Get the Best DORLAND'S The New St ar- 1 *** ' ; V AMERICAN ILLUSTRATED MEDICAL DICTIONARY A New am Dentist! new an of Bad Operati< ment, e Pocket flexible JUST I H con This boo) tionary, and finest quality, and is just th stant referem defines hundi is especially i great practica A new featur them in color " I must ac COLLEGE OF PHYSICIANS AND SURGEONS tively small sps finding some of Reference Library Given by Surgery, her with ns, etc.; Diseases, f Treat- imerican i in full )RDS tm nts' dic- er of the e leather, r. for con- >rds, and nary. It ndred of Methods, many of \ ithin rela- Lerested in :ll Park, Professor of Principles and Practice of Surgery and LUnicaL Surgery, University of Buffalo. " Dr. Dorland's Dictionary is admirable. It is so well gotten up and of such convenient size. No errors have been found in my use of it." — Howard A. Kelly, Professor of Gyne- cology, fohns Hopkins University, Baltimore. W. B. SAUNDERS COMPANY, 925 Walnut St., Phila. London: 9, Henrietta Street, Covent Garden Sixth Edition, Just Issued With Complete Vocabulary THE AMERICAN POCKET MEDICAL DICTIONARY EDITED BY W. A. NEWMAN DORLAND, A.M., M. D., Assistant Demonstrator of Obstetrics, University of Pennsylvania. HUNDREDS OF NEw" TERMS Bound in Full Leather, Limp, with Gold Edges. Price, $1.00 n«ti with Patent Thumb Index, $1.25 net. The book is an absolutely new one. It is not a revi- sion of any old work, but it has been written entirely anew and is constructed on lines that experience has shown to be the most practical for a work of this kind. It aims to be complete, and to that end contains practically all the terms of modern medicine. This makes an unusually large vocabu- lary. Besides the ordinary dictionary terms the book contains a wealth of anatomical and other tables. This matter is of particular value to students for memorizing in preparation for examination. " I am struck at once with admiration at the compact size and attractive ex- terior. I can recommend it to our students without reserve." — James W. Hol- land, M. D., of Jefferson Medical College. ** This is a handy pocket dictionary, which is so full and complete that it puts to shame some of the more pretentious volumes." — Journal of the American Medical Association. " We have consulted it for the meaning of many new and rare terms, and have not met with a disappointment. The definitions are exquisitely clear and concise. We have never found so much information in so small a space." — Dublin Journal of Medical Science. " This is a handy little volume that, upon examination, seems fairly to fulfil the promise of its title, and to contain a vast amount of information in a very small space. . . . It is somewhat surprising that it contains so many of the rarer terms used in medicine." — Bulletin Johns Hopkins Hospital, Baltimore. W. B. SAUNDERS COMPANY, 925 Walnut St., Phila. London: 9, Henrietta Street, Covent Garden ESSENTIALS OF GYNECOLOGY. Since the issue of the first volume of the Saunders Question=Compends, OVER 290,000 COPIES of these unrivalled publications have been sold. This enormous sale is indisputable evidence of the value of these self-helps to students and physicians. Cx • 'gJ L * — . SAUNDERS' QUESTION-COMPENDS._ No. iO. ESSENTIALS OF GYNECOLOGY ARRANGED IN THE FORM OF QUESTIONS AND ANSWERS PREPARED ESPECIALLY FOR STUDENTS OF MEDICINE BY EDWIN B* CRAGIN, M*D. Professor of Obstetrics and Gynecology, College of Physicians and Surgeons, New York; Attending Physician to the Sloane Maternity Hospital; Consulting Gyne- cologist to the New York Infirmary for Women and Children ; Consulting Obstetric Surgeon, City Maternity Hospital, the Sydenham Hospital, and the New York Infant Asylum ; Consulting Gynecologist and Obstetrician to the Lincoln Hospital and Home SEVENTH EDITION, THOROUGHLY REVISED BY FRANK S. MATHEWS, M.D. Instructor in Gynecology, College of Physicians and Surgeons, New York ; Associate Surgeon, St. Mary's Free Hospital for Children; Assistant Surgeon to the General Memorial Hospital; Attending Gynecologist, Roose- velt Hospital, Out-Patient Department WITH 59 ILLUSTRATIONS PHILADELPHIA AND LONDON W. B, SAUNDERS COMPANY J909 Set up, electrotyped, printed, and copyrighted February, 1890. Reprinted September, 1890. Revised, reprinted, and recopyrighted June, 1891. Reprinted November, 1892. Revised, reprinted, and recopyrighted February, 1894. Reprinted June, 1895. Revised, reprinted, and recopyrighted October, 1897. Reprinted May, 1899. Revised, reprinted, and recopyrighted July, 1901. Reprinted May, 1903. Revised, reprinted, and recopyrighted August, 1905. Reprinted June, 1906. Revised, reprinted, and re- copyrighted August, 1909 Copyright, 1909, by W. B. Saunders Company PRINTED IN AMERICA PRESS OF W. B. SAUNDERS COMPANY PHILADELPHIA PREFACE TO SEVENTH EDITION The frequent editions through which this little work has passed seem to indicate that it occupies a useful niche in the book-world, and therefore justifies an at- tempt once more to make it harmonize with present ideas and teaching. E. B. C. 9 PREFACE TO FIRST EDITION. No one appreciates more fully than the Author the inadequacy of this little work for a thorough study of Gynaecology. This has not been the aim. He only hopes that as a means of review and as a summary of the results of more extensive reading, the student may find the work of some value. The Author wishes also to state that in its compilation he has freely consulted, and made use of, the standard works of Hart and Barbour, Thomas, Schroeder, The American System of Gynaecology, notes on the lectures of Prof. Geo, M„ Tuttle at the College of Physicians and Surgeons, New York, and numerous journals. E. B. C. n CONTENTS PAGE Mons Veneris 17 Labia Majora 17 Labia Minora IS Clitoris 18 Vestibule 20 Fourchette 20 Fossa Navicularis 20 Bulbs of the Vestibule 20 Vulvo-vaginal Glands , 21 Hymen ■ 21 Vagina 21 Vaginal Secretion 22 Uterus 24 Mucous Membrane of Uterus 25 Fallopian Tubes 31 Ovaries 33 Parovarium , 35 Urinary Tract 35 Bladder 36 Kectum 38 Pelvic Floor 40 Perineal Body 41 Muscles of the Perineum 42 Ischio-rectal Fossa 42 Development of Pelvic Organs 43 Physical Examination of Pelvic Organs 43 Positions for Examinations 44 Vaginal Examination 45 Bimanual Examination , 46 Rectal Examination 48 Instruments 49 Specula 49 The Sims Speculum 49 13 14 CONTENTS PAGE Instruments, Specula, the Simons Speculum 51 The Fergusson Speculum 52 The Brewer Speculum 53 Cystoscopes - 54 Volsella 55 Uterine Sound 56 Uterine Probe 60 Uterine Applicator 60 Dilators 60 Tents 60 Graduated Hard Dilators 61 Elastic Dilators 63 Stem Pessaries , 64 The Curette ♦ . . 64 Drugs Acting on the Pelvic Organs 66 Vulvitis i 68 Acute Simple Catarrhal 68 Chronic Catarrhal 69 Gonorrhoea and Gonorrhoea! 69 Phlegmonous 72 Croupous 74 Gangrenous ... 74 Follicular 74 Cyst and Abscess of Vulvo-vaginal Gland 75 Pudendal Hernia 77 Pudendal Hematocele 77 Haemorrhage from Vulva ■ 79 Skin Diseases of the Vulva 79 Erythema of the Vulva 79 Eczema of the Vulva 80 Herpes of the Vulva 81 New Growths of the Vulva 81 Simple Papillomata 81 Pointed Condylomata 82 Syphilitic Condylomata 82 Adherent Prepuce 82 Pruritus Vulvae 83 Kraurosis Vulvae 84 Hyperesthesia of the Vulva 85 Vaginismus 86 Coccygodynia 86 Irritable Urethral Caruncle 87 CONTENTS 15 PAGE Prolapse of Urethral Mucous Membrane 88 Malformations of the Vulva 89 Diseases of the Vagina . 89 Bacteria of the Vagina 89 Simple Catarrhal Vaginitis • 90 Gonorrheal Vaginitis 91 Ulcerative Vaginitis 92 Croupous Vaginitis 93 Pelvic Peritoneum 93 Pelvic Peritonitis 94 Pelvic Cellulitis 97 Pelvic Hematocele and Hematoma 100 Menstruation 104 Disorders of Menstruation 105 Amenorrhoea 105 Vicarious Menstruation 107 Menorrhagia and Metrorrhagia 107 Dysmenorrhcea 108 Obstructive 109 Congestive , . . . . 110 Neuralgic Ill Ovarian . m Membranous . HI Sterility 113 Malformations of the Vagina 115 Atresia of the Vagina 115 Stenosis of the Vagina „ 117 Malformations of the Uterus 117 Displacements of the Uterus 122 Anteversion , 122 Anteflexion 122 Retroversion and Retroflexion 125 Pessaries 130 Alexander's Operation 133 Hysterorrhaphy 135 Prolapsus Uteri 137 Laceration of the Perineum and Relaxation of Vaginal Outlet . . 141 Hegar's Operation „ . . 143 Emmet's Operation 144 Saenger-Tait Operation 146 Warren's Operation 150 Noble's Operation 150 16 CONTENTS PAGE Laceration of the Perineum and Relaxation of Vaginal Outlet, Cragin's Operation 151 Anterior Colporrhaphy 152 Hypertrophy of the Cervix 154 Stenosis of the Cervix „ 155 Laceration of the Cervix 156 Trachelorrhaphy 160 Endometritis 161 Acute . . 161 Chronic 163 Metritis 170 Acute Metritis 170 Chronic Metritis 171 Atrophy of the Uterus 173 Fibroid Tumors of the Uterus 174 Inversion of the Uterus 185 Polypi ' . . . 190 Carcinoma Uteri 193 Vaginal Hysterectomy 197 Sarcoma of the Uterus 199 Chorio-epithelioma 200 Salpingitis 201 Tubercular Salpingitis 205 Affections of the Ovaries 206 Haemorrhage into the Ovaries 206 Ovaritis 207 Prolapse of the Ovary 210 Tumors of the Ovary - 210 Cysts of the Ovary . . . . 211 Parovarian Cysts 217 Preparation of Catgut 220 Ectopic Gestation 221 Fistula 'v.--" 226 Recto-vaginal Fistula . -• . 228 Index 229 ESSENTIALS OF GYNECOLOGY. What is included in the term external genitals ? That portion of the genital tract which is visible when the patient is in the dorsal position, with knees elevated and the labia separated with the fingers, viz. : Mons Veneris, Labia Majora, Labia Minora, Clitoris, Vestibule, Fourchette and Fossa Navicularis. What other terms are in common use for the external genitals ? Pudendum and Vulva. The term vulva is inexact, as it originally applied to the labia, nevertheless it is in common use. What comprise the internal organs of generation ? The Uterus, Fallopian tubes and Ovaries. The Vagina connects the external with the internal generative organs. Budin regards the Hymen as anatomically a folding in of the vaginal walls. Mons Veneris. Describe. The Mons Veneris is a triangular projection, or cushion of adipose tissue, situated over the symphysis pubis. Anatomically, in addition to adipose tissue, it contains fibrous and elastic tissue. After puberty it is covered with hair, which has a tendency to curl, and is usually somewhat darker than the hair of the head. Numerous sebaceous and sweat glands are present. Labia Majora. Describe them. The labia majora are two folds of skin which extend from the mons veneris in front to meet in the fourchette posteriorly ; they 2 17 18 ESSENTIALS OE GYNECOLOGY. are covered externally with coarse hair, and richly supplied with sebaceous and sweat glands ; they also contain adipose, fibrous and elastic tissue. Above, the round ligament can be traced into them on either side ; also the remains of the canal of Nuck, which sometimes continues pervious and admits of hernia. The inner surface of the labia is smooth, and somewhat resembles mucous membrane, a few fine hairs, however, are visible on close inspection. The labia majora in the virgin lie in contact ; in old women they become atrophied and allow the labia minora to protrude. The arterial supply is the superficial perineal branch of the internal pudic and the superficial external pudic. The veins communicate with the bulbs of the vagina and take the course of the arteries. The lymphatics empty into the inguinal glands. The nerve supply is from the superficial perineal branches of the internal pudic, the ilio-inguinal, and the genito-crural. Labia Minora. Describe. The labia minora, or nyniphse, are two folds of muco-cutaneous tissue which arise about the middle of the labia majora on their inner surfaces, and extending upward divide into two portions ; the two lower uniting just below the clitoris to form the fraenum, the two upper just above the clitoris to form the prepuce. The venous supply is rich ; it communicates with the bulbs of the vagina and with the pudic and perineal veins. The arterial supply, nerves and lymphatics are the same as for the labia majora. The sebaceous glands are very abundant. Clitoris. Describe. The clitoris, the analogue of the penis in the male, is situated at the apex of the vestibule ; it consists of a glans, a body, and two crura. The glans, the only part visible, is a mass of erectile tissue, about the size of a small pea, very abundantly supplied with nerves and partially covered by its prepuce. The body also consists of erectile tissue ; it is about an inch long, surrounded by a firm fibrous covering, and shown, on section, to consist of two halves, corpora cavernosa, separated by an imperfect septum. CLITORIS. 19 The crura are two prolongations of erectile tissue with a dense fibrous sheath ; they arise from the anterior borders and inner sur- faces of the pubic and ischiatic rami, and extend forward to unite in the body just beneath the pubic arch. Give the vascular supply of the clitoris. The arterial supply is from the two terminal branches of the in- ternal pudic. The blood is returned by the dorsal vein which empties into the vesical plexus. Describe the lymphatics of the clitoris. The clitoris is surrounded by a plexus of lymphatics which termi- nate in the inguinal glands. Describe the nerve supply of the clitoris. The clitoris receives numerous filaments both from the sympa- thetic system and from the pudic nerve. According to Savage, "small as this organ is compared with the penis, it has in proportion four or five times the nervous supply of the latter." What are the differences between the clitoris and the penis ? The clitoris has neither corpus spongiosum nor urethra, both of which are present in the penis. What are the points of resemblance between the clitoris and the penis ? They are both erectile. They each consist of a glans, a body and two crura. They each have two corpora cavernosa separated by an incomplete septum. The glans in each is partly covered by a prepuce, with its frsenurn attached below. What do we find in the female as the analogue of the corpus spongiosum in the male ? The bulbs of the vestibule and the labia minora, which, in the female, lie at the side of the urethra, correspond to the corpus spongiosum in the male. What in the male is the analogue of the labia major a in the female? The scrotum. 20 ESSENTIALS OF GYNAECOLOGY. Vestibule. Describe. The vestibule is the remains of the uro-genital sinus. It is the space seen on separating the labia minora. In front of it lies the clitoris, behind is the fourchette, and on either side is a labium minus. Some authors unwisely restrict the term which should describe a space to the triangular surface of mucosa anterior to the vagina and between the labia, the area in the center of which is the urethral orifice. Beneath its mucous membrane lie venous plexuses, the bulbs of the vagina, and the pars intermedia. The vestibular mucosa differs from the labia and mons veneris in having no seba- ceous glands. The urethra, vagina, and ducts of Bartholin open into it. Fourchette. Describe. The fourchette, or posterior commissure, is a mere fold of skin formed by the junction of the labia majora at the anterior edge of the perineum. Fossa Navicularis. Describe. The fossa navicularis is a boat-shaped cavity which is formed between the lower portion of the hymen and the inner aspect of the fourchette, when the latter is pulled down with the finger, or the labia are separated. When the parts are at rest, no such hollow exists. Bulbs of the Vestibule. Describe them. The bulbs of the vestibule are two oval masses of erectile tissue situated on either side of the ostium vaginae and base of the vesti- bule ; posteriorly, they lie in contact with the anterior layer of the triangular ligament ; they are partially covered in front by the bulbo- cavernosi muscles ; they extend as high as the meatus urinarius, and are connected by the pars intermedia with the cavernous tissue of the clitoris. Their size varies greatly from that of a bean, as given by Hart and Barbour, to a mass an inch and a half long. VAGINA. 21 Vulvo-Vaginal Glands. Describe. The vulvovaginal, or Bartholinian glands are small oval bodies about the size of an almond, lying just behind the lower extremities of the bulbs ; they lie between the layers of the triangular ligament, and each gland has a duct about half an inch in length which opens just in front of the hymen on each side. They are the analogue of Cowper's glands in the male. They secrete a glairy mucus which lubricates the parts. Hymen. Describe. The hymen is a fold of mucous membrane which surrounds the ostium vaginae ; it has a connective tissue framework, and contains blood-vessels and nerves, and has a squamous epithelial covering. From its histology and embryology, it is a fold of the vaginal wall. The hymen may be of several forms ; the most common being the crescentic. Other forms are the annular, making a ring about ihe ostium ; the cribriform, perforated by numerous small holes ; and the fimbriated, with a fringed edge. It is sometimes imperforate, a pathological condition. What value has the hymen as a criterion of chastity ? Very slight, as neither is its absence proof that intercourse has taken place, nor is its presence an absolute proof to the contrary. What are the caruncuiae myrtiformes ? In women who have borne children there are found papillary elevations surrounding the vaginal orifice. These are the remains of the hymen, and are called caruncuiae myrtiformes Vagina. Describe. The vagina is spoken of by Hart and Barbour as " a mucous slit in the pelvic floor;" it is the canal connecting the uterus and the vulva, lying between the bladder and urethra in front and the rectum behind ; its walls, which are anterior and posterior, are normally in contact. 22 ESSENTIALS OF GYNECOLOGY. The anterior wall measures 2-2J inches in length, the posterior 3-3J inches. The anterior wall is shorter than the posterior, from the fact that the uterus is set into the anterior wall. The vagina is very dilatable, and when distended is conical in shape, being much more roomy above than below. The vaginal walls on section are seen to consist of three layers : 1, mucous ; 2, muscular ; 3, connective tissue. The mucous membrane on both anterior and posterior walls presents at the lower portion of the canal numerous ridges or rugae, extending transversely from a central column ; the anterior being the more distinct. The epithelium covering the mucous membrane is of the squamous variety. The vaginal mucous membrane normally con- tains no glands. The muscular coat consists of two layers of unstriped muscle, the outer longitudinal one being well developed, the inner circular one being poorly developed except at the orifice. The outer coat is of connective tissue, and contains the external plexus of veins. The roof, or fornix of the vagina, that portion of the canal sur- rounding the cervix, is, for convenience, divided into four portions : the anterior fornix, the posterior fornix, and the lateral fornices ; of these the posterior is the deepest. Describe the vaginal secretion. It is a rather scant, white, opaque, curdy material, made up of exfoliated cells of the vaginal mucous membrane, a few leucocytes, and some exudate from the blood-vessels. It contains mucus only from admixture with the cervical secretion. It has a decided acid reaction due to lactic acid, resulting from the action of the many saprophytic bacteria normally found in the vagina. What changes may occur in the vaginal reaction ? It becomes alkaline during menstruation and for a short pe- riod after labor. In pathological conditions of the vagina, such as gonorrhoea, it is alkaline. During pregnancy the acidity is increased. What follows the introduction of pathogenic germs into the normal vagina ? Other organisms than the tubercle bacillus and gonococcus disap- pear within a few days. Their destruction is due to the acidity of the vagina, its anaerobic condition, and, what is of more importance, VAGINA. 23 the bactericidal power of the serum of the vaginal secretion. The absence of crypts, glands, and hair-follicles, as well as its being less subjected to trauma than the vulva, explain the less susceptibility of the vagina to gonorrhoeal, chancroidal, and other infections. What is the arterial supply of the vagina ? The arterial supply is from the vaginal arteries, which supply the lateral walls ; branches of the uterine arteries supplying the upper portion, and branches of the pudendal arteries the lower. These anastomose with each other and with the vesical and rectal arteries. Describe the veins of the vagina. The vaginal veins form plexuses which surround the canal like sheaths ; one being external to the muscular layer, the other just beneath the mucous membrane. "These communicate freely with the pudendal, vesical and hemor- rhoidal plexuses below, and with the plexuses of the broad ligament above." These veins contain no valves. Describe the lymphatics of the vagina. The lymphatics of the lower fourth of the vagina, together with those from the external genitals enter the inguinal glands. The lymphatics from the upper three-fourths of the vagina join with those from the cervix and bladder, and enter the iliac glands. According to Poirier, some of them enter a gland at the side of the cervix in the base of the broad ligament. Describe the nerve supply of the vagina. The vagina is supplied by branches of the inferior hypogastric plexuses of the sympathetic system. These plexuses lie on either side of the vagina. Give the relations of the vagina. The anterior vaginal wall is connected in its lower half with the urethra, in its upper half with the neck and fundus of the bladder ; the former connection is much more intimate than the latter. The posterior vaginal wall in its lower fourth lies in connection with the perineal body, in its middle two-fourths with the rectum, in its upper fourth with the cul-de-sac of Douglas. The anterior fornix is distant l£ inches from the utero-vesical pouch, and through this fornix can normally be felt the body of the uterus and the angle it makes with the cervix. 24 ESSENTIALS OF GYNAECOLOGY. Fig. 1. The posterior fornix is in contact with the cul-de-sac of Douglas. The lateral fornices are in relation with the bases of the "broad liga- ments, and through these fornices can normally be felt the vessels of the broad ligament, and occasionally the ovary and tube of that side. The vagina makes an angle of 60° with the horizon when the woman is erect. Uterus. Give the gross anatomy. The uterus, the organ of gestation, is a hollow, pear-shaped organ, flattened antero-posteriorly, situated in the pelvis between the bladder and rectum. It measures in the virgin about 3 inches in length, 2 inches in breadth, at the level of the Fallopian tubes, and 1 inch in thickness. The weight of the virgin uterus varies from 1 to 1 g- oz. It consists of three portions: the cervix, body and fundus. As viewed externally, the uterus, on its anterior surface, is nearly flat, its posterior surface convex ; a little below the centre is a slight constriction called the isthmus. The cervix is that portion of the uterus below the isthmus, and which projects in part into the vagina. The body is that portion between the isthmus and the line joining the en- trance of the Fallopian tubes. The fundus is the portion above this line. Diagram of Uterus, to show di- visions of Cervix. (Schroeder.) a, Infra-vaginal portion; b, In termediate portion ; c, Supra- vaginal portion ; Bl, Bladder ; P, Peritoneum. The dotted line shows peritoneum. Describe the uterine canal. The uterine canal measures normally in nulliparous women 2 h inches, and holds about 12 drops ; the cervical portion of the canal is spindle- shaped and measures at least 1 inch in length ; the remainder is triangular, with anterior and posterior walls in contact. What are the openings into the uterine cavity? There are three : the os externum, which communicates with the MUCOUS MEMBRANE OP THE UTERUS. 25 vagina ; and the orifices of the Fallopian tubes at the upper angles, which connect the uterine with the peritoneal cavity. The os internum connects the cavity of the cervix with that of the body. What divisions of the cervix are made ? Schroeder divides the cervix into three portions, as seen from the accompanying figure, (Fig. 1, a, b, c). a. The infra-vaginal portion. b. The intermediate portion. c. The supra-vaginal portion. The infra-vaginal portion of the cervix (a) is that below the level of the attachment of the anterior vaginal wall. The supra-vaginal portion (c) is that above the level of the attach- ment of the posterior vaginal wall. The intermediate portion (6) is that between the infra- and supra- vaginal portions. What portions of the cervix project into the vagina ? The infra-vaginal portion of the anterior lip, and the infra-vaginal and intermediate portions of the posterior lip. For practical purposes, it is sufficient to divide the cervix into the supra-vaginal portion, that above the attachment of the vagina ; and the infra-vaginal, that within the vagina. What are the three elements in the structure of the uterus ? 1. The mucous membrane. 2. The muscular coat. 3. The peritoneal coat. Mucous Membrane of the Uterus. Describe that of the cervix. The mucous lining of the cervix differs from that of the body of the uterus. In the cervix it is thrown into folds presenting the arbor vitse appearance, there being a central ridge on both anterior and posterior walls, and from these ridges secondary ridges extend- ing obliquely. The anterior and posterior ridges are not directly opposite, but fit past one another. The epithelium is ciliated on the ridges, non- ciliated in the depressions, according to some writers ; others have failed entirely to demonstrate cilia; in the cervix . 26 ESSENTIALS OF GYNAECOLOGY. The mucous membrane of the cervix is rather sparingly supplied with acinus glands whose secretion is mucous. The mucous membrane covering the vaginal portion of the cervix closely resembles that of the vagina, consisting of vascular papillae covered by squamous epithelium. Describe the mucous membrane of the body of the uterus. The mucous lining of the body of the uterus is smooth, velvety and of a grayish red color ; it is directly connected with the muscu- lar coat, with no submucous layer. It averages about >} 5 of an inch in thickness, and consists of columnar, ciliated epithelium, on a base of connective tissue between whose fibres numerous lymph spaces are found. The mucous membrane is thickly studded with glands, the utricular glands, which penetrate the whole thickness of the mucous layer. These glands are of the tubular variety, and are fre- quently bifurcated at their blind extremities. They are lined with cylindrical epithelium, resting on a thin membrana propria. Their direction is not at right angles to the surface, but, according to Turner, more or less oblique. Their secretion is less thick and tenacious than that of the cervix. To what changes is the normal uterine mucosa subject? 1. That of the child is destitute of glands. These make their appearance a few years before puberty. 2. Preceding each menstrual flow the cells of the stroma become swollen, the superficial capillaries dilated, and finally there is an exu- dation of plasma and diapedesis of red cells under the epithelium. There is no extensive shedding of mucosa with the menstrual flow, as was formerly thought, except in the condition known as mem- branous dysmenorrhea. 3. Should pregnancy occur, the stroma cells become much larger and polygonal, glands disappear from the surface of the mucosa, and are only seen as distorted and cystic ones in the deep layer. Thus altered the mucosa becomes the "decidua." 4. After the menopause the mucosa atrophies and nearly all glands disappear. Describe the muscular structure of the uterus. The muscular structure of the uterus is most marked after im- pregnation ; it can then be separated into three layers : — MUCOUS MEMBRANE OP THE UTERUS. 27 1 . The external or longitudinal. 2. The middle or oblique. 3. The internal or circular. The external layer is most distinct on the anterior and posterior surfaces, where it is seen to consist of fibres running up longitudi- nally over the fundus ; it sends fibres into the broad, round, ovarian and utero-sacral ligaments and also into the Fallopian tubes. The middle, or oblique layer has no regular arrangement ; some of the fibres run longitudinally, some transversely and some obliquely ; they surround the blood vessels, and on this account this layer is of great importance ; it constitutes the chief portion of the uterine wall. The internal or circular layer shows fibres arranged in a circular manner, most distinct around the orifices of the Fallopian tubes and at the os internum. Describe the peritoneal coat of the uterus. The peritoneum covers the anterior surface of the uterus above the level of the internal os ; it extends over the fundus, covers its posterior surface as low as the attachment of the posterior vaginal wall, and extends down the latter for about an inch. Describe the arterial supply of the uterus. The uterus is supplied by the uterine and ovarian arteries, as seen by the accompanying figure. (Fig. 2. ) The uterine artery arises from the anterior division of the internal iliac, runs between the folds of the broad ligament to about the level of the os externum, and then turns upward along the side of the uterus to unite with the descending branch of the ovarian artery ; it gives off numerous lateral branches to the uterus, anastomosing with those of the opposite side ; these are very tortuous and are called the ' ' curling arteries of the uterus. ' ' Sometimes the vaginal artery springs directly from the uterine. Opposite the internal os, the uterine artery gives off a branch which, uniting with its fellow of the opposite side, surrounds the cervix and is called "the circular artery." The ovarian artery arises directly from the aorta, enters the pelvis in the in fundibulo- pelvic ligament, runs between the folds of the broad ligament, at its upper part, to the upper angle of the uterus ; it gives off a few large vessels to the outer extremity of the tube, and then a number of very tortuous vessels which surround the ovary. 28 ESSENTIALS OF GYNECOLOGY. Just before reaching the uterus, it gives off a number of branches to the proximal extremity of the tube and one to the round ligament. At the angle of the uterus it divides into two branches : one sup- plies the fundus and anastomoses with its fellow of the opposite Fig. 2. Distribution of ovarian, uterine and vaginal arteries (Hyrtt). a, ovarian artery; a' and b\ branches to tube ; c', branches to ovary ; b, branch to round ligament; c, branch to fundus; d, branch to join uterine artery ; e, uterine artery ; /, anterior branch of internal iliac ; g, vaginal arteries ; h, azygos artery of vagina. MUCOUS MEMBRANE OP THE UTERUS. 29 side; the other descends along the side of the uterus and anasto- moses with the uterine artery. The tortuosity and free anastomoses across the median line are noticeable features of the arteries of the uterus. Describe the venous supply of the uterus. The uterus is surrounded beneath the peritoneum by a plexus of veins, called the uterine plexus ; this receives the blood from the uterine walls and communicates with the vaginal and vesical plexuses below and the pampiniform above ; it empties into the internal iliac and ovarian veins. Describe the lymphatics of the uterus. The lymphatics from the body of the uterus join with those from the ovary and tube and terminate in the lumbar glands. The lymphatics from the cervix pass beneath the base of the broad ligaments to the iliac glands. The lymphatics of the uterine cornu follow the round ligament and terminate in the inguinal glands. Give the nerve supply of the uterus. The chief nerve supply of the uterus is from the inferior hypo- gastric plexus of the sympathetic. The cervix also receives branches from the upper sacral nerves. What is the normal position of the uterus ? This question has been frequently discussed and at great length. It is now sufficient for practical purposes to say that the uterus, when the pelvic organs are normal and when bladder and rectum are empty, lies slightly anteflexed and slightly anteverted. This brings the long, axis of the uterine body when the woman is standing erect about into the plane of the horizon. Distention of bladder and rectum, especially the former, and the pregnant state make the axis shift more toward the ver. tical. Since the uterus is not a fixed but a movable organ, the remark of Waldeyer seems apropo : ' ' The uterus has one typical, but many normal, positions." What are the ligaments of the uterus ? There are two utero- vesical ligaments, two round, two broad, and two utero-sacral. 30 ESSENTIALS OF GYNECOLOGY. Describe the utero-vesical ligaments. They are two folds of peritoneum passing between the bladder and the lower portion of the uterus on each side. Describe the round ligaments. They are two musculo-fibrous cords, 4-5 inches in length, which extend from the superior angles of the uterus, in the anterior folds of the broad ligaments and below the Fallopian tubes, forward and outward to the inguinal canal ; thence through this canal where they terminate in three points of insertion : the external, middle and internal. The external blends with the outer pillar of the ring near Gimbernat's ligament. The middle terminates in the upper portion of the external ring. The internal unites with the conjoined tendon. Besides muscular and fibrous tissue, these ligaments contain areolar tissue, vessels and nerves. They are of importance surgically as being those shortened in operations for the correction of posterior displacements. Describe the broad ligaments. They are two folds of peritoneum which extend from the sides of the uterus to the wall of the pelvis, ' ' along a line which is situ- ated between the great sacro-sciatic notch and the margin of the obturator foramen as far down as the level of the ischial spine. ' ' The greater part of its superior border, on each side, is occupied by the Fallopian tube ; the part of the superior border not so occupied is called the infundibulo-pelvic ligament. What is the " mesosalpinx " ? It is that portion of the broad ligament lying between the tube, ovary, and ovarian ligament. It contains the parovarian tubules between its folds. What two folds are made in the broad ligament in addition to that occupied by the Fallopian tube ? An anterior fold caused by the round ligament and a posterior fold caused by the ovarian ligament. Describe the ovarian ligament. It is a fibro-muscular cord about an inch in length, which connects the ovary with the side of the uterus, just below the entrance of the Fallopian tube. It lies in, and is surrounded by, the posterior fold of the broad ligament. FALLOPIAN TUBES. 31 What are contained between the folds of the broad ligament on either side ? The round ligament, Fallopian tube, ovarian ligament, the paro- varium, cellular tissue, uterine and ovarian arteries, the pampiniform plexus and other veins, numerous lymphatics and nerves. When the broad ligament is held tense the ovary appears as if stuck on its posterior surface. Describe the utero-sacral ligaments. These ligaments are composed of muscular and fibrous tissue and are covered with peritoneum. In front they blend with the sides of the cervix and lower uterine segment. They pass backward and outward on either side of the rectum to become lost in the connec- tive tissue on the front of the sacrum from the third sacral vertebra downward. What is the action of the uterine ligaments ? These ligaments come into play only when the uterus by strain- ing or otherwise is considerably displaced from its typical position. They limit the normal excursion of the uterus. Their greatest tax comes during labor, when they fix the cervix, and by so doing allow the uterine contractions to drive the uterine contents against the pelvic floor. They involute with the uterus during the puerperium. The amount of force which they must resist during labor attests their strength. One realizes their strength when he grasps with volsella the cervix and pulls against them in the course of vaginal hysterectomy. What is the meaning of the term "uterine appendages," as usually employed ? The Fallopian tubes and ovaries. Fallopian Tubes. Describe them. They are two tubes 3-5 inches in length, which extend laterally from the superior angles of the uterus ; they lie within the folds of the broad ligaments, and their direction is first outward, then for- ward, backward and inward toward the ovary. They are divided for consideration into three portions : the isth- mus, the ampulla and the fimbriated extremity. 32 ESSENTIALS OE GYNECOLOGY. The isthmus is the narrowest portion ; it measures about an inch in length, and extends from the angle of the uterus directly outward, joining the ampulla ; its lumen is only large enough to admit a fine bristle. The ampulla is the curved, dilated portion of the tube ; its lumen admitting an ordinary uterine sound. The fimbriated extremity (infundibulum) is the expanded, funnel- shaped outer end, which is surrounded by fringe-like processes (fim- briae), both primary and secondaiy, the latter arising from the former, which are 4-5 in number. The longest of the primary fimbriae lies to the inner side, is grooved, and is attached to the ovary ; this is called the fimbria ovarica. The tubes, on section, are seen to consist of four layers or coats ; the peritoneal coat ; two muscular coats, the outer being longitudinal, the inner circular ; and a mucous coat. There is no" submucous layer. The mucous membrane is thrown into longitudinal folds ; the epi- thelium is columnar and ciliated. Give the arterial supply of the Fallopian tubes. The Fallopian tubes are supplied by the ovarian arteries, which send branches directly to the outer and inner portions of the tube and supply the middle third through branches from the plexus about the ovary. Describe the veins, lymphatics and nerve supply of the Fal- lopian tubes. The veins of the tubes enter the pampiniform plexus on either side. The lymphatics join with those from the upper part of the uterus and frorn the ovaiy, and terminate in the lumbar glands. The nerve supply is from the inferior hypogastric plexuses. What is the direction of the current due to motion of the ciliae of the epithelium in the uterus and tubes ? The ciliae have such a motion as to propel fluids outward, i. e., in the tube toward the uterus, and in the uterus toward the vagina. OVARIES. 3d Ovaries. Give their gross anatomy. The ovaries are two " flattened ovoid " bodies lying in the plane of the brim of the pelvis, on either side of the uterus, and appear as elevations on the posterior surface of the broad ligament'. They are situated below the outer extremities of the tubes. They present for consideration two borders, an anterior and pos- terior ; two surfaces, a superior and an inferior ; and two extremi- ties, an outer and an inner. The anterior border is nearly straight ; the posterior is convex. The anterior border is called the hilum, and serves for the en- trance of blood vessels and nerves. The superior surface is nearly flat ; the inferior is convex. The outer extremity is broad and convex ; the inner is narrow and tapers into the ovarian ligament. An ovary averages about 1} inches in length, f of an inch in breadth and j an inch in thickness; it weighs about 87 grains. Give the minute anatomy of the ovary. The ovary, on section, is seen to consist of a medullary and cor- tical portion ; the former being more vascular and of a softer con- sistency than the latter. The microscope shows connective tissue, numerous Graafian follicles scattered through the cortex, blood ves- sels, lymphatics, nerves and unstriped muscular fibres. At the base or attachment of the ovary to the broad ligament can be seen a white line which marks the transition from the flat cells of peritoneum to the cuboidal ones, the "germinal epithelium'' covering the surface of the ovary. The origin of both sorts of cells is the same. Both are derived from the mesothelial cells of the mesoblast, and later become differently modified to fit them to fulfil their very dissimilar functions. The layer of "germinal epithelium " rests on a thin, dense mus- culo -fibrous layer, called the tunica albuginea. The Graafian follicles are small vesicular bodies, more numerous and smaller in the superficial zone of the cortex than in the deeper, with the exception of a few which have matured and approached the surface of the ovary. Foulis estimates that at birth each human ovary contains not less than 30,000 Graafian follicles (Playfair). 3 34 ESSENTIALS OF GYNECOLOGY. Give the structure of a Graafian follicle. On examining a Graafian follicle from without inward, we find the following structures (Fig. 3) : — The theca folliculi, which is divisible into an outer fibrous layer, the tunica fibrosa, and an inner vascular and cellular layer, the tunica propria ; within this is the membrana granulosa, a layer of columnar epithelium which encloses the liquor foil iculi ; at one side there is a cellular eminence called the discus proligerus, which encloses the ovum. The outer covering of the ovum is the vitelline membrane, or zona pellucida, surrounding the vitellus or yolk. At one point of the latter is seen the germinal vesicle, and within this the germinal spot. A Graafian follicle measures from xio to 2V inch in diameter ; a germinal spot, not over 3^00 inch. Give the arterial and venous supply of the ovaries. The ovaries are supplied by the ovarian arteries, which arise directly from the aorta. The veins of the ovary emerge at the hilum and enter the collec- tion of veins called the " bulb of the ovary." This communicates with the veins from the Fallopian tube and upper portion of the Diagrammatic Section of Graafian Follicle. 1. Ovum. 2. Membrana granulosa. 3. External membrane of Graafian follicle. 4. Its vessels. 5. Ovarian stroma. 6. Cavity of Graafian follicle. 7. External covering of ovary. uterus, forming a collection called the pampiniform or ovarian plexus ; from this springs the ovarian vein, which, on the right side, terminates in the inferior vena cava, on the left side, in the left URINARY TRACT. 35 renal vein. The left ovarian vein has no valve at its termination. Some apply the term pampiniform plexus to all the veins in the broad ligament. Give the lymphatics and nerve supply of the ovary. The lymphatics join with those from the tube and upper portion of the uterus and terminate in the lumbar glands. The nerve sup- ply is from the inferior hypogastric plexus. What is the position of the long axis of the ovary ? This question has been much discussed. The long axis of the ovary may be regarded as lying a little obliquely to the transverse axis of the pelvis, and with a direction slightly backward. His describes the long axis as vertical, but this does not coincide with the results of autopsies where the pelvic contents have been normal. Parovarium. Describe it. The parovarium, which is the remains of the Wolffian body, con- sists of a series of tubes situated between the folds of the broad ligament, on either side of the uterus, and lying between the am- pulla of the tube and the hiluni of the ovary. One of the tubes is horizontal and runs toward the uterus ; the others are nearly vertical, converging toward the hiluni ; they vary greatly in number, in fact, from 6 to 30. The outer 6-10 have a well-marked lumen and are lined with ciliated epithelium ; those internal to these are merely fine fibrous cords. The horizontal tube running toward the uterus is called the duct of Gartner. It is rarely continued down along the side of the uterus or even to the vagina. The parovarium is of pathological importance, as occasionally the seat of cysts. What in the male corresponds to the parovarium in the female ? The epididymis. Urinary Tract. Describe the urethra. The female urethra is a musculo-membranous canal about If inches in length, imbedded in the anterior vaginal wall, and extend- 36 ESSENTIALS OF GYNAECOLOGY. ing from the vestibule to the neck of the bladder ; it runs upward and backward, " parallel with the plane of the pelvic brim." It consists of three coats; the outer two being muscular, the inner, mucous membrane. Of the muscular coats, the outer is circular, the inner longitudi- nal. The mucous membrane in the lower portion of the canal is covered with squamous epithelium, while higher up the epithelium is transitional, like that of the bladder. The meatus urinarius, the outer extremity of the urethra, is situ- ated in the median line of the vestibule, lying a short distance in front of the vaginal orifice. Describe Skene's tubules. Just within the meatus, on each side, are the openings of Skene's tubules, which he describes as lying near the floor of the urethra, just beneath the mucous membrane, and extending parallel to the canal about three -fourths of an inch. Their function is unknown. Their orifices can usually be seen by everting the meatus urin- arius. Bladder. Describe it. The bladder is a hollow musculo-membranous organ, situated in the pelvis ' ' between the symphysis pubis in front and the vagina and uterus behind. ' ' The bladder presents for consideration a body, a base or fundus, and a neck. The body is all that portion above the lines joining the ureteric openings and the centre of the symphysis pubis. All below these lines is the base or fundus. The portion of the fundus between the urethral and ureteric orifices is the trigone. The constricted portion continuous with the urethra is the neck. The wall of the bladder consists of three coats : a peritoneal, a muscular and a mucous. The peritoneal coat is found only on the summit of the bladder and on the upper part of the posterior surface. The muscular coat consists of two layers : an outer longitudinal and an inner circular ; the latter being most marked around the urethral orifice. The mucous membrane consists of several layers of transitional epithelium resting on a membrana propria ; the superficial cells are squamous. It contains no glands. BLADDER. 37 The mucous membrane is thrown into numerous folds, except at the trigone, where it is more closely connected with the underlying tissue. The mucous membrane is supported by a submucous layer of fibrous and elastic tissue, containing blood vessels, lymphatics and nerves. What is the arterial supply of the bladder and urethra ? The bladder receives its arterial supply from the superior, middle and inferior vesical, and from branches of the uterine and vaginal arteries. They are all derived from the anterior division of the internal iliac. The urethra is supplied by branches from the vaginal arteries. What is the venous supply of the bladder and urethra ? " The veins form a complicated plexus round the neck, sides and base of the bladder. ' ' (Gray. ) This is called the vesical plexus ; it lies external to the muscular coat and terminates in the internal iliac vein. The urethra is surrounded by a venous plexus which communi- cates with the vaginal plexus. Give the lymphatic and nerve supply of the bladder and urethra. The lymphatics of the bladder and urethra empty into the iliac glands. Their nerve supply is derived from the inferior hypogas- tric plexuses of the sympathetic system, and from the 3d and 4th sacral nerves of the cerebrospinal system. What are the principal venous plexuses of the pelvis % The vaginal plexuses. The vesical plexus. The hemorrhoidal plexus. The uterine plexus. The pampiniform, or ovarian plexus. The bulb of the ovary. Describe the course of the ureters in the pelvis. The ureters cross the external iliacs just beyond the bifurcation of the common iliacs ; they then pass downward and forward along the lateral walls of the pelvis, enter the broad ligaments, and run forward 38 ESSENTIALS OF GYNAECOLOGY. and inward. At the level of the internal os they are crossed in front by the uterine arteries (see Fig. 4), and are there situated about half an inch from the uterus. They pass alongside of the vagina a little way, converge still more, enter the vesico-vaginal septum, and pierce the bladder a little above the middle of the anterior vaginal wall ; they are here separated two inches from each other and one- half to three-fourths of an inch from the cervix. Fig. 4. Drawing from a dissection made to show relations of ureters, uterine arteries, bladder, etc. (J. Greig Smith.) ur., ureter; ut.Ar., uterine artery; ou , os uteri exposed by an incision, x, made through the top of the vagina ; bl., bladder, the walls of which are cut down to the insertion of the ureters into its base, Vag., vagina. Rectum. Describe. The rectum is the lower extremity of the large intestine, about 8 inches in length, extending from near the left sacro-iliac synchron- drosis to terminate in the anus between the coccyx and perineum. RECTUM. 39 It presents three curves : — 1. Downward, backward, and inward to the third sacral vertebra. 2. Forward to the apex of the perineum. 3. Backward to the anus. The recent anatomies call the first portion, which is entirely- covered by peritoneum, the "pelvic colon," and restrict the term rectum to the part of the gut uncovered or incompletely covered by peritoneum. It consists of a mucous and a submucous layer and two muscular layers — a longitudinal and a circular, the former being external. The mucous membrane is covered with columnar epithelium and contains numerous follicles of Lieberkiihn. At its lower portion the mucous membrane is thrown into perpen- dicular folds called columns of Morgagni ; the depressions between them being called the sinuses of Morgagni. There are three oblique folds of importance, including not only the mucous and submucous layers, but part of the muscular coat. One projects from the anterior wall 1 J inches from the anus. Another is on the right side near the sacral promontory, and a third is situated midway between the two, on the left side. The external orifice is guarded by the sphincter ani muscle which surrounds the canal, and is inserted into the coccyx behind and the perineum in front. Give the vascular and nerve supply of the rectum. The arterial supply of the rectum is from the superior, middle and inferior hemorrhoidal arteries. The veins form a plexus beneath the mucous membrane which communicates with another surround- ing the exterior of the canal ; from this spring veins corresponding to and accompanying the arteries. The superior hemorrhoidal vein empties into the inferior mesen- teric of the portal system. The middle and inferior hemorrhoidal empty into the internal iliac of the general venous system. The lymphatics terminate in the sacral glands. The nerves are derived from the hypogastric and sacral plexuses. 40 ESSENTIALS OF GYNAECOLOGY. Give the relations of the rectum. At its upper portion the rectum is surrounded by peritoneum and lies in direct relation anteriorly with the cul-de-sac of Douglas. At about 3 inches from the anus the peritoneum leaves the rectum, which then lies, loosely attached to the posterior wall of the vagina for 1| inches. The remainder is separated from the vagina by the perineal body. Posteriorly, the rectum is connected at its upper part by the meso- rectum to the sacrum ; at its lower part by fibrous tissue to the sacrum and coccyx. On each side it receives the insertion of the levatores ani and is surrounded below by the sphincter ani. Pelvic Floor. Describe the segments of the pelvic floor. According to Dr. Hart, the pelvic floor consists of two segments : the pubic and sacral ; the pubic consisting of the bladder, urethra, bladder peritoneum and the anterior vaginal wall ; the sacral com- prising the rectum, perineal body and posterior vaginal wall. According to the same authority, also, the pubic segment is made up of loose tissue, loosely attached to the pubes, and is drawn up during labor ; the sacral segment is made up of dense tissue, closely attached to sacrum and coccyx, and is driven down during labor. Describe the muscles and fascia of the pelvic floor, as dis- sected from above. On examining the pelvic floor from abo',e, we find the pelvic fascia attached laterally to the brim of the pelvis, to the spine of the ischium behind, to the lower portion of the symphysis pubis in front, and to a tendinous band — "white line " — joining the two latter points. Behind the spine of the ischium the pelvic fascia is con- tinuous with a thin layer covering the pyriformis muscle. At the 1 ' white line ' ' the pelvic fascia divides into the recto-vesical fascia, which covers the upper surface of the levator ani muscles, and the obturator fascia, covering the obturator muscles. The recto-vesical fascia arising from the ' ' white line ' ' extends downward and inward, and unites in the median line with its fellow of the opposite side. PERINEAL BODY. 41 This forms a fascial diaphragm which is perforated by the rectum and vagina, to each of which it is firmly attached and furnishes a sheath from that point downward. The bladder and rectum also receive ligaments from this fascia. On removing this fascial diaphragm, we meet with a muscular diaphragm formed by the levator ani and coccygeus muscle of each side meeting in the median line. The coccygei arise from the ischial spines, and are attached to the sides of the lower segment of the sacrum and to the sides and ante- rior surface of the coccyx. The levatores ani arise from the posterior aspect of the pubes, from the spine of the ischium and from the "white line " of the pelvic fascia connecting these points. They extend downward and backward and are attached to the vagina, the rectum, to each other, and to the tip of the coccyx. This muscular diaphragm surrounds both vagina and rectum. The under surface of this muscular diaphragm is covered by a thin layer of fascia which is attached on each side to the obturator fascia. On removing the muscular diaphragm with its upper and lower fascia, there remains, filling the pelvic outlet, the perineal body, the muscles of the perineum and the ischio-rectal fossa. Perineal Body. Describe. The perineal body is a mass of muscular, fibrous and adipose tissue, somewhat pyramidal in shape, lying between the lower ends of the vagina and rectum ; it measures 1$ inches in height, lj inches in breadth and f inch antero-posteriorly. Its base is covered by skin which is sometimes wrongly spoken of as "the perineum," which should always refer to the perineal body. The muscles which are attached to the perineal body are the bulbo-cavernosi, transversi perinei, sphincter and levatores ani. Give the vascular and nerve supply of the perineal body. The arterial supply of the perineal body is from the internal pudics. The veins terminate in the pudic veins. 42 ESSENTIALS OF GYNAECOLOGY. The lymphatics end in the inguinal glands. The nerve supply is from the pudic nerve. What are the functions of the perineal body ? 1 . To prevent vaginal rectocele. 2. To help form a compact pelvic floor. 3. To serve as a fixed point for muscular attachment. Muscles of the Perineum. Name and describe them. On each side of the vaginal orifice we find three muscles : bulbo- cavernosus, ischio-cavernosus or erector clitoridis, and the trans- versa perinei. The bulbo-cavernosus arises from the perineal body on each side of the vagina, with its fellow encircles the vaginal bulbs and vesti- bule, and divides into three slips ; one going to the posterior surface of the bulb, another to the under surface of the corpus cavernosum of the clitoris, and the third to the mucous membrane of the vestibule. The bulbo-cavernosi compress the bulbs of the vagina. The transversus perinei arises from the ramus of the ischium and is lost in the perineal body. The ischio-cavernosus or erector clitoridis, arises from the front of the tuberosity of the ischium and is inserted into the crus clitoridis. These muscles are supplied by the internal pudic artery and by branches of the pudic nerve. The veins enter the pudic veins. The lymphatics terminate in the inguinal glands. Ischio-rectal Fossa. Give its gross anatomy. It is a pyramidal-shaped area, largely filled with fat, situated on either side of the rectum ; the sides are formed by the obturator internus without and the levator ani within • the base by the trans- versus perinei and the lower edge of the gluteus maximus. Describe the fascia covering the pelvic floor below. From without inward we find the superficial fascia in two layers, the external being continuous with the general superficial fascia of the body. The deep layer is attached to the border of the pubic PHYSICAL EXAMINATION OF THE FEMALE PELVIC ORGANS. 43 arch in front and laterally ; posteriorly, it passes around the trans- versus perinei muscles and is attached to the base of the anterior layer of the triangular ligament. Beneath the perineal muscles we find the triangular ligament, consisting of two layers of fascia, the anterior and posterior, filling in the pubic arch. Development of the Pelvic Organs. Describe briefly. In the latter part of the first month there appear in the foetus, on either side of the primitive vertebras, the urogenital folds, in which develop the Wolffian bodies, which play the part of tempo- rary kidneys. They soon wither, and by the end of the 3d month have largely disappeared, but their remains persist, in the female, in the parovarium and Gaertner's duct. At the inner side of the Wolffian bodies there appears an invagination of the germ epithe- lium ; this develops into the duct of Mueller, one for each Wolffian body. These coalesce below to form the uterus and vagina. The ovary first appears as a white ridge on the inner side of the Wolffian body ; this ridge being formed of connective tissue covered with germ epithelium ; from the former is developed the stroma of the ovary, and from the latter are formed the Graafian follicles and ova. Until the latter part of the second month of foetal life the urinary, genital and intestinal canals open into a common vault — the cloaca. At about the 6th-7th week this common opening is divided into the anal opening posteriorly and the uro-genital anteriorly. This sepa- ration is completed by the formation of the perineal body at about the tenth week. The uro-genital canal is later divided into the urethra anteriorly and the vagina posteriorly. Physical Examination of the Female Pelvic Organs. What are the methods of examination? I. Non-instrumental. II. Instrumental. I. Non-instrumental. 44 ESSENTIALS OF GYNECOLOGY. a. Inspection of external genitals. b. External abdominal examination. c. Vaginal examination. d. Bimanual examination, with its modifications. e. Rectal examination. What positions of the patient are used in gynaecological examinations ? 1. Dorsal, with knees and thighs flexed and feet separated. 2. Lithotomy — same, with feet raised from table. 3. Sims' position. 4. Knee-chest position. 5. Trendelenburg position. 6. Standing position. What should you notice on inspection of the external gen- itals ? 1. Notice whether or not the vulva is the seat of venereal sores warts, abscesses, pediculi, etc. 2. Separate labia and notice condition of hymen and perineum, whether intact or lacerated ; the shape of hymen if intact. If peri- neum lacerated, notice whether through the sphincter ani or not ; notice, also, condition of urethra. 3. Tell patient to strain, and with labia still separated, notice whether anterior or posterior vaginal walls prolapse or not, thus forming cystocele or rectocele. 4. During this inspection it is well to pass the thumb and fore- finger along each labium majus to ascertain whether the vulvo- vaginal glands or their ducts are enlarged or not. What are the principal elements in a complete external ab- dominal examination ? 1. Position and Preparation of patient. — Patient should be on back with knees drawn up ; the abdomen should be uncovered as low down as the pubes ; the latter not being exposed ; bladder and rectum should be empty. 2. Inspection. — Observe the form and color; notice whether irregularities in form are present or not. 3. Palpation. — Use both hands ; they should be warm ; use the .palms and palmar surface of fingers rather than their tips ; employ very little force. If a tumor is present, notice whether it is solid or VAGINAL EXAMINATION. 4-J fluctuating, whether fixed or mobile ; if possible, determine whether or not it is attached to one of the pelvic organs. Notice whether it pulsates or is the seat of intermittent contrac- tions. Palpate inguinal regions for enlarged glands or herniae. 4. Percussion. — Patient should be first percussed in usual manner while lying on back and then when turned on either side. Vaginal Examination. Describe the method of performing it. Have the patient on back ; knees drawn up ; if a married woman, employ two fingers, if 'unmarried, use one. Have the examining finger or fingers well lubricated and folded into the palm until you approach the vulva ; then let them sweep over the perineum and fourchette between the labia till they enter the vagina, orifice. Do not pass from above downward over the clitoris. After entering the vagina pass the finger or fingers back- ward toward the hollow of the sacrum. What are the contraindications to a vaginal examination ? A vaginal examination should not be made in an unmarried woman unless there are strong reasons for suspecting trouble with the pelvic organs, and then only in the presence of a relative or female friend. It should not be made during a normal menstruation. What is the value of a vaginal examination per se ? The value of a vaginal examination by itself is comparatively small ; and it is rarely employed save as a part of a bimanual examination. One can, however, determine the following points by a vaginal examination, and they should be carefully noted : — The condition of perineum and vaginal orifice. Presence or absence of Painful Spots ; Spasm ; Enlargement of vulvo-vaginal glands ; etc. Condition of vaginal walls : — Heat; Moisture ; 46 ESSENTIALS OF GYNAECOLOGY. Presence or absence of Rugae ; New growths ; Fistulas ; etc. Projections of vaginal walls from Faeces in rectum ; Condition of cervix :— Condition of os : — Inflammatory deposits ; Tumors in the peritoneal pouches. Position ; Density ; Shape ; Mobility ; Size ; Lacerated or not Size ; Shape ; Projections through it. Bimanual Examination. What is the method of performing" it ? The position of the patient and the method of introducing fingers are the same as for the vaginal examination just described. As regards which hand shall be used internally, the right is usually employed first ; but to make a complete bimanual, it is best to employ internally the right hand for the right side of the pelvis, and the left hand for the left ; in this way the palmar surfaces of the internal and external fingers are approximated, and any depart- ure from the normal, on either side, is better mapped out than when the right hand alone is used for the internal examination. Describe the use of the external hand in the bimanual. The ulnar surface of the external hand should be used rather than the palm ; it should be applied to the abdomen some distance above the pubes and steadily depressed toward the opposing fingers within the vagina, while the patient relaxes her abdominal muscles and breathes quietly, with mouth open. Describe the use of the internal examining fingers in the bimanual. While the ring and little fingers are strongly flexed into the palm and the thumb lies on the pubes or between the thighs, place the BIMANUAL EXAMINATION. 47 middle examining finger on the cervix and the index in the anterior fornix and raise the uterus toward the external hand. The first step for the student in acquiring skill in the bimanual is to feel, through the abdominal wall, a body which transmits motion from the external hand to the finger on the cervix. This, in a normal case, is the fundus of the uterus ; future examinations will enable one to map out more and more the shape of the fundus. What is a good order to follow in making a bimanual exam- ination ? 1. Determine the position of the uterus by attempting to approxi- mate external and internal fingers ; the internal being placed first on cervix, then in anterior fornix and then in posterior ; the external hand exerting counter pressure. 2. Determine condition of tubes, ovaries and parametria ; using right hand internally for right side of the pelvis and left for left. Should you normally feel a hard body in any of the four for- nices of the vagina ? If so, which one, and what is it ? Yes, in the anterior fornix ; the body of the uterus. Should you normally feel a hard body in the posterior or either of the lateral fornices ? No. What mass might you feel in the anterior fornix ? 1. A fibroid on anterior wall of the uterus. 2. Inflammatory or blood effusions, rarely. What mass might you feel in either of the lateral fornices % Inflammatory deposit from cellulitis or peritonitis. Blood effusion. Enlarged tube or ovary. Body of uterus latero-flexed. Lateral fibroid. What mass might you feel in posterior fornix % Displaced fundus. Faeces in rectum. Fibroid on wall of uterus. Peritonitic or cellulitic deposit. Haematocele. 48 ESSENTIALS OF GYNAECOLOGY. Displaced ovary. Tumor. Rectal Examination. What are the methods ? 1. Simple rectal. 2. Abdomino -rectal. 3. Simon's method. What are the preliminaries to any rectal examination ? Have bowels empty. Tell patient what you are to do. Have soap under finger-nail. Lubricate finger. Or, better still, use a finger-cot. How would you perform the simple rectal examination ? Having observed the preceding preliminaries, pass the finger for- ward, noting the presence or absence of hemorrhoids, fissures, polypi, stricture, etc. , till the cervix is felt, then pass along posterior wall of the uterus. How would you perform the abdomino-rectal examination ? Passing the right index finger into the rectum as just described, use the left hand externally, placed on the abdomen as in the i>rdi- nary bimanual. What is Simon's method ? This consists in passing the whole hand, shaped like a cone, gradually through the anus into the rectum. What is the value of the different methods of rectal exami- nation ? Both the simple rectal and abdomino-rectal are of especial value in virgins, where the ordinary bimanual is painful or objected to. By means of a volsella forceps you may draw down the cervix, and then, with finger in the rectum, palpate the posterior . surface of uterus, tubes and ovaries. The above methods of rectal examination are of value in any case where you wish to reach higher than is possible with the ordinary bimanual. Advantage is sometimes gained by making the rectal examination with patient in Sims' position. INSTRUMENTS — SPECULA. 49 Simon's method is dangerous and seldom justifiable. What are the instrumental methods of rectal examination ? Where information is sought regarding the rectum itself rather than adjacent organs, the Sims position or the knee-chest position are employed. The speculum most generally useful in exploring the lower rectum is a small Sims'. It is inserted slowly, the patient is asked to strain so that the mucosa prolapses, and then the speculum is shifted from side to side till all parts of the mucosa Fig. 5, have been examined. For examination higher up an instrument like the Kelly cystoscope is useful. For most complete and thorough examination of the rectum and pelvic colon the Tuttle proctoscope is admirable. This instrument consists of a tube with concealed light, and is closed at the proximal end by a glass window. There is also an attachment for distending the rectum with air. The rectum is distended and the instrument advanced to succeeding rectal segments, guided by sight through the proctoscope. Sims' Speculum INSTRUMENTS. Specula. What are the three classes of specula in most common use ? 1. TheSpatular. 2. The Cylindrical 3. The Bivalve. Give one of the best examples of the spatular variety; describe it. The Sims speculum (see Fig. 5) is the best example of this class ; it consists of two blades united by a handle at right angles to them, 4 50 ESSENTIALS OF GYNECOLOGY. the blades being convex on the sides facing each other, concave on the opposite. Many modifications are made by which the length of blade, angle at which it joins the shaft, and weight of the whole instrument are altered. One blade of the Sims speculum is usually made shorter and smaller than the other. What are the advantages of Sims' speculum ? It does not distort cervix. It gives a good view of all but the posterior vaginal wall, and is the best suited for operations on cervix and anterior vaginal wall. What are the disadvantages of Sims' speculum ? It requires an assistant with some training to hold it. It requires, in most cases, the use of a vaginal depressor, thus employing one hand. What is the proper position of the patient for the use of Sims' speculum ? A patient in the so-called ' ' Sims position ' ' should lie on her left side, with left buttock on the left corner of the table, as you ftice it ; the head being at the right corner of the head of the table, the left- arm behind the patient ; the right arm should lie over the right edge of the table, the right shoulder being kept as near the table as possible. The knees should be drawn up, the right a little above the left. How would you introduce a Sims speculum ? Having placed the patient in the correct Sims position, select the blade you are to use ; warm and lubricate the convex side of it ; Fig. 6. take the speculum in the right hand with the index finger lying in the concavity of the blade, and introduce finger and blade together. INSTRUMENTS — SPECULA. 51 The breadth of the blade should be in line with the labia until it has entered the vaginal orifice ; it should then be rotated till the convexity lies in apposition with the posterior vaginal wall, which it should hug closely till the posterior fornix is reached and the index finger detects the cervix in front of it ; the speculum is then given to an assistant to hold. Some introduce the finger first and pass the blade along it. Fig. 7. Simon's Speculum. How would you hold a Sims speculum ? There are two methods in common use : — (a) One is to grasp the outside blade with the right hand, the angle between blade and handle fitting over index finger, as seen in Fig. 6 ; the thumb lying in the concavity of the blade over the angle. The right buttock should be raised with the left hand. (b) The other method is to grasp the handle of the speculum with the right hand, having the convexity of the outside blade rest in the hollow between the thumb and index finger. The right buttock being raised as in the other method. What is a Simon's speculum % A very valuable speculum of the spatular variety is called Simon's (see Fig. 7.) It consists of a common handle into which fit, at right angles to it, blades of different sizes and shapes. It is of especial value with the patient in the dorsal position, for retracting the perineum in curetting the uterus or operating upon the cervix. 52 ESSENTIALS OF GYNAECOLOGY. What is one of the best examples of a cylindrical speculum ? Describe it. The cylindrical speculum of Fergusson (see Fig. 8) is probably the best of its class ; it is a cylinder of glass or hard rubber, with one extremity beveled and the other trumpet-shaped. The glass ones usually present a mirrored surface from within. The beveled extremity is the one first introduced. Fig. 8. Fergusson's Speculum, What are the merits of the Fergusson speculum ? It is of very limited use ; it may be employed for inspecting the cervix and vaginal wall or making applications to it. It is useless for operations on the cervix ; it is only partially self-retaining, and Fig. 9. Brewer's Speculum. its introduction in nulliparae is painful. It is sometimes used for introducing gauze packing into the vagina. How would you introduce a Fergusson speculum ? In this country the Fergusson speculum is usually employed with the patient in the dorsal position. INSTRUMENTS — SPECULA. 06 Separate the labia with the fingers of the left hand ; holding the trumpet-shaped extremity with the right hand, introduce the beveled extremity into the vaginal orifice, having the shorter side anterior ; depress well the perineum, directing the speculum toward the hollow of the sacrum ; by slight vertical, horizontal or rotatory motion of the speculum while looking into it, the cervix is now usually brought into view without difficulty. It is occasionally convenient to draw the cervix more fully into view by means of a tenaculum. Some gynaecologists use the Fergusson speculum with the patient in Sims' position. Fig. n. Kelly's speculum ready for introduction (a); b, speculum with obturator removed What is one of the best examples of a bivalve speculum? Describe it. The Brewer bivalve (see Fig. 9) is probably the best speculum of its class ; it consists of two blades, the outer extremities being trumpet-shaped where they are jointed ; the anterior blade is shorter than the posterior, and has a slot in its outer half, to avoid pressure on the urethra ; this also facilitates the introduction of the sound or probe. The speculum is opened by approximating the handles of the blades and held there by a thumb-screw. There are two sizes of Brewer's speculum, the long and short. 54 ESSENTIALS OF GYNAECOLOGY. How would you introduce a Brewer speculum ? Place patient in dorsal position ; pass speculum into vaginal orifice with the blades lateral, then rotate till they are antero-posterior ; begin to open blades just before they reach the cervix ; when com- pletely open, hold with thumb-screw. What are the merits of Brewer's speculum ? For inspection of, and applications to, the cervix, it is very valu- able ; it is self-retaining, thus obviating the necessity of an assistant. The long instrument is better than the short, as with it the vaginal walls are not as likely to obstruct the view by falling in be- yond the blades, and at the same time it accomplishes all that the short instrument does. What are the disadvantages of Brewer's speculum? It distorts the cervix, obscures the anterior vaginal wall, and can- not be used for operations on the cervix or vagina. What is a simple speculum for examination of the interior of the bladder? The simplest speculum for direct inspection of the interior of the bladder is that devised by Dr. Kelly, of Baltimore (Fig. 9J). It is a tubular speculum with obturator, and comes in several sizes. Describe its use. The bladder is emptied ; the patient is placed in an exaggerated lithotomy position, with hips elevated 8 to 16 inches above the table. One of the smaller sized specula is introduced, and then a larger, until the desired size is reached. The obturator is then withdrawn, and air enters and distends the bladder. The residual urine is removed by pledgets of cotton held in long thumb-forceps ; light is thrown into the bladder by means of a forehead mirror, and by turning the speculum in different directions nearly the whole of the interior of the bladder may be inspected, and through the spec- ulum the ureters may be catheterized. For a thorough examination anaesthesia is desirable. Sometimes during such an examination the bladder will not dis- tend sufficiently with air. In such cases the object can be accom- plished by putting the patient in the knee-chest position. INSTRUMENTS — VOLSELLA. 55 Fig. 10. What other types of specula are used ? The simple Kelly tubes have been replaced by more elaborate instruments, which can be used without pain and without either local or general anaesthesia. These instruments are used with the patient in the dorsal position, and the bladder is distended to a capacity of six ounces or over, either with air or water, according to the instrument used. They consist of a hollow tube, with an elec- tric light attached to the end which enters the bladder and which illuminates its interior. Into this tube is passed the telescope of the instrument. These are of two kinds, the direct vision and indirect vis- ion cystoscopes. In the former one sees the portion of bladder wall lying in line with the axis of the instrument ; in the indirect vision cystoscope the object-glass is placed on the side of the telescope, hence one sees a portion of bladder wall at right angles to the axis of the instrument. Most of the instruments are equipped with ureteral catheterizing attach- ments. The Nitze and Otis instruments are good examples of the simple indirect vision- examining cystoscope. Volsella. Describe it. The volsella, or vulsellum forceps (see Fig. 10), consists of a pair of hooks with scissor handles and joint ; the hooks usually con- sist of two or more teeth ; the handles fasten with a catch. What are the uses of the volsella ? In all operations on the cervix, trachelorrhaphy, dilatation, etc., the volsella, or one of its substitutes, is almost indispensable, to draw down and hold the cervix. For applications to, or operations on, the interior of the body of the uterus, the volsella is also of great value. The use of the volsella to draw down the cervix, in connection 56 ESSENTIALS OF GYNECOLOGY. with the finger in the rectum, in the combined rectal examination, is of great importance. How would you introduce and apply the volsella? If used in operation on the cervix with the patient in the Sims position, it may be introduced either without or with the use of the speculum ; if without the speculum, the first two fingers of the right hand are introduced till the anterior lip of the cervix is felt ; the volsella is then passed along them and applied to the anterior lip, which is then drawn down. The better way is usually to employ Sims' speculum and apply the volsella directly to the anterior lip by sight. The volsella is also employed with the patient in the dorsal position, the instrument being introduced either by touch, or sight aided by a perineal retractor. Fig. 11. Sir J. Y. Simpson's Sound. What could you substitute for a Volsella ? A bullet forceps with a catch makes a very good substitute for a volsella and is getting to be preferred to it, as, having but one pair of teeth, it occupies less space on the cervix. A tenaculum, such as Sims', which is a sharp hook on a long slender shank, is often of great use in holding the cervix and draw- ing it in any direction, and can sometimes be substituted for a vol- sella. Uterine Sound. What are the two sounds in most general use ? their descrip- tion and merits ? The Sir J.-Y. Simpson's sound and that of A. R. Simpson are the two in most general use. They are both rods of copper, nickel-plated, and so pliable that they can easily be bent with the fingers. INSTRUMENTS — UTERINE SOUND. 57 The sound of Sir J. Y. Simpson (see Fig. 11 j is 12 inches long, with a notched knob 2§ inches from the end, and notches at ?>\. \\. etc. , up to 8 i inches. The handle is roughened on the side of the concavity of the curve. The sound of A. R. Simpson (see Fig. 12) is only 9 inches long ; it has a prominent ring at 2§- inches and two rings at 4J inches ; there are also markings at 3J and 5 J inches. This sound has an advantage over the preceding in that, being only 9 inches long, the handle, which is broad, can rest firmly on the ball of the little finger even when the tip of the index finger is on the 2\ inch ring, thus giving one a complete control of the instrument when the finger is in the vagina with the sound. This is impossible with the sound of Fig. 12. A. R. Simpson's Sound. (Hart and Barbour.) Sir J. Y. Simpson, as in similar circumstances the handle is far above the hand, and one can only grasp the shank, which readily rotates. The presence of the double ring is also an advantage in an enlarged uterus. What are the contraindications to the use of the sound ? Patient has skipped a menstrual period. Menstruation present. Acute inflammation present in uterus or neighborhood. Malignant disease of uterus. 58 ESSENTIALS OF GYNECOLOGY. What are the preliminaries to the use of the sound ? 1. Thoroughly sterilize the sound. 2. Be sure that the patient has not skipped a menstrual period. 3. Determine position of uterus by a careful examination. 4. Curve sound to the curve of the uterus. 5. Cleanse the vagina with an antiseptic solution. This is of im- portance to avoid carrying septic material from vagina to uterus by the sound. For this reason it is always wiser to introduce the sound with the aid of a speculum, which separates the vaginal walls and enables you to reach the os directly. 6. Position of the patient :— This is largely a matter of choice, but in this country the dorsal position is usually selected, and it has the advantage that in this position the bimanual may be easily combined with the use of the sound. How would you introduce the sound with patient in the dor- sal position ? Having introduced a speculum and thoroughly cleansed the vagina, be sure your sound is aseptic and then pass it by sight directly into the os. The introduction is often most easily accom- plished if the uterine body lies forward by starting the sound with its concavity backward, then, when the point is engaged in the cer- vical canal, turning the sound, not by rotating the shank, but by making the handle . describe a semicircle from behind, to the left and forward ; the point of the instrument remaining nearly station- ary. By depressing the handle toward the perineum, the sound will then usually pass without trouble. If the point catches in the crypts of the cervix, slight motion will usually disengage it. What variation in this procedure would you make if the fundus lay posteriorly? Having introduced the sound into the cervix as before, with con- cavity backward, continue the introduction without the semicircular motion of the handle. In this position of the fundus the sound is sometimes most easily introduced by a maneuver similar to that in the preceding case but in the opposite direction, viz., starting with the concavity of the INSTRUMENTS— UTERINE SOUND. 59 sound forward, make the handle describe a semicircle from before backward. How would you pass the sound in a marked case of ante- flexion ? If the uterus is anteflexed, the introduction of the sound is facili- tated by curving the sound sharply, and drawing down and steady- ing the cervix with a bullet forceps. How would you introduce the sound with patient in Sims' position ? Here, as in the dorsal position of the patient, the introduction of the sound should be preceded by the introduction of the specu- lum and the cleansing of the vagina and cervix ; the sound rendered aseptic is then passed by sight directly into the os without being- allowed to touch the vaginal walls : in this way the introduction of sepsis into the uterus is avoided. The further introduction of the sound may be continued with the concavity forward, or starting with the concavity backward the semicircular motion of the handle from behind forward may sometimes be employed with advantage. If the uterus lies posterior, the sound can usually be introduced directly with its concavity backward. What are the uses of the uterine sound ? (a) To determine — 1. The length of uterine canal. 2. Its permeability. 3. Its direction. 4. Condition of endometrium. 5. Growths in uterus. 6. Relation of uterus to tumors. (b) To replace a displaced uterus. The mobility of the uterus and the relation of cervix and body should be determined by the bimanual, not by the sound. The sound is wisely much less used now than formerly. What are the dangers in the use of the sound ? 1. Pelvic peritonitis or cellulitis, from introduction of sepsis. 2. Abortion. 3. Hemorrhage, especially in malignant disease. 4. Perforation of uterine walls. 60 ESSENTIALS OF GYNECOLOGY. Uterine Probe. Give its description and uses. The uterine probe is usually a slimmer instrument than the sound, made of silver, hard rubber or whalebone, with end slightly bulbous. Except in cases of stenosis, it is harder to introduce than the sound, and of less general value. It should be introduced by sight, while cervix is steadied with a tenaculum. Uterine Applicator. Give its description and uses. It is usually made of a piece of flexible steel or copper wire flattened at one end and attached to a handle at the other. It is used to apply medication to the uterine mucosa. The applicator is thrust into a small piece of cotton held between the thumb and finger. It is then rotated until the cotton is so firmly twisted about the end that it cannot be easily pulled off. It is then dipped into the fluid to be used and inserted in the same manner as the uterine sound. As a general rule it is safer to make such applications only to the cervix. Dilators. What are the methods of dilating the cervical canal ? 1. By tents. 2. By graduated hard dilators. 3. By dilators of the glove-stretcher variety. 4. By elastic dilators — Barnes' bag or Allen's pump. Tents. What do you mean by a tent as employed in gynaecology ? Give the varieties in use. A tent is a cone of some expansile material, which, by absorption of moisture, expands after introduction into the cervix sufficiently, both in extent and force, to dilate the canal. INSTRUMENTS — GRADUATED HARD DILATORS. 61 There are several varieties of tents in use, named according to their material. 1. Sponge. 2. Sea-tangle (Laminaria digitata). 3. Tupelo (Nyssa aquatilis). 4. Cornstalk. What are the merits of each ? The sponge tent expands easily, but it is the most dangerous of all, from the fact that it absorbs so readily material which easily becomes septic. The sea-tangle tent is less dangerous than the preceding, and dilates well, but it expands unevenly, and its edges are rough after expansion. The tupelo tent is the best of all. It expands evenly and smoothly, and is the least liable to cause sepsis. The cornstalk is feeble in action and seldom used. What are the indications for the use of tents ? 1. To dilate the cervical canal for purposes of diagnosis or opera- tion. 2 To check hemorrhage. What are the merits of tents for these uses ? The employment of tents has greatly, and very wisely, diminished of late. For diagnostic purposes they are still occasionally employed to dilate the cervical canal, so that the finger can be introduced, but they are dangerous, slow and painful, and we have, in most cases, better means, in dilators of the glove-stretcher variety, for accom- plishing the same result. The use of tents to check hemorrhage was chiefly in abortion ; the dilatation of the canal being sought for at the same time. We now have better means. Graduated Hard Dilators. Describe them. There are several varieties in common use, among which are Peas- lee's, Kammerer's, Hank's, etc. 62 ESSENTIALS OF GYNAECOLOGY. The first two resemble male sounds, except that the curve is less acute, and at 1\ inches there is a bulb. Hank's dilators consist of two sounds on each handle, one at each end. They are often made in sets of six and of hard rubber. Ordinary male sounds, Nos. 15 to 18, French, may often be sub- stituted for the dilators just mentioned. What are indications for the use of graduated hard dilators ? 1. By themselves to dilate a stenosis of the cervix causing dys- menorrhea or sterility. Under stenosis here is included that caused by flexions. 2. To maintain a dilatation produced by one of the more power- ful dilators. Describe the mode of employment of these graduated hard dilators. Place the patient in the dorsal position ; thoroughly cleanse the vagina and expose the cervix with a speculum ; draw down and hold cervix with a tenaculum or volsella ; introduce dilator by sight, as you would the uterine sound, beginning with the smallest size and increasing to the largest. Pack the vagina loosely with iodoform gauze or sterilized gauze. In employing these graduated dilators for stenosis of cervix causing obstructive dysmenorrhea, how often should they be introduced? It is usually necessary to introduce them once a week during the first month, and once or twice a month for a few months afterward ; exercising each time the same antiseptic precautions. Describe the dilators of the glove-stretcher variety. The two chief styles of these are the Sims and Ellinger's ; in the latter of which the blades are caused to move parallel, and on the handle there is a graduated scale. There are numerous modifica- tions of these dilators, among which may be mentioned Wylie's and Goodell's. What are the indications for the employment of these dila- tors? The same indications obtain as for the preceding, and in addition where a more complete dilatation of the cervix is desired. The first and more complete dilatation is often performed with a ELASTIC DILATORS— BARNES' BAGS, ALLEN'S PUMP. 63 dilator of this class, and then the dilatation maintained by the graduated hard dilators. What are the preliminaries to the use of the glove-stretcher dilators ? The patient should have an antiseptic douche, and for complete dilatation, anaesthesia. Describe the method of employing these dilators. The patient is usually placed in the dorsal position. Retract the perineum with a Simon's speculum ; thoroughly cleanse the vagina and cervix ; draw down and steady the cervix with a bullet forceps and introduce dilator to the shoulder, separate blades gradually to the desired extent, being careful that the instrument does not slip suddenly and lacerate the cervix. While most of the dilatation is performed in the lateral-diameter of the cervix, it is often well to rotate the dilator and dilate somewhat in other diameters. The dilatation may also be performed with the patient in Sims' posi- tion and with the aid of Sims' speculum. To what extent should you carry the dilatation? Usually from % to 1 inch. ELASTIC DILATORS. Barnes' Bags, Allen's Pump. Describe them and the method of using them. They consist of India-rubber bags, of different sizes, the former being fiddle-shaped, the latter more elongated. They are intro- duced under strict antiseptic precautions, in a collapsed condition, and are then slowly distended with air or water, usually the former ; the Barnes' bags by means of a Davidson's syringe, Allen's by the pump. What are the advantages of these elastic dilators ? Their method more closely resembles the physiological method of dilating the cervix ; the dilatation can be made extensive ; the danger of laceration of the cervix is slight. 64 ESSENTIALS OE GYNECOLOGY. They are chiefly used to start labor or abortion after the third month of pregnancy. What are the dangers of mechanical dilatation ? Laceration of the cervix. Endometritis. Salpingitis. Peritonitis. Stem Pessaries. Describe them and their uses. They consist of a hard-rubber or non-corrosive metal rod about If inches long, at one end of which a wide flange projects to keep the pessary from slipping too far into the uterus. There is usually a groove in the rod or else it is hollow to allow the escape of secretion. Their use, which is to maintain a dilatation of the cervix, accom- plished in one of the above-mentioned ways, is attended with con- siderable danger if not introduced with aseptic precautions or if left in for too long a time. The Curette. Describe it. The curette consists usually of a loop of wire, either blunt or sharp, on a rather long shank, used for scraping irregularities or new growths from the endometrium. The shank should, as a rule, be made of flexible material such as copper. Occasionally, it is made like a small cup, with a sharp edge, at- tached to a long shank. Simon's spoon is of this description. What are the varieties in common use ? Thomas' wire loop, dull and flexible. Sims' curette. Recamier curette. Simon's spoon. What is the value of the curette ? It is a very valuable instrument, both for diagnosis and treatment. a. For diagnosis, to scrape away some of the contents of the uterus for examination, to determine the cause of hemorrhage. THE CURETTE. 65 h. For treatment, to scrape away hyperplastic endometrium, villous growths or retained products of conception, which, by their vascularity, easily cause hemorrhage. In malignant disease of the uterus, the curette is also of value to remove sloughing masses. What are the preliminaries to the use of the curette ? The patient should be anaesthetized, placed in the dorsal position on a Kelly's pad, and knees supported with a leg-holder. The va- gina should be scrubbed with soap and water ; an antiseptic douche should be given, and all antiseptic precautions should be observed in regard to instruments, hands, etc. The perineum should be retracted with a Simon's or Sims' spec- ulum ; cervix drawn down and steadied with a bullet forceps, then dilated. A gentle curettage can sometimes be performed without anaesthe- sia, but for the thorough operation anaesthesia is usually necessary. Describe briefly the method of curettage. After dilatation of the cervix, the curette should be introduced very gently until the fundus of the uterus is reached, then with- drawn with the working edge of the instrument pressed firmly against the wall of the uterus. This process is repeated until the walls of the uterus feel smooth. The cavity of the uterus should then be irrigated with an aseptic or antiseptic solution. If necessary to check hemorrhage, to stimulate contraction, or to maintain dila- tation, a strip of gauze may then be introduced. As a rule, gauze packing in the uterus hinders rather than helps drainage of its cavity. The patient should be confined to bed for five to ten days. When would you prefer the dull to the sharp curette ? When the uterus is softened by pregnancy or septic processes. However, more depends on the way the instrument is used than its sharpness. What are the dangers of the curette ? Perforation of the uterus ; septic inflammation of the uterus or its adnexa ; peritonitis ; and induction of abortion. 5 66 ESSENTIALS OF GYNAECOLOGY. Drugs Acting on the Pelvic Organs. Discuss drugs having some special action on the pelvic organs. 1. Iron is classed as a tonic emmenagogue. It is of use in anaemia accompanied by amenorrhoea. 2. Ergot is of undoubted efficiency in causing uterine contractions. It is an important abortifacient. Its chief use is in controlling uterine hemorrhage in such conditions as subinvolution and intra- mural fibroids and endometritis. It often favors the expulsion of moles, secundines, or polypi from the uterus. It is of no value in malignant uterine tumors, and of no permanent value in fibroids in checking their growth. In gynaecology it is given chiefly as the fluidextract (HI xv-gj) or ergotin (gr. \-%). 3. Hydastis Canadensis has been relied on by clinicians to some extent in the same class of cases in which ergot is of value. It was believed to raise blood pressure, and even' to have a selective action on uterine muscle. Experimental work has recently shown that it does not raise pressure. The present verdict on all its supposed virtues is not proved. 4. Quinine seems to stimulate uterine contractions during labor. In malarial districts it has been believed to be an abortifacient, but the abortions can as well be attributed to the malaria as to quinine. It has been given to normal women in considerable quantities for a number of days for the purpose of producing abortion without success. If a pregnant woman is known to have malaria, give it, and in curative quantities, otherwise avoid it in pregnancy. Savine, rue, parsley, pennyroyal, and tincture of cantharides are classed as stimulating emmenagogues, and have considerable popu- larity among the laity as abortifacients. Their use for this purpose is quite dangerous, since, if given in sufficient quantities to be efficient, they are likely to cause grave gastro- intestinal and renal irritation. 6. Cathartics, especially the salines, are of value in relieving pelvic congestion. Clinical evidence is conclusive that dysmenor- rhoea is aggravated by constipation, and that a saline given a day or two before the expected period is among our most valued means of diminishing menstrual pain. DRUGS ACTING ON THE PELVIC ORGANS. 67 A possible exception to the rule is to be noted in the case of aloes, whose action is chiefly on the lower bowel. It is a common constit- uent of abortifacient mixtures, and in large doses may bring on ' ' an attack of piles," hence the feeling that it increases rather than decreases congestion. It is wiser to use some other cathartic in women with threatened abortion. 7. Alcohol, and especially gin, is a household remedy for dysnienorrhoea, and undoubtedly gives considerable temporary relief. The effect is partly due to the flushing of the superficial capillaries, though blood pressure is not shown by the sphygmo- graph to be changed by alcohol in small doses. Probably the effect is more due to the well-known ansesthetie effect of alcohol, to which the volatile oil of juniper may contribute. Though efficient in relieving dysnienorrhoea, alcohol and opium are not to be recommended, as the regular recurrence of the pain favors the formation of a drug habit. The coal-tar antipyretics effect dysnienorrhoea much as they do neuralgias, and are to be preferred, if drugs are needed. 6. Viburnum. — According to clinical evidence, this drug has some value in congestive dysnienorrhoea. It is wise to give it a trial in intractable cases of dysnienorrhoea, though, like other drugs recom- mended for the condition, it is likely to prove disappointing. 9. Thyroid extract, the thyroid gland of a sheep desiccated to about one- eighth of its original weight, is of value in some cases of menorrhagia. The cases where it is of value show other signs of hypothyroidism, such as obesity and dry skin. 10. Ovarian Extracts. — The ovary probably produces two har- mones : a. One produced by the corpus luteum, whose action is exerted on the uterus if pregnancy occurs. It has been shown in animals that if the corpus luteum be removed within six days after coitus that the ovum cannot be implanted upon the uterine mucosa. b. A substance is presumably produced in certain cells lying in the ovarian stroma, but originally derived from germinal epithelium, which is necessary to the development of the sexual instinct and to the formation of secondary sexual characters. In young male animals there are described similar cells in the stroma of the testis which do not atrophy with the tubules when the vas is tied, and which are believed to produce the testicular internal secretion. Clinically, ovarian extracts have been given a trial with some 68 ESSENTIALS OF GYNAECOLOGY. evidence that they ameliorate the nervous phenomena of the artificial but not the natural menopause. Vulvitis. What are the varieties ? a. Occurring in both children and adults : 1. Simple catarrhal, acute or chronic 2. Gonorrhceal ; 3. Phlegmonous ; 4. Croupous; 5. Gangrenous ; b. Occurring in adults : Follicular. I. Acute Simple Catarrhal Vulvitis. What are the causes ? Lack of cleanliness ; Strumous diathesis ; Discharges from cervix, or vagina ; Injuries or friction from exercise ; Masturbation ; Awkward, or excessive coitus ; Pregnancy ; Foreign bodies ; Parasites ; Acute exanthemata ; Diabetic urine. What are the symptoms ? General malaise ; some local pain and burning ; parts are oedema- tous, congested, covered with a glairy, mucous, excoriating discharge, which may extend to the urethra. What is the treatment ? Rest in bed ; warm sitz-baths ; lead and opium wash frequently applied to the vulva ; lint soaked in it kept between the labia. Bis- muth, starch, or borax may with advantage be dusted on the vulva in the intervals between the applications of the lead and opium wash. If the vulvitis is from ascarides, employ enemata of infusion of quassia, § ij-Oj. vulvitis. 69 Chronic Catarrhal Vulvitis. Describe its occurrence and course. Catarrhal vulvitis in children is most apt to be chronic ; it Is seen most frequently in strumous children, often with no history of the acute stage. What are the symptoms ? 1. Discomfort in walking and in micturition ; 2. Pruritus ; 3. Stains on linen. What is the treatment ? Build up the constitution by tonics and fresh air ; observe cleanli- ness ; if much discomfort, use lead and opium wash, followed later by nitrate of silver (gr. x-^j) applied to the vulva ; bismuth .or borax being dusted on between the lotions. II. Gonorrhoea and Gonorrheal Vulvitis. What is the etiology ? It is produced either directly by intercourse with one who has contracted gonorrhoea, or indirectly by soiled linen, instruments, etc. What is the diagnostic value of Neisser's gonococcus, found in the discharge ? The gonococcus of Neisser is the sole cause of gonorrhoea, and the disease can only be transmitted through its agency. Give an account of the gonococcus and its inflammations. The gonococcus is a diplococcus pathogenic only for man. It is found in the discharges of gonorrheal inflammations and is usually contained in the cell body of pus cells, but, as a rule, is found be- tween rather than in the epithelial cells. It is also found extra- cellular in the gonorrhoeal discharge. It readily stains with the analin dyes but is decolorized by Gram's iodine solution. It grows best on media containing human body fluids, such as blood-serum, various exudates, ascitic and hydrocele fluid, and albuminous urine. It is possible to grow the organism on animal fluids, such as dog's serum. It must be kept at body temperature and frequently transplanted. 70 ESSENTIALS OF GYNECOLOGY. In chronic gonorrhoea the germ is difficult to identify, and in closed cavities, such as pyosalpinx and Bartholinitis, it soon suc- cumbs. On mucous surfaces, as in the cervix or deep urethra of the male, it may persist for years. Its usual inflammations are those of the genital tract, but it may cause conjunctivitis, synovitis, teno-synovitis, bursitis, or malignant endocarditis. The gonococcus very rarely produces a general peri- tonitis. The urinary tract is less susceptible to the gonococcus than the genital with the exception of the urethra. Probably the acid urine in the bladder inhibits its growth in that organ. It is rarely found associated with other bacteria in its lesions. The female genital organs most often the seat of gonorrhoea are the urethra, vulvo-vaginal glands, cervical and corporeal endometrium, and the Fallopian tubes. Discuss latent gonorrhoea. By this we mean symptomless gonorrhoea. The germs still re- main and can produce acute gonorrhoea with its usual severity when transplanted to another person. The subject of a latent gonorrhoea may at any time light up an attack as the result of excesses, alcoholic or sexual or severe physical exertions. The germs in latent gonor- rhoea may be few and hard to find. They are usually concealed in some crypt, gland, or fold of mucosa. In the female the cervix is a favorite spot. Discuss immunity to gonorrhoea. No one is immune to the disease. Because of its greater severity and more rapid extension in some individuals it has been inferred that there may be germs of differing virulence. Predisposing fac- tors, such as congestion, abrasion, etc., are not essential, and per- fectly normal mucous membranes can be attacked. The nearest approach to immunity is seen in the case of two individuals having frequent sexual intercourse and having gonorrhoea in the latent form. Each has a tolerance to the germs of the other, so that acute infection does not follow intercourse with each other. Either is capable of communicating the acute form to a third person. Upon what points would you base a diagnosis of gonorrhoea in the female? Absence of history of labor, abortion or use of instruments, sud- VULVITIS. 71 den onset of symptoms, moderate rise of temperature, as a rule, without chill, yellow purulent discharge, urethritis, Bartholinitis, or redness about the orifice of its duct. Any or all of these signs may be present. The diagnosis becomes positive when the gonococcus can be identified. It is best sought for in the urethral pus. Pyo- salpinx is gonorrhceal in a majority of cases. What is the differential diagnosis between gonorrhoeal vul- vitis and acute simple catarrhal vulvitis ? In gonorrhoeal vulvitis, the onset is more violent ; more fever, pain, and oedema ; the inflammation extends up the vagina, urethra, and vulvo-vaginal glands; pus can often be pressed out of the urethra ; gonococci can be found in the discharge ; often warts or buboes are present, and sometimes gonorrhoeal rheumatism. What is the method of examining discharges for the gono- coccus ? Collect a small drop of discharge, preferably from the urethra, Bartholin's duct, or interior of the cervix. Spread over several slides or cover-glasses. Stain one with methylin fluid. Look for organisms resembling the gonococcus, note whether the discharge is purulent and whether the suspected germs are largely intracellu- lar. This examination will often suffice if, as in acute cases, the discharge is purulent and the gonococcus alone is seen. If the dis- charge is not purulent and many varieties of bacteria are present, the case is presumably not gonorrhoea. If any doubt exists, use Gram's stain, counterstaining with Bismarck brown. This will distinguish the Neisser from other diplococci. How would you decide a gonorrhoea has been cured? The vaginal reaction should again become acid. Repeated exami- nation of carefully selected specimens must fail to reveal the gonococ- cus. If the discharge is purulent, but no germs of any kind are seen, still suspect the gonococcus. When it has disappeared other germs will reappear. Lesions should have disappeared from the vulva, and the discharge should contain epithelial rather than pus cells. What is the value of gonococcus anti-serum and vaccine? With the anti-gonococcus serum favorable results are claimed only in the case of the most chronic types of the disease, such as 72 ESSENTIALS OF GYNECOLOGY. rheumatism. The vaccine is a sterilized culture of the gonococcus. A suspension of roughly 100,000,000 germs is injected hypodermically as a dose. It is too soon to state results, but favorable reports have been made of its use in joint complications and in the vulvo -vagi- nitis of children, both acute and chronic. What is the treatment of gonorrheal vulvitis ? Keep patient quiet ; give light diet ; keep bowels open ; disinfect the parts with bichloride 1-5000, or lysol 1-100 or 200 ; then have the parts irrigated every hour or two with borax water 3j-Oj. If discomfort is very great, lead and opium wash may be frequently applied to the vulva, and patient may take warm sitz-baths. The labia should be kept separated with lint or gauze. The organic preparations of silver, such as protargol and argyrol, will be found of value applied to the external genitals in the form of watery solutions of a strength of 10 to 25 per cent. If the vulvitis tends to become chronic, apply nitrate of silver, gr. x-xx-^j. III. Phlegmonous Vulvitis. What is the etiology ? It may arise from the following : — Traumatism ; Irritating discharges ; Acute exanthemata ; Furunculosis. What are its pathology and symptoms ? It is a circumscribed or diffuse suppurative process manifesting itself by the following symptoms : — a. Subjective : Heat and pain, increased by standing or walking. b. Objective : Congestion, swelling, induration ; later, suppura- tion. From what must you differentiate phlegmonous vulvitis ? a. Pudendal hernia ; b. Dislocated ovary ; c. Hydrocele of round ligament ; d. Haematoma of vulva. VULVITIS. 73 How would you differentiate phlegmonous vulvitis from pu- dendal hernia ? vs. Pudendal Hernia. Phlegmonous Vulvitis Signs of acute inflammation. Dullness on percussion. No impulse on coughing. Not reducible. History of traumatism, etc. None unless strangulated, or injured. Tympanitic on percussion. Impulse on coughing. Usually reducible. History of strain. How would you differentiate phlegmonous vulvitis from a dislocated ovary ? Phlegmonous Vulvitis vs. Signs of acute inflammation. Gradual development. No especial exacerbation during menstruation. No sense of ovarian compression when pressed upon. Not the shape of an ovary. How would you differentiate phlegmonous vulvitis from hydrocele of the round ligament ? Dislocated Ovary. Usually absent. Sudden development. Larger and more sensitive during menstruation. Peculiar sensation when pressed. Has the shape of an ovary. Phlegmonous Vulvitis Signs of acute inflammation. Opaque. Never communicates with ab- dominal cavity. vs. Hydrocele of Pound Ligament. No signs of acute inflammation. Translucent. Sometimes communicates with abdominal cavity. How would you differentiate phlegmonous vulvitis from haematoma of vulva ? Phlegmonous Vulvitis Gradual formation. Less frequent during parturi tion. Color, red. First hard, then soft. Less often preceded by varicosi ties. What is the treatment of phlegmonous vulvitis ? Tonics: Arsenic, quinine, etc. vs. Hematoma of Vulva. . Sudden onset. More frequent during parturi- tion. Color, purplish. First soft, then hard. More often preceded by varicosi- ties. 74 ESSENTIALS OF GYNECOLOGY. Wet antiseptic dressings, as gauze soaked in cool aluminium acetate solution. When pus has formed, open, drain, and dress antiseptically. IV. Croupous Vulvitis. Give the etiology, symptoms, and treatment. A vulvar inflammation with the formation of a false membrane may be due to diphtheria or other infectious disease, including puerperal infection. True diphtheria may appear first on the vulva, the membrane resembling that of pharyngeal diphtheria. The treatment is that of the infectious disease with local use of antiseptics. V. Gangrenous Vulvitis. Give the etiology and treatment. Gangrenous vulvitis is most frequently found complicating preg- nancy, severe types of acute exanthemata, and very violent cases of vulvitis of other varieties. The disease known as noma or cancrum oris is a variety of gangrene usually occurring about the mouth, but it may attack the genitals of children. The treatment consists of constitutional tonics and local antiseptics. VI. Follicular Vulvitis. Give the pathology. Follicular vulvitis is an inflammation of the mucous and sebaceous glands and hair follicles of the vulva ; all may be simultaneously affected, or one set alone involved. What is the etiology ? It occurs only in adults ; any of the causes of simple acute catarrhal vulvitis may produce it ; among the most common are the follow- ing :— a. Lack of cleanliness ; b. Discharges from above, especially senile leucorrhoea ; c. Pregnancy ; d. Acute exanthemata. What are the symptoms ? a. Subjective : — Local heat and pain ; Pruritus ; CYST AND ABSCESS OF VULVO- VAGINAL GLAND. 75 Increased secretion ; Hyperesthesia ; Vaginismus occasionally present ; Vulvar extremity of urethra is sometimes affected, then ardor urinae results. b. Objective: — The mucous membrane appears very red in spots, resembling the papillae of the tongue. When the sebaceous glands and hair follicles are chiefly affected, they will be found as little round red papillae, scat- tered over labia and base of prepuce and clitoris, not on vestibule ; later, a drop of pus appears in the apex of these papillae ; they then disappear. How would you treat a case of follicular vulvitis? Pay strict attention to cleanliness ; during the acute stage use mild antiseptic lotions, as borax water (3j-Oj) or alum-acetate solu- tion; later, apply nitrate of silver (gr. x-^j). Bismuth or calomel may be used as a dusting powder ; keep labia separated. Cyst and Abscess of Vulvo-vaginal Gland, Cyst op Vulvo-vaginal Gland. Give the etiology and pathology. A cyst of the Bartholinian or vulvo-vaginal gland is formed by a distention of the duct, or gland itself, caused by any occlusion of the duct, especially from inflammation, either simple catarrhal or gon- orrhceal. A cyst of the duct is more elongated than of the gland itself ; a cyst of the gland is occasionally multiple. Abscess of the Vulvo-vaginal Gland. What is the etiology ? The causes of a vulvitis may produce abscess of the vulvo-vaginal gland ; gonorrhoea is the most common cause. What are the symptoms ? Pain ; heat ; swelling and redness, especially near orifice of duct ; it is tender on pressure ; at first hard, later fluctuating. 76 ESSENTIALS OE GYNECOLOGY. How could you differentiate a cyst from an abscess of the vulvo-vaginal gland ? Cyst vs. Abscess. Gives no signs of inflammation. Shows inflammation . Insensitive to pressure. Sensitive to pressure. Duration long. Duration shorter. What is the treatment of a cyst of the vulvo-vaginal gland ? The usual treatment is to excise an elliptical area of mucous mem- brane over the sac on its inner surface ; this exposes the sac ; now cut out a large ellipse from it ; empty the sac, pack it with iodoform gauze, and apply an antiseptic outside dressing. . A better plan is usually to dissect out the whole sac, if possible, and bring together the edges of the wound with catgut ; then apply an antiseptic dressing as before. From what may you get considerable hemorrhage in extir- pating the sac ? From the transversus perinei artery, and from the bulbs of the vagina. How would you treat an abscess of the vulvo-vaginal gland ? Before the presence of pus is detected, keep the patient quiet in bed ; apply soothing lotions like alum-acetate solution. As soon as pus is detected, proceed as with the cyst till sac is opened, then with a sharp curette scrape the interior of sac wall ; irrigate with bichloride (1-1000); pack with gauze, and apply an outside dressing of sterile gauze, absorbent cotton, and a T-bandage. From what must you differentiate vulvo-vaginal cyst or abscess ? From hernia and phlegmonous vulvitis. How would you differentiate vulvo-vaginal cyst or abscess from hernia ? Cyst or Abscess vs. Hernia. No impulse on coughing. Impulse on coughing. Irreducible. Usually reducible. Dull on percussion. Tympanitic on percussion. Abscess shows signs of inflam- None, unless strangulated, or mation. injured. More circumscribed. Less circumscribed. PUDENDAL HEMATOCELE. 77 How would you differentiate abscess of vulvo-vaginal gland from phlegmonous vulvitis ? The vulvo-vaginal abscess is more distinctly circumscribed and globular ; the phlegmonous vulvitis is more diffuse. Pudendal Hernia. Describe. The process of peritoneum which follows the round ligament through the inguinal canal to its termination in the labium majus ia usually obliterated at birth ; occasionally this obliteration does not occur, and this channel, called the canal of Nuck, furnishes a path for hernia. The hernia may consist of intestine, omentum, ovary 01 bladder. The uterus has even been said to follow this canal. What are the causes ? Blows, falls, coughing or violent muscular exertion. What are the symptoms ? The patient experiences a feeling of discomfort, especially on walking, and finds a swelling, which, if intestine, presents the fol- lowing features : It gives an impulse on coughing ; is tympanitic on percussion ; can usually be reduced, and, unless strangulated, or injured, presents no signs of inflammation. If the hernia consists of an ovary, it gives the ovarian sensation on pressure, and its size and tenderness are both increased during menstruation. What is the treatment ? Place patient on her back, with knees elevated ; reduce by gentle taxis, if possible, and apply a suitable truss. If strangulation has occurred, a surgical operation is necessary. If the hernia consists of an ovaiy which has become adherent, protect it from pressure by a hollow pad, or if it occasions great distress, remove it. Pudendal Hematocele. What are the synonyms ? Hseinatoma or thrombus of vulva. 78 ESSENTIALS OF GYNAECOLOGY. Define. Pudendal hematocele (better hsematoma) consist of an effusion of blood into the tissue of the vulvo-vaginal region, usually into one labium, or into the areolar tissue surrounding the vaginal walls. What is the etiology? Pudendal haematocele is predisposed to by any condition causing, or accompanied by, a dilatation of the vessels of the vulva : — Pregnancy ; Tumors ; Varicocele ; Labor. The exciting causes are blows, falls, muscular efforts, etc. Describe the symptoms and course. The patient experiences pain of a tearing character, which, if the effusion is large, may be accompanied by faintness. Sometimes the effusion presses on the urethra and causes difficulty in micturition. The swelling is at first soft ; later, hard. If small, it is usually absorbed ; it sometimes remains for a long time ; sometimes suppurates. How would you differentiate pudendal hematocele from hernia ? Pudendal Hcematocele vs. Hernia. History. History. No impulse on coughing. Impulse on coughing. Dull on percussion. Tympanitic. Irreducible. Usually reducible. First soft, then hard. More uniform. How would you treat a case of pudendal hematocele ? While effusion is in progress, apply ice and pressure. If the effusion is large, occurs during labor and obstructs the passage of the head, incise, turn out the clots and pack with iodoform gauze. If the effusion is small, apply soothing lotions like alum-acetate solution ; if suppuration occurs or if absorption is long delayed, incise, irrigate with an antiseptic solution, and pack with iodoform gauze. ERYTHEMA OE THE VULVA. 79 Hemorrhage from Vulva. What is the etiology ? The predisposing causes are the same as for pudendal hemato- cele and hematocele itself. The existing causes are the following : — Violent muscular efforts ; Blows ; Punctures or lacerations. What is the treatment ? If it is a ruptured hematocele, incise, turn out the clots and pack ; otherwise, catch bleeding points and ligature, or apply pressure, assisted by a tampon in the vagina. Skin Diseases Affecting the Vulva. What are the most common? Erythema, eczema, and herpes are most frequently seen ; eczema may be acute or chronic. Erythema of the Vulva. Give the etiology, symptoms and treatment. Etiology. — Erythema is most apt to occur in fleshy people, espe- cially in hot weather. The exciting causes are : — Lack of cleanliness ; Irritating discharges ; Exercise. Symptoms. — The parts become red, sensitive, often excoriated and painful, especially in walking. Treatment. — Cleanliness ; Attention to bladder and urine ; Desiccating powders, such as bismuth subnitrate, oxide of zinc, or calomel. 80 ESSENTIALS OE GYNECOLOGY. Eczema of the Vulva. Give the etiology. Eczema is predisposed to by functional disturbance of the gastro- intestinal tract, gout or rheumatism ; it is especially apt to occur in women near the menopause. The most frequent exciting cause is an irritating discharge from the cervix or vagina. What are the symptoms ? The disease may be acute or chronic. In the acute form, the parts become reddened and edematous ; vesicles appear, break and dis- charge a thick, tenacious fluid, which forms crusts. The subjective symptoms are severe burning and itching. In the chronic form, the parts become thickened and scaly ; the subjective symptoms resemble those of the acute, but are a little less marked. What is the treatment ? In the acute form, observe strict cleanliness ; if the burning is very severe, use alkaline sitz-baths and sedative lotions ; later, or at first if burning and itching are not intense, an ointment like the follow- ing is very good : — R. Acidi salicylici,. . gr. xv, Zincioxidi, ^ij ss, Pulv. amyli, 3 jj ss, Petrolati, ^j. M. Sig. — Apply locally. In the chronic form, use the same treatment during the exacerba- tions as for the acute ; later, an ointment containing oil of cade will be found of value. What are the most common parasites found on the vulva ? The pediculus pubis, or crab louse, is the parasite most often found infecting the vulva. The acarus scabiei, or itch mite, is occasionally, but rarely, found on the vulva as part of a general infection. Give the etiology, symptoms and treatment of infection with pediculi pubis. Etiology.— The pediculus pubis is almost always conveyed directly from person to person, usually in sexual intercourse. NEW GROWTHS OF THE VULVA. 81 Symptoms. — There is burning and itching; often an eruption resembling eczema. The diagnosis is made by finding the pediculus closely adherent to the roots of the hair. Treatment. — Any one of the following : — Corrosive sublimate, 1-1000 ; Tincture of delphinium ; Carbolic 5 per cent, solution. It is often best to shave the pubes before applying the lotion or ointment. Give the etiology, symptoms and treatment of scabies of the vulva. Etiology. — The acarus scabiei is rarely found on the vulva, but this occasionally occurs as part of a general infection. Symptoms. — There is an intense pruritus, worse when the body is warm. The diagnosis is made by finding the burrows on other parts of the body, especially between the fingers. Treatment. — A warm soap and water bath, followed by an oint- ment composed of sulphur alone, or combined with balsam of Peru. Discuss herpes of the vulva. This disease occasionally involves the parts about the vulva as it does the mouth. Sometimes it is unilateral and affects the area supplied by a single nerve. The diagnosis is made by the appearance of more or less pain in the region, followed in a short time by the characteristic vesicles. When occurring over the distribution of a single nerve, it is more accurately spoken of as zoster. Treatment. — While the vesicles are appearing, a wet dressing of aluminium acetate will give relief. Afterward apply an ointment of menthol or a dusting powder. Allow the vesicles to dry up rather than open them. New Growths of the Vulva. Mention the principal new growths occurring on the vulva? a. Papillomata — 1. Simple ; 2. Pointed condylomata ; 3. Syphilitic condylomata. 6 82 ESSENTIALS OF GYNAECOLOGY. u. Cyst of vulvo-vaginal gland. c. Carcinoma. d. Sarcoma. e. Elephantiasis. / Fibromata. g. Lipomata. h. Neuromata. i. Lupus. Discuss adherent prepuce In children the prepuce is often found adherent to the clitoris, and in most cases gives rise to no symptoms. In some, however, there, as in the male, retained smegma and consequent irritation of the parts lead to such symptoms as itching, rubbing, masturbation, and enuresis. When symptoms are present, separate the adhesions or, better still, to avoid their reforming, amputate the prepuce. Simple Papillomata. What is the etiology and treatment? Etiology. — A simple papilloma, or wart, occurs rarely on the vulva ; it is usually congenital and of little importance. Treatment. — It may be destroyed with nitric acid, or it may be excised under cocaine, and the wound closed with fine sutures. Pointed Condylomata. What is the etiology and appearance ? Pointed condylomata, or gonorrhoeal warts, as they are commonly called, are due to acrid macerating discharges on the vulva, usually but not necessarily gonorrhoeal; they are always multiple, and occur most frequently on the inner surfaces of the labia majora, on the perineum and about the anus ; they are of a grayish color and often pediculated ; their summit is divided into pointed lobules. When on the skin, they are sometimes dry and hard ; on a mucous surface they are soft. The congestion of the vulva accompanying pregnancy predisposes to them, and they are then, as in other cases, frequently but not necessarily gonorrhoeal. What is the treatment of pointed condylomata ? Treat the discharge and keep the parts clean by frequent wash- SYPHILITIC CONDYLOMATA. 83 ing. Then dry and dust with powder, such as calomel and starch, and keep adjacent surfaces apart with gauze or cotton between the labia. If this does not suffice, cut them off with knife or scis- sors and touch the base with a caustic ; under cocaine this may be made practically painless. Pedunculated ones may be removed bloodlessly by tying a silk thread about the base. They will then drop off in a few days. Syphilitic Condylomata. What is the etiology, appearance and treatment ? Syphilitic condylomata, or mucous patches, are the result of the syphilitic poison. They are broad and flat, situated most frequently on the inner surface of the labia majora, and usually covered with a grayish, mucus-like secretion. According to Duhring, they some- times take on a more warty growth. Treatment. — Cleanliness ; Calomel locally ; Constitutional treatment for syphilis. Discuss syphilitic chancre in women. The typical Hunterian chancre is infrequently seen on the vulva. Mixed infection leads to a more or less ulcerated lesion. Multiple chancre is more common than with men. It is often small and evanes- cent, consequently secondary symptoms are frequently the first to attract attention, and then the chancre may have largely disappeared. Chancres are most often found on the labium majus, less often on the labium minus and fourchette. In some cases the sore is small, but there is an area of indurative oedema widely transcending the limits of the sore. Chancre occurs infrequently on the cervix. It is said to disappear before the secondary manifestations. Discuss tertiary syphilis of the vulva. This may lead to extensive loss of substance with deep and chronic ulcers, which later cicatrize. Rectal and urethral fistulse occur. In the vicinity of the ulcer there is usually an area of indurative oedema resembling elephantiasis. Elephantiasis is by many thought to be syphilitic when occurring on the vulva. Do not rule out syphilis of the vulva simply because you find no signs of the disease elsewhere, 84 ESSENTIALS OF GYNECOLOGY. Pruritus Vulvae. Define. Pruritus vulvas, a symptom rather than a disease per se, consists of an irritation of the nerves of the vulva, accompanied by intense itching, at first localized, later extending, from the mechanical irrita- tion of scratching. What is the etiology ? The predisposing causes are : — a. Poor health. b. Disorders of the digestive tract. c. Anything producing congestion of the vulva, such as— Pregnancy ; Tumors in neighborhood ; Diseases of uterus or appendages ; Menopause. d. Lack of cleanliness. The exciting causes are chiefly the following : — 1. Irritating discharges from cervix, vagina, urethra or vulva. 2. Diabetic urine. — „ 3. Eruptions. 4. Parasites. 5. Masturbation. 6. Yegetations on vulva. 7. Kraurosis vulvae. This is an atrophic condition of the vulva. It is thought to be an atrophic stage of long-continued inflammation of the parts. It begins about the clitoris, and chiefly involves cli- toris, vestibule, and labia minora. There is an increase of fibrous tissue in the mucous membrane, with a disappearance of its papillae, giving the parts a smooth white appearance. It usually causes an intense itching and hyperaesthesia ; other cases are painless. What are the symptoms ? An intense itching, at first only at intervals after active exercise, over-indulgence at the table, lying in a warm bed, or sexual inter- course. Later, the itching becomes constant ; the desire to scratch becomes irresistible, causing the patient to avoid society ; it some- times leads to nervous depression and melancholia. HYPERESTHESIA OF THE VULVA. 85 What is the treatment ? First ascertain the cause, if possible. Build up the general health. Regulate the diet. Observe strict cleanliness. Destroy parasites if present. Treat diabetes if present. Treat eruptions. If there is an acid discharge from above, tampon vagina. Let patient use frequent warm sitz-baths. Apply any one of the following : — Hot lead and opium wash ; Carbolic solution, 2-3 per cent. ; Bismuth or calomel dusted on vulva , Nitrate of silver (gr. x-Jj) ; Cocaine, 4 per cent, solution ; An ointment containing oxide of zinc and oil of cade. Hyperesthesia of the Vulva. Describe. This consists of an excessive sensibility of the nerves supplying the mucous membrane of some portion of the vulva. What is the etiology ? The menopause seems to predispose to it ; also the hysterical and melancholic state. An irritable urethral caruncle sometimes acts as an exciting cause. A peculiar atrophic condition of the skin of nymphae and vestibule, called kraurosis vulvae, is an occasional cause. Often no cause can be assigned. What are the symptoms ? Hyperesthesia, especially about the vestibule and labia minora ; there is no pruritus, and signs of inflammation are absent except occasional erythematous spots ; dyspareunia is very marked ; the slightest friction causes pain. What is the treatment ? Build up the constitution with tonics, change of air, etc. Interdict sexual intercourse. 86 ESSENTIALS OF GYNECOLOGY. Administer the bromides internally. Externally apply one of the following : — Carbolic lotion, 2-3 per cent ; Nitrate of silver solution (gr. x-xx-^j) ; Lead and opium wash ; Four per cent, solution of cocaine. Vaginismus. Define. Sims defined vaginismus as ' ' an excessive hyperesthesia of the hymen and vulvar outlet, associated with such involuntary spasmodic contraction of the sphincter vaginae muscle as to prevent coitus. ' ' What is the pathology? There are usually found sensitive papillae about the base of the hymen ; an hypertrophy of the papillae and connective tissue of the hymen ; occasionally the lesion seems to be at a distance, as in the uterus or appendages ; sometimes no lesion is visible. What is the etiology? The predisposing causes are — 1. A narrow vagina. 2. A dense, thick hymen. 3. Malposition of the vulva. The exciting causes are — 1 . Disturbances of the sexual function. 2. Masturbation. 3. Inability of the male to complete the sexual act. It usually occurs in the newly married. What is the treatment ? Palliative. — Interdict efforts at coitus for a time. Forcibly di- late the hymen, under anaesthesia, by inserting and separating the thumbs ; then insert one of Sims' glass vaginal plugs. Radical. — Excise the hymen and insert one of Sims' plugs. Coccygodynia. Define and give the etiology. Coccygodynia, or coccyodynia, is a "painful affection of the mus- cles, tendons, and nerves of the coccyx, with or without disease of the bone itself. " (Mann). IRRITABLE URETHRAL CARUNCLE. «7 It occurs most frequently after childbirth, but is also produced by mechanical causes, such as blows, falls, kicks, etc. Among other causes are disease of the pelvic organs, rheumatism and gout. Hys- teria largely predisposes to it ; in some cases no cause can be assigned. What are the symptoms ? Pain in the coccygeal region, increased by motion bringing into play the muscles attached to the coccyx ; especially rising after sit- ting, defecation, coitus, sometimes even walking. Pressure on the coccyx elicits the characteristic pain. The condition must be differentiated from disease of the rectum or anus, and from pure hysteria. What is the treatment ? First attend to the general condition, rheumatism, hysteria, etc., if this fails, we have two operations : — 1. Cutting the attachments of the muscles to the coccyx. 2. Extirpation of the coccyx. Neither operation is attended with any great success. Irritable Urethral Caruncle. Define. An irritable urethral caruncle is a deep red mass, veiy vascular and sensitive, situated at the mouth of the urethra, or just within the canal ; it consists, according to Hart and Barbour, of dilated capil- laries in connective tissue, the whole being covered with squamous epithelium. What is the etiology ? But little is known of its etiology ; it occurs at all ages, and in both married and single women. What are the symptoms ? The patient complains of frequent and painful micturition ; later, this dysuria increases, and pain is caused by walking, pressure or friction of any kind. Intercourse causes both pain and hemorrhage. The nervous symptoms are well-marked ; hysteria, melancholia, etc. On examination, one finds a raspberry-looking mass at the meatus ; it is very sensitive and bleeds easily ; it may be single or multiple. 88 ESSENTIALS OF GYNECOLOGY. From what must you differentiate an irritable urethral caruncle, and how ? From polypi, venereal warts and prolapse of the urethral mucous membrane. Polypi are usually higher in the urethra, are less vascular and less sensitive. Venereal warts are less vascular, insensitive, and usually accom- panied by others. The history may aid. Prolapse of the urethral mucous membrane may resemble a caruncle in appearance, but it usually surrounds the meatus more, is less vascular and less sensitive, is continuous with the urethral mucous membrane, and can usually be reduced. What is the treatment ? Employ anaesthesia ; cut off the caruncle and touch the base with nitric acid or the actual cautery. You may ligate before cutting. What is the prognosis ? If the growth is single and near the meatus, the prognosis is good ; if multiple and extending up the urethra, they may recur. Prolapse of the Urethral Mucous Membrane. Describe. Prolapse of the urethral mucous membrane may involve the whole circumference of the meatus, or only a portion ; if the latter, it is the lower portion which is usually affected ; a slight redundancy at the meatus is common ; a prolapse sufficient to form a tumor is rare. At first the exposed mucous membrane is of its normal pink color ; later it assumes an angry red color, often becomes excoriated and sensitive ; urethritis and cystitis may accompany it. What is the etiology ? Frequent child-bearing, dilatation of the urethra and a lax condi- tion of the tissue, from whatever cause, undoubtedly predispose to prolapse of the urethral mucous membrane. The exciting causes are usually vesical and rectal irritation, accompanied by straining. What are the symptoms ? Frequent micturition, which soon becomes painful, tenesmus, and if vesical tenesmus previously existed, it becomes much aggravated. DISEASES OF THE VAGINA. 89 What is the treatment ? If the prolapse is recent, an attempt at cure may be made by reducing the mucous membrane, keeping the patient quiet in bed, making astringent applications to the urethra and removing the cause of previous vesical or rectal tenesmus, if present. If these procedures fail, remove the prolapsed portion by one of the following methods: — 1. If small, ligate and excise; if more extensive, excise the redundancy and stitch mucous membrane of urethra to the border of the meatus. 2.' Emmet's "button-hole " operation. The first method is usually the preferable one. Malformations of the Vulva. What are the principal malformations of the vulva ? 1. Absence of the vulva. 2. Hypospadias, in which the posterior wall of the urethra is defective. 3. Epispadias, in which the anterior urethral wall is defective, usually combined with a defect in the anterior wall of the bladder. 4. The clitoris may be absent, rudimentary, or hypertrophied. 5. The labia minora may be absent, rudimentary, or greatly hyper- trophied, as in the " Hottentot apron." 6. Less often the labia majora may be hypertrophied. 7. No well attested case of true hermaphrodism, i. e., an indi- vidual with both ovary and testicle, has ever been reported. True hermaphrodism is common in animals below the vertebrates. 8. Pseudo-hermaphrodism. This is spoken of as male or female pseudo-hermaphrodism, depending on whether ovaries or testes are present. There will be accessory sexual characters of the opposite sex ; thus a male may have a vagina and rarely a uterus. Most of the individuals are essentially males with deficiency of development of the external genitals, soprano voice, and little hair on face or genitals. Diseases of the Vagina. Discuss the relation of the normal vagina to bacteria. The vagina normally contains a number of bacterial species which affect an entrance into it soon after birth. None of these bacteria 90 ESSENTIALS OF GYNECOLOGY. are pathogenic. If pathogenic ones other than the gonococcus are introduced into the vagina they disappear in a few days, or if they remain longer their virulence is diminished. A number of factors contribute to this result, the chief being the acid reaction and an- aerobic condition of the vagina and the bactericidal power of the serum of its secretion. The last is of the most importance. Kronig showed that the normal secretion when removed from the vagina was a poor culture medium for pathogenic germs, but became a good culture medium when heated to the coagulating temperature for blood serum. What are the varieties of inflammation of the vagina ? 1. Simple catarrhal vaginitis, or colpitis. 2. Gronorrhoeal. 3. Ulcerative, senile or adhesive. 4. Croupous. Simple Catarrhal Vaginitis. What is the etiology ? The predisposing causes are— a. General bad health. b. Anything causing local congestion, as — Disease of heart or lungs ; Disease of the pelvic organs ; Pregnancy. The exciting causes are : — a. Irritating discharges from the cervix. b. The use of too hot, too cold or irritating douches. c. Awkward or excessive coitus. d. Foreign bodies, as pessaries, tampons, etc. What are the symptoms ? Simple catarrhal vaginitis may be acute or chronic. The subjective symptoms of the acute are a feeling of heat in the vagina, pain in the pelvis, and sometimes vesical and rectal irrita- bility. The objective symptoms are a muco-purulent vaginal discharge which may irritate the vulva ; the vagina appears red, perhaps gran- ular or cystic in places. GONORRHCEAL VAGINITIS. 91 The chronic form resembles the acute except in degree ; in it the subjective symptoms, save itching caused by the leucorrhoea, are usually absent. What is the treatment of simple catarrhal vaginitis ? In the early stages, keep the patient quiet ; keep the bowels open, and give light diet ; keep the urine bland by alkaline diluents. If the itching is severe, let the patient take frequent warm alkaline sitz-baths ; in addition, irrigation of the vagina with warm water containing either of the following will be found of value : Liquor plumbi subacet. 3j-Oj ; borax 3j-Oj. After irrigation it is well to dust some desiccating powder, like bismuth, upon the vulva. When the vaginitis becomes subacute or chronic, make applica- tion to the vagina of nitrate of silver gr. x-xxx-^j, or pyroligneous acid. Let the patient use daily vaginal douches of hot water containing borax, 3j-Oj ; or sulphate of zinc, 3ss-3j-Oj ; or alum, 3j-Oj. The douches should be taken while the patient is in the dorsal position, not sitting. Gonorrhoeal Vaginitis. What is the frequency of gonorrhoeal vaginitis ? This variety of vaginitis is quite uncommon in adults. The vagina escapes acute inflammation even when the cervix and vulva are involved. This is due to the absence of glands in the vagina and its skin-like character. The case is different with children, the vagina in them being a favorite spot for infection. Owing to the many folds in the child's vagina and the narrow opening in the hymen it is particularly hard to treat. How does gonorrhoeal vaginitis differ from the simple catar- rhal? a. The onset is usually more acute. b. The discharge is more purulent, viscid and offensive than in the simple catarrhal. c. Urethritis is more common. 92 ESSENTIALS OF GYNAECOLOGY. d. Sometimes a history of exposure to infection can be obtained. e. Often gonorrheal warts or buboes are present. / The most certain diagnostic point is the presence of gonococci. What are the frequent complications and results of gonor- rheal vaginitis ? Vulvitis, urethritis, endometritis, salpingitis, ovaritis and perito- nitis. The dangers of gonorrhoeal vaginitis have been greatly under- estimated. What is the treatment of gonorrhoeal vaginitis ? Keep the patient quiet ; attend to diet ; move the bowels with salines ; keep urine bland. During the acute stage, let the patient have bichloride vaginal douches, 1-10,000, three or four times a day. After the acute stage has passed, thoroughly disinfect the vagina with bichloride, 1-1000, and loosely pack the vagina with sterile gauze to keep the walls separated and the labia apart, thus insuring drainage. Repeat this process every 24 hours until the disease has subsided. If the condition tends to become chronic, apply nitrate of silver, gr. xx-xxx-^j, two or three times a week, letting the patient use daily douches of borax water. The most feasible method of treating the condition in children is by means of suppositories of gelatine and glycerine impregnated with protargol or argyrol. These are easily inserted, and on melting the medication readily reaches all parts of the vagina. Ulcerative Vaginitis. Describe. Ulcerative, senile or adhesive vaginitis is present to a greater or less extent in nearly every woman over 60. It may occur earlier in life. There is a desquamation of the squamous epithelium in spots, and where these raw areas lie in apposition, adhesion is apt to occur. There is usually a thin leucorrhoea, which irritates the PELVIC PERITONEUM. 93 vulva and causes pruritus. Hemorrhages are frequent, espe- cially after examinations or intercourse. The bleeding is not likely to be so severe as in cases of carcinoma of uterus and vagina. What is the treatment ? The treatment consists in the application to the vagina of such solutions as nitrate of silver, gr. x-xx-^j, or pyroligneous acid, and the use by the patient of astringent vaginal douches, such as sul- phate of zinc 3ss-Oj, alum 3j-Oj, or borax 3j-Oj. Croupous Vaginitis. What is the etiology and treatment ? It occurs in conjunction with puerperal infection, diphtheria, and severe forms of the infectious diseases. The treatment is the general treatment of the disease and the local use of antiseptics. Pelvic Peritoneum. Describe. The pelvic peritoneum is a continuation of that lining the inner surface of the walls of the abdomen ; it covers, more or less com- pletely, the pelvic organs (the ovary is regarded as not covered by peritoneum), lines the pelvic walls and also the floor of the pelvis. Traced from before backward, in the median line, it leaves the anterior abdominal wall about 1J inches above the symphysis, is reflected over the fundus of the bladder and down its posterior surface to about the level of the internal os ; it then passes over to the uterus, covers its anterior surface above that point, passes over the fundus and down its posterior surface to the vaginal junction, thence down the vaginal wall for about an inch ; it then passes to the rectum, covers the anterior surface of the middle portion, and surrounds the upper portion completely. The pelvic peritoneum is thrown into several folds and forms several pouches. Describe the folds and pouches of the pelvic peritoneum. The principal folds are the broad, utero-vesical and utero-sacral 94 ESSENTIALS OF GYNAECOLOGY. ligaments (so-called). The broad ligaments, extending from the sides of the uterus to the sides of the pelvis, in front of the sacro-iliac synchondrosis, divide it into two fossae, the anterior and posterior ; these are also subdivided, the anterior by the utero- vesical ligaments, the posterior by the utero-sacral. The pouch between the utero-vesical ligaments is called the utero-vesical pouch ; that between the utero-sacral, the pouch of Douglas, which is the deepest part of the peritoneal cavity. The pouches between the utero-vesical and broad ligaments are called the para-vesical pouches ; those between the utero-sacral and broad ligaments are called by Polk the l ' retro-ovarian shelves. ' ' Two other pouches are mentioned, which depend on the condition of the bladder : the vesico-abdominal, when the bladder is distended ; and the utero-abdominal, when the bladder is empty and contracted. What are the boundaries of the utero-vesical pouch ? It is bounded in front by the posterior surface of the bladder, behind by the anterior surface of the uterus, and laterally by the utero vesical ligaments. What are the boundaries of the pouch of Douglas ? It is bounded in front by the posterior surface of the uterus and the upper portion of the posterior vaginal wall, behind by the rec- tum, and laterally by the utero-sacral ligaments. What are the boundaries of the retro-ovarian shelves ? They are triangular in shape, bounded in front by the base of the broad ligament, internally by the utero-sacral ligament, and exter- nally by the wall of the pelvis. Pelvic Peritonitis. What is the pathology ? The peritoneum first becomes hypersemic ; it loses its lustre, and exudation materials are poured out. 1. There may be scarcely any serum exuded ; the inflamed area is coated with fibrin, and adhesions form, binding together the pelvic organs and intestines, PELVIC PERITONITIS. 95 2. The exudation may consist largely of serum, either free in the peritoneal cavity, or encapsulated by adhesions. 3. The exudation in severe, especially septic cases is often puru- lent. Hence the varieties : — a. Adhesive. b. Serous. d. Purulent. What is the etiology ? In a general way, the etiology of pelvic peritonitis may be stated as an extension to the peritoneum of inflammation of the uterus, ovaries or tubes ; in a large majority of the cases, inflammation of the tubes. There may be first an endometritis, then a salpingitis, and then a peritonitis ; or the infection may extend by the way of veins and lymphatics from the uterus into the broad ligament, and from there infect peritoneum without the intervention of the tube. Individual causes are as follows : — a. Introduction of sepsis during parturition, abortion or operations. b. Gonorrhoea. c. Introduction into the uterus of septic instruments. d. Injection of fluids through uterus and tubes into the peritoneal cavity. e. Catching cold during menstruation. /. Tubercular or cancerous disease of the pelvic organs. g. Tumors causing irritation of the peritoneum. h. Pelvic cellulitis and peritonitis are often associated as being produced by the same causes. What are the symptoms ? Pelvic peritonitis may be either acute or chronic. Acute pelvic peritonitis is usually ushered in by a rigor; this, however, is not always present. There are pain and tenderness in the lower part of the abdomen ; patient lies on the back, with the knees elevated ; the pulse is small, wiry and rapid ; the temperature is elevated, 101°-103°, sometimes higher; nausea and vomiting are com- mon ; more or less tympanites is present ; the bowels are constipated ; there is frequently irritability of the bladder ; often menorrhagia. Chronic peritonitis may exist and present scarcely any symptoms 96 ESSENTIALS OF GYNECOLOGY. save a dull pain in the pelvis ; usually, there is vesical and rectal irritability, dyspareunia, leucorrhcea, and a disturbance of menstrua- tion, especially menorrhagia. Chronic peritonitis may follow the acute, or may begin as chronic. Pelvic peritonitis is often characterized by exacerbations. What are the physical signs of acute pelvic peritonitis ? The vagina is hot and dry ; pressure in either fornix, or on the abdomen, is intensely painful ; the bimanual is impracticable ; the uterus, tubes and ovaries are usually bound fast ; the slightest attempt to move them causes intense pain. The fornices may seem to be covered by a hard, flat roof, formed by a matting together of the pelvic contents, often compared to plaster-of-Paris poured into the pelvis and hardened ; you may feel a tumor close to the uterus, consisting of serum or pus, roofed in by adhesions ; the most com- mon situation of this tumor is in the pouch of Douglas. What are the common results of pelvic peritonitis ? Displacement of uterus, ovaries and tubes, the tubes being often distorted and stenosed by the traction of adhesions ; as a result of these conditions we get disturbances of menstruation, sterility and ectopic gestation. What is the prognosis of pelvic peritonitis ? Simple adhesive peritonitis often ends in complete recovery ; dis- placement of the pelvic organs may remain, however, and give rise to symptoms. The prognosis of purulent peritonitis is grave. What is the treatment of pelvic peritonitis ? In the acute form, keep the patient quiet in bed, give fluid diet, apply cold to the lower portion of the abdomen, either in the form of the ice-bag or cold-water coil. In some cases hot applications are more grateful to the patient ; if there is great pain, give a little morphine ; after a few days, move the bowels gently, as by calomel gr, j every hour for 3-4 doses, assisted, if necessary, by an enema. After the acute stage has passed use hot douches, and in chronic cases, iodine externally and per vaginam, and vaginal tampons of boroglyceride or ichthyol and glycerine. A wet towel, covered by a dry one for a protective, worn about the pelvis at night, is sometimes PELVIC CELLULITIS. 97 of value in chronic peritonitis. Look after the general health by attention to fresh air, administering tonics, and regulating the bowels. Pelvic Cellulitis. What are the principal situations of the cellular tissue in the pelvis ? 1. Between the abdominal wall and peritoneum, behind the pubes, 2. In front of and behind the cervix. 3. In the broad ligaments. 4. In the utero-sacral ligaments. What is the etiology of pelvic cellulitis ? The etiology of pelvic cellulitis may almost invariably be summed up in two words — traumatism and sepsis ; the traumatism being, usually, labor, abortion, or operations on the cervix. Pelvic cellulitis was formerly considered very common, but in the light of recent experience, gained by laparotomies, the "masses," "thickenings," etc., are most often found to be salpingitis and peritonitis. In other words, pelvic cellulitis, although it does exist, is com- paratively infrequent. What is the pathology ? There is an exudation of serum, fibrin and white cells ; this may resolve, it may form new connective tissue, cicatricial tissue, or it may, and often does, suppurate. If suppuration occurs, the pus may point above the pubes ; this is especially common in puerperal cases. It frequently ruptures into the vagina, bladder or rectum, sometimes into the uterus ; it occasionally makes its way through the sciatic or obturator foramen ; rarely, it ruptures into the peri- toneal cavity. What are the symptoms of pelvic cellulitis ? The disease is usually ushered in by a rigor, which is often marked ; the temperature rises, 103°-105° ; the pulse is full and rapid ; the pain is not very acute ; nausea is occasionally present ; vomiting is usually absent, unless peritonitis is a complication. If pus forms, septic symptoms become pronounced. There is often irritability of bladder and rectum, 7 98 ESSENTIALS OE GYNAECOLOGY. Chronic cases may present few symptoms save a feeling of weight in the pelvis, irritability of bladder and rectum, and menorrhagia. What are the physical signs ? Usually, there is a tense, elastic tumor bulging into the vagina, most commonly on the left side, pushing uterus over to the right ; it is sensitive, but not acutely so. Sometimes the inflammatory process involves nearly all the connective tissue of the pelvis, and the exudation can be felt in the iliac fossae and above the pubes. When pus forms you have the physical signs of an abscess — tenderness, fluctuation, etc. From what should you differentiate pelvic cellulitis ? From — a. Pelvic peritonitis. b. Pelvic haeniatocele. c. Fibroid tumor of uterus. d. Impaction of faeces. e. Ovarian tumor. / Salpingitis. How would you differentiate pelvic cellulitis from pelvic peritonitis ? In many cases it is almost impossible to differentiate the two ; they frequently complicate each other. The chief points of difference are these : Pelvic cellulitis almost never occurs except after labor, abortion, or operation on the cervix ; pelvic peritonitis may arise from any cause of inflammation of the uterus or its adnexa, which may extend to the peritoneum. Pain and tenderness, as a rule, are less marked in cellulitis than in peritonitis. Cellulitis is more apt to bulge into the vagina than is peritonitis. Cellulitic deposits are more apt to suppurate than are peritonitic. Vomiting is less frequent in cellulitis than in peritonitis. How would you differentiate pelvic cellulitis from pelvic hematocele ? Chiefly by the history of an haematocele, i. e. , sudden sharp pain, pallor, faintness, and the physical signs of a collection of fluid which afterward coagulates and hardens. The above symptoms of shock and hemorrhage are wanting in cellulitis. PELVIC CELLULITIS. 99 How would you differentiate cellulitic or peritonize deposits from fibroids of the uterus ? Cellulitic or peritonitic deposits vs. Fibroid tumors. History of acute inflammation. Slow growth. Pain and tenderness. Insensitive. Less plainly outlined. Outlines more distinct. _ Less intimately connected with Closely connected with the the uterus. uterus. Perhaps menorrhagia during the Usually menorrhagia, gradually acute stage, then irregular increasing till the menopause. menstruation. How would you differentiate impaction of faeces from pelvic peritonitis or cellulitis ? In impaction of fseces, the mass is sausage-shaped, has a doughy feel, is situated in the position of the rectum, and is less closely con- nected with the uterus than an exudation of peritonitis or cellulitis ; it is not as tender on pressure, and gives no history of acute inflam- mation. The diagnosis is made certain by clearing out the rectum. How would you differentiate a small ovarian tumor from pelvic peritonitis or cellulitis ? There are no signs of acute inflammation as in cellulitis or perito- nitis ; the ovarian cyst is usually fluctuating ; its multilocular char- acter can sometimes be felt. The menstrual disturbances common in peritonitis and cellulitis are usually absent in cases of ovarian cysts ; an ovarian cyst gradually increases in size. How would you differentiate pelvic cellulitis from salpin- gitis ? By a careful bimanual, in a case of salpingitis, you can generally map out an enlarged, tortuous tube, usually distended, extending from the side of the uterus to the region of the ovary ; if distended with fluid, you may detect fluctuation. It does not bulge into the vagina as does cellulitis. The history of the case is of value in the diagnosis. What is the treatment of pelvic cellulitis? 1. Prophylactic :— . Strict cleanliness and antiseptic precautions during labor, abortion, operations, etc. 100 ESSENTIALS OF GYNAECOLOGY. 2. Abortive : — Put patient to bed, apply cold to the lower portion of abdomen. 3. When exudation has occurred : — Apply heat to the abdomen, administer hot-water vaginal douches, move bowels, and attend to the general health. 4. If the exudation suppurates: — As soon as pus is detected, incise under antiseptic precautions and drain. The two most favorable sites for incision are through the vagina and through the abdominal wall just above Poupart's liga- ment. In doubtful cases it is sometimes advisable to open the abdomen in the median line, and then determine by the relations of the mass, the best mode of procedure. This, however, is rarely necessary. Pelvic Hematocele and Hematoma. Define, and give the pathology. Pelvic hematocele is an effusion of blood into the cavity of the pelvic peritoneum. Pelvic hematoma is an effusion of blood into the connective tis- sue of the pelvis beneath the peritoneum, usually between the folds of the broad ligaments. In a pelvic hematocele, the effusion is usually into the pouch of Douglas ; if this is closed by adhesions, or if the effusion is very large, the blood may flow over into the utero-vesical pouch. The former condition gives rise to the name retro -uterine, the latter to ante-uterine hematocele. The blood is at first fluid ; it then slowly coagulates and is roofed in by peritonitic exudate binding together adjacent structures : — coils of intestine, omentum, uterus, etc. This blood mass, if small, may be absorbed ; usually, however, it is due to a ruptured ectopic gestation sac or a tubal abortion and under these circumstances recurrent hemorrhages into the mass, sufficient to burst its limiting wall are common. Occasionally, apparently from proximity to the intestine, it suppurates. What is the etiology of pelvic hematocele ? Formerly long lists of causes were given for this condition. We now know that in most cases it is due to a ruptured ectopic gesta- tion sac or a tubal abortion. It is probable that exceptions to this rule occasionally occur, such as — PELVIC HEMATOCELE AND HEMATOMA. 101 Rupture from traumatism of vascular peritonitic adhesions. Oozing after removal of diseased tubes and ovaries. Excessive haemorrhage from the rupture of a Graafian follicle. Rupture of an ovarian hsematoma. What is the etiology of pelvic haematoma ? Here again a rupture of an ectopic gestation sac is a very com- mon cause. Other causes, however, are probably more frequent than in the case of pelvic haematocele, for varix of the broad liga- ment, due to various causes of venous congestion is common, and when such a varix exists, but a slight traumatism is needed for a blood effusion. What are the symptoms of pelvic haematocele ? A sudden sharp pain, and symptoms of shock and hemorrhage. The face becomes pallid, the expression anxious ; the pulse is rapid and feeble ; temperature subnormal ; surface covered with a cold perspiration : perhaps nausea and vomiting. Later if the patient survive, we have symptoms of peritonitis and of pressure, either from the effusion or the displaced uterus. The pain and tenderness continue for several days ; there is usually painful defecation and dysuria ; usually metrorrhagia is present. In a few days, if sup- puration does not occur, the effusion diminishes in size and the symptoms abate. If suppuration occurs, septic symptoms appear. The above are the symptoms of a well-marked case ; where the effusion is small the symptoms may be much less severe. How do the symptoms of pelvic haematoma compare with those of pelvic haematocele ? In pelvic haematoma there is, as a rule, less pain and less shock. If the effusion is large, however, there may be the symptoms of shock and hemorrhage. What are the physical signs of pelvic haematocele ? At first no tumor is felt ; only an indistinct sensation of fulness in the pouch of Douglas ; as the blood coagulates and is roofed in by adhesions, one can feel a boggy tumor bulging downward in the posterior vaginal fornix and pushing the uterus forward. What are the physical signs of pelvic haematoma? In this case there is felt a distinct tumor even at first ; it bulges 102 ESSENTIALS OF GYNECOLOGY. down on one side of and behind the cervix ; pushes the uterus for- ward and to the opposite side ; seems attached to the side of the pelvis and can be felt above Poupart's ligament when it has opened out the folds of the broad ligament and lifted up the peritoneum from the pelvis. A finger introduced into the rectum will usually detect a stricture. What is the prognosis of pelvic hematocele ? The prognosis is usually that of ruptured ectopic gestation and will be discussed under that condition. What is the prognosis of pelvic hematoma ? Usually good. If the effusion suppurates, the prognosis is less favorable. It may rupture into rectum, vagina, bladder, or rarely above the pelvic brim. How would you differentiate pelvic haematocele from acute pelvic peritonitis ? Pelvic hcematocele vs. Acute pelvic peritonitis. History of sudden, sharp pain, Less sudden in onset ; symptoms with symptoms of shock and of shock and hemorrhage hemorrhage. wanting. Absence of acute inflammation Symptoms of acute inflammation at first. at first. Uterus usually displaced for- Uterus fixed, not markedly dis- ward. placed. How would you differentiate pelvic haematocele from a fibroid tumor of the uterus ? Pelvic hcematocele vs. Fibroid tumor. History of sudden, sharp pain Of slow growth ; symptoms and symptoms of shock and gradually developed. hemorrhage. Soon followed by signs of in- Absence of signs of inflamma- flammation. tion. Less intimately connected with More intimately connected with the uterus. the uterus ; moves with it, Sensitive to pressure. Insensitive to pressure. Density less. Density greater. PELVIC HEMATOCELE AND HEMATOMA. 103 How would you differentiate pelvic hematocele from a retro- flexed or retroverted uterus ? Pelvic hematocele vs. Retroflexed or retroverted uterus. Acute history of pain, shock and Usually a long history. hemorrhage. Fundus of uterus usually lies Fundus backward ; absent in forward. front. Sensitive to pressure. Less sensitive, unless surrounded by peritonitis. How would you differentiate pelvic hsematocele from an ovarian cyst ? Pelvic hematocele vs. Ovarian cyst. Acute history of pain, shock and History of slow growth, with few hemorrhage. general symptoms. More sensitive to pressure. Less sensitive to pressure. First elastic and soft, then hard. Usually fluctuating throughout. How would you differentiate pelvic hsematocele from im- pacted faeces ? By the history, rectal examination, and thorough emptying of the rectum. How would you differentiate pelvic hsematocele from retro- uterine carcinoma ? Pelvic hematocele vs. Retro-uterine carcinoma, Acute history of pain, shock and History of a chronic disease. hemorrhage. Uterus usually pushed forward. Uterus but little displaced. How would you differentiate pelvic hsematoma from pelvic cellulitis ? Pelvic hcematoma vs. Pelvic ceUiditis. History of sudden, sharp pain, History of labor, abortion, or perhaps symptoms of shock operation on the cervix. and hemorrhage. Signs of acute inflammation ab- Signs of acute inflammation sent at first. from the first. Less sensitive. More sensitive. 104 ESSENTIALS OF GYNAECOLOGY. What is the treatment of pelvic hsematoma ? Keep the patient quiet in bed : at first apply cold, later heat, both externally in the form of poultices and per vaginam by hot water douches. If suppuration occurs, open and drain through the vagina. If repeated hemorrhages are added to this hematoma two courses are open according to the size of the tumor. If the tumor is small and low in the pelvis, incise through the vagina, clean out clots, etc., and drain. If the tumor is large and extends high in the pelvis, it is probably better to open the abdomen and govern the treatment by the condition found. The treatment of pelvic hematocele will be considered under ectopic gestation. MENSTRUATION. Define. Menstruation is a periodical series of phenomena, the most marked of which is a discharge of blood from the uterine mucous membrane, beginning, on an average, in this country, at fourteen, and recurring monthly till forty-five. The relation of menstruation to ovulation is still unsettled. As a rule they are simultaneously present or absent, but either may be present for a short time without the other. Describe the factors which influence the onset of menstrua- tion ; what is the average frequency and duration of each period ? In temperate climates, menstruation usually appears at 13-15 years ; it is earlier in warmer climates, later in cooler ; it appears in girls who live an indoor, city life, earlier than in the country. The periods normally appear every 28 days, but in this there are great variations ; some women in perfect health menstruate every 3 weeks, some only every 5 weeks. The average duration of each period is 3-4 days, but this varies between 2 and 8. The discharge of blood is usually slight at first, reaches maximum on the second or third day, then gradually dimin- ishes. MENSTRUATION — AMENORRHEA. 105 Discuss the normal menopause and the deviations from the normal. The menopause occurs anywhere from the fortieth to fiftieth year. Probably the majority of women have it between the forty- third and forty-fifth year. It seldom occurs suddenly, but for a year or two the intermenstrual periods lengthen and the flow becomes scant. There is a popular belief that profuse flow or hemorrhages are to be expected at the time of the climacteric. When this is the case it is always an evidence of disease. This is the decade which brings most trouble from fibroids and carcinoma. Hyperplastic endometritis causes some of the hemorrhages. Skipped periods, the result of pregnancy at this time, are likely to be attributed to the menopause. Very rarely repeated hemorrhages at this time require removal of a uterus which, on microscopic examination, shows only arteriosclerosis, atrophy of uterine muscle, or chronic metritis. Disorders of Menstruation. Amenorrhea. Define. Amenorrhoea is the absence of menstruation between puberty and the menopause. It is the normal condition during pregnancy and lactation. Menstruation may be present, but ' ' concealed, ' ' due to atresia of the lower part of the genital tract. It may be divided into : — a. Emansio mensium — Where menstruation has never appeared. b. Suppresio mensium — Where menstruation has appeared, but fails to reappear. What is the etiology of amenorrhea ? The most frequent cause is anaemia, especially that form called chlorosis. Other causes are phthisis, or other debilitating diseases ; acute diseases at puberty ; non-development of the generative organs ; atrophy of the generative organs ; increasing obesity ; removal of ovaries and tubes by operation ; hyperinvolution of uterus ; change of climate, as the amenorrhoea of immigrants ; excessive curettage 106 ESSENTIALS OF GYNECOLOGY. or cauterization of the uterus. It has resulted a number of times from treating the interior of the uterus with live steam, a procedure known as atmokausis. What are the symptoms ? Amenorrhoea is itself more a symptom than a disease, and the symptoms which usually accompany amenorrhoea are those of the disease which causes it — most frequently anaemia or phthisis. Thus, from anseniia we have : — Pallor. Dyspnoea and palpitation of the heart on exertion. Depraved appetite. Constipation. Headache. (Edema. Murmur at the base of the heart. Neuralgic pains. Hysteria. From phthisis we get the regular symptoms of cough, emaciation and night sweats. "What is the prognosis ? When associated with simple anaemia the prognosis is good. When due to non-development of the generative organs the amen- orrhoea usually continues. When associated with phthisis or other wasting disease, the prognosis is that of the disease. What is the treatment of amenorrhoea ? a. When due to anaemia : — Some form of iron, as Blaud's pills; oxygen; nourishing food; fresh air ; regulation of the bowels, and attention to the mode of life. b. When due to imperfect, or non-development of the generative organs : — Determine, under anaesthesia, whether ovaries are present or not ; if absent, do not attempt to induce menstruation. If the ovaries are present, besides attention to the general health, the following methods may be employed : — Hot water vaginal douches ; Boro-glyceride tampons ; Electricity to uterus and over ovaries. MENSTRUATION— MENORRHAGIA AND METRORRHAGIA. 107 c. When associated with phthisis, or other wasting disease, the treatment is that of the associated disease. In cases of acute suppressio-mensium, due to exposure to cold, etc. , rest in bed, a saline cathartic, hot mustard foot baths, hot ap- plications to the pelvic region and diaphoretics internally, may be used with safety and advantage. Vicarious Menstruation. Describe. Vicarious menstruation is a periodical discharge of blood from some part of the body other than the interior of the uterus. It may occur with either amenorrhcea or scanty menstruation ; it usually appears at about the time of the regular flow. It may come from almost any mucous membrane : from the nose, mouth, etc. ; it may also come from the nipple or from an open sore ; it is usually due to a watery condition of the blood and a poor condition of the blood- vessels. Direct treatment is usually not required. Menorrhagia and Metrorrhagia. Define. Menorrhagia is a prolonged or excessive menstrual flow. Metrorrhagia is ' ' uterine hemorrhage occurring independently of the menses." What is the etiology? Menorrhagia and metrorrhagia may be produced by causes acting at a distance, or local, in or about the uterus itself. Acting at a distance are : — 1. Obstructed general circulation from disease of heart, lungs or liver. 2. Low condition of blood and vessels in certain wasting diseases. Acting about the uterus are : — 1. Tumors. 2. Ectopic Gestation. 3. Disease of tubes or ovaries. The most common causes are situated in the uterus itself, and among them are the following : — 108 ESSENTIALS OF GYNECOLOGY. 1. Subinvolution of the uterus ; 2. Retained secundines ; 3. Submucous, or interstitial fibroids ; 4. Polypi ; 5. Carcinoma; 6. Tuberculosis of uterus ; 7. Retro-displacements ; 8. Fungous granulations of the endometrium. The last is the most common cause of all. What is the treatment of monorrhagia and metrorrhagia ? When due to causes acting outside of the uterus, the treatment is that of these causes ; at the same time, there will often be found fungous granulations of the endometrium which magnify the influ- ence of the distant causes ; unless otherwise contraindicated, these fungosities need to be removed by the curette under antiseptic pre- cautions ; the uterine cavity is then washed out, and an application of iodine or carbolic acid or a mixture of the two may then be made to tho endometrium. In mild cases of menorrhagia or metrorrhagia ergot and hydrastis canadensis are of value even without the use of the curette, and in nearly all except malignant cases after curetting. Diseases of the tubes and ovaries and ectopic gestation require their own treatment. Fibroids may demand removal of the tumor or hysterectomy. Polypi require removal. Carcinoma indicates hys- terectomy. Fungous endometritis demands curetting as above. Dysmenorrhea. Define. ' ' Dysmenorrhcea may be defined as the occurrence of pain just before, during or after the menstrual period ' ' (Hart and Barbour). What are the varieties of dysmenorrhea ? The following varieties are mentioned, but seldom distinctly differentiated : — 1. Obstructive ; 2. Congestive; 3. Neuralgic; 4. Ovarian ; 5. Membranous. MENSTRUATION — DYSMENORRHEA. 109 The above, like all classifications of dysmenorrhoea, is not alto- gether satisfactory. Some replace the word l ' obstructive ' ' by " mechanical," and include under the term not only obstruction to the outflow of blood from the uterus, but also conditions, as, for instance, flexions, in which the normal menstrual erection of the organ is rendered difficult. Others consider the pain in all cases largely inflammatory. The above classification will be found of value chiefly in drawing atten- tion to some of the causative factors of menstrual pain. There are women whose only menstrual pain is a severe headache. Other women become melancholic or have other types of mental derangement, such as suicidal tendency, though showing no such tendency in the intermenstrual periods. Obstructive Dysmenorrhea. What is the etiology ? Both the etiology and pathology of the different varieties of dysmenorrhoea are still far from settled, but the conditions usually associated with obstructive dysmenorrhoea are : — a. Flexions of the uterus ; b. Stenosis of os externum, os internum, or the whole cervical canal ; c. Polypi; d. Fibroids distorting uterine canal ; e. Long, conical cervix ; f. Spasmodic contraction of os internum. What are the symptoms ? Intermittent, cramp-like pains, accompanying the expulsion of blood clots which have formed above the obstruction ; this expulsion is followed by relief. A sound passed between the periods usually shows hypersesthesia of the internal os. What is the treatment ? During the intermenstrual period dilate the cervical canal with one of the dilators of the glove-stretcher variety. If there seems to be any endometritis present, curette the uterus and wash it out. Pack the cavity with iodoform gauze, and unless the pain is severe leave it for forty-eight hours ; this will maintain the dilatation for 110 ESSENTIALS OF GYNECOLOGY. quite a period. In order to prevent future recontraction, the occa- sional introduction of graduated sounds is of value. All this must be done under strict asepsis. For the temporary relief of the several varieties of dysmenorrhea the preparations of viburnum are of value. Congestive Dysmenorrhea. What is the etiology ? "Congestive dysmenorrhea depends upon an advance of the menstrual congestion beyond the physiological limits ' ' (Reeve). The conditions associated with congestive dysmenorrhosa are the following : — a. Exposure to cold ; b. Defective general circulation ; c. Metritis ; d. Endometritis ; e. Displacements of the uterus ; / Pelvic tumors ; g. Pelvic peritonitis. What are the symptoms ? Between the periods there are usually symptoms of pelvic trouble, or defective general circulation. Just before the flow begins, there appear feelings of weight and heat in back and pelvis, headache, flushing of the face, and some rise of temperature ; the pulse is rapid. The symptoms are usually relieved by a free flow. What is the treatment ? a. During the attack — 1. Hot mustard foot-baths ; 2. Hot sitz -baths ; 3. Diaphoretics, such as Dover's powder; 4. Hot pelvic applications. 5. The coal-tar antipyretics. b. During the intermenstrual periods — 1. Seek to remove the cause ; 2. Scarify cervix occasionally ; 3. Employ glycerine tampons ; 4. Avoid excessive coitus and exertion. Just before the flow begins, use hot-water vaginal douches. menstruation — dysmenorrhea. 1 1 i Neuralgic Dysmenorrhea. What is the etiology ? This frequently occurs in combination with some of the other forms of dysmenorrhcea, especially the congestive ; it is most often associated with an indolent, indoor life, anaemia, malnutrition, chronic malarial disease or hysteria. Sometimes no cause can be assigned. What are the symptoms ? Pain, sometimes referred to uterus, sometimes to ovaries, some- times elsewhere ; it changes its situation ; is often shooting in char- acter ; usually begins a little before the flow ; is sometimes relieved by a free flow. Between the periods, no pathological changes can be detected in the pelvic organs, but patient suffers from neuralgia elsewhere — facial, intercostal, etc. What is the treatment? Attention to the mode of life ; fresh air ; exercise ; tonics, espe • cially iron, arsenic and quinine ; at the onset of the pelvic pains employ hot sitz-baths and hot-water vaginal douches, and give inter- nally such anti-neuralgics as phenacetin. Ovarian Dysmenorrhea. What is the etiology ? This is applied to a class of cases associated with disease of the ovaries, but the etiology is far from settled, and the class not distinct. What are the symptoms ? Between the periods there is pain and tenderness over the region of the ovary, increased by exercise, defecation and coitus ; these symptoms are increased at the menstrual periods. Membranous Dysmenorrhea. Describe. Membranous dysmenorrhea is characterized by the expulsion at the menstrual periods of organized membranes either as a whole or in pieces." (Reeve.) What is the etiology and pathology? These are both matters of dispute, but we usually find in these cases poor general health. The inner surface of the membrane 112 ESSENTIALS OF GYNECOLOGY. is smooth and shows the openings of the utricular glands ; its external surface is rough and shaggy (see Fig. 13). Microscopically it resembles the decidual membrane occurring in pregnancy. According to Hart and Barbour, " It is of the greatest importance to remember that it is not a product of conception, and should not be mistaken for an early abortion. " It is composed of the super- ficial layer of the endometrium, with increased connective tissue ; blood accumulates under it and dissects it off. Some writers refer to this condition under the name of "exfoliative endometritis," but it is more than doubful whether the condition is an inflammatory one. Fig. 13. Sketch of a Dysmenorrhoeal Membrane as seen under Water (Sir J. Y. Simpson). What are the symptoms ? Severe colicky pain, usually recurring at each period ; the flow is often intermittent ; thus the symptoms resemble those of obstructive dysmenorrhcea. The course is usually protracted. How would you differentiate membranous dysmenorrhea from an early abortion ? By the absence of chorionic villi and by the repeated occurrence STERILITY. 113 What other condition might be mistaken for membranous dysmenorrhcea ? Ectopic gestation. A similar membrane is cast off in the two conditions. In ectopic pregnancy the symptoms of early pregnancy, the presence of a mass to the side of the uterus, symptoms of internal hemorrhage, and the fact of a membrane not having been cast off at the preceding menstruation, will serve to eliminate mem- branous dysmenorrhcea. What is the treatment ? a. Between the periods — Dilate the cervix, curette the uterine canal, and apply to the endometrium iodized phenol, pure carbolic, or tincture of iodine. b. During the menstrual period — Use hot baths, hot applications to the pelvis, and diaphoretics. Sterility. Discuss sterility. Sterility is a symptom and not a disease. Various authorities state that it is of male origin in from 10 to 50 per cent, of cases. By strictest definition it means an inability to conceive ; but used in the larger sense, in the case of the female of inability to produce young, we may divide it into three varieties: — 1. Inability to conceive. 2. Inability to incubate the ovum. 3. Inability to bring forth a live child. As a cause of the first variety might be mentioned occlusion of any part of the genital tract ; of the second are diseases causing abortion or death of foetus ; of the third, grave general diseases or toxaemias which result from the pregnancy or are aggravated by it and would cause the death of the patient should she attempt to go to term. Mention some individual causes of sterility. 1. Congenital malformations. These are rare, with the exception of an infantile type of uterus characterized by long cervix, anteflex- ion, and narrow os. In these cases we can never assume the uterus too small to admit of pregnancy if menstruation occurs normally. 2. Septic inflammations. These may close the tubes, bury the ovaries in adhesions, or rarely destroy the uterine mucosa. S 114 ESSENTIALS OF GYNAECOLOGY. 3. Gonorrhoea is the most important single cause of sterility. It accounts for most cases of male sterility and much of it in the female. Even very mild gonorrhoeal salpingitis may permanently occlude both tubes. 4. Endometritis of any variety predisposes to early abortion. 5. Syphilis, gout, malnutrition, and wasting diseases cause steril- ity by arresting ovulation, as indicated by suspension of menstrua- tion. Syphilis in the later part of its course does not inhibit con- ception, but causes the foetus to die in utero. 6. Uterine displacements are frequently the cause of sterility, or it may be through arresting conception, but more often by causing early abortion. Among other causes are hyperinvolution of the uterus, fibroids, ovarian tumors, visceral diseases, and toxsemias. It is often very difficult to assign a cause in an individual case. How soon after marriage is pregnancy likely to occur? Among the lower animals, including most of the domestic ones, a single intercourse usually results in pregnancy. In the human spe- cies this is by no means so invariable, chiefly because intercourse is not restricted to the times when ovulation is occurring. With the marriage of normal individuals, unless preventive methods are em- ployed, pregnancy will occur within the first year in the vast major- ity of cases, and in the larger part of these within the first few months. On the other hand, without artificial prevention the first pregnancy may not occur for years and no cause be assignable. If two years have passed after marriage without pregnancy resulting, we are safe in assuming that some definite barrier to pregnancy probably exists, and that the case is liable to be one of permanent sterility unless there is a removable cause, such as retroversion, too narrow os, or hyperplastic endometrium. What is " one-child sterility " ? The term is applied to cases where a pregnancy occurs shortly after marriage, but is never repeated. It is about as common as absolute sterility. In such cases we are to look for the cause in something that occurred during the pregnancy or puerperium. Gonorrhoea is a common cause of the condition, as is sepsis occur- ring after labor or abortion. Some cases result from subinvolution, displacements, or hyperplastic endometrium. MALFORMATIONS OF THE VAGINA. 115 Malformations of the Vagina. What are the important varieties ? a. Atresia vaginae ; b. Double vagina; c. Absence of vagina ; d. Stenosis of vagina. Atresia Vagina. Give the varieties and etiology. Atresia of the vagina may be either at the hymen, forming atresia hymenalis, or higher up in the vagina, forming atresia vaginalis. Etiology. — Atresia hymenalis is usually congenital, from mal- development. Atresia vaginalis is either congenital, or may be acquired from cicatrization following — a. Sloughing incident to parturition ; b. Adhesive vaginitis ; c. Traumatism ; d. Caustics. What are the symptoms of atresia vaginae ? They are dependent on the accumulation of the menstrual blood, hence in congenital cases they are absent till puberty. The subjective symptoms of menstruation come on, but there is no appearance of blood ; at the next period the subjective symptoms are repeated. The periods then usually come more frequently, and soon a tumor forms. If the atresia is at the hymen, the latter bulges, and the vagina is distended with blood, forming a hsemato-colpos. In atresia hymenalis the cervix is usually not dilated ; in atresia vaginalis the dilatation may extend to the uterus and tubes. If the atresia is acquired, of course there will be no symptoms till the menstrual blood is retained. What are the results of atresia hymenalis if unrelieved by operation ? If the hymen is thin, it may rupture ; if thick, the vagina may rupture ; after rupture, septicaemia may occur. What are the results of atresia vaginalis ? The vagina may rupture. 116 ESSENTIALS OF GYNECOLOGY. The uterus and tubes may become distended, forming hsemato- metra or hseinato-salpinx, and may rupture. The atresia may rupture. After rupture septicaemia may occur. Where else in the genital tract than in the vagina may atresia occur ? Give the etiology and symptoms. Atresia may occur at the cervix. Atresia of the cervix may be congenital, or acquired from cicatri- zation following parturition, the use of caustics, or from a too close trachelorrhaphy. Symptoms appear when the menstrual blood ac- cumulates behind the atresia, and resemble those of atresia vaginae. The amenorrhoea and enlargement of the uterus may make one suspect pregnancy. What are the results of atresia of the cervix if unrelieved by operation ? If it is present during menstrual life, the uterus and tubes become distended, and are liable to rupture, with the danger of peritonitis and death. If it occurs for the first time after the menopause, it usually causes no trouble. What is the character of the retained fluid ? During menstrual life the blood is of a brownish, chocolate color ; it is grumous and treacle-like in consistency, kept from clotting by the mucus. After the menopause, the retained fluid is honey-like, and the condition is spoken of as hydrometra. If the fluid becomes infected it becomes pyometra. What is the treatment of atresia of the genital tract with retention of the menstrual blood ? Aspirate slowly ; under strict antisepsis incise the obstruction, and maintain the opening by iodoform gauze or a rigid drainage-tube. What are the dangers of rapid evacuation of a hsemato- metra ? The tubes are probably distended, and have formed adhesions ; the rapid collapse of the uterus would tend to tear the tubes from their adhesions, with the danger of rupture of the tubes, and perito- nitis. malformations of the uterus. 117 Stenosis of Vagina. Give its cause and describe. It may be acquired from cicatrization of the vagina or be congeni- tal. The congenital stenosis is not infrequent just in front of the cervix. It interferes with coitus and labor and gives rise to vaginitis by interfering with the drainage of the upper part of the vagina. Malformations of the Uterus. How are the congenital anomalies to be explained ? Chiefly as arrests of development : 1. The Miillerian ducts when first formed are solid cords, and from failure to become hollowed out, atresia may result. 2. There may be failure of development of one or both ducts or unequal development of them, resulting in uterine asymmetry. 3. The ducts fail to fuse properly, resulting in a bifid or septate organ. What are the principal varieties ? 1. Rudimentary uterus ; 2. Uterus bipartitus ; 3. Uterus unicornis p» 4. Uterus bicornis ; _ 5. Uterus clidelphys ; -^ 6. Uterus septus ; -, 7. Infantile uterus ; -- 8. Congenital atrophy of the uterus ; 9. Complete absence of the uterus, very rare. Describe the rudimentary uterus. In this case (see Fig. 14) "the uterus is represented by a band of muscular fibre and connective tissue on the posterior wall of the bladder." (Hart and Barbour.) Describe the uterus bipartitus. In the uterus bipartitus (see Fig. 15) the rudimentary horns are present, and are either hollow or solid and cord-like ; they are con- nected to each other and to the vagina by the cervix, which is repre- sented by a fibrous band. The ovaries, breasts and external genitals may be well developed. Describe the uterus unicornis. The body of the uterus in this variety (see Fig. 16) is long and US ESSENTIALS OF GYNAECOLOGY. narrow, and is directed to one side ; its fundus lias attached to it one Fallopian tube and ovary ; on the opposite side of the body is seen the representative of the other horn, which is either solid or hollow ; connected with this, and separated from it by the attachment of the round ligament, are the tube and ovary of that side. Describe the uterus bicornis. In this form (see Fig. 17) the division into two horns is distinctly visible externally ; the division is usually seen also in the interior of the uterus on section. What is the uterus didelphys? Here the two halves of the uterus are separated throughout (see Fig. 18). This condition is very rare. Describe the uterus septus. Here the division is entirely internal (see Fig. 19); beginning at the fundus, it extends a variable distance toward the os externum, sometimes reaching it. There is no indication of the division from the outside. What is an infantile uterus ? In this condition (see Fig. 20) the cervix is 2-3 times longer than the body, the relation of cervix to body remaining as at birth. The uterus as a whole is smaller than normal. What is meant by congenital atrophy of the uterus ? The relative lengths of cervix and body (see Fig. 21) conform to those of a virgin uterus, but the whole uterus is atrophied. What is the occurrence of complete absence of the uterus? It is very rare indeed, and can only be ascertained by a post- mortem examination. Many cases of supposed absence of the uterus are proved, on autopsy, to be cases of rudimentary uterus. What are the importance and danger of uterine malforma- tions ? Pregnancy in such cases may endanger the patient's life. The diagnosis is difficult. Menstruation may occur from one half and pregnancy be present in the other. The pregnant cornu may be mistaken for a tumor or it may rupture with symptoms like those of ectopic gestation. MALFORMATIONS OF THE UTERUS. Fig. 14. 119 Rudimentary Uterus (Veit). Sa, sacrum; U, solid rudiment of uterus; h . rudl- Sar^hornr^/bladder; 6, ovary; T, Fallopian tube ; r round ligament. Fig. 15. Uterus Bipartitus (Rokitansky). V, vagina; U, uterus ; ft, rudimentary horn ; 0, ovary; T, tube; r, round ligament ; b, broad ligament. Fig. 16. Uterus Unicornis (Schroeder). E, right side; L, left side. The left horn (h) is well developed and communicates with the uterine cavity. The right horn is in the form of an elongated band; its point of connection with the Fallopian tube is indicated by the insertion of the round ligament, which is hypertrophied. Other letters as in preceding diagrams. 120 ESSENTIALS OF GYNECOLOGY. Fig. 17. Uterus Bicornis Unicollis (Schroeder). r, round ligament. Fig. 18. Uterus Didelphys. a, right cavity ; b, left cavity; c, right ovary ; d, right round ligament; e, left round ligament; /, left tube; g, left vaginal portion; h, right vaginal portion; i, right vagina; j, left vagina; k, partition between the two vaginas. (From De Sinety, after Ollivier.) MALFORMATIONS OF THE UTERUS. 121 Fig. 19. Fig. 20. Uterus Septus in Vertical Transverse Section (Kuss- maul). [/"(uterus), placed on septum which divides cavity into two lateral portions ; T, Fallopian tubes ; V, vagina divided into lateral cavities by prolonga- tion of septum downward. Infantile Uterus (Schroeder). Fig. 21. Primary Atrophy of the Uterus (Virchow). 122 ESSENTIALS OE GYNECOLOGY. Displacements of the Uterus. "What do we mean by a displacement of the uterus in a clinical sense ? ' ' Changes in the position of the uterus only become displacements, in the clinical sense, when they are more or less stable. Limitation or hindrance of the normal movements of the uterus is a main characteristic of its displacements." (Schultze.) What are the principal displacements of the uterus * a. Anteversion ; b. Anteflexion ; c. Retroversion ; d. Retroflexion ; e. Prolapse. What is the difference between a "version" and a "flexion?" In a "version " the canals of the cervix and body are in the same straight line ; in a ' l flexion ' ' they make an angle with each other. Anteversion. Discuss briefly. The uterus is sometimes fixed in a position of anteversion owing to the pressure of encysted fluids, tumors, inflammatory masses, peritoneal adhesions, or increased weight of the organ. The symp- toms are those of the causal condition. The anteversion, per se, gives rise to no symptoms, hence it is not usually considered among Uterine displacements. Anteflexion. What is the pathology ? In anteflexion the body of the uterus is bent forward on the cervix (see Fig. 22) ; in order for this to be pathological, there must be rigidity at the point of flexion. The posterior wall of the cervix is elongated by stretching, the anterior is shortened, and there is atrophy at the angle. What is the etiology ? It may be congenital (puerile, Schultze) or acquired. DISPLACEMENTS OF THE UTERUS. 123 The former is much the more common and is due to a lack of development in a woman whose general development is apt to be below normal. The most common causes of the acquired ,anteflex ion are a me- tritis occurring in a flexible uterus, or an inflammatory process occurring in the utero-sacral ligaments, drawing the upper portion of the cervix upward and backward. Fig. 22. Anteflexion of the Uterus (Schroeder). It is sometimes caused by the adhesions of peritonitis drawing the upper portion of the cervix backward. What are the symptoms ? a. Dysmenorrhoea ; b. Sterility ; c. Disturbance of bladderjunctipns — frequent micturition ; d. Leucorrhcea ; e. Othersymptoms are those of the accompanying inflammation. What are the physical signs ? The cervix lies rather high ; the os is directed downward and forward ; as you pass the finger up along the anterior wall of the 124 ESSENTIALS OF GYNECOLOGY. cervix, it runs into a marked angle between cervix and body. The body can be felt lying in front of the cervix, just above the anterior vaginal wall. The cervix is often long and the os small. The sterility is more dependent upon the long cervix plugged with mucus than any actual stenosis of the internal os. The uterus is sometimes both anteflexed and retroverted. From what must you differentiate an anteflexion ? From — 1 . A fibroid tumor in the anterior wall of the uterus ; 2. An inflammatory deposit in front of the cervix. How would you differentiate an anteflexed uterus from a fibroid tumor in the anterior wall? In an anteflexion you cannot feel the fundus elsewhere, and a sound passes when sharply curved into the body felt in front of the cervix. In a fibroid in the anterior wall I S^^A\ *\ U1Y ' W ( see -^ig- 23) the sound does not pass into the body felt in front of the cervix, but behind it, and the fundus can be felt above and behind the fibroid. How would you differentiate an inflammatory deposit from an anteflexion ? The former is comparatively rare, but when present is usually more sensitive than an anteflexion ; in the case of an inflammatory deposit in front of the cervix, a careful bimanual examination will usually show the fundus elsewhere. During the acute, inflammatory period the sound is contraindicated. What is the treatment of anteflexion ? First treat all existing pelvic inflammation, by means of hot-water douches i counter-irritation and glycerine tampons. When all inflam- matory symptoms have subsided, dilate the cervix, under antiseptic Sound passed to show that a Fibroid of the Anterior "Wall is not an Anteflexion (Leblond). DISPLACEMENTS OF THE UTERUS. 125 precautions, with one of the glove-stretcher dilators, and pack the cavity with iodoform gauze, leaving it for forty-eight hours ; or a stem pessary long enough to pass through the internal os may be inserted and left in place while the patient remains in bed, say from one to two weeks. Maintain the dilatation by the introduction of the graduated hard dilators, or sounds, once or twice a month for two or three months. Retroversion and Retroflexion. Define. .' 1 Retroversion may be defined as the permanent dislocation back- ward of the fundus uteri, when the form of the uterus is such that axis of body and axis of cervix are identical. Retroflexion denotes the permanent backward dislocation of the fundus uteri, with simul- taneous flexion of the uterus over the posterior surface. ' ' (Harrison. ) What is the etiology and pathology ? Retroversion (see Fig. 24) may exist by itself, but with retroflexion there is always more or less retroversion. Usually the uterus is first retroverted, and then intra-abdominal pressure continuing, if the uterus is flexible, the fundus is pushed backward and downward. The combination of the two is thus most common, and is described as retroversio-flexio (see Fig. 25). Retro versio-flexio is most fre- quent in multiparse following parturition, where the lig aments a re lax and patient lies on the back, and especially if the patient rises before- involution has occurred. It may occur, however, in nulliparae or virgins, from severe blows, falls, lifting, straining, etc. ; also from inflammatory adhesions, drawing the uterus backward. The most common agent in pushing a movable uterus behind the perpendicular is distention of the bladder ; intra-abdominal pressure may then act on the anterior surface of the uterus. Relaxation of the utero-sacral ligaments, and thickening and shortening of the utero-vesical, favor retroversio-flexio. Pathologically, we usually find the body of the uterus congested and enlarged, its mucosa hyperplastic, and more or less rigidity at the junction of cervix and body, from development of fibrous tissue. 126 ESSENTIALS OF GYNAECOLOGY. What are the symptoms ? 1 . More or less constant pain, in the back ; 2. Symptoms of pelvic inflammation ; 3. Constipation ; 4. Irritability of the bladder ; 5. Leucorrhoea ; 6. Menorrhagia ; 7. Dysmenorrhea, especially when flexion is marked ; 8. Abortion ; 9. Sterility^ 10. Keflex neuroses. Fig. 24. Retroversion of the Uterus (Schroeder.) What are the physical signs ? On making the bimanual examination, you find the cervix nearer the vulva than normal, the fundus absent in front, and the os pointing more or less forward ; on running the vaginal fingers along the pos- terior wall of the cervix, you find a body which, in a retroversion, continues the line of this wall, in a retroflexion makes an angle with it. This body moves as a part of the uterus ; the sound passes into it DISPLACEMENTS OF THE UTERUS. 127 From what must you differentiate retroversio-flexio ? 1. Fibroid tumor on posterior wall of the uterus ; 2. Faeces in the rectum ; 3. Inflammatory deposits ; 4. Prolapsed ovaiy or small ovarian tumor. How would you differentiate retroversio-flexio from a fibroid on the posterior wall ? Make a careful bimanual examination. In case of a backward displacement of the uterus, we find an absence of the fundus in front, the cervix points more or less forward, and the sound, when intro- duced, goes backward. Fig. 25. Retroversio-flexio. In case of a fibroid on the posterior wall, the fundus may be felt in front of it, and the sound passes forward. The tumor may feel more irregular and harder than the uterus. How would you differentiate the fundus uteri from faeces in the rectum ? On bimanual examination, the fundus can often be felt forward, and the sound passes forward ; the faeces have a more doughy feel 128 ESSENTIALS OF GYNECOLOGY. than the uterus ; if doubt exists, always empty the rectum before making a diagnosis. How would you differentiate the fundus uteri from inflam- matory deposits in the pouch of Douglas ? During the stage of acute inflammation this may be very difficult, as the sound is then contraindicated. Finding the fundus in front is the chief element in the diagnosis. When acute inflammation has subsided, introduction of the sound will give great assistance. How would you differentiate the fundus uteri from a pro lapsed ovary or small ovarian tumor ? By making a careful bimanual examination, the uterus is found lying in front of the prolapsed ovary or tumor. Assistance may be given by the use of the sound, or drawing down the cervix with a volsella. What are the indications in the treatment of retroversio- flexio ? 1. To treat the pelvic peritonitis or cellulitis, if present, according to the regular methods ; 2. To replace the uterus ; 3. To retain it in place. What are the methods of replacing a retroverted or retro- flexed uterus when movable ? 1. Place the patient in Sims' position ; introduce index and middle fingers of the right hand into the posterior fornix vaginae ; have patient breathe deeply and slowly ; during an expiration, raise the body of the uterus with the backs of the vaginal fingers till it passes the promontory of the sacrum, then transfer one or both fingers to the front of the cervix, and push that backward ; this throws the fundus forward. 2. Another method is to replace the uterus while patient is in the dorsal position, by means of the bimanual, either vagino-abdominal or recto-abdominal. In this method the body of the uterus is raised by the fingers in the vagina or rectum until it can be grasped by the external hand, when it is then brought forward. In some cases this DISPLACEMENTS OF THE UTERUS. 129 operation is facilitated by first grasping the cervix with a vulsella and pulling it downward in the axis of the vagina, thus straightening the uterine canal, making the fundus easier to reach by the examin- ing finger and easier to lift above the sacral promontory. 3. When the body of the uterus is very sensitive, so that pressure by the fingers is very painful, the uterus may be replaced by means of the sound, as follows : Introduce the sound with the concavity backward ; then make the handle describe an arc of a circle from behind forward ; then slowly depress the handle toward the perineum ; this throws the uterus forward. 4. To replace the gravid uterus, the following method is sometimes employed : Place patient in the genu-pectoral position ; draw down cervix with the volsella, and press fundus uteri toward the bladder, with the finger in the rectum. When the uterus in a retroversio-flexio is rigid at the angle of flexion, we do not expect to remove the flexion, but only to correct the version. What are the methods of replacing a retroverted or retro- flexed uterus when fixed by adhesions ? If signs of pelvic inflammation are present, treat the inflammation by hot douches, sitz-baths, wet pelvic packs, attention to the bowels, etc. When the inflammation has subsided, the uterus may gradu- ally be replaced by cautious manipulation and stretching of the adhesions, and gentle attempts at raising the uterus, a few moments at a sitting, with the fingers in the posterior fornix vaginae ; after the manipulation insert a wool tampon, to be worn for twenty-four hours. At first the tampons are to be pressed firmly into the posterior for- nix to exert an upward pressure on the fundus. Later, when the fundus can be nearly replaced, put the tampon in the anterior fornix to press the cervix backward and thus maintain the reposition already accomplished. The manipulations may be assisted by hot- water vaginal douches between the sittings. It is well to have the patient assume the knee-chest position once or twice daily. Schultze's method of forcible reposition consists in placing the patient under anaesthesia, in the lithotomy position, inserting index and middle fingers of left hand high up into the rectum, and with these fingers forcibly, but gradually, elevating the fundus uteri and breaking up the adhesions ; the right hand is placed on the abdo- 9 130 ESSENTIALS OF GYNAECOLOGY. men, and as the uterus is elevated, it is grasped by this external hand and brought forward. This method is rarely advisable. What are the means for retaining 1 the uterus in place after reposition ? 1. Pessaries ; 2. Operative procedures. Pessaries. What are the varieties in most common use ? 1. The Albert Smith ; 2. The Emmet; 3. The Thomas. Describe them. They are usually made of hard rubber; the Thomas pessary, how- ever, is often made of soft rubber. The Albert Smith (see Fig. 26) is a modification of the Hodge pessary ; its anterior extremity is narrow, the posterior broad ; the posterior extremity curves upward behind the cervix, the anterior downward away from the urethra. The Emmet pessary is usually made of a larger bar than the Albert Smith, and the curve is much flattened. The Thomas (see Fig. 27) is long, narrow, and has its posterior bar much enlarged. How does a retroversion pessary act ? Not by pushing up the body or fundus, but by making the poste rior vaginal wall tense, thus drawing the cervix backward, and in this way throwing the fundus forward. What are the contraindications to the use of a pessary ? A pessary should not be introduced till all pelvic inflammation has subsided, and, as a rule, not until the uterus can be well brought forward; "but occasionally, when the uterus is elevated to about the promontory, the pessary may be applied. ' ' What is the proper position of a retroversion pessary after introduction ? The broader extremity should lie behind the cervix and curve upward ; the narrow in front and curve downward. PESSARIES. 131 How would you introduce one of these retroversion pessaries ? They may be introduced with patient either in the dorsal or in Sims' position, preferably in the latter, and in the following manner : Standing at the side of the table, near the buttocks of the patient, separate the labia a little with the fingers of the left hand ; taking the pessary by the smaller end with the thumb and index and middle fingers of the right hand, introduce it between the labia, with the breadth of the pessary in the line of the labia (see Fig. 28) ; depress the perineum with the pessaiy as you introduce it about half way, Fig. 26. Fig. 27. Albert Smith Pessary. Thomas Pessary, then rotate, so that the breadth of the pessary lies at right angles to the labia ; now grasp the external portion of the pessary with the left hand ; pass the index finger or index and middle fingers of the right hand in front of the posterior bar (see Fig. 29) and carry the pessary along the posterior vaginal wall, being careful that it does not slip up in front of the cervix. What are the precautions to be observed in the employment of a pessary ? A patient after the introduction of a pessary should be made to walk a little about the room, then to sit on a chair and cross one knee over the other, to ascertain if the pessary causes pain ; if it does, it should not be kept in. A patient should always be told, on 132 ESSENTIALS OF GYNAECOLOGY. leaving, that if the pessary causes her pain, she must introduce her finger and remove it. She should be seen in a few days after its introduction, to ascertain if the pessary is in position and is holding the uterus in place. If one is not able to insert the finger between the pessary and vaginal wall the pessary is too large and may cause Fig. 28. Introduction of Pessary, First Stage (Hart and Barbour). ulceration. The pessary should be removed and cleaned as often as once a month ; in the meantime the patient should be instructed to use a vaginal douche for cleanliness two to three times a week. Always before re-inserting the pessary examine the posterior fornix through a speculum to see that no pressure-sore is forming. PESSARIES. 1 °' 1 ■>■ What are the operative procedures for holding a retroverted uterus in place after reposition ? a. Alexander's operation; b. Hysterorrhaphy ; c. Intra-abdom- inal operations on the round ligaments. Describe briefly Alexander's operation. Alexander's operation for shortening the round ligaments is per- formed as follows : The skin about the pubes is shaved and prepared Fig. 29. Second Stage : Pessary carried on by Finger (Hart and Barbour). antiseptically ; the pubic spine is taken as the first landmark ; an incision is then made, 2 inches long, from that point upward and outward, in the direction of the inguinal canal ; the incision is deep- ened until the tendon of the external oblique is seen ; the external abdominal ring is now visible ; the intercolumnar fascia is cut through in the long diameter of the ring ; if necessary the incision may be continued up to the internal ring ; the round ligament can 134 ESSENTIALS OF GYNAECOLOGY. usually now be seen, with the genital branch of the genito-crural nerve along its anterior surface. The ligament is then separated from neighboring structures and gently drawn out a little to show that it is free. Alexander then leaves this side covered with a clean sponge and operates on the other side in the same way. The uterus is then thrown forward by the sound in the hands of an assistant and the ligaments drawn out till they are felt to control the uterus ; the ligaments are then given to an assistant to hold, and they are each sutured with catgut to the pillars of the ring ; the bruised ends are cut off and the wound closed. The patient is kept in bed two to three weeks, and wears a pessary for several months. What are the indications for Alexander's operation? The field of the operation is very limited. Where a retroverted uterus is movable, unaccompanied by disease of the appendages, and either cannot, with comfort to the patient, be held in position by a pessary, or the patient is unwilling to wear a pessary, Alexan- der's operation may be employed. Some men employ it as a part of the operative treatment of prolapsus uteri. What are the advantages of Alexander's operation as com- pared with hysterorrhaphy ? In Alexander's operation the uterus itself is only held by liga- ments which normally hold it. It is therefore better fitted for growth in pregnancy than where the fundus is firmly attached. It is performed without invading the peritoneal cavity, and leaves the patient with a moderately movable uterus. What are the objections raised to Alexander's operation? It is not applicable unless the uterus is freely movable. The ligaments are sometimes difficult to find ; one or both may be poorly developed. Hernia occasionally, though rarely, occurs. The round ligaments are not true ligamentous structures, but muscular cords, and it is doubtful whether they are to be considered as normal supports of the uterus. Hence, when tension is put upon them, they are likely to stretch. The distal end is the weaker end of the ligaments. What are the synonyms of hysterorrhaphy ? Ventral suspension, ventrofixation, and hysteropexy. PESSARIES. 135 Describe briefly the operation of hysterorrhaphy for retro- versio-flexio. The abdomen is opened in the median line as for an ovariotomy ; the adhesions binding the uterus backward are broken up, the fundus brought forward and the uterus stitched to the anterior abdominal wall. The sutures are usually two in number, of either silk or chromicised catgut, and are inserted one just posterior to the middle of the fundus and the other posterior to that, so that when the sutures are tied the uterus will be slightly anteverted. These sutures pass through aponeurosis, muscle, and parietal peritoneum of one side, then through a portion of the fundus of the uterus, then through parietal peritoneum, muscle, and aponeurosis of the other side. These sutures are buried in. the closure of the abdominal wound. Another method is to pass the suture through the entire thick- ness of the abdominal wall, then through the fundus and out through the abdominal wall. This suture can be removed later and avoids the possibility of later trouble from a non-absorbable buried suture. The usual antiseptic dressing is applied. A pessary is often inserted for a time. What are the indications for hysterorrhaphy ? Hysterorrhaphy is indicated in a retro verted fixed uterus, especially where pregnancy is improbable ; in a retroverted uterus after the removal of both appendages ; as one stage in the operation for pro- lapsus uteri. Kelly says: "Suspension of the uterus should be resorted to only in cases of persistent retroflexion which refuse to yield to simple plans , of treatment through the vagina, and then only when the discomforts of the retroflexion are sufficient to inter- fere seriously with health. ' ' What are the disadvantages of hysterorrhaphy ? Experience shows that in pregnancy following hysterorrhaphy the portion of the uterine wall behind the point of suture is that which undergoes the chief distention and thinning. Although obstetric accidents due to the operation are rare, disturbances of parturition, and even rupture of the thinned posterior uterine wall, may occur. What modification has Kelly advocated to obviate the dis- advantages of hysterorrhaphy? He sutures the fundus to the abdominal wall with two silk sutures, 136 ESSENTIALS OF GYNECOLOGY. botli passed through the posterior aspect of the uterus behind a line connecting the inner ends of the Fallopian tubes. These only include with the fundus the parietal peritoneum and subperitoneal connective tissue. The fundus is not so firmly secured as by the former method. It gradually recedes from the abdominal wall and is connected with it by a band of adhesions. In subsequent opera- tions on patients so treated Kelly has found this band measuring three to five centimeters. What is the chief force in retaining the uterus in a forward position after hysterorrhaphy or Alexander's operation ? It is intra-abdominal pressure now brought to bear on the posterior aspect of the uterus. Describe briefly intra-abdominal shortening of the round ligaments. After opening the abdomen and separating the adhesions, the uterus is brought forward into normal position and held there by taking up the slack in the round ligaments. This has been accom- plished in a great variety of ways, among them may be mentioned the following : The round ligaments are folded upon themselves and the folded ligament sutured to itself. A fold of the round ligament may be sutured to the uterus. The ligaments near the uterine cornua may be sutured to the inner surface of the abdominal wall. Webster divides them at their uterine end, makes a hole in the broad ligament just under the Fallopian tube, and through this passes the round ligament. The two round ligaments are then sutured together over the posterior surface of the uterus. Gilliam draws a fold of each ligament through a small hole in each rectus muscle and sutures it there. Describe the Gilliam operation through the Pfannenstiel incision. The Pfannenstiel incision is made as follows : A transverse in- cision, slightly bowed, with the convexity downward, is made about 1J inches above the symphysis pubis. This can usually be brought into one of the natural folds of the skin. The incision is carried through skin, fat, and aponeurosis covering the pyramidalis and rectus muscles. The upper edge of the aponeurosis is retracted upward, and thus is exposed an area of the rectus and pyramidalis PROLAPSUS UTERI. 137 muscles. The pyramidalis muscles are now separated and the peri- toneum divided also by a median incision. The Gilliam operation is now performed as follows on each round ligament : A needle and suture are carried under the round ligament 1 to 1 J inches from the uterus. This suture is left long and not tied, but simply used as a tractor. In the line of the transverse incision a blunt forceps is thrust through the rectus muscles and peritoneum into the ab- domen, the point of entrance being some distance lateral to the median line. The instrument is opened and grasps the ends of the tractor and is withdrawn until a loop of the round ligament is drawn out through the muscle. When both ligaments are brought into view the median incision through peritoneum and muscle is closed by sutures. Then the transverse incision through the aponeu- rosis is sutured with chromic gut, two sutures on each side including the round ligaments, so that the ligament comes through the peri- toneum and muscles and is sutured to the deep surface of the apon- eurosis. As described by Gilliam, the simple median incision is em- ployed, and the ligaments are drawn through aponeurosis as well as muscle. Skin and fat suture completes the operation. Prolapsus Uteri. What is meant by this expression? Hart and Barbour define prolapsus uteri as a downward displace- ment of entire displaceable portion of pelvic floor, uterus, and ap- pendages past entire fixed portion, with coincident descent of small intestine. It is not unlike a hernia, the vagina and uterus being considered the coverings of the sac, the vulvar orifice the ring through which the hernia protrudes, and the contents of the sac being the prolapsed intestine. What is meant by the " entire displaceable portion of pelvic floor"? ' ' The entire displaceable portion comprises bladder, urethra and vaginal walls. It has resting upon it the uterus, broad ligament, Fallopian tubes and ovaries. ' ' What is the " entire fixed portion of pelvic floor " ? That outside of the entire displaceable portion, i. e. , tissue attached to the posterior surface of the symphysis ; all outside the inner 138 ESSENTIALS OF GYNAECOLOGY. aspect of the levatores ani ; the rectum and tissue attached to the sacrum. Explain the function of the two segments. The displaceable portion of the floor is also called the pubic segment or the supported segment. It is everywhere loosely, at- tached to its surrounding structures. The fixed portion is called the sacral segment or supporting seg- ment, since the displaceable portion rests upon it and is supported by it. This division of the pelvic floor structures into two segments has its real significance from the behavior of the two parts during labor. The entire displaceable portion and the anterior lip of the cervix are drawn up into the abdomen above the head, as autopsies on women dying in labor have shown ; the fixed portion is some- what displaced downward. The displaceable portion of the floor must of necessity then be loosely attached to the pelvic wall to allow it to recede into the abdomen during labor. What are the degrees of prolapsus uteri ? According to Thomas there are three : — 1. When the organ has sunk in the pelvis. 2. When the cervix is at the ostium vaginae. 3. When a part or the whole of the uterus lies between the thighs. The third degree is sometimes called procidentia. What is the etiology ? The three elements in the etiology of prolapse are — 1. Relaxation of the ligaments of the uterus, combined with lack of tone in the entire displaceable portion of the pelvic floor and " slackening of loose tissue around it. " 2. Lack of support in the entire fixed portion of the pelvic floor, especially laceration of the perineum. 3. Intra-abdominal pressure. The chief predisposing causes are parturition, laborious occupa- tions, anything increasing weight of the uterus, advanced age. Pro- lapse is sometimes produced acutely by blows, falls, heavy lifting, etc. , but is usually the gradual result of the three elements mentioned above. Give its pathology. All the pelvic contents may prolapse and not the uterus only. PROLAPSUS UTERI. 139 Those cases in which the uterus first descends and is followed by the vaginal walls, which invert as it descends, are called pri- mary prolapse. In secondary prolapse the vaginal walls and struct- ures attached to them first descend, and as they do so drag the uterus after them. Most commonly the process begins as a descent of the bladder and anterior wall of the vagina in cystocele The uterus in its descent usually follows a curve, the cervix moves to- ward the vulva and the fundus falls back into the hollow of the sacrum. Retroversion must precede any considerable degree of prolapse, though slight prolapse with the direction of the uterine axis unchanged is possible. The circulation in the uterus is ob- structed, leading to swelling of the organ and hyperplasia of its mucosa. The elongation of the cervix is chiefly due to swelling and traction of vaginal walls upon it, but to a less degree^ and in some cases only from an actual hypertrophy. What is the relation of the pubo-coccygeus muscles to pro- lapse ? They are the most important single structure in guarding the vul- var orifice against a hernia through it. In bad cases they are usually found completely torn across. We usually find prolapse asso- ciated with lateral tears that injure these muscles rather than with median tears, no matter how deep. What are the symptoms ? Those of the acute prolapse are sudden, severe pain, vomiting, retention of urine and signs of peritonitis. The symptoms of the gradual prolapse are a dragging sensation in lower abdomen and back, and the discomfort from the protrusion and excoriation of the parts ; difficulty in urination is sometimes present. What are the physical signs ? These depend on the degree of the prolapse. If the prolapse is partial, the anterior vaginal wall bulges at the ostium vaginae, the cervix is lower than normal, and if there is marked laceration of the perineum the posterior vaginal wall also bulges. The uterus becomes more and more retroverted as it sinks in the pelvis. When the pro- lapse is complete, the cervix and more or less of the body of the uterus lies outside of the vulva; the anterior vaginal wall and part of the lower bladder wall have prolapsed with the cervix; the posterior 140 ESSENTIALS OF GYNECOLOGY. vaginal wall with or without part of the anterior rectal wall is also everted. The uterus is usually enlarged and the supravaginal por- tion of the cervix elongated. From what must you differentiate prolapsus uteri ? 1. Hypertrophy of the cervix: — {a) Vaginal portion ; {b) Supra-vaginal portion ; (c) Intermediate portion. 2. Cystocele. 3. Rectocele. 4. Inversion and polypi. How would you differentiate prolapsus uteri from a cysto- cele? In prolapse the uterus is sunken in the pelvis ; in cystocele the uterus lies in nearly its normal position, and the protruding mass is found, by the introduction of the sound into the bladder, to consist of the anterior vaginal and posterior vesical wall. How would you differentiate prolapsus uteri from a recto- cele? In prolapse the uterus is sunken in the pelvis ; in rectocele, pure and simple, the uterus lies in nearly its normal position, and the protruding mass is found, by the introduction of the finger into the rectum, to consist of the posterior vaginal and anterior rectal wall. Both cystocele and rectocele are common complications of prolap- sus uteri. What is the treatment of prolapsus uteri ? 1. By pessaries ; 2. By operation. If the prolapse is slight in amount, the perineum preserved, and the anterior vaginal wall protrudes but a little, a pessary like that of Albert Smith may suffice to hold up the uterus. If this fails, a ring pessary will sometimes answer. The two most important points in the operative treatment are to restore the anteversion of the uterus and to repair the pelvic floor. If the prolapse is marked, the following combination of operations or of some of them give good results : 1. Curettage of the uterus ; 2. Amputation of the cervix ; 3. Anterior colporrhaphy ; LACERATION OF PERINEUM. 141 4. Perineorrhaphy; 5. Hysterorrhaphy, or shortening of the round ligaments. These can all be done at the same sitting. In some cases 1 , 2, or 3 may be omitted, in others the plastic operations will suffice without the hysterorrhaphy, but in a well-marked case all five are indicated. Vaginal hysterectomy is very seldom indicated for prolapsus uteri, the patient's condition may be worse after it than before it, as the vagina inverts and bladder prolapse is increased. If hysterectomy is done the stumps of the broad ligaments should be sutured to the vaginal vault, to aid in resisting the tendency to vaginal inversion. A number of operations have been devised which approximate the bases of the two broad ligaments in front of the cervix, the object being to shorten the ligaments, thereby drawing the uterus upward, and to throw the cervix backward into the sacral hollow. Duhrsen, through an anterior colpotomy wound, ante verts the fundus to a position between the base of the bladder and the vaginal wall, and sutures it there, so that the fundus is only covered by vaginal wall. This operation would never be justifiable before the menopause. Laceration of Perineum and Relaxation of Vagi- nal Outlet. What is the etiology ? The most common cause of laceration of the perineum is child- birth, either natural or instrumental ; rarely, however, it may arise from external violence, as fehin^asiride^of' some sharp object. This occasionally happens to little children. Relaxation of the vaginal outlet, aside from being produced by these visible lacerations, is also caused by submucous and subcutaneous rupture or overstretch- ing of the fibres of the levator ani muscle, or perineal fascia ; this, too, occurs most often during parturition. What are the varieties of perineal laceration ? 1. Median. They may be : — a. Incomplete, extending more or less deeply into the perineal body. b. Oomp_lete, extending through the sphincter ani and up the rectum for a variable distance. Complete lacerations are less likely to be followed by relaxation and rectocele than are the incomplete. 142 ESSENTIALS OE GYNECOLOGY. 2. Lateral. These result in dividing some of the fibers of the levatores ani, first those fibers that end at the rectum, then if the tear extends more deeply, injuring the fibers that pass back to the tip of the coccyx. The torn ends of the muscle retract toward their in- sertion, and the lateral sulci of the vagina are felt to be deepened. Such tears may lie entirely within the vagina, the "skin perineum " remaining intact. 3. Perineal relaxation. Cases without apparent distinct tear, but with all their results. These are cases where there has been more or less subcutaneous rupture of levator ani fibres due to over- stretching. What is the importance of laceration of the perineum ? It consists in the fact that in cases of marked laceration, the fibres of the levatores ani, the chief support of the vaginal outlet, are torn; especially those fibres which are attached to the rectum ; at the same time there is laceration of the fibres of the perineal fascia. These conditions cause relaxatiojua£ the vaginal outlet, with a tendency to rectocgle, cystocele and prolapsus uteri. If the laceration is througETthe sphincter ani, incontinence of faeces usually results. What are the subjective symptoms of laceration of the peri- neum with relaxation of the vaginal outlet ? The patient usually feels incapacitated for any great exertion, complains of a dragging pa in in th e back and the feeling of weight in the pelvis. What does a physical examination show ? An enlarged vaginal orifice, cystocele or jrectocele • the anus may be drawn back toward the tip of the coccyx by the sphincter ani fibres attached to its tip and now unopposed by the torn anterior fibres of the levator ani ; the depression between the buttocks at the bottom of which is the anus may be less deep than usual owing to the relaxation and descent of the pelvic floor. How would you determine relaxation of the vaginal outlet? Insert the thumbs or index fingers into the vaginal orifice ; sepa- rate the labia by carrying the thumbs or fingers backward and out- ward, at the same time telling the patient to strain ; the lax condi- LACERATION OF PERINEUM. 143 tion of the outlet will then be readily felt, and anterior and posterior vaginal walls will be seen to protrude. What are the principal operative procedures for repair of lacerated perineum or relaxation of the vaginal outlet ? The three following operations are in common use — 1. Hegar's operation. 2. Emmet's operation. 3. The Saenger-Tait operation. Describe the Hegar operation. (Martin suture.) In this as in all perineal operations the patient's bowels should be freely moved and the vulva shaved. Just previous to operation, the vagina and vulva should be thoroughly cleansed with soap and water and then irrigated with an antiseptic solution. In the Hegar Fig. 30. A denudation which is triangular in shape (see Fig. 30), three points are taken, A. B. and C. That which is to be the apex of the tri- angle, A, is in the median line of the posterior vaginal wall ; this is seized with a bullet forceps or tenaculum and drawn upward and forward. The points B and 0, at the extremities of the base line, are points on the labia majora which when the operation is com- pleted will form the fourchette. These points B and C are also seized by bullet forceps or tenacula and are drawn apart, thus facilitating the denudation of the triangular area A. B. C. 144 ESSENTIALS OF GYNECOLOGY. This denuded surface may either be closed by sutures introduced from side to side, or it may be closed by a continuous catgut suture in tiers, according to Martin. This is similar to the Martin method of suturing used in an anterior colporrhaphy. (See further on.) When the operation is completed the point A is high up in the vagina, B and C are in apposition. Hegar's operation is well suited to tears which are median or to cases where time is an important element, as in prolapse cases where the perineorrhaphy is but one of several operations performed at a sitting. Compare the methods of suture. The Martin suture passed in a number of layers seeks to concen- trate at the perineum as much tissue as possible and build up a rather pyramidal perineal body. The normal perineal body is not of this form, as can be shown if one passes a finger into the rectum and one into the vagina of a nulliparous person. The supporting parts of the perineum, as distinguished from its mucosal or skin surfaces, is felt to be a small and rather thin layer of fascia, not at all suggesting the keystone or pyramidal form. Inasmuch as the vaginal mucosa normally lies directly on the pelvic fascia, and since the skin perineum is often intact, best results will usually be ob- tained by using interrupted sutures of chromic catgut placed within the vagina, being careful that each suture catches some of the pelvic fascia on either side. By this method comparatively little harm is done if one suture gives way, whereas when continuous sutures are used too much importance attaches to the holding of a single knot. The same objection applies to any method relying for approxima- tion of pelvic fascia on one or two figure-of-eight sutures. Most operators prefer not to use buried sutures in the perineum. Describe Emmet's operation for restoration of the perineum. The patient is prepared for operation as usual, with antiseptic douches, etc. She is anaesthetized and placed in the lithotomy position ; a point is selected in the centre of the crest of the bulging posterior vaginal wall, and a point on each labium majus correspond- ing to the lowest vestige of the hymen. These three points are to be brought together by the completed operation. Between the central point chosen and the two lateral are two triangu- lar areas, with apices running into the vaginal sulci on each side of the LACERATION OF PERINEUM. 145 eolumna. These triangular areas are first denuded as follows : One tenaculum is inserted into the central point chosen, and another into one of the lateral points ; these are given to an assistant, who draws the central point forward and -to the side opposite the other tenacu- lum. This draws the apex of the triangle nearly in line with the two tenacula ; a narrow strip is then denuded with the scissors along this line. When the tension is relieved, the area marked off is seen to be triangular, as before. The denudation of this triangle is then completed by long snips of the scissors. The lateral point on the other side is now seized with the tenaculum, and the central point drawn toward the denuded side ; this triangle is denuded as before, also, as much of the skin surface of the perineum as is necessary. The parts are now thoroughly irrigated and the sutures introduced as follows : The two triangular areas are to be in the vagina, and are sutured with either silkworm gut or catgut. The apex of one tri- angle is first closed, the suture entering and emerging from the vaginal mucous membrane near the denuded surface ; the succeed- ing sutures of this triangle are made to enter the vaginal mucous membrane on one side, slant toward the operator, emerge at the centre of the denuded surface, re-enter, slant away from the operator and emerge from the mucous membrane of the other side a little in front of the preceding suture. This method is repeated in the other triangle. There then remains but a small external denuded area to be closed ; this is best done with silkworm gut. The upper or crown suture, entering the skin on one side, passes through the anterior extremity of the eolumna of the posterior vaginal wall, and emerges from the skin on the other side. The bowels are moved about the third day and the sutures removed on the eighth. This opera- tion is best suited to bilateral tears. The two triangles denuded up into the vagina lie in two depressions formed by the separation of levator ani fibres from their attachment. Hence when the sides of these triangles are brought together the tendency is to bring the levator ani fibres into apposition with the perineal body. Students find difficulty in understanding this operation from written descrip- tions, but will find it quite simple when once they have seen the triangles located on the living subject. Compare the Emmet perineorrhaphy with the Hegar. The Hegar operation can be done more quickly and easily than the Emmet. If the central point in the Emmet operation is brought 10 146 ESSENTIALS OE GYNECOLOGY. down too far it is apt to intervene between the lateral portions of the pelvic fascia, upon the union of which in the middle line we chiefly depend for restoration of pelvic support. As Kelly does the opera- tion the mid-point is left well inside the vagina. In the Hegar operation the upper limit of the denudation — i. e. , the crest of the rectocele — is made to recede farther and farther up into the vagina as the suturing proceeds, instead of being drawn downward as in the Emmet. Fig. 31. Describe the Saenger-Tait operation. The patient is prepared for operation by having the bowels freely moved, the vulva shaved, and an antiseptic vaginal douche given. She is then anaesthetized and placed in the lithotomy position, with LACERATION OP PERINEUM. 147 knees supported by Clover's crutch and hips resting on Kelly's perineal pad. The vagina and vulva are now scrubbed with soap- water and irrigated with an antiseptic solution, and an assistant so stationed that he can allow a mild antiseptic solution or sterilizer! salt solution to trickle on the wound during the operation. A tampon is inserted into the rectum, the string left projecting. The index and middle fingers of the left hand are now inserted into the rectum, as seen in Fig. 31 ; the labia are separated by an assistant, the blades of the scissors (Tait uses angular scissors and inserts only one blade; scissors curved slightly on the flat, with points rather sharp, and both blades in- serted, may be used with advantage) inserted into the recto-vaginal septum just in front of the anus, and the vaginal and rectal mucous membranes separated for some distance around the point of inser- tion. A horizontal incision is now made through the point of inser- tion, extending on either side to a perpendicular through the lower extremity of the nymphse ; an incision is made with the scissors up along this perpendicular to the lower extremity of the nymphae. The flap so marked out is then dissected up to the crest of the bulging posterior vaginal wall. See Fig. 32. The parts are now freshly irrigated, and the sutures of silver wire introduced as follows : Either a Peaslee's needle or a long, straight needle with a thread loop maybe used ; the sutures, 3-4 in number, are inserted just within the denuded area on one side, and brought out just within the denuded area on the other. See Fig. 33. The tampon is removed from the rectum, the sutures twisted up and either left long or shotted and cut short. The skin is now brought into apposition by supei-ficial silkworm-gut sutures introduced be- tween the wires, giving the result seen in Fig. 34. An antiseptic dressing and a T-bandage are applied, and the patient is put to bed. The bowels are moved about the third day, and the sutures re- moved on the eighth. Discuss the merits of the Saenger-Tait operation. The results of this operation were not good. Skin and vulvar structures were approximated, but the efficiency of the pelvic floor as a support was not improved. The operation would now be of only historic interest were it not that in recent years other operators (Webster, Mayo) employed methods of operating based on the flap- splitting principle — i. <■., separating vagina and rectum — then by suture approximating pelvic fascia and muscle between. The ad- 148 ESSENTIALS OF GYNAECOLOGY. Fig. 32. Fig. 33. LACERATION OF PERINEUM. 149 vantages of these operations are that they are quickly performed, and that they do not present a suture line in the vagina. These advantages will only have weight if the pelvic support can be as well restored as in the other method of operating. Mention another modification of operative technique. Some writers have suggested that inasmuch as the restoration of the physiological action of the pelvic floor presupposes a restoration of the normal muscular attachments, that we should cut down upon Fig. 34. Fio. 35 and identify the levatores ani and pass our sutures through the muscle bundles. We see no reason why they cannot be as well brought together in their sheaths of fascia as denuded of it. ^ If the sutures include muscles as well as fascia, the muscle within their grasp is sure to atrophy. The more extensive dissection will cause longer operation and greater blood loss. What is a good method of procedure when the laceration extends through the sphincter ani ? Thoroughly cleanse the vagina and lower portion of the rectum. 150 ESSENTIALS OF GYNAECOLOGY. Denude a V-shaped area with apex up the rectum, representing the torn walls of the latter, and with the arms of the V resting on the ends of the divided sphincter ani muscle. The denuded sur- face had best be a little larger at these latter points. It is well to dissect out and identify the torn ends of the sphincter to insure their being brought together by the sutures. Sutures of silkworm gut or chromicized gut are now introduced as seen in Fig. 35 with ends in the rectum and tied. The ends of the silkworm gut sutures are left long and protruding from the anus. This repairs the rectal rent, and now the further restoration of the perineum may be accomplished by any of the ordinary methods of denudation and suturing. The Hegar's denudation answers admirably here. What are the disadvantages of this operation ? As formerly employed, the sphincter ends were not isolated, but were brought together with their surrounding of scar tissue, which often resulted in a cicatricial bridge intervening between the ends of the muscle and somewhat impairing its efficiency. In recent years, following the recommendation of Kelly and others, we isolate the muscle ends and place sutures so as to accurately approximate them. A suture line and sutures in the rectum are an objection to this operation. Infection is favored by way of the rectum, and occa- sionally the whole perineum will give way, or a rectoperineal or rectovaginal fistula result. What is Warren' s method of operating when the sphincter is torn? Warren, of Boston, in 1883 described an operation, the feature of which was the dissecting from above downward of an apron of vaginal mucosa, and turning it down so as to face toward the rectum. This mucosa extended beyond the anus, and allowed the sphincter to be sutured over it. By this means a rectal wound and rectal sutures were avoided. The only objection to this procedure is that in some cases extensive cicatrization in the rectovaginal septum make it difficult to construct the apron and make it liable to slough. What is the method of procedure introduced by Noble ? In 1902, Noble, of Atlanta, described his method. With a knife LACERATION OF PERINEUM. 151 he makes an incision splitting the rectovaginal septum ; this incision extends from one sphincter end to the other. The sep- aration of rectum and vagina continues upward until the loosen- ing of the rectal wall permits it to be drawn down to or below the anus, much as one loosens and draws down the rectal mu- cosa in the Whitehead operation for hemorrhoids. The edge Fig. 36. of the mucosa is kept well outside the anus and the sphincter sutured around it. Describe the operation as performed by Cragin. Cragin also draws down the rectal wall till it protrudes through at the anus; the technique is, perhaps, a trifle simpler than Noble's. The accompanying drawings illustrate the method. Fig. 36 shows the removal of a transverse strip of cicatricial tissue, which at either end reveals the sphincter ends. 152 ESSENTIALS OF GYNAECOLOGY. Fig. 37 shows the rectal wall drawn down, the vaginal wall drawn Tip, and the sutures for the sphincter in place. The denudation for a perineorrhaphy is made, and in Fig. 38 we see the sutures all inserted, those through the sphincter being already tied. As the figure shows, the point that was formerly at the apex of the rectal tear is now visible as a tab outside the anus. Fig. 37. Describe the operation of anterior colporrhaphy. The most frequently employed operations have been (1) that of Stoltz, which denuded a circular area on the anterior vaginal wall, and then puckered the area by putting a purse-string suture around its periphery and drawing it tight. (2) Another method, formerly much in vogue, made an oval denudation in the anterior vaginal wall, and closed the denuded area by Martin's method of suture. LACERATION OF PERINEUM. 153 This consisted in placing several rows of superimposed sutures, each narrowing the raw area a little more than the preceding. These operations have not proved satisfactory. The former shortened the vagina; in neither was much support afforded, the sutured area usually stretching out again. We now employ an operation based on different principles. It Fig. 38. is not unlike the Mackenrodt operation for retroversion of the uterus. The Mackenrodt colpotomy incision is used — i. e. , a trans- verse incision through vaginal wall just in front of the cervix. From the middle of this and extending down the middle of the anterior wall of the vagina an incision is made down to bladder wall. By dissecting laterally with the finger and up along the cervix the bladder is considerably loosened from its connections to vagina and uterus, and pushed upward out of the way. Any redundancy of 154 ESSENTIALS OF GYNECOLOGY. vaginal wall may be cut away along the edge of the incision. Sutures are then inserted, beginning at the posterior end of the incision. The needle is entered through mucosa on one side of the incision, then grasps the tissue of the anterior surface of the cervix, and comes out through mucosa on the other side of the incision. When a row of such sutures are inserted, the vagina is in contact with the cervix and lower uterine segment, occupying a position in relation to the uterus formerly occupied by the bladder. The bladder is displaced higher up on the uterus. This procedure has met with much greater success than the former methods. Hypertrophy of the Cervix. Give the varieties and etiology. Hypertrophy of the cervix may involve either the infra-vaginal or supra-vaginal portions. Some authorities mention hypertrophy of the intermediate portion of the cervix. Little is known of the etiology. Hypertrophy of the infra-vaginal portion is usually congenital. Hypertrophy of the supra-vaginal portion usually accompanies prolapse of the uterus or vaginal walls. In these cases it is more of an elongation and chronic oedema of the cervix than an actual increase of cervical tissue. What are the physical signs and symptoms ? The os is nearer vulva than normal ; it may even project beyond the vulvar opening. In hypertrophy of the infra-vaginal portion, the cervix is long, usually conical, with small os ; the vaginal fornices and fundus uteri are in their normal position. If the cervix protrudes from the vulva, it may be ulcerated, from friction. ' ' In hypertrophy of the supra-vaginal portion both anterior and posterior fornices are obliterated. ' ' ' ' In hypertrophy of the intermediate portion the posterior fornix re- mains, while the anterior fornix is obliterated . ' ' (Hart and Barbour. ) What are the symptoms ? The symptoms of hypertrophy of the infra-vaginal portion are chiefly mechanical : — STENOSIS OF THE CERVIX. 155 Leueorrhoea, from vaginal irritation. Discomfort in exercise. Sense of weight in the pelvis. Sterility. The symptoms of hypertrophy of the supra-vaginal portion are those of the prolapse of the uterus or vaginal walls, which it usually accompanies. What is the treatment of hypertrophy of the infra-vaginal portion of the cervix ? Amputation of the cervix. The best method is probably a circular amputation, proceeding in a manner somewhat similar to that employed in amputation of an extremity, viz. , cutting through and retracting superficial struc- tures, go through cervix higher up, thus making the portion of cervix removed conical. The tissues retract so that the stump left also appears conical, but the superficial structures can easily be brought over it. The vaginal mucous membrane opposite the uterine canal is stitched to the mucous membrane of the cervi- cal canal both anteriorly and posteriorly, care being taken to make the sutures include a portion of the substance of the cervix so as to fasten the flaps down to the stump to prevent oozing and pocket- ing. At the sides of the cervix the flaps will usually come into easy apposition and should be sutured together, taking care as above, that the sutures include the deeper structures and prevent oozing. The lines of suture thus extend from the os a little way into each lateral fornix. Before the cervix is completely removed a few of the sutures may be introduced and used as tractors. Another very good method is that of Simon and Marckwald, in which the cervix is first divided by a transverse incision into an an- terior and posterior lip ; a wedge-shaped piece is then removed from each (see Fig. 39), and the flaps of each lip are brought together with sutures, either of silkworm gut, catgut, or silver wire. Stenosis of the Cervix. What is the etiology ? It may be either congenital or acquired. When congenital, it is usually associated with a small uterus, long cervix, and anteflexion. Stenosis of the external os is more frequent than of the whole canal. 156 ESSENTIALS OF GYNECOLOGY. Acquired stenosis results from cicatrization following the use of too strong caustics, endocervicitis, or a too complete closure of the cervical canal in a trachelorrhaphy. What are the symptoms ? Dysmenorrhea and sterility The stenosis results in an insufficient drainage of the cervical canal. The retained secretion gives rise to an endocervicitis which, rather than the stenosis, is to be considered the direct cause of the sterility. Fig. 39. Marekwald's method of splitting the cervix into an anterior and posterior lip and then uniting cervical to vaginal mucous membrane {Schroeder). What is the treatment ? Dilate the cervix with one of the glove-stretcher dilators and maintain the dilatation by the occasional introduction of graduated sounds. Iodoform gauze packing may be used for the first few days following the dilatation of the canal. Laceration of the Cervix. What is the etiology ? The usual cause is parturition or abortion ; it occasionally occurs as a result of mechanical dilatation of the cervix. It occurs in par- turition in about 32 per cent, of women ; especially in tedious, pre- LACERATION OF THE CERVIX. 107 cipitate or instrumental deliveries. It is predisposed to by a rigid os, faulty presentation or condition of the foetus, premature rupture of the membranes and previous disease of the cervix. What is the pathology ? The laceration may be — 1. Complete. Penetrating the whole thickness of the cervix. 2. Partial. Including cervical mucous membrane, but not ap- pearing on the vaginal surface. It may be — (a) Unilateral (see Fig. 40). (b) Bilateral. (c) Stellate (see Fig. 41). The unilateral laceration is most apt to occur in the line of the Fig. 40. Single Laceration. The flaps are held apart with a double tenaculum (Emmet). right oblique diameter of the pelvis ; i. e. , either anteriorly and to the left or posteriorly and to the right, especially the former. This is supposed to arise from the greater frequency of the first position of the vertex. Bilateral lacerations are usually more dangerous than those of the anterior or posterior lip. because opening up the cellular tissue of the broad ligaments. Stellate lacerations are more apt to be superficial. If the surfaces of laceration are kept clean, more or less union 158 ESSENTIALS OF GYNAECOLOGY. will occur. Usually there is partial union, with eversion and pro- liferation of the cervical mucous membrane, hyperplasia of the con- nective tissue and proliferation of the glandular structure. What are the complications and results ? The most frequent complications are — 1. Cellulitis. 2. Peritonitis. 3. Endometritis, especially cervical endometritis. -The common results are — 1. Subinvolution. 2. Chronic metritis. 3. Displacements of the uterus. 4. Sterility. Fro. 41. Multiple or Stellate Laceration (Emmet). 5. Abortion. 6. Epithelioma. If the laceration has extended through the anterior fornix, a vesico- vaginal or vesico -uterine fistula may remain. What are the symptoms ? The symptoms are due to the inflammatory processes to which the laceration gives rise. The patient usually complains of a feeling of weight in the pelvis ; LACERATION OF THE CERVIX. 159 leucorrhoea, disturbances of menstruation, especially menorrhagia ; sterility; neuralgia and various reflex neuroses, such as suboccipital headache. At the time of the laceration there may be considerable hemorrhage. What are the physical signs ? On making a vaginal examination the cervix usually feels enlarged and more sensitive than usual ; the fissure can, as a rule, be readily detected ; also, if present, the eversion of the cervical mucous membrane, which usually feels velvety, often granular or cystic. Sometimes the eversion is so extreme that one does not notice the fissure, simply feeling the velvety or granular area about the os. The latter may be so patulous as to admit the finger. On making the bimanual examination the uterus is often found enlarged as a whole ; cicatrices may be felt extending from the laceration into one of the vaginal fornices. With the aid of the speculum one sees the erosion on one side of or surrounding the os, and by drawing the edges of the laceration together with tenacula the extent of the tear is visible. Without this latter procedure, one is greatly deceived, in some cases, as to the degree of the injury. What is the treatment ? Opinions differ as to whether lacerations of the cervix, unless accompanied by hemorrhage, should be immediately repaired or not. When hemorrhage accompanies the laceration, the cervix should be drawn down to the vulva and the laceration closed with silkworm gut or catgut sutures. The treatment after the puerperium is as follows : The complica- tions, if present, are first treated, especially peritonitis or cellulitis, by counter-irritation, hot- water vaginal douches, glycerine tampons, etc. The cervical endometritis is treated by pricking the cysts, if present, and applying to the cervical mucous membrane carbolic acid, iodine, silver nitrate, or alumnol, 10 per cent, in glycerine. The corporeal endometritis is treated by the curette, if necessary, and applications as in cervical endometritis. The growth of the squamous epithelium over the erosions is stimulated by astringent applications, such as pyroligneous acid. Under the above procedures the uterus often returns to its normal size, and the symptoms associated with the laceration disappear. 160 ESSENTIALS OF GYNECOLOGY. If the symptoms continue after the foregoing treatment, and neither peritonitis nor cellulitis is present, Emmet's operation of trachelorrhaphy is indicated. Where the cervix is much hypertro- phied when it is riddled with cysts, and therefore is not fitted to the operation of trachelorrhaphy, a Schroeder's amputation of the mucosa may be substituted or a circular amputation. Fig. 42. Trachelorrhaphy for Bilateral Laceration of the Cervix li teri. Sutures introduced. Describe briefly the operation of trachelorrhaphy. The patient, after the usual preparation regarding bowels, bladder, and antiseptic vaginal douche, is anaesthetized and placed in the dorsal position, with Kelly's pad beneath the hips, and legs sup- ported with a leg-holder. The vulva and vagina are thoroughly scrubbed with soap and water, and an antiseptic douche given. The perineum is retracted with a speculum ; the anterior lip of the cervix is seized with a bullet-forceps, and the uterus drawn down and steadied by an assistant. The edges of the laceration are now pared with scissors or knife, giving the denuded area seen in Fig. 42, and leaving enough mucous membrane in the center for the cervical canal. Care should be taken to excise the plug of cicatricial tissue at the angle of the laceration. ENDOMETRITIS. 161 The parts are now irrigated with sterile solution, and the sutures of silkworm gut or chromicized catgut introduced, usually 3-4 on a side, beginning at the upper angle. Each is passed from the surface of the vaginal portion, through the thickness of one lip, emerging in the edge of the unclenuded mucous membrane ; thence is passed into the edge of the unclenuded mucous membrane of the other lip, through the lip's substance, and emerges on the sur- face of the vaginal portion. The other sutures of the same side are introduced in a similar manner, care being taken to bring the parts into close apposition and leave no pockets. If the laceration is bilateral, the suturing of the other side is conducted in the same manner. The parts are again irrigated and the sutures tied. A sterile dressing is applied to the vulva and the patient placed in bed. The sutures are left 8-10 days when silkworm gut is used ; they may be left longer if the perineum is repaired at the time of the trachelorrhaphy. Endometritis. Define and give the varieties. Endometritis is an inflammation originating in the lining mem- brane of the uterus, but not necessarily confined to the endo- metrium ; it usually involves the muscular wall more or less deeply, but in a less degree than the endometrium. Some authors abandon the term and call all uterine inflammation metritis. The term seems of value in calling attention to the point of origin and greatest severity of the inflammatory process. It may be either acute or chronic. Acute endometritis usually involves both cervix and body. The chronic is often confined to either cervix or body, and called in the former case cervical endometritis, endocervicitis, or chronic cervical catarrh ; in the latter case, corporeal endometritis. Occasionally, chronic endometritis affects the whole uterus. Acute Endometritis. What is its etiology ? It is always due to bacteria, most often the gonococcus but fre- quently the pyogenic organisms. It is predisposed to by traumatism, 11 162 ESSENTIALS OF GYNAECOLOGY. unclean Lands or instruments used in examinations, catching cold during menstruation, excessive coitus near menstruation, severe types of exanthemata, labor, abortion, foreign bodies in the uterus, sloughing tumors and polypi. What are its varieties ? 1. Saprsemic. This results from the action of putrefactive germs on retained products of conception or sloughing tumors in the uterus. 2. Septic. It may result from the introduction of sounds, from surgical operations or other trauma, but most frequently complicates childbirth or abortion. Williams gives the bacteria causing puer- peral infection in the order of frequency, as follows : Streptococcus, staphylococcus, gonococcus, colon bacillus, Bacillus diphtherise, Ba- cillus aerogenes capsulatus, and Bacillus typhosus. 3. Gonorrhoea! This is the most frequent variety. 4. Diphtheritic. 5. Exanthematous. What is the pathology ? Usually the endometrium of both body and cervix is involved, but the former more than the latter. The mucous membrane is swollen and softened ; extravasations of blood into it occur ; the epi- thelium is in places destroyed and desquamated. Sloughing of mucosa, suppurative inflammation of the uterine wall, and phlebitis of broad-ligament vessels may occur in the septic cases. The secre- tion is first serous, later purulent, perhaps bloody. In the gonor- rhoeal type the process is more superficial; there is an abundant purulent discharge, but no extensive cellutitis, phlebitis, sloughing, or loss of substance. What are the complications ? The most common are — Vaginitis; Urethritis; Salpingitis; Peritonitis; Metritis; Septicaemia. What are the physical signs ? The cervix is enlarged, soft, and slightly sensitive ; the endome- trium is very sensitive to the sound or probe, and these should be avoided. There is often an erosion about the os, which is usually filled with a ropy secretion. The cervix sometimes looks and feels ENDOMETRITIS. 163 like that of early pregnancy. The broad ligaments may be thick- ened and tender. What are the symptoms ? These vary with the nature of the infection. In gonorrhoea there is the abundant yellowish muco-purulent discharge with slight fever, slight pain and tenderness. In the septic cases there is the septic temperature characterized by great oscillations. The lochia is suppressed and is followed by a sanguino-purulent discharge. The pain in and about the uterus may be severe. In the sapremic cases there is temperature, and the lochia, if the case follows parturition, is replaced by a discharge with a putre- factive odor. What is the treatment ? Acute gonorrhceal inflammation is to be treated on the expectant plan, by rest in bed, light diet, free catharsis, and hot vaginal douches. Intra-uterine applications are not advised, as they increase the danger of extension to the tubes. When the condition has become chronic, curettage may be employed. In the sapremic cases remove the putrefying material with finger, forceps or dull curette with as little trauma to the uterus as possible. In septic cases be sure the uterus is empty. Do not use a sharp curette. Give occasional intra-uterine douches of salt solution if discharge accumulates and temperature is favorably influenced by them. Keep up the patient's strength with nourishing food. Alcoholic stimulation will usually be needed. Temperature is controlled by cold sponging. Unguentum Crede and collargol are said to favor- ably affect septic processes. If abscesses form drain them. Hysterectomy is rarely indicated. Chronic Endometritis. What are the varieties ? (a) Chronic cervical endometritis. (b) Chronic corporeal endometritis. 164 ESSENTIALS OF GYNECOLOGY. A. Chronic Cervical Endometritis. What are the synonyms ? Chronic cervical catarrh and endocervicitis. What is the etiology ? Chronic cervical endometritis is predisposed to by any low state of the system, from whatever cause produced. The most common exciting causes are — (a) Laceration of the cervix. (b) Extension upward of a vaginitis. (c) Extension downward of a corporeal endometritis. (d) Displacements of the uterus, especially flexions. (e) Stenosis of the cervix. (/) Traumatism, especially septic. (g) Excessive coitus. (h) Catching cold during menstruation. What is the pathology ? In mild cases the mucous membrane alone may be involved, but often more or less of the substance of the cervix is affected. In a well-marked case the epithelium, glands, and interstitial tissue are all involved in the change. The cylindrical epithelium of the canal proliferates and replaces the squamous epithelium on the vaginal portion of the cervix. This is especially true where the cervix is lacerated, and the cervical mucous membrane is everted. The glands of the cervix are hypertrophied and proliferated, and in addition to this, according to Huge and Yeit, the surface of the mucous membrane is thrown into numerous folds, producing gland- ular recesses and processes, which may later form cysts. The connective tissue of the cervix is also increased. The reddened areas about the os, where cylindrical epithelium has replaced the squamous, and the glandular structure has increased, are called erosions, sometimes wrongly spoken of as " ulcerations. ' ' What are the so-called cervical erosions ? The term has been applied to a number of distinct pathological conditions : 1. Small ulcers without epithelial covering ; these are rare. ENDOMETRITIS. 165 2. A congenital ectropion of the uterine mucosa. 3. Pseudo-erosions. They are covered by a single layer of cylin- drical epithelium and are due to two distinct processes : First, there may be an outgrowth of the mucosa of the cervical canal over the exposed portion of the cervix, gradually pressing back the squamous epithelium from the external os. These heal by a reversed process, i. e., a proliferation of the squamous epithelium, causing a receding of the cylindrical. Second, the irritation of secretions ma}' cause a maceration and desquamation of the superficial squamous cells of the cervix, leaving exposed the deeper cylindrical ones. Such erosions appear as red spots scattered over the cervix. They heal by a metaplasia of their epithelium. They are classified as simple, papillary, and cystic. What are the physical signs of chronic cervical endome- tritis? In nulliparae the cervix may feel normal, save a little swollen and sensitive ; sometimes the neighborhood of the os has a granular or velvety feel. In multiparae, especially where the cervix is lacerated, the gran- ular area about the os is larger, and small cysts in greater or less numbers can usually be felt. What are the symptoms ? The characteristic symptom is the leucorrhoea ; this may irritate the vulva, causing pruritus. Pain in the back and loins, especially on exertion, is usually present, but may be slight. Other symptoms are disturbances of menstruation, especially men- orrhagia, sterility and reflex neuroses. What is the treatment ? Attend to the general health and remove, as far as possible, the causes of the endometritis. In mild cases, especially in nulliparae, use hot-water vaginal douches containing an astringent, as sulphate of zinc 3j-Oj. If more severe, remove the ropy mucus from the canal with a large-mouthed syringe and apply iodized phenol. When the cervix is cystic or much congested, prick the cysts or 166 ESSENTIALS OF GYNAECOLOGY. scarify the cervix. The use of the actual cautery point has been recommended. If the above treatment fails, dilate the cervix and curette thor- oughly and drain the uterus with iodoform gauze. Schroeder's operation consists in dividing the cervix into an ante- rior and posterior lip, excising the mucous membrane by a Y-shaped incision (see Fig. 43), and turning in and uniting the lips as seen in Fig. 44. When the cervix is badly lacerated trachelorrhaphy is indicated. B. Chronic Corporeal Endometritis. What is the etiology ? It sometimes follows the acute, more often begins as chronic. Fig. 44. Schroeder's excision of the cervical mucous membrane in cervical catarrh. Fig. 43. Line of incision in mucous mem- Fig. 44. Mucous membrane "excised and brane. flap be turned in on ab (Schroeder). The most common causes are — 1 . Parturition, especially when the secundines are not thoroughly removed. 2. Displacements. 3. Traumatism, especially septic. 4. Tumors, especially fibroids and polypi. 5. Excessive coitus. 6. Extension of inflammation from the cervix. 7. Chronic metritis. ENDOMETRITIS. 167 What is its bacteriology? The majority of cases are not bacterial in origin. An examina- tion of the endometrium and secretion shows no bacteria except gonococci occasionally. What is the pathology ? The term chronic endometritis as here used is a clinical one and covers two distinct processes : 1. A chronic interstitial inflammation having the features of a chronic inflammation elsewhere, i.e., a proliferation of the connective- tissue stroma cells. Glandular changes are secondary. They may be dilated, compressed or diminished in number, due to the pressure of the new connective tissue. It may finally become an atrophic en- dometritis. Long-continued gonorrhceal infection is a frequent cause. . 2. Hyperplasia of the endometrium. This is what is commonly meant by the term chronic endometritis. This is not a true inflam- mation, nor due to bacteria, but the result of congestion and chemical irritation. The hyperplasia primarily affects the glands. They may be increased in length and tortuous, penetrating the mucosa in corkscrew fashion. They are frequently dilated and may form cysts. Many new ones may be formed. If all portions of the endometrium are equally involved, then it is uniformly thickened and smooth. Often this is not the case, and the unequal involvement of different portions of endometrium results in the formation of ' ' uterine fungosities ' ' and ' ' villous endo- metritis." In some cases stroma and glands are both affected. Chronic corporeal and chronic cervical endometritis are often associated. What are the symptoms of chronic corporeal endometritis ? (a) Leucorrhcea. (h) Menstrual disturbances, especially menorrhagia. (c) Dysmenorrhcea. (d) Pain in back and pelvic region. (e) Sterility. (/) Abortion. [g) Reflex neuroses. 168 ESSENTIALS OF GYNECOLOGY. What are the physical signs ? On bimanual examination the uterus is usually found a little enlarged ; perhaps a little tender. The sound, on introduction, shows the cavity enlarged, and. usually detects irregularities in its mucous membrane ; it frequently causes slight bleeding. What are common complications ? Metritis. Salpingitis. Peritonitis. Displacements. Vaginitis. What is the treatment? 1. Prophylactic. — Be careful that the uterus is thoroughly emp- tied after labor or abortion. Avoid exposure during menstruation. Observe strict cleanliness and antisepsis in the use of uterine in- struments. 2. Tonics, laxatives, change of air, and regulation of mode of life are often of value. 3. Remove the cause, such as displacements and tumors, and attend to any peri-uterine inflammation. 4. The fluid extracts of ergot and Hydrastis canadensis check the flow and act as a uterine tonic when given in doses of fifteen drops of each three times a day. 5. Proper drainage of the uterus will call for dilation of the cervix or correction of flexions. 6. Especially when associated with cervicitis, hot douches and cervical depletion with glycerine tampons and scarification of the cervix will give considerable relief. 7. Applications at intervals of iodized phenol was formerly much advocated, but have now been largely replaced by curettage. Ap- plications of formalin have recently been recommended. 8. When hyperplasia of the endometrium is detected, if no acute inflammation is present in the neighborhood, dilate the cervix and curette the uterus under antiseptic precautions ; wash out the uterus with a hot aseptic solution, making use of a double-current catheter. The curetting, if thorough, is best done under anaesthesia. It is well to confine the patient to bed for a week, and occasional ENDOMETRITIS. 169 applications of iodized phenol to the endometrium may be necessary. Packing the uterus with iodoform gauze for twenty- four hours after the curetting is often of value to check bleeding, maintain dilation or stimulate uterine contraction. 9. In the chronic interstitial or atrophic endometritis curettage is much less valuable, but the patency of the cervix must be main- tained by the use of sounds or glove-stretcher dilators. What are the indications for curettage of the uterus ? Hyperplastic endometritis. Polypi. Retained secundines. In malignant disease for the control of bleeding. For diagnosis, having the currettings submitted to microscopical examination. How and for what purpose are uterine curettings examined ? Clinical experience often enables one to make a fairly certain diagnosis from the macroscopic appearance of currettings, hyper- plastic or normal endometrium being distinguished from chorionic tissue or malignant growths with ease in the majority of cases. Under the microscope we are able, as a rule, to recognize the fol- lowing conditions of the mucosa : oedema, acute inflammatory changes, hypertrophy and hyperplasia of glands, increase of inter- stitial tissue, vascular engorgement, carcinoma or sarcoma. Preg- nancy present or recently terminated — either uterine- or tubal — may be diagnosed from the recognition of any of the following : Decidual cells, the glandular changes characteristic of the spongy layer of the decidua, foetal elements, such as villi, syncytium, or Langhans' cells. At times small islands of degenerated decidual cells are retained in the mucosa, and characterize the picture of "endometritis post abortum." Exfoliative endometritis exhibits changes in the mucosa strongly simulating the early changes of the compact layer of the decidua of pregnancy. A knowledge of the normal structures of the uterine mucosa must precede an ability to diagnose its diseases. This includes recognition of the varieties of epithelial covering, forms of cervical and corporeal glands, their relation to the muscularis, and the age changes and modifications due to pregnancy. 170 ESSENTIALS OF GYNECOLOGY. Metritis. Describe and give the varieties. Metritis is an inflammation of the parenchyma of the uterus, as distinguished from that of its mucous lining or serous covering. The two varieties are the acute and chronic. Acute Metritis. What is the etiology? Acute metritis rarely if ever exists as an independent condition ; it is almost always associated with an endometritis or peritonitis ; especially the former. The chief causes are — 1. Septic infection during or soon after labor, abortion, or opera- tion ; 2.. Gonorrhoea. Acute metritis occasionally arises from exposure to cold during men- struation or sexual excess, but these usually first produce endome- tritis, secondarily metritis. What is the pathology ? The uterus is enlarged, especially antero-posteriorly, infiltrated with serum, soft and tender. The endometrium is also thickened and congested. The peritoneal investment is often covered with lymph. " Microscopically the muscular bundles are infiltrated with pus corpuscles " (Hart and Barbour). Circumscribed abscesses oc- casionally, though rarely, occur in the uterine walls. These often prove fatal, but sometimes are absorbed, sometimes become encap- sulated and cheesy, and sometimes empty into the uterus, bladder, rectum, vagina, intestines, peritoneum, or through the abdominal walls. Acute metritis may resolve at the end of a week ; it may pass into the chronic form ; if a result of puerperal infection, it is often fatal. What are the symptoms? They usually resemble those of acute endometritis, but are more severe. The disease is often ushered in with a rigor ; temperature and pulse rise ; there is pain in the hypogastrium and in pelvis. The uterus is very tender on pressure ; there is nausea, usually vesi- cal and rectal tenesmus, and menstruation, as a rule, is disturbed, sometimes suppressed ; more often menorrhagia is present. METRITIS. 171 What is the treatment ? If due to sepsis, try to remove the cause ; giving, if necessary, intra-uterine irrigations of bichloride (1-5000). Keep the patient quiet in bed ; apply poultices or turpentine stupes to the hypogas- trium ; if temperature is very high, use the ice coil. Empty the bowels with saline cathartics ; if pain is very severe, allow opium by suppository. Later, employ long hot-water douches and glycerine tampons. When intramural abscesses form, hysterectomy may be necessary. Chronic Metritis. What are common synonyms? Areolar hyperplasia (Thomas). Chronic parenchymatous inflam- mation of the womb (Scanzoni). Diffuse interstitial metritis (Noeg- gerath). What is the etiology ? According to Hart and Barbour, the causes may be divided as follows : — (a) Causes which operate through interference with the normal involution of the puerperal uterus. (b) Causes which operate through the production of repeated or protracted congestion of the uterus. (J.) Frequent causes of subinvolution are — 1. Retained secundines. 2. Laceration of the cervix. 3. Pelvic inflammation following parturition. 4. Rising too soon after parturition. 5. Non-lactation. 6. Repeated miscarriages. (B) Causing repeated or protracted congestion are the following — 1. Chronic endometritis. 2. Displacement of the uterus. 3. Tumors near the uterus. 4. Chronic pulmonary, cardiac, hepatic or nephritic disease. 5. Excessive coitus. Chronic metritis sometimes follows the acute but usually begins as chronic. 172 ESSENTIALS OF GYNECOLOGY. What is the pathology ? The pathological changes may be divided into three stages— 1. Hypersemic; 2. Hyperplastic; 3. Sclerotic. In the first or hypereemic stage the uterus is enlarged, soft, tender, and contains more blood than normal. In the second or hyperplastic stage there is an increase of the intermuscular connective tissue, with or without a slight increase of the muscular tissue. The vascularity is decreased by the growth of connective tissue around and compressing the blood vessels. The third, or sclerotic stage is a result of the former, the uterus becoming more dense, less and less vascular and finally atrophied. What are the symptoms ? Most of the symptoms are either due to the increased size of the uterus or to the complicating endometritis. The symptoms usually date from parturition or abortion. The following are common — A feeling of weight in the pelvis. Pains radiating to the back, limbs and different parts of the body. Irritability of bladder and rectum. Leucorrhoea. Menstrual disturbances, especially menorrhagia, due to the endo- metritis. Abortion in the early stages. Sterility, later. Reflex neuroses. What are the physical signs ? The uterus in the early stages is uniformly enlarged, soft and tender ; later harder, and in the late stages irregularities of shape may be detected. The canal is enlarged in all its dimensions and the sound passes easily. The os is usually patulous ; the cervix may be large and nodular. What are common complications of chronic metritis ? (a) Chronic endometritis. (b) Salpingitis. (c) Peritonitis. (d) Ovaritis. (e) Vaginitis. (/) Displacements. ATROPHY OP THE UTERUS. 17o What is the treatment of chronic metritis ? 1. Prophylactic. — Care during and after confinement. 2. Curative. — First treat the complications, if present, especially endometritis and displacements, in the usual manner. Attend to the general health, bowels, exercise, etc. Let the patient rest a part of each day, especially at menstruation ; limit coitus. Weir Mitchell's treatment of rest, over-feeding and massage is sometimes of value. Local treatment. — Prolonged hot- water vaginal douches; glycer- ine or boroglyceride tampons ; tincture of iodine to cervix and fornices of the vagina ; scarification of the cervix with Buttle' s spear. Emmet's operation of trachelorrhaphy, or amputation of the cervix by the Simon and Marckwald method is sometimes indicated. Atrophy of the Uterus. What is the etiology ? It is the natural condition after the menopause, and is produced artificially by the removal of ovaries and tubes. It occasionally occurs as the result of a too forcible curettage. It is sometimes associated with phthisis and other exhausting diseases. It occurs as a superinvolution after childbirth, especially as a result of metritis, peritonitis, ovaritis or salpingitis, or from prolonged lactation. This superinvolution is the variety of most importance. What are the symptoms ? Amenorrhoea. Sterility. Reflex neuroses. What are the physical signs ? The uterus is small, both in body and cervix, and the canal is shortened. What is the treatment ? Attend to the general health. Before the menopause, galvanism of the uterus and ovaries may be tried. The treatment is generally unsatisfactory. 174 ESSENTIALS OF GYNECOLOGY. Fibroid Tumors of the Uterus. What are common synonyms ? Fibro-myomata and myomata. Strictly speaking, fibro-myomata is the more correct designation, as the tumors are composed of both Fig. 45. im. Interstitial fibroids. sm. Submucous. (Schroeder.) fibrous and muscular tissue. They are to be classed as benign growths. What is the etiology ? Little is known of the cause of fibroids. They are much more common in the African than in the white race ; are most frequently found between the ages 30-45, and are said to be more common in FIBROID TUMORS OF THE UTERUS. 175 married than in unmarried women. They rarely, if ever, begin before puberty, and never after the menopause. What is their structure ? Fibroids, or fibro-myomata of the uterus, are tumors composed of both fibrous and muscular tissue, either of which may predominate over the other. The fibrous tissue is usually in excess. Those composed chiefly of fibrous tissue are usually more or less encapsulated, of slow growth, and chiefly of the subperitoneal variety. Those composed chiefly of muscular tissue are rare, not encapsu- lated, and are of rapid growth. They derive their blood-supply from a network of vessels in their capsules, the central portions being without large vessels. What are their situations ? They are much more frequent in the body of the uterus than in the cervix. They are most often found on the posterior wall or fundus, next in frequency on the anterior wall, rarely on the lateral walls. The soft, rapidly growing fibroids are more frequent in the fundus. The tumors usually begin in the substance of the uterine walls ; they may continue their growth there ; may extend into the uterine cavity, lifting up the mucous membrane, or outward, lifting up the peritoneum. Hence the three varieties : — 1. Interstitial. 2. Submucous. 3. Subperitoneal. Describe the three varieties. The interstitial or intramural fibroids (see Fig. 45) are usually multiple and are situated in the substance of the uterine wall. The submucous fibroid (see Fig. 46) may be either sessile or attached by a long pedicle. In the latter case it is called a fibrous polypus. The subperitoneal or subserous fibroids (see Figs. 47 and 48) are often multiple ; may be sessile or pedunculated ; may grow upward into the abdominal cavity and draw uterus up, or grow downward into the pelvis, and perhaps become incarcerated. They may form adhesions with other organs, get their nutrition through the adhe- sions, and become detached from the uterus. These are the most fibrous, least vascular, and slowest-growing fibromyomata. 176 ESSENTIALS OF GYNAECOLOGY. What changes may occur in fibroids ? 1. They may undergo softening due to oedema or myxomatous degeneration, rarely fatty degeneration. By this softening fibro- cysts may be formed. 2. They may undergo hardening, due to (a) atrophy, especially after the menopause, or removal of ovaries and tubes. The mus- cular tissue degenerates, and the fibrous tissue contracts, (b) Calci- fication, with the deposit of lime salts, beginning usually in the centre, sometimes at the periphery. Fig. 46. Fig. 47. Submucous fibroid. (Schroeder.) Subperitoneal Fibroid. 3. They may suppurate. This occurs most often in submucous fibroids, especially after instrumental traumatism ; rarely in the subperitoneal variety after torsion of the pedicle. 4. Submucous fibroids may become more and more pedunculated, forming polypi. They are sometimes extruded from the uterus. Sometimes the capsule ruptures, and spontaneous enucleation occurs. 5. Cysts are formed by the softening of tissue and by the dilation of lymph-spaces. FIBROID TUMORS OF THE UTERUS. 177 6. Fibromyomatous uteri are occasionally the seat of carcinoma of their mucosa. 7. The fibroid nodules occasionally undergo a sarcomatous trans- formation. 8. The subperitoneal ones alone or with the uterus may undergo axial rotation. Minor degrees of this are quite common. When the rotation occurs suddenly, and through a considerable arc, there may be pain, shock, and increase of size of the tumor, due to inter- stitial hemorrhages. Fig. 48. Subperitoneal Fibroid. What changes occur in the uterus ? The muscular wall hypertrophies especially in the submucous or interstitial varieties. The mucous membrane also hypertrophies, both in glands and connective tissue. Over the tumor the mucous membrane is thin and sometimes ulcerates. The uterine hemor- rhages come chiefly from the hyperplastic areas. Changes in the position of the uterus are often produced : — 1. It may be drawn up into the abdomen. 2. It may be prolapsed. 3. It may be inverted, especially from submucous fibroids attached to the fundus. Describe briefly fibroids of the cervix. They, too, may be either interstitial, submucous or subperitoneal ; they are usually hard and single. 12 178 ESSENTIALS OF GYNAECOLOGY. The subperitoneal often grow out between the folds of the broad ligament. The submucous and interstitial are apt to become pedunculated and form polypi. The interstitial fibroid of the cervix is sometimes mistaken for inversion of the uterus. What are the symptoms of fibroid tumors of the uterus ? 1. Hemorrhage. — First, menorrhagia, later metrorrhagia ; delayed menopause ; these occur especially in the submucous variety. 2. Pain. — (a) Dysrnenorrhcea, chiefly in the submucous variety. (b) Pain due to pressure on the pelvic nerves or to peritonitis around the tumor. 3. Symptoms due to pressure : — On bladder, causing : — Irritability. Retention. Cystitis. On urethra, causing : — Difficulty in micturition. Perhaps retention. On ureter, causing : — Hydronephrosis, pyonephrosis, or pos- sibly chronic nephritis. On rectum, causing : — Constipation. Diarrhoea. Sometimes tenesmus. .Rarely complete obstruction. On pelvic nerves, causing : —Neuralgia. Numbness. On veins, causing : — Varicosities of the legs. Haemorrhoids. 4. Sterility. 5. Abortion. What are the physical signs ? Except in the case of some subperitoneal fibroids, the uterus is enlarged. If within reach, a tumor is felt, harder than the muscular sub- stance of the uterus, and movable with the uterus unless it is attached with a very long pedicle. If it is a small fibroid in the cervix it may bulge into the vagina and resemble inversion of the uterus. If it is a submucous fibroid, high up in the uterus, the sound may FIBROID TUMORS OF THE UTERUS. 179 detect it, but often it is necessary to dilate the cervix and introduce the finger. If it is subperitoneal and on the anterior wall, a hard mass is felt in the anterior fornix moving with the uterus ; the fundus may be felt behind it, and the sound on introduction does not pass into it. If on the posterior wall, a hard mass is felt in the posterior fornix ; the bimanual shows fundus in front of it, and the sound passes in front of it. If it is a large fibroid extending into the abdomen, it is flat on per- cussion unless intestine overlies it ; auscultation may detect the ute- rine souffle, especially at the sides, and the mass seems to belong to the uterus. What is their bearing upon pregnancy ? They may cause sterility or abortion. They are apt to take on rapid growth as pregnancy progresses. The amount of hindrance to labor depends more on their position than size. A fibroid may interfere with uterine contraction and thus be a cause of postpartum hemorrhage. On the other hand, they may largely involute with the uterus. From what must you differentiate a fibroid tumor of the uterus? Chronic metritis. Flexions of the uterus. Pregnancy. Ovarian cyst. Ectopic gestation. Pelvic haematocele. Inflammatory deposits. Inversion of the uterus. How would you differentiate a small fibroid tumor from chronic metritis 1 Small Fibroid vs. Chronic Metritis. Enlargement not uniform, usually Enlargement uniform. hard irregularities. Less sensitive. More sensitive. Os usually unaffected. Os usually everted. Both conditions may co-exist. 180 ESSENTIALS OF GYNAECOLOGY. The differential diagnoses between fibroids and flexions of the uterus have already been given (see page 124, Fig. 23). How would you differentiate a fibroid tumor from preg- nancy ? Fibroid Tumor vs. Pregnancy. Menstruation continues ; usually Amenorrhoea is the rule. increased. Cervix not softened. Cervix softened. Later. Absence of positive signs of preg- Positive signs present, nancy. How would you differentiate a fibroid tumor from an ovarian cyst? Fibroid Tumor vs. Ovarian Cyst. Hard and firm. Soft and elastic. More intimately connected with LesTTntimately connected with uterus. uterus. More central. More lateral. Menorrhagia common. Menstruation normal or irregu- lar ; Tnenorrhagia rare. How would you differentiate a fibroid tumor from an ectopic gestation ? Fibroid Tumor vs. Ectopic Gestation. No menstrual period skipped. Menstrual period or periods usually skipped. Grows less rapidly. *_ Grows more rapidly. More central. More lateral. More intimately connected with Less intimately connected with uterus. uterus. No decidual membrane cast off. Decidual membrane cast off. Absence of attacks of very severe Such attacks occur. sharp pain, with symptoms of collapse. FIBROID TUMORS OF THE UTERUS. 1*1 How would you differentiate a fibroid tumor from a pelvic hematocele ? Fibroid Tumor vs. Pelvic Hematocele. Gradual development. Rapid development. Absence of acute symptoms. Symptoms of sudden sharp pain, shock and hemorrhage. Insensitive to pressure . Sensitive to pressure. Hard and firm. First soft, later harder. Moves with uterus. Does not move with uterus. How would you differentiate a fibroid tumor from a pelvic inflammatory deposit ? Fibroid Tumor vs. Inflammatory Deposit. Slow growth ; no history of acute History of rapid development, inflammation. and acute inflammation. Moves with uterus, and seems a Usually does not move with part of it. uterus, and seems less a part of it. Insensitive to pressure. Sensitive to pressure. What is the prognosis of fibroid tumors ? It will depend on nearness to the menopause, rapidity of growth, pressure symptoms, and endometritis ; the size of the tumor is of comparatively small importance, as a large one may produce few symptoms. On the other hand, a small one, no bigger than a pea, can occasion d3 T smenorrhoea or hemorrhages. Death results from anaemia, sepsis, urinary disease complicating pregnancy, or intestinal obstruction. What is the treatment ? A fibroid if small may give rise to no symptoms and need no treatment. Treatment, if needed, may be (1) palliative or (2) curative. Palliative Treatment. — (a) Drugs. — The administration of ergot alone or in combination with hydrastis may control the symptoms until the menopause is reached, when the tumor usually diminishes in size ; the menopause, however, is often considerably delayed. (b) Curettage. — If the symptoms are chiefly menorrhagia or 182 ESSENTIALS OF GYNAECOLOGY. metrorrhagia, a thorough curettage of the uterus, followed at inter- vals by astringent applications to the endometrium, will often give marked relief. A curettage, however, is frequently, if not usually, impossible. In some cases it will start a sloughing of the growth. (c) Diminution of Blood- supply. — Ligation of the uterine arteries from the vagina has been employed, but has now given place to more reliable methods. Tait's operation of removal of the ovaries and tubes has in many cases been not only palliative but curative, but its present interest is only historical. Curative Treatment. — This consists of either myomectomy or hys- terectomy. Describe the operation of myomectomy. Myomectomy consists in exposing the tumor in the uterus, either from the abdomen or vagina, incising the capsule, enucleating the tumor, and closing its bed with catgut sutures. This operation is indicated where the tumor can be easily removed without serious mutilation of the uterus. The operation is gaining in favor and may be employed even when the tumors are multiple. Hysterectomy is easier and less shock often than the removal of many tumors by myomectomy ; hence, if patient is near the meno- pause, if children are not desired and a sound ovary can be left, hysterectomy is to be preferred in the presence of many tumors. What are the varieties of hysterectomy ? Hysterectomy, removal of the uterus, may be performed : (a) Through the vagina — vaginal hysterectomy, indicated when the uterus and tumor are small. (b) Through the abdomen — abdominal hysterectomy, indicated when the uterus and tumor are large. Describe the operation of vaginal hysterectomy for fibro- myoma uteri. This differs from the operation described under carcinoma uteri only in the fact that in cases where fibro-myomata are large enough to cause symptoms the uterus with its tumors is often too large to come through the vagina without removing it piecemeal, i. e. by morcellation. After thorough disinfection of vulva and vagina, the uterus is curetted and irrigated with a sterile solution ; the cervix FIBROID TUMORS OF THE UTERUS. 183 is drawn down and separated from its vaginal attachments ; the peritoneum is opened anteriorly and posteriorly and the uterine arteries are tied on both sides. If the uterus is too large to be removed as a whole, wedge- or disc-shaped pieces are removed from its centre or the uterus is divided in the median line and each half removed separately, care being taken to keep up traction on the uterus by volsellse placed above the part to be removed. The broad ligaments are either ligated in section, or if more convenient during the operation, they may be clamped, and after the uterus is removed these clamps may or may not be replaced by ligatures according to the judgment of the operator. After the removal of the uterus, the pedicles are inverted into the vagina and sterile or iodoform gauze placed against them. Describe the operation of abdominal hysterectomy for fibro- myoma uteri. The preceding operation, owing to the amount of technical skill required and the difficulty in safely handling intestinal adhesions, has largely fallen into disrepute and given place to one of the two following forms of abdominal hysterectomy : a. In one the cervix is removed — total extirpation. With this are associated the names Eastman, Martin, Chorbak, Polk. b. In the other the cervix is left in the abdominal cavity — supravaginal hysterectomy. This is called Baer's method. In both of these methods, after opening the abdomen, the broad ligaments are tied in section and cut close to the uterus. In the total extirpation this ligation and cutting is continued down to the vagina : this is freed from the cervix and the whole uterus removed. In the supravaginal hysterectomy (Baer) the ligation and cut- ting of the broad ligaments is continued until the cervix is reached and the uterine arteries are tied and cut ; the uterus is then ampu- tated at the cervix, and the latter is left, the vagina not being opened. In each of these methods flaps of peritoneum are taken from the anterior and posterior surfaces of the uterus before its removal, and before closing the abdomen these flaps are brought together over the pedicles in the bottom of the pelvis. 184 ESSENTIALS OF GYNAECOLOGY. Discuss the choice of operation. Myomectomy has been performed so long that we may speak with some certainty regarding its result. It has been followed by preg- nancy, and the scars left by removal of fibroids have not seemed to interfere with the enlargement of the organ or its postpartum con- traction. It is not contraindicated, even if the uterine cavity is invaded, provided the removal of the growth does not sacrifice a complete segment of the mucosa — a continuous strip must be left from fundus to cervix. Recently Russell and, following him, others have, when curettage has failed to check menorrhagia and no fibroid could be felt, opened the abdomen, split the fundus, thus exposing the uterine cavity, and removed pea-sized fibroids from the uterine cornua, and closed the cut in the uterine wall. Submucous growths of large size have been removed much after the manner of a Csesaran section. Hysterectomy is easier and produces less shock than the removal of many tumors by myomectomy, and has hitherto given a slightly lower mortality ; hence, if the patient is near the menopause, and if children are not desired, hysterectomy is to be preferred in the presence of many tumors. Vaginal hysterectomy is the operation of choice when the vagina is roomy and there are numerous small fibroids. When the fibroid mass is large it may still be removed in pieces (morcellation) b\ r vagina, though this course is not recommended. If the operation has been clone without immediate accident, the convalescence is usually shorter than in abdominal hysterectomy. Abdominal hysterectomy is the operation of choice in the difficult cases and in most patients past forty. If the cervix is not invaded by the growth nor otherwise diseased, we prefer to leave it, as the operation is surgically cleaner and easier, and the architecture of the vagina is not altered. In some cases one may even go a step further, when the fibroids are well up toward the fundus, and make the amputation somewhat higher than the internal os, thus allowing the continuance of menstruation, though pregnancy is impossible. Should oophorectomy accompany hysterectomy for fibroids ? It is wiser to leave the ovaries unless they are diseased. If there is any normal ovarian tissue it is better to leave one, or apart of one ovary, than to remove both, and thereby bring on the menopause. INVERSION OF THE UTERUS. 185 The nervous symptoms of the artificial menopause are likely to be more exaggerated the earlier in life it occurs. Inversion of the Uterus. What is the pathology? In inversion, the uterus is turned more or less completely inside out (see Fig. 49). It may be either — 1. Partial— where the depressed uterine wall does not extend beyond the os externum ; or Fig. 49. Inversion of Uterus (half-size, Barnes from Crosse's essay). The fundus lies in the vagina- the cervix is not inverted; the lips are flattened out to a swelling seen below the angle of inversion. The ovaries (seen from behind) are not in the peritoneal cup. 2 Complete -where the inverted body, covered with mucous- membrane, lies outside of the os externum, either in the vagina or between the labia. The mechanism of production of the inversion is as lol- A portion of the uterine wall loses its tone, is depressed into the uterine cavity, usually by traction from below or abdominal pressure from above; the depressed portion is then grasped by the unde- pressed portion and forced toward or through the cervix. 186 ESSENTIALS OF GYNECOLOGY. The peritoneum follows the depression of the uterine wall, and lines the cup thus formed. The appendages may or may not lie within the cup. The inversion occurring during the puerperium usually begins at the placental site ; when produced by intra-uterine tumors, it usually begins at the attachment of the tumor. The uterine mucous mem- brane is usually congested ; it may ulcerate ; sometimes it becomes gangrenous. Occasionally it becomes covered with squamous epi- thelium, and resembles skin. What is the etiology ? Inversion is predisposed to by — (a.) Parturition. (b. ) Distention of the uterus from any cause. ( c. ) Intra-uterine tumors. (d. ) Degeneration of uterine walls. According to the time and cause of production, two varieties are recognized : — 1. Puerperal. — Produced during the puerperium, either by ab- dominal pressure or mismanagement in the delivery of the placenta, especially the latter, traction on the cord being one of the most fre- quent causes. 2. Non-puerperal. — Secondary to intra-uterine tumors ; especially pedunculated fibroids growing from the fundus. The puerperal variety is much more common than the non-puer- peral. The former is usually rapid in development ; the latter gradual. When the inversion is developed and reduced during the puer- perium, it is called acute ; otherwise, chronic inversion. What are the symptoms ? At the time of the occurrence of acute inversion, there is pain, hemorrhage, shock, a feeling as of something giving way, and of full- ness in the vagina. This belongs especially to obstetrics. The symptoms of the chronic inversion are hemorrhage, dragging pain in the pelvis, discomfort from the foreign body in the vagina, leucorrhoea, anaemia and general malaise. Rarely inversion exists with very few symptoms. INVERSION OF THE UTERUS. 187 What are the physical signs ? These depend on whether the inversion is partial or complete, acute or chronic. In the partial variety the cupping may be felt by the hand on the abdomen, and the inverted portion detected by the use of the sound in the uterus. In the acute, complete inversion, one feels a soft, bulging tumor in the vagina or between the labia ; it bleeds easily, is sensitive and smaller above where it is encircled by Fig. 51. Fig. 50. Inversion of Uterus (after Thomas). A cup-shaped depression is in the place of the uterus. Sound ar- rested at angle of flexion. Uterine Polypus (after Thomas). The uterus in its normal position. Sound passes into uterine cavity. the cervix ; it may or may not have the placenta attached to it. The sound passes around the tumor, but only a short distance into the cervix. The hand on the abdomen detects the absence of the fundus and the presence of the cervical ring. The physical signs of the chronic inversion are similar, save that the mass in the vagina is smaller, harder, and in the non-puerperal variety perhaps has attached to it the tumor which was its cause. From what must you differentiate inversion of the uterus ? From polypi and prolapsus uteri. 188 ESSENTIALS OF GYNECOLOGY. How would you differentiate inversion of the uterus from a polypus ? The diagnosis of a complete inversion (see Fig. 50) from a polypus lying in the vagina (see Fig. 51) would be made as follows : — Inversion Fundus not felt in the abdomen ; cervical ring felt. Sound passes all around tumor, but only a short distance into the cervix. vs. Polypus. Fundus felt in the abdomen. Sound passes into the uterus, at the side of the tumor, more than 2J inches. The differential diagnosis between a partial inversion and an intra- uterine polypus (see Figs. 52 and 53) is often quite difficult. Careful examination by the ordinary bimanual and by the abdomino-rectal method may detect the cup-shaped depression of the partial inver- Fig. 53. Fig. 52. Partial Inversion of Uterus (after Thomas). Polypus still Intra-uterine (after Thomas). sion. Enlargement of the uterus rather favors the diagnosis of polypus. Both of these conditions may rarely coexist. How would you differentiate inversion of the uterus from complete prolapse ? This rarely causes difficulty. It is made by finding in the latter INVERSION OF THE UTERI'S. 189 the external os, the obliteration of the fornices, and by passing the sound into the uterine canal. What are the results of an untreated inversion? Very rarely it reduces itself. Rarely the patient suffers little inconvenience from it. Usually the patient dies from hemorrhage or sepsis. What is the treatment ? The object sought is the reposition of the fundus uteri. Emmet's method (see Fig. 54) consists in inserting the right hand into the vagina, grasping the fundus in the palm, inserting the fingers into the cervix and pushing upward ; at the same time sepa- rating the fingers as much as possible. The left hand meanwhile exercises through the abdomen counter-pressure on the cervical ring. Noeggerath begins the reposition by dimpling in one horn of the uterus, and then uses this as a wedge to dilate the cervix. Fig. 54. Reposition of the Inverted Uterus with the Hand alone (after Emmet). Instead of the hand alone, cup-shaped repositors are often made use of. In all these methods the patient is usually best prepared for the manipulation by the administration of prolonged hot-water douches, 190 ESSENTIALS OF GYNAECOLOGY. and the introduction of a vaginal elastic bag, to be distended with air or water, and worn twelve to twenty-four hours. The manipulations are best performed under anaesthesia. When the above methods fail, hysterectomy probably offers the best result. Fig. 55. Polypi. What is meant by the term " uterine polypus," and what are the varieties? A polypus is a pedunculated tumor attached to the uterine mucous membrane. The following varieties are recognized : — 1. Fibrous polypi. 2. Mucous polypi. 3. Pedunculated Na- bothian follicles. 4. Placental polypi. 5. Papillomata of the cervix. Describe briefly the fibrous polypi. Fibrous polypi are sub- mucous fibroids which have become peduncu- lated ; at first lying within the uterus ; later, dilating the cervix and becoming vaginal (see Fig. 55), some- times even projecting be- yond the vulva. They spring from the muscular wail of the ute- rus, more often from the body than cervix ; they are composed chiefly of fibrous tissue with few blood vessels. Their pres- ence sets up uterine contractions, which gradually expel them. Their shape is usually pyriform or ovoid. Intra-uterine Submucous Fibroid which is becoming Vaginal {Sir J. Y. Simpson). POLYPI. J'J] Describe the mucous polypi. These spring from the uterine mucous membrane, chiefly that of the cervix. There are usually more than one (see Fig. 56) ; they are small, soft, vascular, and on section present the structure of mucous membrane. What are the pedunculated Nabothian follicles ? They are the glands of the cervical mucous membrane which have become obstructed, formed retention cysts and assumed the polypoid shape. What are placental polypi ? They are portions of undetached placenta which have received nutri- Fig. 56. Group of Mucous Polypi growing in the Cervix Uteri (Sir J. Y. Simpson). ment from their attachment to the uterus, have become coated with fibrin and so increased in size. By the uterine contractions they are made more pedunculated, and may be extruded from the cervix. Describe the papillomatous variety of polypus. Papilloma of the cervix is almost always either a malignant new 192 ESSENTIALS OF GYNECOLOGY. growth or tends soon to become so. It is often called a "cauli- flower excrescence" (Clarke) (see Fig. 57), is usually soft, friable, and bleeds easily. What are the symptoms of polypi ? 1. Hemorrhage. — First menorrhagia, then metrorrhagia, the source of the blood being the mucous membrane, which covers, or in the mucous variety forms, the substance of the polypus. 2. Leucorrhoea. — Due to the accompanying endometritis. 3. Pain. — Due to the efforts of the uterus to expel the tumor. 4. Sterility. — Due to the mechanical obstruction and to the endo- metritis. Fig. 57. 5. Anaemia and general malaise. — Resulting from the foregoing condi- tions. What are the physical signs ? When the polypus has passed the os externum, the finger in the vagina de- tects a pyriform or ovoid body, hard or soft according to the variety; it is movable and seems to come from the os. The use of the speculum deter- mines its appearance. If it is a fibrous polypus, the bi- manual examination usually shows the uterus enlarged, and the sound proves the cavity elongated. When the polypus is intra-uterine, the sound in some cases will detect its presence ; in other cases dilatation of the cervix and introduction of the fin- ger is necessary. What is the treatment ? When the polypus is of considerable size and lies within or external to the os, the best treatment is removal by the wire ecraseur, putting the wire loop as near the uterine attachment of the pedicle as possible. Small polypoid projections may be scraped away with the curette ; cervical polypi may usually be twisted off with the forceps. Cauliflower Excrescence growing from the Cervix Uteri (Sir J. Y. Simpson). CARCINOMA UTERI. 193 When the polypus lies within the uterus, dilate the cervix and apply the ecraseur. If the pedicle is small, blunt, dull scissors may be substituted for the ecraseur. If the pedicle is large or dilatation of the cervix is necessary, anaesthesia is to be employed. All antiseptic precautions are to be used. Carcinoma Uteri. What is the pathology ? Carcinoma may begin in the cervix or body, being five times more frequent in the former. That of the cervix is of several forms. It may begin in the squamous cells of the vaginal surface ; this is the epithelioma or cauliflower excrescence of the cervix. Microscopically it consists of plugs of epithelial cells extending deeply into the cervical tissue. Epithelial pearls, common in epithelioma of the skin, are rarely seen here. This variety spreads early to involve the vaginal wall. Carcinoma of the cervical canal originates from the epithelium lining the canal or from that of the glands. These growths break down, forming necrotic ulcers with indurated edges. The vagina and body may become involved by direct extension and, through the agency of the lymphatics, the musculature and broad ligaments are involved. Involvement of lymph-nodes is a late occurrence. Carcinoma of the uterine body arises from the lining epithelium of the cavity or from its tubular glands, and presents the appearances common to adeno-carcinomata. The occurrence of primary squa- mous-celled carcinoma of the body of the uterus is admitted by Amann and others. Carcinoma of the body is diffuse, circumscribed, or polypoid. What is the etiology ? The etiology of cancer of the uterus is still unsettled. The factors which favor its development are age, heredity, parturition, laceration of the cervix, with erosion and depreciation of the vital powers. 1. Age. — It occurs at any age from 20-80, but is most common at middle life. It is because of its frequency at this time that women have come to think of the menopause as an especially dan- gerous period of life. 13 194 ESSENTIALS OF GYNAECOLOGY. 2. Heredity. — Although regarded as of less importance than for- merly, its influence seems to be exemplified in some cases. 3. Parturition. — Frequent child-bearing apparently creates a marked predisposition to carcinoma of the cervix. When a mucip- arous woman gets carcinoma it is usually of the body of the uterus. 4. Laceration of the Cervix. — Cancer of the cervix seems often to arise from a laceration, with erosion and cervical endometritis. Fig. 58. 70-79 yrs... 4 2 cases 60-69 YP5.. /|lk36CAS£5 117 CASE5 *W9WI5. ZMCAJEJ 158 CASES 20-29 YRS VP TO ZQYRJ.NO CASES.* Analysis of 631 cases, indicating the ages at which carcinoma most frequently occurs (adapted by Clark from Kroemer's statistics). 5. Depreciation of the Vital Powers. — Poor surroundings, poor food and air, and hardships of any kind seem to predispose to cancer. What are the symptoms ? 1. Hemorrhage. — This is usually the first symptom. If hemor- rhage occurs after the menopause, always suspect cancer. Even at its beginning it is a metrotaxis having no relation to menstruation. The first hemorrhage may follow trauma, such as coitus or sudden exertion, and appears earlier in the cauliflower variety. 2. Offensive Discharge. — Does not occur until ulceration begins. CARCINOMA UTERI. 195 The odor is due to putrefaction of the broken-down tissues. The discharge is totally unlike ordinary leucorrhoea. It is serous in character — i e. . an exudate — and is often described as ' ' watery ' ' or " dish-watery," because its fluid is mingled with broken-down par- ticles of tumor. 3. Pain. — When the cervix is alone involved, pain is usually absent. When the disease has extended to the cellular tissue or peritoneum, or involves the body of the uterus, pain is common. 4. Cachexia. — This is always present to a greater or less extent in the later stages. 5. Septic infection is not infrequent and gives rise to pyometra, salpingitis, or pyosalpinx. What other conditions may cause bleeding after the meno- pause ? Though carcinoma is the usual cause, it may be due to senile vaginitis or sarcoma, more rarely to a mucous polypus or sloughing fibroid. What are the physical signs? If the disease affects the vaginal portion of the cervix, the examin- ing finger detects a roughs ul cerate d, and indurated area, or perhaps a fungoid mass. On withdrawal, the finger is usually stained with blood and emits a foul odor. The speculum gives us the appearance of the growth. When the cervical canal is the point of origin one may feel a nodular cervix larger than normal and of almost stony hardness, or, more commonly, the examining finger enters a crater-like cavity in the cervix, with indurated walls that readily break clown and bleed during examination. The nodular type of growth is characterized by induration, the excavated type by ulceration. Carcinoma of the body of the uterus enlarges it and may be de- tected by the sound. In some cases the growth early infiltrates the muscular wall of the uterus, in others remains for a considerable time as a polypoid growth, and hence offers a better prognosis. When the disease has extended beyond the limits of the uterus, the broad ligaments and base of the bladder will give the impression of stony hardness to the examining finger, and the normal mobility of the uterus is much restricted. At times the lymph -nodes are enlarged and the broad ligaments 196 ESSENTIALS OF GYNECOLOGY. thickened by complicating inflammation, and this gives us the im- pression that the growth is more extensive than is really the case. What is the prognosis? It is better in cancer of the corpus uteri than of the cervix, but is bad in both. Many have passed the operable stage when first applying for treatment. The percentage of operability has been variously stated, some put it as low as 11, some as high as 50 per cent, of the cases diagnosed as carcinoma. It can be improved by earlier diagnosis made by microscopical examination of curettings in all suspected cases. So much depends on early diagnosis that in Germany the education of the lay public has been attempted in re- gard to the early symptoms of cancer and the necessity of an exam- ination when suspicious symptoms are present. Are iliac nodes involved early in cancer of the cervix ? On this subject opinions are at variance. Some nodes that are enlarged, on section prove to be only hyperplastic. Almost all writers think the metastasis in lymph-nodes is later in cancer of the uterus than of the breast. What is the treatment of carcinoma of the uterus ? 1. Radical. — When the disease is limited to the uterus, either cervix or body, hysterectomy is indicated. Aside from the appearance of the dis- eased area viewed through a speculum, the mobility of the uterus largely determines whether or not the disease has extended beyond it. If the uterus is fixed in the pelvis, hysterectomy is usually contraindicated. The combined abdominal and vaginal method offers some advan- tages. Werder ligates both broad ligaments through the abdomen, and continues his dissection downward till the upper part of the vagina is separated from its attachments. The patient is then, put into the lithotomy position, a circular incision is made through the vaginal wall some distance below the cervix, and the mass, consisting of uterus, appendages, and part of the vagina, is removed through the vagina. Some operators advocate a very extensive operation through the abdomen, removing the broad ligaments clear out to the pelvic wall, Hgating the uterine artery at its origin ; removing the iliac nodes CARCINOMA UTERI. 197 and dissecting out the ureter, and removing a portion of it if it is involved in the cancerous mass. Such a procedure is still subjudice, since the operative mortality from shock and ureteral sloughing and infection is much increased while the question of permanent recovery is yet undecided. 2. Palliative. — When a radical operation is contraindicated, the following methods of treatment are of value : — If hemorrhage is a marked symptom, and sloughing masses are present at the seat of ulceration, thoroughly curette the surface and apply carbolic acid, iodized phenol, a solution of chloride of zinc, or the actual cautery. Frequent insertions of iodoform gauze soaked in a 4 per cent, solution of chloral will be found to act as an anti- septic and anaesthetic to the ulcerated surface. For the foul discharges, vaginal douches of a weak solution of creo- lin, peroxide of hydrogen, or permanganate of potash are of value. Pure acetone, applied directly to the sloughing area through a tubu- lar speculum, is highly recommended for controlling the putrefaction. The pain and distress in the later stages demand opium. Attention to the general health is of course indicated. Describe briefly the operation of vaginal hysterectomy. Different operators differ somewhat in the details of the operation. The main features of the operation are as follows: The vulva is shaved, and the vagina and vulva thoroughly disinfected. The uterus is drawn down and held by an assistant; a semicircular incision is made around the cervix in the anterior fornix, and the cervix is separated from the bladder up to the utero-vesical pouch of the peritoneum. The cervix is drawn forward and the posterior fornix opened by a semicircular incision about the cervix, which is then freed up to the pouch of Douglas. The pouch of Douglas may now be opened, and a clean sponge with a long piece of silk attached, introduced to keep back the intestines. The uterus is freed from the lower portion of the broad ligaments by ligaturing in section, and then cutting with scissors close to the uterus. The latter may now be retroverted through the opening in the pouch of Douglas, and freed from the upper portion of the broad ligaments by ligaturing, and cutting close to the uterus. It is well to draw the ovaries into the ligature, so that they will be removed with the 198 ESSENTIALS OP GYNECOLOGY. uterus. The anterior reflection of peritoneum may now be divided, or, as practiced by many operators, this may be done before retro- verting the uterus. All hemorrhage is checked and the parts are cleaned ; the peritoneum is stitched to the vaginal wall ; and a single suture unites the anterior and posterior vaginal walls in the median line. Two small strips of iodoform gauze are placed in contact with the stumps of the broad ligaments and their ends brought out through the vagina. Some use clamps throughout the operation instead of ligatures. What are the relative merits of abdominal and vaginal hys- terectomy in carcinoma ? The vaginal operation is usually the easier, and can at times be done in a short time with scarcely any shock or blood loss. When one recalls the age of the patients, the anaemia and poor physique of many of them at the time of operation, the importance of these considerations is apparent. With the narrow, contracted vagina of the nulliparous the operation may be very difficult. Vaginal hys- terectomy, however, can remove little beside the uterus and the adjacent portion of the vaginal wall. Since this is a much less radi- cal operation than that performed upon the breast, and, since early local recurrence is the rule, attention was turned to the abdominal route as offering the only chance of a more thorough operation. Reiss, Wertheim, and Clark have advocated the abdominal removal of uterus, broad ligaments, upper vagina, and glands. This opera- tion is much more difficult than hysterectomy for fibroid or pyosal- pinx. It is a two-hour operation in most hands, and without con- siderable experience will have a much higher primary mortality than the vaginal operation. Clark has receded from his former position in that he no longer recommends routine removal of glands. Wer- der, whose former operation was extensive, has now gone to the opposite extreme of using the galvano-cautery methods of Byrne. He claims that the permanent results are equally good, and there is no primary mortality. It may be too soon to speak definitely on the choice of operation, but we think the ease of operation in an indi- vidual case will have a bearing. We shall have to take into consid- eration such matters as the thickness of the abdominall wall, the roominess of the vagina, the extent and direction of growth, and the operator's facility with the two operative routes. SARCOMA OF THE UTERUS. 199 Sarcoma of the Uterus. What is the pathology ? Sarcoma of the uterus is a growth usually originating in the con- nective tissue of the mucosa and early appearing as a diffuse infiltra- tion of it, and later extending to the uterine muscle. It may, how- ever, begin as a nodule in the muscular wall. It usually affects the body of the uterus, being rare in the cervix. The masses are usually grayish in color, soft and brain-like ; occasionally the circumscribed masses are firm and resemble fibroids, but have no capsule. They usually do not ulcerate as rapidly or deeply as carcinoma, but form larger tumors, and metastases are less common. What is the etiology ? Little is known concerning it. It is most frequent between the ages forty to fifty, but, unlike carcinoma, often occurs in nulliparous women. What are the symptoms ? 1. Hemorrhage. 2. Watery discharge. 3. Pain. 4. Cachexia. Thus the symptoms are similar to those of carcinoma. Some authors claim, however, that the discharge is less offensive than in carcinoma, because there is less tissue necrosis. It is much less common than carcinoma uteri. What are the physical signs ? The uterus is usually enlarged; the sound, when introduced, detects great irregularity of the endometrium, and usually causes bleeding. If the curette is used, a grayish, brain-like material is removed. With what are sarcoma and carcinoma of the body of the uterus most likely to be confused, and how is the diagnosis made ? They are chiefly to be confused with villous endometritis, sloughing polypi or retained secundines. The diagnosis is made by removing fragments with the curette, knife or scissors, and subjecting them to 200 ESSENTIALS OF GYNAECOLOGY. microscopical examination. Marked anaemia and emaciation would lead one to suspect malignant disease, yet severe endometritis or a vascular polypus may cause similar symptoms. What is the treatment ? Hysterectomy gives us the only prospect of cure. The palliative treatment consists in curetting and applying caustics to the interior of the uterus, keeping the vagina clean with anti- septic douches, as weak creolin, and relieving pain with opium. Chorio-Epithelioma. What are its synonyms ? Syncytioma, decidual celled sarcoma, syncytial carcinoma, and deciduoma malignum. These terms have been applied to a fairly well-defined group of cases of malignant uterine disease, whose pathological appearances have varied somewhat in different cases. Give its pathology. The tumors consist of masses of cells often surrounding spaces filled with blood and fibrin. The cells are round, spindle, or polyg- onal, depending on how close they are packed together. Further- more they contain irregular masses or streaks of protoplasm with nuclei scattered through them, but with no division of the proto- plasm into cells. When first described by Sanger the tumor was called a deciduoma, since he thought its cells closely simulated the maternal decidual cells. It is now pretty thorough^ established that these tumors are of foetal trophoblastic origin. In some cases both syncytium and Langhans' cells are recognizable. Indeed, even fairly well con- structed villi are seen. It is known that villi may be transported through the maternal veins as emboli in normal pregnancy, but these do not proliferate, but are absorbed by other body cells. Chorio-epithelioma is one of the most remarkable of tumors, since it is a tumor of one individual — the foetus growing in the tissues of another individual — the mother. Though of epithelial origin, it forms metatases through veins rather than lymphatics. Ewing thinks the term, as at present used, includes several varieties of growths: 1. Syncytioma, almost entirely composed of syncytium and of fairly good prognosis. 2. Chorio-adenoma, in which re- SALPINGITIS. 201 covery may occur, and which exhibits a villous structure. 3. Chorio- carcinoma, which has always proved fatal. Give its course and symptoms. It occurs most often between the age of twenty and thirty-five years. It always follows a pregnancy, and in nearly half the cases has followed hydatidiform mole. Hemorrhage, watery discharge, and pain rapidly appear. Metastases are early and numerous. The vagina and vulva are often involved by extension or metastasis, and before death a number of abdominal and thoracic organs will show tumors whose microscopic appearances closely imitate those of the uterine growth. Unlike tumors in general of epithelial origin, its metastases occur chiefly through the veins, hence the lungs are usually infected early. Death will follow, as a rule, within six months of the termination of the preceding pregnancy. What is the treatment? The symptoms given describe the most malignant type. In some cases curettings have shown a condition of chorio-epithelioma, yet death has not followed, whether the uterus was or was not removed. Hence we are led to infer that we are dealing with different classes of tumors, as Ewing maintains. If the pathologists are able to distinguish the classes by examination of curettings. we may be able to modify our treatment in the direction of conservatism. At present early hysterectomy would seem the only safe procedure. Salpingitis. What is the pathology ? In salpingitis there is usually first a catarrhal or suppurative inflammation of the mucous membrane of the tube ; this, extending to the peritoneum, sets up a localized peritonitis which usually closes the fimbriated extremity, and often by adhesions distorts the tube. From the closure of the outer extremity and the narrowing of the lumen in different places by the traction of peritonitic adhesions, the secretions are retained and distend the tube. This distention is favored by the softening arising from the inflammation. Other portions of the tube may be thickened, partly from inflammation of the tube itself and partly from the neighboring peritonitis. We distinguish, according to their severity, the following forms of salpingitis : 202 ESSENTIALS OF GYNAECOLOGY. 1. Catarrhal, due to germs of impaired virulence or to extension of nearby inflammatory processes. 2. Suppurative: a. Endo-salpingitis, chiefly gonorrhoea! b. Parietal salpingitis, chiefly secondary to broad ligament inflammations. 3. Chronic. The tortuous, clubbed, or adherent tubes resulting from previous acute processes. How do the tube ends become occluded ? The lumen at the uterine end is closed by swelling of m ucosa , but is not, as a rule, completely obliter ated. Th e term "salpingitis profluens," or intermittent salpingitis, is appli ed to cases where, owing to re-establishment of the lumen, fluid is discharged into the uterus. The condition is rare. —> The abdominal ostium is closed in one of two ways: 1. Peri- tonitic closure. Peritonitic adhesions, the result of a localized inflammatory process aTSout the tube-end, cause it to be glued to any organ with which it may come in contact. 2. Sal pingitic closure. The fimbriae become swollen, so as to more nearly fillthe tube end. The circular-muscular coat, by swelling, narrows the lumen of the outer end. Then the tube becomes lengthened by the swelling, so that the muscular coats expand out over the tips of the fimbriae, giving one the impression that the fimbriae have been drawn in. Einally, the swollen fimbriae, pressed together by the constricting muscular ring, adhere so firmly that, even should the inflammation subside, the lumen is not re-established. When both ends are closed, we name the variety of salpingitis, according to tube con- tents, as — 1. Hydrosalpinx. 2. Haematosalpinx. 3. Pyosalpinx. What is the etiology of salpingitis ? It usually arises from an extension to the tube of an inflammation of the endometrium, and its etiology is that of the endometritis, especially — 1. Sepsis during parturition or abortion. 2. The use of septic instruments. 3. Gonorrhoea. SALPINGITIS. 203 What is the bacteriology of salpingitis ? The normal tube is free from bacteria. The most frequent inciter of salpingitis is the gonococcus, after this organism and about in the order of frequency in which they are found are the tubercle bacillus, streptococcus, staphylococcus, bacterium coli commune, and pneumo- coccus. Mixed infection is very rare. After a time bacteria die out in a pyosalpinx, so that a majority of such tubes examined have been found sterile. What are the routes of infection? Give the usual path followed by the different organisms. 1. By continuity of mucosa from the uterus ; gonorrhoea; endo- salpingitis ; pyosalpinx. 2. By way of the abdominal ostium ; tuberculosis. 3. Lym phatic route ; streptococcus and staphylococcus. This "is the common method by which puerperal infections reach the tube. The germs pass from the uterus to the lymphatics of the broad ligaments and thence to the outer walls -of the tube. The result is a parietal or perisalpingitis. 4. Direct extension, as from adjacent abscesses or hollow viscera; colon bacillus! ** 5. Blood ; pyemia ; tuberculosis. What are the characteristics of a hydrosalpinx ? In a hydrosalpinx the tube is distended with serum, its mucosa showing changes due to pressure, but without evidence of severe inflammation. The softening of the walls easily allows the dis- tention, which varies in position" according to the traction of peritonitic adhesions. Hydrosalpinx is occasionally associated with fibroids of the uterus, and is probably not then of bacterial origin. It results from peri- rather than endo-salpingitis. The theory that it is a transformed pyosalpinx has been discredited. What are the characteristics of a hematosalpinx ? Blood in a tube may have one of three sources : 1. It may be exuded from the tubal mucous membrane as a re- sult of inflammation, the commonest form of haematosalpinx. 2. It may occur as an extension of a hsematometra due to atresia of vagina or cervix. 3. It most often occurs as a result of a tubal pregnancy. This is not classed as hiematometra. 204 ESSENTIALS OF GYNECOLOGY. The tube is usually first hypertrophied, later thinned, and it may rupture ; this accident is usually delayed by peritonitic thickening about the tube. The blood is generally thick and tarry. In tubal pregnancy it clots. What are the characteristics of a pyosalpinx ? The tube is usually more thickened and surrounded by more peri- tonitic adhesions than is hydrosalpinx. The pus may be slight in amount, or the tube may be immensely distended with very fetid pus. The mucous membrane of the tube may be fairly well preserved and the seat of suppurative inflammation, or may be replaced by granulation tissue. Pus-tubes may be drained by rupture into hol- low viscera or intraperitoneal rupture may occur, resulting in pelvic abscess or general peritonitis. We are coming to think of pyosalpinx as gonorrhoeal, except in a small minority of cases. What are the symptoms of salpingitis ? The patient usually suffers from a burning and dragging j3ain, in the region of the affected tube, especially on standing and walking. Dysmenor rhea is common ; repeated attacks of peritonitis are not infrequent. In the case of pyosalpinx septic symptoms may be pres- ent. There is ten derness on pressure in~the lateral vaginal fornix, and on making a bimanual examination an elongated cys tic mas s can usually be detected at the side of or behind the uterus. What are the results of salpingitis ? A hydrosalpinx or hematosalpinx occasionally subsides so as to cause few symptoms ; they may become purulent and form pyo- salpinx. A hematosalpinx may rupture into the peritoneum or into the broad ligament, forming an hematocele in the former case, and a hematoma in the latter. A pyosalpinx if unrelieved by operation may continue for years, producing chronic invalidism, and may rupture and cause septicemia or peritonitis. A salpingitis rarely subsides completely. Tubes are usually left adherent or closed so as no longer to act as oviducts. If not occluded, TUBERCULAR SALPINGITIS. 205 their kinks and adhesions favor ectopic gestation. Recrudescences follow exposure to cold, even without any reinfection. What is the treatment of salpingitis ? 1 . Prophylactic. — Cleanliiuess and antisepsis during the puerperiuni and in the use of all instruments. 2. Palliative. — During the acute stage of invasion, rest in bed, poulti ces or ice coil, laxatives, and, if much pain is present, allow orjium. When the case becomes subacute, i. e. , when fever has entirely subsided, apply counter-irritation to vaginal fornix over the affected tube or tubes, and employ tampons of boric acid and glycerine and hot-water vaginal douches. So long as pain and tenderness exist, rest in bed is advisable during menstruation. Sexual intercourse is to be avoided. 3. Radical. — If the distention and thickening of the tube fail to subside under the foregoing treatment, remove the tube and ovary of the side affected. Often both sides are involved and require removal. When the tube is simply adherent and its abdominal ostium occluded and no infection is present, a salpingostomy can be done, restoring the patency of the tube. Tubercular Salpingitis. Give its pathology. The infection may reach the tube either through the blood, lymph- channels, endometrium, or peritoneum. It is usually secondary to a general, pulmonary, or peritoneal tuberculosis. Rarely the bacilli enter through the vagina and thus cause a primary genital tuber- culosis. The tubes are much more frequently affected than other parts of the genital tract. The tubercular lesions are most marked near the abdominal ostia, and both tubes are, as a rule, affected. Williams describes three varieties : 1 . Miliary tuberculosis. 2. Chronic diffuse tuberculosis. 3. Chronic fibroid tuberculosis. The abdominal ostia may or may not be occluded. The tubes vary in their degree of distention with pus or cheesy material. The lesion 206 ESSENTIALS OF GYNAECOLOGY. may be confined to the mucous membrane or involve the entire thickness of the tubal wall. What are the predisposing causes ? The disease occurs from infancy to old age, but is most frequent between the ages of twenty and forty, and seems predisposed to by child-bearing and the puerperal state. It has followed sexual inter- course when the male genitals were tubercular. Upon what would you base a diagnosis of tubercular salpin- gitis ? Absence of other causes of pyosalpinx, as gonorrhoea or infection following labor or abortion. Evidence of other tubercular lesions. Pallor, emaciation, and cough. Physical examination, as a rule, reveals two large sausage-shaped masses lying close to the uterus, firmly adherent and less sensitive than is the rule with pyosalpinx. Presence of tubercle bacilli in the uterine discharge. Absence of an initial acute stage. Chronicity or failure to respond to ordinary methods of treatment. What is the treatment ? The usual climatic and medicinal treatment of tuberculosis. In many cases this is the only treatment. If, however, the tube or. tube and peritoneum alone arc tuberculous, cosliotomy is indicated.' The ovaries and tubes are removed and with them the uterus. The cervix may be left, as it is rarely diseased. The abdominal incision is closed without drainage. Affections of the Ovaries. Hemorrhage into the Ovaries. Discuss briefly. A small amount of hemorrhage into a follicle at the time of rupture is normal. Interstitial hemorrhage or apoplexy of the ovary, as it is called, results from congestion due to general circulatory dis- turbances or local inflammations. When hemorrhage occurs there is pain, and if hemorrhage is excessive, which is rarely the case, the symptoms may resemble those of a ruptured ectopic gestation. affections of the ovaries. 207 Ovaritis. What is the pathology ? Ovaritis or inflammation of the ovary may be acute or chronic. Tubercular ovaritis is usually described separately. Acute ovaritis may be follicular or interstitial ; the two are often combined. In the follicular form, the epithelium of the follicles degenerates, the liquor folliculi becomes purulent, and the ovum is destroyed. In the interstitial form, the stroma is infiltrated with serum and leucocytes and the connective tissue cells are increased ; abscesses often form between the bundles of fibers ; sometimes gangrene occurs. Chronic ovaritis, often the result of the acute, may exhibit 3 forms— 1. The atrophic. 2. The hyperplastic. 3. The cystic. In the atrophic form the ovary is small, hard, and nodular ; the tunica albuginea is much thickened. In the hyperplastic form, the ovary is enlarged, hard, and com- paratively smooth ; it usually prolapses from the increased weight. In the cystic variety, the change is not confined to the follicles, but the stroma is involved as well. The atrophic form may be present in one part of the ovary and the hyperplastic in another; the tunica albuginea is thickened and prevents rupture of the cysts. Ovaries the seat of ovaritis are often more or less surrounded by peritonitis. What is the etiology of ovaritis ? It occasionally occurs in severe cases of the infectious diseases or metallic poisoning, but is most often secondary to disease of the tubes or peritoneum. It is predisposed to by anything causing con- gestion of the ovary, such as displacement of the uterus or ovary or excessive venery. A salpingitis with its own etiology is the most frequent cause of ovaritis. Among individual causes, the following are especially to be mentioned : — iSepsis during labor, abortion or operations. Gonorrhoea. Catching cold during menstruation. 208 ESSENTIALS OF GYNECOLOGY. What are the symptoms ? The symptoms of acute ovaritis are usually mingled with those of the accompanying salpingitis or peritonitis. There is generally sharp pain in the ovarian region or regions, radiating to the back ; often pain in micturition and defecation, and various reflex neuroses. If an abscess forms, septic symptoms may be present. In the chronic form the symptoms are usually less marked ; there is dull pain in the ovarian region, increased by walking. There is dyspareunia and, especially if the ovary is prolapsed, painful defe- cation. What are the physical signs ? These may be obscure, from the fact that the ovary and tube are bound together by peritonitic adhesions into one indistinct mass. When definable, we feel, on making a bimanual examination, a round body at the side of the uterus, but separated from it by a slight interval ; it is sensitive to pressure, producing pain of a sick- ening character ; it may or may not be movable. When the ovary is prolapsed, this round, tender mass may be felt in the pouch of Douglas. From what must you differentiate an inflamed ovary ? From — Salpingitis. Peritonitic deposit. Exudation into the broad ligament. Fibroid tumor. Faeces in the rectum. How would you differentiate ovaritis from salpingitis ? This is often very difficult, from the fact that the two conditions frequently coexist. The chief features in the differential diagnosis are found in the physical signs, as follows :•— Ovaritis vs. Salpingitis. Lies farther from the uterus ; Lies nearer the uterus ; more more globular in shape. elongated. The ovary cannot be felt else- The ovary can often be felt sepa- where. rate from the mass. More sensitive. Less sensitive. AFFECTIONS OF THE OVARIES. 209 How would you differentiate an ovaritis from an exudation in the broad ligament ? Ovaritis vs. Exudation in Broad Ligament. More circuru scribed. Less circumscribed. Less closely related to vaginal More closely related to vaginal vault. vault. Less fixity of the uterus. More fixity of the uterus. How would you differentiate ovaritis from a lateral uterine fibroid ? Ovaritis vs. Lateral Fibroid. Sensitive to pressure. Insensitive to pressure. Less intimately connected with More intimately connected with the uterus. the uterus ; moves with it. Density less. Density greater. Menorrhagia less common. Menorrhagia more common. How would you differentiate ovaritis from faeces in the rectum? Ovaritis vs. Faeces. More sensitive. Less sensitive. Globular. Elongated in shape. Does not indent on pressure. Indents on pressure. Found after emptying rectum. Disappears on emptying rectum. What is the treatment of ovaritis ? During the acute stage keep patient quiet in bed ; apply hot poultices to the lower abdomen ; keep bowels open and feces soft ; give an anodyne, if necessary. Later, apply counter-irritation by means of iodine to the vaginal fornix over the affected organ, and support the ovary with a tampon. An excellent method is to soak a roll of gauze in a solution of iodoform 1 part, chloral 1 part, and glycerine 4 parts, and place this about the cervix, especially on the affected side. After the withdrawal of this support, which may be - left in twelve to twenty -four hours, a hot-water vaginal douche may be used with advantage. As a last resort, after a faithful trial of the above palliative measures for months without avail, and if the patient is a great sufferer, removal of the offending organ is indicated. 14 210 ESSENTIALS OF GYNECOLOGY. If abscess of the ovary is present, early operation is indicated. An ovary the seat of ovaritis may be removed through the vagina. Prolapse of the Ovary. What is the etiology and pathology ? Prolapse of the ovary may occur either as a result or cause of disease. From the increase in size, due to congestion, inflammation or small tumor, the ovary is apt to prolapse. In a retroversion or retroflexion of the uterus, the ovaries also are usually drawn backward, and from their disturbed circulation become congested and diseased. In their descent they usually first lie on the retro-ovarian shelves, and may then further descend, especially the left, into the pouch of Douglas. What are the symptoms ? They are those of ovaritis and of ovarian compression ; the latter being most marked, viz. : painful defecation and dyspareunia. (The differential diagnosis has been given under ovaritis. ) What is the treatment ? (a) Palliative. — If due to a displacement of the uterus and both uterus and ovaries are movable, replace the uterus and maintain it in position by means of a pessary. When the ovary alone is displaced, if movable, support it at first with a tampon ; later a soft rubber ring pessary may be worn about the cervix. When the ovary is fixed by adhesions, an attempt should be made to cause resolution of the adhesions by counter-irritation, glycerine or boroglyceride tampons, hot- water douches and gentle massage. (b) Radical. — If the palliative measures fail and the symptoms are severe, operation is indicated, either to remove the prolapsed ovary, or, if the uterus is displaced backward, to break up the adhe- sions and fasten the uterus forward by hysterorrhaphy or by short- ening the round ligaments. Tumors of the Ovary. What are the chief causes of enlargement of an ovary? {a) Inflammation. (d) Carcinoma. {b) Cysts. (e) Fibroma. (c) Papilloma. (/) Sarcoma. (gr) Tuberculosis, AFFECTIONS OF THE OVARIES* 211 Discuss ovarian sarcoma and fibroma. Sarcomata are chiefly of the round-celled variety, but may be spindle-celled. They occur at all ages, and not infrequently in children : both ovaries are often affected, and they frequently give rise to ascites. Hemorrhagic cysts may be formed in the large ones. Fibromata, as a rule, are not so large as sarcomata, grow slowly, and do not cause ascites. The sarcomata when removed early arc not very malignant. Discuss ovarian papilloma and carcinoma. Papillomata occasionally originate on the surface of the ovary, but more begin in the wall of a cyst, whose wall they penetrate and then spread over the ovary and peritoneum. They resemble warts else- where, and may be the starting-point of carcinoma. Any ovarian cyst may have warty growths in it, but they are regularly found on the walls of the serous cyst-adenomata, Rarely, when warts have spread to the peritoneum and seem to be taking on malignant char- acters, the removal of the ovary is followed by the disappearance of the peritoneal warts. The ovaries become the seat of carcinoma rarely primarily, but often from extension or metastasis. A cyst-adenoma or ovarian papilloma may become carcinomatous. What are the varieties of ovarian cyst ? Describe them. The varieties of ovarian cyst are — Corpus lnteum cyst. Simple follicular. Cyst-adenoma pseudo-mucinum. Cyst-adenoma serosum. Dermoid. Corpus luteum cysts rarely attain the size of a child's head. They contain fluid more or less stained with blood-pigment, and are lined by a lutein membrane. The simple follicular cysts are often multiple, and originate in distended Graafian follicles. They are lined by a layer of epithelium and contain clear serous fluid as a rule. The cyst-adenomata of the ovary form its largest cysts. They are the ordinary multilocular cysts and may attain a very great size. They are adenomata whose alveoli become distended with fluid, and by breaking through of partition walls, cavities of several quarts' 212 ESSENTIALS OF GYNAECOLOGY. capacity are formed. Protruding into the larger loculi several smaller "secondary" or "daughter" cysts are often seen. Rarely the daughter cysts grow outward from the walls of the parent cyst and give the tumor an outline like that of a bunch of grapes. Their fluid is viscid, gelatinous, sometimes blood-stained, and contains pseudomucin. They originate in primordial ovarian follicles. Cyst-adenoma pseudo-mucinum seems the most appropriate name. They were formerly called the "proliferating glandular cysts." Tlie cyst-adenomata serosa or proliferating papillary cysts. Any ovarian or parovarian cyst may have warty growths on its inner surface, but there is a variety of cyst which invariably contains them, though in variable numbers, and is thought to originate in the portions of the Wolffian ducts which are imbedded in the hilum of the ovary. The presence of ciliated epithelium in many of them makes this origin probable. The warts often grow so luxuriantly as to fill the entire cyst cavity, and even grow through its walls, spread- ing over the surface of the peritoneum. The growth then behaves as a papillo-carcinoma. The dermoid cyst on a part of its interior is lined with skin. Hair or teeth may grow from the skin surface projecting into the cavity of the cyst. This fluid content is made up of the secretions of the cutaneous glands, chiefly oil or sebaceous material. When the latter preponderates, they are semisolid in consistency. Bone cartilage, nerve tissue, and epithelial-lined tubular structures are found in the solid portions of the growth. It is believed that epi- blastic, mesoblastic, and hypoblastic tissues are all represented. One view as to the origin of dermoid cysts is that they are caused by an abnormal inclusion of the epiblast — i. e., that certain mis- placed embryonic cells grow within the ovary and produce the tissue to which they were destined. The other theory is that they are to be considered as teratomata, originating by a kind of parthenoge- netic development of an ovum in the affected ovary. In favor of this as compared to the other view is the fact that they are never found congenital. The ovary is the only abdominal viscus that forms them. They are most nearly paralleled by certain of the tumors of the testis classed as teratomata, which contain a great variety of tissues, including syncytium. AFFECTIONS OF THE OVARIES. 213 What is the etiology of ovarian cysts ? Concerning this little is known. They occur most frequently between the ages of 20-50, but are found in both the young and old. Simple ovaritis or injury of the ovary are said by some to predis- pose to the formation of a cyst. What changes may occur in an ovarian cyst ? The principal changes are the following : — It may rupture, usually from traumatism. Hemorrhage may occur into it. It may become gangrenous or may suppurate. The hemorrhage, gangrene and suppuration are usually the result of torsion of the pedicle. Suppuration may also arise from the introduction of sepsis if the tumor is tapped, as formerly practiced. What are the symptoms of an ovarian cyst ? They are chiefly those of pressure. There may be difficulty in urination and defecation ; in the later stages the patient is greatly exhausted by the great weight, and often suffers with dyspnoea. What are the physical signs of an ovarian cyst ? These vary with the location. When small and in the pelvis we get a tense elastic mass, usually fluctuating and insensitive to pres- sure. The multilocular variety may seem hard. The uterus is dis- placed by the tumor. When the cyst has extended to the abdomen, we get distention of the abdomen and dullness on percussion over the tumor. Fluctua- tion can usually be detected. What is the relation of ovarian cysts to the uterus ? When small the cyst prolapses from its own weight into Douglas' cul-de-sac ; hence the uterus will lie in front of the tumor. When the tumor is too large to lie in the pelvis it rises into the abdomen, the uterus then retroverts and lies under the tumor. Double ovarian cysts, even of large size, may continue to lie behind the uterus and displace it forward. 214 ESSENTIALS OF GYNECOLOGY. From what must you differentiate an ovarian cyst when small and situated in the pelvis ? From (a) Distended tube. (b) Peritonitic exudation. (c) Inflammatory exudation into broad ligament. (d) Extra-uterine gestation. How would you differentiate a small ovarian cyst from a dis- tended tube ? Ovarian Cyst vs. No inflammatory history; gradual development ; little if any pain. More globular. Less intimately connected with the uterus. Insensitive to pressure. Less fixity. Distended Tube, History of acute inflammation ; pain usually prominent. More elongated. More intimately connected with the uterus. Sensitive to pressure. More fixity. How would you differentiate a small ovarian cyst from a peri- tonitic exudation ? Ovarian Cyst No history of acute inflammation. Insensitive. More mobile. More lateral. How would you differentiate flammatory exudation Ovarian Cyst Absence of history of inflamma tion. More mobile. Induration of parametrium want ing. Insensitive. Bulges less into vagina. vs. Peritonitic Exvdatfon. History of acute inflammation. Sensitive to pressure. Fixed. Usually in pouch of Douglas. a small ovarian cyst from an in- into the broad ligament ? vs. Inflammatory Exudation. History of inflammation follow- ing labor, abortion, or opera- tion. If a haematoma, history of sharp pain, shock, perhaps symptoms of hemorrhage. Fixed. Induration present. Sensitive to pressure. Bulges more into vagina. AFF'ECTTONS OF TIFF OVARIES. 21. How would you differentiate an ovarian cyst from an extra- uterine pregnancy? Ovarian Cyst Slow growth. No symptoms of pregnancy. Menstruation usually not far from normal. More mobile. Uterus usually not enlarged. Pain only from pressure ; no acute attacks. vs. Extra- off: rine Pregnancy. Growth more rapid. Constitutional symptoms of preg- nancy. Anienorrhoea usually followed by monorrhagia. More fixed. Uterus enlarged. Attacks of pain ; finally a severe attack, symptoms of shock and hemorrhage. From what must you differentiate a large ovarian cyst occupying the abdomen? From (a) Pregnancy. (b) Ascites. ( c) Fibroid tumor of the uterus. (d) Distended bladder. (e) Haematometra. How would you differentiate a large ovarian cyst from a pregnant uterus ? Ovarian Cyst vs. Pregnant Uterus. More lateral. Menstruation continues. Positive symptoms of pregnancy absent. Uterus small, separate from tumor ; cervix not softened. Fluctuating. Intermittent contractions absent. Growth less rapid. More central. Amenorrhcea the rule. Positive symptoms of pregnancy present. Uterus forms the tumor ; cervix softened. Less fluctuating; fetal parts felt. Intermittent contractions present. Growth more rapid. 216 ESSENTIALS OF GYNECOLOGY. How would you differentiate a large ovarian cyst from ascites ? Ovarian Cyst Patient on back : — Swelling central or unilateral. Dullness in front. Tympanitic on the sides. Percussion note varies little on turning patient from side to side. Circumscribed. vs. Ascites. Patient on back : — Swelling bilateral. Tympanitic in front. Dullness on the sides. Percussion note varies greatly in turning from side to side. Diffuse. How would you differentiate a large ovarian cyst from a large fibroid tumor of the uterus ? Ovarian Cyst vs. Fibroid. Fluctuating. Less intimately connected with the uterus. Menorrhagia uncommon. Uterus usually not enlarged. Firm, non-fluctuating. More intimately connected with the uterus ; moves with it. Menorrhagia common. Uterus usually enlarged. How would you differentiate a large ovarian cyst from a distended bladder ? Ovarian Cyst vs. Distended Bladder. More lateral. Central. Enlargement slow. Enlargement rapid. Remains after patient is cathe- Disappears when patient is terized. catheterized. How would you differentiate a large ovarian cyst from a hsematometra ? Ovarian Cyst Menstrual flow appears. vs. More lateral ; separate from the uterus. Pain only from pressure. Atresia absent. Hwrnatornetra. Menstrual blood retained. Central ; tumor formed by the distended uterus. Periodical attacks of pain, due to increase of contents. Atresia of vagina or cervix present. AFFECTIONS OF THE OVARIES. 217 What is the treatment of an ovarian cyst ? The only treatment is removal. If large, through abdominal coeliotomy ; if small, it can often be easily removed through the vagina. Parovarian Cysts. Describe briefly. They are cysts developed in the broad ligament from the parova- rium, the remains of the Wolffian body. These cysts are usually unilocular ; the contents colorless, thin and watery, of a specific gravity of about 1005. The cyst wall is usually thin, and fluctu- ation very distinct. As the cyst grows, it opens up the folds of the broad ligament, and obliterates the mesosalpinx. The Fallopian tube lies stretched out over its upper surface, and the ovary will be found attached to the cyst. How would you distinguish between an ovarian and par- ovarian cyst? Ovarian Cyst vs. Parovarian Cyst Has a pedicle. No pedicle. Somewhat movable. Deep-seated in pelvis and immovable. Uterus in front when small ; behind Uterus pushed to opposite when large. side when small ; forward against symphysis when large. What is the treatment ? Removal by coeliotomy is the best treatment. The broad ligament, which is spread out over the tumor, is incised near to and parallel to the tube, and the tumor is enucleated from its bed. The cavity in the broad ligament is then either closed so as to leave no pockets, or the edges of the broad ligament are brought together above and the bed of the cyst is drained through the vagina. The former practice is usually preferable if there is no bleeding and the opera- tion has been performed aseptically. What are the chief points in the technique of an abdominal coeliotomy for the removal of the uterine appendages or a cyst? Have the bowels of the patient thoroughly emptied and let her 218 ESSENTIALS OF GYNAECOLOGY. take a thorough warm bath. On the evening before the operation, place upon the abdomen a towel soaked in a solution of soft soap to be left until the following morning. On the day of the operation, the abdomen and pubes are shaved, scrubbed with soap and water, washed with alcohol, and then with bichloride 1-1000. All antiseptic precautions must be observed in regard to instru- ments, hands, sponges, etc. The patient having been anaesthetized, a final cleansing of the abdomen with alcohol and bichloride is performed. An incision, about three inches long, is made in the median line, beginning just below the umbilicus ; this incision is deepened to the peritoneum and bleeding points are clamped. The peritoneum is raised with thumb forceps, one held by the operator, the other by an assistant, and the peritoneum cut between the forceps ; the incision is length- ened with the scissors, cutting on the finger to the length of the abdominal wound. The latter may be lengthened, if necessary. If the operation is for the removal of the appendages, the fundus of the uterus is felt for as a landmark ; the ovary and tube of the affected side are brought into the abdominal wound and surrounded by warm sponges or pads. The broad ligament is tied in section beneath the appendage and the parts outside the ligature cut away, leaving just enough to prevent the ligature from slipping. The first ligature should be placed external to the ovary including the infun- dibulo-pelvic ligament, which contains the ovarian artery. The liga- ture placed at the proximal end of the tube should include the anasto- motic branch between the uterine and ovarian arteries. The ligature is then cut short and the stump dropped back into the abdominal cavity. The other side is treated, if necessary, in the same way. If the operation is for an ovarian cyst, after opening the abdomen the cyst is punctured with a trocar, the emptied sac drawn out of the abdominal wound, the adhesions separated, if necessary, the pedicle tied, and the stump treated as before. If pus has gotten into the abdominal cavity, the latter is freely irrigated with warm sterilized salt solution ; drainage may or may hot be indicated. The abdominal wound is closed by one of several methods. An ideal method is that which sutures each layer of the abdominal wall separately. A continuous catgut suture is used for the peritoneum, another for the aponeurosis, interrupted catgut sutures unite the AFFECTIONS OF THE OVARIES. 219 subcutaneous fat, and the skin is united by any desired method of suture. The wound is then cleansed, a sterile dressing is applied and held in place by plaster strips and an abdominal binder, and the patient is transferred to bed. The bed should be warmed with hot- water bottles, but great care should be taken that the patient is not burned by them. What is the after-treatment of the case ? The patient receives no food by the mouth for twelve to twenty- four hours, nutrient enemata being used if needed. After vomit- ing, due to the anaesthetic, has subsided, thirst is quenched by the repeated administration of small doses of hot water ; later conl or carbonated water is given. The urine is drawn with a catheter. As little opium as possible is used. The bowels are moved on the third day by enema, calomel gr. iv (gr. j every half hour) or salines. If tympanites occurs at any time, the bowels are moved. If silk or silk-worm gut sutures have been used they should be removed within a week. The patient is allowed up on the four- teenth to twenty-first day. Describe the vaginal operation for the removal of a diseased appendage or an ovarian cyst. The same preliminary preparations are observed as for an abdom- inal cosliotomy. At the time of the operation the vulva and vagina are thoroughly disinfected, the patient being in the lithotomy posi- tion and on a Kelly's pad. The perineum is retracted with a spec- ulum. If endometritis is present the uterus is first curetted. The posterior lip of the cervix is then seized with a volsella and drawn forward. The vagina is grasped with a toothed thumb-forceps about where it joins the rectum, and drawn downward. Between this point and the junction of vagina and cervix a cut is made with scis- sors directed toward the uterus ; first going through the vagina, then into the pouch of Douglas. This incision may be enlarged laterally. Two fingers are inserted into this opening and the pelvic contents examined. If a diseased tube and ovary are found, a gauze pad or sponge, each with a long silk attached, is inserted above the mass to be removed, to keep back intestines or omentum ; the ap- pendage is freed, brought down into the vagina, ligated and re- moved. The gauze pad or sponge is now removed and the vaginal 220 ESSENTIALS OF GYNAECOLOGY. opening may either be closed or the pelvic cavity may be drained with gauze, according to the indications. If an ovarian cyst is to be removed, after opening the pouch of Douglas the cyst is tapped and emptied ; the sac drawn clown into the vagina, ligated, and removed. What are the advantages and disadvantages of the vaginal as compared with the abdominal operation ? In the vaginal operation the shock is less and the abdominal cicatrix with its tendency to hernia is avoided. The vaginal operation requires greater skill in operating ; there are greater possibilities of injuring gut in separating adhesions, and greater difficulty in repairing the damage ; it may be hard to locate and control bleeding. In some cases the appendages cannot be removed by vagina until after the removal of the uterus. Hence if there is doubt as to the diagnosis and a possibility that the whole or a part of an ovary or tube may be allowed to remain, the abdominal route is to be selected as favoring conservative surgery. What are the indications for a vaginal operation ? In those cases in which the patient's condition will not warrant a severe operation, a pelvic abscess, pus-tube, or ovarian abscess may be drained through the vagina. Later, after recovery from sepsis, an abdominal operation may be performed with safety. A small ovarian cyst or prolapsed ovary may be removed with advantage through the vagina, as may also a small fibroid in the lower uterine segment through either anterior or posterior fornix. The vaginal route is to be selected for the drainage of any large collection of blood, serum, or pus in the pelvis, which is well walled off by intestinal adhesions. Vaginal hysterectomy is the operation usually done for carcinoma of the uterus. What operations are performed through the anterior fornix ? Small fibroids of the cervix or anterior uterine wall are removed through the anterior fornix. This route is also employed for short- ening the round ligaments, and by some surgeons for removal of ovaries or tubes. How would you prepare catgut for ordinary ligature and suture? The following methods may be relied on to kill all spores, such as those of tetanus and anthrax, as well as all germs : ECTOPIC GESTATION. 221 1. The catgut is placed in small tubes half filled with alcohol and hermetically sealed. They are then placed in a steam sterilizer and the pressure run up to ten pounds of steam. 2. The catgut may be placed in a heavy metal jar half filled with alcohol and the lid tightly clamped on. The jar is then kept in boiling water for a half hour. 3. Cumol is a hydrocarbon which boils at 1 79° C. The catgut is first dried, then heated in cumol over a sand-bath to a temperature near its boiling-point. A temperature of 165° C. is maintained for an hour. The cumol is poured off and the catgut kept dry or trans- ferred to sterile alcohol. Absolute alcohol should always be used in preference to 95 per cent. 4. The Bartlett Method. This gives a very strong yet pliable gut. The gut is placed on asbestos in a drying oven and kept at a temperature not to exceed 220° F. for a half hour. This is to rid it of all water and make it penetrable by oil. It is then soaked for twenty-four hours in albolene, after which it is heated in albolene in an asbestos-lined vessel. The temperature is slowly run up and maintained for an hour or two just under 320° F. The albolene is allowed to drip off and the gut is transferred with sterile forceps to a solution of iodine 1 part to Columbian spirits 100 parts, in which it is kept until required for use. How would you prepare the chromicized (McEwen's) catgut ? Soak the gut for 48 hours in the following solution : — R . Acidi chromici, J iij- g vss Aquae, q. s. ad Oj M. et adde Glycerini, Ov. Then store the gut in carbolized glycerine 1-5. Wipe with a bichloride towel before using. Ectopic Gestation. Ectopic gestation, as a rule, is primarily tubal. Three varieties are recognized : 1. Tubal proper (free tubal). 2. Tubo-uterine (interstitial) ; in that portion of the tube em- braced by the uterine wall. 222 ESSENTIALS OF GYNECOLOGY. 3. Tubo-ovarian. — Between the tube and the ovary, originally tubal. Abdominal pregnancy is believed to have been originally tubal. Ovarian pregnancy, apparently resulting from the impregnation of the ovum while still in a Graafian follicle, can no longer be doubted as a possibility, but the number of well-authenticated cases is still small. What is the etiology? It has long been recognized that tubal inflammation, peritoneal adhesions, and pressure upon the tube preaispose to tubal pregnancy. In the case of inflammations, however, not until the tubal mucosa has become practically normal is tubal pregnancy likely to occur. Hindrance to the passage of a fertile ovum into the uterus will not of itself cause tubal implantation of the ovum. An hypothesis has been advanced by Webster that under normal conditions the tube will not undergo the decidual change necessary for pregnancy, but that the tubal mucosa of a few women possesses the property, com- mon in many of the lower animals, of responding to the stimulus which the fertilized ovum offers by forming a decidual membrane. In such individuals, if the passage of the ovum into the uterus is interfered with, tubal pregnancy results. Doderlein states that while there was a history of tubal inflammation in 90 per cent, of his cases, very few of the number were gonorrhoeal, and that the tubal pregnancy was the first conception but three times in forty-five cases. Others consider gonorrhoea the commonest predisposing cause. Discuss decidua formation. In extra-uterine as in intra-uterihe pregnancy a decidual membrane forms in the uterus. It is cast off at any time from the fifth week on, usually accompanying rupture of the tube or death of the foetus. A decidual membrane also forms in the tube, usually confined to a small part near the ovum. What are the symptoms ? There is usually a history of a number of years of sterility and also of pelvic inflammation. 1. Before*rupture*of the tube there are symptoms of early preg- nancy and at times slight pains, usually thought to be gas pains, in the vicinity of the affected tube. 2, The symptoms at the time of rupture are those of shock, ECTOPIC GESTATION. 223 internal hemorrhage, and severe pain in the pelvis. At about this time the uterine bleeding begins ; it is usually not great in amount, but continues for a great number of* days. The symptoms of hem- orrhage may occur but once, or be repeated a number of times. Fatal hemorrhage may occur within a very short time. 3. After rupture has occurred in the stage of pelvic hematoma there is anaemia and often for a time a rise of temperature. Blood examination reveals signs of a secondary anemia, and, in addition, a moderate leucocytosis. There may be pressure symptoms, and, as a rule, uterine bleeding continues. 4. If pregnancy goes on to term, labor pains appear and are re- peated for a number of days. The foetus then dies and is converted into a lithopredion, to remain indefinitely or to be discharged piece- meal into hollow viscera or through sinuses in the abdominal wall. At times suppuration and sepsis supervene. The abdominal press- ure caused by the spurious labor may cause rupture of the sac and internal hemorrhage. Why does the tube rupture ? The thin tube wall is incapable of much expansion, while the ovum grows rapidly. Further, the villi are well formed, but the maternal portion of the placenta formation is defective. The syncytium, too, is found to have the power to penetrate tissues and to make its way through the walls of blood vessels. By this syncytial action the tube is further weakened, hemorrhage is favored from the opened-up tubal vessels, and when hemorrhage has occurred about the ovum, the sudden increase of size of the mass causes the tube to burst. Many cases terminate without an actual tube rupture with mole formation or tubal abortion. What are the prospects of the fcetus in extra-uterine preg- nancy ? The ovum may become apoplectic and foetus die within the first six weeks. The majority of the foetuses succumb at the time of rupture or tubal abortion. They may die at the time of second- ary rupture of the gestation sac. Probably not 1 per cent, live to term. 224 ESSENTIALS OF GYNAECOLOGY. What are the physical signs ? Before ruptare^ geurs , the uterus is felt to be enlarged and soft- ened, and at the side is found a mass formed by the distended tube. At the time of rupture, if it has occurred with hemorrhage into the peritoneal cavity, very few physical signs may be present ; simply an indistinct feeling of fluid in the pouch of Douglas. Later, as the blood coagulates, a tumor is formed behind the uterus. If the rupture has occurred into the broad ligament, a tumor is formed at once by the blood-distended ligament. This tumor pushes the uterus forward and toward the opposite side. It tends to bulge into the vagina, and a finger introduced into the rectum detects a narrowing of it. What is the course and result ? Ectopic gestation is nearly always tubal. At or shortly before the third month, either a rupture of the tubal wall may occur, with the escape of the foetal products, or the escape may take place through the fimbriated extremity, constituting a tubal abortion. When a rupture of the tubal wall occurs, it may take place ( 1 ) through a portion covered b}^ peritoneum, i. e.. into the peritoneal cavity, or (2) through a portion not covered by peritoneum, /. e. , down be- tween the folds of the broad ligament. The intraperitoneal rupture may prove fatal, although often not until several hemorrhages have occurred. In an extraperitoneal rupture the hemorrhage is usually limited. The foetus usually dies when it escapes from the tube. When the rupture, however, is extraperitoneal, i e. , between the folds of the broad ligament, the foetus may survive, being nourished by a placenta attached to the floor and walls of the pelvis or broad ligament, and go to term. At any time after the middle of pregnancy the foetal sac may rupture and the foetus lie free in the peritoneal cavity. This con- stitutes secondary rupture and explains the cases of so-called ab- dominal pregnancy. Primary rupture may be delayed in the cases of interstitial pregnancy until the sixteenth week ; rupture is then likely to prove fatal. When the blood effusion is small it may be absorved. Sometimes suppuration occurs, ECTOPIC GESTATION. 225 From \vh it must you differentiate extra-uterine pregnancy ? Suppurative cellulitis. Fibroid tumor. Ovarian cyst. Dermoid cyst. Parovarian cyst. Salpingitis. Retroversio-flexio. What is the treatment ? If a diagnosis is made before rupture occurs, the best treatment consists in the removal of the tube with its contents. At the time of rupture there are two courses advocated. First, immediate opera- tion, by opening the abdomen quickly, reaching down into the pelvis and determining from which tube bleeding occurs , and drawing the tube up to the wound. This traction temporarily checks hemorrhage and the mesosalpinx is ligated off. After this has been done, blood or clots are washed away and the abdomen closed. In favor of this course is the uncertainty as to whether bleeding will stop spon- taneously. Second, treat the case by rest and external heat in the hope that as blood-pressure falls bleeding will cease, and that in a few hours the subnormal temperature and shock will be followed by reaction. Then operate when the patient's condition will warrant. Advocates of this course say a first hemorrhage is rarely fatal ; opera- tion with patient's pulse at 150 or over usually is : reaction is seen to take place remarkably quick in some cases that seem hopeless, since the blood is not an entire loss to the body, but its fluid portion at least is quickly reabsorbed once the bleeding has stopped. When bleeding has recently begun, if the patient's condition is good, and if proper facilities are at hand, operate. If the condition has reached a point where it is reasonably certain that even a short operation would prove fatal, if proper facilities for a clean and quick operation are not at hand ; moreover, if patient must be transported in a condition of profound shock to a distant hospital, the safer plan is the expectant one. If the rupture has taken place into the broad ligament and tj^ resulting hyematoina is small, this may be left with the hope--oT its absorption. If" repeated hemorrhages occur, surgical Interference 15 226 ESSENTIALS OF GYNAECOLOGY. is indicated. If suppuration take place, the mass should he opened from the vagina and drained. If the life of the foetus continues after the rupture, and the case is seen during the early months, the life of the foetus should be disregarded in the interest of the mother. The foetus and mem- branes should be removed and the sac drained. If the case is first seen after the viability of the foetus, an attempt should be made to save both lives. Fistulse. What are the chief varieties met with in gynaecology ? They may be either urinary or fecal. Urinary fistulse present the following varieties (see Fig. 59) : — 1. Urethro-vaginal. 2. Vesico-vaginal. 3. Yesico-uterine. 4. Uretero-vaginal. 5. Uretero-uterine. The most common is the vesico-vaginal. The fecal fistula which especially concerns us is the recto-vaginal. What is the etiology of a vesico-vaginal fistula ? The most common cause is sloughing following long-continued pressure, usually in parturition, but occasionally from a pessary. It may be produced by direct laceration through the septum. It is predisposed to by a tedious labor. It may result from cancer of the cervix. What are the symptoms ? The involuntary escape of urine. A urinous odor about the person. Irritation and excoriation of the vulva and parts around. How is the diagnosis made ? If the fistula is not evident on exposing the parts with a Sims' speculum, the patient being in Sims' position, the bladder may be distended with some colored antiseptic fluid, like creolin solution, and by the exit of the latter the fistula may be detected, and then verified by a probe, FTSTUL^E. 227 What is the treatment ? The treatment usually pursued in this country is the operation of Sims, which is performed as follows: The patient is anaesthetized, an antiseptic vaginal douche given, and all antiseptic precautions observed during the operation. She is placed in Sims' position and Sims' speculum introduced. The edges of the fistula are pared with the knife or scissors, the mucous membrane not being included in the incision. Silkworm-gut or silver-wire sutures are then intro- duced, about one-fifth to one-fourth inch apart, not penetrating the mucous membrane. The parts are brought into apposition by tying or twisting the sutures, and then a self-retaining catheter is intro- duced. The sutures are left for eight days. The operation for Fig. 59. To REPRESENT THE CHIEF VARIETIES OF URINARY FlSTlTLA— URETHku-VAGINaI , Vesicovaginal and Vesicouterine— Those with the ureters are not, seen! The seat of a recto-vaginal fistula is indicated (De Sinety). a urethro-vaginal fistula is similar to the above. When the fistula is a large one and the traction necessary to bring the vaginal edges together would be too great, other methods must be employed. The vaginal wall may be separated from the bladder wall and the two sutured separately. The vaginal sutures may be so placed as to make the suture line transverse, or lateral incisions may be made in the vaginal wall to relieve tension, much as is done in the operation of uranoplasty. 228 ESSENTIALS OE GYNAECOLOGY. What are the chief steps in the operation for the cure of a vesico-uterine fistula ? Emmet regards the condition as due to a laceration of the cervix extending into the bladder, the laceration healing only below. The operation is based on this idea, viz. : The cervix is split up to the fistula ; the edges of the latter are denuded, and the whole brought together in a manner similar to a trachelorrhaphy, especial care being taken with the upper sutures. Recto- vaginal Fistula. What is the etiology ? This, like the vesico-vaginal fistula, is usually due to sloughing caused by long-continued pressure in parturition, or may be produced by laceration through the septum, either by the unaided efforts of nature or by instrumental delivery. Cancer or syphilis may, of course, cause fistula, but this will not concern us here. What is the treatment ? It is similar to Sims' operation for vesico-vaginal fistula. The edges are denuded and brought together by silkworm gut or silver wire, the rectal mucous membrane being uninjured. If the fistula is near the vulva, it is usually best to divide the sphincter ani and perineum up to the fistula, to dissect this out, and then close the parts as in a laceration of the perineum through the sphincter ani. INDEX Alcohol, 67 Alexander's operation, 133 Allen's pump, 63 Amenorrhcea, 105 Anterior colporrhaphy, 152 Applicator, uterine, 60 Atresia of cervix, 116 of vagina, 1 15 Atrophy of uterus, 173 Bacteria of endometritis, 161 of salpingitis, 203 of vagina, 89 Barnes' bags, 63 Bartlett method of preparing cat- gut, 221 Bimanual examination, 46 Bladder, 36 Bulbi vestibuli, 20 Cancrum oris, 74 Cantharides, tincture of, 66 Carcinoma, ovarian, 211 uteri, 193 Catgut, preparation of, 220 Cathartics, 66 Cellulitis, pelvic, 97 Cervical erosions, 164 Chancre, 83 Chorio-epithelioma, 200 Cilia;, 32 Clitoris, 18 Coccygodynia, 86 Colon, pelvic, 39 Colporrhaphy, anterior, 152 Condylomata, pointed, 82 syphilitic, 83 Corpus luteum cyst, 211 Cragin's operation, 151 Curettage, 169 Curette, 64 Cystoscope, Kelly, 49, 54, 55 JS T itze, 55 Otis, 55 Cysts of ovary, 211 Decidua formation, 222 Development of the pelvic organs, 43 Dilators, 60 elastic, 63 graduated, hard, 61 Displacements of uterus, 122 anteflexion, 122 ante version, 122 retroversion and retroflexion, 125 Drugs, action on pelvic organs, 66-68 Diihrssen operation for prolapse, 141 Dysmenorrhcea, 108 Ectopic gestation, 221 Eczema of vulva, 80 Emmenagogues, 66-68 Emmet's operation, 144 compared with Hegar's, 145 Endometritis, 161 acute, 161 chronic, 163 villous, 167 Ergot, 66 Erosions, cervical, 164 Erythema of vulva, 79 229 230 INDEX. Fallopian tubes, 31 Fibroid tumors of uterus, 174 ovarian, 211 choice of operation, 184 Fistula, rectovaginal, 228 Fistulae, 226 Follicular cysts, 211 Fornix, anterior, operations through, 220 Fossa navicularis, 20 Fourchette, 20 Fungosities, uterine, 167 Gilliam operation through Pfan- nenstiel incision for shortening round ligaments, 136 Gonococcus, 69 antiserum, 71 examination of discharge for, 71 vaccine, 71 Gonorrhoea, 69 Gynecologic positions, 44 Hematocele and haematonia, pelvic, 100 pudendal, 77 Haemorrhage from vulva, 79 Hegar operation, 143 compared with Emmet's, 145 Hernia, pudendal, 77 Herpes of vulva, 81 Hydrastis canadensis, 66 Hymen, 21 Hyperaesthesia of vulva, 85 Hypertrophy of cervix, 154 Hysterectomy, 183 abdominal and vaginal, relative merits, 198 and oophorectomy for fibroids, 184 vaginal, 182, 197 Hysterorrhaphy, 134 Kelly's, 135 Instruments, 49 Inversion of uterus, 185 Iron, 66 Irritable urethral caruncle, 87 Ischiorectal fossa, 42 Kelly's hysterorrhaphy, 135 Kraurosis vulvae, 85 Labia majora, 17 minora, 18 Laceration of cervix, 156 of perineum, 141 Mackenrodt colpotomy incision, 153 Malformations of uterus, 117 of vagina, 115 atresia of, 115 stenosis of, 117 of vulva, 89 Martin suture, 143, 144 Menopause, 105 bleeding after, 194, 195 Menstruation, 104 disorders of, 105 amenorrhoea, 105 dysmenorrhoea, 108 congestive, 110 membranous, 111 neuralgic, 111 obstructive, 109 ovarian, 111 menorrhagia and metror- rhagia, 107 vicarious, 107 Mesosalpinx, 30 Metritis, 170 acute, 170 chronic, 171 Mons veneris, 17 Myomectomy, 182 New growths of vulva, 81 Noble's operation, 150 Noma, 74 One-child sterility, 114 Oophorectomy and hysterectomy for fibroids, 184 Ovarian extracts, 67 Ovaries, 33 affections of, 206 cysts, 211 enlargement of, 210 haemorrhage into, 206 INDEX. 231 Ovaries, prolapse of, 210 tumors of, 210 Ovaritis, 207 Papillomata, ovarian, 211 simple, 82 Parovarian cysts, 217 Parovarium, 35 Parsley, 66 Pelvic colon, 39 hour, 40 organs, drugs acting on, 66-68 Pennyroyal, 66 Perineal body, 41 Perineum, muscles of, 42 Peritoneum, pelvic, 93 Peritonitis, pelvic, 94 Pessaries, 130 stem, 64 Physical examination of pelvic organs, 43 Polypi, 190 Positions, gynecologic, 44 Prepuce, adherent, 82 Probe, uterine, 60 Proctoscope, Tuttle, 49 Prolapse of urethral mucous mem- brane, 88 Prolapsus uteri, 137 pubo-coccygeus muscles and, 139 Pruritus vulvae, 84 Pubic segment of pelvic floor, 138 Pubo-coccygeus muscles and pro- lapse, 139 Pudendal hematocele, 77 hernia, 77 Quinine, 66 Rectal examination, 48 instrumental methods, 49 Rectum, 38 Round ligaments, Gilliam opera- tion through Pfannenstiel incision for shortening, 136 intra-abdominal shortening of, 136 Rue, 66 Sacral segment of pelvic floor, 138 Saenger-Tait operation, 146 Salpingitis, 201 tubercular, 205 Sarcoma of uterus, 199 ovarian, 211 Savine, 66 Skin diseases of vulva, 79 Sound, uterine, 56 Speculum, 49 Brewer's, 53 Fergusson's, 52 Kelly's, 49, 54, 55 Simons', 51 Sims', 49 Sphincter, torn, operations for, 150 Stem pessaries, 64 Stenosis of cervix, 155 of vagina, 117 Sterility, 113 Stoltz's anterior colporrhaphy, 152 Syphilis, 83 Syphilitic chancre, 83 condylomata, 83 Tents, 60 Tertiary syphilis, 83 Theca folliculi, 34 Thyroid extract, 67 Tincture of cantharides, 66 Trachelorrhaphy, 160 Urinary tract, 35 Uterine applicators, 60 fungosities, 167 ligaments, action of, 31 Uterus, 24 displacements of, 122 malformations of, 117 mucous membrane of, 25 changes of, 26 Vagina, 21 atresia of, 115 bacteria of, 89 diseases of, 89 malformations of, 115 pathogenic germs in, 22 secretions of, 22 stenosis of, 117 232 INDEX. Vaginal examination, 45 outlet, relaxations of, 141 reaction, changes in, 22 Vaginismus, 86 Vaginitis, croupous, 93 gonorrhoea^ 91 simple catarrhal, 90 ulcerative, 92 Vestibule, 20 Viburnum, 67 Vicarious menstruation, 107 Volsella, 55 Vulva, chancre of, 83 malformations of, 89 Vulva, syphilis of, tertiary, 83 Vulvitis, 68 acute simple catarrhal, 68 chronic catarrhal, 69 croupous, 74 follicular, 74 gangrenous, 74 gonorrhoeal, 69 phlegmonous, 72 Vulvovaginal gland, 21 cyst and abscess of, 75 Warren's operation when sphinc- ter is torn, 150 SAUNDERS' BOOKS Practice, Pharmacy, Materia Medica, Thera- peutics, Pharmacology, and the Allied Sciences W. B. SAUNDERS COMPANY 925 Walnut Street Philadelphia 9, Henrietta Street Covent Garden, London SAUNDERS' SUCCESSFUL PUBLISHING AS is well-known, the lists of most publishers contain a number of books that have never paid, and for which the publisher will never get back the money invested. Messrs. W. B. 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Professor of Medicine, Johns Hopkins University " I am delighted with it, and it will be a pleasure to recommend it to our students in the Johns Hopkins Medical School." — — — ^— l^l^l ■■ ■ ! Ill I I Friedenwald and Ruhr ah on Diet Diet in Health and Disease. By Julius Friedenwald, M. D., Professor of Diseases of the Stomach, and John Ruhrah, M. D., Professor of Diseases of Children, College of Physicians and Surgeons, Baltimore. Octavo of 764 pages. Cloth, $4.00 net. JUST ISSUED— NEW (3d) EDITION This work contains a complete account of foodstuffs, their uses, and chemical composition. Dietetic management in all diseases in which diet plays a part in treatment is carefully considered, the articles on diet in diseases of the digestive organs containing numerous diet-lists and explicit instructions for administration. The feeding of infants and children, of patients before and after anesthesia and surgical operations, are all taken up in detail. George Dock, M. D., Professor of Theory and Practice of Medicine and Clinical Medicine, Tulane Uni- versity of Louisiana. " It seems to me that you have prepared the most valuable work of the kind now avail- able. I am especially glad to see the long list of analyses of different kinds of food." MATERIA MEDIC A. Stevens' Modern Therapeutics A Text=Book of Modern Materia Medica and Thera- peutics. By A. A. Stevens, A. M., M. D., Lecturer on Phy- sical Diagnosis in the University of Pennsylvania. Handsome octavo of 700 pages. Cloth, $3.50 net. JUST ISSUED— THE NEW (5th) EDITION Dr. Stevens, by his extensive teaching experience, has acquired a clear, concise diction that adds greatly to his work's pre-eminence. New articles have been added on Scopolamin, Ethyl Chlorid, Theocin, Veronal, and Radium, besides much new matter to the section on Radiotherapy. The numerous changes in name or strength of. various drugs and preparations, as called for by the new Pharmacopeia, have also been made. The work in- cludes the following sections : Physiologic Action of Drugs ; Drugs; Reme- dial Measures other than Drugs ; Applied Therapeutics ; Incompatibility in Prescriptions ; Table of Doses ; Index of Drugs ; and Index of Diseases ; the treatment being elucidated by more than two hundred formulas. University Medical Mag'azine " The author has faithfully presented modern therapeutics in a comprehensive work . . . and it will be found a reliable guide and sufficiently comprehensive for the physician in practice." Camac's Epoch-Making Contributions Epoch=making Contributions to Medicine and Surgery. By C. N. B. Camac, M. D., of New York City. Octavo of 450 pages, illustrated. Artistically bound, $4.00 net. JUST READY Dr. Camac has collected certain articles that record masterpieces of scien- tific research, presenting them in the original. Therapeutic Gazette " Dr. Camac has provided us with a most interesting aggregation of classical essays." IO SAUNDERS' BOOKS ON AMERICAN EDITION NOTHNAGEL'S PRACTICE UNDER THE EDITORIAL SUPERVISION OF ALFRED STENGEL, M.D. Professor of Clinical Medicine in the University of Pennsylvania ; Visiting Physician to the Pennsylvania Hospital. BEST IN EXISTENCE FOR THE PRACTITIONER It is universally acknowledged that the Germans lead the world in Internal Medicine, and of all the German works on this subject, Nothnagel's " Speci- elle Pathologie und Therapie " is conceded by scholars to be without question the best Practice of Medicine in existence. So necessary is this book in the study of Internal Medi- cine that it comes largely to this country in the orig- inal German. In view of these facts, Messrs. W. B. Saunders Company arranged with the publishers of the German edition to issue an authorized Ameri- can edition of this great Practice of Medicine. The work has been issued in twelve volumes, and those subjects selected that are of the greatest importance to the physician engaged in general practice. In fact, these volumes contain the real essence of the entire work, so that the purchaser obtains at less than half the cost the cream of the original. This work is a Practice of Medicine for the general practitioner. The work has been translated by men possessing thorough knowledge of both English and German, and each volume has been edited by a prominent specialist. It has thus been brought thoroughly up to date, and the American edition will be more than a mere translation ; for, in addition to the matter contained in the original, it represents the very latest views of the leading American and English specialists in the various de- partments of Internal Medicine. Moreover, as each volume has been revised to the date of its publication by the eminent editor, the objection that has heretofore existed to treatises published in a number of volumes has been obviated, since the subscriber receives the completed work while the earlier volumes are still fresh. The American publication of the entire work is under the editorial supervision of Dr. ALFRED STENGEL, who has selected the sub- jects for the American Edition, and has chosen the editors of the different volumes. The usual method of publishers when issuing a publication of this kind has been to require physi- cians to take the entire work. This seems to us in many cases to be undesirable. Therefore, in pur- chasing this Practice physicians are given the opportunity of subscribing for it in entirety ; but any single volume or any number of volumes, each complete in itself, may be obtained by those who do not desire the complete series. This latter method offers to the purchaser many advantages which will be appreciated by those who do not care to subscribe for the entire work at one time. Subscription. SEE NEXT TWO PAGES FOR LIST PROMINENT SPECIALISTS VOLUMES SOLD SEPARATELY THE PRACTICE OF MEDICINE. ii AMERICAN EDITION Nothnagel's Practice Per Volume : Cloth, $5-00 net WORK NOW COMPLETE Ha lf Morocco, $6.00 net Typhoid and Typhus Fevers By Dr H. Curschmann, of Leipsic. The entire volume edited with additions, by Wm. Osler, M.D., F. R. C. P., Regius Professor of Medi- cine, Oxford University, Oxford, England. Octavo, 646 pages, illus- trated. Smallpox (including Vaccination), Varicella, Cholera, Erysipelas, Pertussis, and Hay Fever By Dr. H. Immermann, of Basle ; Dr. Th. von Jurgensen, of Tubincren • Dr. C. Lieberm lister, of Tubingen ; Dr. H. Lenhartz, of Hamburg; and Dr. G. Sticker, of Giessen The entire volume edited, with additions, by Sir J. W. Moore, M. D F. R C. PI. Professor of Praciice, Royal College of Surgeons, Ireland. Octavo, 682 pages, illustrated. Diphtheria, Measles, Scarlet Fever, and Rotheln By William P. Northrup, M. I)., of New York, and Dr. Th. von Jurgensen, of Tubingen. The entire volume edited, with additions, by William P. Northrup, M. D., Professor of Pediatrics, University and Bellevue Hospital Medical College, N. Y. Octavo, 672 pages, illus. Bronchi and Pleura; Inflammations of the Lungs By Dr. F. A. Hoffmann, of Leipsic ; Dr. 0. Rosenbach, of Berlin ; and Dr F. Aufrecht, of Magdeburg. The entire volume edited, with additions, by John H. Musser, M. D.. Professor of Clinical Medicine, University of Pennsylvania. Octavo, 1029 pages, illustrated. Diseases of the Pancreas, Suprarenals, and Liver By Dr. Oser, of Vienna ; Dr. E. Neusser, of Vienna ; and Drs. H Quincke and G. Hoppe-Seyler, of Kiel. The entire volume edited, with additions, by Reginald H. Fitz, A. M., M. D., Hersey Professor of the Theory and Practice of Physic, Harvard University; and Frederick A. Packard, M. D., Late Physician to the Pennsylvania Hospital. Octavo, 918 pages, illustrated. Diseases of the Stomach By Dr. F. Riegel, of Giessen. Edited, with additions, by Charles G. Stockton, M. D., Professor of Medicine, University of Buffalo. Octavo of 835 pages, illustrated. Second Diseases of the Intestines and Peritoneum Edition By Dr. Hermann Nothnagel, of Vienna. The entire volume edited, with additions, by H. D. Rolleston, M. D. (Cantab.), F. R. C. P., Physician to St. George's Hospital, London. Octavo of 1 100 pages, illustrated. 12 SAUNDERS' BOOKS ON AMERICAN EDITION Nothnag'el's Practice WORK NOW COMPLETE Per ^"fJ CIoth « g-00 net Half Morocco, $6.00 net Tuberculosis and Acute General Miliary Tuberculosis By Dr. G. Cornet, of Berlin. Edited, with additions, by Walter B. James, M. D., Professor of Practice, Columbia University, New York, Octavo of 806 pages. Diseases Of Blood {Anemia, Chlorosis, Leukemia, Pseudoleukemia) By Dr. P. Ehrlich, of Frankfort-on-the-Main ; Dr. A. Lazarus, of Charlottenburg ; Dr. K. VON NOORDEN, of Frankfort-on-the-Main ; and Dr. Felix Pinkus, of Berlin. The entire volume edited, with additions, by Alfred Stengel, M. D., Professor of Clinical Medicine, University of Pennsylvania. Octavo of 714 pages, illustrated. Malaria, Influenza, and Dengue P-y Dr. J. Mannaberg, of Vienna, and Dr. O. Leichtenstern, of Cologne. The entire volume edited, with additions, by Ronald Ross, F. R. C. S. (Eng.), F. R. S., University of Liverpool; J. W. W. Stephens, M. D., D. P. H., University of Liverpool ; and Albert S. Grunbaum, F. R. C. P., University of Liverpool. Octavo of 769 pages, illustrated. Kidneys, Spleen, and Hemorrhagic Diatheses By Dr. Ff. Senator, of Berlin, and Dr. M. Litten, of Berlin. The entire volume edited, with additions, by James B. Herrick, M. D., Pro- fessor of the Practice of Medicine, Rush Medical College. Octavo of 815 pages, illustrated. Diseases of the Heart By Prof. Dr. Th. von Jurgensen, of Tubingen ; Prof. Dr. L, Krehl, of Greifswald ; and Prof. Dr. L. von Schrotter, of Vienna. The entire volume edited, with additions, by George Dock* M. D., Professor of Theory and Practice of Medicine and Clinical Medicine, Tulane University of Louisiana. Octavo of 848 pages, fully illustrated. SOME PRESS OPINIONS London Lancet {Typhoid volume) "We welcome the translation into English of this excellent practice of medicine. The first volume contains a vast amount of useful information, and the forthcoming volumes are awaited with interest." Journal American Medical Association ( Tuberculosis volume) " We know of no single treatise covering the subject so thoroughly in all its aspects as. this great German work. . . . It is one of the most exhaustive, practical, and satisfactory- works on the subject of tuberculosis." EACH VOLUME COMPLETE IN ITSELF AND SOLD SEPARATELY MATERIA MEDIC A. Sollmann's Pharmacology Including Therapeutics, Materia Medica, Pharmacy, Prescription -writing, Toxicology, etc. A Text=Book of Pharmacology. By Torald Sollmann, M. D., Professor of Pharmacology and Materia Medica, Western Reserve University, Cleveland, Ohio. Octavo of 1070 pages, fully illustrated. Cloth, $4.00 net; Half Morocco, $5.50 net. THE NEW (2d) EDITION This work has been entirely reset to conform with the new (1905) Phar- macopeia. The author bases the study of therapeutics on a systematic knowl- edge of the nature and properties of drugs, and thus brings out forcibly the intimate relation between pharmacology and practical medicine. J. F. Fothering'ham, M. D., Professor of Therapeutics and Theory and Practice of Prescribing, Trinity Medica? College, Toronto " The work certainly occupies ground not covered in so concise, useful, and scientific a manner by any other text I have read on the subjects embraced." Butler's Materia Medica Therapeutics, and Pharmacology A Text=Book of Materia Medica, Therapeutics, and Pharmacology. By George F. Butler, Ph. G., M. D., Pro- fessor and Head of the Department of Therapeutics and Pro- fessor of Preventive and Clinical Medicine, Chicago College of Medicine and Surgery, Valparaiso University. Octavo, 702 pages, illustrated. Cloth, $4.00 net; Half Morocco, $5.50 net. THE NEW (6th) EDITION In this new edition the chapters on Organo-therapy, Serum-therapy, and cognate subjects have been enlarged and carefully revised. An important chapter is the one devoted to the newer theories of electrolytic dissociation and its relation to the topic of pharmacotherapy. Medical Record, New York " Nothing has been omitted by the author which, in his judgment, would add to the completeness of the text." 14 SAUNDERS' BOOKS ON Lusk on Nutrition The Elements of the Science of Nutrition. By Graham Lusk, Ph. D., Professor of Physiology at Cornell Medical School. Octavo volume of 325 pages. Cloth, $2.50 net. THE FOUNDATIONS OF DIETARY MANAGEMENT Dr. Lusk presents the scientific foundations upon which rests our knowl- edge of nutrition and metabolism, both in health and in disease. There are special chapters on the metabolism of diabetes and fever, and on purin meta- bolism; and the nutritive requirements during pregnancy, lactation, growth, etc., are also clearly discussed. Lewellys F. Barker, M. D. Professor of the Principles and Practice of Medicine, Johns Hopkins University. " I shall recommend it highly to my students. It is a comfort to have such a discus- sion of the subject in English." Eichhorst's Practice Practice of Medicine. By Dr. H. Eichhorst, University of Zurich. Edited by A. A. Eshner, M. D. Two octavos of 600 pages each, with 150 illustrations. Per set : Cloth, $6.00 net. Hatcher and Sollmann's Materia Medica A Text-Book of Materia Medica : including Laboratory Exer- cises in the Histologic and Chemic Examination of Drugs. By Robert A. Hatcher, Ph. G., M. D.; and Torald Sollmann, M. D. i2mo of 411 pages. Flexible leather, $2 00 net. Mathews* How to Succeed in Practice How to Succeed in the Practice of Medicine. By Joseph M. Mathews, M. D,, President American Medical Association, 1898- 99. i2mo of 215 pages, illustrated. Cloth, $1,50 net. Bridge on Tuberculosis Tuberculosis. By Norman Bridge, A. M., M. D. i2mo of 302 pages, illustrated. Cloth, $1.50 net. MATERIA MEDIC A AND THERAPEUTICS 15 The American Pocket Medical Dictionary. Sixth Edition, Revised — Just Issued •" The Amkrican Pocket Medical Dictionary. Edited by W. A. Newman Dorland, M. D.. Assistant Obstetrician to the Hospital of the University of Pennsylvania. Containing the pronunciation and defi- nition of the principal words used in medicine and kindred sciences, with 64 extensive tables. Flexible leather, with gold edges, $1. 00 net; with thumb index, $1.25 net. Pusey and Caldwell on X-Rays Second Edition The Practical Application of the Rontgen Rays in Thera- peutics and Diagnosis. By William Allen Pusey, A. M., M. D., and Eugene W. Caldwell, B. S. Octavo of 625 pages, with 200 illustrations. Cloth, $5.00 net. Cohen and Eshner's Diagnosis. Second Revised Edition Essentials of Diagnosis. By S. Solis-Cohen, M. D., Senior Assistant Professor of Clinical Medicine, Jefferson Medical College, . Phila. ; and A. A. Eshner, M. D., Professor of Clinical Medicine, Phila- delphia Polyclinic. Post-octavo, 382 pages; 55 illustrations. Cloth, fil.oo net. In Saunders' Question- Compend Series. Morris* Materia Medica and Therapeutics, Recently Issued — New (7th) Edition Essentials of Materia Medica, Therapeutics, and Prescrip- tion-Writing,. Bv Hexry Morris, M. D. Revised by W. A. Bas- tedo, M. D., Instructor in Materia Medica and Pharmacology, Columbia University. 1 2mo, 300 pages. Cloth, $1. 00 net. Saunders' Compends. Williams' Practice of Medicine Essentials of the Practice of Medicine. By W. R. Williams, M.D., formerly Lecturer on Hygiene and Instructor in Medicine, Cornell University, N. Y. l2mo of 460 pages. Double number, #1.75 net. In Saunders 7 Question- Compend Series. Barton and Wells' Thesaurus A Thesaurus of Medical Words and Phrases. By Wilfred M. Barton, M. D., Assistant to Professor of Materia Medica and Thera- peutics, and Walter A. Wells, M. D., Demonstraior of Laryngology, Georgetown University, Washington, D. C. l2mo of 534 pages. Flex- ible leather, $2.50 net; with thumb index, $3.00 net. Stoney's Materia Medica for Nurses N ew ( 3r< i) Edition Materia Medica for Nurses. By Emily M. A. Stoney, Super- intendent of the Training School for Nurses at the Carney Hospital, South Boston, Mass. Handsome octavo volume of 306 pp. $1.50 net. Grafstrom's Mechano-Therapy Second Revised Edition A Text-Book of Mechano-Therapy (Massage and Medical Gym- nastics). By Axel V. Grafstrom, B. Sc, M. D., Attending Physician to the Gustavus Adolphus Orphanage, Jamestown, N. Y. i2mo of 200 pages, illustrated. Cloth, #1.25 net. 1 6 SAUNDERS' BOOKS ON PRACTICE, Etc. Saunders' Pocket Formulary New (9th) Edition Saunders' Pocket Medical* Formulary. By William M. Powell, M. D. Containing 1900 formulas from the best-known authorities. In flexible leather, with side index, wallet, and flap. #1.75 net- Jakob and Eshner's Internal Medicine and Diagnosis Atlas and Epitome of Internal Medicine and Clinical Diag- nosis. By Dr. Chr. Jakob, of Erlangen. Edited, with additions, by A. A. Eshner, M. D. 182 colored figures on 68 plates, 64 text-cuts, 259 pages of text. Cloth, $3.00 net. In Saunders' Hand-Atlas Series. Lockwood's Practice of Medicine Revi5e f3 d E „ E iS A Manual of the Practice of Medicine. By Geo. Roe Lock- wood, M. D., Attending Physician to the Bellevue Hospital, New York City. Octavo, 847 pages, illustrated. Cloth, $4.00 net. Gould and Pyle's Curiosities of Medicine Anomalies and Curiosities of Medicine. By George M. Gould, M. D., and Walter L. Pyle, M. D. Octavo of 968 pages, 295 en- gravings, and 12 full-page plates. Cloth, $3.00 net. Jelliffe's Pharmacognosy An Introduction to Pharmacognosy. By Smith Ely Jelliffe, Ph. D., M. D., Columbia University, New York. Octavo of 265 pages, illustrated. Cloth, $2.50 net. Stevens' Practice of Medicine New (8th) Edition A Manual of the Practice of Medicine. By A. A. Stevens, A. M., M. D., Professor of Therapeutics and Clinical Medicine, Woman's Medical College, Philadelphia. i2mo, 558 pages, illustrated. Flexible leather, $2.50 net. Paul's Materia Medica for Nurses Materia Medtca for Nurses. By George P. Paul, M. D., Assistant Visiting Physician and Adjunct Radiographer to the Samaritan Hospital, Troy, N. Y. i2mo of 240 pages. Cloth, #1.50 net. Todd's Clinical Diagnosis Recently issued Manual of Clinical Diagnosis. By James Campbell Todd, M. D., Associate Professor of Pathology, Denver and Gross College of Medicine, Denver. i2mo of 319 pages, illustrated. Flexible leather, $2.00 net. "The book before us presents an excellent epitome of the more important labora- tory methods of clinical usefulness which have been tried by the test of experience." — Boston Medical and Surgical Journal.