intI)cCitpof3^tag< of EciiiiioH and Ihemostasls. pressure on the needle then eoiniciling, a miisci;hir consensus automatically employs for the second a force correlative to the first. For sutures of the intestines, sometimes necessary in lapa- rotomy, it is better to \ise round sewing-needles, as they make a smaller hole. In Figure 8 are given the siitures of Lemhert, of Czerny and of Gussenhaur, the most used in such cases. Materials for sutures. — The older operators used hemp, silk or linen ; as antisepsis had not taught the utility of perfect pui'ity of suture materials, these sutures contained nests of microbes, and suppuration in their track was the rule. The introduction of metallic sutures by Sims and Bozemaun was at that time a great advance, the silver thread was so much more aseptic than the others that the results, without doubt, gave rise to the enthusiasm con- cerning it. To-day they are employed very generally, as they have maiiy advantages. But they have also some disadvantages : they kink and break easily, they cut more than other sutures, their use demands more time. Finally, if cut short, their sharp ends wound the vagina and perinseum, and if cut long they are disposed to dragging. For these reasons I seldom use them, replacing them in most cases Avith aseptic catgut or silk. Hegar uses silver wire in the vagina where the permeable silk easily becomes septic. But I believe tlais can be obviated by frequent sublimate injections and by iodoform powder. Silk-worm gut (made from the silk glands of the silk-worm) is at once impermeable and not absorbed, Hke the silver wire ; it is not so easily kinked or broken, but is less flexible. It has the stiiiuess of horsehair. For the various purposes for which metallic sutures have been employed, it is prefered by some authorities. I have found that in a knot it does not hold as well as catgut or silk, and that it is as refractory to torsion as wire, so that its sutures do not afford perfect security. Finally its ends become very sharp on dr3'- ing, a fault in plastic operations on the Milva and vagina. It is, however, a very good suture in some cases. The best silk-worm gut is of a light-red tint. It must be soaked for a quarter of an hour in carbolic or sublimate solution before using, or it will have an inconvenient stiffness. The strongest silk is the plaited (and not the twisted). It is ex- cellent suture material when it is made aseptic as indicated. It can be employed as a deep or buried suture or even left in the ab- dominal cavity. Experiments have proven that it is capable of absorption. However, there is no doubt that it is inferior in tills respect to catgut. In all cases consequently, when long persistence of the suture is not desired, I prefer to substitute catgut. On the contrary, in suture of the intestine, stomach or bladder, I use, by preference, very fine silk tln-ead. In certain i^laces when a long line of catgut sutiires is used, the sustaining points of the suture Means of Reunion and Hcemostasis, 37 should be of silk. But silk has the disadvantage, owing to its porous nature, that must be noted, of the possibility of secondary infection. Consequently silk sutures and ligatures, left in places where suppuration can occur, are often the cause of obsti- nate fistulfe, which last until the elimination of the septic thread. It is preferable, then, to use catgut for ligatures and silk- worm gut for sutures in such places. Tliis precept has one of its principal ap- plications in pyosalpynx and pelvic abscess. Likewise, sutures of the abdommal walls m contact with a dramage tube should not be of silk but of catgut, silk- worm gut, or silver wne. There is no suture or ligature in general surgery or gynsecology comparable to catgut. Its property of being absorbed m eight to fifteen days, according to its size and preparation, makes it of in- estimable value for ligatures left in the abdommal cavity, and for sutures of the cervix and vaguia after plastic operations, when the secondary ablation of the suture is so difficult and sometimes so painful. For a long time I have used catgut exclusively for all my sutures, placing silk or silver wire at sustaining points. The tendency of catgut knots to sKp should be remembered, and, in tying, three superposed, tightly-drawn knots should be made. Different styles of sutures. — The varieties of sutures are multiple, but the tendency is now to simplification, and at present, in every- day practice of gynsecology, only the follo^ving are in common use : 1. Interrupted suture; 2. Simple contini;ed suture; 3. Contuaued suture in superposed planes; 4. Mixed or combined suture; 5. Quilled suture. Fig. 9. — Interrupted sutures, a a, deep sutures; b b, suture passing under a part of the surface of the wound ; c c, superficial suture uniting the edges. 1. — Interrupted suture. — Whatever the extent of the wound, all its surface must be in perfect coaptation, under penalty of an accumu- lation of fluids m the angular spaces, compromising the success of the suture by distention and rapid septic infection. To fulfill tliis important indication, in deep sutures, the needle passes under the whole tliickness of the raw surface, or there may sometimes be left in the middle a surface of one to two centimetres that the suture crosses as a bridge instead of passing under it (Fig. 9). The needles 38 Means of licimion and Hainostasis. employed for certain coaptations (colpo-perineon-haphy, etc.) should be very long and strong. After these deep sutures it is necessary to use superficial ones ■nith a fine needle to secure exact union of the edges of the skin. To obtaui gi-eat precision these superficial sutm-es must be placed very near the edges of the wound. They should be placed last and tied at once, while the deep sutures should be placed first and tied last. More exact coaptation' is thus secured. The deeper the suture, the more distant from the edge of the wound should be the point of entry. 'WTiererer it may be, the traction of a single long suture unites the large surfaces like a purse-stiing and is liable on excessive traction to cause puckering. Hence arose the idea of superposed bm-ied sutui-es. By a first row, or first tier, of in- terrupted sutm-es of catgut, the deep part of the wound is closed, a second, and even a thu-d row, closes the remaining sui'face. This procedui'e is valuable in some cases, but has the fault of leaving knots at the bottom of the wound which hinder coaptation. Fig. 10. — I. Continued suture: commencement of the suture ; 1 1, catgut thread. 2. Continued suture almost finished. 2. — The contlmioits suture overcomes this difficulty. It offers the great advantage of being very efficacious while being also very ex- peditious. It is especially valuable when one has to make many operations at one time, for example, amputation of the cervix with Means of Reunion and HcBinostasis. 39 anterior colporrhaphy. Simple continuous suture is always suf- ficient Avhen the surface is neither too large or too deep ; it is also used for haemostasis. We connnence by passing the needle through one angle of the wound and by tying tln-ee superposed knots on the terminal extremity of the suture, of which there should be a short end left. This end is taken in the jaws of the forceps (in the illus- trations this is Baumgartner's, especially constructed to facilitate traction on the threads in deep ligature), an assistant holds this and it serves as a support for the continuation of the suture (Fig. 10). The needle is then entered three or four millimetres from the edge of the wound, carried under the whole surface and brought out again at an opposite point on the other side of the wound ; the thread is moderately dra^ai on, and given to the assistant holding the forceps to be kept tight while the second stitch of the continuous suture is made. He must be careful not to let go the tln-ead abruptly, when this second stitch is drawn through, but to follow by maintain- ing it close to the wound, to avoid relaxing the preceding stitch. It is well, when the middle is reached, to make slight teirsion on the opposite angle of the wound with the forceps to make sure that the edges are parallel. A useful precaution to avoid the constant slipping of the thread in the eye of the needle is to fix it by a single knot. 3. — The continuous suture in superposed %ilanes is more complicated. If one row of stitches is manifestly insufficient to effect complete coaptation, the needle not being able to take up all the raw surface, the sutures should be made in superposed rows or in tiers. For this, at the point where the wound shows an excessive width, in place of entering the needle outside the edge of the wound, it should be entered inside on the raw surface, one or two centimetres if necessary, always calculating this distance according to the depth of the surface of the wound under which the needle can be passed. When this has sufficiently diminished the largest part of the wound, recommence the insertion of the needle now in the skin and termi- nate the closing of the wound by a superficial overcasting, at first direct then reversed (Fig. 11). Three rows may thus be stiperposed. It is necessary not to tie too tightly, and not to bring the points of the suture too near together. In finishing and fastening the suture •by overcasting we find two circumstances : if the terminal end of the thread has been brought near the original extremity, by a second complete row, the two ends have only to be tied together (three knots), otherwise the end of the thread is tied to the last point of the overcasting, which is stretched so as to leave a sufficiently long loop, or the thread is drawn in the eye of the needle so that the terminal end is doubled in the last stitch, and to this loop the end is tied. If the tln-ead of the lower row is cut by accident in placing the superficial tier, or if the thread is broken, a separate deep 40 Means oj lieunioii and Htemostusia. Fig. II. — I. Continued suture in superposed planes (one at the angles, two in the middle of the wound). 2. The same, with three sutuers in the center. Fig. 12. — Continued sutures in tiers in perineorrhaphy. I 2 3, track of the suture; a b, simple continued suture; c, sustaining interupted sutures; d, commencement of the superposed sutures. Means of Reunion and Hcemostasis. 41 stitch is immediately taken, at the break, and the previous suture continued. Finally, I cannot recommend too highly the placing, at points which have to sustain strong traction (particularly those where the direction of the suture is changed, or where a sort of keystone to the structures exists), one or two isolated sutures, in silk or in silver wire. These are true supporting sutures, which prevent too great strain on the catgut (Fig. 12). In perineorrhaphy I use two, one at each extremity of the perinseum, the anterior embracing the end of the reconstructed recto-vaginal septum, the posterior uniting the extremities of the anal sphincter. In colpo- perineorrhaphy, only one is placed at the edge of the fourchette. Fig. 13. — Suture of the abdominal walls after hysterectomy. First stage of the continud suture (peritonseum). Fig. 14. — Second stage (musculo- aponeurotic plane). 4. — Mixed or comiined sutures. — It is sometimes useful to combine the continuous and interrupted sutures. As example of these mixed sutures, I shall describe my method of closing the abdominal wound after laparotomy. As soon as the toilet of the peritonaeum is com- pleted, the abdominal wound is brought together and held closed, by an assistant, above a compress- sponge spread over the surface of the intestines and intended to protect these organs during the suture. The peritonseum is then transfixed at the inferior part of 42 Means nf Reaiiioii and Hcemostasis. of the wound by a curved needle supplied with a long needleful of medium catgut. A separate stitch is placed at this point, with the lower part of the long needleful of catgut. The needle is always kept on the longer portion, while on the shorter end of the initial stitch is placed a pair of forceps, intended to make traction. The operator then continues to sew the peritonaeum very quickly with large stitches up to the end of the wound (Fig. 13) ; before finishing he withdraws the compress-sponge, then he places on the aponeu- rosis a second row of stitches, a little closer than the others, closing the sheath of the rectus muscle if it has been opened (Fig. 14). He reaches thus the place where he commenced, removes the forceps which holds the slioi-t end of catgut, and ties thet\\"o ends. The abdomen is then firmly closed, there is nothing left but to reunite the edges of the integmnent and of the subcutaneous cellular tissue, winch sometunes forms a mass of considerable thickness. With a very large curved needle and silk of a strength in proportion to the thickness of the parts, a series of separate stitches is placed about thi-ee centimetres apart. These sutures enter two to thi-ee centimetres from the edge of the woimd, pass directly through aU the thickness of the fatty layer, close to the aponeurosis and emerge in reverse dii-ection thi-ough the other hp of the wound. As each row of these separate deep stitches is placed a forceps is fastened on each end. The wound being washed vdth a strong carbohc solution, the edges are brought together and ^\ith a very small needle and fine eatgiit, or silk-worm gut, one or two separate stitches of superficial sutm-e are taken in each of the intervals between the two deep sutm-es. These stitches are placed as near as possible to the edges of the ui- tegumeut and should ensure perfect coaptation. (I often replace them ^^•ith a continuous sutm-e of catgiit.) It is not imtil they are entnely placed and knotted, that the points of the deep suture should be dra\\-n and tied after ha^"ing loosened the forceps that held the ends temporality (.Fig. 15). If the abdominal walls are very rigid (in nuUiparfp) or tense, silk should be used in place of catgut for the deep sutures. 5. — Quilled sutures. — Small rolls of iodoform gauze should be substituted for the quiUs or the ends of bougies formerly used. Lister's lead plates, \\iththe large silver \\ire are thus advantageouslj' replaced. This sutiu-e is not employed now in perineorrhaphy, but there are exceptional eases m which it may be useful. In the case of very large adherent abdominal tumors, there exists, after then ablation, a very large raw sm-face formed by the walls of the ab- domen more or less stripped of theii- peiitouieum by the ruptmre of adhesions. Tliis large oozing surface gives lise to danger of sep- tdcsemia. It is useful then to place at each side, before closing the abdomen, a long deep sutm-e, supported at each end by a roll of iodoform gauze. These exercise an eSicient pressure on the raw Means of Reunion and Hamostasls. 43 surfaces, stop the haemorrhage or the serous oozing, and eliminate one of the causes of early infection. These sutures ought to be re- tained about iive or six days. Htemostasis may be obtained in various ways : compression for capillary haemorrhage, torsion for small arteries, and suture for the surface of a wound, but the two great methods are ligature and forcipressure. Isolated ligatures of the vessels call for no attention as they present nothmg special. Fig. 15. — Suture of the abdominal walls after hysterectomy. Interrupted suture of the subcutaneous adipose tissue and of the integument. Ligature en masse offers great interest in gynecology, since with its help we control haemorrhages, often formidable, of the pedicles of abdominal tumors. This ligature is made, according to circum- stances, with wire, with silk or catgut tliread, or with elastic tubes. We shall better study this question in treating of ovariotomy and hysterectomy. Silk is the most used in ligature en masse of the pedicle, because of the great resistance in a small volume ; plaited and not twisted silk should always be chosen. There is no doubt, however, that when a large quantity of thread has to left in the ab- domen (as after hysterotomies by Schrceder's method), it is a dis- advantage to use, in the serous cavity, material which takes long 44 Means of Reunion and Htemostasis. for absorption and of a porosity that renders it liable to secondary infection. Thus since the preparation of catgut in juniper oil has put into our hands a material superior to that formerly employed, many gynscologists do not hesitate to reject silk completely, sub- stituting catgut, although it is more difficult to tighten iu a ligature. Fig. i6. — l. Surgeon's knot badly made. 2. Surgeon's knot tied correctly. 3. Trans- fixion of a pedicle by a needle. 4. Crossing of the two threads after transfixion. 5. Bantock's knot. 6. Tait's knot (StaflTordshire knot). 7. Chain ligature for a larye pedicie. S. Chain ligature tied. I shall confine myself to the usual modes of ligature en ma^se. If the portion to be tied is relatively small and one loop of the ligature is sufficient, it should be passed around, drawn tightly, and tied with a siu-geon's Imot (Fig. 16, 1 and 2). If the pedicle is large and two loops are necessary, it should be transfixed at the middle by a needle, threaded with a double tlu-ead (Fig. 16, 3) ; the loop can then be cut so as to have two ends, cross them and luiot to the right and left (Fig. 16, 4). 'What is better, m order to avoid two knots (the knots are less easily tolerated than the rest of the ligature), make the Bantockknot (Fig. 16, o), or Lawson Tait's knot, Staff ordshii-e knot (Fig. 16, 6). If the pedicle is laminated (certain ovarian pedicles, membranous adhesions, or simply the broad ligaments) a sei'ies of Means of Reunion and Hcemostasis. 45 ligatures should be made, connected in such a manner as to cause no tear m drawing them tight (Fig. 16, 7 and 8). The Figures 17, 18 and 19 show plainly the ordinary procedures employed for in- troducing these sutures, and that wliieh Wallich has recently proposed Fig. 17. — Chain ligature. to substitute for them. This last approaches closely to those of J. W. Long, (Fig. 20) with this difference, we use a single thread (a double eye appears useless) in place of the series of ordinary pointed needles used by Long. When ligature en masse is made outside the abdomen, it causes sphacelus of the constricted tissues. When it is left, with antiseptic precautions, in the peritoneal cavity, the ligated parts do not slough, they preserve a minimum of vitality from the vessels of the adhesions and those which pass above the ligature. At the end of some time the stump is sluiveled and absorbed. Catgut ligatures are quickly absorbed,while silk threads are first infiltrated with cells, then encysted, then disappear ; but it takes months for this and it is possible for them to play the part of a foreign body, even after the lapse of some time. This late infection can only be explained by the passage of germs tlu'ough the intestines or fallopian tubes, unless we admit a latent microbism, rekindling under a bad local or general condition. To avoid primary infection, when the surface of the section of a pelicle is suspected (salpingitis, etc.), it is better to tie with catgut or at least to combine cauterization with ligature en masse. The aseptic eschar is rapidly absorbed. 46 Means of Reunion and Hcenwstasis. As to elastic ligature, whether maintained outside or left iu the peritonaeum, I shall here keep to generalities, referring for technical details to the chapter on hysterectomy, where its principal appli- cation is found. To fasten the elastic band Olshausen is content to tie the ends tmce, placing some stitches of silk to fasten the band to the pedicle to prevent slipping. Fig. iS.— Chain ligature (Wallich). Thiersch passes the two ends thi"ough a lead rhig, Avhicli is crashed on them. Hegar places on the two stretched ends, first a ligatm-e of silk, then a second ligatm-e for safety t,Fig. 21 and •22). Various kinds of apparatus for fastening elastic ligatures have been proposed (since I constnicted the first) either to facilitate placing the ligatm-e or to hold it in place. My instrument, the ligator (Figs. 23, 12 3; 2-4 and 25), is proposed solely to facilitate the placing of an elastic band iu a narrow space, as the pelvic or vaginal ca^"ity. Its use is very simple and, its parts being easily separated, it can be kept perfectly aseptic. Means of Reunion and Hcemoiitasis, 47 Fig. 19. — Different stages of the chain ligature (Wallich). Foreipressiure. — The compression of the vessels by the jaws of a pedicle forceps or by a clamp is of great service, as it immediately arrests the blood-flow by a provisional hsemostasis, which becomes permanent in some instances. Thus in the course of a laparotomy ligatitig can be avoided until toward the end of the operation. In plastic operations this procedure must not be abused for the small bits of tissue that are crushed in the jaws of the forceps are an obstacle to immediate reunion. As with ligatures, forcipressure may be used for smgle bloodvessels or for the compression en masse of thick tissues. It is therefore useful to have at disposal various patterns and sizes, adapted to any emergency, from the powerful pedicle forceps of Billroth to the small haemostatic forceps of Koeberle. Although forcipressure is usually reserved for cases of necessity in vaginal hysterectomy, some surgeons have proposed its use in prefer- ence to the ligatures. As many have taken up this practice I shall return to its consideration in the chapter on cancer of the uterus. 48 Means of Reunion and Hamustasis. Fig. 20. — Long's chain sutures with a series of needles. Fig. 21. — Hegar's forceps for fixing the elastic ligature while a thread passed behind it can be tied. Means of Reunion and Hmmosta 49 Here it is only sufiScient to remark that foreipressm-e to the neces- sary extent always causes an incomparably greater sloughing than that succeeding to ligature. It is therefore of less value in an anti- septic point of view. Fig. 22. — Elastic ligature fastened by a silk threrd. (Ilegar.) Fig. 23. — Pozzi's Ligator for applying elastic ligature Drainage. — It will be sufficient here to take up some general principles and indicate the means of fulfilling them. Drainage of wounds. — In the superposed sutures of the abdominal walls after laparotomy it is generally iimiecessary to place a drainage tube between the layers. But this may become necessary if the cut surface has come into contact with septic material, pus for examj)le. Then, in spite of the most careful cleaning, a serous or sero-puru- lent oozing may compromise primary reunion, unless the fluid is promptly evacuated by drainage. In such cases a small dramage tube is placed between the sutures uniting the aponeuroses and those uniting skin and cellular tissue. This tube is generally divided into several segments and each is prevented from slipping into the wound by transfixing the external extremity with a safety pin. The best drainage tubes are of thick rubber, as they can be curved at need, and on account of their thickness, preserve their calibre when bent 50 Meiuis of lieuitlon (Did Htemustasis. Fig. 24. — Application of the elastic ligature with Poz?i s li^itor. i. First stage ; The lower end of the elastic ligature is held in the fork of the handle; the ligature passing under the uplifted pedal is engaged in the head of the instrument by pressure. 2. Second stage : The ligature has been passed twice around the pedicle; then it is again engaged in the head of the instrument Isy pressure. Draina(/e of the peritoiucum. — The fear of accuiimlatiou of liquid in the peritonfeum led, in the early times of laparotomy, to the practice of preventive periton-pnl drainage. In 1872 Sims recom- mended systematic cbainage iu every ovariotomy. This extravagance had, at least, the merit of showing the harmlessness of drainage when surrounded hy proper precautions. In fact, it is well to know that at the end of a few^ hours the tube is shut off by the formation Means of lieumon and Hfemostasis. 51 of pseudo membranes which surround and isolate it. It is only when there is persistent oozing that a cavity remains at its extremity in which fluid accumulates. A new element now simplifies the problem, that is the knowledge of the great power the peritonaeum possesses for resorption, when this property has not been destroyed by exten- sive tears, or by long exposure to air and paralysis of the intestine. From this it results that in simple laparotomy, a very great quantity of liquid, blood or serum, is rapidly absorbed without danger to the patient. The difficulty is to judge if it will take place, for if it does not, there are strong probabilities of septicaemia. In a preceding note it is said that irrigation of the peritonaeum temporarily para- lyzes the absorbent power of the serosa. Fig. 25. — Application of the elastic ligature with Pozzi's ligator. I. Third stage: The ligature is drawn under the pedal and fixed by lowering this. 3. Fourth stage : The inferior end is detatched from the fork ; the head of the instrument is detatched and remains in place. (To the left is a chain suture of the broad ligament.) 52 Means of Reunion and Hccmostasis. Supposing that the toilet of the peritonseum has been made with compress sponges, it only remains in establishing the indication for drainage to consider, not what remains in the abdomen, but what may be effused and remain. The elements of appreciation are so many that it is difficult to establish absolute rules, each surgeon nmst be his own judge in the individual case. However, the follow- ing may be formulated as the principle indications for di-ainage : 1. The fear of abundant oozing of blood or serum, after closing the abdominal walls, in consequence of special anatomical or clinical conditions, the absorbent power of the peritona;um not being intact. 2. Existence in the peritonajal cavity of a septic sm-face capable of furnishing a fluid exudate, the resorption of which would be dan- gerous — existence of lesions of peritonitis. 3. Extensive denudation of the peritonaeum, acting : (a) as a source of persistant oozing ; (b) by loss of the normal power of absorj)tion. 4. Long duration of the operation and laborious manoeuvres compromising the tonicity of the intestine and the vitality of the peritoufeum. Vaginal Drainage. — Douglas' cul-de-sac being the most dependent point of the pelvic cavity, it is natural to take it as the point of departure for the issue of liquids. Besides, there is the advantage of not weakening the abdominal wall and favoring a future hernia by retarding primary union at one point. The only objections to vaginal drainage is the richness of the vaginal canal in micro- organisms and the difficulty of perfect asepsis. I will omit the inefficient or complicated processes and confine myself to those that are best. One of these is the introduction of a tube in the form of a cross (Fig. 26). After laparotomy this tube can be introduced into the posterior cul-de-sac tln-ough an mcision, or directly by puncture ■with a large trocar. The transverse branch of the tube keeps it in place without preventing its withdrawal by forcible traction. The lower extremity is always ■s\Tapped in iodoform gauze. This drainage-tube is left in place from six to eight days, or more, on special indication. A disagreeable sensation, a sense of weight in the lower part of the abdomen, indicates that it is not well tolerated. It is not prudent to make any injection tlu'ough the tube nor in the vagina while it remams in place ; the liquids are absorbed by iodoform gauze softly packed in the vagina. Drainage of the abdommal ca^^ty has been made chieflly ^^ith glass tubes. It is better to have them made \vith openings in then- lower end only. Thej' are mtroduced into Douglas' cul-de-sac and the upper external extremity of the tube is enveloped in an absorbent dressing. Lawson Tait uses a special instrument to evacuate the fluids from the tube. Since 1867, Kceberle has filled the canula \vith carbohzed absorbent cotton, destined to absorb them. Hegar • in adopting tliis procedure improved it by taking advantage of the capillary attraction of the substance contamed in the tube, which Means of Reunion and Hcemostasis. 53 is frequently renewed. Hegar has now abandoned this for capillary drainage with gauze alone. Thus it is that capillary drainage has long been the auxiliary of drainage of the abdomen by the tube. Fig. 26. — I. Rubber drainage-tube in form of a cross. 2. Method of seizing with the forceps for introduction into a cavity. The indications for simple capillary drainage of the peritonaeum, independently of its combination with tamponing (of which I shall treat later), are, I believe, very limited. I employ it only after vaginal hysterectomy. Instead of introducing one or two tubes into the opening in the peritonaeum, or of leavmg it gaping, after the method of some surgeons, I prefer, after havmg reduced it to a small opening by two lateral sutures, to push into ii, to the depth of about an inch, a strip of iodoform gauze doubled at its upper end, the ends being rolled up in the vagina. At the end of a variable time, according to the amount of oozing, the other strips of iodoform gauze, which complete the intra- vaginal dressing, are renewed, the one placed in Douglas' cul-de-sac remaining untouched, as it main- 54 Means of Reunion and Heemostasis. tains the di'aiuage opening. At the end of six to eight days this too is removed. Antiseptic tamponnement of the peritonaiun. — It is certainly a bold idea to pack a part of the peritouseal ca%"ity with an antiseptic tampon in such a way as to isolate the portion tamponed from the rest of the peritonaeum. This result is produced during the first few hours by the bulwark formed by tamponing, ultimately by adhesions that it produces at its periphery. A similar audacity, inspired by its success, is the substitution of tamponing for drainage. Antiseptic tamponnement of the peritonaeum was suggested by M. Mikuhcz. Mikulicz advises, first, plaemg at the bottom of the cavity to be tamponed, a sort of pm-se made by pushing in a bit of iodofonn gauze (20-100). In the middle of this gauze is fixed a double thi-ead of antiseptic silk to aid in withdrawing it. Once the pm-se is in place, two to five long strips of iodoform gauze are introduced, disposed in such a way as to cover aU the surface of the cavity. Then- superior ends pass thi-ough the neck of the pui'se and issue ■with it from the inferior extremity of the abdominal wound (Fig. 27). This procedm-e can be suuphfied, in smaU spaces, by packing the strips of gauze directly into the depths of the cavity, but care must be taken to scrape the edges of the gauze, so that no filaments can be detached. A useful precaution consists in introducing, at the same time, a large drainage tube m the center of the tampoimement, to avoid retention of hquid too thick to filter thi-ough the gauze. I wish to recommend also that all excess of iodoform be avoided for fear of toxic effects. What length of time should the tampon be left ? Mikuhcz recom- mends withdrawal of the inner strips after forty-eight hours, and of the sac itself two or thi-ee days later. The amount of oozing and the state of the tamponed parts should guide us. In all cases it is necessary to remove the sac before the fifth day, allowing time for the peripheral adhesions to consohdate. There is no difficulty in removal if a mark is placed on the gauze rolls to distinguish the superficial fi-om the deep. The external tampons must be changed, however, as often as necessary, that is about thi-ee times a day. They rapidly imbibe the sanguinoleut serum oozing from the bottom of the wound and transmitted by capillary attraction from the deep part of the tamponnement. It is as impossible to give rales for the cases that need tamponne- ment as it is for drainage. Much is left to the tact of the operator. Tampoimement should eertauily be the exception, an ultima ratio, either against parenchymatous hi^mon-hage (hemostatic tamponne- ment") , or against infection ( antiseptic protective tamponnement) . In the latter case two different circumstances present themselves : (a), the infection of a part of the wound existing at the time of operation ation and not controUable by ii-rigation, or the presence of a por- Means of Reunion and Hcemostasis. 55 tionof infected tissue that it is dangerous to remove ; (b). infection is to be feared after the occlusion of the abdominal wound, from the slouglnng out of a suture made ujider bad conditions, or from perforation of an organ compromised before or during the operation. In such circumstances I have had recourse to antiseptic tamponne- ment of the peritonseum. Fig. 27.- -Tamponnement of the peritonaeum {after hysterectomy), a a, sac of iodoform gauze; b, silk thread; c c, strips of gauze. Intrauterine drainage. — Capilary dramage of the uterus with iodo- form gauze has been employed as a means of antisepsis in uterine catarrh. A fine strip of iodoform gauze is generally used by pushing it up into the uterus mth a sound. At the end of twenty-four hours this is renewed and the ca\'ity will then be dilated enough to make its introduction much more easy. Drainage with a rubber tube, with holes in the portion contamed m the uterus, has beeia used, but the idea of evacuation of mucus by this means is an illusion. It is a mistaken procedure and it may even cause infection of the uterus in place of removing it. The situation is different when the uterus is sufficiently dilated to allow the introduction of the drainage-tube in the shape of a cross. Tins is preferable to the metallic di-ainage- tube that has been recommended. The drainage-tube of two crossed pieces of rubber, renders great service Avhen there exists in the dilated 56 Means of Rcun'wn and Hceriwstasis. iiteiiiii a permanent source of infection, as, for example, sloughing fibroid or debris of foetal membranes. At need, this drainage may be made the first stage of a eontmuous irrigation and in all cases it facilitates the exit of the secreted fluids and the administration of intrauterine injections. Continuous irrigation. — As a preliminary the cruciform drainage- tube is introduced into the uteiine canity. The uteiine cavity being dilated m cases where its use is necessary, this offers no difficulty. Fu-st, two or three litres of an antiseptic solution (carbolic acid 30-1000 or sublimate 1-2000) are quickly passed through the uterus. Irrigation is continued until the water issues clear, this is followed by continuous in-igatiou, di'op by di-op, bj' the aid of a special apparatus or simply by regulating the flow of water by the ordinary stop-cock. For this a weak solution (10-1000 carbolic acid or 1-5000 sublimate) is employed. The temperatm^e of the injection should be 33^ C. to 38° C. To avoid excoriation the external genital organs may be smeared mth vaseline. Antiseptic tamjwnnement of uterine cavity. — Long strips of iodoform gauze are pushed carefully into the utems with a blunt iustrnment or a long curs'ed forceps, and packed up toward the fundus little by little. As an antiseptic measm-e the gauze can be left in place three to six days. Intrauterine tamponnement may also be used as a hfemostatic. Exceptionally a little perchloride of iron may be added after curetting for uterine cancer, or after enucleation of a fibroid. Tamponnement of the vagina. — The application of a tampon must not be confounded with tamponnement. That the last term may be applicable the whole extent of the vaguial canal must be filled with a continuous column of a more or less elastic substance, chai-pie, cotton, gauze or wool, rendered aseptic and antiseptic by proper preparation. In these may be iucoi-porated various medicinal agents which add their special action to the mechanical effect of the tam- ponnement. They are utilized for two purposes : 1. Hemostatic; 2. Antiphlogistic. 1. Hcemostatic tamponnement. — This is never a measure of choice, but always one of necessity — when a profuse metrorrhagia demands prompt attention to avert a fatal result. It would be preferable, of course, in each individual case to direct treatment to the cause, but as this is not always possible, we have recom'se, to gam time, to a vaginal tamponnement, packing against the cervix a substance not easily pemieated, that compels the blood to coagulate in the uterus. It must be vmderstood that this is an expedient and not a treatment ; it cannot be prolonged without serious danger, resulting either from the cause of the hnemorrhage, or fi-om the reaction caused by the pressure of the foreign body which fills the vagina. Tamponnement should be applied as follows : The rectum and bladder are emptied. The most favorable position to expose the vagina, without tiring Means of Reunion and Hcemostasis. 57 the patient too much, is Sims' position. The speculum pulls back the posterior vaginal wall and an irrigation with carbolized water 10-1000, clears the vagina of clots and accumulated blood. It only remains to fill the cavity. For this I recommend the preparation of a series of small tampons of absorbent cotton, dipped, some in a„ concentrated solution of alum, the greater number in a weak carbolic solution which has served for irrigation. These are squeezed as dry as possible at the moment of using and then form disks the diameter of a silver dollar and double or triple the thickness. With a long forceps five or six of the alum disks are quickly disposed around the cervix in the cul-de-sac and at the os uteri. As soon as these are placed the carbolized disks are used to complete the tamponnement. A large quantity of the cotton disks are necessary, although they should not be packed with much force, but only superposed so as to form a homogeneous whole. In proportion as the vagina is filled the speculum should be withdrawn and wholly removed a little before completing the packing. It is sometimes necessary to cathe- terize these patients on account of the pressure on the neck of the bladder. The cotton should not be left in place more than twenty- four hours ; after having removed it a copious hot douche is given. 2. Antiphlogistic tamponnement lifts the uterus up mechanically, relieving the ligaments from its weight, diminishing the venous stasis due to the descent of the organ, and limiting the access of the arterial blood by excentrio compression. Thus it combats congestion, in- flammation, putting the tissues in a state favorable to the resorption of exudates and to the cessation of pathological reflexes. The position of the patient most favorable to its application is the genu- pectoral. There should be at least : 1. Small tampons of absorbent cotton prepared in antiseptic glycerine and squeezed out: 2. Fine surgeon's wool, purified by the sterilizing oven, washed in carbolic solution, 10-1000, then well dried, this substance being employed on account of its great elasticity. Tamponnement made with absorb- ent cotton in its whole extent would be too compact. The first tampons are placed in the posterior cul-de-sac, then all around the cervix, which should be thus immobilized. The remainder of the vagina is then fiUed with the wool. It is better to keep the patient in bed for one or two days after the first tamponnement. After this she may be allowed on her feet. If erythema follows the use of dry packing, a dressing coated with vaseUne may be substituted. The tamponnement is renewed every two or three days, and in order to produce its full effects it must be persistently employed for some weeks. If the cotton or wool be impregnated with medicinal substances, such as the glycerole of tannin, etc., it will act as a topical application to aU the vaginal mucosa. But strictly speaking, when it is made for this purpose it is no longer a tamponnement, but an aggregation of tampons. 58 Gyiuecologiad Exaininations. CHAPTER IV. GYNECOLOGICAL EXAMINATIONS. Position of the patient — By examination in the upright position only very Umited knowledge can be gained. Exammatiou thus practiced affords useful information, however, in displacements of the genital organs and abdominal tumors. The physician kneels on the left knee so that his right thigh, semi-flexed, serves as a sup- port for his elbow of the same side. But the upright position is unfavorable for complete examination, and only deserves mention. The principal positions are : the dorsal, the lateral, and the genu- pectoral. The simple dorsal. — It is sufficient for a cursory abdominal and digital examination, to place the woman on her back the head resting on a cusliion, the thighs slightly flexed and abducted. This is the ordinary position for examination in bed. It has the disadvantage of allomng only slight relaxation of the abdominal muscles, ob- structmg xmlpation, and is wholly unsuitable for the use of the speculum. Modified doral lithotomy j)osition. — This both procures relaxation of the abdominal walls and allows easy introduction of the linger and speculum. It is used by prefference for complete examination. The nates are brought to the edge of the bed or table, the trunk and head are moderately elevated, the thighs are flexed on the pelvis and the legs on the tliighs and maintained in this position by the assistants or by the use of special apparatus. Dorso-sacral position . — Tliis is the most convenient for aU opera- tions on the external genitals, or on the vagina and uterus through the natural passages. It brings all the parts within easy access. The patient is placed at the edge of a bed or table, the head sHghtly elevated by a cushion, the trunk is horizontal and the peMs is elevated and flexed on the vertebral column in such a way as to present marked obliquity from above do^nrward and from before backward. The legs are flexed and carried toward the abdomen by the assistant, who holds the limbs so flexed as to keep one hand free to help the operator. When there are no assistants at hand, Fritsch's apparatus and speculum can be utiUzed. There are several instruments of this type for separation of the thighs and flexion of the legs. A very useful modification of this position con- sists in great elevation of the pelvis above the rest of the trunk. Gyncecological Examinations. 59 This greater elevation of the pelvis causes the intestines to fall toward the diaphragm and permits a more easy exploration of the pelvic organs. This position is of great help to the operator by re- lieving pelvic pressure in examinations, especially of small tumors of the uterine appendages. To facilitate exploration and to render the pelvic organs more accessible during an operation it is equally useful to have an assistant lift up the uterus Avith two fingers in the vagina, or to employ, for the same purpose, an inflated air-pessary. Sims' position. — In gynecology only the modified lateral or ab- dominal lateral, better known as Sims' position, is in general use. It is adapted for examination with the speculum of the same author. (The weight of the viscera falling forward, the air then easily sepa- rates the vaginal walls.) This position is of great service in various cases. Finally, it caters to the modesty of some women. The woman should lie on the side at the edge of a bed or table, the legs flexed on the thighs at a right angle. The lower limbs are supported by an assistant or by a sidepiece to the table The trunk, in place of resting on the side, undergoes torsion so that the face is turned toward the table ; to facilitate this the corresponding arm is dis- engaged from under the trunk and embraces the table. Genu-pectoral position. — Women scarcely ever submit to this position, and it is only exceptionally necessary in cases of displace- ment. By lowering the viscera it lowers the abdominal pressure, allows the uterus to incline forward and balloons the vagina by allowing the air to rush in as soon as the walls are separated. The woman is put on all-fours, on knees and elbows, the nates project- ing a little over the edge of the table. According to the corpulence of the woman she may rest on the elbows or chest. This position is cramped and becomes painful if long maintained. Simple abdominal palpation — The patient is placed in the dorsal position, with the knees slightly flexed. She is told to breathe without effort, mouth open, and to relax the muscles. Care is taken to have the bladder and rectum empty. The operator's two hands are simultaneously employed. They must not be cold, for fear of reflex contractions. At first, proceed very gently and then, after having accustomed the abdomen, so to speak, to manipulations, employ more force and sink the fingers into the abdominal walls for a deeper exploration. It has even been claimed that a certain amount of massage disarms the reflexes. Proceed methodically, palpate first the hypogastric region, then the ihac fossae- in such a way as to determine the changes in the volume or situation of the internal genital organs. Finally turn to the flanks, to the epi- gastrium and to the hypochondriac regions. The normal consistence of the abdomen presents variations that it is necessary to take into account. The age of the patient, the absence of anterior fat, multiparity, the thinness or the obesity, the 60 Gyn (ecological Examinations. distention of the stomach and intestines by gas in dyspeptics, etc., are important conditions wliicli introduce sources of error. If care has been taken to empty the bladder and rectum, this will guard against mistaking their contents for a tumor. The peculiar con- sistence of fecal material contained in the rectum, or tlie cnecum, or the sigmoid flexure, their position in the region of the flanks, possibility of making a persistent impression, are characteristic enough. It often happens that in spite of energetic purgation scybala may accumulate, especially if there exists a mechanical cause for constipation. An enormously distended bladder has been taken for a cyst. Its unusual proportions may proceed fi'om compression of the neck, or fi'om an affection of the nervous system which blunts the sensibOity. I was once called to an asylum to puncture an ovarian cyst which was only a distended bladder in a general paralytic. Finally it is necessary to know that catheterism quickly done does not always completely empty the bladder. In some cases the bladder is bilobed from being compressed between a pelvic tumor and the pubes. The rectus muscles have given rise to the sensation of a tumor by the rigiditj' of their contracted mass and the distinctness of their border. This occurs especially when there is a certain separation at the linea alba. It also appears that these muscles can contract partially between two aponeurotic intersections thus adding to the difficulties. Meteorism may simulate a tumor or even pregnancy. Percussion will be of service, but ■s\'iU not remove all doubts. Masses of fatty tissue, especially in the region of the flanks, sometimes give rise to doubt. I will remark on this subject that I have often observed an extra amount of fat in the hypogastrium of women affected with a chronic disease of the genital apparatus, and even among dyspeptics one sees an accumulation of fat in the epigastrium. Finally, there are some women that have so gi-eat an hyperses- thesia or so little courage that they become rigid on the slightest touch. In these cases and especially if an important decision is concerned, it is necessary to aniesthetize. Thus a knowledge in- comparably more precise may be obtained, especially when ab- dominal palpation is combined with vaginal touch (bimanual exami- nation). Save in exceptional cases of thinness and flaceidity one can scarcely accomplish palpation of the tubes and ovaries ^vithout anesthesia. The relations of swellings or tumors cannot be made out with any precision without it. Often, for example, a tumor which is apparently attached to the uterus when the patient is awake, separates itself very clearly when she is imder anaesthesia. Finally, a tumor which appears hard may become manifestly fluctuant under chloroform. Vacfmal touch. — The index finger, coated with an antiseptic oily Gynrecological Examinations. 61 substance (borated vaseline, carbolized oil), glides over the fourcliette into the vagina. Many gynaecologists use an antiseptic injection after the examination. To my mind it is no less necessary before. The finger, which brings with it a mass of germs, may inoculate the patient by abrading, even very slightly, the cervix. In general, the examination should be, so to speak, sandwiched between two anti- septic injections. The index finger is the most convenient. The thumb remains extended and is placed obliquely toward one or the other of the genito- crural folds, always avoiding the median line. The other three fingers, semi-flexed, depress the perinseum. The finger follows the posterior or lateral part of the vagina to arrive at the cervix. When this is not found directly in the axis, a movement of rotation is made from behind forward and fi-om before backward, seeking it until the external orifice is felt. Account is then taken successively of the direction of the cervix, its size, its form, its con- sistence, the size of the os, and the state of its commissures. Then the finger explores the posterior cul-de-sac, the lateral, the anterior. This examination is completed only by combining with it abdominal palpation, that is to say, by bimanual exploration. In withdrawing, the finger sweeps over the vaginal walls to take an account of their condition. It may be that the uterus is very high and the cervix very difficult of access, deeper exploration can then be accomplished by introducing the middle finger with the index. Thus the perinseum is strongly depressed. Finally in some cases the cervix is hidden behind the pubes and can be examined only with the woman in the genu-pectoral or in Sims' position. Exceptionally the woman may be examined in the upright position (displacemients, abdominal tumors). The presence of the hymen may be an obstacle to ex- amination. However, this membrane is usually so distensible that cautious digital examination can be made without tearing it. This procedure being somewhat painful, it may be necessary to use chloro- form, if sufficient ansesthesia cannot be induced by cocaine. Rectal touch cannot replace the vaginal completely, as some authors assert. Rectal touch. — It is especially to examine the state of Douglas' cul- de-sac and of the posterior surface of the uterus that it is necessary to introduce the finger into the rectum. Tumefactions and tumors of this region cannot be thoroughly examined in any other way. It is also useful to verify thus the absence of fecal lumps, which, felt through the vagina, may be taken for pathological products. On the contrary I have seen beginners feel the cervix through the rectum and mistake it for a tumor. The combination of vaginal and of rectal examination is useful to ascertain the state of the recto- vaginal septum. Manual examination of the rectum is resorted to in exceptional cases. The patient being anaesthetized, the sphincter is dilated as for anal fissure and the fingers, massed together and smeared with vaseline, are gradually introduced into the orifice. 62 Gyncecological Examinations. I eoiisider this procedure dangerous, especially if the hand of the surgeon is not paiiicularly narrow and flexible. Vesical touch has only a very restideted appHcation. The extreme dHatahility of the female urethra usually allows introduction of the finger without cutting. It has been advised in cancer of the uterus with doubtful invasion of the vesical wall. The association of vesical and of rectal touch is of great service in atresia vaginae, to examine the uterus and the tubes. Finally I need only mention the com- bination of rectal or vaginal examination mth a catheter in the bladder. Bimanual exploration. — I have separately described vaginal and rectal examination for the sake of convenience. But in practice they are rarely made Avithout the aid of abdominal palpation. The patient is placed in the dorsal decubitus or, in case tliis presents some difficulty, in the lithotomy position. Wliile the index finger of the right hand practices the vaginal examination explained above, the left hand is placed over the pubes and the fingers pressed gently in, pusliing the internal genitals toward the vaginal finger. First is attempted an accurate account of the position of the uterus in the hypogastrium, then the lateral parts are examined, and while the abdominal hand depresses the flanks the vaginal finger meets it by exploring the culs-de-sac. Thus are explored the broad ligaments and the uterine appendages. At the same time are noted the sensi- tiveness of the parts ; in health, pressure on the appendages and baUottement of the uterus are not painful. Bimanual examination may also be made Ijy combining abdominal palpation AAdth the rectal touch. It is then useful for exploration of the api^endages. "With bimanual examination, in tliin females, the ovaries can be palpated without, and especially with, anaesthesia. If the uterus is drawn down by an assistant holding a volseUa fixed in the cervix, wliile duriirg abdominal palpation one finger is in the vagina or rectum, the ovary will ghde between the two fingers feeUng like a small testicle. The left is generally more accessible than the right, Avliich is attributed to the fact that the rectum pushes it forward. However that may be, this examination presents great difficulties, especially in women with thick abdominal walls. In difficult cases, where exploration of the ovaries appears in- dispensable, the bladder is emptied and into the rectum is introduced a rubber bag filled with two hundred or two hundred and fifty gi'ammes of water. If bimanual exploration is made now it ■niU be found that the uterme appendages are pushed up and supported on a resisting plane so that they are more accessible. Examination ■with the speculum. — Speculums are of three types : the cylindrical, the univalve and speculums mih two or more valves. Cylindrical speculums are especially useful for topical applications Gyncecological Examinations. 63 (Fig. 28). Of wood or ivory, they protect the vaginal walls against the action of the heat of a cautery; of glass, they are valuable for their good illumination, for the facility of introduction and for ap- plications to the cervix. It is necessary to have at least three sizes of this speculum. Before introduction the speculum should be dipped in warm water. The exterior is smeared with vaseline and the instrument introduced with one hand while the other separates the ^^alvar parts. The position of the cervix should have been previ- ously ascertained by digital examination, to know what direction to give the instrument. The speculum will be made to glide over the fourchette, depressing it strongly, avoiding pressure against the anterior wall of the vagina as much as possible. As soon as the vulvar ring is passed, the instrument is inclined in the direction of the cervix. The beaJv of the Fergusson speculum should always be directed backward. Fig. 28. — Ferguson's tubular speculum. Speculums of several valves. — The bivalve instruments (Fig. 29) are preferable. Their introduction is made in accordance with the same principles as those given for the Fergusson. The valves are sepa- rated only after the whole extent of the speculum has entered, to avoid distending the vulvar orifice. As to the instruments of more than two valves I will only mention Meadow's, Bozeman's and Nott's (Figs. 30, 31, 32). Fig. 29. — Brewer's bivalve speculum. Univalve speculums are especially useful for purposes of operation. With a single one, access to the wall of the vagina opposite to the speculum is possible and the cervix is also brought into view, with 64 Gyncecological Examinations. the patient in Sims' position. With two valves, simultaneously employed, we have the best possible means for examination of the vagina and cervix, the only inconvenience lies in the necessity for an assistant. Open. Fig. 30. — Meadow's quatrivalve srtculum. G. r/CMANfJ-CO. F;g. 31. — Bozeman's speculum. Fig. 32. — Nott's speculum (plain). Gynacological Examinations. 65 Sims' speculum (Fig. 33) or depressor is intended for use with the patient in the latere- abdominal position. In this lateral position, this instrument offers no inconvenience, but in the dorsal position the shape of Sims' speculum makes it almost impossible to use the double retractor. For this position a single retractor, mounted on a handle, is preferable. Besides using two of these to retract, one the anterior .and one the posterior wall, a tlm-d, and even a fourth, can be inserted to hold back the lateral walls. Fig, 33. — Sims' speculum. The use of the uterine sound. — The various models of the uterine sound have been greatly multipUed without any real gain in value. The simplest is the best. It may be reduced to a simple" metaUic probe, terminating above in a small l)ulb, below in a handle, which serves both for grasping it and as an indicator of the position of the uterine extremity. It should have a certain rigidity, but yet retain sufficient flexibility to receive and preserve the different curvatures that it may be desirable to give it. Inflexible sounds should be rejected. It is also necessary to proscribe the slides in- tended to mark the depth to which the instrument enters the uterus. As a substitute for these the sound can be seized in the jaws of a pair of forceps at the os uteri. The uterus should never be sounded without having previously acquired some idea of its position and condition by bimanuel ex- amination. The most favorable position for using the sound is the dorso-sacral. It can be used without the aid of a speculum by gliding the sound over the palmer surface of the index finger, which guides it into the os uteri. The finger-nail can be used to mark the depth to which the probe has entered. But it is far preferable to probe the uterus with the aid of the speculum, and it may be made even easier by fixing the cervix at the same time with a forceps or tenaculum. In some cases this is the only means of reaching the OS uteri, when the cervix is luxated into one or other cul-de-sac by deviation of the body. It may be added that a slight traction on the cer\d$: considerably facilitates exploration- by straightening the cavity. The most rigorous antisepsis is indispensable in probing the uterus ; not only should the instrument be disinfected but it should 66 GyruBcological Examinations. be passed thi-ough the flame of an alcohol lamp always after using. A vaginal injection and an antiseptic cleansing of the cenical canal, \\ith a bit of absorbent cotton twisted on a probe, are necessary before the introduction of the sound. In using the uterine sound be assm-ed of two capital points : 1. That the uteras is empty ; 2. That the sound is rigorously aseptic. The use of the uterine sound gives an exact knowledge of the state of the cervical canal, of the longitudinal diameter of the uteras and also its transverse diameter, and of the direction of the canal. In the normal state the sound penetrates easily, except for a slight re- sistance at the internal os. It passes to a depth varying fi-om five or six centimetres in the nulliparous woman to six or seven in those who have borne childi-en. The extent of the lateral movement which can be given to the sound is very limited. When the uterine ex- tremity can be turned in various directions the cavity is enlarged. Can the sound be passed by chance into the tubes? This is the explanation given by a number of authorities in cases where the instrament has been pushed far into the abdomen and has been felt vmder the skin. That this may be possible, it is necessary that some very exceptional conditions be present, as latero-version of the uteiTis, bringing the opening of the tube in the prolongation of the a3ds of the cervix, and abnormal enlargement of that orifice. This existed in an observation made by Bischoff . In almost aU the cases published as supposed catheterism of the tubes, it is probable that there was a uterine perforation. It is also necessary to note the possibihty of permanent false passages (metro-peritonaeal fistulae) permitting the introduction of the sound into the peritonaeal cavity. Fixation and depression of tlie uterus. — I believe that this manoeuvre should be classed among the means of exploration, not that it is such by itself, but because it renders great service when associated -with other procedures. Hegar has shown that it is possible to explore the whole of the posterior surface of the uterus even to the fundus, by rectal touch, pro\-ided the cenix is seized ^rith the forceps and the uterus di-awn do^Mi into the peh"ie cavity. I have ah-eady spoken of fixation in connection -ndth the use of the uteiine sound, and it will be seen that direct exploration of the \iteruie cavity will caU for the same procedure. Nothing is more harmless than a moderate downward traction of the utenis when antiseptic precautions are taken ; even forced depression (brmging the cervix to the vulva) is not dangerous, with a rigorous anti- septicism. I have daily used one or the other and have never ob- served any accident that could be attributed to this procedui-e. It is necessary to remember that tliis mauceuvre is mnocent only when there exist no sjTnptoms of acute or subacute perimetric inflam- mation. I beheve it is useful to estabUsh a distiuctiou between simple fixation and depression. The first consists in holding the Gyncecological Examinations. 67 uterus in place, drawn downward slightly, without stretching the ligaments ; the second carries it markedly below its normal level. The technique is very simple : The patient being in the dorso- sacral position the anterior hp of the cervix is seized through the speculum with a volseUa or tenaculum forceps (Fig. 34), and held firmly, or drawn down to a lower level. Fig. 34. — Wooster's tenaculum forceps. Artificial dilatation and intrauterine touch.. — There are some rare cases where exploration of the uterine cavity with the finger is necessary to confirm the diagnosis (or as a prehminary to an operation). Different means have been proposed to attain this end. One distinction is indispensable : the cervical canal is not an orifice, it is a canal that has a superior supravaginal opening, a cavity of narrow dimensions and an external orifice. Now the conditions vary greatly, according to the state of these different portions, not only according to their dilatation but to their dilatability What is necessary to consider especially is the state of the internal opening and of the supravaginal part of the cervical canal. There are cases where their dila-tation, or at least their softening, leaves no obstacle in the way of reaching the mucosa of the body of the uterus, for ex- ample, in fibrous tumors or intrauterine polypi, after abortion, etc. These cases are essentially different from those where the whole length of the cervix is rigid. Procedures which apply in the one case do not find place in the other. In passing these procedures in review I will indicate the best. We can divide them into two classes : 1. Non-bloody, which include : (a) slow dilatation with turgescent substances; (b) divulsion; (0) immediate progressive dilatation. 2. Bloody procedures, compris- ing two operations : (a) incision of the external orifice ; (b) total bilateral incision of the cervix. None of these operations should be used unless absolutely necessary and all intrauterine explorations should be regarded as dangerous. Non-bloody procedures. — (a). Slojc dilatation with, tuvgescent substances is made by introducing into the cervix tents of various kinds. In turn, there have been advised, prepared sponge, lami- naria, gentian root, decalcified ivory, tupelo, etc. Laminaria, to me, appears the best, and though I do not absolutely reject prepared 68 GyiKScolof/ical Examviatious. sponge, rendered antiseptic, I believe its appKcations are very limited. Laminaria is sufficient for almost every need. It is employed as follows, after being disinfected by immersion in a solution of iodoform in ether : The vagina is cleansed with care. The patient is placed in the dorso-sacral position and the cervix exposed \vith a bivalve speculum. It is of advantage then to seize the anterior hps with the volseUa and thus fix the cervix during the introduction of the tent. Care is pre^iously taken to ascertain the position of the uterus by bimanual examination and the uterme sound. The tent can then be bent sHghtly to adapt it to the cun'e of the uterine canal. The tent, coated weU mth vasehne, is fixed in the jaws of the forceps and gently introduced. It is not necessary that its extremity (to which a thread is fastened) should disappear mthin the cer\ical cavity. If the introduction of a single tent of sufficient size is too difficult, two or three smaller tents may take its place ; ■violence should never be used in pushing them into the cavity. The volseUa removed, a tampon of iodoform gauze is placed against the cervix and the speculum withdrawn. About ten hours are necessary for complete sweUing of the laminaria. The tents are usually removed by aid of the thread which is attached to the vaginal extremity. It sometimes happens that this is difficult, the dilatation having taken an hour- glass form (Fig. 35). It is then necessary to seize the end ^vith the forceps and withdraw by traction combined with rotation, while the finger furnishes a support to the cervix during the dislodgement of the tent. In spite of aU antiseptic precaution this slow dilatation cannot be considered inoffensive. Symptoms of acute metritis are sometimes observed with intense paui and a marked febrile dis- turbance. (b). Divulsion or immediate forced dilatation has given rise to many instruments. I prefer EUinger's dilator, with two parallel blades. Most of the dther instniments have the disadvantage of taking their supporting points on too Umited an area. (c). Immediate progressive dilatation. — This mode of dilatation is well kno^vn to general sm'geons, as they have long applied it to the treatment of stricture of the urethra. Hegar's dilators seem to be the most convenient. They are bougies of hard ruliber, cylindrical, and conical at theii- extremity. Then length is from twelve to four- teen centimetres, not incluchng the handle which is five centimetres long. The diameter of No. 1 is two miUimetres, and it increases by one mOlimetre for each bougie ; this increase is a Httle too rapid for the high numbers and it is better, in difficult cases, to have the diameter increase by one-half millimetre only. They should be kept in a strong carbolic solution. The patient is aniesthetized and put in the dorso-sacral position (Hegar prefers Sims' position). The fourchette is pressed back with a short retractor, the anterior hp of the cervix is seized and fixed with the vnlsellum and the exact Gynmcological Examinations . 69 direction of the uterus is ascertained by bimanual examination and the sound. The first dilator is then dipped in vaseline and intro- duced. It should be of a diameter that will pass into the cavity with gentle pressure. Immediately after, a second and then a third is passed. If resistance is met with, the dilator is allowed to remain from one to three minutes. It is possible to reach very quickly, in a quarter of an hour, a dilatation of the cervix, naturally or arti- ficially softened, sufficient to aUow the introduction of the entire index finger. When the cervix is not softened, an hour, and even more, may be necessary to attain tliis result. Thus it finds its greatest usefulness after miscarriages and in certain morbid states. If it is necessary to use this method in the case of a rigid cervix, a laminaria tent may be first introduced to induce a commencement of the dilatation and dilatability of the tissues. When this tent is ■withdrawn the dilatation is rapidly completed by Hegar's dilators. Fig. 35. — Laminaria tents before and after their use. Bloody procedures for dilatation of the cervix are indicated, either when the only obstacle to the introduction of the finger is located at the external orifice alone, when the urgency of the case will not per- mit the loss of an instant, or, finally, when the surgeon has not at hand the special instruments for bloodless dilatation. (a). Incision of the external as. — It is sometimes sufficient to make an incision on each side of the orifice to permit entrance into 70 Gynfecolofi'icnl E.rani'inations. an already enlarged cervical cavity. Then this method is the most simple and expeditious. Scissors with long handles may be used, after insertion of the speculum and fixation of the cervix. Kuchen- meister has constructed special scissors for tliis purpose, but they are not indispensable. An incision of fi-om one centimetre to one and one-half on each side will be sufficient for the passage of the index finger. After the exploration and intrauterine irrigation the incisions should be closed with catgut. (b). Complete bilateral incision. — It is necessary to make a pre- liminary ligation of the uterine arteries. The patient bemg anaes- thetized and in the dorso-sacral position, the fourchette is depressed with a short Sims' speculum and the vagina drawn to one side with a retractor, while a tenaculum forceps draws the eei-vix to the opposite side; one of the lateral culs-de-sac is thus accessible. Tliis is explored mth the finger for the throbbing of the uterine artery. A strongly-curved needle, threaded "nith silk, is then entered in the cul-de-sac a finger's breadth beyond the cervix, taking care not to pass the transverse line representing a tangent to the cervix anteriorly, to avoid the ureter. With this needle the greatest possible thickness is seized and it is brought out posteriorly in the vagina as nearly as possible to its point of entry and always at the same distance from the cervix. By approximating the point of entry to that of exit less of the vaginal mucous membrane is in- cluded in the loop. This loop of silk is tied tightly, and we proceed in hke manner mth the opposite side. This done the' Instom-y can be used N^dthout fear of hfemorrhage. The cervix being drawn doAvn, an incision is made on each side as far as the vaginal insertion, and attempt is made to pass the finger to the uterine cavity. If this proves difficult, a probe-pointed bistoury is introduced into the cervix along the palmer surface of the finger and in returning scari- fies each side of the internal surface of the cervix until the finger can enter. After exploration and irrigation the cervix must be restored with great care. For this purpose a needle threaded mth catgut is pushed deeply into the cerxdx, at its junction with the vagina, and, guiding it by the finger, an attempt is made to pass the suture across the cervical canty at the highest point of the incision. It is necessary to place the symmetrical suture of the other side before tying the first ; without tliis, the ca^dty being narrowed, the finger cannot perform its office as a guide. The two superior stitches being placed and tied, a sufiicient number of sutures are placed below them, care being taken to produce as perfect coaptation of the mucosa of the cervical canal as of that outside. It is useless to leave the ligature of the uterine arteries in place indefinitely. Save on special indications it can be cut at the end of three or four hours. It is not necessary to dwell on the fact that this ablation will be Gyncecological Examinations. 71 urgent if the symptoms cause fear of having inchided the ureters in the ligatures. Permanent dilatation. — Dilatation once accomplished, by whatso- ever means, it is possible to maintain it by tamponing the uterine and cervical cavities. Recently attempts have been made to apply this method in the diagnosis and the treatment of certain uterine affections, as it makes it possible to observe their evolution. Vulliet, who advocates this continued dilatation, proceeds as follows : The patieiit being in the genu-pectoral position and the cervix exposed with a speculum, the cervical canal is explored. If it is strictured or deviated, a preliminary treatment re-establishes its proper direction or caliber. If it is normal, a smaU tampon of cotton is placed at the os and pressed into its cavity. These tampons vary in size from that of a pea to that of an almond, and each has a thread attached. They are first immersed in a solution composed of one part of iodoform to ten parts of ether, then dried and pre- served in a tightly- corked bottle. VuUiet introduces the tampons successively until the cavity is fiUed to the external orifice. They are withdrawn at the end of forty-eight hours. If they have been well packed, the walls have softened and given way by this time and there is formed a free space of which the operator takes possession by introducing a greater number of tampons than the first time. Proceeding thus with tampons gradually increasing in size, eight or ten insertions will be sufficient to accomplish such a degree of dila- tation that the cavity of the uterus will be visible throughout its whole extent. To gain time and a more regular dilation, it is an advantage, according to Vulliet, to substitute for the tampons an occasional laminaria tent. This procedure is not always appli- cable even in the conditions indicated by its originator. There are a certain number of cases where complete dilatation cannot be obtained and others where it is necessary to stop the repeated introduction of the tampons, either because they produce too much pain, or because they provoke nervous symptoms. However, I do not believe that inspection of the uterine cavity can furnish any information not obtainable by the methods previously described, and it is probable that Vulliet's method of exploration will not long survive the interest awakened by its novelty. This remark does not apply, however, to haemostatic or antiseptic tamponnement of the uterus. Examination with the index finger in the uterine cavity permits full knowledge of softening or irregularities of the walls, vegetations, tumors, or abnormal growths in the cavity. This exploration is always combined with hypogastric palpation. It should be quickly performed and should be followed by an intrauterine injection of carbolized water, 1-100, by the application of an iodoform tampon, and by rest in bed for two days. If the htemorrhage, which is 72 Gyncecoloyical Examinations. exceptionally provoked, does not yield to very hot intrauterine injections (45^ C. to 50- C), tlie uterine cavity is tamponed for a few hours with iodoform gauze. , Excision or curetting for the purpose of securing microscopical specimens for differential diagnosis, is sometimes necessary, es- pecially in doubtful cases of carcinoma. The technique of excision is most simple : it consists of fixation of the cervix, excision of a fragment Avith the narrow scissors or with the bistoury, and sub- sequent hsemostasis if necessary by the thermo-cautery. When it is necessary to determine the condition of the uterine mucosa, scraping with the curette will furnish sections sufficient for ex- amination. The use of the curette will be described in detail in connection with the subject of metritis. Exploration of the ureters. — (a). Palpation. — The ana- tomical relations of these organs to the cervix uteri and to the vagina have been specially studied in recent years on account of the extreme importance of this knowledge in certain operations. It is known that it is possible to feel thi'ough the vagina the anterior portion of the pelvic division of the ureters, when injected in the cadaver, passing from the bladder to the base of the broad liga- ments, equal to about six to seven centimetres in extent, that is, half their pelvic or a quarter of their total length. In pregnant women it is possible to recognize them to a length of ten centi- metres. Sanger has been able to identify the ureters when notably indurated in cases of blennorrhagic ureteritis and calculous pyelo- ureteritis. When there is an old inflammation of the broad liga- ment the ureter is found enlarged on the opposite side, as if it had undergone hypertrophy. I believe, however, on account of the great difficulties which it presents, as well as the uncertainty of its results and the rarity of practical deductions, that this method of examination will never come into general use. But, as there are a few to whom it may be of service, I give its technique. Some anatomical considerations present themselves. The field of these researches is limited to the superior third of the anterior wall of the vagina. Schematically, this is a trapezium, of which the oblique and diverging sides correspond to the ureters and to the union of the anterior wall with the lateral walls of the vagina. The small base of this trapezium, or better, the blunted extremity of a triangle, is horizontal and inferior ; it correspends to the inter- ureteral ligament. The long side of the trapezium, horizontal and superior, is formed by a line uniting the points where the ureters emerge from the broad ligaments. In this space, in certain cir- cumstances, the finger recognizes, at one and a half to two centi- metres be5'ond the os uteri in the thickness of the vaginal septum, two cords, hard, longitudinal, directed backward, from -within outward, and from below upward, describing a concavity opening Gynaecological Examinations. 73 inward (Fig. 36). Ordinarily they cannot be made out to their whole accessible length, which is six to seven centimetres from the base of the vesical triangle, indeed in some cases only for a distance of two centimetres. ' w ^'7 : ..•"'/ ': --'__ Fig. 36. — Portion of the ureters accessible to touch. (Schematic: the posterior vaginal wall removed and the ureters supposed to be seen through transparent tissues.) a, base of broad ligament; b, ureter; c, cervix uteri; d, inter-ureteral ligament; e, vesical trigone; f, urethra; g, vagina. Normally the ureters are symmetrical, but they cease to be so in consequence of various lesions, and then their direction becomes devious (cicatricial retractions), so that the ureter of one side is found carried toward the opposite side, or that the concavity is directed upward instead of inward. Finally, only a single ureter can be felt in some cases. The normal ureters have a diameter of about one millimetre ; in disease they acquire the diameter of a goosequill or even that of a large pencil. They are more or less mobile under the fingers, or fixed in the tissues by the exudation of periureteritis. In the normal state they are not sensitive ; ab- normally they become more or less sensitive to pressure. By vaginal examination we seek them thus : With the index finger the urethra is followed to its junction with the bladder, thus the anterior vaginal cul-de-sac is reached, care being taken to recognize the direction of the cervix uteri. It is in the portion of the anterior vaginal wall comprised between the internal orifice of the urethra and the anterior cul-de-sac of the vagina that we seek 74 Gynecological Examinations. the ureters. This region extends scarcely more than two to five centimetres and is distinguished by great laxity. "With the lateral surface of the finger the anterior and lateral vaginal walls are pal- pated in the direction of the broad ligament. For the right ureter the right index finger is used, and for the left ureter, the left index. Nevertheless the right finger can be used in palpation of the left ureter, but it is then the palmar surface that seeks it. At first it is necessary to proceed carefully, slipping the finger little by little along the anterior vaginal wall. To delicate palpation, the ureter, when normal or only slighly hypertrophied, feels like an artery deprived of pulsation. When the ureters can be compressed against a hard body, as a foetal head, they are displaced in their sheath and roll under the finger. Palpation is easier when the vesico-vaginal wall is flaccid. The ureters may be confounded with the arteries, with periuterine cicatricial cords, and according to Sanger, even with the muscular fasciculi of the levator ani and of the sphincter ani. These errors are avoided by taking strict account of the anatomical or the anatomico-pathological situation of the ui-eters. Catheterism. of the ureters. — There are cases where it would be useful to determine if both kidneys are diseased or if one only is attacked. Pawlik has been able to demonstrate the utility of this procedure in one case, and in another he evacuated a hydro- nephi-osis, and even allowed the catheter to remain in the ureter. Some anatomical considerations are necessary to the description of the technique indicated by Pawlik for catheterism of the ureter. The openings of the ureters occupy, in front of the has fond of the bladder, on the posterior half of the antero-inferior wall, the two posterior angles of Lieutaud's trigone. The anterior angle of this triangle marks the situation of the urethral orifice. Each of these thi'ee openings is seated in the center of a more or less cylindrical projection consisting of a muscular thickening and covered by mucous membrane. These mamillated projections of the orifices of the ureters serve as landmarks. They are united by a promi- nent transverse band of the same structure, thick and resisting enough, even in its middle portion where it is thinned, to arrest the end of a sound if gently pushed, and to be perceptible to direct palpation. This projection is called the inter-ureteral ligament. It constitutes the curvilinear base of Lieutaud's triangle, the sides of which are indicated by similar projections, but less marked, converging toward the urethra. The height of the tri- angle, the distance from the urethra to the middle of the inter- iireteral ligament is from one to two centimetres (Warnoots), or thi-ee centimetres (Hart). Pawlik places his patients in the genu-pectoral position, but the catheterism can also be performed in the dorso-sacral position. Gynmcological Examinations. 75 It is important only tlaat the head be placed low and the nates much elevated to allow the viscera to fall toward the diaphragm. A large retractor is introduced and the posterior vaginal wall depressed, thus stretching the anterior wall. This tension of the anterior wall permits Pawlik to note a number of folds of great im- importance, as regards anatomical topography. He notes first, near the external orifice of the urethra, an elongated ridge, from before backward, median, transversely plaited, well marked, cor- responding to the intraparietal track of the urethra. This ridge terminates at the edge of the vesical orifice of the uretln-a. To this ridge succeeds a small triangular space, corresponding to Lien- taud's triangle, bounded by three projecting folds (Fig. 37). On the cadaver it has been determined that the triangle thus limited on the vaginal wall corresponds, line for line, to the intravesical triangle of Lientaud. It has been called the vaginal trigone of Pawlik. -B Fig. 37. — Vaginal trigone of Pawlik on the anterior vaginal wall. Z L, labia minora; 0, urethral orifice; 0' O' , prominence of the urethra; Fi mucosa of the cervix ; B, transverse fold of the vagina a little behind the inter-ureteral ligament forming the base of the trigone ; S S, lateral diverging folds of the vagina correspond- ing to sides of the vesical trigone. Pawlik uses a metal catheter terminating in a bulb. Its total length is twenty-five centimetres, the beak is one and one-half 76 ■ Gynecological Examinations. millimetres in diameter. The eye of the catheter is much elongated and has rounded edges. It is situated at the base of the beak at a slight curvature, by which this is continuous with the rest of the instrument, which is somewhat conical. ll At one and one-half centimetres from the other extremity is placed an octahedral handle (Fig. 38) with a mark on one face corresponding to the direction of the beak. To render the instrument aseptic, the wu-e is withdrawn and water injected, then it is filled with ether several times and passed thi-ough the flame of an alcohol lamp. Before introducing the sound, a certain degree of arti- ficial distention of the bladder must be induced. The quickest and sui-est way is to completely evacuate the organ and then inject two hundred cubic centimetres of water. The ureteral sound is then withdrawn and the ureteral catheter introduced. As soon as this has passed the in- ternal urethi'al opening, the handle is turned so as to bring the beak of the catheter in contact with the vesico-vaginal septum. The bulb of the instrument, as it is pushed hghtly onward, produces a projection on the anterior vaginal wall. In proportion as the catheter is advanced this projection is' displaced and the instrument can be thus directed along one of the lateral sides of the vaginal trigone toward the opening of the ureter. In this direction is met the most prominent part of the inter-ureteral line. If the sound is kept too near the median line this limit may be passed without perceiving it, as its middle portion is much flattened. Arriving at this point, the sound is given slight movements of gliding, of rotation, of elevation and of depression, but always holding it to the region of one of the angles of the vaginal trigone, which is constantly kept in mind. Once the sound is engaged, it is pushed from one to two centi- metres toward the posterior vesical wall. The penetration of the catheter into the ureter is recognized by the fact that no resistance is felt in front of the instriiment ; on the contrary, lateral movements and lowering the handle are obstructed in proportion to the distance it has entered the ureter. At the end of some time the urine flows from the ureter by drops. The catheter is now pushed to the level of the superior strait, at which point the ureter slightly changes its direction. The manoeu\Te at this stage becomes Fig. 38. very difficult, especially when the canal of the urethi-a Ureteral closely hugs the pubes and is but slightly distensible, as ui "f,g'" nuUiparous women ; on the contrary, if the urethi-a is large Pawlik. and flaccid, there is not much difliculty in the penetration. The catheter is pushed gently onward while the handle is lowered Metritis. — Pathological Anatomy. — JEtiology. 77 as much as possible. This last part of the catheterism is as easy as the first, if the instrument has been entered through a fistula in the bladder or urethra. Thus the pelvis of the kidney is reached. The ureter has become rectilinear. Ordinarily in contact with the pelvic wall, it is now separated from it to the extent of four and one -half centimeters. The cellular tissue which surrounds the ureter permits this sepa- ration when it is in normal condition and lax. The catheterism should be made slowly anfl gently, especially if there is reason to fear causing an inflammation of the ureters. The only serious consequences that have been noted are, fever, abdominal pains (not lasting more than twenty-four hours), a mild, circumscribed peritonitis (in a case where it had previously existed), and finally, in the urine have been found blood and epithelial debris, the products of traumatism of the ureter. It is not impossible, how- ever, that this catheterism may be followed by ureteral fever analogous to urethral fever. If catheterism of the ureter is necessary, and the method advised by Pawhk appears of doubtful propriety, Simons' method may be substituted: chloroformization, dilatation of the urethja, intro- duction of the catheter on the finger, which directly recognizes the inter-ureteral ligament and the orifice of the ureter. Incontinence of urine need not cause imeasiness ; it is only of short duration. CHAPTER V. METRITIS. — PATHOLOGICAL ANATOMY.— -ffiTIOLOGY. Metritis. — Definition. — According to the etymology of the word, metritis is an inflammation of the uterus. I will keep to this general term although it is open to criticism. The generic term, inflammation, applies to all these morbid states of which the anatomical substratum is confined to irritative lesions without termination in the formation of specific neoplasms. How numerous and varied these lesions are will soon be shown. But they are all united in one class by their characteristics : at first infectious, then purely defensive and limitative in their evolution. Whether there is proliferation of the mucous membrane or of the parenchyma, all the processes consist in a local irritation, proceeding from an external or internal factor, and have no tendency to pass certain limits. Thus the metrites are clearly distinguished from neoplasms, 78 Metritis. — Pathological, Anatomy. — ^-Etiology. properly so-called. Do there exist, aside from metritis, " morbid states without neoplasms " which merit a distinctive nomenclature ? Taking as a basis dogmatic ideas and a narrow conception of in- flammation, the older aiithors did not hesitate to exclude from the framework of metritis all which was not comprehended in the classic quartette, swelling, redness, heat, and pain. In consequence of this, granulations, ulcerations and leucorrhcea each became a separate disease. We find traces of this even Avith recent writers. Have they not described fluxion as congestion, engorgement, cedema, hypertrophy, arrest of involution, granulations and ulcerations of. the cervix ? The idea of symptom should not be confounded with that of a disease. Thus it is that other authors have indicated idiopathic metritis and symptomatic metritis, a classification that we will not adopt. Metritis should remain a clinical term and not an anatomo-pathological one. The study of disease serves us as a guide, that of the anatomical section is only complementary. Because there are lesions of endometritis in fibroids, or of paren- chymatous metritis in cancer, ought we to describe in this chapter myomatous metritis or cancerous metritis '? That would be per- plexing and confusing indeed. Certainlj^ all classifications are somewhat artificial because it is impossible to make them definite so long as nothing is absolute in nature. They are none the less indispensable, and justifiable if care is taken to specify the basis on which they are founded. That used here ^vill be the cHnical, which alone gives the personality of the disease. I cannot, however, leave this subject without a few words on the pseudo metrites or the so-called symptomatic metrites. Inflammatory lesions of the uterine mucosa are exceedingly fre- quent in fibroid tumors, and it is, no doubt, to these changes in that membrane that the haemorrhages are due. The irritation is pro- pagated in these cases by continuity of tissue. It is in the same waj', but in an opposite direction, perhaps even in consequence of reflex congestions predisposing to infection, that the lesions of endometritis occur in diseases of the appendages. These pseudo metrites, as I shall call them, are characterized by the fact that the inflammation of the uterine mucous membrane is here only an epiphenomenon Mhich follows late after the appearance of the symptoms on the part of the appendages or the pelvic peritonaeum. Divisions. — We now approach the study of metritis proper and its various forms. If we consult other authors, we shaU find a varied classification according to point of departure taken in each system : the progress, into acute and chi'onic ; the seat, corporeal, cerAdcal, endo-, parenchymatous, and meso- metritis ; the etiology, puerperal, post-puerperal, blennorrhagic, traumatic, diathetic, etc. ; pathological anatomy, granular, fungous, and ulcerative metritis. Metritis. — Pathological Anatomy. — JStiology. 79 All these classifications have one fault, they are artificial. They are based on a single characteristic, arbitrarily chosen, and one that is not of as great value as others which are made subordinate to it. To approach as nearly as possible to a natural classification there is only one guide to follow, that is the clinical one. I propose, then, to classify the metrites according to their dominant clinical character, whether it be drawn from the prorgess, or whether it be the result of the marked predominance of an order of symptoms. We have thus the following forms: 1. Acute inflammatory; 2. Haemorrhagic ; 3. Catarrhal; 4. Painful (chronic). Only these terms will henceforth have for us a classifying value. We shall employ indifferently all the other qualifications by giving them a purely descriptive value. Pathological anatomy. — For methodical description of the anatomical lesions met with in metritis it is necessary to depart momentarily from the clinical classification and to follow simply the topographical order, lesions of the body and lesions of the cervix. Fig 39 — Mucous membrane of the body ot the uterus Noimal state (shghtly magnified) (Wyder ) The surface of the mucosa is to the leit, the fibres of the muscular layer are to the light Fig. 40. — Mucous membrane of the cervix. Normal state (slightly enlarged). (Wyder.) 80 Metritis. — Pathological Anatomy. — jEtiology. Fig. 41. — Section of the normal mucosa of the body of the uterus, examined under a magnifying power of two hundred diameters (Cornil.) Fig. 42. — Uterine mucous membrane during menstruation. Normal state (Wyder). Lesions of the body. — lu most works they divide metritis, acute and clii'onic, iuto parenchymatous and endo- metritis and the anatomo- pathological and clinical study follow this schematic classification. I do not adopt it in the clinic ; nor shall I follow it in the description of lesions. I shall indicate as a whole the lesions of all the coats in acute inflammation, then then* lesions in chronic inflammation. Metritis. — Pathological A natomy. — Mtiology. 81 ^ Jim r ion. B. Chori.cn C2om cef/ulafuji' Zcna exfohatwnis- [ Zo2ia glandulamm > Fig. 43. — Decidua, normal state (Friedlander). This figure is somewhat schematic for the sake of clearness. It represents the decidua at the end of pregnancy. Fig. 44. — Acute metritis (septic). Slightly enlarged, a b, surface of the mucosa ; under it is the layer of muscular fasciculi. 82 Metritis. — Pathohijical A natoimj. — ^-Etiohgy. Acute metritis. — The descriptions which have been given of lesions of the parenchyma in acute metritis are almost all marred by one fault : acute metritis, non-puerperal, not being fatal and not justify- ing hysterectomy, the descriptions have been given from the post- mortem findings in puerperal women, where the lesions of the parenchyma and of the mucous membrane of the uterus were in fact anything but comparable to what should be found in the acute phases of inflammation of a nou-gra^dd uterus. It is necessary at the start to get rid of these old ideas, among them those which so many authors have laid down simply from observations on puerperal women. We find as notes : increase of volume, softening of the tissues, deep-red color studded with yeUow points, dilatation of the vessels, exfoliation of the mucosa. In order to complete the cycle of acute inflammation, there remains suppuration ; here again the authors adopt blindly a certain number of old observations which are all open to criticism and capable of a different interpretation. The assumed abcesses of the walls of the uterus are : 1. Purulent collections contiguous to that organ, as is so frequently observed in pyosalpingitis. 2. Suppuration of gangrenous myomata, which has no relation to metritis. Certainly if they mean to say that suppuration of the muscular coat of the uterus is possible, we should agree with them, but we can denj^ that it suppurates in metritis. What we know most precisely of the acute lesions of the mucosa is revealed by the examination of the membranes of membranous dysmenorrhoea. The mucous membrane is soft and thick ; under the microscope we see that the glands are not altered, but that the inter-glandular tissue undergoes particular metamorphosis. The cells appear in much greater mumber than commonly and they are so pressed against one another that there remains but little space for the homogenous inter-cellular substance. They preserve their normal size and differ by that, and by the small quantity of their protoplasm, from the cells of the decidua. Finally, it is an acute interstitial inflammation (Fig. 45). Chronic Metritis. — -The lesions of the parenchyma in chronic metritis are above all characterized by hypertrophy of the con- nective tissue, causing, generally, an increase in the volume of the organ, which, however, does not ordinarily exceed the size of a fist. This increase in size may be entirely wanting and be replaced in inveterate cases by a diminution of the body of the organ. We admit, somewhat theoretically, according to Scanzoni, two periods in the morbid evolution : infiltration and induration. The first period corresponds to an active or passive congestion of the organ, from which arises the areolar aspect that its walls, traversed by dilated vessels, present. There are a great number of embryonic nuclei all tlu'ough the thickness of the tissues, the predominant Metritis . — Pathological A natoviy. — ^Etiology. 83 histological lesion is hyperplasia of the connective tissue. Authors are not agreed as to whether the muscular tissue takes part in the hypertrophy. Finn admits this hypertrophy and denies the im- portance of the fatty degeneration that is occasionally described. De Sinety, on a section he has studied, has found considerable dilatation of the normal lymphatic spaces, an hyperplasia of the circumvascular connective tissue diminishing in places the calibre of the vessels, giving place to a sort of special sclerosis. The muscular tissue does not seem affected. When the uterine pa- renchyma has thus been altered by a profound inflammatory pro- cess of long duration, it is rare that there are not at the same time traces of perimetritis, adhesions in Douglas' cul-de-sac giving rise to deviation of the organs, traces of salpingitis, perisalpingitis and periovaritis. The uterine mucosa is also always more or less diseased. Fig. 45 — Acute endometritis. Membranous dysmenorrhoea (highly magnified). (Wyder.) In many cases of endometritis of the body and cervix, inde- pendent of parturition, or in aged women who have had children a long time before, Cornil has seen an hypertrophy of the uterine wall due, above all, to the new formation of connective tissue situ- ated between the muscular fasciculi. Most often the fibrous bundles examined by the naked eye are reddish, and are crossed by a series of bridges or of opaque lines, which are the thickened and sclerosed arterioles in artheromatous degeneration- When they are observed under the microscope we note a considerable 84 Metritis. — Patlwlogical Anatomy. — Etiology. thickening of the wall of the vessels by an increase of elastic ele- ments, which show at the same time cells in fatty degeneration. The sclerosis of the connective tissue is accompanied in such cases by that of the arterial and venous coats. There is no cicatricial retraction of the connective tissue but, on the contrary, permanent augmentation of its volume. The microscopical and histological lesions of the mucosa of the chi-onically-inflammed utems are to- day perfectly known, thanks to the operations which allow numerous specimens of this lesion to be studied in a fresh state. Fig. 46,~Chronic metritis, a a, muscular coat, with some fasciculi of inodular tissue to the left; b b, connective tissue; ^ c, vessels with thickened walls; d, lymphatic space. I cannot better describe the habitual aspect of a uterine mucous membrane thus altered than by quoting verbatim the statement wliich Professor Cornil has made in his remarkable lectures recently published : " The mucosa," he says, " has not the whitish appear- ance, the smooth surface and special stiffness which it presents in the normal state. The surface is uneven, it is swollen, soft, pulpy, resembling in its consistence and aspect currant jelly ; the color is sometimes a little deeper, and it has then the appearance of a layer of blood transformed into blackened soft clots. This flabby layer, formed by the inflamed mucous membrane, is easily dis- placed by the scalpel, as if one had to do with a softened tissue. It is easily removed and torn by slight traction. An intense congestion is found in all the thickness of the uterine wall, in the ■ interstices of the muscular fibers ; but it reaches its maximum at the deep surface of the mucous membrane, where it is extremely pronounced. If a clean section of the mucous membrane is made Metritis. — Pathological Anatomy. — Etiology. 85 with a very sharp knife and the ciit surface is observed, it is very difficult to distinguish the mucous membrane from the muscle, the two having an almost analogous appearance. The difference is always found by tearing softly the uterine surface with a curette ; the mucosa is removed, while the muscular tissue resists the action of the instrument. This is the advantage of curetting the mucous membrane, for the curette cannot penetrate the muscular tissue itself unless the latter is very much softened by inflammation, which is very rarely the case. When a section of it has been hardened in alcohol in order to fix the parts, and sections are made, the mucosa appears considerably thickened. When the sections have been stained withpicro-carmine the thickening of the mucous membrane is clearly apparent to the naked eye. It has a slightly yellowish color, by which it differs from the muscular layer, which is red. It is, besides, more trans- parent, especially the deep layers, due to the microscopic openings caused by the glandular tubes. To appreciate these details with the naked eye, it is sufficient to look at the section colored with pico-carmine by daylight. It is thus shown that the mucous mem- brane attains a thickness of two, three, four, five millimetres, sometimes even one centimetre, while in the normal state it is only one millimetre. Its surface, examined in the sections, in place of being smooth has become fungous, and presents rounded pro- jections and smooth depressions. The pathological vegetations of the surface have received the name of villosities, villous processes, fungosities, vegetations, and the disease has thus been called vil- lous, fungous, granular or vegetating metritis. These vegetations are sometimes considerable ; they have a rounded, elongated form and sometimes become veritable polypi which may be sessile or pedunculated. In other cases, besides these new productions, small cysts are seen, the size of the head of a pin, altogether analogous to the Nabothian glands, which are so common in the cervical cavity and on the surface of the mucosa of the cervix and which have the same glandular origin. They always dift'er from the latter in the character of their fluid contents. Their contents differ especially in being more liquid, more serous, less consistent, less gelatinous than in the Nabothian glands of the cer-^dx. The small glandular cysts of the body of the uterus are observed oftener in the internal metritis of aged women. Such is the microscopic aspect of the chronically inflamed uterus." In the histological point of view there exist three types, often very distinct in some sections, although combined in others. I shall follow in this discription the recent work of Wyder. Interstitial endometritis (chronic). — The inter-glandular tissue, which we have seen so gorged with cells in the acute form that it then almost resembles granulation tissue, is transformed into a 86 Metritis. — Pathological A natomy. — JStiology. true cicatricial tissue in which the number of cellular elements predominate more and more. The glands suffer the consequences of tliis morbid process, they are either compressed in parts and transformed into cysts, or compressed in their whole extent and more or less atrophied, so that, in some cases, only very few glands are found in the middle of the coimective tissue (Fig. 47), and in Fig. 47. — Interstitial endometritis; partial atrophy of the glands (Wyder). others, cysts are produced (Fig. 48 A) or even a complete de- struction of the glands (Fig. 48 B). In cases of atrophy so pro- nounced the muscular tissue is lined with only a thin layer of sclerosed conuectiA'e tissue, covered with ej)ithelium. We can see them (Fig. 47) under the surface, still covered ^dth the pavement epithelium, some fibrous lamellne which traverse the mucous mem- brane, anastomosing and forming meshes, filled in general with homogeneous substances, although in its depths they are filled with round cells much serrated. Near the surface the inter-glandular tissue is more regular. It is composed of a series of layers of fusiform cells with elongations between them. The section con- tains but very few glands. At many points cystic canities are seen (Fig. 48), cubical epithelium, and surrounded by bundles of con- nective tissue with fusiform cells. At other points there is com- plete absence of glands, and the mucosa is represented by a homogeneous connective tissue, poor in cells and stronglj'' undu- lating, which, by the clearness of its outline, resembles the muscular layer. Near its surface this mucous membrane is partly smooth Metritis . — Paiholoc/ical A natomy . — AStioloyy . 87 and partly covered with large and flat villosities. There are all the signs of an advanced sclerosis of the connective tissue. Fig. .48. — Interstitial endometritis; total atrophy of the glands (Wyder). A, cystic dilatation, last glandular vestige ; B, total disappearance of the glands. Chronic glandular endometritis.— Huge, and after him, Wyder, recognized two forms of glandular endometritis, one of hypertrophic form, one of hyperplastic. In the first, the proliferation of the epithelium takes place without multiplication of the glands them- selves. In place of being represented by a more or less straight tube, the glands have then an irregular form and are often twisted into a spiral form. In the hyperplastic form there is a multi- plication of the glands. Figure 49 represents a mixed form of hypertrophy and hyperplasia combined, less rare than is believed. The glandular tissue is absolutely normal, as to structure, but the glands are much distorted or present lateral prolongations. PolyjMid endometritis (chronic). — Tliis is characterized, to the naked eye, by the enormous development of the mucosa, which has a fungous appearance and which may sometimes be filled with soft polypoid productions. It is, from an histological point of view, a mixed form, at once interstitial and glandular,, with marked cystic degeneration. At the surface, with the naked eye, are seen small vesicles of one millimetre in diameter, transparent and a little pro- jecting. With the microscope (Fig. 50) these cysts evidently proceed from the degenerated glands, covered with cubical epi- thelium. They are separated by bundles of connective tissue. In 88 Metritis. — Patholo(jical Anatomy. — Etiology. the superficial part of the mucosa, dilated glands are found. In the deep parts they are often normal but tortuous, and lying some- times paraUed to the surface of the muscular fibers, sometimes ob- Hquely. The glandular culs-de-sac oftener pass the deep limit of the mucosa and force themselves between the adjacent muscular fibers, according to Cornil (Fig. 49). It is there a remarkable example of that which in old general anatomy is called glandular heterotopia, showing what can be produced under the influence of simple inflam- mation mthout malign influence. In this encroachment of muscu- lar tissue, the glands are accompanied with a certain quantity of comaective tissue which surrounds them. The inter-glandular tissue is very rich in vessels. At the points corresponding to glandular dilatations it sometimes encloses numerous fusifrom ceUs Fig. 49. — Glandular endometritis of the body ol the uterus (Wyder). Slightly magnified. with prolongations which give them a striated appearance, some- times it assumes the form of fibrous tissue relatively poor in cellular elements ; it is this which is observed in the immediate neighborhood of the vessels. Deeply, and around the intact glands, as well as between the cysts, the inter-glandular tissue is replaced by a homogenous substance, rich in round cells, pressed one against the other (Fig. 50). Finally, there is an lustological variety of endometritis which surely does not merit elevation to the dignity of a special form, but which it is useful to specify — that is, post-abortum endomrtritis. According to Schi-oeder, it is invariably interstitial endometritis that is observed after abortion; the glands become Metritis. — Pathological Anatomy. — .Etiology. 89 diseased to their whole length. But what gives a characteristic aspect to this anatomical picture, is the incomplete or defective involution of the true decidua. This undergoes regressive meta- morphosis so incompletely, that more or less extended islets of membrane are seen to exist, around which is produced a very active Fig. 51. — ^nAoraAriWs, post-adori-u?n showing the islets of the decidua, around which cellular proliferation is taking place. proliferation of small cells (Fig. 51). These inflammatory modi- fications, says Shroeder, differ essentially from placental retentions, which are often desiganted wrongly by the name of post-abortwm endometritis, which are only a post-ahortum hemorrhagic accident due to the incomplete contraction of the uterus and its vessels. 90 Metritis. — Pathological Anatomy. — -.Etiolofiij. Lesions of the cervix. — It is not anatomically exact to say that there are distinct cervical and corporal metritis, for the inde- pendence of these two portions of the uterus is never complete. Most frequently the lesions are contemporary and evolved together. However, it is possihle that the inflammation is localized more especially in one or the other of these parts. Cervical metritis ordinarily predominates, for this part is more exposed to the ex- citing causes. If it is the mucosa that is suddenly attacked and diseased, its alterations are quickly propagated to the musculo- iibrous tissue, and a true parenchymatous cervical metritis suc- ceeds to all inflammations of the cervix of some duration. Cornil explicitly describes these lesions of parenchymatous metritis, which may be partial. For example, these lesions are sometimes confined in the cervix to the ectropion of this organ, caused, not only by the thickening of the cervical mucosa, turned outward into the vagina and infiltrated, but also by the thickening of the con- nective tissue situated uiider the mucous membrane and between the muscular fasciculi. In this connective tissue, the lesions of recent inflammation are often found, in the thickening of the fasciculi and in the interposition of flat cells. The cervix uteri in the antritis, may offer special and very diverse lesions : lacera- tions, ectropion of the mucosa, hypertrophy, congestion, varicosity, granulations, folliculitis, erosions, ulcerations, cysts of Nabothian glands, etc. As this portion of the uterus is accessible to view, the microscopical description of these lesion enters into the clinical account. But it is important to state precisely the exact nature of some of them as made by liistological examination. Nabothian Glands. — Granulations and FolUcHHtis. — Nabothian glands are small cysts, granulations or folliculitis are small ulcer- ations (I shall explain the value of this word further on) distributed on the surface of the cervix. They both sometimes simulate a sort of eruption, according to some authors, erythema, eczema, herpes, acne, or pemphigus. Erosions, Ulcerations. — The cervix may show, in the neighborhood of the external orifice, a red and roughened aspect, without pro- jection or depression. This is an erosion, properly so-called. It may be observed in the case of an acute vaginitis with abundant secretion, or again following the contact of a foreign body (pessary). Under the microscope we find that there has been a simple sub- stitution of cylindrical epithelium for the normal pavement epi- thelium. Fischel has shown that we sometimes find at birth, a pseudo erosion of the mucosa of the cervix, due to the fact that at the external border of the external orifice the epithelium is there cylindrical in a certain external zone. Later, tliis epithelium changes to the pavement variety, but if it desquamates under any influence, the primitive aspect reappears. Thus will be created a Metritis. — -Pathological Anatomy. — ^Etiology. 91 very curious congenital predisposition to erosions. The remarks 'of Klotz are in keeping with this view; according to this author there are women who have erosions or ulcerations from the in- fluence of any very slight inflammation, while others, attacked by intense cervical catarrh, never show them. It seems, then, there. are women especially predisposed to cervical metritis, by a true congenital idiosyncracy. Ulceration is the name given to another condition. On all the circumference of the orifice, or only on a part, exists an apparent excavations, generally circumscribed by a circular border, the surface of which appears smooth and red, or again velvety and even villous. Gynsecologists have long seen in this a loss of substance, with detruction of tissue, from which comes the name ulceration, ulcerated cervix, and some of them singularly exaggerate the importance of this lesion. A reaction has set in. Gosselin first had the audacity, great at the period when he formulated his opinion, to contend that i;lceration is not a disease at all, but only a symptom of uterine catarrh. Tyler Smith, and after him Eosa, saw in this lesion only a hernia of the mucosa of the interior of the cervix, and according to the expression of Eosa, an ectropion comparable to that of the eyelids when the conjunctiva is everted or inflamed. This author distinguishes a traumatic or cicatricial ectropion due to laceration of the cervix, and inflammatory ectropion due to hernia of the cervical mucosa It is certainly nec- essary to take into account this sort of decent of the tumified intracervical mucous membrane beyond the orifice and on the external face of the cervix. It may constitute, in cases of deep lacerations, the greater part of the exposed surface of ulceration. But in many cases the closed orifice of the cervix leaves projecting only a thin strip of the internal mucosa, and as ulceration invades a great part of the convex surface of the cervix it is absolutely necessary to recognize that there has been an alteration of this surface. What is the exact nature of this alteration. Is the old notion of ulceration exact and does it represent an anatomical reality or only an appearance ? The work of Veit and Euge pre- sents this question in a new light. These authors affirmed that there is no destruction of tissue, but neoformation. While cylin- drical epithelium replaces the pavement epithelium at the ulcerated border of the external surface, it produces juxtaposed glands and the inter-glandular substance takes a palisade-like appearance, its projections producing the papillary aspect of the surface. When a bilateral lacertion of the cervix permits this glandular neofor- mation to grow toward the exterior, it borders the external orifice as a cuff of crimson velvet on a sleeve. At other times, these glands become cystic and form mammillated projections in the base of the ulceration, which then takes the follicular aspect (more 92 Metritis. — Pathological Anatomy .^jEtiology . evident still in a cut than to direct inspection) (Fig. 52 C). These cysts may form masses detached from the surface of the cervix under the form of mucous polypi. These are small reddish masses, semi-transparent or \-iolaceous, more or less freely pedunculated in the cavity or outside the orifice of the mucous membrane of the cervix. When the cystic transformation of the glands takes place in the thickness of the cervical tissue, it may provoke, by pene- trating and dilating its substance, its elongation by follicular hy- pertrophy (Fig. 56 A). Finally, glandular vegetation and cystic transformation may also take place in the interior of the half-open cervix and then constitute, in the cavity, sessile projections easily comparable to a tonsil (Fig. 56 B). F'g- 52 — a ^, simple papiUar) eiosion, f, follicular Slightly magnified. The theory of Euge and Veit, true in the great majority of cases, is not, however, as absolute as these authors have contended. Fisehel has questioned their exclusiveness and sho-mi that there is some- times ti-ue loss of substance — ulceration in the proper sense of the word. The epithelium is then desquamated and the mucous mem- brane is covered with patches of inflammatory granulations starting from the papillje. Doderlein has verified the fact of these two processes, that of pseudo ulceration (Euge and Veit) and that of true ulceration (Fisehel). Laceration of the cervix is the most frequent lesion after ac- couchement. It is even observed after miscarriage at two months. Me tritis . — Pathological A natomy . — Etiology . 93 a time when the elasticity of the ovum renders this lesion im- probable a ^jrjoj'i, but if the cervix is not sufficiently soft and dilated it may be torn even at this time. It is almost always at the first accouchement, according to the statistics of Munde, that this lacer- ation appears. It is possible, however, that the cervix, like thp perinseum left intact by preceeding deliveries, may be torn subse- quently. Although there sometimes does not exist the least nick "Si Vi "-^ '^^*-^% Fig. 53. — Transverse section of the upper part of the cervix (enlarged twelve diameters). (Cornil.) The vacant central space represents the cavity of the cervix; d 6, internal surface of the mucosa presenting small projections, superficial glandular depressions, and deep depressions; d, intermedium of the' arior vita; g g, deeply situated glands; m m, muscular tissue of the uterine wall. 94 Metritis., — Pathological Anatomy.- — ^Etiology. on the cervix of a -vvonian who has had children, the frequence of laceration is considerable. Their pathological role has been made prominent and certainly exaggerated by Emmet, who has gone so far as to say : " Half, at least, of the uterine affections of women who have had children arise from lacerations of the cervix." PaUen estimates the proportion of such cases as 40 per cent, Goodell says one-sixth, Munde, out of two thousand five hundred women deUvered, found six hundred and twelve lacerated (25 per cent), but two hundred and eighty (12 per cent) only being deep enough to be able mmm Fig. 54. — Section of the vaginal portion of the cervix in chronic inflammation (forty diameters). ^, papillse covered by a single layer of cylindrical epithelium; at c, the epithelium become pavementous ; >. sometimes feeble, but actual, on the part of the tubes. From this proceeds the paiu in the region of the appendages, wliich is rich in nerve ramifications. With regard to the predomiuance on the left side it is as difficult to explain as the predominance of the epididy- mitis on this side. Another focus of pam exists in the lumbar region. The pain is augmented by fatigue, by missteps, and the jolting of a carriage. It may not be immediately exaggerated under these mechanical influences, the painful exacerbation being felt only at the end of some time. The pain is dull, persistent, di-aggiug, giving rise to a sense of weight, of fullness in the ijerinaial region and in the pelvis, it appears to the patient as if she had a foreign body that tended to escape, she feels her uteras. Her walk, in acute cases, is characteristic ; in place of seating herself carelessly she sits down with caution, taking support from the ai'ms of the chair, for fear of awakening her dormant pain. The paiu is exaggerated by pressure, and especially by palpation associated ^ith digital examination. It is easily perceived, however, that it is not dii-ect pressure on the cervix Avhich is painful, for this organ is not sensitive (except in cases of lumbar-abdominal neuralgia), but the shock propagated by ballottemeut of the body of the uterus itself. Leucorrhcca is a constant symptom. It may be more or less masked by blood, exaggerated by-pm-ulent, sanious discharge, etc., Init it is always present. Leucorrhoea is so important a symptom in gynaecology that certain authors in early times made a disease of it, the principal disease of the uterus, gi'ouping aromid it the other inflammatory phenomena. Courty, himself, made of cei'tain leucor- rlioeas a morbid entity, an idiopathic affection. Leucorrhoea is the exaggeration and the alteration of physiological uteriue and vaginal secretion. The uterus and vagina secrete, in the normal state, a very small quantity of a mucous liquid which always contains leucocytes. It is an oozing due to the slow destruction of the epithelial covering. If it exceeds a certain degi-ee, if it becomes more abundant and punilent, it is abnormal aud constitutes leucor- rhoea. It proceeds fi-om two sources, fi-om the vagina and from the uterus. Vaginal leucorrhcea, which often exists alone, consists of a very fluid discharge, of milky appearance, only slightly stift'erung the Imen ; in certain cases contains pus and has a greenish-yellow tinge. Its reaction is acid. Leucorrhoea fi-om the body of the uterus is of a yelloAA-ish- white color aud but slightly viscous. That fi-om the cervix is gelatinous ; in the normal state it is transparent, resembling the white of an egg and gi-eatly stiffens the linen. In a pathological state it is puiident and of a gi-eenish-yeUow color. Its reaction is alkahue. The leucorrhoeal flow is not constant, it accumulates in the vagina and escapes in small masses fi'om time to time. Finally, ill some cases tnie secretory crises have been observed, a large quantity of liquid appearing suddenly after some severe pains. Symptoms, Progress and Diagnosis of the Metrites. 105 This has often led to a belief in an intermittent evacuation of a hydrosalpynx. But this symptom may exist also in metritis with- out a tubal collection, as I have observed several times. JProperly speaking, it is a pathological reflex hypersecretion. Some authors have sought a means of establishing the difference between vaginal^ leucorrhoea and that from the uterus. Schultze proposes the intro- duction of a tampon of cotton, which is left against the cervix for twenty-four hours. On withdraM-ing tMs the quantity and quality of the uterine secretions can be recognized. Leucorrhoea, may be simply dependent upon some fault of the general health, as anaemia or chlorosis. Metrorrhagia, Dysmenorrua^a. — ^Menstrual disturbances may be observed m uterine affections but they are not necessarily constant. Dysmenorrhoea, or painful menstruation, is often observed in metritis, in consequence of certain mechanical obstacles to the menstrual flow (flexions, narrowness of the cavity of the cervix), as these obstacles favor inflammation. Amenorrhoea is sometimes the consequence of the debility produced by a long-lasting metritis. Metrorrhagias, on the contrary, are certauily directly dependent upon metritis, especially Avhen the mucosa of the body of the uterus is affected by an interstitial endometritis (either primary or con- secutive to fibroids or cancer). The loss of blood may occur during the menses, which are then prolonged, or outside the catamenial period. In the fii'st case we have menorrhagia; in the second, metrorrhagia. The majority of metrites are generally an obstacle to conception. However, pregnancy has been observed even in cancer and in fibroid tumor, likewise in metritis. But in these cases abortion is frequent. Symptoms relating to contiguous organs and reflex phenomena. — In all uterine affections we obseiTe symptoms re- lating to the neighboring organs (independently of the phenomena of compression). The woman very frequently has pain in iirinating, frequent micturition, and even vesical tenesmus. Every disease of the uterus affects the bladder, more or less, and sometimes the patient draws the attention of the physician to the vesical phe- nomena alone. As women often suffer in defecation, on account of the efforts that tliis act demands, communicating a disturbance to the diseased uterus, they accustom themselves to going mthout stool as long as possible and constipation becomes habitual. Uterine dyspepsia. — There is no function on wliich uterine affections react with more constancy than digestion. The want of recognition of this fact is often the cause of serious errors. The dyspepsia is well explained by a reflex action dependent upon the sympathetic nervous system. Dilatation of the stomach is very frequent in metritis of long duration. Meteorism caused by 106 Symptoms, Progress and Diagnosis of the Metrites. dyspepsia is a great obstructiou to palpation of the abdomen and to bimanual exploration. Uterine cough. — In diseases of the uteras, outside of any affection of the respii-atory organs, and ^\ithout hysteria, there is often observed a di-y cough, either in paroxysms or isolated, but very frequent. It is generally a stuffy cough, exceptionallj' it has a sonorous and metallic character which makes the patient anxious. It is characteristic that there is no ausculatory symptom and that the cough disappears with the rehef of the metritic trouble. Reflexes affecting the central and peripheral nervous system. — Nev- ralgias and neuroses of genital organs. — The cause of these reflexes can be easily explained by the riclmess of the genital nerve supply. Neuralgias are very fi-equent. Intercostal neuralgia is so frequent that Bassereau pretends that this symptom is almost always hiiked to a metritis. There are also observed facial neuralgia, sacral neu- ralgia and, very frequently, lumbo-abdominal, with radiation of the pain into the femoro-cutaneous branch, especially to the left thigh. Peripheral reflexes may affect the sensorial nerves, as in asthenopia. Finally, I only mention the palpitation of the heart, which may be imputed both to nervous reflexes and to the anaemia. The distui'b- ances of the general nervous system are of extreme variability. In women predisposed to hysteria the least disturbance in the internal genital organs may call out the manifestations of a neurosis. Thus is at once explained the intensity of the symptoms that can be legitimately attributed to such an insignificant lesion as the cica- tricial tissue in the scar of a lacerated cervix, and the marvelous success of certain operations. We could almost say that there is a special uterine pathologj' for hysterical women, and that results may be hoped for in measures that will remam withoiit effect in women whose nervous system is less vulnerable. There is also a sequel to genital affections, that has been especially observed in diseases of the uterus (metritis, displacements) of long duration. This is a state of asthenia, an excessive depression of the nervous system, that renders a woman incapable of any effort, without, however, a corresponding muscular weakness, or an impairment of the general health. General state. — The pain, which prevents exercise ; the dyspepsia, which is an obstacle to alimentation ; the state of the nervous system, which has a depressing influence upon nutrition, all concur in producing a rapid alteration of the general health giving the usual chloro- anaemic aspect, the earthy tint of the face, the dark cii'cles around the eyes and the expression of suffering to the face which characterizes what we call the uterine facies. Such is the assemblage of rational signs which constitute the group common to all diseases of the internal genital organs, but which is never so marked as in metritis. The study of the physical signs Symptoms, Progress and Diagnosis of the Metrites. 107 revealed by direct examination will enable ns to locate the disease in the uterus. Physical signs. — On digital examination, which should always be associated with abdominal palpation — bimanual exploration — the cervix is found enlarged and altered in consistency (except in very rare cases where only the body of the uterus is the seat of inflam- mation). It is larger, more open, sometimes unctuous or velvety to the touch when it presents an ulcerated surface. In certain points can be felt small, hard, shot-like bodies, which are glandular cysts. The finger also finds the lacerations, on which I have dwelt at length in connection with of the pathological anatoniy. By pressing on the cervix, either at the edge of one of the lips, or at the torn commissure, a very sharp pain is sometimes produced, which may present the acute character of neuralgia. If this explo- ration is not painful, ballottement is sometimes so. The finger also permits recognition of the mobility of the uterus and of the fact that the culs-de-sac are fi-ee in cases not complicated by periuterine in- flammation. The first examination with the speculum will be made, by prefer- ence, with the patient in the dorsal position, by the use of a bivalve speculum, or with two retractors. It shows that the cervix is larger than normal, sometimes filling the fundus of the vagina and changed in form ; in nuUiparous women, in place of being conical, it is cyl- indrical, in the woman who has borne children it is swollen and if there are lacerations, it assumes various forms. The color varies from a bright red to a violet red. A viscid flow of mucus, either purely purulent or streaked with purulent striae and sanguineous filaments, escapes from the os uteri, especially if care is taken to press softly several times with the valves of the speculum in such a way as to express the discharge. The mucosa of the os often presents an ulcerated appearance. These apparent losses of substance will sometimes be very small, disseminated (the folliculities of some authors) or superficial, resembling a slight vesication (erosion), sometimes deep, smooth and glazed, sometimes gi'anular (ulceration) or sometimes yellowish, granular bodies similar to the small pustules of acne, wiU indicate Nabothian cysts. Lacerations of the cervix are not so perceptible to the eye as they are to the touch, and their ulcerated surface is better exposed by the bivalve speculum than by the cylindrical. To separate the two lips a divergent volsella may be used, or simply two small tenaculums. Eectal touch is a useful supplement to vaginal exploration. Its results are negative in metritis. The introduction of the uterine sound will develop a few interest- ing characteristics. The uterine cavity is usually found enlarged. It is necessary, however, to guard against one source of error. When the uterus is sHghtly deviated to one side the sound does not 108 St/nqitonis, Proc/ress and D'uuino^h of the Metrites. really meaaure the deptli of the organ hut that of aii oblique line described toward the angle of the fundus opposite the side to whic-h it is deviated. To obviate this error the uterus is brought into position by bimanual manipulation, or by placing the woman in the genu-pectoral position. The sound often causes pain, but it is to far tosay that the exact points most affected by the endo-metiitis can thus be located. In reality it is more often the movement imparted to the whole of the organ, rather than any pressure on the mucosa, that causes the pain A flow of blood, when the sound has penetrated without effort, is a sure indication of the alteration of the mucous membrane. If there are marked fuugosi- ties they may even be felt sometimes with the sound. Different forms of metritis. — Acute form. — In the beginning of a metritis, for example, that from a dilatation or a probing done without antiseptic precautions, etc., there maybe observed rigors and fever. Acute phenomena also occur in the course of a chronic metritis, in consequence of fatigue, or simply at the time of menstruation. However, when metritis assumes this form at its onset, or by acute exacerbations of the chronic disease, direct exploration permits recognition of the sensitiveness of the organ and the heat of the vagina, and also reveals tln-obbing, redness and swelling of the mucosa of the cervix, in a word, all the classic symptoms of acute inflammation. The symptoms usually diminish in intensity some- what rapidly but are subject to reappearance in a new exacerbation. Catarrhal form.— This is characterized by the predommance of two symptoms, the lesions of the ceiTix and the intensity of the leucorrhcea. This form is especially observed among young women and is frequentlj' accompanied liy the phenomena of nervous reflexes that have been mentioned. The principal location of the disease is in the cervix, it is the cervical catarrh of certain authors. I be- lieve, however, that it is a mistake to describe it as a circumscribed lesion. In these cases there is always, a concomitant alteration of the mucosa of the body of the uterus which should not be neglected therapeutically. Hamorvhaific form . — Here, on the contrary, it is the body of the organ that is diseased and the cervix may present a relatively healthy appearance. This form is observed among young girls at the time of estabUshment of the menstruation, and among women at the menopause. Finally this is the form particularly assumed by post- abortiim metrites ; when simple, almost invisible particles of the decidua are grafted upon the uterine mucosa. It milst be remembered that early abortions are fi-equently um-ecognized, and that this pathological condition intervenes more fi-equently than is supposed. It is in the inveterate cataiThal and luemorrhagic forms that the profound alterations of the mucous membrane of the body of the Symptoms, Progress and Diagnosis of the Metrites. 1U9 uterus become vegitating, fungous, polypoid. This exuberant pro- liferation of the interstitial and glandular elements may also affect the cervical mucosa. The diseased condition then becomes apparent and constitutes a new symptom, but does not make it neccessary to change the name of the affection. Mucous polypi and follicul^ir hypertrophies of the cervix are lesions of metritis and should be described with them, both anatomically and clinically. The appear- ance of these polypi recalls the soft polypi of the nasal fossae ; they are reddish or purplish, of the volume of a pear or a nut, sometimes with a thin pedicle, sometimes sessile. Follicular hypertrophy of the cervix is formed by vegetation of glandular tissue in the thiclmess of one of the lips, wMch thus undergoes an hypertrophic elongation of soft consistency, grooved or anfractuous. Its size may be such as to present at the vulva. The polypi often produce grave intei'mittent hfemorrhages. Hypertrophic elongatioii especially accompanies the catarrhal form. The hfemorrhagic form may cause continual losses, with short respites, during some weeks, so that some patients are brought to a state of extreme anaemia. The flow occurs most frequently without colic, the patients complain only of more or less intense lumbar pains and present various neuralgic points. Chronic paivful form. — I have characterized this form by the term painful because the painful state of the organ is the prominent symptom. It is absolutely false to represent chronic metritis as the consequence and as the remains of an acute metritis. It is much more exact to say that it is the result of an infection of slow evolution, which sometimes is quiescent, before making its appear- ance, long enough to allow the infecting caiise to disappear. There are here, in a word, some facts analogous to those which Yerneuil has grouped under the term latent microhism. This form has an insiduous course, misleading intermissions and unnoticed exacer- bations. It is most frequently due to a locahzed puerperal infection of very late date. Delay of normal involution, engorgement char- acterized by abnormal size of the organ, sense of weight, pain in the loins making walking and standing painful and dysmenorrhcea, such are its first symptoms. It may even pass unnoticed during the first months ; the woman who only feels ill in consequence of some fatigue attributes to this occasional cause the origin of her affection. Later, the pains become more severe and may condemn the patient to complete repose. Local examinations give very different results according as they are made during acute exacerbations or between these periods. In the first case we have the symptoms noted before as occurring during the acute form. In the second case, between the periods of acute exacerbations, the cervix is found a little swoUen, hard, as if sclerosed, often iiTegular from the presence of old lacer- ations, of a consistency almost wooden in parts, in other pai-ts 110 Symptoms, Progress and Diagnosis of the Metrites. covered with small uodules. The speculum shows this tumefaction and a variable congestion; often there is a very characteristic appearance as if the cei-vix were covered with pimples. If there are lacerations of the cer\ix ectropion may be observed, but without the fungous appearance of the catan-hal form ; it is smoother, like a cica- trizing ulcer. There is frequently a concomitant uterine deviation. Probing the uterus gives only a shghtly marked increase in the length of the cavity. There is a variety of chi-onic, painful metritis which merits special description, that is membranous or erfoliaceous dysmemorrhuia. The capital symptom is the painful eUmination at the menstnial period of a part or the whole of the uterine mucosa which presents the histo- logical alterations of acute inflammation (interstitial endometritis). (Fig. 45). The patient may suffer but little in the intervals between menstruation, although they present, however, symptoms of metritis, among others that of leucorrhoea. Many authors have not recognized this relation, but have made membranous dysmenorrhcea an affection wholly distinct fi-om the metrites. Others have clearly seen the relationship. If the origin of the affection is sought, it is almost always found that it relates to a previous accouchement or miscaniage, more rarely to the estabhshment of menstmation (the importance of these phases of genital Hfe in the development of the metrites is well known). We can say then that membranous dys- menorrhcea is a true chi'onic metritis, ^vith escerbations of the form of acute metritis and inflammatory desquamation at the moment of the menstnial period. This is why it enters into the category of the chi'onic forms, in a clinical point of view, and into the class of the acute forms, in an anatomical. Sometimes only fi-agments are exfoliated, sometimes the membranous sac is complete and the form of the uteiine ca%"ity can be recognized — an internal smooth face riddled with small openings, and an external surface, irregular and ragged. This wiU not be mistaken for the membrane produced by a miscarriage if examined attentively (after a short immersion in picric acid) and the absence of the ^•iUi of the chorion noted. On the contrary the presence or absence of the cells of the decidua is not pathognomonic, as has been beheved. This special manifestation of certain chi-onic metrites usuaUy lasts until the menopause, unless energetic treatment is instituted. It may be accompanied bj' menon"hagia. Although it ustiaUy causes sterihty, pregnancy has been noted during tliis disease, with return after delivery. Clinical coiirse. — Prognosis. — All forms of metritis are obstinate. As soon as the mucosa has been diseased for a certain length of time, the muscular coat, the parenchyma, becomes altered in turn. If the structiu'al lesions of the mucosa subside, the sclerosis of the utenis and the small cysts of the cei-vix still remain none the less distinct. Now these remaining lesions are sufficient to cause the Symptoms, Progress and Diagnosis of the. Metrites. Ill morbid state which constitutes chi-onic metritis, and this is why every metritis, which is not promptly relieved, is liable to become incurable. Does metritis predispose to cancer ? It has been con- tended that an inflammation of the uterine mucosa of long standing, when it takes a glandular form, may easily terminate in adenoma ; that the typical adenoma may become atypical, and that, by a pro- gressive transition, a malignant neoplasm a true cancer of the body may result. Diagnosis. — Error may arise from magnifying the importance of symptoms, the concomitant signs being few. The increase in the size of the uterus together with dyspeptic symptoms may lead to the diagnosis of pregnancy, especially if a temporary amenorrhoea adds to the doubt. Time will dispel the doubt. An abundant leucorrhoea associated with ulceration of the cervix gives rise to suspicion of cancer. The character of the discharge, however, is different in the two diseases. In cancer the leucorrhoea is not muco-purulent and viscid, it is serous, reddish and of a special fetid odor. The ulceration is full of cavities, is marked by yellowish points, and has hard borders when it is not surrounded by a cauliflower vegetation. It destroys the tissues that support it, giving rise to loss of substance not found in the pseudo ulceration of metritis. The hard and irregular sweUiug of the cervix produced by the development of cysts and the concomitant sclerosis, give, it is true, a sensation to the touch analogous to that of cancerous nodules. Punctures of the cervix, by evacuating the cysts and relieving the congestion will facihtate the diagnosis. If necessary a smaU piece may be excised and examined histologically. From the sharp and regular pains, the tenacious discharge of fetid muco- pus mixed with blood, the considerable increase in the size of the uterus and the examination of fragments removed by the curette, we will be able to make a diagnosis of cancer of the body of the uterus. A hsemorrhagic metritis must not be confounded with the metror- rhagia induced by an early miscarriage. The history and the examination of the clots expelled are important. Fibrinous polypi, that are only the debris of the placenta, or of the viUi of the chorion, remaining grafted in the uterus and preserving some degree of vitality for several weeks and even months after an accouchement or an abortion, are distinguished by the anamnesis and the histological examination of a small section removed by the blunt curette. Fibroid tumors and intrauterine fibrous polypi give rise also to a group of symptoms analogous to that of metritis and to copious haemorrhages. The examination of the uterus by bimanual explo- ration, by the sound, and, if need be, by dilatation of the cervix serves as a guarantee against error. Salpingitis, as I have said, often co-exists with metritis. The 112 Symptoms, Pnxjress and Tfmiinims of the Metrites. examinatiou must determine which oue of these two lesions pre- dominates. By bimanual exploration, T\'ith the aid of anaesthesia, the condition of the appeiadages will lie carefully examined. If they are not enlarged, hut only sUghtly tender to palpation, while the uterus presents the objective signs described, the diagnosis of metritis is made. I have already mentioned the existence of metrites symptomatic of primary and non-inflammatory diseases of the appendages. It is difficult to determine hi what way the uterus becomes diseased in these eases. A small ovarian tumor has been observed to be the principal point of dei)arture, apparently, of profuse haemorrhages associated with an hyperplastic endometritis. Brenuecke and Loehlein, who have reported observations of this kind, believe that the reflex hyperemia provoked by the ovarian irritation is sufficient to cause the hyperplasia of the uterine mucosa. It is better to say that this state of permanent congestion creates a true morbid recep- ti\dty by reason of wliich the numerous causes of congestion — genns inhabiting the vagina, and germs fi-om ^^-ithout — are able to exercise their noxious influence, and, by overcoming the enfeebled organic resistance, to provoke an inflammation. However this may be, two facts appear to be established which should not be forgotten by the physician: 1. There exists an inti- mate relation between inflammation of the utems and that of the appendages (ovaries and tubes), and the last should always be sought, because, whether idiopathic or deuteropathic, it is the most important in its bearing upon the question of operative interference. 2. Alterations of the ovaries, whatever their natiu-e, may fi-om the first simulate metritis by their indirect effect iipou the uterus. The uterine lesion, at first simply congestive, tends to develop into a true inflammation. Cystitis may be associated with an mflammation of the utetus, or give rise by itself to painful sjanptoms which simulate a metritis. The same is true of proctitis, with tenesmus, and even glaiiy secretion (anal leucorrhoea), which sometimes appears wth a metritis. It is necessary, then, to always guard against taking an effect for a cause. I have observed a case of pain in the sphincter ani which disappeared after the cure of a catarrhal metritis. It is exceptional, on the other hand, that a disease of the rectum causes the symptoms of a pseudo metritis. I have reported a case of polypus of the rectum which gave rise to distui'bances that were attril)uted to metritis. Removal of the polypus caused the dis- appearance of the iiterine symptoms. Distm-bances of the general health or reflex troubles are often so marked that they mask the local lesion. A woman complains of constant cough, of difficult breathing, of progi-essive loss of flesh, and (inly a little of leucorrhcea and abdominal pains. Tuberculosis Treatment of the Metrites. 113 might be suspected until auscultation of the chest and local exami- nation dissipate this error. Again, it is the stomach that seems affected by the prominence of the symptoms. Want of appetite, vomiting, flatulence, associated with the physical signs, would lead to the diagnosis of dila'tation of the stomach. This may really exii^it, hut is symptomatic of a metritis, which should demand the first attention. Finally, a gi-eat number of young women believe they have clilorosis or heart disease because they suffer precordial anxiety, palpitations, and because auscultation reveals cardiac and vascular souffles. But if the uterus is examined it will be quickly recognized that these symptoms are due to a metritis. The same is true of various neuralgias and of the different nervous states which simulate hysteria. In any woman affected ^\\i\\ a chronic disease examination of the uterus should not be neglected. CHAPTER VII. TREATMENT OF THE METRITES. The prophylaxis of uterine inflammations was greatly advanced by the introduction of antisepsis after accouchement, for it is to puerperal infection, more or less attenuated and localized, that the majority of metrites are due. The perfect cleansing of tlie uterine cavity of the deliris of membranes and placenta are of the greatest importance. The question whether expectation is better than active interference, in my opinion, has been wrongly discussed. Budin is too much opposed to what he calls the exaggerated fear of accidents in consequence of abstention. This he bases on statistics drawn from cases treated at the Charity hospital during a period of three years, comprising forty-six retentions out of two hundred and ten cases of miscarriage. He has only seen septicfemia four times, out of this number, and only one death (septic pneumonia :'). Budin con- trols hfemorrhage by the tampon, septic accidents by intrauterine and vaginal injections of subhmate solution (1-2000 to 1-3000) or of carbolic (20-1000 to 30-1000) associated with the administration of quinine internally. It is certainly not to be doubted that immediate accidents can be thus avoided, but can the same be said of ulterior troubles, of metritis and of salpingitis. Are these patients truly eihred, by having escaped death ? Certainly not. I cannot condemn such timid therapeutics too much. However little there is reason to suspect the retention of fcetal appendages in the uterine cavity, it is 114 Treatment of tlie Metrites. necessary to hasten to make exploration, cleansing and disinfeetiou, without waiting for the appearance of hnemon-hages, for when they do appear the mucosa is already infected. Even the finger itself can be used during a delay, soon after labor or miscarriage. After a careful curetting (completed by an hemostatic injection of per- chloride and by antiseptic irrigation), the temperature falls from two to three degrees, if fever is ah-eady estabhshed ; its reappearance is prevented and rapid return to the normal is assui-ed, in cases where decomposition of the debris has not ah-eady commenced. The intrauterine ecoui-Ulon, or swab, which has been advised, is a verj' inefficient instrument. Before taldng up the therapeutic indications applying to the diverse forms of this affection, I ■will discuss first the common treat- ment which apphes equally to all : Immobilization of the abdomen is recommended with an abdominal belt of di-illing ^vith a large flannel bandage, passed twice around the lower abdomen, and iucliuing a Httle fi-om above downward. This immobilization is a gi-eat comfort to patients in walking. All fatigue, \ioleut efforts, and sexual relations are proscribed. Constipation is eombatted, preferably by a choice of ahments (gi-een vegetables, rye bread, prunes) and nuld purgatives, and emollient injections to which are added some spoonfuls of glycerme. Some patients find it well to take at each meal a tablespoonful of linseed meal or of white mustard in a glass of water. These small foreign bodies mechanically excite hpyersecretion and contractions of the intes- tines. The use of drastic purgatives (aloes, podophyllum) long continued has disadvantages, but should be employed as required. It is very important to excite regular evacuations of the bowels to diminish pelvic congestion. Attempt is made to restore general nutrition, so often altered, by tonics of the kind suitable to the patient : in the lymphatic temperament, cod-liver oil, phosphate of lime ; in the arthi-itic, arsenical preparations, and to all, ii-on asso- ciated A\ith quinine and rheubarb vnll he administered with success. Finally, hydrotherapy is a powerful auxiliary that should not be neglected, especially if the metritis has produced antemia and has caused nervous sjTnptoms. There is no disease in which thermal waters have been more advised. It is certain that they have a very salutary effect on the general health especially, and indirectly on the local condition. The principal indication should be draMii from the general condition of the patient and from the reflex tlisturbances. For very anaemic patients ^vill be prescribed by preference the femrginous, sulphurous and arsenical waters and sea baths ; to dyspeptics, alkaline or slightly purgative waters ; to neuropathic patients, indifferent waters, choosing an agreeable site and a some- what elevated altitude. Finally the sodium chloride waters have an incontestable action, not only on the lymphatic and scrofulous Treatment of the- Metrites. 115 constitution but also on viceral congestions and are of actual benefit in the beginning of some forms of chronic metritis, when engorgement of the body predominates without great alterations of the cervix. Special treatment. — In acute metritis repose in bed is absolutely necessary. Sitz baths are prescribed, with the appKcation in the bath of a small speculum to admit the liquid to the cervix. Mild, repeated purgatives are also given. If the pain is very severe, it is soothed by douches containing laudanum or suppositories containing opiates. The daily application of glycerine tampons, left in place twelve hours, is an excellent antiphlogistic. The affinity of the glycerine for water causes a considerable serous flow. Prolonged vaginal mjections or hot douches (45° F. to 50° F.) are of great service. This therapeutic means is susceptible of numerous appli- cations and it is useful to give some exact indications for its employment. The injection should be given with the woman at the edge of the bed, the legs supported on each side, and the pelvis slightly elevated. An impervious sheet should be placed under the buttocks and folded below into the form of a trough which empties into a receptacle. The douche-can, which should hold at least three litres, is filled with water at 45° (there is a loss of about two degrees in passing through the apparatus) and elevated about three feet above the patient. If the vestibule of the vagina, the vulva and the perinseum are smeared with vaseline, before commencing the injection, the action of the hot water will be less disagreeable. At least three htres are used, and ten or more successively. The injection is repeated twice a day. On finishing, two fingers depress the fourchette to afford outlet to the accumulated liquid. It is useful to introduce a glycerine tampon immediately after. The patient should remain in a recumbent posture an hour after this irrigation. If the acute state is prolonged recourse is had to local blood- letting. For this we have a special instrument, the uterine scarifi- cator, but the ordinary bistoury, rolled in an adhesive plaster so as to leave only one centimetre of the blade free, is efficient. After having irrigated the vagina, the speculum is introduced and the cervix is punctured with the bistoury in a dozen points, not too distant from the os uteri. As much to make this operation antiseptic as to favor the flow of blood, continued irrigation with a warm carbolized solution, 1-100, is useful. When the flow of blood is judged sufficient, the speculum is withdrawn, the vagina emptied, and a tampon of iodoform gauze introduced against the cervix controls the haemorrhage. This procedure is preferable to the employment of leeches. It is not painful and calls for no angesthetic. In order that this local bleeding may be efficacious, it should be renewed several times (every two days). Membranous dysmenorrhoea.— Any treatment but curet- ting generally fails. On the contrary this procedure gives excellent 116 Treatment of the Metrites. results. It should be followed by injeetious of tincture of iodine and made according to rules that will be given later. If there is also stenosis of the cer\-ix, dilatation with the laminaria tents or \s-ith EUinger's dilator, is uidicated. Landowski has pubhshed some successes obtained by the galvano-caustie. I believe this procedure is good but curetting is more certain and more expeditious. Acute blennorrliagic metritis should be energetically treated by vaginal and intrauterine iujec-tions, both antiseptic and slightly caustic. Guerin has shown the good effects of the intrauteiiue injection of a weak solution of silver nitrate (five eentigi-amnies to thirty gi-ammes of Avater). Fritsch has recently recommended cldoride of zinc, 1-100, for vaginal injections, and more concentrated for intrauterine cauterization. Vaginitis and endometritis should be similarly treated in parallel cases. It should not be forgotten, however, that blenuorrhagia may have long disappeared fi-om the vagina and stiU remain in the utenis and in the urethra. It is in the latter that the last traces, which characterize the nature of the uteiiae affection, should be sought. Against the vaginitis and the urethritis subhmate injections, 1-2000, associated with the use of iodoform suppositories, have given me exceUent results. In acute blemioiThagic metritis I use curetting, followed by intrauterine cauterization with concentrated zinc chloride, appHed on a bit of cotton twisted on the sound Catarrlial metritis. — The general treatment indicated should be especially followed as this form quickly induces chloro-anaemia. This form of metritis also demands the most scrupulous cleanliness and antisepsis of the vagina. For this treatment acts indirectly, it is triie, but not the less efficaciously on the cerA"ix, which is usually the region most affected. Patients wiU be adnsed to remain in a recumbent posture after the morning injection, as they keep a certain amount of the hquid in the upper part of the canal. Subh- mate solution, 1-3000, is the best injection, but its use should not be too much prolonged. Another exceUent injection may be made by adding to a htre of water a tablespoonful of boracic acid, a tea- spoonful of tannic acid, or a half-teaspoonful of powdered alum. But to completely cure an inflammation of the mucosa of the body of the utenis intrauterine treatment will be necessary. This we may divide into thi-ee principal procediu-es : antiseptic cleansiug, cauteri- zation, currettmg. These may be employed singly in combination. To this hitrauterine treatment it is frequently necessary to add surgical treatment for the lesions of the cerrix, the ulcerations and lacerations which are of such gi-eat importance in this catarrhal form of metritis. Antiseptic cleansing. — (a). Intrauterine irrigation. — The anti- septic irrigations of large quantity, but of feeble strength, of which we speak here, must not be confused with the injections of a small Treatment of the Metrites. 117 quantity of a substance which powerfully modifies the uterine miicosa, to greater or less extent. The latter belong to the second class. Schultze, especially, has advised the first procedure. He dilates with laminaria and introduces an intrauterine recurrent sound and irrigates the cavity with carboHzed water (2-100). This treatment is not sufiieient in the inveterate cases. It appears apph-,. cable only to mild cases of endometritis, without deep imphcation of the mucous membrane. An irrigation is made every day of a half litre. If necessary the cervix is dilated with a dilator, or by lami- naria tents. When rehef is still delayed, after the use of tins simple means, we proceed at once to cauterization and curetting. (b). Drainage. — Fehling has constructed glass drainage-tubes, pierced with smaU holes ; Ahfield, hoUow rubber cylinders, and Schwartz, meshes of glass threads, acting by capillary attraction. It does not appear, however, that these procedures have given good results. It is probable by the presence of the foreign body in the uterus, that they are adapted to cause, rather than to cure, metritis. Tliis is not the case with drainage by the capillary action of iodo- form gauze, which can not be separated fi'om tamponnement. (c). Tamponnement. — In 1882 Fritsch employed a procedure especially appHed to bleunorrhagic metritis. A strip of gauze seventy- five centimetres long and two to thi-ee centimetres wide is pushed into the uterus and packed into the cavity. This strip is then removed and the manoeuvi-e repeated in such a way as to carefully cleanse the uterine ca^dty. Then a final strip of iodoform gauze is introduced and left from twenty-four to forty-eight hours (or removed earher if it provokes coHc). I beheve that this means is much less simple than curetting followed by cauterization, and in ]ny practice it is reserved for cases where energetic disinfection is necessary (cancer of the body of the uterus, sloughing fibroid) ; it is also used as a simple haemostatic after enucleations and the detach- ment of fibroids in pieces. Fig, 58. — Doleris' ecouvillon. (d). Ecouvillonage. — Many gynaecologists are contented, after dilating the cervix if neccessary, with cleansing the uterine cavity by the aid of a sound on the end of wliich is twisted a small quantity of absorbent cotton. This is a very simple means. The cotton tampon on the end of the sound can be easily adjusted as to the amount of the dilatation of the cervix. The cotton is tvnsted on the end of the sound, dipped in a solution of sublimate, 1-1000, or of carbohc, 20- 1000, then squeezed out gently before introducing it into the uterine cavity. After introduction it is turned about in such a way as to clean the uterine walls. This cleansing can be made the first step of a 118 Treatment nf the Metrites. cauterization by means of a new tampon. Doleris prefers, instead of this simple procedure, the use of the ecouvillon, or swab (Fig. 58), an instrument similar to those used for cleaning bottles. The in- stniment is immersed in a solution of subUmate, 1-1000, and introduced into the iiterine cavity by a spkal movement and turned m the opi^nsite direction on being withdra^vn. The swab can also be charged ■with medicated solutions, the same as the cotton tampon. Doleris beheves that in using the ecouvillon, it produces a cleansing and scraping \\-ith destruction of the mucosa. Those who know the force that must be used to remove the mucous membrane with a blunt instrument will see that this last point is a delusion. I believe it is impossible to destroy by simple rubbing with a brush all the elements of this diseased membrane. The ecou\-illon, hke the cotton tampon, can only aspke to the role of a cleansing agent or of an intrauterine medicator. There are some eases, especially among nulHparous women, in which, though the cervical canity is dilated and full of mucus, the external orifice is very small and opposes the exit of the secretion. It is better, then, in place of dilatation, to incise the external os. The incision should be made crucial, with scissors curved on the flat, or a blunt bistomy. After this it will be easy to explore the cer\'ical cavity. The small incisions cicatrize spontaneously. Intrauterine cauterization. — The du-ect and momentary appHcation of the caustic, by means of a caustic holder, is preferable to the use of crayons blindly left in the uterine cavity for a certain time and then withdrawn. The use of the latter method may produce a destruction of tissue leading to obliteration of the orifices of the tubes and to strictures of the cervical canal. The galvano-caustic of Apostoli is less convenient and less sure than the curette and to me it appears liable to the danger of causing sterility and cicatrices in the uterine cavity. Toucliing with caustic liquids can easily be done by the use of the absorbent-cotton tampon twisted on the cotton carrier. Professor Pajot uses, according to the case, nitrate of silver in various preparations, acid nitrate of mercury, anhydrous nitric acid, chloride of zinc, percliloride of iron, and the thermo- and actual cautery. Numerous other caustics are used by various authors, but I do not employ this method of treatment. In spite of all precautions it is difficult to avoid narrowing the cervical opening. But this is not the principal olijection, unless a dilatation is made before each application, or a tamponade in the mterval between, we cannot be certain of penetrating much beyond the cervix. Only a partial application is made, and while the cerrical portion is too strongly cauterized, the therapeutic action in the body of the uterus is nil. Cauterization by caustic injections have been the subject of long discussion, as to the danger of the liquid passing into the fallopian tubes. This passage, wliieh is easily accomphshed on the cadaver. Treatment of the Metrites. 119 owing to conditions that do not exist in the hving, is in reaUty very difficult, provided two conditions are ohserved : The canula, by which the injection is made, should leave space between it and the walls of the cervical canal sufficient to allow easy exit to the return- ing liquid. The injection should not be made with force, and the jet of hquid should not be thrown in the axis of the uterine canal. Several kinds of caustic liquids are used, the best appears to be the tincture of iodine, ereasoted glycerine, and the perchloride of iron. Aljout three grammes are injected with the intrauterine syringe. I frequently employ injections of the perchloride of iron, but only some days after a preliminary curetting, itself followed by an injection of perchloride of iron. I begin the iodine injection five days after the operation and, in cases of very intense catarrh, give an injection every two days for two weeks. I prefer the tincture of iodine to the solutions of creasote in glycerine, one-third to one-tenth, employed by Doleris. The canula of the syringe is introduced into the uterine cavity, by the aid of the eye, at the bottom of a specu- lum. . The direction of the cavity is first ascertained with the sound. If there are difficulties the cervix is fixed with the tenaculum and a shght traction made in direction opposite to the deviation of the body of the uterus. The injection is forced in slowly, the canula being with- drawn a little from the fundus of the organ. Ordinarily it is not necessary to dilate the cervix, this is only done if there is not free exit for the hquid by the side of the canula of the syringe. During the intrauterine injection free irrigation of the vagina must be made to prevent cauterization of its walls. I have seen quite severe pain, vomiting and syncope follow an intrauterine injection, but I have never observed any serious accident. The tincture of iodine has been accused of precipitating the albumen and of forming clots in the uterine cavity. This error has been refuted by Nott. The iodine simply forms a very fine precipitate and its antiseptic action is thus prolonged. The essential oils and the aromatic compositions, such as creasote, have a more fugitive action. With regard to iodoform, it is dangerous to inject it into the uterus in solution, on account of toxic absorption. Curetting'. — Curettement of the uterus has lately come into new favor under the ase of antiseptics. It now occupies a considerable place in the treatment of metritis. The choice of a curette is of importance. There are several varieties the principal ones being : Simons' sharp curette (which should be reserved for cancer of the cervix and for largely-developed uterine fungosities), Sims' sharp curette (excellent for the detachment of polypoid products), the flexible, blunt curette of Thomas, modified by Simpson, and the Eecamier-Eoux eurrette which Martin has adopted and which I prefer (Fig. 59). I am a resolute partisan of the blunt curette in endometritis, as here it is only necessary to forcibly scrape a hard 120 Treatment of the Metrites. muscular wall, lined with a covering that is naturally soft and becomes still more softened by inflammation. Thus it is sufficient to scrape the interior of the uterus viith a thin blade to he sure of detacliiug aU that has little resistance, that is, precisely, the chseased mucosa. Blunt curettes have also the advantage of not exj)osing the uterine parenchyma to wounds, while they act ii\ith a sufficiently great force. If this force is always used obliquely the danger of perforation (outside the post-partum period) is reduced to a mimimum. Fic. 59. — Recamier-Roux curette. The whole thiclmess of the mucosa is never removed by curetting. The glands peneti'ate into the muscular layer, and these tenninal culs-de-sae and a smaU portion of mucous chorion remain attached to the parenchjTna in spite of the most energetic scraping. They then serve for a rapid reconstruction of this membrane. For this reason curetting for metritis becomes a modifn'ing agent, in distinction fi-om destructive cui'et ting for neoplastic gro\\i:hs, and aside hiovaevplorative curetting designed to remove a fi-agment for cUagnostic pm-pose. In the last two procedures the shaii) curette is preferable. The uterine mucosa can not be compared to other mucous membranes ; it has a special power of regeneration. The changes in menstruation and pregnancy show that a gi-eat thickness, even almost its total thick- ness, may be exfoliated and then rapidly restored. Cnretting pro- vokes, artificially, a therapeutic end, an exfoliation of the mucosa comparable to that of the decidua. It substitutes a new mucosa, regenerated in an antiseptic medium, for a membrane infected by germs and that has iindergone profound alterations, the repair of which would be very long and difficult. After curettmg, the fecundity of the woman is no more compromised than after deKvery or mis- caniage. It should be remarked that after the operation the first menstruation is often absent, it may even be delayed until the fourth mouth. Technique of curetting. — The operation is made preferal)ly during the first few days wliich foUow menstruation. Although there is so httle pain that it is sometimes done \nthout anaesthesia, I generally use it. The prehminary antisepsis of the vagina and vulva is made according to the established rules. The patient is placed in the dorsal position, two assistants supporting the hmbs. The one to the left of the operator holds the short speculum which depresses the fourchette: the one to the right holds the fixation forceps and the tube tor continuous irrigation. The knees of the ptitient bemg Treatment of the Metrites. 121 supported under the arms of the assistant, one hand of each remains free to hold the vaginal retractors. The cervix is drawn toward the vulva by a vulsellum fixed in the anterior lip. The direction and the depth of the uterus are ascertained with the sound. The currette is then presented at the cervical opening. Nine times out of ten the currette passes without resistance. If there is resistance it is overcome by EUinger's dilator or by the passage of two or three of Hegar's bougies. The currette is then directed toward the fundus and the scraping is made by carrying it successively over the anterior and posterior surfaces aiid the fundus to the angles and lateral borders. A certain force is necessary, to such an extent as to make the uterine tissue squeak under the effoi-t. The instrument is then withdrawn and quickly plunged, to cleanse it, into a glass of strongly carbolized water held to the right of the operator. A second time the curette is passed to the same extent, and a second curetting performed by following the uterine surface as before. The operator will proceed rapidly, a complete scraping scarcely demanding three minutes. Immediately after, a recurrent sound is introduced and the canula for continuous irrigation (which has been used on the cervix during the curetting . adjusted to it. The uterine cavity is then weU washed out with the hot carbolic solution, 1-100, which has served for irrigation. A quarter to half a litre is used until the Avater returns scarcely tinged with blood. This irrigation is haemo- static and antiseptic and serves to remove the clots and pieces of membrane from the uterine cavity. The sound is withdrawn and replaced by the intrauterine syringe (filled with a solution of perchloride of iron, or with the tincture of iodine), wliichis pushed to the fundus. In injecting, the syringe is withdrawn by degrees, so as to place the last of the injection in the cervix. During this time the liquid from the irrigator, which is continually playing on the cervix, serves to dilute the caustic liquid as it escapes from the uterine cavity and to prevent it from nritating the vulva and vagina. The recurrent catheter is again introduced and a new douching of the cavity is quickly made. This removes from the ceiwix the excess of caustic and the last clots. If there is diificulty in introducing the catheter, by reason of the contraction of the cervix from the action of the caustic, smaU intermittent jets can be thrown into the uterine cavity without danger, by the aid of the long, fine canula which serves for the continued irrigation. It is only necessary to take care not to distend the uterus, and not to pass the canula too far into . the cervix. This terminates the operation, the vulseUum is removed, the uterus replaced, and a tampon of iodoform gauze is placed in the fundus of the vagina, to be left until the third day. Every morning and evening after, a profuse vaginal irrigation is made with sublimate solution, 1-2000, and, if the x^atarrhal metritis was of long standing, if the mucosa 122 Treatment of the Metrites. removed presented many vegetations, if there are symptomss of a slight concomitant salpingitis, an intrauterine injection of tincture of iodine should be given every second day. From four to eight injections will constitute a complete treatment. The tincture of iodine I use for the first caustic injection, which immediately follows the curetting, where there is a recent catarrhal metritis. In invererate cases, or when considerable oozing of blood calls for it, I use the percliloride of iron. As a general rule, in women who have borne children, the pre- liminary stage of dilatation, recommended by many authors, may be dispensed with. It is useless, as regards the introduction of the instrument ; it is illusory, as regards the ease of the escape of tlie secretions, for the artificial dilatation only persists for a few hours. As to the debris of the mucosa and the clots they should be carefully expelled by intrauterine doucliing. The omission of tliis step is of importance. Slow dilatation of the cervix is. often painful. The woman who undergoes it the night before operation, generally has a night of uisomnia and the next day is in a state of great nervous irritation and sometimes has a little fever from an exacerbation of her disease excited by the dilatation. The perforation of the uterus so much dreaded by some is not to be feared m endometritis, if only the blunt curette is used and always obhquely in relation to the uterine tissue. It is necessary, however, to be mindfiil of the consistency of the uterus after paiiu- rition or recent miscarriage. It is then very soft and tliin and may be perforated Avith unexpected facility. Tliis danger A\'iU generally be avoided by the liistory and by the enlargement of the uterme cavity and the softness of the cernx. Haemorrhage has also been cited among the possible accidents from curetting the uterus. I have not observed it once out of hundreds of operations. The astringent injection which terminates the operation leaves only an insignificant oozmg. I will not dwell on peritonitis, even subacute and locahzed, as I have not seen a single case. Curetting the uterus is the true rational treatment for catarrhal metritis. As soon as simple means fail (general treatment, vaginal and intrauterine injections and local treatment) eurettmg should at once be resorted to. To Mait too long, will be to give the lesions of the mucosa time to accentuate themselves; will be to expose the parenchyma of the body and cervix to sclerotic alterations and to follicular degeneration, and will be to allow time for the possible propagation in the fallopian tubes, so frequent in inveterate ca- tarrhal metritis. Mvcom polypi of the cennx are removed by seizing with the forceps and giving them sufficient torsion to break then- pedicle. If they are numerous and sessile they are scraped off with Sims' sliai-p curette and the bleeding surface touched with the thernio-cautery Treatment of the Metrites. 123 or with perehloride of iron. Finally if the cervix is much altered, especially if it presents follicular hypertrophy, recourse to Schroeder's operation is necessary (excission of the mucosa as described later). Ulcerations of the cervix, which are ordinarily, as has been shown in their pathology, only glandular neoplasms, more or less hyper- trophied, scarcely exist independently of a more profound inflam- mation of the body of the uterus. From this it follows, that to cure the ulceration in its first stage, it is generally sufficient to cure the inflammation. But this is only true in cases taken early. Later, the glandular proliferation is an acquired legion which necessitates topical treatment, or even removal with the knife. As the first treat- ment, then, of ulcerations of the cervix, that of the concomitant endometritis is necessary ; in the second place, topical applications of nitrate of silver or tincture of iodine every two days. Nitric, acetic, carbolic and chromic acids are also employed, but all these caustics tend to strictures of the cervix and I am very suspicious of them. When these procedures fail, or when the patient demands instant relief, even at the price of an operation, the surgical treat- ment will be of great service. Schroeder's operation, or excision of the diseased mucosa, should then be made, following the explanation made later. This operation gives excellent results by substituting a healthy surface for a diseased one, permitting at the same time removal of the sclerosed portions of the cervix and of those that have undergone cystic degeneration. It does not create a cicatrix and consequently should not be an obstacle to delivery, as has been stated by numerous observers. I have always associated it with curetting of the cervix. It appears especially indicated : in cases of ulceration of long duration, with hypertrophy of the cervix; in ulceration, with narrowing of the cervical cavity ; in ulceration, with deep laceration of the cervix. It is much superior to Emmet's operation, fulfilling all its indications, as well as others that this procedure does not cover. Ulcerations complicated tvith lacerations. — We know the capital role that Emmet makes these factors play in uterine pathology. His views have had, at least, the good effect of showing that these lesions cannot always be neglected. Is it the previous inflammation of the cervix which impedes cicatrization of the laceration, as Schoeder believes, or, the laceration which causes the catarrh and the ulcerations, as Emmet maintains? I think that these two opinions can be reconciled and form by. their union one of those vicious circles so frequent in pathology. However that may be, it is evident that the freshening of the cervix and suture, or Emmet's operation, can be undertaken on an ulcerated cervix only after cure of the ulceration. In fact, Emmet prescribes a preparatory treat- ment which often lasts some months. There is no parallel, then, between Schi-oeder's operation and that advised by Emmet. The 124 Treatment of the Metrites. first is especially addressed to cerncal eatan-h, the second to the cicatricial tissue dependent upon laceration. The catarrh or the ulceration are, for Emmet, only accessory phenomena, the princi- pal pathological element being the sclerosed tissue wliich compresses the vessels, glands and nerves. It is not then apropos of the treat- ment of ulcerated laceration dependent upon catarrhal metritis, but under the head of the cicatrized lacerations observed in chronic meti'itis that I shall describe trachelorrhaphy. Schroeder's operation, although directly indicated, as has been said, in the cer^ical laceration coexisting with a large ulceration, will also be described by the side of Emmet's operation, since it too is called for in the treatment of painful clnonic metritis. When the ulcerated lacer- ation is of small extent cicatrization can sometimes be caused by simple cauterizations with the thermo-cautery. But this means should not be used in large ulcerated surfaces and in deep tears. The cicatricial tissue that they produce becomes in itself then a pathological condition. Hsemorrliagic metritis. — The treatment divides itself into two portions : that for the hsemorrhage, which is a palliative and may be required at once ; and that for the affection itself, wliich should be curative. Treatment of the hcemoirhage. — The patient ^\ill be kept in a hori- zontal position. Prolonged vaginal injections of very hot water may he employed. Ergot is rarely useful. Digitalis has been praisrd as acting both on the hemorrhage and the inflammatory stati-. Hydrastis, in the fluid extract, twenty drops, thi-ee times a day, has been used with excellent results. The use of a laminaria tent will sometimes cause cessation of the hasmorrhage for several days, without doubt from the contraction of the uterus or from a vaso- motor reflex action. A short respite is thus obtained. The same is true of intrauterine injections of perchloride of iron, which give rise to a temporary amelioration, although cures have been published after their use. In case of serious htemorrhage it may be necessary to tampon the vagina. This should be done with the tampons impregnated with alum, or with strips of gauze as already indicated. Ordinary iodoform gauze should not be used. Lister's carbolized gauze is preferable and maj' be powdered with iodoform. I will note a palliative measure which has given Fritsch good results, that is, the ligature of the uterine arteries. This can be practiced without incision, as already described, or by incismg the culs-de-sac on each side of the cervix to an extent of tlu-ee centi- meters. The two vaginal rami are first met and tied, then the tnink of the uterine artery itself receives the ligature. The best hiemostatit- in biemorrhagic metritis, and at the same time the best cm-ative treatment, is curetting. This will be practiced as soon as possible, according to the rules indicated, and followed Treatment of the Metrites. 125 by an injection of perchloride of iron. One can operate in the face of haemorrhage. I have very often seen it arrested instantaneously after the curetting, and attribute this not only to the destruction of the bleeding surface, but also to the contraction of the muscular walls and bloodvessels caused by the scraping. A single intra- uterine injection is generally sufficient. Cure is thus rapidly obtained. There are some rare cases, qualified by the name hemorrhagic metritis, in which all these means fail and the metror- rhagia persists until it threatens the woman's life. In these cases castration and even vaginal hysterectomy have been turned to as a last resort. Painful chronic metritis. — Local bleedings by scarification of the cervix have a frequent application in this form. Here, not only the immediate antiplilogistic effect is sought, but also the evacuation of the small superficial cysts, which, after having been one of the effects of the inflammation, in their turn cause a hyper- semic condition. With regard to cauterization with the thermo- cautery, and in particular igni puncture, I believe they are inferior to punctures and scarifications with the knife. The cicatrices, which succeed to the employment of cauterization, add to the sclerosis of the cervix and favor cystic degeneration, stenosis of the cervical canal, and the compression of nervous filaments with their consequent morbid reflexes. Better than these are anti- plilogistic dressings, discutient and antiseptic, consisting in an application to the cervix of the tincture of iodine, followed by a glycerine tampon lightly powdered with iodoform. Aside from the exaggerated estimate of the beneficial action of tampons, it is necessary to attribute to it a certain mechanical role. I often use it by placing with care a series of small masses of cotton soaked in glycerine around the cervix in the culs-de-sac, packing them in lightly. These tampons may be left in place four to five days if care is taken to add a little iodoform to the glycerine. Hot injections will often be of great help, especially in two con- ditions, one, in the case where the chronic metritis is complicated by perimetritic inflammation, more or less marked, the other, when very sensitive patients complain of sharp pains, as in the cases which Lisfranc called hysteralgia and which Eouth qualified by the ^expressive term, irritable uterus. Great amelioration of these pains has also been obtained by the use of electricity, introducing into the uterus the bipolar excitor. Massage has been advised in chronic metritis as well as in pro- lapsus, displacements, chronic perimetritic inflammations, etc. It is necessary to distinguish general massage, a species of passive gymnastics which favors nutrition, and local massage, ha^dng for its object the relief of congestion and the diminution of volume by manipulation of the diseased organ. The last is practiced by two 126 Treatment of the Metrites. or three fingers introduced into the vagina or rectum, sustaining the posterior face of the uterus, while the other hand placed above the pubes exerts gentle and progressive manipulations amounting to a sort of kneading. There remain a great number of painful chronic metrites in which all these procedures are without effect. The cervix remains large, swollen, hard and mammillated, in spite of scarifications, topical applications and thermal treatment. The corpus uteri is augmented in volume, heavy and painful to ballottement. The patients are so infirm that the least exertion prostrates, all exercise is painful. It is in these cases that surgery renders very great service by an operation which acts on the cervix and reacts on the body of the uterus, that is, amputation of the cervical mucosa. In consequence of amputations of the cervix there results a great diminution in the volume of the body. Whether this regression is due to fatty metamorphosis of the hypertrophied connective tissue, or due to a true reflex vaso-motor or trophic action, is not clearly made out. But whatever the explanation may be, the fact of its occurrence is i;ndeniable. Amputation is indicated as an ultimate operation in the case of chronic metritis with increase in volume of the corpus uteri. Besides this, in cases of marked sclerosis of the cervix, it gives to the external orifice a calibre and a suppleness which causes a cessation of the dysmenorrhoea, due sometimes to the ridgidity and irregu- larity of this segment. A formal centra-indication will be found in an acute perimetritic inflammation ; but I do not consider as an absolute contra-indication, the existence of an old, extinct peri- metritis, which has left plastic deposits and adhesions around the uterus. It is essential, however, to know that an old focus of inflammation may be rekindled in consequence of any operation, even perfectly aseptic, practiced on the uterus. If not always abstaining from surgical interference in such cases one should at least be on guard, and assured, before attacking the cer'S'ix, that it is not rather in the appendages or in adhesions that the causes of the symptoms should be soiight. The technique of the operation of amputation of the cer^dx has been very much perfected and at the same time simplified by the employment of cutting instruments. The fear of haemorrhage was legitimate at a time when the operation was laboriously performed. Thus the cervix was amputated only with means of exercising haemostasis, extemporaneous ligature, linear ecraseur, galvano- or thermo-cautery. The preliminary compression of the cervix with a rubber ring attests the same excesssive care. In operating rapidly the loss of blood is insignificant and the sutures arrest it quickly and completely ; it is only essential to make the knots with care, and to tie three superposed knots if catgut be used. Treatment of the Metrites. 127 I will not tarry to describe those processes of which I disapprove. Every section with the ecraseur or by incandescent instruments has the great disadvantage of leaving a cicatrix, a concentric retraction, ending in stenosis. Circular amputations without flaps are dangerous in a hcemorrhagic point of view. For the cervix uteri the only procedures to be recommended are those which' permit, by exact coaptation and perfect union, the reconstruction of an OS uteri not susceptible of contraction. Two procedures of this kind may be employed according to the special indications : 1. Amputation with two flaps (for each lip) ; 2. Amputation with one flap (which can be graduated at will in such a jvay as to make as needed only a simple excision of the internal mucosa). Fig. 6o. — Amputation of the cervix with two flaps (Simon). A. Seen in section. B. Sutures in place. 1. Amputation with two flaps (conical excision or with conical flaps) should be preferred when the internal mucosa of the cervix is not diseased and does not require excision. The technique may be briefly described : Anaesthesia. Patient in lithotomy position ; vagina irrigated ; fourchette depressed by a short speculum. Con- tinued irrigation, made by a small jet from a long canula in charge of an assistant, who also holds the fixation forceps. Incision of the commissures of the cervix, as far as the cul-de-sac, with a large convex bistoury or with strongly-curved scissors. Incision of the 128 Treatment of tlie Metrites. anterior lip from the internal mucous membrane toward the bottom and from below upward. Second incision from the external mucosa passing to rejoin the other and in such a way as to cut off a conical segment of the anterior lip, with its base below, its summit above. Suture of the two flaps thus obtained with a strong needle threaded with catgut, taking care to pass the needle under all the raw surface ; five or six stitches are necessary. Same procedure for the inferior lip, after having withdrawn the holding forceps, using the threads of the sutures in the anterior lip to keep the cervix depressed. Suture of each commissure by one or two stitches. Section of the ends of the suture thi-eads, vaginal irri- gation, replacement of the uterus and iodoform tampon (Fig. 60). At the end of thi-ee days the tampon is withdrawn and morning and evening antiseptic irrigations (sublimate 1-2000) given. It is necessary to keep the patient in bed for at least fifteen days ; the cure is then complete without the removal of the catgut sutures, as they disappear spontaneously. 2. Amputation with one flaj:), or excision of the mucous membrane (Schi-oeder's operation), is especially applied to the treatment of a special form of metritis, the catarrhal form, with rebellious ulcer- ation and more or less profound foUicular degeneration of the cervix. However, it may require application in chi-ouic metritis, when it appears the most convenient, by reason of the configuration or the consistency of the cervix. I describe it here so as not to separate the description of operative procedures. Its execution is a little more difficult than that of the preceding operation. The cervix is made accessible in the same mamier and the bilateral incision is the same. From this moment the technique is as follows : Trans- verse incision of the internal mucous membrane of the anterior lip and semicircular incision of the external mucosa, surrounding a lamella of the tissue of the cer%-ix which is dissected obliquely to the edge of the internal transverse incision, where the lamella is completely detached. To this excised portion is given a thickness varying according to the hypertrophy or to the alteration of the tissues. Inversion (entropion) of the external flap thus obtained ; suture of this flap to the internal mucosa with five or six catgut stitches; the curved needle should pass under all of the raw surface ; two or three supplementary stitches are ordinarily neces- sary. Same dissection and same suture for the posterior hp and sutiire of the commissures, etc., as before (Fig. 61). Sometimes there is an advantage in applying the two-flap operation to one lip and Schi-oeder's method to the other. It is generally useful to pre- cede or to follow this operation by a curetting of the body of the uterus, as the mucosa is always more or less altered. I use the curette last so as not to be hindered by the oozing, and not to Treatriunt of the Metrites. 129 operate on a cervix that has been shriveled by an injection of the perchloride. Trachelorrhaphy, or Emmet's operation, should give way to Sclu'oeder's operation whenever cervical catarrh coexists with a unilateral or bilateral laceration. It should be reserved exclusively for chi-onic metritis without ulceration of the cervix. In such cases one can hope, by removing the cicatrical tissue and restoring to the cervix its natural foi-m, to remove the cause of the pain and irritation. Besides, it cannot be doubted that trauma of the cervix generally has a favorable effect on the body of the uterus, as much in the case of simple freshening of the tissues, as in the case of amputation. Fig. 6i. — Schroeder's operation. A, Position of the sutures in the anterior lip. B. Section of the incision. C. Disposition of the flap. The patient anaesthetized, the assistants are disposed as for amputation of the cervix. The uterrrs is drawn down with the volsella (or by two threads passed through one of the lips). One pair of forceps seizes the cervix at the border of the anterior lip, near the laceration, the other pair grasps the posterior lip at a corresponding point. One dissects then in a single piece all of the bottom of the laceration, taking care to penetrate well to the base of the angle and to remove all of the connective tissue. The wound is smoothed to an even surface, if necessary, with the curved scissors. A first thread is then passed with a sti'ougly curved needle near the angle of the wound. The tlu-ead passes through the whole thickness of the lips, at two millimeters from the external surface and at one millimeter from the internal. It is better to tie each suture as it is placed, so as to assure perfect coaptation. Five 130 Treatment of the Metrites. to six sutures are tbiis passed successively. I use catgut as it has the advantage of not requii-ing removal. Two sizes should be at hand, to afford some fine thi-eads for the supplementary sutures, which are especially necessary if the rupture extends to the vaginal cul-de-sac. An iodoform tampon, left in place thi-ee days, comprises the dressing. After this time, prescribe antiseptic vaginal irri- gaions morning and evening, and repose in bed for fifteen days. When the laceration is bilateral, it is almost impossible, in making trachelorrhaphy on both sides, to avoid narrowing the cervical canal. I prefer then Schroeder's operation, as it is in these con- ditions much more expeditious and permits the sclerosed tissues to be removed more extensively. After all operations of this kind it is useful to explore the uterine cavity with a curette and if the mucosa is soft and friable to remove it by a complete curetting. Can castration be legitimately practiced for a chronic metritis ? I do not hesitate to respond in the negative. In all discussions on this subject it is suiificient to carefully analyze the cases published to see that castration owes its incontestable successes to the fact that it has been dir-ected much less against the uterine lesion than against the alterations of the appendages which have resulted from inveterate or badly treated metritis. In these conditions the me- tritis is a subordinate condition and the treatment is instituted against a complication which has now become the predominating morbid element. But to practice at once ablation of the ovaries and tubes on the sole indication of painfiil paroxysms following upon each menstruation, to bring about an artificial menopause, is a misuse of the operation. Pean'has performed vaginal hysterectomy several times, for painful metritis, belie-^dng its results preferable to those from removal of the appendages. He recognizes, however, that after the ablation of the uterus it may be necessary to open the abdomen for removal of the altered appendages, so often difficult to ac- complish through the vagina. This appears to me only to prove that the supplementary operation should have preceded the princi- pal one and that in some cases the removal of the appendages might have been sufficient. Vaginal hysterectomy has been per- formed many times by other authors for obstinate hiemorrhages or painful metritis. This certainly has been a mistake in many eases. But it is not always unjustifiable. Eecent researches have demonstrated that metritic glandular hypertrophy, which resists a seric^ of curettings, shows by this fact a tendency to a transfor- mation into epithelioma. Fibroid Tumors of the Uterus. 131 CHAPTER VIII. FIBROID TUMORS OF THE UTERUS. PATHOLOGICAL ANATOMY. The names fibromata, fibrous tumors, myomata, fibro-myomata, fibro-leio-myomata, fibroids, and hysteromata, have been given to neoplasms of the uterus that have a structure resembling that of the uterine tissue itself. They are benign, that is to say, not sus- ceptible of becoming generalized and infecting the economy, but, although the great majority pass more or less unnoticed and thus constitute either a hidden deformity or a slight infirmity, there is a large number which are grave and death may result from the accidents they produce. Histogenesis. — Velpean- and a number of authors following him have attributed the development of fibrous tumors to a morbid change resulting from the presence of a blood clot deposited in the uterine tissue. At that time they believed in the spontaneous organization of the clots after ligature of an artery and applied tliis idea to the various neoplasms. Now experimental studies have demonstrated that this organization of the clot is only a penetration by the growth of elements coming from the muscular walls and this theoretic edifice is completely overthrown. Krebs claims that the genesis of the fibro-myomata has for its origin a prolifer- ation of the connective and muscular tissue of certain vessels, the different nodules thus formed becoming agglomerated to produce a tumor. Kleinwachter describes the evolution of the fibroids as due to the species of round cells that is found around capillaries which are becoming slowly obliterated. These cells are first transformed into fusiform bodies, then grouped into nodules. In short, our knowledge on this subject is still but little advanced. These neoplasms are very frequent, according to Bayle, a. fifth of the women over thirty-five years of age having fibrous tumors. Their number is variable ; in some eases the uterus contains a gTeat number of small tumors, interstitial or pedunculated, and presents what might be called a myomatous degeneration. More frequently there are only three or four distinct tumors. Sometimes a single one is present, yet even then it is only clinically speaking that there exists but one tumor. It is rare that there is not in the thickness or at the surface of the organ another small nucleus, which either remains latent indefinitely or begins to grow sooner or later. This is frequently observed in laparotomies. 132 Fihru'ul Tumors <>f the Uterus. The size of the fibrous body may attain gi-eat proportions. It is especially in the case of fibro-cystic growths that an enormous weight has been reported. Even solid fibroids aquire gi'eat size. The body of the uterus is more j. frequently attacked than is the cervix. According to its situa- tion, relative to the various coats of the organ, we distinguish : 1. Interstitial fibroids, occupying the thickness of the muscular parenchyma. 2. Submucous fi- broids, immediately under the mucosa. 3. Polypi, or peduncu- lated fibrous bodies, only re- tained in the iiterine cavity by a pedicle formed by a fold of mucous membrane, some mus- cular fibres and vessels. 4. Sub- peritonaeal fibroids with a large , , Fig. 62. — Small interstitial fibroid, a. base or a more or less narrow Walls of the hypertrophied uterus; b, fibroid; pedicle. When they do affect c, uterine mucosa affected by endometritis ., , ..... and polypoid vegetations. the form of polypi, it IS not con- venient to give them that name, as it is better reserved for the variety that affects the uterine cavity. An important variety of Fig. 63. — Submucous fibroid (cedematous) with hypertrophy of the w.ills of the uterus. Fibroid 'Ihmiors of the Uterus. 183 the sessile subperitoneeal fibroids is that wliich develops in the thickness of the broad ligaments, intra-ligamentous fibroids. But they generally proceed from the cervix and will be described with the tumors of that organ. Whatever their situation, they provoke in the uterus a concomitant hypertrophy which is marked in various Fig, 64. — SubperitoiiiEal and interstitial filjroi -is of ilie fundus Fig. 65. — Interstitial fibroids of the fundus. The muscular wall is sometimes so thickened as to enclose the multiple tumor in a setting, making a single mass. The muscular layers of the uterus then resemble those of a gravid womb. A great vasculaj- development generally accompanies this globular hypertro- phy (Fig. 63). The increase in the volume of the uterus, caused by the perpetual excitation in-oduced by the neoplasm, may be 134 FUinnil Tumors of the Uterus. compared to that of the organ in the first months which follow fecundation. Very smaU fibromata are sufficient to produce it (Fig. 62). The uterine cavity is found enlarged by this eccentric dilatation, and often besides by the traction on the fundus of a heavy, and sometimes adherent, mass. Fig. 66. — Uienne polypus Fig. 67.— Subperitonseal peundculated fibroid tumor. Fibromata of the cervix deserves a special paragraph. They may affect the different situations that have been indicated, and the same divisions apply. But the separation of the eer^dx into two distinct regions imposes another classification, intravaginal and supravaginal. A. — Intraraginal. — Whether interstitial or submucous they give to the lip of the cervix, in which they develop, a more or less Fibroid Tumors of the Uterus. 135 cylindrical and elongated form. Thus they may fill the whole vagina (Fig. 68). Submucous fibromata, arising in the cervical cavity, effect a polypoid character. At times these small fibrous polypi of the cervix contain a layer of glandular neoformatiou and present a papillary appearance (Fig. 69). Exceptionally fibro- mata arising in the body of the uterus descend into a lip of the cervix. Interstitial fibroid of the posterior lip of the cervix. B. — Supravaginal. — The only ones which deserve mention are those which arise from the external sui-face of the region, and are thus found at first in the tissues of the pelvic floor, remaining incarcerated in the pelvis. They develop most frequently behind the cervix pushing aside Douglas' cul- de-sac to come in contact with the posterior wall of the vagina and with the rectum. They often push between the folds of the broad hga- ments at each side, thus consti- tuting one of the most dangerous varieties of the intra-ligamentous fibromata. They may even pass this region burrowing between the uterus and the bladder, throwing out prolongations, as far as the iliac meso-colon. Imprisoned as they are, by their origin in the cavity of the bony pelvis, they cause all the accidents of com pression. I have proposed calling them pelvic fibromata. Fig. 69. — Small polypus of the cervix (papillary fibroma with hypertrophy of the glands). (Ackermann.) 136 F'lhro'id Tiiinnr.'i of the I'lcniH. Co7ineetionis of jihrumata with uterine tissue. — Generally the fibro- mata are separated from the uterine tissues by a zone of loose connective tissue forming a capsule, from which they can be enucleated with little effort. This disposition is sometimes so marked that simple incision of the capsule will cause the tumor to roll out of its bed under the influence of muscular contractions. But more frequently this independence is not complete, and the fibroma, in place of being enclosed in the uterine parenchyma like a simple foreign body, is retained by more or less dense fibrous bundles, which also establish vascular connections. Finally, there exist rare cases in wliich there is no appreciafljle demarkation between the fibroma and the uterine wall. Fig. 70. — Intra-ligamentous fibroid. A. Abdominal variety. B. Pelvic variety. Structure and teoctv/re. — To the naked eye fibrous tumors are constituted by a dense, white, or rosy-white, elastic tissue, giving either a clear or unequal section, shghtly convex. With the help of a lens there can ))e distinguished at the surface interlacing fibres and vortices, as if the fibres were wound around multiple axes (Fig. 71). The vessels are relatively few. However, in very large fibromata, they are sometimes seen extensively ramifying over the surfaces, under the peritouieum or in the capsule. In one case I observed a bloodvessel of the broad ligament of the calibre of the brachial artery which gave rise to a very loud thrill. The peripheral veins may have the volume of the jugular and be adherent in all parts to the muscular fibres. When this disposition is marked and when the neoplasm possesses a multiple of vascular lacunae due to dilated capillaries they belong to the variety described by Virchow as telangiectasic myomata (myoma telangiectodes, seu cavernosum). The portions thus degenerated resembles a sponge filled with blood. Fibroid Tumors of the Uterus. 137 In polypi the pedicle rarely contains large arterial vessels. Even when they do exist, the thickness of the vessel wall and their retractility, added to the contractility of the pedicle itself, assure rapid spontaneous hsemostasis when the pedicle is divided. The spaces which divide the gi-oups of fibres are considered by Klebs as, lymphatic spaces. Nerves have been traced into these tumors by Astruc and Dupuytren. Bidder has lately demonstrated their presence and Hertz has even described their mode of termination in the nuclei of the smooth fibres. Fibrous tumors, examined under the microscope, present non- striated muscular fibres and con- nective tissue fibres in variable pro- portions. According to Eobin the muscular fibres never constitute more than half and sometimes only one-tenth. According to the pre- domination of one or the other of these varieties of fibres these tumors have been divided into fibromata, myomata and fibro-my- omata. This last term is the only exact expression, for these elements are almost always mixed. Gusse- row proposes to distinguish the hard fibromata, in which connec- tive-tissue fibres predominate, and soft fibromata, which are especially muscular. The last are less clearly encapsulated and more vascular. Generally, in section, the mucular fasciculi and the fibres of con- nective tissue are seen cut transversely, obliquely, or even in their whole length. The first are easily distinguished by the fusiform aspect of their elements and by their characteristic nuclei, which the transverse section shows in a mosaic. This horizontal section of the fibres and their nuclei may be confused with the projection of a round cell. Between these fasciculi exist the fibrous tissues, unequally thickened and interlaced in different directions. They are composed in part of fasciculi of connective-tissue fibres, poor in cells, in part of fasciculi of fusiform bodies with long branches. Connections with neighbori^ig organs. — When a fibroid tumor arises by a broad base from a free part of the uterus, fundus, anterior or posterior surface, it extends into the abdominal cavity above the superior strait and floats in the midst of the intestinal mass. The uterus is enlarged upward and sometimes drawn upward, the cervix is thinned and the cavity elongated. If the origin of the fibroid is narrow, the uteras no longer serves as a support. It may fall into Douglas' cul-de-sac and become fixed there, with or without Fig. 71. — Fibroid tumor of the uter- us. Section showing the disposition of fibres as seen by the naked eye. 138 Fibroid Tumors of the Utents. adhesions. If it becomes large, without beeomiug fixed, it will float up into the abdominal cavity, irritating the peritonaeum until it causes an exudation, either ascitic or plastic. The ascites is gener- allj' of small quantity, of lemon-colored liquid, rarely tinged with blood, the latter condition being more frequently found in malig- nant tumors. A chylous ascites has also been observed, probably from the transformation of fibrinous exudates. Fig. 72. — Fibro-myoma of the uterus. Microscopic appearance of a section. The adhesions generally take place with the great omentum or with the intestine. The intestinal loop is sometimes so nearly fused with the surface of the fibroid as to defy dissection. These adhesions then become the principal source of nutrition for the neoplasm and the pedicle may become extremely thin without ces- sation of the gi-owth of the tumor. The pedicle may even be broken and leave the fibrous body independent of the uterus, grafted on some point of the pelvic contents. Elongation and torsion of the pedicle may also produce changes in the nutrition of a fibroid, leading to consecutive degeneration. Alterations and degenerations of neoplasms. — The majority of fibro- mata undergo a progi'essive induration from the time of the meno- pause. At the same time they decrease in size and the litems presents senile involution and atrophy. The tumor still remains but without causing any morbid reaction. Such is the condition of many of the fibromata, uni-ecoguized during life, that are found in the autopsies of old women. Calcification (not ossification) is a somewhat rare condition. The deposits of the phosphate and carbonate of lime take ijlace especially in the center of the tumor and form either an incomplete structure or true uterine calculi. They are scarcely ever observed except in the subserous pedunculated fibromata or in the polypi. Softening may arise from two causes. During pregnancy fibroids acquire a considerable size, as they participate in the exaggerated nutrition of the uterus. Thus swollen thev are generallv softer Fibroid Tumors of the Uterus. 139 after parturition. By a process, Avhich has been somewhat hypo- thetically attributed to fatty degeneration, they may disappear by degrees, participating thus in the invohition of the uterus. Fatty degeneration has never been found microscopically except in two cases, where diminution of the tumor had not resulted. Amyloid degeneration has been observed by Stratz in a polypus: This case is unique. CEdema, which is the first stage of mortiiication, may cause softening of the fibroid tumor. Colloid or myxomatous degeneration is characterized, according to Virchow, by the effusion of a mucous material between the muscular fasciculi. It is dis- tinguished from simple cedema by the presence of mucine and the proliferation of nuclei and of round cells in the interstitial tissue. Fig. 73. — Pedunculated fibroid of abdominal evolution. MS, fibroma of lobe; MC, fibro-cystic lobe. (Schroeder.) The formation of fibro-cystic tumors may succeed to any one of these infiltrations when the meshes which separate the small cells of the oedema are destroyed. There is, then, no distinct wall to these cysts, as they are simply made up of the lacunfe of the tissues of the tumor. Fibro-cystic tumors have a very different origin from other growths and belong to a special anatomo-patho- logical species. The cysts occur in preformed cavities that are 140 Fihrn'td Tiimitra of thr TVovis. clilatatious of the lymphatic vessels comijarable to those sometimes attaiuecl by the bloodvessels. The contained liquid is limpid and coagulates on exposure to air. Leopold has caDed them lymphan- giectasic uiyomata. On the internal surface of these lymphatic cysts there exist an endotheUal lining, which distinguishes them from the simple cavities formed by softening of the neoplasm or by hiemorrhage into its thickness. Mixed forms are observed, both telangiectasic and lymphangiectasic. It is essential not to confound tibro-cystic tumors of the uterus, either with intra-ligamentous ovarian cysts, very adherent to the uterus, or ^nth the accumu- lations of serum that are sometimes found in the foci of pelvic peritonitis around that organ. This mistake has been made more than once. Finally some pseudo-cysts are formed by the foci of molecular, granulo-fatty degeneration, which may be produced in the center of large tumors when the nutrition is impaii-ed. The mortification may not be followed by gangi-ene, because of the absence of germs. There is then produced a necrobiosis, Avith the formation of soft masses, falling later into dehquescence and constituting cavities with more or less liquid contents. Sanguineous effusions often increase the dimensions of these false cysts. Eupture of such a focus into the uterus has been noted. In some rare cases, in which there is obliteration of the uterine orifice through elongation of the cervix, partial rotation, or inflammation, a special haematometra occurs. By way of resume it ^^"ill be seen that from an anatomical point of view the myo- or the fibro-cystic tumors do not constitute a natural gi'oup. We may recognize, as to origin: 1. Closed spaces, resulting from the dilatation of the lymphatics, lymphangiectasis. •2. GEdematous and myxomatous infiltrations, in the last stage. 3. Lacuna? formed in the center of tumors by the disintegi-ation of the tissue, myomata or sarcomata. Hfemorrhagic foci may com- phcate these conditions. Injiammat'w)! , suppuration , (jatKjrene. — It is probable that the origin of inflammation in fibromata is always a more or less extended loss of ^■itality which infects the capsule and provokes a supjjuration in this zone where the tissue is at once more vascular and more lax. This initial death is due either to surgical interference, opening the capsule of the tumor as a therapeutic procedui-e, or to an infection from without in consequence of a septic exploration (dilatation, probing). It may also proceed from the compression or the obhter- ation of the nuti'itive vessels, together with an erosion of the mucosa which covers it and protects against the entrance of germs. It is especially in polypi that tliis last mode of gangrene is observed. If it is true that the death of a small portion of an interstitial or of a submucous filn-oid precedes inflammation and suppuration, it Fibroid Tumors of the Uterus. 141 is also true that these are in their turn the causative agent of the gangrene of the whole mass. The sloughing parts are eliminated spontaneously or with the aid of surgical interference ; but they may also cause a putrid infection. The pus may then extend into the pelvic cellular tissues. Cancerous degeneration. — Can a fibroid become the starting point' of a cancer ? Simpson has maintained that the irritation caused by the presence of the fibroid becomes the starting point for a malign growth. To-day we express the same idea by saying that this presence constitutes a locus minoris resistentice, causing the local determination of the diathesis. Eecent researches have permitted an exact statement of the processes. It is probable that in certain cases it is the chi-onic inflammation of the mucosa, usually accompanying the fibroid, that causes first a proliferation of the glands. This passes from the typical form, adenoma, to the atypical form, epitheloma. A second mode of transformation of the fibroid into cancer is sarcomatous degeneration of the connective tissue frame-work itself, by infiltration -wdtli round cells. It is possible that these myosarcomata undergo cystic transformation, either by distention of the lymphatic spaces or by softening and hsemorrhagic effusions. They produce then a sarcomatous variety of fibro-cystic tumors. With regard to carcinomatous degeneration of fibroid tumors of the uterus, the researches by Gusserow show that it is far from being demonstrated. The observations which have been cited generally relate to cases where carcinoma has invaded the uterus by the side of fibromata, very different in a pathogenetic and anatomo-pathological point of view, although very analogous in the clinical. C. Liebman has published a case in wliicli the carcinomatous degeneration appeared certain. There was at the same time cancer of the two ovaries. The association of cervical epithelioma with fribromata of the body is quite frequent. Contiguous and distant lesions. — Endometritis exists in almost every case of fibroid. The mucosa of the uterus undergoes an interstitial or glandular hyperplasia. Wyder has observed that this last is met almost exclusively in fibromata quite distinct from the uterine cavity, wliile the interstitial form accompanies the fibroids that are not distant from the mucosa. A mixed form is also observed sometimes. These lesions account for the haemorrhages sympto- matic of the fibromata. An endo-salpingitis often exists by extension of the disease. Rosa, in the course of a myomotomy, found an hsematoma of the tube which had so thinned this organ that perfo- ration was imminent. Bantock has often found a fatty liver among patients affected by large fibromata and he attributes this lesion to the presence of the tumor. Fibroid tumors, by compressing the ureters, often prodiice serious kidney troubles. The lesions of the heart, which occur in 142 Fibroid Tudujvs oJ the Uterus. all large abdominal tumors, are frequently a complication of uterine fibroids. They sometimes appear associated with a renal trouble, but tills correlation is not always found. The cardiac hypertrophy, with or without dilatation of the cavities or consecutive alteration of the fibres, have, without doubt, a pathogeny analogous to that which cause hypertrophy during pregnancy. With regard to the tiltimate degeneration of the heart, it is greatly favored by the state of anaemia and the cachexia of some subjects. CHAPTER IX. FIBROID TUMORS OF THE UTERUS.— SYMPTOMS, DIAGNOSIS, AETIOLOGY. The symptoms of uterine fibromata are of two varieties : 1. The rational symptoms which reproduce the uterine group of symptoms have been described, with some special peculiarities and with the predominance of the symptom, haemorrhage. 2. The physical signs arising from the presence of the tumor. 1. Rational symptoms. — The developments into which I entered in the discussion of the uterine group of symptoms permit abridge- ment of the description of these symptoms. The haemorrhages are especially marked here and become the predominating symptom in the majority of cases. They occur as menorrhagias or metror- rhagias. They are intimately associated with the lesions of inter- stitial metritis which always accompany the fibromata that are a little distant from the mucosa. The glandular metritis, which coexists with the fibromata that are more distant, only give rise to leucorrhoea. In general, the htemorrhage is more marked in proportion as the neoplasm approaches the uterine cavity. It attains its maximum in polypi. These losses of blood weaken the patient very much but eases of death are exceptional. In one autopsy, reported by Matthews Duncan, a large uterine sinus was found ruptured. Leucorrhoea is usual. Sometimes there is an abundant flow of a serous nature, but distinguished from that of cancer by the absence of odor and by its intermittent character. The pains are of various kinds. Usually there exists a painful sense of weight, of lumbar dragging, so frequent in all uteruie affections. To this is added, in tumors which project into the uterine cavity, colic or expulsive pains, sometimes very severe at Fibroid Tuviors of the Uterus. 143 the menstrual period. Some large tumors, by pressure on the sacral plexus, cause sciatica. These pains are intermittent and particu- larly severe at the time of the menses. The phenomena of compression are very frequent, as regards the bladder. It is especially at the monthly period that the vesical troubles are pronounced. They sometimes assume the importance of true cystitis by retention of urine. The compression of the neck of the bladder may produce a chronic distention of the organ, which has been mistaken for an ovarian cyst. The pressure upon the rectum, less frequent than that of the bladder, sometimes causes hsemorrhoids and unites its influence with that of the habitual dyspeptic in producing constipation. Barnes attributes a great importance to the resorption of excre- mentitious material which follows obstinate constipation, calling its result copraemia. The recent researches on ptomaines and leucomaines give a certain weight to this opinion. In fibroids fixed in the pelvic cavity the pressure upon the rectum may cause a strangulation leading to death. The compression of the ureters and the serious renal troubles that this causes become an important indication for operation. A very great number of the deaths in consequence of hysterectomy or of castration should be attributed to pathological changes in the kidneys, often unrecognized, Avhieh the surgical interference and the long inhalation of antesthetics have aggravated. On the con- trary, suppurating pyelitis and albuminuria, with threatening symptoms of ursemia, have been seen to disappear after the ablation of a fibroid that compromised the ureters. Every abdominal tumor is the cause of an increase of vaScular pressure and consequently reacts on the cardiac muscle. It is not astonishing then that even a slight heart lesion may be aggravated by the presence of a fibroma. A part of the diseases of the heart observed in patients affected with large fibromata have this origin. But this complication is too frequent to receive a similar interpre- tation in every case. Hofmeier relates a series of eighteen cases in which sudden death by arrest of the heart was caused by an abdominal tumor. In three cases there was advanced fatty degeneration of the cardiac fibre. In fifteen cases there was brown atrophy of the heart. Five deaths occurred before any operation, nine after an operation, and five after accouchement. Auscultation should then be made with great care in every patient affected by a fibroid tumor of a certain volume. I agree with those surgeons who see in tliis lesion a new indication for operation and at the same time a grave element in prognosis. Among the signs furnished by local examination, the increase in the length of the uterine cavity should be placed in the first rank as the most constant, being common to both large and small tumors. 144 FUiroid Tumors 'pe (small interstitial fibroidj. Fibroid Tumors of the Uterus. 145 f A. Fibroids of the infravaginal part of / Sessile. I tlie cervix. \ Pedunculatea. B. Submucous fibroids (of tlie body). II. Type of vaginal evolution -{ C. Fibroids (of the f(a). Intrauterine. I body), polypi or J (b). Presenting intermittently. I pedunculated fi- 1 (c). Intravaginal. — [ broids. [ var. enormous polypi. f A. Pedunculated fibroids. TTT T r uj ■ I It- B. Sessile fibroids, not included in the broad III. Type of abdominal evolution ,. ^ ' C K > , 1 • fp ttt' ]\ ■{ ligaments. ^ '^ ' " ' ' j C. Sessile fibroids included in the f Abdominal. I broad ligaments. \ Pelvic. I. Diagnosis of fibroids of metritic type (small interstitial fibroids). — When the tumor is small and has not yet separated the walls of the uterus (Fig. 62), it is sometimes difficult to recognize the true origin of the symptoms observed. The guiding symptoms then will be the persistence of haemorrhages coincident with an increase in the volume of the uterus, the enlargement of its cavity and the presence of a tumor when it can be found. Thus htemor- rhagic metritis will be excluded. The beginning of pregnancy is characterized by the absence of the menses; here the occasional eases in which menstruation persists should be remembered. Mis- carriage with retardation of uterine involution, caused by a partial retention of the placenta, is distinguished by its special course as well as by the study of the products expelled or furnished by the curette. Cancer of the body of the uterus gives rise also to haemorrhages and to increase in the size of the organ, but these symptoms are accompanied by fetid leucorrhoea, and, in doubt, microscopic examination of a fragment removed by the curette will determine the natu.re of the disease. Inflammations of the tubes and ovaries are a very frequent cause of error, especially from the misleading fact of frequent haemor- rhages and the tumor (hygro-, haemato- or pyo-salpinx) which often appears as a part of the uterus, either at the side or behind in Douglas' cul-de-sac. Fluctuation must be sought for to clear up the diagnosis. It is generally wanting in small tense tumors and besides it is dangerous to seek for it Avith too much persistence. The very great rapidity of the formation of the tumor, the history, the rational signs, minute local examination under anaesthesia, the absence of increase in the length of the uterine cavity, will be valuable signs in the recognition of an affection of the appendages. Anteflexion and retroflexion of the uterus, even when accom- panied by hfemorrhages, will not be long in doubt. The nature of the tumor that is felt in one of the vaginal culs-de-sac Avill be quickly recognized by bimanual examination and by the sound. I only mention the small faecal tumors that accumulate in the rectum and confuse the young practitioner. They are compressible to the finger and a rectal enema causes their disappearance. 146 Fibroid Tumors of the Uterus. II. Diagnosis of fibroids of vaginal evolution. — A. Of the infrardijinal portion "nfecology makes it possible to-day to avoid for the most part abdominal section. I will discuss, in this chapter, only the fibrous tumors that are pushed toward the vagina by theii- evolution and that are accessible through this passage. A. Fibrous tumors of the vaginal portion of the cervi.i. — About the cervix, from the thinness of the tissues, there is no chance to dis- tiaguish fibroids as submucous and interstitial. They are usually easily detached from the contiguous tissue. An attempt may be made to eniicleate them ^vith the finger and a spatula, after having removed then- inferior portion and having sufficiently diminished their size by ablation of a pari or by a conoidal section, so as to facilitate the procedure. It is quite useless to complicate the oper- ation by using for the morccllement the ecraseur or the galvano- cautery loop. The last is dangerous to the neighboring parts and requires deUeate management. ' It should only be employed in very exceptional cases. The ecrasem- that so many sui-geons still advise is open to many objections, some of them very gi-ave. It breaks easily on tissues of extreme resistance, it cuts very slowly and causes the loss of considerable time, during wliich the uterus may bleed Treatment of Fibroid Tumors. 157 above the tumor, and finally it has a tendency to creep up the tissues, so that it has sometimes caused an opening into the peritonaeum. To lose as little blood as possible I believe that the best method is to proceed quickly with the knife. In fact, fibroids are but slightly vascular, and if some vessels are divided, it is easy to arrest haemor- rhage by placing forceps on them, or by using the thermo-cautery. If the tumor of the cervix is prolonged upward toward the uterus, it should not be followed too far, only the parts easily accessible should be removed, leaving the base in place, as it will, without doubt, be pushed outward later by the uterine contractions and can then be extirpated. If there is a myoma not enclosed in a capsule, ampu- tation of the tumor is made as high as possible, preserving two flaps which are reunited. When there is a clean wound after enucleation its edges can also be pared and sutui'ed. But if primary union is deemed impossible the debris is dissected from the capsule and the wound dressed with iodoform gauze. B. Pedunculated fibroids {of the body) or polypi. — When the polypus is intrauterine a preliminary operation is necessary to render it accessible. Bilateral incision of the cervix is preferable. This is made with strong scissors as far as the vaginal insertion. The supravaginal portion of the cervix is generally dilated by the efforts of the polypus itself. If not, softening is induced with a laminaria tent and the dilatation finished with Hegar's dilators. Then, if necessary, the bilateral incision is made. The ablation of a polypus is usually very simple. The patient is placed in the dorsal position ; the vagina is held open with retractors ; the polypus is seized with the forceps and drawn down as much as possible, while the hand above the pubes makes sure that the uterus is not inverted. The polypus is then given a movement of rotation on its axis, in such a way as to twist the pedicle. After two or three turns a pair of strong scissors curved on the flat glides over the tumor to the insertion of the pedicle and the incision is commenced by making slight snips, meanwhile continuing the torsion. This has a double effect, it aids the detachment of the pedicle and it favors hsemostasis. It is gen- erally advised to cut the pedicle as high as possible. By the opposite course, one is put, I believe, more on guard against the chances (very problematic) of secondary htemorrhage. The cut pedicle retracts into the uterine cavity and the portion which remains shi'ivels and is rapidly obliterated in consequence of the torsion it has undergone. All the means employed for fear of haemorrhage should be abandoned. They have caused more victims than they have saved patients. The galvano-cautery loop, the serre-noeud, the eeraseur, the ligature, all prolong and infinitely complicate an operation, which should be rapid to remain benign. In those very rare cases where the pedicle contains large vessels, the danger of haemorrhage 158 Treatment of Fibroid Tumors. may be recognized by previous palpation, and may I^e avoided by placing on the pedicle, before cutting it, long i^ressure-forceps- that are to be left some hours. If haemorrhage ensues, injections of hot water, ergot, and, if necessary, antiseptic tamponade of the uterine cavity mth iodoform gauze Avill overcome it. I have proposed to call enormous jiolypi those, which Ijy tiUing the cavities of the vagina, do not allow the finger to reach the pedicle and usually not even to pass the vulva except after certain manoeuvers. The enormous polypi i)resent special operative indi- cations. Section of the pedicle camiot be essayed without a previous dimininution of their volume. This result is very simply attained by combining the different means which have been praised by turns. That wliich is called operative elongation is obtained by deep incisions, made hke steps in the tumor, wliile it is being drawTi out- ward. The same end is attained by spiral incisions in the capsule of the tumor wliich is the most resisting part. Finally, morcellement by the ablation of sections or of conoidal fi-agments, which scoop out the tumor, appears to be the best means. It is better to attack the tumor than to incise the fourchette as has been advised. As soon as the tumor is sufficiently diminished it is seized in the large forceps. Compression reduces its volume still more, and section of the pedicle can be made by the scissors at the same time that it is being twisted. It is especially in cases of women who are enfeebled and cachectic to a high degree, that it is necessary to employ these expedients and not to prolong the anaesthesia and the operation. After ablation of the polypi it is well to do at once, or at the end of some hours, a curetting followed by cauterization, to cure the metritis, which is constant, and to cause a more rapid involution of the uterus. Suhmitcous fibroids. — It should be understood that, clinicaUy, we include under this name fibroids which, although separated from the mucosa by a muscular layer, are much nearer than to the peri- tonseal surface, and that cause a notable projection into the uterine cavity. At certain times, duiing the menses or metrorrhagias accompanied by colic, the cervix may be more or less effaced and open so as to allow the finger to penetrate as far as the projection of the tumor. Artificial dilatation, in default of the natural, permits us to appreciate these anatomical conditions. A pressing indication for active interference is the onset of gangrene. The laxity of the connections between the uterus and the tumor contained in its walls, the many examples of spontaneous expulsion by the simple efforts of nature, directs the surgeon's attention to their enucleation. According to Schroeder, the volume of tumors justifying emicle- ation may reach that of a fcetal head at term. This operation wiU be attempted, he says, only in the case where the neoplasm has already descended in greater part into the vagina. We shall see. Treatment of Fibroid Tumors. 159 however, that segmentation of the tumors permits a much greater extension of the limits for operations through the vagina. Besides, it is not alone when there are very small fibroids that one can proceed to operate by enucleation without segmentation. The narrowness and the rigidity of the vagina are a sufficient contra- indication in some cases. Attempts may be made to overcome tliis' by the previous application of tampons. In the absence of sponta- neous dilatation, a passage may be made with laminaria tents and Hegar's dilators before bilateral incision of the cervix. Chobak prefers multiple radiating incisions that are sutured carefully after the operation. If the tumor exceeds the size of the fist, enucleation of the tumor in totality should not be attempted, preference then being given to segmentation. The operation varies considerably according to the volume, the consistency and the connections of the fibroid. Before giving the rules for the operative technique, I will remark, once more, that we rarely make an enucleation as of old, since a greater bold- ness has rendered segmentation famOiar to the ma- jority of surgeons. The most convenient position appears to be the dorso-sacral, though some operators prefer Sims'. Anaesthesia is necessary. Two assist- ants support the patient's limbs ; one depresses the uterus by pressing above the pubes, the other attends to the continued irrigation, both hold the retractors. It is useful to have extra assistants as this work is very fatiguing. When the cervix is not sufficiently dilated we do not hesitate to incise it up to the vaginal in- sertion after having made the precautionary hgature of the inferior branches of the uterine artery. This is the prehminary stage. If the tumor is small and if the cervix is not too much thinned afixation forceps on one lip will be of great service in drawing down the uterus and giving a point of support for the manceuvres of enucleation. The first stage consists in opening the capsule. The most projecting part of the tumor is seized with the polypus forceps, and at the point where the mucosa is reflected from the growth to the uterus an incision is made with the knife or scissors to the greatest possible extent, if it cannot be torn with the nails. In the second stage the tumor is peeled out with the fingers introduced into the capsule. A spatula is necessary in some eases. It should be blunt and slightly concave. I have designed an enucle- ator which has done me great service (Fig. 74) . I prefer it to Sims Fig. 74. Pozzi's Enuc- leator. 160 Treatment oj Fibroid Tumora. enucleator and to Thomas' serrated scoop. In proportion as the adhesions of the fibroid have been destroyed to a certain extent, it is drawii doNMiward bj- taldug a new grasp with the polypus forceps. The fibroid is thus made to roll on its axis, if nec-essary cutting \\ith the scissors the fibrous bands that do not yield to the enucleator. The third stage, or the delivery of the tumor, is troublesome onlj' if it is voluminous ; then segmentation and reduction with the small forceps may be necessary, as in enormous polypi. I was able to deliver in a mass, mth the ovum forceps, an intrauterine fibroid larger than the fist, that I enucleated, not from its capsule, but from the uterine canity where it had contracted adhesions. This was a very curious case of a polypus with intermittent presentation. Various instmments hate been constructed for the extraction of voluminous tumors, but the armamentarium can be reduced to the instmments I have indicated. When fatigue on the part of the operator or the exhaustion of the patient have suspended the operation before completing the extir- pation, there is sometimes seen either spontaneous elimination of the rest of the tumor at the end of some days, or, at a second operation, few^er difficulties in consequence of infiltration of the capsule and relaxation of the adhesions. This last fact gave to some operators the idea of making the operation in several stages. But this is transforming a condition of necessity into one of choice. It exposes the patient, in fact, to the dangers of septicaemia which has followed in cases treated in this manner. There is another operation in two stages : in place of making two sittings for the enucleation there is only made in the first, after the method of Atlee, a deep incision in the capsule. Several days later, when it is supposed that the uterine contractions have produced the dehiscence of the incision and a certain detachment of the tumor, enucleation is proceeded with. Vulliet has recently taken up Atlee's method and perfected it. He fii'st tries, somewhat theoretically, to direct the fibroid from its very first appearance toward the uterine ca\ity, rather than toward the abdominal cavity, by the use of electricity (galvanic current). Then, the fibroid having become submucous is treated by incision of its capsule ; finally, ergotuie and electricity will give to the tumor a tendency to spontaneous enucleation. This is still more accentuated by the intrauterine tamponnement with iodoform gauze renewed evei-y forty-eight hours. Finally, operative interference terminates the work of si^ontaneous expulsion, which sometimes takes place in the form of a polypus, sometimes in sections. This method may be reproached with extreme slowness, the multiplicity of manoeuvres to which the uterus is exposed and useless temporizing when the tumor has become accessible to operation. Tf it is impossible to remove the whole of the tumor, except by Treatment of Fibroid Tumors. 161 the use of dangerous force, we are resigned to leaving a portion in the uterus, pro\ided that by an appropriate antiseptic treatment (iodoform tampon, carbohzed intrauterine injections, etc.), we guard against septicaemia wliieh is Uable to be caused by the gangrene of the remaining portion. But these incomplete ablations of fibromata have given rise to disaster when antiseptic precautions were not taken or did not succeed. Although this emergency is always unfortunate we can hope in such cases for one of two termi- nations : either the more or less tardy expulsion of the remnant of the fibroma, or the retraction and the atrophy of the intrauterine fragment. After the enucleation of an intrauterine fibroma there remains a cavity, often quite large, bleeding, traversed by floating debris and a uterus in a state of more or less completed relaxation. The Avound should be smoothed by excising the ragged edges of the mucosa and the fibrous filaments. A hot antiseptic injection is then given. It is better to use a carbolic solution (20-1000) than the sublimate, on account of the large absorbent surface. The temperature will be raised to 50° C, if there is marked oozing of blood. The cavity may also be tamponed. Finally, a hypodermic injection of ergotine to- gether with massage over the uterus, wUl cause contractions of the organ. A tight body-bandage will be placed over small thicknesses of cotton-wool and the patient will be left entirely at rest. The principal accidents of enucleation are hsemorrhage, wounding the uterine waU, and secondarily, septicaemia. For the haemorrhage the best remedy is to terminate the operation rapidly. The slu-inking of the uterine walls causes haemostasis. If necessary, compression of the abdominal aorta and intrauterine tamponnement wiU be made. Perforation is very grave only in case septic inflammation attacks the cavity. Otherwise an adhesive peritonitis soon closes the wound, as after vaginal hysterectomy. , Inversion may be produced during the operation under the influence of excessive traction and may even facilitate the work of the surgeoir by making the tumor more accessible, but it is dangerous if not recognized, for it may lead the efforts in a faulty direction. After the operation the thin- ness of the organ has sometimes favored a secondary inversion. Bischoff, in such a case, obtained gradual reduction by aid of the tampon. Septicaemia, with its various local manifestations, metro- peritonitis, thromboses, etc., is to be feared when a very large cavity exists in consequence of want of contraction of the walls of the uterus. It is then useful to make repeated intrauterme injections and antiseptic dressings. The cruciform drainage-tube may be left in the uterus. In cases where the secretion is very abundant and putrid continued irrigation should be employed. Gravity of the operation. — According to the judicious remarks of West and of Gillette it is impossible to arrive at an exact idea of 162 Treatment of Fibroid Timiors. the gravity of euucleatiou from .statistics obtained by combining all the published cases. On the one hand, successes are more frequently pubhshed than failures. On the other hand, very dis- similar cases will be tabulated together, complete or incomplete enucleations in one or more sittings, on intact or on gangrenous tumors, treated aseptically or not, etc. Finally the word enucle- ation is not understood in the same sense by all authors. To be able to judge this operation correctly — as well as all others — it is necessary to collect individual series or authentic cases from com- petent surgeons and properly classified. For the present we must content ourselves with more or less incomplete statistics. I had thus, in 1875, collected sixty-four cases with sixteen deaths, or 25 per cent. Gusserow has been aljle to collect one hundred and fifty- four operations, to 1877, with fifty-one deaths, or 33 per cent. Lomer, who restricted his inquiries to the antiseptic period, from 1873 to 1883, has found one hundred and thii'ty cases ^vith eighteen deaths, or 16 per cent. FinaUy, by adding to the statistics of Lomer some still more recent facts, Gusserow obtained one hundi-ed and fifty-thi-ee cases, with twenty-three deaths, or 14.6 per cent. The enormous gain accomplished by antisepsis will be noted. A. ilartiu, out of twenty-seven operations, had five deaths, two by wound of the peritonseum and peritonitis, two by septiciemia (before the era of autisepticism), one death from collapse. He declares that he has entu'ely renounced vaginal enucleation for tumors of the body of the uterus, even when they are half intravaginal. He much prefers extraction thi'ough the abdomen, and makes an enucleation that respects the integrity of the uteras as we shall see later. I believe, with Martin, that the indications for enucleation thi-ough the vagina have been carried too far. Tumors reaching up toward the umbilicus are much better removed by laparotomy. However, enucleation (alone or with segmentation) remains a A^aluable resource, relatively benign, in fibroids of the cervix, and for those of the inferior j)ai-t of the body of the uterus, not exceed- ing the volume of a foetal head, and which have already commenced dilatation of the cervix. Transvaginal enudcation. — It may happen that the myoma, arising from the supravaginal portion of the ceiTix or fi-om the posterior surface of the uterus, projects behind the posterior vaginal wall in such a manner that the most direct way to arrive at its enucleation is afforded by iucision of this waU. The same may occur, though more rarely, with regard to the anterior cul-de-sac. In such cases the more rational operation is to fi'eely iucise the vagina for the extirpation of the fibroma. It will be understood that the pro- cedm-es wiH be relatively simple for tumors exclusively developed in the pelvic connective tissue and not covered by the peritonaeum. Treatment of Fibroid Tumors. 163 When the tumor is very large, it is better to add segmentation to the enucleation. When the fibroid projects, both toward the vagina and toward the peritoneal cavity, the danger of opening the peritonaeum complicates the operation very much and renders it more grave. There have been several deaths due to consecutive peritonitis. But many successes have also been reported. Segmentation or vaginal myomotomy . — The difficulty of enucleation, when the tumor has a considerable volume or close connections with the uterus, and the gravity of opening the abdomen, compared with operation through the vagina, have caused venturesome surgeons to undertake the ablation of successive large fragments, by the vagina, through the cervix, nearly effaced either by natural dila- tation or by incision. Emmet has designated by the name, extraction of fibroids by traction, a procedure that he has practiced since 1874, but unfortunately it is not clearly described. His aim, he says, is to pedunculate the tumor by traction, and then he excises it by a mixed procedure of segmentation and enucleation. But he describes his technique in so imperfect a manner that it is difficult to obtain a precise idea of it. The isolated facts of Czerny and other German surgeons are no better fox'mulated into a definite method. This criticism does not apply to the method that Pean has adopted. The chief idea of his procedure consists in using segmen- tation first, as the initial manoeuvre and not as an aid to enucleation. In place of attacking the tumor at its periphery first, the surgeon enters the fibroid at once and does not arrive at the fibrous capsule until the tumor is scooped out. More, Bean's operation comprises a special preliminary operation, of discision and even excision of the cervix to allow easy access to the fibroid. The cases to which tins surgeon has applied segmentation through the vagina comprise not only submucous tumors the size of a child's head at term, but also cases of interstitial and subperitonseal tumors, wliich certainly necessitate opening the serous membrane largely. Thus in these cases Pean has often been obliged to terminate the operation by total ablation of the uterus, either through the vagina or by lapa- rotomy. This is perhaps an extreme and dangerous application of the operation. The weak point of this operation is truly, it appears to me, in the difficulty of determing the limits which must not be passed, and the possibility of being obliged to perform hysterectomy at the end of an already laborious operation. The operation is divided into several stages: 1. Liberation of the cervix from its vaginal insertions. 2. Section of the cer^dx and of the segment of the uterus as far as the limits of the tumor. 3. Segmentation of the tumor, followed or not by the enucleation of a part of the tumor. 4. Excision or suture of the cervical lips. For this operation Pean employs a whole series of forceps, straight 1()4 Treatment of Fibroid Tumors. and curved, with jaws of various shapes, long, Hat, deutated or non- dentated, with or without i)oints, round or square, especially designed for segmentation (Figs. 75 and 76). Finally it is necessary to have an ample number of forcipresure forceps, either of the ordinary model or with loug handles. The preliminaries are the same as for all gynfficologieal operations. The patient is placed iu the left lateral position. Left leg extended, right leg flexed and supported by an assistant. Besides two other assistants placed, one to the right and one to the left, of the operator, a fourth, mounted on a foot-stool and placed a little further back will be useful to hold the retractors. Fig. 75. — Dentated cyst forceps that can be utilized for segmentation. Fig. 76. — Pean's forceps for segmentation. First ST.\(iE. — JAheration of the neck. — Two or tlu-ee curved re- tractors held by two assistants uncover the cervix in the fundus of the vagina. The cer^dx is seized and immobilized with a strong vol- sella. A circular incision is made with the loiife at the vaginal insertion. The haemostatic forceps are placed, if needed, on the bleeding points of the vaginal surface. This is the time when these Treatment of Fibroid Tumors. 165 forceps are most necessary, for before preceding with the opera- tion it is important to obtain complete hsemostasis. The dissection is carried to a sufficient lieigiit around the cervix. The cervix is encircled near this with the knife, especially in front, so as not to injure the bladder or the ureters. The cervix then becomes very mobile like the tongue of a bell. In this stage of the operation care must be taken not to wound the peritonteum. This accident is not so serious, however, as has been supposed. In some cases, accord- ing to Pean, this perforation is necessary to reach a fibroid that projects into the cul-de-sac. Second st.\gb. — Incisions of the cervix and of the inferior segment of the uterus. — Long straight scissors, with blunt ends, are intro- duced open, with one blade in the cervical cavity, and a clean bilateral section is made. A volsella is placed on each lip, ante- rior and posterior. The finger introduced into the uterine cavity indicates the exact site of the tumor, the part Avhere it will be most easily reached. The tumor is distinguished from the uterine walls by its wliitish aspect, and especially by its greater density. During this exploration, aid may be obtained by traction on the uterus. Fig. 77. — Segmental Thied stage. — Seginentation of the tumor. — The tumor may be projecting toward the uterine cavity, toward the peritonaeum, or toward the vagina. It is drawn down by a sustained traction, with the volsella, or with long forceps furnished with flat dentated or 166 Treaiment of Fihrvid Tumors. fenestrated jaws or with points (Figs. 75 and 76). With these forceps the tumor does not tear so quickly, the grasp is more soHd. The curved retractors are introduced, krge ones into the vagina, small ones into the uterus, uncovering the field of operation as much as possible. These retractors serve not only to admit light, but con- stitute at tne same time a valuable hasmostatic measui-e by the pressm-e and the traction that they exercise. If needed an electric light can be made to thi-ow a bright light on the field of operation. The fibroid tumor is uncovered or felt ^^ith the finger ; it is seized with the forceps and forcibly drawn doT\Tiward. It may be first grasped at one part by strong dentated forceps ; a deep incision pei-pendicular to the long axis of the tumor is made ; each Hp of this section is seized as far up as jjossible with the dentated forceps, or that ^^ith points m the jaws ; the part subjacent to the forceps is ex- cised. Before removing the first pair of forceps a second paii" is fastened above it, catching a new part of the fibroid ; the scissors or the knife divide the parts subjacent to the preceding pair of forceps. Thus by the aid of the forceps, the knife and the scissors, a poi-tion of the tumor is extirpated piece by piece. The knives used by Pean are of very gi-eat strength, resembling small metacarpel laiives, straight or curved on the flat, with long handles. Quite often, the proeeding is simpUfied. The myoma does not bleed, so that the use of the forceps can be limited to grasping the tumor and drawing it down. The scissors or the knife divide the tumor above the fragment seized \\ith the jaws of the forceps. The removal of the pieces is continued alternately on the different parts of the tumor. In proportion as the operation progresses, the tractions permit the removal of larger fragments. These vary from the size of a nut to that of an apple. The segmentation of some fibroids is very simple, each traction permitting the ablation of a large fi'ag- ment of hard tissue, absolutely exsanguinated. The operation will be almost bloodless if it has not l)een necessary to hberate and incise the cervix. The introduction and M"ithdrawal of the forceps fom" or five times permits the extractioai of successive fragments. This procedure in other instances may require an hour. WTien the lower parts of the tumor have been removed it is sometimes possible to obtain, by traction aided by movements of rotation, the spontaneous enucleation of the remaining part, the length of the operation may thus be materially diminished. According to Pean, segmentation aided by enucleation permits the ablation of a tumor equal to or greater than that of a foetal head at term. 'When the fibroid presents such a thickness, the intra-miiscular layers, which envelope it, are almost always ex- tensively opened, communicating with the interior of the uterus and peritonaeum, and bleeding so freely that it may be necessary to place forceps on the large vessels. Tliis stage of the operation then Treatment of Fibroid Tumors. 167 necessitates the dissection of all the lower part of the uterus in such a way as to free the organ and permit it to be drawn down near the vulva. If necessary, to faciUate the procedure, Pean excises the two lips of the cervix and sutures them finally to the lips of the wound made in the mucosa of the vaginal culs-de-sac. He makes tliis suture with metallic threads. With regard to the communica- tion which exists with the peritonasal cavity, Pean leaves it open or if too much bruised draws it together with a few interrupted sutures. It is not difficult to perceive the point where the ablation is com- plete ; the last portions extracted by traction and enucleation offer a convex surface, smooth, red, covered with small cellular debris. This stage of the operation is not complete until the surgeon has taken exact account, with the finger, of the state of the contiguous uterine structures. If a new myoma is found near the first, he should proceed at once to its extraction. He will have recourse to a more extensive division of the uterus if necessary, arriving thus at this tumor, proceeding to its segmentation as before. Thus, the operator may find it a necessity to remove a series of small tumors from the parenchyma. Hysterectomy will be indicated in case the uterine incisions thus produced would be too extensive. The idea of making a complete operation should always be kept in view. Opera- tion at a single sitting is much preferable to su.ccessive seances. Fourth stage. — Toilet of the uterus; Suture of the cervix. — As soon as the tumor has been removed, there remains a large pocket, which communicates freely with the uterus. Haemostatic forceps with long handles are fastened on the bleedmg points and left remaining, to the number of twelve, fifteen or twenty. The forceps are not placed blindly. During the operation small sponges, carried in sponge holders, are used by Pean to cleanse the walls and to discover the bleeding points (I replace them with tampons of absorbent cotton). Tliis last part of the operation consists of the toilet of the operative field and should be executed with care. The smallest clots should be removed. Between the forceps that are left remaining, as an hsemostatic measure, it is prudent to place some tampons of iodoform gauze. An intrauterine irrigation of a hot antiseptic solution should precede the application of these tampons. The forceps are removed thirty-six to forty-eight hours after the operation. In cases where the tumor is small and its capsule of small extent, the operation may be terminated by suturing the lips of the cervix. During the first few days that follow, it is well to give small doses of ergot. It is difficult to pronounce on the gravity of segmentation of fibro- mata by this method. Pean has not published his entire statistics. TerriUon, out of five operations, has had five successes; Bouilly, four out of five. I have been successful in the single case in which I have employed it. It appears to me certain that this bold pro- 168 Treatment of Filiroid Tumors. cedure should give excellent results when the tumor, even vei-y large, is always submucous or markedly interstitial, furnished with a capsule which permits a clean enucleation of the superior part of the tumor. But, if one attacks, either at once, or secondaiily, a subperitouffial tumor, or one so intimately fused with the uterine parenchyma that there is no clear demarcation Itetween the patho- logical and the normal tissue, it is evident that the operation becomes very grave and leads almost surely to a vaginal hyster- ectomy made in bad conditions. Although, in a daring operation, Mikulicz has, immediately after operative inversion, resected a poi-tion of the uterine wall to remove a tumor of this kind, then sutui'ed the periton»al wound of ten centimetres, replaced the uterus and cured his patient, stUl Ave would not hold tliis up as an example to be followed. It is not a sufficient recommendation that an operation may be possible and even that it may have given briDiant results, it is more especially necessary for it to be preferable to all other operations which can be made in the same case ; that is to say, it must be less fatal. Now, in the absence of comparative statistics, it does not appear, a priori, probable that segmentation of very large fibromata, through the vagina, is simpler and less dangerous than abdominal hysterectomy or intra-abdominal enucleation (Martin). Besides, it should be said, that the temperament and the methods of the sm-geon often play here an important role. Vaginal hysterectomy. — The total ablation of the uterus for fibro- mata has been advised in two different circumstances : 1. In cases of small tumors, simple or multiple, giving rise to serious sjTnptoms. 2. In cases of large tumors, when at the end of segmentation there is a certainty that a portion of the uterine wall must be removed ; it is then an operation of necessity on which I shall not enlarge. In small tumors, on the contrary, the operation of hysterectomy, performed by choice, has still only a few partisans and the majority of surgeons prefer, justly I believe, a less serious procedure, cas- tration. It appears that here again indi\-idual preferences are preponderant. Thus, for example, Pean prefers to make a vaginal hysterectomy for the same cases in which some authors practice' al)dominal hysterectomy and stiD others ovarian castration. In fact either of these thi-ee operations has good chance of success only in cases of small and multiple fibromata. Colpo-hysterectomy for fibromata was fii-st systematized into a method by Kottmaun. According to Galabin, out of forty cases of vaginal hysterectomy there were only two deaths, or 1-1.29 per cent. Leopold, out of seventeen operations, had only two deaths. Several times this operation was performed for tumors having the volume of the foetal head at term. The operative technique is to be described in vaginal hysterectomy for cancer. It is only to be Treatment of Fibroid Tumors. 169 remarked here that the segmentation offers no clanger of infection for the wound, the neoplasm (except in suppuration or gangrene) not being septic. Great benefit may be derived from section of the uterus or from segmentation of the tumor in facilitating its extraction. Eecourse may also be had either to a previous dilatation of the vagina and vulva (Pean), or to incisions in these regions (Mikulicz, Leo- l^old) that it will be necessary to restore at the close of the operation. I will note the absolute necessity of making the hysterectomy complete, without leaving in the abdomen even one fragment of the uterine tissue adherent to the broad ligament. The decomposition of such a fragment has caused death by peritonitis. Tliis method of treating fibromata, it appears to me, should be reserved for cases where the uterus, relatively small but compro- mising important organs, can be extracted without great effort and without prolonged segmentation with easy ligature of the broad Hga- ments. It is only in this way that the operation is benign and can be substituted for abdominal hysterectomy. To be more explicit, I would counsel vaginal hysterectomy in cases where the uterus does not notably surpass the size of the fist, and in the following cir- cumstances : 1. Haemorrhage threatening fatal termination if not immediately controlled. 2. Serious pressure-effects (on the ureter, bladder, nerves, rectum) exercised by a smah pelvic fibroma, on the development of which the indirect action of castration will be too long or perhaps insvifficient. In all other cases, if the tumor cannot be enucleated through the vagina or through the abdomen by respecting the uterus, I would prefer castration for hemorrhagic accidents and abdominal hysterectomy when the size and connec- tions of the tumor require extirpation of the organ. In spite of the undeniable dangers of laparotomy a simple abdominal hysterectomy will always be less grave than a very laborious vaginal hysterectomy. Destruction of fibromata through the I'agina. — I will unite under this head the different operations that do not enter into the preceding class and which should be noted historically. Partial destruction by Baker Brown's method ; incision of the capsule ; introduction into the depth of the fibroid with special scissors, cutting by their external border and discision of the mass ; at other times ablation of conoidal fragments or perforation with a kind of trepan ; partial destruction by cauterization. Greenhalgh, for the same object, in- cised the capsule with the actual cautery and when suppuration was established, removed the debris with the hand. In eases of retro- vaginal tumors he perforated, with the actual cautery, the points that projected most into the vagina. In two cases out of three death followed from peritonitis. Koeberle's procedure can be classed here. He dilates the cervix and then makes a series of parallel incisions into which he throws a sufficient quantity of perchloride of iron to determine death of the interposed layers. 170 Treatment of Fibroid Tumors. CHAPTER XL TREATMENT OF FIBROID TUMORS OF ABDO- MINAL EVOLUTION. — MYOMECTOMY AND HYSTERECTOMY. The ablation, thi-ough the abdomen, of fibroid tumors projecting into this cavity, or hysterectomy, is the daughter of ovariotomy. Tliis operation at first was not premeditated ; it was the result of errors of diagnosis. After having opened the abdomen to remove tumors, presumably ovarian, some surgeons found themselves ui the presence of uterine fibromata. The first who committed this mistake shrank from the dangers of an unknown operation, they hastened to close the abdomen without completing the operation. Others, however, had the courage to extu-pate subserous peduncu- lated fibroids. Clay and Heath in 1843, then Burnham in 1853, iindertook the first partial amputations of the utei-us. Gihnann Kimball was the first surgeon who made a hysterectomy for an inter- stitial fibroid giAdng rise to -sdolent hfemorrhages. The patient was cured. Koeberle was only the second, but the exact determination of diagnosis, the rational choice of an operative technique and the absolute novelty of the subject in Europe, gave to his observation an exceptional value. It is the work that he published at this time that truly made hysterectomy the order of the day. Koeberle was the originator of the hgature of the pedicle with a metallic loop and the serre-noeud, which was a considerable advance over the ligature en masse with tlu'ead, which had been practiced to that time. From this time the isolated facts multiplied. From 1866, Caternault, a pupil of Koeberle, published forty-two observations of amputation of the utenis and twenty cases of gastrotomy with extirpation of pedunculated tumors. Many authors, in place of the serre-nceud, employed at that time the ecraseur and the clamp. The eminent surgeon of Strassburg had scarcely made known his operations when Pean followed, with rare good fortune, in the same path. The presentation of a patient that he cured to the Academic de Medecme (August, 1870), then three years later the publication of an important work in which the rules for operation were established with a precision until then unknown, has hnked the name of Pean to that of hysterectomy with extra-peritona?al treatment of the pedicle. The technique consisted especially in the extensive employment of forcipressure (which Koeberle was then the only one to use as fi-eely), in the segmentation of large tumors Treatment of Fibroid Timwrs. 171 after metallic ligature in order not to enlarge the abdominal opening, in the external fixation of the pedicle by long needles passed tln-ough it, and by a loop of iron wire applied with the ingenious serre-noeud of Cintrat. After this first stage in the progress of hysterectomy it is con- venient to distinguish a second. This was characterized by the application of antiseptic procedures to this operation as to all those of general surgery. Finahy a tliird phase has been inaugurated by perfecting the technique and in particular by the introduction of the elastic ligature for temporary or definitive Iwemostasis. The most marked features of this period are the struggle between intra- and extra-peritonseal treatment and the event of castration as a substitute for hysterectomy in a great number of cases. Synonymy. — It is necessary to understand first of all the value of the words. The term hysterotomy, which signifies, etymologically, section of the uterus, is essentially comprehensive. With the qualification abdominal it can be applied to any operation whatever where the uterine tissue is incised after opening the abdomen. An other precise term is supravaginal hysterectomy, which plainly inphes section and ablation of the uterus above the vagina. Tillaux, in 1879, proposed the use of the word hysterectomy for the cases where a part or the whole of the organ is removed. This more exact term prevailed rapidly, although the old word is still met with quite often. The Germans use myomotomy or myomectomy when all or part of the uterus is respected. Finally, imder the name of enucleation (intra-peritonseal), are comprehended the cases where a simple incision into the uterine walls permits removal of the tumor and conservation of the whole of the organ. General indications for abdominal hysterectomy. — We will see later that the possibility of substituting for this grave operation another procedure which is less fatal (castration), reduces, in certain cir- cumstances, the field of hysterectomy. However that may be, we can formulate the indications for abdominal hysterectomy as follows : Rrapid increase ; galloping progress of tumor ; serious hemorrhages, that do not yield to any palliative ; ascites, produced by the irritation of a very mobile fibroid ; compression of the organs contained in the pelvis or in the abdomen ; considerable volume of the tumor, and in particular its cystic degeneration, oedematous or suppurative; symptomatic prolapsus of the uterus; pregnancy, when the fibroid would be manifestly a serious cause of dystocia. The classification that can be established in view of operation through the abdomen is the following : I. Pedunculated fibroids II. Fibroids of a single nucleus (or predominantly so), enucleable. III. Fibroids of multiple nuclei. IV. Intra-ligamentatous and pelvic fibroids. For the first class the ablation of the tumor is of extreme simplicity, and scarcely differs from that of ovariotomy. This is 172 Treatment of Fibroid Tumors. what should be exclusively called myomectomy. For the second and tliii'd class partial hysterectomy or supravaginal hysterectomy will generally he undertaken, according to the disposition of the tumors. In certain cases, intra-peritomeal enucleation can be made. For the fourth class an intra-hgamentous decortication should be made when recourse to a palHative operation, castration, eaimot be had. Finally, total extirpation thi'ough the abdomen has been practiced for some multiple myomata extending to the cervix, ^\ith such hypertrophy of the tissues that any conservation of the stumjjs is impossible. Before passing in review these different operations and their varieties, I w'ill say something of an operative manceuvre appHcable to all and which has completely changed the conditions of the technique since its introduction into abdominal surgery. Provisional hcemostasls. — Whatever the nature of the operation performed in the abdomen on the uterus, it is very valuable to be able to accomplish it without loss of blood. Older operators employed to this effect constriction \nth the ecraseur. Billroth constructed a special forceps. A valuable means of provisional hsemostasis is afforded by the temporary elastic ligature. Kleeberg, of Odessa, was the first to employ the elastic rubber-cord as a Hgature to the uterine pedicle m the place of the metallic wu-e used by Koeberle and Pean. Martin has sj'stamatized Kleeberg's procedure by making the ru-bber Ugature fulfill in uterine surgery the role that Esmarch's bandage plays in general surgery. In Germany rubber tubing of a thickness of about five millimetres is generally used. I prefer the plain cords of five millimetres diameter, and they have been generally adopted in France. It is easier to be assured of their asepsis and in equal sizes they are more resisting. For provisional Hgature the elastic cord is strongly stretched and carried two or tlu-ee times around the part it is intended to constrict. I. Peduncidateil fbromata ; Myomectomy. — First an elastic lig- ature, designed to ensure temporary htemostasis, is placed on the uterus as low as possible by depressing the broad ligaments. Then, if the pedicle is thin, it is sufficient to pass a needle mth a double silk tlu-ead through it, and tie the two ends with a Bantock or Lawsou Tait knot (Fig. 16). If not famihar ^nth tliis special knot, the loop may be cut and the ends tied, to the right and left, after having crossed them by a half turn. The thr-ead should always be passed twice through the loop to make the surgeon's knot. If the pedicle is thick it will be well to gi-asp it with BiUroth's large clamp and compress it strongly while the fibroid is separated by a cut a finger's breadth above it, taking care to leave a sort of collar of peritonaeum and of cortical substance. The clamp is then removed and in the groove that it has caused on the pedicle there Treatment of Fibroid Tumors. 173 are placed a series of silk sutures. The excess of tissue that was left above the compressed part is excised, saving ouly Avhat is neces- sary to exactly cover the wound, which is brought together with sutures previously passed and some superficial stitches. The pro- visional elastic ligature is withdrawn and if the blood oozes by the sutures, some deep ones are added. If at the moment of section of the tissues, it has been possible to see some of the vessels, they may be ligated separately. It is only when assured that all sanguineous oozing has been arrested that the pedicle is abandoned to the abdominal cavity. If there are still doubts as to the hsemostasis, the Wolfler-Hacker method is employed, permitting tamponnement of the stump. Especially in pedunculated fibrous tumors we find ourselves in the presence of extensive ad- hesions to the intestmes, form- ing true adventitious vascular roots, more important than the pedicle. To detach these ad- / ^ ^' hesions, when they are ulti- mate, we use the procedure recommended by Schroeder; the superficial or peritonseal layer of the fibroid is left ad- herent to the intestine and Fig. 78. — Suture orr^all section of a several tlrreads of catgut are fibroid adherent to the intestines and resulting -■ 1111 from an intimate adhesion. I, Intestine; P, so passed as to close the raw Peritonaeal covering from the fibrrid ; S, Silk surface (Fig. 78) . or catgut thread. II. Fibroids ivith a single nucleus (or preponderating), encapsulated; Intraperitonceal enucleation. — These are also relatively exceptional cases. Most often fibroids are multiple deforming a notable segment of the uterus. To make enucleation of the numerous nuclei, and to treat each pocket resulting from this procedure is not possible. But it is different when' the tumor is solitary, whether it be formed by a single or an agglomerated mass, whether it be interstitial or sub- mucous. Then we can conceive and realize the project of removing by enucleation the single neoplasm, by respectmg the integrity of the uterus and its appendages, so that the woman's genital life wiU not be interrupted. This consideration has weight only when it relates to a patient not near her menopause. It will then be exceptionally performed. More fi'equently enucleation will only be considered as a simplification of the operative technique applicable to ceriaiu cases. The operation begins by drawing the uterus up on a bed of com- press-sponges and by placing around the cervix an elastic cord, confining the two ends by a pair of forceps or by my ligator. Having thus ensured provisional hsemostasis, the uterus is incised over the 174 Treatment of Fibroid 'Tumors. projection of the tumor and the fibroid enucleated, if possible, with- out penetrating the uterine cavity. As this procedure has often been performed for submucous fibroids, the uterine cavity has frequently been opened (ten times out of sixteen, Martin). In this event Martin reunites the mucosa by a continued suture of catgut. The opening in the uteriue wall is closed by a series of sutures buried deeply under the whole extent of the wound. At present, Martin makes all these sutures with juniper catgut, in place of the carbohzed silk that he formerly employed (Fig. 79). When the cavity resulting from the enucleation appears too great, Martin places in it the drainage tube, of the two crossed pieces of rubber tubing, passing the extremity through the cervix into the vagina. Freund, in a remarkable case, inasmuch as there was an inflamed fibroid, re- placed the rubber tube with iodoform gauze and tamponed the uterine cavity. The cavity resulting fi'om the enucleation can also be diminished by resecting portions of it. Fig. 79. — A, enucleation of an interstitial myoma: B, suture after enucleation. Martin counsels castration in case of suspicion of another fibrous nucleus in the uterine walls that is inaccessible. Out of sixteen cases he has had three deaths. Once, he was obhged to perform a consecutive supravaginal amputation of the uterus, in consequence of the development of a new fibroid, the nucleus having passed uuperceived during the fu'st operation. This event is e\"idently the weak point of this method. To avoid it, castration should always be combined with the enucleation. But, then enucleation looses its chief end, that of maintaining the genital functions intact, and the operation becomes a simple case of partial hysterectomy with intra- peritonseal treatment of the pedicle. Treatment of Fibroid Timwrs. 175 III. Fibroids of multiple nuclei; Supravaginal hysterectomy. — According to Schroeder it is necessary to distinguish two different cases, according as the fibroid is situated at the level of the fundus above the appendages, the body of the uterus being almost intact, or as the body of the uterus is invaded in such a way that the appendages are lifted up by the tumor, at the side of which they form a sort of appendix more or less sessile. In the first case, the rule is not to detach the broad hgaments, thus making the operation more rapid and less grave. But, as one can never be sure that there does not exist in the rest of the uterus one or more small nuclei, in the process of evolution, it is prudent to perform extir- pation of the ovaries as the last stage of the operation. Thus there is not generally obtained a pedicle as narrow as in ablation of the whole body of the uterus. This reason would be sufficient for the rejection of partial hysterectomy, if one serious consideration did not plead in its favor, at least for the partisans of intra-peritongeal treatment. Tliis is the possibility of performing the operation with- out opening the uterine cavity, permitting reduction of the jjedicle into the abdominal cavity by considerably diminisliing the chances of infection. Thus the distinction established by Schroeder is legitimate, at least in that which concerns the application of his procedure. But it loses much of its value for the supporters of extra-peritonseal treatment of the pedicle, among whose numbers I place myself. Partial hysterectomy presents no essential difference from supra- vaginal amputation, with the exception of the absence of the stage which consists in detachment of the broad ligaments. The pro- visional elastic ligature is made below the tumor, which is removed with the capsule that contains it, preserving a collar of peritonaeum and subserous tissues. This operation is distinguished from enucleation in that the tumor is largely removed at once by encircling it with the knife. Biit this should never be resorted to at once, I advise a preliminary vertical incision to assure that enucleation is not possible, for if so it is then preferable. The pedicle is treated by one or other of the methods applied to supra- vaginal hysterectomy. Hysterectomy or supravaginal amputation is the typical amputation and one to which we have recourse in the majority of cases, either at once, or after having vainly attempted a more conservative operation — enucleation or partial hysterectomy. The two methods, according to the preference of surgeons, are : 1. That, in which the pedicle is treated externally to the abdominal wall, the extra-perito- naeal treatment, to which are attached the names of Koeberle and of Pean, the originators, and of Hegar who brought it to a high degree of perfection. 2. The method in which the pedicle is left in the peritonseal cavity, the intraperitonaeal treatment, which Sclu'oeder 176 Treatment of Fihruhl Tumors. has made his own, but which many other authors have used mth modifications. Fmally, I will describe a mixed method that has the advantage of including the cervix in the ablation of the uterus, that is, total hysterectomy. Technique of supravaginal hysterectomy. — The first stages of the two methods intra- and extra-i^eritoneeal are the same. The abdomen is rapidly opened through the linea alba without stopping to place forceps on the small vessels, in particular the veins which bleed during the first moments but on contact with the air are spontaneously closed. If the tumor is small and has a marked development on the pelvic side, the incision should be extended to the pubes, talung the precaution to be assured of the situation of the bladder by means of a sound. Elongations of this organ in front of the tumor are to be feared. To admit more light one of the recti muscles may sometimes be di-\dded. If the tumor is very large and soft its volume may sometimes be diminished by the puncture of cystic cavities. In other cases it is better to prolong the incision to the xiphoid appendix, if necessary, than to proceed by the long, difficult and perilous process of segmentation, formerly advised by Pean. It is then necessary to disengage the uteinas so that the elastic Hgature for provisional hsmostasis can be appUed. The relations of the bladder to the tumor should again be ascertained, as it may happen, even to experienced surgeons, that the ligature will incliKle a fragment of this organ. To protect the bladder in diSicult cases, Albert places, at the start, a long pin thi-ough the tumor just above the organ, in such a way as to prevent the elastic ligature from slipping down on it. The broad ligaments are then cut between a chain of double ligatures. For this a blunt needle, either straight or- a little cmwed toward the point, is used, or else Deschamps' needle. The tube and round ligament are ligated separately. On liberating the superior part of the cervix the elastic ligature is placed there. Some authors advise going ^ovm to search for the uterine arteries at once, attempt being made to feel their pulsation or then- pro- jection on the sides of the uterus. It ^nU be necessary to descend to the folds on either side of Douglas' cul-de-sac and draw them a finger's breadth away from the cervix to avoid the ureters. This ligature is en. masse and comprises a small portion of the contiguous parts, that is included with the artery in passing a blunt needle. This is only necessary when the elastic ligature is not suflicient and should be removed as in the methods of intra-peritonseal treatment of the pedicle. One of the great advantages of the extra-peritom^al method, it appears to me, consists in being able to dispense with this dangerous stage of the operation. It is always better to I'emove the appendages. Some operators. Treatment of Fibroid Tumors 177 it is true, attach little importance to leaving them in situ, believing that atrophy takes place after hysterectomy, but it is always prefer- able. In fact accidents have been noted, pelvic hsematocele (Pean, Koeberle), extra-uterine pregnancy (Koeberle), that should lead to simultaneous castration, when it does not offer difficulties in con- sequence of extensive adhesions. When the uterus is thus sufficiently freed from its peripheral attachments, the elastic cord is placed on the cervix and the tumor is excised. A primary antero-posterior incision divides it freely to a finger's breadth from the haemostatic ligature, then the fibroid is rapidly removed by section and eni\oleation. From this time the course pursued will differ according as he intends to follow Hegar's example (extra-peritonseal treatment of the pedicle) or that of Schroeder (intra-peritonsal treatment. Intra-peritonaal method. — In describing this, I will conform to Shr-oeder's technique as described by his pupil Hofmeier. In pro- ceeding with the ablation of the tumor care will be taken to finish by a circular incision, distant from the ligature by at least three centimetres, carried first on the peritonaeum and going deeper only after having detached this membrane a little, in such a manner that the collar of tissue saved is formed in part by the serous membrane. This is then trimmed with the scissors in such a way that it may be made to cover the surface of the wound by a slight traction. On the surface of the wound, the gaping vessels that can be found are ligated with catgut. An important stage is the destruction and the disinfection of the cavity of the uterine mucosa in the bottom of the wound. It cannot be doubted that this opening of tlie uterus constitutes an un- favorable element of the intra-peritonseal treatment, for infection may proceed from it. Some authors, Martin, for example, attribute little importance to it, but Hofmeier in an analysis of Schroeder's operation, has demonstrated its influence (out .of twenty-one oper- ations without opening, U\o deaths ; out of fifty-nine with opening, eighteen deaths). It is important, then, to reduce this danger to a minimum, partly by assuring rapid cicatrization by exact coap- tation, partly by energetic treatment of the mucous membrane in the neighborhood of the wound. To this end, Olshausen has advised scooping the base of the wound out to a funnel-shape, by dissecting and removing as much of the mucosa as possible. It is also neces- sary to cauterize the base of the wound with a strong solution of carbolic acid (10-100), or better, with Paquelin's thermo-cautery, which one should not fear to sink deeply and peri^endicularly in the cervical canal. The cautery should not be carried on the suprficial parts of the wound, so as to compromise the primary union that is so carefully sought. The suture is then proceeded with. Veit and Martin employ only 178 Treatment of Fibroid Tumora. juniper catgiit. Schroeder and Hofnieier combine the use of catgut and silk. If there is a raw siu-face of but little extent, it is sufficient to pass with a strong needle some sutures buried deeply under all the wound and forming a series of separate stitches wMeh are strongly tied. The coaptation of the peritonseuni is completed by some superficial stitches. It is very necessary not to lose sight of the fact that an exact coaptation is indispensable for primary union. The difficulty is to suture sufficiently to obtain tliis and yet not enough to compromise the nutrition of the tissues. If the wound be of considerable extent tins simjjle means must be renounced for, to obtain perfect coaptation, we w^ould have to tie the deep sutures too tight. To avoid this recourse is had to the continued sutui-e of catgut in superposed row^s, as preferable to the interrupted suture of silk that Schroeder first employed. However, to guard against too rapid absorption of the catgut, especially to be feared if the tissues are very resisting, care should be taken, before beginning the con- tinued suture, to place some sustaining stitches of silk passed under the whole thickness of the woiuid. They are tied only after having completed the continued sutui-e. It is better to place them in advance and avoid the danger of cutting the other sutures with the needle. They should be placed a little on the Inas and not entirely perpen- dicular to the axis of the wound (Hofmeier), in such a way that they wiU not be parallel to the vessels that they are intended to constrict (Fig. 80). The wound should be reunited longitudinally, that is, parallel to the abdominal wound. Fig. 8o. — Suiure of pedicle in the intraperitoneal method (Schroeder). S, deep suture of silk ; C, continued suture of catgut in superposed rows : P, peritonaeal covering. When the pedicle has been sutured according to Schroeder's method and when- after removal of the elastic cord drops of blood Treatment of Fibroid Tumors. 179 ooze from the surface along the sutures, Martm does not hesitate to traverse the pedicle from before backward with a strong needle furnished with a quadruple tlu'ead and to ligate in two halves. In the autopsies that he has made he has never seen a trace of mortifi- cation in consequence of this ligature. Leopold often employs the same procedure of supplementary ligature. Fig. 8i — Vaginal drainage, wuh cross shaped tube, after vaginal hysterectomy (Martin) Martin always practices drainage after intravaginal hysterectomy, however simple the operation may have been. He depresses Douglas' cul-de-sac with one hand introduced through the abdomen behind the uterus and with a long forceps holding the cruciform drainage-tube, he iiierees the vagina from below upward. The inferior extremity of the tube in the vagina is always surrounded by antiseptic gauze. The tube is withdrawn about the third or fourth day, when the patient begins to feel a certain peculiar uneasiness in the lower abdomen (Fig. 81). This drainage, after simple operations, \\ithout ragged edges or infection of the peri- tonaeum by septic products, is not generally employed. Extra-peritonceal method. — The abdominal cavity is kept closed above the tumor as much as possible and the growth is surrounded with compress-sponges to soak up the blood. The section of the pedicle is then made transversely at two finger's breadth above the elastic Hgature. At this moment there are sometimes seen on the cut surface some fibrous nuclei which penetrate into the pedicle. They can be enucleated without danger of haemorrhage. If vessels 180 Treatment of Fibroid Tumors, are seen they are ligatecl separately. The surface of the stump Is trimmed and it is strongly drawn outward with a volsella. The toilet of the peritouteum comes next and then the pedicle is to be fixed in the lower part of the wound. The provisional elastic ligature can often he used as a permanent Hgature if it is con- veniently placed. If it is situated so low that it cannot be easily drawn outside the wound, a new hgature may be placed above the first before loosening this. When the pedicle is very thick it is useful, according to Hegar, to tie it in two halves after having transfixed it with a double elastic cord by the use of Kaltenbach's needle. I believe this complication can be avoided by placing an extra turn of the elastic cord on these large pedicles. Great care must be taken, in applying the permanent hgature, not to include any organ, bladder, intestine or omentum. In order to do this, touch should always be controlled Ijy vision. Fig. 82. — Suture of the abdominal walls about the pedicle in supravaginal hysterectomy. Extra-peritonseal method. The permanent ligature is placed as follows : "WTiUe an assistant holds the pedicle in place mtli the forceps, the ligator which holds the elastic cord is given two turns so as to cross the ends of the hgature and tighten them a little, and at the place of crossing, between the instrument and the cerA-ix, a hgature of strong silk is applied and tied with a surgeon's knot. A slight traction is again given to the instrument in such a way as to tighten the elastic cord a little more and to leave room to place a second ligature for safety some millimeters in front of the first. Finally the ends of the silk thi-ead are cut, leaving them a little longer than those of the elastic ligature, after having removed the forceps of the ligator. The elastic is an immense improvement on the ordinary ligature. Its Treatment of Fibroid Tumors. 181 constriction, always active, so to speak, is maintained by the virtue of the elasticity of the cord which has been strongly stretched from the moment of its application. It is not exposed to relaxation, to sagging, like unyielding thi-eads. One of the most important peculiarities of Hegar's procedure is the perfect isolation of the pedicle outside the abdominal cavity by the suture of the peritonaeum under the elastic ligature. Hegar constructs thus the base of a peri-pedicular space, that he leaves open by the non-union, in the immediate vicinity of the pedicle, of the aponeurotic, adipose and tegumentary planes. Tliis fossa prevents narrow imprisonment of the pedicle in the thickness of the soft parts and their infection by its subsequent mortification. It remains isolated, like a pistil in the center of the calyx of a flower, and can be surrounded by topical applications intended to keep it aseptic and to mummify it. It is especially in fleshy women that this particular technique is of great interest. Fig. 83. — Suture of the abdominal walls about the pedicle in supravaginal hysterectomy. Extra-peritonseal method. For the suture of the peritonseum around the pedicle, Tauffer fixes by a knot a long tliread with two ends at the inferior angle of the abdominal incision. Each of these ends is armed with a needle. These are used to sew the peritonaeum to the surface of the pedicle immediately under the ligature, to the right and to the left. For myself, I prefer to make an overcasting of catgut with a single needle (Figs. 82 and 88). It is necessary to do this with great care, uniting a collar of peritonaeum immediately under the elastic ligature. Only the serous membrane should be comprised in this suture and a very fine curved needle should be used to avoid 182 Treatment of Fibroid Tumors. bleeding points if possible. It is useful in this peripeduncular suture to seize the stumps of the broad ligaments and bring them close to the pedicle in such a way as to fix them in immediate contact with the uterine stump. When the peritoneal collar is fixed around the pedicle the same needleful of catgut can be used to continue the isolated suture of the peritonaeum to the whole length of the abdominal incision (Fig. 13). There are added, if needed, some separate stitches to complete the coaptation. The suture of the other planes of the abdominal walls is only commenced at two finger's breadth above the pedicle (Fig. 15). Above the pedicle itself it is usually well to place one or two more stitches. To prevent the pedicle from descending too far into the pelvis, under the elasticity of the tissues, movements, etc., it is transfixed above the elastic ligature by two strong pins, disposed in an X, cutting their points immediately after. These pins have the advantage also of impeding the slipping of the elastic ligature. Under their extremities are placed small rolls of iodoform gauze to avoid wounding the integument. With the scissors the pedicle is then given its final shape, and its surface is cauterized after having surrounded it with moist antiseptic compresses. Until lately Hegar, Kaltenbach, Tauffer, etc., made finally the following dressing : In the peripeduncular space there is placed absorbent cotton, soaked in the chloride of zinc (10-100) and care- fully squeezed out. The surface of the stump is painted with a solution of 50-100, and in the center of the pedicle, in the cavity that it presents, is placed a tampon of cotton soaked in the same caustic. After an antiseptic dressing (iodoform gauze) it is covered with thick layers of cotton-wool held in place by a flannel bandage. This first dressing is left in place five to seven days, except on special indications. The stump is then found hard and dry. The tampons around the pedicle are replaced \sith strips of iodoform gauze and the stump is touched anew with the caustic solution to mummify the eschar and prevent it from becoming soft and fetid. From this time the dressings are renewed every day and if the stump is very large the gangrenous portions are removed little by little. More recently Kaltenbach has replaced the chloride of zinc (which has the inconvenience of producing too extensive eschai-s and exposing to capillary hemorrhages) Avith a thin dressing of iodoform gauze. But in very anaemic and in very fat subjects, when the peripeduncular space is very deep, absorption occurs quickly and gives rise to sj^mptoms of poisoning. Kaltenbach has there- fore employed a mixture of three parts of tannin with one part of salicylic acid, recommended by Freund, in the operation for extra- uterine pregnancy. He obtains the best results with it, and Hegar also. I have replaced the salicylic acid with powdered iodoform in Treatment of Fibroid Tumors. 183 the proportion of one to five of tannin. I lia^e only praise for this mixture. The dressings are thus often very simple. Immediately after the operation, the peripeduncular space is filled and the pedicle covered with the powder (after a previous cauterization with the thermo-cautery), then the dressings are placed. In this way the pedicle has the henefit of the tannic acid without fear of cauterizing the living parts. This first dressing can be left from eight to ten days. This modification constitutes a very great advance. It leaves the patient undisturbed in place of fatiguing her with repeated dressings. Finally, the mummification being obtained by a single application and as a whole, it is not necessary to cut away the stump from time to time with the scissors, a procedure which by disturb- ing it may cause small pulmonary emboli (Kaltenbach). On the third or fourth day after hysterectomy there is often a slight bloody flow from the vagina. It has no serious significance. The elastic ligature generally falls off on the fifteenth or twentieth day, bringing with it the pedicle and pins. There remains a granu- lating cavity that is dressed with iodoform gauze lightly packed in. It often presents a considerable depth, for it is rare that necrosis of the pedicle is arrested at the level of the ligature, it generally passes this limit more or less. The cicatrix creates a weak point in the abdominal wall and necessitates the use of a belt. If the ovaries have been left in place, a hsemorrhage may appear from the cicatrix at each monthly period. An abdomino-cervical fistula has been found to persist at this point in rare cases. Vaiious procedures. — Although he was anticipated to some extent by Czerny and by Kaltenbach, Olshausen was the one Avho especially recommended dropping the elastic ligature into the abdominal cavity. He first tied, then sutured it around the pedicle to prevent slipping. This procedure has been employed by Olshausen only in exceptional cases, such as those where the haemostasis presented gi-eat difficulties. The pedicle thus tied did not slough, but received ■ a little nourishment, either passing beneath the ligature or coming from the contiguous parts. However that may be, its nutrition is very insignificant and it undergoes a granulo-fatty necrobiosis. There were, besides, some cases where it suppurated and caused gi'ave symptoms terminating either in escape of the ligature (Hegar) or in fatal peritonitis (Olshausen, Czerny, Hegar). At other times the elastic cord has been cast off without danger to the patient. Ahlfeld cites a remarkable case where this mode of ligature was made still more complicated by fixing the rubber cord with a lead ring five millimetres in diameter. After passing the ligature twice around the pedicle the ring was crushed on it with a strong forceps. Tliis mode of fixation of the elastic ligature was first employed by 184 Treatment of Fibroid Tumors. Thiersch, but only for the extra-peritonseal treatment. It has also been imitated by Sanger, who abandoned it later for his mixed method, after having obtained nine successes without a single failure. Fig. 84. — Ligature of the pedicle by Zweifel's method (schematic). A, transfixion of the pedicle by a needle armed with the first thread /a lb : B, the extremity, lb, of the first thread being drawn out of the eye of the needle, a second thread Ila lib is introduced, after which the needle is drawn back; C, the needle armed with the second thread transfixes the pedicle anew, a finger's breadth from the first puncture. The same procedure will place the third thread, etc.; D, a series of threads disposed as they are to be tied. I cite the f ollomng procedures only on account of their originality : Swarz originated a method consisting in covering the elastic ligature Treatment of Fibroid Tumors. 185 with a slip of the peritoneum cut from the pedicle after provisional hsemostasis. The pedicle was then left in the abdomen. Meinert has proposed to open Douglas' cul-de-sac and invert the pedicle into the vagina. He resorted to this procedure once ; the patient died. I simply mention hysterectomy in two stages, the first consisting in opening the peritonaeum, followed by the production of adhesions ; the second stage relating to the extraction of the myoma. Nussbaum employed this dangerous procedure in a case of suppurating myoma ; the patient died. Vulliet has recently tried to make use of this method : his patient had not yet recovered at the date of this publication. Fig. 85. — Suture of the pedicle by Zweifel's method. Suture of the broad ligaments and placing the provisional elastic ligature. Partial juxtaposed ligatures. — Under this name Zweifel has de- scribed a procedure of suturing the stump which certainly ensures better hsemostasis than that of Schroeder, but which appears a priori a step behind it in technique, from the point of view of primary union, and its chances of mortification. However, the good results announced by Zweifel challenge attention. Out of ten cases operated by this method, he had only a single death at the time of publication of liis book (1888), and in 1889 he announced a new series of twenty-two operations followed by recovery. His technique is as follows : He uses aseptic silk for all his ligatures and employs a strong needle with a blunt extremity. He first ligates the broad ligaments by a series of partial sutures. The ligaments are then divided and an elastic cord applied. Care is taken to leave long ends to the silk ligatures of the broad ligaments 186 Treatment of Fibroid Tumors. that are nearest to the uteraa, and iu placing the elastic cord these ends are brought up under it (Fig. 85). The uterine tumor is excised iu such a way as to produce a small musculo-peritonasal flap iu front and behind (Fig. 86). The uterine and cei-vical cavities are cauterized with the thermo-cautery. A number of partial ligatures, forming a continuous series, are then placed as indicated in the illustration (Fig. 84). Suture of the stump is completed with some superficial catgut stitches of the peritonieum (Fig. 87). There is no drainage unless there is a persistent oozing, when drainage is made thi-ough the vagina with the cruciform tube. Fig. S6. — Ligature of the pedicle by Zweifel's procedure. Mixed method. — This originated from the impossibihty that some surgeons found of fixing too short pedicles outside the abdominal walls, while they dared not, however, drop them back into the abdomen. Such was the case of Kleeberg who brought a short and thick pedicle to the bottom of the abdominal wound, fastening it by bringing the extremities of the elastic ligature outside. Pean also has had analogous cases. But these were cases of necessity. The fixation of the pedicle immediately under or in the thickness of the abdominal walls, with persistence at this point of a communi- cation with the exterior, has recently been proposed as an operation of choice. It permits a watch over those cases where hsmostasis has been difficult and provides an outlet for products which might infect the peritouieum. Wolfler and von Hacker, of A'ienua, and Sanger, of Leipzig, have proposed mixed methods that are worthy of description in detail. Treatment of Fibroid Tumors. 187 The Wolfier-Hacker method. — The pedicle is sutured according to Sehroeder'c method, then it is allowed to descend so that its summit is at the level of the deep surface of the abdominal wall. To fix it in this place, against the incision in the pai-ietal peritoneum, a needle threaded with car- bolized silk is passed to the right and to the left, traversing the superficial layers of the pedicle, then the abdominal walls. These loops of thread are tied over small rolls of iodoform gauze in such a way as to draw the surface of the stump between the lips of the peritoneal wound. At this place the wound is left open, and the parietal peritonaeum sutured to the stump so that the of pedicle by Zweifel's abdominal cavity is closed above it, and that it "^' ° ' becomes truly extra-peritonaeal and at the same time juxta-parietal. The abdominal walls are sutured, leaving only the place necessary for the passage of a roll of iodoform gauze and of a drainage tube ■which is insinuated as far as the pedicle (Figs. 88 and 89). Fig. 87. — Ligature Fig. 88. — Treatment of the pedicle by the mixed method (Wolfler-Hackler procedure). Schematic median section. Although this method may not be brought into constant use, it is certainly a very useful procedure to understand. It is applicable to a very short and thick pedicle, that cannot be drawn between the lips of the abdominal wound without excessive traction, and where the abundance of the vessels and the number of ligatures appear to make it dangerous to drop it into the abdominal cavity from fear of secondary haemorrhage. 188 Treatment of Fibroid Tiimort Fig. 89. — Treatment of the pedicle by the mixed method (Wolfler-Hacker methodj. Sanger's method consists iu sutuiing the parietal peritonseum closely to the pedicle, fixuig it along the posterior surface of the uterine stump. The ahdominal cavity is thus separated from the space in -which the pedicle is sequestered. Sanger distinguishes two classes of cases: 1. Pedicle treated by sutui-es according to Schroeder's method, hut from "nhich hsemoiThage is f eai'ed. It may be fixed under the abdominal -wall by suturmg it to the parietal peritoujeum. Drainage is establisded at this point (Fig. 90). 2. Pedicle too short to be drawn out ; pins placed at a distance from the elastic hgatiu-e, disposed as for treatment by Hegar's method. In this last case the peritonaeum is sutm-ed to the upper part of the pedicle even in front of the elastic cord, so as to isolate it outside the peritoufeum. A sort of barrier is formed above it. Attempt is thus made at an extra-peritonsal elastic hgature, although inti'a- abdominal. Sanger had good success with this method in a difficult case where the stump was short, thick and very vascular (Fig. 91). Fig. 90. — Treatment of the pedicle by the mixed method (Sanger's method). If these two procedures of Sanger are carefully examined it v,i\l Treatment of Fibroid Tumors. 189 be seen, in fact, that the first does not differ essentially from that of Wolfier-Hacker. With regard to the second, it is the Hegar's method applied to a short pedicle where the peripeduncular suture is replaced by a supra-peduncular suture of the peritonaeum. It has, however, this original point, that the peritonaeum is sutured (with catgut) above the elastic ligature and consequently on the parts that will mortify. Sanger finally powders the stump with a mixture of salicylic acid, iodoform and tannin. To this I add a tampon of iodoform gauze. Fig, 91. — Treatment of the pedicle by the mixed method (Sanger's method). Extripation of the ])edicle or total hysterectomy. — Bardenheuer has recommended this as a procedure of choice even in the most simple cases. He advises final inversion toward the vagina of the broad ligaments on which are placed solid ligatures. He considers the establishment of drainage essential. Total hysterectomy may be attempted in cases where the infiltration of the cervix by the fibroma makes the conservation of a pedicle appear impossible. However, a pedicle can always be made by enucleating and emptying the stump and applying on the shell an elastic ligature. This may be left in the abdomen or treated by the mixed method if the stump is too short to be brought outside. The methods of Olshausen and of Sanger appear to be less formidable than total extirpation, although Bardenheuer has had from the beginning six successful operations 190 Treatment of Fibroid Tumors. out of seven. But it appears that these were simple cases that should have done well under any method. Lately Martin is advising total hysterectomy. He first makes supravaginal hysterectomy through the abdomen, after provisional elastic ligature. Then an assistant frees the cer^•is thi'ough the vagina, after which the surgeon terminates the operation through the abdomen Ijy ligatiug the broad ligaments and detaching the bladder. Maiiin recommends protecting the intestines by a sponge soaked in an aseptic oil, believing that this is unfavorable to the development of adhesions. IV. Intra-Ugamentous and pelvic fibroids. — From a sm'gieal point of view these varieties are united in one group, by the extreme difficulty of constricting a pedicle and their intimate and extended relations with the walls of the pelvis and with the pehic %'iscera. The sugieal treatment of these tumors presents many difficulties. It may be necessary after opening the abdomen, if they appear so great that extii-pation offers no real chances of success, to have recourse to castration (palliative) in the place of ablation (curative). It must be gi-anted, however, since it is not iTsually the hiemorrhages but the pressure effects that are to be feared in this class of cases, that castration is of doubtful value ; it should only be performed as a last resort. I propose to give the name decortication to the procedure which consists in extracting these tumors from their celliilar bed, reserving the term enucleation for the extraction of fibroids from the uterine tissue. The common use of the same word for two so different operations often gives rise to confusion. It is absolutely impossible to give a regular and typical deseiiption where the cases depart so much from all rules and are atypical. The application of a provisional elastic ligature wiU be only rarely possible. Care is here redoubled not to iuclude the bladder, as it is generally much elongated on the anterior surface of the uterus. If a portion of the fibroid projects largely into the peritonaeal cavity, the ligature will be placed as deeply as possible on the base of this lobe, and it may be removed without fear. Attempt is made to enucleate the deeper parts by exercising strong traction. The elastic ligature foUows the slu-inking jof the tumor and always makes a sufficient liiTpmostatic constriction of the shell that has been emptied. More frequently it is necessary to commence the operation by the ligature and section of the appendages of the side operated on. If possible in the begimiing to place a deep ligature on the trunk of the uterine artery, this should not be neglected. In some cases these procedures may be impossible and it may be necessary to come at once to the fundamental stage of the operation, to the opening of the ligamentous surroundings of the tumor. This done the Ups of the incision are grasped in the forceps and the decortication of the tumor is made with the fingers or a Treatment of Fibroid Tvmors. 191 spatula. Strong tractions will be made with the volsella, turning out the tumor as perfectly as possible, while on the bleeding points forceps are placed, taking care not to lose sight of the ureters. Once the fibroid is removed the large veins of the broad ligaments are spontaneously closed and fewer ligatures may be needed than was expected. The connections of the tumor with the uterus determine the pro- cedures with regard to that organ. When they kie of but limited extent the necessary ligatures or sutures are made at these points, leaving the uterine body in situ. But if they are intimate or hsemostasis is difficult, it is better to decide without hesitation upon supravaginal hysterectomy. It may also happen that, at the end of a laborious decortication of a fibroid filling the whole pelvis, we arrive at last at a pedicle which is at once recognized as the cervix uteri itself. It only remains to treat the cavity resulting from the decortication, a cavity which is often large and which has diverticula behind the rectum and bladder or on the sides of the vagina. One or the other of the two following plans will be adopted : If there is full confidence in the asepticism of the operation, immediate union is attempted without drainage. If there are no tears or ragged edges to the peritonaeum, as in some operations for relatively small tumors, or of loose connections, we may confine ourselves to placing some sutures to reunite the divided parts, to making the toilet of the peritonaeum and to closing the abdomen. If the pocket is very deep and vascular, a continued suture in superposed rows can be made, both for the purposes of reunion and hsemostasis. We do not hesitate to excise the debris that would be exposed to sloughing. Fig. 92. — Intra-ligamentous fibroid. A. Horizontal section B. Suture of the pocket after enucleation (Kaltenbach). But this course will be justifiable only in exceptional cases. If the cavity be of considerable extent (Fig. 92) and if oozing be feared drainage will be prudent. This can be made in two ways : Martin recommends drainage tlrrough the vagina with the cruciform tube introduced by incising the cul-de-sac (Fig. 93). Kaltenbach has 192 Treatment of Fibroid Tumors. adopted the same method. Sanger, after having dropped a pedicle into the abdomen, was obliged to open the cavitj- thi-ough the vagina and tampon the sac of the tumor. Fig. 93 -Intra-ligamentous fibroid. Decortication and suture of the pocket and vaginal drainage (Martin). Drainage by the inferior portion of the abdominal wound vrill be preferable in some eases according to the situation of the pocket. It offers the certain advantage of less exposure to infection. Terrier has recently treated in this way a large pocket left by a myoma of the broad ligament ; there resulted a fistula. Howard A. Kelly has left open and drained the cavity resulting from the enucleation of a pelvic fibroid compromising the bladder, which he fortunately decorticated. He used carbolized injections thi-ough the di'ainage tube, the ca^vity of the peritonaeum being separated from the first days by protecting adhesions. For myself, I prefer to use both as a means of ha?mostasis and as capillary drainage, tamponne- meut with iodoform gauze. I have irsed this A^-ith success in a case of intra-Ugamentous fibroid which weighed fifteen pounds. Tauft'er has obtained smgular success with partial resection of large intra- ligamentous fibroids, fixing the stump in the abdominal wound and treating it with energetic cauterizations of zinc chloride. Accidents. — Haemorrhage formerly constituted one of the dangers that was most feared and numbers of patients have died on the operating table fi-om this cause. To-day it can be avoided by the judicious use of the temporary ela'stic ligature. It should be noted Treatment of Fibroid Tumors. 193 that this does not contemplate here, as in Esniarch's bandage of the limbs, the production of ischsemia of the tumor. The operator should not be surprised, on incising the uterus above the constrict- ing cord, to see quite a flow of residual blood, which was imprisoned at the time of the ligature. If there is a telangiectasic tumor, or if the broad ligaments contain dilated veins, these ligaments must be ligated with great care, being divided only between two ligatures. The 'ligatures must be passed with blunt needles to avoid wounding the vessels. For greater rapidity, these ligatures can often be replaced by the application of long forceps. In excising the tumor above the elastic ligature care should be taken not to carry the knife too near this cord, to avoid escape of the pedicle from its control in any portion of its circumference. Extra-peritonseal treatment with the elastic ligature of the pedicle completely avoids secondary hasmorrhage. The same cannot be said of intra-peritonseal treatment with ligature of the stump with silk or catgiat. It must be remembered that the uterine arteries should then be tied with a very light mediate ligature placed to the right and to the left of the pedicle, witlia strong needle taking up a considerable thickness of tissue. In spite of this pre- caution fatal hiemorrhage has often been noted some hours and even some days after the operation, in consequence of slu'inking of the tissues and loosenmg of the ligatures. The possibility of wounding the bladder should always be taken into consideration. If this organ is elongated in front of the tumor ft must be detached to an extent sufficient to permit it to be pushed outside the elastic cord. In even extensive wounds of the bladder, attempt should be made to place an immediate continued suture of catgut in two or tln-ee superposed rows. Catgut is preferable to silk in extra-peritonasal treatment of the pedicle, on account of the danger of infection of the silk by secretions from the peripeduncular wound. On the contrary silk should be used if the pedicle is left in the abdomen. A soft catheter furnished with a tube forming a syphon may be kept in the bladder for ten days. Sanger has used a different method, imposed by circumstances, in a case where the elongated bladder was included by sutures in the pedicle of an ovarian tumor. He closed the peritonaeum perfectly around the vesical pedicle by a method of isolation analogous to that which he employs for the uterine pedicle. The patient recovered without fistula. The urachus has remained pervious after being divided during an operation and has thus caused fistula in rai-e cases. It has, however, a tendency to spontaneous closure (Atlee, Sanger). It is better, however, to guard against this accident by carrying the abdominal incision outside the cord, where it is encountered. If wounded, it should be attached to the thickness of the abdominal 194 Treatment of Fibroid Tumors. wall by deep sutures (Spencer Wells). The patient should be carefully catheterized every three hours after the operation to avoid distention of the bladder. I believe that ligature of the ureter has often been made during haemostasis of the stump, and that more than one death has been attributed to shock, when it was due to this. The intestine may be simply applied to the surface of the fibrous tumor and can then be easily separated with the fingers. But it may also be fused with a tumor that derives nutrient vessels from it. I have observed this fact in a large subperitonaeal fibroid. It is then necessary to leave a thin layer of the tumor adherent to the intestine by detaching it by careful dissection. This fibrous flap, if it is not too extensive can be doubled on itself and sutured (Fig. 78). If, on the contrary, a large surface of the intestine is thus laid bare, there is a risk of narrowing its calibre by a similar coaptation of the raw siu-f ace. It is better in this case to touch this surface lightly \vith the thermo-cautery, and then to fix it by catgut sutures to the parietal peritoneum, as near as possible to the abdominal wound if drained. Simply dropping it into the abdomen will expose to adhesions and possible ileus. Causes of death after abdominal hysterectomy. — The haemorrhage, the septicaemia and the complex sjTnptoms designated by the term shock, are the three gi-eat causes of death after this operation. Less frequent causes are embolism, ileus and tetanus. I have akeady spoken of primary haemorrhages. When the pedicle is retui-ned to the abdomen after Schi-oeder's method, secondary haemorrhage is always to be feared. We are warned of this by the excessive agitation of the patient, the acceleration and softness of the pulse, the swelling of the abdomen, and the paleness of the face and mucous membranes. Some patients have had a very distinct sensation of a hot jet flowing in the abdomen. In other cases the bloodv' serum has been seen to ooze thi-ough the external sutures of the abdominal wall. The blood may also be effused in great abundance under the peritoneum, between the broad ligaments, and form an enormous retro-peritonaeal haemato- cele, or, again it may accumulate in the pocket left by a tumor enucleated from the pelvic celliilar tissue, and then protrude into the ecchymosed vagina. If internal haemorrhage is suspected, the abdomen must be opened at once to ligate the vessels and to remove the liquid and clots. Besides, if the state of the circulation per- mits, if the force of the heart is not too much compromised, there should be injected into the cephalic vein about a litre of sterilized water at 38° C, containing chloride of sodium, 6-1000. If the pulse is so feeble that it appears dangerous to suddenly increase the contents of the vessels, an injection will preferably be made into Treatment of Fibroid Tumoi's. 19-5 the subcutaneous cellular tissue, in small quantities at a time, of one hundred to two hundred grammes of a saline solution. Septicaemia may be produced in different ways. It may proceed from operative faults, from insufficient antisepsis or asepsis. But the most frequent cause is certainly the infection of the peritonaeum by germs from without through a pedicle left in the abdominal cavity. From this arises the necessity for the precautions recommended, of destroying the mucosa, and of vigorous coaptation of the surfaces to obtain a perfect occlusion. The constriction of the sutures is evidently not sufficient to explain the mortification of the pedicle when sutured and dropped into the abdomen. It is known, that when beyond the action of germs the tissues deprived of circulation only undergo a granulo-fatty degeneration. Besides, circulation may be re-established by adhesions, or even by bridges of tissue thrown above the ligature wliich is thus encapsulated little by little. The action of germs is indispensable. There exist some obser- vations on late or secondary infection of the sutures of the intra- peritonseal stump, that are of interest in connection with the use of silk sutures or to elastic ligature. The infection may then come by the tubes or even through the intestines, in consequence of a temporary coprostasis. Finally, a latent microbism may be in- invoked in some cases. Under the term shock has been comprised an assemblage of symptoms of depression from various causes, from which death ensues after grave or prolonged operations. No doubt a great number of these cases may be attributed to haemorrhage. Others may be only due to an acute uraemia arising, either from accidental ligature of the ureter, or to complete abolition of the action of the kidneys, when these organs were already diseased, under the influence of traumatism and the absorption of the anaesthetic. Finally, degeneration of the heart may be looked to in a number of cases. Against shock should be advised, first, among women whose circulation is bad, the mixed method of anaesthesia with preliminary injection of atropine and morpliine. I would recom- mend also a rapid operation. Care should also be taken to protect the intestines fi-om the air by the use of the hot compress-sponges. Ordinarily a very small opening in the abdomen ■\^^R be made. To combat the phenomena of extreme depression, we have the use of hot frictions, hypodermic injections of ether, alternated every quarter hour with injections of caffeine. If it is supposed that acute anaemia plays a pari in the symptoms, an injection may be given under the skin, in the subclavicular region, of one hundred to two hundred grammes of a sterilized saline solution (6-1000). Embolism has caused death in some cases, even in convalescence. Absolute repose cannot be insisted on too much, especially if the 196 Treatment of Fibroid Tumors. tumor was Tery vascular or the broad ligameuts were varicose. Intestinal occlusion has been observed after hysterectomy, as after all abdominal operations. But it should be noted that some cases published under this heading were only pseudo strangulations due to intestinal paralysis, showing the existence of an unrecognized infectious peritonitis. To prevent any chance of this terrible complication one should be sparing of antiseptics in the peritouseal cavity if he use them at all there. These substances act with an extreme intensity on the delicate epithelium of the serous membrane and predispose to plastic exudates. Care also should be taken not to leave any raw surfaces in the abdomen. The section of the stump should be covered by the peritonaeum carefully sutiu-ed. Sutures of catgut should close the broad ligaments when divided or lacerated in the process of decortication. In the treatment of ileus, before reopening the abdomen, trial should be given the method praised by Bode and Leopold, which consists in forced enemas of a hot infusion of chamomile, with the addition of soap and on, then turning the patient on the side. Gravity of hysterotomy. — Comparison of the results of different methods. — It is exceedingly difficult to establish the actual gi-avity of the operation from statistics, the majority of authors taking no care to divide their observations into comparable categories. Thus a t j'pical supravaginal amputation cannot be made to figure by the side of decortication of large pelvic fibroids. There is more dif- ference between these operations than between an amputation of the leg and an amputation of the thigh. For want of better, how- ever, it is necessary to have recourse to what statistics we have. I present the most recent, for it is evident that no account should be taken of the older data, when the technique was incomplete and the antisepsis insufficient. The first series is taken from Paul Wehmer : A. — INTHA-PEKITON^AL METHOD. Numbe: r of Operations Deaths. Mortality per 100. Gusserow, 19 6 316 Kaltenbach, s 3 60.0 Martin, S6 15 17-4 Olshausen, 29 9 31.0 Spencer Welli >, 26 10 38.0 Schroeder, 135 41 300 Tauffer, 12 4 33-0 Bantock, 22 Hegar, 22 Kaltenbach, 22 Keith, 3S Pean, 52 Tauffer, 17 Spencer Wells, 20 -EXTEA-PERITON.EAL METHOD. Deaths. Mortality per 100. 2 9.0 6 27.0 1 4.5 2 S-3 iS 340 2 11.7 10 50.0 Treatment of Fibroid Tumors. 197 Lawson Tait, Thornton, 37-0 13.0 262 63 24.0 Zweifel has collected a still more recent series from among the German surgeons alone : A. — EXTKA-VERITON^AL METHOD. Number of Operations. Deaths. Carl Braun von Femwald, from 1880 to 1887, 63 12 Fehling, 15 1 Gusserow, 3 3 Kehrer, 9 2 Leopold, 14 3 Saxinger, 10 3 Schauta, 5 2 Schultze, I I Werth, 2 I Zweifel, 8 I 130 29 B. — INTRA-PEEITONiEAL METHOD. Number of Operations. Deat Carl Braun von Femwald, 5 2 Dohrn, 9 Fehling, 3 2 Gusserow, 23 6 Kehrer, 3 2 Leopold, 19 7 Range, II 4 Saxinger, 7 6 Schauta, I I Schultze, 12 3 Werth, II Winckel, 2 I Zweifel, 10 I 116 38 In this series the mortality for the extra-peritonseal method is 22.3 per 100, and, even excluding Braun's exceptional resmts, it remains at only 25.3 per 100. The mortahty for the intra- peritonaeal method is 32.7 per 100. The relative benignity of the fii'st method is apparent from these figures. An objection has been raised to these statistics. It has been remarked that in the pre- ceeding lists the avowed partisans of the extra-peritonseal treatment (Kaltenbach, Thornton, S. Keith) are also among the operators by the intra-peritonaeal method. Evidently their cases were not similar in the two series, and those where they left the pedicle in the abdomen were more serious than those to which they applied their favorite treatment. It is better, then, to take the number of surgeons exclusively practicing the intra-peritonaeal treatment of the pedicle. Here is the list extracted from the preceding : Numbe: r of Operations. Deaths. Mortality. A. Martin, 86 IS 17.4 Olshausen, 29 9 31.0 Schroeder, 136 41 30.1 Gusserow, 23 6 26.0 Schultze, 12 3 25.0 198 Treatment of Fibroid Tuin