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 I 
 
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 College of l^l^v^itiam anb ^urgeon£; 
 Hibrarp 
 
 
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The Students' Quiz Series, 
 
 A series covering the essential subjects of a thorough medical 
 education, arranged in form of question and answer. By 
 qualified teachers and examiners in New York. Illustrations 
 wherever desirable. Priced at uniform low rate of $1.00, 
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 ANATOMY {Double Number)— By Fekd J, 
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 of Anatomy, College of Physicians and 
 Surgeons, New York, and A. O'Malley, 
 M. D., Instructor in Surgery, New York 
 Polyclinic. ^1.75. 
 
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 Attending Surgeon, Manhattan Hospital, 
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 CHEMISTRY AND PHYSICS-By Joseph 
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 MATERIA MEDICA AND THERAPEU- 
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 PRACTICE OF MEDICINE— By Edwin T. 
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 SURGERY ipouble Number)— By Bern B. 
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 GENITOURINARY AND VENEREAL 
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 DISEASES OF THE SKIN-By Charles 
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 DISEASES OF THE EYE, EAR, THROAT 
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 OBSTETRICS — By Charles W. Hayt, 
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 GYNECOLOGY— By G. W. Bratenahl, 
 M. I)., Assistant in Gynecology, Vander- 
 bilt Clinic, New York, and Sinclair 
 TousEY, M. D., Assistant Surgeon, Out- 
 patient Department, Roosevelt Hospital, 
 New York. $1.00. 
 
 DISEASES OF CHILDREN — By C. A. 
 
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 LEA BROTHERS & CO., PUBLISHERS, PHILADELPHIA. 
 
Th^ Students' Quiz Scries. 
 
 QYNECOLOGY. 
 
 A MANUAL FOR STUDENTS AND PRACTITIONERS. 
 
 BY 
 
 G. W. BRATENAHL, M. D., 
 
 Assistant in Gynecology, Vanderbilt Clinic, New York, 
 AND 
 
 SINCLAIR TOUSEY, M. D., 
 
 Assistant Surgeon, Out-Patient Department, Roosevelt Hospital, New York. 
 
 SERIES EDITED BY 
 
 BERN B. GALLAUDET, M.D., 
 
 Demonstrator oj Anatomy, College of Physicians and Surgeons, New York ; Visiting 
 Surgeon Bellevue Hospital, New York. 
 
 PHILADELPHIA : 
 LEA BROTHERS & CO. 
 
Entered according to Act of Congress, in the year 1892, by 
 
 LEA BROTHERS & CO., 
 
 In the Oflace of the Librarian of Congress, at Washington. All rights reserved. 
 
 "KG- 1" 
 
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PREFACE 
 
 In compiling this quiz compend we have discussed the various 
 diseases which affect the female generative organs, in the order of 
 the anatomical position of the latter, beginning at the vulva ; and 
 we have given under each heading as complete a resume of the 
 subject as possible in the space at our disposal. As our authori- 
 ties we are indebted to the works of the following authors, and 
 to notes taken from the lectures of Prof. G. M. Tuttle : Pozzi, 
 Thomas and Munde, Mann's System^ Martin, Schroeder, Shultze, 
 Hegar and Kaltenbach, Skene, and Hart and Barbour. 
 
 It is hoped that the compend will prove of service both to the 
 student and to the practitioner who wishes to refresh his memory 
 upon some of the more important features of gynecology. 
 
 G. W. BRATENAHL, 
 SINCLAIR TOUSEY. 
 
CONTENTS 
 
 PAGE 
 
 Causation of Gynecological Disease 17 
 
 Diagnosis of Gynecological Disease : Eational Examination ; 
 Physical Examination ; Inspection ; Touch ; Bimanual Examina- 
 tion ; Sounds ; Steel and Hard-Kubber Sounds ; Steel Branched 
 Dilators; Dilatable Tubes; The Curette as a Diagnostic Agent . . IS 
 
 External Organs of Generation : Anatomy 40 
 
 Diseases of the Vulva: Malformation; Tumors and New Growths; 
 Inflammations ; Nervous Affections of the Vulva ; Irritable Urethral 
 Caruncle ; Coccygodynia or Coccyodynia ; Prolapsus Urethrse . . 45 
 
 Diseases of the Vagina : Inflammations of the Vagina ; Vaginal 
 Cysts ; Vaginal Ulcers ; Malformations of Vagina ; Displacements 
 of the Vagina ,..-.... 57 
 
 The Perineal Body and Pelvic Floor: Anatomy; Lacerations 
 
 of the Perineum and Pelvic Floor ; Operations 65 
 
 The Urethra and Bladder : Anatomy ; Diseases of the Urethra 
 
 and Bladder 77 
 
 The Internal Organs of Generation 84 
 
 Diseases of the Uterus : Anatomy ; Malformations and Diseases 
 of the Uterus ; Hypertrophy ; Atrophy ; Displacements of the 
 Uterus; Anteversion ; Anteflexions; Eetroversion and Retro- 
 flexion; Pessaries; Descent and Prolapse of the Uterus; Acute 
 Metritis; Chronic Metritis ; Applications through the Speculum; 
 Endometritis ; Acute Endometritis ; Chronic Endometritis ; Chronic 
 Corporeal Endometritis ; Chronic Catarrh of the Cervix (Chronic 
 Cervical Endometritis) ; Laceration of the Cervix 84 
 
 Neoplasms of the Uterus: Fibroid Tumors, or Fibro-myomata ; 
 Subserous Fibroids ; Interstitial Fibroids ; Submucous Fibroids ; 
 Fibro-cystic Tumor of the Uterus ; Uterine Polypus ; Carcinoma 
 of the Uterus; Adenoma of the Uterus; Sarcoma of the Uterus . . I4G 
 
 5 
 
6 CONTENTS. 
 
 PAGE 
 
 Inversion of the* Uterus: Amputation of the Uterus 165 
 
 Diseases of the Ovaries: Anatomy of the Fallopian Tubes and 
 Ovaries ; Malformation of the Ovary ; Atrophy of the Ovaries ; 
 Displacements of the Ovary ; Ovarian Apoplexy ; Inflammations 
 of the Ovary ; Abscess of the Ovary ; Neoplasms of the Ovary ; 
 Dermoid Cyst of the Ovary ; Ovarian Cysts ; Cysts of the Broad 
 Ligament, or Parovarian Cysts ; Laparotomy for the Eemoval of 
 
 the Uterine Appendages or of Cysts 170 
 
 Diseases of the Fallopian Tubes: Salpingitis; Pyosalpinx; 
 Hsematosalpinx ; Laparotomy for Pyosalpinx, etc., " Salpingo- 
 
 Oophorectomy " 185 
 
 Extra-uterine Pregnancy 187 
 
 Diseases of the Pelvic Peritoneum and Fascia : Pelvic Peri- 
 tonitis ; Pelvic Cellulitis or Parametritis ; Pelvic Ha^matocele and 
 
 Hsematoma 188 
 
 Menstruation : Disorders of Menstruation 1 99 
 
 Electricity in Gynecology = 206 
 
GYNECOLOGY. 
 
 CAUSATION OF GYNECOLOGICAL DISEASE. 
 
 What are the chief causes of gynecological diseases ? 
 They may be divided into predisposing and exciting. 
 Predisposing Causes : 
 
 (1) Neglect of out-door exercise. 
 
 (2) Imprudence during menstruation, such as violent exercise 
 at the menstrual period, going out too lightly clad, or getting wet 
 feet, which result in cessation of the menstrual flow, endometritis, 
 and other inflammatory conditions, with subsequent dysmenorrhoea, 
 sterility, pelvic pain, etc. 
 
 (3) Undue mental work during the period when the generative 
 organs are developing, resulting in malnutrition of these organs. 
 
 (4) Improprieties of dress, such as tight lacing, having skirts 
 suspended at the waist, resulting in uterine displacements and con- 
 gestive disturbances. 
 
 (5) Improper postures, such as too much sitting down, sewing- 
 machine work, high-heeled shoes tilting the body forward, etc. 
 
 (6) Prevention of conception. 
 
 (7) Improper care or neglect during parturition. 
 
 (8) Induction of abortion. 
 
 (9) Marriage with existing uterine diseases. 
 (10) Habitual constipation. 
 
 Exciting Causes : 
 
 (1) Injuries at parturition, lacerations of the cervix and peri- 
 neum, pudendal and subperitoneal haematocele, inversion of the 
 uterus. 
 
 (2) Derangements of involution, subinvolution, superinvolution, 
 retention of foetal envelopes, displacements of the uterus. 
 
 (3) Congenital anomalies. 
 
 (4) Sudden violent efl"orts, producing flexions, versions, and 
 prolapse. 
 
 2— Gyn- 17 
 
18 DIAGNOSIS OF GYNECOLOGICAL DISEASE. 
 
 (5) Neoplasms developing in the genital tract. 
 
 (6) General peritonitis, producing deposits of lymph in the pel- 
 vis, and thereby displacements of the uterus. 
 
 (7) Local treatment, sounds, tents, etc. 
 
 (8) Gonorrhoea. 
 
 (9) Syphilis. 
 
 (10) Means adopted in criminal abortions. 
 
 DIAGNOSIS OP GYNECOLOGICAL DISEASE. 
 
 What are the means employed in attaining a diagnosis of gyne- 
 cological diseases? 
 
 1st. Rational testing of patient ; 
 2d. Physical examination. 
 
 RATIONAL EXAMINATION. 
 
 What questions should be asked in taking a history? 
 
 Name ? Age ? Occupation ? Residence ? Married ? Single ? 
 Widow? If married, how long? Number of children? First? 
 Last ? Labors easy or instrumental ? Number of miscarriages ? 
 Last ? 
 
 Age when first appeared ; 
 Type; 
 Duration ; 
 Amount ; 
 ^ Pain before, during, after. 
 
 C Character ; 
 Leucorrhoea ? -j Amount ; 
 (^ Constancy. 
 
 C Locality ; 
 Pain ? -j Degree ; 
 
 (^ Character. 
 
 Bladder: Micturition, whether frequent or painful? 
 Bowels? Previous and family history? Duration of present 
 illness ? Chief symptoms ? 
 
 PHYSICAL EXAMINATION. 
 
 What means are employed in making a physical examination? 
 
 (1) Inspection ; (2) vaginal touch ; (3) bimanual manipulation ; 
 
 Menstruation ? < 
 
PHYSICAL EXAMINATION. 19 
 
 (4) rectal touch ; (5) abdomino-rectal exploration ; (6) abdominal 
 palpation ; (7) speculum ; (8) sound and probe ; (9) abdominal 
 palpation, with use of sound; (10) tents and dilators; (11) dull 
 curette ; (12) exploring needle and aspirator ; (13) microscope ; 
 (14) auscultation and percussion. 
 
 Describe the method of making an examination. 
 
 A table covered with a blanket and provided with a small pillow 
 should always, when practicable, be employed for examinations, 
 instead of a bed or lounge. The patient should lie upon her back, 
 with the knees well drawn up and abducted. A sheet should be 
 spread over her, so as to conceal the entire person except the 
 vulvar region. When a table is impracticable, the patient should 
 be placed crosswise on her bed, the nates close to the edge, and the 
 knees drawn up. 
 
 INSPECTION. 
 
 What is the diagnostic value of inspection ? 
 
 By a thorough examination of the external genitals we may find 
 enlargements of the labia majora, nymphae, or clitoris ; mucous 
 patches and ulcers ; pediculi pubis ; character of the vulvar mucous 
 membrane, whether inflamed or not, or violet-colored as in preg- 
 nancy. We note the condition of the perineum, whether lacerated 
 or not; protrusion of the vaginal walls; urethral caruncle; cha- 
 racter of any discharge coming from the vagina ; condition of the 
 hymen. Examine the orifices of Bartholin's glands ; note whether 
 reddened or not (a point in the diagnosis of gonorrhoeal inflamma- 
 tions). Feel for enlargements of the glands themselves. Inspec- 
 tion of the abdomen will reveal the shape and size of a suspected 
 tumor. 
 
 VAGINAL TOUCH. 
 
 What are the steps in performing a vaginal or a digital examina- 
 tion? 
 
 The patient having been placed on her back as described, the 
 index finger of either hand is anointed with vaseline and introduced 
 into the vagina from below up over the perineum, never from above 
 downward. The other fingers are strongly flexed into the palm, while 
 the thumb lies on the symphysis between the thighs. In married 
 women two fingers, the index and middle, are employed, and intro- 
 
20 DIAGNOSIS OF GYNECOLOGICAL DISEASE. 
 
 duced backward into the hollow of the sacrum until the cervix 
 is reached. 
 
 Fig. 1. 
 
 Showing the Position of the Hand in Digital Examination (Hart). 
 
 What conditions are sought for during this examination ? 
 
 (1) Thickness of the perineal body, as determined by approxi- 
 mating the thumb and index finger ; presence or absence of painful 
 spots or spasm. 
 
 (2) Presence or absence of rugae in the vaginal wall ; relaxation 
 of the latter ; note whether dry, moist, or hot ; tumors of the 
 vaginal wall or foreign bodies ; presence of faeces or tumor in the 
 rectum. 
 
 (3) The cervix being reached, place the palmar surface of the 
 finger against the os ; note direction, shape, size, consistence, and 
 mobility of the cervix ; character of the surface, whether soft and 
 velvety or roughened ; note character of the os, whether lacerated, 
 stenosed, or patulous ; note bodies projecting through. 
 
 (4) Passing the finger along the posterior surface of the cervix 
 into the posterior fornix, any tumor or hardness there should 
 be noted. 
 
 What may be felt through the posterior fornix ? 
 
 (1) Pieces in the rectum ; 
 
 (2) Acute or chronic inflammatory deposits ; 
 
 (3) Retroverted or flexed fundus uteri ; 
 
 (4) Blood eff"usions ; 
 
PHYSICAL EXAMINATION. 21 
 
 (5) Fibroids attached to the posterior wall ; 
 
 (6) Ovary and tube prolapsed, inflamed, or cystic ; 
 
 (7) Ascitic fluid ; 
 
 (8) Extra-uterine foetation ; 
 
 (9) Retro-uterine and peritoneal abscess ; 
 
 (10) Thickened and tender utero-sacral ligaments ; 
 
 (11) Hydatid cysts and dermoid cysts (rare). 
 
 What may be felt through the anterior fornix? 
 
 The fundus of a normal, anteverted, anteflexed, or pregnant 
 uterus ; angle between the body and cervix normally ; fibroids ; 
 inflammatory or blood affusions ; tender ovaries (rare). A full 
 bladder gives the sensation of a cystic tumor here. 
 
 What may be felt in the lateral fornices? 
 
 Tumors, fibroids, cysts, etc. ; dilated Fallopian tube ; tubal preg- 
 nancy ; exudation masses ; cellulitis, peritonitis ; blood effusions 
 into the broad ligaments ; prolapsed and enlarged ovaries and 
 tubes ; latero-flexed uterus. 
 
 BIMANUAL EXAMINATION. 
 
 Describe bimanual examination. 
 
 This combines vaginal touch with abdominal palpation. The 
 patient is placed as before, and the fingers introduced until the 
 cervix is reached. The palmar surfaces of the fingers are then 
 placed against the os externum and pushed upward toward the 
 abdominal wall. At the same time the external hand is placed on 
 the abdomen just above the symphysis, and a steady, gentle, but 
 firm pressure is made with the balls of the fingers, the patient being 
 told to breathe quietly, keep her mouth open, and relax the abdom- 
 inal muscles. In this manner an attempt is made to approximate 
 the internal and external fingers, and any intervening structures 
 can be accurately mapped out. It is well to have a definite order 
 to follow in making a bimanual examination : First push up the 
 cervix, and if the uterus is in its normal position the fundus will 
 come in contact with the abdominal hand and a transmitted motion 
 will be felt. Next pass the internal fingers into the anterior fornix, 
 and note any transmitted motion from a body felt here ; this would 
 be the fundus normally and in antepositions. Next pass back into 
 the posterior fornix, behind the cervix, and continue the attempt at 
 approximation of the two hands. In the same way the lateral for- 
 
22 
 
 DIAGNOSIS OF GYNECOLOGICAL DISEASE. 
 
 nices are thoroughly palpated. The right hand should be used 
 internally for the right side, and the left for the left side. The 
 
 Fig. 2. 
 
 Position of the Hands in a Bimanual Examination. 
 
 most important step is first to ascertain the exact position, shape, 
 and size of the uterus : after this the lateral fornices can be pal- 
 pated, using the uterus as a landmark. 
 
 Describe the method of performing a rectal examination. 
 
 (1) Tell the patient what is going to be done. 
 
 (2) Scrape soap under the finger-nail and anoint the finger with 
 vaseline. 
 
 (3) Introduce the finger slowly, first forward, then upward. 
 
 What should be noted in this examination? 
 
 (1) P]xistence or absence of hemorrhoids. 
 
 (2) Fissures, fistular ulcers, strictures (specific or malignant), 
 polypi. 
 
 Note position and size of cervix, posterior uterine wall, position, 
 etc. of ovaries, existence of tumors. 
 
 Ahdominal-rectal examination combines the above with pressure 
 from the hand on the abdomen, as in bimanual examination. 
 
PHYSICAL EXAMINATION. 
 
 23 
 
 Where is this method particularly valuable ? 
 
 In virgins and where the abdominal wall is rigid. 
 
 Recto-vagino-ahdoininal examuiadon combines the middle finger 
 in the rectum, the index finger in the vagina, and the other hand 
 on the abdomen. 
 
 What is Simon's method? 
 
 The introduction of the whole hand into the rectum. This is a 
 dangerous practice, and is very seldom required. 
 
 SPECULA. 
 
 What are the three main forms of specula ? 
 
 (1) Spatular — Sims's and Simon's speculum. 
 
 (2) Tubular — Fergusson's. 
 
 (3) Bivalve — Brewer's, Cusco's. 
 
 Describe the Sims or duckbill speculum. 
 
 This is composed of two blades, set at right angles to an inter- 
 mediate handle. Each blade is concave on the outer aspect and 
 
 Fig. 3. 
 
 Sims's Speculum. 
 
 convex on the inner. Usually one blade is shorter and smaller 
 than the other. 
 
 What is the Sims position? 
 
 The patient lies on her left side and chest, with the left arm 
 behind her over the edge of the couch or table ; the hips close to 
 the edge ; knees well drawn up ; and the upper knee touching the 
 table with its inner aspect. 
 
24 DIAGNOSIS OF GYNECOLOGICAL DISEASE. 
 
 How is the Sims speculum introduced? 
 
 The bhide to be introduced is warmed and oiled on its convex 
 aspect ; the labia are separated with the fingers of the left hand. 
 
 Fig. 4. 
 
 Simon's Specula. 
 
 The blade is then grasped in the right hand, with the index finger 
 lying in the concave surface, and passed into the vagina over the 
 perineum backward toward the hollow of the sacrum, as far as the 
 posterior fornix behind the cervix. Traction is now made by an 
 assistant backward, elevating the posterior vaginal wall, and the 
 
PHYSICAL EXAMINATION. 
 Fig. 5. 
 
 25 
 
 Cleveland's Self-retaining Speculum. 
 
 internal extremity is tilted somewhat forward. The anterior vaginal 
 wall is depressed with a depressor, and the cervix brought into view. 
 
 How should the speculum be held ? 
 
 (1) The outside blade can be grasped by the right hand of the 
 
26 
 
 DIAGNOSIS OF GYNECOLOGIC^AL DISEASE. 
 
 assistant from below, with the thumb extended along the concave 
 surface and over the angle. 
 
 (2) Another and easier method is to grasp the handle from 
 below, the angle of the speculum lying in the hollow between the 
 thumb and forefinger, and the convexity of the blade resting on the 
 dorsum of the hand. The upper labia and buttocks of the patient 
 are elevated by the left hand of the assistant. 
 
 Describe the Simon's speculum. 
 
 This is composed of several blades, varying in shape and size, 
 capable of being fastened to a handle. They are introduced as a 
 Sims speculum, either in the dorsal or Sims position or in Simon's 
 position. 
 
 Describe the the Cleveland self-retaining speculum. 
 
 It is composed of double blades, which are held in position by a 
 broad band, with a buckle, passed over the patient's shoulder. It 
 is introduced, as is a Sims speculum, in the Sims position. 
 
 Describe the Fergusson speculum. 
 
 This is the best form of the tubular variety, and consists of a 
 glass or hard-rubber cylinder, trumpet-shaped at one end and bev- 
 
 Fi«. G. 
 
 Fergusson's Speculum. 
 
 elled at the other. It is from four to five inches long, and comes 
 in sets of three or four of suitable sizes. When made of glass it is 
 silvered internally and covered with caoutchouc externally. 
 
 Describe the mode of introduction. 
 
 The speculum, being warmed and oiled, is grasped by the trum- 
 pet end in the right hand, the labia are separated, and the bevelled 
 extremity passed into the vaginal orifice, short side to the front. 
 The perineum must be well depressed and the instrument pushed 
 
PHYSICAL EXAMINATION. 
 
 27 
 
 slowly backward until arrested. The cervix is brought into view 
 by drawing the instrument out a little and pushing it back in 
 various directions, at the same rotating it. The dorsal or Sims 
 position may be used. 
 
 What are the uses of this speculum ? 
 
 In applications to the cervix, endometrium, and vagina. It can- 
 not be used in operations upon the cervix or vagina, and its intro- 
 duction in nulliparae is painful. 
 
 Describe the the bivalve speculum. 
 
 Brewer's is the best type of this class. It consists of two 
 blades, trumpet-shaped, which expand when they are joined 
 
 Fig. 7. 
 
 Brewer's Bivalve Speculum. 
 
 together posteriorly, and are held open by a screw-bolt. The 
 upper blade is notched at its expanded extremity to prevent 
 pressure on the urethra and facilitate the passage of the uterine 
 sound. 
 
 How is it introduced? 
 
 The patient lying in the dorsal position, the exact location of 
 the cervix is ascertained by digital examination. The labia are 
 then separated, and the tip of the closed instrument is introduced — 
 
28 
 
 DIAGNOSIS OF GYNECOLOGICAL DISEASE. 
 
 first in the long axis of the vulva, then turned transversely and 
 pushed backward toward the cervix. Just before the latter is 
 reached the blades are separated, bringing it into view. 
 
 What are the disadvantages of the bivalve speculum ? 
 
 It conceals the anterior vaginal wall ; it distorts the cervix ; it 
 cannot be used for operations on the cervix or vagina. 
 
 What are its advantages? 
 
 It is self-retaining, thus obviating the necessity of an assistant. 
 It is the most convenient form of speculum for inspection of the 
 cervix and local applications. 
 
 Describe the volsellum and bullet forceps. 
 
 The volsellum consists of two pairs of hooks on the ends of long 
 
 Fig. 8. 
 
 Volsellum Forceps. 
 
 There 
 
 scissor handles, which are provided with a spring catch 
 may be two or more teeth on each hook. 
 
 The bullet forceps are the same as the above, with a single pair 
 of teeth. These are of great use in drawing down the cervix for 
 all operations, dilatations, etc. ; to draw down and steady the uterus 
 in rectal examinations ; and to steady the uterus while making 
 intra-uterine applications. 
 
 Describe the Sims tenaculum. 
 
 This consists of a steel hook, bent as shown in the figure, and 
 
 Fig. 9. 
 
 Sims's Tenaculum. 
 
 fastened into a slender handle. It is indispensable in all operations 
 upon the cervix and perineum. 
 
PHYSICAL EXAMINATION. 
 
 Fig. 10. 
 
 QeoTIEMANNScCo. 
 
 29 
 
 uterine Sound. 
 
 SOUNDS. 
 
 Describe the uterine sound. 
 
 The best form of this instrument is the one devised by Simpson. 
 
 Fig. 11. 
 
 Method of Holding the Uterine Sound. 
 
30 
 
 DIAGNOSIS OF GYNECOLOGICAL DISEASE. 
 
 It consists of a graduated flexible metal rod having a knob 2J inches 
 from the end, marking the depth of the normal uterus. 
 
 Fig, 12. 
 
 Method of Introducing Uterine Sound. 
 
 What are the contraindications to its use? 
 
 1st, pregnancy ; 2d, presence of menstruation ; 3d, any peri- 
 uterine inflammatory condition, or tenderness of the uterus and 
 appendages ; 4th, malignant disease of the uterus. 
 
PHYSICAL EXAMINATION. 
 
 31 
 
 Describe the method of introduction. 
 
 (1) The exact curvature and position of the uterus are ascer- 
 tained by bimanual examination, 
 
 (2) The vagina is thoroughly cleansed. 
 
 (3) The curvature of the sound is made to conform to that of 
 the uterus. 
 
 (4) The index finger of the right or left hand is introduced into 
 the vagina to the cervix, and the sound, passed along this with its 
 concavity backward, is guided into the uterus (Figs. 11 and 12). 
 When it is thoroughly engaged in the cervix the handle is made to 
 describe a semicircle from left to right, bringing the concavity 
 forward (Fig. 13). Now, if the handle is depressed toward the 
 
 Fig. 13. 
 
 Diagrams illustrating Introduction of Uterine Sound. 
 
 perineum, the sound will readily pass into the fundus, as shown in 
 Fig. 14. No force is to be used, and the handle should be held 
 lightly between the thumb and forefinger. 
 
 What can be ascertained by the use of the uterine sound ? 
 
 (1) Potency and size of the external os and cervical canal. 
 
 (2) Presence of intra-uterine growths. 
 
 (3) Condition of the endometrium. 
 
 (4) Sensitiveness of the internal os. 
 
32 
 
 DIAGNOSIS OF GYNECOLOGICAL DISEASE. 
 Fig. 14. 
 
 Uterine Sound Tntroduced. 
 
 (.5) Direction of the cervical canal and exact position of the 
 fundus. 
 
 (6) Relation of the uterus to a tumor. 
 
 It should not be used to replace a malpositioned uterus or to 
 test its mobility. 
 
 What four classes of instruments are employed in obtaining a 
 dilatation of the cervix ? 
 
 (1) Tents ; (2) graduated steel and hard-rubber sounds ; (3) steel 
 
 branched dilators ; (4) dilatable rubber tubes. 
 
 TENTS. 
 What are the three varieties of tents ? 
 
 (1) Sponge, consisting of a cone of compressed sponge rendered 
 aseptic and covered with a layer of grease. It is provided with a 
 tape at the base to assist in removal. 
 
 (2) Laminaria or sea-tangle tents, made from the Laminaria 
 digit at a. 
 
 (3) Tupelo-wood, made from the Nyssa aquatilis. 
 
PHYSICAL EXAMINATION. 
 
 33 
 
 Describe the advantages and disadvantages of each. 
 
 Sponge tents dilate rapidly, but are painful and likely to give 
 rise to septicaemia from abrasions of the mucous membrane. They 
 
 Fig. 15. 
 
 Introduction of a Tent (Sims). 
 
 are now entirely discarded. Laminaria tents dilate much more 
 slowly, but are more aseptic, and from their small size it is possible 
 to introduce several at a time into the cervix. Tupelo tents are 
 
 3— Gyn. 
 
34 DIAGNOSIS OF GYNECOLOGICAL DISEASE. 
 
 tlie best of call. Their expansibility is equal to the sponge tents, 
 they dilate equably, and do not abrade the mucous membrane. 
 Sepsis following their use is rare. 
 
 "What are the indications for the use of tents ? 
 
 (1) Uterine hemorrhage unexplainable by other diagnostic meas- 
 ures. 
 
 (2) Locating polypi and other intra-uterine growths. 
 
 (3) For the treatment of the latter and for the removal of prod- 
 ucts of conception. (This is a dangerous practice.) 
 
 Describe the mode of introduction of tents. 
 
 The patient is placed in Sims position. Sims's speculum being 
 introduced, the cervix is grasped with a pair of bullet or volsellum 
 forceps and drawn down. The vagina is now thoroughly irrigated 
 with 1 : 1000 bichloride-of-mercury solution and the cervical canal 
 swabbed out. Previously the exact position of the uterus should 
 have been ascertained by a bimanual examination, and the curva- 
 ture of the tent made to conform to that of the uterus. The tent 
 is then grasped with a pair of forceps or a tent-passer and gently 
 inserted in the direction of the uterine canal (Fig. 15). A pledget 
 of cotton is placed against the cervix and the patient put to bed. If 
 pain is experienced, a morphine suppository may be administered. 
 The tent should not be left in more than from six to twelve hours, 
 and the patient should be kept in bed a day longer. Tents should 
 never be introduced at the physician's office. 
 
 How are tents now regarded as a means of diagnosis and treat- 
 ment? 
 
 They have been almost entirely superseded by the other dila- 
 tors, and, according to Thomas, should be discarded entirely. 
 
 STEEL AND HARD-RUBBER SOUNDS. 
 
 What forms of graduated steel and hard-rubber sounds are in 
 use? Describe them. 
 
 (1) Peaslee's; (2) Hank's; (3) Hegar's. 
 
 The Peaslee dilators (Fig. IG) resemble male sounds, with less 
 curvature and a bulb 2^ inches from the end. They range in size 
 from a 15 to 20 French male sound. The Hanks variety have oval 
 
PHYSICAL EXAMINATION. 
 
 35 
 
 extremities of various sizes, capable of being screwed into a sigmoid 
 handle. The Hegar dilators are made of hard rubber with a de- 
 tachable handle, and are shaped like male 
 sounds. They range in size from 1 to 30. Fig. 16. 
 
 Describe the mode of introduction. 
 
 The patient being placed in Sims posi- 
 tion, a Sims speculum is introduced. The 
 vagina is thoroughly irrigated with 1 .: 
 1000 bichloride-of-mercury solution, and 
 the cervical canal is swabbed out. The 
 anterior lip of the cervix is grasped with 
 volsellum or bullet forceps, and drawn 
 down. Dilator is introduced by the right 
 hand as the uterine sound. After comple- 
 tion of dilatation the cervix is swabbed 
 off again and dusted with iodoform. An 
 iodoform gauze tampon is introduced, and 
 patient put to bed for twelve hours. The 
 dorsal position may be used. 
 
 STEEL BRANCHED DILATORS. 
 
 What are the best forms of the steel 
 branched dilators? 
 
 (1) Groodell's modification of Ellin- 
 ger's ; (2) Wylie's modification of Sims's ; 
 (3) Palmer's. 
 
 The Goodell-Ellinger is probably the 
 best, though the most expensive variety. 
 It is constructed in two sizes, small 
 slender blades and large powerful ones. 
 These blades separate in parallel lines ; 
 the handles are provided with a grad- 
 uated scale having a screw attachment. 
 
 Peaslee's Dilators. 
 
 What are the indications for the use of dilators ? 
 
 (1) Stenosis of the cervix ; (2) constriction at the internal os 
 from anteflexions, etc. ; (3) dilatation of the cervix for diagnostic 
 purposes or to clean out the uterine cavity after abortions, etc. 
 
36 
 
 DIAGNOSIS OF GYNECOLOGICAL DISEASE. 
 Fig. 17. Fig. 18. 
 
 Goodell-Ellinger Dilator. 
 
 Wyle's Modification of 
 Sims's Dilator. 
 
 How are the branched dilators used? 
 
 Tliese are best introduced in the lithotomy or Simon's position, 
 with the use of Simon's speculum, owing to the advantages of excit- 
 
PHYSICAL EXAMINATION. 37 
 
 ing counter-pressure on the fundus. The vagina is thoroughly 
 cleansed with 1 : 1000 bichloride-of-mercury solution. The cervix 
 is drawn down and the blades introduced up to the shank. Dila- 
 tation is made gradually by means of the screw, so as to enable the 
 muscular fibres of the cervix to yield instead of rupturing. The 
 blades may be separated 1 or 1^ inches. Anaesthesia should always 
 be employed for complete dilatation, and subsequent treatment 
 should be as described above for the graduated sounds. 
 
 DILATABLE TUBES. 
 
 Describe Barnes's bags. 
 
 These are small rubber bags of various sizes, provided with 
 a rubber tube. On one side of the bag is a small pocket for the 
 end of the bougie, by means of which it is introduced into the 
 cervix. They are inserted empty, under the usual antiseptic pre- 
 cautions, by sight with a speculum or by touch. They are then 
 injected slowly with air or warm water by means of a Davidson 
 syringe. 
 
 What is another good dilator of this variety ? 
 
 The Allen's surgical pump, which is provided with india-rubber 
 bags similar to Barnes's, and expanded with air or water by means 
 of the pump. 
 
 Under what conditions are these elastic dilators most useful? 
 
 (1) In a pregnant uterus ; (2) intra-uterine growths with pat- 
 ulous OS. 
 
 What are the dangers from the use of dilators ? 
 
 (1) Lacerations of the cervix ; (2) endometritis ; (3) salpingo- 
 oophoritis ; (4) sepsis. 
 
 THE CURETTE AS A DIAGNOSTIC AGENT 
 
 What are the two forms of the curette ? 
 The sharp and the dull. 
 
 Which of these is used in diagnosis ? 
 
 The dull curette. 
 
38 
 
 DFAGNOSIS OF GYNECOLOGICAL DISEASE. 
 
 Describe it. 
 
 It consists of a smooth wire loop on the end of a flexible metal 
 
 Fig. 19. 
 
 ^^ 
 
 Thomas's Dull Curette. 
 
 shaft (Figs. 19 and 20), and is made in three sizes. 
 
 Fig. 20. 
 
 -—s^ 
 
 -^o<i 
 
 Sims's Sharp Curette : o, h, showing the angles at which it may be bent. 
 
 What can be ascertained by its use ? 
 
 (1) The character of the contents of the uterus and the condi- 
 tion of the endometrium ; (2) the cause of persistent hemorrhage 
 or profuse leucorrhoial discharge. It scrapes away fungous growths 
 from the mucous membrane, and removes sloughing masses in 
 malignant disease and retained secundines after abortions. 
 
 How is it employed? 
 
 The patient is placed in the Sims or the dorsal position (the latter 
 is somewhat ihe better, owing to the advantage of exerting counter- 
 pressure over the fundus). A Sims or Simon speculum is intro- 
 duced ; the cervix is grasped by its anterior lips with a pair of ])ul- 
 let or volsellum forceps, and drawn down. The cervix and vagina 
 are thoroughly irrigated and swabbed out with 1 : 1000 bichloride-of- 
 mercury solution. Dilatation of the cervix may be recjuired. The 
 direction of the uterine canal having been previously ascertained, 
 the curvature of the curette is made to correspond. It is then in- 
 troduced into the fundus as a sound with the right hand, the left 
 exerting counter-pressure over the fundus. 
 
PHYSICAL EXAMINATION. 39 
 
 The anterior wall is now gently scraped down and the curette 
 removed, bringing with it any uterine fungositics or other matter 
 that may be present. It should be rinsed off in 1 : 20 carbolic- 
 acid solution before being reintroduced. For diagnostic purposes 
 this will suffice, but for a curative effect the whole lining mem- 
 brane must be scraped down until it becomes smooth. The uterine 
 cavity is then thoroughly irrigated with several quarts of hot 1 : 100 
 carbolic-acid solution by means of a double-current catheter. 
 When the hemorrhage following curetting is severe, .^ij or ^iij of 
 tr. iodi may be added to the hot water. The vagina is then dried, 
 and the endometrium painted with pure carbolic acid or iodized 
 phenol : 
 
 ^. Tr. iod., gr. xl ; 
 
 Pure carbolic ac, §j. 
 
 An iodoform gauze tampon is placed over the cervix, the volsel- 
 lum and speculum are removed, and the patient is put to bed for at 
 least twenty-four to forty-eight hours. 
 
 Thorough antiseptic precautions must he preserved with regard 
 to the hands and instruments throughout a curetting. An anaes- 
 thetic should be admistered when practicable, particularly if a 
 sharp curette is employed. 
 
 What other forms of curettes are in use ? 
 
 Martin's (Fig. 21), shaped like the original Recamier, but having 
 
 Fig. 21. 
 Martin's Curette. 
 
 a dull edge; Simon's spoon; Sims's and Emmet's sharp curettes. 
 
 What are contraindications of curetting ? 
 
 (1) Suspicion of pregnancy ; (2) evidences of recent exudation 
 about the uterus ; (3) tenderness in the fornices. 
 
 What are the dangers of curetting ? 
 
 (1) Sepsis, causing inflammation of the uterus, appendages, or 
 peritoneum ; 
 
 (2) Hemorrhage ; 
 
40 EXTERNAL ORGANS OF GENERATION. 
 
 (3) Curetting with coexisting tubal disease, such as pyosalpinx, 
 is likely to cause rupture. 
 
 Describe the Bozeman-Fritsch double-current uterine catheter. 
 
 This consists of two tubes — one enclosing the other at its ex- 
 tremity, where it is curved to conform to the uterine cavity. The 
 outer tube is 'provided with a fenestrum on either side, and a third 
 opening on its convex aspect about three inches from the end. 
 
 Fig. 22. 
 
 Bozeman's Intra-uterine Back-flow Tube. 
 
 The fluid flows in by the small tube through the large fenestrum, 
 irrigating the uterine cavity ; passes back through the large fenes- 
 trum, and out at the smaller opening. The latter lies outside of 
 the external os. 
 
 EXTERNAL ORGANS OF GENERATION. 
 
 ANATOMY. 
 
 What are the external organs of generation? 
 
 The external genitals, also called vulva and pudendum^ include 
 that portion of the genital tract which is visible when the subject 
 lies upon her back with the knees drawn up and abducted and the 
 labia majora separated. They are as follows : 
 
 (1) Mens veneris ; (7) Fourchette ; 
 
 (2) Labia majora ; (8) Fossa navicularis ; 
 
 (3) Labia minora ; (9) Ostium vagina? and vagina ; 
 
 (4) Clitoris; (10) Bulbs of the vagina ; 
 
 (5) Vestibule; (11) Bartholin's glands. 
 (0) Meatus urinarius J 
 
ANATOMY. 41 
 
 The hymen is sometimes included with these, but really separates 
 the external genitals from the vagina. 
 
 The hulhs of the vagina and Bartholin s glands are structures 
 regarded as common to the vulva and vagina. 
 
 The mons veneris is a triangular cushion of skin and adipose 
 tissue situated in front of the symphysis pubis, and it is covered 
 after puberty with a thick growth of coarse, curly hair, usually a 
 few shades darker than the hair of the head. It is bounded above 
 by a slight groove at the lower limit of the hypogastrium, and 
 below becomes continuous with the labia majora. The collection 
 of fat is supported by connective tissue ; the skin is thick and con- 
 tains numerous subaceous and sweat glands. 
 
 The labia majora are two thick folds of integument, enclosing 
 fat, connective tissue, and blood-vessels, which extend from the 
 lower part of the mons veneris (anterior commissure) downward 
 and backward, uniting with each other in the posterior commis- 
 sure about an inch in front of the anus. Each has an inner and 
 outer surface, the latter after puberty being covered with hair, and 
 they are rich in sebaceous and sweat glands. The inner surface 
 resembles mucous membrane, but contains a few hair-follicles. 
 
 The elastic tissue of each labium is arranged in the form of a 
 sac, with its neck at the external inguinal ring, and here are some- 
 times found the remains of the canal of Nuck, a process of peri- 
 toneum prolonged upon the round ligament. When this is pervious 
 it may be the seat of a labial hernia. The terminal fibres of the 
 round ligament are also found in this portion. Normally, in the 
 adult the labia are full and rounded and lie in contact with each 
 other. In old age they become atrophied and separable, allowing 
 the labia minora to protrude. 
 
 The arterial supply is derived from the superficial perineal branch 
 of the internal pudic and superficial pudic. The veins begin in a 
 rich subcutaneous plexus and unite with the vaginal bulbs. They 
 accompany the arteries. The nerves are derived from the superficial 
 perineal branch of the pudic and the inferior branch of the small 
 sciatic. The lymphatics enter the inguinal glands. 
 
 Describe the labia minora, or nymphae. 
 
 These are two muco-cutaneous folds situated between the labia 
 majora. They begin anteriorly below the anterior commissure in 
 two divisions. The upper divisions, or roots, unite with each other 
 above the clitoris, forming its prepuce ; the lower divisions unite 
 
42 EXTERNAL ORGANS OF GENP:RAT10N. 
 
 below to form its fraenulum. Each labium descends along the base 
 of the inner surface of the labia majora, with which it blends in 
 the middle third. In the virgin they are completely hidden by 
 the labia majora and are of a pinkish-red color. In appearance 
 they resemble a cock's comb. They may be continued into the 
 fourchette. The nerve- and blood-supply is the same as for the 
 labia majora. They contain numerous sebaceous and sweat glands. 
 
 Describe the clitoris. 
 
 The clitoris is a curved oblong body, the analogue of the male 
 penis, situated below the anterior commissure. It consists of the 
 glans, the body, and two crura. The glans is a mass of erectile 
 tissue of the size of a small pea, covered by mucous membrane rich 
 in nerve-supply. It is concealed by the prepuce, and is only seen 
 when the labia minora are widely separated. The vessels of the glans 
 are connected with those of the pars intermedia of the bulb. The 
 body, which seldom exceeds an inch in length, curves upward and 
 backward to the anterior edge of the arch of the pubis, where it 
 divides into two crura. It consists of spongy erectile tissue enclosed 
 in a dense capsule. The two crura curve downward along the pubic 
 rami, to the anterior and inner surface of which they are firmly 
 attached. These are also formed of spongy tissue enclosed in a 
 capsule. The slender erector clitoridis muscles extend along their 
 inner sides. The arterial supply is derived from the two terminal 
 branches of the internal pudic. The dorsal vein returns the blood 
 and joins the vesical plexus. The nerve-supply is very abundant, 
 derived from the sympathetic system and from a branch of the 
 pudic nerve. The lymphatics form a plexus around the clitoris, 
 and terminate in the inguinal glands. 
 
 Describe the vestibule. 
 
 This is a triangular area with its apex immediately below the 
 clitoris, its base formed by the upper margin of the vaginal orifice, 
 and its sides formed by the bases of the labia minora. It is covered 
 by mucous membrane, beneath which is a dense plexus of veins, 
 the pars intermedia. It contains the orifice of the urethra at its 
 base, and five or six depressions or crypts of variable size, the 
 glandulae vestibulae minores. 
 
 Describe the bulbs of the vagina (bulbi vestibuli). 
 
 'J'Ik! v<i(jiii((l hitlhfi are two oblong leecli-slia|)ed masses of veins 
 situated on either side of the vestibule and extending two-thirds 
 
ANATOMY. 43 
 
 down the sides of the vaginal orifice. They measure, when dis- 
 tended, about 1 inch. Anteriorly they are covered partly by the 
 bulbi cavernosi muscles ; internally they are in contact with the 
 mucous membrane of the vagina ; and posteriorly they rest upon 
 the triangular ligament. Their vessels communicate anteriorly 
 with each other through those of the pars intermedia. The arterial 
 supply is derived from the internal pudic. The nerves come from 
 the sympathetic. 
 
 What is the fourchette ? 
 
 This is a fold of skin formed by the junction of the labia majora 
 posteriorly. It is the posterior commissure, and is best seen when 
 the labia are widely separated. 
 
 What is the fossa navicularis? 
 
 When the labia are artificially separated a depression exists 
 anterior to the fourchette. Its anterior margin is formed by the 
 ostium vaginae and the lower edge of the hymen. 
 
 Describe the vulvo-vaginal or Bartholin glands (analogues of 
 Cowper's glands in the male). 
 
 They are two compound racemose glands which range in size 
 from a bean to an almond, situated on either side of the vaginal 
 orifice just below the ends of the bulbs of the vagina. They lie 
 behind the anterior layer of the triangular ligament, beneath the 
 superficial perineal fascia, and in front of the transversus perinei 
 muscles. Each has a long duct, the orifice of which can be seen 
 just external to the base of the hymen and internal to the labia 
 minora in the fossa navicularis. They secrete a tenacious mucus 
 which lubricates the parts and which is much increased by coition. 
 
 Describe the hymen. 
 
 The hymen is a crescentic fold of mucous membrane, containing 
 connective tissue, blood-vessels, and nerves, which surrounds the 
 orifice of the vagina. It is said to be an infolding of the entire 
 vaginal wall, and to disappear completely at parturition (Budin) 
 by being unfolded. There are other shapes aside from the crescen- 
 tic — i e. annular, with a central opening ; perforated, with several 
 small holes ; cribriform, or it ma}'^ be fimbriated at its edges. 
 
 The imperforate hymen is a pathological condition. Carunculae 
 myrtiformes were supposed to be remains of the hymen after labor, 
 but are really tags of tissue resulting from tears and sloughs of 
 the mucous membrane during childbirth. 
 
44 EXTERNAL ORGANS OF GENERATION. 
 
 Describe the vagina. 
 
 The vagina is a musculo-membranous canal connecting the ute- 
 rus with the vulva, situated between the bladder and urethra in 
 front and the rectum and perineal body behind. Its walls lie nor- 
 mally in contact with each other antero-posteriorly. The anterior 
 wall measures 2 to 2^ inches, the posterior 3 to 3|, owing to its 
 higher attachment to the cervix. Its lumen increases from below 
 upward, so that when distended it takes the shape of an inverted 
 truncated cone. Above it completely surrounds the cervix, and 
 below it is attached to the pubis rami. The walls are composed 
 of three coats from within outward — mucous membrane, muscular 
 and connective tissues. The mucous membrane is thrown into folds 
 or rugae, most marked below. The median longitudinal ridges on 
 the anterior and posterior walls are called the columns of the vagina. 
 Transverse folds extend from these. The epithelium is of the squa- 
 mous variety. The muscular coat is composed of two sets of fibres 
 — a circular and a longitudinal, the latter being external. The con- 
 nective-tissue coat serves to connect the vagina with the adjacent 
 organs and to support a plexus of veins. 
 
 Vasculai' Sajiply. — The arteries are derived from the vaginal 
 branches of the anterior division of the internal iliac, from the 
 uterine above and pudendal below. — all anastomosing freely with 
 each other. The veins are derived from two plexuses, one internal 
 beneath the mucous membrane, and one in the connective tissue. 
 These communicate with the pudendal and hemorrhoidal plexus 
 below and the plexuses of the broad ligaments above. All the 
 veins are without valves. The nerve-sup2)ly is derived from the 
 inferior hypogastric plexus of the sympathetic and fourth sacral 
 and pudic nerve. Lymphatics enter the inguinal glands below and 
 the internal iliac above. 
 
 What are the relations of the vagina ? 
 
 Anteriorly the vagina is in contact with the bladder at its upper 
 half, and is intimately connected to the urethra throughout its 
 lower half. Posteriorly it is in contact with the rectum at its mid- 
 dle third, being separated from the latter above by the pouch of 
 Douglas and below by the perineal body. Laterally the levator 
 ani muscles are attached to it. 
 
 The anterior fornix is I] inches from the vesico-uterine perito- 
 neal fold. The posterior fornix lies in contact with the cul-de-sac 
 
DISEASES OF THE VULVA. 45 
 
 of Douglas, and the lateral fornices are in relation to the bases of 
 the broad ligaments. 
 
 DISEASES OF THE VULVA. 
 
 What may he included under this term? 
 
 I. Malformations ; 
 II. Tumors and new growths ; 
 III. Inflammations. 
 
 MALFORMATIONS. 
 
 Name and describe malformations of the vulva. 
 
 (1) Hypertrophy of the labia majora and minora (the latter called 
 the Hottentot apron). The causes are syphilis, elephantiasis, inflam- 
 matory hypertrophy, masturbation. It is usually seen in tropical 
 climates. The treatment is surgical when required. 
 
 (2) Hypertrophy of the clitoris. Due to above causes ; it is 
 most frequently seen in prostitutes. The treatment is surgical. 
 
 (3) Atrophy or absence of the organs of the vulva is either con- 
 genital or senile. There is no treatment. 
 
 (4) Hypospadias is absence of the posterior urethral wall. 
 
 (5) In epispadias the anterior wall of the urethra and usually 
 of the bladder is defective. 
 
 (6) Hermaphroditism. 
 
 TUMORS AND NEW GRO'WTHS. 
 
 What tumors and neoplasms may be met with in the vulvar 
 region ? 
 
 Condylomata acuminata (gonorrhceal, warty) ; 
 
 Condylomata lata (syphilitic) ; 
 
 Simple papillomata ; 
 
 Vulvar cysts (rare) ; 
 
 Vulvar hernia ; 
 
 Vulvar phlebectasia or varicocele ; 
 
 Vulvar hasmatocele and pudendal hemorrhage ; 
 
 Labial abscess ; 
 
 (Edema labiorum ; 
 
 Abscess and cysts of vulvo-vaginal glands ; 
 
 Hydrocele of the round ligament • 
 
46 DISEASES OF THE VULVA. 
 
 Elephantiasis vulvae ; 
 
 Fibroma, 
 
 Lipoma, 
 
 Carcinoma, 
 
 Sarcoma, 
 
 Lupus, y rare. 
 
 Myxoma, 
 
 Osteoma, 
 
 Enchondroma, 
 
 Neuroma, 
 
 Describe condylomata acuminata. 
 
 These are also known as pointed condylomata and gonorrhoea! 
 warts. They are warty excrescences found on the inner surfaces 
 of the labia majora and minora and on the posterior commissure, 
 due to gonorrhoeal or other irritating discharges. They are always 
 multiple, of a grayish color, and are divided on the summit with 
 pointed lobules. The treatment is removal with knife or scissors 
 and cauterization with nitrate of silver. 
 
 Describe the condylomata lata. 
 
 These are flat, broad excrescences found mostly on the inner 
 sides of the labia majora and around the anus, and are usually 
 covered by a grayish secretion. The treatment is antisyphilitic, 
 touching with nitric acid and dusting with calomel powder. 
 
 Describe simple papilloma or wart. 
 
 This is rare on the vulva. 
 
 Treatm,ent. — Removal with nitric acid or the knife. 
 
 Describe vulvar cysts. 
 
 These rare affections are due to occlusion of one or more of the 
 glands of the vulva. They are usually small and cause no symp- 
 toms. 
 
 Treatment is excision. 
 
 Describe vulvar hernia. 
 
 This is a rare condition, "predisposed to" by a pervious "canal 
 of Nuck." It is caused by severe exertion, strains, etc. Symp- 
 toms. — Correspond to those in the male. Swelling of the labia 
 majora, impulse on coughing, tympanitic percussion. It may con- 
 sist of gut, omentum, bladder, ovary, or whole uterus. Differ- 
 entiation from vulvar hn3matocele, hydrocele of the cord, phlegmon- 
 
TUMORS AKD NEW GROWTHS. 47 
 
 ous vulvitis, cysts, and abscess of Bartholin's glands. Treatment. — 
 Reduction by taxis when possible, and application of a truss ; 
 otherwise operative. 
 
 Describe vulvar varicocele. 
 
 This is commonly seen in pregnancy, and consists of a dilatation 
 of the vulvar veins. The dilatation may be permanent and give 
 rise to great swelling. 
 
 Causes. — Pregnancy, tumors, obstinate constipation with strain- 
 ing at stool. Symptoms. — Discomfort from the swelling. The 
 latter is irregular in outline, soft and compressible, more prominent 
 when the patient is standing. Danger. — Rupture of the veins. 
 Treatment. — Very little can be done. Pressure with a T-bandage 
 may be beneficial. Keep the bowels regulated. 
 
 Describe vulvar hsematocele. 
 
 This is a tumor formed by effused coagulated blood in the tissues 
 of the labium or areolar tissue around the vagina, due to rupture of 
 the bulbs of the vestibule. Causes. — Predisposed by pregnancy, 
 tumors, varicocele, and labor. Exciting causes are muscular exer- 
 tions, blows on the labium, and punctures. St/mjJtoms. — Sense 
 of discomfort, pain, and throbbing. If the effusion reaches the 
 urethra, there will be obstruction to urination. It is first soft, 
 then hard. 
 
 Prognosis. — If small, there will be spontaneous absorption ; if 
 large, it may result in hemorrhage or suppuration, especially when 
 the hsematocele occurs in pregnancy. 
 
 Differentiation from labial abscess, phlegmonous vulvitis, puden- 
 dal hernia, suppurative bartholinitis, oedema labiorum. Treatment. — 
 During the effusion cold, and pressure later ; if small, lead-and-opium 
 wash applied locally. If too large to absorb or if it obstructs 
 labor, open and evacuate it. If suppuration takes place, evacuate 
 and pack with iodoform gauze or wash with 1 : 1000 bichloride-of- 
 mercury solution, and apply acetate-of-aluminum dressing. 
 
 Describe vulvar hemorrhage. 
 
 It is due to the above predisposing and exciting causes. Treat- 
 ment. — If due to ruptured vulvar hematocele, open, turn out clots, 
 and pack tightly ; apply T-bandage. If due to rupture of a small 
 vessel, ligate. 
 
 What is oedema labiorum? 
 
 Swelling of the labia is most common in pregnancy. It is also 
 
48 DISEASES OF THE VULVA. 
 
 due to cardiac, renal, and liver diseases, cancer of uterus, wasting 
 diseases, fibroids, and ovarian tumors. Treatment directed to cause ; 
 puncture if necessary, recumbent position, T-bandage. 
 
 Describe abscess of labium. (See Phlegmonous Vulvitis.) 
 Describe cysts and abscess of vulvo-vaginal or Bartholin's glands. 
 
 Cysts are due to occlusion of the duct from inflammation, either 
 of simple or gonorrhoea! origin. There may be distension of the 
 duct alone, forming an oblong swelling, or of the gland itself. The 
 causes of abscesses are much the same as vulvitis, which they 
 frequently complicate. Gonorrha3a is the most common cause. 
 Symptoms. — Pain on pressure, heat, and pruritus. The mouth of 
 the duct is reddened, and remains always of a deeper hue than the 
 surrounding inflamed mucous membrane. The swelling may reach 
 the size of a hen's egg. It is first hard, then fluctuating. 
 
 Differentiation from cysts, phlegmonous vulvitis, labial abscess, 
 and vulvar hernia. 
 
 Abscess : Cysts : 
 
 Signs of inflammation. No signs of inflammation. 
 
 Tenderness on pressure. Movable round mass, not tender 
 
 to pressure. 
 
 Abscess : Phlegmonous Inflammation : 
 
 Circumscribed. Non-circumscribed. 
 
 Cyst or Abscess : Hernia 
 
 History. 
 
 No impulse on coughing. Impulse on coughing. 
 
 Not reducible. Reducible. 
 
 Dull percussion. Tympanitic percussion. 
 
 Abscess shows signs of inflam- No signs of inflammation unless 
 mation. strangulated. 
 
 Treatment of Vulvo-vaginal Cyst. — Cut down, remove an ellipti- 
 cal portion of cyst-wall, pack with iodoform gauze, and allow to 
 heal by granulation ; or, cut down carefully to the cyst-wall and 
 dissect out the whole sac ; then bring the edges of the wound 
 together with catgut and dress antiseptically. 
 
 Treatment of Vulvo-vaginal Abscess. — Apply soothing lotions until 
 pus is detected ; then make a long incision from top to bottom of the 
 abscess on the inner side of the labium. Curette out the cavity 
 
INFLAMMATIONS. 49 
 
 thoroughly with a sharp curette. Irrigate with 1 : 1000 bichloride- 
 of-mercury solution, pack with iodoform gauze, and dress antisep- 
 tically. 
 
 Describe hydrocele of the cord. 
 
 This is very rare, and is caused by fluid collecting in the process 
 of peritoneum surrounding the round ligament when pervious 
 (canal of Nuck.) It appears gradually, is painless, and sometimes 
 communicates with the peritoneal cavity. It is fluctuating and 
 translucent, and is to be differentiated from hernia and abscess. 
 
 Treatment is by aspiration or injections of iodine. 
 
 Describe elephantiasis vulvse. 
 
 This usually involves the labia majora and minora, and consists 
 of a connective-tissue hyperplasia. The growth often attains an 
 excessive size. 
 
 Treatment is surgical. 
 
 INFLAMMATIONS. 
 
 What six forms of vulvitis are described ? 
 
 (1) Simple catarrhal vulvitis, acute and chronic ; (2) gonor- 
 rhoeal vulvitis ; (3) follicular vulvitis ; (4) diphtheritic vulvitis ; 
 (5) phlegmonous vulvitis ; (6) gangrenous vulvitis. 
 
 Describe simple acute catarrhal vulvitis. 
 
 The causes are (1) irritating discharges from the vagina and 
 cervix; (2) injury, or friction from exercise; (3) uncleanliness ; 
 (4) excessive coitus ; (5) parasites, pediculi and ascarides ; (6) dia- 
 betes ; (7) pregnancy ; (8) foreign bodies ; (9) acute exanthemata ; 
 (10) strumous diathesis. 
 
 The si/mptoms may be general malaise and mild fever. The local 
 signs are heat, redness, swelling, pruritus ; the mucous membrane 
 is at first tense and shiny, later it becomes covered with a glairy 
 excoriating secretion. The inflammation may extend to the urethra 
 and around the anus and nates. 
 
 Treatment. — Remove the cause. If parasitic, use unguentum 
 hydrarg. ; infusion of quassia, ^ij-Oj, for ascarides. If due to dis- 
 charges from the vagina and cervix, remove these by hot vaginal 
 douches containing a little alum and zinc sulphate. Always ex- 
 amine for sugar in the urine, and if it is found treat general system 
 with opium or codeine, etc., and apply a solution of sodium hypo- 
 sulphite, ^ss-Oj, to prevent fermentation of the saccharine urine 
 4— Gyn. 
 
50 DISEASES OF THE VULVA. 
 
 on the vulva. When the inflammation is very acute apply lead- 
 and-opium wash and enjoin rest in bed and hot sitz-baths. Later 
 in the disease applications of nitrate of silver, gr. xx-^j, can be 
 made every two days. 
 
 Describe simple chronic catarrhal vulvitis. 
 
 This is the most common form in children. 
 
 Causes. — Strumous diathesis, ascarides, continuation from acute 
 vulvitis. 
 
 Symptoms. — Pruritus, burning micturition, discomfort in walk- 
 ing, discharge from vulva. 
 
 Treatment. — Tone up the general system by tonics ; locally, lead- 
 and-opium wash can be applied first, followed later by nitrate of 
 silver, gr. xx-^j, and boric-acid powder. 
 
 Describe gonorrhceal or purulent vulvitis. 
 
 The cause is specific infection, due to the gonococcus of Neisser. 
 
 The symptoms are its sudden onset, pain, heat, redness, and 
 swelling, followed rapidly by a profuse purulent, offensive excori- 
 ating discharge. It is frequently complicated by urethritis, barthol- 
 initis, and vaginitis. Labial abscess is a common complication. 
 The pus infects any mucous membranne with which it is brought 
 in contact. The orifices of Bartholin's elands are reddened. 
 
 &' 
 
 Differentiation . — 
 
 Gonorrhoeal Vulvitis : Simple Vulvitis : 
 
 More severe. Less severe onset. 
 
 More fever, pain, and oedema. Less fever, pain, and oedema. 
 
 Urethra and vagina often in- Urethra and vagina not compli- 
 
 volved. cated. 
 
 Gonococci. No gonococci in discharges. 
 Gonorrhoeal warts. 
 Gonorrhoeal rheumatism. 
 
 Bartholin s glands and ducts in- Bartholin's glands and ducts not 
 
 flamed. usually affected. 
 
 Treatment. — Hot sitz-baths ; rest in bed ; bowels moved. Local : 
 Irrigation with bichloride ; paint with nitrate of silver, gr. xx-.|_j ; 
 powder with bismuth, calomel, or iodoform, and separate labia with 
 a little lint. 
 
INFLAMMATIONS. 51 
 
 Describe follicular vulvitis. 
 
 It occurs only in adults. 
 
 The causes are unclean! iness, pregnancy, vaginitis, eruptive dis- 
 eases, excessive venery. 
 
 The symptoms are increased secretion, burning and itching, heat, 
 and soreness between the labia. The mucous membrane is red, 
 elevated in patches ; lips swollen ; villi which bleed easily ; or there 
 may be little red prominences which break down, discharge, and 
 leave little ulcerated points. 
 
 Treatment. — Cleanliness, lead-and-opium wash, nitrate of silver, 
 gr. X— ^j; bismuth. 
 
 Describe diphtheritic vulvitis. 
 
 This is really diphtheria of the vulva, and a complication of the 
 general disease. The patches of false membrane are like those 
 found in the throat, and resemble wash-leather. 
 
 Treatment. — General : for diphtheria. Local : antiseptic. 
 
 Describe phlegmonous vulvitis. 
 
 Causes. — Traumatism, chancroidal ulcers, irritating discharges, 
 furuncles, acute exanthemata. 
 
 Symptoms. — Heat, pain, swelling, redness, induration, suppura- 
 tion. 
 
 Differentiation. — 
 
 Phlegmonous Vulvitis : Pudendal Hernia : 
 
 Signs of inflammation. No inflammation, unless strangu- 
 
 lated. 
 Dulness on percussion. Tympanitic. 
 
 No impulse on coughing. Impulse on coughing. 
 
 Not reducible. Keducible. 
 
 History. History. 
 
 Phlegmonous Vulvitis: Vidvar Hsematocele: 
 
 More gradual onset. Sudden onset. 
 
 First hard, then soft. First soft, then hard. 
 
 Not frequent during pregnancy More frequent during pregnancy 
 
 and parturition. and parturition. 
 
 Not preceded, as a rule, by vari- Preceded by varicose veins. 
 
 cose veins. 
 
52 DISEASES OF THE VULVA. 
 
 Phlegmonous Vulvitis : Hydrocele of the Cord : 
 
 Signs of inflammation. No inflammation. 
 
 Opaque. Translucent. 
 
 May communicate with abdom- 
 inal cavity. 
 
 Phlegmonous Vulvitis : Abscess of Bartholin s Glands : 
 
 Not circumscribed. Circumscribed. 
 
 Describe gangrenous vulvitis. 
 
 Usually indicates a low vitality of the system. It is sometimes 
 a complication of pregnancy, puerperal septicaemia, severe cases of 
 scarlet fever, measles, and continued fevers. 
 
 Symjjfoms. — Severe constitutional disturbance, labia dark-colored 
 and swollen. A patch of purplish hue becomes indurated at edges 
 and ulcerates. The gangrenous process spreads, and discharges 
 a foetid, ichorous fluid. 
 
 Treatment. — Tonics. Local : Antiseptics and cauterizing with 
 nitrate of silver or actual cautery. 
 
 What is the most common of the eruptive diseases that may 
 appear on the vulva? 
 
 Eczema. 
 
 Give the etiology, symptoms, and treatment of eczema vulvae. 
 
 It is most common near the climacteric and in fleshy women. 
 By far the most common ca.use is diabetes, from the fermentation 
 of the saccharine urine. Other causes are irritating discharges, 
 scratching from pruritus vulva?. There is a predisposition if a 
 a gouty or rheumatic diathesis exists. 
 
 ^iymj)toms and Appearances. — It usually begins on the inner sur- 
 faces of the labia in the shape of small vesicles and abrasions. 
 These extend to the other parts of the vulva. Intense pruritus is 
 a prominent symptom. Later there are redness, heat, and numer- 
 ous little vesicles rupture and discharge a serous, sticky fluid. 
 Finally, the labia become dry, hard, fissured, and swollen, covered 
 with crusts and scales ; the mucous membrane is white and sodden, 
 especially at the anterior commissure. 
 
 Treatment. — If due to diabetes, frequent applications of a solu- 
 tion of hyposulphite of soda, sss-Oj, will relieve the pruritus 
 and allay the inflammation. Give codeine, gr. ^, t.i. d., internally. 
 If due to other causes, lead-and-opium wash in the acute stage is 
 
CUTANEOUS AND NERVOUS AFFECTIONS OF THE VULVA. 53 
 
 good. In the chronic form an ointment of 8 per cent, ichthyol in 
 lanoline is highly recommended, or 5 per cent, creolin emulsion. 
 
 What ulcerations may be met with in the vulva? 
 
 Hard and soft chancres, non-specific ulcerations, sometimes in 
 childbed and prostitutes, forming small sensitive sores around the 
 entrance of the vagina and hymen. 
 
 CUTANEOUS AFFECTIONS OF THE VULVA. 
 What forms of skin diseases may affect the vulva ? 
 
 Alopecia, herpes labialis, prurigo, acne, simple erythema, ery- 
 sipelas, pityriasis versicolor, scabies, pediculus pubis. 
 
 What two forms of parasites may be found on the vulva ? 
 
 Scabies (rare), pediculi pubis (common). 
 Give etiology, symptoms, and treatment of scabies. 
 
 Due to the presence of the acarus scabei. This is rarely found 
 on the vulva, but may complicate the general infection. 
 
 Symiotoms. — Intense pruritus ; the presence of the burrows on 
 the vulva, with others on the hand and between the fingers, will 
 lead to the diagnosis. 
 
 Treatment. — Sulphur ointment, gr. xx-^j, or combined with bal- 
 sam of Peru. 
 
 Give the etiology, symptoms, and treatment of pediculi pubis. 
 
 This is due to the presence of the pediculi pubis, or crab-louse, 
 under the skin. It is conveyed by direct infection nearly always. 
 
 Symptoms. — Intense itching ; presence of small red spots, in 
 which the parasite can be seen with its ova and excrement. The 
 eruption resembles eczema. 
 
 Treatment. — It is well to begin the treatment of most eruptions 
 on the vulva with a 5 per cent, solution of carbolic acid as a lotion. 
 Mercurial ointment and the tincture of delphinium will destroy the 
 parasites. 
 
 NERVOUS AFFECTION OF THE VULVA. 
 
 Describe pruritus vulvae. 
 
 Pruritus vulvae is an intense itching and burning of the vulva. 
 It is a common symptom of a large number of the eruptive and 
 inflammatory diseases just considered, but the symptom may exist 
 without any apparent anatomical lesion. 
 
54 DISEASES OF THE VULVA. 
 
 What are the causes? 
 
 (1) Irritating discharges : ((() Urine ; (6) vaginal ; (c) uterine ; 
 (d) urethral ; (e) from the vulvo-vaginal glands and from Skene's 
 ducts. 
 
 (2) Diabetic urine ; 
 
 (3) Eruptions ; 
 
 (4) Masturbation ; 
 
 (5) Uncleanliness ; 
 
 (6) Neurotic influences, met with most commonly during preg- 
 nancy ; 
 
 (7) Parasites ; 
 
 (8) Ascarides ; 
 
 (9) Vegetable parasites : 
 
 (10) Anything giving rise to a congestion may cause pruritus : 
 
 (a) Pregnancy ; 
 
 (b) Tumors ; 
 
 (c) Menopause ; 
 
 (c?) Carcinoma uteri. 
 
 Symptoms. — Intense itching on the surface of the vulva, at first 
 localized over a limited area, the anterior commissure, inner sides 
 of labia majora and nymphae, later extending to all the external 
 organs. The sensation is not generally constant, except after the 
 menopause, being brought on or increased in severity by exercise 
 or coitus. It may only appear at night or early in the morning, 
 and is usually much increased by the warmth of bed-clothes. In 
 young women the symptom is generally intermittent ; after the 
 menopause it becomes more intractable and constant. 
 
 Treatment. — Directed to the cause. If of parasitic origin, re- 
 moval. If diabetic urine, hyposulphite of soda locally, 5ss-0j, and 
 codeine or salicylate of soda internally. If due to irritating dis- 
 charges, these must be treated. A plug of dry borated cotton 
 pushed into the vagina, to prevent the contact of a discharge, will 
 often afford great relief. Build up the system ; regulate diet if 
 there is a gouty diathesis ; frequent hot sitz-baths ; 2-3 per cent, 
 carbolic solution applied locally ; 4 per cent, cocaine solution ; nitrate 
 of silver ; boric-acid dusting powder. 
 
 B. Acidi acetici. f^j ; 
 
 Glyccrini, ' f^'ij._M. 
 
 Sig. Apply locally. 
 
NERVOUS AFFECTION OF THE VULVA. 55 
 
 What is hypersesthesia vulvae? 
 
 (This condition was first described by Thomas). It consists of 
 an excessive sensibility of the nerves supplying some portions of 
 the vulva — labia majora, minora, vestibule, or urethra. It is not 
 very frequent. 
 
 Give its etiology, symptoms, and treatment. 
 
 It occurs most commonly about the menopause, and is predis- 
 posed by an hysterical state. Chronic vulvitis and irritable urethral 
 caruncles may be exciting causes. Often no cause can be found. 
 
 S^mjjtoms. — Dyspareunia, or painful intercourse, is usually the 
 most prominent symptom, sometimes pain in walking or on bathing 
 the parts. The general health may suffer, and a state of melan- 
 cholia may be developed. 
 
 Treatment. — Change of scene unsatisfactory, better separation 
 from husband, tonics, bromides. Locally : Carbolic acid, 3 per 
 cent. ; cocaine, cyanide of potash (with caution). 
 
 Define vaginismus. 
 
 Vaginismus is an intense hypersesthesia of the vulvar outlet 
 and spasm of the constrictor vaginae muscle, brought about by 
 attempted coitus. The spasm may become general. 
 
 What are its causes ? 
 
 It may be due to some pathological lesion of the vulvar outlet 
 or hymen, to disease of the uterus, ovaries, or tubes, or it may be 
 purely nervous, or it may be caused by a rigid hymen, small vul- 
 var orifice, or by the vulva being placed too high under the sym- 
 physis. Sometimes tender spots are found on the hymen, due to 
 inflammation of the papillae. In nervous women inability of the 
 male to perform the sexual act is sometimes the cause. 
 
 What are its symptoms? 
 
 Excessive pain and muscular spasm around the vulva, induced 
 by attempted coition or any endeavor to pass the vulvar opening. 
 
 What is the treatment? 
 
 Excising the hymen and uniting the edges to prevent granula- 
 tion, afterward inserting a glass plug ; forcible dilatation under 
 anaesthetics and introduction of glass plug ; local applications of 
 cocaine, nitrate of silver, tr. iodine, hot douches, and sitz-baths. If 
 due to diseases of uterus, rectum, etc., treat these. 
 
56 DISEASES OF THE VULVA. 
 
 IRRITABLE URETHRAL CARUNCLE. 
 
 Give its pathology, etiology, symptoms, and treatment. 
 
 Pathology. — Urethral caruncles appear as briglit-red vascular 
 tumors projecting from the meatus or extending up into the urethra. 
 They are exceedingly painful to the touch and bleed easily. They 
 consist of hypertrophied papillae and areolar tissues. They are 
 very richly supplied with blood-vessels and nerves. They may be 
 single or multiple, sessile or pedunculated. 
 
 Etiology. — The cauae is unknown. They occur in young and old 
 alike ; often follow acute urethritis or chronic gonorrhoeal urethritis ; 
 may be due to a pathological state of the urine. 
 
 Symptoms. — Severe pain on urination may be accompanied by 
 spasm of muscles of vulva and sphincter ani ; pain on coition and 
 walking ; the constitution may run down. Excessively painful to 
 the touch. 
 
 Differentiation from prolapse of urethral mucous membrane, 
 polypi, and venereal warts. 
 
 Treatment. — Ligate and remove with knife. Prognosis is good 
 if single, worse if multiple. Cauterizing may be employed-, pre- 
 ceded by dilatation of the meatus under anaesthesia. 
 
 COCCYGODYNIA OR COCCYODYNIA. 
 Describe coccygodynia or coccyodynia. 
 
 Coccygodynia is a painful affection of the muscles, tendons, and 
 nerves of the coccyx, due most frequently to childbirth, but may 
 be caused by traumatism, with fracture and fixation of the coccyx 
 in an abnormal position, or dislocation. It may be the expression 
 of disease in other organs, as the uterus, ovaries, and rectum. It 
 may be rheumatic or brought on by exposure to cold, or it may be 
 hysterical. There may or may not be disease of the bone. 
 
 Symptoms. — Pain at the end of the spine, inability to rise from 
 sitting posture, due to the stretching of the fascia ; painful defeca- 
 tion ; painful coitus ; pain on walking or sitting down. 
 
 Diagnosis. — This is made by placing a finger in the rectum and 
 moving the bone, or by pressure on the coccyx from the outside. 
 
 Treatment. — If hysterical or due to disease of other organs, they 
 must be treated. If rheumatic or gouty, these conditions must be 
 attended to. Counter-irritation by actual cautery or blisters ; elec- 
 tricity. If these fail, operative measures : (1) Separation of the 
 
DISEASES OF THE VAGINA. 57 
 
 coccyx from tendinous and muscular attachments : (2) total extir- 
 pation. 
 
 PROLAPSUS URETHRJE. 
 
 Describe prolapsus urethras. 
 
 This is a prolapse of the urethral mucous membrane, witli pro- 
 liferation of the underlying connective tissue ; slight, is common ; 
 considerable, is rare. It is met with in old, feeble women and 
 young girls before puberty. It appears as a protrusion entirely 
 or partially encircling the meatus. After existing some time it 
 becomes inflamed and red, bleeding readily. 
 
 For what can this be mistaken? 
 
 Urethral caruncle, polypi, carcinoma. 
 
 How would you differentiate it from irritable urethral caruncle ? 
 
 It entirely encircles the meatus as a rule, while caruncle does 
 not. It is less painful ; may be reducible. 
 
 Symptoms. — Painful and frequent micturition. It may give rise 
 to urethritis and cystitis. Pruritus may be set up by the dis- 
 charge. 
 
 Treatment. — If slight, astringents ; if severe, angesthetize the 
 patient ; draw down the prolapsed mucous membrane with toothed 
 forceps and remove with scissors. Then sew the edges of the 
 mucous membrane together ; afterward catheterize the bladder and 
 do Emmet's buttonhole operation. Another method is to draw 
 down the mucous membrane, ligate, and remove with a knife or 
 cautery. 
 
 DISEASES OF THE VAGINA. 
 
 What diseases may be met with in the vagina? 
 
 Inflammations, cysts, ulcerations, malformations, displacements. 
 
 INFLAMMATIONS OF THE VAGINA. 
 
 Describe vaginitis occurring in children and before puberty. 
 
 May be acute or chronic. Acute (rare), due to injuries and rape 
 (gonorrhoeal). Symptoms and treatment are the same as for acute 
 vulvitis. Chronic (more common) may continue from acute or 
 be caused by dentition, errors of digestion, pin-worms, extension 
 from vulvitis. 
 
58 DISEASES OF THE VAGINA. 
 
 Symptoms. — Local irritation, milky discharge, unlike the secre- 
 tion from the vulva. The vulva is usually reddened and inflamed. 
 
 Treatment. — Constitutional tonics. Local: Cleanliness; irriga- 
 tion with 1 : 1000 bichloride if gonorrhocal, or weak bichloride 
 with lime-water. 
 
 What are the varieties of vaginitis in adults ? 
 
 {acute 
 chronic ; 
 
 (2) Gonorrhoeal ; 
 
 (3) Granular, papillary ; 
 
 (4) Ulcerative, adhesive, or senile ; 
 
 (5) Cystic ; 
 
 (6) Follicular. 
 
 Give the etiology, symptoms, diagnosis, and treatment of simple 
 acute catarrhal vaginitis. 
 
 Causes. — Predisposing, anything leading to congestion of the 
 parts, diseases of heart, lungs, and liver, abdominal tumors, preg- 
 nancy, menstrual epoch, menopause, chronic constipation, etc. Ex- 
 citing, exposure to cold during menstruation ; irritating discharges 
 from the cervix ; cancer ; putrid contents of uterus ; sloughing 
 placenta or tumors ; abuse of sexual intercourse ; too hot or too 
 cold douches ; use of local irritants, iodine, etc. ; foreign bodies, 
 sponges, pessaries, etc. ; lacerations and contusion during parturi- 
 tion ; acute exanthemata. 
 
 Symptoms and Diagnosis. — Burning heat and throbbing in the 
 vagina, sometimes severe pelvic pain of a bearing-down character ; 
 oifensive purulent leucorrhoea ; burning and excoriation at the 
 vulva ; sensation of weight in the perineum ; frequent micturition. 
 The mucous membrane is at first hot, dry, red, and swollen. 
 AVithin twenty-four hours there is an acrid discharge, which 
 becomes rapidly purulent and excoriates the vulva. Through 
 a speculum the mucous membrane is found red and congested with 
 abrasions and ulcerations on the surface. 
 
 Complications. — Extension of the inflammation to adjoining 
 organs — uterus. Fallopian tubes, peritoneum, Bartholin's glands, 
 urethra, bladder, ureters, and kidneys. 
 
 Treatment. — Put the patient in bed on a low diet. Prescribe 
 salines internally, and use opium in alkaline diluents for the bladder. 
 Vaginal injections three or four times a day of a weak solution of 
 
INFLAMMATIONS OF THE VAGINA. 59 
 
 liq. plumbi subacetatis or boric acid in warm water. Boric-acid 
 dusting powder on the vulva. Later touch the vagina with nitrate 
 of silver, gr. xx-^j, through a speculum. 
 
 Give the etiology, symptoms, and treatment of simple chronic 
 catarrhal vaginitis. 
 
 Etiology same as acute. From chronic leucorrhceal discharges, 
 as in phthisis, chlorosis, anaemia. 
 
 Symptoms^ same as acute, but less severe. Difficult to differenti- 
 ate from gonorrhoeal : in 90 per cent, gonorrhoeal. 
 
 Treatment. — Daily douches of hot water containing alum, sulph. 
 5J-0j, zinc sulph. 3J, or boric acid ^ij-Oj. Touch vagina once in 
 three days with nitrate of silver, gr. x-xxx-^j. 
 
 What are the points in which gonorrhoeal vaginitis differs from 
 simple catarrhal ? 
 
 (1) Symptoms more severe ; (2) onset more sudden ; (3) greater 
 liability to infect other organs, such as urethra, bladder, uterus. 
 Fallopian tubes, etc. ; (4) redness and excoriation about orifices 
 of Bartholin's glands are more common ; (5) history of infection ; 
 (6) gonorrhoeal warts and buboes ; (7) presence of gonococcus of 
 Neisser. 
 
 What is the frequency of gonorrhoeal vaginitis as compared with 
 other inflammations? 
 
 Between 80 and 90 per cent, of all cases of vaginitis are prob- 
 ably of gonorrhoeal origin. 
 
 Is the vagina as apt to become inflamed as other genital organs ? 
 No, because in character its mucous membrane resembles 
 the skin. A gonorrhoeal infection will frequently pass directly 
 from the vulva and urethra to the cervix uteri without setting up 
 a vaginitis. 
 
 What is the treatment of gonorrhoeal vaginitis? 
 
 General treatment is the same as for catarrhal vaginitis. Irri- 
 gate vagina thoroughly with 1 : 1000 bichloride of mercury. It 
 should be swabbed out through a speculum. To prevent exten- 
 tion of the inflammation to the cervix it is well to paint the en- 
 dometrium with iodized phenol (iodine gr. xl to carbolic acid ,^j). 
 Then swab out the vagina with nitrate of silver, gr. xx— 3J. Pow- 
 der the surface well with iodoform. Separate the walls with tam- 
 pons soaked in iodoform, glycerin, and chloral solution. 
 
60 , DISEASES OF THE VAGINA. 
 
 What are the great dangers of gonorrhoeal vaginitis? 
 
 (1) Infection of the endometrium ; (2) infection of the Fallopian 
 tubes and the formation of pyosalplnx and ovarian abscess ; (3) 
 pelvic peritonitis. 
 
 What are the causes, symptoms, and treatment of granular vagi- 
 nitis ? 
 
 Causes. — It may result from either of the preceding forms, but 
 is almost always associated with pregnancy. 
 
 Symptoms. — The subjective symptoms are similar to those of 
 simple vaginitis. On examination numerous granulations are felt 
 scattered over the mucous membrane and cervix. In appearance 
 they resemble a raspberry. The granulations are due to a swelling 
 of the papillae, either individually or in groups, caused by round- 
 cell infiltration. The epithelium on the surface is shed. 
 
 Treatment. — Sulphate-of-copper solution, 10 per cent., applied to 
 granulations ; crude pyroligneous acid, poured into the vagina 
 through a Fergusson speculum. 
 
 Describe ulcerative vaginitis. 
 
 The condition is usually met with in women past the menopause, 
 and affects chiefly the epithelium. It consists of a shedding of 
 the epithelium over papilla?, leaving raw, red, angry-looking patches. 
 It usually affects the upper third of the vagina. 
 
 Symptoms. — These are very slight. There may be a little thin 
 bloody discharge and severe pain. It tends to form adhesions be- 
 tween the vaginal walls and between the vaginal walls and cervix. 
 
 Treatment. — Crude pyroligneous acid poured into the vagina 
 through a Fergusson speculum or bivalve ; the vaginal walls and 
 escoriated patches dusted with iodoform, and kept separated by a 
 strip of iodoform gauze or a tampon. 
 
 Describe cystic vaginitis. 
 
 Cystic vaginitis is a rare condition, the cause of which is un- 
 known. It consists of numerous little cysts which contain gas or 
 fluid scattered over the vaginal walls. These are produced by a 
 swelling of the rugae into folds, adhesion of the edges, and the 
 formation of fluid or gas in the interstices. The fluid is clear and 
 honey-like. The cysts may be the size of a pea. 
 
 Describe follicular vaginitis. 
 
 Follicular vaginitis is generally of gonorrhoeal origin, and is due 
 to inflammation and occlusion of the mouths of the follicles, usually 
 
VAGINAL CYSTS. — MALFORMATIONS OF VAGINA. 61 
 
 at the upper portion of the vagina. Retention cysts are thus 
 formed, and round-cell infiltration takes place in the tissue sur- 
 rounding the gland. On digital examination these cystic follicles 
 feel like shot under the surface. 
 
 Symptoms. — There is a thick leucorrhoeal discharge. 
 
 Treatment. — Open each cyst with a knife and touch with nitrate 
 of silver. 
 
 VAGINAL CYSTS. 
 
 Define and give the etiology of vaginal cysts. 
 
 These are small cysts which appear on the wall of the vagina, 
 usually near the vulva, but they may be seen at the upper portion. 
 They are generally due to the collection of fluid in the ducts of 
 Gartner where pervious. Gartner's ducts are the horizontal 
 tubes of the parovarium which extend toward the uterus and are 
 lost upon the anterior vaginal wall. These cysts are usually single, 
 and contain a clear, serum-like fluid or a dark, chocolate-colored 
 material. Retention cysts are sometimes formed by the enfolding 
 and adhesions of the folds of the vagina. 
 
 Differentiation. — Cysts of Gartner's duct may be mistaken for 
 cystocele, urethrocele, and prolapse. 
 
 Symptoms. — Small cysts cause no symptoms. When large they 
 press upon neighboring organs. 
 
 Treatment. — Small, none ; large, total extirpation, or excising a 
 piece of the sac-wall and sewing the edges to the vaginal wall. 
 
 VAGINAL ULCERS. 
 
 What varieties may be met with ? 
 
 (1) Specific, hard and soft chancres ; 
 
 (2) Non-specific, resulting from one or other of the preceding 
 inflammatory conditions. 
 
 MALFORMATIONS OF VAGINA. 
 
 Define atresia and stenosis. 
 
 A complete or partial obstruction in the genital tract. The word 
 "atresia" means the state of being imperforate, but is sometimes 
 erroneously used in place of stenosis for partial closure. 
 
 Describe the varieties and sites of atresia. 
 
 It is congenital or acquired. In the congenital form the sites 
 
62 DISEASES OF THE VAGINA. 
 
 are the labia minora, hymen, inner part of vagina, cervix uteri. 
 In the acquired form the sites are the vagina and cervix uteri. 
 
 In the congenital form the labia minora are usually incomplete, 
 permitting the passage of urine. The hymen is dense and thick- 
 ened. 
 
 Atresia of Vagina. — The affection is due to atrophy or lack of 
 development of the ducts of Miiller. There may be one or more 
 transverse membranes. The vagina may be entirely obliterated or 
 replaced by a cord. It may be double, or one tube alone developed. 
 Septa may be at any portion, but usually near the uterus. They 
 may be single or multiple. 
 
 In the cervix the atresia may be at the os internum or throughout 
 the whole cervical canal. 
 
 What are the causes in the acquired form ? 
 
 (1) Injuries ; (2) chemical agents ; (3) prolonged labor and 
 injuries; (4) ulceration and adhesion of surfaces; (5) adhesive 
 vaginitis ; (6) gangrene. 
 
 May occur at any time after puberty. 
 
 The symptoms are due to retained menstrual flow and interfer- 
 ence with coition. Therefore there are no symptoms before puberty 
 and after the menopause. 
 
 Amenorrhoea. — There are signs of menstruation, but no flow, and 
 at each successive menstrual epoch the symptoms become worse 
 and more prolonged, the intervals shorter. There is a sense of 
 fulness and bearing down in the pelvis, and cramp-like pain ; 
 finally, the retained blood forms a tumor with pressure symptoms 
 of the rectum and bladder. 
 
 What are the physical signs? 
 
 Inability to introduce the finger into the vagina. Rectal exami- 
 nation reveals an absence of the vagina, a fibrous cord, or a tumor 
 from the distension of the vagina with blood. 
 
 What are the results? 
 
 If the atresia is at the hymen or vulva, a very large tumor may 
 form. The uterus is generally unaffected, but may be distended, 
 forming a hrematometra. The tubes may be filled with blood — haema- 
 tosalpinx. The hymen may rupture and let out the blood, or there 
 may be a rupture of the vagina, uterus, or Fallopian tubes, result- 
 ing in haematoccle, peritonitis, and septicajmia. 
 
DISPLACEMENTS OF THE VAGINA. 63 
 
 If the atresia is nearer the uterus, we get haematometra and 
 haematosalpinx. 
 
 What is the character of the retained blood ? 
 
 Before the menopause it is dark, grumous, and chocolate-colored, 
 having a heavy peculiar odor. After the menopause it is clear, 
 greenish, and honey-like. 
 
 Differentiation from uterine fibroids, malignant growths, ovarian 
 cysts, hsematocele, and pregnancy. 
 
 Treatment^ Operative. — If the atresia is at the hymen, make a 
 crucial incision and evacuate the blood, either slowly or rapidly, 
 under strictly antiseptic precautions. Irrigate thoroughly and insert 
 a glass plug. If the atresia is higher up, same treatment. If there 
 is absence of vagina, but the uterus and ovaries can be palpated, 
 make an artificial vagina with a knife and insert a glass plug. 
 When the atresia is at the cervix the retained blood should be 
 aspirated slowly to prevent rupture of a distended tube. When 
 thoroughly evacuated, dilate the cervix and use copious irrigation ; 
 insert a glass plug. The irrigations should be frequently repeated. 
 
 DISPLACEMENTS OF THE VAGINA. 
 
 What are they ? 
 
 Prolapse, rectocele. cystocele, enterocele. 
 
 Describe prolapse of the vagina. 
 
 When there is a pouching of the relaxed walls of the vagina into 
 its own canal, so that it rolls down toward the vulva, the condition 
 is known as prolapse. The condition is rare without coincident 
 descent of the bladder (cystocele) and rectum (rectocele), owing 
 to the attachment of the vagina to these organs. Redundancy of 
 the posterior wall without rectocele is more common than of the 
 anterior without cystocele. 
 
 Pathology. — Any influence which impairs the tone of the vagi- 
 nal walls, such as subinvolution, or which destroys its lower sup- 
 port, as in lacerations of the perineum, will tend to induce this 
 affection. It is very rare in women who have not borne children, 
 and is frequently associated with uterine prolapse. 
 
 Causes. — Repeated parturitions, rupture of perineum, senile atro- 
 phy, subinvolution, violent exertion of abdominal muscles. 
 
 Symptoms. — It may be acute, due to sudden violent exertion, or 
 chronic, the result of months or years. It causes a sense of dis- 
 
64 DISEASES OF THE VAGINA. 
 
 comfort in the vagina, bearing-down feeling, sense of heat and 
 fulness at the vulva. Tendency to become fatigued. Presence 
 of a tumor is felt by exploration. The mucous membrane may be 
 normal, dark purple color, eroded, or resembling skin. 
 
 Treatment. — Local astringents on tampons introduced daily in 
 the vagina ; pessaries ; abdominal supports ; surgical operations.* 
 
 Define rectocele. 
 
 This is a prolapse of the posterior wall of the vagina, carrying 
 with it a portion of the anterior wall of the rectum. It protrudes 
 from the vulva and may become quite large. The causes are the 
 same as for prolapse. 
 
 Symptoms. — The rectal pouch becomes filled with impacted 
 faeces, is irritated, and gives rise to tenesmus, discharge, consti- 
 pation, hemorrhoids. The finger introduced into the rectum will 
 decide the diagnosis. 
 
 Treatment. — Same as for prolapse. When large, some form of 
 posterior colporrhaphy is always performed. 
 
 Define cystocele. 
 
 This is a prolapse of the anterior wall, dragging with it the 
 closely adherent bladder and urethra. 
 
 Causes. — Same as for prolapse. When the vagina ceases to give 
 support to the base of the bladder, to which it is attached, a cysto- 
 cele results. 
 
 Symptoms. — Diagnosis can be made by passing a sound into the 
 bladder. Cystitis due to fermentation of the urine remaining in 
 the pouch ; vesical tenesmus ; burning on urination. It may form 
 a tumor of considerable size, protruding through the vulva. 
 
 Treatment. — When large, some form of anterior colporrhaphy ; 
 when small, same as for prolapse. A Gehrung pessary will eifect- 
 ually keep up a prolapsed anterior wall. 
 
 Describe enterocele. 
 
 This is very rare, and consists in the descent of a portion of 
 small intestine into the pelvis, encroaching on the vaginal canal. 
 Usually a deep Douglas cul-de-sac. It may attain considerable 
 size. It is of particular importance during parturition, when the 
 gut may become strangulated. 
 
 * Colporrhaphies. {See Perineal Operations.) 
 
THE PERINEAL BODY AND PELVIC FLOOR. 65 
 
 THE PERINEAL BODY AND PELVIC FLOOR. 
 
 ANATOMY. 
 Describe the perineal body. 
 
 The perineal body is a mass of fibro-muscular tissue filling in 
 the space between the lower ends of the rectum and vagina. It is 
 an irregular four-sided pyramid. Two sides rest against the pos- 
 terior vaginal wall, one against the anterior wall of the rectum, 
 and one is covered by the skin and fascia between the posterior 
 commissure and the anus.^ The perineal body is IJ inches in 
 length, 1^^ inches in width, and f inch antero-posteriorly. Above 
 it becomes continuous with the recto-vaginal septum, and laterally 
 it is bounded by fat. The whole body lies below a line joining 
 the tip of the coccyx and the subpubic ligament. 
 
 The muscles entering into its formation are the bulbo-cavernosus, 
 the transversus perinei, and the sphincter and levator ani. Its 
 function is to give a fixed point to many muscles, to prevent pouching 
 forward of the rectal wall, and to give strength to the pelvic floor. 
 It also indirectly supports the anterior vaginal wall and prevents 
 cystocele. 
 
 The arterial supply of the perineum is derived from branches of 
 the internal pudic ; the nerve-supply from the pudic nerve ; the 
 veins terminate in the pudic veins and the lymphatics in the in- 
 guinal glands. 
 
 Describe the pelvic floor. 
 
 The pelvic floor includes all the soft parts which close the outlet 
 of the pelvis : rectum, vagina, bladder, levator ani, and coccygei 
 muscles, fascia above and below them, perineal body, ischio-rectal 
 fossae, and integument. 
 
 Examining the structures from above downward, the pelvic and 
 recto-vesical fasciae are first seen. The pelvic fascia is attached to 
 the pelvic brim and to the tendinous band called the " white line " 
 which extends from the lower portion of the symphysis pubis to 
 the ischial spine. The recto-vesical fascia is the continuation of 
 the pelvic, extending downward and inward from the white line, 
 covering the levator ani muscles and uniting in the median line 
 with its fellow of the opposite side. Posteriorly it is continuous 
 with the fascia covering the pyriformis muscle. It is pierced by 
 the vagina and rectum, being prolonged downward upon each in 
 
 * This skin is often erroneously spoken of as the perineum. 
 5— Gyn. 
 
66 THE PERINEAL BODY AND PELVIC FLOOR. 
 
 the form of a sheath. The obturator fascia is the other division of 
 the pelvic fascia at the white line, and covers the obturator muscle. 
 
 Beneath the pelvic and recto-vesical fascia is the muscular 
 diaphragm, formed by the levator ani in front and the coccygei 
 behind. 
 
 The coccygei are two thin, triangular muscles which arise from 
 the ischial spine and lesser sacro-sciatic ligament, and are inserted 
 into the lateral borders of the lower segment of the sacrum and to 
 the sides and anterior surface of the coccyx. The two levatores ani, 
 meeting with each other in the median line, form a concave mus- 
 cular diaphragm across the outlet of the pelvis. Each arises from 
 the posterior aspect of the pubis, from the " white line," and from 
 the inner surface of the ischial spine. They extend inward to the 
 median line, uniting with each other and surrounding the rectum 
 and vagina, to which they are firmly attached.^ Behind the vagina 
 the fibres forn,i part of the perineal body and blend with the deep 
 transversus perinei muscles. Some fibres are attached to the coccyx. 
 
 The under surface of the levator ani is covered by a thin mem- 
 brane called the anal fascia, which has its attachment on either 
 side to the obturator fascia, and in the median line to the opposite 
 lamina and to the rectum and vagina. Below the anal fascia the 
 remainder of the pelvic outlet is filled by the perineal body and 
 the ischio-rectal fossae. 
 
 What muscles enter into the formation of the perineal body ? 
 
 The hulho-cavernosi arise posteriorly in the perineal body and 
 encircle the vaginal bulbs. Each divides into three slips — one 
 going to the posterior surface of the bulb, another to the lower 
 surface of the corpus cavernosum, and the third being lost on the 
 mucous membrane of the vestibule. Their action is to compress 
 the bulbs. 
 
 The transversus perinei muscles are divided into two layers, a 
 superficial and a deep, separated by the anterior layer of the tri- 
 angular ligament. They arise from the rami of the ischium and 
 the anterior triangular ligament, and are inserted into the median 
 raphe of the perineal body. 
 
 The sphincter ani arises from the tip of the coccyx and superficial 
 fascia, and is inserted into the perineal body. 
 
 The levator ani has been described. It is divided into an 
 anterior or j;?<?>o-i;cf^m<7i portion, which surrounds the vagina and 
 
 * The vagina pierces the pelvic floor at an angle of about 00°. 
 
LACERATIONS OF PERINEUM AND PELVIC FLOOR. 67 
 
 acts to contract the outlet, and a posterior portion, the obturato- 
 coccygeal, surrounding the rectum. 
 
 The urethra is surrounded by the compressor iirethrse muscle 
 (called by some the sphincter or constrictor vaginae), which forms 
 a figure of 8 around the vagina and urethra. 
 
 Describe the ischio-rectal region. 
 
 This corresponds to the portion of the pelvic outlet behind the 
 perineal hodj. It contains the termination of the rectum and a 
 deep fossa filled with fat on either side of the latter, between it and 
 the tuberosities of the ischium. The ischio-rectal fossse are pyra- 
 midal in shape, with the apex directed upward. They are one inch 
 in breadth and two inches in depth, bounded internally by the 
 levator ani, sphincter ani, and coccygei muscles, externally by the 
 tuberosities of the ischium and the obturator fascia ; anteriorly 
 they are limited by the division of the superficial and deep perineal 
 fascia, posteriorly by the gluteus maximus and great sacro-sciatic 
 ligament. 
 
 The external covering of the pelvic floor is made up of skin 
 and fascia. 
 
 Describe the superficial perineal fascia. 
 
 It is separated into two layers — a superficial and a deep. The 
 superficial or subcutaneous layer contains considerable adipose 
 tissue and the superficial perineal and hemorrhoidal vessels and 
 nerves. The deep layer is attached to the rami of the pubes and 
 ischium posteriorly, and curves around the transversus perinei to 
 become continuous with the anterior layer of the triangular liga- 
 ment. 
 
 The trianpdar ligament, or deep perineal fascia, is composed of 
 two layers, and closes the front part of the outlet of the pelvis. 
 It is attached to the under surface of the symphysis and to the 
 pubic and ischial rami. It is divided in the middle by the vagina. 
 
 LACERATIONS OF THE PERINEUM AND PELVIC 
 
 FLOOR. 
 
 What are the chief facts to be borne in mind in the consider- 
 ation of lacerations of the perineum ? 
 
 A thorough knowledge of the anatomy and functions of the peri- 
 neum and pelvic floor is necessary to fully understand the import- 
 ance of these lesions. The levator ani muscles and pelvic fascia 
 
68 THE PERINEAL BODY AND PELVIC FLOOR. 
 
 are the most important features in the support of the pelvic vis- 
 cera, acting as a tight sling of fibres across the pelvic outlet. 
 Laceration or overstretching of these fibres, especially posteriorly 
 at their attachment to the rectum, results in a relaxation of the 
 outlet through which the superincumbent structures roll out, caus- 
 ing rectocele, cystocele, prolapse of the vagina and uterus. 
 
 What are the causes of lacerations of the perineum ? 
 
 Parturition is by far the most important cause; acting, when 
 there is a large head, in occipito-posterior position, rotated into 
 the hollow of the sacrum ; when there is a narrow pubic arch ; in 
 elderly primiparae, with rigidity of the parts ; the careless use of for- 
 ceps, etc. Besides parturition, lacerations may, rarely, be produced 
 by external violence, such as falling astride sharp objects. Rape 
 in children sometimes results in a laceration, as may also syphilitic 
 ulcerations of the perineal body. Occasionally there is a loss of the 
 perineal body due to senility, debility, and subinvolution. 
 
 What are the varieties of perineal lacerations ? * 
 
 (1) Laceration into the body of the perineum, including slight 
 tears and those extending to the sphincter without injury to the 
 levator ani. (2) Rupture of the perineum with radiating tears into 
 the sulci on either side of the posterior columns of the vagina. 
 These are the Y-shaped tears which leave the tip of the posterior 
 column as a tongue of tissue. The laceration may extend upon 
 one or both sides. (3) Rupture of perineal body through the 
 sphincter ani without laceration of the levator ani. (4) Lacera- 
 tion through the sphincter ani with injury to the levator ani. (5) 
 Invisible, concealed, or subcutaneous ruptures when the levator ani 
 muscles and fascia have been overstretched and torn, resulting in 
 subinvolution and relaxation of the vaginal outlet. These kinds 
 of laceration are the most frequent and of the greatest importance. 
 They are generally unrecognized. 
 
 How would you test for relaxation of the vaginal outlet and the 
 extent of laceration ? 
 
 By placing two fingers in the vagina and pressing downward and 
 outward, at the same time telling the patient to bear down as if at 
 stool. If relaxation exists, the walls of the vagina will be seen to 
 bulge downward and protrude. It is well to place a pledget of cot- 
 ton over the anus to prevent evacuation of fsBces. To test the 
 
 * Taken from Dr. Cleveland's classification. 
 
OPERATIONS FOR LACERATION OF PERINEUM. 69 
 
 extent of laceration place the thumb against the anterior margin 
 of the anus, and the tip of the finger just within the vagina, and 
 bring the two together. 
 
 What is the significance of rupture of the perineum ? 
 
 Septicaemia may be an immediate consequence, due to the expos- 
 ure of the extensive raw surface, rich in blood- and lymph-vessels, 
 to the lochial fluid. 
 
 Tears through the sphincter will lead to complete or partial incon- 
 tinence of fasces. Tears involving the levator ani muscles and 
 fascia will result in subinvolution, relaxation of the vagina, prolapse 
 of uterus and vagina, rectocele, cystocele, subinvolution of the ute- 
 rus, and displacements. Tendency to abortion, tenderness at the 
 site of the tear, may result. Sometimes air enters the vagina and 
 escapes with a noise. 
 
 What are the symptoms of lacerated perineum ? 
 
 These are due to the above consequences, and have been described 
 under Rectocele and Cystocele. 
 
 OPERATIONS. 
 What are the two classes of operations ? 
 
 Primary and secondary. The primary operation, or immediate 
 repair of the injury at the close of labor, belongs to the province 
 of obstetrics. It should be the object in performing the secondary 
 operation to reduce the tear by proper denudation to its original 
 condition — i. e. the recent form — and then to suture. 
 
 How long should you wait after labor before performing the sec- 
 ondary operation? 
 
 It is better to wait until involution is complete, and operate from 
 five to six months after confinement. 
 
 What are the preliminary preparations and instruments required 
 for a primary operation ? 
 
 Regulate the patient's diet for two or three days previous to the 
 operation. Grive a mild laxative for two nights before to secure 
 complete evacuation of the bowels. An enema should be admin- 
 istered and the bladder emptied immediately before operating. The 
 patient is then anaesthetized and placed in the lithotomy position, 
 the knees being held up by a Clover's crutch. The vulva should 
 be shaved and thoroughly cleaned with 1 : 1000 bichloride, and the 
 
70 
 
 THE PERINEAL BODY AND PELVIC FLOOR. 
 
 vagina thoroughly swabbed out with the same solution. The abdo- 
 men and limbs of the patient are surrounded with towels wrung 
 out of 1 : 1000 bichloride. 
 
 The necessary instruments are 2 pairs of sharp-pointed scissors, 
 straight and curved on the flat ; 1 pair of straight, blunt-pointed 
 scissors ; 1 pair of sharp-pointed straight scissors, curved on the 
 side ; 4 tenacula, Emmet's ; 2 bullet forceps ; 6 sponge-holders ; 
 1 needle-holder ; 2 mouse-toothed forceps ; 1 plain dissecting for- 
 ceps ; 1 pair of tissue forceps ; 6 pairs of artery forceps ; 1 counter- 
 pressure hook ; 1 shield ; 1 Emmet's twisting forceps ; 12 per- 
 forated shot; 1 shot-compressor; 12 needles, small curved, large 
 
 Fig. 23. 
 
 Method of Repair adopted in Previous Cases. 
 
 curved, spear-point, long, straight ; 1 Peaslee's needle ; sterilized 
 catgut, sizes Nos. 2 and 3 ; small-size silk ; silkworm gut ; silver 
 wire, No. 24 ; Kelly's rubber pad. 
 
OPERATIONS FOR LACERATION OF PERINEUM. 
 
 71 
 
 What are the most important operations? 
 
 Perineorrhaphies and posterior colporrhaphies : (1) Tait's flap- 
 splitting perineorrhaphy for complete laceration; (2) Tait's flap- 
 splitting perineorrhaphy for incomplete laceration, modified by 
 Sanger ; (3) Cleveland's perineorrhaphy ; (4) Hegar's posterior 
 colporrhaphy ; (5) Emmet's posterior colporrhaphy. 
 
 Describe Tait's perineorrhaphy? 
 
 This operation is based on the principles of the healing of an old 
 tear. If the buttocks and labia are widely separated, a white line 
 of cicatrix will be seen extending from side to side transversely to 
 the axis of the old wound. The object of the operation is to 
 restore the old rent, and unite it in a vertical axis — i. e. at right 
 angles to the present cicatrix. 
 
 The patient is prepared as described. An assistant stands on 
 either side, the one on the right holding an irrigator nozzle and 
 allowing a slight stream of 1 : 10,000 bichloride to trickle over the 
 parts during the operation. A tampon is introduced into the rec- 
 tum. The middle finger of the left 
 hand is then inserted into the rec- 
 tum and the buttocks and labia 
 strongly separated by an assistant, 
 so that the cicatrix is put on a 
 stretch. The point of an angular 
 pair of scissors is introduced into 
 the extreme end of the cicatrix on 
 one side, and run through to the 
 other extremity. From each end 
 of this incision another is carried 
 forward to the bases of the labia 
 minora, and again backward for 
 one-third of an inch ; the edges of 
 the upper flap a are caught with 
 a pair of tissue forceps and dis- 
 sected upward, the same being done 
 to the lower flap h downward, 
 and the wound assumes the shape 
 
 represented by the dotted lines in Fig. 24. The sutures are 
 now introduced by means of a Peaslee's needle well curved, which 
 is run through from side to side, entered, and brought out just 
 within the margin of the denuded area. This is threaded with 
 
 / 
 
 Fig. 24. 
 
 Va^na 
 
 Rectum 
 
72 THE PERINEAL BODY AND PELVIC FLOOR. 
 
 silkworm gut and withdrawn. The sutures are then tied and the 
 edges of the skin brought together by intermediary superficial 
 sutures. The rectal and vaginal flaps fold in on each other and, 
 retracting, point to the rectum and vagina respectively. The 
 resulting cicatrix is linear, and leaves scarcely any trace after 
 healing. 
 
 What are the advantages of this operation ? 
 
 (1) No tissue is removed, the recto-vaginal septum is simply split, 
 the flap turned up, sides / denuded and united. (2) The sutures 
 are all external. (3) The parts are brought back into their original 
 position. 
 
 What additional method of repair may be done in case the lace- 
 ration extends through the sphincter ani and up the recto- 
 vaginal septum? 
 
 After dissecting up the vaginal flap as just described, a V-shaped 
 denudation is made with its apex up the rectum. The ends of each 
 arm of the V lie against the separated ends of the sphincter ani. 
 which can be seen as little retracted dimples on either side of the 
 anal opening. Rectal sutures of silkworm gut are then introduced, 
 beginning at the apex, and are tied in the rectum. The ends of 
 the sutures are left long, and protrude from the anus. A suture 
 of silver wire may be passed around the inverted V. 
 
 It is well to introduce the perineal sutures first, in order to 
 avoid stretching the rectum, whose edges have just been brought 
 together. The rectal sutures may be left in for several weeks. 
 
 Describe the Sanger-Tait operation. 
 
 This operation differs only in detail from the one just described. 
 The middle finger alone, or the index and middle fingers, may be 
 introduced into the rectum. The points of a pair of curved scissors 
 are inserted into the recto-vaginal septum between the cicatrix and 
 the margin of the anus, and pushed upward to the crest of the 
 rectocele. The septum is now split before making the horizontal 
 incision. This avoids undue hemorrhage. Sanger also recommends 
 a thin-bladed knife to be used for this splitting instead of scissors. 
 The horizontal incision may now be made, running out to a point 
 on cither side vertically below the extremities of the nymphae, 
 and then carried upward to the bases of the labia minora, or 
 the incision may be curved in the form of a U. The dissection 
 of the flap is now completed. Silver-wire sutures instead of silk- 
 
OPERATIONS FOE LACERATION OF PERINEUM. 
 
 73 
 
 worm gut are introduced by means of a straight needle threaded 
 with carrying thread. The rectal tampon is removed, and the 
 sutures twisted up and shotted. Intermediary silkworm-gut 
 sutures are required. 
 
 Describe Cleveland's operation. 
 
 After the usual preparations the patient is anaesthetized and 
 placed in the lithotomy position, as just described for Tait's opera- 
 tion. The field of operation is put on the stretch by two tenacula 
 hooked into the bases of the labia majora on either side and re- 
 
 FiG. 25. 
 
 Cleveland's Suture for Lacerated Perineum. 
 
 tracted. The crest of the rectocele is caught with a pair of bullet 
 forceps and drawn up by an assistant. A triangular area is now 
 denuded, having for its base the line joining the two lateral tenacula, 
 and for its apex the crest of the rectocele. The denudation may 
 
74 
 
 THE PERINEAL BODY AND PELVIC FLOOR. 
 
 be made with a knife or pair of scissors. After thoroughly irri- 
 gating the parts the sutures are passed in the following manner : 
 A long straight needle, threaded with catgut, size No. 3, is inserted 
 at the point 1 A in the figure, carried to the mid-line, as shown by 
 the dotted lines, and brought out. The needle is then introduced 
 where it came out, and, curving downward, is brought out at 2 A. 
 The catgut is now drawn through, and the needle again introduced 
 at 3 A, carried up to the mid-line crossing the loop, and is brought 
 out at 4 A, finishing the first suture, iV. The second suture, B, is 
 passed as indicated by the dotted lines. In the figure the apex of 
 the triangle is shown foreshortened. A third suture. E, is now 
 passed as in the figure. Suture A is first tightened and tied, 
 making a figure of 8 and really two sutures. Next B is brought 
 together, making another figure of 8, and finally E is tied. The 
 advantages of this operation are the rapidity with which it can be 
 performed and its applicability to primary as well as secondary tears. 
 
 Describe Hegar's operation. 
 
 The patient is prepared in the usual manner and placed in the 
 lithotomy position. Two tenacula are fixed in the lowest part of 
 the labia majora, points B and C, and drawn forcibly to both sides 
 
 Fig. 2G. 
 
 Hegar's Operation, foreshortened. 
 
 by assistants. The cervix is caught by its posterior lip with a pair 
 of bullet forceps and drawn downward, forward, and lifted up, as 
 
OPERATIONS FOR LACERATION OF PERINEUM. 
 
 75 
 
 shown in the figure. A triangular area is now marked out with a 
 knife, having for its base the line B C, which runs across the pos- 
 terior commissure, and for its apex A, a point just below the cervix. 
 The mucous membrane is denuded from this triangular area, either 
 with a knife dissecting down a flap from the apex A, or with a pair 
 of scissors. The sutures are of silver wire for the vaginal, and silk 
 for the perineal, and are both deep and superficial. The deep 
 sutures are introduced one-third of an inch apart, underlying the 
 whole denuded area. The superficial sutures unite the mucous 
 membrane between each of the deep sutures. 
 
 What modifications of this operation may be made with advan- 
 tage? 
 
 The area of denudation may be brought together with a continu- 
 ous catgut suture in layers, as used by Martin in his anterior col- 
 porraphy, to be described. The apex. A, may be taken at a little 
 above the highest point on the crest of the rectocele and held up 
 with bullet forceps. 
 
 Describe Emmet's operation. 
 
 This operation is more especially advantageous when the tear 
 takes a Y-shaped form up the sulci, and when there is considerable 
 relaxation. 
 
 Preparation of the pa- 
 tient is done as usual, 
 and she is placed in the 
 lithotomy position. A 
 point on the crest of the 
 rectocele, A, is caught 
 with a tenaculum. Two 
 other tenacula are intro- 
 duced into the lowest 
 caruncles of the hymen 
 on either side, C and B. 
 These three points are 
 approximated at the end 
 of the operation. The 
 points D and E are in 
 the sulci on either side 
 
 of the column of the ^ 
 
 vagina. Two triangular ^""^ 
 
 areas, A D B and A E C, Emmet's Operation. 
 
 Fig. 27. 
 
76 THE PERINEAL BODY AND PELVIC FLOOR. 
 
 Fig. 28. 
 
 el^^' 
 
 Emmet's Operation : Insertion of Sutures. 
 
 are thus formed, and are now denuded as follows : An assistant draws 
 the crest A first strongly to the operator's left side, making the lines 
 
 A D B nearly straight. The mucous 
 Fig 29. membrane extending along this line is 
 
 now stripped up with scissors. The 
 same thing is done for the opposite 
 side, drawing the tenaculum at A to 
 the right. Denudation of the whole 
 area shown in the figure is then com- 
 pleted with scissors. The edges of the 
 lateral triangles are united together 
 with sutures carried deep into the sulci 
 and entirely under the denuded area, 
 so as to catch up the ends of the sep- 
 arated fibres of the pelvic fascia. The 
 manner in which the sutures are passed 
 is shown in Fig. 28. There remains 
 now a small area to be united on the 
 perineal surface with silk or wire su- 
 tures. 
 
 Describe Martin's anterior colporrha- 
 phy for cystocele and prolapse. 
 
 The usual preliminaries having been 
 
 gone through with in the preparation 
 
 of the patient, she is anaesthetized and 
 
 placed in the lithotomy position. The 
 
 anterior lip of the cervix is grasped with a pair of bullet forceps 
 
 and well drawn down. This exposes the anterior wall of the vagina. 
 
 B 
 
 Martin's Suture. 
 
THE URETHRA AND BLADDER. 77 
 
 Another pair of bullet forceps is placed just below the urethra 
 and drawn up. The whole surface is put on the stretch by lateral 
 tenacula. Then an incision is made around an ovoid figure which 
 has one point just below the urethra and the other near the cervix. 
 This area, marked out by the line of incision, and which includes 
 to a greater or lesser extent the anterior wall of the vagina, is now 
 denuded with a knife, dissecting down a flap, or with a pair of 
 scissors. Suturing of the area is now performed as follows : A 
 long No. 2 catgut suture is threaded into a medium-sized spear- 
 point needle, and passed through at the apex A and tied. The end 
 of the suture is given to an assistant to hold, and the bullet forceps 
 are removed. The needle is then inserted into the denuded area, 
 passed under the surface, and brought into the denuded area as 
 shown in Fig. 29. In this way, with an over-and-over continuous 
 stitch, the suture is carried to the inferior angle B, then back again 
 to the top in the same manner, until the edges of the mucous mem- 
 brane are brought near enough together to approximate by addi- 
 tional sutures. 
 
 THE URETHRA AND BLADDER. 
 
 ANATOMY. 
 Describe the urethra. 
 
 The urethra is a canal If inches in length, extending from the 
 meatus to the neck of the bladder. Its lower three-fourths is im- 
 bedded in the anterior vaginal wall; its upper fourth is firmly 
 bound to the vagina by connective tissue. It extends upward and 
 backward parallel to the plane of the pelvic brim. 
 
 The mucous membrane is covered with squamous epithelium at 
 its lower part, and transitional epithelium, like the bladder, at its 
 upper position. It contains mucous glands, papillae, lacunae, and 
 villous tufts. On cross-section the urethra is seen to be slit-shaped 
 transversely at its vesical end, and stellate below. Just within the 
 meatus, on either side, are the orifices of Skene's tubes or ducts. 
 These extend along the floor of the urethra, beneath the mucous 
 membrane, upward for a distance of three-fourths of an inch. 
 
 The muscular coat consists of two layers of unstriped fibres, an 
 internal longitudinal and an external circular. 
 
 Describe the bladder. 
 
 The bladder is a hollow muscular organ situated between the 
 
78 THE URETHRA AND BLADDER. 
 
 symphysis in front and the uterus and vagina behind. Its shape 
 when empty is like the letter Y. The upper and lower walls, 
 coming in contact, form the two horizontal arms. The urethra forms 
 the vertical arm. It has opening into it the internal orifice of the 
 urethra and the two ureters: the latter, one on cither side, are IJ 
 inches from each other and from the urethra. 
 
 The bladder is divided into a body, neck, and base. 
 
 The hoilij is " all that portion of the organ lying above an imagi- 
 nary line drawn from the ureteric openings to the symphysis pubis " 
 (Skene). All below is the base, and includes the trigone (that 
 triangular portion between the ureteric openings and the inter- 
 nal orifice of the urethra) and the has-fond (that portion behind 
 the openings of the ureters, which in old subjects may be a deep 
 pouch). The neck is the thickened portion surrounding the 
 urethral orifice. 
 
 The bladder is composed of three coats, mucous, muscular, and 
 peritoneal. The mucous membrane is thrown into numerous folds, 
 and is lined with several layers of transitional epithelium and a 
 superficial squamous layer. It is loosely attached to the submucous 
 tissue, except at the trigone, and is thicker at the urethral open- 
 ing, where it has a valve-like function to prevent the escape of 
 urine (Hart and Barbour). The muscular coat is composed of three 
 irregular layers of unstriped fibres, an external and internal longi- 
 tudinal and a middle circular. At the openings the circular fibres 
 are more developed and have a sphincteric action. 
 
 The peritoneal coat covers the fundus and part of the posterior 
 bladder-wall, from which it is reflected on to the anterior surface 
 of the uterus at the level of the isthmus, forming the vesico- 
 uterine ligaments and pouch. The arterial supply is derived from 
 the utero-vesical branches of the anterior division of the internal 
 iliac and from the uterine artery. 
 
 The urethra is supplied from the vaginal arteries. 
 
 The veins form plexuses outside the muscular coat, and unite 
 with those of the uterus, vagina, nymphae, and rectum. They 
 empty into the internal iliac vein. The plexus of the urethra com- 
 municates with that of the vagina. 
 
 The lymphatics accompany the veins, and enter the hypogastric 
 glands near the internal iliac artery. The nerves are derived from 
 the hypogastric plexus of the sympathetic, and from the third and 
 fourth sacral, the latter supplying mainly the base and neck. 
 
DISEASES OF THE URETHRA AND BLADDER. 79 
 
 Describe the course of the ureters. 
 
 At the brim of the pelvis the ureters cross over the iliac vessels 
 just below the division of the common iliacs. Here the left 
 ureter lies behind the sigmoid flexure of the colon, and the right 
 behind the lower end of the ileum. They then run downward, 
 backward, and outward along the pelvic wall until near the ischial 
 spines. Here they bend downward, forward, and inward behind the 
 uterine arteries, passing beneath the bases of the broad ligaments. 
 At the level of the os uteri externum, and three-fifths of an inch 
 distant from the uterus, the uterine arteries cross the ureters. 
 From this point they continue to converge, lying in relation to the 
 anterior vaginal and posterior bladder-walls, and pierce the latter 
 obliquely at a point one-half to three-fourths of an inch in front 
 of and below the cervix. They run for a distance of half an inch 
 in the muscular coat, still converging, so that their internal open- 
 ings are separated from each other by about one and a half inches. 
 
 DISEASES OF THE URETHRA AND BLADDER. 
 
 What are the diseases to which the urethra is liable? 
 
 Malformations (hypospadias), urethral caruncle, (see p. 56), and 
 prolapse of the mucous membrane (see p. 57), inflammation (ure- 
 thritis), urethrocele. 
 
 Give the etiology, symptoms, and treatment of urethritis. 
 
 It is nearly always due to gonorrhoeal infection, but may be simple. 
 The chronic form may be caused by caruncles or chronic cystitis. 
 
 Symptoms. — Dysiiria, muco-purulent discharge. 
 
 Treatment. — Tepid irrigations, application of nitrate of silver, 
 iodoform bougies. Skene's tubules may become inflamed and keep 
 up a urethritis until they are slit up and cauterized. 
 
 Give the etiology, symptoms, and treatment of the acute and 
 chronic forms of cystitis. 
 
 Etiology. — Acute : gonorrhoea ; exposure to cold ; injuries dur- 
 ing parturition ; peritonitis. Chronic : continuance from acute ; 
 stone in the bladder ; pressure of a tumor or uterus on the blad- 
 der ; pyelonephritis. 
 
 Symptoms. — Acute : severe pain over the bladder ; chill, fever ; 
 painful micturition ; high-colored urine. May last a few days to a 
 week, and subside or pass on to the chronic form. Chronic : Fre- 
 quent micturition, more especially at night ; vesical tenesmus and 
 
80 THE URETHRA AND BLADDER. 
 
 sensation of weight over the bladder ; cloudy, scanty urine, con- 
 taining pus-cells and cells from the bladder. It may debilitate the 
 whole system and cause the patient's health to be undermined. 
 The walls of the bladder may become encrusted with lime and other 
 salts, which give rise to stone in the bladder. 
 
 Treatment. — Acute : rest in bed ; hot poultices over the lower 
 part of the abdomen ; demulcent drinks of flaxseed tea and muci- 
 lage ; opium to check the pain. Chronic: The administration of 
 alkaline diluents, such as citric acid, acetate of potassium, uva 
 ursi, lithia-water ; unirritating diet. Washing out the bladder with 
 a 1 : 1000 solution of boric acid by means of a double-current cathe- 
 ter and fountain syringe ; may be done twice daily if necessary or 
 every other day. The pain is relieved by morphine suppositories. 
 If all these means fail, as a last resource an opening may be made 
 into the bladder through the anterior vaginal wall and the urine 
 allowed to constantly flow away until the condition is relieved. 
 
 Describe the operation for buttonholing the bladder (colpocyst- 
 otomy). 
 
 The patient is anresthetized and placed in the Sims position. 
 A Sims speculum is introduced and a sound passed into the blad- 
 der. At the most prominent point in the median line between 
 the neck of the bladder and the urethra an incision is made longi- 
 tudinally an inch long, care being taken to cut through the bladder 
 mucous membrane as much as the vagina. This enters about half 
 way in the trigone vesicae. Now with a sharply-curved needle and 
 small catgut the mucous membrane of the bladder is sutured to 
 that of the vagina to prevent healing. Instead of these sutures a 
 sigmoid glass tube, provided with a flange at one end, may be but- 
 toned through this opening and allowed to remain. It is usually 
 necessary to keep the fistula open from three to six months. The 
 bladder in the mean time is frequently irrigated and treated. This 
 operation gives great relief in severe chronic cases. The opening 
 is finally closed as any other fistula. 
 
 What are the varieties of fistulse of the genital tract ? 
 
 The uterus and vagina may be connected by one or more aper- 
 tures of variable size and shape with some viscus in immediate 
 proximity, such as the bladder, rectum, peritoneum, etc. They are 
 named according to the parts connected : 
 
 Vesico-vaginal fistula (2 and 8, Fig. 80). 
 
FISTULA. 
 
 81 
 
 Vesico-uterine fistula (1, Fig. 30). 
 Urethro-vaginal fistula (4, Fig. 30). 
 
 Fig. 30. 
 
 Xocation of Various Forms of Fistula : 1 , vesico-uterine fistula ; 2, vesico-utero-vaginal 
 fistula; 3, vesico-vaginal fistula; 4, urethro-vaginal fistula; 5, recto-vaginal fistula; 
 6, recto-labial fistula ; 7, fistula in auo. 
 
 Recto-vaginal fistula. 
 Entero-vaginal fistula. 
 Peritoneo-vaginal fistula. 
 
 Give the etiology, diagnosis, and treatment of fistula. 
 
 Etiology. — The majority of the cases of fistula result from pres- 
 sure of the child's head during parturition, causing a slough ; but 
 rarely they have their origin in abscesses, stone in the bladder, 
 pessaries, cancerous and syphilitic ulcerations. 
 
 Diagnosis. — Continuous escape of urine from the vagina, causing 
 vaginitis and vulvitis, and the strong urinous odor will indicate 
 urinary fistula. Escaped faeces into the vagina will show a rectal 
 fistula. If the opening is large, it can readily be felt with the 
 finger. If too small to be seen or felt, milk may be injected into 
 6— Gyn, 
 
82 
 
 THE URETHRA AND BLADDER. 
 
 the bladder, which is seen to escape from the fistula, and indicates 
 the site. 
 
 Describe Sims's operation for vesico-vaginal and ure thro -vaginal 
 fistula. 
 
 Treatment. — Operative. — The patient having been prepared for 
 operation as in perineal operations, she is anaesthetized and placed 
 in Sims's position. A Sims speculum is introduced and the ante- 
 rior vaginal wall and fistula are exposed. The edges of the fistula 
 
 Fig. 31. 
 
 Operation for Vesico-vaginal Fistula. 
 
 are now pared, care being taken not to injure the mucous mem- 
 brane of the bladder. The wound thus formed will be bevelled 
 from the bladder out. The sutures are of fine silver wire threaded 
 on carrying threads, and passed with small curved needles. The 
 needle enters first at the most accessible angle, half an inch from 
 
VESICO-VAGINAL FISTULA. 
 
 83 
 
 the edge of the denudation ; it is brought out at the vesical sur- 
 face, but not involving the mucous membrane, counter-pressure 
 being exerted with a hook or tenaculum. The wire is now drawn 
 through, and the point of the needle reintroduced into the other 
 lip and drawn out half an inch from the edge of the incisions. In 
 this manner a sufficient number of sutures, one-fifth of an inch 
 apart, are introduced and twisted with wire-twisters. A self-retain- 
 
 FiG. 32. 
 
 Simon's Position for Operation on Yesico-vaginal Fistula. 
 
 ing sigmoid catheter is now introduced into the urethra, through 
 which the urine constantly drains until the wound has healed. 
 The sutures may be removed in eight or nine days. 
 
 What modification of this operation may be used with advan- 
 tage ? 
 
 Simon's operation. This consists in placing the patient in 
 
84 DISEASES OF THE UTERUS. 
 
 Simon's position — i. e. an exaggerated lithotomy position, the pelvis 
 elevated. The cervix is grasped and drawn down as for a Martin's 
 anterior colporrhaphy, and the field of operation thus well exposed. 
 The edges are pared as before with scissors or knife, and sutures 
 passed, which in this case are of silk. 
 
 What is the treatment for vesico-uterine fistula? 
 
 Split up the anterior lip of the cervix to the fistula, freshen its 
 edges, and pass sutures through the cervix so as to unite the walls 
 of the cervix and lips of the fistula. When the fistular opening is 
 too high up for this operation, the cervix may be closed entirely 
 and the uterine contents allowed to discharge through the bladder. 
 
 What is the treatment for recto-vaginal fistula ? 
 
 The edges may be pared and brought together as in the opera- 
 tion for vesico-vaginal fistula. If the opening is near the vulva, 
 the tissues between it and the surface may be split and the edges 
 of the fistula dissected out, and the whole united, as in laceration 
 of the perineum, through the sphincter. 
 
 THE INTERNAL ORGANS OF GENERATION. 
 DISEASES OF THE UTERUS. 
 
 ANATOMY. 
 Describe the uterus. 
 
 The uterus is a hollow muscular, pear-shaped organ, situated in 
 the centre of the pelvis between the bladder and rectum. It meas- 
 ures 3 inches in length, 2 in breadth at the level of the Fallopian 
 tubes, and 1 inch in thickness. It lies normally, when the bladder 
 and rectum are empty, in a position of anteversion and slight ante- 
 flexion. The cervical os points downward and backward, but its 
 position is constantly changing, owing to distension of the bladder 
 and rectum. 
 
 It is divided into a body, neck, and fundus. The fundus is that 
 portion above the entrance of the Fallopian tubes ; the body is the 
 portion between the fundus and the neck ; the neck is the lower 
 half of the uterus, its junction with the body being marked by a 
 slight depression or sulcus called the isthmus. The cavity of the 
 body is triangular in shape, the anterior and posterior walls being 
 in contact. It has a capacity of about twelve drops in nullipar.ie. 
 
ANATOMY. 85 
 
 The cavity of the cervix is spindle-shaped, being constricted at 
 the internal and external os. 
 
 The cervix is divided into two portions anatomically — that above 
 the attachment of the vagina (supravaginal), and that below the 
 attachment, protruding into the vagina (vaginal). Schroeder makes 
 a third division, an intermediary portion, below the vaginal junc- 
 tion behind, and above it in front. The vaginal portion varies 
 much in shape and size. At its centre is the external os, which in 
 virgins is slit-shaped, feeling something like the cartilage at the 
 end of the nose. The entire cavity of the uterus measures 2^ 
 inches in length. 
 
 The uterine wall consists of three layers : (1) internal mucous 
 membrane ; (2) middle muscular ; (3) external peritoneal. 
 
 The mucous membrane of the body diifers from that of the 
 cervix. It is smooth, grayish-pink in color, and directly connected 
 to the muscular layer, without the intervention of a submucous 
 coat. It consists of a single layer of columnar ciliated epithelial 
 cells, the cilia moving upward. These rest on a connective-tissue 
 base, which is rich in lymph-spaces, vessels, and nerves. Imbedded 
 in its substance are a large number of tubular glands, the utricular 
 follicles, which may be straight, tortuous, single, or branching, and 
 have their blind extremities terminating in the muscular coat. 
 They are lined with a single layer of prismatic ciliated cells resting 
 on a membrana propria, and they secrete an alkaline mucus. 
 
 The mucous membrane of the cervix is thicker and less red than 
 that of the body. It is thrown into numerous folds called the 
 " arbor vitae," which consist of an anterior and posterior ridge, 
 from which lateral folds branch off. The surface is covered by a 
 single layer of epithelial cells, which are ciliated on the ridges and 
 non-ciliated in the depressions (De Sinety). 
 
 The cervical glands are racemose, and secrete a clear alkaline 
 mucus. When these become pathologically occluded, they produce 
 the retention cysts known as the follicles or ovula of Naboth. The 
 mucous membrane covering the vaginal portion is continuous with 
 that of the vagina, and consists of vascular papillae covered with 
 many layers of squamous epithelium. There is a sharp line of 
 demarcation between this latter and the columnar ciliated epithe- 
 lium of the cervical canal. 
 
 The vaginal aspect has no glands. The muscular coat consists 
 of three layers of unstriped fibres : (1) External, a thin longitu- 
 dinal layer called the platysma, most marked on the anterior and 
 
86 
 
 DISEASES OF THE UTERUS. 
 
 posterior walls, which sends prolongations into the ligaments of the 
 uterus and out to the Fallopian tubes. (2) Middle is the thickest, 
 and consists of longitudinal, transverse, and oblique fibres. (3) 
 Internal, concentric and most marked about the orifices of the Fal- 
 lopian tubes and internal os. 
 
 The peritoneal coat folds over the entire posterior surface of the 
 uterus, except the vaginal portion of the cervix. It covers the 
 anterior surface as low as the isthmus, and is here reflected on to 
 the bladder. Laterally, the two folds come together, forming the 
 broad ligaments, and extend to the wall of the pelvis. Anteriorly 
 it is firmly connected to the uterine wall ; posteriorly a layer of 
 areolar tissue is interposed. It is composed of a base of fibrous 
 
 Fig. 33. 
 
 Position of Parts in Female Pelvis. 
 
 and clastic tissues covered by a layer of endothelial cells, and is 
 very rich in lymphatics. 
 
ANATOMY. 87 
 
 Name and describe the ligaments of the uterus. 
 
 Two broad ligaments ; two round ligaments ; two utero-vesical ; 
 two utero-sacral. 
 
 The broad ligaments are double folds of peritoneum which run 
 from the sides of the uterus to the pelvic wall. Internally they are 
 continuous with the peritoneum covering the anterior and posterior 
 walls. Externally they are attached to the pelvic wall " along a 
 line situated between the great sacro-sciatic notch and the margin 
 of the obturator foramen, as far down as the level of the ischial 
 spine." Their upper free margin contains the Fallopian tubes. 
 The portion of the margin not occupied by the tube, and extend- 
 ing from it to the pelvic wall, is called the infundibulo-pelvic liga- 
 ment. 
 
 The ovary projects through the posterior lamella, and is covered 
 by germinal epithelium. It is attached at its hilum to the anterior 
 lamella. 
 
 The round ligaments lie in a fold formed by the anterior lamella. 
 
 The portion of broad ligaments extending between the ovary and 
 the Fallopian tube is called the mesosalpinx. In the mesosalpinx 
 below the middle of the tube is the parovarium. 
 
 The structures included between the folds of the broad ligament 
 are, from above downward, (1) the Fallopian tube ; (2) ovarian 
 artery, nerves, and lymphatics ; (3) the pampiniform plexus of 
 veins ; (4) the round ligament ; (5) the parovarium ; (6) the ova- 
 rian ligament ; (7) the ovary ; (8) the uterine artery and venous 
 plexus ; (9) connective tissue and lymphatics near the base. 
 
 The round ligaments spring from the anterior superior portion of 
 the uterus, and extend outward and forward in the anterior folds 
 of the broad ligaments to the internal inguinal rings. They then 
 pass through the inguinal canal and terminate in three fasciculi. 
 
 The inner fasciculus blends with the tendons of the internal 
 oblique and transversalis muscles ; the middle with the superior 
 column of the external abdominal ring ; and the external terminates 
 just above Gimbernat's ligament. They are composed of fibrous 
 tissue, striped and unstriped muscular fibres, and blood-vessels and 
 nerves. 
 
 The peritoneal investment of the round ligaments usually ends 
 at the internal ring, but is sometimes prolonged into the labia 
 majora. This, when pervious, is called the " canal of Nuck." 
 The chief interest attaching to the round ligaments is their con- 
 nection with Alexander's operation. 
 
88 DISEASES OF THE UTERUS. 
 
 The utero-sacral ligaments are two folds of peritoneum reflected 
 
 Fig. 34. 
 
 Diagram showing the Three Minor Folds of the Broad Ligament (Ranney) : 1, 2, 3, ante- 
 rior, middle, and posterior folds; A', round ligament; /<', Fallopian tube ; O, ovary ; K, 
 vagina; h, pouch of Douglas; A, anterior layer of broad ligament; P, posterior layer; 
 £, reflection of peritoneum to bladder; i?, reflection to rectum • (S, space containing 
 muscular and connective tissue, enclosing vessels and nerves. 
 
 from the sides of the uterus at the level of the isthmus backward, 
 outward, and upward to the second sacral vertebra. They form 
 
ANATOMY. 
 
 89 
 
 the upper lateral boundaries of the pouch of Douglas, and are of 
 great importance in some malpositions of the uterus. 
 
 The utero-vesical ligaments are the folds of peritoneum reflected 
 from the lower portion of the uterus on to the bladder. 
 
 What is the vascular supply of the uterus ? 
 
 Arterial: From the uterine and ovarian arteries. The uterine 
 branch of the internal iliac runs along the base of the broad ligament 
 
 Fig. 35. 
 
 Ovarian /Jrtery 
 
 Uterine Hrtery 
 
 The Ovarian, Uterine, and Vaginal Arteries (Hyrtl) : n, ovarian artery ; a' and 6'» 
 branches to tube; 6, branch to round ligament; c', branches to ovary; g, vaginal 
 artery ; /«, azygos artery of vagina. 
 
 to a point below the level of the os externum near the cervix ; then 
 it curves upward along the uterine wall and anastomoses with the 
 ovarian. Its branches in the substance of the uterus are very 
 tortuous, and are known as the " curling arteries." At the junc- 
 tion of the body with the cervix a large branch is given off which 
 unites with its fellow of the opposite side to form the " circular 
 artery." 
 
 The veins, form a plexus around the uterus beneath the peri- 
 toneum, and communicate with the vaginal and vesical plexuses 
 below and the pampiniform above. They empty into the internal 
 iliac vein. 
 
90 
 
 DISEASES OF THE UTERUS. 
 
 The lymphatics are very numerous, and form a dense network in 
 the broad ligaments, terminating in the lumbar and hypogastric 
 glands. 
 
 The nerve-supply is derived from the hypogastric plexus of the 
 sympathetic, and a few fibres from the third and fourth sacral 
 nerves. 
 
 MALFORMATIONS AND DISEASES OF THE UTERUS. 
 
 Malformations. 
 It is of the greatest importance, in the study of malformations 
 of the uterus, to bear in mind the mode of development of the 
 genital tract. 
 
 Give a brief description of the development of the female genitals, 
 and state how malformations of the uterus are produced. 
 
 Before the end of the second month of foetal life the Wolffian 
 
 Fig 36. 
 
 uterus Bipartitus of a servant sixty years of age: «, vagina, about one inch deep, and 
 ending at the anterior wall of the rectum, above the internal sphincter; b, connec- 
 tive tissue interspersed with muscular fibres, simulating the shape of a uterus; c. c, 
 fleshy strings representing the horns of the uterus ; (/, (/, swellings of the size of a 
 bean, one cui open and showing a cavity of tlie size of a lentil and lined with mucous 
 membrane; e,e, rudimentary ovaries; /,/, Falloi)iau tubes; g, round ligaments; h, 
 broad ligaments. (From Kussmaul, after Mayer.) 
 
 bodies appear, one on either side of the vertebral column. Kach 
 
MAI.FOR^rATIONS. 
 
 91 
 
 consists of a large number of convoluted tubules closed at one 
 end, and opening by the other into a common duct. In a 
 fissure at the inner border of these bodies lies the genital gland on 
 each side, which subsequently develops into the ovary. The ducts 
 of Miiller spring from the inner sides of the upper ends of the 
 Wolffian bodies, one on each side. These approach each other, and 
 coalesce to form the uterus and vagina, the septum being absorbed. 
 The upper portion of the ducts forms the Fallopian tubes. 
 
 Malformations are produced when there is an arrest of develop- 
 ment in one or both of the ducts of Miiller ; when they fail to 
 unite ; when the septum between them is not absorbed. 
 
 What are the varieties of malformations ? 
 
 (1) Absence of, or a rudimentary, uterus, occurring when there is 
 an arrest of development of the ducts of Miiller. This condition is 
 
 Fig. 37. 
 
 uterus Bicornis Unicollis of a Virgin ; a, vagina ; 6, single neck ; c, c, horns ; (f, d, tubes ; 
 e, e, ovaries; /,/, round ligaments. (From Kussmaul.) 
 
 usually accompanied by absence of the entire generative tract. 
 
 (2) Unicorn uterus, due to an arrest in the development of one 
 duct of Miiller. 
 
 (3) Uterus bicornis, where the union of the Miillerian ducts is 
 imperfect, resulting in two horns. 
 
92 
 
 DISEASES OF THE UTERUS. 
 Fig. 38. 
 
 Uterus Unicornis: LH, left horn; /vT, left tube; Xo, left ovary; Z/Z,-, left round liga- 
 ment ; Rll, right horn ; RT, right tube ; Ro, right ovary ; RLr, right round liga- 
 ment. (From Schroeder.) 
 
 (4) Double uterus (very rare), in which the two horns have de- 
 
 FiG. 39. 
 
 uterus Didelphys: o, right cavity; h, left cavity ; c, right ovary; d, right round liga- 
 ment; e, left round ligament ;/, left tube; f/, left vaginal portion; //, right vaginal 
 portion ; /, right vagina; j, left vagiua ; k, partition between the two vaginae. (From 
 De iSinety, after Ollivier.) 
 
MA LFORM ATIONS. 
 
 Fig. 40. 
 
 93 
 
 Uterus Bicornis Duplex : «, double entrance to vagina; 6, meatus urinarius ; c, clitoris ; 
 d, urethra ; e, e, double vagina ; /, /, external orifices of uterus ; g, g, double cervix ; h 
 h, bodies and horns of uterus; i, t, ovaries; f:, k, tubes; I, I, round ligaments; m, jn, 
 broad ligaments. (From Kussmaul, after Eisenmann.) 
 
 veloped separately, not coalescing. This is usually associated with 
 a double vagina. 
 
 (5) Divided uterus, in which the septum has not been absorbed. 
 
94 
 
 DISEASES OF THE UTERUS. 
 
 (G) Foetal or infantile uterus, in which the uterus remains 
 small, and there is a disproportionately large neck. At birth the 
 
 Fig. 41. 
 
 UtfTus .Septus Duplex (natural size), completely double uterus and incompletely double 
 vagina of a girl twenty-two years old : n, a, tubes ; h, b, fundus of the double uterus; 
 c, <;, c, partition of uterus ; d, d, cavities of the uterine bodies; e, e, internal orifices; 
 f, f, external walls of the two necks; {/, (/, external orifices; h, h, vagrnal canals ; i, 
 "partition which divided the upper third of the vagina into two halves. (From Kuss- 
 maul.) 
 
 neck is normally small, larger than the body, and if arrest of de- 
 velopment takes place at this stage the above condition results. 
 
 (7) Congenital atrophy. This condition results from a lack of 
 development after the uterus has reached its normal proportions, 
 remaining small. 
 
MALFORMATIONS. 
 
 95 
 
 Fk4. 43. 
 
 Infantile Uterus of a girl twenty-one years old : A, uterus and appendages diminished : 
 a, body; A;, neck; c, c, tubes; rf, rf, ovaries ; e, e, round ligaments;/, /, broad liga- 
 ments; ^, right ovary cut open longitudinally, showing large Graafian follicles; C, 
 left ovary with smaller follicles. (From Kussmaul.) 
 
 HYPERTROPHY. 
 In what sites may hypertropliy of the cervix occur ? 
 
 In the supravaginal portion, the median 
 portion, or the infra vaginal portion of the 
 cervix. Hypertrophy of the infravaginal 
 portion alone requires extended description. 
 It is seen in its purest type in unmarried 
 women, and is spoken of as the penis-like 
 hypertrophy of the cervix. 
 
 What is its pathology? 
 
 The histological elements are uniformly 
 increased (especially in their length). The 
 mucous membrane covers a more extensive 
 surface, but is not diseased. As the in- 
 fravaginal portion increases in length, it 
 tends to become conical. The external os 
 
 is usually small and at the apex. The cer- Classification of the Cervix 
 
 vix is tense and firm ; it presents none of jroneum ;%a 'biadfer?!;; 
 the sicjns of inflammation. It may protrude portio vaginalis ; ^, portio 
 
 n "ii 1 1 1 • Ti i • media; C. portio supravag- 
 
 trom the vulva, lookmg hke an erect penis. inaiis. (After ^chroeder.) 
 
96 
 
 DISEASES OF THE UTERUS. 
 
 What are its symptoms? 
 
 (1) Dysmenorrhoea ; (2) disturbance of coitus ; sterility ; (3) 
 symptoms due to mechanical irritation if it protrudes from the 
 vulva. There is no great degree of dragging pain. 
 
 From what conditions must it be diagnosed, and how ? 
 
 From prolapse and from inversion of the uterus. In hypertro- 
 phy of the cervix a bimanual examination shows the existence of 
 the body of the uterus and of the anterior and posterior fornices 
 of the vagina, all in their normal positions. 
 
 What is the treatment ? 
 
 The only treatment of any effect is surgical — viz. amputation of 
 the cervix — 
 
 (a) By the galvano-cautery, a poor method ; 
 (h) Schroeder's operation, a wedge-shaped excision of anterior 
 
 and posterior lips, followed by suture 
 Fig. 44. of 
 
 membrane 
 
 the vaginal and uterine mucous 
 
 What is its prognosis? 
 
 Spontaneous cure does not take 
 place. The prognosis after operation 
 is very good indeed. The removal of 
 even a small portion often causes in- 
 volution of the rest. 
 
 ATROPHY. 
 
 What are the two varieties of acquired 
 atrophy of the uterus ? 
 
 (1) Senile atrophy ; (2) premature 
 atrophy. 
 
 Describe senile atrophy of the uterus. 
 The uterine walls are thin and atro- 
 phic ; the mucous membrane thin and 
 without glands ; the os internum is often 
 constricted, and sometimes there is re- 
 tention of secretions. The vaginal portion of the cervix is oblite- 
 rated, and the os externum is felt as a dimple. The vagina is short 
 and narrow ; its walls are thin and membranous, and there is no 
 fat in the surrounding tissues. The labia majora lie far apart. 
 
 Schroeder's Operation. 
 
DISPLACEMENTS OF THE UTERUS. 97 
 
 The nymphae are almost obliterated. The clitoris is small, and has 
 neither prepuce nor frgenulum. The condition is normal after about 
 the sixtieth year, and gives rise to no symptoms and requires no 
 treatment. 
 
 What are the causes of premature atrophy of the uterus ? 
 
 It occurs usually between the ages of twenty and forty-five 
 years, (a) Puerperal fever, especially if the ovaries or the peri- 
 toneum is involved ; (6) tuberculosis ; (c) perhaps sometimes 
 removal of ovaries. 
 
 What are the symptoms? 
 
 The involution is abnormal, leaving the uterus soft and flabby, 
 and of less than the normal size, (a) Anaemia and debility ; (6) 
 amenorrhoea after confinement, e-ven after stopping lactation : in 
 fact, most of these patients do not nurse their children ; (c) change 
 in general appearance (prematurely old, distressed, and sick); 
 
 (d) hot and cold flashes, and rushing of blood to the head or face ; 
 
 (e) disturbed vision ; (/) cold hands and feet; (^) hysterical fits 
 of crying, etc. 
 
 Upon what is the diagnosis based? 
 
 Absence of menstruation ; uterus small, thin, and flabby ; with 
 the probe in the uterine cavity the uterus feels thin, and not firm. 
 The cavity measures about two inches, but may measure two and 
 a half inches. 
 
 What is the treatment ? 
 
 (a) General : Change of climate, exercise, diet, attention to func- 
 tions of the skin and digestive tracts. 
 
 (h) Local: Irritation; occasional use of the sound; occasional 
 use of tents (cautiously) ; the galvanic pessary. 
 
 What is the prognosis ? 
 
 The disease does not threaten life. A return to the normal con- 
 dition is exceptional, but the unpleasant symptoms may often be 
 ameliorated. 
 
 DISPLACEMENTS OF THE UTERUS. 
 
 Describe the normal position of the uterus in the living woman, 
 and the factors which influence it. 
 
 " The normal position of the uterus is determined by its con- 
 nection with the tissues adjacent to it, by its fixation in the vagina 
 
 7-Gyn. 
 
98 
 
 DISEASES OF THE UTERUS. 
 
 and pelvic fascia, and by its attachment to the bladder and to the 
 peritoneum " (Shultze). 
 
 The muscular fibres in the round ligaments and in the folds of 
 Douglas are important factors, the former drawing the fundus 
 
 Fig. 45. 
 
 Horizontal Section of Body, showing uterus and round ligaments (Savage) : B, bladder ; 
 U, uterus ; C C, utero-sacral ligaments ; L L, round ligaments ; O, ovaries ; T T, 
 tubes ; iJ, rectum. 
 
 forward, and the latter drawing the cervix backward. Intra-ab- 
 dominal pressure and its own weight also influence the position of 
 the uterus, the former much more than the latter during life. 
 
 The uterus is capable of considerable mobility, being pushed 
 backward by a distended bladder (Fig. 47), forward by a distend- 
 ed rectum (Fig. 48), and upward when both are full (Fig. 49). 
 Bimanual examination and the uterine sound are the methods em- 
 ployed in determining the position of the uterus. 
 
 " When a woman is standing upright, and her rectum and 
 bladder are empty, her uterus is nearly horizontal, is more or less 
 
Fig. 46. — Position of the Uterus in a Frozen Section when the Rectum and Bladder 
 are Empty (Martin). Differing from the representations usually given. 
 
 Fig. 47.— Uterus pushed Backward by a Distended Bladder (Martin). 
 
 99 
 
Fig. 48.— Uterus pushed Forward by a Distended Rectum (Martin). 
 
 Fig. 4'J.— Position of Uterus in a Frozen Section when both the Bladder and Rectum are 
 
 Distended (Martin). 
 
 100 
 
DISPLACEMENTS OF THE UTERUS. 
 
 101 
 
 anteflexecl, and is turned a little to the right" (Shiiltze). (See 
 Fig. 50.) In the dorso-horizontal position of the woman the fundus 
 uteri lies behind and a little above the symphysis, the os uteri 
 faces the rectum, and the cervix makes nearly a right angle with 
 the vagina. When the bladder is empty its superior and inferior 
 walls come in contact, and the fundus uteri lies forward on these, 
 
 Fig. 50. 
 
 Normal Position of the Uterus during life when the bladder and rectum are empty. 
 
 as shown in Fig. 50. This is determined by the use of the 
 sound in the bladder and bimanual examination. 
 
 The uterus is normally much more flexible than is usually sup- 
 posed, being easily bent at the junction of the body with cervix 
 (i. e., the os internum) by the fingers during bimanual examina- 
 tion. After death this flexibility ceases. 
 
102 DISEASES OF THE UTERUS. 
 
 Define what is understood by pathological displacements of the 
 uterus, and state the varieties. 
 
 Any variation from the normal position of the uterus which 
 is permanent constitutes a displacement. Abnormal mobility or 
 fixation is also looked upon as a displacement, which is classified 
 accordino; to the direction from the normal. 
 
 The varieties are — elevation, descent, prolapse, anteposition, 
 retroposition, latero-position, anteversion, retroversion, anteflexion, 
 retroflexion, latero-flexion. 
 
 The uterus may be twisted about its long axis, constituting 
 torsion. 
 
 Combinations may exist of retroversion with anteflexion, ante- 
 version with retroflexion, etc. 
 
 What is the frequency of uterine displacements ? 
 
 They are among the most common afi"ections of the female 
 generative organs. 
 
 What is meant by flexions, and what by versions of the uterus ? 
 
 Flexion of the uterus signifies a bending of the uterine body at 
 its junction with the cervix (the internal os), and is in the majority 
 of cases only an expression of the normal flexibility of the uterus. 
 By version is meant an inclination of the whole uterus without 
 flexion, the canal being straight, and it is due to rigidity and loss 
 of the normal flexibility. Therefore versions, either retro- or ante-, 
 are more serious than flexions. 
 
 Flexions are always associated with more or less version, but 
 version presupposes the absence of flexion. 
 
 ANTEVERSION. 
 
 What are the etiology and pathology? 
 
 Pathological anteversion is that position of the uterus in which 
 the fundus lies forward on the bladder, with its axis straightened 
 out and the cervix pointing backward to the hollow of the sacrum, 
 the whole uterus less than normally movable and rigid. This is 
 due to inflammatory thickening and infiltration, destroying the 
 normal flexibility of the uterus. It is always associated with peri- 
 or parametritis and metritis, the former forcing the cervix back- 
 ward and above 'and the fundus below, and the metritis causing 
 a general enlargement of the uterus and thickening, chiefly at the 
 junction of the body with the cervix. 
 
DISPLACEMENTS OF THE UTERUS. 
 
 103 
 
 The causes are those which produce para- and perimetritis and 
 cellulitis : subinvolution, lacerations of the cervix, sepsis, and other 
 
 Fig. 51. 
 
 Normal Position of the Uterus in a Parous Woman (Scbultze). 
 
 acute and chronic inflammations affecting the peritoneum and 
 uterus. 
 
 What are the symptoms? 
 
 The symptoms are those of the accompanying perimetritis and 
 metritis ; also frequent micturition, due to pressure of the fundus 
 on the bladder and thus preventive of its proper expansion. 
 
 The movements of the heavy tender uterus due to varying ful- 
 ness of the bladder and the postural changes of the back cause 
 discomfort and metrorrhagia. 
 
104 DISEASES OF THE UTERUS. 
 
 What is the diagnosis? 
 
 This is made by bimanual examination. The fundus lies forward 
 on the anterior vaginal wall, the cervix points backward and up- 
 ward into the hollow of the sacrum, and there is complete absence 
 of flexion. 
 
 What is the treatment? 
 
 This is directed to the cure of the metritis and pelvic peritonitis 
 by hot douches, iodine to the cervix and fornices, and boroglycerite 
 tampons. After the inflammatory conditions have been removed, a 
 soft rubber ring or a Graily-Hewitt's cradle pessary may be ad- 
 justed with advantage. Ergot and hydrastis may be administered 
 for the metrorrhagia. Scarification of the cervix is useful. Schroe- 
 der's amputation of the cervix by curing the metritis relieves all 
 the symptoms. 
 
 ANTEFLEXIONS. 
 
 What are the etiology and pathology? 
 
 Anteflexion is the inclination forward of the body of the uterus 
 alone, the bend nearly always taking place at the level of the inter- 
 nal OS. It is an exaggeration of the normal condition, and only 
 becomes pathological when there is rigidity at the point of flexion. 
 
 What is the etiology? 
 
 Anteflexion may be congenital (puerile, in which there is the 
 elongated cervix) or acquired. The latter is due to causes situated 
 within or without the walls of the uterus. Causes within are — 
 metritis, fixing the point of flexion ; irregular involution, during 
 which the posterior wall remains large ; tumors of the posterior 
 wall with broad bases. Causes from without are the most common : 
 parametritis and perimetritis, followed by contractions in the folds 
 of Douglas and utero-sacral ligaments, drawing the middle segment 
 of the uterus upward and backward. The posterior parametritis 
 may be of puerperal origin or due to laceration of the cervix, cer- 
 vical catarrh, etc. 
 
 What are the symptoms ? 
 
 They are chiefly those of the causes, especially posterior para- 
 metritis. The two most important symptoms are dysmenorrhoea 
 and sterility. Other symptoms are frequent and painful micturi- 
 tion, pain on defecation, leucorrhcjca, backache. 
 
DISPLACEMENTS OF THE UTERUS. 
 
 105 
 
 What is the diagnosis ? 
 
 The diagnosis consists in the establishment of the stability of 
 the flexion. This can be determined by bimanual and recto-abdomi- 
 nal examination and the use of the sound. Note whether the flex- 
 
 FiG. 52. 
 
 Anteflexion of Uterus. 
 
 ion remains with a distended bladder ; note a thickening contraction 
 and tenderness in the folds of Douglas and utero-sacral ligaments. 
 On digital examination the cervix is found lying in the axis of the 
 vagina, rather high, os pointing forward, and, as the finger is passed 
 along the anterior wall, a sulcus is felt at the junction of the body 
 with the cervix. The fundus is found lying forward. 
 
106 DISEASES OF THE UTERUS. 
 
 What is the treatment? 
 
 Except for those cases in which the rigidity is due to tumors of 
 the posterior wall and to metritis the treatment consists in the re- 
 moval of the existing posterior parametritis. This is done by the 
 use of boroglycerite and depleting tampons, local applications of 
 iodine and iodide-of-potash solution in glycerin, hot vaginal douches, 
 and sitz-baths. Keep the bowels well regulated. For existing en- 
 dometritis the cervical canal to above the internal os may be dilated, 
 and the endometrium thoroughly washed out with carbolic solution, 
 1 : 100. After all inflammatory conditions have been removed, 
 the uterine cavity may be dilated with Peaslee's steel dilators and 
 Goodell's dilator, and an intra-uterine stem, such as Outerbridge's 
 wire stem, introduced. This stem may be left in place for one 
 month, or the dilatation may be maintained by passing the steel 
 dilators once or twice a month. Chlorosis is a frequent complica- 
 tion, and must be treated. 
 
 For what might anteflexions be mistaken ? and what is the differ- 
 ential diagnosis ? 
 Anteflexions might be mistaken for a fibroid of the anterior wall 
 and anterior inflammatory and cellulitic exudations. The sound 
 passed into the uterine cavity will determine these conditions. 
 
 RETROVERSION AND RETROFLEXION. 
 
 Define these. 
 
 Ketroversion is the stable inclination of the fundus uteri back- 
 ward, the shape of the organ being extended or slightly anteflexed 
 (Shultze). Retroflexion is the stable or permanent backward dis- 
 location of the fundus uteri, with simultaneous bending of the 
 uterus over its posterior surface. There is usually first a version, 
 then a flexion, due to a continuance of the intra-abdominal pressure 
 acting upon the anterior aspect. 
 
 What are the etiology and anatomy? 
 
 The cause may be acute or chronic. Acute (rare) : falls, blows 
 on \\\Q, abdomen, lifting heavy weights, all of these accompanied by 
 the condition of a full bladder. 
 
 Chronic: arrest of development, resulting in a long cervix and 
 short anterior vaginal wall. The dilatation of the bladder pushes 
 the uterus back into retroversion. If metritis is present, it be- 
 comes rigid and stable. Senile shortening of the anterior vaginal 
 wall also produces this condition. 
 
DISPLACEMENTS OF THE TJTEEUS. 
 
 107 
 
 Retroversions and flexions are more common in married than 
 in unmarried women, due to the effect of parturition. The dorsal 
 position with an habitually full bladder, relaxation of the ligaments, 
 and getting out of bed too early after labor are also causes. 
 
 Relaxation of the utero-sacral ligaments alone, caused by para- 
 
 Retroversion and Retroflexion of the Uterus. 
 
 metritis posterior or combined with anterior fixation of the cervix, 
 due to shortening of the utero-vesical ligaments, will result in 
 posterior displacements, and is their most common cause. 
 
 These conditions being present, the distended bladder pushes the 
 uterus back, and the intra-abdominal pressure comes to act directly 
 on the anterior wall, completing the displacement. 
 
 Flexions result from differences in the nutrition of the anterior 
 and posterior uterine walls. 
 
 What are the complications? 
 
 There is usually more or less catarrhal endometritis present. 
 The uterus is enlarged and rigid, due to metritis. The ovaries 
 become displaced, enlarged, and tender. Relaxation of the anterior 
 vaginal wall, with prolapse, is a common complication. Peritonitic 
 adhesions, forming between the fundus uteri and the rectum, are 
 complications. 
 
108 DISEASES OF THE UTERUS. 
 
 What are the symptoms of retroversions and flexions ? 
 
 Menorrhagia and metrorrhagia ; sterility ; painful micturition and 
 defecation ; tender ovaries, due to traction and displacements and 
 causing iliac pain; backache; leucorrhoea; dysmenorrhoea ; tend- 
 ency to abortion ; reflex neuroses. 
 
 What is the diagnosis? 
 
 This is determined by digital and bimanual examination. The 
 cervix will be found pointing forward nearer the vulva, and in the 
 anterior part of the pelvis. The finger being passed backward 
 along the posterior wall of the cervix into the posterior fornix, the 
 fundus uteri will be felt. In retroversions the body is directly 
 continuous with the cervix. In retroflexions a sulcus or kink will 
 be found in the posterior wall, and it is more difiicult to recognize 
 the connection between the body and cervix. This last can best 
 be accomplished by bimanual examination. The body moves with 
 the cervix, and the sound passes backward. 
 
 For what might you mistake retroversions and flexions? 
 
 Tumors and exudation masses behind the uterus. Bimanual 
 examination will always show the presence of the uterine body in 
 front of a tumor. The uterine sound may be employed, except 
 during the acute stage of inflammation. Drawing down the uterus 
 with the volsellum will often show the relation of the fundus to 
 the tumor. 
 
 What is the treatment? 
 
 Indications : (1) Cure the exciting complications ; (2) replace 
 the uterus ; (3) retain in position. Retroversion due to arrest of 
 development can usually be easily replaced, but it is difficult to 
 keep in position. Pregnancy has a favorable influence upon this. 
 
 When due to senile involution, as a rule, there are no symptoms, 
 and therefore no treatment is required. When due to anterior fixa- 
 tion of the cervix, promote absorption of the results of parametri- 
 tis. When due to high posterior fixation of the cervix, treat the 
 posterior parametritis. W^hen due to shrinking of the posterior 
 wall or elongation of the anterior wall, remove tumors or inflam- 
 matory condition and place an intra-uterine stem. When due to 
 relaxations of the utero-sacral ligaments, the treatment consists in 
 replacing the uterus and keeping it in position by a suitable pes- 
 sary. 
 
DISPLACEMENTS OF THE UTERUS. 109 
 
 What methods are employed to replace a retroverted uterus? 
 
 (1) Bimanual vagino-abdominal and recto-abdominal manipula- 
 tion ; (2) sound and uterine repositor ; (3) genu-pectoral position 
 and manipulation ; (4) Sims's position. 
 
 Describe the bimanual method. 
 
 This, as described by Shultze, is said by him to be the " only 
 proper method." The patient being placed in the dorso-horizontal 
 position, the index and middle fingers of the left hand are intro- 
 duced into the posterior fornix of the vagina, or, if this does not 
 reach high enough, they may be introduced into the rectum. The 
 body of the uterus is now pushed upward on one side of the sacral 
 promontory to the brim of the pelvis. The right hand, on the 
 abdomen, now grasps the fundus and draws it forward, while the 
 internal fingers are placed in front of the cervix and push it back- 
 ward and upward, in this way completing the reposition. 
 
 Describe reposition by the uterine sound. 
 
 This may be employed when the uterus is too sensitive to be 
 pushed upward by the fingers, but is always more or less unsafe. 
 The sound is first enveloped in cotton and dipped in a carbolic solu- 
 tion. It is then introduced, concavity backward, and the handle 
 made to describe a circle from behind forward; then slowly de- 
 pressed, throwing the uterus forward. 
 
 Describe the genu-pectoral position. 
 
 This method is applicable when a gravid uterus becomes wedged 
 below the sacral promontory. The patient being placed in the genu- 
 pectoral position, the cervix is grasped with a pair of volsella or 
 bullet forceps and drawn down ; at the same time the fundus is 
 pushed forward by the finger in the rectum. 
 
 What is the treatment by Sims's position? 
 
 The patient is placed in Sims's position and the fingers of the 
 right hand introduced into the posterior fornix. The fundus uteri 
 is first raised to the brim of the pelvis ; then during expiration 
 the fingers are shifted in front of the cervix, and this is' pushed 
 strongly backward, completing the reposition. 
 
 Describe the method of treatment in cases where the fundus is 
 fixed posteriorly by adhesions. 
 
 Gentle massage of the adhesions through the posterior fornix 
 
110 
 
 DISEASES OF THE UTERUS. 
 
 with one or two fingers for five or ten minutes at a time, stretching 
 the adhesions at the same time by gently pushing up the fundus ; 
 hot douches and sitz-baths ; boroglycerite or iodide-of-potash tam- 
 pons, pushed well into the posterior fornix and allowed to remain 
 twelve to twenty-four hours. Forcible breaking up of adhesions 
 under angesthesia by bimanual manipulations is sometimes resorted 
 to, but is dangerous. 
 
 How is the uterus retained in position after reposition? 
 By pessaries and operations. 
 
 PESSARIES. 
 
 What are the best varieties ? 
 
 (1) Figure-of-eight, made of copper wire covered with soft rub- 
 ber, or, after being fitted, copied in hard rubber. (2) Sledge-shaped, 
 made of same materials. (3) Hodges' and its various modifications 
 by Emmet, Thomas, and Albert Smith. 
 
 What is the main object to be attained by a pessary ? 
 
 The retention of the cervix backward, not the pushing of the 
 fundus forward. 
 
 Describe the figure-of-eight pessary. 
 
 A ring of the materials named, and of suitable size for the case, 
 
 is first drawn out into an oval shape, 
 Fig. 54. and then twisted on itself, forming 
 
 two loops, the upper one small and 
 curved upward, the lower one larger, 
 somewhat pointed at its extremity, 
 and curved down. 
 
 Describe the sledge pessary. 
 
 The same ring is first drawn into 
 an oval form, and then one end, 
 which is to be the lower, is bent for- 
 ward on inself and flattened. Hodges' 
 pessary and its modifications are 
 made of hard rubber. 
 
 The Albert Smith pessary is nar- 
 row at the lower end and curved down, broader at the upper end 
 and curves up behind the cervix. 
 
 Hodges' Closed Lever Pessary. 
 
DISPLACEMENTS OF THE UTERUS. 
 
 Ill 
 
 The 
 
 Fig. 55. 
 
 What is the method of introducing a pessary ? 
 
 This may be done in the Sims or dorso-horizontal position, 
 pessary is grasped firmly be- 
 tween the thumb and fore- 
 finger of the right hand by its 
 lower extremity. The labia 
 are separated by the left hand 
 from below. Introduce the 
 pessary first in a vertical or 
 slightly oblique axis, pressing 
 strongly down on the peri- 
 neum, thereby gaining room. 
 As soon as the ostium vaginae 
 is passed halfway, turn the 
 pessary into a horizontal posi- 
 tion and continue the intro- 
 duction by the index finger of 
 the right or left hand placed 
 against the internal loop or 
 bar, and carry this along the 
 posterior wall up behind the 
 cervix, as shown in the figure. 
 
 In the figure-of-eight pessary the cervix must be fitted into the 
 smaller loop. 
 
 The sledge pessary is particularly adaptable to relaxed conditions 
 of the pelvic floor. 
 
 What are the contraindications to the use of pessaries ? 
 
 They should never be used until all pelvic inflammation has been 
 removed. They should rarely be used unless the uterus can be 
 thoroughly replaced. 
 
 How long may a pessary remain in situ ? and what precautions 
 are to be observed? 
 
 A pessary should be removed once a month, cleaned, and replaced. 
 After the introduction of a pessary for the first time the patient 
 must be questioned as to pain or discomfort in walking, sitting 
 down, crossing the legs, etc. She should be told to remove it if 
 it causes pain. She should be seen every day for a few days, to 
 see that the uterus remains in position. 
 
 Albert H. Smith's Pessary. 
 
Fig. 56. — Introduction of Pessary. 
 
 Fig. 57.— Introduction of Pessary. 
 112 
 
DISPLACEMENTS OF THE UTERUS. 
 
 113 
 
 What operative procedures may be resorted to for retaining a 
 replaced retroverted or retroflexed uterus ? 
 
 (1) Shortening the round ligaments (Alexander's operation), now 
 rarely resorted to ; (2) ventro-fixation or hysterorrhaphy ; (3j 
 Shiicking's operation. 
 
 Describe Alexander's operation. 
 
 The mons veneris is shaved and prepared antiseptically. An 
 incision is made, IJ to 3 inches in length, parallel to Poupart's 
 
 Fig. 58. 
 
 The Pessary in Position. 
 
 ligament, in an outward direction from the pubic spine. This in- 
 cision is made down to the intercolumnar fascia covering the ring, 
 which is indicated by the oblique fibres crossing the ring and by 
 the protrusion of fat at the lower end. The protruding tissue, in- 
 cluding the round ligament, is now lifted by an aneurism needle, 
 8— Gyn. 
 
114 DISEASES OF THE UTERUS. 
 
 grasped by the fingers, pulled out, and sutured to the pillars of the 
 ring. The same thing is done for the other side. The wound is 
 now closed with catgut, silk, or silver wire, and the usual anti- 
 septic dressings applied. The patient is kept in bed for two or 
 three weeks, and a pessary must be worn for some months. 
 
 The operation is rapidly going into disuse, on account of its 
 being unsuccessful in permanently holding the uterus forward, and 
 owing to its establishing one pathological condition, anteversion 
 with fixation, for another. It is also inapplicable unless the uterus 
 is replaceable, and does not influence the relaxation of the utero- 
 sacral ligaments, which is the main cause of the displacement. 
 
 Describe the operation of ventro-fixation. 
 
 This is accomplished by laparotomy, and is indicated, rarely, when 
 all other means have failed and there is considerable posterior 
 fixation. An incision is made in the median line of the abdomen, 
 as for any abdominal section. The adhesions of the uterus are 
 broken up, and the fundus brought forward and sutured to the 
 anterior abdominal wall with chromicized catgut or silk sutures. 
 The abdominal incision is closed in the usual manner. A pessary 
 must be worn here also for some time. 
 
 Describe Shucking's operation briefly. 
 
 The uterus having been replaced and held anteriorly and to one 
 side, a sound is passed into the bladder and pushed strongly to the 
 other side to avoid injury to the bladder-wall. A curved canula, 
 containing a concealed needle threaded with carrying thread, is 
 now introduced to the fundus of the uterus. The needle is pushed 
 forward by its handle through the canula. piercing the uterine wall, 
 curving downward, and appearing through the anterior vaginal 
 wall near the cervix. The carrying thread is then grasped and 
 the needle and canula withdrawn. A loop of floss silk is passed 
 through the loop of carrying thread and drawn back and out at 
 the external os. The two ends are now tied together, producing 
 a pathological anteflexion. 
 
 DESCENT AND PROLAPSE OF THE UTERUS. 
 Define these. 
 
 The uterus is said to descend when it comes to lie at a lower 
 plane in the pelvis than normal, and a digital examination encoun- 
 ters the vaginal portion too soon. Prolapse is said to take place 
 
DISPLACEMENTS OF THE UTERUS. 115 
 
 when the vaginal portion emerges from the vulva (Shultze). The 
 latter may be incomplete when the cervix just appears at the vulva, 
 or complete^ in which the uterus lies entirely outside the body 
 between the thighs. It is always accompanied by more or less 
 complete inversion of the vagina and prolapse of the posterior 
 bladder-wall. 
 
 Other displacements may coexist with descent and prolapse. 
 The uterus is usually retroverted and flexed. 
 
 What are the etiology and anatomy? 
 
 The uterus is maintained in position by the support of the 
 vagina, the bladder, its own ligaments, and the pelvic floor. 
 
 The predispomig causes of prolapse are childbirth, causing a 
 relaxed condition of the vagina, and of the peritoneal and liga- 
 mentary attachments of the uterus ; retroversions, due to an 
 habitually distended bladder. In these cases the intra-abdominal 
 pressure, acting through the intestines, is brought to bear upon 
 the uterus unsupported by the bladder, and descent and prolapse 
 result ; relaxation of the pelvic floor, such as is produced by lacera- 
 tion of the perineum and in old age ; and laborious occupation and 
 increased weight of the uterus. 
 
 The exciting causes may be acute, blows, falls, severe exertion, 
 heavy lifting, etc., or chronic, which is much more common. The 
 chronic causes are practically the same as the above predisposing 
 causes, resulting in gradual relaxation of the uterine supports. 
 
 Hypertrophies of the cervix, either of the infravaginal, supra- 
 vaginal, or intermediary portion, and usually accompanied by pro- 
 lapse, abdominal tumors, and ascites, are caused by pressure of the 
 uterus downward. 
 
 What are the symptoms and diagnosis? 
 
 The symptoms of descent are those of retroversion and any coex- 
 isting complications. The symptoms of the acute form are violent 
 pain, vomiting, vertigo, fainting, followed by retention of urine, and 
 signs of peritonitis ; of the chronic form are, first, a feeling of 
 weight and tension in the hypogastric, iliac, and sacral regions, 
 followed by frequent and difficult micturition ; in complete prolapse 
 discomfort from the protrusion and excoriation of the parts. 
 
 What is the diagnosis? 
 
 Inspection when the prolapse is partial shows the prolapsed ante- 
 rior and posterior vaginal wall, the protruding cervix and os in the 
 
116 DISEASES OF THE UTERUS. 
 
 centre. Ascertain by vaginal examination whether the anterior 
 and posterior fornices are in their normal position or are driven 
 down. If the anterior fornix is obliterated and the posterior for- 
 nix normal, there will be an hypertrophy of the intermediary por- 
 tion of the cervix. 
 
 When the prolapse is complete, the external covering of the 
 tumor can be distinguished as the vaginal wall by its smooth, dry 
 surface and remains of columnse rugarum. The external os is at 
 the apex of the tumor. By palpation the body of the uterus can 
 be felt, and it is characteristic in shape. A sound introduced into 
 the cavity is a convincing proof after fornices of the vagina are 
 obliterated. 
 
 The uterus is usually enlarged and the cervix hypertrophied and 
 eroded in complete prolapse. A sound introduced into the blad- 
 der through the urethra reveals the extent to which the bladder is 
 displaced. 
 
 For what conditions may prolapse be mistaken? 
 
 (1) Hypertrophies of the cervix without prolapse ; (2) prolapse 
 of the vagina ; cystocele and rectocele ; (3) prolapse of an inverted 
 uterus ; (4) uterine polypus ; (5) tumors of the vagina or vulva. 
 
 One diagnostic mark of prolapse is that the tumor is reducible, 
 but the diagnosis should first be made before reduction. 
 
 What is the treatment? 
 
 PropJiylactic : By preventing laceration of the perineum, and by 
 timely and appropriate treatment of retroversions. 
 
 Immediate : (1) Replace the uterus, and keep it in position by 
 pessaries or operations ; (2) amputation of the cervix ; (3) vaginal 
 hysterectomy. 
 
 Reposition in difficult cases is best accomplished in the knee- 
 elbow position. When first replaced the uterus is usually in retro- 
 flexion, and the reposition should be completed by the hand on the 
 abdomen. A cradle pessary or an Albert Smith in slight prolapse, 
 without rupture of the perineal body, will usually suffice to retain 
 the uterus. 
 
 The various operative measures for cure of prolapse are — (1) 
 repair of the perineum and narrowing of the vulva by uniting the 
 lower portion of the labia majora (episio-perineorrhaphy) ; (2) nar- 
 rowing of the vagina (colporrhaphy) ; (3) combination of the above 
 methods ; (4) peritoneal fixation and Alexander's operation ; (5) 
 
DISPLACEMENTS OF THE UTERUS. 
 
 117 
 
 amputation of the cervix alone or with any of the above ; (G) vagi- 
 nal hysterectomy (extirpation of the uterus). 
 
 Repair of the perineum and uniting the lower portion of the 
 labia majora are indicated in cases of slight prolapse with a torn 
 perineum. 
 
 When the prolapse is more extensive a combination of Hegar's 
 posterior colporrhaphy and perineorrhaphy with a Martin's ante- 
 
 FiG. 59. 
 
 Diagram representing some of the Minor Forms of Uterine Displacement. 
 
 rior colporrhaphy will in the majority of cases suffice to hold the 
 uterus in position. Amputation of the cervix is indicated in hyper- 
 trophies of the latter. 
 
 Vaginal hysterectomy is only resorted to in those cases of com- 
 plete prolapse where other means of treatment seem useless. 
 
 Describe briefly the minor displacements of the uterus mentioned 
 under Varieties. 
 
 Elevation results from myomata, ovarian cysts (especially those 
 
118 DISEASES OF THE UTERUS. 
 
 between the folds of the broad ligaments), haematocolpos, cicatricial 
 contraction in the folds of Douglas, and superior fixation, due to 
 perimetritic adhesions after pregnancy. 
 
 Anteposition, due to retro-uterine tumors, chiefly pelvic hasmato- 
 cele. 
 
 Retroposition is due usually to peri- and parametritic inflamma- 
 tions. 
 
 Later o-positions. versions, and flexion are usually due to inflam- 
 matory exudations and tumors to one or other side of the uterus 
 or to arrests of development. 
 
 ACUTE METRITIS. 
 
 Define acute metritis. 
 
 An acute inflammation of the parenchyma of the uterus (mus- 
 cular and connective tissue). 
 
 What are its causes? 
 
 Almost always septic. 
 
 (a) Sepsis after labor or abortion ; (li) sepsis from other causes 
 (as after the sudden evacuation of a large amount of retained secre- 
 tions), from the use of sponge tents, from any operation upon the 
 uterus without antiseptic precautions ; (c) acute endometritis ; (d) 
 acute perimetritis ; (e) intra-uterine injections or stem-pessaries ; 
 ( /) caustics and cutting instruments used within the uterine cavity ; 
 (^) exposure to cold and wet at menses ; (K) excessive coitus, 
 especially at menses ; (i) gonorrhoeal infection ; (y) direct injury ; 
 (]{■) rarely from a simple vaginal pessary. 
 
 What is its pathology? 
 
 It generally includes more or less endometritis and perimetritis. 
 The uterus is hyperaemic, infiltrated with serum and leucocytes, and 
 is soft and succulent. There may be ecchymoses. There may, in 
 addition, be small collections of pus or abscesses of considerable 
 size. There is catarrhal endometritis with its characteristic dis- 
 charge. 
 
 What are its symptoms? 
 
 Sudden, sharp chill ; fever, 103° or 104° F., usually of a sthenic 
 type, with a full rapid pulse; pain, heavy and dragging; also a 
 good deal of intermittent, sharp pain (peritonitic) ; vesical and rec- 
 tal tenesmus; uterus extremely sensitive to the touch; discharge 
 
CHRONIC METRITIS. 119 
 
 due to the endometritis ; nausea and vomiting (especially if peri- 
 tonitis exists). 
 
 What is the course of the disease ? 
 
 (1) Mild cases may recover completely in a few days or may 
 leave a chronic metritis. (2) Cases with formation of abscesses 
 have repeated chills, irregular rise of temperature, sweating. The 
 abscess, if small, may disappear. A large abscess — 1, may become 
 encapsulated ; 2, may rupture into the peritoneal cavity — usually 
 fatal ; 3, may rupture into the uterine canal, when the prognosis 
 is favorable ; or,-4, may rupture into the rectum, bladder, or through 
 the abdominal wall. 
 
 Upon what is the diagnosis based? 
 
 (1) Upon the cause and symptoms ; (2) upon the physical signs. 
 These are tenderness on pressure or on attempting to raise or depress 
 the uterus ; enlargement, chiefly antero-posterior, giving the uterus 
 a globular feel, such as it presents in early pregnancy. 
 
 What is the prognosis ? 
 
 The prognosis is grave, owing to the danger of abscess-formation. 
 
 What is the treatment? 
 
 (1) In the early stages antiphlogistic : long-continued hot 
 vaginal douches ; leeches applied to the groins ; ice-bag over the 
 hypogastrium ; recumbent posture with the hips elevated ; a 
 cathartic (castor oil). If due to sepsis, the uterine cavity should 
 be repeatedly irrigated with 1 : 40 carbolic ; opium is required to 
 relieve pain. 
 
 (2) In the later stages, essentially a chronic metritis, hot vaginal 
 douches ; glycerin tampons ; scarification of the cervix. 
 
 (3) When an abscess forms, wait until it points ; then incise it. 
 But where it is distinctly extending toward the peritoneal surface, 
 it is better not to wait, but at once to evacuate it through the 
 uterine canal or the vagina. 
 
 CHRONIC METRITIS. 
 Define chronic metritis. 
 
 An enlargement of the uterus, due to an increase in connective 
 tissue, and in which the uterus is sensitive to pressure. (This in- 
 cludes subinvolution.) 
 
120 DISEASES OF THE UTERUS. 
 
 What different opinions are held in regard to its occurrence? 
 
 (1) Some authors say that it never occurs ; (2) some say that 
 it is the most frequent disease of women ; (3) Seifert considers it 
 merely subinvolution ; (4) Klob, followed by Thomas, considers it 
 merely areolar hyperplasia following long-continued congestion ; 
 (5) Tuttle's definition is as stated above. 
 
 What are the predisposing causes? 
 
 (1) Any disease, acute or chronic, impairing the general health ; 
 (2) frequently-repeated parturition or abortion. 
 
 What are the existing causes? 
 
 A. Those producing subinvolution : (1) Getting up too early 
 after parturition ; (2) retention of placenta, membranes, or clots ; 
 (8) pelvic peritonitis or cellulitis ; (4) laceration of the cervix ; (5) 
 all forms of septic infection ; (6) early resumption of hard work ; 
 (7) early resumption of coitus ; (8) non-lactation ; (9) abortion if 
 the woman gets up and resumes sexual relations too early. As a 
 result of these the retrograde metamorphosis does not take place, 
 and the uterus is left with an abnormal amount of connective and 
 muscular tissue. 
 
 B. Causes producing constant or repeated active hypergemia : (1) 
 Excessive coitus ; (2) intercourse with impotent men ; (3) cold 
 douches to prevent conception ; (4) masturbation ; (5) obstructive 
 dysmenorrhoea ; (6) neglected gonorrhoeal endometritis. 
 
 C. Those producing passive congestion : (1) Interference with 
 the general circulation by lesions of the heart, lungs, or liver ; (2) 
 local obstruction by tumors or inflammation (especially by habitual 
 distension of rectum or bladder). 
 
 D. Comparatively rarely has been preceded by acute metritis. 
 
 Describe its pathology. 
 
 There is a proliferation of connective tissue, chiefly localized 
 about the blood-vessels. There is no noticeable increase of mus- 
 cular tissue. The lymphatic spaces are dilated. The uterus is 
 always enlarged, but not usually very greatly. 
 
 In the Jirst stage the new connective tissue is being produced. 
 The uterus is enlarged, globular, antero-posterior diameter increased, 
 and is soft and succulent. It thus resembles the uterus in early 
 pregnancy. The mucous membrane is congested. 
 
 The second stage^ or the stage of cirrhosis, is not often observed. 
 The new connective tissue contracts, forming irregular bands or 
 
CHRONIC METRITIS. 121 
 
 cicatrices or nodules. This tends to obliterate the blood-vessels, 
 and, as the arteries are comparatively thick-walled, the venous 
 circulation is most impaired. The size of the uterus may be 
 diminished. It is firm and white, cutting almost like cartilage. 
 The uterine cavity is larger than normal. 
 
 As to site^ chronic metritis may be general or may be confined 
 chiefly to either the body or the cervix. 
 
 Describe chronic metritis of the cervix alone. 
 
 This is found in cases of uterine or vaginal prolapse. In the 
 first stage the os externum is engorged and patulous, the lips are 
 separated, and the mucous membrane everted. In the second stage 
 the cervix is hard, irregular, and nodular ; the lips are broad and 
 thick ; there is chronic cervical catarrh. The nodular masses in the 
 cervix are characteristic, and closely resemble commencing carcinoma. 
 
 What are the symptoms of subinvolution resulting in chronic 
 metritis ? 
 
 The trouble dates from a labor or abortion (especially abortion, 
 as the patient gets up too early, that her friends may not suspect 
 the nature of the trouble, and is also apt to resume intercourse too 
 early). 
 
 a. In the early stages there are — (1) a sense. of weight and 
 pressure and dragging pain, increased by walking or standing ; 
 (2) pain in the hypogastrium or groin (apt to place hand over 
 pubes to support the uterus) : patients cannot ride over rough 
 pavements, and they walk carefully ; (3) vesical irritability ; 
 (4) obstinate constipation ; (5) leucorrhoea and menorrhagia or 
 metrorrhagia ; (6) dyspareunia ; (7) many of the signs of preg- 
 nancy (often there is morning vomiting, the breasts may be en- 
 larged and pigmented, and the patient may have the subjective 
 symptoms of pregnancy), but there is no cessation of menstruation. 
 
 h. In the later stages there are occasional acute exacerbations, 
 each leaving the uterus a little larger. These are — general debility ; 
 pains (sciatic, sacral, or coccygeal), neuralgias, headaches, sterility, 
 or repeated abortions. 
 What are the symptoms of chronic metritis from congestion ? 
 
 There is, first, dysmenorrhoea, and in the course of years the 
 general health is impaired and the uterus becomes enlarged, pain- 
 ful, and sensitive. There are leucorrhoea and menorrhagia or 
 metrorrhagia. The patient finally presents the same symptoms as 
 one in whom the chronic metritis originated in subinvolution. 
 
122 DISEASES OF THE UTERUS. 
 
 What are the physical signs of chronic metritis ? 
 
 a. Early stage : Uterus uniformly enlarged and sensitive ; uterus 
 usually prolapsed, and there is often retroflexion and fixation. The 
 uterine cavity is always enlarged and more roomy. The uterine 
 walls are doughy. The cervix in a nullipara is enlarged, swollen, 
 and tapers to a point, where the os is patulous, eroded, and presents 
 a plug of mucus. The cervix in a multipara is blunt and swollen, 
 the OS is broad and its lips are swollen and eroded. There is cer- 
 vical catarrh. 
 
 h. Later stages : The cervix is indurated and nodular, and is 
 larger than the body of the uterus. The body of the uterus is not 
 sensitive to pressure. 
 
 What are the complications of chronic metritis ? 
 
 Chiefly inflammatory. (1) Peritoneal adhesions and bands ; 
 
 (2) acute and chronic ovaritis ; (3) distortions of the tubes (some- 
 times hydrosalpinx) ; (4) displacements of the uterus ; (5) endo- 
 metritis ; (6) disturbances of menstruation. 
 
 What are the chief diagnostic features of chronic metritis ? 
 
 (1^ Uniform enlargement of the uterus ; (2) sensitiveness ; 
 
 (3) pain ; (-4) chronicity. 
 
 From what conditions must you diagnose chronic metritis ? 
 
 (1) Pregnancy ; (2) fibroid tumors of the uterus ; (3) carcinoma 
 of the cervix. 
 
 Give the differential diagnosis between pregnancy and chronic 
 metritis. 
 The symptoms common to both are morning vomiting, pigment- 
 ation and enlargement of the breasts, and changes in the cervix. 
 But in pregnancy menstruation is absent, and in chronic metritis 
 it is irregular and profuse. 
 
 What is Hegar's sign of pregnancy ? 
 
 It is a change in the convexity of the posterior wall of the 
 uterus (a slight bulging) above the vagina. It is excellent, but 
 the exclusion of chronic metritis is essential. 
 
 Give the differential diagnosis between chronic metritis and 
 
 fibroids. 
 
 a. In the case of a small submucous fibroid the uterus would 
 
 not be sensitive, and the uterine cavity would be smaller. (In case 
 
 of doubt dilate the os and examine the uterine cavity with the finger.) 
 
CHRONIC METRITIS. 123 
 
 h. With an interstitial fibroid the uterus is not sensitive, and, 
 while the cavity of the uterus is enlarged, there are none of the 
 other symptoms of chronic metritis. On bimanual examination a 
 localized swelling of the uterine wall can be felt. 
 
 How would you diagnose carcinoma of the cervix from chronic 
 metritis ? 
 
 By the coexistent cancerous cachexia ; by the age (carcinoma 
 rarely occurring before thirty-five) ; by microscopical examination 
 of a portion cut from the cervix. 
 
 What is the course of the disease ? 
 
 Exceptionally it may give no serious trouble, but generally it 
 undermines the health. Many get worse at the menopause, and 
 then get practically well, but some go on for ten years longer, with 
 profuse and irregular menstruation. The few cases that pass into 
 the stage of cirrhosis are freed from almost all the troublesome 
 symptoms. 
 
 What is the prognosis? 
 
 When confined to the cervix it may be cured. When the whole 
 uterus is involved there is little danger to life, but the prospect of 
 cure is very poor. Some few cases are spontaneously cured by 
 passing into the second stage. The only danger is from hemor- 
 rhage or peritonitis. 
 
 What is the prophylaxis? 
 
 Remaining in bed until the fundus is at the level of the sym- 
 physis ; remaining in bed seven or eight days after abortion : lac- 
 tation if possible. 
 
 What is the curative treatment? 
 
 (1) Remedying existing causes of congestion Ccatarrh of the 
 cervix, laceration, and displacements). 
 
 (2) General Treatment. — Bowels and bladder regulated ; diet 
 wholesome and nutritious ; iron if anaemic (strychnine, iron, and 
 quinine form an excellent tonic) ; ergotine in doses of \ grain three 
 times a day is almost a specific ; baths, but never cold nor sea- 
 baths ; change of climate is often beneficial. 
 
 Weir Mitchell's treatment consists in absolute rest, a stuffing 
 diet, electricity, and passive motion. The patient lies perfectly 
 still ; does not make a voluntary motion, so much as even to raise 
 a hand, for two months ; receives a very liberal diet, and the nutri- 
 
124 DISEASES OF THE UTERUS. 
 
 tion is maintained by electricity and passive motion daily. This is 
 rarely practicable, and where it is not the best treatment consists 
 in moderate exercise in the open air (a walk of a mile or two daily, 
 no driving or riding), having the patient keep at her ordinary work, 
 but avoiding straining or heavy lifting. Restrict sexual intercourse, 
 but it is often not best to prohibit it. (Do so, of course, if it causes 
 prostration or aggravates the symptoms.) Support the uterus by a 
 suitable pessary. Remove pressure from above by the use of sus- 
 penders, loose waistbands, and a well-fitting abdominal belt. Reg- 
 ulate the bowels (this is very important) : the diet should not be 
 of too great bulk and should be laxative ; fresh fruits are especially 
 desirable. An enema of 1 or 2 drachms of glycerin (undiluted) 
 every night or morning causes a satisfactory movement of the bow- 
 els, and is free from any objectionable effects. 
 
 (3) Local Treatment. — a. Local Depletion. — Scarification, punc- 
 ture, leeches. Scarification or puncture may be done twice weekly ; 
 neither is contraindicated by any degree of anaemia, and each is 
 very effective ; especially useful a few days before menstruation. 
 For scarification : longitudinal incisions in the cervical mucous 
 membrane: a straight bistoury is used; and for puncturing: an 
 instrument called Buttle's spear is thrust into the cervix to the 
 
 Fig. 60. 
 
 Buttle's Spear. 
 
 depth of one-fourth of an inch in a number of places. The 
 amount of blood drawn should be ^ss to ^ij. Hemorrhage is 
 readily checked by the application of alum or tannin. It is not 
 necessary to apply suction, as by cups. (Do not tell the patient 
 what you are doing, but tell her that the tampons will be stained.) 
 Leeches are applied through a cylindrical speculum. The cervix 
 is first plugged with a bit of cotton, and then punctured. Leeches 
 are uncertain as to the amount of blood they will withdraw, and 
 there is a liability to profuse subsequent hemorrhage. 
 
 h. Vaginal Douche.^. — Prolonged injections of hot water, 100° to 
 110° F., or of hot salt solution, are very beneficial in all conditions 
 where there is congestion. 
 
 How should a vaginal douche be administered? 
 
 " The injection can be better given after the patient is undressed 
 
CHRONIC METRITIS. 125 
 
 for the night and in bed. She shoukl be placed near the edge of 
 the bed, with the hips elevated as much as possible by the bed-pan, 
 and a small pillow under her back, the lower limbs being flexed. 
 Her body must be covered to protect her from the cold, and her 
 position made perfectly comfortable : whenever the bed is a soft 
 one, for the purpose of keeping the hips elevated a broad board 
 should be placed under the pan to prevent it from sinking into the 
 bed from the weight of the patient. The vessel of hot water is 
 placed on a chair by the bedside, and the nurse passes the nozzle of 
 the syringe into the vagina, over the perineum, directing it along 
 the recto-vaginal wall until it has reached the posterior cul-de-sac. 
 The water must be thrown in at first very carefully, until the 
 vagina has become distended "' (Emmet). 
 
 A fountain syringe may be used instead of the bulb syringe, as 
 above described, and in every case the perforations in the nozzle 
 used should be lateral, to avoid the danger of the fluid being in- 
 jected into the uterine cavity. 
 
 c. Tampons. — The most useful are glycerin tampons, with chlo- 
 ral or iodoform as an anodyne. Tampons impregnated with alum 
 are not so desirable, as their astringent action cannot be limited to 
 the cervix, but extends to the vagina. 
 
 d. Counter-irritatw7i. — This is best effected by tincture of iodine 
 or Churchill's tincture, diluted one-half with glycerin and applied 
 to the entire mucous membrane of the uterine canal. The canal 
 is first moderately diluted by graduated sounds ; then an applica- 
 tor wound with cotton soaked in the solution is passed rapidly 
 into the uterine canal and allowed to dry there (always protect the 
 vagina from the excess). Then freely paint the vaginal surface of 
 the cervix with tincture of iodine. (A glycerin tampon should 
 then be introduced, to be removed by the patient in twenty-four 
 hours.) The solid stick of nitrate of silver may be passed into 
 the uterine cavity, or the cervix may be blistered by painting its 
 vaginal surface with cantharidal collodion. But these measures 
 are not often necessary. 
 
 e. Operations. — (1) Martin's operation consists in amputation 
 of the anterior lip of the cervix. It will often cause reduction in 
 the size of the entire uterus. The objection to it is the distortion 
 produced. (2) Emmet's operation, or trachelorrhaphy, is for the 
 repair of laceration of the cervix, and is often followed by brilliant 
 improvement. It is the one to be chosen in most cases. (3) Schroe- 
 der's amputation of the cervix consists in the removal of a circular 
 
126 
 
 DISEASES OF THE UTERUS. 
 
 wedge and suturing the vaginal to the cervical mucous membrane. 
 It is eflfective and is to be preferred in some cases. 
 
 (A) 
 1. 
 2. 
 
 3. 
 4. 
 5. 
 
 6. 
 
 9. 
 10. 
 11. 
 12. 
 
 APPLICATIONS THROUGH THE SPECULUM. 
 
 In substance (stick, crystals, or powder) : 
 Nitrate of silver, 
 
 Caustic potash. 
 Chloride of zinc. 
 Chromic acid, 
 Alum, 
 Tannin, 
 
 Persulphate of iron, 
 Sulphate of copper, 
 Iodide of lead, 
 Iodoform, 
 
 Hydrate of chloral. 
 The bromides. 
 
 are escharotics, and must not be kept 
 in contact with the cervix or 
 vagina. 
 
 may be kept in contact with the cer- 
 vix for several hours. 
 
 Caustics. 
 
 (B) Fluids: 
 
 ' Nitric acid, fuming. 
 
 Chromic acid, sat. sol. in water or diluted. 
 Escharotics. ■{ Bromine sol. in alcohol, 1 : 5 or 10. 
 
 Acid nitrate of mercury (sat. sol.). 
 (^Chloride of zinc (sat. sol.). 
 
 Nitrate of silver in strong solution, Ij— ^. 
 
 Carbolic acid, pure. 
 ■^ Iodized phenol, carbolic acid, tr. iodine, equal parts. 
 
 Acetic acid, pure. 
 
 Pyroligneous acid (crude or rectified). 
 ' Sol. of perchloride of iron. 
 
 Sol. of persulphate of iron (Monsel's). 
 
 Sat. sol. of alum. 
 
 Sat. sol. of acetate of lead. 
 
 Sat. sol. of sulphate of zinc. 
 
 Sat. sol. sulphate of copper. 
 
 Glycerites of alum and tannin. 
 
 Fluid extract of pinus Canadensis. 
 
 Fluid extract of hydrastis Canadensis. 
 
 Fluid extract of eucalyptus globulus. 
 
 Fluid extract of witch hazel. 
 ^ Bismuth and glycerin. 
 
 Astringents 
 and 
 
 Styptics. 
 
ENDOMETRITIS. 
 
 127 
 
 Alteratives. < 
 
 r Tincture of iodine. 
 Compound tr. of iodine. 
 Churchill's tincture of iodine. 
 Sol. of iodide of potash. 
 Sol. of iodoform in glycerin. 
 Impure carbolic acid and glycerin, equal parts. 
 Sol. of nitrate of silver, gr. x— ^ss to ^j. 
 Sol. of chromic acid, .^j to ,^j of water. 
 Sol. of sulphate of zinc, 10 per cent. 
 Sol. of sulphate of copper, 10 per cent. 
 Sol. of persulphate of iron, with glycerin, equal 
 
 parts. 
 Sol. of perchloride of iron, with glycerin, equal 
 
 parts. 
 
 Narcotics. 
 
 Tincture of belladonna. 
 
 Tincture of hyoscyamus. 
 
 Tincture of opium. 
 
 Tincture of conium. 
 
 Sol. of chloral hydrate. 
 
 Sat. sol. of bromide of potassium. 
 
 Sat. sol. of bromide of sodium. 
 
 Sat. sol. of bromide of ammonium. 
 
 Cocaine. 
 
 Hydragogue. Glycerin. 
 
 Disinfectants. < 
 
 ' Corrosive sublimate, 1 : 2000. 
 Carbolic acid, 1 : 50. 
 Boracic acid, sat. sol. 
 Chlorine-water. 
 Chlorinated soda. 
 Bromo-chloralum. 
 Thymol. 
 Permanganate of potash. 
 
 ENDOMETRITIS. 
 What are the varieties ? 
 
 (1) Acute ; (2) chronic. 
 
128 DISEASES OF THE UTERUS. 
 
 ACUTE ENDOMETRITIS. 
 What are its definition and occurrence? 
 
 It is an acute inflammation of tlie mucous membrane of the ute- 
 rus, and is usually general — i. e. not confined to the cervix or to 
 the body exclusively. It is not very common, and is said never 
 to occur before puberty. 
 
 What are its causes? 
 
 (1) Gonorrhoeal infection (there is not necessarily any ante- 
 cedent infection of the vagina or urethra, but this is quite often 
 the case). (2) Injurious influences during menstruation (cold, 
 local injuries, as by stem-pessaries, sounds, and intra-uterine appli- 
 cations). (3) It may complicate typhus fever, small-pox, measles, 
 etc. (4) Sepsis after labor or abortion. 
 
 What is its pathology ? 
 
 The mucous membrane is red and thickened ; it is soft and vel- 
 vety, and can be stripped oif with a scalpel. It presents small 
 ecchymoses. The body is more affected than the cervix. The 
 latter is soft, dark red or purplish, and presents a ring of small 
 superficial erosions about the os. Secretion is increased. That 
 from the body is at first serous, but later becomes cloudy from 
 desquamated epithelium, which under the microscope is seen to 
 form casts of the tubular glands. The secretion from the cervical 
 canal is yellowish-green or rusty, according to the preponderance 
 of pus or blood. It excoriates the vagina and vulva. 
 
 What are the complications ? 
 
 Acute salpingitis, acute metritis, acute peritonitis, vaginitis. 
 
 What are the symptoms? 
 
 (1) Chill not present in the majority of cases. (2) Rise of tem- 
 perature to 100° or 101° F. (3) No pain unless there are compli- 
 cations. (4) After two or three days increased secretion of the 
 character above described. (5) In gonorrhoeal or severe septic 
 cases we have added nausea, vomiting, pain, vesical tenesmus, and 
 tympanites. 
 
 What are the physical signs? 
 
 (1) Bimanual examination shows the uterus to be of normal size 
 and slightly sensitive. (2) The sound should never be used in an 
 acute process like this, especially if gonorrhoeal or septic. It would 
 show great sensitiveness at the os internum and at the fundus, and 
 
CHRONIC ENDOMETRITIS. 129 
 
 its use would be followed by marked hemorrhage. (8) The use 
 of the speculum would show the os patulous, with a ropy secretion, 
 and the cervix either simply reddened or dark purple, or with exten- 
 sive superficial erosions. 
 
 What is the prognosis ? 
 
 Doubtful if septic or gonorrhoea!, because of the liability to com- 
 plications. In other cases the prognosis is good if the patient will 
 take proper care of herself. 
 
 What is the course? 
 
 The fever subsides in a few days, but the discharge continues 
 two or three weeks. If neglected it may pass into chronic endo- 
 metritis. 
 
 What is the treatment? 
 
 (1) Rest in bed should be insisted upon while the acute symp- 
 toms last. (2) Cathartics, if required to keep the bowels free. 
 (3) Pain if present is treated by hot hypogastric fomentations, and 
 Thomas uses opium. (4) Vesical irritation is treated by mineral 
 waters and the salts of potash. (5) When the discharge becomes 
 purulent simple vaginal douches are given (plain water or with 
 some astringent). (6) Depletion, as by leeches or cups, is never 
 indicated. 
 
 CHRONIC ENDOMETRITIS. 
 How frequent is its occurrence? 
 
 It is perhaps the most common of gynecological diseases. It 
 may be limited to either the body or the cervix of the uterus, or 
 it may be general. 
 
 CHRONIC CORPOREAL ENDOMETRITIS. 
 
 What are its causes? 
 
 (1) Those producing active hyperaemia. (2) Those producing 
 passive congestion. (3) It may be consequent upon acute endo- 
 metritis. 
 
 The causes most frequently operating are — 1, sexual excesses ; 
 2, local irritation by too hot or too cold vaginal injections or by 
 injudicious treatment by gynecologists ; 3, displacements of the 
 uterus, especially prolapse, and in virgins flexions and stenosis ; 
 4, neoplasm, especially fibroids ; 5. gonorrhoea is the most import- 
 ant of all, and there need not necessarily be a history of vaginitis. 
 9— Gyn. 
 
130 DISEASES OF THE UTERUS. 
 
 What is the pathology? 
 
 The mucous membrane is congested and thickened (may be 
 ^S- inch, or even i or 2 inch, in thickness) ; there are superficial 
 ecchymoses, which when old appear as yellow or brown or black 
 spots ; the surface is smooth, velvety, and of a pinkish hue, but 
 may be thrown into folds or papillary masses completely tilling 
 the uterine cavity. The utricular glands are dilated, their mouths 
 being blocked, and some may rupture. 
 
 What varieties are distinguishable microscopically? 
 
 I. Glandular endometritis : 1 , hypertrophic ; 2, hyperplastic. 
 II. Interstitial endometritis. 
 
 III. Mixed endometritis. 
 
 IV. Fungous endometritis. 
 
 Describe glandular endometritis. 
 
 (1) In simple or hypertrophic glandular endometritis there is 
 marked proliferation of the epithelium lining the utricular glands. 
 Thus the glands become distorted and their walls are thrown into 
 dentate elevations. As seen from the surface, the mouths of the 
 glands are irregularly stellate. 
 
 (2) In hyperplastic glandular endometritis new glands are added, 
 and may be so numerous as to fairly honeycomb the mucous mem- 
 brane. They may be diverticula from the general surface or from 
 the old glands. 
 
 Describe interstitial endometritis. 
 
 It is chiefly cellular in the early stages. The round cells of the 
 stroma are increased in size and number, and have large nuclei. 
 Later the cells become spindle-shaped, the nuclei oval and less well 
 defined, and finally dense connective tissue results, which compresses 
 and distorts the glands. If the intercellular substance is princi- 
 pally affected, there is marked production of dense new connec- 
 tive tissue ; the glands are after a time obliterated and the secre- 
 tion destroyed. 
 
 Describe mixed or diffuse endometritis. 
 
 All the elements of the mucous membrane are involved, but to 
 different degrees at different parts of the surface. This is the most 
 common form. 
 
CHRONIC ENDOMETRITIS. 131 
 
 Describe fungous endometritis, or fungoid degeneration of the 
 endometrium. 
 
 This is a clinical class in which a certain number of growths (ute- 
 rine fungosities) occur as a result of an endometritis (most often mixed, 
 but it may be glandular or interstitial). To the naked eye these 
 look like white or red currants ; they are very vascular and bleed 
 readily. They may be sessile or pedunculated. Microscopically, 
 they consist merely of hyperplastic mucous membrane. They are 
 said to occur almost exclusively after labor, or especially after 
 abortion, as the result of chronic endometritis set up by retained 
 bits of placenta. 
 
 What are the symptoms? 
 
 (1) Hemorrhage is the characteristic symptom. (If the dis- 
 charge is purulent, it probably comes from the Fallopian tubes ; if 
 there is a free watery discharge, the existence of a tumor is to be 
 thought of.) There is profuse menstruation and irregular hemor- 
 rhage between the periods. 
 
 (2) Pain is excessive at the periods, especially in the interstitial 
 form. (In the glandular form hemorrhage is the most prominent 
 symptom.) (a) Dysmenorrhoea, severe colicky pains, and there 
 may be membranous dysmenorrhoea, especially in virgins. (6) 
 " Middle pain " is a sudden uterine colic occurring halfway be- 
 tween the periods. (c) Constant pain with exacerbations. (cT) 
 Others feel best at or after menstruation (especially those with 
 free flowing), (e) Indefinite pain. 
 
 (3) Sensibility to the Sound. — There are great pain and hemor- 
 rhage on passing the sound. The greatest sensitiveness is at the 
 OS internum and at the fundus. 
 
 (4) Sterility or a tendency to abortion. 
 
 (5) Symptoms like those of pregnancy — " morning sickness," 
 changes in the breasts. 
 
 (6) Distiirhance of Digestion. — True dyspepsia or a nervous 
 form characterized by a capricious appetite and distress after eating. 
 
 (7) Disturbance of the Nervous System. — Melancholia or some 
 change of temperament. 
 
 What is the diagnosis? 
 
 (1) History. (2) Uterine sound : (a) Grlandular. The cavity 
 is lengthened and more roomy. Sensitiveness is not extreme. 
 Rough excrescences can be felt at various points, (b) Interstitial. 
 
132 DISEASES OF THE UTERUS. 
 
 The cavity is narrow, and the sound cannot be turned from side 
 to side. The mucous membrane is pretty smooth, but not elastic, 
 and there may be fungosities. (c) Fungous. The roughnesses 
 are felt at once. They may be scraped out and the fungosities 
 examined. 
 
 What are the complications? 
 
 In nulliparae it is not apt to be complicated except in gonor- 
 rhoea! cases, where the inflammation may extend to the tubes and 
 peritoneum. In multiparae it often causes metritis, cervical catarrh, 
 vaginitis, displacements of the uterus, or pruritus vulvae. 
 
 What is the prognosis? 
 
 Best in recent cases : glandular ; uterus, not much enlarged ; 
 cavity roomy ; not much connective-tissue formation ; not much 
 debility. 
 
 Bad in old cases : glands mostly deformed or obliterated ; men- 
 struation scanty ; pain excessive ; general health undermined. (In 
 fifty per cent, of all cases the climacteric brings no relief at all.) 
 
 What is the treatment? 
 
 General. — Tonics and hygiene (especially regulation of bowels, 
 bladder, sexual relations) ; treat displacements if present ; use of 
 ergotine if the uterus is enlarged. 
 
 Local. — (1) Ointments may be introduced by a long syringe and 
 left to melt in the uterine cavity. They are unscientific, uncertain, 
 and useless. Those which have been tried contained lead, bismuth, 
 iodoform or calomel combined with cocoa butter. 
 
 (2) Solid alteratives; pencils or suppositories containing iron, 
 alum, tannin, or copper. (The best method is by fusing the sub- 
 stance on the end of a copper wire. It takes four or five minutes 
 to melt inside the uterus.) These are not very valuable. 
 
 (3) Solutions are excellent. The cervix is thoroughly dilated 
 (e. ^. by a cervical speculum), and an applicator, wound with cot- 
 ton saturated with the solution, is passed quickly into the uterine 
 cavity. The uterus contracts, and it is necessary to wait a few sec- 
 onds for it to relax before withdrawing the applicator. The most 
 desirable applications are — a. Tincture of iodine, pure ; h. Church- 
 ill's tincture of iodine, pure or with 50 per cent, glycerin ; c. Bat- 
 tey's solution (iodine, alcohol, and carbolic acid) ; J. Liq. ferri 
 persulph., or liq. ferri sesquichloridi (each with 50 per cent, gly- 
 cerin) ; e. Saturated solution of zinc or copper sulphate. Others are 
 
CHRONIC ENDOMETRITIS. 
 
 133 
 
 nitrate of silver or chromic acid, gr. xx-gj. and crude carbolic acid. 
 Be sure there is room for the fluid to escape, else it may be forced 
 into the tubes. 
 
 (4) The dull curette (Thomas's wire curette. Fig. 61) is used 
 for the removal of fungosities. The cervix is moderately dilated, 
 and then every portion of the surface of the endometrium is cjone 
 
 Fig. 61. 
 
 ^^ 
 
 Thomas's Wire Curette. 
 
 over with the wire loop. Then a single application is made of a 
 solution of either chromic acid, nitrate of silver, sulphate of zinc 
 sulphate of copper, persulphate of iron, chloride of zinc, tincture 
 of chloride of iron, or carbolic acid. The operation can be done 
 without an angesthetic. 
 
 (5) Intra-uterine Injectio7is. — The syringe is long, with lateral 
 orifices. The fluids injected are — tincture iodine ; tincture iodine, 
 
 Fig. 62. 
 
 Applicator Syringe for Fluids or Ointments. 
 
 Churchill's ; nitrate of silver, ^ss or less to gj ; pyroligneous acid ; 
 solutions of iron, copper, or zinc salts. 
 
 Contraindications. — (1) Never employ this method without hav- 
 ing the cervix fully dilated, and never in cases of acute flexion. 
 (2) Never just before, during, or just after menstruation. (3) 
 Never if there is acute inflammation in or about the uterus. 
 
 Dangers. — (1) Uterine colic and slight collapse. (2) Fluid may 
 pass out through the tubes into the peritoneal cavity. (3) Or into 
 the veins and produce acute phlebitis. (4) Entrance of air into 
 the veins. 
 
 Rules.— (V) Fluid should be at least 80° or 90° F. ; (2) exclude 
 air; (3) bladder and rectum empty : (4) confine patient to bed for 
 a few hours afterward. 
 
 Methods. — (1) Bandl's canula, pyroligneous acid. A double tubu- 
 
134 
 
 DISEASES OF THE UTERUS. 
 
 lar speculum is introduced (a long speculum with a short wide one) ; 
 the cervix is seized by a tenaculum and drawn well down, the 
 long inner speculum being removed. Bandl's canula is intro- 
 duced about one-fourth of its length into the uterine cavity ; the 
 
 Fig. 63. 
 
 Bandl's Canula. 
 
 cylindrical speculum is filled with crude pyroligneous acid, and the 
 canula is pushed on into the uterus. 
 
 (2) Tincture of iodine, ten or twelve drops introduced into the 
 uterine cavity through a long uterine syringe with pinhole lateral 
 orifices. 
 
 (3) In old, long-standing cases dilate the cervical canal thor- 
 oughly, and irrigate the uterine cavity with 3 per cent, carbolic 
 acid by means of the Fritsch-Bozeman intra-uterine catheter. Then 
 scrape out the entire endometrium with a sharp curette. 
 
 The patient .should remain in bed for four or five days, and 
 then ten or twelve drops of pure tincture of iodine are injected, 
 and the patient may get up twenty -four hours later. The injection 
 of tincture of iodine should be repeated twelve times, at intervals 
 of two or three days. 
 
 Some objections urged against this last method are — 
 (1) That it is dangerous. (It is not dangerous if performed 
 with antiseptic precautions.) (2) That it is impossible to scrape 
 out the endometrium. (Others say that they can do it.) (3) That 
 
CHRONIC CERVICAL ENDOMETRITIS. 135 
 
 it causes sterility. (This is not true : furthermore, it sometimes 
 cures sterility.) 
 
 Menstruation is generally absent the first two periods after this 
 treatment, but returns at the third period. 
 
 CHRONIC CATARRH OF THE CERVIX [CHRONIC CERVICAL 
 
 ENDOMETRITIS). 
 
 What is the occurrence? 
 
 It is the most common gynecological disease. In virgins and 
 nulliparae it is limited to the mucous membrane ; in multiparae the 
 inflammation involves all parts of the cervix. 
 
 What are the causes ? 
 
 I. Predhposing. — (1) Long conical cervix (in nulliparae) ; (2) 
 general debility from rheumatism, gout, tuberculosis, nephritis, 
 chlorosis or anaemia, bad surroundings, and exposure ; (3) frequent 
 parturition. 
 
 II. Exciting. — (1) Immoderate sexual intercourse ; (2) attempts 
 to prevent conception ; (3) intercourse with impotent men ; (4) 
 masturbation ; (5) extension of inflammation from vagina or body 
 of uterus ; (6) stenosis of os externum ; (7) local injuries, mechani- 
 cal and chemical ; (8) labor (laceration and subinvolution) is the 
 most common cause in multiparae. 
 
 What is the normal histology of the cervix ? 
 
 There is no serous coat. The muscular is quite subordinate to 
 the connective tissue, and does not form layers. Then come the 
 mucous membrane ; a submucous layer, which does not exist in 
 the body of the uterus ; and the parenchyma. 
 
 The mucous membrane is paler and firmer than in the body. It 
 presents anteriorly and posteriorly an arbor vitae. These are formed 
 by an anterior and a posterior median pillar with countless lateral 
 rugae, and these and the grooves between them are still further 
 subdivided, so that the surface presents ever so many minute 
 depressions or crypts, and everywhere there are seen the mouths 
 of the glands, which number about ten thousand. The glands are 
 simple, tubular, or bottle-shaped, or compound racemose, and open 
 into the crypts. The Nahothian glands are glands of any of the 
 above forms, the mouths of which have been occluded and the 
 secretion retained. The glands are lined by cuboidal epithelium. 
 The general surface is covered by a single layer of cylindrical 
 
136 DISEASES OF THE UTERUS. 
 
 epithelium which is ciliated (in the depressions only) from the 
 internal to the external os. It is continuous with that lining the 
 glands, and at the external os changes abruptly to flat epithelium. 
 The vaginal surface of the cervix is covered by stratified pavement 
 epithelium, beneath which there are papillae and no glands ; it is 
 thus very much like a cutaneous surface. The cervix is poorly 
 supplied with spinal nerves (hence is relatively insensible), but 
 richly with sympathetic nerves. 
 
 What is the pathology? 
 
 In simple recent cases the mucous membrane is congested, thick- 
 ened, and softened. There is increased discharge. In old, long- 
 standing cases — (a) There is a iiroliferation of the epitlielial cells. 
 This is always in a single layer, and results in an increase in the 
 surface of the mucous membrane in several ways : (1) Chiefly by 
 the cylindrical displacing the flat epithelium on the vaginal surface, 
 thus producing " erosions." (2) At certain points on the vaginal 
 surface the flat epithelium desquamates, leaving exposed the 
 cuboidal epithelium covering the papillae, and this in turn changes 
 to cylindrical epithelium. The surface is thrown into folds sepa- 
 rated by deep clefts, forming really new glands. The effect of all 
 these is the creation of a large additional secreting surface. 
 
 (6) The glands are chiefly occluded (both old and new glands), 
 and the contents of these retention cysts may be — 1, ordinary 
 secretion ; 2, pus ; 3, caseous material ; or, 4, chalky concretions. 
 Each one is about the size of a pea, and may extend toward the 
 cervical canal or toward the vaginal surface, where are normally 
 no glands, and there form knobs. 
 
 Cystic degeneration of the cervix is the name given to those 
 cases in which such occluded glands occupy the greater part of 
 the cervix, including its vaginal aspect. 
 
 What are the varieties of erosions of the cervix ? 
 
 (1) Simple ; (2) papillary ; (3) follicular. 
 
 (1) Simple Erosions are bright-red spots on the vaginal aspect 
 of the cervix, where the flat epithelium has been replaced by 
 cylindrical. They set up a continuous and protracted discharge, 
 and should always be treated. 
 
 (2) Papillary Erosions diff'er from simple erosions only in the 
 fact that the mucous membrane is furrowed by crypts which leave 
 papilliform eminences. The furrows are sometimes so deep as to 
 
CHRONIC CERVICAL ENDOMETRITIS. 137 
 
 simulate lacerations of the cervix, and might cause unpleasant 
 complications in the case of an unmarried woman. 
 
 (3) F<jllicidar Erosions are like simple erosions, with the addi- 
 tion of retention cysts, some of which may have ruptured. 
 
 Coxcomb GramdatAons are the hypertrophic folds or ridges of 
 the cervical mucous membrane which occur in all long-standing 
 cases. 
 
 What are the symptoms of cervical catarrh ? 
 
 (1) Pain is not a prominent symptom : it is often wholly absent. 
 Later, especially with hypertrophy, there is dull pain in the back 
 (lumbar and sacral) and pelvis. With retention cysts there is con- 
 stant burning pain in the cervix. 
 
 (2) Dyspareunia : severe itching and burning follow sexual inter- 
 course. 
 
 (3) Discharge may be absent. In simple cases it is clear and 
 viscid ; in old cases, turbid, purulent, and more viscid ; in the worst 
 cases extremely viscid and elastic. 
 
 (4) Sterility, the discharge acting as a mechanical barrier. 
 
 (5) Dehility, as the discharge may be a constant drain on the 
 system. 
 
 (6) Vesical irritability. 
 
 (7) Constipation. 
 
 (8) Functioned Disturbances : (a) Reflex congestion of ovaries 
 and uterus (menorrhagia or metrorrhagia) ; (i) neuralgia, head- 
 ache, sometimes hysteria. 
 
 What are the physical signs? 
 
 In Virgins. — There may be a long, narrow cervix, which is en- 
 larged, sensitive, and succulent. No erosions. On dilating the os 
 the cervical canal is found dilated and filled with coxcomb granu- 
 lations. Abundant discharge. In another class of cases the os is 
 rather wide, and there are large papillary erosions which resemble 
 a laceration or eversion of the cervix. 
 
 In Multiparse.. — The lips of the cervix are usually lacerated and 
 the mucous membrane everted, with possibly deep clefts and the 
 formation of cysts. The last are better felt than seen. 
 
 What is the diagnosis? 
 
 (From catarrh of the body of the uterus.) (1) The cervix alone 
 is tender ; (2) presence of erosions ; (3) thick tenacious discharge. 
 
138 DISEASES OF THE UTERUS. 
 
 What is the course? 
 
 Exceedingly slow, and showing no tendency toward spontaneous 
 recovery. A certain number of cases are followed by carcinoma 
 of the cervix. It is often impossible to distinguish under the 
 microscope between an erosion which is healing and carcinoma. 
 
 Is the prognosis good? 
 
 Yes, if the case is properly treated. 
 
 What is the treatment? 
 
 It may be — («) General. — Remove the regular causes ; improve 
 hygienic conditions ; limit sexual intercourse ; regulate the bowels 
 and bladder ; and remedy displacements of the uterus. Or 
 
 (6) Local. — 1. For Simple Erosion. — (1) Emollient vaginal 
 douches, salt, bran, starch, linseed oil, tincture of opium, or bella- 
 donna in warm water. (2) Applications : the best is pyroligneous 
 acid, poured into a tubular speculum, so as to bathe the cervix for 
 a few minutes. This is done three times a week. 
 
 2. For Papillary Erosions. — Cut them away with scissors, and 
 treat the base with nitrate of silver or chromic acid. 
 
 3. For the Cervical Canal. — Best, tincture of iodine, or Battey's 
 solution (carbolic acid, alum, and iodine), or nitrate of silver. 
 
 4. For Cysts. — Puncture them from the vaginal surface with a 
 Buttle's spear or a tenotomy knife, and then bore into them with 
 the solid stick of nitrate of silver. 
 
 5. For Cases requiring Removal of the entire Mucous Memhrane. — 
 (1) Caustics. — Clean away the secretion (best, a probe with cotton 
 powdered with alum and used with a twisting motion). Introduce 
 an applicator covered with cotton soaked in fuming nitric acid or 
 W'ith chromic acid. The applicator is left in until it dries. Later, 
 repeated applications of nitrate of silver solution or of tincture of 
 iodine are made to prevent exuberant granulations. (2) Surgical 
 Measures. — Several longitudinal incisions are made through the 
 mucous membrane, and two or three days later the entire cervical 
 mucous membrane is scraped out with a sharp spoon. Pack a lit- 
 tle iodoform gauze into the cervix, and introduce a vaginal tampon. 
 This cures all cases except those with extensive cystic degenera- 
 tion, and is more desirable than the use of caustics, which is often 
 followed by cicatricial stenosis. It can be done in the office or 
 dispensary. (Of course the after-treatment consists in alterative 
 applications to prevent excessive growth of the mucous membrane.) 
 
LACERATION OF THE CERVIX. 
 
 139 
 
 6. For an Extensive Laceration. — Emmet's operation. 
 
 7. For Great Cystic Degeneration. — Schroeder's operation. By 
 this method cases can be cured which are otherwise incurable. 
 
 Fig. 64. 
 
 Schroeder's Operation. 
 
 Its only disadvantage is that it leaves the cervix shorter than 
 normal. 
 
 LACERATION OF THE CERVIX. 
 What is its occurrence? 
 
 It constitutes 32.8 per cent, of all gynecological cases. Perhaps 
 some laceration always occurs during parturition, but in most cases 
 it is slight, is not recognized at the time, and heals readily. It 
 occurs in all stations of life, but in instrumental cases it is more 
 frequent among the poor. 
 
 What are its causes? 
 
 (1) Labor. — Tedious, most frequent ; precipitate ; instrumental ; 
 manual delivery ; rigid os and premature rupture of membranes ; 
 cicatricial or malignant tissue in cervix : incision of cervix for fail- 
 ure to dilate. 
 
 (2) Abortion. — Criminal. 
 
 What are its varieties ? 
 
 Complete, partial, unilateral, bilateral, stellate. 
 A partial laceration extends only through the mucous and sub- 
 mucous layers, and leaves the vaginal surface intact. 
 
140 
 
 DISEASES OF THE UTERUS. 
 
 What is its site ? 
 
 Most frequently through the anterior lip a little to the left, due 
 to pressure by the occiput in the first position. 
 
 Next in frequency, double, anterior lip to the left and posterior 
 lip to the right ; bilateral ; stellate ; unilateral, more often to 
 the left. 
 
 (1) Laceration of the anterior lip usually heals readily, because, 
 as a rule, it does not extend into the pelvic connective tissue. If 
 it does so, we may have vesico-cervical fistula. 
 
 (2) Laceration of the posterior lip as a rule heals readily, but 
 it may extend into the connective tissue and produce cellulitis in 
 one of the utero-sacral ligaments, resulting in contraction of the 
 ligament and displacement of the uterus. 
 
 (3) Bilateral laceration constitutes the great bulk of the cases 
 requiring treatment. It is very apt to extend into the connective 
 
 Fig. 65. 
 
 Multiple or Stellate Laceration of the Cervix (Kmmet). 
 
 tissue of the broad ligaments, and we have cellulitis, interference 
 with the circulation, causing ectropion, or, starting from the bottom 
 of the tear, erosions of the cervix, subinvolution, and prolapse (es- 
 pecially if the perineum is lacerated), and retroversion, catarrh, 
 cystic degeneration, and a cicatricial plug are produced. The latter 
 
LACERATION OF THE CERVIX. 
 
 141 
 
 is a dense mass of cicatricial tissue formed at the deepest angle 
 of the laceration by an incomplete attempt at healing by granula- 
 tion. This tissue must be removed in any operation for repairing 
 the laceration. 
 
 (4) Stellate laceration is usually superficial, and produces, as a 
 rule, none of the special symptoms of laceration. There is no 
 sterility, but, on the contrary, often unusual fecundity. 
 
 (5) Unilateral laceration does not produce the characteristic 
 symptoms. The whole uterus is bent toward the injured side (con- 
 traction of ligaments consequent upon cellulitis) ; the anterior for- 
 
 FiG. 66. 
 
 Double Tenaculum separating the Flaps of a [Unilateral] Laceration (Emmet) 
 
 nix is as deep as the posterior. The uterine cavity may be appar- 
 ently of the normal length. 
 
 (6) Partial laceration is about half a dozen longitudinal fissures 
 through the mucous and submucous layers of the wall of the cer- 
 vical canal. This sets up catarrh, and the cervix is somewhat en- 
 larged, but its walls are thinner than normal. (This condition 
 must be distinguished from the ridges and grooves produced by 
 chronic cervical catarrh with coxcomb granulations.) 
 
 What are the symptoms of laceration of the cervix ? 
 
 (1) Pain, lumbar and sacral ; a dragging pain in the groins, and 
 a bearing-down pain. All are increased by any efifort, such as 
 standing or walking. 
 
 (2) Vesical Irritability^ very frequent micturition. 
 
142 DISEASES OF THE UTERUS. 
 
 (3) Dyspareunia, and sometimes hemorrhage after intercourse. 
 
 (4) Leucorrhcea, profuse and constant. 
 
 (5) Menstruation is at first simply profuse ; later it is irregular 
 as to time, and usually profuse, but may be scanty. 
 
 (6) Sterility. Later symptoms : 
 
 (7) Anaemia and headaches (occipital and at the nape of the 
 neck). 
 
 (8) Neuralgiae, insomnia, change of temperament, melancholia. 
 
 What are the physical signs? 
 
 Digital examination is unreliable. Bivalve speculum and a 
 tenaculum in each lip give ocular demonstration of the laceration. 
 (It is sometimes impossible for a number of weeks after labor to 
 determine whether there is a laceration of the cervix.) 
 
 What are the complications? 
 
 (1) Chronic pelvic cellulitis ; (2) chronic endometritis (com- 
 monly fungoid) ; (3) chronic cervical catarrh, with erosions and 
 cystic degeneration of the cervix, and sterility ; (4) hypertrophy 
 of the cervix or of the entire uterus ; subinvolution ; chronic 
 metritis ; (5) displacements of the uterus ; (G) tendency to abor- 
 tion. 
 
 What is the prognosis? 
 
 If untreated, a recent laceration may exceptionally cicatrize and 
 the symptoms disappear ; but, as a rule, the patients are invalids 
 until radical treatment is resorted to. Cases operated upon, as a 
 rule, are cured of all symptoms. 
 
 What is the treatment? 
 
 (1) General; (2) preparatory ; (3) operative. 
 
 (1) General Treatment. — a, Remove pressure from above (skirts, 
 corsets, etc.) ; 5, a pessary is often indicated ; c, tonics. 
 
 (2) Preparatory Treatment. — To lessen local congestion and to 
 cure catarrh, erosions, and cysts — «, emollient vaginal douches ; 
 />, scarification (once or twice weekly) ; c, puncture of cysts and 
 touching their cavity with nitric or chromic acid ; cZ, erasion of 
 mucous membrane and alterative applications ; in mild cases Church- 
 ill's tincture without the curetting ; e, glycerin tampons ; /, if the 
 flaps are very large and very far apart, a single silver suture may 
 be introduced one or two weeks before the operation. 
 
 (3) Operative Treatment. — The results of operations performed 
 immediately after labor are very unsatisfactory. If profuse hemor- 
 
LACERATION OF THE CERVIX. 
 
 143 
 
 rhage occur from a laceration, it may be controlled by one or two 
 silver sutures, but a formal operation had better not be attempted 
 for a number of months. 
 
 Describe Emmet's operation for trachelorrhaphy. 
 
 It is the best operation for the repair of a laceration of the 
 cervix, and depends for its success upon asepsis and perfect apposi- 
 
 FiG. 68. 
 
 Insertion of Sutures 
 
 Sutures in Place. 
 
 tion of denuded surfaces, so that no point of granulation is left. 
 It is usually, but not necessarily, done under anaesthesia. The 
 bladder and rectum should be empty and the vagina disinfected. 
 Three assistants are necessary, and the operation should never be 
 done when there is cellulitis, as indicated by tenderness. 
 
 The patient is in Sims's position, and the uterus is drawn down 
 by two silk sutures, one passed through each lip of the cervix. 
 In denuding the flaps begin at the lower part of the lower right- 
 hand flap, and cut parallel with its surface up to the angle. Then 
 the upper right-hand flap is similarly pared. If a nodular mass 
 (" cicatricial "plug ") can now be felt at the angle, it must be 
 excised. 
 
144 
 
 DISEASES OF THE UTERUS. 
 Fig. 69. 
 
 Position of Patient in Emmet's Trachelorrhaphy. 
 
 The left-hand flap is similarly treated. (Gynecologists use scis- 
 sors, Emmet's curved, but it can be done with a scalpel.) Hemor- 
 rhage is controlled by pressure or by hot antiseptic irrigation. 
 
 In suturing^ Emmet's short cervical needle, threaded with a loop 
 
 Fig. 70. 
 
 Area of Denudation in Trachelorrhaphy. 
 
LACERATION OF THE CERVIX. 
 
 145 
 
 of silk to carry a silver suture eight or ten inches long, is used. 
 Three or four sutures are introduced at each side, beginning close 
 
 Fig. 71. 
 
 Lacerated Cervix after Denudation. 
 
 to the angle, and they are tightened in the same order by means 
 of a wire-twister and shield. The ends are bent flat against the 
 cervix, and the vagina is lightly tamponed. 
 
 The patient is kept in bed two weeks (urination and defecation 
 
 10— Gyn. 
 
 Fig. 72. 
 
 Schultze's Dilator. 
 
146 NEOPLASMS OF THE UTERUS. 
 
 in the recumbent position). Antiseptic vaginal douches every two 
 or three days. The sutures are removed on the ninth day, and in 
 the order in which they were introduced. 
 
 NEOPLASMS OF THE UTERUS. 
 
 Describe their occurrence. 
 
 They are more frequent and more varied than in any other organ. 
 This is due to the complexity of its structure. Congenital tumors 
 of the uterus are almost unknown. It is doubtful also whether 
 uterine tumors ever occur before puberty. 
 
 What is the classification ? 
 
 I. Tumors arising from the parenchyma (i. e. muscular or con- 
 nective tissue) of the uterus : fibromyoma (benign) ; sarcoma (ma- 
 lignant). 
 
 II. Tumors arising from the mucous membrane : mucous polypi 
 (benign); carcinoma (malignant) ; adenoma (doubtful). 
 
 FIBROID TUMORS, OR FIBROMYOMATA. 
 
 Describe their occurrence. 
 
 They are the most common of uterine tumors. Half of all 
 women over fifty have been said to have them, but this is an 
 exaggeration (Tuttle). 
 
 What is the etiology? 
 
 Race. — African (nearly all who have any uterine trouble have 
 them). 
 
 Age. — Thirty to forty (never before puberty, and never originate 
 after the menopause). 
 
 (The influence of marriage and parturition is unknown. Sterility 
 is a result, not a cause.) 
 
 What is the pathology ? 
 
 They all consist of hypertrophic muscular fibres and of connec- 
 tive tissue, and hence are all called fibromyomata. In the great 
 majority of cases the connective tissue is so much in excess that 
 the tumor may be considered a fibroma. 
 
 Fibroma feels and cuts hard. The cut surface is white, and 
 presents even to the naked eye bundles of connective tissue ar- 
 ranged about various centres. There is a distinct capsule of loose, 
 highly vascular connective tissue. As to site, it is most frequent 
 
NEOPLASMS OF THE UTERUS. 147 
 
 in the body of the uterus (in its posterior or anterior wall, rarely 
 at the sides). 
 
 Myoma is soft, red, and succulent ; it consists chiefly of muscu- 
 lar fibres, and may be considered a local hypertrophy of the uterine 
 wall. Microscopically the muscular fibres are seen to be enor- 
 mously hypertrophied, as in the pregnant uterus. It is most com- 
 monly found near the fundus. 
 
 What are the varieties? 
 
 (1) Subserous or subperitoneal ; (2) interstitial (intramural, in- 
 traparietal) ; (3) submucous. 
 
 SUBSEROUS FIBROIDS. 
 
 These begin in the muscular wall near the outer surface, and 
 grow in the direction of least resistance. The most common site 
 
 Fig. 73. 
 
 Subserous Fibroid of Uterus. 
 
 is the posterior wall, less common the anterior wall. They are 
 usually multiple, but the others are apt to be interstitial or submu- 
 cous. They may be simple or compound, and may have a long, 
 narrow or a short, broad pedicle. A large fibroid with a thick 
 pedicle may draw the uterus up, and even stretch it. They most 
 often grow into Douglas's pouch and drag the uterus back. A 
 fibroid, especially one with a long pedicle, may become incarcerated 
 in Douglas's pouch. Adhesions may be excited by the movements 
 of the tumor, and the tumor become attached to the bladder, rec- 
 tum, or abdominal wall. The pedicle in some cases is so stretched 
 as to give way, and the fibroid become an independent tumor. If 
 
148 
 
 FIBROIDS OF THE UTERUS. 
 
 the vascular supply from the adhesions is sufficiently free, we may 
 find the tumor increasing in size in its new situation. 
 
 INTERSTITIAL FIBROIDS. 
 
 These begin deeply in the muscular wall, and develop equally in 
 all directions until finally a bulging of both external and internal 
 
 Fig. 74. 
 
 Interstitial Fibroid. 
 
 surfaces is produced. The tumor is surrounded by normal uterine 
 tissue ; it is usually multiple, may be simple or compound, most 
 common near the fundus, and consists principally of muscular 
 fibres. 
 
 SUBMUCOUS FIBROIDS. 
 
 Beginning in the layer of muscular tissue immediately beneath 
 the mucous membrane and protruding into the uterine cavity, these 
 have usually a broad, thick pedicle, but may have a long, thin pedi- 
 cle, in which case they are called fibrous polypi. 
 
 What are the complications of fibroid tumors ? 
 
 A. Changes in structure of the uterus: (1) The whole uterus 
 
NEOPLASMS OF THE UTERUS. 
 
 149 
 
 may be hypertropliied, its walls thickened, and its cavity increased 
 in size and length. (This is often the case with submucous and 
 interstitial fibroids.) (2) Chronic endometritis, with thickening 
 
 Fig. 75. 
 
 Submucous Fibroid. 
 
 of the mucous membrane and increase in the glands, except over 
 the tumor, where the membrane is atrophic. 
 
 B. Changes in the position of the uterus : (1) Ascent — the ute- 
 rus may be stretched until it measures six or eight inches. (2) 
 Prolapse. (3) Inversion (can occur only with a submucous polypus 
 with a short pedicle). (4) Retroflexion or anteflexion. (5) Incar- 
 ceration of the uterus (by a tumor in Douglas's cul-de-sac, fixed by 
 adhesions and continuing to increase in size). 
 
 C. Degeneration in the tumor. (1) Softening. (2) Induration 
 (as a rule, after the climacteric). (3) Calcification (occurs about 
 the climacteric). (4) Suppuration and gangrene (usually the result 
 
150 
 
 FIBROIDS OF THE UTERUS. 
 
 of violence in examination or treatment). (5) Sarcomatous degene- 
 ration is well proven to occur. (G) Carcinomatous degeneration 
 probably never occurs. 
 
 What are the special features of fibroids of the cervix ? 
 
 Subperitoneal Fibroids are the most important. They start be- 
 
 FiG. 76. 
 
 Fibroid Incarcerated in the Pelvis. 
 
 hind and to one side, and grow either (1) out behind the layers 
 of the broad ligament, tending to fill up the pelvis ; or (2) down- 
 
NEOPLASMS OF THE UTERUS. 151 
 
 ward into the connective tissue alongside the vagina. Pathology. — 
 Almost exclusively connective tissue. They have a short, broad 
 pedicle, and are rather fixed. Dangers. — They cannot rise out of 
 the pelvis, and as they grow they become incarcerated and press 
 upon nerve and other structures. It is sometimes impossible to 
 remove them. 
 
 Submucous and Interstitial Fibroids give rise to distortion of the 
 cervix, and are rather difficult to diagnose. 
 
 What are the symptoms of fibroid tumors ? 
 I. Hemorrhage ; 
 II. Pain; 
 III. Sterility. 
 
 I. Hemorrhage. — At first there is menorrhagia, the duration of 
 the menstrual flow increasing until it lasts three weeks out of 
 every four. There is no sudden flooding, but an insidious loss of 
 blood. The blood comes not from the tumor, nor from the thin 
 atrophic mucous membrane over it, but from the rest of the mucous 
 membrane. Later, there is added metrorrhagia. The mucous 
 membrane over the tumor becomes ulcerated, and the vascular 
 capsule of the tumor is exposed. From this there is irregular 
 hemorrhage excited by any muscular efi"ort or misstep, etc. There 
 is always hemorrhage in the submucous, often in the interstitial, 
 but not so commonly in the subserous, varieties. 
 
 II. Pain. — In submucous fibroids it is worst at menstruation 
 from engorgement of the tumor, which also acts as a foreign body 
 and produces the colicky pains of obstructive dysmenorrhoea. 
 
 In interstitial fibroids there may be colicky pain, but more often 
 it is a tearing or stretching pain during menstruation, from the 
 pressure of the engorged tumor upon the nerves of the uterus. 
 
 In subserous fibroids there is a sensation of dragging and 
 weight, especially during menstruation. There are also attacks 
 of peritonitic pain (with fever and tenderness, indicating local 
 peritonitis). 
 
 III. Sterility may be the mechanical efi^ect of a large tumor, or 
 it may be due to the complication, chronic endometritis. 
 
 There may be Symptoms due to Pressure. 
 
 On the Urethra. — Partial or complete retention of urine. 
 On the Bladder. — Vesical irritability ; sometimes residual urine 
 and cystitis. 
 
152 FIBROIDS OF THE UTERUS. 
 
 On the Ureters. — Partial obstruction or hydronephrosis and 
 death. 
 
 On the Rectum. — Constipation or faecal obstruction. 
 
 On Nerves. — Sciatica, numbness of the limbs, pain in the joints. 
 
 On Vessels. — Haemorrhoids, varicosities of labia and legs. 
 
 What secondary symptoms are sometimes present? 
 
 Abortion ; leucorrhoea (not a prominent symptom) ; ascites, rare 
 (if present it throws doubt upon the diagnosis) ; symptoms of early 
 pregnancy. 
 
 What are the physical signs of small fibroid tumors ? 
 
 (1) In the case of a small fibroid of the cervix (which would 
 have to be difierentiated from inversion of the uterus) find the os 
 externum, pass a sound, and by bimanual examination (under 
 anaesthesia if necessary) determine the presence of the fundus of 
 the uterus in its normal place. 
 
 (2) With a small pedunculated submucous fibroid dilate the 
 cervix and introduce the finger. 
 
 (3) With a submucous fibroid with a broad base and high up in 
 the fundus, bimanual examination shows the uterus to be enlarged. 
 The sound may pass farther than the normal. Pass a finger into 
 the anterior fornix, and judge of the amount of tissue between the 
 finger and the sound, and also whether there is any localized hard- 
 ness. The posterior wall of the uterus is examined in the same 
 way. 
 
 What is the differential diagnosis of small fibroid tumors ? 
 
 (1) Chronic metritis ; (2) early pregnancy ; (3) anteflexion ; 
 (4) retroflexion ; (5) inversion (which see). 
 
 (1) Chronic metritis is characterized by uniform enlargement of 
 the uterus, absence of a hard lump, sensitiveness. 
 
 (2) Early pregnancy : With fibroids the uterus is enlarged, but 
 hard. In early pregnancy the uterus is enlarged, but soft and 
 elastic, the os is velvety, and menstruation is arrested. (In case 
 of doubt wait a month and note changes.) 
 
 (3) and (4) Flexions : A sound with the necessary curve and 
 a finger in the fornix of the vagina show that the uterine wall is 
 of normal thickness throughout. (In the case of a fibroid the 
 uterine canal is straight, and there is a localized thickening and 
 induration of the uterine wall.) 
 
NEOPLASMS OF THE UTERUS. 153 
 
 What are the physical signs of large fibroid tumors ? 
 
 (1) Palpation. — a, Outline distinct, consistence hard ; 6, relation 
 to uterus. An assistant pulls down the uterus with the volsella ; 
 you feel the tumor through the abdominal wall ; c, position usually 
 near median line. 
 
 (2) Percussion. — Usually flat, but may be dull-tympanitic if 
 covered by intestines. 
 
 (3) Auscultation. — A souffle may be heard, most often over the 
 sides, but sometimes over the entire surface of the tumor. It is 
 only present when large vessels enter the tumor. 
 
 (4) Vaginal Touch. — (a) The cervix is hard ; (6) the cervix is 
 drawn up. 
 
 (5) Bimanual Examination. — Grives the impression of a mass 
 belonging to the uterus. 
 
 (6) Sound. — Never use it unless you have excluded pregnancy, 
 and remember that pregnancy and fibroids may coexist, (a) The 
 uterine cavity is increased in length. This is most marked with 
 submucous fibroids, where it may be over four inches long. 
 (6) The uterine cavity may be tortuous and require several at- 
 tempts before the sound is passed quite to the fundus. 
 
 What is the differential diagnosis of large fibroid tumors ? 
 
 (1) From late pregnancy; (2) ovarian tumor; (3) extra-uterine 
 pregnancy ; (4) haematocele and inflammatory exudation. 
 
 (1) From Late Pregnancy. — Symptoms common to each are — 
 1, abdominal enlargement ; 2, enlargement and pigmentation of the 
 breasts ; 3, violet coloration of the vaginal mucous membrane ; 
 4, uterine souffle ; 5, morning vomiting. 
 
 The symptoms peculiar to pregnancy are — 1, the foetal heart- 
 sounds ; 2, foetal movements ; 3, ballottement ; 4, rhythmic contrac- 
 tion of the uterus ; 5, softening of the cervix ; 6, arrest of men- 
 struation. 
 
 (2) From Ovarian Tumor. — 1, Ovarian tumors grow rapidly; 
 fibroids slowly ; 2, ovarian tumors begin at one side ; uterine 
 fibroids near the median line ; 3, on palpation an ovarian tumor 
 feels soft and doughy ; fibroids hard and well defined ; 4, with an 
 ovarian tumor the uterus lies low down in front of or behind the 
 tumor ; with fibroids the uterus is drawn up ; 5, an ovarian tumor 
 does not move with the uterus ; a fibroid does ; 6, with an ovarian 
 tumor neither the uterus nor its canal is enlarged ; both are with 
 fibroids ; 7, with an ovarian tumor there is often irreo;ular and 
 
154 FIBROIDS OF THE UTERUS. 
 
 painful menstruation, but not the menorrhagia and metrorrhagia 
 characteristic of fibroids. 
 
 (3) From Extra-uterine Pregnancy. — Common to both are — 1, 
 abdominal tumor ; 2, enlargement and pigmentation of the breast : 
 3, morning vomiting : 4, uterine souffle : 5, violet coloration of 
 vagina ; G, irregular and profuse menstruation ; 7, attacks of peri- 
 tonic pain. 
 
 Peculiar to extra-uterine pregnancy. — 1, rapid growth and lateral 
 position of the tumor ; 2, the uterus does not move with it ; 3, 
 shreds of membrane (characteristic under the microscope) are oc- 
 casionally cast out of the uterine cavity. 
 
 (4) From Hsematocele or Injiammatory Exudation. — The history 
 is characteristic : sudden onset with fever, pain, and tenderness, and 
 the tumor is at first soft and diffuse ; later it contracts and be- 
 comes hard, but always remains tender. 
 
 What is the course? 
 
 (1) As a rule, the growth is arrested at the menopause. It may 
 then become indurated or calcified, and sometimes reduced in size. 
 The cause is the diminution in vascularity. (2) The same change 
 may take place in younger women in whom from any cause the 
 sexual functions cease. 
 
 How may spontaneous cure occur in fibroids? 
 
 (1) Expulsion by uterine contractions ; (2) rupture of pedicle (if 
 submucous or subserous) ; (3) spontaneous enucleation (the capsule 
 ulcerates through, and the tumor is drawn out by uterine contrac- 
 tions) ; (4) suppuration and gangrene of the tumor itself, and dis- 
 charge piecemeal (commonly by the vagina, rarely by rectum or blad- 
 der) : this is very often associated with fatal septic intoxication. 
 
 What are the causes of death ? 
 
 Hemorrhage, rarely ; exhaustion from long-continued drain ; 
 peritonitis, rarely ; septic peritonitis ; rarely pressure on ureters, etc. 
 
 What is the prognosis? 
 
 Good. Recurrence never takes place ; they are benign. 
 
 Describe the treatment. 
 
 It may be general, or local by electrolysis, surgical removal, re- 
 moval of uterine appendages. 
 
 Describe the general treatment. 
 
 Give tonics and prevent incarceration. Keep the tumor out of 
 
NEOPLASMS OF THE UTERUS. 155 
 
 the pelvis, and if large apply an abdominal bandage to support it. 
 Bromide of potash probably has no effect, and the same is true of 
 iodide of potash, the salts of zinc, and arsenic and phosphorus 
 (Tuttle). All of the above have been recommended at different 
 times. Ergot acts in two ways : it causes contraction of the arte- 
 rioles themselves, and causes contraction of the uterine muscular 
 fibres, further narrowing the vessels and tending to expel the tumor. 
 For administration Squibbs' ergotin is given hypodermically. 
 Ten minims of the following formula may be deeply injected in 
 the abdominal wall, the thigh, or the buttock : 
 
 K{. Ergotin (Squibbs'), ^ij ; 
 
 Chloral hydrate, ^ss ; 
 
 Aquae, q. s. ad gj. — M, 
 
 The effect is visible after fifty or one hundred injections, and the 
 best cases are interstitial fibroids, which may be positively cured. 
 It is useless in submucous or subserous fibroids. 
 
 Describe the local treatment by electrolysis. 
 
 This method of treatment was proposed by Apostoli of Paris, 
 but has not yet been generally adopted. The best battery is one 
 in which the elements are about thirty plates of copper and zinc, 
 6 by 9 inches, in a solution of chromate of potash. Insulated con- 
 ducting wires and silver intra-uterine probes, with a groove to en- 
 sure' the patency of the os, and a broad sponge electrode for the 
 surface of the abdomen, are the apparatus required. No anaes- 
 thetic is needed. The current of 50 to 150 milliamperes should be 
 allowed to flow for three to fifteen minutes, according to symptoms. 
 Galvano-puncture if the tumor is felt in Douglas' pouch. The 
 after-treatment is rest in bed and morphine if required. The re- 
 sults claimed for it are — 50 per cent, arrested ; 40 per cent, 
 benefited ; 8 per cent, not benefited ; 2 per cent, deaths. 
 
 The dangers of this method of treatment are — puncturing the 
 intestines ; exciting suppuration and gangrene in the tumor, with 
 the risk of septic peritonitis, etc. ; hemorrhage and collapse. 
 
 Describe the local treatment by surgical removal. 
 
 I. Removal hy the Vagina (submucous or interstitial fibroids). — 
 (1) Dilate the cervix (after making two superficial lateral incisions) 
 until it is large enough to permit the extrusion of the tumor. (2) 
 Make a crucial incision 1 inch long and \ inch deep over the most 
 
156 FIBROIDS OF THE UTERUS. 
 
 dependent portion of the tumor. (3) Give ergot systematically, 
 and finally, as a rule, the tumor will be expelled spontaneously. 
 (-4) If necessary enucleate the tumor at once with a spoon-saw 
 and volsella, finally cutting the pedicle with the scissors. The ope- 
 ration should be done under ether and all antiseptic precautions 
 observed. 
 
 II. Removal hy Ahdominal Section. — The mortality is very great 
 all over the world (50 per cent., which is very much greater than 
 that of ovariotomy), but in the hands of some operators it is small 
 (8 per cent.). 
 
 Mteps of the Operation. — (1) Anaesthesia and usual antisepsis; 
 incision four or five inches long in the median line. (2) Bringing 
 the tumor out through the incision. (3) Treatment of the stump : 
 (a) intraperitoneal method; (h) extraperitoneal method. 
 
 (a) Intraperitoneal Method. — This is applicable, first, to tumors 
 with small pedicles, which are simply ligated, dropped back into 
 the abdominal cavity, and the abdominal wound accurately sutured 
 throughout. (The results are very good indeed, but these are 
 tumors which do not ordinarily require operation. Indications for 
 operating upon such a tumor would be — 1, hemorrhage uncontroll- 
 able in any other way, and where we cannot remove the appen- 
 dages ; 2, continuance of growth in the tumor after the meno- 
 pause ; 3, extreme size of tumor rendering life a burden ; 4, rarely 
 recurrent ascites.) 
 
 The intraperitoneal method is applicable, second, to tumors with 
 short, broad bases, and is as follows : An elastic ligature is passed 
 around the uterus at the level of the os internum ; the tumor is 
 removed by a V-shaped incision into the substance of the uterus ; 
 this incision is closed by muscular and j^eritoneal sutures (none 
 passing through the mucous membrane) ; the uterus is dropped back 
 into the pelvis, and the abdominal wound accurately closed. (The 
 dangers of this method are — 1, hemorrhage; 2, peritonitis; 3, sep- 
 tic infection from opening the intra-uterine canal. If this has been 
 opened, it must be accurately closed by suture, first of the mucous 
 membrane, then of the muscular wall, and then of the peritoneum.) 
 The results are less satisfactory than those of the extraperitoneal 
 method. 
 
 Schroeder^ s Modification of the Intraperitoneal Method consists 
 in passing a double ligature through the cervix, tying off the ap- 
 pendages, cutting away the uterus, and suturing the peritoneum 
 over the stump. The stump is left free in the peritoneal cavity. 
 
NEOPLASMS OF THE UTERUS. 157 
 
 The abdominal wound is sutured. The vagina and uterine canal 
 are disinfected before operation, and drainage is provided after ope- 
 ration by a strip of iodoform gauze passing into the uterine canal 
 from the vagina. 
 
 (^h) Extraperitoneal MethoJs. — 1 , Ligation and transfixion ; 2, 
 clamp and cautery (Thomas) ; 3, serre-noeud ; 4, elastic ligature. 
 
 1. Ligation and Transfixion. — Pedicle is ligated ; two skewers 
 are passed through it and brought out on the abdominal surface. 
 The tumor is cut oiF beyond the ligature. The abdominal wound is 
 closed above and below the pedicle. Antiseptic dressing changed 
 frequently. 
 
 2. Clamp ajid Cautery (Thomas). — Clamp applied and screwed 
 down. Two skewers passed through the pedicle as above. Tumor 
 cut away. Stump thoroughly cauterized. Clamp loosened, but left 
 in place. Suture of wound above and below. Antiseptic dressing. 
 
 3. Serre-Nrmid. — The pedicle is transfixed by a double wire liga- 
 ture. Each loop is twisted tight in a " serre-noeud." The pedicle 
 is cauterized and secured in the wound. Sutures and antiseptic 
 dressing, 
 
 4. Elastic Ligature (Hegar's). — Elastic ligature, 5 mm. in diame- 
 ter. Cauterization of the stump (a strong solution of chloride of 
 zinc may be used). Closure of peritoneum around the stump 
 separately. Suture and antiseptic dressing. 
 
 Describe the local treatment of large subserous fibroids by re- 
 moval of uterine appendages. 
 
 Tait's Operation. — Removal of ovaries and tubes may be per- 
 formed to check the growth of a large fibroid. 
 
 Battey's Operation. — Removal of the ovaries alone. This does 
 not have the desired effect. 
 
 FIBRO-CYSTIC TUMOR OF THE UTERUS. 
 What is the pathology? 
 
 It is originally a fibroid which undergoes softening, and in which 
 spaces have formed and become filled with serous fluid. Sometimes 
 these spaces have an endothelial lining, and in a few cases the con- 
 tents become gelatinous and fibro-myxoma is produced. 
 
 What are the symptoms? 
 
 Rapid growth ; not much menstrual disturbance ; tumor feels 
 soft in some places ; hard in others, and moves with the uterus. 
 
158 POLYPUS OF THE UTERUS. 
 
 What is the differential diagnosis? 
 
 From ovarian cyst it is made ])y the presence of the fibrous 
 hardness of portions of the tumor and by its relation to the uterus. 
 
 What is the treatment ? 
 The same as for fibroids. 
 
 UTERINE POLYPUS. 
 
 What are the two kinds? 
 
 Fibrous polypus ; mucous polypus. 
 
 Fihrous Polypus. — This is a pedunculated submucous fibroid. 
 
 Mucous Polypus. — This is a pedunculated tumor attached to the 
 mucous membrane (most commonly of the body) of the uterus. 
 The tumors are usually multiple, and vary in size from that of a 
 pea to that of a lima bean. They are soft and pulpy, and are not 
 round or pyriform, but flattened. They are very vascular. 
 
 What is the pathology of mucous polypi ? 
 
 The glands are the same as in the normal mucous membrane ; 
 there is a large amount of connective tissue, and immense vascular 
 supply. Other polypi are formed from retention cysts, occluded 
 cervical glands which have become pedunculated, and from bits of 
 retained placenta or from placentae succenturiatae (placental polypi). 
 
 V/hat are the symptoms of uterine polypi ? 
 
 (1) Hemorrhage ; (2) discharge ; (3) pain ; (4) sterility ; (5) 
 symptoms due to pressure and weight. 
 
 (1) Hemorrhage. — Tn fibrous polypus hemorrhage is from the 
 mucous membrane of the body of the uterus, and, as a rule, is 
 checked when the polypus is pushed into the vagina by uterine 
 contraction. Sometimes the capsule ulcerates, and there is irregular 
 hemorrhage from the tumor itself. In mucous polypus the hemor- 
 rhage is from the tumor itself, and one no larger than a finger-tip 
 may cause death. In polypi formed from retention cysts there is 
 no special hemorrhage. 
 
 In placental polypus hemorrhage is from the tumor itself, and 
 irregular and profuse. 
 
 (2) Discharge. — With fibrous polypus there is little discharge 
 until the tumor enters the cervix or vagina, when leucorrhoca is 
 excited. With the different varieties of mucous polypi leucorrhoea 
 is a regular symptom. 
 
 (8) Pain. — Dysmenorrha\a is always present with fibrous and 
 
NEOPLASMS OF THE UTERUS. 
 
 159 
 
 placental polypi as long as they remain in the uterine cavity, and 
 especially when they are near the os internum. With mucous 
 polypi and those from retention cysts there is usually no pain 
 unless they produce obstructive dysmenorrhcca. 
 
 (4) Sterility. — The polypus may act as a mechanical obstacle to 
 the entrance of spermatozoa or to the entrance of the ovum from 
 the tube. 
 
 (5) Pressure. — If the polypus is very large, there may be vesical 
 and rectal symptoms. 
 
 In rare cases there are present the symptoms of early preg- 
 nancy — morning sickness, enlargement and pigmentation of the 
 breasts, etc. 
 
 What are the physical signs of uterine polypi ? 
 
 Digital Examination. — Fibrous polypus is larger than a walnut, 
 firm, and its attachment is high up ; mucous polypus is small, 
 slippery, and its pedicle may be caught in the cervix. 
 
 Fro. 77. 
 
 Fig. 78. 
 
 Polypus. 
 
 Complete Inversion. 
 
 Bimanual. — In fibrous polypus the uterus is enlarged ; in mucous 
 polypus it is not. 
 
160 POLYPUS OF THE UTERUS. 
 
 Sound. — In fibrous polypus the uterine cavity is lengthened ; 
 in mucous polypus the uterine cavity is not lengthened. 
 
 Speculum. — Fibrous polypus, pale or perhaps ulcerated ; mucous 
 polypus, bright red and either smooth or like a raspberry, 
 
 (When the os is closed, to determine the cause of the hemor- 
 rhage : it is pretty certainly a fibroid polypus if the uterus is 
 enlarged and its cavity lengthened. But if the uterus is not 
 enlarged, then it is necessary, to complete the diagnosis, to dilate 
 the OS and introduce the finger or a cervical speculum.) 
 
 Placental polypi are diagnosed by microscopical examination 
 (club-shaped tufts). 
 
 What is the differential diagnosis of fibrous polypus from complete 
 inversion of the uterus ? 
 
 (1) Pass the finger into the vagina and see whether the mucous 
 membrane is everywhere reflected on to the tumor. If there is 
 an opening into which the sound may be passed, the tumor is a 
 polypus. 
 
 (2) By bimanual examination under anaesthesia the fundus of 
 the uterus is felt in the normal position ; similarly recto-abdominal 
 examination. 
 
 (3) Abdominal palpation is sufficient in a few cases. 
 
 What is the prognosis of uterine polypi ? 
 
 Good if removed. 
 
 What is the treatment of uterine polypi ? 
 
 Removed. — Angcsthesia should generally be employed ; antiseptic 
 precautions ; the cervix is thoroughly dilated. A small mucous 
 polypus may be seized by serrated forceps and twisted off", or it 
 may be snipped off" with scissors. Pedunculated cysts are simply 
 snipped off". With a fibrous polypus, find where the pedicle is 
 attached, and if this is thin seize the tumor with forceps and twist 
 it off". If the pedicle is too thick, draw the tumor down gently 
 and cut through the pedicle with scissors. If hemorrhage is likely 
 to be excessive, the pedicle m;iy be cut through with the 6craseur 
 or the galvano-cautery, or ligated previous to cutting. 
 
 Where you cannot get at the pedicle the tumor may be torn 
 away piecemeal, or it may be removed by Thomas's method : seize 
 the tumor at its lowest part and excise it by a V-shaped incision. 
 Hemorrhage may require the use of the cautery and packing the 
 uterine canal with iodoform gauze. 
 
NEOPLASMS OF THE UTERUS. 161 
 
 CARCINOMA OF THE UTERUS. 
 
 As 98 per cent, of all cases are of the cervix, it is necessary to 
 describe in detail only 
 
 Oarcinoma of the Oervix. 
 
 What is its etiology? 
 
 Predisposing Causes. — Race : Irish and German, Americans less 
 frequently, and negroes rarely ; sexual excesses; multiparae (usually 
 have had about five children). Age : forty to fifty most common ; 
 thirty to sixty are the usual limits ; heredity is not marked. Bad 
 hygiene : it is much more common in the poor. 
 
 Exciting Causes. — Laceration of the cervix ; chronic cervical 
 catarrh with erosions. 
 
 What is its pathology? 
 
 The tumor consists of connective tissue enclosing alveoli which 
 are filled by atypically arranged epithelial cells. When the con- 
 nective tissue is greatly in excess, the tumor is said to be scirrhous, 
 fibrous, or " hard " cancer. When the cells are greatly in excess, 
 the tumor is a medullary, encephaloid, acute, or '- soft " cancer. 
 
 What are the clinical varieties? 
 
 (1) Squamous epithelioma or cancroid is the most common form. 
 It begins on the vaginal aspect of the cervix (where the epithelium 
 is squamous) and spreads to the vaginal wall, but not to the cervical 
 canal until quite late. The cellular elements are abundant, and 
 often produce large " cauliflower masses." It may involve one or 
 both lips of the cervix. Its growth is rapid, the connective tissue 
 at the side of the cervix is soon infected, and finally carcinomatous 
 nodules appear in the substance of the cervix. 
 
 (2) This form begins as small cancerous nodules in the substance 
 of the cervix. These ulcerate their way through to the vaginal 
 aspect or to the cervical canal. The growth is up into the body 
 of the uterus and into the pelvic connective tissue. 
 
 (3) This form occurs rather later in life. It begins as an ulcera- 
 tion of the cervical endometrium, and extends up into the cavity 
 of the uterus, leaving the external os intact for a long time. 
 
 (In the later stage all these forms merge into each other.) 
 
 How does cancer spread? 
 
 1. By direct extension into adjacent tissues. 2. By infection 
 through the lymphatic system. 3. By infection through the 
 
 ll-Gyn. 
 
162 CARCINOMA OF THE UTERUS. 
 
 blood-vessels (rare, but very rapid). 4. Rarely by auto-inoculation 
 from contact of the cancerous cervix with the vaginal wall. 
 
 1. Direct Extension. — To the vaginal walls ; to the body of the 
 uterus; to the pelvic connective tissue; to the peritoneum, pre- 
 ceded by local peritonitis with exudation ; to the ureters (they are 
 almost always affected in advanced cases, and finally hydronephrosis 
 is produced) ; to the bladder (the muscular coat is at first involved, 
 later the mucous membrane, which ulcerates and results in fistula) ; 
 to the rectum rarely. In extreme cases the entire pelvic contents 
 are glued together in an indistinguishable mass. 
 
 2 and 3. Secondary Infection. — To the inguinal, retroperitoneal, 
 and lumbar lymphatic glands ; ovary ; liver ; lungs ; mammary 
 glands, rarely. 
 
 What are the symptcms of carcinoma of the cervix ? 
 
 Hemorrhage, discharge, pain, cachexia. 
 
 Hemorrhage begins as a sudden flooding (not as profuse men- 
 struation) ; it comes from the vascular stroma of the tumor. It is 
 not very profuse, and is rarely fatal. It occurs after coitus or 
 after some muscular effort. 
 
 Discharge is not abundant until ulceration occurs. It can only 
 be characterized as " concentrated rottenness." In the early stages 
 it is light-yellow and watery. Later it is mixed with more or less 
 blood, and may be a bright-red or a dirty chocolate color. 
 
 Pain. — There is not much until the disease extends beyond the 
 cervix ; then there is a dull, gnawing, deep-seated pain. There 
 may be shooting pains. Abdominal pain (late stages from local 
 peritonitis), pain in the breasts, and neuralgiae also occur. 
 
 Cachexia. — There are anorexia, indigestion, emaciation, urinary 
 and rectal symptoms, intense vaginitis and vulvitis from contact 
 with the discharge. The skin is of a characteristic dull, dingy 
 color. 
 
 What are the physical signs? 
 
 1. Digital Examination. — Large epithelioma : the lip is inverted, 
 and a friable cauliflower mass is felt which bleeds readily ; cha- 
 racteristic odor. Small epithelioma : there is slight irregularity of 
 the surface, hemorrhage, and odor. Nodular carcinoma : the finger 
 recognizes a nodular growth in one lip of the cervix. Carcinoma 
 originating in the cervical canal : hemorrhage and offensive dis- 
 charge. 
 
NEOPLASMS OF THE UTERUS. 163 
 
 2. Bimanual and Rectal Examinations should be made to deter- 
 mine the extent of involvement of neighboring tissues. 
 
 3. Sj^eculum. — As a rule unnecessary. The growth is pale 
 yellow, with little white kernels, and has a sharply-defined border. 
 
 4. Sound. — Unnecessary. 
 
 What is the differential diagnosis? 
 
 (1) From simple hypertrophy of the cervix (in this the cervix 
 is hard, the woman young, and there is no cachexia) ; (2) from 
 papillary erosions (these may develop into carcinoma, and the micro- 
 scope must be used to make a difi'erential diagnosis) ; (3) from 
 sloughing fibroid ; (4) from sarcoma ; (5) from diphtheritic or 
 syphilitic ulceration. 
 
 What is the prognosis ? 
 
 Spontaneous cure probably never occurs. Duration of life is 
 from one to two years. The most rapid cases are those of enceph- 
 aloid carcinoma. 
 
 What is the treatment? 
 
 General. — Build up the general health, forbid coitus. 
 Local. — (1) Palliative. (2) Curative (surgical removal). 
 
 (1) Palliative Treatment. — For hemorrhage injections of cool 
 solutions of alum or tannin. Sometimes it is desirable to use the 
 sharp spoon. It is not desirable to tampon the vagina. 
 
 For the discharge^ if not offensive, astringent injections of alum 
 or tannin ; if offensive, add permanganate of potash or some other 
 deodorizer. 
 
 (2) Curative Treatment. — a, Removal by caustics ; 5, removal 
 by curette and cautery ; c, amputation of cervix ; c?, removal of 
 uterus entire. 
 
 a. Removal by Caustics : Nitric acid, bromine dissolved in 
 alcohol. (Cylindrical speculum, caustic applied on a cotton swab.) 
 Not a valuable or desirable method. 
 
 h. Removal by Curette and Cautery : Cut away the mass of the 
 disease with scissors, and then with Sims's sharp curette scrape 
 away all diseased tissue. The vagina is protected by a large 
 tubular speculum while the entire raw surface is touched with the 
 Paquelin cautery. A tampon of iodoform gauze is introduced, 
 and is to be chan";ed in two or three davs. 
 
164 CARCINOMA OF THE UTERUS. 
 
 c. Amputation of the Cervix : The different methods are — 
 
 1, circular amputation with the knife ; 2, circular amputation with 
 the ecraseur or galvano-cautery (both of these are undesirable 
 because followed by cicatricial stenosis) ; 3, Schroeder's amputation. 
 
 d. Removal of uterus entire : 1, Abdominal hysterectomy ; 
 
 2, vaginal hysterectomy. 
 
 Describe abdominal hysterectomy. 
 
 Ether and careful antisepsis. The patient lies upon her back on 
 a flat table or upon Trendelenberg's table (by which the pelvis is 
 raised about nine inches higher than the shoulders, thus causing 
 the intestines to gravitate toward the diaphragm, and giving better 
 access to the pelvic viscera). An incision is made in the linea 
 alba between the umbilicus and the pubes, and hemorrhage is 
 checked before the peritoneal cavity is entered. The broad liga- 
 ment on each side is tied off in sections and divided close to the 
 uterus ; care is taken to secure the uterine artery before it is 
 divided. The fornices of the vagina are cut through all around 
 and the uterus removed. The ureters must be avoided during the 
 operation. The vagina may be partially closed by sutures and 
 packing introduced. The abdominal wound may be sutured 
 throughout or a drainage-tube (to be removed in twenty-four to 
 forty-eight hours) may be inserted at its lower angle. An anti- 
 septic absorbent dressing is applied. 
 
 (This has been almost abandoned as an operation for carcinoma 
 of the uterus.) 
 
 Describe vaginal hysterectomy. 
 
 Ether and the usual antiseptic precautions. The patient is in 
 the lithotomy position, and the vagina opened by two blunt retrac- 
 tors. The cervix is seized by bullet forceps and brought down 
 close to the vulva. The posterior fornix of the vagina is cut 
 through with scissors or a scalpel. Clamps are applied at each 
 side of the uterus, and each broad ligament is ligated in sections. 
 The fundus of the uterus is seized with bullet forceps and drawn 
 down through the incision in the posterior fornix, and the organ is 
 then excised. (The removal may be done equally well by an 
 incision in the anterior fornix. The fundus of the vagina may be 
 partially closed by sutures and the vagina packed with iodoform 
 gauze. 
 
 (This is the best form of hysterectomy for carcinoma. It is con- 
 traindicated where the uterus is not freely movable and in cases in 
 
INVERSION OF THE UTERUS. 165 
 
 which extension of the disease to the pelvic connective tissue has 
 taken place.) 
 
 ADENOMA OF THE UTERUS. 
 
 Describe adenoma of the uterus. 
 
 It is a disease consisting in a hyperplasia of the glandular ele- 
 ments of the endometrium, forming a flattened friable mass at some 
 part of the uterine cavity. The syiin'ptoms produced are similar to 
 those of early carcinoma, hemorrhage being the most prominent. 
 Treatment is dilatation, thorough removal of growth with a spoon 
 saw, and touching the raw surface with fuming nitric acid. The 
 growth has a marked tendency to recur, and each recurrence should 
 be dealt with as above. The ultimate propiosis of cases under 
 treatment is good. There seems to be evidence that neglected 
 cases may become malignant from development of sarcomatous or 
 carcinomatous elements. The diagnosis is made by the microscope. 
 
 SARCOMA OF THE UTERUS. 
 Describe sarcoma of the uterus. 
 
 The tumor consists essentially of a mass of connective-tissue 
 cells ; either small round cells or spindle-shaped cells, not occu- 
 pying distinct alveoli, as do the cells in carcinoma. It begins 
 either as a growth having the gross appearance of a submucous 
 fibroid or as a duffuse infiltration of the uterus. The early symp- 
 toms are commonly those of a submucous fibroid. Later symptoms 
 are like those of carcinoma: the surface ulcerates; there are irreg- 
 ular hemorrhage, oiFensive discharge, and the escape of sloughy 
 shreds of the tumor. The diagnosis is made by the microscojDe. 
 The jjrognosis is bad : untreated it is fatal in two to five or six 
 years. It tends to recur if removed, but early hysterectomy ofi'ers 
 a better chance of non-recurrence than in the case of carcinoma. 
 Treatment is the same as for carcinoma. Hysterectomy is usually 
 indicated. Ergot has been employed, as for a submucous fibroid, to 
 expel the tumor by uterine contraction, but this is never more than 
 palliative. 
 
 INVERSION OP THE UTERUS. 
 
 What are its definition and occurrence? 
 
 It is a condition in which the uterus is either partially or com- 
 pletely turned inside out. 
 
166 
 
 INVERSION OF THE UTERUS. 
 
 Fig. 79. 
 
 In partial inversion some part of the uterine wall (commonly the 
 region of" one of the tubes) is inverted into 
 the uterine cavity ; this is marked on the 
 external surface of the uterus by a ring 
 encircling a deep depression, and on the 
 internal surface by a rounded mass exactly 
 similar to a submucous fibroid. 
 
 In comj)lete inversion the fundus is forced 
 through the external os, and the uterus lies 
 in the vagina or protrudes from the vulva as 
 a pyriform mass covered by endometrium. 
 
 There is good authority for the statement 
 that it can occur in the nulliparous uterus, 
 but this is very rare indeed. It occurs com- 
 monly in uteri relaxed by recent parturition, 
 and is commonly acute — i. e. of sudden production — although a 
 
 Coiuplete Inversion. 
 
 Fig. 80. 
 
 Fig. 81. 
 
 Polypus. 
 
 Partial Inversion. 
 
 chronic form is also described in which the inversion takes place 
 gradually. 
 
INVERSION OF THE UTERUS. 
 
 167 
 
 What is its etiology? 
 
 Predisposing Causes — Parturition ; distension of the uterus by 
 retained fluids ; distension of the uterus by tumors. 
 
 Exciting Causes. — Traction on the placenta ; traction by polypi 
 or tumors ; sudden delivery of child by traction ; muscular efforts 
 when relaxation exists. 
 
 What are its symptoms ? 
 
 On its first occurrence, shortly after labor, there are pain, faint- 
 ness, hemorrhage, and the presence of a large flabby mass (perhaps 
 with the' placenta attached to it) protruding from the vulva. 
 
 Cases which have existed for months or years present the follow- 
 ing : occasional or constant hemorrhage ; dragging pains in back 
 and loins ; difiiculty in locomotion ; difficulty in micturition and 
 defecation ; anaemia, etc. 
 
 What is the differential diagnosis? 
 
 It is based upon the physical signs : 
 
 Polypus. 
 
 Probe will usually pass beyond 
 it into the uterus. 
 
 Bimanual examination will re- 
 veal the body of the uterus 
 in situ. 
 
 Rectal examination gives the 
 same positive evidence. 
 
 Recto-vesical, the same. 
 
 Acupuncture is painless. 
 
 Submucous Fibroid. 
 
 Probe shows uterine cavity 
 lengthened. 
 
 Bimanual examination and Si- 
 mon's method (with hand in 
 rectum) show the body of the 
 uterus to have its normal ro- 
 tundity. 
 
 Gradual development. 
 
 Independent of parturition. 
 
 Acupuncture painless. 
 
 Complete Inversion. 
 Probe is arrested. 
 
 Bimanual examination reveals a 
 ring where the uterus should 
 be. 
 
 Rectal examination is negative. 
 
 Recto-vesical, negative. 
 Acupuncture is painful. 
 
 Partial Inversion. 
 Probe shows cavity diminished. 
 
 Bimanual and Simon's methods 
 both show a small circular de- 
 pression on the surface of the 
 uterus. 
 
 Sudden development. 
 Usually follows parturition. 
 Acupuncture painful. 
 
168 
 
 INVERSION OF THE UTERUS. 
 
 What is the prognosis ? 
 
 Inversion occurring after labor is a grave accident, and may be 
 followed by death from hemorrhage. If untreated, it will com- 
 
 FiG. 82. 
 
 Fig. 83. 
 
 Fibrous Polypus. 
 
 Partial Inversion. 
 
 monly persist permanently, though there are cases on record of 
 spontaneous recovery even years afterward. The mechanism by 
 which this takes place is obscure. The dangers in old cases are 
 connected chiefly with improper diagnosis and treatment. Thus, 
 it may be mistaken for a fibrous polypus, and an operation for this 
 supposed trouble may result in amputation of the uterus ; or in 
 efforts at replacement rupture of the vagina may be produced. 
 The lesion in itself presents in general the dangers of the worst 
 form of fibrous polypus. 
 
 What is the treatment? 
 
 Palliative : Control of hemorrhage by the use of astringent solu- 
 tions (alum, tannin, persulphate of iron, or acetate of lead). 
 
 Curative : Rejiosition ; as a last resort, amputation. 
 
 Gradual 
 reduction. 
 
 Methods hy Reposition. 
 
 r Elastic pressure by vaginal stems and cup or bulb. 
 \ Elastic pressure by vaginal water-bag combined with 
 (_ occasional taxis. 
 
INVERSION OF THE UTERUS. 169 
 
 p , , r Elastic pressure by vaginal water-bags alone. 
 
 T . ^ A stream of cold water directed tbroueli a tubular 
 reduction. ; i + • j 
 
 (_ speculum twice a day. 
 
 ViradeFs method. 
 Emmet's " 
 
 Farrier's " 
 
 Rapid re- ■ Noeggerath's " 
 duction. ' Courty's " 
 
 Thomas's " 
 White's " 
 
 ^Tate's 
 
 All these rapid methods of replacement require anaesthesia, and 
 should not be resorted to (under ordinary circumstances) until the 
 milder methods of gradual replacement have been fairly tried and 
 have failed. They all consist in pressure upon the fundus and 
 counter-pressure upon the cervical ring. For example, Courty's 
 method consists in passing the index and middle fingers up the 
 rectum and dipping them into the cervial ring while pressure is 
 made upon the fundus by the thumb and by the other hand. This 
 method is especially useful in effecting the re-inversion of the cervix. 
 Noeggerath's method consists in placing the index finger on one 
 horn, the thumb on the other, and so compressing as to invert one 
 or both cornua. It is highly effective, but only after re-inversion 
 of the cervix by Courty's or some similar method. Thomas's 
 method is the only one in which the abdomen is opened. Through 
 a suprapubic incision the cervical ring is dilated by an instrument 
 like a glove-stretcher while pressure is made upon the fundus from 
 below. 
 
 Amputation of the Uterus. 
 
 This operation is resorted to in cases in which all attempts at 
 reduction have failed, and in which the symptoms (chief of which 
 is hemorrhage) are sufficient to justify so grave a step. 
 
 Its dangers are — (1) If hernia of the abdominal or pelvic viscera 
 have taken place into the inverted sac ; (2) it frequently pro- 
 duces emansio-mensium with its sequelae ; (3) it produces sterility ; 
 (4) the mortality is very great : 33 per cent, of all recorded cases 
 were fatal. 
 
 Methods. 
 
 1. Elastic ligature, retightened on the second day, the uterus 
 
170 DISEASES OF THE OVAKIES. 
 
 coming away about the fourteenth day. (This is the safest 
 method.) 
 
 2. Knife or ^craseur. 
 
 3. Knife or ecraseur preceded by ligature. 
 
 DISEASES OF THE OVARIES. 
 
 ANATOMY OF THE FALLOPIAN TUBES AND OVARIES. 
 
 Describe the Fallopian tubes. 
 
 The Fallopian tubes are two tubes, from 4 to 6 inches in length, 
 which spring from the upper angles of the uterus and run tortu- 
 ously outward in the free margin of the broad ligaments. Each is 
 divided into three portions — the isthmus, ampulla, and fimbriated 
 extremity. The isthmus is the smaller straight portion. It is 
 1 inch long, and will just admit a bristle into its lumen. The 
 ampulla is the larger external portion, which extends first outward, 
 then forward and downward. It is 6 to 8 mm. in diameter. The 
 fimbriated extremity, or '• infundibulum," is the funnel-shaped ex- 
 pansion, surrounded by numerous little fleshy processes or fimbriae. 
 There are four to five large primary and ten to twelve small 
 secondary fimbriae. One of the long primary fimbria) on the inner 
 side runs to the ovary, and is called the " fimbria ovarica." 
 
 The tubes are composed of three coats — serous, muscular, and 
 mucous membrane. The muscular coat is arranged in two layers, 
 an external longitudinal and an internal circular set of fibres. The 
 mucous membrane is thrown into numerous folds, and is covered 
 by a layer of ciliated columnar epithelium, which becomes con- 
 tinuous with the peritoneal epithelium at the free end of the tube. 
 The cilia move toward the uterus. There is no submucous layer, 
 and the mucous membrane contains no glands. 
 
 The arterial supply is derived from the ovarian artery and the 
 ovarian plexus. The veins enter the pampiniform plexus. The 
 nerve-supply is derived from the inferior hypogastric plexuses. 
 The lymphatics unite with those of the ovary. 
 
 Describe the parovarium. 
 
 The parovarium, or organ of Rosenmiiller (analogue of the epi- 
 didymis in the male), is a rudimentary structure, the remains of 
 the Wolffian body. It consists of a triangular group of small 
 tubules situated between the folds of the mesosaplinx. These 
 tubules converge to the ovary and are lined with epithelium. 
 
ANATOMY OF THE OVARIES. 171 
 
 They are united above by one transverse tubule, which has its 
 blind extremity near the fimbriated end of the Fallopian tube. 
 In the other direction it can be traced as a cord nearly to the 
 uterus, and is known as the persistent duct of Gartner, Cystic 
 dilatations are sometimes seen in these ducts, and may appear 
 in the anterior vaginal wall. The most common form of these 
 cysts is known as the " hydatids of Morgagni," which spring from 
 the mesosalpinx to the inner side of the fimbria ovarica. The paro- 
 varium is thus of considerable importance, from its tendency to 
 form cysts of the broad ligaments. 
 
 Describe the ovaries. 
 
 The ovaries are two small oval bodies situated one on either 
 side of the uterus, and about 1 inch from it, projecting in the 
 posterior layer of the broad ligaments. Each ovary is about the 
 size of an almond, 1-2 inches long, |-1 inch in width, and i-J inch 
 in thickness. Their weight is from 60 to 135 grains. They present 
 for examination an anterior and posterior border, an upper and 
 lower surface, and an outer and inner extremity. The anterior 
 border, called the hilus, is flattened and attached to the anterior 
 layer of the broad ligaments. The blood-vessels and nerves enter 
 here. The posterior border is rounded and free. The upper sur- 
 face is more convex than the lower. The outer extremity is bulb- 
 ous ; the inner is more attenuated, and is connected to the uterus 
 by the ovarian ligament. 
 
 The ovarian ligaments are fibro-muscular bands of the broad liga- 
 ment, one inch long, which spring from the uterus just below the 
 Fallopian tubes. The other ovarian ligaments are the infundibulo- 
 pelvic, which is the outer free margin of the broad ligament, not 
 containing the Fallopian tube, and the fimbria ovarica, which con- 
 nects the ovary to the infundibulum. The external covering of the 
 ovary is composed of a layer of short columnar epithelium called 
 " germinal epithelium," because from their cells the primitive ova 
 are supposed to spring. Its union with the squamous peritoneal 
 epithelium at the hilus is marked by a - white line." Ingrowths 
 of this germinal epithelium in the stroma are called the " tubes of 
 Pfliiger." The epithelial layer rests directly upon a thin layer of 
 dense fibrous tissue called the " tunica albuginea." The paren- 
 chyma of the ovary is composed of a cortical and medullary por- 
 tion. The cortex or superficial portion is less vascular than the 
 medullary. It consists of a network of connective tissue, elastic 
 
172 DISEASES OF THE OVARIES. 
 
 and muscular fibres, imbedded in which are numbers of Graafian 
 vesicles, blood-vessels, nerves, and lymphatics. The medullary 
 layer is composed of the same elements as the cortex, but is less 
 dense and more vascular. 
 
 The Graafian vesicles, or ovisacs, are formed from the tubes of 
 Pfliiger (ingrowths of the germinal epithelium). They vary^ in size 
 when mature from y^^ to ^^^ of an inch in diameter. From 40,000 
 to 70,000 Graafian follicles are contained in the ovary at birth. 
 Each follicle consists of an external covering, the tunica fibrosa, 
 which contains the network of blood-vessels, and the memhrana pro- 
 pria, on which rests a layer of nucleated columnar epithelium, the 
 memhrana granulosa. Inside this the vesicle is filled with a clear 
 fluid, the '-' liquor folUculir At one portion the membrana granu- 
 losa surrounds the ovum and forms the discus proligerus. The 
 ovum itself, j^^ inch in diameter, is composed of an external envel- 
 ope, the vitelline membrane or zona pellncida, within which is the 
 vitellus or i/olk. At one side of this is the germinal vesicle, which 
 contains the germinal spot. 
 
 The arterial supply of the ovary is derived from the ovarian 
 artery, which arises directly from the aorta. From its origin it 
 bends inward and runs tortuously between the folds of the broad 
 ligament to the upper angle of the uterus. Here it divides into 
 two branches, one going to the fundus and anastomosing with its 
 fellow, the other descending to unite with the uterine. It gives 
 branches to the infundibulum, and numerous tortuous branches 
 to the ovary, which enter the hilus and form plexuses about the 
 Graafian follicles. The veins leave the hilus and unite with the 
 uterine plexus and veins from the tubes to form the pampiniform, 
 plexus. They terminate in the ovarian veins, the right emptying 
 into the vena cava direct, and the left into the renal vein. 
 
 The nerves are derived from the ovarian plexus and accompany 
 the arteries. The lymphatics enter the lumbar glands. 
 
 MALFORMATIONS OF THE OVARY. 
 Describe malformations of the ovary. 
 
 Absence of the ovaries is very rare : it is associated v>^ith rudi- 
 mentary development of the rest of the genital system. The patient 
 may retain throughout life the development, physical and mental, 
 of a child, or in rare instances may present the stature, beard, and 
 mental characteristics of the male sex. In any case menstruation 
 
ATROPHY AND DISPLACEMENTS OF THE OVARIES. 173 
 
 never occurs, and the woman is sterile and sexual feeling is absent. 
 Diagnosis is made from the symptoms and from the mal-develop- 
 ment of the other sexual organs. Treatrtient is without benefit, 
 and may do harm in breaking down the health by persistent efforts 
 to excite the functions of the ovaries (under a mistaken diagnosis). 
 
 Imperfect and Irregular Development of the Ovaries. — A woman 
 with imperfectly developed ovaries may present similar general 
 symptoms to one in whom the ovaries are absent. The local 
 symptoms are irregular or scanty menstruation, often sterility. 
 Treatment is directed toward stimulation of the generative func- 
 tions, as by general tonics, uterine irritation (tents or stems), 
 electricity, marriage. 
 
 The cases of irregular development of the ovaries, including 
 supernumerary ovary, would present no special interest, except to 
 the pathologist, but for the fact that they may account for some 
 cases in which removal of the ovaries is followed by menstruation 
 or even conception. 
 
 ATROPHY OF THE OVABIES. 
 
 Describe atrophy of the ovaries. 
 
 The premature development of the senile condition in the ovaries 
 is accompanied by similar changes in the rest of the generative 
 system, and by the cessation of menstruation and the other sexual 
 functions. The ovary may weigh 15 grains, the normal weight 
 being 100 grains. 
 
 What are the causes? 
 
 Ovaritis, acute or chronic ; pelvic peritonitis ; the exanthemata. 
 
 What is the treatment? 
 
 Stimulation of the sexual functions, as for imperfect develop- 
 ment of the ovaries. 
 
 What is the prognosis? 
 
 The condition is not dangerous to life, but if all signs of men- 
 struation are absent the prospect of cure is poor. 
 
 DISPLACEMENTS OF THE OVARY. 
 
 Name the two displacements of the ovary. 
 Prolapse and hernia. 
 
174 DISEASES OF THE OVARIES. 
 
 Describe prolapse of the ovary. 
 
 One or both of the ovaries may be displaced into Douglas's 
 pouch. 
 
 What are the causes? 
 
 Retroversion or retroflexion of the uterus ; enlargement of the 
 ovaries from congestion ; chronic ovaritis, or diffuse cystic degene- 
 ration. 
 
 What are the symptoms? 
 
 Dyspareunia ; pain on defecation when the bladder is distended ; 
 sacral pain, and pain in the ischio-rectal fossa and hip extending 
 down the thigh on the corresponding side. 
 
 What are the physical signs? 
 
 On digital examination one or two bodies the size and shape of 
 the ovaries can be readily felt in Douglas's pouch, movable inde- 
 pendently of the uterus, and producing on pressure a sickening 
 sensation analogous to that from pressure on the testicle. 
 
 What is the treatment? 
 
 (1) Reposition by the knee-chest position (maintained fifteen 
 minutes at a time twice daily). (2) Use of a pessary (the best for 
 most cases is a soft-rubber ring). (3) Palliative treatment (for- 
 bid coitus ; prevent the formation of hard scybala in the rectum ; 
 remove pressure from above by an abdominal belt ; if conception 
 is probable, encourage it in the belief that the nine months' rest 
 from functional activity may restore the ovaries and their attach- 
 ments to their normal condition). (4) Removal of the affected 
 ovary or ovaries by abdominal or vaginal section, if adhesions 
 have rendered other treatment unsuccessful and the system calls 
 for such grave measures. 
 
 Describe hernia of the ovary. 
 
 In congenital hernia of the ovary the ovary on one or both sides 
 lies in the labium majus, having come down through the unobliter- 
 ated canal of Nuck. The swelling may be mistaken for the testis, 
 as in some cases of supposed hermaphroditism ; when congenital it 
 is often irreducible, and may give pain on locomotion and coitus. 
 The treatment consists in the application of a suitable truss where 
 the hernia is reducible. For irreducible hernia a concave protective 
 truss-pad may be worn, or if symptoms are sufficiently severe the 
 ovary may be removed by a labial incision. 
 
OVARIAN APOPLEXY. 175 
 
 In acquired hernia of tlie ovary, the ovary may form part of the 
 contents of an inguinal, femoral, sciatic, or ventral hernia. The 
 symptoma and treatment are the same as for the congenital variety. 
 
 OVARIAN APOPLEXY. 
 
 Describe ovarian apoplexy. 
 
 The lesion is a rapid effusion of blood into the substance of the 
 ovary from rupture of one or more of its larger blood-vessels. (It 
 is not to be confounded with the physiological extravasation from 
 which the corpus luteum is produced.) It may be small^ or it may 
 distend the ovary to the size of an orange, or it may rupture. Its 
 cause is either some mechanical shock or a pathological exaggeration 
 of the hemorrhage during ovulation. Symptoms are : sudden and 
 violent pain over one ovary, combined with some of the symptoms 
 of internal hemorrhage. Diagnosis is difficult. With the symp- 
 toms mentioned above and the presence of a cystic tumor felt on 
 digital examination, the contents of which on aspiration through 
 the vaginal wall were found to be dark-bloody fluid, this diagnosis 
 would probably be correct. Prognosis is grave. The blood-clot 
 may become absorbed or organized, but if the ovarian tissues have 
 been largely disorganized, even this favorable termination may be 
 followed by symptoms (pain chiefly) calling for radical treatment. 
 In unfavorable cases the hematoma may rupture into the peritoneal 
 cavity (forming a pelvic haematocele shut off by peritonitic adhe- 
 sions from the general cavity), or between the layers of the broad 
 ligament, where a mass may be formed giving rise to pressure 
 symptoms. 
 
 Treatment. — Early : check hemorrhage by rest in bed and ice- 
 bags, and control pain by morphine. Later, if peritonitis develop, 
 this is to be treated in the usual way. When the acute symp- 
 toms are over, treatment is directed toward the reabsorption of the 
 effusion, similar to that for inflammatory pelvic exudations. If 
 symptoms are sufficiently severe, removal of the affected ovary is 
 indicated. 
 
 INFLAMMATIONS OF THE OVARY. 
 What are the two degrees of ovarian inflammation ? 
 Acute ovaritis ; chronic ovaritis. 
 
 Describe acute ovaritis. 
 
 This may be puerperal or non-puerperal. In the former case the 
 
176 DISEASES OF THE OVARIES. 
 
 process is more severe, and termination in suppuration is more com- 
 mon, than in the non-puerperal form, where resolution is the rule. 
 The causes are acute endometritis, acute salpingitis, pelvic perito- 
 nitis, gonorrhoea, disturbance of menstruation. The symptoms are 
 those of pelvic inflammation — fever, pain, and sensitiveness. If 
 resolution takes place, the symptoms subside after four or five da3's, 
 but if suppuration occurs, there are rigors and irregular rise of 
 temperature, and finally symptoms referable to the rupture of an 
 abscess into the peritoneum, rectum, bladder, or vagina. The jyrog- 
 nosis in puerperal cases is grave ; in non-puerperal cases it is fairly 
 good. In all cases the ovary is left somewhat damaged, and in 
 gonorrhoeal cases of double ovaritis, sterility is sure to follow. 
 Treatment consists in antiphlogistics and opiates, and, if suppura- 
 tion occurs, extirpation of the ovary by laparotomy or drainage of 
 the abscess-cavity by abdominal, rectal, or vaginal incisions. 
 
 Describe chronic ovaritis. 
 
 Pathology. — In the early stages the condition is that of chronic 
 congestion, followed by infiltration with sero-sanguinolent fluid and 
 an increase in bulk. In the later stages the capsule thickens, the 
 follicles enlarge, and a general hypertrophy takes place. It starts 
 commonly as a subacute or chronic affection, rarely as an acute 
 ovaritis. 
 
 Causes. — They are those that produce prolonged congestion of 
 the generative organs : laceration of the cervix or perineum ; sub- 
 involution ; dysmenorrhoea ; uterine tumors ; displacements and 
 flexions ; sterility ; efforts to prevent conception ; intercourse with 
 impotent men ; masturbation ; emotional causes (long engagements, 
 disappointment in love, reading corrupt literature, etc.). 
 
 Hympto^ns. — Dysmenorrhoea ; fixed ovarian pain ; tendency to 
 hysteria ; rarely pain on locomotion ; sometimes dyspareunia ; pain 
 and exhaustion after defecation ; pain in rectum, hips, and down 
 thighs ; irregular menstruation ; sterility if both ovaries are 
 affected. 
 
 Treatment. — (1) Removal of causes of congestion (thus, repair 
 of laceration of cervix or perineum, correction of displacement or 
 flexion of the uterus, regulation of the bowels and of sexual rela- 
 tions, etc.). (2) Reduce pelvic engorgement directly by scarifying 
 the cervix ; prolonged hot vaginal douches ; painting the vaginal 
 fornix with tincture of iodine if tenderness and induration appear 
 in either broad ligament; rest during menstruation; bromides. 
 
NEOPLASMS OF THE OVARY. 177 
 
 general tonics, and sometimes a sea-voyage. (3) The very best 
 treatment is Weir Mitchell's rest-cure. (4) Some cases resist all 
 treatment, and are sufficiently serious to justify the removal of 
 the affected ovary or ovaries. 
 
 ABSCESS OF THE OVARY. 
 Describe abscess of the ovary. 
 
 It is a collection of pus in the substance of the ovary. It occurs 
 almost exclusively in connection with gonorrhoeal or tubercular 
 inflammation of the genital tract. It gives no very characteristic 
 symptoms in addition to those of the disease it complicates, but 
 may commonly be diagnosed by finding on physical examination 
 the ovary distended with fluid, while the presence of irregular 
 temperature and rigors indicates its purulent character. 
 
 Treatment is commonly removal of the ovary by laparotomy or 
 drainage of the abscess-cavity by the incision which seems most 
 appropriate for the individual case. 
 
 NEOPLASMS OF THE OVARY. 
 
 Enumerate the neoplasms of the ovary. 
 
 I. Solid Tumors. 
 
 r\ • -^ C accompanied by rap- 
 
 Carcmoma, ) ,. , o • ^ ) -n i i • 
 
 q ' V malignant ; lairly common ; < idly developing 
 
 ' ^ (_ ascites. 
 
 Papilloma, ) doubtful; rare;) ,. ,. . i . 
 Fibroma, | benign. " | "° 'J'^t'iS'iislimg symptoms, 
 
 IT. Cystic Tumors. 
 
 Cysto-carcinoma, ) ,. 
 
 ry , ' ^ malignant. 
 
 Cysto-sarcoma, j ^ 
 
 Cysto-fibroma, ") 
 
 Dermoid cyst, y benign. 
 
 Ovarian cyst (mono- or polycystic), j 
 
 DERMOID CYST OF THE OVARY. 
 
 Describe dermoid cyst. 
 
 In various parts of the body (the orbit, floor of the mouth, brain, 
 eye, anterior mediastinum, lung, mesentery, testicle, and ovary) 
 tumors may occur, containing fatty matter, teeth, hair, cartilage, and 
 
 12— Gjn. 
 
178 DISEASES OF THE OVARIES. 
 
 bone. Their origin must be in some foetal inclusion of epiblast and 
 irregular subsequent development of the same. Those occurring 
 in the ovary vary in size from that of a hen's egg to that of a 
 human head. In themselves they give no special symptoms, but 
 always present the risk of rupture into the peritoneal cavity or 
 of suppuration. They should probably always be removed by 
 ovariotomy. 
 
 OVABIAN CYSTS. 
 
 What is the pathology of ovarian cysts ? 
 
 The development of cysts within the ovary without the coinci- 
 dent development of solid elements, as fibroma or carcinoma. Most 
 of the cysts are developed from the Graafian follicles by a sort of 
 colloid degeneration, but it is claimed that some may originate in 
 cystic degeneration of the ovarian stroma. The cyst may be mono- 
 cystic or polycystic ; and in the latter case the separate collec- 
 tions of fluid may be enclosed by thick or very thin walls. The 
 fluid may be very thin and clear, or may be viscid, or even 
 almost gelatinous ; its color varies from a pale yellow to that of 
 weak coff"ee. Under the microscope certain bodies, " Drysdale's 
 cells," are seen which are not distinctly altered by acetic acid 
 (which does markedly change the appearance of leucocytes, etc.) ; 
 they are characteristic of fluid from an ovarian cyst, but not 
 absolutely diagnostic. The pedicle consists of the broad ligament, 
 the Fallopian tube, the round ligament, the ovarian vessels, etc. 
 In one variety, " intraligamentous cysts," there is no true pedicle, 
 and the tumor can only be removed by difficult dissection ; often 
 it can only be drained. 
 
 What are the causes? 
 
 Predisposmg. — Age twenty to fifty most common ; childbearing ; 
 chlorosis ; scrofulous diathesis ; menstrual disorders ; deprivation 
 and bad hygiene. 
 
 Exciting. — Uncertain ; ovaritis, acute or chronic ; the various 
 causes of pelvic congestion. In the great majority of cases the 
 woman has been apparently perfectly well until the tumor has 
 developed and reached a size at which it has given symptoms. 
 
 What are the symptoms? 
 
 They are not pathognomonic, and are largely due to the pressure 
 of the tumor upon the pelvic and abdominal structures as it gets 
 
NEOPLASMS OF THE OVARY. 179 
 
 larger and larger. (The tumor reaches a size from that of a human 
 head to a mass weighing sometimes over a hundred pounds.) The 
 abdomen is distended ; there are marked emaciation of the lower 
 extremities, emaciation of the face, and a peculiar expression, 
 " facies ovariana." 
 
 What are the complications ? 
 
 Pregnancy ; fibroids of the uterus ; carcinoma of the uterus ; 
 renal disease ; disease of the liver, heart, or lungs ; compression of 
 
 the ureters ; elevation of the bladder. 
 
 What is the prognosis? 
 
 If untreated, spontaneous cure is possible by rupture and absorp- 
 tion of the fluid : 50 per cent, of cases rupturing and untreated are, 
 however, fatal : or by calcareous degeneration ; but cure in this way 
 is extremely rare. The ordinary course is for the tumor to go on 
 increasing in size, and finally to cause death in one of the following 
 ways: (1) Eupture of cyst (with or without suppuration) and 
 production of peritonitis. (2) Inflammation of the cyst-wall, filling 
 the cyst with pus : finally septic infection, and death. (3) Twi.st- 
 ing or rupture of the pedicle, gangrene of the cyst, septicaemia. 
 (4) Prolonged interference with the nutrition and respiration. (5) 
 Acute or chronic peritonitis, rapid or slow exhaustion. (6) Fatal 
 hemorrhage into the cyst.. (7) Simply gradual exhaustion. 
 
 Enumerate the conditions from which a small ovarian cyst in the 
 pelvic cavity must be diagnosed. 
 
 Solid ovarian tumors ; cysts of the broad ligaments ; distended 
 tubes ; normal pregnancy ; normal pregnancy with retroversion ; 
 extra-uterine gestation ; fibroid tumors of the uterus ; uterine moles ; 
 peritonitic exudation or abscess ; inflammatory exudation in the 
 broad ligament ; pelvic haematocele ; spina bifida ; faecal accumula- 
 tions ; inflammation of the vermiform appendix ; tumors of the 
 pelvic walls. 
 
 Grive the differentiation from a distended tube. 
 
 Histryry. — This condition begins with the symptoms of an acute 
 inflammation, negative in the case of an ovarian cyst. 
 
 Shape. — Tubal elongated, ovarian globular. 
 
 Relation. — Tubal m'ore intimate to uterus than in the case of 
 ovarian cyst. 
 
 Sensitiveness. — Tubal marked, ovarian slight. 
 
180 DISEASES OF THE OVARIES. 
 
 Contents. — Straw-colored in hydrosalpinx, and pus in pyosalpinx ; 
 in ovarian cyst as above described. 
 
 Give the differentiation from peritonitic exudation or abscess. 
 
 History of acute inflammation, fixation, less rounded outline, 
 and less distinct fluctuation ; pus found on puncture when fluctua- 
 tion does exist. Sensitiveness, usually in Douglas's pouch, while 
 an ovarian cyst is commonly lateral. 
 
 Give the differentiation from an exudation into the broad ligament. 
 
 History of inflammation after some operation or after labor or 
 abortion. Haematoma would give a history of sharp pain with 
 more or less prostration and rapid development of the tumefaction ; 
 fixity and tenderness. 
 
 Give the differentiation from extra-uterine gestation. 
 
 Rapidity of growth and the presence of many of the signs 
 (morning sickness, changes in the breasts and vagina, etc.) of 
 normal pregnancy ; amenorrhoea followed by irregular menorrhagia 
 (in ovarian cyst menstruation is little aflected) ; increase in size of 
 the uterus ; greater fixity of the tumor ; pain from recurrent attacks 
 of acute peritonitis ; finally symptoms of rupture (pain, shock, col- 
 lapse, and, if untreated, death from hemorrhage or peritonitis). 
 
 Enumerate the conditions from which a large ovarian cyst in the 
 abdominal cavity must be differentiated. 
 
 Solid Ahdominal Tumors. — Of the anterior abdominal wall (des- 
 moids) ; of the omentum ; of the spleen, kidney, or liver ; of the 
 ovary or uterus (fibroid or fibro-cystic) ; of the retro-peritoneal 
 connective tissue. 
 
 Cystic Tumors. — Of the omentum or mesentery ; of the liver, 
 pancreas, or kidney ; of the broad ligament ; parasitic cysts (hyda- 
 tid, etc.) ; hajmatometra ; vesicular mole ; hydrosalpinx. 
 
 Pregnancy. — Normal ; with dropsy of the amnion ; abdominal 
 pregnancy. 
 
 Ascites. — Simple ; encysted ; tubercular peritonitis ; tympanites ; 
 phantom tumor ; distension of bladder or stomach. 
 
 Give the differentiation from ascites. 
 
 In this the abdomen is flatter in the recumbent position, and 
 convex when standing. If the patient turn over, the relation of 
 the areas of tympanitic resonance to the area of fluid flatness 
 changes. There is a perfect wave of fluctuation transmitted across 
 
NEOPLASMS OF THE OVARY. 181 
 
 the abdomen. No encysted or circumscribed wave can be made 
 out, and there is generally a history of some cause (as renal or 
 hepatic disease, etc.) to account for it. 
 
 Give the diflferentiation from normal pregnancy. 
 
 This would give the regular changes in the breasts, vagina, 
 cervix, etc., presence of ballottement, uterine bruit, foetal heart- 
 sounds ; perhaps foetal parts may be made out on palpation ; rhyth- 
 mic uterine contractions ; absence of fluctuation and of the haggard 
 expression characteristic of ovarian cyst. Amenorrhoea is not 
 positive evidence, but probable. 
 
 Give the differentiation from distension of the bladder. 
 
 The introduction of a catheter and the immediate disappearance 
 of the swelling are conclusive. 
 
 Give the differentiation from uterine fibroids and fibro-cysts. 
 
 A fibro-cyst of the uterus cannot be positively diagnosed from 
 an ovarian cyst except by exploratory laparotomy. A fibroid 
 would give a history of slow development, menorrhagia, uterine 
 souffle, close connection with the uterus, increased general deposit 
 of fat, and some pigmentation of the skin, as in pregnancy ; uterine 
 cavity increased in length. 
 
 Detail the treatment of ovarian cysts. 
 
 Curative. — Removal by laparotomy. 
 
 Palliative. — Evacuation of cyst-contents by aspiration or tap- 
 ping. 
 
 The procedures indicated under the second heading have many 
 objections, and are resorted to only when, as in pregnancy, the 
 tumor gives rise to urgent pressure symptoms, and a resort to the 
 major operation seems too risky. 
 
 CYSTS OF THE BROAD LIGAMENT, OR PAROVARIAN CYSTS. 
 
 Describe these cysts. 
 
 They develop between the layers of the broad ligament in the 
 parovarium or organ of Rosenmtiller, which is a remnant of the 
 foetal Wolffian body. They are always monocystic, and tend to 
 grow down into the pelvis, and only into the abdominal cavity after 
 they have attained considerable size. They grow more slowly than 
 ovarian tumors, and have no marked eiFect upon the general health. 
 
 The best treatment is laparotomy, incision of cyst, evacuation of 
 
182 DISEASES OF THE OVARIES. 
 
 contents, excision of the excess of cyst-wall, suture of cyst-wall in 
 the abdominal wound, and packing with iodoform gauze. 
 
 LAPAROTOMY FOR THE REMOVAL OF THE UTERINE 
 APPENDAGES OR OF CYSTS. 
 
 Ovariotomy. 
 
 What instruments are required? 
 
 Scalpel ; mouse-tooth forceps, 2 ; dissecting forceps, 2 ; Tait's 
 clamps, small, 6 ; large, 6 ; right aneurism needles, 4 ; left, 1 ; 
 uterine sound ; scissors, curved, straight, angular ; double volsella, 3; 
 trocar and canula ; artery clamps, 12; Paquelin cautery; needles, 
 long, curved, spear-pointed, 6 ; medium, curved, spear-pointed, 6 ; 
 small Hagedorn, 6. 
 
 Also the following materials : silk, heavy floss or braided for 
 pedicles ; finer for sutures and carrying wire sutures ; catgut, Nos. 
 2 and 3 ; silver wire, No. 24 ; glass drainage-tubes ; antiseptic dress- 
 ings. 
 
 What are the steps of the operation ? 
 
 The bladder and rectum have been evacuated shortly before, and 
 no solid food has been taken for five hours preceding the operation. 
 The patient lies upon her back upon a flat operating table, or 
 Trendelenberg's table may be used. 
 
 First Step. — Preparation of the field of operation. The pubes 
 is shaved and the abdomen scrubbed with soft soap and warm 
 water ; it is then wiped ofl" with alcohol, turpentine, ether, and 
 bichloride of mercury 1 : 1000. Wet bichloride towels are spread 
 about.* 
 
 ^ Instruments have been sterilized by boiling in a 1 per cent, solution of 
 carbonate of soda, and are kept in carbolic acid 1 : 40; hands and forearms 
 of operator and assistants have been disinfected by scrubbing with soap and 
 water, followed by alcohol and bichloride. Silk and silver wire are pre- 
 pared by boiling. Catgut is prepared by immersion for eight hours in ether, 
 eight hours in bichloride, 1 : 1000, and then in several changes of alcohol, 
 in which it is finally stored. A most desirable addition is the final boiling 
 in alcohol for one hour over a water-bath ; a condenser may be used to pre- 
 vent loss of alcohol. Chromicized catgut is prepared by washing in alcohol 
 and then immersing for forty-eight hours in water 100 parts, carbolic acid 
 5 parts, and bichromate of potash 0.2 parts: it will not be absorbed by the 
 tissues for a week, and is used for ligatures (as on pedicles) where thi?. 
 property of non-absorbability renders it valuable. 
 
LAPAROTOMY. 183 
 
 Second Step. — Incision in the median line between the umbilicus 
 and the symphysis of an average length of four or five inches. 
 The tissues are divided layer by layer, and hemorrhage is checked 
 before the peritoneum is opened. A fold of peritoneum is held up 
 by two mouse-toothed forceps and nicked ; a grooved director is 
 then introduced, and the peritoneum divided with scalpel or scissors, 
 or the fingers may take the place of the grooved director. 
 
 Third Step. — Tapping the cyst (for tubal disease or solid tumors 
 of course this would be unnecessary). Emmet's long curved trocar 
 and canula are used ; abdominal compression is made as the contents 
 escape ; an effort is made to prevent the entrance of even a single 
 drop of the fluid into the abdominal cavity ; the aperture is clamped 
 as the canula is withdrawn. 
 
 Fourth Step. — Drawing out the sac. This is done with volsella 
 and gentle traction with the fingers. Adhesions to the abdominal 
 wall, omentum, large intestine, and mesocolon may be found, and 
 less frequently to the small intestine, bladder, liver, diaphragm, and 
 the walls of pelvis. These are either gently separated or are ligated 
 and divided : their treatment constitutes the only difficulty in the 
 operation. 
 
 Fifth Step. — Securing the pedicle. This is best done by com- 
 pressing the pedicle with any suitable clamp, 
 cutting off the tumor, ligating the pedicle Fig 84. 
 
 by the Staffordshire knot (Fig. 84), cauter- 
 izing the cut surface with the Paquelin 
 cautery, removing the clamp, and allowing 
 the pedicle to fall into the pelvis.* 
 
 Sixth Step. — Peritoneal toilet. All hemor- 
 rhage has been checked, and in ordinary 
 cases it is necessary simply to lightly sponge Staffordshire Knot, 
 
 out the pelvic and abdominal cavities with 
 
 sponges on holders. In other cases, where trouble is feared from 
 access of the fluid to the peritoneum, the entire peritoneal cavity is 
 flushed out repeatedly with sterilized water or Thiersch's solution 
 at a temperature of 100° F. 
 
 * The Staffordshire knot is tied as follows : pass a strong straight needle, 
 threaded double with heavy pedicle silk, through the pedicle and under the 
 clamp. Then pull the loop through and remove the needle. Now pass 
 both the clamp with the distal extremity of the pedicle and one of the 
 loose ends of the ligature through the loop by drawing the loop forward. 
 Then draw each end tight, and tie very tightly a square knot. 
 
184 DISEASES OF THE OVARIES. 
 
 Seventh Step. — Drainage. A glass drainage-tube is introduced 
 at the lower angle of the wound, and reaches down into Douglas's 
 pouch ; it is lightly filled with iodoform gauze. Drainage may 
 often be omitted. 
 
 Eighth Step. — Suture and antiseptic dressing. The suture may 
 pass through all layers at once, or the peritoneum, the muscles, 
 the fascia, and the skin may be sutured separately. 
 
 After-treatment. — Absolute rest in bed ; an eighth of a grain of 
 morphine hypodermically is often sufficient to control pain and 
 restlessness. The packing in the tube is removed in three hours, 
 and such fluid (bloody serum) as has accumulated is sucked out 
 by a syringe with a long rubber tube attached ; fresh packing. 
 This is repeated at least once in three hours, and the tube is 
 commonly removed in twenty-four hours or less. Vomiting is 
 prevented by not giving anything by the mouth for six or twelve 
 hours after operation. The bowels should be moved in forty -eight 
 hours. Sutures are removed at about the ninth day, and in three 
 weeks the patient is commonly well. 
 
 Battey's Operation, or Oophorectomy. 
 Describe this operation. 
 
 It is the removal of the normal or not very greatly changed 
 ovaries for the relief of symptoms which do not yield to other 
 treatment. The indications for it are — uterine fibroids (to check 
 their growth), chronic pelvic inflammations, chronic ovaritis and 
 ovaralgia, ovarian insanity, ovarian epilepsy (of course only in 
 carefully considered and selected cases). 
 
 The details of the operation are the same as those of ovariotomy, 
 except that the ovary is simply brought up into the wound by tfi^ 
 fingers and seized by fenestrated forceps : its pedicle is transfixed 
 by a double ligature, tied, cut away, and allowed to drop back into 
 the pelvis : the cut surface may be touched with the Paquelin 
 cautery. 
 
 Tait's Operation. 
 Describe this operation. 
 
 It is the removal of ovaries and tubes for the same conditions as 
 Battey's operation. It involves as an additional step ligature of 
 the broad ligament in sections before the ovary and tube can be 
 cut away. 
 
DISEASES OF THE FALLOPIAN TUBES. 185 
 
 DISEASES OF THE FALLOPIAN TUBES. 
 
 SALPINGITIS. 
 Describe salpingitis. 
 
 The acute variety is commonly the extension of a gonorrhoeal 
 inflammation of the lower genital tract. It may, as latent gonor- 
 rhoea in the female (Noeggerath), be a very common cause of 
 sterility, and may be acquired from a very old and aj)parently cured 
 gonorrhoea in the male. Acute salpingitis may, however, occur 
 without venereal infection. Chronic salpingitis may follow an 
 acute attack or may develop gradually of itself. 
 
 What is its pathology ? 
 
 The mucous membrane is thickened and thrown into ridges ; 
 the inflammation extends to the peritoneal coat, and, from cicatricial 
 contraction and pressure and traction by adhesions, deformity and 
 stricture of the tube may result, the lumen at each extremity may 
 be obliterated, and a collection of the hypersecretion of the mucous 
 membrane may take place. The condition is termed hydrosalpinx, 
 pyosalpinx, or hsematosalpinx according as the contents of the 
 distended tube are clear, limpid fluid, pus, or principally blood. 
 
 What are the causes of salpingitis ? 
 
 Gonorrhoeal infection, septic infection from other causes, expo- 
 sure during menstruation. 
 
 What are the symptoms ? 
 
 Acute salpingitis : Sharp pain in one or both sides of the pelvis ; 
 moderate rise of temperature ; tenderness in the region of the tube, 
 which may sometimes be felt on bimanual examination. 
 
 Chronic salpingitis : Menstrual colic ; leucorrhoeal discharge. On 
 bimanual examination the tube can commonly be felt to be thick- 
 ened and irregular. 
 
 What is the treatment? 
 
 Acute salpingitis : Rest in bed ; antiphlogistics (ice over hypo- 
 gastrium or prolonged hot vaginal douches) ; leeches perhaps ; 
 blisters. 
 
 Chronic salpingitis : Repeated blisters over iliac region ; counter- 
 irritants to the fornix of the vagina ; tampons of boroglyceride, or 
 8 per cent, ichthyol in glycerin ; hot douches ; alterative sitz- 
 baths (warm solution of sea-salt, etc.) ; galvanic current ; salpingo- 
 
186 HEMATOSALPINX. 
 
 oophorectomy if the symptoms are sufficiently urgent and persist 
 in spite of treatment. 
 
 What are the special features of hydrosalpinx ? 
 
 History of catarrhal salpingitis and very mild pelvic peritonitis ; 
 symptoms of pain and pelvic pressure. A tense, smooth, elastic 
 oval mass is felt in Douglas's pouch ; it may be fixed or movable. 
 Clear fluid is drawn on aspiration per va^mam. The disease 
 seldom threatens life. 
 
 Treatment is either by evacuation per vaginam or removal of 
 ovary and tube by laparotomy. 
 
 PYOSALPINX. 
 
 What are the special features of pyosalpinx ? 
 
 In consequence of repeated attacks of salpingitis both extremities 
 of the tube have become impermeable, and the cavity is distended 
 with several ounces of pus. The symptoms are those of recurrent 
 pelvic peritonitis, with freedom from pain between the attacks. 
 A tense, fluctuating, rather fixed, mass is felt in Douglas's pouch, 
 which on aspiration yields pus. Dangers are of rupture into the 
 peritoneal cavity, but this is commonly prevented by adhesions. 
 
 Treatment is in most cases best by removal of ovary and tube 
 by laparotomy. Where the abscess is opened through the vagina 
 and drained or packed it is very difficult to bring about oblitera- 
 tion of the cavity. ** 
 
 HJEMATOSALPINX. 
 
 What are the special features of hsematosalpinx ? 
 
 The tube is distended with fluid blood from rupture of a tubal 
 pregnancy, from the regular monthly hemorrhage from the mucous 
 membrane of the tube, or from regurgitation from the cavity of 
 the uterus. Symptoms are pain and pressure. Even when its 
 production is sudden, the amount of blood taken from the general 
 circulation is not enough to give the symptoms of anaemia. The 
 chief danger is of intraperitoneal rupture. 
 
 Treatment is removal of ovary and tube by laparotomy, or, if the 
 cavity be intraligamentous, not a true hoematosalpinx, incision and 
 drainage from the vagina. 
 
EXTRA-UTERINE PREGNANCY. 187 
 
 LAPAROTOMY FOR PYOSALPINX, ETC.—" SALPINGO- 
 
 OOPHORECTOMY. ' ' 
 
 This operation differs from ovariotomy in the fact that both tube 
 and ovary on the affected side are removed, and that it is thus neces- 
 sary to ligate the broad ligament in sections before cutting the tube 
 away. 
 
 EXTRA-UTERINE PREGNANCY. 
 
 What are the principal varieties ? 
 
 Tubal, interstitial, and abdominal pregnancy. 
 
 What are the causes? 
 
 Stricture of the tube ; constriction or flexion of the tube by 
 adhesions ; tumefaction of the mucous membrane of the tube from 
 chronic salpingitis. 
 
 What are the symptoms? 
 
 For the first two or three months there are amenorrhoea and th.e 
 ordinary symptoms of pregnancy. Then the patient may suddenly 
 exhibit the symptoms of pelvic haematocele: intense pain, nausea, 
 and collapse ; if untreated, death may follow from acute anaemia 
 or septic peritonitis, or a slow recovery may take place. In other 
 cases the symptoms which first attract attention are irregular and 
 profuse discharges of blood from the uterus, pain, and a rapid 
 enlargement of the hypogastrium. 
 
 What are the physical signs? 
 
 The uterus is distinctly enlarged and softened, and is displaced 
 upward and to one side. Its cavity is slightly increased in length, 
 and on dilatation of the cervix it is proven to be empty. In 
 Douglas's pouch or a little to one side a tumor may be felt : it is 
 rather fixed, not very sensitive, fluctuating, and sometimes gives 
 ballottement. 
 
 What is the diagnosis? 
 
 It must be differentiated from uterine fibroids or fibro-cysts ; cyst 
 of the ovary or broad ligament ; pelvic hsematocele ; gestation in 
 one horn of uterus bicornis ; pregnancy in a retroverted uterus ; 
 pelvic inflammatory exudation or abscess. 
 
 What are the course and prognosis? 
 
 The prognosis is bad. If untreated, rupture sooner or later 
 
188 DISEASES OF THE PELVIC PERITONEUM AND FASCIJE. 
 
 occurs in almost all cases, and death may then occur from hemor- 
 rhage, septicaemia, peritonitis, and perforation of important viscera ; 
 or the haematocele thus produced may terminate favorably, and the 
 foetus, now dead, may be converted into a lithopsedion and may give 
 no further trouble, though it is always liable to do so. 
 
 What is the treatment? 
 
 For a ruptured extra-uterine gestation there is only one thing 
 to be done : laparotomy and removal of the sac and its contents. 
 Unruptured cases may properly be first treated by methods calcu- 
 lated to destroy the life of the foetus, and hence, by reduction of 
 vascularity, the subsequent removal may be very much less dan- 
 gerous. These methods are — electricity (faradic current, one pole 
 placed either in the vagina or rectum ; sittings repeated until the 
 sac ceases to grow : it would be worse than useless if there were 
 any symptoms of impending rupture). Aspiration of the amniotic 
 fluid was formerly performed ; also the injection of different sub- 
 stances into the sac ; but these have been abandoned. 
 
 In cases of distinctly abdominal pregnancy which have passed 
 the first three or four months, interference should be withheld 
 until, at about full term, an attempt at labor gives the indication 
 for laparotomy, with a moderate chance for both mother and child. 
 
 DISEASES OF THE PELVIC PERITONETJM AND 
 
 FASOIiB. 
 
 PELVIC PERITONITIS. 
 
 Define and give the synonyms. 
 
 Pelvic peritonitis is an inflammation of that portion of the 
 general peritoneum which lines the pelvis and invests the pelvic 
 viscera. It is one of the most common diseases. The synonyms 
 are perimetritis and pelveo-peritonitis. 
 
 Describe the pelvic peritoneum. 
 
 From before backward it is reflected on to the bladder from the 
 anterior abdominal wall about 1^ inches above the symphysis; 
 covers the fundus, and crosses to the uterus on a level with the 
 OS internum, forming the vesico-uterine pouch and vesico-uterine 
 ligaments. The vesico-uterine pouch is normally empty, and lies 
 more than ^ an inch above the anterior fornix of the vagina. The 
 jteritoneum invests closely the anterior surface of the uterus, passes 
 
PELVIC PERITONITIS. 
 
 189 
 
 over the fundus, and covers the entire posterior surface. Laterally 
 it passes off to the sides of the pelvis, forming the broad ligaments. 
 Posteriorly it continues down, investing the vaginal wall for about 
 
 Fig. 85. 
 
 Pelvic Peritoneum, indicated by dark line, PP, which does not extend sufficiently 
 
 between U and B. 
 
 an inch ; passes on to the rectum, forming the pouch or cul-de-sac 
 of Douglas and the utero-sacral ligaments. It covers the anterior 
 surface of the middle portion of the rectum, and completely sur- 
 rounds the upper part. 
 
190 DISEASES OF THE PELVIC PERITONEUM AND FASCIJE. 
 
 What fossae are formed by reflections of the pelvic peritoneum? 
 
 The utero-vesical in front and two lateral pouches, the para- 
 vesical ; the pouch of Douglas behind, and two lateral pouches just 
 outside the utero-sacral ligaments. 
 
 The pouch of Douglas is the lowest part of the pelvic peri- 
 toneum. It is the first part to be filled with fluid, and may contain 
 loops of intestine or tumors, ovaries, etc. It is separated from the 
 vagina by only one-fourth of an inch of tissue, and extends down a 
 little deeper on the left side. 
 
 What is the pathology of pelvic peritonitis ? 
 
 Pelvic peritonitis is usually localized. The serous membrane 
 first loses its shiny, glistening appearance from loss of epithelium 
 and from exudation. If there is a slight amount of fluid, the 
 surfaces may adhere to each other ; if the serum is considerable, 
 adhesions may be prevented and the fluid absorbed ; or it may be 
 encapsulated, forming peritoneal cysts. The inflamed surfaces 
 are covered with a reddish-yellow pseudo-membrane, consisting 
 chiefly of newly-formed connective tissue (plastic lymph), which 
 may be so profuse as to fill up all the cracks and cause adhesion 
 of all the viscera. 
 
 In severe forms, such as are produced from puerperal septicsemia 
 and gonorrhoea, the fluid becomes purulent. The varieties of pelvic 
 peritonitis are — adhesive 2)erltomtis, sero-adhesiv^eritonitis, purulent 
 peritonitis. 
 
 What is the etiology? 
 
 Pelvic peritonitis is generally secondary to inflammation of the 
 uterus, ovaries, and tubes, and these are generally induced by — 
 
 1. Taking cold during menstruation, first giving rise to endo- 
 metritis, then salpingitis, and finally peritonitis. 
 
 2. Gonorrhoea. 
 
 3. Traumatism, passage of sound, applications to the cervix 
 having been known to cause peritonitis. 
 
 4. Septic infection by instruments or during parturition and 
 abortion. 
 
 5. Entrance of foreign substances into the pelvic cavity ; rup- 
 ture of a pyosalpinx or ovarian abscess, or injection of fluids 
 through the uterus and tubes ; hoematocele. 
 
 6. Mechanical irritation ; displaced uterus or ovary ; improperly 
 applied pessary. 
 
PELVIC CELLULITIS OR PARAMETRITIS. 191 
 
 7. New growths ; cancer ; tubercular peritonitis. 
 
 Pelvic cellulitis. Owing to the intimate anatomical connection 
 of the pelvic fascia and peritoneum usually both inflammations 
 result from the same cause. 
 
 What are the symptoms? 
 
 These may be acute or chronic. 
 
 Acute: Sharp chill; temperature not high, 101°-102° ; rapid 
 pulse, 120 or more ; pain and tenderness in lower part of abdomen ; 
 knees drawn up ; tongue furred early ; nausea and vomiting ; con- 
 stant desire to pass water ; severe rectal and vesical tenesmus ; 
 constipation ; tympanites ; sometimes menorrhagia. Temperature 
 may rise later to 105° or 106°, with general involvement of the 
 peritoneum ; but the inflammation usually subsides in a few days, 
 or becomes chronic, or goes on to the formation of an abscess. 
 
 Chronic : The symptoms of the subacute and chronic form may 
 be very indefinite, and at first unrecognized. The whole pelvic 
 contents may be massed together without any symptoms. There 
 are usually dull aching pain in the pelvis, dyspareunia, menor- 
 rhagia, and metrorrhagia. The pain may be intermittent in cha- 
 racter, but all the symptoms may be remittent, with exacerbations. 
 Obstinate constipation, with rectal and vesical tenesmus, is a com- 
 mon symptom. 
 
 What are the physical signs? 
 
 Tenderness on pressure in the fornices ; utero-sacral ligaments 
 thickened, tender, and feeling like tense cords behind the cervix. 
 The uterus may be fixed by adhesions. When the exudation of 
 plastic lymph is considerable, we may get the " cardboard feel," in 
 which the fornices feel hard and resistant, as if plaster of Paris had 
 been poured into the pelvis and hardened. When there is con- 
 siderable serum or pus shut ofi" by adhesions, it may form a tumor 
 behind the uterus and bulge into the vagina. 
 
 What are the complications? 
 
 Diseases of the uterus, ovaries, tubes, bladder, and rectum ; 
 displacements of the uterus and ovaries ; stenosis and inflammation 
 of the tubes, resulting in sterility ; extra-uterine pregnancy ; dis- 
 turbances of menstruation. 
 
 What is the prognosis? 
 
 Mild cases may exist for life and give no discomfort, or may 
 gradually disappear. Large plastic exudations disappear very 
 
192 DISEASES OF THE PELVIC PERITONEUM AND FASCIA. 
 
 slowly, and result in displacements. Serum may be absorbed or 
 go on to suppuration. Pus, more grave, may become encapsulated 
 or rupture into neighboring organs, or give rise to septicaemia, 
 pyaemia, and death. 
 
 What is the differential diagnosis? 
 
 The low temperature may distinguish it from cellulitis. It must 
 be differentiated from fibroid tumors, faecal impaction, and pelvic 
 haematocele. The history will in most cases suffice. 
 
 What is the treatment? 
 
 Acute cases : Absolute rest in bed ; give enough opium or mor- 
 phine to relieve the pain ; limit the inflammation by an ice-bag or 
 coil on the abdomen ; later, apply hot poultices to the abdomen, 
 and give hot vaginal injections ; move the bowels by calomel and 
 an enema. 
 
 Chronic cases : Attend to the general health by the administra- 
 tion of tonics, fresh air, exercise, and keeping the bowels well 
 regulated. 
 
 Hot douches ; tampons of glycerin or ichthyol in glycerin 5 per 
 cent, to 8 per cent. ; painting the fornices with iodine. For the 
 adhesions, properly applied manage or electricity sometimes acts 
 very well. Blisters in the iliac regions are sometimes used. The 
 following prescription is excellent for keeping the bowels regulated 
 in these cases : 
 
 II. Extract, cascara sagrad., fl., ^ss ; 
 
 Tr. nucis vomic, Rv; 
 
 Tr. belladon., n|^iij ; 
 
 Glycerin., ^x; 
 
 Aqua menth. pip. q. s., gj. — M. 
 Ft.sj. 
 
 When there is a collection of pus with no signs of pointing, it 
 must be evacuated and drained. This may be done through the 
 vagina or abdominal wall. 
 
 PELVIC CELLULITIS OR PARAMETRITIS. 
 
 What is the function of cellular tissue ? and where is it found ? 
 
 It acts as a buffer and steadies the pelvic organs ; it binds the 
 organs together. It is found between the bladder and the abdomi- 
 nal wall (the prevesical space of Retzius) ; in front of the cervix ) 
 
PELVIC CELLULITIS OR PARAMETRITIS. 193 
 
 behind the uterus ; between the layers of the broad ligaments ; 
 in the utero-sacral ligaments. 
 
 What are the etiology and pathology of parametritis ? 
 
 The causes are — (1) Septic infection, usually from childbirth or 
 abortions (especially criminal) ; (2) operations on the cervix ; 
 (3) pelvic peritonitis ; (4) cancerous or syphilitic disease. 
 
 The pafhological stages are — (1) Engorgement of the blood- 
 vessels ; (2) exudation of serum, leucocytes, and plastic lymph ; 
 (3) the exudation may resolve, or less frequently go on to the 
 formation of pus, or it may form new connective tissue and 
 remain. 
 
 Cellulitis usually begins in the bases of the broad ligaments, and 
 extends from there. When pus forms, it usually extends around 
 to the prevesical space of Retzius, or it may go posteriorly. Re- 
 cent investigation has shown that most of the cases formerly 
 supposed to be cellulitis are really peritonitis and salpingitis. 
 
 What are the complications? 
 
 Pelvic peritonitis always complicates cellulitis, but cellulitis is 
 not necessarily present with peritonitis. Inflammation of the 
 ovaries and tubes ; displacements of the uterus ; thrombosis of the 
 veins. 
 
 What is the course? 
 
 In cellulitis resulting from criminal abortions or parturition the 
 exudation mass may be absorbed in two or three weeks, or it may 
 remain months and years and become chronic. It may go on to the 
 formation of pus, and the abscess thus formed may rupture into rec- 
 tum, vagina, or bladder, or the pus may follow the inguinal canal 
 and form a labial abscess. Rarely it discharges through the sacro- 
 sciatic or obturator foramen, or into the peritoneal cavity. The 
 abscess may then heal up from the bottom or continue discharg- 
 ing indefinitely. 
 
 What are the ssrmptoms ? 
 
 Acute : These usually appear on the third to the fifth day after 
 labor or abortion : Rigor, fever up to 103°-105° ; sthenic pulse ; 
 pain not in proportion to the symptoms ; leg drawn up on the side 
 where the pain is ; nausea, but rarely any vomiting ; some irrita- 
 bility of the bladder and rectum. (When pus forms there will be 
 septic symptoms and cessation of lochial discharge.) These symp- 
 
 13— Gyn, 
 
194 DISEASES OF THE PELVIC PERITONEUM AND FASCIA. 
 
 toms subside in a few days and the patient gets well, or the disease 
 goes into the chronic form or forms an abscess. 
 
 Chronic : Onset insidious. Patients may go about with a large 
 exudation mass, experiencing only a heavy feeling of weight in the 
 pelvis. The bowels are sluggish, alternating with diarrhoea ; men- 
 struation becomes irregular, profuse, or scanty ; pressure symptoms 
 may be complained of; sciatic pain, etc. ; there may be some vesi- 
 cal and rectal tenesmus. 
 
 What are the physical signs? 
 
 In acute cases the vagina is found dry, hot ; localized tenderness 
 in the fornices, usually to the left of the cervix. Later, an exuda- 
 tion mass, tense, elastic, and moderately tender, is felt bulging into 
 the vagina and pushing the uterus to the other side. The exuda- 
 tion mass is usually lateral, and rarely extends above the brim of 
 the pelvis, as it does in peritonitis. The edge of the broad liga- 
 ment may be felt running to the side of the pelvis. If pus forms, 
 we get fluctuation and other signs of an abscess. 
 
 From what should pelvic cellulitis be differentiated? 
 
 Pelvic peritonitis, salpingitis, pelvic haematocele, fibroids, ovarian 
 tumors, faecal impaction, carcinoffta of rectum high up. 
 
 What is the differential diagnosis between pelvic peritonitis and 
 pelvic cellulitis? 
 
 Pelvic Peritonitis. Pelvic Cellulitis. 
 
 May be caused by inflammations Rarely caused by anything but 
 of the uterus, ovaries, and labor and abortion or opera- 
 tubes, tions on the cervix. 
 
 Pain severe. Pain less severe. 
 
 Temperature not high. Temperature high. 
 
 Exudation mass not apt to bulge Exudation mass usually bulges 
 into vagina, and is usually into the vagina, and is usually 
 bilateral. unilateral. 
 
 Vomiting. Usually no vomiting. 
 
 Suppuration less common. Suppuration more common. 
 In the acute stage it may be very difiicult to difl"erentiate. 
 
 What is the differential diagnosis between salpingitis, containing 
 serum or pus, and pelvic cellulitis. 
 These cases were formerly supposed to be cellulitis. A careful 
 bimanual examination reveals a sausage-shaped elastic tumor in 
 
PELVIC CELLULITIS OR PARAMETRITIS. 195 
 
 salpingitis, extending around the uterus, sometimes fluctuation. 
 The history shows recurrent attacks of peritonitis. The patients 
 are usually run down in health, while in cellulitis they are usually 
 perfectly healthy. In salpingitis the mass does not bulge into the 
 vagina. 
 
 What is the differential diagnosis between pelvic cellulitis and 
 pelvic hagmatocele ? 
 
 Pelvic Cellulitis. Pelvic HBematocele. 
 
 History different from that of History of sharp pain ; symp- 
 pelvic hsematocele. toms of internal hemorrhage, 
 
 pallor, faintness, collapse, etc. 
 (followed by a sharp attack of 
 peritonitis). Physical signs of 
 fluid in the peritoneal cavity. 
 
 What is the differential diagnosis between pelvic cellulitis and 
 fibroid tumors? 
 
 Pelvic Cellulitis. Fibroid Tumors. 
 
 History of inflammation and rapid Slow growth. 
 
 formation of the mass. 
 
 Painful. Not painful or tender. 
 
 Mass fixed. Moves with the uterus. 
 
 Less well defined. More defined. 
 
 Menstruation irregular. Menorrhagia increasing. 
 
 What is the differential diagnosis between pelvic cellulitis and 
 ovarian cysts? 
 
 Ovarian Cysts. Pelvic Cellulitis. 
 
 Slow, painless growth, with no Rapid and painful, with history 
 
 history of fever. of fever. 
 
 No disturbance of menstruation. Disturbance of menstruation. 
 
 Fluctuation. No fluctuation. 
 
 How would you differentiate pelvic cellulitis from carcinoma of the 
 rectum ? 
 
 A rectal examination will reveal the character of the mass, and 
 in carcinoma there will be cachexia. 
 
 What complications arise with cellulitis? 
 
 Endometritis ; salpingitis and distortion of the tubes ; enlarge- 
 ments and displacements of the uterus ; destruction of the ovaries ; 
 sterility. 
 
196 DISEASES OF THE PELVIC PERITONEUM AND FASCIA. 
 
 What is the prognosis ? 
 
 The 2^'^'opiosis is good, the time is uncertain. If suppuration 
 takes phice, and rupture has occurred into the vagina or rectum, or 
 through the abdominal wall, the prognosis is good. If it ruptures 
 into the ureters or bladder, it is bad. 
 
 What is the treatment? 
 
 Frophylactic. — Thorough antiseptic precaution. 
 
 Curative. — (1) Attempt to abort by complete rest; ice-bag over 
 the site of the severest pain. For the pain, opium suppositories. 
 Give Dover's powder, prolonged hot vaginal douches, and poultices 
 may be substituted for the ice-bag. 
 
 (2) After exudation has taken place promote absorption by hot 
 vaginal douches, 2 quarts twice daily ; hot poultices on the abdo- 
 men. Keep up the general nutrition and regulate the bowels. 
 
 (3) In old cases resolvents: vaginal injections, hot sitz-baths, 
 general hot baths, pelvic pack. Counter-irritants : blisters, tr. 
 of iodine, Paquelin cautery. Hydragogues : Glycerin tampons — 
 boroglyceride 1, alum 1, chloral 2, glycerin 15 parts. 
 
 (4) When suppuration take* place, open wherever it points, 
 and drain. 
 
 PELVIC HEMATOCELE AND HEMATOMA. 
 
 Define these. 
 
 A pelvic haematocele is an effusion of blood wholly within the 
 pelvic peritoneal cavity, and which may be enclosed by adhesions. 
 A pelvic hsematoma is an eiFusion of blood outside of the perito- 
 neum into the cellular tissue, usually between the folds of the 
 broad ligaments. They are more common in married women who 
 have borne children than in unmarried ; not infrequent in sterile 
 married women. 
 
 Haematocele is almost always in the pouch of Douglas, dis- 
 placing the uterus forward ; it may be ante-uterine ; haematoma is 
 almost always lateral. 
 
 What are the sources of the effused blood ? 
 
 lleflux of blood from the uterus and Fallopian tubes at time 
 of menstruation, at times due to atresia vagina?; ruptured tubal 
 pregnancy ; ruptured pelvic vessels ; ruptured cyst ; excessive blood 
 from a ruptured Graafian follicle. 
 
 The blood is first fluid, high up, and cannot be felt well. Later 
 
PELVIC HEMATOCELE AND HEMATOMA. 197 
 
 it coagulates and pushes the uterus forward or to one side. Finally 
 it sets up peritonitis (usually twenty-four hours after onset), be- 
 comes enclosed by adhesions, and may go on to suppuration or be 
 absorbed. 
 
 What are the causes? 
 
 Predispomig : marriage state ; frequent childbearing ; mid-men- 
 strual period, twenty to forty years ; profuse menstruation ; 
 anything leading to congestion of the pelvic organs ; diseases of 
 the ovaries, tubes, or pelvic peritoneum (adhesions) ; hard work ; 
 extra-uterine pregnancy ; varicose veins of the broad ligaments ; 
 atresia in the genital tract ; diatheses — bleeders, scurvy ; low state 
 of the system ; working in match-factories. 
 
 Exciting : Violence, usually the result of coitus during men- 
 struation ; blows, falls, etc. ; sudden checking of menstrual flow by 
 cold or emotion. 
 
 The majority of pelvic haematoceles are due to extra-uterine 
 pregnancy. 
 
 What are the symptoms of pelvic haematocele ? 
 
 The previous history usually shows poor health or long-standing 
 pelvic disease, such as chronic pelvic peritonitis. Frequently there 
 is a history of having missed two or three menstrual periods. The 
 onset is usually sudden, ushered in by sharp, tearing pain in the 
 pelvic region, faintness. collapse, pallor, feeble and rapid pulse, with 
 all the other symptoms of an internal hemorrhage. The tempera- 
 ture is normal or subnormal, and there are nausea and sometimes 
 vomiting. In twenty-four hours, if the patient does not die from 
 the initial hemorrhage (usually not), peritonitis is set up. There 
 is a sharp chill, rise of temperature, etc. Then pressure symptoms 
 appear, with more or less dysuria and painful defecation. There 
 may be menorrhagia or the flow may be stopped. 
 
 The symjotoms subside in a few days, and the efl"used blood is 
 slowly absorbed. If suppuration takes place, we get septic symp- 
 toms. 
 
 What are the symptoms of pelvic hsematoma ? 
 
 This usually takes place at a menstrual period or following labor. 
 It may result from a ruptured extra-uterine pregnancy. The symp- 
 toms are much less severe. Shock and pain are less pronounced. 
 The effused blood forms a mass in the exact position of a pelvic 
 cellulitis. The uterus is pushed high up over the symphysis, and 
 
198 DISEASES OF THE PELVIC PERITONEUM AND FASCIA. 
 
 there are pressure symptoms from pressure on the pelvic nerves, blad- 
 der, and rectum. There may be oedema of the lower limbs. 
 
 What are the physical signs of hsematocele and haematoma? 
 
 Hagmatocele is felt as a tense, elastic mass, usually behind the 
 uterus, pushing it well forward against the symphysis. The mass 
 is first fluctuating, then hard. Later on it grows rapidly smaller, 
 harder, and irregular in outline. If suppuration takes place, it 
 usually ruptures into the rectum. HaDmatoma is felt as a smaller 
 mass, usually laterally, between the folds of the broad ligaments, 
 pushing the uterus to one side. It is less tender than a hgematocele. 
 
 What is the course, duration, and termination? 
 
 The course is tedious. If the flow is severe in a hasmatocele, 
 the patient may die at once from shock and hemorrhage. In rup- 
 tured tubal pregnancies the j)'^'Off^osis is bad ; in mild cases it is 
 good, but patients rarely return to health. It may end in disap- 
 pearance, may remain stationary for years, or it may suppurate. 
 The prognosis in pelvic hsemaloma is good. 
 
 What is the differential diagnosis between pelvic hsematocele 
 and the following diseases ? 
 
 Pelvic Hsematocele. Pelvic Peritonitis. 
 
 History of sudden pain, shock, History of more gradual onset, 
 
 fainting, etc., followed by in- with signs of inflammation 
 
 flammation. from the beginning. 
 
 Uterus displaced. Uterus not displaced, but fixed. 
 
 Pelvic Hsematocele. Pelvic Cellulitis. 
 
 History of sudden onset, with History of onset following labor, 
 sharp pain, shock, hemorrhage, etc., and with inflammation 
 etc. from the outset. 
 
 Tumor at first soft, later irregular. 
 
 Less tender. More tender. 
 
 Pelvic Hsematocele. Fibroid Tumors. 
 
 Rapid and sudden development. Slow growth. 
 
 History. History. 
 
 Sensitive. Not sensitive. 
 
 Not attached to the uterus. Attached to the uterus. 
 
MENSTKUATION. 199 
 
 Pelvic Hdematocele. Ovarian Cysts. 
 
 Sudden onset. Gradual development. 
 
 History. History. 
 
 Sensitive. Less sensitive. 
 
 First soft, then hard. Fluctuating. 
 
 What is the differentiation from faecal impaction? 
 
 Be sure and empty the rectum. 
 
 What from carcinoma? 
 
 Chronic history ; uterus not displaced. 
 
 What is the treatment of pelvic haematocele ? 
 
 Expectant : Check the hemorrhage ; absolute rest in bed ; ice 
 on abdomen and pressure by a sand-bag ; hypodermic of morphine ; 
 open the bowels early. If the cause of the hemorrhage is a rup- 
 tured extra-uterine pregnancy, open the abdomen at once under the 
 antiseptic preparations for any laparotomy ; wash out the effused 
 blood ; clamp the bleeding points and tie off the ruptured tube and 
 broad ligament, and remove ; wash out the abdomen with hot 
 distilled water; insert a drainage-tube, and close the abdomen. 
 
 In the second stage treat the symptoms of peritonitis. 
 
 In the third stage promote absorption of the effusion by external 
 and internal counter-irritants and hot vaginal injections. If sup- 
 puration takes place and points in the vagina, open and drain here ; 
 otherwise, open the abdomen, and, if possible, remove the entire 
 mass, or open from the vagina and drain. 
 
 What is the treatment for pelvic hsematoma? 
 
 Absolute rest in bed, cold on the abdomen, opium ; later, hot 
 douches, poultices, and external and internal counter-irritants. 
 If suppuration takes place, open and drain through the vagina 
 or throuoli the abdomen. 
 
 '&' 
 
 MENSTRUATION. 
 
 What is meant by puberty ? and what by the menopause or cli- 
 macteric ? 
 
 Puberty marks the transition from childhood to womanhood, 
 when the several organs develop and menstruation commences. It 
 marks the commencement of the childbearing period. The climac- 
 teric period, or change of life, is that period when menstruation ceases 
 
200 DISORDERS OF MENSTRUATION. 
 
 and an atrophy of the pelvic organs takes place. Both periods 
 are influenced by climate, heredity, and habits of life. 
 
 Puberty usually begins at about the fourteenth year, earlier in 
 hot climates, and menstruation ceases usually between the ages of 
 forty-two and forty-five. During both these periods the entire sys- 
 tem feels the change, and various pathological phenomena may be 
 developed. The climacteric period usually lasts about two years. 
 
 What are phenomena of normal menstruation ? 
 
 The chief feature of menstruation is the periodical discharge of 
 blood from the uterine cavity (every twenty-eight days), which lasts 
 normally between four and five days. The amount varies in indi- 
 viduals. This discharge of blood depends upon the presence of 
 the ovaries,* and is supposed to coincide with the rupture of a 
 Graafian follicle. The superficial and glandular epithelium of the 
 mucous membrane lining of the cavity of the uterus undergoes 
 fatty degeneration once a month, disintegrates, and is cast off". 
 The exposed capillaries beneath are readily ruptured, and cause 
 the bleeding. When the congestion of the pelvic organs is relieved, 
 the flow ceases. The lining membrane of the uterus is now repro- 
 duced by a proliferation of the cells beneath the former layer. 
 
 DISORDERS OF MENSTRUATION. 
 
 What are the disorders of menstruation ? 
 
 Amenorrhoea, monorrhagia, metrorrhagia, dysmenorrhoea, vicari- 
 ous menstruation. All of these are symptoms of more or less well- 
 defined diseases, and not diseases themselves. 
 
 AmenorrhcBa. 
 
 What is meant by amenorrhoea? and what are its causes, prog- 
 nosis, and treatment? 
 
 Amenorrhoea is the absence of menstruation occurring between 
 the ages of puberty and the menopause. During the periods of 
 pregnancy and lactation it is purely physiological. 
 
 What are the causes? 
 
 Local. — Non-development of the generative organs ; atrophy 
 of the uterus and ovaries ; local inflammation of the ovaries ; 
 occlusion of some portion of the genital tract. 
 
 Constitutional. — Debilitating diseases, such as phthisis, etc. ; 
 
 * According to Lawson Tait, the Fallopian tubes have more influence. 
 
DISORDERS OF MENSTRUATION. 201 
 
 anaemia, chlorosis ; plethora ; mental emotions ; cold and wet, as 
 wetting the feet during menstruation ; poor food ; changes of cli- 
 mate, as seen in immigrants ; obesity. 
 
 What is the prognosis? 
 
 This depends upon the exciting causes. If these can be removed 
 the jyrocfnosis is good. Amenorrhoea due to non-development of 
 the generative organs is usually incurable. 
 
 What is the treatment? 
 
 When due to non-development of the generative organs and 
 absence of the ovaries, nothing can be done. When due to ansemia 
 and chlorosis, give Blaud's pills, 2 t. i. d.pc. ; regulate bowels ; good 
 food ; fresh air and exercise. Permanganate of potash and the 
 black oxide of manganese are recommended. A pill containing 
 iron and aloes is sometimes very effectual. When due to imperfect 
 development and with presence of the ovaries, tonics of quinine, 
 iron, and arsenic ; hot douches ; boroglyceride tampons ; electricity, 
 faradic current. For the acute suppression of menstruation due to 
 exposure to cold and wet. hot-water foot-baths and hot sitz-baths ; 
 aconite internally. When due to phthisis and other debilitating 
 diseases the treatment is that of the disease. 
 
 Menorrhagia and Metrorrhagia. 
 
 Define menorrhagia and metrorrhagia. 
 
 Menorrhagia means a profuse menstruation ; metrorrhagia means 
 a discharge of blood from the generative tract between menstrual 
 periods. 
 
 What is the etiology ? 
 
 Menorrhagia and metrorrhagia nearly always indicate local dis- 
 ease of the lining membrane of the uterus, endometritis, fibroid 
 tumors of the uterus and polypi, subinvolution, chronic metritis, 
 retained secundines after abortion, salpingo-obphoritis, carcinoma, 
 sarcoma and laceration of cervix ; other causes, acting indirectly, 
 are cardiac disease, engorgement of the portal circulation, certain 
 wasting diseases, and malaria, menopause, scurvy, haemophilia. 
 
 What is the treatment? 
 
 The causes will indicate the treatment, but there will usually 
 be found coexisting diseases of the endometrium, requiring local 
 interference — i. e. curetting. The patient is placed in Sims's posi- 
 
202 DYSMENOERHCEA. 
 
 tion, Sims's speculum introduced, the cervix dilated with Peaslee's 
 and Goodell's dilators, and the endometrium thoroughly scraped out 
 with a Thomas dull curette or a Sims curette. Strict antisepsis 
 must be observed. The uterus is then thoroughly irrigated with 
 hot 1 : 100 carbolic, to which iodine may be added if the hemor- 
 rhage is profuse. The uterine cavity is then painted with iodized 
 phenol (iodine gr. Ix, carbolic acid 5J), and an iodoform gauze 
 tampon introduced. Drugs, such as ergot, hydrastis Canadensis, 
 and cannabis Indica, are sometimes useful in decreasing the flow. 
 Ergot and hydrastis should be administered for several days after 
 a curetting. 
 
 Fibroids may require to be removed thoroughly, or the removal 
 of the ovaries and tubes. Carcinoma and inflammations of the 
 ovaries and tubes require their own treatment. Retained secun- 
 dines must be removed by curetting as described. 
 
 Vicarious 'Menstruation. 
 
 What is meant by this? 
 
 A discharge of blood from some part of the body other than the 
 uterus at the menstrual epoch. It may be associated with amenor- 
 rhoea and scanty menstruation, and indicates a watery condition 
 of the blood, with a constitutional tendency to bleed. The blood 
 may come from the nose, mouth, throat, JDreasts, open sores, or 
 wounds. 
 
 What is the treatment? 
 
 When this is associated with amenorrhoea, the cure of this will 
 usually stop the vicarious menstruation. If not troublesome, no 
 special treatment is indicated. 
 
 Dysmenorrhcea. 
 
 Define dysmenorrhoea. 
 
 The term dysmenorrhoea signifies an abnormal amount of pain 
 at the time of the menstrual epoch, occurring just before, during, 
 and just after menstruation. It is a symptom, and not a disease 
 by itself. 
 
 How is dysmenorrhoea classified for convenience? 
 
 The varieties of painful menstruation mentioned are neuralgic, 
 ovarian., congestive, obstructive, and memhranous ; but they cannot 
 be distinctly separated, being often combined. 
 
DISORDERS OF MENSTRUATION. 203 
 
 Give the etiology, symptoms, prognosis, and treatment of neuralgic 
 dysmenorrhoea. 
 
 Etiology. — No pathological changes can be detected in the pelvic 
 organs. The same causes producing neuralgia in other parts of 
 the body may act on the pelvic organs — enervating habits, anaemia, 
 or anything depressing the system ; hysteria, masturbation, rheuma- 
 tism, and gout ; lacerations of the cervix. Sometimes no cause can 
 be found. It is often associated with other varieties. 
 
 Symptoms. — The pain is of a sharp, fixed character or lancinat- 
 ing and colicky. It may be referred to the uterus or ovaries or 
 rarely to some distant part of the body. The pain usually appears 
 before the flow, and continues less severe during the discharge, but 
 it may stop with the onset of the flow. It varies in intensity. 
 
 During the intermenstrual period the patients frequently have 
 neuralgia elsewhere. 
 
 Prognosis. — If the patients can be built up in health and adopt 
 good treatment for a cure, recovery is probable. Parturition is 
 said sometimes to produce a cure. 
 
 Treatment. — This is indicated by the predisposing cause. The 
 same treatment as for neuralgia in other parts of the body. Ton- 
 ics, complete change of mode of life and climate, fresh air, exer- 
 cise, sound introduced just before the period, or rapid dilatation, 
 electricity. For the pain, suppositories of cannabis Indica and 
 belladonna or of opium may be given. The tine, of piscidia in tt\^xx 
 doses is highly recommended. Hot sitz-baths. Hayden's vibur- 
 num compound is excellent. 
 
 Give the etiology, symptoms, and treatment of ovarian dysmen- 
 orrhoea. 
 
 Etiology. — It is supposed to be due to disease of the ovaries, but 
 there is often grave disease of the ovaries without any painful 
 menstruation. 
 
 Symptoms.— Voin in the intervals between the menses, coming on 
 a few days before the flow and diminishing with it. The pain is 
 of a dull, aching character, accompanied by tenderness over the 
 region of the ovaries. There may be nervous phenomena and dis- 
 turbances in the tracts. 
 
 Treatment. — For ovaritis build up general health ; Battey's ope- 
 ration as a last resort. 
 
 Define congestive dysmenorrhoea. 
 
 This form is characterized by an excessive congestion of the ute- 
 
204 DYSMENORRHCEA. 
 
 rus and appendages during menstruation, owing to an abnormal state 
 of these organs, which gives rise to pain. 
 
 What is the etiology? 
 
 Peri uterine inflammation, salpingitis, displacements of the ute- 
 rus, uterine fibroids, endometritis, chronic metritis, exposure to cold 
 and wet during menstruation, plethora. 
 
 What are the symptoms? 
 
 Sudden pain at the menstrual period. This may last during the 
 whole period or become gradually less. It is usually accompanied 
 by a decrease or stoppage of the flow, and some constitutional dis- 
 turbances — fever, headache, nausea, constipation, rapid pulse, etc. 
 
 What is the prognosis? 
 
 Good if the cause can be removed. 
 
 What is the treatment? ^ 
 
 Correct the causes. When due to exposure to cold and wet 
 during a period, have the patient soak her feet in a hot mustard 
 foot-bath ; wrap up in blankets and go to bed ; aid perspiration by 
 diaphoretics ; make hot applications to the pelvis. In the inter- 
 menstrual period give hot vaginal douches ; glycerin tampons ; scar- 
 ify the cervix ; prevent tight lacing and hanging heavy skirts on 
 the waist. For the pain the same remedies as for the neuralgic 
 form may be used. 
 
 Define obstructive dysmenorrhoea. 
 
 This form of dysmenorrhoea is due to an obstruction to the flow 
 which may be situated in the cervix or vagina. It is not nearly as 
 common as was supposed. 
 
 What is its etiology? 
 
 Contraction of cervical canal, congenital, or acquired by the ap- 
 plication of strong caustics, labor, or operations on the cervix. The 
 stenosis may be at the external or internal os : the latter is much 
 more commonly a cause of pain than the former. Additional 
 causes are flexions of the uterus, fibroids and polypi, stenosis of 
 the vagina, long conical cervix, spasmodic contractions of the 
 internal os. 
 
 What are the symptoms? 
 
 Pain of a colicky expulsive character, situated in the pelvis and 
 accompanied by the passage of clots. This is due to the collection 
 
DISORDEES OF MENSTRUATION. 205 
 
 of blood distending the uterine cavity until labor-like pains are 
 excited. Uterine contractions finally overcome the obstruction, 
 and there is a gush of blood and clots. This may be repeated until 
 the flow comes. The internal os in these cases is often found hyper- 
 aesthetic on the passage of a sound. 
 
 What is the treatment? 
 
 This consists in removing the cause of the obstruction ; mechani- 
 cal dilatation with Peaslee's graduated dilators and steel branched 
 dilators ; vaginal strictures may be treated by dilatation or divis- 
 ion. 
 
 Describe the method of dilating the cervix. 
 
 The patient may be placed in Sims's or the lithotomy position 
 on the edge of a table. A Sims speculum is introduced, and the 
 parts thoroughly irrigated with 1 : 2000 bichloride. The anterior 
 lip of the cervix is grasped with a pair of bullet forceps and drawn 
 down. The curve of the uterus having been previously ascertained, 
 the smallest sized sound is introduced, and allowed to remain a few 
 minutes ; then a larger sized is used, etc. ; finally a steel branched 
 dilator is introduced and expanded. The canal may be kept patent 
 by means of an Outerbridge wire stem, or by the passage of a 
 graduated sound every few weeks. An anaesthetic is not always 
 necessary in these cases. 
 
 Define membranous dysmenorrhoea. 
 
 Membranous dysmenorrhoea is the expulsion of the lining mem- 
 brane of the uterine cavity, whole or in pieces, at the menstrual 
 period. 
 
 What is its etiology? 
 
 The true cause of this affection is not known. It may be associ- 
 ated with metritis or endometritis, and is usually found in cases of 
 poor general health. The membrane consists of the superficial 
 layer of the endometrium, with an excess of the round cells and 
 fibres. It is usually triangular in form, its internal surface being 
 smooth and its external shaggy. It presents numerous perforations, 
 the openings of the utricular glands. The blood collects under 
 this membrane and dissects it off. 
 
 What are the symptoms? 
 
 Severe pain at the commencement of the flow, increasing in 
 
206 ELECTRICITY IN GYNECOLOGY. 
 
 severity until the membrane is discharged. This usually takes 
 place on the third day, and the pain ceases. The flow is usually 
 profuse. 
 
 For what is this liable to be mistaken? 
 
 Early abortion. It can be differentiated from this by its repeti- 
 tion, by the absence of chorionic villi, and by the absence of the 
 symptoms of pregnancy. 
 
 What is the treatment? 
 
 It is very difficult to cure. Dilatation and curetting, followed 
 by painting the endometrium with iodized phenol or iodine, may 
 be resorted to. For the pain give hot sitz-baths and hot applica- 
 tions to the pelvis, together with the drugs mentioned for neuralgic 
 dysmenorrhoea. ^ 
 
 ELEOTRIOITY IN GYNECOLOGY. 
 
 What apparatus is required? 
 
 1. Galvanic Battery. — Made up of at least 30 cells, with large 
 elements (per ex. : zinc and carbon plates 6X9 inches in a solution 
 of bichromate of potash and sulphuric acid). 
 
 Accessories to Galvanic Battery. — Rheostat^ to regulate the 
 strength of the current by regulating the amount of resistance in 
 the circuit ; milliampere meter, to indicate the strength of the 
 current. 
 
 2. Faradic Battery. — The most convenient is one in which the 
 primary current is generated by a single dry cell. 
 
 3. Conducting Wires. 4. Electrodes. — Large flat electrode with 
 sponge or soft clay surfaces for the abdomen, and a variety of 
 electrodes with insulated stems and cylindrical, globular, or sharp- 
 pointed metal or carbon tips for vaginal and intra-uterine use or 
 for electro-puncture. 
 
 What are the therapeutic effects ? 
 
 Relief of pain (mild faradic current) ; stimulation of growth 
 and function in the uterus and ovaries (medium faradic current) ; 
 hajmostatic (faradic or the positive pole of the galvanic battery) ; 
 absorption of inflammatory masses and adhesions (negative gal- 
 vanic pole) ; destruction of vitality in the foetus in extra-uterine 
 
ELECTRICITY IN GYNECOLOGY. 207 
 
 gestation (galvanic current) ; alterative effect upon neoplasms, 
 especially fibro-myoma (galvanic current). 
 
 What are the indications for the use of electricity ? 
 
 Acute Injlammations. — Mild faradization, and, as a rule, not in- 
 tra-uterine. 
 
 Adhesions and Exudations. — Negative pole in the vagina and 
 a galvanic current of fifteen to fifty milliamperes passed for ten 
 minutes. Galvano-puncture has been recommended, but is less 
 free from danger. 
 
 Amenorrlioia and Dysmenorrhoea. — Spinal galvanization, one 
 pole over the nape of the neck and one over the sacrum ; or the 
 faradic current, with one pole over the lumbar vertebrae and one 
 over the hypogastrium ; or one pole over the hypogastrium and 
 one in the cavity of the uterus, the current being either faradic 
 or galvanic (negative pole in uterus). 
 
 Cervical and Corporeal Endometritis. — The negative galvanic pole 
 is in the uterine cavity, and a current of twenty or thirty milliam- 
 peres is passed for twenty minutes three times a week. For chronic 
 cases the strength of the current may be gradually increased to 
 one hundred or even two hundred milliamperes, but the sittings 
 should be very short. 
 
 Menorrhagia and Metrorrhagia. — The mild faradic current, with 
 one pole in the uterus, sittings daily for twenty or thirty minutes, 
 is quite effective. In extreme cases the positive electrode of the 
 galvanic battery may be placed in the uterine cavity, and a current 
 passed strong enough to act as a cauterant. 
 
 What is the value of electricity in uterine fibro-myoma ? 
 
 This is the chief condition for which the use of electricity has 
 been praised in gynecology ; it is also the one for which very many 
 eminent practitioners consider electricity valueless. The details 
 of the treatment have already been given. The best results are 
 obtained in the submucous variety, in which the hemorrhage may 
 be well controlled, extrusion favored, and the growth often arrested. 
 In the interstitial form similar results may sometimes be obtained, 
 but in the subserous form benefit is rare and the risks are greater. 
 
 Describe the method of administering electricity in ovarian irri- 
 tation. 
 
 A large ball electrode, positive, is placed in the vagina, and a 
 
208 ELECTRICITY IN GYNECOLOGY. 
 
 galvanic current of ten milliamperes is passed for twenty minutes 
 twice a week. 
 
 What are the results of the use of electricity in gynecology ? 
 
 In a certain proportion of cases in the above classes the results 
 are excellent ; in other eases the results are discouraging. While 
 not a panacea, it is still a legitimate and desirable means of treat- 
 ment in gynecological diseases. 
 
INDEX. 
 
 A. 
 
 Amenorrhoea, 200 
 
 Applications through the speculum, 
 126, 127 
 
 B. 
 
 Battey's operation, 184 
 Bladder, anatomy, 77, 78 
 diseases, 79 
 
 C. 
 
 Caruncle, urethral, 56 
 Catarrh of the cervix, 137 
 Cervix, carcinoma, 161. 
 symptoms, 162 
 treatment, 163 
 operative, 164 
 catarrh, 137 
 
 treatment, 138 
 erosions, 136 
 laceration, 139 
 Coccyodynia, 56 
 Colpocystotomy, 80 
 Colporrhaphy, 76 
 Cord, hydrocele, 49 
 Curette, 37-39 
 Cystitis, 79, 80 
 Cystocele, 64 
 
 I>. 
 
 Dilatable tubes, 37 
 Dilators, 35, 36 
 Dysmenorrhoea, 202 
 varieties, 202-205 
 
 Electricity, 206 
 
 14— Gyn. 
 
 E. 
 
 Endometritis, 128 
 acute, 128 
 chronic, cervical, 135, 137 
 
 corporeal, 129 
 fungous, 131 
 
 treatment, 132-134 
 glandular, 130 
 interstitial, 130 
 mixed, 130 
 Enterocele, 64 
 Examination, 18 
 bimanual, 21, 22 
 physical, 18-20 
 rational, 18 
 rectal, 22, 23 
 External organs of generation, 40 
 anatomy, 40-45 
 diseases, 45 
 Extra-uterine pregnancy, 187 
 varieties, 187 
 
 F. 
 
 Fallopian tubes, auatomy, 170, 171 
 Fistulas, 80 
 
 operations, 82-84 
 
 vesico-uterine, 81 
 
 vesico-vaginal, 81 
 
 G. 
 
 Gynecological disease, causation, 17, 
 18 
 diagnosis, 18 
 
 H. 
 
 Hsematosalpinx, 186 
 Hsematothorax, 62 
 Hysterectomy, abdominal, 164 
 vaginal, 1G4 
 
 209 
 
210 
 
 INDEX. 
 
 Laceration of the cervix, 139 
 
 operations for, 142-145 
 
 site, 140 
 
 symptoms, 141 
 
 treatment, 142 
 Lacerations of the perineum, 67 
 
 causes, 68 
 
 operations, 69-71 
 
 symptoms, 69 
 
 varieties, 68 
 
 M. 
 
 Menorrhagia, 201 
 Menstruation, 199 
 
 disorders of, 200 
 
 normal, 200 
 
 vicarious, 202 
 Metritis, 118 
 
 acute, 118 
 
 chronic, 119-122, 124, 125 
 of the cervix, 121 
 operative treatment, 125 
 Metrorrhagia, 201 
 
 o. 
 
 Oophorectomy, 184 
 Ovaries, abscess, 177 
 
 anatomy, 170, 171 
 
 apoplexy, 175 
 
 atrophy, 173 
 
 dis])lacements, 173 
 
 hernia, 174 
 
 inflammations, 175 
 
 malformations, 172 
 
 neoplasms, 177 
 cysts, 178 
 
 diagnosis, 179-181 
 treatni(>nt, 181 
 
 prolapse, 174 
 Ovariotomy, 1S2 
 Ovaritis, acute, 175 
 
 chronic, 176 
 
 P. 
 
 Parametritis, 192-195 
 Parovarian cysts, 181 
 Pelvic cellulitis, 192-195 
 
 Uoor, 65-67 
 
 hai'matocele, 196 
 
 Pelvic hematocele, diagnosis, 198 
 symptoms, 197 
 treatment, 199 
 hsematoma, 196 
 diagnosis, 198 
 symptoms, 197 
 treatment, 199 
 lacerations, 67 
 peritoneum, 188, 189 
 peritonitis, 188, 190 192 
 Perineal body, 65-67 
 Perineorrhaphy, 71-76 
 Pessaries, 110, 111 
 Position, Sims's, 23 
 Prolapsus urethrfe, 57 
 Pyosalpinx, 186 
 
 Eectocele, 64 
 
 K. 
 
 S. 
 
 Salpingitis, 185 
 Salpingo-oophorectomy, 187 
 Sims's tenaculum, 28 
 Sounds, steel and hard-rubber, 34, 35 
 
 uterine, 29 
 Specula, 23 
 
 bivalve, 27, 28 
 
 Cleveland's, 26 
 
 Fergusson's, 26 
 introduction, 26 
 
 Simon's, 26 
 
 Sims's, 23 
 
 introduction, 24, 25 
 Staffordshire knot, 183 
 
 T. 
 
 Tait's operation, 184 
 Tents, 32, 33 
 
 introduction, 34 
 Trachelorrhaphy, 143 145 
 
 u. 
 
 Urethra, anatomy, 77 
 
 diseases, 79 
 Urethritis, 79 
 Uterine catheter, 40 
 
 sound, 29, 30 
 introduction, 31 
 Uterus, amputation, 169 
 
INDEX. 
 
 211 
 
 uterus, anatomy, 84-90 
 anteflexion, 104, 105 
 anteversion, 102, 103 
 atrophy, 96, 97 
 descent, 114, 115 
 
 displacements, 97, 98, 101, 102, 117 
 hypertrophy, 95, 96 
 inversion, 165, 167 
 complete, 166 
 diagnosis, 167 
 partial, 166 
 treatment, 168, 169 
 malformations, 90-95 
 neoplasms, 146 
 adenoma, 165 
 carcinoma, 161 
 fibro-cystic tumor, 157 
 fibro-myomata, 146 
 symptoms, 151-154 
 treatment, 154 
 
 operative, 155-157 
 varieties, 147-150 
 polypus, 158 
 
 symptoms, 159, 160 
 treatment, 160 
 sarcoma, 165 
 prolapse. 114, 115 
 
 treatment, 116, 117 
 retroflexion, 106-109 
 
 operative treatment, 113, 114 
 treatment, 109, 110 
 retroversion, 106-109 
 
 operative treatment, 113, 114 
 
 V. 
 
 Vagina, cysts, 61 
 diseases of, 57 
 
 Vagina, displacements, 63 
 
 malformations, 61, 62 
 
 prolapse, 63 
 
 ulcers, 61 
 Vaginismus, 55 
 Vaginitis, 57 
 
 catarrhal, 58, 59 
 
 children, 57 
 
 cystic, 61 
 
 follicular, 61, 62 
 
 gonorrhceal, 59, 60 
 
 ulcerative, 60 
 Volsella, 28 
 Vulva, cutaneous attections, 53 
 
 cysts, 46 
 
 diseases, 45 
 
 eczema, 52 
 
 elephantiasis, 49 
 
 heematocele, 47 
 
 hemorrhage, 47 
 
 hernia, 46 
 
 hyperesthesia, 55 
 
 malformations, 45 
 
 nervous aff"ections, 53, 54 
 
 oedema, 47 
 
 parasites, 53 
 
 tumors, 45, 46 
 
 ulcers, 53 
 
 varicocele, 47 
 Vulvitis, 49 
 
 catarrhal, 49, 50 
 
 diphtheritic, 51 
 
 follicular, 51 
 
 gangrenous, 52 
 
 gonorrhceal, 50 
 
 phlegmonous, 51 
 Vulvo-vagiual glands, abscess, 48 
 
 cyst, 48' 
 
RGlll 
 
 Bratenahl 
 
 B73