set in, and, as deliveiy by the natural channels is impossible, the sac may burst into the ccelom. Escaping this, the fcetus dies, and, remaining quiescent, becomes mummified or is transformed into a lithopa^dion. Later the soft parts may become adipocere, or decompose. When the fcL-tal tissues putrefy, then the pus bursts through the blad- der, rectum, vagina, or through the abdominal wall, and DISEASES OF THE FALLOPIAN TUBES. 239 fragments of foetal tissue and bones arc discharged from time to time. This is known as " secondary extraperitoneal rupture." A lithop.'udion — that is, a fcetus whose tissues are impreg- nated with lime salts (calcified) — may remain quiescent for many months or even fifty years ; indeed, may never cause subsequent trouble ; but it is always a potential source of danger, for if pathogenic micro-organisms gain access to it, suppuration is the inevitable consequence. Thus, of the two varieties of secondary rupture, the intra- peritoneal may occur at any period from the date of the primary rupture to term ; whereas the extraperitoneal variety may not take place for months or even years. The cases of secondary intraperitoneal rupture where the foetus is found free among the intestines were formerly re- garded as examples of fertilized ova which had become engrafted on the peritoneum and developed into foetuses. Happily, this error no longer prevails, and we now know that all forms of extra-uterine pregnaticy pass their primary stages in the Fallopian tubes. Tubo-uterine Gestation. — When an oosperm lodges in that section of the tube which traverses the uterine wall it is termed tubo-uterine gestation. It is very rare, many specimens described under this name being examples of pregnancy in the rudimentary horn of a unicorn uterus. This variety runs a somewhat different course to the common variety of tubal pregnancy. For example, pri- mary rupture may be delayed to the sixteenth week. The sac may rupture in two directions. It may burst into the coelom, and is often rapidly fatal ; or it may rupture into the uterine cavity and be discharged like a uterine embryo. A tubo-uterine gestation-sac never ruptures into the meso- metrium (broad ligament). Although in many examples of tubo-uterine gestation primary rupture may be longer delayed than in purely tubal gestation, nevertheless the sac sometimes bursts very 240 DISEASES OF WOMEN. early ; in such cases death usually takes place within a few hours from hemorrhaj^e. An examination of the clinical details of cases of un- doubted tubo-uterine <^estation indicates that intraperitoneal rupture of the sac is more rapidly fatal in the tubo-uterine than in the purely tubal form. This is due to the greater amount of hemorrhage, because not only are the walls of the gestation sac thicker, but the rent often extends to, and involves, the wall of the uterus. CHAPTER XXVII. DISEASES OF THE FALLOPIAN TUBES (Continued). DIAGNOSIS AND TREATMENT OF TUBAL PREGNANCY. Diagnosis. — The signs of tubal pregnancy vary accord- ing to the stage of the gestation ; they will therefore be dealt with in sections, thus : 1. Before primary rupture or abortion ; 2. At the time of primary rupture or abortion ; 3. From the date of primary rupture to term ; 4. At and after term. 1. Before Rupture or Abortion. — Since the pathology of the early stages of tubal pregnancy has been carefully investigated and a clear distinction recognized between a gravid tube and a haematosalpinx, many cases have been recorded in which a correct diagnosis was made before the operation was undertaken. This is veiy gratifying, and it is a matter of great importance for the patient, as it spares her the awful peril which attends rupture of the tube. The patient usually gives a definite history of a missed menstrual period after having been previously regular ; fol- lowing on this event she begins to experience pelvic pain which induces her to seek advice. On examination an en- larged Fallopian tube is detected. When there is no his- tory of old tubal disease, or any fact in the history of the patient suggesting septic endometritis or gonorrhoea, then presumption favors a gravid tube. 2. At the Time of Primary Rupture or Abortion. — The tube bursts or abortion occurs at some period before 16 241 242 D I SEAS I. S 01- WOMEN. the twelfth week : the effect upon tlic patient depends upon the seat of rupture. When it takes pkice between the hiyers of the mesometrium (broad Hgament), the symptoms will, as a rule, be less severe than when the tube bursts into the ccelom, because the pressure exercised by the blood ex- travasated into the tissues of the mesometrium tends to check hemorrhage ; whereas the ccelom will hold all the blood the patient possesses, and yet produce no haemostatic effect in the form of pressure. The svniptoms of intraperitoneal rupture are those charac- teristic of internal hemorrhage. The patient complains of a sudden feeling " as if something had given way ; " this is followed by general pallor and faintness ; the voice is re- duced to a mere whisper : sighing respiration ; depression of temperature ; rapid and feeble pulse; usually vomiting ; and in some cases death ensues in a few hours. Should the patient recover from the shock, she will sometimes state that she suspected herself to be pregnant. The symptoms of rupture are often accompanied by hem- orrhage from the vagina, and shreds of decidua will be passed, so that the case resembles in many points, and is occasionally mistaken for, early uterine abortion. Error in such circumstances may be avoided by examining the shreds discharged from the uterus : if they are found to be chorionic villi, the pregnancy is clearly uterine. The rapidity with which the rupture of a gravid tube will sometimes destroy life has caused more than one writer to describe this accident as " one of the most dreadful calami- ties to which women can be subjected ; " indeed, it may be so rapidly fatal that many cases have been recorded in which death has been attributed to poisoning until dissec- tion, instituted in many instances by the coroner, has re- vealed the true cause of death. In extraperitoneal rupture — that is, when the tube bursts so that the blood is cxtravasated between the layers of the mesometrium — the symptoms resemble intraperitoneal rup- DISEASES OE THE EAI.LOPIAN TUBES. 243 ture, but, as a rule, are not so severe and the signs of shock pass off quicker. On examining by the vagina a round, ill- defined swelling will be detected on one side of the uterus; when the effused blood is large in amount the uterus will be pushed to the opposite side. When the bleeding takes place into the left mesometrium (broad ligament), it will sometimes extend backward under the peritoneum and in- vade the connective tissue around the rectum, so that when the exploring finger is introduced into the rectum a semi- circle — sometimes a ring — of swollen tissue will be felt en- circling the gut. The escape of decidual membrane from the uterus accom- panied by blood is also an important and fairly constant sign. Occasionally it will be necessary to pass a sound into the uterus ; when the tube is gravid the cavity of this organ will be found slightly enlarged and the os invariably patu- lous. The greatest difficulty in these cases is to be sure that the rupture is purely extraperitoneal. In a few cases the rupture may involve the peritoneal as well as the meso- metric segment of the tube. Abortion or rupture of a gravid tube is often simulated by lesions of other abdominal organs ; for example : Perforation of stomach or intestine ; Sloughing of the vermiform appendix ; Bursting of a pyosalpinx ; Intestinal obstruction (acute) ; Renal colic; Biliary colic ; Axial rotation of an ovarian tumor (acute) ; Strangulated hernia. 3. From the Date of Pregnancy to Term. — Not infre- quently after primary extraperitoneal rupture the symptoms of shock pass oflf and the embryo continues its develop- ment ; in many instances the patients believe themselves pregnant, and the hemorrhages from which they suffer and 244 niSE/ISFS OF WOMEN. the sij^ns indicative of the primary rupture may merely cause temporary inconvenience. As the embryo increases in size the abdomen enlar^jes, but differs at first from ordi- nary uterine gestation in that the enlargement is lateral instead of median. From the third month onward the leading signs of tubal gestation may be summarized thus : (a) Amenorrhcea is occasionally found ; frequentl}' there is hemorrhage from the uterus occurring at irregular inter- vals, accompanied by the escape of decidual membrane. This last is a valuable diagnostic sign. It is even more valuable if the patient has missed one or two periods. (b) There may or may not be milk in the breasts. Its presence is a valuable indication. From its absence nothing can be inferred. (c) The uterus is slightly enlarged ; the os is usually soft, as in normal pregnancy, and patulous. (d) A large and gradually increasing swelling to one side and behind the uterus. Occasionally the foetal heart can be heard, and in advanced cases the outlines of the foetus may be distinguished. (e) When a woman in whom the existence of tubal ges- tation is suspected is suddenly seized with collapse and all the signs of internal bleeding, it is indicative of rupture of the gestation sac. (f) Tubal pregnancy is very apt to occur after long intervals of sterility. 4. At Term. — In spite of all the risks that beset the life of an extra-uterine child and that of its mother, the preg- nancy may go to term. Then a remarkable series of events ensue : (a) Paroxysmal pains come on, resembling those of natural labor, accompanied by a discharge of blood and mucus, and dilatation of the " os." (b) This unavailing labor may last for hours or weeks. (c) The mammse may secrete milk for several weeks. DISEASES OF THE FALLOPIAN TUBES. 245 These signs sometimes pass away, and as the amniotic jfluid is absorbed the abdominal swelling subsides. Months or years later suppuration takes place in the sac, and foetal tissues may be discharged through the belly-wall, rectum, vagina, bladder, etc., and give a clue to the character of the abscess. Various conditions may complicate the diagnosis of tubal pregnancy ; thus : 1. Uterine and tubal pregnancy are sometimes concurrent. 2. Uterine sometimes follows tubal pregnancy. 3. Tubal pregnancy may be bilateral. 4. Tubal pregnancy may be repeated. 5. Tubal pregnancy and ovarian tumors occasionally coexist. It is also important to bear in mind that tubal pregnancy may be simulated by a variety of conditions : 1. Uterine pregnancy ; 2. Pregnancy in a bicorned uterus ; 3. Retroversion of the gravid uterus ; 4. Spurious pregnancy ; 5. Ovarian tumors ; 6. Tumors of the mesometrium ; 7. Uterine myoma ; 8. Faeces in the rectum. TREATMENT OF TUBAL PREGNANCY. The risks and difficulties of operations for tubal preg- nancy depend mainly on the stage at which they are required : 1. Before Primary Rupture or Abortion. — In this stage the operation required is practically that of oophorec- tomy. 2. At the Time of Primary Rupture or Abortion. — When the symptoms of hemorrhage are unmistakable and the patient's life in grave danger, coeliotomy should be per- formed without delay, unless there is good evidence that the rupture is extraperitoneal. The employment of this 246 DISEASES OE WOMEN. method is in strict accordance with the canon of surgery, vahd in other regions of the body — viz. arrest hemorrhage at the earhest possible moment. There are few accidents that test the skill, ner\e, and re- source of a surgeon more than cteliotomy for a suspected intraperitoneal rupture of a gravid tube, and few operations are followed by such brilliant results. The method of performing the operation before and at the time of primary rupture is identical with oophorectomy. Occasionally the rent in the tube will involve the fundus of the uterus, especially when the embryo is lodged near the uterus. Such rents should be carefully sutured. 3. Subsequent to Primary Rupture. — The majority of cases are submitted to operation at periods varying from a few days to weeks, or even months, after the tube lias ruptured. (It has been already pointed out that in an ex- ceedingly large proportion of cases the tube is occupied by a mole.) When the tube ruptures the hemorrhage may not be so profuse as to induce death, and the woman, recovering from the shock, does not manifest such grave symptoms as to demand surgical aid. The consequence is, that the patient remains for several weeks under palliative treatment (unless a renewal of bleeding kills her), and at last she seeks surgi- cal advice; appreciation of the true nature of the case leads to operation. In such cases, when the abdomen is opened, the free blood in the abdominal cavity is easily removed by irrigation with warm water. The damaged tube and ovaiy are removed as in oophorectomy. When there is much free blood care must be taken that no clots are allowed to remain in the iliac fossae. When the blood has remained in the coelom for several weeks after rupture it is invariably necessary to drain. 4. Mesometric Gestation. — When a Fallopian tube bursts and a mole is displaced between the layers of the DISEASES OF THE FALLOPIAN TUBES. 247 mesometrium, operative interference is rarely necessary. Occasionally repeated hemorrhage renders it imperative to incise tlic abdominal wall, open the mesometrium, and turn out the clot, and, after stitching the sac to the edges of the wound, allow it to gradually close. In those cases where the embryo survives the primary rupture and continues to grow, an operation may be neces- sary at any moment on account of secondary rupture. When gestation has not advanced beyond the fourth month, it may be possible to remove the embryo, tube, ovary, and adjacent portion of the mesometrium with the placenta and to thoroughly clear away all clots. When it has ad- vanced beyond the fourth month, the placenta is too large to be treated in such a summary manner. Certainly after the fifth month operative measures for tubal gestation re- quire consideration under two headings : 1 . The treatment of the sac ; 2. The treatment of the placenta. 1 . The Treatment of the Sac. — The gestation sac in the last stages of tubal pregnancy consists of the remnants of the expanded tube and the mesometrium, which may be thickened in some parts and expanded in others. To the walls of the sac coils of intestine and omentum usually adhere. Experience has decided clearly enough that the safest plan is to incise the sac, remove the foetus, and stitch the edges of the sac to the abdominal wound, precisely as in the plan recommended after enucleating large cysts and tumors from between the layers of the mesometrium, 2. The Treatment of the Placenta. — With our pres- ent experience the rules for the treatment of the placenta may be formulated thus : (i) When the placenta is situated abov^e the foetus it is good practice to attempt its removal. (2) In some instances the placenta becomes detached in the course of the operation and leaves no choice. 248 DISEASES OE WOMEN. (3) When the placenta is below the fcetus it nia)- be left. (4) Should the placenta be left, the sac closed, and symi)- toms of suppuration occur, then the wound must be re- opened and the placenta removed. (5) If the foetus dies before the operation is attempted, the placenta can be removed without risk of hemorrhage. The great risk of violent hemorrhage renders an opera- tion for tubal pregnancy with a quick placenta, between the fifth and ninth months of gestation, the most dangerous in the whole range of surgery ; hence it cannot be urged with too much force that when it is fairly evident that a woman has a tubal pregnancy it should be dealt with by operation without delay. After Death of the Foetus at or near Term. — Ope- rations after the death of the fcetus are less complicated than when it is alive and the placental circulation in full vigor. Not only is the proceeding from the operative point of view simplified, but the results, in so far as the mother is concerned, are much more satisfactory. When the operation is undertaken in cases where the foetus is in the condition of lithopcxdion the procedure is very simple, because the placenta has completely disap- peared. When the foetus is converted into adipocere the foetal tissues adhere to the walls of the sac and render the process of remov^al tedious. After Decomposition of the Foetus and Suppura- tion of the Sac. — After death and decomposition of the f' may occupy a hernial sac either alone or in company with the Fallopian tube, omentum, intestine, etc. ; most frequently it occupies D/SEASKS OF TJIK OVARIES. 253 a sac in the inguinal region, less frequently in the femoral. It has been found herniated through the obturator foramen. Following the method adopted with other varieties of hernia, when the ovary alone occupies a hernial sac it may be termed an oopJiorocclc ; when accompanied by the tube, a salpingo-odpliorocclc ; hernia of the tube alone would be a salpi)igocclc. Oophoroceles may occur in the early months of infancy, but congenital hernia of the ovary is excessively rare. Neck of sac. Cyst in ovary. Fallopian tube. Parovarium. Tubal JifnbricB, Sac. "*'>»T'^ Fig. 85. — Hernia of the ovary and tube into the canal of Nuck (from a child three months old). Many writers on hernia refer to it as a common condition ; hence it is necessary to point out that the rounded, movable bodies so frequent in the inguinal canals of female infants are in most cases hydroceles of the canal of Nuck. As a rule they disappear. Hernia of the ovary may occur at any age ; it has been observed as early as the third month (Fig. 85) and as late as the seventy-third year. A strangulated oophorocele or salpingocele gives rise to signs such as characterize epiploceles or enteroceles. The 2 54 DISEASES OJ- HO MEN. signs of stranj^ulation sometimes depend on axial rotation (torsion) of the lierniated ovary and tube. The fundus of the uterus as well as the ovary and tube lias been found in an inguinal sac, and several cases have been reported in which a pregnant uterus with its append- ages has occupied a sac protruding through the inguinal canal. In all cases in which a supposed ovary is removed from the inguinal region its nature should be substantiated by the microscope ; in many instances bodies excised in this way have on microscopic examination turned out to be testes, and the supposed women pseudo-hermaphrodites (see p. 57). Treatment. — Herniated ovaries and tubes require removal when they are a source of pain and in women who cannot wear a truss. The operation has been almost entirely con- fined to those who have to maintain themselves by hard work. The operation is performed as for inguinal hernia: The pedicle is secured with silk, the ovary and tube cut away, and the stump returned into the ccelom. The sac is dissected out and its neck secured with reliable catgut. When herniated ovaries or tubes become strangulated or undergo axial rotation (torsion), operation is the only choice, as the urgent symptoms are rarely likely to be differentiated from those which arise from strangulation of herniated in- testine. (c) Prolapse of the Ovary. — At puberty the ovaries lie parallel and on a level with the brim of the true pelvis. From this position they arc liable to be disturbed by pregnancy ; retroflexion of the uterus ; enlargement. Pregnancy. — The alteration in the size of the uterus dur- ing pregnancy, and the stretching to which the pelvic peri- toneum. Fallopian tubes, and ovarian ligaments are sub- jected, cause them, especially if pregnancy be frequently repeated, to become very lax. Under these conditions one or other ovary, instead of retaining its usual position at the DISEASES OE TI/E O VARIES. 255 brim of the true pelvis, may drop upon or near the floor of the recto-vaginal pouch. When the left ovary is thus dis- placed it lies between the upper part of the vagina and the rectum. An ovary thus displaced is said to be prolapsed, and not infrequently is a source of much pain and distress, for it becomes pressed upon during defecation, and patients com- plain of the severe pain they experience during sexual con- gress (dyspareunia). Rctrojlcxion of the Uterus. — In this misplacement the ovaries are drawn into the pelvis and sometimes become adherent to its floor. Enlarged Ovary. — When an ovary is enlarged from the presence of a tumor of moderate dimensions its weight will lead to stretching of the ovarian ligament, and it will fall with the associated structures into the recto-vaginal pouch. A small parovarian cyst will act in a similar way. Diagnosis. — On vaginal examination a small rounded or elongated body will be found low in the recto-vaginal fossa, and usually on the left side. The frequency with which prolapsed ovaries occupy this side is due to the fact that the fossa is deeper on the left than on the right side. On touching the ovary the patient winces and complains of pain. These painful sensations are most acute when the ovary is touched, but they are often evoked when the neck of the uterus is pressed, because the ovary is then squeezed between the uterus and the rectum. Treatment. — When prolapse of the ovary depends on ret- roflexion of the uterus it may be relieved by rectifying the malposition of the fundus and maintaining it in the normal position by a pessary. In troublesome cases it is some- times necessary to perform hysteropexy. When the pro- lapse is due to the presence of a cyst or tumor, then ovari- otomy is the most appropriate method of treatment. The Corpus I^, of iron tonics and mild aperients. Nerve sedatives may be used in both cases before the period, especially chloral, hyoscyamus, and belladonna, but they must be given with discretion. Not too much reliance must be placed on the constitu- tional treatment of .dysmenorrhoea. It has its place, but will also often disappoint. While it should be persevered in patiently when no local cause for the dysmenorrhcca exists, it should not be tried too long before making an examination. For it must be remembered that a rectal examination will often give the information we want ; and it is better in certain cases to make a vaginal examination under an anaesthetic than to go on working in the dark. II. DysnicnorrJiica of Local Origin. — This is the most common kind of dysmenorrhoea, and the following causal conditions are met with : Faults of Confonnatio/i. — An imperfectly-developed uterus DISORDERS OF MENSTRUATION. 309 is often associated with dysmenorrha^a, but the nature of the relation is by no means clear. Stenosis of the os internum, other than congenital, is of two kinds — anatomical and physiological. The first is due to cicatrization or fibroid induration, the second to spasm. Probably both varieties act in the same way, by rendering the uterine contractions painful. The pain in these cases is always referred to the back, and is allied in character to labor-pains. It is seldom that the sound will not pass into the cervical canal, but it may not be possible to introduce it past the internal os without an anaesthetic. If it does so pass, the patient complains of sudden pain in the back, which she will often state to be just like her menstrual pain. Probably the passage of the sound induces reflex spasm, which causes the pain. It should be remembered that the true test of narrowing is difficulty in withdrawing the sound ; difficulty in introducing it may be due to other causes, such as tortuosity or sharp curving of the canal, or want of skill on the part of the operator. The proper treatment is dilatation of the cervical canal under an anaesthetic during an intermenstrual period. It is a good plan, in cases of persistently recurring muscular spasm, to nick the margins of the internal os in one or two places with a fine bistoury. Fmilts of Positioji. — Both versions and flexions may give rise to dysmenorrhoea, as described in Chapter XIV. In the former the pain is due mainly to congestion ; in the latter it is probably produced in the same way as in cases of stenosis — viz. by the occurrence of painful contractions. The condition finds a parallel in the dystocia due to falling forward of the uterus in cases of pendulous abdomen. Many women, however, menstruate painlessly in whom the uterus is markedly flexed ; so the cause is probably com- plex. It is a matter of common experience that dysmen- orrhoea associated with uterine flexion is often found in nervous women. But, whatever explanation we adopt, the 3IO DISEASES OF WOMEN. fact remains that correction of a flexion is followed by relief of the menstrual pain in a certain proportion of cases. This method of treatment should therefore be tried; for details see the section on Flexions and Displacements of the Uterus. Piivic I)iJlaiinnatio)i. — This is a fruitful cause of dysmcn- orrhoea, especially in women who have borne children. It may be peri-uterine or intra-uterinc. In the former the uterus is fixed in the midst of the inflammatory mass, and the extra conj^estion at the menstrual periods and the hampered uterine contractions are alike sources of pain. The history and the condition found on examination will readily lead to a correct diagnosis. Dysmenorrhcea, it must be observed, is not usually a marked feature in pelvic inflammation, and probably the patient will seek advice on other grounds ; but when it is the prominent symptom, the result of treating the inflammation is, as a rule, highly sat- isfactory. We cannot here enter into the subject in detail, but the broad lines of treatment are rest in bed, hot xaginal douching, fomentations to the abdomen, purgatives, and occasional glycerin tampons. Intra-uterine inflammation as a cause of dysmenorrhcea is easy to explain. The mucous membrane of the uterus becomes very sensitive when inflamed ; the menstrual con- gestion causes pressure on the nerve-endings ; and the same effect is produced when the uterine contractions press the inflamed surfaces together. The treatment is that of the causal pathological condition. Membranous Dysmenorrhcea. — This signifies painful menstruation accompanied by the discharge of membrane from the uterus. Causes. — The literature relating to the causes of mem- branous dysmenorrhcea is very great, actual facts are few and relatively unimportant, conjectural causes abundant, positive knowledge practically ////. Signs. — In typical cases the patient during the menstrual DISORDERS OF MENSTRUATION. 3II period passes a membranous cast of the uterine cavity, sometimes entire, more frequently in two or more pieces. When complete, a menstrual decidua is a bag in outline like an isosceles triangle, the base corresponding to the fundus of the uterus ; at each angle there is an opening, to correspond to the uterine ostia of the Fallopian tubes, and the apical opening to the internal orifice of the cervical canal. Menstrual decidual rarely exceed 2 or 3 cm. in length, and are scarcely 2 mm. in thickness. The inner surface is smooth and dotted with minute pits, orifices of the uterine glands. The outer surface is shaggy. The histology is like that of the decidua of pregnancy. The patient complains at the beginning of the flow of pain, intermitting in character, which gradually increases until the membrane is expelled ; then the pain usually ceases. The membrane is discharged usually before the end of forty-eight hours after the onset of the menstrual period. Diagnosis. — Membranous dysmenorrhoea must not be confounded with the decidua discharged from a case of tubal pregnancy or from the unimpregnated horn of a bicorned uterus when its companion cornu is gravid, or the membranes in a case of early abortion. " No case can be regarded as one of membranous dys- menorrhcea unless membranes are discharged regularly, at regular monthly periods, and for a considerable time " (Champneys). Treatment. — Drugs are useless ; pregnancy, even when it goes to full time, does not cure the condition. Dilatation of the uterine cavity and curetting afford temporary relief. CHAPTER XXXV. VAGINISMUS AND DYSl'ARKUNIA ; STERILITY. Vaginismus. — This term is applied to painful reflex contractions of the muscles surrounding the vaginal orifice when attempts are made to effect coitus. The muscles chiefly at fault are the levators of the anus. Causes. — I. It occurs in the newly married owing to rigidity of the hymen, to smallness of the vaginal orifice, to an inflammatory condition of the hymen or carunculne myrtiformes, or to hypera^sthesia. The latter may be the result of mere nervousness or of hysteria ; and vaginismu.s from such causes may persist for months or years after marriage, and lead to much domestic unhappiness. 2. It may be due to vulvitis or vaginitis ; to ulcers, sores, or excoriations about the vulva ; to inflamed Bartholinian glands; to urethritis or urethral caruncle. Piles will often provoke painful contractions of the levators of the anus during copulation. 3. It occurs in later life in connection with kraurosis vulvae, the nerve-endings in the vulva being rendered un- duly sensitive by subcutaneous cicatricial contraction. Dyspareunia should be read in association with this section. Treatment. — The first essential is to discover the anatomi- cal cause, if one exists ; otherwise time and effort may be wasted in the adoption of constitutional treatment, when a simple local application may effect an immediate cure. Thus, in all inflammatory conditions, these must be treated 312 VAGINISMUS AND DYSPARF.UNIA ; STERILITY. 313 by the methods described under their respective headings, and temporary sexual abstinence must be enjoined. When the vaginal orifice is small, the use of simple lubricants such as vaseline may suffice ; if not, it must be dilated with the fingers or with dilators, perferably under an anaesthetic ; a series of Fergusson's specula often answers very well. A rigid hymen should be incised, and a sensitive one excised. Simple vaginal hypera:sthesia may be relieved by a vaginal pessary containing half a grain to one grain of cocaine, and made up with cacao butter ; this is inserted ten to fifteen minutes before intercourse. Hyperjesthesia is also often improved by dilation under an anaesthetic. Caruncles and cysts must be removed. Vaginismus due to kraurosis must be treated by anaesthetic local applications, such as carbolic acid, cocaine, or menthol ; or by dissection, as de- scribed under Kraurosis. In the case of hysterical or nervous women, constitu- tional remedies may be required, including sedatives such as bromides or hyoscyamus. It must be remembered, however, that the cases where no local treatment is available are very rare, and include cases of " incompatibility " which are beyond the reach of medical intervention. Dyspareunia. — This signifies pain during sexual inter- course ; it may exist without vaginismus — that is, without reflex contraction of the vaginal orifice. The causes of dyspareunia are much the same as those of vaginismus, and may be classified as follows : 1. Psychical causes, as mere incompatibility or aversion when the marriage is unsuitable ; nervousness ; or viaiivaise JlOHtC. 2. A)iatomical Causes. — (a) Smallness of the vulva and vagina, congenital and due to under-development ; or ac- quired, as the result of cicatricial contraction or kraurosis vulvae. (b) Inflammatory conditions of .the vulva or vagina. 314 DISEASES OE WOMEN. (c) More deep-seated conditions, as prolapse of the ovaries and pelvic inflammation. Sterility. — With causes of sterihty affectin^^ the man we have not here to do, but they must never be lost si^ht of in investigating a case. Yox the want of carefully-directed inquiry, the woman has not infrequently been erroneously held responsible for a childless marriage. In considering sterility as it concerns women, we must draw a broad distinction between — (A) Conditions which do not allow of conception. (B) Conditions which do allow of conception, but which do not allow of development. (A) Conditions ivhich do not allow of Conception. — (i) Age. — Save under exceptional circumstances conception does not occur before puberty. After this age fertility gen- erally increases, attains its maximum at about the age of twent)'-five, and then declines. Thus Matthews Duncan gives the following figures as the result of the analysis of 4447 cases : Age at marriage : 15-19; 20-24; 25-29; 30-34; 35-39; 40-44; 45-49; 50. etc. Percentage sterile : 7.3; o.— ; 27.7; 37.5; 53.2; 90.9; 95.6; 100. That is, in proportion as marriage is deferred the probabil- ity of sterility is increased. After the age of forty the chances of childbearing are remote. The following laws, which Matthews Duncan enunciates, are also worth bearing in mind : The question of a woman's being probably sterile is decided in three years of married life. When the expectation of fertility is greatest the question of probable sterilit}' is soonest decided, and vice versa. Relative sterility will arrive after a shorter time according as the age at marriage is greater. A wife who, ha\ing had children, has ceased for three years to exhibit fertility has VAGINISMUS AND DYSPAREUNIA ; STERILITY. 315 probably become relatively sterile — that is, will probably bear no more children — and the probability increases as time elapses. (2) Deficient Oindation. — When the ovaries are under- developed sterility is absolute. The atrophy which they undergo as time goes on has the same effect, and to this may be attributed the increasing sterility as the age of mar- riage is postponed. Ovarian disease, such as solid tumors and cysts, also leads to sterility. These conditions may generally be diagnosed by careful bimanual examination. Delay or absence of menstruation cannot be regarded as an absolute indication of sterility. (3) Deficient Uterine CJianges. — When the uterus is very small and menstruation absent or scanty, sterility nearly always results. This may be in some cases due to the concomitant deficiency of ovulation ; in others to the in- ability of the uterus to prepare for an oosperm (fertilized ovum). (4) I)icomplete Sexnal Intercourse. — This may be due to narrowness of the vagina or to a rigid hymen. It must be remembered, however, that conception may occur when penetration has never taken place. (5) Mechanical Obstacles to Impregnation. — Under this head are included all cases of atresia, whether of the vagina, of the internal or external os of the uterus, or of the Fallopian tube. The latter frequently becomes sealed up at its fim- briated extremity, as the result of pyosalpinx ; uterine atre- sia may also be due to disease, but congenital atresia is probably more common. Vaginal atresia is nearly always congenital. The mechanical obstacle may consist not in atresia, but in want of adaptation ; as, for example, in cases where the cervix is pointed markedly forward, either from retroversion or from anteflexion. The spermatozoa, which, as the result of intercourse, come to lie principally in the posterior vaginal fornix, are then unable to make their wa}' through the os externum, which is turned away from them. 3l6 DISEASES OF WOMEN. Polypi and other tumors in tlic genital passages may also be the cause of sterility. (6) Noxious Discharges. — Septic and gonorrhoeal dis- charges are injurious to the vitality of spermatozoa, and to this cause is probably partly due the sterility which is found in cases of gonorrhoea, endometritis, and adenomatous dis- ease of the cervix. Gonorrhoea has perhaps an even more considerable effect in the changes which it induces in the Fallopian tubes. Strong antiseptic and frequent simple vaginal douches also prevent conception. (B) Conditions ivhicJi alUnv of Conception, but ivliicli do not allow of Development of the Oosperm. — Under this head- ing are included, first, the as yet obscure conditions which lead to extra-uterine gestation ; and secondly, pathological conditions of the uterus which cause earl}' abortion, such as disease of the endometrium and acute flexions of the uterus. Treatjnoit of Sterility. — It is most important that the practitioner should first ascertain whether the cause of ster- ility is remediable or not, for nothing leads to greater dis- appointment of the patient, and, as we may add, to greater discredit to her attendant, than the confident holding out of a hope which is doomed to non-fulfilment. Therefore the development of the uterus and ovaries should be first investigated : if under-developed, treatment is useless and no hope should be held out. In cases of atresia the obstacle may often be overcome, as by division of a vaginal septum or by uterine dilatation. Correction of a malposition of the cervix will often be fol- lowed at once by conception. Inflammatory conditions of the uterus give a fair pros- pect of a favorable issue as the result of appropriate treat- ment, whether they have acted by preventing conception or by leading to early abortion. The same cannot, however, be said of tubal disease, where the prognosis is bad. But treatment should nevertheless be undertaken on conserva- VAGINISMUS AND DYSPAREUNIA ; SIKKIUTY. 317 tivc lines. Similarly, polypi and other tumors should be removed, preserving the integrity of the uterus. Harmful discharges will be removed by the treatment of the uterine or vaginal conditions which cause them. Lastly, the conditions of intercourse must be inquired into and the patient advised accordingly. Sterility due to psychical causes is probably irremediable in most cases, but moral treatment is most likely to suc- ceed. Here the judicious husband will probably be a better physician than the medical attendant. CHAPTER XXXVI. DIAGNOSIS. Accurate diagnosis depends upon a systematic method of inquiry into symptoms and e.xamination of physical signs. We shall here give an outline of the way such inquiry and examination should be set about. The anamnesis, or account obtained by questioning the patient. The age, occupation, and civil condition should be first noted as a matter of routine, for these points may influence subsequent inquiries. We may tiien proceed in the following order: (a) Family History. — The present health or cause of death of the nearest relations should be noted. A clue may thus be gained as to the probability of tuberculosis, syphilis, or neuroses in the patient's case. (b) Previous Health. — Inquire concerning exanthemata or rheumatic fe\er in childhood, anaemia after puberty, syphilis or gonorrhcea after marriage, and previous treat- ment for disease of the pelvic organs. Thus, a history of gonorrhoea, followed by repeated attacks of pelvic inflam- mation, will lead one to suspect tubal mischief, and ft may explain the presence of vaginitis, endometritis, or a Bar- tholinian abscess ; tuberculosis may lead to the diagnosis of tubercular peritonitis from other abdominal swellings or of tubercular salpingitis when the tubes are affected ; it may also clear up the nature of vulvar cutaneous affec- tions. A history of operative treatment for dysmenorrhoea will prepare for the finding of congenital smallness or ante- flexion of the uterus ; whilst, if the patient has worn pessa- 318 DIAGNOSIS. 319 lies, a present vaginitis or endometritis may be explained, or retroversion, or hernia of the pelvic floor may be expected. So also the patient may have had curetting, trachelor- rhaphy, amputation of the cervix, perineorrhaphy, or ab- dominal section performed, and these will all shed light on the present condition. (c) Menstruation. — The age of the onset of menstrua- tion, and of its cessation if the patient be past the meno- pause, should be noted ; also its regularity, duration, the quantity of the flow as estimated by the number of diapers used, and its association with pain. It is important to ascertain whether the character of the menses has altered ; thus, if there has been a gradual diminution, followed by cessation, in a young woman, it is probably due to anaemia ; diminution in an adult is often associated with ovarian tumors. Increase in the duration and quantity will point to a polypus, to retention of products of conception, or to pelvic congestion ; it may be due to a fibro-myoma, a poly- pus, or to malignant disease. The diagnosis, especially be- tween an ovarian tumor and a fibro-myoma, is often facili- tated by a careful inquiry as to menstrual changes. Recent amenorrhcea, following on previous regularity, is always suggestive of pregnancy. When the menses have never appeared and the patient has reached adult life there is a likelihood of congenital malformation, with or without re- tention of menstrual products. (d) Confinements ; Miscarriages. — The patient may give a history of sterility after several or many years of married life. This, especially if associated with dysmenor- rhoea, will lead one to suspect under-development of the uterus, or if there is at the same time a history of gonor- rhoea, there is considerable probability of disease of the uterine appendages. This probability is increased if the sterility has supervened after a single pregnancy or after one or two miscarriages ; whilst endometritis will at the same time be looked out for. Relative sterilit)-, when 320 DISEASES OE WOMEN. there has been no ^oiKurhdal disease and when the men- strual loss has increased, will prepare one to find fibroid changes ; but a somewhat similar history, with recent ir- rer serous perimetritis, or extravasation of blood following intra- peritoneal rupture of a gravid tube, or tubal abortion, this method of exploring the recesses of the pelvis is regarded as being safer than an incision through the linea alba. CHAPTER XLIir. GROUP II.— ABDOMINAL OPERATIONS. In this c^roup the following operative procedures will be described: i. Cccliotomy ; 2. Ovariotomy; 3. Enucleation of sessile pelvic cysts and tumors ; 4. Oophorectomy ; 5. Operations for tubal pregnancy ; 6. Hysterectomy ; 7. Hys- teropexy ; 8. Shortening the round ligaments. CCELIOTOMY (LAPAROTOMY). When the surgeon opens the abdomen for the purpose of removing a tumor growing in a viscus, the operation re- ceives a specific name according to the organ concerned, such as ovariotomy, nephrectomy, splenectomy, and so forth. In very many cases the conditions preclude an exact diagnosis, and the operation of making an opening into the belly cavity is styled coeliotomy, but it may become a colec- tomy, or an oophorectomy, etc. There are many condi- tions in the abdomen requiring treatment through an incis- ion in its walls which do not readily lend themselves to a single expressive term — for instance, omental tumors, cysts of the mesenteiy, and echinococcus colonies — so that it becomes convenient to use the term coeliotomy as express- ing an operation by which the belly is opened by a cut. In all the operations described in this section the import- ant step is to gain entrance into the cffilom (or peritoneal cavity) by an incision in its parictcs, most frequently through the linea alba ; it will therefore be convenient to describe the mode of preparation of the patient, the requisite instruments, and the manner of carr}'ing it out. Preparation of t/ic Patient.— It is advantageous to keep 379 380 DISEASES OF WOMEN. the patient confined to bed for two or three days prccedinj^ the operation. She should be prepared as for any other serious surgical proceeding. The rectum should be emp- tied, preferably by enemata, and the patient should abstain from food at least six hours before the operation : this di- minishes the chances of vomiting. The nurse shaves the pubes and washes the abdomen with warm soap and water. Si.x hours previous to the operation the lower part of the belly is swathed in a compress soaked with an antiseptic solution (such as carbolic acid i in 60 or perchloride of mercury i in 2000). Immediately before the patient is placed on the table the bladder should be emptied naturally or by means of a catheter. In all abdominal operations it is a great advantage to employ nurses who have had spe- cial training in " abdominal nursing." Instriunents. — All instruments employed in performing coeliotomy should be constructed of metal, as this enables them to be thoroughly sterilized by boiling. The follow- ing are always necessary: 2 scalpels ; 12 haemostatic for- ceps ; 2 dissecting-forceps ; 2 retractors ; needles ; silk ; catgut ; silkworm gut ; 24 cotton-wool dabs and 2 flat sponges ; 2 sponge-holders. All sponges and instruments should be counted and the number written down before the operation is begun. Instruments should be immersed in hot water. Sponges should be washed in water (at 100° F.) during the operation. Suture and I^igature Material.— The three most useful materials at present employed in abdominal surgery are silk, catgut, and silkworm gut. (i) Silk Thread. — This material has a wide range of useful- ness, as it is employed to secure pedicles, for the ligature of vessels, and for sutures. Silk may be easily sterilized, either by prolonged soaking in antiseptic solutions or by boiling. It is convenient to wind the thread on a glass spool, boil it in the sterilizer for twenty minutes, and then preserve it in a solution of carbolic acid (i in 20). Sets of these .spools ABDOMINAL OPERATIONS. 38 1 provided with silks of three degrees of thickness answer most purposes — a stout plaited silk for ordinary pedicles ; a thinner silk for vessels, omental adhesions, or sutures for the skin ; and fine silk for securing torn edges of bowel. Silkivorni Gut {Salmon Gut). — This material is obtained from the bodies of silkworms when about to spin. It is obtainable in large quantities from fishing-tackle manufac- turers, as it has long been employed by anglers. Silkworm gut is an admirable material for sutures, and is not injured by boiling. It is preserved for use in carbolic-acid solutions (i in 20). Catgut. — A very useful and easily absorbable ligature material prepared from the intestinal wall of sheep. The great difficulty is to obtain it free from germs, because im- mersion in hot water softens and quickly destroys it. A method of sterilizing catgut by steam has been devised ; after rendering it aseptic it is wound on glass spools and kept in a sublimate solution. Although catgut has many drawbacks, it is the only material yet devised which can be left in the wounds to be quickly destroyed by the tissues. Sponges and their Substitutes. — Nothing is so con- venient for removing blood from a wound as sponges : their absorbent powers and softness are excellent, but it is difficult to sterilize them, and their price makes it necessary to use them for a series of operations. Sponges when new are prepared in the following way : They are well beaten to shake out the dust, then immersed several hours in water containing hydrochloric acid (5 c.cm. to the litre) ; they are then washed thoroughly in hot water and kept in a solution of carbolic acid (i in 40). After sponges have been used they are thoroughly washed in water, then immersed in water to which some carbonate of soda is added. They arc again washed in running water, and preserved in carbolic-acid solution (l in 40) or dried and kept in air-tight glass jars. 382 DISEASJ-IS Ul- noMEiW Any spoiiL^c which has been in contact with a septic Wduntl or pus should be promptly cast into the fne. Tile hi^h price of spon^^^s and tlifficulty in their steriliza- tion have induced surgeons to employ pads of cotton-wool or gauze moistened with sterilized water or antiseptic solutions. Another excellent substitute is prepared by making bags of gauze and then filling them with absorbent cotton-wool. These, often called cotton-wool or gauze sponges (or dabs)^ may be easily sterilized in the hot-air sterilizer (oven) or may be impregnated with antiseptic drugs. The Table. — In the majority of cases a table such as is employed in ordinary surgical operations answers every purpose. It is necessary to place beneath the patient a strip of waterproof material covered by a towel. In some cases, in dealing with small cysts adherent to the floor of the pelvis or in searching for bleeding points, it is a great advantage to place the patient in the Trendelen- burg position, in which the pelvis is raised and the head and shoulders lowered ; this allows the intestines to fall toward the diaphragm and leaves the pelvis unen- cumbered. Anaesthesia. — Sortie surgeons prefer chloroform or the A. C. E. mixture ; others employ ether. Ether administered by a skilful anaesthetist is the safest agent yet discovered for prolonged anaesthesia. The Abdominal Incision. — The patient being com- pletely unconscious, the operiitor, with his assistant oppo- site him, divides the skin and fat in the middle line of the belly, between the umbilicus and the pubes, for a space of 7 cm. This incision should reach to the aponeurotic sheath of the rectus : any vessels that bleed freely require seizing with hnjmo.static forceps. The linea alba is then divided, but, as it is very narrow in this situation, the sheath of the right or left rectus muscle is usually opened. Keeping in the middle line, the posterior layer of the sheath is divided ABDOMINAL OPERATIONS. 383 and the subperitoneal fat (which sometimes resembles omentum) is reached; in thin subjects this is so small in amount that it is scarcely recognizable and the peritoneum is at once exposed. In order to incise the peritoneum with- out damaging the tumor, cyst, or intestine, a fold of the membrane is picked up with forceps and cautiously pricked with the point of a scalpel ; air rushes in, destroys the vacuum, and generally produces a space between the cyst (or intestines) and the belly-wall : the surgeon then intro- duces his finger and divides the peritoneum to an extent equal to the incision in the skin. It is important to remember that the bladder is some- times pushed upward by tumors and lies in the subperito- neal tissue above the pubes : it is then apt to be cut. On entering the ccelom (peritoneal cavity) the surgeon introduces his hand and proceeds to ascertain the nature of any morbid condition that he sees or feels ; or he evac- uates free fluid, blood or pus, which may be present. Oc- casionally he finds that attempts to remove a tumor would be futile or end in immediate disaster to the patient; then he desists and closes the wound, and the procedure is classed as an exploratory coeliotomy. Should a re- movable tumor, such as an ovarian cyst, an echinococ- cus colony of the omentum, or the like, be found, it is removed. The recesses of the pelvis are then carefully sponged in order to remove fluid, blood, or pus ; the sponges and for- ceps are counted and preparations made to suture the incision. Closure of the Wound. — This consists in suturing each layer separately. The peritoneum is first secured by a continuous suture of fine silk. The sheath of the rectus is then brought together by interrupted sutures of silkworm gut. Lastly, the skin is secured by interrupted or continuous sutures of silk or other material according to the fancy of the operator. The great advantage of this 3S4 DISEASES OE WOMEN. triple »ii-tliO({ \s that it minimizes the risk of a yielding cica- trix and obviates the use of an abdominal belt. Dressing. — This should be very simple. A fold of sterilized gauze or cyanide gauze, covered with two or three pads of cotton-wool or gamgee tissue, retained in position by a flannel binder fastened with safety-pins, is sufficient. Irrigation. — When the coelom (peritoneal cavity) con- tains free blood, pus, f;ecal matter, etc. previous to or during the performance of coeliotomy, such fluids are most expeditiously removed by thorough irrigation with water at a temperature of 110° F. The precise method mat- ters but little. In well-appointed operating theatres an apparatus for irrigating the belly is certain to be present. In private practice much depends on the ingenuity of the surgeon. A simple and very efficient irrigator may be made by inserting a long piece of india-rubber tubing in a large jug filled with water: on exhausting the air from the tube and elevating the jug, the water will issue in a steady stream from the tube, and its force can be regulated by raising or lowering the jug. When no tube is at hand, the water may be poured into the belly direct from the jug. In order to irrigate the coelom the patient is turned a little to one side, and the waterproof on which the patient lies may be arranged to conduct the water as it escapes from the belly into a receptacle under the table. The irrigation is continued until the water comes away clear, care being taken that the inflowing stream is directed into the iliac fossa; and the recesses of the pelvis. As soon as the out- flowing stream is clean, the water retained in the pelvis, the iliac fossae, and in the neighborhood is quickly soaked up with sponges. Plain ivatcr that has been boiled and allowed to cool to the requisite teniperatnre is the safest viedin>n for peritoneal irrii^atiou. Drainage. — After the removal of an adherent tumor or ABDOMINAL OPERATIONS. 385 uterine appcndafjes blood may ooze from a number of points too small or inaccessible to permit the application of ligatures. In such circumstances it is sometimes desir- able to insert a drain-tube. When peritoneal drainage was introduced glass tubes were used, but india-rubber tubes are more satisfactory, as they admit of being cut to any length, and are less liable to damage the viscera with which they may come in contact. The tube should reach to the floor of the recto-vaginal fossa, whilst its upper end projects from the lower angle of the wound: its sides should be perforated The cuta- neous orifice is surrounded by absorbent dressing to receive the escaping fluid. As a rule, there is at first a free escape of blood or blood-stained serum, and the dressing requires frequent changing : at the end of twenty-four hours it rapidly diminishes. It is impossible to frame definite rules in re- gard to the removal of the tube, as so much depends on the nature of the case, but, as a rule, it may be discarded at the end of the second day. Drainage is rarely necessary after ovariotomy : it is fre- quently needed after the removal of a firmly adherent pyosalpinx. TJie Mikulicz Drain. — In 1886, Mikulicz of Cracow de- scribed a method of draining the pelvic cavity by means of antiseptic gauze. A bag is made of gauze ; to the bot- tom of this bag a double silk thread is attached. The bag is introduced into the bed of the tumor in the pelvic cavity, and is then stuffed with strips of iodoform gauze. It is an advantage to insert a drain-tube in the middle of the bag and stuff the gauze around it. The gauze is quickly infil- trated with the infused fluids which slowly ooze through it, and escape at the free end into the dressing, which needs fre- quent changing (thrice in twenty-four hours). As the ooz- ing diminishes, pieces of the packing are slowly with- drawn, and at last the bag is removed by means of the thread. 25 386 DISEASES OF WOMEN. It is difficult to decide when to remove a drain of this sort : it should not be disturbed for five days, but may re- main without detriment fourteen days. In this way the gauze acts as a haemostatic plug as well as a drain. Peritoneal drains of this kind are, fortunately, rarely necessary. CHAPTER XLIV. OVARIOTOMY AND OOPHORECTOMY. OVARIOTOMY. Ovariotomy signifies the removal through an incision in the abdominal wall of tumors and cysts of the ovary and parovarium. The preparation of the patient is the same as that de- scribed under Coeliotomy, and the additional instruments required are — ovariotomy trocar ; pedicle-needles and silk ; pedicle-forceps. TJlc Ovariotomy Trocar. — Very many ovarian cysts are filled with thin fluid which will easily flow along a narrow tube, and as the cyst-contents sometimes amount to many quarts or even gallons, it is a point in the operation to con- duct this fluid into a receptacle. The ovariotomy trocar is Fig. 109. — Ovariotomy trocar. designed for this purpose. It is constructed so that it has a cutting edge which will enable it to be thrust through a stout cyst-wall : this cutting edge, shaped like the point of a quill pen, is ensheathed in a sliding barrel moved by a mounted thumb-pece, so that it can be protected at the wish of the operator. On the sides of the instrument tlicre are two spring hooks for retaining the instrument in posi- tion after its point has penetrated the cyst-wall. The trocar 387 388 D IS /-.ASKS OF U'OMEJV. is fitted to a metre and a half (about five feet) of iiulia- rubbcr tubin<^. The mechanism of this comphcated instru- ment should be carefully studied by those proposing; to use it. These trocars are very clumsy, aiul unless in constant use work stiffly and easily get out of order (Figs. 109 and no). Pcdiclc-nccdlc. — This instrument is designed to carry the ligature through the pedicle of the tumor. The stem of the needle is about 15 cm. long, and is composed of nickeled steel adjusted to a metal handle (Fig. iii). The stem is curved toward the end, which should be bluntly pointed. Near the free end it is perforated by two lioles, one behind Fig. 1 10. — Ovariotomy trocar with its point guarded. the other ; each should be capable of easily accommodating the thickest ligature silk. As a matter of fact, any needle capable of carrying the ligature will serve the purpose of a pedicle-needle, but the needle represented possesses many advantages which an operator will realize as soon as he begins to acquire experience. Spongc-Jioldcrs. — "Sponges on sticks" are undesirable in abdominal operations. It is useful to employ instruments in which sponges or cotton-wool or gauze dabs can be easily mounted. A useful form of holder is shown in Fig. 112. It is an ovum forceps : the opposed sides of the fenestrated blades are devoid of serrations. The handles are furnished with clips. These holders can be put to many useful pur- poses besides holding sponges : they are easily sterilized. OVARIOTOMY AND OOPHORECTOMY. 3S9 Steps of the Operation. — As soon as the operator enters the ccelom (peritoneal cavity) and recognizes the bluish- i \ Fig. III. — Pedicle-needle. Fig. iic— Sponge-holder. gray, glistening surface of an ovarian cyst, he inserts his hand and passes it over the wall of the tumor to ascertain 390 DISEASES OF WOMEN. the presence or absence of adhesions. Instead of a typical ovarian cyst, he may find a soHd tumor or an enlarged uterus ; secondary nodules may exist on the peritoneum and indicate a malignant tumor, or adhesions may be so strong and so numerous that it will be undesirable to con- tinue the operation. It is of the highest importance to be satisfied as to the nature of the tumor before proceeding further: to plunge a trocar into a pregnant uterus or a uterine myoma is an accident sure to involve the operator in anxious difficulty. Emptyings; the Cyst. — F'eeling satisfied that the tumor con- tains fluid, is not connected with the uterus, and is removable, the operator proceeds to tap it. The trocar is thrust into the cyst, and the fluid rushes through it and is conducted by the tubing into the receptacle under the table. As the cyst collapses, the trocar is rendered harmless by sheathing it ; the cyst-wall is seized with forceps and drawn into the spring clips on the side of the trocar, and as the cyst empties it is gently withdrawn through the incision, whilst the assistant keeps the belly- wall in apposition with the cyst by gentle pressure until the pedicle is reached. Empty- ing the cyst is not always so simple. The fluid is some- times viscid like jelly,' or in the case of dermoids resembles paste. Then it is necessary to make a free opening into the tumor and remove its contents with the hand. It is occasionally necessary', in multilocular cysts containing clear fluid, to introduce the fingers, or even the hand, to break down secondary loculi, in order to facilitate the extraction of the cyst-wall through a small incision. When the tumor is suspected to be a dermoid, and in all cases where it is scarcely larger than a cocoanut, it is more prudent not to tap, but enlarge the incision and withdraw it entire. Adlicsioiis. — Large portions of omentum may require de- tachment, transfixion, and ligature with thin .sterilized silk to arrest the bleeding. Intestinal adhesions require care and patience : sometimes the separation may be effected by OVARIOTOMY AND OdPHOKECTOMY. 39 1 gently wiping with a sponge. Adhesion to the peritoneum in the pelvis is often a source of great difficulty, and care must be taken not to damage the ureters or larg-e vessels. such as the vena cava and the iliac veins. Adhesions to the bladder are rare and require great care ; it is wise to introduce a sound into the bladder whilst sepa- rating it from the cyst. The Pedicle. — When the tumor is withdrawn from the belly the pedicle is usually easily recognized ; the Fallopian tube serves as an excellent guide to it. The pedicle con- sists of the Fallopian tube and adjacent parts of the meso- metrium containing the ovarian artery, pampiniform plexus of veins, lymphatics, nei"ves, and the ovarian ligament. When the constituents of the pedicle are unobscured by adhesions the round ligament of the uterus is easily seen and need not be included in the ligature. In transfixing the pedicle the aim should be to pierce the mesometrium at a spot where there are no large veins, and tie the structures in two bundles, so that the inner contain the Fallopian tube, a fold of the mesometrium, and occa- sionally the round ligament of the uterus, whilst the outer consists of the ovarian ligament, veins, the ovarian artery, and a larger fold of peritoneum than the inner half. Pedicles differ greatly : they may be long and thin or short and broad. Long, thin pedicles are easily managed. The assistant gently supports the tumor whilst the operator spreads the tissues with his thumb and fore finger, and trans- fixes them with the pedicle-needle armed with a long piece of silk. The loop of silk is seized on the opposite side and the needle withdrawn. During the transfixion care must be taken not to prick the bowel with the needle. The loop of silk is cut so that two pieces of silk thread lie in the pedicle. The proper ends of the threads are now secured, and each is firmly tied in a reef knot: for greater security the two ends of the inner thread are brought around the pedicle and tied again, so as to thoroughly secure the vessels. 392 DISEASES OF WOMEN. After the operator has gained some experience in this simple mode of tyinf^ the pedicle he may then, if he thinks it desirable, practise other methods. After securely applying the ligature, the tumor is removed by snipping through the tissues on the distal side of the ligature with scissors. Care must be taken not to cut too near the silk or the stump will slip through the ligature ; on the other hand, too much tissue should not be left be- hind. The stump is seized on each side by pressure-for- ceps, and examined to see that the vessels in it are secure ; it is then allowed to retreat into the abdomen. Should it commence to bleed, it must be retransfixed and tied below the original ligature. Occasionally a broad, short pedicle will contain so much tissue that it will be necessary to tie it with three threads. To do this the pedicle is transfixed with the silk, the loop is divided, and the two threads arc interlocked. The outer thread is tied as usual. The needle is refilled with a single ligature and transfixion performed. The needle is then unthreaded, and the untied end of the silk belonging to the first ligature is passed into the eye of the needle, which is then withdrawn. The second ligature, before it is tied, must be interlocked- with the third thread. When the threads are tied they will hold the tissues firmly. It is impossible to frame absolute rules for ligaturing the pedicle. In this, as in all departments of surgery, common sense must be exercised, and at the present day, when ova- riotomy is practised so widely, no one would think of per- forming this operation without assisting at or watching its actual performance by an experienced surgeon. Having satisfied himself that the pedicle is secure, the surgeon examines the opposite ovar}', and if obviously dis- eased he removes it, securing its pedicle in the way just described. He then proceeds to remove an)' blood or fluid from the recesses of the pelvis by means of careful sponging. Whilst OVARIOTOMY AND OOPHORECTOMY. 393 employed in this way he gives instruction to have the sponges and instruments counted. When the operator Hmits the number of sponges to six, he can easily have them displayed before him. He then proceeds to suture the wound in the manner described on page 383. Sessile Cysts. — It occasionally happens that the sur- geon exposes a cyst in the pelvis through an abdominal incision, and, after tapping it, finds he cannot withdraw the cyst-wall from the pelvis. Sessile cysts of this kind are removed by what is known as enucleation. The peritoneum overlying the cyst is cau- tiously torn through with forceps until the cyst-wall is ex- posed ; then by means of the fore finger the surgeon pro- ceeds to shell the cyst out of its bed, taking care not to tear the capsule or any large vein in its wall : it is also necessary to exercise the greatest care to avoid injury to the ureter. It is not uncommon, after enucleating a cyst in this way, to find a ureter lying at the bottom of the recess. When the enucleation is complete, the operator carefully examines the walls and secures oozing vessels and ligatures them. The edges of the capsule are then brought to the margins of the abdominal wound and secured with sutures to the peritoneum. An india-rubber drainage-tube is then inserted, the abdominal incision closed in the usual way, and the wound is dressed. The capsule of a sessile cyst requiring treatment of this character is formed by divaricated layers of the mesomet- rium (broad ligament). Enucleation is needed for — {ci) Papillomatous cysts and cysts of Gartner's duct burrowing deeply between the layers of tiie mesometrium ; {b^ Myomata of the mesometrium ; {c) Very large examples of hydrosalpinx and pyo- salpinx ; 394 DISEASES OF WOMEN. {c cavity left after enucleation closes completely, but when the wall of an ovarian C)'st or adenoma is left, the tumor gradually reappears, or it may suppurate so profusely that the patient slowly dies ex- hausted. There arc few things sadder in surger}' than the slow, miserable ending of an indi\'idual who has been subject to an incom[)lctc ovariotomy. Anomalous Ovariotomy. — In a few instances, gener- ally under an erroneous diagnosis, surgeons have removed ovarian tumors through an incision other than the classical one in the linea alba. Under the impression that the tumor was splenic an ovarian tumor of the right side has been successfully removed through an incision in the left linea semilunaris. OVARIOTOMY AND OOPIIOR ECTOMY. 395 An ovarian tumor supposed to be a renal cyst has been successfully extracted through an incision in the ilio-costal space. Strangest of all, a small ovarian dermoid has been removed through the rectum under the impression that it was a polypus of the bowel. Repeated Ovariotomy. — Very many cases are known in which women have been twice submitted to ovariotomy. Thus it is the duty of the surgeon when removing an ovarian tumor to examine carefully the opposite ovary. So many examples are known of women who have borne children after unilateral ovariotomy (twins and even triplets) that this alone is sufficient to prohibit the routine ablation of both glands. A second ovariotomy is not attended with more risk than the first, but more care is needed in making the incision, for, should a piece of intestine be adherent to the cicatrix, it would be very liable to injury. OOPHORECTOMY. This signifies the removal of the ovaries and Fallopian tubes through an abdominal incision, for affections mainly inflammatory ; also the removal of healthy ovaries and tubes in order to anticipate the menopause. This operation is performed for the relief of a variety of diseases connected with the internal generative organs: (I.) Tubal diseases, such as pyosalpinx and tubo- ovarian abscess ; hydrosalpinx ; tubercular salpingitis ; tumors of the tube — myoma, adenoma, carcinoma ; gravid tubes ; ha^matosalpinx. (II.) Ovarian diseases; for example, ovarian abscess; apoplexy of the ovary ; hernia of the ovary ; prolapse of the ovary. (III.) To produce artificial amenorrhoea in such conditions as uterine niyomata ; luL-matocolpos or heumato- metra ; osteomalacia. 396 DISEASES OF WOMEN. (IV.) In Nerve Troubles. — Oophorectomy has been performed in order to anticipate the menopause in hystero- cpilcpsy ; epilepsy ; some forms of insanity ; dysmcnorrhoea unassociatcd with demonstrable diseases in the ovaries. For the performance of oophorectomy the patient is pre- pared as for ovariotomy, and the instruments needed are the same with the exception of the trocar. The Trendelen- burg position is of great advantage, as it enables the surgeon to view distinctly the depths of the pelvis. The abdomen is opened in the usual manner and situa- tion : the surgeon then seeks the fundus of the uterus, and with this as a guide he is able to find the ovary and Fallo- pian tube. When the parts are not adherent it is a very simple matter to seize the ovary and tube, draw them into the incision, and retain them in position by pedicle-forceps, whilst the broad ligament is transfixed and secured with silk ligatures. When the tubes are filled with pus and fixed with firm adhesions to the floor of the pelvis, and perhaps intestine, the manipulations necessary to detach the tubes and ovaries from their surroundings demand great care and the exercise of much patience. When the tubes are in the condition of pyosalpinx, the tubal tissues are in places so thin that even under the most cautious fingers the sac bursts and septic fluid rushes into the pelvis. On the other hand, the ovaries may be so firmly fixed to the floor of the pelvis that they break and portions of ovarian tissue are left ; this often impairs the subsequent results, as menstruation continues if only a portic^n of an ovary is left. In the case of oophorectomy for uterine nn'onia the ova- ries in many cases are easily found : occasionally it hai)pcns that the ovary on one side is easily reached and manipu- lated, but the other is so incorporated with the myoma that it cannot be entirely removed ; hence the prudent surgeon assures himself of the possibility of removing both sets OVARIOTOMY AND OdmORECTOMY. 397 of appendages before he proceeds to apply the hga- ture. In order to perform oophorectomy satisfactorily, the es- sential point is to be able to bring the ovaries and tubes into the wound to permit the application of the ligatures ; these are applied in exactly the same manner as in ovari- otomy. The assistant must be especially careful to avoid dragging on the tubes and ovaries, for they tear easily, and the ligatures need to be very cautiously tied, as any jerk- ing is very apt to lacerate the tissues and necessitate retransfixion. When oophorectomy is practised for myoma of the ute- rus, one difficulty is to obtain sufficient tissue between the ovary and the uterus to make a secure pedicle, because the mesometrium is so stretched that when the parts are tied and cut away, the tension upon the ligatures is so great that they may slip off. When this happens in the course of the ope- ration it is sometimes very difficult to discover and secure the vessels, and in very many cases it has been necessary to perform hysterectomy to control the bleeding. Should the accident happen after the patient has been returned to bed, it is in most cases fatal. After-treatment. — This is conducted on the same lines as after ovariotomy. The dangers are the same, but oophorectomy is attended with greater risk to life than ovariotomy. It is, however, important to remember that the greatest operative risk is with those cases in which the necessity for surgical inter- ference is the greatest. When oophorectomy is performed for pyosalpinx, there is risk with the pedicle, because its tissues are often infected, and this may cause it to slough and set up fatal peritonitis or give rise to an abscess in the stump which may burst through the scar, the rectum, or bladder. When only a small portion of an ovary is left behind menstruation will continue, and when double oophorectomy 398 DISEASES OF WOMEN. is pcrfoiiiicd to anticipate the menopause, such an accident will nullify the ^ood expected of the operation. When oophorectomy is performed for my(jma of the ute- rus the ^reat risk is hemorrhage. The scquclie arc the same as after ovariotomy. CHAPTER XLV. OVARIOTOMY AND OOPHORECTOMY (Continued). THE AFTER-TREATMENT AND RISKS. The patient is returned to a warm bed with gentleness, to avoid vomiting : a pillow is placed under her knees. Care must be taken that the hot-water bottles do not come in contact with the patient's skin, so as to cause blisters. As consciousness returns, pain is complained of, and, if se- vere, it may be relieved by morphia, either subcutaneously or in the form of a suppository. The routine use of this drug is injudicious. Vomiting. — This troublesome complication is best re- lieved by keeping the stomach empty at least twenty-four hours. If there is faintness or shock, stimulants, such as brandy and water, or even milk, beef-tea, or the like, may be administered by the rectum. The bowel will easily re- tain three ounces of beef-tea at a temperature of ioo° F.^ slowly injected. In some cases the vomiting persists for two or more days, and when accompanied by increased fre- quency of pulse and distention of the belly, it is usually an unfavorable sign. Diet. — At the end of twenty-four hours small quantities of barley-water, water, or milk and soda-water may be given by the mouth at regular intervals : at the end of three days the bowels should be relieved by an enema, and then boiled fish or fowl may be allowed, and the patient soon requires convalescent diet. Distention of the abdomen is due to the accumula- tion of gas in the intestines. It is usually first observed in 399 400 DISEASES OE WOMEN. the transverse colon. It occasions in some cases nuich dis- comfort, ami it is not always easy to relieve it. The j)as- sagc of the rectal tube every three hours as a matter of routine is useful, or the administration of a small enema. The Bladder. — The urine requires to be drawn off by the nurse every eight hours by means of a clean, soft ca- theter. Before passing the catheter the nurse batlies the orifice of the urethra, so that no mucus is convej'cd from the vulva into the bladder. It is a good plan to encourage patients to pass water unaided. To Clean a Catheter. — Immediately after use the catheter should be syringed with warm water, then with warm sub- limate solution (i in 2000) or a solution of carbolic acid (i in 20); it is then immersed in a glass tube containing one of the above-named solutions. Before using a catheter it should be wiped with a piece of sterilized gauze and thoroughly oiled. Bowels. — At the end of four or five days the bowels will occasionally act of their own accord. Usually, how- ever, it is necessary to use a simple enema ; and this is, in the majority of cases, quite sufficient. When opium has been freely administered, still more active measures may be re- quired. Temperature. — This should be observed every four or six hours and duly recorded in the note-book. The first record after the operation is usually subnormal ; in twelve hours it becomes normal, and may even be raised half a degree. During the first twenty-four hours it may ascend to 100° F. without causing alarm ; beyond this, especially if accompanied by a rapid pulse, an anxious face, and dis- tended belly, it is sufficient to make the surgeon anxious. A temperature of 101° or 102° F., unaccompanied by other unfavorable symptoms, is not a cause for alarm unless main- tained. The very high temperatures which used to alarm surgeons were due to absorption of carbolic acid, especially when the spray was in fashion. oiWKioroMY AND ()0j'noki:cio.\n: 401 Pulse. — This is a valuable !4uiclc, and even more trust- worthy than the temperature. When the pulse remains steady and full there is no cause for alarm. When it in- creases in frequency to 120 or 130 or more beats in the minute and is thin and thready, then there is danger even with the temperature only slightly raised. Metrostaxis. — After operations for the removal of both ovaries and tubes blood sometimes escapes from the uterus and simulates menstruation. It usually begins within the first forty-eight hours after the operation. Metrostaxis occurs in or about one-half the cases, and has nothing to do with menstruation. Sutures. — On the seventh or eighth day the sutures will require removal. It is a good plan to allow two to remain (taking care not to leave any that are causing irrita- tion) twenty-four hours longer. After rerhoving the sutures a broad band of adhesive plaster should be firmly fastened across the abdomen, with a good grip on»each hip. This precaution is necessary, as an incautious or violent move- ment, such as coughing or straining, may cause the skin- edges of the wound to gape. Should suppuration or stitch-hole abscesses occur — and these are rare — they must be treated on general principles. Bed-sores may give trouble after ovariotomy in an el- derly and enfeebled patient, as after any other surgical pro- cedure which requires the patient to remain for several con- secutive days upon her back. With due care and watchful- ness on the part of the nurse, a bed-sore should not occur. THE RISKS OF OVARIOTOMY. The performance of ovariotomy is attended by several risks; the chief are indicated in the subjoined list: (i) Shock; (2) Injur}- to viscera; (3) Bleeding; (4) Perito- nitis; (5) Foreign bodies left in the belly; (6) Tetanus; (7) Parotitis (septic); (8) Insanity; (9) Thrombosis and embolism. 26 402 J)js/:asj:s oi- \vomea\ (i) Shock. — This varies greatly. The removal of even a small ovarian tumor may be followed by ^reat collapse. It is more common after prolonged operations and enuclea- tion of tumors from the mesometrium. Generally the patient quickly reacts on her return to bed. After severe operations the patient may not re^c^ain con- sciousness for some hours, and occasionally collapse ter- minates in death. (2) Injury to Viscera. — Those most liable to injury durini; ovariotom}- are — [ii) The intestines ; (/->) The blad- der ; (r) the ureters ; i^ii) the gravid uterus. {(i) Intestines. — These may be cut or lacerated in making the abdominal incision ; more frequently they are torn in detaching adhesions. The vermiform appendix has been divided before its nature was suspected. The bowel has been pierced by the pedicle-needle whilst passing the liga- tures, and has even been tied to the i)edicle. In suturing the abdominal wall the intestines have not only been pricked, but accidentally stitched to the belly-wall. Wounds of intestine should be immediateh' sutureil with fine silk. A wound of intestine overlooked is almost cer- tainly fatal. (/;) Tlic Bladder. — A full bladder has been punctured with a trocar in mistake for a c)'st : it has been opened in making the abdominal incision and torn in separating adhe- sions. Wounds of the bladder should be immediately closed with fine silk sutures. (r) The Ureter. — This duct has been torn in sei^irating ad- hesions on the floor of the j)elvis and at the brim of the pelvis. It is especially liable to damage during the process of enucleating tumors from the mesometrium. Small wounds may be closed with a suture. When the duct is completely divided, the upj^er end should, if possible, be invaginated into the lower ; failing this, the proximal end is brought out of the wound. This will entail a subsequent ncphrcctonu-. A ureter accidentally OVARIOTOMY AND OdrHORKCTOMY. 403 divitlcd luis been successfully en^rafteti into the wall of the bladder. {d) Injury to a Gravid Uterus. — When ovariotomy is undertaken during pregnancy the surgeon is necessarily on his guard against mistaking the enlarged uterus for a cyst. Injury is very liable to happen when there has been an error of diagnosis and pregnancy mistaken for a cyst. To plunge a trocar into a gravid uterus is a serious mis- fortune, and has happened on several occasions. In such conditions there are three courses open to the surgeon: (i) Perform a Czesarean section ; (2) Amputate the uterus ; (3) Sew up the puncture without disturbing the uterine contents. Each of these methods has been practised with success, but Cesarean section has so far given the best results. (3) Bleeding. — Intermediate hemorrhage may be due to the slipping of an ill-applied ligature from the pedicle or an adhesion. Oozing, which is scarcely appreciable when a patient is collapsed, may become very free when reaction occurs. Severe internal bleeding is manifested by well-known signs — pallor, cold skin, rapid but feeble pulse, and sighing respiration. When these signs are manifested, the wound must be reopened, the clots turned out, and the bleeding point secured. Hemorrhage usually occurs within the first thirty-six hours. After enucleation has been practised and the broad ligament ligatured, but not drained, bleeding may take place within it and form a hajmatoma. As a rule, it is slowly absorbed. (4) Peritonitis. — This wms formerly the terror of the ovariotomist. Its frequency has been diminished by im- proved methods of dealing with the pedicle, greater cleanli- ness, antiseptic and aseptic precautions, and the employment of irrigation with or without drainage. Peritonitis may arise from infection at the time of the operation in consc- 404 J)/sj-:.isj:s oj- U(>a//:a'. quciicc of the escape of pus or utlier lluids from llie interior t)f cysts or tumors ; from sponj^es and instruments inadver- tently left in the abdomen ; from operations conducteil in rooms in which sewer-j^as and similar deleterious a^'ents are present ; from damage to and subsequent sloughing of por- tions of the viscera, gangrene of the stump, pieces of adhe- rent cyst-wall, or adhesions; from decomposition of blood carelessly left in the pelvis or that has oozed after the operation. Its occurrence in a fatal form is not likely to be mistaken. The pulse is rapid (120, 130, or 140), at finst full and bound- ing, then quickly becoming thin and feeble. The tempera- ture may be subnormal, then slowly rise to 100°, 102"^, or 103° F. These signs, accompanied by vomiting, the fluid being bile-stained or like black coffee, an anxious and pinched face, sunken eyes, and distended abdomen, form a picture never mistaken when once seen. Death is rarely long dcl:i\'cd. (5) Foreign Bodies I^eft in the Abdomen. — Iwery writer on ovariotomy insists on the importance of exercis- ing the utmost personal vigilance in counting instruments, and especially sponges, after an abdominal oj)eration. Nearly all the cases in which foreign bodies are left in the abdomen end fatally, and more than one writer has ex- pressed the opinion that the accident has probably been overlooked where no post-mortem examination was made. Besides sponges and forceps, such things as pads of tar- letan, iodoform rauze, and a drainage-tube have been left in the ccelom. In a few lucky cases a sponge or compres.s has given rise to an abscess, and the foreign body has been discharged, .sometimes through the belly-wall, sometimes through the anus. Forceps thus left behind have made their way into the bladder, the caecum, or have escaped at the navel many months after the operation. (6) Tetanus. — Since the clamp has been jjanished, tet- Or.tA'/O'JOA/V AiXD OOPJJORKC'JOMY 405 aims rarely attacks the abdominal wound. Ovariotomy should iu)t be performed in rooms recently plasteretl. In practice it is to be remembered that tetanus arises from infection, and all instruments which have been in contact with a case of tetanus should be sterilized by prolonged boilinc:^. (7) Parotitis. — Inflammation of the parotid gland is apt to complicate injuries to, and operations upon and in, the abdomen. One or both glands may be affected, and in a large proportion of cases suppuration occurs. This form of parotitis runs no regular course : it may subside and recur in the course of the convalescence from the original injury or operation. (8) Insanity. — Acute mania occasionally complicates the convalescence from ovariotomy. It was common dur- ing "the reign of the carbolic spray." In the majority of cases it quickly subsides. (9) Vascular Disturbances. — Thrombosis of the iliac veins sometimes follows ovariotomy, and gives rise to oedema, usually of one leg. Embolism of the pulmonary artery has been several times recorded in the course of convalescence from ova- riotomy, but the diagnosis has only been demonstrated by actual dissection in very few instances. The Sequelae or Remote Risks of Ovariotomy. — These include — (i) Intestinal obstruction; (2) Perforation of the intestine ; (3) Trouble with the ligature ; (4) Yielding cicatrix. (i) Intestinal Complications. — It is difficult to esti- mate with any approach to accuracy the relative frctiucncy of intestinal complications following ovariotomy. The dan- ger is nevertheless real. Intestinal obstruction may be acute or chronic — may su- pervene within a few days of the operation or be delayed for months or years. The causes are fourfold : {li) The formation of a band; (/-') adhesions to the pedicle; (r) ad- 4o6 . J)/s/-:asI':s oi- womj.n. licsions to the cicatrix ; {d) strangulation in a sac formed by a )'ielclin_t^ cicatrix. (2) Perforation of Intestine. — This may arise from pressure of a drain-tulie or daniaj^fe to the wall of the gut in separating adhesions. The rectum is tiie most frequent seat of this accident. (3) The Ima are admirable, as the surj^eon is able to leave not merely the uterus, but the ovaries and the tubes as well. In some instances the patients have become preg- nant aiul hat! happy deliveries. Operations on the Pregnant Uterus. — The opera- tions which come strictly under this heading are — Caesarean Section ; Porro's Operation ; (3) Caesarean ^^Q.\.\.ovi signifies tJic removal of a fcvtus and placenta from the uterus t/wougJi an incision involving the alxlominal and uterine trails. When it is known some days beforehand that the patient will be submitted to this 0[)eration, she should be prepared as for ovariotomy, the vulva and the vagina being thor- oughly washed and douched. Often it happens that the operation is undertaken after laljor has commenced and in circumstances which make time very precious. Even then the abdomen, pubes, and vulva can be thoroughly washed with warm soap and water and lightly rubbed with chloro- form and cotton-wool. Instrunioits. — A scalpel ; probe-pointed knife ; volsella ; six pressure-forceps; scissors; suture-needles, curved and straight; catheter; sterilized ligature silk, catgut, and silk- worm gut. The Abdominal Incisioti. — After the patient is under the influence of ether and the bladder emptied with the catheter, an incision is made in the linea alba from the umbilicus to the pubes. The belly-wall of a woman advanced in preg- nancy is very thin, and, unless the surgeon be cautious, the knife will come in C(Mitact with the uterus before he is aware of it. The uterus lies just under the incision, and the opera- OPERATIONS ON THE UTERUS. 417 \.ox ascertains that it lies centrally (often the uterus is somewhat rotated to the rii^ht or left), and then makes a free incision through the uterine wall and extracts the fcutus and placenta: as the uterus contracts he slips his left hand behind the fundus and grasps the uterus near the cervix, and effectually controls the bleeding. The assist- ant passes a large warm fiat sponge into the belly to restrain the intestines and omentum. Should the surgeon be anx- ious about the bleeding, he may apply a whipcord ligature around the uterus. The uterine cavity is sponged out, and the finger passed along the cervical canal into the vagina in order to ensure a free passage for blood and serum. We now come to the most important stage of the opera- tion — namely, suture of the uterine incision. The wall of the uterus has an inner layer of mucous membrane, then a thick stratum of muscle-tissue, and finally an outer layer of peritoneum. The wound is first closed wnth a series of sterilized silk sutures which involve the mucous and adja- cent half or thereabouts of the muscular layer. These sutures should be fairly close together, for they not only bring the parts into apposition, but serve to restrain the bleeding. A second row of silk sutures is now inserted, including the serous coat and adjacent half of the mus- cular layer. These threads should not be tied too tightly, as the tissues of a gravid uterus are soft and easily tear. In closing the uterine incision the surgeon should not spend time in vainly endeavoring to staunch the bleed- ing from the edges of the incision : this is best effected by dextrously inserting and securing the sutures. The recesses of the pelvis are carefully cleaned by gentle sponging, and the parietal wound closed as after ovariotomy. The dressing varies according to the fancy of the operator : whatever its nature, it is secured by a firniK' adjusted bandage or roller. Steriliijation.— When C;esarean section is performed the uterus is preserved, and after convalescence the patient 27 41 8 /)/sj:as/-:s or womex is in a position to ic-conccivc. There may be coiulitioiis in which the patient is desirous to prockice more chikheii, even with the terrible risk before her of havin^^ them extracted by Cicsarean section. On the other hand, women, kncnvin^^ the ^^rcat risk they run, ask that steps may be taken to prevent what they con- sickr a catastrophe. This is a very simple matter, and in order to sterilize the jxilient the surgeon may perform double oophorectomy, or adoj^t a simpler method and pass two silk ligatures around each l^dlopian tube by transfixing the mesosalpinx, and after tying them firmly divide the tube between the ligatures. Any measure short of this is useless : conception has on several occasions taken place when the tubes have been secured with a single thread on the plan employed in the ligature of an arteiy in continuity. The advantage of sterilization by ligature and di\'ision of the tube over double oophorectomy is, that young patients are spared the inconveniences which almost always result from an artificial menopause. Porro'S Operation. — This signifies the removal of a foetus from the uterus as in Cajsarean section, followed by hysterectomy. In the original method of performing this operation the abdomen is opened, the uterus incised, and the fcetus ex- tracted as in Caisarean section : the uterus is then with- drawn through the wound and encircled with the wire of a serre-nceud ; needles are inserted and the uterus cut away above the pins. The paiietal peritoneum is then sutured to the .stump below the wire and the abdominal incision sutured. This clum.sy method of removing the pregnant uterus is now replaced by that described under the title of supra-vaginal li\-stert-ctonn- (p. 411). Operations for Displacements of the Uterus. — These are of two kinds : 1 l\-steropex\' (\entro-fixation ol the uterus), and Alexander's operation (shortening the round ligaments). OPERA'J'IONS ON THE UTERUS. 419 (4) Hysteropexy implies the fixation of the uterus by means of sutures to the anterior abdominal wall. This operation is performed for two conditions : severe retro- flexion of the uterus and prolapse of the uterus. The instruments required are those necessary for incising the abdominal wall as for coeliotomy, plus some curved nee- dles of various sizes and degrees of curvature. I. Retroflexion of the Uterus. — The Steps of the Opera- tion. — The patient is prepared with the same rigid precau- tions as for ovariotomy, and the abdomen is opened as for that operation, except that the incision is shorter. On entering the coelom the operator determines with his fingers the position and condition of the body of the uterus. If it be free, it is then straightened and the condition of the ovaries and the tubes ascertained. In a fair proportion of cases of severe retroflexion of the uterus much of the distress depends upon a prolapsed ovary : should the surgeon deem it necessary to remove the painful ovary and tube in such a case, he can secure the uterus in position by transfixing the stump by a silk or fishing-gut suture to the peritoneal edges of the wound : in some cases it may be desirable to carry this restraining suture through the muscle and fascia as well as the peritoneum. When he finds it undesirable to interfere with the ovaries or tubes, then with a curved needle, armed with fishing gut or silk, he first passes it through the peritoneum at the edge of the wound, then through the anterior surface of the ute- rus, and finally through the opposite peritoneal edge : when this suture is tightened it will be found to draw the uterus to the anterior abdominal wall, and at the same time ap- proximate the divided edges of the peritoneum. If desir- able, two or more sutures may be introduced (Fig. 115). The rest of the wound is then carefully closed in single, double, or triple layers according to the habit of the operator. 420 DISEASES OF WOMEN. 2. Prolaf^sc of the Uterus. — When hysteropexy is needed for a hu'L^e, bulky, and prolapsed uterus, the steps of the operation are tlie same as for retroflexion, but it is necessary to introduce a greater number of retaininc^ sutures. Further, as the uterus tends to slip downward into the vagina, it is an advantage, as soon as the fundus of the uterus is drawn into the wound, to transfix it with a stout suture cither of silk or fishini^ gut, in order that the assistant may use itas a holdfast to keep the uterus in position whilst the surgeon introduces the main sutures. In some cases where the ute- FiG. 115. — Hysteropexy : to show the sutures in position (A. E. G.). rus is very large it may be requisite to employ four, five, or even six sutures to secure the uterus to the abdominal wall. In all cases of hysteropexy the uterus is of necessity su- tured to the lower angle of the wound, and is therefore in close relation to the bladder. It facilitates the operation to introduce the lowest sutures first and then gradually work up to the fundus. The wound is then closed and dres.sed as described for cceliotomy. After-treatment. — This is comlucted on exactly the same lines as after ovariotomy. OPERATIONS ON THE UTERUS. 42 1 The Risks. — When hysteropexy is performed by sur- geons experienced in abdominal work it should have no mortality. In a small percentage of cases it has been fol- lowed by difficulties during labor. These risks are small when the attachments are made as directed above. (5) Alexander's Operation : Shortening the Round I/igamentS. — The principle of this operation consists in exposing the round ligament of the uterus in each inguinal canal, and shortening it so as to straighten a retroflexed uterus. Instruments required: Scalpels; dissecting-forceps ; pres- sure-forceps ; scissors ; needles and suture material ; re- tractors. Tlic Steps of the Operation. — The patient is prepared and placed in position as for coeliotomy. The skin is incised as if for the radical cure of an inguinal hernia, and the sub; cutaneous tissues divided until the intercolumnar fascia and pillars of the external abdominal ring are clearly exposed. On dividing the fascia, the round ligament will be seen as a round red cord lying in relation with the genital branch of the genito-crural nerve. The ligament is now gently dis- sociated from the loose tissues in which it lies imbedded. The ligament of the opposite side is next exposed. As soon as both ligaments are freed the assistant passes a sound into the uterus and holds the organ in its natural position. The operator then draws evenly and gently upon the ligaments until the sound is moved. The ends of the round ligaments are then secured in the following manner: A thin strand of catgut is passed by means of a curved needle through one pillar of the ring, then through the round ligament, and finally through the other pillar : by this means when the suture is tied it not only secures the round ligament, but at the same time closes the external abdominal ring — the skin-edges are secured with thin sutures, and the wound is then dressed. When the patient is returned to bed the knees are bent over a pillow. 422 DISEASES OE U'OME.V. TIic wound is drcssLcl at the end of furty-ei^ht hours and the drain-tube removed. It is customary to keep the patient in bed for three weeks. The chief difficulty experienced in this operation is an anatomical one — viz. the ready recognition of the round ligament as it issues from the inguinal canal. This is, as a rule, a matter of simplicity to surgeons accustomed to ope- rate on inguinal hernia. It is certain that man\' operators, not too familiar with the anatomical details of the inguinal canal, have found difficulty in carrj^ng out this operation on the lines introduced by Dr. Alexander. Like the operation of radical cure of inguinal hernia, it ought to be free from risk. INDEX. Ar.noMiNAi. distention after ovariot- omy, 399 examination, 38, 325 incision in creliotoniy, 382 hernia, 406 swellings, 326 Abscess, ovarian, 258 pelvic, 293 tubo-ovarian, 218 vaginal, 124 vulvar, 84 Accessory ostium tuba;, 215 ovaries, 251 Adenoma (Gr. cuViv, a gland) of the ovary, 265 of the uterus, 207 Adenomatous disease of the cervical endometrium, 174 of the corporeal endome- trium, 178 Adhesions, treatment of, 390 Age-changes in the ovaries, 250 in the uterus, 127 in the vagina, 102 in the vulva, 77 influence of, on sterility, 314 Alcoholism, a contraindication for operation, 334 Alexander's operation, 141, 421 Amenorrhoea (Gr. a, negative ; ////i', a month ; piu, to flow) 301 concealed. See Crypto- menor- rha-d. 301, 303 primary, 301 Amenorrhnea, secondary, 302 Amputation of the cervix for cancer, 370 for hypertrophy, 372 Ana:sthesia, 382 examination under, 48, 332 Anamnesis (Gr. ava, anew ; fivrjaic, memory), in diagnosis, 318 Anatomy of the Fallopian tube, 18 of the ovary, 17 of the pelvic peritoneum, 26 of the uterus, 19 of the vagina, 20 of the vulva, 21 Anteflexion of the uterus, 128 Anteversion of the uterus, 128 Apoplexy of the ovary, 256 Arteries, ovarian, 23 uterine, anatomy of, 24 in abdominal hysterectomy, 413 in amputation of the cervix, 372 in vaginal hysterectomy, 374 vaginal, 25 vulvar, 25 yVscites, diagnosis of, 283 Atresia (Gr. a, negative; TETpnivu, to perforate) of the cervix, 68 of the cervix, operation for, 358 of the OS externum, 68, 72 of the OS internum, 68, 72 of the vagina, 68, 71 operation for, 357 J23 424 INDEX. Atropliy ((Jr. urjiii(*>/a, want of iiuiir- islimcnt) of the ovary, 250 of the uterus, 146 of the vagina, 102 of the vulva. See A'raurosis, 89 Axial rotation of ovarian tumors, 275 r.ACiM.i's (L. bacilliivi, a little rod), vaginal, 112 I!e1:X. Mons N'cncris, 2i Murccllcnient of inyoniata, 366 Mucoid deycmralion of inyomata, 1S7 Mucosa (1-. iiiitcosus, slimy), ult-riiic, 35. i^S cliangt'S during iiK-iislruulioii, J5 Mucous inciiibraiic. See Eitdatne- / rill 1)1, 16S polypus, 201 Miillers duct, 52 Mumps in relation to oophoriiis, 257 Mytijn:u), anatomy of, 18 cysts of, 269 Parotitis after ovariotomy, 405 Parovarian cysts, 270 Parovarium (Trapa, beside ; ovarium), anatomy of, 18 Pedicle, ligature of, 391 needles, 388 treatment of, 391 twisted, 275 Pelvic abscess, 293 cellulitis, 292 peritoneum, anatomy of, 26 epithelial infection of, 289 septic infection of, 288 tuberculosis of, 291 peritonitis, 288 tumors, diagnosis of, 331 Perimetritis (Gr. ~£/", round; jii/Tfui, the womb), 288 septic, 288 serous, 289 Perineal body, 95 Perineorrhaphy (Gr. -mpUxuin'; pnipi/, a seam), 341 for complete rupture, 345 for partial rupture, 342 Perineum (Gr. Tz^invninv, lit. the sur- rounding district), anatomy of, 94 repair of, 341 rupture of, 95 IVritxiphoritis (Gr. ■Kepi, round; uov, <:,n,,h.>), 258 Peritoneum (Gr. to Trepiruvaiov, lit. that which is stretched over). See Peh'ic Peritoneum, 2S8 432 INDEX. IVritonilis after ovariotomy, 403 septic, 28S serous, 289 tubercular, 291 I'eri-urethral cysts, 126 I'essaries (Low V,. pessariuni, from Gr. neaauc, an oval shaped stone for playing a game like our draughts; afterward a plug of linen, resin, etc. for vaginal medication), 147 Pessary, Hodge, 134, 148 retained, 151 ring, 148 vaginal stem, 150 riianlom tumor, 282 riiysicul examination in diagnosis, 325 Pinhole OS, 61 Placenta, retained portions of, 165 tubal, 236 treatment of, 247 uterine, 236 Placental polypus, 201 Polypus (Gr. iro?.!;, many; nov^, foot), cervical, 201 fibroid, 201 malignant, 20I mucous, 201 operation for, 364 placental, 20I Porro's operation, 418 Pouch of I)oughis. See Recto-vagi- nal I-'ossa, 27 Pregnancy, cornual, 196 diagnosis of, from myoma, 193 diseases arising from, 163 extra-uterine, 229, 40S mesometric, 236 normal, signs of, 194 spurious, 282 tubal, 229, 408 Pregnancy, witli carcinoma of the cer- vix, 211 with myoma, 1 89 with ovarian tumor, 2S5 Preparation of patients for operation, 335, 379 Pressure- forceps in hysterectomy, 375 Primary sexual characters, 49 Procidentia of the uterus, 136 Prolapse of the ovary, 254 of the uterus, 136 of the vaginal walls, 103 Pruritus vulva;, 87 Pseudocyesis (Gr. ■^evdoq, false ; kv- ijcir, pregnancy), ?82 Pseudo-hermaphrodism, 49 Puberty (L./«ii^«, youth), onset of, 30 Pulse after ovariotomy, 401 Pyocolpos (Gr. ■ttvov, pus; ko/.-^w, the vagina), 70 Pyometra (Gr. ttvov; /w'/"^'rt, the womb), 70, 214 Pyosalpinx (Gr. ixvov; cakni-)^, the Fallopian tube), 70, 217 Reci Ai, examination, 40 symptoms, 322 Rectocele (L. rectum^ the bowel; Gr. K-ip.il, a tumor), 103 Recto- vaginal fossa, anatomy of, 27 Remote effects of ovariotomy, 407 Renal disease, a contraindication for ojx-ration, 334 tumors, di.'igno>is of, 284 Keposilor, uterine, 157 Retained menstrual jiroducts, 68 pessary, 151 products of conception, 165 Retroflexion of the uterus, 129 Retroversion of the uterus, 131 of the gravid uterus, 195 Reversible tenacula force|)s, 369 INDEX. 433 Rheumatism, a complication of gon- orrluva, 1 23 KouirI iii^'ainciit of the uterus, anat- omy of, 20 shortening of, 421 tumors of, 296 Rupture of ovarian cysts, 276 tubal, diagnosis of, 241 primary, extra-peritoneal, 235 intra-peritoneal, 234 secondary, extra-peritoneal, 239 intra-peritoneal, 238 treatment of, 245, 408 Salpingitis (Gr. aakiny^, a trumpet, the Fallopian tube), 215 acute, 215, 224 chronic, 220, 225 gonorrhceal, 215 septic, 217 tubercular, 220 Salpingocele (Gr. aakiri-y^; kt]}.)], a tumor), 215, 253 Salpingo-oophorocele, 253 Sarcoma, decidual, 202 of the Fallopian tube, 222 of the ovary, 262 of the uterus, 202 of the vagina, 124 of the vulva, 97 Secondary sexual characters, 49, 407 Secretions, normal, 1 1 1 pathological, 114 uterine, II 4 vaginal, ill Semiprone (Sims') position, 41 Septic infection (Gr. ar/TrriKoc, putrid) of myoniata, 187 of ovarian tumors, 273 of peritoneum, 288 of retained menses, 74 28 Sessile myomata, treatment of, 364 ovarian cysts, treatment of, 393 Shock after ovariotomy, 402 Shot-and-coil sutures, 345 Sound, uterine, 41 Speculum, Auvard's, 47 Cusco's, 47 Fergusson's, 46 Neugebauer's, 47 Sims', 47 Spleen, diagnosis of enlargements of, 284 Sponge-holders, 388 Sponges, preparation of, 381 Stenosis (Gr. arevoc, narrow) of the os externum, 61 of the OS internum, 309 of the ostium tuba:, 221 of the vagina, 59 SteriHty, 314 treatment of, 316 Sterilizer, 339 Sterilizing of instruments, ^^;i of patient during Csesarean sec- tion, 417 Subinvolution of the uterus, 164 Superinvolution of the uterus, 163 Supernumerary ovaries, 251 Suppuration of Bartholinian cysts, 99 of ovarian cysts, 273 Suture material, 380 Sutures, removal of, 401 Symptoms, value of, in diagnosis, 318 321 Table for operating, 382 Tampons, glycerin, 172, 1 78 Temperature after ovariotomy, 400 Tenacula forceps, reversible, 369 Tents, 47 434 INDEX. Tetanus after ovariotomy, 404 Trachelorrhaphy (Gr. rpaxtkor^, the neck, the cervix ; /)o?>//, a seam), 368 Trendelenburg position, 3S2 Trocar, ovariotomy, 387 Tubal abortion, 232 gestation, 229 operation for, after fifth month, 409 after rupture, 409 at the time of rujUure, 40S rupture of, primary extra- j)eritoneal, 235 intraperitoneal, 234 secondary, extraperito- neal, 239 intra-peritoneal, 238 mole, 231 Tuberculosis of the Fallopian tube, 220 of the ovary, 258 of the jieritoneum, 291 of the uterus, 179 of the vulva, 86 Tubo-ovarian abscess, 218 cyst, 219 ligament, 19 Tulx)-uterine gestation, 239 Tumors of the broad ligament, 296 of the Fallopian tubes, 222 of the mesometrium, 296 of the ovarian ligament, 297 of the ovaries, 261 of the round ligament, 296 of the uterus, 181 of the vagina, 124 of the vulva, 97, 349 Twin tubal pregnancy, 229 Twisted pedicle. See Axial Rota- tion, 275 UNDESCENDF.n OVARIES, 252 Ureter, injury of, 402 Uretero-vaginal fistula, 109 ojK'ration for, 354 Urethra, diseases of, 93 Urethral caruncle, 93 operations for, 348 Urethro- vaginal fistula, 109 operation for, 355 Uro-genital sinus, 51 Uterine arteries, 24 changes in menstruation, 34 lymphatics, 26 mucosa, 35, 168 nerves, 26 probe, 171,363 repositor, 158 souffle in myomata, 193 in pregnancy, 194 sound, 41 veins, 25 Utero- vesical fistula, 355 fossa, 28 Uterus (L. uterm,\ht. womb), absence of, 6r adenoma of, 207 age-changes in, 127 anatomy of, 19 anteflexion of, 128 anteversion of, 128 atrophy of, 146 bicornis, 63 carcinoma of, 207 didelphys, 64 displacements of, 128 echinococcus colonies of, 214, 298 epithelioma of, 206 fibroniyoma of, l8l Hexions of, 128 hypertrophy of, I4I infantile, 61 intlammations of, 168 INDEX. 435 Uterus, injuries of, i6o inversion of, 153 measurements of, 127 myomata of, iSi perforation of, 163 procidentia of, 136 prolapse of, 136 retroflexion of, 129 retroversion of, 131 rudimentary, 6 1 sarcoma of, 202 septus, 63 single-horned, 62 subinvolution of, 164 superinvolution of, 163 tuberculosis of, 179 tumors of, 1 81 unicornis, 62 Vagina (L. vagina, a. sheath), abscess of, 124 absence of, 59 age-changes in, 102 anatomy of, 20 atresia of, 59, 68, 122 operation for, 357 cysts of, 125 diseases of, 102 displacements of, 103 double, 60 echinococcus colonies of, 126 epithelioma of, 125 tistulse of, 109 foreign bodies in, 108 hernia of, 107 infection of, in inflammation of, 1 18 injuries of, 107 malformations of, 59 normal secretion of, in sarcoma of, 124 secretions of, in Vagina, stenosis of, 59 tumors of, 124 Vaginal bacillus, II 2 examination, 39 hysterectomy, 373 myomectomy, 363 Vaginismus, 312 Vaginitis, gonorrhoeal, 119 in children, 119 in pregnant women, 120 senile, 119 septic, 119 simple, 118 Veins, ovarian, 25 uterine, 25 vaginal, 25 vulvar, 25 Ventrofixation of the uterus, 419 Vesical symptoms, 322 Vesico-vaginal fistula, 109 operation for, 352 Vestibule, 23 Visceral disease, a contraindication for operation, 334 Volsella, 44 Vomiting after ovariotomy, 399 Vulva (L. vulva, the female external genitals), abscess of, 84 age-changes of, 77 anatomy of, 21 angeioma of, 97 atrophy of. 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It is the special puq:)ose of the Editor, whose experience i>eculiarly qualifies <«* ijj him for the preparation of this work, not only to review the contril)Utions to (jg American journals, but also the methods and discoveries reported in the leading § fes medical journals of Euro]ie, tints enlarging the survey and making the work ^ S characteristically international. These reviews will not simply be a series of § ' undigested abstra.cts indiscriminately rtin together, nor will they be retrospective » 2 ■ of " hews " oiie or two years old, but the treatment jireseiited will be synthetic 2|* •< and dogmatic, and will include only what is new. Moreover, through expert • ^ condensation by experienced writers these discu^sinns will l)e Comprised in a Single Volume of about 1200 Pages. The work will be replete with original and selected illustrations skilfully reproduced, for the most part in Mr. Saunders' own studios established for the purpose, thus ensuring accuracy in delineation, affording efficient aids to a right comprehension of the text, and adding to the attractiveness of the volume. Prices: Cloth, $6.50 net; Half Morocco. , 57- 5° »*''• W. B. SAUNDERS, Publisher, 925 Walnut Street, Philadelphia. JUST ISSUED. PENROSE'S DISEASES OF WOMEN. A Text"Book of Diseases of Women. l?y Cmari.f.s R. Penrosf, M. P., I'n. D., I'l-dlbssor til' (JyiU'colony, Uiiivt-rsity of rulinsylvania; SurKeoii U> the (lyiicccan lliispitiil, riiiliiduliihiii." 0(ttav() Vdluiiie of 52'J paKes, liaiulsoiiiuly illustrated. I'ricf, So.riO net. MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE. Pathological Technique. By Frank B. Mai, lory, A.M., M. D., Asst. Professor of I'iilholoKy, Hiirviu'd Medical School; and James H. WRKiirr, A. M., M.I)., In- stnictoi- in "I'atholouy, Harvard Medical School. Octavo volume of 390 i)ages, liandsoiucly illustrated. Price, SENN'S GENITOURINARY TUBERCULOSIS. Tuberculosis of the Genito=Urinary Organs, iVlale and Female. By NtfiiOLAS Sknn, M. 1)., Ph. J)., LL.I)., Professor of the Practice of Surgery and of Clinical Surgery, Rush Medical College, Chicago. Handsome octavo volume of 320 pages. Illustrated. Price, SUTTON AND GILES' DISEASES OF WOMEN. Diseases of Women. By J. Bland Sutton, F. R. C. S., Asst. Surgeon to Middle- sex Hospital, and Surgeon to Chelsea Hospital, London ; and Arthur K. Giles, M. D., B. Sc. Lond., F. R. C. S. Edin., Asst. Surgeon to Chelsea Hospital, London. 436 pages, handsomely illustrated. Price, $2.50 net. IN PREPARATION. ANDERS' PRACTICE OF MEDICINE. A Text=Book of the Practice of Medicine. By James M. Anders, M. D., Ph. D., LL.D., Professor of the Practice of Medicine and of Clinical Medicine, Medico- Chirurgical College, Philadelphia. In press. MACDONALD'S SURGICAL DIAGNOSIS AND TREATMENT. Surgical Diagnosis and Treatment. By J. W. IMArDGNALD, Jf. D., Professor of the Practice of Surgery and of Clinical Surgery, Minneapolis College of Physi- cians and Surgeons. In press. AN AMERICAN TEXT BOOK OF QENITO=URINARY AND SKIN DISEASES. Edited by L. Bolton Bangs, M. D., Late Professor of Genito-Uri nary and Venereal Diseases, New York P(jst-Graduate Medical School and Hosiiital, and William A. Hardaway, M. D., Professor of Diseases of the Skin, Missouri Medical College. AN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR, NOSE, AND THROAT. Edited by G. E. de Schweinitz, M. D., Professor of Ophthalmology in the Jeffer- son Medical College, and B. Alexander Randall, M. D., Professor of Diseases of the Ear in the University of Pennsylvania. HIRST'S OBSTETRICS. A Text=Book of Obstetrics. By Barton Cooke Hirst, M. D., Professor of Obstet- rics, University of Pennsylvania. MOORE'S ORTHOPEDIC SURGERY. A Manual of Orthopedic Surgery. By James E. Moore, M. D., Professor of ()rthoi)edics and Adjunct Professor of Clinical Surgery, University of Minnesota, College of Medicine and Surgery. HEISLER'S EMBRYOLOGY. A Text-Book of Embryology. By John C. Heisler, M. D., Prosector to tlic Pro- fessor of .\natoiiiy. Medical Department, University of Pennsylvania. jvon jiJCAJH, ronrMES FOR isua am> isut. AMERICAN YEAR-BOOK OF MEDICINE and SURGERY. Edited by GEORGE M. GOULD, A. M., M. D. Assisted by Eminent American Specialiots and Teachers. NoTWiTHSTANDiNC the rapid multiplication of medical and surgical works, still these publications fail to meet fully tlie requirements of the getttral physician, j' inasmuch as he feels the need of something more than mere text-bouks of well- "J- known principles of medical science. Mr. Saunders has long been impressed '^ with this fact, which is confirmed by the unanimity of expression from the pro- '^ fession at large, as indicated by advices from his large coqjs of canvassere. 5 This deficiency would best be met by current journalistic literature, but most Si practitioners have scant access to this almost unlimited source of information, n, and the busy practiser has but little time to search out in periodicals the many ^ interesting cases whose study would doubtless be of inestimable value in his :: practice. Therefore, a work which places before the physician in convenient tu form an epitomization of this literature by persons competent to pronounce upon S The Value of a Discovery or of a Method of Treatment 2. cannot but command his highest appreciation. It is this critical and judicial ^ function that will be assumed by the Editorial staff of the " American Year- "^ Book of Medicine and Surgery." 55^ It is the special purpose of the Editor, whose experience peculiarly qualifies ?! him for the preparation of this work, not only to review the contributions to ^C American journals, but also the methods and discoveries reported in the leading § medical journals of Europe, thus enlarging the survey and making the work ^ characteristically international. These reviews will not simply be a series of "* undigested abstracts indiscriminately run together, nor will they be retrospective * of " news " one or two years old, but the treatment presented will be synthetic ^ and dogmatic, and will include only what is new. Moreover, through expert • condensation by experienced writers these discussions will be Comprised in a Single Volume of about 1200 Pages. The work will be replete with original and selected illustrations skilfully reproduced, for the most part in Mr. Saunders' own studios established for the purpose, thus ensuring accuracy in delineation, affording efiicient aids to a right comprehension of the text, and adding to the attractiveness of the volume. Prices: Cloth, $6.50 net ; Half Morocco, J?7. 50 net. W. B. SAUNDERS, Publisher, 925 Walnut Street, Philadelphia. DUE DATE 1 1 1 Printed in USA >^IU fe^^t XotH tjrt COLUMBIA UN1VERSITY_^^ 0027094936