Columbia (intt)em'tp CoUegc of ^Ijpgiciansj anb ^urgconjs l.iftrarp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/manualofgynecoloOOhirs A MANUAL of GYNECOLOGY BY JOHN COOKE HIRST, M. D. Associate in Obstetrics, University of Pennsylvania; Obstetrician and Gynecologist to the Philadelphia General Hospital; Obstet- rician to St. Agnes Hospital; Gynecologist to Mt. Sinai Hospital; Gynecologist to the American Hospital for Diseases of the Stomach; Fellow of the College of Physicians, Philadelphia WITH 176 ILLUSTRATIONS PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1918 Copyright, 1918, by W. B. Saunders Company PRINTED IN AMERICA PRESS OF W. B. SAUNDERS COMPANY PHILADELPHIA TO THE CLASSES OF THE MEDICAL SCHOOL OF THE UNIVERSITY OF PENNSYLVANIA, PAST PRESENT AND FUTURE, THIS BOOK IS DEDICATED BY THEIR FELLOW-STUDENT, The Author. PREFACE The author has attempted in this volume, so far as it is possible to do so on the printed page, to present the arrange- ment of the subject he has used in teaching during the last twenty years. His ainj has been to present the subject concisely, accurately and without unnecessary waste of space. In several sections, notably those on the injuries of child- birth, their consequences, diseases of the breasts and hemor- rhage, he has thought it best to consider the subject from the point of view of both the obstetrician and the gynecologist, as the two are so intimately connected that to present it in any other way would be at the expense of thoroughness and clarity. Throughout the book, an effort has been made to omit unprofitable discussion, and to give to the student, be he graduate or undergraduate, at least one method of treatment which has proven its value, as a basis on which to build as suggested by the individual's own experience. A special chapter deals witli leukorrhea alone, one of the commonest disorders for which a patient consults her physician, and yet one which, because it is a symptom and not usually a primary condition, is too frequently passed over in the discussion of its primary cause. The operation of dilatation and curettage of the uterus — in the author's opinion is one of the most important, because of its supposed minor character — has been given somewhat extended space, being described three times, as its technic varies slightly for different indications. 11 12 PREFACE Illustrations have been placed to make more clear the points about which students have most often questioned the author, and where he believes their presence is an addition to the explanations in the text. No attempt at lavish illustration has been made. The book is presented with the sincere hope that it may achieve the purpose for which it was written: to give to the medical student a reasonably concise and accurate outline of the subject, and to the busy practitioner the information he may seek, without the need of voluminous reading. • J. C. Hirst. 1823 Pine Street, Philadelphia, Pa., November, tqi8. CONTENTS CHAPTER I Page Normal Pelvic Anatomy 17 The External Generative Organs 17 The Internal Generative Organs 20 CHAPTER II Methods of Examination. Office Treatment 25 Examination of Patient 26 Methods of Local Treatment 41 CHAPTER III Anomalies of Development. Hermaphroditism. Sterility . . 48 CHAPTER IV Diseases of the Vulva 57 CHAPTER V Diseases of the Vagina, Excluding Lacerations and Their Consequences 69 CHAPTER VI Abnormalities of the Cervix Excluding Tears 78 Abnormalities of the Cervix 79 CHAPTER VII The Uterus — Its Normal Position and Relations, Its Abnor- malities OF Position and Diseases 100 Abnormalities and Diseases of Uterus 103 13 14 CONTENTS CHAPTER VIII Page Diseases of Fallopeajn" Tubes 153 I. Normal Anatomy and Relations of Fallopian Tubes .... 15.3 II. Congestion of Fallopian Tubes 155 III. Extra-Uterine Pregnancy(Ectopic Gestation; Tubal Gestation) 156 IV. Hematosalpinx 162 V. Hydrosalpinx (Hydrops Tubae; Sacrosalpinx Serosa) . . . .163 VI. Salpingitis 164 VII. Tuberculosis of Fallopian Tubes 179 VIII. Tumors of Fallopian Tufces 180 IX. Varicocele of Pampiniform Plexus 181 CHAPTER IX Diseases of Ovary 182 Abnormalities and Diseases 185 CHAPTER X Diseases of the Peritoxeum and Pelvic Coxxectr^e Tissue . . 207 I. Pelvic Cellulitis (Parametritis) 208 II. Pelvic Hematocele (Parametrial Hematoma; 213 III. Peritonitis 214 IV. Drainage of the Abdomen, after Operation for Pelvic Infection 216 V. Phleboliths 219 CHAPTER XI .Abxorilalities of Abdominal Wall 220 I. Diastasis of the Recti T;\ath General Visceroptosis 220 II. Exstrophy of the Bladder 221 III. Hernia 221 IV. Obesity ■ 225 V. Patent Urachus 226 CHAPTER XII Injuries of Birth Canal and Their Repair 228 Classification of Injuries _ 228 Injuries to the Pelvis 229 Rupture of the Uterus 229 Lacerations of the Cervix 229 Lacerations of the Anterior Vaginal Wall 235 Vesicovaginal Fistula 237 Tears of the Posterior Vaginal Wall and Perineum 237 CONTENTS 15 CHAPTER XIII Page Pathological Sequels of Childbirth 256 VI. Floating Kidney 256 VII. Fracture of Coccyx 260 VIII. Relaxation of the Sacro-Iliac Joints . 262 IX. Rectocele 262 X. Cystocele 263 XI. Prolapse of Uterus 271 XII. Incontinence of Urine 277 XIII. Genital Fistulae 278 CHAPTER XIV Diseases of the Urinary Tract Including Cystoscopy . . . 283 Cystoscopy 285 Uses of Ureteral Catheter 288 Segregation of Urine ■ . . . 288 Pyelography 288 Diseases of the Urinary Tract 289 CHAPTER XV Gonorrhea .' 305 CHAPTER XVI Normal Menstruation and Its Abnormalities 317 Abnormalities of Menstruation 322 CHAPTER XVII Leukorrhea (The Whites) 336 CHAPTER XVIII Diseases of Breast. 343 I. Anomalies of Development 343 II. Abnormalities of the Nipple 343 III. Non-Inflammatory Diseases of Breast 347 IV. Inflammatory Diseases of the Breast 348 V. Tumors of the Breast 354 ■'■" CONTENTS CHAPTER XIX Diseases of the Rectum ^^^^ I. Congenital Malformations ^^^ II. Fissures of the Anus ^^° III. Fistula in Ano .'.'.'.'.' ^^' IV. Foreign Bodies in the Rectum ^^^ V. Hemorrhoids (Piles) • • • 363 VI. Proctitis (Inflammation of the Rectum) ^^o VII. Injuries of the Rectum ... ^yi VIII. Ischiorectal Abscess .... ' ^ IX. Prolapse of Rectum. . ^ X. Pruritus Ani ' ' ' ^^^ XI. Stricture of the Rectum ^^° XII. Ulcers of the Rectum ^^^ 373 CHAPTER XX Electkicity, x-ray, Radium, Mesothorium and Finsen Light ,74 Radium. ^^^ Mesothorium •^''^ Finsen Light. ^ ■^ 383 CHAPTER XXI Endocrin Glands AND Their Extracts m Gynecology 384 CHAPTER XXII General Technic of Gynecologic Surgery Treatment of Complications after Operation .....[ [ ' 419 Index 441 A MANUAL OF GYNECOLOGY CHAPTER I NORMAL PELVIC ANATOMY The female genitalia are divided into (i) external and (2) internal organs. The external organs are (i) Mons Veneris; (2) Labia majora; (3) Labia minora; (4) CHtoris; (5) Hymen; (6) Vagina, which may properly be included under this head. The internal organs are: (i) The Uterus; (2) The Fallopian tubes and (3) The Ovaries. The following is a brief descrip- tion of these organs. THE EXTERNAL GENERATIVE ORGANS The mons veneris is the name given to the fatty cushion resting upon the anterior surface of the symphysis; covered, in the adult, with a more or less profuse growth of hair. In the female the area covered by the hair is triangular, its base corresponding, to the upper edge of the symphysis. The vulva is the name given to the structures lying beneath the mons veneris. Its direction is horizontal, when the woman is erect. It varies greatly in appearance, depending particularly upon whether or not the woman has borne children. The labia majora are two elongated, rounded masses of fatty tissue covered by skin extending down on either side of the vulva. They are usually 7 to 8 cm. in length, 2 to 3 cm. wide and i to 1.5 cm. thick, becoming narrower and thinner at their lower extremities. They vary in appearance, depending upon the amount of subcutaneous fat. In virgins and nullip- 2 17 1 8 NORMAL pel\t:c anatoaiy arous women they are in close approximation, while in women who have borne children, they frequently gape widely. They are analogous to the scrotum in the male. The labia minora are two narrow, triangular folds of tissue, seen between the upper part of the labia majora, when these are separated. They converge anteriorly, surrounding the clitoris, while posteriorly they merge gradually into the labia majora. Prepuce Labium maius -Labium millu5 ■AntenorVciqmal Wall Pig. I. — Diagram df the external genitalia. The clitoris is analogous to the penis in the male, but differs in having no corpus spongiosum and no urethra. It consists of a glans, a corpus and two crura, and is rarely more than 2 cm. long. Its glans is enclosed by the upper portion of the two labia minora. The vestibule is the almond-shaped area extending from the clitoris to the fourchet, bounded laterally by the labia minora. The portion between the fourchet and the vaginal opening is THE EXTERNAL GENERATIVE ORGANS 19 called the fossa navicularis, and is usually obliterated by childbirth. The vulvovaginal glands, or Bartholin's glands are two compound racemose glands, about the size of a small bean. They are situated under the constrictor vaginae, behind the lower portion of the labia majora. Their ducts, 2 cm. long, open on the sides of the vestibule, just outside of the vaginal opening. They are a frequent lurking place of gonorrhea. They are sometimes called the glands of Duverney, who first described them in the cow. Skene's glands are situated in the floor of the urethra, to either side of the middle line. They are small secretory canals, about half an inch ^' long, whose function is probably that of lubrication. A third, smaller gland is situated in the roof of the urethra. Ordinarily the ducts open through minute orifices inside the meatus, but when inflamed are visible at the meatus. Gonorrhea is prac- tically the only cause of their in- flammation. The hymen is the membranous structure which more or less completely occludes the vaginal opening. It presents marked differences of shape and thick- ness. The most common shape of the hymenal opening is crescentic or circular. The most important of the other forms are the septate, the cribriform and the fimbriated hymen. It is usually ruptured at the first coitus, the ruptures being mul- tiple and most often in the posterior portion. It is usually destroyed by childbirth, the atrophied remains being known as myrtiform caruncles. Very rarely it is imperforate. It may also persist unruptured after coitus or even childbirth. Pig. 2. — Section illustrat- • ing the characteristic form of the vaginal cleft: Ua, Urethra; Va, vagina; L, levator ani; R, rectum. {Henle.) 20 NORMAL PELVIC ANATOMY The vagina is a musculomembranous canal extending from the vulva to the uterus. It runs through the pelvic floor, and its walls are normally in close apposition. A cross-section of the vagina resembles the letter H. The vagina is about 8 cm. long anteriorly and lo cm. long posteriorly. The shape of the anterior and posterior walls is triangular, the canal being broadest near the cervix. A prominent longitu- dinal ridge projects from both the anterior and posterior walls, known as the anterior and posterior vaginal columns. From this ridge, in women who have not borne children, extend numerous transverse folds, known as rugae. These disappear after repeated childbirth, and the vaginal walls are then frequently smooth. The vagina is lined by a mucosa composed of numerous layers of stratified squamous epithelium. The vaginal mucosa contains no glands. In embryos the vagina is composed of a solid mass of polygonal cells. The vaginal lumen is formed about the third month of fetal life, by the degeneration of these cells. THE INTERNAL GENERATIVE ORGANS The uterus is a hollow muscular organ, partially covered with peritoneum. It lies in the pelvis, between the bladder and the rectum. Its axis is approximately at right angles to the vagina. It is pear-shaped, slightly flattened antero- posteriorly, and consists of a body and a neck or cervix. The uterus, in the adult female is about two and one-half inches long and weighs about two ounces. The uterus is composed of an inner epithelial layer, a middle muscular layer and, in its upper two-thirds, an outer or peritoneal layer. The inner layer, which lines the cavity, is called the endo- metrium. It is a thin velvety membrane, about one or two millimeters in thickness, composed of a surface epithelium, a stroma of short spindle cells, and small tubular glands, lined by columnar epithelium. The surface epithelium is a single layer of ciliated columnar epithelial cells. The stroma THE INTERNAL GENERATIVE ORGANS 21 contains numerous blood and lymph channels. In the cervix are seen numerous ridges of mucous membrane, radiating from a central ridge, the figure being known as the arhor vitcB or plica palmatcs. The uterine muscle, or the myometrium, is composed of bundles of non-striated muscle fibers, united by connective tissue containing many elastic fibers. The arrangement of these bundles is still a matter of dispute. The uterine blood- vessels are very numerous, and pierce the uterine wall in all directions. The ligaments of the uterus are ten in number, viz.: Two broad, two round, two uterosacral, two uterovesical and two cardinal. In the bases of the broad figments are two bands of dense connective tissue which are often regarded as ligaments of the uterus — the cardinal, ligaments. They are attached to the supravaginal portion of the cervix. The uterine ligaments are partly suspensory and partly act as guy ropes. The blood-vessels of the uterus are the uterine and ovarian arteries, which anastomose and send numerous branches to the uterus. There is quite free communication between the vessels on the two sides of the uterus. The veins form a large plexus around each uterine artery, form the uterine veins and empty into the hypogastric vein. The return blood from the ovary and upper part of the broad ligament is collected by veins -which form a large plexus— the pampiniform plexus. The vessels from this form the ovarian veins and the ovarian veins empty, the left into the renal; the right, into the inferior vena cava. The Lymphatics of the Uterus. — The lymphatics of the uterus terminate in different glands. Those from the cervix empty into the hypogastric glands; those from the uterus into the deep lumbar glands, situated in front of the aorta, about the level of the kidney. The nerves of the uterus are derived partly from the third 22 NORMAL PELVIC ANATOMY and fourth sacra] nerves, but chiefly from the sympathetic nervous system. The Fallopian tubes are two convoluted muscular canals extending from the uterine cornua through the upper portion of the broad ligaments. They are 12 to 14 cm. long, the left being shghtly the longer. They are divided into the uterine portion, extending from the cornu to the upper angle of the Pig. 3. — The arteries of the uterus and ovaries: 0,A., Ovarian artery; b, artery of the round Hgament; b', branch to the tube; c, c, c, branches to the ovary; d, continuation of main trunk; e, branch to the cornu; U.A.. uterine artery; e, main trunk;/, bifurcation; g, vaginal branches; /;, vaginal branch from the cervical artery. (Hyrtl.) uterine cavity; the isthmus, the narrow portion of the tube ad- joining the uterus; the ampulla, or wider portion of the tube, and the fimbriated extremity or abdominal opening. These fimbria are exuberant folds of the lining mucous membrane, and one of them — the ovarian fimbria — extends nearly or quite to the ovary. THE INTERNAL GENERATIVE ORGANS 23 The tube is composed of an inner mucous, a middle muscular and an outer peritoneal layer. The lining mucous membrane is composed of a single layer of high columnar ciliated cells, resting upon a thin basement membrane. There is no sub- mucosa. The mucosa is arranged in folds which vary from a comparatively simple arrangement near the uterus to an extra- ordinarily complex one near the abdominal end. The cilia lash towards the uterine cavity. The muscular coat is composed of two layers of non-striated muscle, an inner circular and an outer longitudinal one. Some of the inner fibers run longitudinally also. The caliber of the tube varies from the uterine end, which will admit a bristle, to the ampulla which admits a fine probe. The Ovaries. — The ovaries are two almond shaped organs, slightly flattened, lying against a small depression in the pos- terior surface of the broad ligament, and attached to the liga- ment by the mesovarium. The ovary is of a mother of pearl color, 5 cm. long, 3 cm. broad and 1.5 cm. thick, weighing about 8 grams. The hilus of the ovary is that portion of the margin to which is attached the mesovarium. The external appearance of the ovary varies with the age of the woman. In young women its surface resembles mother of pearl, through which show a number of small vesicles— the graafian follicles. In older women the ovary is rough and corrugated, and it atrophies rapidly after the menopause. The ovary is divided into the medulla or central portion, which contains the blood-vessels, and the cortex, which contains the blood-vessels, and the cortex which contains the mature and immature follicles. The blood-supply of the ovary is derived from branches from the ovarian artery. An ordinary Graafian follicle is simply a connective tissue space in the cortex, containing a highly specialized cell — the ovum — and surrounded by a wreath of capillary blood-vessels. A mature Graafian follicle consists of a connective tissue covering — the theca folliculi — ; an epithelial lining and the membrana granulosa; the liquor folliculi and the ovum. The 24 NORMAL PELVIC ANATOMY ligaments of the ovary are two in number, the utero-ovarian running from the inner side of the hilus to the uterus, and the infimdibulo pelvic, a thin band of fascia running from the outer side of the hilus, just under the top of the broad ligament, to the lateral pelvic fascia. The pelvic floor is composed chiefly of the levator ani, the transversus perinei, superficial and deep, the bulbocavernosus, the anterior and posterior triangular ligaments, the coccygeus and the sphincter ani muscles. The levator ani is far the most important. It consists of two halves, passing back from the anterior pelvic wall and encircling the vagina and rectum. It is a muscular band as broad as the first two joints of the index finger, and is the chief support of the rectum and posterior vaginal wall. The deep transversus perinei muscle is that portion of the levator ani which has a separate sheath and is inserted in the perineal body in the middle line. It lies between the super- ficial and deep perineal fascias, or triangular ligament. The anterior triangular ligament is an extension of Colles' fascia. The bulbocavernosus muscles are in the labia majora and keep the labia in apposition. The pelvic floor will be more fully discussed in the Chapter on Injuries of the Birth Canal (Chapter XII). The lymphatics of the perineum and lower two-thirds of the vagina empty into the inguinal glands in the groin. Those of the upper one-third of the vagina, cervix and corpus uteri go as already described. There is a possible metastasis in cancer of the fundus uteri to the groin, along the round liga- ment, which does not exist in cancer of the cervix. CHAPTER II METHODS OF EXAMINATION. OFFICE TREATMENT I. History Taking. — It is important to follow a definite plan in taking the history of any patient, and especially so in gynecological cases, because of the intimate relation of symptoms from the pelvic organs to those of the general organism. It should be remembered, however, that the patient's recital of her symptoms is likely to be influenced by her nervous condition, and no attempt should be made to arrive at a diagnosis by the history alone. Its value is partly relative to the results of the pelvic and abdominal examina- tions. The following points are to be covered routinely: I. Age. 2. Married or single. 3. If married, how many children; how many living; cause of death. 4. Character of pregnancies. 5. Character of labors; spontaneous; long or* short; forceps? Any fever during convalescence? 6. Number of abortions or miscarriages, and at what date o| pregnancy they occurred. 7. Beginning of menstruation; interval; pain and when pain is most marked; duration of flow; amount of flow. 8. Leukorrhea? If so, amount? irritating or not? color? how influenced by menstrual flow? 9. If menopause, how long time, and whether any disagree- able symptoms (hot flashes, nervousness, irregular bleeding). ID. Have the patient explain symptoms which led her to con- sult a physician, and amplify her recital by questions relevant to the complaints (such as backache, headache, constipation, etc.). Backache is one of the most common symptoms and should always be asked for. 11. Family history as regards tuberculosis, carcinoma. 12. Questions regarding previous treatment or operations, particularly the latter. 13. Pre- ss 26 METHODS OF EXAMINATION. OFFICE TREATMENT quency of urination; amount and character of urine passed. 14. Nervous symptoms, if any, such as depression, irritability, worry, sleeplessness, etc. These are the routine questions in the average history; others are often suggested by the symptoms which caused the patient to seek relief. EXAMINATION OF PATIENT I. Abdominal examination is best carried out with the patient flat on her back, with knees slightly elevated, to relieve Pig. 4. — Palpation of the abdomen. (After B. C. Hirst.) tenseness of the abdominal muscles. The corset should be removed, all clothing loosened, and the patient so draped with sheets that there is no unnecessary exposure . Unless the bladder, rectum and sigmoid are empty, a thorough exami- nation cannot be made. The routine points for examination are: I. Elasticity of abdominal wall. 2. Diastasis of recti. 3. Both kidneys examined for position and mobility. 4. EXAMINATION OF PATIENT 27 Palpation for splanchnoptosis and points of tenderness. The latter particularly over the appendix and both groins. 5. Palpation for any growth, mass, or tumor. 6. Percussion of entire abdomen, to note gastroptosis, dilated stomach, or dullness from growths or ascites. 7. In fat subjects, test thickness of abdominal wall. 8. In abdominal tumors, Pig. 5. — Points of tenderness in abdominal examinations, and their prob- able significance. {After Grossest.) mensuration or measuring is required to determine their rate of growth. The diameters measured are: I. The greatest girth of the abdomen. 2. The distance from ensiform to umbilicus. 3. The distance from umbilicus to symphysis. 4. The distance between the anterior superior spines of the iha. 5. The distance between the anterior superior spines of the ilia and the symphysis. 6. The distance 28 METHODS OF EXAMINATION. OFFICE TREATMENT between the anterior superior spines of the iha and the umbilicus. Examination of the pelvic organs by palpation is carried out in one of the following positions : I, The dorsal or lithotomy position is the one in which most examinations are made. The patient is arranged on the table on her back, with her hips at the edge of the table. The Pig. 6. — Lines for mensuration, to determine the rate of growth of ab- dominal tumors. {After B. C. Hirst.) thighs are well flexed on the abdomen and the legs on the thighs, and the feet are supported in stirrups or other suitable leg supports. The patient is then so draped in a sheet, that only the mons veneris, external genitalia and part of the buttocks are exposed, avoiding all unnecessary exposure. When possible, the examination is made with the index and middle fingers of the left hand in the vagina, and the right hand is used for counter pressure on the abdomen (bimanual EXAMINATION OF PATIENT 29 examination). It is often necessary to use only one finger, on account of a narrow vaginal canal, and in this case the index and not middle finger should be used. In virgins vaginal examination is to be avoided and rectal examination substi- tuted. In making the digital examination of the vagina, care should be taken to avoid pressure on the region around the clitoris and vestibule, causing unnecessary pain. All move- ments should be gentle, and the use of rubber gloves for all examinations is wise. Glycerin, glycerin jelly or the glycerin Pig. 7. — Patient draped for vaginal examination in the dorsal or lithotomy position. (After B. C. Hirst.) base unguents dispensed in tubes are all better than vaselin as a lubricant for the examining fingers. In examining for tubes and ovaries, the hand corresponding to the side examined must be used, i.e., the right hand for the patient's right side, and the left hand for her left. Counter- pressure with the free hand on the corresponding groin is required, but this examination is only satisfactory when the patient is thin and does not resist. 2. Rectal examination is often desirable after the ordinary 30 METHODS OF EXAMINATION. OFFICE TREATMENT bimanual vaginal examination, as the patient is already in position for it, and the posterior wall of the uterus and the tubes and ovaries can often be felt better in this way. Rectal examination should always be done in preference to vaginal examination in virgins. The forefinger only, protected by a glove, is inserted to its full length in the rectum, and by counter- pressure on the abdomen a surprisingly satisfactory examina- tion can be made. Fig. 8. — Bimanual examination of the uterus. (After Kelly.) 3. Sims' or left lateral position is used more often in inspection of the cervix and local treatment to the cervix and vagina than in examinations. The patient is placed on her left side, the left leg flexed on the abdomen, the right more so than the left and falling over the left so as to let the right knee touch the table on which she is lying. When the perineum is retracted, the vagina is distended with air, the uterus falls out of the pelvis, and any method of local treatment is thereby facilitated. The position is not adapted for digital examinations. 4. The gemipectoral or knee-chest position has the same ad- EXAMINATION OF PATIENT 3 1 vantages, though to a greater degree, as the Sims' position. It is not adapted for digital examinations. The patient kneels Fig. 9.— .Patient in the Sims or left lateral position. (After B. C. Hirst.) upon the table, and leans forward until her chest touches the table, the head being turned to one side. The hips are Fig 10. — Knee-chest elevated position. (Ashton.) kept as high as possible, and the thighs must be perpendicular to the support on which she is kneeling. The position is 32 METHODS OF EXAMINATION. OFFICE TREATMENT used chiefly in local treatments of the cervix and posterior vaginal vaults, and to replace a retroverted uterus. 5. The erect posture for examination is required to (i) determine the degree of uterine prolapse, which may be masked as the patient lies on her back, particularly if she has been in bed for some days; (2) to determine the fit of a pessary, either for retroversion or prolapse; (3) to detect injuries to the symphysis. The patient is arranged, standing up, with her skirts pinned up or removed, and draped in a sheet, pinned around her waist so that it falls to the ground, and the edges of the sheet overlap in front. The physician kneels facing the patient, his hand is inserted through the opening between the two edges of the sheet, and the forefinger passed into the vagina. The position is not often required, but is useful for its special indications. Examinations under anesthesia are required in the following conditions : I. In young girls. 2. In virgins where on account of re- sistance rectal examination is unsatisfactory. 3. In any patient too nervous or sensitive to permit a satisfactory examination. 4. In vaginismus. 5. In any case of obscure diagnosis. The best anesthetic is chloroform, which gives perfect relaxation, and has a minimum of unpleasant after-effects. Only a very small amount is required, as the anesthesia is short. Ether is unpleasant to take and more likely to cause nausea. Nitrous oxid and oxygen would be the ideal anes- thesia except for the fact that sufficient relaxation is often difficult to secure. Very nervous patients, and particularly young girls, should be anesthetized in bed, and not be arranged in position for examination until completely under the anesthetic. In this way, they have no unpleasant memories of the preliminary preparation for the examination. EXAMINATION OF PATIENT 33 Aids to Diagnosis. — Specula. — The specula required are: (i) Sims', (2) some form of bivalve speculum and (3) a skeleton bivalve speculum. The Sims' speculum is most useful in its original form of a single instrument. The double ended specula, designed to provide two different sized specula in the one handle, are often somewhat awkward to use. The spec- ulum is inserted edgewise, with the handle at right angles to the vertical axis of the vulvar orifice, and then turned so that Fig. II. — a, Collin's bivalve speculum; b, Sims speculum; c, wire valve speculum, for exposure of the cervix and vaginal walls. bi- the handle is directly downward. To give a clear view of the cervix, when the Sims' speculum is used in the dorsal position, a retractor for the anterior vaginal wall is required. This is not necessary in the Sims' or the knee-chest position. Bivalve Speculum. — The most useful form is the Collin. Two sizes should be provided — for nulliparous and multipar- ous patients. To insert the speculum, in the dorsal position, a digital examination is made, with one finger, to determine where the cervix is. The vagina does not run straight, in 3 34 METHODS OF EXAMINATION. OFFICE TREATMENT but downward at an angle of forty-five degrees to the support on which the patient is lying. When the direction of the cer- PiG. 12. — Sims' speculum. Blades of two sizes in one instrument. vix is found, the speculum is lubricated, held in the right hand, with its blades closed. The finger used to find the cer- PiG. 13. — Bivalve speculum in position with blades open. The cervix appears between the blades. vix now pulls the perineum gently downward. The speculum is inserted edgewise, for about one- third of its length; is then EXAMINATION OF PATIENT 35 turned transversely and pushed in the direction of the cervix, downward at an angle of forty-five degrees. When inserted its full length, the blades are separated and the cervix should appear between them. Very commonly, nothing appears but the anterior vaginal wall. This means that the angle at which the speculum has been inserted is not steep enough, and the blades should be allowed to collapse, the speculum is slightly withdrawn, re-inserted at a steeper angle, and the blades reopened. The blades can then be held open by a set screw provided on the instrument, and as this type of speculum Fig. 14. — The commonest mistake in the use of a bivalve speculum. The instrument has been inserted at too slight an angle, and nothing ex- cept the anterior vaginal vault appears between the blades. is self-retaining, both hands of the physician are left free for the necessary treatments. In removing the speculum, it is withdrawn for about an inch, the blades are allowed to collapse, and it is withdrawn, turning it edgewise as it is taken out. Unless it is sHghtly withdrawn before allowing the blades to collapse, the cervix is pinched and pulled upon, causing avoidable pain, by pulling on the uterus and broad ligaments. 36 METHODS OF EXAMINATION. OFFICE TREATMENT The skeleton bivalve speculum is used in precisely the same way as the soHd bladed one. Its advantage is in permitting appHcations to the vaginal walls, which are of course covered by the soHd bladed instrument. Fig. 15.— B. C. Hirst's double ten- acula for the cervix. Fig. 16. — Thomas' uterine dressing forceps. Double tenacula or "bullet forceps" are sometimes very useful in the reposition of a retroverted uterus, or in pulling down the uterus to make examination of its posterior wall easier. The small punctures in the cervix, caused by the teeth of the instrument are negligible, but care should be taken EXAMINATION OF PATIENT 37 to use a model with sufficient clearance between the blades, so that the cervix is not pinched. ■"iG. 17. — Emmet's curet forceps. Fig. 18. — Simpson's uterine sound. Uterine dressing forceps are of two types: The Thomas uterine applicator, a narrow bladed instrument used for appli- cations to the cervical canal, or even uterine cavity, and the 38 METHODS OF EXAMINATION. OFFICE TREATMENT Emmet curetment forceps a heavier instrument, to be used when greater sohdity and grip are required. A uterine repositor, to be used in replacing a retroverted uterus, is a kidney-shaped ball of metal on a long handle. It is used to pry the uterus forward, assisted by a double tenaculum in the cervix, with the patient in the knee-chest position, by making pressure in the posterior vaginal vault. It is not a necessary instrument, as a pledget of cotton held in the grasp of an Emmett curettement forceps makes a more efficient one. The uterine sound is a long probe, with a flat handle to secure a firm grip, graduated from o to 9 inches on the shank. It has been used to determine the direction and length of the uterine cavity, but is fortunately falling more and more into disuse. The less the uterine cavity is invaded, in office work, the safer the patient. When the sound is used it must be inserted by sight, through a bivalve speculum, and after the cervix has been sponged off with an efficient antiseptic solution. It should never be inserted by sense of feel. Artificial light is often required. Reflected light from a head mirror is difficult to control and focus. Specula provided with electric bulbs on the blades are very useful as long as the bulb remains clean and does not blow out, but they cannot be boiled with the bulbs in place. The best light is an electric headUght, with a head band to secure it in place; the current either from the street circuit or a battery. Sterilization of Instruments.- — All instruments must be boiled before and after use. Specula must be warmed before being used, if they have cooled after sterilization, as the touch of cold metal is unpleasant to most patients. Oflfice Equipment.- — Table. — A table permitting the dorsal, Sims', knee-chest, sitting and prone positions is essential for satisfactory examinations. A most satisfactory one has a steel frame, adjustable leg supports and is provided with a drainage trough, for fluids used in irrigating and douching. The table is placed where a good horizontal light is available. EXAMINATION OF PATIENT 39 Vertical light from a skylight without horizontal light from a window is useless. Sterilizers should be provided for instruments, dressings and water. Combination sets of instrument, dressing and water sterilizers, are the most practical and satisfactory. An instrument cabinet is most useful, but not essential. The instruments most often required can be kept in the in- strument sterlizer, as a container, and used from there. Rubber gloves for examinations should be used routinely. They are a great protection to both physician and patient. Artificial light, concentrated in a beam, is often required for inspection of the cervix through a speculum. The best form is a headlight, with forehead band, fed from a battery or street circuit. A pocket flashlight is useful, but a beam re- flected from a head mirror is not satisfactory. Glass jars, to contain pessaries, cotton, tampons, etc., and wide-mouthed glass bottles for solutions such as nitrate of silver, boroglycerid, ichthyol, etc., are essential. Office Nurse. — It is most desirable that the physician be assisted in his examinations by a nurse, or failing this, a woman who can easily be trained in the management of patients, sterilization of instruments and supplies and as assistant in offlce treatments. Such an arrangement is most acceptable to his patients, and affords protection to the physician himself. Instruments required have already been listed under the head of "aids to diagnosis." Other supplies needed will be de- scribed under "methods of local treatment." Electricity is gaining considerable vogue as a method of office treatment, as high frequency, galvanic, f aradic or sinus- oidal current. A wall cabinet or portable apparatus is a most useful, though a somewhat expensive article of office furniture. Gynecologic examinations in private houses are very fre- quently required. It is usually necessary to examine the patient in bed, and for the examination she is arranged across the bed, with her feet on two chairs, and her hips over the edge of the bed. The chairs are arranged facing each other, 40 METHODS OF EXAMINATION. OFFICE TREATMENT with considerable space between them, to give the physician ample room for examination. Should a table be required, one can be improvised out of a kitchen table, with the top suitably padded by a blanket. The patient's knees are held back by a nurse, or can be secured by a rolled sheet, tied above one knee, passing behind the patient's back, over one shoulder and out under the other, and tied above the other knee. Whether Fig. 19. — Proper way to arrange a patient across the bed for vaginal examination. Ther« is plenty of room, and the chairs are out of the way. she is in the dorsal position in bed or on the table, the patient is so draped in a sheet that unnecessary exposure is avoided. For abdominal examination the patient is arranged flat on her back, with the abdomen exposed, but a sheet covering the lower portion of the body and a second sheet or large towel covering the upper portion, so that only the abdomen from the costal arch to the upper margin of the pubic hair is exposed. It is not advisable to try to make abdominal examinations with the abdominal surface covered by a sheet or towel. The METHODS OF LOCAL TREATMENT 41 two greatest problems in examinations in private houses are (i) low beds and (2) poor light. The first can be overcome by using a table, though the bed is rarely so low as to interfere much with examinations. If local treatment be required, however, a table is much better. Sufficient light may be had by a pocket flashhght, or head- light with portable battery, or by having a lamp held by a third person. In emergencies a candle with a large polished Fig. 20. — Wrong way to arrange a patient across the bed for vaginal examination. The chairs are so close together that there is no room for examination. spoon held behind it as a reflector, will furnish a surprising amount of light. METHODS OF LOCAL TREATMENT Tampons are made of wool; wool and cotton; or all cotton. Those made of wool are decidedly, the best. They are de- signed to apply solutions or powders to the vaginal vaults and 42 METHODS OF EXAMINATION. OFFICE TREATMENT retaining them in place for any desired length of time, usually twenty-four to thirty-six hours. Tampons can be made as required by taking a piece of wool or cotton six inches by three inches, doubling the ends in past the middle, so that they over- lap, and tying a piece of string tightly around the mass at the point where the ends overlap. The ends of the string are left about three inches long and tied together so as to form a loop, by which the tampon can be removed after it is inserted. A number should be made up at a time, sterilized, and kept in a glass jar with dust-proof top till required. Pig. 21. — A wool tampon. Uses. — Tampons are used chiefly in the follo'v\nng condi- tions: (i) Erosion of the cervix; (2) moderate pehdc inflamma- tion, with adhesions but without a palpable mass; (3) adherent retroversion of the uterus (to replace by constant pressure); (4) chronic inflammation of the cervix and vagina. Medication. — Any solution or powder may be used, but those in most common use are: (i) Boroglycerid (a 25 per cent, or 50 per cent, solution of boric acid in glycerin) probably the most useful single application; (2) ichthyol and glycerin, in the strength of 60 per cent, ichthyol and 40 per cent, glycerin; (3) nitrate of silver, in strengths of 4 per cent, to 10 per cent.; (4) boric acid powder; (5) tannic acid powder. In using these medicaments, it must be remembered that both ichthyol and nitrate of silver will stain the patient's METHODS OF LOCAL TREATMENT 43 underclothes indelibly, particularly if an excess of solution be used. Insertion of Tampons. — The patient is arranged in the dorsal position, and a Sims' or better a bivalve speculum is inserted. A tampon is grasped in a pair of Emmet curetment forceps and thoroughly saturated with the solution to be used. The tampon is inserted in the vagina, through the speculum, and is placed with moderate pressure against the cervix. Two or three other dry tampons are inserted below it, to retain the first one in place. They are held in place as the speculum is removed. The patient is told how many have been used, so a corresponding number can be removed. If it is desired to make considerable pressure, as in a case of adherent retrover- sion of the uterus, the tampons should be inserted in the knee- chest posture. The patient herself removes the tampons, by the loops of string provided for the purpose on each tampon, at the designated time. A satisfactory chronologic arrangement for tampons is as follows: The patient comes to the office Monday morning and the tampons are inserted. She lemoves them Tuesday morn- ing, takes a douche Tuesday morning and evening, and Wednes- day morning. On Wednesday morning, she comes to the office for a fresh supply, which she removes Thursday morning. She takes a douche Thursday morning and evening, and Friday morning. On Friday morning she comes to the office for a fresh supply. She removes these on Saturday morning, takes a douche Saturday morning and evening, Sunday morning and evening and on Monday morning begins the routine again. Usually a course of tampon treatment should last three to four weeks. Local applications are best made through a bivalve or Ferguson cylindrical speculum. Two methods are available. The solution to be used can be poured in the speculum until the cervix is covered, and the speculum then withdrawn slowly so as to bathe the vaginal walls in the solution. A better and less wasteful method is to apply the solution directly to 44 METHODS OF EXAMINATION. OFEICE TREATMENT the points desired by an applicator wrapped with cotton or a camel's hair brush, through a skeleton wire bivalve speculum. Indications. — (i) Erosion of the cervix; (2) ulcers on cervix or vaginal walls; (3) patches of acute inflammation of cervix or vaginal walls; (4) diffuse acute or chronic inflammation of cervix or vagina. The most useful solutions are: (i) Nitrate of silver 40 or 60 grains to the ounce — by far the most useful; (2) pure car- bolic acid — neutralized later by application of alcohol; (3) tincture of iodin 5 per cent, or 7 per cent.; (4) ichthyol, either pure or diluted equal parts with glycerin. If nitrate of silver solution is used, by pouring in through speculum, the patient will often complain of considerable burning. This can be relieved by a douche of salt solution (half an ounce to four pints of water), either in the office or after she has returned home, Counterirritation to the vaginal vaults of 10 per cent, tincture of iodin is in common use, but of questionable value. As a local disinfectant, in cases of acute gonorrhea or other infection, it has merit, but as a palliative of tubal and pelvic inflammation (the purpose for which it is usually used), it is of doubtful value. Douching. — The vaginal douche is the most frequently used of all methods of local treatment. Uses. — (i) As a cleansing agent; (2) to apply antiseptics or astringents in solution; (3) to apply heat. As in most cases the patient will use the douche herself, and as she is usually uninstructed in its use, the following directions will prove useful. Directions for Taking a Douche. — i. Always in the recumbent posture, preferably in a bath tub, 2. Use fountain syringe and never a forced flow. 3, Boil syringe and nozzle, and use boiled water. 4. Use only mild antiseptics, such as boric acid, 10 grains to the ounce; permanganate 1-3000, and not bi- chlorid or carbolic acid. 5. Have water comfortably hot. Never cold. 6. Have syringe not more than two feet above METHODS OF LOCAL TREATMENT 45 body. 7. Control flow, so that four quarts will take fifteen minutes to flow through. 8. Use nozzle with blind end, and opening in side. 9. Do not use hot douche just before, during, or just after period. The water should never be forced in by a bulb or pressure syringe. If the stream from such a syringe should strike the externa] os, water and leucoriheal discharge might easily be forced in the uterine cavity and thence through the Fallopian tubes into the peritoneal cavity. Instillations. — In chronic cases, where there has been a long standing infection, gonorrheal or otherwise, it is likely to localize in Skene's glands, Bartholin's glands, the cervical canal or the endometrium. It can only be reached by instillation of antiseptic solutions, or better antiseptic paste, into the affected canals. Medication. — (i) Nitrate of silver 40 to 60 grains to ounce; (2) carbolic acid and 10 per cent, tincture of iodin, equal parts; (3) ichthyol and glycerin, equal parts; (4) argentide paste 20 per cent, (much the best); (5) in Skene's glands, obliteration by the electric cautery. Chronic infection of Skene's or Bartholin's glands can be reached by instillation with a hypodermic syringe with blunted needle. The duct of the affected gland is recognized by the reddened areola around it, the needle inserted in the duct and the whole gland injected. Cervical and intra-uterine instillation requires a Braun syringe, merely a hypodermic syringe with a long metal nozzle. Technic. — i. A double tenaculum, bivalve speculum and a Braun syringe and nozzle are boiled. 2. The patient is arranged in the dorsal position and the cervix exposed through the bivalve speculum. 3. If necessary, though usually it is not, the anterior lip of the cervix is caught with a double tenaculum. 4. The cervix is sponged off with i per cent, formalin solution. 5. The Braun syringe is fiUed and the nozzle is inserted in 46 METHODS OF EXAMINATION. OFFICE TREATMENT the cervical canal: the internal os for cervical oi to the fundus uteri for uterine instillation. 6. The contents of the syringe are slowly expelled as the syringe is being wifhdrawn. This method, as well as that of intra- uterine applications (of iodin or other anti- septics) is not free from danger. With the precautions as indicated above, infection is not to be feared, but in spite of all care, certain patients will suffer severely or even alarmingly from uterine colic, with \-iolent pain and severe shock. Should such an acci- dent happen, rest, hot water bag to lower abdomen, hypodermic of morphin gr. 3^^ and atropin gr. ^ {50, and stimulation are required. Local blood-letting and the puncture of Nabothian cysts are methods of ofhce treat- ment belonging to the older school of treat- ment, and rapidly falling into disuse. Irrigations are required for the urethra, bladder, and occasionally for the uterus. Urethral irrigations are nearly always done for urethritis of gonorrheal origin, especially the urethritis that persists after the destruc- tion, by cautery, of Skene's glands. The best instrument is Skene's reflux or corru- gated catheter, inserted first into the bladder and then pulled back so that the tip is out- side the grip of the vesical sphincter, and urine ceases to flow. The catheter is con- nected with the tube of a fountain syringe and the solution (preferably boracic acid, gr. X to oz. i) is allowed to flow through the catheter and back through the corrugations. Bladder irrigation is required for chronic cvstitis and as a means of distention in con- FiG. 22. — Syringe for intra- uterine instilla- tions. Being of metal and glass, it is sterilized by boiling. METHODS OF LOCy\L TREATMENT 47 tracted bladder. Boracic acid solution (gr. x to oz. i) is the solution used. It is best introduced into the bladder by a rubber catheter connected to a four-ounce glass or metal funnel. Four or eight ounces of solution are introduced at a time, and then allowed to flow back through the catheter and funnel. Uterine irrigation is rarely indicated in office work. Con- siderable dilatation of the cervix is required, and patients requiring uterine irrigation are usually confined to bed. The Pig. 23 — Pritsch-Bozemann intra-uterine douche: L, Inlet; R, outlet; 5, screw junction. irrigation is given by means of a Fritsch-Bozemann intra- uterine douche nozzle, connected to a fountain syringe. Not more than two feet elevation of the douchebag is allowable. Sterile water or weak antiseptic solutions (such as boracic acid gr. x to oz. i; nitrate of silver 1-5000; lysol i dram to 4 pints; potassium permanganate 1-3000) should be used. In all irrigations, the temperature of the solution used should be iio°-ii5°F. CHAPTER in ANOMALIES OF DEVELOPMENT, HERMAPHRO- DITISM. STERILITY Absence of genital tract is rare, but possible as a whole or in part. If the entire tract is absent there is nothing to be done in the way of treatment; partial absence, as of the vagina, usually requires extensive plastic work, to be described under the heading of Atresia. Abnormalities of the Hymen. — The hymen is normally a delicate membrane partially occluding the vaginal outlet, with an opening in which the tip of the index finger may be inserted. Its abnormalities are: I. Double opening (septate hymen). 2. Numerous open- ings (cribriform hymen). 3. Dentated (irregular edges of opening). 4. Imperforate hymen. 5. Thickened hymen, so dense as to resist coitus. Occasionally the hymen may be so elastic that it is not rup- tured by coitus, or even by delivery of a child. Normally, however, the membrane is ruptured by coitus, and destroyed by childbirth. After delivery, the hymen is represented by small irregular tabs of tissue, called myrtiform caruncles. A hymen occluding the vaginal opening or so dense as to be a barrier to coitus, demands excision rather than incision. It is trimmed away with scissors, and the edges of the linear wound coapted by enough sutures, of number one chromic catgut, to control bleeding. The bleeding from rupture of the hymen at coitus is normally negligible, but occasionally it is so profuse as to require one or more ligatures. The Development of the Genital Tract and its Anomalies. — At the end of the fourth week in embryonal life, the Wolffian bodies are formed. Two weeks later the genital glands cov- HERMAPHRODITISM. STERILITY 49 ered with "germinal epithelium," appear just inside the Wolffian bodies. Coincidently there appear two ducts, out- side the Wolffian bodies — the Miillerian ducts. The ovaries are developed from the primary genital glands; the entire genital tract, to the vulvar orifice, is developed from the Miillerian ducts. The Miillerian ducts are at first solid, and only from the ninth week of fetal life on do they acquire lumen. The vagina is still solid, after the uterine cavity is formed. Malforma- tions of the genital tract result from either atresia of one or both Miillerian ducts or a failure of fusion. About the fifth month of fetal life, the vaginal portion of the uteruS' — the cervix — is formed. The fundus of the uterus rounds out, and the double cavity disappears. The hymen is formed about this time. The development of glands in the endometrium is late, those of the cervix developing first, but in some instances the glands do not develop before the tenth or twelfth year. At birth, the cervix is much better developed than the uterine body. The retrogression of the Wolffian body and ducts begins at the eighth week and is completed at the sixteenth week of fetal life. The remains of these struc- tures persist in the broad ligament as the parovarium. That portion of the Wolffian duct below the parovarium sometimes persists as a canal, known as Gartner's duct. Usually only short segments remain, but it has been traced through the uterus, anterior vaginal wall to an opening at the hymen. Congenital anomalies of the uterus are due to atresia of one or both ducts of Miiller, or to their failure of fusion. I. Uterus didelphys— with double vagina. 2. Uterus du- plex bicornis, with double or septate vagina. 3. Uterus duplex bicornis, with single vagina. 4. Uterus bicornis uni- collis. 5. Uterus unicornis — where one duct has atrophied. 6. Uterus cordiformis (heart shaped). 7. Uterus incudi- formis (flat top, like an anvil). 8. Uterus septus (external form of uterus normal, but cavity divided). 9. Uterus subseptus 50 ANOMALIES OF DEVELOPMENT (external form of uterus normal, but partial septum in cavity. Normal in horse and ass). lo. Uterus biforis (cervix di- vided by a septum — normal in the ant-eater). ' Double uteri are usually asymmetrically developed, and if pregnancy occurs it is usually in the better developed half — repeated pregnancies occurring in the same half. Pregnancy in a uterus unicornis is usually diagnosed as extra-uterine pregnancy, and the true condition seen only at opera- tion. If the opening of a double or septate uterus is closed, the symptoms and treatment are those of atresia, and will be described under that head. Defects of Urethra and Bladder. — Hypospadias in the female varies from minor defects in the urethra to complete absence of the canal. If the defect is complete, the vesical sphincter is also absent, and operative cure is impossible. In other cases, the defect may be remedied, with fair chance of success, by plastic operation designed to fit the individual case. Exstrophy of the bladder is the absence of the anterior wall of the bladder, and the anterior abdominal wall covering it. In the upper part of the bladder this is called superior vesical fissure; in the lower part, inferior vesical fissure, and in the urethra and vulva, epispadias. The only relief is by plastic operation, with doubtful success. Rectum. — The rectum may be imperforate. In which case it must be recognized and treated immediately after birth. Atresia of the anus varies from a thin occluding layer of super- ficial epithelium* which can be easily perforated, to a thick layer of fibrous tissue requiring extensive dissection. The sphincter ani is always present, so complete control is to be expected in successful operations. Occasionally there is no opening at the anal dimple, but the rectum opens in the vagina, behind the vestibule. This is anus vestibularis, and patients with this defect often reach adult life without knowledge of their condition. It may re- quire no treatment, but if operation is indicated, the rectal pouch is brought down to an opening through the anal dimple HERMAPHRODITISM. STERILITY 51 and sutured there, and the old vestibular opening is denuded and closed. Complete control is the rule, as the sphincter ani is not disturbed. Gjniatresia. — Atresia of the genital canal may be congenital or (more rarely) acquired; it may be comp'ete from the cervix to the vulva, or may involve either the hymen, vagina or cer- vix alone. As a result of atresia of the canal the menstrual blood and cervical and uterine mucus cannot escape, and gradually accumulate. Finally the vagina, cervix, uterine Fig. 24. — Hematocolpos, hematometra, and hematosalpinx caused by an imperforate hymen. (Ashion.) cavity and even the tubes are considerably distended. If the blood is confined to the vagina alone, the condition is called hematocolpos; if the uterus alone, hematometra, if the vagina and uterine cavity are both involved, hematocolpometra or hemelythrometra; if the tubes are distended, hematosalpinx. The blood is very thick, dark and tarry, and is extraordi- narily putrescible when once exposed to the air. Symptoms. — Rarely if ever occur before puberty. At each menstrual epoch, there are marked menstrual molimina, but 52 ANOMALIES OF DEVELOPMENT no flow. The patient suffers with intense cramp-hke pains, and usually recognizes herself that there is some obstruction to the escape of the menstrual blood. Gradually there develops enlargement of the uterus, which can be felt plainly in the* abdominal cavity, and often there are associated symptoms of pelvic inflammation. Usually the tumor of retained blood is so well marked in a few years after puberty that surgical intervention is obviously needed. Diagnosis.— UsuaMy by attempt at vaginal examination, the point of atresia is at once located. If the hymen, it can be seen to be imperforate and bulged outward as soon as the labia are separated. In this case, the vagina is first distended and only after considerable delay is there dilatation of the cervix and distention of first the cervical canal below the internal os. This gives an hour-glass shape to the uterus, and by rectal examination the uterine body can be felt on top of a cystic tumor. If the atresia is cervical, there is usually a uniform distention of the uterine cavity, which may reach very large size, thinning out the uterine walls like paper. The presence of menstrual molimina, with absence of flow; the obvious atresia on inspection and palpation and the cystic tumor should make the diagnosis easy. Prognosis. — Operative interference is nearly always required, and is much the safest plan. Spontaneous rupture may occur, either into the peritoneal cavity or through the vagina or hymen. Rupture into the peritoneal cavity is nearly always fatal from peritonitis. Spontaneous rupture through the vagina or hymen is dangerous, because drainage is rarely complete, the retained blood suppurates and there is a high mortality from sepsis. Treatment.- — -Before any local measures are attempted, the condition of the Fallopian tubes must be determined by rectal examination or by exploratory section, if the rectal examination is a failure. If the tubes are distended they must be removed as the first step in the operative treatment, be- cause of the danger _^ from peritonitis. The local measures HERMAPHRODITISM. STERILITY 53 in the genital canal depend upon the degree of atresia. If the hymen alone is involved, it is best excised. If the vagina is closed, a large urethral sound is placed in the urethra, another in the rectum, as guides, and the vagina opened between them by blunt dissection. If the cervix is involved, a crucial incision is made over the site of the external os, and the opening thor- oughly dilated. Then, in any case, the accumulated blood is washed out by persistent irrigation with a large uterine catheter and hot saline solution, until the fluid returns clear. Then the entire canal, or as. much of it as was dilated by the accumulated blood is packed with iodoform gauze, renewed daily until the canal has resumed its normal proportions. Rudimentary or absent vagina is usually accompanied by rudimentary internal genitalia, so that, because the uterus is functionless, hematometra does not occur. These individuals often have normal sexual instincts and in case of marriage, an artificial vagina may have to be made. The vaginal canal is made by blunt dissection and lined with epithelium from the labia, split for the purpose. A more dangerous procedure, though more successful, is to bring down, through an opening into the peritoneum, a resected piece of small intestine with its mesentery. The permanent results of artificial vagina, however, are most disappointing; the vast majority contract to a narrow sinus or close altogether. Hjrpertrophy of the Genital Organs. — Hypertrophy of the labia majora is rare, except as syphilitic elephantiasis. The treatment, if any be required, is amputation. Hypertrophy of the labia minora is more common, especially in certain races (Hottentots) where the condition is deliberately produced by manipulation. If the labia are inflamed, or interfere with coitus, they are excised. Hypertrophy of the clitoris is common, and sometimes extreme, reaching a length of three to four inches. If it causes discom- fort, it can be amputated, but amputation for nymphomania or masturbation is useless. 54 ANOMALIES OF DEVELOPMENT Hermaphroditism. — True hermaphroditism, where the indi- vidual possesses completely developed and functionating ovarian and testicular tissue, has not been proven in the human being. The true sex is determined by the genital glands (ovaries or testicles), and not by external characteristics. Pseudohermaphrodite is the proper name for the human species. They are either male or female pseudohermaphro- dites, according to which set of glands is developed and functionating. The female type has the external genitals and secondary sexual characteristics of the male, but has ovarian tissue and at least a rudimentary uterus internally. This type is the rarer. The male type has obviously feminine characteristics, but has a rudimentary penis, imperforate urethra or hypospadias, a shallow pouch resembling a vagina, and testicles either un- descended or high up in separate scrotal sacs, the scrotum being cleft. The individual should ordinarily be brought up and educated according to which sexual characteristics predominate; but in cases of doubt "it" should be educated as a boy. Sterility. — May be either primary — in which the patient never has conceived, or secondary — where one or more preg- nancies have been followed by sterility. Causes. — In at least 40 per cent, of cases, the fault lies with the male. In the female, the commonest causes are: I. Anteflexion of the uterus, with cervical stenosis. 2. Pelvic inflammation — endometritis or salpingitis. 3.. Retro- version of the uterus. 4. Acquired cervical stenosis — the so-called one-child sterility; usually due to laceration, eversion or erosion. 5. Congenital ill-development or atresia. This includes infantilism (arrested development). 6. Vaginismus. It is not always possible to determine a cause upon exami- nation; though the influence of the x-ray on both testicles and ovaries of those exposed to its effects must not be forgotten. There is also a relationship between adiposity and hypoplasia HERMAPHRODITISM. STERILITY 55 of the sexual organs. This is not a constant factor, but it seems to be true that very fat women are less fertile. Treatment. — Before any treatment of the wife is instituted, the husband should be examined to determine his power of procreation. Obvious physical vigor does not necessarily mean power to procreate. If the husband is pronounced capable, the most frequently required treatment for the wife is a dilatation and curettage — for anteflexion and stenosis. This is done under anesthesia, branched dilators being used to secure a transverse dilatation of one inch. Very little curettage is done — only at each cornu. Excessive or frequently repeated curettage brings about a superinvolution of the uterus which may render the sterility incurable. Unless some means is taken to maintain the dilatation, it is rarely efhcient. Stem pessary is dangerous and liable to be followed by infec- tion; the same may be said of the Wylie drain — -an aluminum or hard rubber plug worn in the uterus for several weeks following the dilatation; the Schatz metranoikter — preferably the four-bladed modification, is the safest procedure. This is left in place for twenty-four hours, is then removed and the uterus washed out. Cases of atresia are managed by the proper restoration of the patency of the canal; retroversion — if not adherent — -may be remedied by a pessary or operation; pelvic inflammation requires the cure of the endometritis by intra-uterine instillations or by dilatation and curettage. Salpingitis requires abdominal or vaginal section to inspect and restore the patency of the Fallopian tubes — a procedure of doubtful efficiency. Lack of development — the so-called infantile uterus — requires dilatation without curettage, elec- trical stimulation by the galvanic, (negative pole to uterine sound) rapid faradic and sinusoidal current, and hypodermic injections — intramuscularly — • of i mil corpus luteum extract, or whole ovarian extract, given daily in series of twelve doses, with an interval of two to three weeks between series. Sterility of long standing is sometimes relieved spontane- ously and without treatment. S6 ANOMALIES OF DEVELOPMENT Artificial impregnation, by injection of semen into the uterine cavity, by means of an instillating syringe, has been A %, Fig. 25. — Instruments for maintaining dilatation of the cervical canal. I. Sponge tent, expanding by the absorption of moisture. Impossible properly to sterilize. 2. Tupelo tent of porous wood. Open to same objection. 3. Stem pessary of hard rubber. 4. Wylie drain. 5. Schatz's two-bladed metranoikter. 6, B. C. Hirst's four-bladed modification of the Schatz, frequently tried, with disappointing results. Only very few successes are recorded and there is considerable risk of infec- tion, due to contamination in handling. CHAPTER IV DISEASES OF THE VULVA I. Abscess of Bartholin's Gland. — Cause. — ^Much the commonest cause is gonorrhea. Infection by staphylococcus or streptococcus is possible, but much rarer. Kinds. — I. Pseudo-abscess, where it is the result of an in- fection of a retention cyst of the gland. 2. True or gonor- PiG. 26. — Abscess of Bartholin's gland or vulvovaginal abscess. rheal abscess, where the diplococci have reached the depths of the compound racemose gland or have burrowed under the epithelium of the duct. Nearly all abscesses of the gland are of this type. Symptoms.— 1. Pain, usually severe, and throbbing, with difficulty in walking or sitting down. 2, Distention of the 57 58 DISEASES OF THE VULVA labium by a pear-shaped, brawny swelling, the base downward, displacing the vulvar cleft to one side. 3. Palpation between thumb and forefinger reveals the swelling and usually fluctua- tion. 4. Nearly always unilateral. Differential diagnosis from a simple cyst of Bartholin's gland is easy. The cyst is similar in shape, but is painless, not indurated, much less tense and free from any evidence of inflammation. Treatment. — i. Opening of the abscess cavity, and swab- bing out with tincture of iodin (7 percent.) or pure carbolic acid, allowing the cavity to fill up by granulation. 2. Excision of the whole gland — much the better treatment. A longi- tudinal incision is made over the outer edge of the swelling, away from the vulva. The tense gland is dissected out, taking care not to rupture it, if possible. There is always an escape of pus when the finger-like process in the vaginal wall is cut, and here is usually the only bleeding vessel. This vessel is tied, the wound closed with interrupted silkwormgut sutures, leaving an opening at the lower end for a guttapercha tissue drain. Catgut is npt a satisfactory suture material, as it is too soon absorbed. The drain is removed in four days, the sutures in ten. In inflammation of Bartholin's gland, the pre-abscess stage, there are no symptoms, except an area of erosion around the mouth of the duct — the macule of Saenger. This is almost pathognomonic of gonorrhea. The treatment is injection of nitrate of silver solution, 40 grains to the ounce, into the duct by a hypodermic syringe with a blunt needle. 2. Abscess of Skene's Glands.^ — These glands, situated in the floor of the urethra, are inflamed only by gonorrhea. The mouths of the ducts are usually not visible, but due to the eversion of the urethral orifice, they are visible, when inflamed, as two red spots with dark centers. By pressure on the ure- thra, a drop or two of pus can be made to exude. Treatment. — Destruction of the duct by strong antiseptic solutions or better by an electric cautery needle. Occasionally ACUTE DERMATITIS OF LABIA AND PERINEUM 59 the ducts are occluded, and the pus burrows into the tissues of the anterior vaginal wall, forming a swelHng not unlike a cystocele in appearance, but brawny and indurated. Pres- sure on it causes pus to well out of the urethra. Drainage is better secured by a vaginal opening than by opening through the urethra. 3. Acute Dermatitis of Labia and Perineum. — Causes. — (i) Irritating leukorrhea; (2) lack of cleanHness; (3) transitory J .^ Pig. 27. — Skene's glands or tubules. The urethral meatus is split to show their location. at each menstrual period; (4) may occur without demonstrable cause. Symptoms. — (i) The patient complains of severe discomfort, and says she is severely "chafed;" (2) on inspection, the labia are indurated, very sensitive, skin harsh and dry, and this condition extends for some distance on the perineum and inner surface of thighs. The appearance is exactly that of severe sunburn, during the hyperemic and edematous stage. Treatment. — (i) Correction of whatever cause can be found; (2) avoidance of soap and water cleansing; (3) use of sterile olive or sweet oil for cleansing; (4) local application of: 6o DISEASES or THE VULVA I^ Acid carbolic gr. xlv Acid boric 5 iss Pulv. zinc oxid 5iii Glycerin 5 i Aquas camphoras q. s. ad 5 vi M. Sig. To be applied frequently with absorbent cotton. 4. Adherent prepuce of clitoris is most often seen in children where it is a frequent cause of irritation and masturbation. In adult life it is a source of discomfort from retention of smegma. Diagnosis is easily made by inspection, the prepuce covering the glans as a hood, and being impossible to retract. Treatment. — The adhesions are easily broken up, using a small metal strabismus hook. The prepuce is retracted daily and the glans oiled to prevent reforming of the adhesions. If they persistently reform, as they often do, circumcision is the only cure. 5! Chancre of the vulva is usually situated on the inner sur- face of the labium. It is similar in appearance to chancre elsewhere and is usually accompanied by mucous patches on the labia and vagina, and often by flat condylomata. If the infection is old, however, the resemblance to epithelioma is close, and may require microscopical examiration. The treatment is salvarsan, with iodids and mercury, as in any case of syphilis. 6. Condylomata or venereal warts are of two kinds: (i) The pointed, which are due to dirt or gonorrhea; (2) the flat, nearly always associated with mucous patches, and due to syphilis. Diagnosis. — The pointed condylomata are branched papil- lomata, occurring in patches, over the labia and perineum. Occasionally, most often in pregnancy, they extend in the vag- ina, even up to and on the cervix. There is usually a serous discharge, irritating, and partially macerating the growths. In pregnancy, they grow enormously. Flat condylomata are raised flat patches, usually three or DYSPAREUNIA 6 1 four in a group, occurring on the inner surfaces of the labia and around the anus. They are usually associated with mu- cous patches and other constitutional signs of syphihs. Treatment. — Pointed warts should be removed by excision and suture of their bases, or by cautery, if they are peduncu- lated. Unless very extensive, they can be removed under cocain, but never under ethyl chlorid spray if the cautery is used, as ethyl chlorid is inflammable. Flat condylomata should be let alone, and constitutional treatment given for syphilis. 7. Cysts of the labia may be (i) Bartholin's gland; (2) lymphatic cysts; (3) sebaceous cysts; (4) dermoid cysts. They are all better dissected out than incised and drained. They are usually, except those of Bartholin's gland, pedunculated, and removal is easy. Solid tumors of the labia are either (i) lipoma; (2) fibroma or (3) sarcoma. 8. Dyspareunia (painful coitus) while not a disease of the vulva, maybe considered here, as many of its causes are located in the vulva and lower vagina. Causes. — (i) Rigid hymen; (2) acute inflammatory condi- tions of vulva, vagina or urethra; (3) vaginismus; (4) hemor- rhoids; (5) inflammation or infiltration of the pelvic connective tissue; (6) adherent retroversion of the uterus; (7) salpingitis. Symptoms are simply pain on coitus, the site of pain being either at the vulvar entrance, or high up in the pelvic canal, in the cases where there is pelvic inflammation or displace- ment of the uterus. The pain varies from slight discomfort to one of such severity as to make coitus impossible. Treatment. — As the condition is not a primary one, but al- ways a symptom, the treatment consists in removing the cause. A thick rigid hymen is better excised than incised; vaginismus is overcome by progressive dilatation with Hegar's bougies or better by a bivalve speculum, inserted closed and the blades then widely separated; or by incision of the lower two-thirds of the levator ani on each side; hemorrhoids (a 62 . DISEASES OF THE VULVA surprisingly frequent cause) removed by cautery or ligature, and any inflammatory process treated by douches, etc., depending upon its nature. 9. Elephantiasis is usually not the true elephantiasis, but a hypertrophy of the labia due most often to syphilis. Patho- logically, the picture is one of connective-tissue overgrowth with wide lymph spaces. The growth (except in true elephan- tiasis, where it may be enormous) is moderate in size, and is most often accompanied by characteristic mucous patches. In all cases, a Wassermann should be taken. Treatment. — Of the true elephantiasis, excision is the only treatment. The operation is formidable, the bleeding often excessive and difficult to control, even by mass ligatures. Syphilitic elephantiasis will often yield to mixed treatment, salvarsan or neosalvarsan and in many cases operation can be avoided. Obstinate cases require amputation of the labia majora, labia minora and clitoris. 10. Epithelioma. — The vulva is the rarest seat of carcinoma of the genital organs. It occurs most often after fifty years of age. The growth is almost always squamous epithelioma, and the most common point of origin is the clitoris. Adeno- carcinoma of Bartholin's or Skene's gland is possible, but exceedingly rare. Early and extensive metastasis to the inguinal chain of glands is the rule. Symptoms. — A small hard nodule appears near the clitoris or one labium majus, and quickly ulcerates. This ulceration spreads rapidly, over the site of the clitoris down both labia majora, and later into the vagina. The surface of the ulcer is friable, bleeds at the slightest touch and exudes a very foul, thin, purulent discharge. In the early stage pain is slight or absent; later the pain is excruciating, and often increased by thrombophlebitis of one or both legs. Diagnosis should be easy, even in the early stage. In all cases a piece of the growth resected and examined micro- scopically will establish the diagnosis. Treatment. — Early, complete and radical excision offers the INFLAMMATION OF THE VULVA 63 only hope of cure, and at best a poor one. The inguinal glands must always be excised, and all suspicious tissue re- moved. Many cases are seen too late for operation, because of the early metastasis. After operation, all cases should be treated by a;-ray or radium, and the percentage of recurrence is very high. For inoperable cases or for recurrence after operation, radium offers the best chance of relief. 11. Sarcoma of the vulva is much rarer than epithehoma. Its point of origin is most often the labium minus and it is most often melanotic. Diagnosis and treatment is the same as epithelioma, but almost invariably it returns as a diffuse sarcomatosis. Other solid tumors of the vulva, such as fi- broma or lipoma, are rare. They are found almost exclusively in the labia majora, and frequently pedunculated, painless, and demand removal because of the discomfort of their presence, or more particularly because of their tendency to mahgnant degeneration. 12. Inflammation of the vulva (vulvitis) is rare, except in children, because of the resistance of the surface epithelium to infection. In children, gonorrhea is the most common cause; in adults, vulvitis is usually secondary to inflammation higher in the genital tract, is the result of irritating dis- charge of pus or urine, or is due to trauma. Symptoms. — The vulvar mucosa, especially that of the labia minora, is red and edematous. There is marked discomfort in walking, sitting down, or in handhng the parts. There is considerable sero-purulent discharge, most profuse in gonor- rheal cases. In the acute cases, pain is the most marked symp- tom; as the acute stage passes, there is often an intolerable itching. As a result of desquamation, especially in children, adhesion of the labia is a common complication. Treatment. — The treatment of gonorrheal vulvitis is given in the chapter on gonorrhea in general. The treatment of non- gonorrheal vulvitis is: (i) Cleanhness — the best cleansing solutions being either boric acid solution (grains ten to one ounce) or ly sol, half a dram to two pints. The vulva should 64 DISEASES OF THE VULVA be thoroughly cleansed at least four times daily; (2) the treatment of any cause that may be present, such as an irri- tating leukorrhea, or leakage of diabetic urine, or urine from a fistula; (3) antiseptic or astringent solutions such as: nitrate of silver, grains ten to one ounce; zinc sulphate, two drams to two pints of water; solution of formahn, 3:4 of i per cent. ; argyrol solution 10 percent.; or, which has given the best results, the prescription given under the head of acute derma- titis of labia. Vulvitis in the adult is often a very stubborn condition, and occasionally persists for years. If the labia show a tendency to adhere along their inner surfaces, liberal use of boric acid ointment on the abraded surfaces will pre- vent their adhesion. 13. Kraurosis vulvae, or sclerosis of the vulvar skin, is the result of a long-continued irritation, either from discharge or pruritus. The skin becomes white, hard and parchment like, and the patient suffers severely from excessive itching. No local treatment has been of any avail. Several cures have been reported from the use of ovarian extract (due possibly to improvement of the circulation of the external genitals), by mouth 5 grains four times daily, or better hypodermically as the whole ovary extract (i mil representing 20 mg. of ovary, given once daily). Amputation of the external genitalia is not satisfactory, owing to the frequent recurrence of the itching in the scar, so that the patient is just as uncomfortable as before. Resection of the five pairs of sensory nerves supply- ing the vulva is the best surgical treatment; it is a difficult and tedious dissection, but worth while. From long-continued irritation, epithelioma is a frequent sequel of both kraurosis and pruritus. 14. Lupus vulvae is tubercular ulceration of the vulva and is rare. It occurs most often in the decade of thirty to forty years of age, and is supposed to be secondary to tubercular focus elsewhere, and rarely primary. The ulcer may be very extensive, is covered by a gray slough, and has feebly nourished granulation tissue. There is a tendency to spontaneous PRURITUS VULV^ 65 healing in the older portions of the growth, which will dis- tinguish it from cancer. The growth has a marked tendency to involve the anterior vaginal wall and cause vesicovaginal fistula. A positive diagnosis can only be made by excision of portions of the growth and microscopical examination. Treatment is the same as lupus elsewhere. Curettage of the surface, x-ray for fifteen to twenty minutes daily or Finsen light for one hour every other day, a small area being treated at a time, will give the best results. If the ulcer is primary, prognosis is good, though the cicatrix will be extensive. If it is associated with tuberculosis elsewhere, the prognosis is bad. Vesicovaginal fistulae resulting from lupus cannot be closed, and any attempt at repair will only result in making the fistula larger. 15. Pruritus vulvae, characterized by an intense itching of the vulvar and perineal skin, usually accompanied by sclerotic changes in the skin, but not infrequently without any visible lesion. It is a forerunner of kraurosis, and these two must be considered different stages of the same pathologic process, there being no marked dividing line between them. Causes. — (i) Diabetes — the skin change being produced by chemical action of the irritating urine; (2) dirt and parasites; (3) irritating leukorrheal discharge from gonorrhea, sloughing polyps, cancer or endocervicitis ; (4) senile atrophy — post- menopause — of the vaginal and vulvar mucosa; (5) partial atresia of the vagina or cervix; (6) neurotic cases, where no obvious cause can be assigned. Symptoms. — ^The skin is at first reddened and thickened, and there is intense burning and itching. The skin gradually becomes paler and more parchment-like, and numerous fissures appear. This stage progresses until kraurosis develops. Many cases have only the violent itching, without demonstra- ble change in the skin. Treatment. -^Vrmiixx?, is essentially a symptom, and the treatment must therefore be directed toward removing the cause. As diabetes is the commonest cause, the urine of every s 66 DISEASES OF THE VULVA patient should be at once examined for sugar; and the patient put upon appropriate treatment, if sugar is present. The remedy for dirt or parasites is obvious — cleanliness and shaving of the pubic hair, followed by frequent washing with watery solutions of tincture of green soap two ounces to one pint of water, and sponging with lysol solution one dram to one pint of water will give the quickest result. Leukorrheal discharge is controlled by removing the cause, if one can be found, and the discharge is kept from contact with the vulvar mucosa by vaginal tampons with 50 per cent, ichthyol or boroglycerid 25 per cent. The discharge from senile vaginitis is best controlled by painting the vaginal mucosa with 7 per cent, tincture of iodin. Partial atresia is dilated to afford freer drainage, the dilata- tion being repeated at intervals, as the atresia tends to recur. Local applications are usually disappointing or at most give temporary relief. Cocain solution i to 10 per cent.; carbolic acid \'2 of I per cent, to 2 per cent, solutions; nitrate of silver 40 grains to the ounce; menthol in stick form; ichthyol 50 per cent, in glycerin; injection of the sensory nerves with novocain solution 3^^ of i per cent.; alcohol 95 per cent, with I grain of bichlorid of mercury to the ounce; tincture of ham- amelis full strength; formalin i per cent, are the ones offering the best chance of relief, but none of them can be depended upon for more than temporary benefit. The author has found the prescription given under the heading of acute dermatitis of the vulva, the most valuable of all local applications. The diet must be regulated; all highly spiced foods, tea, coffee and alcohol forbidden. X-ray treatments are much more valuable, and give a high percentage of cures. Radium is not so efiicient, on account of the wide area to be treated. Ovarian extract gr. v four times daily, or i mil hypodermically of the soluble extract of whole ovary, given once daily is worth a trial. Surgical Treatment. — Ohstinsite cases, with marked skin changes, or those of the neurotic type where the itching per- URETHRAL CARUNCLE 67 sists, although no demonstrable lesion exists, will not yield to any form of local application, but will require one of two surgical procedures, (i) Vulvectomy or amputation of the external genitalia. This is unsatisfactory, as the itching often persists in its former intensity in the scar, and the patient is just as wretched as before. (2) Resection of the five pairs of sensory nerves supplying the vulva — (i) genital branch of genitocrural; (2) ilio-inguinal ; (3) inferior pudendal; (4) per- ineal branches of the pudic; (5) dorsal nerve of clitoris. Simple section of the nerves is not enough; as long a piece as possible must be resected. The first two are found in the inguinal canal; the last three in the perineum — the perineal incision paralleling the descending ramus of the pubis. The dissection is difficult and tedious, but the results justify it. 16. Pudendal hernia is analogous to scrotal hernia in the male, the gut or omentum descending along the inguinal canal into the labium. 17. Urethral Caruncle. Definition. — A blood-red, flattened, usually pedunculated tumor, hanging from the posterior lip of the urethra. The pathological picture is usually angio- neuroma. The painless type, which is rare, is angioma simplex, and is usually sessile. Symptoms.— (1) Agonizing pain, especially on urination. The slightest touch is unbearable. (2) Inspection shows the characteristic growth which is usually single and pedunculated. The sessile painless variety gives no symptoms, the patient being usually unaware of its existence until it is found in the course of a vaginal examination. Treatment.- — Excision of the growth, with its base, under general anesthesia, and preferably with the cautery. Removal under local anesthesia is not as satisfactory, nor is the attempted destruction of the growth with the electric needle to be recommended. Recurrence is common, especially after removal under local anesthesia. The sessile, painless type need not be removed, unless it shows evidence of increasing in size. 68 DISEASES or THE VULVA 1 8. Urethral prolapse is most common in old age, and due to senile atrophy Moderate cases simulate the sessile type of urethral caruncle, and are simple ectropion or eversion. Severe cases are not unlike cancer in appearance, especially if thrombotic. While the condition is most common in advanced life, it may occur at any age. Moderate cases do not give much if any discomfort and re- quire no treatment. Severe cases require removal of the prolapsed mucosa, after the manner of the Whitehead opera- tion for hemorrhoids. 19. Varicose veins of the vulva (varicocele) are usually negligible except in pregnancy. Then they may form a con- siderable mass, but after delivery they disappear completely or remain simply as one or two visibly dilated veins, usually near the clitoris. Except in pregnancy, they rarely give symptoms unless thrombosed. Diagnosis is easy. Inspection shows the tortuous mass of veins. Treatment. — Rest in bed, knee-chest posture for fifteen to thirty minutes four times daily and moderate pressure with a vulvar pad will control moderate cases. The danger is sub- cutaneous or open rupture. Subcutaneous rupture gives a huge hematoma; open rupture causes dangerous and even fatal hemorrhage. The patient should be instructed how to make pressure on the mass of veins, in the event of rupture. The bleeding is finally controlled by undersewing and ligation of the veins. A hematoma must be widely opened, to give access to the bleeding points. CHAPTER V DISEASES OF THE VAGINA, EXCLUDING LACERA- TIONS AND THEIR CONSEQUENCES 1. Absence of the vagina is rare. Congenital absence is associated with rudimentary internal genital organs, and the uterus is functionless. Apparent absence may be the result of atresia of a part or whole of the vaginal canal. Congenital absence gives no discomfort and patients are unaware of the condition, until the absence of menstruation causes them to seek advice. Atresia of the vagina with apparent absence of the canal causes retention of the menstrual blood at puberty, and its attendant symptoms. Congenital absence of the vagina requires no treatment, unless the patient is to be married and desires the formation of an artificial vagina. This is done by blunt dissection between the bladder and rectum to the depth of the normaV vagina, and the raw surfaces are covered by epithelium turned in from the labia or buttocks. A better, but more dangerous plan, is to bring down through an opening in the peritoneal cavity, a resected piece of small intestine, with its section of mesentery. Both plans are difficult, and the artificial pouch is very likely to close, in spite of all efforts to preserve its lumen. 2. Atresia of the vagina, congenital and acquired, is treated in Chapter III. 3. Carcinoma of the vagina is rare, as a primary growth. Secondary cancer of the vagina is very common, being meta- static from the uterus, rectum and bladder in the order named. Primary carcinoma is almost always squamous epithehoma, but very rarely may be adenocarcinoma from congenital cysts or gland inclusions. The commonest site is on the posterior vaginal wall. Chorionepithelioma may rarely be primary in the vagina; usually it is metastatic from the uterus. 69 yo DISEASES OF THE VAGINA Secondary carcinoma, being usually metastatic from the cervix, is most commonly situated in the upper third of the vagina. Symptoms. — The growth is at first a circumscribed nodule, surrounded by a raised indurated ring. The area spreads slowly, ulceration and bleeding occur early, and a foul seropuru- lent discharge appears. Any doubt as to the nature of the growth can be settled by excision of a piece and microscopical examination. Prognosis is very bad, and even after early extirpation recur- rences are the rule. Treatment. — If the case is seen early enough, total extirpa- tion of the uterus and vagina is required. If the site of the growth is high up, the extended Wertheim operation is the best. If the growth is near the outlet, the lower portion of the vagina can be freed from below, and the operation completed by abdominal extirpation. If the rectum is involved, it also must be removed and an artificial anus made by inguinal colostomy. Metastasis. — In the lower third of the vagina, the direction of metastasis is to the inguinal glands, rectum and bladder. In the upper two-thirds, metastasis takes place to the cervix, rectum, bladder, deep sacral, lumbar and renal glands; and rarely to the groin. Inoperable cases are best treated by radium. X-ray has proved disappointing. Pain, which is often severe, must be controlled by morphin or codein hypodermically. Most cases are seen too late for radical operation. Any indurated vaginal nodule, especially one with ulceration of its surface, should he at once excised and examined microscopically. 4. Condylomata of the vagina are rare, and usually associated with vulvar growths. The warts are pink, covered by normal epithelium, not ulcerated, do not bleed when touched and can be differentiated at sight from carcinoma. Treatment is removal by ligature or cautery, under general FOREIGN BODIES IN THE VAGINA 7 1 anesthesia. They do not tend to recur, provided the patient keeps herself clean. . 5. Cysts of the vagina are of three kinds: 1. Cysts of Gartner'' s duct, found in the anterior vaginal wall. They are thick- walled, contain a thick viscid fluid. They may be so large as to give the appearance of a cystocele. 2. Lymphatic cysts, found anywhere on the vaginal walls. They are thin-walled, look like large bHsters, and contain a thin serum. 3. Epithelial cysts, due to buried epithelium from faulty denudation in a plastic operation. These are at the introitus or in the vaginal sulci. They vary in size from a pea to a wal- nut and contain a thick sebaceous creamy fluid, erroneously described as "pus." These cysts usually cause discomfort, especially those at the introitus. Symptoms are usually absent, except in the epithelial kind, which often cause pain, especially in coitus. Diagnosis is usually easy. Cysts of Gartner's duct look not unlike cystocele, but do not bulge on straining. Lymphatic cysts and epithelial cysts are unmistakable. Treatment is operative. Simple puncture is enough for the lymphatic cysts. Epithelial cysts are dissected out and their bed obhterated by one or two sutures. Gartner's duct cysts can be shelled out by blunt dissection, if they are small. There is some danger of injury to the bladder or urethra. The larger cysts of Gartner's duct often extend into the layers of the broad ligament, and their removal is a formidable procedure. 6. Fistula, including anus vestibularis, are described in Chapter XV. 7. Foreign bodies in the vagina are most often pessaries, inserted and forgotten. Almost any object of suitable size has been inserted by insane women or masturbators. A forgotten pessary is likely to erode its way into the bladder, rectum and vaginal vaults. In any case of foul vaginal discharge, a pes- sary or other foreign body must be sought for as a possible 72 DISEASES OF THE VAGINA cause. In such a case, removal of the offending body and astringent douches for one or two weeks is all that is required, provided the bladder or rectum have not been injured. 8. Garrulitas vaginae is the audible escape of gas from the vagina, following exertion or rapid change of position. The cause is incomplete closure of the introitus, due to laceration of the deep and superficial transversus perinei muscles, and the cure is a plastic operation. 9. Septum formation in the vagina, dividing the canal into two partially or entirely separate canals, is not uncommon. Septa give no symptoms; are found accidentally in gynecolog- ical examinations. In labor they are commonly torn loose at one end, and can then be ligated and amputated. 10. Tuberculosis of the vagina is rare. As a primary condi- tion, it is seen usually in children. In adults it is secondary to lupus vulvae. It shows itself by ragged ulceration, covered by pale edematous granulations, showing some tendency to heal at the edges, and, in the adult form, a marked tendency to form vesicovaginal fistula. It is treated by a;-ray, radium or Finsen light. Local appli- cations have no effect. Vesicovaginal or rectovaginal fistulse due to tuberculosis cannot be closed. 11. Tumors. — Fibromyomata and myomata of the vagina are rare. They arise from the muscle of the vaginal wall. They are usually small, pedunculated, and are especially prone to slough. The site is most often the posterior vaginal wall. Their commonest degenerations are necrosis, sloughing and sarcoma. Treatment is removal, which is usually easy. If they are diffuse and sessile, they may require extensive dissection. This type is usually adenomyoma. 12. Vaginismus is the name given to a spasm of the levator ani and other pelvic floor muscles, provoked by attempts at coitus, examination or the insertion of any instrument into the vagina. VAGINISMUS 73 True vaginismus is that due entirely to psychic reflex, with- out any exciting cause. Pseudovaginismus is that due to some painful affection such as urethral caruncle, rigid hymen, excessive perineal repair, vaginal ulcers, abscess of Bartholin's glands, etc.; the spasm disappearing when the cause is removed. In true vaginismus the muscular spasm is often shown before the parts are actually touched, while in pseudovaginis- mus it is the actual contact that causes the spasm and the lesion causing it is usually obvious. In the former, no lesion or cause can be found. Diagnosis. — It is not always easy to differentiate between true and false vaginismus. A careful digital and specular examination of the genital canal is necessary, and this nearly always calls for an anesthetic. The cervix is examined for erosion, the vaginal vaults for the induration of cellulitis, the anterior vaginal walls and urethra for urethral caruncles, ab- scess of Skene's glands and suburethral abscess, the posterior vaginal walls for fissure; the introitus for rigid hymen, ab- scess of Bartholin's gland or vulvitis. If the case is one of pseudovaginismus, the exciting cause can often be found and removed at this examination. If no cause can be found, the case can be classed as true vaginismus. Any examination without anesthesia must be conducted with great gentleness, as undue roughness or impatience often aggravates the trouble. Treatment. — If there is an obvious cause, the removal of the offending lesion will give prompt relief. In true vaginismus one of several plans of treatment may be required. I. The Walthard method, depending upon the theory of antagonism of the abdominal muscles to those of the pelvis. By causing the patient to strain and bear down strongly, the muscles of the perineum are deadened, so that the finger can be introduced into the vagina, and the patient, realizing that no pain was caused, loses her fear of being hurt and the vaginismus 74 DISEASES OF THE VAGINA disappears. This will succeed in a small minority of patients, and is worth a trial. 2. Gradual dilatation of the vagina by means of a bivalve speculum introduced and the blades separated as widely as possible, until the pressure is uncomfortable. A better plan is the use of Hegar's graduated bougies, loaned to the patient, who inserts daily successive sizes, as she can bear the increased pressure, leaving each in place, in the vagina, for an hour, while she rests in bed. Usually in several weeks they have secured sufi&cient dilatation, so that they are no longer needed. 3. Obstinate cases require incision of the perineal body, in the middle line, half way to the anus, and also incision of each sulcus about an inch in depth, so that the appearance is that of a double sulcus tear in labor. Sutures are then inserted from above downward, converting the Y-shaped incision into a transverse line, and causing a gaping vulvar orifice. 4. In all cases of true and pseudovaginismus, ovarian extract, either by mouth gr. v four times a day, or preferably hypodermically i mil daily for 24 doses, is of distinct value. 13. Vaginitis (Colpitis) : Inflammation of the Vagina. — The vagina, considering the provocation to infection, is com- paratively immune during adult life, due to the protection of its squamous epithelium covering (really a modified skin) and to the acid secretion (lactic acid, secreted by Doderlein's bacillus) that inhibits the growth of many pathogenic bacteria. In childhood vaginitis, especially the gonorrheal type, is much more common. In adult life, vaginitis without a preliminary mechanical or chemical injury to the surface epithelium, is rare. In the senile type, past the menopause, it occurs in patches, giving the characteristic mottled appearance. Kinds. — -(i) Diffuse granular, most common in gonorrhea; (2) Senile — in patches varying from a pinhead to one or two centimeters in width; (3) Mycotic — due most often to thrush fungus, leptothrix or Otdiuni albicans. Diabetic urine dis- tinctly favors the growth of fungi. (4) Emphysematous, with VAGINITIS 75 formation of gas vesicles in the mucosa, seen most often in pregnancy. (5) Acute septic, seen in puerperal infection. In any kind of vaginitis, but most often in the senile type, desquamation of the surface may occur, and possibly cause adhesion of the opposing vaginal surfaces. In this way are formed most of the partial or complete atresias of the vagina. Catises. — (i) Gonorrhea — the cause of most cases of acute vaginitis; (2) senile atrophy; (3) long-standing irritating cervical or uterine leukorrhea — causing chemical injury to the surface epithelium; (4) neglected pessaries or tampons — causing mechanical injury; (5) infectious diseases like typhoid, small-pox and diphtheria; (6) puerperal fever; (7) fungi of various kinds, the commonest being thrush, leptothrix and Oidimn albicans; (8) prolapse of the uterus, causing ulceration of the vaginal mucosa by exposure and friction; (9) rarely, in children, wandering thread-worms from rectum. Symptoms. — (i) Leukorrhea is the most constant symptom, varying from a thin serous discharge to a thick creamy puru- lent and very profuse flow. (2) Pruritus, probably chemical in origin, from the irritation of the discharge. (3) Moderate burning pain (in the acute cases only) referred deep into the pelvis. Certain varieties show special symptoms. In acute granular vaginitis the vaginal mucosa appears to have been dusted with large granules of red pepper and the discharge is profuse and creamy. This is almost certainly gonorrheal. In senile vaginitis, the mucosa is mottled, areas of redness contrasting with normal mucosa, and often, in the upper third, there are adhesions of the opposing surfaces. Puerperal vaginitis is usually streptococcic, and produces a thick, greenish yellow false membrane. Diphtheritic false mem- brane is dirty gray. Fungi usually grow in white patches, easily wiped off, and leaving a bleeding surface behind. The thick leathery mucosa and wide patches of ulceration seen in prolapse are unmistakable. Diagnosis. — The best view of the entire vaginal canal is given by the wire Ferguson bivalve speculum. The blades 76 DISEASES OF THE VAGINA do not cover the vaginal walls, and it is the best instrument for both diagnosis and for making local applications. Smears for microscopical examination can be taken from any portion of the canal. Treatment varies with the kind of inflammation. Acute gonorrheal vaginitis requires: (i) Rest in bed; (2) milk diet; (3) large amounts of water (12 to 15 glasses daily) ; (4) twice daily a thorough vaginal douche with a hot 1-2000 permanganate of potassium solution (4 quarts during a period of 15 minutes) followed by 2 quarts of hot sterile water; (5) through a skele- ton speculum, the entire vagina is painted, with pledgets of cotton on an applicator, with 25 per cent, argyrol or i per cent, nitrate of silver solution; (6) a tampon soaked with 50 per cent, ichthyol in glycerin or 25 per cent, boroglycerid is inserted, to remain until the next treatment. (7) If the vaginal mucosa is not markedly sensitive, douches of acetate of lead 2 per cent. , or pyroligneous acid, 4 drams to the quart are of value. (8) Between treatments, the patient wears a sterile vulvar pad, thickly dusted with boric acid. If the vaginitis has persisted for a considerable time or if the above-described treatment does not subdue the infection in ten or fourteen daj^s, the vagina is bathed in a 40 grains to the ounce (8 per cent.) solution of silver nitrate, poured in through a bivalve or cylindrical speculum, and the instrument slowly withdrawn, to smooth out the folds of the mucosa. This is followed by a douche of normal salt solution, to convert the nitrate of silver into the insoluble chlorid. The application is repeated every other day. If two or three such applications do not effect a cure, the vagina is wiped out, through a skeleton bivalve speculum, with equal parts of glycerin and carbolic acid, followed immediately by a douche of 50 per cent, alcohol. The buttocks and labia should be thickly coated with vaselin before carbolic acid is applied. Chronic vaginitis yields best to astringent douches, such as the following: VARICES OF THE VAGINA 77 Acid carbolic 2 drams Acid boric i ounce Zinc sulphat i ounce Alum, exsiccat 3 ounces M. Sig. 2 teaspoonfuls to 2 quarts of hot water, twice daily. Dis- solve the powder before adding it to the douche water. A course of vaginal tampons of 50 per cent, ichthyol or 25 per cent, boroglycerid, as described in the section on office treat- ment, with the above douche in the intervals is the most satis- factory treatment. Senile vaginitis is best treated by (i) suppositories of glycerin with thymol (5 per cent.) or eucalyptol (gr. 5) or iodoform (gr. 5) inserted at bedtime and followed in the morning by a douche of boric acid (two ounces to the quart). If this does not give prompt relief, paint the entire vaginal mucosa, through a skeleton speculum with 7 per cent, tincture of iodin. Emphysematous colpitis responds to puncture of the vesicles, which do not refill, and boric acid douches, twice daily. All forms of mycotic colpitis (thrush, etc.) respond promptly to boric acid douches, after the mycotic patches have been wiped off with gauze. In any case, the entire genital tract should be searched for any cause (endometritis, abscess of Skene's or Bartholin's glands, endocervicitis) which might be the primary source of the irritant which keeps alive the vaginal inflammation. Prognosis. — In all cases except the gonorrheal, the prognosis is good. Gonorrheal cases are often most obstinate and recur after apparent cure, due to latent infection in Skene's or Bartholin's glands, the cervix or endometrium. In these cases, Skene's glands must be obliterated, Bartholin's dissected out, the uterine cavity disinfected, after dilatation of the cer- vix, by iodin and carbolic acid, equal parts, and often the cervix must be amputated, before even a relative cure can be obtained. 14. Varices of the vagina are rarely seen except in pregnancy and may then reach large size, with considerable danger of serious bleeding. CHAPTER VI ABNORMALITIES OF THE CERVIX, EXCLUD- ING TEARS Normal Anatomy and Relations. — The cervix or neck of the uterus is that portion extending from the internal os (or lower border of the lower uterine segment) to the external os. The vaginal portion (about 3^-^ of the total length) projects like a nipple into the vagina. The hps of the cervix, anterior and posterior, are separated by the external os. The supravaginal (and longer) portion of the cervix extends from the point of a b c Pig. 28. — a, NuUiparous cervix, with circular os uteri ; b, nulliparous cervix, with transverse os; c, multiparotis cervix, without laceration. attachment of the vaginal mucosa to the internal os. Anterior to this portion is the bladder and vesico-uterine pouch of peritoneum; posteriorly lies the rectum and Douglas' pouch. The ureters lie close to this portion of the cervix; nearer the anterior half. The left ureter is much closer than the right, and the more the cervix is prolapsed or pulled down, the nearer are the ureters to it. This is a point to be remembered in vaginal hysterectomy. The shape of the cervix in a nullipara is conical; in a multip- ara, cylindrical, 78 ABNORMALITIES OF THE CERVIX 79 The external os in a nullipara is circular or more often oval; in a multipara (whose cervix is not torn) it is a transverse slit. In both, the canal is normally closed by a plug of thick tena- cious clear mucus — the corpus mucosum. The shape of the cervical canal is spindle — narrowest portions at either os, and the broadest in the middle. The mucosa of the vaginal portion is squamous epithelium and is normally pale pink. The mucosa of the cervical canal is grayish red, soft, cylindrical epithelium, with long slender ciliated cells with the nuclei at their bases. There is no sub- mucosa. On the anterior and posterior walls of the cervical canal, the mucosa shows transverse folds, like the ribs of a leaf — the arbor vUcb or palmcB plicatcB. The glands of the cervix are tubular, usually much con- voluted, and extend deeply into the muscle. Methods of Examination of the Cervix.^ — i. Digital examina- tion, misleading in its results, and never solely to be depended upon. 2. Sims' speculum in either the dorsal or Sims' (left lateral) position, requiring a retractor to elevate the anterior vaginal wall as well. 3. Bivalve specuhmi (duck-bill) used in the manner de- scribed in the chapter on routine office treatment (Chapter II). This is much the best plan. ABNORMALITIES OF THE CERVIX Atresia of the Cervix Atresia of the cervix is (i) congenital or (2) acquired. Congenital atresia is discovered only after puberty, when the menstrual blood is retained. Symptoms. — (i) Severe menstrual molimina, without flow; (2) increasing pain; (3) a spherical cystic tumor in the pelvis; (4) specular examination demonstrates the closure of the canal. Acquired atresia results from: (i) Ulceration of the cervix 8o ABNORMALITIES OF THE CER\TX, EXCLUDING TEARS — from injury, sepsis, malignant growths or the apphcation of strong caustics in the canal; (2) cicatrization following repair or amputation of the cervix. Symptoms are about the same as in the congenital variety, except that in the former the menstrual flow has never ap- peared. The treatment of both is given in detail under the heading of gynatresia in Chapter III. Atrophy or Subinvolution Atrophy or superinvolution is a part of the same process in the uterus, and any symptoms proceed from the latter. The cervix is exceedingly small, and presents in miniature the features of a normal cer\dx. The treatment is that of superinvolution of the uterus {q. v.) Cancer of the Cervix (Cervecal Carcinoma) Frequency.- — -The uterus is the commonest site of cancer in the human body. Cancer is four times as frequent in the cer- \dx as in the body of the uterus. Age of Occurrence. — ]\Iost commonly between the ages of forty and fifty. About one-third of the cases are between thirty and forty. It is occasionally seen prior to thirty and after sixty, but these are rare. It has been reported at eight- een, and as late as eighty-two years of age. Cause. — Nearly aU patients with cancer of the cervix have had children (98 per cent.) and the vast majority have had several — five being the average. Therefore inflammation or traumatic lesions of the cer\dx, due to childbirth, are very constant etiologic factors. Neglected laceration of the cervix, mth eversion and particularly erosion, is the most frequent cause. Cancer in a nullipara may start in an erosion, or in some injury to the cerv^ix, as after forcible dilatation. The actual exciting cause in not known. Heredity does not play an important part. Many theories have been advanced but none proven. ABNORMALITIES OF THE CERVIX 61 Classification. — Cancer of the cervix is classified under two heads: the clinical and the pathological. The clinical varieties are: (i) Cauliflower — the only squa- mous-cell variety — and much the commonest type. It origi- nates from the squamous epithelium of the vaginal portion; (2) ulcerative — 'Originating in the cylindrical epithelium of the cervical canal, and is adenocarcinoma; (3) interstitial or Ca Vagina Ulceration Pig. 29. — a, Cauliflower squamous-celled cancer of the cervix; b, ulcera- tive adenocarcinoma of the cervical canal. {After Graves.) indurating — originating in the deeper portions of the cervical glands, and only secondarily ulcerative — in its later stages. Of the clinical varieties the cauliflower bleeds the most, the interstitial the least; and the interstitial is the most insidious and most likely to be overlooked. The pathological varieties are: (i) Squamous epithelioma, with epithelial pearls (the cauliflower type); (2) adeno- carcinoma — with hyperplasia of the lining epithelium of the glands, perforation of the basement membrane and infiltration ABNORMALITIES OF THE CERVIX, EXCLUDING TEARS of the myometrium (the ulcerative and interstitial types); (3) malignant adenoma — malignant hyperplasia of the glands themselves without hyperplasia of the lining (more rarely in the ulcerative and interstitial t5Apes); (4) malignant endothelioma— Si rare growth from the endothelium of the lymph spaces and vessels. Ca-t\cer,,\ \J\CLercxCvoxv ^Crater Infiltration ' of Vagin/z. Fig. 30. Fig. 31. Fig. 30. — -Inverting cancer of the cervix. In this case the growth is invading the walls of the cervix with little tendency to extend outward into the vagina. In this type there is an earlier invasion of the para- metrium. It can be seen from the drawing that the disease might escape detection by the examining finger. This form of the disease is especially treacherous, as it is liable to be overlooked. {After Graves.) Pig. 31. — Extensive crater formed by carcinoma of the cervix, with in- filtration of the vagina. (After Graves.) Direction of Metastasis. — ^Lymphatic metastasis takes place into the deep sacral, lumbar and finally the renal glands. Cancer of the cervix also spreads by direct continuity to the bladder, rectum and vaginal vaults. It almost never gives metastasis to the groin, and rarely to distant organs. Vesico- vaginal and recto-vaginal fistulse are common complications of the later stages. ABNORMALITIES Ol' THE CERVIX 83 How Cancer Kills.^ — (i) Cachexia, secondary anemia and exhaustion; (2) hemorrhage; (3) intestinal obstruction; (4) septic pyelitis; (5) general septicemia; (6) rarely from distant metastases; (7) pulmonary embolism from the accompany- ing thrombophlebitis. The usual duration from the appear- ance of the first symptoms is one to three years. Clinical History and Symptoms. — There are three cardinal symptoms of cancer of the cervix: Bleeding. — This is irregular from the start, due to capillary erosion, and occurs either near the time of the menopause or after the menopause has been established. It may be a blood-stained watery discharge, but is usually frank bleeding. Irregular bleeding in any patient past .35 is a symptom that demands immediate and thorough investigation. Ignorance or neglect of this dictum is why over 60 per cent, of cases first present themselves for treatment after the cancer is inoperable. 2. Fold Discharge. — This occurs relatively early in the cauli- flower growth, later in the ulcerative and latest in the inter- stitial. It is due to necrosis and sloughing. Periodic gushes of pus are due to obstruction of the cervix and pyometra. The discharge is very foul, and is most profuse in cauliflower growths. In the others, it is likely to be watery for a con- siderable time. 3. Pain, is a late symptom, and of no value in an early diagnosis. The cervix is relatively insensitive, and pain appears only when the growth has involved the vaginal vaults or the sacral plexus. The presence of pain, with rare excep- tions, means that the case is inoperable. Cachexia occurs very late, and never in cases that are oper- able. It is extreme, however, when it does occur. Fever is common, and due to infection and not the ulcerated mass per se. Diagnosis is comparatively easy. All cases are operable in the early stage. Any patient who complains of irregular bleed- ing should be examined, in the dorsal position, and the cervix inspected through a bivalve speculum. A suspicious erosion 84 ABNORMALITIES OF THE CERVIX, EXCLUDING TEARS or induration, particularly if it bleeds to a slight touch, should have a piece removed by tenaculum and scissors, for micro- scopical examination. This is painless and the resulting bleed- ing slight and easily controlled by a tampon. If the source of the bleeding is not in the cervix an exploratory dilatation and curettage of the uterine cavity must be done, and the scrap- PiG. 32. — Jung-Hobel freezing microtome; ether spray. ings examined microscopically. With these simple precau- tions, most if not all cases can be recognized early enough to give operative removal a brilliant chance of success. In the stage where the patient usually presents herself for treatment, recognition is easy. The cauliflower growth fills the vaginal vault with a friable, bleeding, sloughing mass, surrounded by an indurated ring of cervix. The ulcerative growth (adeno- carcinoma) shows as a sloughing crater in the cervix, bleeding ABNORMALITIES OF THE CERVIX 85 easily to the touch. The interstitial, prior to the stage of ulcera- tion, shows a stony, hard, hypertrophied cervix, usually fixed and immovable, and requires for diagnosis curettage of the cervical canal or removal of a piece of the cervix for micro- scopical diagnosis. In any case where doubt exists, the micro- scope will infallibly decide. Simple erosion of the cervix bleeds easily, but is not indurated, is not friable, causes no destruction of tissue, has no foul discharge, and the microscope will show benign growth. A normal polyp is not ulcerated and does not infiltrate. A sloughing polyp has no infiltration at its base, no deep ulcera- tion, no infiltration of surrounding tissue, but is friable and can be broken up with the fingers. Syphilis yields promptly to specific treatment. Sarcoma is only distinguishable by microscopic examination. Tuberculosis shows a punched out ulcer with undermined edges, pale granulation, little bleeding, and the microscope and inoculation experiments will settle all doubts. In cases where time is an object, the freezing microtome will give a diagnosis in a few minutes. In all cases, it is wiser to take, if possible, the slower but more accurate paraffin or cello^din method. A case is operable: i.e., suitable for hysterectomy, (i) When the uterus is movable; (2) when there is no invasion of the broad ligaments; (3) when there is no involvement of the vaginal vaults, bladder or rectum. Conversely when the uterus is fixed, the broad ligaments infiltrated, the vaginal vaults indurated and extension to the bladder and rectum walls, any attempt at radical operation is hopeless. The interstitial variety reaches the inoperable stage earliest, and only about one-third of the cases presenting themselves for treatment permit of radical operation. The presence of enlarged lymph-glands does not mean that these glands are cancerous, and if they are, it does not mean the case is hopeless, though the prognosis is unquestionably worse. 86 ABNORMALITIES OF THE CERVIX, EXCLUDING TEARS These glands can be extirpated with the uterus, and perma- nent cure result. Methods of radical operation are of three types, (i) Abdominal pan-hysterectomy — preferably by the technic of Wertheim. (2) Vaginal panhysterectomy. (3) Combined vaginal and abdominal panhysterectomy, where the uterus is freed from its lower attachments through the vagina, and is removed through the abdomen. Abdominal panhysterectomy is preferable as a routine pro- cedure. Vaginal hysterectomy has certain advantages: (i) Rapidity of operation; (2) absence of shock; (3) in fat women; (4) a lower primary mortality. Its disadvantages are: (i) Lack of room; (2) danger of clamping of ureters; (3) danger of injury to bladder and rectum in advanced cases; (4) difficulty in dealing with adhesions; (5) a lower percentage of five-year cures; (6) danger of secondary hemorrhage. The ideal case for vaginal hysterectomy is the patient who is very fat, who could not stand the Trendelenburg position demanded by the abdominal route; who has a movable uterus, with no direct metastases, with relaxed pelvic floor. All advanced cases are best done by the abdominal route. Technic. (i) Wertheim Abdominal Panhysterectomy. — (i) The patient is prepared as for any pelvic operation and anes- thetized. 2. She is arranged in the dorsal position and the vagina cleansed. 3. Any sloughing mass is removed, and its base thoroughly seared with the cautery. 4. The vagina is painted with 5 per cent, tincture of iodin and packed with sterile gauze. 5. The patient is placed in the extreme Trendelenburg position and the abdomen opened in the middle line, the lower end of the incision being on the symphysis; a seh-retaining abdominal retractor is put in place and all intestines packed out of the pelvis. ABNORMALITIES OF THE CERVIX 87 6. The uterus is caught by a Somers clamp and held forward. 7. The ovarian arteries and round ligaments are ligated on both sides, and a clamp placed above the ligatures to control reflex bleeding. 8. The broad ligaments and peritoneum are split anteriorly from one side of the pelvis to the other, above the attachment of the bladder. 9. The bladder is freed anteriorly, and both broad ligaments dissected down until the ureters are exposed. Pig. 33. — Diagram illustrating the tissue to be removed in the radical operation for cancer of the cervix. (After Kelly.) ID. The uterine arteries are caught outside the ureters, cut and hgated. 11. The peritoneum is separated posteriorly and both utero- sacral ligaments caught and tied. 12. The uterus is pulled strongly upward, and a clamp placed on each side so as to include the angle of the vagina. 13. The vagina is cut across and the uterus removed. 14. The vagina is immediately closed, with number 3 chromic catgut. 15. Two ligatures are placed under the clamps securing the angles of the vaginal wound and tied outside the clamps. This 88 ABNORMALITIES OF THE CERVIX, EXCLUDING TEARS secures, with one stitch, the troublesome uterovaginal venous plexus. 1 6. Any obvious glands are removed. Extended search is not necessary. 17. The peritoneum is closed over the vaginal stump, with number 3 chromic catgut. 18. The packs are removed and the abdomen closed. 19. The vaginal packing is removed at the completion of the operation. Technic of Vaginal Hysterectomy. — i. The patient is pre- pared as for any pelvic operation and anesthetized. 2. The cervix is sterilized with the cautery, and pulled down by a double tenaculum. 3. The cervix is freed from its vaginal attachments by a circular incision. 4. The bladder is pushed up anteriorly, with gauze, a retrac- tor placed under it for protection, and the anterior pouch of the peritoneum caught and opened. 5. The uterus is caught with a volsellum and anteverted through this peritoneal opening. 6. The broad ligaments are caught in clamps, and cut through near the uterus. Three clamps to each side are needed. 7. A better, though more difficult plan, is to ligate the broad ligaments, with three ligatures, cutting free each section as it is tied, and holding the stumps with a hemostat. 8. When the broad ligaments are tied or clamped and cut, the peritoneum is opened posteriorly, and the uterus reinoved. 9. If ligatures have been used, the stumps of the broad liga- ments are sewed together, the peritoneum and vaginal walls closed over them with number 3 chromic catgut. If clamps were used, the pelvis and vagina around the clamps is packed with gauze, and the handles of the clamps so supported by a suspensory bandage that the blades are not dragged upon. Clamps are cautiously removed, after seventy-two hours. ABNORMALITIES OF THE CERVIX SQ Technic of Combined Hysterectomy. — i . This is the same as the vaginal operation until the peritoneum is opened anteriorly. 2. From this point it is the same as the Wertheim. Prognosis after operation depends greatly upon how advanced the disease was when the operation was done. The most optimistic reports give 30 per cent, as free from recurrence for five years. Ten per cent, would be a more accurate average. The primary mortality is from 6 per cent, to 10 per cent., the chief causes of death being peritonitis and secondary hemorrhage. Palliative Treatment of Inoperable Cases. — This is applicable to cases so far advanced that complete removal is not possible. Methods. — ^I. Ctiret, Heat and Chemical Cautery. Pig. 34. — Paquelin's cautery. Note that the benzene is contained in the handle of the apparatus. (Ashton.) Technic- — i. The patient is anesthetized, and placed in the dorsal position. 2. The crater of the cervix is exposed by a cylindrical wooden Ferguson or water-cooled cylindrical speculum. The ordinary metal ones get too hot during the cauterization. 3. The sloughing mass of cancer is curetted away by a curet with saw-tooth edges. 4. As soon as reasonably firm tissue is reached, the crater is thoroughly cooked with the electric dome or Paquelin button 90 ABNORMALITIES OF THE CERVIX, EXCLUDING TEARS cautery. The electric is much the better, and the point in either one should be a dull cherry red, to minimize bleeding. 5. The cavity is then packed with a tampon soaked in 50 per cent, zinc chlorid solution, or equal parts of adrenalin Fig. 35. — Transformer for electrocautery. This is a rheostat and motor, as required for the direct current. An alternating current requires the rheostat only, which is a much less expensive apparatus. The cable shown can be boiled, but the insulation rots quickly. It is equally good to cover the cable with sterile towel. {B. C. Hirst.) i-iooo and 40 per cent, formaldehyd solution (the stock solution) . 6. The wet tampon is held in place by other tampons thickly smeared with an ointment of 30 per cent, sodium bicarbonate in vaselin, to prevent vaginal eschars. Pig. 36. — Electrocautery point. The dome-shaped spiral is kept at a constant dull red heat. {B. C. Hirst.) 7. The tampons are taken out in eight days, the patient kept in bed for ten. H3^podermics of morphin are used, in ascending doses, to control pain. yVBNORMALlTlES OF TTIE CERVIX QI II. The Percy low-heat method is based upon the theory that cancer cells cannot withstand a temperature of 45°C. for ten minutes, while the normal cell will withstand 6o°C. The cervix is exposed through a water-cooled cylindrical speculum, the electric cautery point is pushed into the mass and the current turned on. An assistant, through a small abdominal incision, holds the fundus uteri in his hand, and when the uterine body becomes uncomfortably hot to his gloved hand, the direction of the cautery point is changed. Frequently, preliminary ligation of the internal iliacs is done, when hemor- rhage is feared. By this method the gross malignant mass is often removed at one sitting, though usually several are re- quired. It is not free from danger, hemorrhage, fistulas and deep-seated abscess being frequent complications. III. Byrne Method — the oldest of the cautery methods. By means of the cautery knife and button cautery the uterus is slowly burned out, so that a mere shell is left. The degree of heat is a dull cherry red, and the knife or button are always placed in contact with the tissue to be cut, before the current is turned on. This is to minimize bleeding. The results have been excellent. IV. X-ray in the treatment of cancer of the cervix has been a disappointment. V. Radium is of great value, particularly in the recur- rences after operation. It is applied for three or four hours to five days at a time, being either implanted in the cervix, or held in place by a tampon. One hundred milligrams are used and two or three weeks rest between treatments is given. The gamma rays penetrate three to four centimeters. The therapeutic value of radium depends on: (i) The amount used; (2) the nature of the filter (brass being the best); (3) the method of application; (4) the length of exposure; (5) the frequency of treatment. The results are often brilliant, sometimes utterly disappoint- ing, but occasionally radium will transform an inoperable into an operable case. No operation should be undertaken until 92 ABNORMALITIES OF THE CERVIX, EXCLUDING TEARS three weeks from the last radium treatment, because of the danger of sepsis. VI. Mesothorium is used as radium, but the supply is very limited and it is no more effectual than radium. Length of life after palliative treatment varies with the extent of the disease when seen. After curetment and cauteriza- tion, the patient usually markedly improves, the discharge and bleeding cease, and for a time she will even gain in weight. Life is prolonged for eighteen months to five years, and, rarely, repeated cauterization has resulted in a sympto- matic cure. After-treatment of palliated cases consists in: (i) Frequent vaginal douches (two daily) of lysol solution one dram to two pints or formalin i per cent.; (2) full diet; (3) laxatives to secure daily movements; (4) local applications of acetone to the cervical crater, when the bleeding and discharge return; (5) morphin in sufficient doses to control the pain. This will be needed first at night, and later at frequent intervals, night and day; (6) the patient had better not be told she has cancer, on account of the mental depression. Recurrence after removal of the uterus takes place any time from a few weeks to five or more years. The vast majority occur in the first six months, and after five years recurrence is very rare. The first symptom is slight irregular bleeding. Vaginal examination shows a hard nodule in the scar in the vaginal vault, with a small granulating area, and bleeding easily to the touch. The extent of involvement is best made out by rectal examination. Pain is of a burning character and is usually very severe. Treatment is radium, either with or preferably without a preliminary superficial cauterization. No other treatment offers any hope, but radium will often cause the prompt disappearance of surprisingly large recurrences. The patient must be closely watched, however, as re-recurrence is very possible, and is treated in the same way. abnormalities op the cervix 93 Cervicitis and Endocervicitis (Chronic Cervical Catarrh) Cervicitis and endocervicitis, except where caused by lacera- tion in childbirth, are due to specific or non-specific infection. Pathology.- — The glands are dilated, the lining epithelium in places absent. The stroma is edematous and infiltrated with round cells. Symptoms.- — ^Leukorrheal discharge, of thick, stringy, mucopus, profuse enough to require a napkin for protection, is the only symptom. Through a bivalve speculum, erosion of the vaginal portion of the cervix, especially on the posterior lip, and the discharge issuing from the canal can be seen. Treatment- — (i) Repeated vaginal douches (two a day.) of zinc sulphate and alum; (2) tampons of boroglycerid 25 per cent, or ichthyol 50 per cent. ; (3) local application, through a bivalve speculum, of 7 per cent, tincture of iodin or, better, nitrate of silver 8 per cent. (40 grains to the ounce) ; (4) instilla- tion, every other day, into the cervical canal of 50 per cent, ichthyol, 50 per cent, argyrol or 5 per cent, silvol paste. In- stillations are best in the form of a slowly melting paste, rather than solutions, as the paste is retained long enough to penetrate into the glands. The technic is described in Chapter II; (5) in obstinate cases, amputation of the cervix, or Schroder's operation of removal of the cervical mucosa, by wedge-shaped excision of each lip. The condition is often very stubborn, and will persist for years. Ectropion of the Cervix (Eversion) This is the result of bilateral laceration, the lips of the cervix diverging like a split stalk of celery. The lips are asymmetrical, the anterior being usually the longer. The deep red mucosa of the cervical canal is exposed. If the tear is stellate, there is often considerable hypertrophy of the cervix. Symptoms.- — ^Leukorrheal discharge. The diagnosis is made through a bivalve speculum. 94 .ABNORMALITIES OF THE CERVIX, EXCLUDING TEARS Treatment.^ — Repair of the injury, or, of the cervix is hyper- trophied, amputation of the cervix. For details of technic see Chapter XII. Erosion of the Cervix- This is a prolapse of the deep red columnar epithelium of the vaginal portion of the squamous epithelium of the vaginal portion of the cervix.. It is not ulceration, though it has that appearance. It is most often caused by laceration of the cervix, though it may be the result of any irritation. It is not infrequently seen in virgins, supposedjy due to mal- position of the cervix with re- troflexion or anteflexion of the uterus, so that there is undue Pig. 37. — Bilateral laceration Fig. 38. — Erosion and aversion of of the cervix, with marked ever- the cervix, secondary to bilateral sion, as seen through a bivalve laceration. {After Crossen.) speculum. {After B. C. Hirst.) friction between the cervix and the vaginal walls. Erosion is common in gonorrhea and in non-specific infection of the cervix. Symptoms. — ^Leukorrheal ' discharge, often blood-stained, because the cylindrical epithelium bleeds at the slightest touch. The diagnosis is made through a bivalve speculum, which shows plainly the red, angry area of hyperplastic cervical mucosa. ABNORMALITIES OF THE CERVIX 95 Digital examination alone is unsatisfactory; the erosion is not. easily felt, and its extent cannot be ascertained. Treatment. — (i) If due to laceration, repair or amputation of the cervix, the latter if it is hypertrophied, is required. No form of local application will cure permanently an erosion due to laceration; (2) if due to non-gonorrheal endometritis, dilatation and curettage of the uterus. In gonorrhea, this is to be avoided, as it will very probably be followed by pus tubes; (3) nitrate of silver (8 per cent.; 40 grains to the ounce) applied through a bivalve speculum three times a week; (4) tampons of boroglycerid 25 per cent, or ichthyol 50 per cent.' — three times weekly; (5) daily vaginal douche of zinc sulphate and alum solution (see Chapter II); (6) in- stillations into the cervix of 5 per cent, silvol paste, three times weekly; (7) in the erosion of virgins, instillation or amputation of the cervix. Any erosion is a possible site of cancer, hence intractable ones should be excised and examined microscopically. Hypertrophy of the Cervix This is nearly always the result of laceration and consequent hyperplasia of the cervical connective- tissue stroma. The complicated racemose glands easily become obstructed and cystic, and often show on the vaginal portion, as small pearly cysts, the Nabothian follicles. Hypertrophic elongation of the cervix is a consequence of prolapse of the uterus, due to the pull of the vaginal walls. Diagnosis is made by palpation, inspection through a bivalve speculum, or by simple inspection, if the case is one of prolapse. Treatment is amputation of the cervix. Cervical Myoma Cervical myoma is primarily very rare. Most cervical myomata are polypoid, and have originate'd in the lower uterine segment and grow downward. True cervical myoma grows as any other fibroid, causes pressure symptoms on the g6 7VBNORMALITIES OF THE CERVIX, EXCLUDING TEARS bladder and rectum comparatively early. The diagnosis is made by bi-manual examination. Because of their bulk, a satisfactory specular examination is difficult or impossible. The treatment is removal through the vagina, usually by morcellation, and is attended with considerable risk of injury to the bladder and rectum. Nabothian Follicles When as a result of chronic irritation, the cervical glands are obstructed and cystic, they often show upon the vaginal portion of both hps as small pearly cysts. These are the Nabothian follicles, but the glands from which they come are noi Nabothian glands. The follicles contain cervical mucus, as a rule clear, but sometimes purulent from secondary infection. They may be felt by digital examination, but a bivalve speculum shows them plainly. If punctured, they usually refill, and the only satisfactory cure is trachelorrhaphy or amputation of the cervix. Cervical Polyps Cervical polyps are very common. They are seen most frequently after forty years of age, though no age is exempt. They are a very common cause of bleeding after the menopause. Kinds.- — I. Mucous Polyps — the commonest — represents a hypertrophy of the endocervical mucosa. They are often multiple, rarely of large size, are bright red or purplish in color, grow from any portion of the cervical canal and are most often pedunculated. 2. Fibroid or fibro-adenomaious polyps are larger, may attain the size of a child's head, and either project from the cervix or are contained in a cavity representing the dilated cervical canal, like a ball in a socket. They are usually single. They are bright red in color, and very firm to the touch — a marked contrast to the soft mushy mucous pol}^^. They might easily be mistaken for the ovum in inevitable abortion, retained within the cervical canal, but are much more solid in feel. ABNORMALITIES OF THE CERVIX 97 Attachments. — (i) Pedtmculated- — much the commonest, the pedicle being relatively slender, especially in the mucous type. (2) Sessile, where the attachment is broad and firm. Symptoms. — (i) Bleeding — irregular and often very profuse. (2) Leukorrhea — varying from the thin serous discharge of the fibroid polyps to the profuse mucopurulent type seen in infected mucous polyps. (3) Pain is not present, except in globular fibroid polyps in the cervical canal, when it is expulsive, like that of miscarriage, but less intense. Fig. 39- -Fibro-adenomatous polyps, hanging from the cervical canal. (After B. C. Hirst.) Diagnosis.- — (i) Digital examination. The mucous polyp is soft, the fibroid hard and firm. (2) Bivalve speculum shows the growth protruding through the os or visible in the dilated canal. Before any attempt is made to remove a large fibroid polyp, inversion of the uterus must be excluded. Degenerations.- — (i)lnfection, (2) cystic, (3) gangrene, (4) malignant (carcinoma in the mucous, sarcoma in the fibroid. Treatment.- — No polyp is innocent, and all must be removed. The method of removal depends upon the attachment. Mucous polyps are pedunculated, fibroid polyps may be grasped with a forceps and cut off, snared off or best twisted off. Bleeding is not to be feared. Sessile polyps require splitting of the cervix anteriorly, incision of the capsule at the base of the 7 gS .ABNORMALITIES OF THE CERVIX, EXCLUDING TEARS growth, when the pol>^ may be seized with a volsellum and enucleated with the lingers . No ligatures are required, as the blood supply is poor. A very broad base will require two or three transverse catgut sutures to close it, and the incision in the anterior lip of the cervix is closed after the tumor is removed. In every case, the removal of the polyp should be followed by a dilatation and curettage, and both the polyp and scrap- ings should always be examined microscopically for malig- nancy. A polyp of any kind is best removed under anesthesia and in proper hospital surroundings and not as an ofi&ce pro- cedure. Dangerous infection may follow neglect of this precaution. Sarcoma of the Cervix Sarcoma is exceedingly rare, except as sarcomatous degenera- tion of a fibroid pol}^. Primary sarcoma occurs as a hyda- tidiform growth, of a purple color, extended from the cervix. The symptoms and treatment are those of cancer of the cervix. Radium is said to be more active and efficient in sarcoma than in cancer, but this is very doubtful. The prognosis is bad. All the reported cases have died. Tuberculosis of the Cervix Tuberculosis is rare, much less common than in the body of the uterus. The infection is primary and appears as an irregular punched out ulcer, with ragged undermined edge and pale granulations. The accurate diagnosis is made by excision and microscopic examination. Treatment.- — If there is widespread tuberculosis elsewhere, palliative treatment (local cauterization) alone is required. If there is no evidence of general tuberculosis, amputation of the cervix, or panhysterectomy. Ulceration of the Cervix Ulceration of the cervix is a much abused term. Usually it is synonymous with erosion, which is not a true ulcer. True ABNORMALITIES OF THE CERVIX 99 ulceration, with actual loss of substance, is seen in prolapse of the uterus, chancre, chancroids, cancer and tuberculosis. The ulcers of prolapse arg treated by reposition of the uterus, rest in bed, and boroglycerid tampons. Chancre heals promptly under neosalvarsan. Chancroids require cauterization with the cautery, carbolic acid or fuming nitric acid. Cancer and tuberculosis both require panhysterectomy. CHAPTER VII THE UTERUS— ITS NORMAL POSITION AND RELA- TIONS, ITS ABNORMALITIES OF POSITION AND DISEASES At birth, the uterus lies high in the pelvis, its axis is straight, and it is normally pressed backward. During childhood it gradually sinks deeper in the pelvis. The normal angulation r''i- .J /- f atrcnhied lower poftim • bartners d^cT. of Wolffian duct) Pig. 40. — Diagram of the uterus and vagina, and the structures of the broad ligament. (Kelly after Cidlen.) between the body and the cervix does not appear until near puberty. The uterus grows in size for some years after puberty. Childbearing increases its size in all dimensions by about i cm. and its weight about 25 grams. .ABNORMALITIES AND DISEASES OF THE UTERUS lOI The virgin uterus is normally 7 to 8 cm. long and weighs 50 grams. The natural position in the adult, in the standing posi- PlG. 41. — Normal position of the uterus. (Ashton.) Pig. 42. — Normal position of the uterus, seen from above. tion, is horizontal, its axis meeting the vaginal axis at an angle of 90 degrees. The anterior wall lies on the back wall and fundus of the bladder; on the posterior wall rest the intestines. 102 ■ THE UTERUS It can change its position through wide Hmits; it may be rotated backward through an angle of i8o degrees; laterally through one of 45 degrees, to each side; it moves backward and forward with every breath, is pushed far back when the bladder is full; and on straining, it is pushed to a lower level in the pelvis. How Retained in Position. — By (i) the support of the peri- neum, (2) intra-abdominal pressure, exerted on the posterior wall, keeping it normally anteverted; (3) the^uterine ligaments, which are partly suspensory and partly guy-ropes. Ligaments of the uterus are ten in number — five pairs, (i) Two broad ligaments — the folds of peritoneum at either side; (2) two round— horn each cornu to the internal inguinal rings and thence down the inguinal canal to the pubic spine; (3) two uterosacral; (4) two uterovesical, though commonly fused so as to appear one; (5) two cardinal — bands of connective tissue in the parametrium in the bases of the broad ligaments, running from about the level of the internal os, through the bases of the broad ligaments to fuse with the fascia on the lateral pelvic wall.. Peritoneal coat of the uterus (perimetrium) covers the posterior wall, above the level of the internal os; the fundus; the anterior wall as far as the attachments of the bladder. It is tightly adherent everywhere except on the anterior and posterior surfaces of the lower uterine segment. The parametrium is the connective tissue in the base of the broad ligaments and under the anterior and posterior peritoneal reduplications — -in Douglas' pouch and behind the bladder. The myometriimi is the uterine muscle— arranged in three layers and unstriped. The endometriimi is the mucous membrane layer lining the cavity. It has no submucosa. It is 1-2 mm. thick, com- posed of a spindle-celled connective tissue strewn with many tubular glands, lined by ciliated columnar epithelium. The epithelium of the body differs from that of the cervix. ABNORMALITIES AND DISEASES OF THE UTERUS lO,^ The cervical cells are long, thin, with nuclei at the bot- tom. The corporal cells are short, fat, with nuclei in the center. The cilia lash toward the os uteri. The uterus during lactation is much smaller than normal, a temporary condition due to shrinking of the muscle fibers. Any curetment done after miscarriage or during lactation, causes an extra risk of perforation of the uterus. When lactation ceases, the uterus returns to its normal size. The uterus after the menopause is permanently atrophied, its axis is straight, and its mucosa atrophied. ABNORMALITIES AND DISEASES OF THE UTERUS Anterior Displacement : Anteflexion, Anteversion, Anteposition anteflexion of the uterus Anteflexion of the uterus is an increase in the normal angulation between the cervix and corpus uteri. It is often associated with ill-development of the uterus and stenosis of the cervical canal. It is essentially a condition of nulli- parae only. Causes. — Unless it is caused by the pull of adhesions or a tumor behind the uterus (both of which are rare) the condition is congenital, due to faulty development. Symptoms. — (i) Dysmenorrhea, the pain being most severe for the first twenty-four hours of the period, and gradually subsiding as the flow is established; (2) a brown leukorrhea, at the end of the period, due to slow draining of retained blood; (3) sterility; (4) in many cases, pronounced neurotic symptoms. Diagnosis. — If the examining finger is passed along the anterior wall of the cervix, and pressed deeply into the anterior vaginal vault, the sharp U-shaped bend can be felt; bimanual examination reveals the anterior position of the uterus; specular examination shows a long conical cervix and a pin- hole OS uteri. I04 THE UTERUS Treatment. — The most satisfactory treatment is forcible dilatation of the cervical canal, thus straightening out the axis, followed by Schatz's metranoikter, left in place for 24 hours. Technic. — (i) The patient is prepared as for any vaginal operation, arranged in the dorsal position and anesthetized. 2. The anterior lip of the cervix is caught with a double tenaculum and held by an assistant. Pig. 43. — Anteflexion of the utertis. A lateral view. 3. The cervical canal is dilated with a light Goodell dilator, just enough to admit the blades of the heavy Wathen dilator. In very tight stenosis, the internal os must be first penetrated with a probe and then a uterine sound before the light dilator can be inserted. 4. With a heavy Wathen dilator the cervix is dilated to one inch transverse measurement, making pressure by the side screw of the instrument and never by pressing the handles together, nor should the instrument be rotated from side to side. Ten minutes should be taken to reach the one inch mark, to avoid tearing. ABNORMALITIES AND DISEASES OF THE UTERUS 105 5. With a four-bladed Cleveland dilator, a dilatation of go mm. circumference is now secured. 6. No curettage is desirable, unless the patient has leukor- rhea. If done, it is performed gently, with a sharp Sims curet. Dull curets are useless here. 7. The uterus is washed out with sterile water. 8. The two-bladed Schatz metranoikter, or better its four-bladed B. C. Hirst modification, is inserted in the uterine canal, as far as it will go, and the vagina packed with gauze. Pig. 44. — Replacing uterus in proper position after curettement. If this is neglected, permanent retroversion may result. {After Crossen.) 9. Twenty-four hours later, the metranoikter is removed, and the uterus washed out with sterile water, this lavage is most essential. 10. The patient is kept in bed for one week. About half the patients require a dose of 3^^ grain morphin sulphate hypodermically during the night following operation, due to pain from pressure of the metranoikter. Io6 THE UTERUS Alternate Methods of Treatment. — (i) The Wylie drain is often used in place of the metranoikter. It is a plug of aluminum or hard rubber, channeled to permit escape of discharge. It is inserted in the uterine canal at the point where by the above technic the Schatz instrument is used. It is not as efficient as the metranoikter, has some risk of infection of the endometrium and pyosalpinx, and fatal infection has followed its use. From all these objections, the metranoikter has proven 'itself free. One of these instru- ments must be used, however, to secure satisfactory permanent dilatation. The simple instrumental dilatation is not permanent. (2) Tents. — Plugs of compressed sponge or tupelo wood, designed to absorb moisture after being inserted in the uterine canal, and by their swelling to dilate the cervix, have fallen into deserved disrepute. They cannot be satisfactorily sterilized. (3) Dudley's operation is discission of the posterior cervical lip, through the internal os, and se\ving the wound trans- versely, to cause gaping. It is efficient in relieving the stenosis, but is often followed by annoying leukorrhea from endo- cervicitis and erosion, and may require repair of the cervix or even amputation. Palliative treatment, of a condition which is largely mechanical, is usually a waste of time, and often a real danger, due to the use of habit-forming drugs. For temporary use, the following will be found useful, but not over long periods. (i) Rest in bed during the first two days of the period; (2) hot water bag to lower abdomen ; (3) hot vaginal douches (11 5'-! 20') three times daily (hot enemata in young single women); (4) tincture of gelsemium, TUx four times daily; (5) acetanilid gr. 2, ammonium carbonate gr. 3 every three hours; (6) if stronger sedatives are needed, codein sulphate gr. 3^^ hypodermically and not morphin. Pessaries for anteflexion are practically useless. The intra- uterine stem pessary of any form is dangerous because of infec- ABNORMALITIES AND DISEASES OF THE UTERUS tO'J tion; Schultz's sleigh, Thomas' anteversion and Hewitt's cradle pessaries are all of so little use as hardly to be worth a trial. ANTEVERSION OF THE UTERUS Anteversion of the uterus is its normal position, and the use of this term to describe a pathologic condition is erroneous. ANTEPOSITION OF THE UTERUS Anteposition of the uterus is the pushing forward of the organ by a tumor or abscess behind it, or is due to the pull of adhe- sions. The symptoms are dysuria and irritability of the bladder, due to pressure. When the cause is removed, the uterus resumes its normal position. The irritability of the bladder in early pregnancy is due to pressure from anteposition of the uterus, because the increased weight of the body and greater flexibility of the lower uterine segment permit the uterus to fall forward on the bladder. Lateral flexion of the uterus is due to (i) adhesions; (2) pressure of a growth; (3) congenital deformity (uterus uni- cornis). Backward Displacement of the Uterus : Retroflexion AND Retroversion In retroversion, the uterus is turned back as a flail; in retroflexion, it is bent back at the lower uterine segment. Except for the position of the cervix, which in retroversion is often further anterior, the two conditions are practically identical in causes, symptoms and treatment, and will be so considered. Causes. — (i) Congenital, where the uterus has developed in the posterior position; (2) relaxation of the uterine supports or musculature; (3) the drag of adhesions; (4) pushed back by a tumor. By far the greatest number of cases follow childbirth, and hence belong under the second head. I08 " THE UTERUS Predisposing causes are: (i) Violent jars or falls, producing a traumatic displacement, which may be permanent if neg- lected; (2) long-continued overfilling of the bladder; (3) perineal lacerations; (4) subinvolution of the uterus after childbirth. Time of occurrence is, in the cases following childbirth, most commonly between the third and sixth weeks of the puerperium. Symptoms.-^(i) Backache, low down over sacrum, and always central; (2) headache, most marked over the vertex or occiput; (3) pelvic pain, on one or both sides, due to conges- tion from torsion of the broad ligaments; (4) increased men- strual flow; (5) often dysmenorrhea; (6) nervous irritability; (7) leukorrhea. The backache and headache are usually re- lieved on lying down; all symptoms are more marked at the menstrual periods. None of the symptoms are constant, and many women with retroversion exhibit no symptoms whatever. Diagnosis is made by bimanual examination, with the pa- tient in the dorsal position, preferably on a table. It is absolutely essential that the bladder be empty; a full bladder temporarily pushes the uterus backward and may cause a mistaken diagnosis. I. With the patient in the dorsal position, two fingers of one hand are placed in the vagina, with the finger tips in front of the cervix; (2) with the free hand, pressure is made on the abdomen, in the middle line, just above the symphysis; (3) if the uterine body is in good position, it can be felt between the fingers. If not, the fingertips, provided the patient is not fat and does not resist, will meet with only the tissues of the abdominal wall and vaginal vault between them; (4) the fingers of the vaginal hand are then moved behind the cervix, and the body of the uterus can be felt posteriorly. The use of a sound for diagnosis of position is unnecessary and dangerous. Degrees of Retroversion. — First degree — with the fundus tilted away from the bladder; second degree, with the fundus ABNORMALITIES AND DISEASES OF THE UTERUS 109 pointing about to the middle of the sacrum; third degree, with the fundus completely back in Douglas' pouch. Differential Diagnosis. — The commonest error is to mistake an anteflexed uterus, with retrocession, for a retroversion. The sharp anterior angle of flexion can always be felt; (2) myoma; (3) ovarian cyst; (4) dense pyosalpinx adherent in Douglas' pouch. Rectal examination is often required in (i) young girls, (2) when patient resists vaginal examination. The cervix feels considerably larger by a rectal than by vaginal examina- FiG. 45. — Diagram illustrating the three degrees of retroversion of the uterus. The third degree is often called complete retroversion. {After Skene.) tion. In any case of doubt, examination under anesthesia is required. Pathology. — (i) The uterus is large, heavy and softer than normal; (2) it has a deep purple, mottled color, from chronic congestion; (3) varicocele of the broad ligament is common; (4) the endometrium is hypertrophied; (5) the tubes are congested; (6) the ovaries, being in secondary prolapse in Douglas' pouch, with the uterus lying on top of them, show a tendency to cystic formation; (7) adhesions are rare, except as a result of infection. no THE UTERUS TREATMENT Treatment may be (i) palliative or (2) operative. Cases which exhibit no symptoms require no treatment. Cases which show a tendency to abort, or there is associated sterility, require correction, even though no other symptoms are present. Palliative Treatment. — Indications: (i) Recent traumatic retroversion; (2) retroversion shortly after childbirth; (3) non-adherent retroversion, where the patient makes the choice; (4) certain cases of adherent retroversion (treated by tampons). A recent traumatic case (from a fall or severe jar) requires only reposition, under anesthesia if necessary, and no method of mechanical support is needed. As soon as the uterus is freed from the pressure of the uterosacral ligaments, between which it is caught, it resumes its normal position and stays there. Reposition in these cases is best done by rectal pressure. Methods of Reposition. I. Bimanual — (i) The patient is arranged on a table, not a bed, in the dorsal position. 2. Two fingers of one hand are placed in the vagina, behind the cervix. 3. The uterine body is lifted, by these fingers, until the fingers of the other hand, on the abdomen, can catch behind the fundus and pull it forward. This maneuver can be as- sisted materially by a double tenaculum catching the anterior lip of the cervix. It will not succeed if the uterus is adherent, if the patient is fat or if she resists the_ examination. II. Reposition in the Knee-chest Posture. — (i) The patient is arranged in the knee-chest posture, on a table; (2) the perineum is retracted by a Sims speculum; (3) the anterior lip of the cervix is caught with a double tenaculum; (4) with a repositor, in the posterior vaginal vault, the uterine body is pried, not pushed, forward, as the double tenaculum on the cervix is pulled down. .ABNORMALITIES AND DISEASES OF THE UTERUS III Fig. 46. — ^The different steps in bimanual reposition of a retroverted uterus. This is only possible when the patient is thin, relaxed, and the uterus is not adherent. 112 ■ THE UTERUS III. Rectal manipulation is often of value in both the above methods. It is best carried out with a curved, heavy sound; the finger is too short for the purpose. IV. The uterine sound or more safely, a small intra-uterine Bozemann douche nozzle may be used, in cases which cannot be replaced by other methods, provided extreme asepsis and gentleness be observed. For this method the uterus must not he adherent. A bivalve speculum is inserted in the vagina and the cervix exposed; the cervix is wiped off with pledgets of cotton soaked in i-iooo bichlorid solution; the sound, bent in a good curve, or the douche nozzle — ^if there is sufi&cient dilatation of the cervix — is passed into the uterine canal and the uterus gently pried forward. This method is useful in very fat women, but must be cautiously used and all instru- ments boiled. V. Anesthesia may be required in any of the above methods. VI. Adherent retroversion may sometimes be replaced by the following method: (i) The patient is arranged in the knee- chest posture, on a table; (2) the perineum is retracted by a Sims speculum; (3) a small, wool tampon is grasped with placental forceps, dusted with boric acid powder, and placed in the posterior vaginal vault with as much pressure as the patient can stand; (4) other tampons are placed below this, until the vagina is full. A count is kept of the number used. (5) The tampons are removed by the patient, after forty-eight hours. She takes a vaginal douche, and returns to the office for a fresh supply. (6) The treatment lasts ten or twelve weeks, being interrupted during menstruation. If the patient has the patience to persist, this method is often successful. Pessaries. — After a uterus is replaced, if it will not remain in place without support, it may be kept in proper position by a pessary. Except in cases immediately following the puerperium, a pessary is not a cure, simply a crutch, but patients can be kept comfortable for as long as they choose to wear it. The pessary requires regular inspection every six ABNORMALITIES AND DISEASES OF THE UTERUS II3 to eight weeks, must then be removed, cleaned and replaced, and if the vaginal vault shows any sign of erosion, it must be left out for two to four weeks and the erosion treated by- vaginal douching and boroglycerid tampons. Kinds of Pessaries. — (i) Hodge — with a broad lower bar, usually uncomfortable because of pressure on the urethra, but valuable when there is slight relaxation of the outlet. (2) Smith, narrower at its lower end, and the most comfortable type. (3) Thomas — the same shape as the Smith, but with a very heavy upper bar, to span the angle of flexion in retro- Hodge Smith Thomas Pig. 47. — The three types of retroversion pessary in common use. flexion. Pessaries are made of hard, vulcanized polished rubber. How Retained: — (i) The fit of the shaped pessary to the vaginal canal; (2) the cervix, behind which the upper bar is hooked; (3) the pressure of the perineum; (4) the elastic and muscular tissues of the vaginal walls. How it Acts: — As a lever in the vagina, the force of the short (upper) arm of the lever behind the cervix being exerted on the uterosacral ligaments and posterior vaginal vault. This pulls the cervix up and back and tilts the fundus forward. Indications for a Pessary. — (i) Uterus free from adhesions; (2) a patient able to abstain from hard work; (3) uterus re- placeable and in place when the pessary is inserted; (4) good perineal support (if the perineum is torn, the pessary will drop out as soon as the patient stands up) ; (5) ovary must not be prolapsed. 114 THE UTERUS Contra-huiicaiions,~~{i) A patient who must do hard work; (2) adherent retroversion; (3) prolapse of the ovary; (4) a uterus that cannot be replaced; (3) young single women (due to the narrow vagina and consequent difficulty of insertion and after care). A pessary should never be inserted with the hope that it will pry the uterus into proper position. Insertion of a Pessary.- — (i) The patient is in the dorsal position; {2) the uterus is in proper position; (3) the pessary Fig. 48. — The first step in the insertion of a pessary. {After B. C. Hirst.) is grasped by the lower bar and greased (glycerin); (4) the forefinger of one hand presses down in one vaginal sulcus; (5) the pessary is inserted obliquely in this sulcus, and upside down> for about one-half its length; (6) the pessary is turned right side up; (7) the forefinger of the other hand makes pressure on the upper bar of the pessary, carrying it up and behind the cervix (never in front of the cervix). Qualifications for Proper Pessary. — (i) No portion of it is visible after insertion. (If so it is too long, and can be short- ened by increasing the curvature.) (2) It should reach from ABNORMALITIES AND DISEASES OF THE UTERUS II 5 the posterior vaginal vault to the anterior vaginal wall, at the level of the internal urinary meatus. (3) There should be room to pass the finger all around it. (4) It should be the smallest that will satisfactorily support the uterus. (5) It should cause no pain. (6) It does not interfere with coitus. (7) In cases of retroflexion the Thomas pessary is used to span the angle of flexion. It is not usually possible to find at the first trial a pessary satisfactory in all respects. The instrument must be fitted Pig. 49. — The pessary in position. {After Skene.) to each case. The shape of the pessary can be varied by immersing in boiling water, moulded to the desired shape, and then plunged in cold water to harden it. After-treatment. — The patient is told to report in two weeks, or sooner if she is uncomfortable. She then reports every four weeks, for three months. At each visit, the pessary is removed by hooking the forefinger //'ow helow, under the lower bar; the vaginal vaults are inspected through a bivalve specu- lum for possible erosion or irritation, and if none is found, Il6 * THE UTERUS the pessary is reinserted. After three months, an attempt is made to do without the pessary, for two weeks; if the uterus is found in good position, and again four weeks later, the patient may be discharged as cured. If the displacement recurs, the pessary is again inserted for three months, with examination as before. If then, after the pessary has been worn for six months, the uterus will not stay in place without support, the patient is given her choice between the constant wearing of a pessary or operation. During the period of trial, the patient may undergo a course of pelvic massage and Swedish movements, designed to strengthen the pelvic muscles and ligaments, but of doubtful value. The long-continued wearing of a pessary is not desirable. It requires constant watching, the pressure of it is irritating, it tends to aggravate any neurosis of the patient, and to convince the patient that she requires constant medical atten- tion. Frequent vaginal douching while the pessary is worn is not advisable; a douche of salt solution twice a week is ample. Operative Treatment for Backward Displacement of the Uterus. — Indications: (i) Adherent retroversion, when the uterus cannot be replaced; (2) a patient who must do hard work; (3) as an operation of election, after a pessary has been tried and has failed to keep the uterus in position; (4) when a pessary cannot be worn, due to the irritation it produces in the vagina; (5) in cases with associated tendency to abortion or with sterility, even though other symptoms are absent. The ideal operation is one that (i) is free from risk; (2) does not open, or entails a minimum of invasion of the peritoneal cavity; (3) has a minimum of recurrences; (4) does not add any difficulty in future childbirth; (5) withstands subsequent childbirth. As eighty-one different technics have so far been devised, it is obvious that no single operation answers all these factors. Those of most value are described below. I. Alexander operation ( Adams- Alquie-Edebohl's) the princi- ABNORMALITIES AND DISEASES OF THE UTERUS II 7 pie of which is the extraperitoneal shortening of the round ligaments in the inguinal canal. Indications. — (i) Non-adherent retroversion, without suspi- cion of pelvic disease or appendicitis; (2) patient preferably under thirty-five; (3) patient not too fat. Advantages. — (i) Extraperitoneal; (2) negligible percentage of failure; (3) never any trouble in subsequent childbirth; (4) withstands subsequent childbirth. Disadvantages. — (i) Does not permit inspection of the pelvic organs or appendix; (2) unsuspected pelvic adhesions may cause subsequent pain; (3) inguinal hernia — this danger largely theoretical, as the operation properly done is really a Bassini for hernia. The greatest disadvantage of the Alexander operation can be avoided by opening both internal rings, after the ligaments are found and stripped out. Adhesions can be broken up, the tubes inspected and the appendix removed. When the adhesions are very dense or pyosalpinx exists, this is not appli- cable, but for cases without gross pathologic lesions it is nearly ideal. The peritoneum of the rings is closed separately, and the rings themselves closed as the round ligaments are sewed fast. Causes of Failure. — (i) Infection; (2) failure to puU out enough round ligament; (3) in a small percentage of cases, the round ligaments are too thin to give proper support, and very rarely they are entirely absent. Very rarely the round ligaments run from the internal ring to the anterior-superior spines, instead of the pubic spines, a fact to be remembered when they cannot be found in their normal situation. Technic. — (i) The patient is prepared as for any section, and anesthetized. The operation is not satisfactory under local anesthesia. 2. An incision is made parallel to the upper border of Poupart's ligament, for a distance of two or three inches from the pubic spine. This is extended through the superficial Il8 . . THE UTERUS fascia and fat until the fascia covering the inguinal canal is exposed. All bleeding vessels are caught 'and tied, as the wound must be dry. 3. Midway between the pillars of the external ring, the fascia over the inguinal canal is cut, in the same line as the skin incision. 4. The edges of the fascia are retracted with hooked retract- ors, and the round ligament is picked up on a blunt hook, from its position along the floor of the canal. The ilio-inguinal nerve lies just above it. The ligament can be recognized, when it is lifted, by its white color. 5. The band of cremasteric fascia, running along the liga- ment is cut, and the ligament, by blunt dissection with a pad, is stripped out of the internal ring for six or eight inches. 6. The wound is covered, and the opposite groin opened and the ligament stripped out in the same way. 7. Both ligaments are then pulled tense, crossed over the symphysis, and a hemostat clamped at the point of intersec- tion. The fundus can be felt to bump against the anterior abdominal wall, as the ligaments are pulled on. 8. The hgaments are then sewed into the canal with a continuous stitch; each bite of the needle taking in turn: (i) The upper edge of Poupart's ligament; (2) the floor of the inguinal canal; (3) the middle of the round ligament (so as not to strangulate it); (4) the external oblique muscle; (5) the external oblique fascia. Number i chromic catgut is used, and the stitch ends at the pubic spine, closing the external ring. 9. The excess of ligament is cut off. 10. The skin and fat is closed as in any operation. 11. For six weeks it is desirable, except in young unmarried women, to have the uterus supported by a pessary. II. Alexander operation, with Pfannenstiel incision is designed to utilize the principle of the Alexander operation and at the same time, permit inspection of the appendages and appendix. ABNORMALITIES AND DISEASES OF THE UTERUS II9 Disadvantages. — (i) It is exceedingly difficult to remove a badly adherent appendix, on account of limited room; (2) deep- seated hematomata are not uncommon, due to the extensive dis- section; (3) there is some danger of injury to the bladder, in open- ing the peritoneum, as the wound is very near the symphysis. Advantages. — (i) It permits inspection or removal of tubes, ovaries and appendix; (2) unsuspected adhesions can be dealt with; (3) the scar is almost entirely hidden in the pubic hair; (4) it withstands subsequent childbirth, due to the Alexander principle. Technic. — (i) The patient is prepared as for any section and anesthetized. 2. The Pfannenstiel semilunar incision is made down to the fascia. 3. The inguinal canals are opened, and the round ligaments dissected out, as in the Alexander operation. 4. The two groin fascia wounds are then connected above the symphysis, the pyramidahs muscles cut loose, the rectus muscles separated and the peritoneum opened in the middle line, by a vertical incision. 5. The appendages and appendix are inspected, adhesions, if any, broken up and the uterus suspended by a single stitch of plain number 3 catgut, to act as a pessary. 6. The peritoneum is closed. 7. The round ligaments are sewed fast, as in the Alexander operation. 8. The rectus and pyramidalis muscles are repaired and the fascia, fat and skin closed as in any operation. III. Combined Alexander and Section. Indications. — (i) Cases where the uterus is adherent, the patient is not too fat, and is under thirty-five. Past this age, the round ligaments are often atrophied, and the risk of failure considerably increased. Advantages. — Permits thorough inspection of tubes and ovaries and appendix, and allows proper management of any gross pathologic lesion. I20 ■ THE UTERUS Disadvantages. — None, except the theoretical one of three incisions, which, however, involve no mutilation or exten- sive dissection, and leave the patient in normal anatomical condition. Technic. — (i) The patient is prepared as for any section and anesthetized; (2) both groins are protected with gauze sponges, soaked in 70 per cent, alcohol; (3) a short central incision is made and any necessary pelvic work done. The round ligaments are inspected, to make sure they are suflS- ciently thick and the abdomen closed at once ; (4) the abdom- inal wound is covered with gauze and from this point the technic is the same as the Alexander operation. For any case where future childbearing is possible, this is one of the most satisfactory operations yet devised. IV. Ventro suspension (Hysterorrhaphy; Hysteropexy) is the suspension of the uterus, by sutures, against the anterior abdominal wall, just above the symphysis. Advantages. — (i) The operation is quick and easy. It takes less time than any other method. (2) In patients who will never bear children, it is satisfactory. Disadvantages. — (i) It pulls the uterus out of the pelvis; (2) it has a high percentage of failures; (3) it never withstands subsequent childbirth; (4) it cramps the bladder for room; (5) there is some danger of intestinal obstruction; (6) if the wound is infected, the silk or Pagenstecher stitches cause an annoying sinus; (7) as a result of infection, the uterus may be fixed, instead of suspended. The uterus does not remain tight against the abdominal wall. In a few weeks, a suspensory ligament, about two inches long is formed, by which the uterus hangs in place. If the sus- pensory stitches take in the fascia of the anterior abdominal waU, the result is a ventrofixation of the uterus, which is to be avoided in women of childbearing age. Indications: — ^(i) In patients past the danger of childbear- ing; (2) in ovarian cyst operations, as a precaution against secondary retroversion; (3) as an adjuvant in round liga- ABNORMALITIES AND DISEASES OF THE UTERUS 121 ment operations; (4) in all other cases, with appreciation of the risks of failure. Technic. — (i) The patient is prepared as for any section and anesthetized; (2) the abdomen is opened in the midhne, and all necessary work done; (3) just before the abdomen is closed, the uterus is suspended by two silk or, better, Pagen- stecher linen thread stitches passed through the peritoneum of one side from within, through the inner one-third of the Fig. 50. Fig. 51. Fig. 50. — The suspension stitch in ventro-suspension. When the stitch is tied, and the flap of peritoneum closed over it, the stitch is in the peri- toneal cavity, and less likely to cause a persistent sinus should the wound become infected. (After B. C. Hirst.) Fig. 51. — A lateral view of the operation of ventro-suspension of the uterus completed. Notice how the bladder is cramped for room. {After Crossen.) rectus muscle and down through the peritoneum again; through the fundus uteri, between the tubes, taking a bite one-half inch wide and one-quarter inch deep; through the peritoneum and inner one-third of the rectus muscle of the other side and down through the peritoneum again. When the knots are tied, they will be inside the peritoneal cavity. Catgut is not satisfactory, because of stretching and premature absorption. One stitch passes close behind the other through the fundus. If they are too far apart, 122 THE UTERUS two suspensory bands may result, with possible intestinal obstruction; (4) an assistant, with one finger in the wound behind the uterus, keeps intestines out of the way until the knots are tied; (5) the abdomen is closed in the ordinary way. V. Baldy operation, the principle of which is pulling the round ligaments through the broad ligaments, under the ovarian ligaments, and sewing the loops together behind the uterus in the middle line, fixing them to the uterus as well. The Webster operation is the same in principle, but the round ligaments are fastened where they come through the broad Fig. 52. -The Baldy operation for retroversion, seen from above and from behind. {After Graves.) ligaments instead of in the middle line. It is not nearly as satisfactory. Advantages. — (i) Leave the uterus in normal position; (2) plenty of room for the bladder; (3) utihzes the thick ends of the round ligaments; (4) ovaries are suspended. Disadvantages. — (i) Extensive adhesions from traumatism of the broad ligaments and uterus; (2) some difficulty in sub- sequent pregnancies, with added risk of miscarriage; (3) frequent recurrence of retroversion after delivery. Indications. — -Any case of retroversion where the appendages do not require removal, and the uterine attachments of the round ligaments are not interfered with. ABNORMALITIES AND DISEASES OF THE UTERUS 12,-^ Technic. — (i) The abdomen is opened in the middle line, as in any ordinary section; (2) any necessary abdominal work is completed; (3) the broad ligament of one side is held tense, through a bloodless space under the ovarian ligament a long hemostat is passed, and the round ligament caught about three inches from the cornu and pulled through the broad ligament; (4) the opposite side is secured in the same way; (5) the loops are sewed to each other in the middle line, and to the uterine body. They are spread out rather widely and secured with Pagenstecher thread near the fundus. If they are sewed low down on the uterus, the organ may fall backward over them; (6) the abdomen is closed as usual. VI. The Gilliam operation, in which the round ligaments are pulled through the peritoneum and muscle, under the fascia, at either side of the lower end of the median abdominal incision, and sewed together in the midline and also where they emerge from the muscle. The Mayo modification of this tunnels under the fascia and catches the ligaments where they enter the internal ring and pulls them over to the middle line. Advantages. — -(i) Withstands subsequent childbirth fairly well; (2) ovaries are suspended. Disadvantages. — -(i) Owing to variation in the point of attachment of the round ligaments, the uterus is often not far enough forward, but points toward the umbilicus; (2) some danger of intestinal obstruction; (3) some danger of sloughing of the ligament, which is obviated if the ligament is not bruised in handling and the opening in the muscle is large enough not to constrict it. Indications. — ^Any case where by removal of the tubes, the uterine attachments of the round ligaments are not interfered with. Technic. — (i) The abdomen is opened in the ordinary way, by median incision; (2) any necessary intra-abdominal work is completed; (3) on each side of the wound, at its lower angle, a forceps is thrust through the muscle and peritoneum, the round ligament grasped midway in its course through the broad 124 THE UTERUS ligament, and pulled through the opening made by the forceps ; (4) the peritoneum is closed; (5) the loops of ligaments are sewed together in the middle line and also to the muscle, where they emerge, using number i chromic catgut; (6) the fascia, fat and skin are closed in the usual way. VII. Cofey operation, a modification of the old Mann opera- tion. The round ligaments are folded down the anterior face of the uterus as far as the peritoneal reduplication, and then back again to the cornu, and secured by suture. Advantages. — None, over the above-described methods. Disadvantages. — The same that caused the discarding of the Mann and similar operations: (i) Depends upon the thin Fig. 53. — The Coffey operation for retroversion, seen from in front. {After Cross en.) pubic end of the round ligament; (2) extensive adhesions from the suturing; (3) does not withstand subsequent child- birth; (4) high proportion of failures. Technic. — (i) Ordinary abdominal incision and completion of intra-abdominal work; (2) the round ligament is carried down to the peritoneal reduplication on the anterior face of the uterus and held there by a stitch. It is then carried back to the cornu and held by another one; (3) the two layers of the ligament are sewed to the anterior face of the uterus, using number i chromic catgut; (4) a fold of peritoneum from the broad ligament is then sewed over the reduplicated round ligaments; (5) the abdomen is closed in the usual way. ABNORMALITIES AND DISEASES OF THE UTERUS 1 25 VIII. Vaginal fixation of the uterus is never justifiable in women of childbearing age. It always causes severe dystocia. In women past the menopause, the most satisfactory technic is the Watkins-Wertheim interposition operation, as used in the cure of cystocele, but unless the patient has had children, the vaginal operation is better not attempted. III. Cancer of the Fundus or Body of the Uterus Cancer of the fundus or body of the uterus is seen usually at a later age than cancer of the cervix, forty-five to sixty being the usual. It is much less frequent than cancer of the cervix — about one-eighth. It is also more common in nullip- arous women, just the reverse of cervical cancer. Its progress is slow, it is slow to give metastases, and there- fore is surgically more favorable than cervical cancer. Metas- tases take place into the deep sacral lumbar or renal glands, but may go into the groin along the lymphatics of the round ligament. Symptoms. — (i) In over 80 per cent, of cases, the first symptoms appear after the menopause; (2) the first symptom is a watery, seropurulent uterine discharge, without odor and rather scanty; (3) then irregular bleeding, not profuse, but persistent; (4) a foul blood-streaked discharge, in the intervals of bleeding, as the growth begins to slough; (5) pain of an intense burning kind — a late and usually unfavorable symptom. When the disease begins during menstrual life, it is often mistaken for profuse menstruation as an indication of the impending menopause — a most dangerous fallacy. Any ir- regular persistent bleeding in a woman past forty demands immediate investigation as to its cause. Cancer of the body of the uterus is frequently found associ- ated with fibroid tumor. If in a case of bleeding myoma, radical operation is for any reason deferred, a dilatation and curettage should always be done, to exclude cancer, especially if :i;-ray treatment or radium is to be begun. The rays often stimulate active growth of the malignant process. 126 • THE UTERUS Diagnosis. — (i) Bimanual examination of the uterus reveals practically nothing abnormal; at the most a uterus slightly enlarged; (2) specular examination shows a normal or slightly eroded cervix; (3) exploratory dilatation and curettage with microscopic examination of the scrapings is the only means of diagnosis, and should promptly be done. Kinds of Cancer. — (i) Adenocarcinoma — much the common- est; (2) malignant adenoma; (3) chorionepithelioma. Squa- mous-celled epithelioma does not occur in the body of the uterus. Treatment. — Abdominal panhysterectomy (Wertheim) is much the best. The technic is precisely that described under cancer of the cervix, with the following exceptions: (i) The uterine cavity is injected with strong (40 per cent.) formalin solution, to sterilize it; (2) the cervix is sewed up, to prevent leakage; (3) curetment and cauterization of the crevix are of course omitted. Prognosis.- — Favorable — about 75 per cent, should be per- manently cured. The presence of adhesions is of great prog- nostic value, recurrence being much more likely if they are present. The operation is much easier than that for cancer of the cervix, and the primary mortality is low. When recur- rence does take place it is as a retroperitoneal growth or as general abdominal carcinomatosis. Both are inoperable, and even palliative treatment by a-ray or radium offers little hope. Chorion epithelioma (Deciduoma Malignum, Syncytial Cancer) is a most malignant growth, following labor, abortion or frequently hydatid mole. About one-half of the reported cases of chorion epithelioma have been preceded by hyatid mole. It arises from malignant proliferation of the syn- cytium, and gives most rapid metastases all over the body, but particularly to the lungs, vagina and brain. The nodules are soft, spongy, purplish in color. Microscopically they con- sist mainly of masses of syncytial cells and large blood spaces. It may occur coincident with pregnancy or hydatid mole, or at any interval up to several years thereafter. ABNORMy^LITIES AND DISEASES OF THE UTERUS 1 27 Symptoms are usually irregular bleeding from the uterus occurring after the puerperium is completed, accompanied by a foul-smelling discharge. In many cases the appearance of metastases in the vagina is the first symptom detected. The uterus is large and soft and the os patulous. The diagno- sis rests upon the microscopic examination of a portion of the tissue. Treatment. — Abdominal panhysterectomy as soon as the diagnosis is made. Prognosis. — If detected early and promptly treated by panhysterectomy, recurrence is unlikely. If seen in the stage when vaginal or other metastases have appeared, the outcome is dubious. Operation is always advisable, however, as metastases have been reported to disappear. The growth may occasionally be extruded like a miscarriage, and spontaneous cure result. It is usually the most rapidly growing and spread- ing of all the malignant tumors. IV, Endometritis Endometritis is the commonest disease of women. By itself it is rare, but it is associated, in a chronic hyperplastic glandular form, with most of the abnormalities of the pelvic organs. Kinds. — (i) Acute; (2) chronic — the usual form. The causes of acute endometritis are (a) sepsis; (b) gonorrhea; (c) rarely infectious diseases like diphtheria, typhoid, etc. The causes of chronic are: (i) Chronic hyperplasia of the glands, secondary to chronic congestion of the uterus from any cause; (2) persistent after the acute form, as in gonorrhea; (3) tubercular — secondary to tuberculosis of the tubes; (4) syphilitic. The types of chronic endometritis are (i) Chronic hyper- plastic glandular — where the glands are enormously increased in number (much the commonest) ; (2) chronic interstitial — where the stroma is hypertrophied without corresponding increase of the glands; (3) chronic atrophic, where the glands 128 THE UTERUS have disappeared and the stroma is represented by a thin fibrous band. Causes. — (i) Acute septic, due to infection after labor, miscarriage or dirty instruments used in treatment; (2) acute gonorrheal, due to gonococcus; (3) acute infectious, due to intense hyperemia, caused by bacterial invasion; (4) tubercular is secondary to tuberculosis of the tubes; (5) chronic hyperplastic glandular and chronic interstitial are secondary to any pelvic condition causing chronic congestion of the uterus. These causes are so numerous, that^chronic hyperplastic endometritis is the commonest disease of women; (6) atrophic is physiologic after the menopause and rarely seen at other times, except over the dome of a submucous fibroid. Symptoms. — -(i) Leukorrheal discharge, varying in kind and amount, depending on the cause. In sepsis it is seropurulent, bloody and usually foul. In gonorrhea profuse, yellow and irritating. In chronic endometritis it is milky; (2) erosion of the cervix; (3) usually menorrhagia, with increased fre- quency of menstruation. In acute infectious fevers, uterine bleeding justifies a diagnosis of acute endometritis; (5) rarely pain, except midway between the periods (Mittelschmerz). The cause of this pain is unknown. Treatment. — Depends upon the cause. The acute septic form requires: (i) Rest in bed; (2) four hot vaginal douches a day; (3) ice-bag constantly to lower abdomen; (4) if after abortion or labor, a daily intra-uterine douche of tincture of iodin 3 drams, alcohol (95 per cent.) 8 ounces, sterile water q.s.ad. four pints; (5) no curettage. The acute gonorrheal form is described in the chapter on Gonorrhea. (Chapter XVI). Tuberculosis of the endometrium requires abdominal pan- hysterectomy, provided other important organs are not in- volved, and all apparent evidence of the disease can be removed with the uterus tubes and ovaries. The treatment of chronic hyperplastic glandular endome- ABNORMALITIES AND DISEASES OF THE UTERUS 1 29 tritis is: (i) The correction of its cause (retroversion, lacerated cervix or any other cause of chronic uterine congestion). Unless this is done, no permanent cure is possible. Local treatment is (i) Palliative or (2) Radical. Palliative treatment consists in (i) hot vaginal douching, twice daily; (2) boroglycerid tampons (both these of temporary benefit only) ; (3) instillations into the uterine cavity of argyrol 25 per cent., silvol 10 per cent, or nitrate of silver i per cent.; (4) in cases accompanied by bleeding, pituitrin }/2 cc. hypo- dermically twice daily for 10 doses. Radical treatment consists of dilatation of the cervix and curettage of the uterine cavity. This is permissible only in chronic cases (except those of gonorrheal origin) and never in acute ones. The danger in acute or chronic gonorrheal cases is the prompt development of pyosalpinx. Technic. — (i) The patient is prepared as for any plastic operation, and arranged in the dorsal position on a table (not bed). Anesthesia is necessary. 2. The anterior lip of the cervix is caught by a double tenaculum, and the cervix pulled down by an assistant. 3. A light Goodell dilator is inserted in the cervical canal and the blades separated to one inch on the scale. 4. A heavy Wa,then dilator is inserted and the blades slowly separated, by the screw in the handle and not by manual pressure, until a transverse dilatation of one inch is secured. 5. With a sharp Sims curet, used with only the grasp of the thumb, and two fingers, the uterine cavity is firmly and systematically curetted. The order is first the anterior wall, then the right lateral, posterior, left lateral and the fundus in the order named. As the soft velvety endome- trium is curetted off, the curet grates on the harder muscle, this feel should be uniform all over the cavity before the curettage is discontinued. 6. A Martin spoon curet is used to curet out the angles of each cornu, as the Sims is too broad to enter them. 7. The uterine cavity is explored, for possible polyps, with 130 THE UTERUS the Emmett curetment forceps. This is very important in cases where hemorrhage is a symptom. The curei will sUp over surprisingly large polyps, without removing them. 8. The uterus is washed out through a two-way Bozeman catheter, ^^ith sterile water. 9. No packing is necessary, unless there is profuse bleeding, which is very rare. 10. The patient is kept in bed for seven days after the operation. 11. All scrapings should be examined microscopically. Appearance of Curetted Material. — Some idea of the probable result of the microscopic examination is gained by the appear- ance of the curetted material. (i) Normal endometrium is soft thick, dark red, infiltrated with blood; (2) hypertrophied endomeirium is the same, with numerous whitish granules like sago ; (3) chorion is white and shaggy, when floated out in water ; (4) decidua reflexa is dark on one side, gray and shaggy on the other; (5) old blood-clots are jet black; (6) cancer is Uke brain tissue; (7) chorion epithe- lioma is dark purple and solid like a blood clot. Regeneration of the endometrium after curettage takes place from the deep utricular glands in about five days. Too vigorous use of the curet may result in obliteration of the uterine cavity. Perforation of the uterus during curettage is recognized by the sudden slipping in of the curet, far beyond the normal length of the uterus. In a clean case, the accident is not a serious one. All further manipulations should stop at once, and above all, the uterus should not be washed out. The patient should be put to bed and let alone. Abdominal section is unnecessary. In a septic case: (i) Cease all further intra-uterine manipula- tions; (2) open the posterior vaginal vault; (3) pack Douglas pouch with gauze; (4) return to bed, in Fowler position; (5) continuous enteroclysis, 40 drops to minute. After forty-eight hours the gauze packing is removed and replaced ABNORMALITIES AND DISEASES OF THE UTERUS 131 by a T drainage tube. Abdominal section is rarely needed, and then only if there are signs of peritonitis. V. Fibroid Tumors of the Uterus (Myoma Uteri; Fibromyoma Uteri; Leiomyoma Uteri) These are composed of fibrous and muscular tissue (the more fibrous tissue the harder the tumor) and develop in the wall of the uterus. Frequency. — At least 50 per cent, of women have some degree of fibroid tumor. Most of them remain insignificant, cause no symptoms and require no treatment. A fibroid is rare in a woman under twenty-five years of age, and most tumors begin their growth between the ages of twenty-five and forty. New tumors rarely develop after the menopause, and rapid growth of a tumor at this time nearly always means sarcoma. Cause is unknown; heredity plays some part; they are very common in single women past forty; and their frequency in negroes suggests a racial cause. As they develop only during menstrual life, the function of menstruation is a definite factor, and women who have not borne children are more likely to develop fibroids. Site of development is chiefly in the wall of the uterus, above the internal os. Cervical fibroids are rare. Kinds. — (i) Interstitial (intramural), when the fibroid is in the uterine wall; (2) subserous, when it has grown outward, toward the peritoneum; (3) submucous when it bulges into the uterine cavity; (4) intraligamentary, when it has grown into the layers of the broad ligament. Bleeding is most profuse in submucous growths; least so in subserous; pain is most common in submucous (explusive) or in intraligamentary (pressure on sacral plexus) . A subserous myoma may grow outward, until it is attached to the uterus only by a pedicle. If this pedicle becomes twisted, it may slough through and the fibroid become para- sitic, getting a meager blood supply from adherent omentum. 132 THE UTERUS A submucous myoma may grow so far in the uterine cavity as to develop a pedicle and become a fibroid polyp. Due to efforts of the uterus to expel it, the pedicle is often so lengthened as to allow the polyp to hang outside the cervix. General Life History. — Fibroids are of slow growth, usually moderate size, have a capsule, do not infiltrate the surrounding muscle, have poor blood supply and are nearly always multiple. The only fibroid which cannot be shelled from its capsule is the rare adenomyoma. Suhperitoneal interstitial- 'uhmueous Pig. 54. — Showing varieties of uterine fibroma. {After Stewart.) Degenerations. — (i) Edematous (cystic) due to passive congestion; (2) hyaline (unimportant, seen in portions of all fibroids); (3) myxomatous (really cystic edema); (4) throm- bosis and red degeneration (seen in fibroids in pregnancy) dangerous because of infection; (5) necrosis — usually second- ary to thrombosis in pregnancy; (6) fatty — most common in pregnancy, but also seen postmenopause; (7) calcification, usually postmenopause; (8) malignant — nearly always sar- coma. Carcinoma is possible by (a) invasion from the endometrium, or {h) carcinomatous degeneration of included glands, but is very rare. Pregnancy usually causes rapid ABNORMALITIES AND DISEASES OF THE UTERUS 133 Pig. 55. — a. Multiple, subperitoneal fibroids of the uterus; b, large single interstitial myoma (fibroid) in the anterior uterine wall. This is the type that simulates pregnancy. (After Graves.) Fig. 56. — Moderate sized submucous fibroid. These growths cause the most bleeding, and are prone to become necrotic from reduction of their blood supply. {After Graves.) 134 'i'HE UTERUS growth in fibroids, due to the increase in blood supply. Mter delivery, the fibroid may shrink. After the menopause, tliere is commonly a considerable reduction in size, but the presence of the tumor, especially if submucous, delays the appearance of the menopause for five to fifteen years. Adenocarcinoma of the endometrium, associated with fibroid tumor is not uncommon, especially after the menopause. This is entirely distinct from any de- generation of the fibroid itself. Sjrmptoms. — Many fibroids present no symptoms whatever, even though of large size. The symptoms depend to a large extent upon the situation of the tumor. (i) Bleeding. — This is at first menorrhagia, due to a dia- •pedesis through the vessels. The periods are at first length- ened, increased in amount with many clots, and later may be almost continuous. A secondary anemia always results, hemoglobin being as low as 25-30 per cent. A large subserous growth may cause no abnormal bleeding. Bleeding from a fibroid is always venous and therefore serious only by its long continuance. (2) Pain — which is either expulsive (in submucous growths) or pressure, in subserous and intraligamentary. In the latter, sciatic neuralgia is common. In pregnancy, pain is often diffused over the whole tumor and is severe. (3) Presence of the tumor, which when it reaches sufficient size, gives a bold outline to the abdominal enlargement, with sharp rise and fall. The tumor is usually irregular, nodular and very hard and firm. Large single submucous or intramural tumors give an outline startlingly like that of a pregnant uterus. Secondary symptoms are: (i) Anemia; (2) hyperthyroidism; (3) very irritable nervous system; (4) heart lesion (compensatory dilatation, "myoma heart"). All these tend to return to nor- mal after the removal of the tumor. Diabetes is very common with fibroids. ABNORMALITIES AND DISEASES OF THE UTERUS 135 A foul vaginal discharge usually means a necrotic gangren- ous fibroid polyp and not malignancy. Leukorrhea is common, being a thin serous discharge from the atrophied endometrium over the dome of a submucous fibroid, mixed with a thicker mucoid discharge from the hyper- trophied glands around its base. Effect of Fibroids on Pregnancy. — To some extent they pre- vent conception, about 30 per cent, of women with myoma being sterile. This is more than double the normal percentage. Diagnosis is usually easy. Bimanual examination shows the hard, irregular nodular uterus, though there are many chances of mistake, such as: (i) A pelvic abscess or pyosalpinx adherent in Douglas' pouch — not a serious mistake as abdominal section is indicated in either; (2) a very tense ovarian cyst pushing the uterus far forward; (3) adenocarcinoma of the body of the uterus, causing moderate symmetrical enlargement. Only to be diagnosed by exploratory curettage; (4) a large symmetrical intramural or submucous fibroid may simulate most closely a pregnant uterus. Successive examinations, a week apart, will clear up the diagnosis. The most valuable single sign is the consistency of the cervix, which shows none of the soften- ing characteristic of pregnancy. TREATMENT Treatment is either (i) palliative or (2) radical. Palliative treatment consists in (i) styptics; (2) dilatation and curetment; (3) electricity; (4) ovarian or mammary extract; (5) radiation — x-TSiy or radium. Palliative Treatment.^ — Indications: (i) Small tumors, presenting as their only symptom moderate menorrhagia, with no suspicion of malignant degeneration; (2) tumors which are stationary in size or growing very slowly; (3) tumors which give no pressure symptoms; (4) women near the meno- pause, remembering always that the menopause may be delayed for five to fifteen years. (i) Styptics are usually of little value and then only when 136 THE UTERUS the bleeding is a moderate menorrhagia. Pituitrin Y2 mil twice daily for two days before and the first two days of the period; hydrastinin gr. ^i, by mouth four times daily during the period; ergotin gr. i (or i ampule aseptic ergot) hypodermic- ally twice daily for the first three days of the period; a pill of ergotin gr. i, hydrastinin gr. ^"2, stypticin gv. 3^-2 (exceedingly expensive) four times daily for two days before and the first two days of the period are the most reliable, but not much is to be expected of them. (2) Dilatation and curettage, in the hope of controlling the bleeding temporarily by removal of the h3^ertrophied en- dometrium or possibly a polyp, is often of value. It will be possible only if the uterine cavity is not distorted by nodular growths, hence it should not be attempted unless the uterus is fairly symmetrical in outline. (3) Electricity — intra-uterine application of galvanic current, positive pole to the uterine sound, using a current of forty to sixty milliamperes for fifteen minutes three times a week for a series of thirty treatments, is of moderate value. It is contraindicated in tumors with severe bleeding, degeneration or in the presence of pelvic inflammation. (4) Ovarian extract (gr. 5 four times daily by mouth); Mammary extract (gr. 5 four times daily by mouth) ; adrenalin ITLx of Mo solution hypodermically or by mouth four times daily are all of practically no value, and while recommended from time to time by different authors, are not v/orth a trial. (5) Radiation — either x-ray or radium — is the most valuable and powerful of all palliative agents, in spite of certain dis- advantages. In young women there is danger of a permanent menopause, with both x-ray and radium. Neither have any efifect upon the development of subsequent degeneration, and in cases of early and possibly unsuspected malignancy, may stimulate it to the utmost activity. X-ray is attended with considerable danger of severe skin burns and the risk of burning is considerably increased in ABNORMALITIES AND DISEASES OF THE UTERUS 137 severe anemia and, above all, syphilis. Often severe nervous disturbances follow its use. With radium the danger of genital fistula is present, as the radium tube is inserted in the cervix and uterine canal. Radiation is not advisable in bleeding fibroids, after the meno- pause, as this symptom always means degeneration. Neither method is at all safe unless used by an expert, and the expense of radium removes it from the armamentarium of the general practitioner. In spite of the dangers, radium remains the most efficient means of checking the bleeding of fibroids, and is the only method to be considered in those patients constitutionally unfit for surgical relief. Radical treatment comprises (I) vaginal hysterectomy, (II) abdominal supravaginal hysterectomy; (III) abdominal myomectomy; (IV) vaginal myomectomy; (V) Battey's operation; (VI) ligation of the uterine arteries. Indications. — (i) Large tumors with marked symptoms; (2) severe pain; (3) severe bleeding; (4) rapid growth —nearly always indicating sarcoma; (5) omophobia — the mental state of the woman who dwells upon the presence of the tumor and becomes practically mentally unbalanced upon this one point. I. Vaginal hysterectomy has no advantage over abdominal hysterectomy, and is in most cases very much inferior to it. It must never be attempted if the bulk of the tumor is such that it cannot be delivered easily through the opening of the anterior vaginal vault. Its field is in fat women, in whom an abdominal section would be a formidable undertaking, or in women who, because of heart lesion, would not stand the Trendelenburg position usually required in abdominal hysterec- tomy. The best technic is supravaginal, extraperitoneal hys- terectomy, but the uterus must be free from adhesion, whichever technic is chosen. Technic. — (i) The patient is prepared for both abdominal and vaginal operation; (2) she is arranged in the dorsal posi- tion under anesthesia; (3) the anterior and posterior lips of 138 THE UTERUS the cervix are caught with double tenacula and pulled down, (4) the anterior vaginal wall is incised longitudinally from the urethra to the cervix, and transversely across the cervix; (5) the flaps of anterior vaginal mucosa are dissected free from the bladder and the uterovesical hgament cut; (6) the bladder is pushed up, until the peritoneal reduplication is visible. This is opened and the uterine body pulled out through the opening with double tenacula. The presence of adhesions makes this step difhcult, if not impossible; (7) the peritoneum of the prevesical space is sewed to the uterine body, as low as possible on the posterior wall. This shuts off the peri- toneal cavity and the rest of the operation is extraperitoneal ; '(8) the ovarian artery is tied, the stump clamped in a hemo- stat and cut away. The round ligament is tied and cut, and these procedures repeated on the opposite side; (9) the uterine arteries are tied and cut, and the cervix ampu- tated by a V-shaped excision, just above where the peritoneum has been attached posteriorly; (10) the cervical stump is closed by interrupted suture, and the vaginal wound sutured. II. Abdominal supravaginal hysterectomy (in which a stump of cervix is left) is the operation of choice in the majority of cases. It is much easier and quicker than panhysterectomy. The only advantage of the latter is that it prevents subsequent development of cancer in the cervical stump, an occurrence so rare as to be negligible. Supravaginal hysterectomy is indicated in (i) Women near the menopause; (2) very large tumors; (3) nodular tumors, in which the uterus iz hopelessly involved; (4) degenerations; (5) pelvic inflammation. Technic. — (i) The patient is prepared as for any abdominal section, and anesthetized. 2. The abdomen is opened, in the midline, by an incision long enough to permit delivery of the tumor. 3. The edges of the incision are held apart by a self-retaining retractor. ABNORMALITIES AND DISEASES OF THE UTERUS 139 4. The uterus is grasped with a heavy volsellum, is dehvered through the wound and held far forward over the symphysis. 5. The intestines are packed back by pads, so that none of them are visible, and Douglas' pouch is shut off by the pads. 6. The ovarian artery of each side is clamped, the round ligaments also, and a clamp placed above these, to control reflux bleeding. Pig. 57. — Left ovarian vessels tied, vesical peritoneum divided and pushed down, and left uterine vessels ligated. Cervix amputated and uterus pulled up and out, exposing right uterine artery, which is clamped an inch above the cervical stump. The two following steps are clamping the right round ligament and right ovarian vessels, when the mass is removed. (Kelly.) 7. The broad ligaments are cut between the hemostatic and reflux clamps, as far as the uterine artery. 8. The anterior peritoneal reduplication is cut, straight across, to connect the two incisions already made, and the bladder pushed down. I40 THE UTERUS 9. The posterior peritoneum is cut across, at the level of the attachments of the uterosacral ligaments. 10. The uterine arteries are clamped and cut and the cervix amputated by a V-shaped exsection. 11. The cervical canal is sterilized by the actual cautery. 12. The cervical stump is closed at once by interrupted suture of number 3 chromic catgut, taking the muscle but not the peritoneum. 13. The ovarian, round ligaments and uterine arteries are tied, across the pelvis in regular order, using number 3 chromic catgut. Pig. 50. — The stump of the cervix and broad ligaments, after completion of supravaginal hysterectomy. 14. The two layers of peritoneum are closed across the pelvis, by a continuous number 3 chromic catgut stitch, and the abdomen closed as usual. 15. It is doubtful whether leaving one or both ovaries, to prevent the surgical menopause, is worth while. Many of these cases require subsequent operation for cystic ovaries. The disagreeable symptoms of the menopause can be controlled better by hypodermic injections of corpus luteum extract. Surgical Menopause.— In nearly all cases where the uterus, tubes and ovaries have been removed, prior to the natural meno- pause, the disagreeable symptoms of the surgical menopause (flashes of heat, tremors, nervousness, headache, etc.) can be relieved entirely by hypodermic intramuscular administra- tion of either corpus luteum extract or whole ovarian extract, beginning on the fourth day after operation. The injections ABNORMALITIES AND DISEASES OF THE UTERUS 141 are made deep in the deltoids, alternately, giving i mil a day (representing each 40 grains of the dried substance) for twenty- four doses, and repeating in series of twelve doses as the effects (which are cumulative) wear off. Usually forty-eight doses in all are required. Several weeks separate the series of doses. The younger the patient, the more doses are needed. III. Abdominal myomectomy is indicated when the tumor is single or, if multiple, can be shelled out without extensive mutilation of the uterus. It is absolutely contraindicated in (i) y''* ""^^ women near the menopause; (2) degenerations; (3) pelvic inflam- mation. Technic. — (i) The technic is the same as supravaginal hysterec- tomy, until the uterus is delivered from the wound. 2. The uterine wall is incised over the growth, until the capsule is opened, and the tumor is shelled out with the finger or spatula. The bleeding is negligible and no ligatures are required, as a rule. 3. The bed of the tumor is ob- literated by interrupted sutures of number 3 chromic catgut, not in- volving the peritoneum. 4. The excess of capsule, uterine muscle and peritoneum is trimmed off, to secure an accurate fit in closing the wound. 5. The peritoneal coat is closed by continuous number 3 catgut suture. 6. Several separate growths may thus be enucleated. . 7. When all are removed the abdomen is closed in the usual way. Advantages. — (i) Leaves the uterus and does not establish the menopause. CX Fig. S9.-Pointsof en- trance of the needle in infil- tration of the cervix in local anesthesia by novocain or other solutions, preliminary to anterior vaginal hysterotomy. a. The cervix; b, anterior in- filtration under the bladder; c, c, lateral infiltration; d, d, infiltration of the cervical muscle, parallel to the cervical canal; e, posterior infiltration. The crosses are the points of insertion of the needle. 142 THE UTERUS Disadvantages. — (i) Danger of infection, especially if, during the enucleation of the tumor, the uterine cavity has been opened. (2) Other tumors, unnoticed during the operation, may develop later and require removal. (3) Danger of in- testinal adhesions to the uterine wounds (4) Weakens the uterine wall, in case of subsequent pregnancy. (5) The scar tissue, in extensive resections, may cause pernicious vomiting in subsequent pregnancies. The operation is advisable in young women who wish, if possible, to bear children, and in women who for sentimental reasons. prefer it to removal of the uterus. In other cases, the disadvantages should be fully weighed before performing it. rV. Vaginal myomectomy is indicated in intra-uterine growths (polyps) even of considerable size, or in necrotic fibroid polyps. Technic: — (i) The patient is prepared for both plastic and section, (the latter in case it proves impossible to remove the tumor by the vaginal route); She is arranged in the dorsal position under anesthesia. 2. The anterior lip of the cervix is caught with a double tenaculum and the canal dilated. Unless the growth is small, dilatation of the cervix does not give sufficient room. In many cases, the anterior vaginal wall must be separated from the bladder, the bladder pushed up and the cervix cut in the middle line, through the internal os (anterior vaginal hysterotomy). 3. The growth is caught with a volsellum, and if it has a pedicle, it is twisted off and removed. 4. If the attachments are firm (as they usually are) the capsule is incised near the base, with scissors, and the growth enucleated with the finger, strong traction downward being made on the volsellum holding it. 5. If the growth is of large size, it is necessary to remove it piecemeal, cutting off piece after "piece with heavy scissors {morcellation) . 6. The hysterotomy wound in the cervix is repaired with ABNORMALITIES AND DISEASES OF THE UTERUS 1 43 interrupted sutures of number 3 chromic catgut, and the vaginal walls sewed back in place. 7. The. uterine cavity is washed out, and the vagina packed with sterile gauze, which is removed in twenty-four hours. Uterine packing is rarely needed, and only if there is persistent bleeding. V. Battey's operation — double oophorectomy to secure shrink- age of the fibroid by establishing the surgical menopause — is an illogical procedure now rarely used. VI. Ligation of the uterine arteries, to starve the tumor by shutting off the major portion of its blood supply, has been extensively recommended, but is now obsolete. Fibroids in pregnancy are often stimulated to excessive growth. They should be let alone, unless they cause severe pain, severe bleeding or grow alarmingly. Myomectomy is to be preferred to hysterectomy, to allow, if possible, the continuance of pregnancy. RECURRENT FIBROIDS Recurrent fibroids, so called, after supravaginal hysterec- tomy, are sarcomata, and are inoperable. They should be treated by massive doses of radium, in repeated short exposures, but the prognosis is bad. ADENOMYOMATA Adenomyomata are a special type of fibroid. They grow diffuse in the uterine wall, contain glands identical with those of the endometrium (from which they are derived) and em- bedded in endometrial stroma. They develop mostly in the posterior uterine wall, near the fundus. They are usually small, and do not as a rule produce serious symptoms. Symptoms. — (i) Menorrhagia; (2) menstrual pain; (3) moderate asymmetrical enlargement of the uterus. Treatment — A"-ray, radium or hysterectomy, if the symp- toms are sufficiently severe. 144 THE UTERUS These tumors are prone to malignant degeneration, which is carcinoma from the enclosed glands. VI. Hysteralgia Hysteralgia or excessive pain referred to the uterus, without demonstrable cause, is usually rheumatic. It is sometimes so severe as to simulate peritonitis, though the absence of fever, rapid pulse and high leukocyte count will differentiate it. The treatment is aspirin gr. lo four times daily, which will promptly relieve the pain. A single dose of morphin sulphate gr. y^i hypodermically at the onset is justifiable, but should not be repeated. VII. Infantile Uterus Infantile uterus is of two types: (i) Dwarf uterus, where the uterus is much below the normal size, but perfectly propor- tioned; (2) disproportion of cervix to body, so that the cervix is much longer than the body, though both are below normal. This is much the commoner form. Causes. — (i)_ Congenital, (2) superinvolution after child- birth; (3) repeated curettage of the uterus (really another cause of superinvolution). S3nnptoms. — (i) Scanty menstruation, often with long intermissions between the periods; (2) dysmenorrhea; (3) sterility. Treatment. — (i) Dilatation of the cervix, without curettage, to relieve dysmenorrhea; (2) hypodermic injections intra- muscularly of I mil corpus luteum extract, daily doses in series of twelve doses, with two weeks' intermission between series; (3) electrical stimulation, with negative pole to uterine sound, using galvanic, slow faradic and sinusoidal current for fifteen minutes each (total forty-five minutes for each treatment) every other day for six to eight weeks. Much better results can be hoped for in acquired infantilism (super- involution) than in the congenital form. ABNORMALITIES AND DISEASES OF THE UTERUS 145 Vni. Inversion of the Uterus Inversion of the uterus is one of the rarest of diseases of women, and nearly always occurs as a complication of childbirth. Kinds. — (i) Acute — due to traction of the placenta after dehvery; (2) chronic due to prolonged traction of tumors; (3) incomplete, where the fundus does not pass the cervix, (4) complete, when the fundus is in the vagina. Causes. — (i) Traction of the placenta — either spontaneous or due to manual efforts at extraction — after labor. (2) Prolonged traction of fibroid polyp. Symptoms. — In the acwte variety (i) shock; (2) hemorrhage; (3) fundus felt in the vagina; (4) abdominal palpation shows a deep cleft across what remains of the uterine body. This variety requires immediate manual reposition, and its symp- toms are so alarming that it can hardly be overlooked or neglected. Occasionally it does persist, however, and becomes chronic. Symptoms of Chronic Inversion. — (i) Bleeding — irregular and profuse; (2) considerable leukorrheal discharge, often offensive; (3) bimanual examination shows a tumor in the upper vagina, surrounded by a collar of healthy cervix; (4) also that the uterine body cannot be felt, but if the deep pressure above the symphysis is made, a deep cleft extending across what remains of the corpus uteri; (5) a uterine sound will show that there remains no uterine cavity. Differential diagnosis is from myomatous polyp. This forms a polypoid mass, surrounded by a collar of healthy cervix, and causes bleeding and discharge, but here the resem- blance ceases. The uterine body is plainly felt, there is no depression across it, the uterine cavity is not obliterated and is always longer than normal. Complications. — (i) Contraction of the cervix (always pres- ent in the chronic variety, and occurring in the acute after a 146 THE UTERUS few hours), (2) Gangrene of the corpus uteri, where the cervical contraction is tight enough to cut off circulation. Treatment (of the chronic variety) . — (i) Attempt to reduce the inversion by taxis, like a hernia, will almost certainly fail. (2) Long-continued pressure, by gauze packing, renewed every twenty-four hours; a ball and stem pessary, supported by a belt and perineal straps. Both have been occasionally successful, but there is considerable danger of sepsis. (3) Operative treatment, by far the simplest, safest and quickest. Pig. 60. — Diagram to illustrate the differential diagnosis between inver- sion of the uterus and a fibro-adenomatous polyp protruding from the cervix. Methods. — (i) With the patient in the dorsal position, anes- thetized, the cervix is held wth tenacula, and cut posteriorly in the midline, far enough to relieve constriction. The uterine body is replaced and the cervical cut repaired. This will succeed in the vast majority of cases. (2) Spinelli Operation. — The bladder is separated from the cervix, as in anterior vaginal hysterotomy. The uterus is spHt in half, along its anterior border, as far as the fundus. It is re-inverted, and the uterine and vaginal wounds closed. This is merely an extension of the first operation, is much more formidable and usually unnecessary. ABNORMALITIES AND DISEASES OF THE UTERUS 147 (3) Abdominal section for the relief of inversion is never necessary. (4) If the fundus is gangrenous, vaginal hysterectomy should be performed. IX. Metritis Acute metritis is exceedingly rare, outside the puerperium. It is due to bacterial invasion, usually streptococcic. The moderate inflammatory and circulatory changes occurring as a result of prolonged congestion from any cause is usually called chronic metritis, though it is not, strictly speaking, inflammatory. As a result, there is a fibrous change in the myometrium, the muscle becoming almost like cartilage. True bacterial invasion may occur, independent of the puer- perium, from (i) gonorrhea; (2) tuberculosis; (3) dirty instruments used in treatment. Symptoms of the acute form are those of acute sepsis, and treated by rest in bed, ice bag to the lower abdomen, hot vaginal douches and stimulation. Symptoms of the chronic form are: (i) Backache; (2) bearing-down pain in pelvis; (3) bleeding — at first menorrhagic and later continuous and profuse; (4) leukorrhea; (5) blood- tinged mucous discharge midway between periods, with con- siderable pain; (6) as this form of metritis is often seen in syphilis, a Wassermann test should always be made. Bimanual examination shows a large, heavy and very firm uterus. Treatment. — (i) Correction of any cause of chronic con- gestion of the uterus which may be found; (injuries of child- birth being the most common); (2) styptics such as ergo tin gr. I four times daily, hydrastinin gr. i four times daily, pituitrin one-half mil hypodermically twice daily for ten doses; (3) dilatation and curettage to remove hypertrophied and angiomatous endometrium; (4) radium, in massive doses with short exposure; (5) .T-ray — with due regard to the danger of burning; (6) salvarsah, if due to syphihs; (7) abdominal hysterectomy, if all other means have failed. 148 ' THE UTERUS X. Polyps Polyps are of two kinds: (i) Small mucous polyps of the endometrium; (2) fibromyomatous polyps, sessile or peduncu- lated, varying in size from a cherry to the fetal head. The latter are submucous myomata which have grown doT\Ti into the uterine cavity. Uterine polyps are much less common than cervical ones. Symptoms. — (i) Menorrhagia, becoming metrorrhagia; (2) moderate leukorrheal discharge; (3) often expulsive pain, from the uterus trying to expel a myomatous polyp, as a foreign body; (4) mucous polyps cause no enlargement of the uterus; fibromatous often cause a very considerable increase in size. Treatment. — Dilatation and curettage, followed by exploration of the uterine cavity with placental forceps. This is most essential, as the curet will slip over poh'ps that the placental forceps will grasp and extract. If a pedunculated myomatous polyp is found, it can be twisted off and removed. A sessile polyp, mth a broad attachment, requires anterior vaginal hysterotomy (to secure sufficient dilatation) and enucleation after its base has been incised with scissors. A polyp too large to be removed whole must be cut in pieces .(morcellation). In every case, both polyp and endometrial scrapings must be examined microscopically, for carcinoma. As polyps are often multiple, the operator must search the uterine cavity thoroughly and not be satisfied that with the finding of a single pohqD his operation is complete. Degenerations. — (i) Necrosis and sepsis. These are most common in elderly women, who are bad surgical risks. The tumors are so soft and friable that, if they can be easily reached, they can be removed with the forceps, without anesthesia. (2) Malignant degeneration, diagnosed only by the microscope, is an absolute indication for panhysterectomy. XL Prolapse of the Uterus Prolapse of the uterus is, in the vast majority of cases, a consequence of childbirth, and will be discussed in its proper place in Chapter Xlll. ABNORMALITIES AND DISEASES OF THE UTERUS 1 49 Prolapse is possible in nulliparous women, independent of childbirth, from the following causes: I. Congenital (rare, but the most hkely cause in young girls). (2) Excessive muscular effort. (3) Rupture of an ovarian multilocular cyst, with the weight of the extruded fluid causing total prolapse of the uterus and inversion of the vagina. (4) Ascites, having the same effect. (5) In elderly women, due to- increased intra-abdominal pressure and relaxed tissues, post-menopause. Congenital prolapse in young girls is usually only apparent, being due to a great supra- and infravaginal hypertrophy of the cervix, the uterine body remaining at or near its proper level. These cases are relieved by amputation of the cervix. The other cases are usually true prolapse, of which the palha- tive and curative treatment is identical with that for cases due to childbirth, described in Chapter XIII. XII. Sarcoma of the Uterus Sarcoma of the uterus is forty times less frequent than carcinoma. Point of origin is either (i) the connective tissue of the endo- metrium; (2) connective tissue of the myometrium. That from the endometrium is very rare; that from the myometrium is almost invariably a degeneration of a fibromyoma and is called myosarcoma. Sarcoma of the endometrium is usually polypoid, most commonly in the cervical canal and hangs from the cervix like a bunch of purple grapes — hydatidiform sarcoma of the cervical canal. Rarely sarcoma of the endometrium is diffuse, and invades the uterine wall as does carcinoma. Sarcomatous degeneration of a fibroid usually starts in the center of the growth and spreads rapidly. On section it appears gelatinous. Age of occurrence is usually thirty to fifty, the disease being very rare either side of these limits. Histology. — (i) Mixed-cell sarcoma is the commonest; (2) spindle cell next in frequency; (3) sarcoma of the endometrium 150 ' THE UTERUS is usually round-cell; (4) very rarely it is melanotic; (5) also very rarely, carcinoma and sarcoma are found in the same uterus. Symptoms. — (i) Bleeding; (2) foul discharge; (3) pain; essentially the same as carcinoma. Hydatidiforrn sarcoma of the cervix is recognized at a glance, though a piece must be ex- cised and examined microscopically. Sarcoma of the endo- metrium of the corpus uteri can be diagnosed only by curettage and microscopic examination. Sudden growth in a fibroid, particularly with ascites, usually means sarcomatous degen- eration and is an indication for immediate panhysterectomy. About 3 to 5 per cent, of fibroids undergo sarcomatous change. Persistent bleeding from the vagina in children, before puberty, if precocious menstruation be eliminated, is most often due to cervical sarcoma. Metastasis is much more common and occurs earlier than in carcinoma, hence the operative results are less favorable. Diffuse sarcoma gives metastasis earliest, next is the polypoid type, and latest is sarcoma of a fibroid. Metastasis occurs to distant portions of the body, is very common retroperito- neally, and often appears as a general sarcomatosis. Treatment. — Abdominal section, with panhysterectomy if possible, as soon as the diagnosis is made. Palliative treatment is unsatisfactory, neither x-ray nor radium having much, if any, effect. In degenerated myomata, .T-ray and radium are positively contraindicated, as they stimulate the malignant process to new activity. Prognosis is best in degenerated fibroids, recurrence being about 50 per cent. In other types, recurrence is almost invariable, either locally or by distant metastasis. XIII. Subinvolution of the Uterus Subinvolution of the uterus is the failure of the uterus to regain its normal size after childbirth or miscarriage. The condition is always secondary to a primary cause, and is due to congestion or failure of firm contraction. ABNORMALITIES AND DISEASES OF THE UTERUS 151 Causesr— (i) Retained portion of the ovum; (2) lacerations; (3) displacement of the uterus; (4) hyper trophied decidua; (5) puerperal sepsis; (6) peri-uterine adhesions. Symptoms. — (i) Bearing down and backache; (2) headache (vertical or occipital); (3) leukorrhea; (4) metrorrhagia; (5) bladder irritabihty. Diagnosis is easily made by bimanual examination, the uterus being larger and less firm than normal. Treatment is the removal of the cause. If this is done, the uterus rapidly regains its normal size, without further treat- ment. The process can be hastened by (i) hot vaginal douches, three times daily; (2) tincture of digitahs TUv t. i. d.; (3) hypodermic of pituitrin 3^^ mil twice daily for six doses; though these measures are unnecessary. [XIV. SUPERINVOLUTION OF THE UTERUS Superinvolution of the uterus is an exaggerated reduction in size of the uterus. It is much rarer than subinvolution. Causes. — (i) Hyperlactation ; (2) pelvic inflammation; (3) hemorrhage; (4) rapidly repeated pregnancies; (5) repeated curetment of the uterus, at short intervals. There is a moderate form, common during lactation or after miscarriage, occasionally going to extreme diminution in size, called lactation atrophy. The uterine walls are thin and easily perforated, a fact to be remembered in curetments on nursing mothers or after miscarriage. Diagnosis. — Bimanual examination shows a uterus much reduced in size, sometimes so small as scarcely to be felt. Treatment^— Spontaneous return to normal or near normal size, is the rule, if the cause be found and removed. In cases without obvious cause: (i) Electrical stimulation of the uterus, negative pole to uterine sound; galvanic, slow faradic and sinusoidal currents each fifteen minutes (total forty-five minutes for each treatment) three times weekly; (2) hypo- dermic extract of corpus luteum i mil (representing 40 grains 152 • THE UTERUS of the dried substance) daily in series of 12 doses; (3) hypo- dermics of whole ovarian extract, in the same dosage. Rarely the condition resists all treatment and is permanent. XV. Tuberculosis of the Uterus Tuberculosis of the uterus is usually confined to the endo- metrium, and is nearly always secondary to tuberculosis of the tubes. It is found in patches in the endometrium and only rarely invades the muscle. Sjrmptoms. — (i) Persistent leukorrhea; (2) rarely bleeding; (3) occasionally long-continued amenorrhea. Diagnosis. — By bimanual examination the uterus is slightly enlarged, fixed and the salpingitis associated with it can be felt. Exploratory curettage and examination of the scrap- ings is useful as a diagnostic measure, but is never curative, as the disease is secondary to the tubes. Treatment is abdominal section, with double salpingectomy, and also hysterectomy, if curettage has shown the endometrium to be extensively involved. Prognosis, in the absence of extensive active foci elsewhere in the body, is good. If these foci are present, any operation for tuberculosis of the uterus is not worth while. CHAPTER Vlll DISEASES OF THE FALLOPIAN TUBES I. NORMAL ANATOMY AND RELATIONS OF THE FALLOPIAN TUBES The Fallopian tubes run from each cornu of the uterus, through the upper layer of the broad hgaments, to the ovaries, with which the lower fimbriae of the tube are usually in \ Fig. 6i. — Section of the normal Fallopian tube near the uterine cornu. {Beyea.) contact. They are about 12 cm. long, the left being slightly the longer Structure. — The tubal walls consist of a mucous, muscular and serous coat. The mucosa is in longitudinal folds, simple 153 154 DISEASES OF THE FALLOPIAN TUBES and slightly elevated in the inner portion; exceedingly com- plicated and well marked in the outer third and the ampulla. There are no glands and no submucosa; the cells are columnar and ciliated, the cilia lashing toward the uterus. Fig. 62. — Section of the normal Fallopian tube near the abdominal ostium. (Beyea.) The muscular coat is in three layers: (i) An inner longitudinal (not well marked); (2) a middle circular and (3) an outer longitudinal. The serous coat is in three closely knit layers, and is best marked in the inner two-thirds of the tube. CONGESTION OF THE FALLOPIAN TUBES I55 The caliber of the tubes, is, at the uterine end, that of a bristle of an average hairbrush. It increases steadily toward the fimbriated extremity, where it is the size of a goose quill (.8 cm.). Divisions. — (i) Uterine mouth (funnel-shaped) in each cornu; (2) interstitial portion (that running through the uterine wall); (3) isthmus (the narrow portion of the inner one-half); (4) the tube proper; (5) the infundibulum (the expanded outer third of the tube) ; (6) the fimbrice (folds of mucosa at the abdominal end). The portion of the broad ligament through which the tube runs is called the mesosalpinx. Arteries are four or five small branches from the utero- ovarian anastomosis. Veins accompany the arteries; they terminate in the ovarian and uterine veins. The left side is more subject to engorge- ment because the left ovarian vein empties into the left renal vein at a right angle and has no valve, while the right ovarian vein empties into the inferior vena cava and has a well-marked valve. For this reason, which favors congestion, and because the rectum dips down behind the broad ligament on the left side, pain from inflammatory reaction is usually more marked on the left than on the right side. Lymphatics empty into the deep lumbar glands. Nerves come from the uterovaginal and ovarian plexus. There is a well-marked tubal plexus in the subserosa. Hydatid of Morgagni is a small cyst, representing the ter- minal end of the Miillerian duct, hanging from the ovarian fimbria by a long slender pedicle. It has a connective tissue wall, is lined with pavement epithelium, and contains a clear serum. Its maximum size is that of a hazelnut, II. CONGESTION OF THE FALLOPIAN TUBES Congestion of the tubes without inflammation, is always secondary to some interference of the circulation, most com- 156 DISEASES OF THE FALLOPIAN TLBES monly from retroversion of the uterus. There are no symptoms by which the condition can be diagnosed; it is seen at opera- tion, when the tubes are inspected. The tubes are dark red or purple, swollen, and usually blood can be expressed from the lumen. The canal is not obstructed, and it is not neces- sary to remove them. The congestion disappears when the cause is removed. In intrahgamentary ovarian cyst the tube is stretched over the top of the cyst, congested and enormously elongated (one case thirty inches long). III. EXTRA -UTERINE PREGNANCY (ECTOPIC GESTATION; TUBAL GESTATION) Extra-uterine pregnancy may occur at any point from the peritoneal cavity (primary abdominal pregnancy) to the intra- mural portion of the tube (cornual pregnancy). It is most common in the outer one-third of the tube. Causes. — (i) Some interference with normal progress of the ovum through the tube, most likety adhesions from a previous salpingitis, or from destruction of the cilia of the epithelium. (2) Lodging of the ovum in a diverticulum of the tube (rare). (3) Unusually long and convoluted tubes. (4) External transmigration of the ovum (from the right ovary to- the left tube or vice versa). In the last two, the length of the journey is such that before it is finished the ovum is too large to progress further. Classification. — (i) Tubal (much the commonest); (2) ovarian; (3) abdominal; and (4) combinations of the above, such as tubo-uterine (cornual); tubo-ovarian, etc. Primary abdominal pregnancy is where the fertilized ovum lodges in the peritoneal cavity; secondary abdominal pregnaticy is one which began in the tube, escaped through the fimbriated extremity into the peritoneum, and there continued its career. Frequency is said to be one in five hundred cases, and most often between the ages of twenty and thirty years. Tubal pregnancy is by far the commonest. Ovarian pregnancy is EXTRA-UTERINE PREGNANCY 157 exceedingly rare. Primary abdominal pregnancy is also very rare but secondary abdominal pregnancy, where the embryo was originally in the tube, but escaped into the abdominal cavity and there continued its development for some time is not very uncommon. In such a case a child may die at the time of its extrusion into the abdominal cavity, and be retained as a lithopedion for an indefinite time (fifty- six years in one case) , or it may partially absorb and the bones ulcerate through into the bowel or bladder; or it may continue Pig. 63. The possible sites of extra-uterine pregnancy: i, Cornual or interstitial; 2, tubal in the isthmus; 3, tubal; 4 and 5, ampullar. Ovarian and primary abdominal pregnancy are exceedingly rare. {Gilliam.) its development until term, or past it, and be delivered alive by abdominal section. Development.^ — In the tube the ovum behaves much as it does in the uterus. It burrows into the mucosa; this is im- perfectly transformed into decidua and the chorion and am- nion develop as in normal pregnancy. Decidua is also formed in the uterine cavity, but is not as thick as in normal pregnancy. This decidua after the death or removal of the embryo is cast off, but sometimes must be removed by curetment. Terminations.^ — Most commonly tiihal abortion, or extrusion of the ovum through the dilated fimbriated extremity of the 158 DISEASES OF THE FALLOPIAN TL^E tube, with more or less severe hemorrhage, at about the sixth to tenth week of pregnancy. Next in frequency, erosion of the tubal wall (the so-called rupture) with severe internal hemorrhage; erosion of the tube with hemorrhage into the layers of the broad ligament; the conversion of the fetus into a lithopedion or calcification of the fetus; rarely death of the embryo and complete resolution. (?) A tubo-uterine or inter- FiG. 64. — The site of the hematocele in extra-uterine pregnancy, felt as an exceedingly tender mass in Douglas' pouch. {After Crossen.) stitial pregnancy may make its way into the uterine cavity and progress normally to term and very rarely a tubal preg- nancy may develop to term. Tubal pregnancy not infre- quently occurs twice in the same individual. Rarely combined extra-uterine and intra-uterine pregnancy have been found. Pelvic hematocele is the collection of blood in Douglas' pouch, palpable by vaginal examination. It is soft and doughy, and may reach a very considerable size, being often palpable by abdominal examination, and extending as high as the umbihcus. When the tube ruptures, or the ovum is EXTRA-UTERINE PREGNANCY I59 extruded through the fimbriated extremity, the embryo is usually rapidly absorbed, and no trace of it is found in the mass of blood-clots forming the pelvic hematocele. The uterine bleeding associated with ectopic pregnancy is venous in origin, comes from the endometrium and is never by reflux from the tube. Clinical History and Symptoms.^ — The patient has usually had children before, but the last some years previously. She misses one or two periods, which then return as irregular bleeding. At the same time occurs violent stabbing pain in the lower abdomen, severe enough to make her faint, and when she recovers consciousness, she is nauseated. The pain recurs in paroxysms, increasing in frequency and severity, but the interval between thdm is free from pain. Finally after one of these attacks of pain, the symptoms of internal hemorrhage appear. Frequently, however, this entire history may be negative, and the first symptom is a violent attack of pain with the signs of internal hemorrhage. There is often a discharge of decidua from the uterus, described by the patient as "a piece of flesh, different from a blood-clot," but no ovum is dis- charged, except in the rare instances when there is a combined intra-uterine and extra-uterine pregnancy. There is a slight elevation of temperature, averaging 99.5°F. and a leukocytosis of 12,000-14,000. On vaginal examination the patient presents confirmatory signs of pregnancy, the uterus not- so large as one would expect to find it, and behind it, or to one side, a pelvic mass, extremely sensitive to the touch. The average time of rupture or tubal abortion is from the eighth to twelfth week of pregnanc5'\ Diagnosis and Differential Diagnosis. — The diagnosis between the different varieties of extra-uterine pregnancy is made by operation, as the clinical history and symptoms of the tubal, ovarian and abdominal varieties are practically identical. The differential diagnosis from conditions closely resembling it may be of extreme difficulty. Two conditions that are practically indistinguishable from it are (i) hem- l6o DISEASES or THE FALLOPIAN TUBES orrhage from a ruptured varicose vein in the broad ligament and (2) severe hemorrhage from the wall of a ruptured Graafian follicle. Others in which a mistake is excusable are (3) acute sal- pingitis with or without coincident intra-uterine pregnancy; (4) ovarian cyst twisted on its pedicle; (5) appendicitis with or without coincident intra-uterine pregnancy. In salpingitis there should be a leukorrheal discharge; higher fever; higher leukocyte count; no decidua passed; less sensitive mass; often bilateral. The twisted ovarian cyst would be spherical in shape; lower temperature (shock); lower leukocyte count, no decidua. In appendicitis the point of tenderness would be over Mc- Burney's point; higher fever, higher leukocyte count, no decidua; absence of a pelvic mass. The diagnosis is not so clear in practice. Acetonuria, said to be pathognomonic of internal hemorrhage, has proven of no value as a diagnostic aid, as it is found very often in cases of pyosalpinx. In all cases in which a diagnosis of extra-uterine pregnancy is justifiable, the diagnosis should be made and acted upon. All the above require abdominal operation, and the only mistake is that of a possibly unnecessary hurried operation. A common but unjustifiable error in diagnosis is to mistake extra-uterine pregnancy for an incomplete abortion. In incomplete abortion, the cervix would be dilated; chorion would be found in the material discharged from the uterus; the visible bleeding would be considerably greater; shock is less; no palpable pelvic mass and little if any tenderness in the vaginal fornix. In cases of abdominal pregnancy, past the sixth month of development, the a;-ray will often afford a means of clearing up the diagnosis between extra-uterine pregnancy and other ab- dominal tumors as the shadow of the fetal skeleton can be seen. Treatment is abdominal section as soon as the diagnosis is made. The vaginal route is not advisable. After as complete a preparation as possible under the circumstances, the abdomen EXTRA-UTERINE PREGNANCY l6l is opened in the middle line, under general or local anesthesia. When the peritoneum is reached, its color is dark slate, if the tube is ruptured, from the clotted blood underneath. When the peritoneum is opened, the blood gushes forth in large quantity. No attention should be paid to it. The affected tube and ovary should be brought up into the wound, ligated and removed. The blood-clots are removed from the abdomen best by irrigation with sterile water or salt solution. The abdomicn is closed without drainage. Rapidity of opera- tion is essential. The need for rapidity is over, however, as soon as the blood-supply of the affected tube has been con- trolled. Any intravenous stimulation or transfusion can be done on the table, during the operation. The expectant plan of treatment, of waiting until the patient has recovered from shock before operation, is not to be recommended. Occasion- ally these patients will not rally from shock but will bleed to death, and nothing is gained by delayed operation. When the pregnancy has progressed, as it occasionally does, to the latter months, the danger of rupture is small and the operator is justified in waiting till the child is viable. If the child is alive, in these cases, often extreme difficulty will be found in controlling the bleeding from the placental site, and packing will usually be required. In cases where the child is dead and has been long retained, the placenta, blood- clots and decidua are very putrescible, and drainage is uni- formly required. When the tube has ruptured into the layers of the broad ligament, and the patient has recovered from the immediate shock, the resulting hematoma is best evacuated by incision through the vaginal vault. Active stimulation is the rule in all bad cases. Salt solu- tion intravenously (2500 mil or more) is required. The common mistake is in giving too little. Intravenous trans- fusion of blood (500-750 mil by Kemp ton tube or by sodium citrate method) : digalen TUx or digipuratum i ampule every three hours hypodermically : strychnin sulph. grain 3^^o every three hours hypodermically; oxygen for a few hours if very 1 62 DISEASES OF THE FALLOPIAN TUBES desperate; and external heat with bandaged extremities. These patients must be v/ell covered both on the operating table and afterward and surrounded by hot water bags, as they are very siibject to postoperative pneumonia. Prognosis. — Without operation 66 per cent, succumb to internal hemorrhage. Of the remaining 34 per cent, a large proportion are invalids or ultimately lose their lives from complications directly a result of the extra-uterine preg-^ nancy (suppurating pelvic hematoma, etc.). With abdominal section, the mortality should be very small (i per cent, or less), if seen in time, and few, if any, cases are too desperate for operation. A few cases will first rally and then die of acute anemia, in spite of stimulation. Postoperative pneumonia is a common and dangerous complication. Pregnancy in one horn of a uterus unicornis or bicomis, sometimes occurs. It cannot usually be diagnosed from tubal pregnancy and its complications and treatment are the same. It will probably rupture at the cornu of the uterus, but later in pregnancy than the tubal variety. The ovum may, however, be expelled through the cervix, as in ordinary abortion. A true cornual pregnancy may either rupture at the third or fourth month, or more likely spontaneously move into the uterine cavity and continue to term. Metrorrhagia after operation for ectopic pregnancy is due to hypertrophied angiomatous decidua. When it occurs, any time spent in palliative measures is wasted. Dilatation and curetment is the only cure. Removal of both tubes, with the idea of preventing a second ectopic, is not justified,' unless the other tube shows marked evidence of inflammation. At least 33 per cent, of all cases have normal intrauterine pregnancies later, while less than 15 per cent, have a repeated ectopic. IV. HEMATOSALPINX Hematosalpinx is a collection of blood in the closed tube. Causes. — (i) Extrauterine pregnancy; (2) acute tubal conges- HYDROSALPINX 1 63 tion; (3) acute tubal inflammation (gonorrheal) ; (4) associated with gynatresia; (5) tubal menstruation. The form associated with gynatresia differs from the others in being liable to cause fulminant infection of the peritoneum if it ruptures. Sjonptoms are those of salpingitis. The diagnosis of the true condition is made on inspection, as the mass palpable by vaginal examination differs little if at all from the ordinary pyosalpinx. Treatment is abdominal section, with removal of the tube affected. V. HYDROSALPINX (HYDROPS TUB^; SACROSALPINX SEROSA) This is a collection of serum or thin mucus in the closed tube. Pathology. — The tube is markedly distended, the walls very thin and almost transparent; perisalpingitis is present, and the cause of the closed abdominal end of the tube, but no inflammatory condition of the tube itself need be present. The mucosa has almost or quite disappeared. Rarely the tubal walls are thickened by inflammation. The condition is usually bilateral and is a sequel of gonorrheal or puerperal infection. The tubes are moderate in size, because the thin walls permit a certain amount of leakage, when the tension becomes great. Varieties. — ^(i) Simple hydrosalpinx; (2) pseudofollicular, where the atrophied mucosa suggests gland spaces; (3) hydrops tubge profluens; (4) tubo-ovarian cyst. Symptoms.^ — All give symptoms of moderate pelvic Inflam- mation, but the tenderness on palpation is much less than in salpingitis. Hydrops tubas profluens or recurrent hydro- salpinx is the name given to the variety which periodically empties itself through the uterine cavity, as evidenced by increasing discomfort, a gush of fluid from the vagina, and then relief from discomfort until the sac has refilled. Diagnosis. — Bimanual examination shows a fixed uterus and a palpable pelvic mass behind it. The diagnosis will 164 DISEASES OF THE FALLOPIAN TUBES usually be salpingitis, though the true condition may be sus- pected by the lack of great tenderness. Hydrops tubs profluens, due to the periodic gushes of fluid, is sufficiently obvious to avoid a mistaken diagnosis. Treatment. — Abdominal section, removing the tubes but conserving ovarian tissue where possible. VI. SALPINGITIS Salpingitis, or inflammation of the Fallopian tubes is of two kinds: (i) Non-infectious; (2) infectious, the latter being much the commoner. The non-infectious variety is due to cold, injuries or the escape into the tubes of such fluids as iodin, nitrate of silver or other solutions used in local application to the uterine cavity. It is of short duration, marked by a few days of acute pain from pelvic peritonitis, and relieved by palliative treatment. Bacteria in infectious salpingitis are: (i) Gonococcus; (2) streptococcus; (3) tubercle bacillus; (4) Bacillus coli com- munis; (5) staphylococcus. This is approximately their order of frequency. Most pathogenic bacteria can be the cause of salpingitis, but the five given account for the vast majority of cases. Gonococci, responsible for more than any other organism, pass the barrier of the internal os usually just after a menstrual period. This may not occur for months or years after the original infection. They do very little harm to the endome- trium of the uterine body, but find productive soil for growth in the tubal mucosa. Streptococci are introduced after labor, miscarriage or dirty instrumentation, and very rarely by hematogenous infection from acute foci in other parts of the body (notably the tonsils). Stages. — Every case of salpingitis, except possibly the tubercular passes through two stages: (i) acute; (2) chronic. Pathology. — (i) Acute Stage, (i) The mucosa is swollen, red and edematous; (2) the mucosa and fimbria are bathed SALPINGITIS 165 in a purulent exudate; (3) the tube is elongated, thickened and stiff; (4) the abdominal end is open and there is free exit for pus into the peritoneal cavity; (5) there is marked round-cell infiltration of both mucosa and tubal wall. This is the stage of purulent salpingitis. (2) Chronic Stage. — (i) The tube cell is markedly thickened; (2) the abdominal ostium is closed; (3) the tubal lumen is distended by pus, this being most marked in the outer two- thirds of the tube; (4) the uterine end is closed off and the Pig. 65. — Acute double purulent salpingitis. The ampullse of both tubes are open and dripping pus. {After Graves.) tube becomes a closed sac, which may grow to very considerable size; (5) the epithelial layer loses many of its folds as all of its cilia, and the remaining folds adhere to each other; (6) the tube is elongated, convoluted, and bound down by dense adhesions to the posterior layer of the broad ligament and posterior uterine wall; (7) local hypertrophy is seen any- where in the course of the tube, but most commonly as a marked elevation at the uterine cornu — salpingitis isthmica nodosa; (8) the blood-vessel walls in the muscular coat show hyaline degeneration. This is the stage of pyosalpinx or pus-tube. Not infrequently the fimbriated extremity is closed i66 DISEASES OF THE FALLOPIAN TUBES by adhesion to the ovary, over the site of a Graafian follicle. This follicle ruptures and pus from the tube invades the ovarian LeffTubo-Ovar I an Abscess r^ W^i Tubed Abscess Pig. 66. — The type of adhesions found in double gonorrheal pyosalpinx. (After Graves.) Fig. 67. — Salpingitis isthmica nodosa: a type of bilateral gonorrheal pyo- salpinx. (After Graves.) substance. Gradually the whole ovary is invaded and con- SALPINGITIS 167 verted into a pus-sac continuous with the tube. Even if both ovaries are involved, the ovarian tissue is never wholly de- stroyed, as menstruation does not cease. The ovary is per- manently damaged, however, and usually must be removed at operation with the offending tube. This is a tuho-ovarian abscess. How the Ends of the Tube are Closed. — (i) By adhesion and retraction of the fimbria, probably the commonest way; (2) by adhesions in Douglas' pouch around the fimbria, which shut off the tubal lumen from the peritoneal cavity, though the lumen itself is open; (3) by adhesions of the fimbria to the surface of the ovary and formation of a tubo-ovarian abscess. A pyosalpinx results only after the tube is closed; as long as the tube is open it is called purulent salpingitis. After the tube is closed off, the bacteria contained in the pus gradually die, being destroyed by the compression in the distended tube, and lack of fresh infection from the uterine cavity. The pus becomes sterile usually three or four weeks after the tube is closed, but is liable to fresh infection from the uterine cavity, by ill-advised curetment, or from the bowel, at any time. Bacteria may be found in the pus in acute cases, when the abdominal ostium is still open. It is useless to look for them in slides made from the pus from the ordinary closed pyosalpinx. This sterility of the pus explains why such a tube can be rup- tured at operation with impunity, and the abdomen closed without drainage; a thing never possible in an appendicial abscess, for instance. Pelvic peritonitis is always present in acute salpingitis, because the seropurulent discharge from the open abdominal ostium inevitably flows into the peritoneum of Douglas' pouch. This causes the dense adhesions in and following salpingitis, usually spoken of as chronic pelvic inflammatory disease. The older the infection the -denser the adhesions; and above all other infections they are densest in syphilis. The adhesions involve the bladder, pelvic organs, intestines, and in severe 1 68 DISEASE'S OF THE FALLOPIAN TUBES cases the whole pelvis is filled with a conglomerate mass of the organs affected. These are the most serious cases, due to the danger of bowel injury and intestinal obstruction. Sjnnptoins differ markedly in the acute and chronic stages. The s3nnptoms of chronic pyosalpinx and tubo-ovarian abscess are identical. Symptoms of the Acute Stage. — (i) Acute abdominal pain, most marked in the lower abdomen; (2) rigidity of the abdom- FiG. 68. — Double gonorrheal salpingitis, showing the extent of adhe- sions usually met with. It is these adhesions and the necessary trauma in separating them that is responsible for the danger in these operations. {After Graves.) inal muscles, much greater in the lower than the upper portion; (3) great increase of pain on any muscular exertion, or any jolt or jar, such as sneezing, coughing etc.; (4) temperature elevated, the average being about 102, except in streptococcic infection, where it is much higher; (5) leukocytosis 18,000 to 20,000; (6) leukorrheal discharge. Bimanual examination shows a uterus fixed and immovable; (2) excessive pain on touching either vaginal vault; (3) rarely SALPINGITIS 169 in the acute stage a palpable mass for two reasons: (i) The abdominal end of the tube is still open and the tube is moderate in size and (2) the excessive tenderness prevents any deep examination. The acute pain in these cases is due to leakage of pus from the open abdominal end of the tube into the peri- toneum of Douglas' pouch, and a sharp pelvic peritonitis. These attacks of pain recur at intervals until the tube is closed and no further leakage is possible. Differential diagnosis must be made from extra-uterine pregnancy, acute appendicitis and ovarian cyst twisted on its pedicle. Accurate diagnosis is a matter of importance, be- cause it is highly desirable to avoid abdominal section in the acute stage of salpingitis, due to the risk of diffuse peritonitis. Extra-uterine Pregnancy.- — ^(i) Cessation of menses and then irregular bleeding; (2) violent pain, paroxysmal, with evidence of shock; (3) discharge of decidua and usually absence of leukorrhea; (4) temperature only 99.5 to 100; (5) leukocytosis rarely over 14,000; (6) confirmatory signs of pregnancy. Acute Appendicitis. — -(i) Pain higher up ; (2) tempera- ture and leukocyte count about the same; (3) no vaginal ten- derness; (4) uterus not fixed; (5) no palpable mass; (6) absence of leukorrhea. Ovarian Cyst Twisted on its Pedicle. — (i) Severe shock; (2) absence of fever, leukocytosis and leukorrhea; (3) uterus displaced forward and to one side by a globular mass filling the pelvis. The diagnosis is often one of extreme difficulty, if not impossibility, and immediate operation will often be decided upon, based upon a mistaken diagnosis. Positive smears for gonococci, the gonorrheal stigmata, and positive complement fixation test are strong arguments in favor of salpingitis and against the other possibilities. Sjnnptoms of the Chronic Stage.^ — (i) History of leukorrheal discharge, usually of long standing; (2) history of repeated attacks of sharp pain, recurring at intervals; (3) present history of constant dragging pain in lower abdomen; (4) pain invariably increased by the premenstrual congestion, relieved 170 DISEASES OF THE FALLOPIAN TUBES by the flow, and returning when the flow ceases; (5) menor- rhagia; (6) pain increased by any muscular exertion, coitus, or defecation; (7) usually secondary anemia, due to toxemia; (8) pain is often referred to distant regions, as headache, backache or in the nape of the neck; (9) nearly always a history of neurasthenia, digestive disturbances and chronic consti- pation, due to the pelvic disease; (10) rarely, even extensively inflamed and adherent tubes may give rise to very little local disturbance and present practically no symptoms. Usually, however, patients with chronic salpingitis look prematurely aged, anxious and worn. Diagnosis. — Abdominal palpation shows marked tenderness to deep pressure over the lower abdomen, but rarely a palpable mass. Bimanual Examination. — (i) The uterus is fixed and im- movable, and almost always shows some backward displace- ment; (2) there is a hard, irregular, sensitive mass fiUing Douglas' pouch, in which it may be possible to outline the tubes, ovaries and posterior uterine wall; (3) rarely the tubal mass lies in front of the uterus; (4) pressure on the tubes always causes considerable pain and is often agonizing; (5) the cervix is usually eroded and there is profuse leukorrheal discharge. Differential Diagnosis. — (i) Retroversion of the uterus may be excluded by the irregularity of the mass filling Douglas' pouch and by the symptoms given above for chronic sal- pingitis. (2) An old pus tube, densely adherent in Douglas' pouch and to the back wall of the uterus, is often so hard and unyielding as to be mistaken for a subperitoneal fibroid, or for a retroverted uterus. (3) In gonorrheal cases, the comple- ment-fixation test is of value, as a differential point, but is negative until at least four weeks after the onset of gonorrhea. (4) Other possibilities are as given under acute salpingitis. (5) A pus tube may rupture and cause diffuse peritonitis, but this is so rare that the presence of acute, diffuse peritonitis points strongly toward the appendix as origin of the infection. SALPINGITIS 171 (6) Diverticulitis of the sigmoid is almost impossible to diagnose from left-sided salpingitis. It usually occurs in women beyond the age at which salpingitis is likely, but in other respects is indistinguishable. DIFFERENTIAL DIAGNOSIS BETWEEN GONORRHEAL AND STREPTOCOCCIC PYOSALPINX Gonorrhea (i) Can occur at any time. (2) Often bilateral. (3) Cornual abscess rare. (4) Abdominal end of the tube closed. (5) Tube lengthened, convoluted and adherent. (6) Broad ligament rarely thick- ened. (7) Infection travels to tube under mucosa. (8) Ovary affected secondarily. (9) Temperature 101-102. (10) Leukocytosis 18,000 plus. (11) Rarely a palpable abdominal mass. (12) Gonorrheal stigmata (Skene's and Bartholin's glands)present. (13) Complement-fixation test posi- tive. (14) Gonococci in discharge. Streptococcic Infection (i) Rare except after miscarriage or labor. (2) Most often unilateral. (3) Cornual abscess common. (4) Abdominal end of tube open. (s) Tube thick friable, beefy and dark red. (6) Broad ligament always thick- ened. (7) Infection travels to tube through lymphatics of broad ligament. (8) Ovary affected primarily. (9) Temperature 104-105. (10) Leukocytosis 25,000 plus. (11) Usually a palpable abdominal mass, due to omentum ad- herent cornu. (12) Gonorrheal stigmata absent. (13) Complement-fixation test nega- tive. (14) Streptococci in discharge. Treatment of Salpingitis I. Acute Stage, Palliative Treatment. — Acute salpingitis, except the streptococcic form, is rarely fatal, the peritonitis is limited to that portion of the pelvis where absorption is slowest, and the disease tends to subside either partially 172 DISEASES OF THE FALLOPIAN TUBES or completely in six to ten days. The treatment, therefore, is expectant. (i) Rest in bed; (2) liquid or soft diet; (3) four hot vaginal douches a day, using normal saline solution, as hot as the patient can bear them; (4) ice-bag constantly to lower ab- domen; (5) bowels kept well open (best by magnesium citrate solution /a^, oz. 4 twice daily) (6) for the minority of patients to whom heat is more grateful than the ice-bag, a hot flaxseed poultice to lower abdomen, or hot water bag constantly; (7) no local vaginal treatment such as tampons or applications (other than the douches mentioned above); (8) leukocyte count daily; (9) above all, no curettage or other intra-uterine applications. This treatment will usually cause temperature, pulse and leukocyte count to drop normal inside of three to seven days, and all pain to disappear. Should the leukocyte count steadily rise, or should a diiferential diagnosis between salpingitis and extra-uterine pregnancy be impossible, prompt operation is the safest course, though there is some danger of diffuse peritonitis and the case will probably require drainage. If there is a bulging mass in Douglas' pouch, vaginal puncture is the proper procedure; otherwise abdominal section is necessary. Palliative treatment, in the chronic stage is usually a waste of time. Except in cases of acute exacerbation of a chronic process, which are treated as the acute form, not much if anything can be gained. If the patient's complaint is pain and there is no palpable mass, palliative treatment is desirable; if a mass is present, nothing permanent can be expected from it. (i) Rest in bed during menstrual periods, and avoidance of physical exertion at other times; (2) avoidance of coitus or any other cause of pelvic congestion; (3) hot vaginal douching three times daily; (4) application of 5 per cent, iodin to vaginal vaults three times a week; (5) boroglycerid or ichthyol tampons, renewed three times a week (see chapter on office treatment); (6) no curetment, unless it is to be followed immediately by abdominal section. SALPINGITIS 173 OPERATIVE TREATMENT OF ACUTE AND CHRONIC SALPINGITIS Indications. — (i) Where a large tubal mass is palpable; (2) when palliative treatment has failed to give relief; (3) in cases with great pain, unrelieved by treatment; (4) in working women, who cannot afford the time required for palliative treatment; (5) in acute cases, where there are signs of diffuse peritonitis, or a pelvic mass develops. Operations. — (i) Breaking of adhesions, without removal of any of the pelvic organs; {2). salpingectomy — removal of the tube alone; (3) salpingo-oophorectomy — removal of both tube and ovary; (4) salpingostomy — reopening a closed tube, in sterility; (5) hysterectomy, with removal of both tubes and ovaries as well; (6) vaginal section, with breaking up of adhesions, or drainage of an abscess or of the tubes themselves. As it is not possible, before operation, to judge how much must be removed, it is always wisest to obtain written consent of both the patient and her husband, or some other responsible member of the family, to do whatever in the surgeon's judgment seems necessary. (i) Breaking up of adhesions, may be done either by the vaginal route (undesirable) or by abdominal section. It is indicated only when there is no gross change in the tubes themselves, and the tubes are simply bound down by adhesions. The tubes are rolled out of the bed of adhesions holding them, by pressure from below upward and behind forward. This minimizes the danger of injury to the bowel. The prospect of permanent success is not brilliant. In the majority of cases, the adhesions promptly "reform. (2) Salpingectomy — removal of the tube alone, by abdominal section. Technic. — ^i . The tube is freed from adhesions and delivered through the wound. 2. It is grasped with one hemostat at the cornu of the uterus and by another just below the fimbriated extremity, above the ovary. 174 DISEASES or THE FALLOPIAN TUBES 3. The tube is cut loose from the cornu by a wedge-shaped excision of the uterine muscle. 4. It is cut loose from the mesosalpinx, each vessel being clamped as it is cut; four or five hemostats are needed. 5. With a number i chromic catgut stitch, soaked in water so as to be pliable, the cornu and upper edge of the broad ligament are sewed over, taking a half hitch at each stitch, A simple running stitch is not hemostatic. This stitch is tied at the cornu, where it begins, and again outside the outer hemostat. 6. One or two small mattress stitches, to secure bleeding points may be required. This has the great advantage over other methods that it does not distort the broad ligament, and that slipping of the ligature, provided the catgut is pliable, is hardly possible. The method is not possible if the broad hgament is infiltrated and stiff. Alternative Method. — (i) A ligature of number 3 chromic cat- gut is passed through the broad ligament under the round liga- ment; (2) the tube is cut loose from the cornu; (3) the first ligature is tied under the excised end of the tube; (4) a second ligature is placed near the first and tied down, across the whole mesosalpinx, just above the ovary; (5) the tube is cut off; (6) the cornual wound is closed. The outer ligature in this method is prone to slip, especially if the mesosalpinx is stiff. The tube may be removed by anterior vaginal section, under the bladder, dehvering the uterus out under the bladder and then the tube removed by either of the methods described above. The small amount of working space and the difficulty in dealing with adhesions make the method undesirable. (3) Salpingo-oophorectomy^ — removal of tube and ovary, is indicated when the ovary is badly damaged, or forms part of the wall of an abscess. Technic. — (i) The tube and ovary are freed from their bed and delivered in the wound; (2) the tube is grasped at the cornu with a hemostat; (3) a second hemostat grasps the free ovarian SALPINGITIS 175 edge of the broad ligament; (4) the tube is excised at the cornu and tube and ovary are removed together by cutting across the upper edge of the broad Hgament, clamping vessels as they are cut; (5) the cornu and broad ligament wounds are closed by a running lock stitch (half stitch) of number i chromic catgut, pliable, as in salpingectomy. This is the ideal method, but is not always possible because for it the broad ligament must be free from infiltration. Alternative Method. — (i) The tube and ovary are freed as before; (2) a ligature of number 3 chromic catgut is passed through the broad ligament, under the round ligament, close 'm-. Fig. 69. — The condition often found at operation for gonorrheal pyo- salpinx. The bowel is extensively involved in dense adhesions. {After Crossen.) to the uterus; (3) the tube is excised at the cornu and the ligature tied under the excised end. This secures the uterine artery; (4) a second ligature is passed through the broad liga- ment, near the first and tied on the free ovarian edge of the broad ligament; (5) the ovarian artery is tied again, just be- yond this ligature, as the free edge of the broad ligament has a strong tendency to slip from the bite of the single ligature. From this edge of the broad ligament come most of the second- ary hemorrhages after operation; (6) the ovary and tube are removed; (7) the cornu is closed and with the same stitch, 176 DISEASES or THE FALLOPIAN TUBES the cut edge of the broad ligament is whipped over. This is the best method, when the broad Hgament is infiltrated. Vaginal section for salpingo-odphorectomy is open to the same objection as for salpingectomy. Conservatism is rnost desirable in these operations. It is often possible to remove the outer portions of the tubes only, and do an ovarian resection, so as to leave at least part of the adnexa, if they are reasonably free from pathological changes. There is some chance of future trouble necessitating a second operation and this should be explained to the patient before operation, and the choice left with her. (4) Hysterectomy is usually not necessary, unless the uterus itself is greatly diseased. Even if both tubes and ovaries have been sacrificed, the uterus is not a useless organ. It affords marked support for the vaginal vaults, and the two objections to leaving it (leukorrhea and metrorrhagia) can be met by the curetment which should always precede any section for pelvic inflammatory disease, except that due to streptococcic infection. If hysterectomy is required, the technic is exactly that described in the removal of a fibroid tumor (Chapter VII). In all the operations thus far described, an important step is to pack off, with gauze, the upper abdominal cavity, above the pelvic brim, to prevent contamination if an abscess is opened into. This is desirable in any case; it is absolutely essential in streptococcic cases. (5) Salpingostomy is the reopening of closed tubes, either by dilatation of the fimbriated extremity or by cutting a window in the side of the tube, for the possible relief of sterility. Technic. — (i) The tube is delivered into the wound; (2) with scissors a small opening is made over the closed fimbriated end; (3) a hemostat is inserted in this opening and the blades opened, to dilate it, this method causing a minimum of trauma, or a window is cut in the side of the tube, in its outer third, and the mucosa united to the serous coat with interrupted sutures. The results are not satisfactory; only rarely has pregnancy SALPINGITIS 177 resulted, and there is considerable risk of extra-uterine preg- nancy, rather than intra-uterine. (6) Vaginal section and drainage, while usually undesirable, has a field. In acute cases, with large pelvic mass, or in the profound cachexia seen with large chronic tubes it is decidedly useful. Technic.—{i) The patient is arranged in the lithotomy position and prepared as for any vaginal operation; (2) the posterior lip of the cervix is caught with a tenaculum and pulled up toward the symphysis; (3) a semicircular incision is made through the vaginal vault, and with a pair of scissors, inserted close to the uterus and in the middle line, the mass is punctured and the scissors withdrawn open; (4) the cavity is explored with the finger, as far as it will reach, and then washed out; (5) the cavity is drained with gauze (if not much pus has escaped) or with a T-drainage tube, and irrigated daily until all discharge has ceased. This method is indicated to relieve the acute septic symptoms and as a preparation for a subsequent abdominal section. Drainage in abdominal sections is needed in many cases for (i) persistent oozing from the posterior wall of the uterus, broad ligaments and Douglas' pouch or (2) infection. The best method is a glass tube and gauze, through the lower end of the abdominal incision. Drainage into the vagina through the posterior vaginal vault is satisfactory for hemorrhage but not for infection, and especially not for the streptococcic kind. Drainage, its method and after care is described in Chapter X under peritonitis and pelvic abscess. Two classes of patients do not admit of drainage: (i) Tubercular salpingitis, because drainage means a per- manent abdominal fistula. (2) Syphilis, because around the gauze there is such an exudate of lymph that the whole pelvis is filled by a solid mass and there is great danger of intestinal obstruction. Sterility after double salpingo-oophorectomy is almost in- variable, though pregnancy may result from the remains of an 178 DISEASES OF THE FALLOPIAN TUBES ovary left adherent to the broad ligament, the ovum gaining access to the uterine cavity through the uterine cornu, which has not healed tight. Efforts at transplantation of the ovary, from the same or another patient, and sewing it into the cornu have not been successful. In any case the patient should not be told she is sterile, as the mental effect on her is often unfortunate. The surgical menopause, which is the more severe the younger the patient, can be controlled by hypodermic intra- muscular injections of corpus luteum extract or whole ovarian extract; i mil daily for thirty doses and repeated in series of twelve doses at intervals of several months, if needed. This method is better and more certain in its results than the implantation in the abdominal wall, next the fascia, of ovarian tissue. If this latter is done, it is important to use only ovarian grafts (slices) and not the whole ovary. The thin grafts are not subject, as is the whole ovary, to cystic degeneration. Removal of both, tubes in cases known to be gonorrheal, where one is obviously infected, is a matter of individual choice. It should be explained to the patient beforehand that the disease is most often bilateral, and that she might need a second operation within one or two years, if the at present inoffensive tube is left, and the choice left with her. The wisest plan is to obtain consent for whatever is necessary in the surgeon's judgment, and be as conservative as possible. If the second tube shows evidence of beginning inflammation, it is better removed; if it is free from all signs, it may be left, but with some misgivings. Routine curetment of the uterus is the rule in all cases requiring abdominal section for pelvic inflammatory diseases, except the streptococcic cases. The uterus is dilated, curetted and then wiped out with 7 per cent, tincture of iodin or pure carbolic acid. The acid application is followed by one of alcohol to the vagina (not uterus) to prevent vaginal burns. Ligature material in all operations should be number 3 TUBERCULOSIS OF THE FALLOPIAN ^TUBES 1 79 chromic catgut. Silk or any permanent suture material should be avoided as secondary abscesses and abdominal sinus are very common after their use. Several methods to combine pressure and heat as hemostatics and thus do away with ligatures altogether have been devised. Most notable is the Downs electrothermic angiotribe, but none of these appliances give even reasonable safety from secondary hemorrhage, and they are not to be recommended. VIL TUBERCULOSIS OF THE FALLOPIAN TUBES Tuberculosis of the tube is more common than in any other portion of the genital tract. It attacks both the mucosa (endosalpingitis) and the peritoneal covering (perisalpingitis) . Cause. — ^(i) Hematogenous infection from some distant focus which may be latent, while the tubal process is active. This is the usual, and apparently primary, type. (2) Descending infection from the peritoneum; (3) ascending infection from the external genitalia (exceedingly rare). Pathology.^ — (i) Except in general miliary tuberculosis, the condition is always chronic; (2) it is always bilateral; (3) the mucosa and tube wall are infiltrated with round cells, among which are many typical tubercles, with giant and epithelioid cells; (4) the abdominal end closes early, so that pyosalpinx promptly develops; (5) the peritoneal coat is studded with hard yellowish tubercles, like millet seed; (6) the contents of the tube are white, cheesy pus if the process is purely tubercular; or creamy yellow pus if it is a mixed infection (as is common) ; (7) tubercle bacilli can be demonstrated in section of the tube wall. (8) The adhesions of tubercular pus tubes are often very dense, and sometimes absolutely inoperable — in contrast to gonorrhea, which are rarely so. (9) Tuberculosis of the tube can exist in fetal life. Symptoms are like those of any other salpingitis. Tuber- cular salpingitis is fairly common in young girls, so that an inflammatory pelvic mass, in a patient with intact hymen, may safely be diagnosed as tubercular. l8o DISEASES OF THE FALLOPIAN TUBES Progress is slow and insidious. If it appears in youth, it is associated with general under-development. Amenorrhea is common, and sterility is inevitable. Treatment.- — Abdominal section with removal of both tubes and such other portion of the genital organs as show marked involvement. Drainage of the abdomen is contra-indicated. At operation the mass of adhesions may be inextricable, and the case abandoned as inoperable. In such cases the simple opening of the abdomen and admission of air may, as in tuber- cular peritonitis, effect extraordinary cures, by spontaneous absorption and disappearance of the adhesions. Operation is contra-indicated, if there are remote active lesions threatening the patient's life, or in acute general miliary tuberculosis. VIII. TUMORS OF THE FALLOPIAN TUBES Tumors are rare. They are either benign or malignant. The benign growths are fibroma, fibromyoma or adenomyoma; they are small, usually in the inner one- third of the tube, give no symptoms and are usually accidentally found at operation. Malignant growths are carcinoma, sarcoma, chorion-epithe- lioma and endothelioma. Primary carcinoma of the tube occurs most often after the menopause, between fifty and sixty. It is originally in the mucous membrane and is supposed to be caused by pre-existing inflammation. It is a papillary growth, and is usually in the outer third of the tube. It is also secondary to cancer of the uterus (fundus) or general abdominal carcinomatosis. Symptoms are those of the pelvic inflammation which accompany it. The true diagnosis is made at operation. In doubtful cases a small piece is excised and a rapid diagnosis made by the freezing microtome. Treatment is abdominal panhysterectomy. Recurrence is common, due to abdominal adhesions. Cysts of Morgagni — small pedunculated cysts hanging from VARICOCELE OF THE PAMPINIFORM PLEXUS 1 61 the fimbriated extremity of the tube, have no clinical or pathological significance. They are limited in size. K. VARICOCELE OF THE PAMPINIFORM PLEXUS This is very common, being associated with any chronic congestion of the genital organs. It is more common on the left side, and the discomfort is more marked, due to the left ovarian vein emptying into the renal at a right angle, without a valve. Pig. 70. — Varicocele of the pampiniform plexus and the placing of the first ligature. (After B. C, Hirst.) Symptoms. — (i) Heavy, dull aching pain in the groin, usually the left, worse on standing, worse at the periods, and relieved by lying down. It is aggravated by exertion. The symptoms are not distinctive and a definite diagnosis cannot be made by vaginal examination. The condition is usually found coincident with other pelvic disease. Treatment.^ — (i) Remove any cause of uterine congestion which can be found. (2) Pituitrin 3^^ mil hypodermically every day for ten doses. (3) If the veins are found, at opera- tion, to be distended, ligature and excision is the only cure. CHAPTER IX DISEASES OF THE OVARY GENERAL ANATOMY AND RELATIONS OF THE OVARY The ovary secretes ovules during the period of the woman's sexual activity, from the fifteenth to the forty-fifth year, on the average. It is an elliptical gland, 5 cm. long, 3 cm. broad and 3^^ cm. thick and weighs about 8 grams. It lies against the posterior border of the broad ligament, in a depression on the lateral pelvic wall {the ovarian fossa) ^ to which it is attached by a reduplication of the peritoneum of the broad Ugament — the mesovarium — containing the blood-vessels, nerves and lymphatics. The ovary is the only structure projecting into the peritoneum which has no peritoneal covering. Ligaments.^ — From the uterine pole of the ovary runs the utero-ovarian ligament; from the tubal pole runs the infun- dibulopelvic ligament (a thin band of connective tissue in the upper margin of the broad ligament). To the tubal pole is attached the ovarian fimbria. Arteries are branches of the ovarian artery and ovarian branch of the uterine artery. They enter the ovary at the hilus. The veins leave the ovary at the hilus. They empty into the pampiniform plexus, which in turn leaves the broad liga- ment as the ovarian vein. This empties into the renal on the left; into the inferior vena cava on the right. The lymphatics leave the ovary with the veins and empty into the deep lumbar glands. The nerves are derived from the plexus surrounding the ovarian artery. They are sensory and vasomotor. Histologic divisions are (i) the hilus — where the mesovarium is attached and where the vessels enter and leave the ovary; GENERAL ANATOMY AND RELATIONS OF THE OVARY 1 83 (2) the o'ophoron — ^the egg-secreting portion, containing the Graafian folHcles; (3) the paroophoron — ^containing the micro- scopical remains of the Wolffian body; (4) the parovarium (epoophoron) — in the mesovarium, consisting of six to twelve small ducts, like the teeth of a comb, emptying into a common duct (Gartner's duct) representing the back of the comb. Gartner's duct runs parallel with the tube, and usually ends in a blind pouch in the broad ligament. Occasionally it can be traced through the broad ligament, uterine wall, vaginal vault Oophoron v [^ydafld of or Egg bearing porrionj Mdr^agnl ok Mullerj duet- Fig. 71. — Diagram of the tube, ovary and broad ligament, and their structure. {After Stewart.) and down the anterior vaginal wall as far as the vulvar orifice. Development of the Ovary. — The ovary is developed about the sixth week of fetal life, the genital glands appearing to the median side of Miiller's ducts and the Wolffian body. The germinal epithelial cells permeating the ovary are cut off and confined in connective tissue spaces. A primordial follicle is one of these connective-tissue spaces surrounded by a wreath of capillaries and contains a highly specialized cell — the ovum. Descent of the ovary takes place at the third month of fetal life, being drawn down by the gubernaculum of Hunter. This gubernaculum fuses in its upper portion with the Miiller- ian ducts at their point of union — at the fundus uteri, and finally remains as the ovarian and round ligaments. Graafian Follicles. — The chief function of the ovary is the 184 DISEASES OF THE OVARY development and ripening of Graafian follicles and the dis- charge of ova. At birth each ovary contains about 30,000 primordial follicles, and no new ones are created after birth. The follicles are all contained in the oophoron or parenchy- matous layer of the ovary. There are three stages in the maturing of the follicle: (i) The primordial; (2) the ripening and (3) the mature follicle. The primordial follicle lies embedded in the ovarian stroma, and consists of the ovum surrounded by a single layer of low fiat epithelium. When the follicle begins to ripen, the epi- thelial cells surrounding it multiply into several layers, and lie closely around the ovum. In the mass of cells appears a clear space, which becomes filled with fluid — the liquor folliculi, and partly surrounds the ovum. The ovum is still surrounded by several layers of epithelial cells, which project into the clear space like a peninsula. These cells form the discus proligerus, and the rest of the epithelium, around the follicle, is called the membrana granulosa. At the same time the outside of the follicle is being surrounded by an envelope of connective tissue, the theca folliculi, which has two layers, an external and internal. The ovum itself is now surrounded by a capsule — the zona pellucida, which contains fluid, so that the ovum is not in direct contact with its capsule. The ovum is nourished through this fluid and the liquor folliculi. As the follicle ripens, it at first retreats into the ovary, but later, when fully ripe and distended with liquor folliculi, it again approaches the surface and bulges out on it. At a point opposite the ovum there appears a pale translucent spot — the stigma, and through this the follicle ruptures and dis- charges its contents. The ovum is carried into the tubal canal by the current set up by the ciliated epithelium, or it may be discharged directly into the ampulla. Ovulation should normally occur a few days before or syn- chronously with menstruation. This rule is by no means constant and practically the two processes can occur independently. ABNORMALITIES AND DISEASES 1 85 The corpus luteum begins to be formed as soon as the ovum is discharged. The empty follicle fills with blood. The yellow wrinkled membrane surrounding the central blood mass is derived from hypertrophied cells of the membrana granulosa — now called lutein cells^ — and is of connective tissue origin. This layer contains connective tissue and blood-ves- sels. The regression of the corpus luteum takes about four weeks, except for that of pregnancy, which lasts seventy-five to one hundred and twenty days. The yellow coloring matter is absorbed, and by hyaline degeneration and shrinking the corpus albicans is formed. This white body persists for a long time, but finally disappears completely, leaving only a small indentation on the surface of the ovary. As only a small proportion of follicles ever develop and mature, the others are absorbed by "atresia of the follicle." Ovarian Internal Secretion. — The exact nature and its source are not known. Part comes from the follicle apparatus, which presumably controls the growth and development of the genitalia; part from the corpus luteum and probably con- trols menstruation and prepares the endometrium for the reception of the fertilized ovum. Part comes possibly from the interstitial portion of the gland, though this is as yet entirely theoretical. Atrophy of the ovary is permanent after the menopause, and to a certain extent temporary during lactation. Absence of the ovary is seen only in absence of the entire genital system, or in unilateral development of the uterus — uterus unicornis. Accessory ovary is rare; it is not known whether it is a diverticulum from the normal ovary or an independent gland. ABNORMALITIES AND DISEASES I. Cirrhosis of the Ovary Cirrhosis of the ovary is physiologic at the menopause, the ovary becoming much smaller, harder and wrinkled. It is occasionally seen during menstrual life, involving only a 1 86 DISEASES OF THE OVARY part of the ovary as a rule, but at times the whole gland. It is common in single women, past the age of thirty-five. Its only symptom is dysmenorrhea persisting in spite of dilatation of the cervical canal. It may require abdominal section, if the pain is severe enough to demand relief, with resection or removal of the ovary. Medical treatment, either general or by local application, is useless. 11. Congestion of the Ovary Congestion of the ovary is physiological at each menstrual period, during coitus and in pregnancy. At other times it is secondary to retrodisplacement of- the uterus, coitus inter- ruptus or any other cause of general pelvic congestion. A consequence of prolonged congestion is chronic parenchymatous hypertrophy with multiple cysts. Ordinarily the condition is promptly relieved by the correc- tion of its cause. III. Cysts of the Ovary Classification. — Cysts of the ovary are classified according to the histologic division of the ovary from which they spring; or according to their clinical importance. Histologic Classification. — i. Cysts of the Oophoron. — (i) Simple follicular cysts; (2) multiple follicular (cystic ovary); (3) cysts of corpus luteum; (4) dermoid. . II. Cysts of the Paroophoron. — (i) Cystadenoma or glandular cysts. III. Cysts of Parovarium. — (i) parovarian. Clinical Classification. — I. Simple or non-proliferating — ^(i) Simple follicular; (2) cystic ovary; (3) corpus luteum. II. Proliferatijtg Cysts. — (i) Cystadenoma or glandular; (2) parovarian. III. Ovigenous. — (i) Dermoid; (2) teratomata. IV. Degenerations. — (i) Papillary; (2) carcinoma. Characteristics of Ovarian Cysts. — I. Follicular cysts may be either single or multiple. They are frequently a result of chronic interstitial inflammation. They are of slow growth, ABNORMALITIES AND DISEASES 1 87 of limited size (about that of the fist) , have a thin translucent wall and most of them are unilocular. They are intraperi- toneal, benign, and have a pedicle. The contained fluid is clear. II. Corpus luteum cysts are limited in size, of slow growth, are intraperitoneal and have a pedicle. The cyst wall on section is yellow, and the contained fluid reddish and turbid. These cysts are especially prone to intracystic bleeding. The Fig. 72. — Simple follicular cyst of the ovary. {After B. C. Hirst.) bleeding is rarely serious, and is usually completely absorbed. When it is not, it forms the so-called tarry hematoma of the ovary, the old blood being black as tar. The lutein cysts associated with hydatid mole or chorion- epithelioma are called theca-leutin cysts. III. Cystadenomata (glandular cysts; pseudomucin cysts) are of two kinds; (i) pseudomucinous and (2) serous. The pseudomucin cysts are said to be the commonest form of ovarian tumor. They are of unlimited size and usually rapid growth; unilateral; always multilocular; the locules varying widely in size, containing a thick mucoid substance, alkaline in reaction, closely resembling true mucus, but differing in that it does not give the mucin reaction with acetic acid 1 8s DISEASES OF THE OVARY (hence pseudomucin). The cysts are intraperitoneal, and have a pedicle. The pseudomucin may be of various colors, due to bleeding or local necrosis in the cyst, varying from clear glassy mucus to black. The locules are lined with high non-ciliated cylindrical epithe- lium, which secretes the pseudomucin. These cysts rarely undergo papillary or malignant degeneration. Serous cystadenomata are often bilateral, always multilocu- lar, though the locules are fewer. They are intraperitoneal, have a pedicle and contain a clear yellow serum, rich in albu- min, but without pseudomucin. They nearly all show papil- lary proliferation of the lining epithelium and are very prone to become malignant, and hence often recur after operation as local or general peritoneal carcinomatosis. Both pseudomucin and serous cystadenomata originate from the germinal epi- thelium, but their cause is not known. IV. Parovarian cysts arise from an abnormal section of the lining epithelium of the longitudinal duct. They are therefore retention cysts and not really proliferating growths. They are unilocular, and contain an opalescent serum. They are of rapid growth, reach a large size, extraperitoneal between the layers of the broad ligament. They rarely have a pedicle. The Fallopian tube is stretched out over the surface of the cyst. The ovary is not destroyed, but is attached to the surface of the tumor. This cyst has two coverings: the peritoneum of the broad ligament and its own wall. The lining epithelium is ciliated. Papillary degeneration is very rare and rarely if ever do they become malignant. V. Dermoid cysts constitute about lo per cent, of all ovarian tumors. They are of slow growth, limited size (that of the clenched fist) are intraperitoneal and have a pedicle. They are prone to become adherent, and cause more pain than any other cyst of moderate size. They are unilocular and contain all kinds of fetal structures — sebaceous matter, hair, and bone in that order of frequency. No fetal membranes have ever been found. ABNORMALITIES AND DISEASES 1 89 Dermoids rarely become malignant, though malignant degen- eration of their epithelial contents is not rare. They are often associated with pseudomucin cysts, are not infrequently bilateral. They have long pedicles, and are therefore espe- cially prone to twist on their pedicles. Their contents are very putrescible and if ruptured usually cause peritonitis. Teratomata are the rarest of ovarian growths. They are like dermoids, in the fetal structures present, but are essentially malignant (sarcoma). They grow rapidly, reach large size and give early and free metastasis. Only about fifty cases are on record. Certain teratomata, containing a preponderance of thyroid tissue, are known by the term "struma ovarii." There are two theories for the origin of dermoid cysts: (i) Fetal inclusion; (2) parthenogenesis — from imperfect segmenta- tion and development of the true germ cell, or, as has been lately advanced, from a blastomere — -separated from the true cell. The pedicle of an ovarian cyst is composed of the ovarian ligament, the infundibulopelvic ligament, the free edge of the broad ligament, the tube and the utero-ovarian anastomosis of vessels. It is not possible, as a rule to tie off only the meso- varium, which should be the true pedicle. All the above- mentioned structures are included in the ligature. Rate of growth of cysts is usually considerably more rapid than a solid tumor, such as a fibroid, because being a secreting tumor, it can form fluid faster than a solid tumor can form new cells. Like a fibroid, the presence of ascites usually means malignancy or papillary degeneration. Sym.ptoms naturally differ, with the type of cyst. Symptoms of Simple Follicular, Cystic Ovary and Corpus Luteum Cysts. — These depend to a great extent upon the size and weight of the cyst. If uncomplicated, they are often unnoticed, as tension on the ovarian substance by the growing cyst does not cause pain. Very often these cysts are first diagnosed by a vaginal examination made for other reasons. When symptoms are present they are as follows: I go DISEASES OF THE OVARY (i) Moderate pelvic pain, sometimes that of subacute salpingitis; (2) pressure on bladder and rectum; (3) men- strual irregularity, usually scanty, infrequent flow; (4) sense of weight in pelvis and backache; these usually only when the cysfis adherent. Diagnosis is made by bimanual examination, when the globular, cystic tumor can be felt, often displacing the uterus to one side and forward. No diagnosis of ovarian cyst should ever he made, until the bladder is known to he empty. Symptoms of Glandular Cysts (Adenocystomata). — (i) Rapidly increasing size of the abdomen; (2) menstrual ir- regularity, usually amenorrhea; (3) emaciation (facies ovari- ana); (4) irregular resistance of the abdominal wall, on pal- pation, due to large locules and areas of greater density; (5) if the growth is intraligamentary and papillary, menor- rhagia and ascites are usually present; (6) pressure symptoms on bowel and bladder appear early, and are most severe in intraligamentary growths; (7) edema of both legs (a late symptom due to pressure). Diagnosis of glandular cysts is made by the above symptoms, and by bimanual examination, which shows the uetrus pressed far forward and to one side, and the pelvis blocked by a cystic mass evidently continuous with the abdominal mass. Differential diagnosis between pseudomucin and serous cystadenomata is made only at operation. Symptoms of parovarian cysts are the same as the glandular. The rate of growth is slower, they are usually intraligamentary and therefore pressure pain is a more prominent symptom, but clinically the 'diagnosis is made only at operation. Symptoms of dermoid cysts are the same as those of the simple cysts, except that pain is a prominent one. They are the commonest ovarian tumors in young subjects, but the actual diagnosis is made at operation. The cyst wall is white, with marked adhesions and often red blotches, in contrast to the smooth shining bluish wall of the simple cyst. ABNORMALITIES AND DISEASES 191 Symptoms of Teratomata. — These are solid tumors, with areas of cystic degeneration, reach a large size, grow very rapidly and are associated with ascites. Differential Diagnosis of Ovarian Cysts. — i. Pregnancy may be closely simulated in appearance by an ovarian cyst, but the absence of confirmatory signs of pregnancy by vaginal examination; the absence of fetal movements and heart sounds; the absence of a shadow of the fetal skeleton on an a;-ray plate; the small hard uterus pushed foward or backward and to one side should make the diagnosis clear. Pig. 73. — The outline of the abdomen in a case of large ovarian cyst. The outline of an overdistended bladder is very similar. {After Cross en.) 2. Full bladder may be at once diagnosed by catheterization, a precaution that should always be taken in any case of supposed cystic abdominal tumor. 3. Fibroid tumor is hard, nodular, bold in its outlines, usually with a history of menorrhagia; the uterus forms part of the growth and the cervix moves in unison with the abdominal mass. A dense firm intraligamentary cyst cannot be differentiated, as a rule. 4. Ascites does not displace the uterus; the contour of the abdomen, unless the fluid is encysted, changes as the patient changes her position; no cystic mass can be felt by vaginal 192 DISEASES OF THE OVARY examination. Encysted ascites may so closely simulate an ovarian cyst as often to be indistinguishable from it. Abdominal fat can easily be differentiated by bimanual examination; tympanites by percussion and bimanual ex- amination. Tumors of the kidney are rarely large enough to be mistaken for ovarian cysts; they do not extend low enough to be palpated through the posterior vaginal vault, and they cause bulging in the triangular space of the costovertebral angle, when the patient is erect. Pig. 74. — Parovarian cyst, showing the great elongation of the Fal- lopian tube. {After Graves.) Treatment of an ovarian cyst is operative. Palliative treatment is not advisable, because of the ever-present danger of twist on the pedicle. Medical treatment, of course is useless. Technic of operation for simple, corpus luteum and dermoid cysts: 1. Usual median abdominal incision. 2. The cyst is freed from any adhesions and dehvered through the wound. If there is any suspicion that the cyst ABNORMALITIES AND DISEASES I93 is dermoid, it should be delivered unruptured. In the others, rupture of the cyst in delivery makes no difference. 3. The mesovarium is transfixed by a pedicle needle carrying a number 3 chromic catgut ligature, which is then tied down around the pedicle formed by the tense mesovarium, several encircling ties being made. 4. The ligature is guarded by hemostats clamped above it and the cyst removed with scissors. 5. The other ovary is always inspected, as dermoids particularly are often bilateral. 6. The abdomen is closed as usual. If a dermoid is ruptured during removal, the sebaceous contents must be sponged out of the abdomen with the greatest care. Although they are sterile, they are extra- ordinarily putrescible and fatal peritonitis may follow neglect of the precaution. Technicjor cystadenomata, or parovarian cysts with a pedicle: 1. The abdomen is opened in the usual way, the peri- toneum being first opened near the umbilicus, as the bladder is often carried high up. 2. The operator's hand is inserted in the abdomen and all adhesions are freed. 3. As long as the cyst wall is blue in color and free from adhesions, it may be puctured with impunity. 4. The cyst wall is punctured by a large cannula, with rubber tube attached, and the main locule drained into a bucket or basin, at the side of the table. 5. The cyst wall is caught with clamps and pulled out of the wound, as it collapses. In this way a huge cyst may be brought out through a moderate incision. 6. The cannula is removed, as soon as the cyst is delivered and the hole in the cyst closed by a clamp. 7. The pedicle is tied off, including the tube, with number 3 chromic catgut and the cyst removed. 8. The broad raw pedicle is sewed over with number i chromic catgut, to minimize the danger of adhesions. 194 . DISEASES OF THE OVARY 9. The other ovary is inspected. In serous cystadenomata with papillary degeneration, both ovaries are better removed, as recurrence is almost certain if one is left. 10. The uterus is suspended, as otherwise the weight of the pedicle may pull it backward and cause adherent retroversion . 11. The abdomen is closed as usual. Technic for intraligamentary cysts, without pedicle: 1. Median abdominal incision. 2. If very large, the cyst is tapped as described above. If small, this is unnecessary. 3. The ovarian artery in the outer edge of the broad ligament is tied in two places and cut between. 4. The broad ligament is spht across its anterior face. 5. The cyst wall is sheUed out (easily, if not adherent) from its bed in the broad hgament. Close watch must be kept for the ureter, which is often displaced. It can be peeled off the cyst wall and thus saved from injury. 6. The bed of the cyst is inspected for bleeding vessels, usually very few, which are tied. If there is profuse general oozing (in inflamed adherent cysts only) the cavity of the broad Hgament is packed with gauze and the end carried down into the vagina, through an opening in the posterior vault. 7. The cut in the broad ligament is repaired and the ab- domen closed as usual. 8. If gauze packing is used, it is removed in forty-eight hours. Tapping of large cysts, either through the abdominal wall or posterior vaginal vault, is objectionable. Its fancied advantages are: (i) Reduction in size of the cyst (temporary only, as it rapidly refills), (2) prevention of shock at operation for removal, if done two or three days previously (fallacious). Objections. — (i) Rapid refilHng of the cyst; (2) implantation metastasis; (3) hemorrhage, if a large vein be punctured; (4) infection; (5) adhesions, making subsequent operation more ABNORMALITIES AND DISEASES 195 difScult; (6) danger of puncturing a dermoid, with consequent peritonitis. Tapping will not cause permanent disappearance of a cyst, as the small puncture closes promptly and the cyst refills. If it is done, the cannula must be of large caliber, as the thick pseudomucin will not run out through a small one. Marsupialization of a cyst is required when: (i) At operation the cyst wall is too densely adherent for complete removal; (2) in virulently infected cysts. It consists in securing the Fig. 75. — Ovarian cyst, twisted on its pedicle. The cyst wall is very dark purple, almost black. {After Graves.) fibrous cyst wall to the edges of the abdominal incision, after opening the cyst and dissecting out its secreting glandular layer as far as possible. The cavity is packed with gauze, renewed daily until granulation obliterates it. The method is to be avoided whenever possible, as convalescence is exceed- ingly prolonged. Accidents to Cysts. — (i) Twist on the pedicle; (2) rupture; (3) intracystic hemorrhage. (i) Twist on the pedicle is an ever-present danger. The 196 DISEASES OF THE OVARY pedicle of every ovarian cyst, as it grows out of the pelvis, is partly twisted into a spiral, the turn being to the side from which the tumor sprang; right-sided cysts twist to the right, and vice versa. As a result of pressure of the intestines, sudden exertion, relaxation of the abdominal walls, or often without obvious cause, the cyst may twist from one to seven complete turns. Moderate size tumors are more likely to twist than large ones, dermoids are especially prone to twist, and the accident is very common after childbirth. As a result of the twist, the circulation is interfered with or entirely cut off, the tumor becomes bluish black. It usually increases in size suddenly, and may rupture. If the blood supply is completely cut off, it becomes gangrenous. Symptoms. — (i) Sudden severe pain; (2) shock; (3) fever (101-102°); (4) rapid pulse (130-150); (5) intense abdominal tenderness (due to non-infectious peritonitis); (6) if the cyst has ruptured, collapse. Treatment. — Immediate operation, and removal of the cyst, as described in the treatment of simple cysts. Care should be taken not to rupture the cyst in delivering it, and many light adhesions will be found. Thrombosis of the pelvic veins in the broad Kgament is a frequent complication and influences the prognosis, due to the danger of embolus. Delayed operation is not advisable, as the cyst once twisted stays so, and the patient may at any time become septic. (2) Rupture of a Cyst. — The consequences depend entirely upon the nature of the contents, but as a rule it is not a danger- ous accident. Causes. — (i) Trauma — such as a fall or kick; (2) violent abdominal pressure; (3) pressure in labor; (4) bimanual exami- nation; (5) rapid increase in size; (6) necrosis or degeneration of the cyst wall. The simple folhcular and parovarian cysts are the most likely to rupture. Symptoms. — In the case of a small follicular cyst there are ABNORMALITIES AND DISEASES I97 usually no symptoms whatever. The cyst, during a bimanual examination, is simply felt to disappear. The symptoms of rupture of a large cyst are: (i) Sudden sharp pain; (2) change in contour of abdomen; (3) moderate shock; (4) rarely symptoms of internal hemorrhage; (5) in dermoids, plastic peritonitis; (6) a remote consequence is total prolapse of the uterus and inversion of the vagina, due to the weight of the contents. If a dermoid ruptures, the contents cause a plastic peritonitis, with considerable fever and abdom- inal pain. When such a case is operated upon, there is consider- able difficulty in cleansing the peritoneum, and a fatal peritonitis may result from putrefaction of portions impossible to remove. The rupture of a pseudomucin or particularly a serous cyst- adenoma is likely to be followed by implantation metastasis of the epithelial elements on all portions of the parietal and visceral peritoneum {pseudomyxoma peritonei). Prognosis. — A ruptured cyst does not necessarily demand immediate operation. Small follicular cysts and more rarely parovarian cysts may be spontaneously cured in this way. The opening in the cyst usually closes, and the cyst refills. Cystadenomata and dermoids require prompt operation. Treatment. — (i) If the cyst is a small one, which ruptures during a bimanual examination, and there are no immediate symptoms, wait. (2) If the cyst is large, immediate operation, being careful to cleanse the peritoneum and remove all visible traces of the cyst contents, to prevent implantation meta- stasis. (3) In a dermoid cyst, unless sure that all particles have been removed, it is safer to drain. (3) Intracystic hemorrhage is usually a consequence of twist on the pedicle. It is often profuse enough to cause severe shock, and may be fatal. It is rarely seen at other times, but may be due to: (i) tapping; (2) spontaneous rupture of a vein. The symptoms are the same as those of severe internal hemorrhage from any cause, and the treatment is immediate operation, removal of the cyst and stimulation, with either intravenous injection of salt solution or transfusion. iqS Dis:EASES OF THE OVARY Degenerations of Ovarian Cysts. — (i) Papillary degeneration can occur in any type of ovarian cyst, but is rare except in the serous cystadenomata. These latter almost invariably show it. The papillary masses are found in the cyst, and on its surface (by the rupture of a locule overfilled with papillary growth). They give implantation metastasis everywhere throughout the abdomen. There is usually associated ascites, so that an ovarian cyst with ascites may safely be assumed to be papillary or malignant. Papillary degeneration is essentially malignant, and recurrences (inoperable) after removal are the rule. If the papillary growth is extensive, the operation is likely to be complicated by excessive bleeding. Pig. 76. — Bilateral serous cystadenoma of the ovary, with papillary degeneration. The cyst on the right has ruptured and turned inside out. {After Penrose.) (2) Carcinomatous degeneration is usually a result of primary papillary degeneration, and associated with ascites. It has a tendency to give early metastasis into the retroperitoneal tissues of the broad ligament and also by inplantation meta- stasis over the peritoneum. Cachexia and wasting are marked and rapid. These patients do not stand operation well, and if the involvement of neighboring structures is extensive, complete removal is better not attempted. Even in appar- ently uncomplicated cases, recurrence is the rule and prognosis ABNORMALITIES AND DISEASES 1 99 for cure is very bad. The most favorable cases are those where the malignant process is confined to an unruptured cyst. (3) Infection and suppuration occurs: (i) As a result of infec- tion after labor; (2) as a result of twisted pedicle; (3) by infection from bowel adhesions; (4) by tapping. Any cyst may become infected, but dermoids are the commonest. Symptoms are those of acute infection from any cause: fever, rapid pulse, leukocytosis, chills, etc.- — plus the cystic abdominal mass. Treatment. — -Early operation and removal of the cyst without opening it. The septic intoxication is often profound and delay is dangerous. Adhesions are found early and rupture into the bowel, bladder, vagina or peritoneum is not uncommon. The latter is aways fatal. In other cases the drainage is only partial and operation is urgently required. Drainage is required, especially in those cases where there has been rupture of the cyst into the bladder, bowel or vagina. The fistula should be closed, but will usually reopen. In desperate cases, where no prolonged operation can be attempted, marsupial- ization of the cyst to a small abdominal incision and its drain- age is advisable. Later the cyst can be removed. (4) Implantation metastases are the result of: (i) Papillary degeneration; (2) malignant degeneration; (3) rupture of a cyst; (4) spilling the contents in the peritoneum during operation. They occur all over the visceral and parietal peritoneum even in distant portions of the abdominal cavity. They are com- posed of the epithelial elements of the cyst and secrete pseudo- mucin, until the whole cavity becomes filled with semisohd gelatinous masses that cannot be removed. This condition is called pseudomyxoma peritonei and while in itself benign, it causes a form of chronic peritonitis which eventually kills the patient. Life may be prolonged by repeated laparotomies and removal of as much of the growth as possible, and rarely it happens that a single operation effects a cure. As a rule the prognosis is bad. Prognosis of Ovarian Cysts.— If papillary degeneration be 200 DISEASES OF THE OVARY included in malignancy, about 25 per cent, of cysts are malig- nant. In uncomplicated cysts, operation is simple and safe. In intraligamentary cysts it may be a most formidable pro- cedure. The complications with the greatest immediate danger are twist on the pedicle and suppuration. The prog- nosis of malignant growths is bad, and the recurrence is usu- ally rapid and always inoperable. The least dangerous of all cysts are the simple follicular and parovarian. Serous cysta- denomata are constantly bilateral, the others only occasionally. IV. Displacements of the Ovary Displacements of the ovary occur through a rather limited range. It may become adherent, during the puerperium while the uterus is large, and remain fixed high out of the pelvis. Congenitally the ovary may fail to descend, but remain at the embryonic level, near the kidney. Clinically, the chief displacement is prolapse of the ovary into Douglas' pouch. Causes. — (i) Violent exercise or traumatism; (2) secondary to retroversion of the uterus; (3) increase in size and weight of the ovary; (4) tumors. It is more common in nulliparous women and is due to elonga- tion of the infundibulopelvic ligament. It is either (i) primary or (2) secondary (to retroversion of the uterus) and, if primary, is commonest on the left side. Symptoms. — (i) Very often no symptoms whatever, being discovered accidentally during an examination for other con- ditions; (2) pelvic pain, worse when on feet; (3) pain worse before and just after menstruation; (4) worse on coitus and defecation; (5) occasionally nausea and sickening pain, par- ticularly after any jar or jolt. Diagnosis. — The ovary can be felt best by rectal examina- tion, as a round, tense and elastic body, lying in Douglas' pouch, below the uterosacral ligaments. Any doubt as to its character can be settled by the distinctive sickening pain caused by pressure on it. ABNORMALITIES AND DISEASES 20I Treatment is either palliative or operative. In patients without symptoms, treatment is of course unnecessary. Palliative Treatment. — (i) Digital reposition of the ovary to as high a level as possible, by pressure through the rectum or vaginal vaults; (2) knee-chest posture for one-half hour three times daily; (3) pessaries and tampons are useless. Pallia- tive treatment is of use only when the ovary is not adherent. Operative Treatment. — (i) Through a median abdominal incision the ovary is brought up and inspected. (2) If any por- tion is diseased or cystic, that portion can be resected by a V-shaped excision, and the wound closed with interrupted (never continuous) stitches of number i chromic catgut, taking a deep bite of the ovarian tissue and tied gently so as not to cut. (3) The infundibulopelvic ligament is caught with a hemostat near the ovary and again at the pelvic wall, under the sigmoid. (4) With a curved intestinal needle, armed with fine linen thread, the ligament is picked up at three or four places about one-half inch apart, using the stitch as a continuous one. (5) When the stitch is tied, the ligament is so shortened as to lift the ovary to the level of the cornu of the uterus. (6) If the ovary is grossly diseased, it must be re- moved and not suspended. (7) The abdomen is closed. Ovarian prolapse, secondary to retroversion of the uterus usually disappears on correction of the retroversion. If not, the ligament can be shortened in addition. V. Inflammation (Oophoritis) and Abscess Inflammation of the ovary is either (i) acute or (2) chronic. Acute inflammation is due to: (i) Streptococcus pyogenes after miscarriage or labor at term; (2) gonorrhea; (3) colon bacillus; (4) pneumococcus; (5) typhoid bacillus. This is approximately the order of frequency of the most common infections, puerperal streptococcic being overwhelmingly the most common. Gonorrheal ovarian abscess is almost invariably secondary to tubal abscess. Except in gonorrheal infection, the bacteria enter the ovary through the lymphatics 202 DISEASES OF THE OVARY and blood-vessels at the hilus. Gonorrhea invades the ovary from the lumen of the tube, through a recently ruptured Graafian follicle. Symptoms are those of acute pelvic inflammation and cannot be diagnosed, except at operation, from acute tubal inflam- mation. This latter is the commoner condition and operation, if needed, is based upon this diagnosis, (i) Acute abdominal pain; (2) fever; (3) rapid pulse; (4) leukocytosis (18,000 to 24,000); decubitus of peritonitis; (6) by bimanual examina- tion, a very sensitive pelvic mass, behind the uterus. An acutely inflamed ovary is much more painful than an acutely inflamed tube, which fact may aid in diagnosis. Treatment. — As many cases do not reach the suppurative stage, palliative treatment is advisable, by: (i) rest in bed; (2) milk or liquid diet; (3) ice bag or hot flaxseed poultice to lower abdomen; (4) hot vaginal douches, i2o°F., four times a day; (5) moderate laxatives. Under this treatment the acute stage may completely subside, and spontaneous recovery occur. There are often dense adhesions formed, however, which necessitate secondary operation, for relief of pain, especially at the periods. If the acute symptoms do not subside within three days, or if there .is steady increase in leukocytes and fever, operation is usually required. The affected ovary and tube are removed, as described in the operative treatment of salpingitis. In all except the gonorrheal or tubercular variety, drainage is required. Prognosis. — In all except the streptococcic variety, prog- nosis is good. A streptococcic ovarian abscess is the most virulent of all the localizations of septic infection, drainage is absolutely necessary, and in spite of this, the mortality from peritonitis is high. Chronic oophoritis is secondary to salpingitis, or any other chronic inflammatory process in the pelvic cavity, or it persists after an acute attack, without abscess formation. Pathology. — (i) The whole ovary is enlarged, firm and heavy; ABNORMALITIES AND DISEASES 203 (2) hyperplasia of the interstitial connective tissue; (3) many follicle retention cysts; (4) few corpora lutea, but many corpora fibrosa; (5) many extensive and dense adhesions; (6) as a late stage, great shrinkage of the ovary, with wrinkling of its surface (cirrhosis). Symptoms. — -(i) Pain low down in the groin, worse just before and after menstruation; (2) pain on defecation, coitus or any sudden jar or jolt; (3) menorrhagia, with a tendency to become scanty in the later stages; (4) intermenstrual pain; (5) profound and varied neurosis. The pain in these cases is due to peritoneal adhesions, and not to the ovary itself. Hence "ovarian neuralgia" is a misnomer. Diagnosis. — (i) By bimanual examination the ovary is felt enlarged, fixed by adhesions and very tender to palpation; (2) it is often impossible to differentiate from salpingitis, except by the much greater pain of oophoritis. Treatment. — -(i) Palliative consists in removing any cause of chronic pelvic congestion, if one can be found; (2) hot vaginal douching; (3) boroglycerid tampons; (4) application of tincture of iodin to the vaginal vaults. Palliative treatment is at best of very doubtful value, and of no value at all if there is much actual disease of the ovary. Operative Treatment. — Indications: (i) Excessive pain; (2) patients past thirty-five years of age; (3) long-standing dis- ability; (4) degree of incapacity of the patient; (5) women of the working class. The operation should be as conservative as possible. It is frequently possible to break up adhesions and, if the ovary is not grossly diseased, to suspend it as described in prolapse of the ovary. Multiple cysts can be punctured; if the disease is confined to one portion of the ovary, that portion can be resected, especially in young women who desire children; if the whole ovary is grossly diseased, oophorectomy is necessary. If the condition is bilateral, a small portion of one ovary should be saved, if possible, to avoid the surgical menopause. 204 DISEASES OF THE OVARY VI. Implantation and Transplantation of the Ovary If, after castration, a piece of the ovary is transplanted, preferably into the muscle of the abdominal wall, or between the leaves of the broad ligament, the follicles continue for awhile to ripen and menstruation can be maintained. Eventually, and in a comparatively short space of time, atrophy takes place, and menstruation ceases. In a few cases, where the ovary has been transplanted into the uterine cornu or tube, pregnancy has occurred, even when the ovary is transplanted from one individual into another. If a piece of ovary is transplanted into the muscular layer of the abdominal wall, or into the broad ligament, to prevent the surgical menopause, thin slices and not the whole ovary, are used. The whole ovary is sure to undergo cystic de- generation. In the slices, a satisfactory blood supply is much more quickly established. VII. Solid Tumors of the Ovary Solid tumors of the ovary are (i) benign or (2) malignant. The benign are fibromata; the malignant carcinoma, endo- thelioma and sarcoma. Fibromata are entirely benign and while they often cause ascites, this disappears after their removal and they do not recur. They are subject to calcareous degeneration and become as hard as stone. They are moderate in size, of very slow growth, pedunculated and rarely bilateral. They occur at any time of life, give few if any symptoms, unless they twist on their pedicle, or cause excessive ascites. By bi- manual examination they are felt as hard, very firm, rounded tumors, usually very freely moveable. They should be re- moved because of the possibility of twisted pedicle and because of the associated ascites. Malignant Solid Tumors. — (i) Carcinoma is primary or metastatic. It is usually medullary, commonly cystic, and ABNORMALITIES AND DISEASES 205 is most frequent as a degeneration of a papillary cyst. They are moderate in size, round and pedunculated. Metastatic cancer comes from the uterus, tube, bowel or even from dis- tant organs like the liver. Cancer is commonest between forty-five and fifty years. It is usually bilateral, grows rapidly and causes marked ascites. Pain is almost constant and is early and intense. Cachexia comes late but progresses rapidly. Diagnosis. — Bimanual examination shows a round, moder- ately soft tumor, with marked ascites. The growth is often mistaken for a uterine fibroid. Because of the pain and ascites, its malignant character is fairly obvious. Treatment. — Immediate operation, with removal of the uterus and both ovaries, even though the disease is uni- lateral. Prognosis. — Recurrence is the rule, in almost 90 per cent. The recurrences do not respond to x-ray or radium; re-opera- tion is useless. (2) Endotheliomata are derived from the endothelium of the lymph-channels and blood-vessels. They are an inter- mediate form of growth, between cancer and sarcoma. Clinically their symptoms and treatment are those of cancer. (3) Sarcomata are spindle-celled, round-celled or mixed. About 25 per cent, are bilateral. They are very much like fibromata in appearance, but of rapid growth. They give metastasis early, into the retroperitoneal lymph glands and to the visceral and parietal peritoneum. They occur at any age, and are the commonest solid ovarian tumor in childhood. The younger the patient the more likely a round-celled sarcoma, and these cases are nearly always bilateral. Ascites is marked, as it is in all solid ovarian tu- mors. Clinically the symptoms and treatment are the same as cancer. Prognosis. — It is not quite as malignant as cancer, but recurrence can be expected in at least 66 per cent. 206 DISEASES OF THE OVARY vni. Tuberculosis of the Ovary Tuberculosis of the ovary is secondary from the tube or peritoneum. It is very doubtful if it is ever primary. Miliary peritoneal tuberculosis attacks the surface of the ovary but not its stroma. The symptoms and treatment are the same as tubercular salpingitis. CHAPTER X DISEASES OF THE PERITONEUM AND PELVIC CONNECTIVE TISSUE General Anatomy. — The pelvic peritoneum covers all the pelvic viscera except the ovaries. It dips into Douglas' pouch, thence up over the posterior uterine surface, over the fundus uteri, along the anterior uterine wall and over the top of the bladder and becomes continuous with the parietal peritoneum Pig. 77. — Heavy black lines indicate reflection of peritoneum. Note the difference in the anterior and posterior uterine reduplication. of the anterior abdominal wall. The uterorectal pouch or Douglas' pouch is deeper than the uterovesical. The pelvic connective tissue (pelvic cellular tissue) fills the space under the pelvic peritoneum and in the bases of the broad ligaments. That lying near the uterus is the para- 207 2o8 DISEASES OF THE PERITONEUM metrium; near the bladder, the paracystium; near the rectum, the parapr odium. The general term for inflammation of any portion of the cellular tissue is pelvic cellulitis. I. PELVIC CELLULITIS (PARAMETRITIS) This is always due to infection, and is most common in that portion near the uterus. Pathology. — (i) The overlying peritoneum is always in- volved; (2) the process is first edema, then round-cell Fig. 78. — The areas involved in pelvic cellulitis. I. Broad ligaments. 2. Base of broad ligaments and lateral vaginal fornices. 3. Ischio- rectal fossag. infiltration, then either suppuration or, by absorption of the edema, a dense pelvic exudate; (3) the veins passing through the tissue involved are always thrombotic, and wide extension of the thrombosis is possible; (4) suppuration is often wide- spread and the abscess may break into neighboring organs, usually the rectum, vagina or bladder. Causes. — (i) Secondary to puerperal sepsis; ('2) secondary to abdominal operation (most often hysterectomy for pelvic inflammation); (3) secondary to salpingitis; (4) perforation of the uterus, at curettage; (5) possibly spontaneous, from lowered resistance and colon bacillus infection. PELVIC CELLULITIS (PARAMETRITIS) 209 Terminations. — (i) Complete resolution; (2) resolution with pelvic exudate and adhesions; (3) pelvic abscess; (4) rupture into bowel, bladder, or vagina; (5) diffuse peritonitis and death; (6) general septicemia. Symptoms. — i. General symptoms of infection: (i) Fever; (2) rapid pulse; (3) leukocytosis (18,000-20,000); (4) pelvic pain; (5) chills. Local symptoms are characteristic; the cervix is firmly fixed, usually displaced forward or to one side, and the tissues beyond the vaginal vaults are as hard as stone. Differential diagnosis from pelvic peritonitis is largely theoretical. In pelvic peritonitis the greatest induration should be anteroposteriorly; in cellulitis, laterally. As the two are always associated, this dis- tinction is of no value. Diagnosis from a pelvic hematocele, the only other condition simulating cellulitis, is im- possible without operation. Treatment.' — Palliative: The majority of cases subside without suppuration under palliative treatment: (i) Rest in^ fig. . TpT^agram to bed; (2) liquid diet; (3) moderate lax-" illustrate the difference atives; (4) ice bag to lower abdomen; "..^^raM Sit£ (5) hot vaginal douches Qy'2 OZ. salt to Practically this is of Uttle Civ.- hot water, 1.0° F.) four times a -.t^^ *:.;;r "' » day; (6) tampons do no good and often harm. If in a week of this treatment, there is not marked improvement, operation will usually be necessary. Operative Treatment. — Indications: (i) When there is no improvement after palliative treatment; (2) persistent fever and chills; (3) persistent high leukocyte count; (4) softening of the pelvic mass, bulging of the lateral or posterior vaginal vaults. If there is any doubt as to the mass being extra or intra- peritoneal, exploratory section is indicated. If the mass is intraperitoneal, it is drained through the lower end of the abdominal incision; if extraperitoneal, the abdominal wound 14 2lO DISEASES OF THE PERITONEUM is closed and the abscess drained through the posterior vaginal vault. Pointing of the Abscess. — Most commonly, the pus burrows between the vagina and rectum, bulging the posterior vaginal vault forward. Depending upon the point of infection, it may point in the thigh, perineum, abdomen or even the back, but the posterior vaginal vault is overwhelmingly the most common. Posterior vaginal section (posterior colpotomy) is the opera- tion of choice, if the abscess is extraperitoneal. Technic. — (i) The patient is arranged in the dorsal position, prepared as for any vaginal operation and anesthetized. Pig. 8o. — Opening a pelvic abscess through Douglas' pouch. 2. The posterior lip of the cervix is seized with a double tenaculum. 3. A semicircular incision is made, through the vaginal mucosa at its attachment to the cervix. 4. A long-handled, curved, sharp-pointed scissors, with the blades closed, is plunged in the mass, keeping strictly to the middle line and close to the uterus. The blades are widely opened and withdrawn open. 5. To secure a wider space, the opening is dilated with ordi- nary branched uterine dilators. PELVIC CELLULITIS (PARAMETRITIS). 211 6. The cavity is explored with the finger (to avoid hemor- rhage and injury to the ureter) and all palpable septa are broken. 7. The cavity is washed out with sterile water. 8. If much pus was found, the cavity is drained at once with a large T-tube. If only broken-down cellular tissue and Fig. 81. Fig. 82. Pig. 81. — T-shaped rubber drain. It is important that the rubber tubing be of large caHber, to prevent occlusion by clots. The straight bar extends completely through the T arm, so that drainage is in a straight line. The function of the cross bar is solely to hold the tube in. {B.C. Hirst.) Fig. 82. — T rubber drain seized in grip of dressing forceps preparatory to insertion through hole in vaginal vault. {B. C. Hirst.) little pus was found, the cavity is packed with gauze for forty- eight hours; the gauze is then removed and a T-tube inserted. 9. Through the tube, which is cut off so as to project about 212 DISEASES OF THE PERITONEUM one-half inch from the vulva, the pelvis is irrigated once daily and the tube is not removed untU the temperature is persist- ently normal and all pus has ceased. If the pelvic cellulitis is due to a large pyosalpinx, palliative treatment and abdominal section after the acute symptoms have subsided is better than vaginal section. This latter may have to be done as a life-saving measure, but it always compH- cates the section. Fig. 83. — Drainage of a pelvic abscess, with a T rubber drainage tube. Prognosis. — (i) Puerperal infections are not as favorable as the non-puerperal; (2) the end result is usually one of chronic pelvic cellulitis, requiring prolonged treatment; (3) prolonged necrosis in the cellular tissue may prove fatal; (4) phlegmasia alba dolens (milk leg) and pulmonary embolus are not uncommon. Chronic Cellulitis. — After the acute stage has subsided and resolution is established, or after posterior colpotomy, there often remains induration of the uterosacral ligaments and bases of the broad ligaments, without fever or leukocytosis, but with considerable pain: The thickened areas can be felt plainly, by vaginal examination. Treatment. — (i) Hot vaginal douching; (2) boroglycerid PELVIC HEMATOCELE (PARAMETRIAL HEMATOMA) 213 tampons; (3) 7 per cent, tincture of iodin to vaginal vaults, once weekly; (4) laxatives; (5) avoidance of coitus or any other cause of pelvic congestion (heavy exercise or work, cold baths, rest at time of periods, etc.). Pig. 84. — A pelvic abscess opened through the posterior vaginal vault and drained with gauze. 11. PELVIC HEMATOCELE (PARAMETRIAL HEMATOMA) This is a collection of blood in the uterorectal or uterovesical pouch, or between the layers of the broad ligament. Causes.- — (i) Much the commonest is tubal abortion in extra-uterine pregnancy; (2) injuries to the uterine walls (rup- ture or perforation) ; (3) imperfect hemostasis after operations, especially hysterectomy; (4) rupture of a varicose vein in the broad ligament. Symptoms.^ — (i) Essentially those of cellulitis, with less fever and leukocytosis, unless the hemorrhage is sudden and profuse; (2) in the latter case, shock, signs of internal bleeding and acute anemia; (3) after the mass is encapsulated by adhe- sions, pressure on bowel and bladder are marked; (4) at any time it is subject to infection from colon bacilli and abscess formation. 214 DISEASES OF THE PERITONEUM Diagnosis.- — ^Bimanual examination shows the same pelvic mass as cellulitis. Treatment.^ — (i) If the hemorrhage is acute and severe, as in extra-uterine pregnancy, abdominal section, tie the affected tube and remove, and remove blood clots by flushing the abdomen with sterile water. (2) If old and encapsulated palliative treatment as described in cellulitis, and posterior colpotomy and drainage only if it becomes infected. III. PERITONITIS Peritonitis may be either (i) local or (2) diffuse. It is localized: (i) in the pelvis, either in Douglas' pouch or in the uterovesical space, secondary to either a tubal or uterine infection; (2) around the appendix; (3) around intestinal perforations; (4) around the gall-bladder. Diffuse peritonitis is most common from (i) acute appendici- tis with perforation; (2) streptococcic infection after labor or miscarriage; (3) rupture of gonorrheal pyosalpinx; (4) per- foration of stomach or bowel; (5) perforation of gall-bladder. Tjrpes. — (i) Serous, with ascites; (2) seropurulent; (3) purulent; (4) plastic (tubercular usually); (5) fulminant. Pelvic peritonitis is much most commonly due to gonorrhea. Every case of gonorrheal salpingitis is accompanied by pelvic peritonitis. It is also associated with all cases of cellulitis. The symptoms and treatment are the same as cellulitis. Diffuse peritonitis is a much more dangerous type. That from a perforated appendix is the least dangerous; that from streptococcic infection of the uterus, tubes or ovaries the most fatal. Symptoms. — (i) Great abdominal pain; (2) usually but not invariably, abdominal rigidity; (3) fever (which is usually much higher by rectal temperature); (4) leukocytosis; (5) peritonitis decubitus; (6) rapid, thready, wiry pulse; (7) paresis of the bowel, with absence of peristalsis and apparent obstruction; (8) increasing abdominal distention. The treatment is abdominal section, removal of the cause, PERITONITIS 215 if one can be found, flushing of the abdomen with large quanti- ties of sterile salt solution, drainage by rubber or glass tube. Fowler position and active stimulation. The prognosis is always doubtful. It is best in appendiceal cases; worst in streptococcic. In these latter there is often a deceptive im- provement for a few hours, and then a rapid change for the worse and death in a short time. Tubercular peritonitis occurs in three forms: (i) Diffuse miliary tuberculosis, always with ascites. This is the type most common in the young; (2) diffuse peritonitis, with exten- sive adhesions, without ascites. This is the plastic or chronic adhesive type; (3) nodular tubercular peritonitis, with numerous nodes in the peritoneum and mesentery. This type is the rarest, and most often mistaken for cancer. The source of tubercular peritonitis is: (i) Secondary to tuberculosis of the tubes (most common); (2) by blood-current infection from active foci elsewhere in the body. Symptoms vary with the type of the disease. In the first tj^e; there are often no symptoms until considerable ascites has collected. The patient is ill-developed, thin, often with amenorrhea, often shows general constitutional symptoms such as night sweats, slight fever and digestive disturbances. The ascites is often sufficient to cause considerable distention and dyspnea. The symptoms of the second type are the same, except for less distention and more abdominal pain. The symptoms of nodular peritonitis are more grave. The patient is obviously seriously ill, with fever and rapid pulse; there is often pus and blood in the stools and even in the urine; the nodular masses can be felt, and because this type occurs in patients in middle life, cancer is likely to be suspected. Diagnosis. — In the ascitic type, marked ascites in a patient (especially in youth) not associated with kidney, heart or liver disease, is almost certainly of tubercular origin. The tuberculin and von Pirquet tests are not conclusive, though valuable presumptive signs. 2l6 DISEASES or THE PERITONEUM In the second and third types, accurate diagnosis is often impossible, exploratory section being the only means of making certain. Treatment. — Ascites, if excessive, is best removed by a small incision, rather than tapping, because of the danger of perforat- ing an adherent coil of intestine. If the Fallopian tubes are affected they should be removed, as little handling of the intestines as possible being essential, and the abdomen closed. In the plastic type, the adhesions are usually too extensive to be broken up, and the abdomen should be closed without meddlesome attempts to achieve the impossible. In the nodular type, the abdomen is closed at once, with- out attempt at removal of any of the nodes. No tubercular peritonitis case should ever he drained, as a permanent fistula is sure to result. Prognosis is usually good. Astonishing improvement and often complete symptomatic cure will follow a simple explora- tory section. No definite reason can be proven for this, though these theories are advanced; (i) admission of light and air (doubtful); (2) change from the ascitic to the plastic type, by evacuation of the ascites; (3) the old ascitic fluid is replaced by fresh, with a high bacteriolytic power. IV. DRAINAGE OF THE ABDOMEN AFTER OPERATION FOR PELVIC INFECTION Indications. — (i) All streptococcic cases, without exception; (2) Abscess sacs, difficult or impossible of enucleation; (3) where intestine is injured and perforation is feared (here by tube or rubber tissue only and never gauze) ; (4) to control bleeding; (5) diffuse peritonitis. Contra-indications. — (i) Tubercular peritonitis; (2) syphilis; (3) in any case of doubt as to the necessity, do not drain. Dangers of Drainage. — (i) Intestinal obstruction; (2) adhesions; (3) perforation of bowel; (4) hemorrhage when drain is withdrawn. Methods of Drainage.^ — (i) By tube and gauze, through the DRAINAGE OF THE ABDOMEN 217 lower end of the abdominal wound; (2) by tube or gauze through Douglas' pouch, into the vagina; (3) by a combination of the above, or through-and-through drainage. The best method, where drainage is needed for infection, is by glass tube and gauze through the lower end of the abdominal incision. This is especially necessary in cases of streptococcic infection. Technic. — (i) Just before the abdomen is closed the pelvis is sponged as clean as possible. 2. A curved glass drainage tube about the size of the fore- PiG. 85. — Abdominal drainage by glass tube and gauze; the most ef- ficient type of drainage in septic conditions in the pelvis. finger is put in the bottom of Douglas' pouch. The curved is better than the straight tube, because it can be brought out nearer the symphysis, and hence lessens the danger of hernia. 3. Under and around the tube is packed a gauze strip, usually four layers one and one-half inches wide (made by folding a six- inch bandage), so that the entire pelvis and all the intestines held above the pelvic brim. The end of the gauze is brought out along the tube. 2l8 DISEASES OF THE PERITONEUM 4. The protective sponges are now removed and the abdomen closed around the tube and gauze. The vaginal method of drainage (through an opening in Douglas' pouch) is not safe, in septic cases, and should be avoided. After-care. — (i) Every twenty-four hours, the glass tube is sucked out, by a piston syringe and catheter, for the first five days. The amount of fluid will diminish from about an ounce the first day to a couple of drams on the fifth. (2) The patient is kept in the Fowler position and the Murphy drip (glucose one and a half ounces, sodium bicarbonate one and a hah ounces, water two pints, forty drops a minute, temperature kept near 1 10°) is used. (3) All these patients need rather active stimu- lation, particularly in the second twenty-four hours. (4) On the fifth day the glass tube is removed. (5) Beginning on the sixth day, the gauze is removed, taking out about one-quarter of the total amount each day, so that by the tenth or eleventh day, it is all out. (6) As soon as the last of the gauze is out, a rubber tube is inserted, in the sinus left by the gauze, as deep as it will go, and a safety pin put through the outer end. (7) Through this tube the pelvis is flushed daily with sterile water, run in by gravity, and the tube shortened as it is pushed out from below. (8) The usual convalescence lasts four to six weeks. Except for these points, the after care is that of the ordinary section. Drainage through the posterior vaginal vault is indicated chiefly for bleeding from intractable oozing, in cases without active infection. Technic. — (i) An assistant places two fingers of one hand in the vagina, making strong pressure upward in the posterior vaginal vault, with the finger tips separated. 2. The operator, with these fingers as a guide, perforates between them, with scissors, into the posterior vaginal vault. 3. The end of the gauze packing is grasped in a clamp and pushed into the vagina, where the assistant grasps the packing and pulls it through for a short distance. PHLEBOLITHS 219 4. The pelvis is packed full and the abdomen closed. 5. The vagina is repacked, with fresh packing, after the operation is completed. After-care.- — ^The packing is left undisturbed for four days, is then gradually removed over another four days and the drainage hole kept open by a T-tube, if there is much discharge. V. PHLEBOLITHS Phleboliths are calcified thrombi in the dilated pelvic veins. They are of no clinical importance and do not justify operation. They often cause deceptive shadows in a;-ray plates and lead to erroneous diagnosis of ureteral stones, even when the picture is taken with catheters in place. CHAPTER XI ABNORMALITIES OF THE ABDOMINAL WALL I. DIASTASIS OF THE RECTI WITH GENERAL VISCEROPTOSIS In the last three months of every pregnancy the abdominal recti are gradually separated, by the pressure of the enlarging uterus. In cases of hydramnios or multiple pregnancy where the abdomen is overdistended, the separation may be extreme. If an abdominal binder is worn, and kept properly tight, during the puerperal convalescence, the muscles gradually assume their normal parallel course, and the support of the anterior abdominal wall is not markedly diminished. Where the abdominal binder is not worn, or discarded too soon, or not kept properly tight, permanent separation, with consequent splanchnoptosis and pendulous abdomen wiU result. The effects of a diastasis are chiefly those of splanchnoptosis and practically a ventral hernia. The patient, if the diastasis is marked, is incapacitated. Diagnosis is easy. The abdominal skin is flaccid and wrink- led; coils of intestine can plainly be seen moving under the thin skin and fascia; when the patient strains, the center of the abdomen rises like a dome, and the edges of the separated muscles can be felt. Treatment.- — A separation of less than four fingers in breadth can usually be disregarded, as the symptoms are so moderate that no relief is needed. Greater separation than this gives symptoms whose severity is in direct ratio to the degree of separation. A moderate case can be relieved, temporarily at least, by an abdominal binder, preferably one which supports the abdomen as well as compresses. A straight front corset will give good support; adhesive straps will give temporary relief. Massage and electricity EXSTROPHY OF THE BLADDER 221 are not likely to have any beneficial effect. Exercises tending to strengthen the abdominal muscles often help the moderate cases greatly, but are useless where the separation is over four or five fingers. All these methods are merely temporary (except possibly after the first labor) and cannot be used in women obliged to do hard work. In these patients, the Webster operation will effect a cure. The principle is a long incision from the ensiform to the pubes, dissecting back the skin and fat on each side to the retracted muscles. In this process the peritoneal cavity is usually opened as the umbilicus is cut across. The small opening is closed at once, and the rest of the operation is extraperitoneal. The sheaths of the sepa- rated recti are sewed together without opening them, in the middle line, using interrupted chromic catgut number 2 for tension sutures and continuous number i chromic catgut stitch for approximation. The tissue lying between the muscles, is allowed to arrange itself behind the suture line, and is not excised. The excess of the skin is trimmed off, and if desired, a new umbilicus can be made, by a purse-string suture inverting the skin edge, at the proper point. This operation withstands subsequent labor provided it does not occur too soon after the operation (two years at least) and proper attention is given to the abdominal binder during puerperal convalescence. II. EXSTROPHY OF THE BLADDER Exstrophy of the bladder is a rare condition where a part of the anterior abdominal wall, together with the fundus of the bladder is missing, and the interior of the bladder is exposed. It is associated also with failure of development of the sym- physis. There is naturally complete incontinence of urine. The defect can be remedied, in part at least, with flaps taken from the abdominal wall from above and from each side. IIL HERNIA Hernia may be: (i) umbiHcal; (2) incisional; (3) inguinal; (4) femoral. 222 ABNORMALITIES OF THE ABDOMINAL WALL Abdominal hernia is much more common in women than in men, and unless diastasis of the recti be called a hernia, umbil- ical is the commonest type. Umbilical hernia varies in size from a small protrusion to an enormous sac, containing most of the intestines. There is a well-defined ring, and a marked tendency for the omentum and intestines to adhere to the sac. Incarceration, strangula- tion and intestinal obstruction are common complications. In all umbilical hernias there is coincident diastasis of the recti. Symptoms. — (i) Protrusion of the umbilicus; (2) abdominal pain; (3) often constipation (due in part to the adherent bowel); Umbilicus Hernial Sac Separated Rectus M Abctommal ■ Tot Pig. 86. -A lateral view of an incarcerated umbilical hernia. {After Graves.) (4) symptoms of strangulation (pain, vomiting and obstruction) if this takes place. The diagnosis is sufi&ciently obvious, due to the protruding sac at the umbilicus. Treatment. — (i) Palliative, by the use of an abdominal binder, abdominal corset or by adhesive straps. It is difficult in many cases to get a properly fitting corset or binder, due to the obesity of the patient. Adhesive straps irritate the skin, if used for any length of time. PaUiative treatment is recom- mended only if there is an absolute contra-indication to opera- tion, or if the patient refuses operation. HERNIA 223 (2) Operative. — If the hernia is large and the patient fat, the operation is a dangerous one. The chief compHcations are: (i) local infection and fat necrosis; (2) embolism; (3) pneumonia; (4) effects of anesthesia (on heart and kidneys). Recurrences are not infrequent and are much harder to manage than the original hernia. Techmc.—{i) A long incision is made in the middle line, encircling the protruding mass. 2. The sac, often found considerably to one side of the mid- line, is dissected out and opened. -^^^ \ "^^'.^V Sutures 3. All adhesions are broken up, the contents of the sac returned to the abdomen, the sac tied off and removed and the peritoneum closed. 4. The skin and fat are dissected back until the firm white aponeurosis is exposed. 5. The edges of the apon- eurosis are united with number 3 chromic catgut interrupted sutures, left for the moment untied. 6. Six or seven silk- worm-gut sutures are in- serted, entering through the skin, fat and fascia on one side and emerging through the fascia, fat and skin on the other. Also untied. 7. The edges of the fascia are united by a continuous number I chromic catgut stitch, tying each interrupted stitch as it is reached. 8. The skin is closed and the silkworm-gut stitches tied. The .wound is dressed as usual, and dressings are changed in forty-eight hours due to the excessive serous oozing. Patients , . pectus JVluscles Fig. 87. — The closure of a ventral hernia. {After Graves.) 224 ABNORliALlTIES OF THE ABDOMINAL WALL are kept in bed at least three weeks, the silkworm-gut sutures removed in the third week. The same principle of operation may be carried out through a transverse incision (Mayo) though there is no special gain in so doing. Incisional Hernia, after Abdominal Operation. — Causes: (i) Drainage; (2) infection; (3) premature absorption of catgut; (4) excessive muscular exertion, or strain within a few months of the operation. Development. — First there is a small protrusion at one point, usually one end of the wound. It is tender and has impulse on coughing or straining. It gradually grows, until it involves the whole wound and extends to either side. There may be a single ring or several, each with its own sac. The contents are usually omentum and this is always adherent. These adhesions usually prevent the entrance of intestine, but not if the ring grows large. There is marked tendency to strangula- tion and obstruction, after intestine has entered the sac. Diagnosis is usually easy, as the protrusion is obvious and the edges of the ring or rings can be plainly felt. Treatment is essentially the same as that given for umbilical hernia, both palliative and operative, except that a transverse incision cannot be utilized. It not infrequently happens that the edges of the aponeurosis cannot be brought together, due to loss of tissue from infec- tion. This difficulty can be met in several ways: (i) trans- plantation of fascia taken from the thighs (Bartlett's method); (2) placing a row of mattress sutures number 3 chromic catgut, across the gap, tying them as tight as possible and trusting to granulation to fill up the meshes between the stitches; (3) sewing in a silver wire mat, which must later be removed. Recurrence after operation is disastrous, as it is much worse than the original" hernia. Inguinal hernia is much easier to manage in women, as the spermatic cord (in this case the round ligament) does not have to be considered. The fascia covering the canal is opened, the sac opened, its contents returned to the abdomen OBESITY 225 and the sac tied off; the internal ring closed, and the inguinal canal obliterated as in the Bassini operation. Femoral hernia is managed on the same principles in both sexes. It is often complicated by acute adenitis of the glands at the femoral ring and these must be removed at operation. IV. OBESITY Obesity, while not a disease of the abdominal wall, has there its most marked evidence. It is a source of considerable dis- PlG. ?. — Testing the actual outline of the abdomen, by eliminating the superficial fat. comfort to the patient, and, because it is frequently attended by sexual underdevelopment, she may be sterile. Treatment.^ — (i) Diet, all starches, fats, and sugars being eliminated or minimized; (2) regular exercise (the hardest thing to get these fat patients to do), preferably walking; (3) frequent hot baths; (4) sufficient laxatives to give two move- ments a day; (5) thyroid extract, 5 grains three or four times daily; (6) whole pituitary gland — the anterior lobe being a IS 226 ABNORMALITIES OF THE ABDOMINAL WALL sexual developer, the posterior lobe limiting carbohydrate absorption — four grains by mouth four times daily. Pig. 89. — Testing the abdomen for fluctuation in ascites. The hand in the center stops the fat wave on percussion. V. PATENT URACHUS Patent urachus usually causes an umbilical fistula, with constant, or periodic, purulent discharge. The fistula is excised and the opening packed. VL TUMORS OF THE ABDOMINAL WALL Tumors of the abdominal wall are: (i) Adenomyoma of the round ligament; (2) fibrosarcoma of the sheath of the rectus; (3) lipoma; (4) sarcoma, often invohdng enormous areas. Phantom tumors are due to spasmodic contraction of the recti. They disappear under anesthesia; the others are permanent. Myoma of the round ligament is in the groin, is very rare, simulates inguinal adenitis and inguinal hernia, and should be removed. The inguinal canal must be obliterated, to prevent hernia. TUMORS OF THE ABDOMINAL WALL 227 Fibrosarcomata are small hard tumors, growing from the sheath of the recti muscles, and are in the midline. They should be removed, and are very slightly malignant. Lipomata are essentially benign, and do not demand removal unless uncomfortable or infected. ^ii;ry~A).^ ^ Pig. 90. — Mixed-cell sarcoma of abdominal wall, starting in a pig- mented mole near the umbilicus. Two years growth. (Seen by courtesy of Dr. H, F. Taylor, Ridley Park. Pa.) Sarcoma starts usually from a pigmented mole, is usually melanosarcoma, grows rapidly and is very malignant. Early removal and x-ray or radium offer the only chance, though a small one, of relief. CHAPTER XII INJURIES OF THE BIRTH CANAL, AND THEIR REPAIR CLASSIFICATION OF INJURIES I. Injuries to the Pelvis. — (i) Fracture or separation of the symphysis; (2) fracture or separation or sprain of the sacro-ihac joints; (3) fracture of ramus of pubes; (4) fracture of coccyx. II. Rupture of the Uterus. — (i) Complete; (2) incom- plete. III. Lacerations of the Cervix. — (i) Unilateral (open or submucous): (2) bilateral (open or submucous); (3) stellate (open or submucous) ; (4) annular detachment. IV. Lacerations of Anterior Vaginal Wall. — (i) Clean cuts of mucous membrane; (2) open or submucous tears of muscle or urogenital trigonum. V. Lacerations of the Perineum. — (i) Tears of the levator ani; (2) tears of deep transversus perinei; (3) tears of anterior and posterior layers of triangular ligament; (4) tears of the bulbocavernosus ; (5) tears of the superficial transversus perinei; (6) Tears of sphincter ani (complete tear). Further divisions into: (i) Complete tear (involving sphincter ani); (2) incomplete tear {not involving sphincter); (3) central perforation of the perineum; (4) laceration and abrasion of labia. VI. Fistulas. — (i) Vesicovaginal (on anterior vaginal wall); (2) uretero vaginal (in vaginal fornix) ; (3) rectovaginal (on posterior vaginal wall). 228 LACERATIONS OF THE CERVIX 229 INJURIES TO THE PELVIS Recent injuries of the pelvic bones, except fracture of the coccyx, are complications of the puerperium, and hence belong in works on obstetrics. Relaxation of the sacro-iliac joints gives great discomfort, persisting often for many months after delivery. It is also possible from sudden muscular exertion or strain, entirely independent of childbirth. Symptoms. — (i) Intense backache, aggravated by exertion, most marked over the affected joint; (2) inability to sit long in any position; (3) difi&culty on arising from bed or chair; (4) occasionally so severe, if bilateral, as to make walking impossible. Treatment.- — A binder of unyielding material like heavy muslin or light canvas, laced tight over the hips to immobilize the joint; in moderate cases, lacing the lower third of the ordinary corset gives sufficient relief. The binder is worn constantly, except in bed, and is put on before the patient arises in the morning. Recovery is slow, usually four to six months being required, and the condition returns in subsequent pregnancies. Fracture of the coccyx is discussed in Chapter XIII, under the sequelae of childbirth. RUPTURE OF THE UTERUS Rupture of the uterus is purely an obstetrical accident, and needs no discussion here. LACERATIONS OF THE CERVIX Causes.— (i) Childbirth (by far the commonest); (2) forcible dilatation; (3) passage or extraction of large sub- mucous fibroids. Forceps delivery accounts for the greatest number. The cervix is always torn if the forceps is applied before the head has passed through the cervical ring. Kinds. — (i) Unilateral; (2) bilateral; (3) stellate; (4) an- nular detachment. 230 INJURIES OF THE BIRTH CANAL A unilateral tear involves only one side of the cervix. This type often heals spontaneously, does not cause eversion (because the uninjured side acts as a splint), and not in- frequently causes no erosion. A bilateral tear, involving both sides and usually more extensive on one side than the other, always causes eversion and erosion, and is the commonest type of cervical tear. A stellate tear means a tear in three or more directions, Pig. 91. — I. Unilateral laceration of the cervix. 2. Bilateral lacera- tion of the cervix. 3. Stellate laceration of the cervix. As seen through a speculum. usually bilateral with a vertical split in the anterior lip. This type causes eversion, erosion and hypertrophy. Annular detachment is of no importance in gynecologic work. The cervix, partially dilated, has been torn off in labor, and unless tabs of tissue are left, the circular wound has healed and requires no repair. Terminations. — (i) Spontaneous healing, which is uncom- mon, except in unilateral tears, though it may occur in the most extensive stellate ones; (2) eversion of the lips, where they LACERATIONS OF THE CERVIX 23 1 are rolled apart and gape widely; (3) erosion, a prolapse of the red columnar epithelium of the cervical canal over the squamous epithelium of the portio; the condition erroneously called "ulceration;" (4) hypertrophy of the cervical tissue, most marked of the anterior lip, and a constant accompaniment of prolapse; (5) Nabothian cysts; small pearly cysts, containing clear mucus, showing on the vaginal portion of the cervix and due to occlusion of the mouths of the glands: (6) as a late development, carcinoma. (For details of all these, see Chapter VI.) Consequences of cervical tears, in addition to those mentioned above are: (i) leukorrheal discharge — profuse thick stringy mucopus; (2) sterihty- — either from changed cervical secretions or stenosis of the internal os; (3) menor- rhagia — from uterine congestion; (4) multiple miscarriages. Symptoms.^ — (i) Leukorrhea, of the cervical type, very pro- fuse; (2) pelvic discomfort, if the scar tissue extends in the vaginal vault; (3) dyspareunia, for the same reason; (4) menorrhagia usually, and, if there is marked erosion, often metrorrhagia; (5) reflex symptoms (backache, hysteric neu- roses, headache, etc.) of doubtful value and obscure cause. The only constant symptom is leukorrhea. Profuse muco- purulent discharge, sufflcient to require a napkin for pro- tection, in a patient who has had a child and is free from gonor- rhea, is practically always due to lacerated, eroded cervix. Diagnosis. — (i) Digital examination is unreliable. The scar of a healed tear feels astonishingly like an open one; (2) a bivalve speculum should always be. used, and the diagnosis is made by it only. It is often very difficult to diagnose between a badly eroded cervix and early carcinoma. Both bleed easily to the touch, and in any case in the least suspicious, a piece must be excised for microscopic diagnosis. If the tear has been extensive and involves the vaginal vaults, the resulting immobihty of the uterus is very like that of sal- pingitis with extensive adhesions. 232 INJURIES or THE B-IRTH CANAL Treatment Palliative treatment is useless for a cervical tear; while erosion can be temporarily diminished, it recurs as soon as treatment is stopped. The only treatment is (i) repair or (2) amputation. Choice of Method. — It is difl&cult to lay down a dogmatic rule, and each case must be judged on its merits; but as a general thing it is safe to say that unilateral and bilateral tears, without hypertrophy, can be repaired, while stellate tears and hypertrophy of the cervix require amputation. Cicatricial bands often form from the side of the cervix to Pig. 92. — I. The method of denudation and placing the stitches for Emmet's trachelorrhaphy. 2. The repair completed. the vaginal vault. They are usually raised ridges of dense scar tissue, but may be actual circular bands. They should be excised before any repair is attempted. Repair of the cervix (Emmet's trachelorrhaphy) is one of the few operations in gynecology, if not the only one, still done in its original form, and never improved upon, except for the kind of suture material. Technic. — (i) The patient is anesthetized and prepared as for any vaginal operation. 2. The anterior and posterior lips of the cervix are caught with tenacula, pulled down and separated. LACERATIONS OF THE CERVIX 233 3. The edges of the denudation are marked out, as in the diagram, care being taken to limit the denudation to the area of the laceration and not to encroach upon the cervical canal. The shape oi: the denudation is triangular, on each lip. 4. Interrupted stitches, of number 3 forty-day chromic catgut are placed, beginning on the mucous membrane of the vaginal aspect of the anterior lip, emerging close to the mucous mem- brane of the cervical canal, entering again close to the edge of the mucous membrane of the canal on the posterior lip, and emerging on the vaginal aspect of the posterior lip, opposite the point of entrance on the anterior lip. Three or four sutures to a side are required. 5. The stitches are tied, after all are inserted. Care should be taken not to close the canal too tightly. When all stitches are tied, the cervical canal should have a caliber of a number 17 French sound, otherwise there may be a secondary dysmenorrhea. If the tear is unilateral, only one side is denuded and repaired. At times an accurate repair of a bilateral tear may be pre- vented by hypertrophy of the mucous membrane of the canal. A wedge-shaped exsection of the mucosa will obviate the difficulty and avoid amputation of the cervix. A repaired cervix never withstands subsequent childbirth and is sure to tear again. Amputation of the cervix is best done by the Hegar method, as no other gives such uniform accurate coaptation of the edges of the wound. Indications.' — ("i) Stellate tears; (2) hypertrophy of the cer- vix, (3) very extensive tears, unilateral or bilateral, involving the vaginal vaults; (4) severe endocervicitis with marked erosion and excessive leukorrhea; (5) in all cases of prolapse of the uterus. Advantages.' — (i) It allows a neater coaptation of the wound edges, in the cases where it is indicated; (2) leukorrheal dis- charge is greatly lessened; (3) it withstands subsequent child- birth much better than repair. 234 INJURIES OF THE BIRTH CANAL Disadvantages.- — (i) Danger of secondary cervical stenosis and dysmenorrhea; (2) tendency to repeated miscarriage, if the cervix is amputated high; (3) unnecessary if a neat result can be obtained by repair, which is both quicker and easier. Technic of Amputation. — (i) The patient is in the dorsal posi- tion, prepared as for any vaginal operation and anesthetized. 2. The anterior and posterior lips of the cervix are caught by tenacula. 3. A circular incision is made around the cervix, to free the vaginal walls at their attachments. Fig. 93. — Hegar's amputation of the cervix. 4. The cervix is amputated as a cone, and any actively bleeding points (usually few) tied with number o plain catgut. 5. With heav}^ curved needle, armed with number 3 chromic (40-day) catgut, the sides of the cervix are repaired, taking the anterior vaginal mucosa, the muscle of the cervix and the posterior vaginal mucosa. Two interrupted stitches are placed on either side of the cervical canal; none are tied as yet. 6. With the same needle and similar catgut, two interrupted stitches are placed in each lip, in the middle line, emerging in the cervical canal, so as to make, when tied, a new external os. 7. All the stitches are now tied, the lateral ones first, then LACERATIONS OF THE ANTERIOR VAGINAL WALL 235 those forming the anterior Hp of the new external os and then the posterior. 8. If any extra stitches are required to secure perfect coapta- tion they are inserted after the others are tied. The cervical canal should be about 17 (French scale) in caliber. After either repair or amputation of the cervix, patients should remain in bed for one or two weeks, depending upon whether other plastic work was done at the same time. Coitus should be forbidden for at least two months. If secondary stenosis results, the canal can be dilated, as an office procedure, by steel bougies, under strict asepsis. Dates of Repair.- — ^Like any other plastic operation, these may be primary (within forty-eight hours of injury); inter- mediate (two to fourteen days after injury) or secondary (after fourteen days). The first two are concerned with the puer- perium only. The secondary repair is the usual gynecologic operation. LACERATIONS OF THE ANTERIOR VAGINAL WALL Lacerations of the anterior vaginal wall are (i) clean cuts of the mucous membrane (of importance only directly after de- livery, because of bleeding); (2) laceration of the muscle and fascia of the urogenital trigonum; (3) vesicovaginal fistula. Causes. — (i) Injuries of childbirth, almost exclusively. 2. Very rarely, the passage of a submucous fibroid, large enough to simulate the mechanism of delivery of a fetal head. Muscle of the Urogenital Trigonum.^This is the analogous muscle to the compressor urethras in the male. It arises at the junction of the symphysis and descending ramus of the pubis, and runs diagonally back above the anterior vaginal wall. It divides and joins its fellow from the opposite side above and below the urethra, inserting into the fascia of the anterior vaginal wall. It is the only direct muscular support possessed by the lower third of the anterior vaginal wall, to which it is a levator, and acts as a compressor urethrae. A tear of 236 INJURIES OF THE BIRTH CANAL this muscle is one of the factors in the production of a cystocele, and also accounts for many cases of incontinence of urine in later years. Diagnosis of Injury. — With the patient in the dorsal position, the forefinger of one hand is inserted in the vagina, and pressure made straight up, to either side of the urethra, against the lower edge of the pubic bone. If the muscle is torn, the finger presses against the sharp edge of the bone. If it is not torn, a flat ribbon of muscular tissue and fascia is felt between the finger and the bone. On inspection, the lower portion of the anterior vaginal wall bulges down- ward, if the muscle is torn. Consequences of lacera- tion are: (i) Cystocele; (2) urethrocele; (3) inconti- nence of urine on effort, such as sneezing, coughing, etc. Technic of Repair. — (i) Dorsal position, usual prep- aration and anesthesia. 2. The anterior vaginal wall is caught by a double tenaculum, just to the outer side of the urethra. 3. A second tenaculum catches the labium on the same side, at the same level. 4. When these are separated, a triangular sulcus is seen on the lateral aspect of the anterior vaginal wall, with the point toward the cervix. 5. This sulcus is denuded and the muscle repaired with a continuous tier stitch of number i forty-day chromic cat- gut. Interrupted sutures can be used, but the continuous is quicker and better. Pig. 94. — Repair of the muscle and fascia of the urogenital trigonum. TEARS or THE POSTERIOR VAGINAL WALL 237 VESICOVAGINAL HSTULA ' Vesicovaginal fistula is discussed in Chapter XV on Genital Fistulas. TEARS OF THE POSTERIOR VAGINAL WALL AND PERINEUM As perineal tears are almost invariably the result of child- birth, and as practically all of them admit of repair during the puerperium, the subject is considered here from the obstetrical as well as the gynecologic standpoint. Were all patients properly repaired after delivery, the need for any plastic operation at a later date would be nearly eliminated. The great majority of patients who have had children have some degree of perineal tear. The degrees of tear are vari- ously classified, the more common division being (i) first- degree tears, involving only the tissues of the perineal body in the middle line; (2) second-degree tears, involving the levator ani and (3) third-degree tears, involving the sphincter ani. Lacerations of the vulva and labia are really only abrasions. They are rarely deep, and unless attended by bleeding, do not require sutures. Tears of the Vagina, Pelvic Floor and Perineum. — The struc- tures injured are: (i) Levator ani (the main muscular support of the pelvic floor; (2) deep trans versus perinei — torn in the middle line, and retracting to either side; (3) the fascia anterior and posterior to the deep transversus perinei — the anterior and posterior layers of the triangular ligament; (4) the super- ficial transversus perinei; (5) the bulbocavernosus; (6) the sphincter ani, if the tear extends that far in the middle line. Tears of the levator ani are two kinds : (i) Forceps cuts, which may be anywhere in the course of the muscle and are usually a more or less complete division at right angles to the fibers and (2) spontaneous tears, in which the muscle tears loose from its tendinous attachment to the descending ramus of the pubes, and tears obliquely downward across the fibers of the 238 INJURIES OF THE BIRTH CANAL muscle, but not through them, so that the tear opens out as a book is opened, when stood upon its back. This muscle is the main support of the pelvic floor, and its injuries are attended by the well-known effects of such a tear; sense of loss of support, rectocele, and later prolapse of the uterus. The tear may be either open or submucous; the open tears are easy to see and feel, the submucous tears are often over- looked and result later in the misnamed "relaxation of the pelvic floor." Causes of Perineal Tears.^ — (i) Spontaneous delivery; (2) forceps (almost invariably cause a tear); (3) hurried delivery; (4) posterior shoulder of child will often make or extend a laceration; (5) contracted pelvis — the narrow pubic arch forcing the head posteriorly; (6) occipitoposterior positions; (7) edema from prolonged labor; (8) rigidity. In multiparae, who have been properly repaired, it is common for the perineal body to give way, in subsequent labors, but re-injuries of the levator are much less common. Symptoms of a Perineal Tear. — Tears of the first degree, in- volving for a short distance only the central perineal body, often cause no syrnptoms at all. Tears involving the levator ani cause the following: (i) Sense of loss of support, "as if everything were dropping out;" (2) this sensation is aggravated by standing or exertion, and at the menstrual periods; (3) backache; (4) often the pro- trusion of a rectocele, referred to usually by the patient as "falling of the womb;" (5) if a rectocele is present, the patient often has difficulty in defecation. All these symptoms are much more marked if there is an associated retroversion; even extensive tears may cause very slight sjonptoms if there is no backward displacement of the uterus. Diagnosis. — The patient is placed across the bed, in the dorsal position. (2) She is asked to strain, when the degree of gaping of the labia is noted. (3) After careful cleansing of the vulva, the labia are separated, when any obvious tear can be TEARS OF THE POSTERIOR VAGINAL WALL 239 seen. (4) The thickness of the perineal body is palpated by- one gloved finger in the vagina and the thumb outside, on the perineum. This will disclose injury to the bulbocavernosus, superficial and deep transversus perinei muscles. (5) The levator ani is tested as follows : the forefinger is inserted in the vagina, up to the second joint, and pressed downward and out- ward, to note a cleft, if any, in the muscle. The forefinger is swept from one pubic ramus to the other, to note whether the muscle forms an unbroken horseshoe curve. With the forefinger in the vagina and the thumb outside, the thickness Pig. 95. — Testing the levator ani muscle. The forefinger is inserted in the vagina up to the second joint; the thumb is midway between the tuberosity of the ischium and the anus. of the levator Is palpated. (6) The sphincter ani is always tested last, by feeling the complete circumference of the muscle with the forefinger in the rectum and the thumb outside. It is easy to overlook a submucous tear of the sphincter, and a serious mistake to do so. Mere inspection of the perineum is no guide to the extent of injury present. Results of Lacerated Perineum. — (i) Rectocele; (2) hemor- rhoids; (3) prolapse of the uterus. 240 INJURIES OF THE BIRTH CANAL Central Tear of the Perineum. — In very rigid perinei, when overdistended by the head, a circular perforation sometimes appears midway between the posterior commissure of the vulva and the anus. This should be at once opened through into the vagina by scissors, followed by a double episiotomy. Unless so treated, the head is likely to emerge from the rectum, with disastrous results to the sphincter. Symptoms of Tear Through the Sphincter Ani (Complete Tear). — (i) Incontinence of gas and feces (which may mean Fig. 96. — Testing the sphincter ani for laceration. (After B. C. Hirst.) only overstretching of the sphincter); (2) the sphincter forms a slightly curved line across the posterior border of the anus; (3) its ends are marked by two visible dimples or pits; (4) the folds of skin, or rugae, normally surrounding the anus are gone anteriorly and deepened posteriorly; (5) if the sphincter be palpated with one finger in the rectum, the gap in the ring muscle can be felt plainly. Time of Repair. — The immediate repair directly after labor of the perineum is not advised, for the following reasons: (i) Accuracy of diagnosis is impossible; (2) the bruised and edema- TEARS OF THE POSTERIOR VAGINAL WALL 24 1 tous tissues are not good material for repair; (3) the danger of infection is very much greater; (4) these repairs are often only the closure of the perineal skin, with entire disregard of the muscular injuries; (5) failure is common, necessitating a second operation later. Above all does this apply to operations for complete tear of the sphincter ani. All these disadvantages can be obviated by repair on the seventh day after delivery, unless the patient has fever, in which case the repair is postponed until the temperature has been normal for a week. With ordinary care, sepsis is not to be feared, and objections based upon supposed difficulty or unfavorable healing are not based upon fact. Treatment Preventive. — Avoidance of undue haste in delivery; protec- tion of the perineum by retarding the head; lack of haste in forceps delivery; using small forceps (Hale-Sawyer) whenever possible; episiotomy when indicated; avoidance of large doses or indiscriminate use of pituitrin. By observance of these details, many, but by no means all, lacerations can be avoided or at least limited in extent. Technic of Repair.^ — Immediate: No matter what the physician's preference may be, this should never be undertaken if the vulva and vagina are badly bruised; if there is reason to believe that there is beginning infection; if the patient is excessively exhausted or if she is an eclamptic; or if the laceration dates from a previous labor. It is not advisable to place the sutures before the placenta is delivered, and the old practice, recently revived, of putting sutures in the perineum before delivery of the head, and removing them, if not needed, after delivery, is absurd. Anesthesia is said not to be needed, because the overstretched tissues are not sensitive. The patient's actions, while the repair is in progress, will often cause the physician grave doubts as to the accuracy of this statement. Technic of Immediate Repair. — (i) The patient is arranged 16 242 INJURIES OF THE BIRTH CANAL across the bed, with her feet on two chairs, and her hips over the edge of the bed. 2. The vulva is carefully cleansed with cotton and lysol solution (one dram to two pints). 3. If much blood is trickling down from above, a large gauze or cotton sponge may be inserted in the vagina, against the cervix, and removed after the stitches are in place, but before they are tied. 4. The labia are separated and the extent of the injury inspected. This is materially aided by retraction of the anterior vaginal wall by an assistant. 5. Visible open tears of the levator may be sutured with a continuous number i chromic catgut stitch. 6. The perineal body is repaired by interrupted stitches of number 3 chromic catgut or silkworm-gut, placed so that the entire depth of the tear is included, and not the skin of the peri- neum only. Episiotomy wounds are sutured in the same way. Plain catgut is not to be used, as it disappears too Soon. Silk has the disadvantage of cutting through the tissues. The after-care of these repairs is as described under the delayed repair of the perineum. The silkworm-gut sutures are removed on the twelfth day. The catgut ones will disappear spontaneously. The sphincter ani may be repaired immediately, if torn, but much better results are attained by delaying the repair for at least a week. If the repair is undertaken at once, it is done as described in the delayed repair. Technic of the Delayed Repair of the Perineum. — Prepara- tion for Operation: Day before operation: 4 p.m. Shave pubes completely, g p.m. Magnesium sulphate 3^^ ounce, or citrate of magnesia, flat, 8 ounces. Day of Operation. — Early in the morning, cup of beef tea, no other breakfast. Clear lower bowel out thoroughly by re- peated enemas, so that last enema is given at least two hours before operation. Continue enemas until water returns clear. Two hours before operation give paregoric 13^^ teaspoonfuls. TEARS OF THE POSTERIOR VAGINAL WALL 243 This inhibits peristalsis much better than morphin. Cathe- terize just before etherization. Do not give hypodermic of morphin and atropin. The paregoric takes its place. Local preparation done on the table, by careful and complete scrubbing of vulva and vagina by cotton pledgets and tincture of green soap and hot water. Choice of Operation. — Of the multitude of operations de- scribed for perineorrhaphy, there are three that answer all e / \, e Pig. 97. — The Emmet and Hegar denudations compared. a, Lowest myrtiform caruncle, the same in both operations; b, tip of rectocele; c, highest point in Hegar operation on posterior vaginal wall; d, lines of Emmet denudation; e, lines of Hegar denudation. The solid lines show the shape of the Emmet denudation; the dotted lines that of the Hegar. requirements, provided the special indications of each are considered. (i) The Emmet operation, satisfactory in moderate tears, with slight rectocele, but unsatisfactory if the rectocele is large and worthless in prolapse of the uterus; (2) the Hegar opera- tion, of value in large rectocele and prolapse, but unneces- sarily extensive in moderate tears; (3) the B. C. Hirst ana- tomical restoration, designed to repair the various muscles in the lines of their original injuries. It is done with the Em- 244 INJURIES OF THE BIRTH CANAL met denudation if there is not much rectocele; though the Hegar denudation if there is. The Emmet operation denudes the lateral vaginal sulci separately and repairs them ; the Hegar makes one large central triangular denudation and joins the levator of one side to the levator of the other, above the rectum which is crowded back in the process. Hence the Hegar operation overcorrects and narrows the vagina; the Emmet does not. Emmet Operation. — (i) The patient is in the dorsal position, Fig. 98. — The Emmet perineorrhaphy. {After Stewart.) the vagina carefully cleansed with tincture of green soap, hot water and lysol solution. 2. As nearly all lochial discharge contains pathogenic organ- isms, the uterus should be washed out with lysol solution, and a large pledget of cotton soaked in lysol solution placed against the cervix. This must always be removed as soon as the operation is completed. In secondary operations, long after childbirth, this step is of course omitted. 3. Each labium is caught with a bullet forceps just below the lowest myrtiform caruncle (above which is the duct of TEARS or THE POSTERIOR VAGINAL WALL 245 Bartholin's gland) or more conveniently the labia are sepa- rated with the Gelpi self-retaining perineal retractor. 4. The tip of the rectocele is caught with a volsellum (the d d c c 1a I, ^-'' r e e 99- — Diagram of the Emmet perineal repair, a, Denuded area; h, area not denuded; c, interrupted stitches in sulcus; d, continuous stitches in sulcus; e, crown stitches. Pig. Pig. 100. — The Gelpi self-retaining perineal retractor, for use in plastic operations. It is especially useful where one has only one assistant. tip is the portion nearest the cervix, in the midline, which without tension can be brought down to the posterior commis- sure of the vulva). 5. The lateral sulci are denuded in one piece or in strips. 246 INJURIES OF THE BIRTH CANAL 6. The central perineal triangle is denuded, and if any granulation tissue is present, itds curetted off with the edge of a knife. 7. The lateral sulcus wounds are closed by continuous or interrupted sutures of number i chromic catgut, or interrupted sutures of silkworm-gut. Catgut stitches are tied, silkworm- gut are secured with perforated shot, as it makes their removal easier. 8. The crown stitches of number i chromic cat- gut or silkworm-gut are inserted. The stitch passes through one labium, just below the tenaculu m, emerges in the sulcus just below the last sulcus stitch, transfixes the tip of the rectocele, and passes through the other labium to emerge on the skin per- ineum, just opposite its point of insertion. Two or three of these stitches are required. They are tied from above downward, after all are inserted. 9. The vagina is douched and packed with sterile gauze. Hegar Operation. — (i) The patient is prepared as for the Emmet operation. 2. The labia are caught, as in the Emmet operation. 3. A point in the middle of the posterior vaginal wall, about two-thirds of the way from the vulva to cervix, is caught with a volsellum. 4. The large single triangle formed by these three instruments is denuded, care being taken to avoid wounding the rectum, an accident likely to occur unless great care is exercised. Any granulation tissue in the area to be denuded is curetted off. Fig. ioi. — The Hegar perineorrhaphy. TEARS or THE POSTERIOR VAGINAL WALL 247 5. Transverse interrupted stitches are placed across this triangle from the apex downward. The upper ones may be of number 3 chromic catgut, the lower three vaginal and the perineal stitches should be silkworm -gut, because they are under considerable tension. 6. The perineal stitches are placed, beginning with the one nearest the anus, so as to close the wound in the perineal body, f r r f Fig. 102. Fig. 103. Pig. 102. — Denudation in the Hegar operation, and suture of the rectocele above the levator ani. a, Myrtiform caruncles; h, denuded area; everything included in triangle is denuded; c, stitch puckering up tip of triangle. Pig. 103. — Hegar operation, second stage, a, Myrtiform caruncles; 6, denuded area; c, puckered up tip of triangle; e, interrupted stitches of levator ani; /, interrupted suture of perineal body. entering from and emerging in the perineal skin, and are tied from above downward. 7. The vagina is douched and packed with sterile gauze. The Hegar operation disregards the normal perineal anatomy and its injuries but is a satisfactory operation in the cases where it is indicated. Technic of the B. C. Hirst Perineorrhaphy. — (i) The patient is prepared as for the Emmet operation. 248 INJURIES or THE BIRTH CANAL 2. The labia and tip of the rectocele are caught as in the Emmet operation. 3. The sulci and central triangles are denuded as in the Emmet operation. 4. The fascia covering the levator ani is incised, on each side, in a line parallel to and just beneath the edge of the sulcus denudation. 5. The tear in the levator ani is closed on each side, inside the sheath of the muscle, by a continuous stitch of number i chromic catgut. 6. Two interrupted stitches are placed through the sheath and end of the deep transversus perinei muscle, but are not tied. The stitches pass through the sheath and muscle of one side, pick up the perineal body floor in the middle line, between the anterior and posterior layers of the triangular ligament, and through the sheath and muscle of the other side. 7. The posterior layer of the triangular ligament is closed over the bulging rectum, it being through the tear in the ligament that the rectocele protrudes. 8. The lateral sulci are closed in the Emmet operation, by a continuous stitch. 9. The tip of the rectocele is fastened down to the posterior column of the vagina, inside the posterior commissure of the vulva, where it originally belongs. 10. The tension of the Gelpi retractor is relaxed, and the two stitches securing the deep transversus perinei are tied. 11. The tears of Colles fascia, bulbocavernosus, superficial transversus perinei and anterior layer of the triangular liga- ment, all in the perineal body, are closed by interrupted stitches placed so that, when tied, the knots will be covered in when the perineal skin is closed. 12. The perineal skin is closed. 13. The vagina is douched and packed with sterile gauze. All catgut used is number i chromic catgut, of forty-day durability, except in the skin sutures, where overchromicized TEARS OF THE POSTERIOR VAGINAL WALL 249 number i gut, of greater durability, is used. This operation is designed to correct the lacerations in the planes in which they occur, and to effect a normal anatomical restoration. No perineal operation should be attempted from a written description. For its understanding, actual demonstrations are necessary. It is not usually advisable in recent injuries to put in any vaginal packing, as it tends to dam back the lochia. This applies only to operations done immediately after delivery or early in the puerperium. Routine After-care of Plastics. — (i) Morphin sulph. gr. l^, atropin sulph. gr. K50 6th hour p.r.n. ; (2) water p.r.n. first twenty-four hours; (3) irrigate perineal stitches with sterile water four times daily, and also after each urination or bowel movement, and keep sterile vulvar pad in place after irriga- tion; (4) inspect stitches frequently; if stitches are soiled, clean with cotton on appHcator and peroxid of hydrogen. Moder- ate cutting may be disregarded; (5) vaginal douche sterile water every day after fifth day; (6) simple enema once or twice in second twenty-four hours; (7) end forty-eight hours, calomel gr. }-^ every hour for six doses followed, 2 hours after the last dose by flat magnesium citrate, 6 ounces; (8) soft diet after first twenty-four hours, light diet fifth day, full diet seventh day; (9) catheterize 8th hour p.r.n.; (10) take out vaginal packing in twenty-four hours, if any is inserted, and note its removal on the chart; (11) as a routine laxative use compound cathartic pills, one at bed time. If too active, give only half a pill. If these cause griping, use A. B. S. and C. pill. Operation for Complete Tear. — Repair of a complete tear should never be attempted as long as there is any edema, sloughing, unhealthy granulation, or fever. Failure is sure if this precaution is disregarded. If a complete, or any other perineal tear, shows sloughing or edema, restoration to healthy condition is more quickly attained by thrice daily douches of hot sterile water, and application of weak solutions of nitrate of silver (gr. 10 to oz. i) to any place showing persistent false 2SO INJURIES or THE BIRTH CANAL membrane. These precautions are necessary in the puer- perium only. Preparation for repair of complete tear is the same as any plastic operation, except that several days must be devoted to getting the bowels to move freely, before the operation is attempted. Technic. — (i) The patient is arranged and cleansed as for any plastic operation. Connect, Tissue _s . Bridge \ Sphincter — C\jsTocele Pig. 104. — A typical complete tear of the perineum through the sphincter ani. {After Graves.) 2. The sphincter is stretched .by grasping between the thumbs and forefingers, and stretched for a full minute. 3. The labia and tip of the rectocele are caught as in the Emmet operation. 4. An incision is made from one sphincter pit, around the tear in the rectovaginal septum, to the other sphincter pit. 5. The rectovaginal septum is spht, between the vagina and TEARS OF THE POSTERIOR VAGINAL WALL 25 1 rectum, so as to secure an ample margin of raw tissue, without sacrifice of any unnecessary portion. 6. The tear in the rectovaginal septum is repaired by inter- PiG. 105. — Arrows indicate direction of traction. Stretching the sphincter ani in a complete tear operation. rupted silkworm-gut stitches, put in from the rectal side, so that the knots, when tied, will be in the rectum. Interrupted chromic catgut stitches with the knots buried e Fig. 106. — Diagram for complete tear operation, a, Lateral sulci in vagina (denuded); b, rectocele (not denuded); c, sphincter pits; the empty ends of the sphincter sheath; d, tip of tear in rectovaginal septum; e, sphincter ani, retracted in its sheath. in the perineal body may be used, but with a greater likelihood of perineal fistula. 252 INJURIES OF THE BIRTH CANAL 7. The ends of the sphincter are pulled out of the pits into which they had retracted, by single tenacula, and cleared Pig. 107. — Bringing up the ends of the sphincter ani. The ends of the muscle are retracted in the sheath, J:^ to J^ inch below the surface of the denudation. {After Crossen.) of any granulation tissue which may cover them. The sphinc- ter may be recognized by palpation, noting that the tissue Fig. 108. — The stitches of the complete tear operation, a, The tip of the tear in the rectovaginal septum; b, the sphincter ani; c, denuded area around the tear in the rectovaginal septum; d, end of sphincter, dug out of its pit. I. Interrupted suture closing apex of tear in recto- vaginal septum. 2. Interrupted suture, through sphincter and sheath. Only one of each kind is shown. pulled up by the tenacula is continuous with the buried TEARS OF THE POSTERIOR VAGINAL WALL 253 part of the muscle, and also by the yellowish-red color of the exposed ends. This color is a very marked contrast to the much deeper red of the surrounding denudation. Two interrupted stitches of number i chromic catgut are passed through the ends of the muscle, so that when tied the knots will be buried in the perineal body. These are for approximation only. Two silkworm-gut stitches are next passed through the sphincter and sheath, beginning at the mucocutaneous junction at the anus on one side, and emerging at a corresponding point on the opposite side. Pig. 109. — The sphincter repaired. {After Crossen.) These are for approximation and tension. With this plan, further tension stitches are unnecessary. 8. All the rectal stitches are tied from above downward. 9. The rest of the perineal injury is repaired as may be required by the extent of the tear, disregarding the rectal feature of the tear. In complete tears it is comm.on for the levator to escape injury, and the tear is confined to the perineal body in the middle line. After-treatment is the same as any plastic except for the care of the bowels. Much the safest plan is to keep the bowels liquid from the start, usually either magnesium citrate (flat), or Carlsbad water and Sprudel salts (one dram to the tumbler 254 INJURIES or THE BIRTH CANAL of water). Either of these is used quantities varying in each case, but sufficient to give two Hquid movements a day. This plan is much safer than keeping the bowels locked, and infection is not to be feared. The stitches are removed on the sixteenth day, best in the knee-chest posture through a rectal speculum, cautiousty opened; and the bowels must be kept liquid for at least a month and soft for two or three months thereafter. The commonest cause of failure, next to infection, is neglect of the bowels. Infection is likely to result in either complete failure, or rectovaginal or rectoperineal fistula. These latter rarely if ever heal spontaneously, and must be closed by a second operation. In this or any other plastic it is unnecessary to keep the knees bound together, unless the patient is unruly or delirious, and she may turn on either side after twenty-four hours. Factors Essential to Success in Complete Tear Operations. — (i) Choice of proper time and condition for operations; (2) stretching of the sphincter; (3) exposure and cleansing of granu- lation tissue from ends of sphincter; (4) permanent suture material (silkworm-gut); (5) pass sutures deep enough to catch sheath of sphincter; (6) leave stitches in at least sixteen days; (7) keep bowels liquid from start; (8) avoid constipation after the stitches are removed. If the bowels should be locked, the first movement must be secured under oil enemata, and in all probability breaking up of the fecal mass by the gloved finger, inserted in the anus and morcellating the mass by pushing back toward the sacrum and never forward. With proper management, and, if necessary, timely episi- otomy, a repaired sphincter will usually withstand subsequent delivery without giving way. Time in Bed. — Silkworm-gut sutures in the operation for incomplete tears are removed on the twehth day, the patient gets up on the fourteenth day and goes home on the seventeenth day. In complete tears, the stitches are removed on the six- TEARS OF THE POSTERIOR VAGINAL WALL 255 teenth day, the patient gets up on the eighteenth day and goes home on the twenty-first day. It has seemed, to the author, advisable to consider the sub- ject of lacerations of the birth canal from the obstetrical view- point of the recent injury as well as the gynecological one of delayed repair. In no other way can a complete grasp of the subject be gained. CHAPTER XIII PATHOLOGICAL SEQUELS OF CHILDBIRTH While many of the conditions herein described can occur from other causes, childbirth is responsible for them in the vast majority of cases, and hence this classification is used for convenience. The commonest pathologic sequelae of childbirth, injuriously affecting a patient's health, are: (i) Lacerations of the birth canal; (2) retroversion of the uterus; (3) pelvic inflammation. These three account for a large proportion of the ailments for which women consult their physicians. The other sequelee, not arranged in order of frequency are: (4) erosion of the cervix; (5) diastasis of the recti; (6) floating kidney; (7) fractured coccyx; (8) incontinence of urine; (9) relaxed sacro-iliac joints; (10) rectocele; (11) cystocele; (12) prolapse of the uterus; (13) genital fistulae. 1. Lacerations of the birth canal have been described in Chapter XII. 2. Retroversion of the uterus has been described in Chapter VII. 3. Pelvic inflammation has been described in Chapter VIII. 4. Erosion of the cervix has been described in Chapter VI. 5. Diastasis of the recti has been described in Chapter XL VI. FLOATING KIDNEY Cause. — (i) Loss of supporting fatty capsule; (2) drag on kidney by movable cecum or colon; (3) secondarily only, the relaxation of the lower abdomen by the distention of pregnancy. Symptoms. — In most cases, symptoms are absent. Only a small percentage (5-8 per cent.) require any relief. A dull 256 FLOATING KIDNEY 257 dragging pain in the loin (nearly always the right) associated with a "sense of looseness" in the corresponding side of the abdomen. The discomfort is not transmitted down the ureter, as it is likely to be in stone. Sudden, sharp attacks of pain, due to the twist in the ureter with temporary hydronephrosis, are common. Often a large quantity of urine is passed, follow- ing such an attack of pain. The severity of the symptoms does not depend upon the degree of looseness, and coincident appendicitis is frequent, due to congestion on the appendiceal Pig. 1 10. — The normal relation of the kidneys, seen from behind. veins by pressure of the kidney on the mesenteric veins (Edebohls). Diagnosis. — The patient is arranged flat on her back, with knees flexed on the abdomen. It is impossible, except in thin individuals, to feel the normally placed kidney. The left hand is placed flat under the left flank, and pressed upward, while the right hand makes counter pressure on the abdomen, just below the costal margin. The patient takes a deep breath and then exhales quickly. The smooth, elastic body of the kidney is unmistakable. As the kidney is often low, the examination should extend as far down as the pelvic brim. In doubtful cases, the pelvis of the kidney may be injected and an a;-ray will show its position. Pyelography is 258 PATHOLOGICAL SEQUELAE OF CHILDBIRTH not entirely safe, however, as extensive penetration of the silver salt into the parenchyma of the kidney will sometimes occur. Treatment is only required when definite symptoms demand relief. Muscular exercise, full diet and a properly fitting abdominal binder, with a pad, will relieve the moderate cases. Where Dietl's crises of pain occur however, or in very low and very movable kidneys, operation is required. The principle is decapsulation of the kidney, with suspension by stitches through the capsule against the cut edge of the quadratus lumborum, outside the erector spinae, just below the last rib. The kidney should not be fixed too high, above the last rib, as Pig. III. -Nephrorrhaphy. sutures. Shows the method of passing the fixation {Ashton, after Edebohls.) it is likely to rotate over the points of support. The kidney thus fixed, is always palpable, and the patient should be in- formed of this fact, to avoid errors of diagnosis in any future examination. Technic of Edebohls^ Suspensioii of Kidney. — (i) The skin of the back is prepared in the same way as the abdomen for section. 2. The patient is arranged lying on the abdomen, with a cylindrical air cushion under her upper abdomen. 3. An incisipn is made parallel to the outer border of the erector spinae muscles, about three inches long. 4. The deep fascia is cut through and the fatty capsule of the kidney exposed. FLOATING KIDNEY 259 5. By grasping the capsule with forceps, the kidney is gradu- ally coaxed out of the wound. In this step the patient's body will often have to be pulled up or down over the air cushion, to bring the kidney into the wound. 6. The kidney should never be turned transversely to hold it in place in the wound, but is left as it emerges, parallel to the axis of the wound. 7. The capsule is spht in the middle line from pole to pole and is dissected back laterally, so the kidney is completely decapsulated. 8. Four stitches of number 3 chromic catgut (40- day) are passed through the capsule, one at each corner, taking multiple bites to prevent tearing out. The ends are left long and caught in hemostats. 9. The air cushion is deflated and the kidney returned to its bed at the bottom of the wound. 10. The ends of the stitches in the capsule are rethreaded in needles and passed through the muscle at each side of the wound, so that raw edge of muscle is turned against the de- capsulated surface of the kidney. They are then tied down snugly. „, . / . 1 . Pig. 112.— The type of 11. Three interrupted stitches of adhesion and the position number 3 (40-day) chromic catgut are of the kidney (upper pole J , . , at the last rib) as secured used to bring the muscle edges to- by the Edebohls' neph- gether over the kidney to prevent rorrhaphy. (After Ede- hernia. 12. The fascia, fat and skin are closed as in any wound. The wound is dressed with gauze and collodion and adhesive straps. 13. The patient is kept in bed for three weeks, but need be off her 'back only for the first twenty-four hours. Dystopic kidney is the congenitally low kidney, at, near ^ 26o PATHOLOGICAL SEQUELAE OF CHILDBIRTH or even below the pelvic brim. The vessels come from the internal iliacs, and the ureter is short, hence the reposition to its normal position is impossible. Diagnosis can be made definitely by catheterizing the ureters with a;-ray catheters and a;-ray picture. The condition is of no importance except in labor, but should be excluded before any attempt at reposi- tion of the kidney is made. VII. FRACTURE OF THE COCCYX Fractured coccyx is most common in justominor pelves, especially where forceps have been used, and in elderly primip- arse. The injury may occur spontaneously. It is most commonly a rupture of the joint between the first and second pieces of the coccyx. Mechanism. — The mechanism of a fracture of the coccyx, resulting in permanent mobility, is first a fall, where the coccyx is driven in the pelvic canal, rupturing the posterior longitudinal ligament, and causing the coccyx to project much further than normal into the pelvic canal. In labor, the head pushes the coccyx in the opposite direction, causing a rupture of the anterior longitudinal ligament, and a separation of the joint between the first and second pieces. Terminations. — (i) The coccyx may ankylose inward (into the pelvic canal) when spontaneous cure results, until the next labor breaks it again; (2) ankylosis backward, in a straight line, so that the patient sits upon the tip of it, like a nail; (3) permanent painful mobility, coccygodynia — much the commonest. The first requires no treatment, the others require removal of the bone. Causes of Coccygeal Pain. — Pain is not always due to injury of the bone. The causes of coccygeal pain are: (i) Injury; (2) reflex (from retroversion of the uterus); (3) rheu- matic; (4) neurotic. It should be an invariable rule never to remove the coccyx unless injury can be demonstrated. Symptoms of Painful Mobility. — (i) The patient complains FRACTURE OF THE COCCYX 261 of pain, at the end of the spine, on walking, sitting or par- ticularly on defecation; (2) she has difficulty on arising from a chair; (3) she sits on one buttock, and cannot -remain long in one position. Diagnosis. — With the patient in the Sims' (left lateral) posture, one forefinger, protected by a fingercot or glove, is inserted in the rectum and the coccyx grasped between this finger and the thumb outside. There is always normal anteroposterior motion of about 1.5 cm. If the coccyx can be moved laterally; if the movement causes pain, and if by pres- PiG. 113. — Testing the coccyx for fracture by separating the fragments. (After B. C. Hirst.) sure a step can be made between the upper and lower frag- ments, the bone is injured. X-ray does not show the injury. Treatment. — At least six months after labor should be allowed, for possible spontaneous ankylosis. A mild ointment (i per cent, or 2 per cent, iodin) may be used externally over the bone, chieify as a placebo. If spontaneous cure is not effected, or if the coccyx ankyloses backward, its removal is in- dicated. The coccyx is exposed by an incision over it, as far from the anus as possible. The bone is dissected loose from its attachments with scissors, care being taken not to wound the rectum, which is close underneath. The dissection is carried 262 PATHOLOGICAL SEQUELS OF CHILDBIRTH above the lateral alae on the first piece of the coccyx, and the bone amputated with a Gigli saw between these alae and the tubercles marking the last piece of the sacrum. It is important tha,t all the coccyx be removed; amputation through the rup- tured joint will not relieve the symptoms. The median sacral artery is tied, the deep wound drained with a few strands of silkworm-gut (horsehair drain) and closed with interrupted stitches of silkworm-gut, so that all dead space is obliterated. Serious or even fatal infection may result if the wound is im- properly closed. It is dressed with gauze and collodion, and kept as clean as possible. The stitches are removed in two weeks. For some weeks the patient will have to sit on an air cushion, as the wound is exceedingly tender . A horseshoe-shaped cushion is best, and is used with the open end at the back. The wound, during convalescence, is exceedingly Fig. 114.— The line of ,.„ ^. , , ' , , */ amputation in coccy- difficult to keep clean, and frequently gectomy. The last piece suppurates. It is not necessary nor of the sacrum has tuber- ,..,.,. , cles but no lateral als; advisable, m this casc, to remove the the first piece of the stitches, as the wound can be flushed coccyx has lateral alse -, , . , but no tubercles. The through the drainage tract and between Hne of amputation Hes the stitches, twice daily, with Dakin's between them. n • i n • i • 1 i i i- nuid, which is much the best tor irrigation. To remove the stitches for infection retards heal- ing for many weeks. VIII. RELAXATION OF THE SACRO-ILIAC JOINTS This is a common consequence of childbirth, but may also occur from any sudden jar or strain. The condition is described in Chapter XII. IX. RECTOCELE Rectocele is caused by a bulging forward of the anterior wall of the rectum, covered by the posterior vaginal wall, through a tear in the fascia between the levator and deep CYSTOCELE 263 transversus perinei muscles, and the triangular ligament. The patient will usually mistake the condition for prolapse of the uterus, and will complain of difficulty in defecation, due to the column of feces being diverted from its normal path. Diagnosis. — With the patient in the dorsal po- sition, the labia are sepa- rated, and she is asked to strain. The bulging forward of the rectocele is obvious. Treatment. — Proper re- pair of the perineal floor and body, as described under lacerations of the birth canal, is the proper treat- ment. In all cases where the rectocele is marked, the Hegar shape of denudation is better than the Emmet. A common cause of re- currence of a rectocele, after even a properly performed plastic operation, is chronic constipation and the conse- quent forward push of the column of fecal matter, with ^^ a u 1 ^- c .u _ ' i^iG. 115.— An old laceration of the the patient's straining ef- perineum in both sulci. Rectocele. forts. It is vital to the Jhe mouth of the vagina is held open to show the appearance of the parts success of a plastic opera- before operation: a, Apex of the rec- tion that constipation be *°^^^«- (P'^^°''-^ prevented, and this should be done by laxatives. Merely emptying the lower bowel by enema is not sufficient. X. CYSTOCELE Cystocele is a bulging downward of the bladder, and anterior vaginal wall. 264 PATHOLOGICAL SEQUELS OF CHILDBIRTH Causes. — (i) Laceration of the muscle of the urogenital trigonum; (2) diastasis of the anterior vaginal fascia; (3) elongation of the utero vesical and cardinal Hgaments. While a cystocele often develops after spontaneous delivery, the most important predisposing cause of a cystocele is traction by forceps, particularly axis-traction forceps, before the head has passed through the cervix, and improper direction of puU on the forceps at any stage (outward instead of downward until the head is under the pubic arch) . The injury often does not appear until several months or even many years after labor. Its proper correction in all cases is one of the as yet unsolved problems of gynecology. Cystocele ma}^ occur in nulliparous women or even virgins, but except as a consequence of childbirth it is exceedingly rare. It is always associated with some degree of prolapse, and in procidentia, the greatest part of the protruding mass is the cystocele. Mechanism. — Cystocele usually begins in the upper part of the anterior vaginal wall, near the cervical attach- ment. As a result of intra-abdommal pressure, in the erect posture the vaginal wall is gradually dragged away from its attachment to the pubic rami, and the anterior vaginal wall first appears at the vulvar orifice and later bulges through it. Occasionally only the anterior third of the vaginal wall is m- volved, and in this case the moderate protrusion is called ure- throcele. This is to be distinguished from the hypertrophy Fig. 116.- -Rectocele and cystocele. (Penrose.) CYSTOCELE 265 of the suburethral vaginal mucosa, often seen as a result of pregnancy. Symptoms. — (i) The patient complains of some protrusion from the vulva, which she is likely to call the uterus; (2) vesical irritation, from decomposition of residual urine, in the pouch below the urethra. Diagnosis. — With the patient in the dorsal position, the labia separated, she is asked to strain. The protrusion of the anterior vaginal wall is very obvious. It is not advisable to test the position of the;, bladder by the insertion through the urethra of a sound. There is great danger of injury to the vesical mucosa and consequent ulcer. A suburethral ab- scess, from Skene's glands, looks not unlike a cystocele, but the absence of bulging on straining, the brawny feel and pus oozing from the urethra should make the diagnosis easy. Treatment. — Palliative by the globe, ball-and-stem, air-cushion ring, Menge, Schatz, or Gehrung pessaries. The pal- liative treatment is never curative, and is simply a crutch, and is indicated in those cases only where operation is inadvisable or impossible. 1. The globe pessary is a hard rubber ball, inserted in the vagina and held in place partly by its size and partly by a protective napkin worn by the patient. It has the advantage of simplicity, but is likely to be forced out if the patient strains. 2. The ball-and-stem pessary is a hard rubber ball on a stem, which in turn is held in place by an abdominal belt with peri- neal straps. It is efficient, but is a cumbersom.e harness and usually objectionable to the patient. 3. The soft rubber air-cushion, either singly or as the Hewitt Pig. iiy.^Globe pessary with stem. (B. C. Hirst.) 266 PATHOLOGICAL SEQUELS OF CHILDBIRTH triple ring should never be used. It becomes very foul after a short residence, and there is considerable danger of sepsis. 4. The Schatz door-knob pessary is simple and efficient. It is shaped exactly like a door knob, and is inserted with the Pig. 118. — Different forms of the ring pessary for prolapse or cyslocele. Unsatisfactory because they usually turn sideways and drop out. knob against the cervix. The shank of the pessary keeps the knob transverse in the vagina, and hence the pessary does not drop out. It completely fills the vagina, and makes coitus impossible. Pig. 119. — Schatz's door-knob pessary for prolapse of the uterus. Not quite so efficient as the Menge, but based upon the same principle. 5. The Menge pessary is similar in principle to the Schatz, except that the bulb forming the shank of the pessary is detach- able, to facilitate removal. It is very efficient, but also fills the vagina completely. 6. The Gehrung pessary consists of two horseshoe-shaped CYSTOCELE 267 arches joined at their heels. It is inserted so that the heels of the arch are laterally pressing against the remains of the pelvic floor, and the keystone of the arch up against the bladder. It is fairly efi&cient, as long as it does not change its position, which it is very prone to do. Pig. 120. -The Menge pessary for prolapse, inserted. Showing its position when The Menge and Schatz pessaries are the best. They must be removed every six to eight weeks, the vagina inspected for erosion and if none be found, the pessary is cleaned and re- inserted. Usually after some months there has been some contraction of tissue, so that a smaller pessary than the one 268 PATHOLOGICAL SEQUELS OF CHILDBrRTH at first used can be inserted. If any erosion occurs, the pessary must be left out for several weeks and the patient takes a daily douche of normal salt solution. After the erosion has disap- peared, the pessary can be reinserted. In the average case, erosion will occur about twice a year; more frequently the older the patient. These directions apply to some degree to all pessaries, but particularly to the Schatz, Menge and Gehrung. Operative Treatment. — A great number of operations have been devised, but there is no single operation applicable to all cases. The age of the patient, the degree of cystocele, and the method of its production must be considered. I. The Stoltz purse-string operation is applicable only to small cystoceles, and particularly to urethrocele. It is a Fig. 121. — Operations for cystocele. Prom left to right: i. Stoltz purse string operation. 2. Old oval denudation. 3. Martin operation. 4. B. C. Hirst operation, a, Urethra; b, cervix; c, denuded area; d, stitch. an archaic method, but fairly effective. The technic is denudation of a circular space covering the arch of the cysto- cele and a purse-string suture of number 2 chromic forty- day gut is then placed around this, taking care that the needle does not penetrate the bladder. 2. The Martin operation is efficient, except in large cysto- celes. An oval denudation is made, covering the area of the cystocele, and wit! a running stitch of number 2 chromic forty- day catgut, the denuded area is gradually obliterated, with several tiers of stitches. If this denudation is carried out far enough laterally to expose the retracted fascia, the results are very satisfactory. CYSTOCELE 269 3. The Hirst (B. C.) operation is valuable, also in moderate cases. The cervix is caught and pulled down. A longitudinal incision is made from the base of the urethra to the cervico- vaginal attachment, and a transverse incision across the cer- vix, so the shape of the incision is an upside down T. The anterior vaginal mucosa is dissected away from the bladder, until the lateral fascia is exposed. The uterovesical ligament is cut and the bladder pushed up. The lateral fascia is then brought together in the middle line, using interrupted stitches of number 3 chromic catgut. The excess of mucosa is cut off and the vaginal flaps closed. Interrupted stitches are better than continuous, as the latter causes too snug a closure and favors development of a hematoma. 4. The Goffe operation is like the preceding until the bladder is dissected free and the uterovesical ligament cut. Then a retractor is placed under the bladder, the peritoneaL pouch caught and opened, and the bladder suspended to each uterine cornu and the uterine fundus with stitches of linen thread. The peritoneum is closed and the vaginal wound repaired. 5. The Watkins-Freund-Wertheim operation of interposi- tion of the uterus under the bladder, by opening the anterior vaginal vault is the surest cure, but is not usually done where any further childbearing is to be expected, unless the patient is artificially sterilized, by resection of the Fallopian tubes at the uterine cornu. It is the only method to be depended upon in very large cystoceles, particularly those occurring very soon after delivery by axis-traction forceps. Technic. — (i) The bladder is dissected free and the perito- neum opened as just described in the Goffe operation. 2. The uterine body is caught with a tenaculum and gently pulled through the peritoneal opening. 3. A stout curved needle, with number 3 chromic cat- gut catches the lateral fascia near the urethra, the fundus uteri between the tubes and the lateral fascia on the other side. 270 PATHOLOGICAL SEQUELS OF CHILDBIRTH 4. Four or five similar stitches are inserted, gradually approaching the cervix. 5. The bladder is pushed back, over the fundus, and the stitches tied from above downward. This fixes the uterus imder the bladder, in a position of extreme anteflexion. 6. The excess mucosa is trimmed off and the vaginal wound closed. 7. In all interposition operations the convalescence is marred by some degree of bladder irritation or actual Fig. 122. — The position of the uterus and its relation to the bladder after the Watkins-Wertheim operation of interposition. {After Crossen.) cystitis. This can be minimized by the routine use of urotropin, 10 grains four times daily, for the first three days after the operation. Permanent suture material is not desirable, as a sinus fre- quently results. These patients have difficulty in urination for a time, and have to be catheterized. They often have menorrhagia, for many periods afterward, but usually the excess flow is not great. In spite of these drawbacks, the opera- tion gives good results, when future childbearing is not to be expected. 6. The author has used, for some years, with great satisfac- PROLAPSE OF THE UTERUS 27 1 tion, a variation of the above technic by which the uppermost uterine stitch grasps the uterus at the junction of the middle and upper thirds, so that the uterus with the lateral vaginal fascia forms a shelf on which the bladder rests, but is not anteflexed. Several patients, on whom this was done have passed through subsequent childbirth, without dystocia and without recurrence of the cystocele, and he has, in 141 cases, seen no primary failures. 7. In very severe cases, recurring after other methods, it may be necessary to open the abdomen and sew the bladder fan-shaped to the anterior abdominal walls. By one of these methods, practically any case can be managed. XI. PROLAPSE OF THE UTERUS While the great majority of cases result from the inju- ries of childbirth, there are other causes: (i) Sudden severe muscular effort; (2) constant muscular shocks (as in a chronic cough) ; (3) rupture of an ovarian cyst (the weight of the fluid in the lower abdomen acting as a mechanical cause). Too early rising after labor, with the. resumption of hard work, associated with unrepaired lacerations is the commonest cause of prolapse; a predisposing factor is forceps delivery through a partially dilated or partly effaced cervix, axis-traction forceps, or improper direction of pull in any forceps operation. Degrees of prolapse are named from the position of the cervix; such as: Prolapse with cervix on the pelvic floor, or at the outlet. Any prolapse in which the cervix or rest of the uterus is outside the vulvar orifice is called total prolapse or procidentia uteri. Mechanism. — (i) Laceration of the pelvic floor, allowing the uterus to sag until its ligaments become suspensory; (2) retroversion of the uterus, until its axis coincides with that of the vagina; (3) descent of the uterus by stretching of the uterosacral ligaments and the vaginal attachments to the pubic rami. 272 PATHOLOGICAL SEQUELS OF CHILDBIRTH Symptoms. — (i) Loss of support, felt worst toward evening, when the patient has been on her feet all day; relieved by rest in bed; (2) complaint of protrusion through the labia of the cervix or other portion of the uterus (depending upon the degree of prolapse) . The degree of prolapse is named from the position occupied by the cervix, when the patient is in the erect Fig. 123. — The different stages of prolapse of the uterus. (After Kelly.) posture. A prolapse in which the cervix or uterine body emerges from the vulva, is called complete, or procidentia uteri. Diagnosis is easy. The cervix, or more of the uterus, is seen to protrude between the labia. It is important not to make an examination when the patient has been some time in bed or just after the removal of a pessary, as the true degree of pro- lapse may not be apparent. Cystocele is always marked, and usually forms the greater part of the protruding mass. The PROLAPSE OF THE UTERUS 273 vaginal mucosa is usually thickened and rough, and may be the site of extensive ulceration, especially near the cervix. Treatment. — Palliative treatment is indicated only when operation is inadvisable. It is never curative and while it gives immense relief, patients must be made to understand that they must be constantly under supervision. Occasion- ally, after the menopause, the genital atrophy will effect a Pig. 124. — Prolapse of the uterus. The cervix is pulled down by a double tenaculum on the posterior lip. (After B. C. Hirst.) spontaneous cure, but this is never to be expected. Usually prolapse gets worse after the menopause. The palliative treatment consists in support by a pessary, the same as used in cystocele. The Schatz and Menge are much the best in prolapse, and their use here is exactly the same as in cystocele. Operative Treatment, i. Preparatory. — Most cases require no preparatory treatment, but often, as a result of constant 274 PATHOLOGICAL SEQUELS OF CHILDBIRTH exposure, friction of the thighs clothing and irritation by urine and perspiration, the vaginal mucosa is the seat of extensive iilcers. These must be healed, before any operation is undertaken. 1. The patient is kept off her feet. 2. The uterus is replaced and held in place by tampons with 25 per cent, boroglycerid. 3. The ulcers are painted with 20 grains to the ounce nitrate of silver solution, three times a week. 4. The patient takes twice daily in the interval between tampons, a vaginal douche of hot normal salt solution. Under this treat- ment, the ulcers disappear in four to six weeks. Irreducible prolapse is the name given when the uterus has been so long prolapsed that it is con- gested, swollen and cannot easily be replaced. It can be managed, however, by (i) knee-chest posture; (2) wrapping the protruding mass in towels, wrung out of very hot water; (3) pressure to reduce engorgement; (4) taxis, upward, like in incarcerated hernia. Operation. — The best method is that which does not do too much violence to the normal anatomy and leaves the patient in as normal a condition as possible. The following technic has given excellent results: 1. The patient is arranged as for a plastic operation, in the dorsal position. 2. The cervix is caught with double tenacula and pulled down. Pig. 125. — Prolapse of the uterus and rectum. {A uthor's case, Phila- delphia General Hospital.) PROLAPSE or THE UTERUS 275 3. The cervix is amputated, by the Hegar technic. 4. The cervical canal is dilated and the uterine cavity curetted. This is done after amputation, because the cervix is usually too long for effective dilatation. Fig. 126. — Prolapse of uterus and bladder Notice that the bulk of the protruding mass is cystocele. 5. A Watkins-Freund operation is done for the cystocele. 6. An extensive Hegar perineorrhaphy is done. Pig. 127. — The Goddard pessary for prolapse, cheap and efficient, but requires a bandage around the waist for support. No abdominal operation is necessary for prolapse. The cystocele operation eliminates retroversion, and the plastic work, properly done, is ample for support. A common mistake is to perform vaginal or abdominal 276 PATHOLOGICAL SEQUELS OF CHILDBIRTH hysterectomy. This should never be done unless there is uterine carcinoma and should then be followed by extensive plastic work on the anterior and posterior vaginal walls, to prevent inversion of the vagina, which will surely follow if this be neglected. Neither vaginal hysterectomy nor ventro- fixation of the uterus will alone cure prolapse of the uterus, unless combined with extensive vaginal repair. Most operations for prolapse are done at an age when further Fig. 1 2 8. ^Complete inversion of the vagina, following vaginal hysterectomy for prolapse of the uterus. {Author's case, St. Agnes Hospital.) childbearing is unlikely. In young women, however, lacera- tion is likely to recur at any future delivery, but proper repair at that time will usually prevent any recurrence of the prolapse. In most cases of prolapse in women in the child- bearing age, it is desirable that no further pregnancy occur. INCONTINENCE OF URINE 277 This can be managed by resection of the tubes at the uterine cornua, during the cystocele operation, and hysterectomy is an unnecessarily radical method. XII. INCONTINENCE OF URINE Incontinence of urine is due to fi) Paralysis of the vesical sphincter; (2) overflow from retention; (3) laceration of the urogenital muscle (compressor urethrae); (4) fistula; (5) pull upon the vesical neck by a retroverted uterus. The sjmiptoms are obvious. There is a leakage of urine, either constantly or upon any exertion. The diagnosis of the cause may be difficult. The in- continence of the overflow is easily overcome by the catheter (soft rubber or silk and not glass). That due to fistula can be managed only by the closure of the fistula. Incontinence only upon sudden muscular effort is almost always due to laceration of the muscle of the urogenital trigonum, the repair of which will be found described in the chapter on the injuries of the birth canal. Retroversion is diagnosed by manual examination. If none of these causes are responsible, the cause is paralysis of the vesical sphincter. Moderate cases tend to recover spontaneously. Cases of long standing are exceedingly difl&cult to treat. Large doses of strychnin (grain }y^Q four times a day) over a long period and the slow interrupted faradic current, one pole in the urethra and the other on the abdomen, applied for 45 minutes every day will often hasten a cure. If a reasonable trial fails, injections of paraffin (melting point iio°F.) are often successful. The injection is made in the tissues between the anterior vaginal wall and the vesical neck, and is dumb-bell shaped, with the transverse bar across the vesical neck. The effect is that due to slight pressure. The paraffin can be removed at any time, by incision and enucleation, and this should be done in the event of future pregnancy, as the pressure of the child's head on the mass of paraffin might be disastrous to the bladder. In otherwise intractable cases, surgical methods are (i) 278 PATHOLOGICAL SEQUELS OF CHILDBIRTH shortening the vesical sphincter; (2) extensive cystocele opera- tion; (3) interposition operation. They should be tried in this order. XIII. GENITAL FISTULA The causes of genital fistulae are: (i) Sloughing from con- tinued pressure in obstructed labor — now becoming rare, due to better management; (2) lacerations from violent delivery or slipping forceps; (3) abscess; (4) tuberculosis; (5) syphilis; (6) cancer — in its later stages. Kinds. — A long list of fistulae may be made by connecting in every possible way the bladder, vagina, rectum, ureter Pig. 129. — Fistulas of the genital organs: a, Vesico-uterine fistula; b, vesicocervical fistula; c, vesicovaginal fistula; d. urethrovaginal fistula; e, rectovaginal fistula; /, perineovaginal fistula. (Beigel.) intestine, uterus and urethra. By far the commonest are, in order: (i) Vesicovaginal; (2) rectovaginal; (3) uretero vaginal; (4) vesico-cervico-vaginal. Diagnosis of Vesicovaginal Fistula. — The patient complains of constant dribbling of urine; usually excoriation of the labia and thighs, and, if the fistula is of long standing, cicatricial GENITAL FISTULA 279 contractions of the vagina. In very small fistulas there may be leakage only in certain positions, or when the bladder is full. Almost always there is a complicating cystitis. The demonstration of a fistula may not be easy. Large ones can usually be seen at once, but a small fistula may be so hidden by a fold of the vaginal mucosa, that it is difficult or impossible to see it. If the fistula cannot be seen (usually near the cervix and toward one vaginal vault) when the vagina is expanded by a bivalve speculum, other means of diagnosis must be used, (i) Searching with a probe — a rather clumsy method; (2) cystoscopy, as the bladder end of the fistula is usually easier to see, and a probe or ureteral catheter can then be passed through it; (3) injection into the bladder of colored fluid, when its point of leakage can be seen. The best fluid is sterile milk, and four ounces is enough. If the fistula is so small that leakage only occurs in the erect posture, the bladder may be injected with 2 per cent, methylene blue solution, small pledgets of cotton placed in the vaginal vaults and the patient allowed to walk about for a few minutes. The pledget of cotton marking the site of the fistula will be stained blue. By these injections, incontinence due to paralysis of the vesical sphincter may be excluded. Treatment of Vesicovaginal Fistula! — No attempt should be made to repair the fistula until puerperal involution is complete. Two or three months after labor is the most favorable time. Very small fistulse may sometimes be made to heal by cauteri- zation with nitric acid or a red-hot probe or electric needle. This method is not usually safe, as it may cause the fistula to enlarge instead of heal. Usually, the steps of repair are: (i) For at least a week before operation, the bladder should be flushed with boric acid solution, twice daily. 2. For the operation, the patient is anesthetized, placed in the dorsal (or Sims) position, and prepared locally as for a plastic. 3. The fistula is located, and denudation is made around it, down to but not through the vesical mucosa. 28o PATHOLOGICAL SEQUELS OF CHILDBIRTH 4. The edge of the fistula is spht, so as to separate it from the anterior vaginal wall. 5. The bladder wall is closed with interrupted number i chromic catgut or linen thread stitches. 6. The vaginal mucosa and fascia is closed over the bladder wall by interrupted stitches of linen thread. The denudation should be so planned that as little tension on the stitches as possible will result. Fig. 130. Fig. 131. Fig. 130. — The simplest form of operation for vesicovaginal fistula. Fig. 131. — The flap-splitting operation for vesicovaginal fistula. 7. The bladder is kept from overflowing by a permanent mushroom catheter, or better by catheterization every four hours, as the permanent catheter is likely to cause trouble- some cystitis. The linen stitches are removed in two weeks. Com- plete success is not common at the first trial, and re-operations are frequent. If the vagina is the seat of cicatricial contrac- tion, the bands must be cut, the vagina dilated with glass GENITAL FISTULA 261 plugs and the normal elasticity restored as far as possible, be- fore any repair is attempted. Syphilitic, tubercular and cancerous fistulae should not be touched surgically, as they are impossible to repair. Very large fistulae, so large that no flaps can be made by dissection and undermining of the edges may be treated in one of two ways, (i) Opening the anterior vaginal vault, anteverting the uterus, and sewing the uterine body, as a plug, in the opening in the bladder; (2) complete closure of the vagina^ — colpocleisis — so that the bladder and vagina form one cavity. This is so often followed by ascend- ing infection of the ureters, pyelonephrosis and fatal sepsis, that its use seems unjustifiable. Diagnosis of Rectovaginal Fistulae. — The patient complains of passing fecal matter and gas through the vagina. The same symptoms seem to occur in tear of the sphincter, and the patient is unable to distinguish between them. The fistula is usually easy to see, and is most often just inside the vagina or on the perineum. Milk may be injected and its point of exit noted. Treatment of Rectovaginal Fistulae.^ — Repair is much easier and more certain of success than in vesical fistula. An oval denudation is made around the fistula down to but not includ- ing the rectal mucosa. The edge of the fistula is split, to separate the rectal wall. The opening in the rectum in closed with number i chromic catgut, interrupted stitches, and the vaginal wall closed over it. The bowels are kept loose from the start, two movements a day being required. Before any attempt is made to close an apparent rectovaginal fistula, anus vestibularis must be excluded. In these cases the anus opens just inside the vaginal orifice, and has all the appearance of a fistula. A little care in diagnosis will prevent this mistake. Here also syphilitic, tubercular and cancerous fistulae cannot be repaired. Diagnosis of Ureterovaginal Fistulae.^ — Constant dribbling of urine, irrespective of the patient's position, but in amounts 282 PATHOLOGICAL SEQUELS OF CHILDBIRTH smaller than would be expected from a vesicovaginal fistula. No opening from the bladder can be found, but the fistula, or at least the source of the urine, can usually be seen in one vaginal vault. These fistulae are most common after high forceps deliveries, or in rapid delivery of a breech or in version. Such a history may help in directing attention to the site of the fistula. If the fistula cannot be seen, a hypodermic injection of indigo-carmine (2 mils) is given. Then by placing cotton pledgets near the supposed site, the blue stain on the cotton will serve to locate it. Treatment of Ureterovaginal Fistulae.^ — Either implantation of the ureter into the bladder by the vaginal route — colpo- ureterocystostomy, or by the abdominal route — laparo-ure- terocystostomy. Implantation of the ureter in the bowel is likely to cause ascending infection and pyelitis and is not desirable if it can be avoided. Vesicocervicovaginal fistula, from violence in forceps deliv- eries or too rapid extraction of the child after version or in a breech presentation, is one of the most difficult of fistulse to treat. The urine can be seen emerging from the cervix. The only way to close the opening is to dissect the anterior vaginal wall from the bladder, free the bladder by cutting the utero- vesical ligaments, and closing the fistula in the bladder, which is thus exposed, by interrupted sutures of linen thread. It is, fortunately, rare. It is difficult to lay down any set rules for operation for a condition in which each case is a separate problem. The method of closing genital fistulae must be adapted to the needs of the individual^ case. The foregoing is merely an outline of typical cases. CHAPTER XIV DISEASES OF THE URINARY TRACT INCLUDING CYSTOSCOPY General Anatomy. — The kidney is essentially the same, in its anatomical relations, in both sexes. The ureter in the female is wider than in the male; it runs retroperitoneally to the pelvic brim, crosses the common iliac just before the internal iliac branches off; dives into the pelvis and passes through the base of the broad ligament, near the cervix, and thence into the base of the bladder, to empty into the trigone. The uterine arteries lie in close relationship with the ureter, crossing in front at the level of the internal OS. The left ureter lies much closer to the cervix than the right; and both ureters lie much closer than normal to the cervix when the uterus is prolapsed or pulled down. The bladder is broader than in the male, its normal capacity is less, and its waits thinner. It is much more dilatable than the male, and lies deeper in the pelvis. The fundus and upper portion of the anterior wall are covered by peritoneum, the posterior wall is not. The trigone is a triangular space formed by lines drawn between the ureteral orifices and the urethra. Between the ureters runs a slightly raised band in the bladder wall, called the interureteric fold, which is of great value in locating the ureteral orifices in cystoscopy. The urethra is short, of large caliber, very dilatable and is lined with pavement epithelium in its lower, cylindrical in its upper portion. In the floor lie Skene's glands. The blood-supply of the bladder and urethra comes from the internal pudic, inferior vesical and in part from the uterine arteries. 283 284 DISEASES OF THE URINARY TRACT The veins empty into the vesicovaginal plexus. The nerves are from the pudic. The lymphatics empty into the deep hypogastric and ingui- nal glands. Technic of examination of the female urinary tract, (i) Catheterization is often necessary to collect urine uncontami- nated by admixture of vaginal secretions. There is great danger of cystitis unless it is carefully done. A satisfactory technic is as follows: 1. Catheters must be thoroughly cleaned after using and boiled before being put away. 2. Catheters must be boiled for ten minutes just before use. Pig. 132. — The trigone of the bladder with the ureteral orifices and the interureteric fold. 3. Use soft rubber catheters, and not metal or glass ones. 4. Get ready i small basin lysol solution (2 drams to i pint), I small basin sterile water; sterile cotton; sterile gloves. At night have candle or flashlight. Use catheter from basin and water in which it has been boiled, and do not handle except with gloves. 5. Have patient arranged on her back, knees drawn up and separated. Use two fingers of gloved hand to separate labia and expose urethral orifice. With other gloved hand, wipe off urethral orifice with cotton and lysol solution, followed by . sterile water. 6. Pick up catheter, lubricate end with sterile albolene, and insert gently. CYSTOSCOPY 285 7. When bladder is emptied, withdraw catheter, and wipe off urethral orifice again with cotton and lysol solution, followed by sterile water. 8. Always have light enough to see, and never trust to feeling for the urethra. 9. Cleanse catheter after using and always boil before putting away. 10. Failure to observe these precautions may result in serious disability to a patient. There is no excuse for a patient's developing inflammation of the bladder after the use of the catheter. CYSTOSCOPY Cystoscopy is done by two methods: (i) Water distention of the bladder; (2) air distention. The method of air distention is clumsy and inconvenient. It requires an exaggerated Trendelenburg or the knee-chest posture, and is of use only when there is so much pus in the bladder that a clear fluid for vision is not obtainable. The instrument used is the Kelly open channel cystoscope, requir- ing reflected light from a head light or mirror, and the view obtained is limited and unsatisfactory. Water distention is much more desirable. It does not require anesthesia, can be done as a routine ofiice procedure, and rarely gives the patient more than passing discomfort. A very satisfactory instrument is the Brown-Buerger special, with a wide visual field. With this cystoscope it is just possible to see both ureteral orifices in the same field. Directions for its use are as follows: 1. Patient in lithotomy position, no ether. 2. Cleanse urethral orifice, and if very small, use small urethral sound (22). 3. Have cystoscope, cord and catheters sterilized by forma- lin vapor. If wiped off with alcohol, never get it or any other fluid on the eyepiece. 4. Easiest to use examining lens first to locate ureters, and 286 DISEASES OF THE URINARY TRACT then change to catheterizing lens. This only in the older models with limited field of vision. 5. Lubricate light of scope only, never get anything on lens, and use only glycerin or water soluble lubricant. 6. Insert cystoscope, turn upside down (except in direct vision scopes), attach irrigating tube, and light cord. 7. Allow water to run in bladder, until patient feels de- sire to urinate, then cut off and turn light on slowly. Too little water in bladder is the commonest cause of trouble. 8. Always work with as little light turned on as possible. Lights are easily burned out and are expensive. ' 9. If fluid is cloudy, let water run in and out until clear. 10. Look for ureters by turning cystoscope at angle of 45 degrees to perpendicular on each side of bladder. If a doubt- ful spot is seen and you cannot be sure whether it is the ureter, watch it for a few seconds. If it is a ureter, it will spout urine. Where the ureteral orifices are difi&cult to find, it is a good plan to inject into the patient's thigh one mil of indigo-carmine. After about twelve minutes both kidneys will begin to ex- crete the color, and the spurts of blue urine from the ureters makes their detection easy. II. When finished with examining lens, turn light off, Pig. 133. — Sterilizing plant for cystoscopes and catheters. Loose formaldehyd powder in bottom of jar. Efficient and inexpensive. CYSTOSCOPY 287 remove cystoscope, change to catheterizing lens, insert cathe- ters and proceed as before to insert cystoscope and find the ureters. Only in instruments of limited field. 12. To catheterize ureter, when located, focus it at about 5 o'clock (right) or 7 o'clock (left) using the field as a clock face. Push catheter down till visible past lens. Guide it in proper direction with the hinged flap worked from the handle of scope and push in mouth of ureter. When in, put flap down flat again and then push catheter up to pelvis of kidney. 13. To push catheter in, grasp it with fingers as near where it enters the cystoscope channel as possible, and push m by very short steps. Otherwise it will bend. 14. Never catheterize a healthy ureter from an infected bladder. 15. To wash out pelvis of kidney use a Luer glass or Ricord syringe and boric acid solution and then hegonon i per cent, or silvol 5 per cent. The pelvis of the kidney should hold 10 to 15 c.c. but be guided by patient's complaint of pain, and never persist after pain starts, and never force the fluid through the catheter. 16. To remove cystoscope turn off light, disconnect water tube, be sure guiding Hap is Hat down and remove. 17. To leave catheters in, push up as far as possible, allow- ing them to curl up in bladder. Leave only ^^^ inch of catheter beyond eyepiece of cystoscope. Then remove cystoscope as in number 16. When catheters appear at urethral orifice, hold them and pull cystoscope away from them. Fix them to thighs with adhesive tape, let drain into bottles and be sure before re- moving the cystoscope that you know which is right and which left. 18. After using, dry cystoscope with gauze, dry catheters by wiping off and keep them with stylets in them. The stylets should be German silver and not steel wire, or the latter rusts badly. Never get any moisture in the eyepiece of the scope. This end is not watertight. 19. After any case of ureteral catheterization, there is liable 286 DISEASES OF THE URINARY TRACT to be severe pain, of short duration, from the passage of a blood-clot down the ureter. The pain simulates stone, is short lived, but may require morphin hypodermically to relieve it. 20. Injections into ureter, of antiseptic solution, are most useful in pyelitis. The most satisfactory are silvol, 5-10 per cent., arg}Tol 25 per cent., protargol 2 per cent., hegonon i per cent, and boric acid solution gr. 10 to oz. i. All in- jections are made slowly and discontinued as soon as the patient complains of discomfort in the back. USES OF URETERAL CATHETER \^i) To collect urine from the kidneys separately; (2) diagno- sis of stricture; (3) diagnosis of stone; (4) irrigate pelvis of kidney; (5) .-v-ray picture; (6) to locate the ureter, in opera- tion for cancer. SEGREGATION OF URINE In cases where it is impossible or inadvisable to catheterize the ureters, urine may be collected from each side of the bladder separately by segregation. The Harris instrument is a double bar inserted in the bladder, separated, and the vaginal and bladder walls pushed up between the ends, by a third bar in the vagina, so as to make a watershed. The urine is then removed by suction with a s}Tinge. The Cathelin or Luys instruments use a water-tight rubber diaphragm for the same purpose. Segregation is not as good as ureteral catheteri- zation and should not be used when the latter is practicable. PYELOGRAPHY Pyelography, or the injection into the pelvis of the kidney of a solution opaque to the a;-ray, and then taking an .x--ray picture, is of great value in diagnosis of position and hydrone- phrosis, but is not without danger, as the solution wiU some- times penetrate into the renal parenchyma or cause necrosis and suppuration. The best solutions are:(i) thorium nitrate 5 per cent.; (2) collargol 10 per cent.; (3) argentide emulsion. PYELITIS 289 The amount used varies from 5 to 20 c.c, depending upon the capacity of the kidney pelvis, and no force must be used in the injections. When the pelvis is full, the patient feels some discomfort in her back, the injection is stopped and the x-ray taken at once. DISEASES OF THE URINARY TRACT I. Diseases of the Kidney PYELITIS Pyelitis is a bacterial infection of the mucosa of the pelvis of the kidney. There are two avenues of infection: (i) hematogenous, through the circulation; (2) ascending infec- tion from the bladder, along the ureter. The first is much the commonest. Bacteria. — (i) Bacillus aerogenes mycosum (of the colon bacillus group); (2) colon bacillus; (3) pneumococcus; (4) staphylococcus; (5) streptococcus; (6) gonococcus. In chronic cases the colon bacillus or Bacillus aerogenes mycosurn are present in pure culture; in acute cases staphy- lococci, pneumococci and streptococci are commonly found. Causes. — Predisposing causes are the tendency to hydro- ureter and hydronephrosis due to a movable kidney or direct pressure on the ureter against the pelvic brim. Actual Causes. — (i) Widespread sepsis, postoperative; (2) stone; (3) puerperal infections; (4) cystitis and retention of urine. In many cases no exciting cause can be demonstrated. Symptoms. — Acute Cases: (i) Chills and high fever; (2) leukocytosis; 18,000-24,000; (3) pain in loin, referred down ureter; (4) pyuria. Chronic form persists after an acute attack, but more com- monly is subacute or chronic from the beginning. (i) Pyuria; (2) sensitiveness to pressure in kidney region. (3) pain referred intermittently along ureter; (4) moderate leukocytosis; (5) irritability of the bladder. Acute pyelitis is a dangerous and sometimes a fatal infection; chronic pyelitis may persist for years with very moderate symptoms. 19 290 DISEASES OF THE URINARY TRACT Site. — It is most commonly unilateral, and on the right side. It may affect either side, however, and is occasionally bilateral. Urine Examination. — The amount of albumin in the urine is at first in direct ratio to the amount of pus present; a greatly increased amount of albumin shows pyelonephritis with in- volvement of the parenchyma. Casts are not present in simple pyelitis. Functional tests for excretion of urine, in simple pyelitis, show little difference in the two sides. Where the parenchNona of the kidney is invaded, however, that side always shows retarded function. {i) Indigo-carmine. — If i mil of indigo-carmine is injected in the thigh, blue urine should be seen, through the cystoscope, to emerge from the ureters in about twelve and a half minutes. Delay usually indicates improper function, though exceptions are numerous. Phenol sulphonphthalein. — Two to 4 mils of phenolsulphon- phthalein are injected deep in the patient's thigh. She is catheterized immediately before the injection; again in one hour and ten minutes and again in one hour. The last two specimens are saved. Their color is compared with that in the colorimeter vials. About 60 per cent, is the normal excre- tion in two hours. Less indicates improper function, although wide variations are seen. Diagnosis is easy. Cystoscopy will show the mouth of the aflfected ureter to be eroded, edematous, and cloudy urine can be seen to spout from it. Causes of right-sided pain in women are: (i) Cholecystitis or gall-stones; (2) fecal impaction in hepatic flexure of colon; (3) floating kidney with hydronephrosis; (4) kidney stone; (s) ureteral stone; (6) pyelitis; (7) appendicitis; (8) salpingi- tis; (9) extra-uterine pregnancy; (10) ovarian cyst tmsted on pedicle; (11) varicose veins in broad ligament. Differential Diagnosis. — Pyelitis is commonly mistaken for chronic appendicitis, but urine examination and cystoscopy PYELITIS 291 should clear up the diagnosis at once. It is safer never to operate for chronic appendicitis in women, until pyelitis has been excluded. Treatment.- — Palliative: (i) Rest in bed, on side opposite the affected one; (2) ice bag to affected loin; (3) large amounts of water, twelve to fifteen glasses a day; (4) milk diet; (5) urinary antiseptics (salol, urotropin, helmitol gr. 10 every four hours; (6) bladder irrigations, to help ureteral peristalsis and aid drainage. This usually causes rapid improvement in acute cases. Radical. — Cystoscopy; catheterization of affected ureter, washing out of pelvis of kidney with boric acid solution, followed by 10 to 15 c.c. of 5 per cent, silvol solution, or i per cent, hegonon, or 25 per cent, argyrol. This, possibly repeated, will cure most cases. It can be done at once in chronic cases., but in acute ones is not advisable, due to the danger of pyelonephrosis. Vaccine Treatment. — In chronic cases, which do not clear up with two or three irrigations of the pelvis of the kidney, the affected ureter should be catheterized, the exciting organ- ism isolated and cultured and an autogenous vaccine made. Injections of this vaccine (100 million to the dose) will often give most brilliant results, and should always be tried in cases not responding to treatment. It is of value only in the chronic cases and does no good in the acute ones. Surgical Treatment. — (i) Decapsulation of the kidney is illogical and does no good; (2) if pyelitis is due to stone in the pelvis, the stone must be removed; (3) nephrotomy for drain- age is required for pyelonephrosis or (4) nephrectomy if the kidney is badly diseased or tubercular. Prognosis. — A simple pyelitis will last for a long time with- out involving the kidney parenchyma, but may do so at any time. Most cases yield readily to irrigation of the pelvis of the kidney; unilateral cases have fewer complications than bilateral; a quiescent pyelitis is likely to be lighted up by preg- nancy or pelvic operations. 292 DISEASES OF THE URINARY TRACT STONE IN THE KIDNEY Stone in the kidney gives the same symptoms in both sexes, though they are less frequent in women, and a discussion of their symptoms and treatment belongs in works on general surgery. TUBERCULOSIS OF THE KIDNEY This is of two types: (i) Ascending infection (more common in men) ; (2) descending infection (hematogenous) representing two-thirds of the cases and more common in women, and most often secondary to a lesion elsewhere, notably in the lung. Sjmiptoms are those of pyelitis and cystitis. Diagnosis is made by cystoscopy, which shows a dilated, retracted ureteral orifice, usually with ulceration of the bladder wall around it. The affected ureter is catheterized and the urine secured is sedimented and examined for tubercle bacilli. In doubtful cases, a guinea-pig is injected (usually in the peri- toneal cavity). The von Pirquet test is not positive proof. Treatment.^ — If there is no active lesion elsewhere, and the disease is unilateral, nephrectomy with excision of the ureter, is necessary. Prognosis is favorable if all the diseased tissue can be re- moved; unfavorable if there are active tubercular foci elsewhere. HYPERNEPHROMA Hypernephroma is the most frequent tumor of the kidney. Symptoms are (i) pain; (2) hematuria; (3) a tumor in the kidney region, movable and behind the colon. It gives early metastases, to the lungs, liver and bones, is rapidly malignant. Treatment. — Nephrectomy. Prognosis doubtful, due to the frequency of metastases. V. Floating Kidney Floating kidney has been described under the sequelae of childbirth (Chapter XIII). CYSTITIS 293 II. Diseases of the Ureter INFLAMMATION Is always secondary to pyelitis or cystitis. There are two forms: (i) dilated — where the ureter is dilated and tortuous; (2) fibroid form where the ureter is thick, straight, and has numerous strictures. Diagnosis.^ — (i) Symptoms of pyelitis or cystitis usually mask any from the ureter; (2) the thickened ureter can sometimes be palpated through the vaginal vault; (3) the cystoscope shows an eroded, red, pouting ureteral orifice, with cloudy urine issuing from it. Treatment^ — is that of the causative pyelitis or cystitis. STONE IN THE URETER Stones in the ureter are renal calculi, small enough to enter the ureter and pass down it to the bladder. Symptoms. — (i) Violent pain, referred into the pelvis; (2) blood and pus in the urine; (3) ureteral catheterization shows an obstruction; (4) x-Ya.y will show the stone. Treatment. — (i) During the acute attack hot fomentations to the affected side; (2) morphin hypodermically; (3) if complete obstruction to the flow of urine, immediate operation; (4) if the ureter is not completely blocked, cystoscopy with catheterization of the ureter and injection of sterile sweet oil; (3) if the oil does not dislodge the stone, operation with, if practicable, extraperitoneal incision of the ureter. III. Diseases of the Bladder CYSTITIS Cystitis is caused by invasion of bacteria and their entry into the bladder wall through a break in the lining epithelium. The presence of bacteria in the urine does not mean cystitis, unless accompanied by the products of inflammation (leuko- cytes, ropy sediment and epithelium). Routes of Infection. — (i) By the urethra, either by sponta- neous ascending infection (possible theoretically at least) or much more likely catheterization; (2) hematogenous infec- 294 DISEASES OF THE URINARY TRACT tion; (3) lymphatic infection; (4) fistula (vesicovaginal, vesico-intestinal or rupture of a cyst or pus tube). Causes. — Predisposing causes are lowered resistance from : (i) cold; (2) physical exhaustion; (3) chronic pelvic congestion; (4) irritating drugs (cantharides) ; (5) ammoniacal urine, as in a cystocele. Exciting Causes. — (i) Catheterization, either by a dirty catheter or by carrying organisms from the external genitalia into the bladder by means of the catheter; (2) injuries of the bladder in labor, or in operations, such as cystocele or hysterec- tomy; (3) foreign bodies, inserted accidentally or for mas- turbation; (4) infection through blood or lymph or by ascend- ing urethral infection in cases of lowered resistance; (5) by descending infection from the kidney. Kinds. — (i) Acute; (2) chronic. Site of infection may be anywhere in the bladder; the trigone being the most and the vertex the least common situation. Pathology.- — i. Acute Form: (i) Mucosa red; (2) vessels enlarged and tortuous; (3) edema of the mucosa, with ecchy- moses, most marked in the trigonum; (4) in the later stages, necrosis of the epithelium with ulcers, false membrane or extensive sloughs; (5) rarely gangrene with secondary shrink- ing in healing. 2. Chronic Form. — (i) Mucosa reddened in circumscribed areas; (2) vessels enlarged and tortuous; (3) edema of the trigo- num; (4) epithelial proliferation with polypoid elevations; (5) areas of simple ulceration, most commonly at or near the trigone; (6) diminished capacity from contraction of the wall. S3miptoms.' — Acute Form: (i) Severe pain in lower abdo- men; (2) fever; (3) leukocytosis; (4) dysuria; (5) tenesmus; (6) frequency of urination; (7) pyuria; (8) urine usually neutral or alkaline. The pain often radiates into the vagina or legs. Dysuria is most severe before urination and relieved by the act; in this it differs from urethritis, where it is most severe during the act. CYSTITIS 295 Course of Acute Cystitis. — Acute cystitis usually subsides completely under treatment, and does not often persist in a chronic form. Symptoms of Chronic Cystitis. — (i) Frequent urination; (2) pain just before urination; (3) moderate tenesmus; (4) cloudy urine; (5) ropy mucopurulent sediment; (6) bleeding only if due to stone, papilloma or cancer. Course of Chronic Cystitis.^ — Chronic cystitis is often very intractable and resists treatment and often recurs after appar- ent cure. Diagnosis. — Acute cystitis is made sufhciently clear by its symptoms alone and cystoscopy is contra-indicated; chronic cystitis can be diagnosed with certainty by cystoscopy. Through the cystoscope the vessels are seen enlarged and tor- tuous, the bladder mucosa reddened and dull, and in patches puffy and edematous. Ulcers are common, and stalactites of mucopus hang from the bladder wall. The diagnosis should not be made from cloudy urine alone unless pus is found micro- scopically, as the cloudy appearance of freshly passed urine is often only phosphates or urates. Prophylaxis. — Many cases can be avoided by proper care during operations and above all by proper technic of catheteri- zation, a safe technic of which is described in the beginning of this chapter; with the elimination of these two causes, cystitis is a rare affection. Treatment.^ — i. Acute Cases: (i) Rest in bed; (2) milk diet; (3) hot water bag constantly over the bladder region; (4) large amounts of water by mouth (12-15 glasses a day); (5) uro tropin 15 grains, acid sodium phosphate or benzoate of soda ID grains four times a day. Urotropin, cystogen or helmitol are given in as large doses as the patient can take without bladder irritation. The benzoate of soda is given to acidulate the urine, so that the formaldehyd contained in the urinary antiseptics is freed. This will not occur if the urine is alkaline. (6) All forms of local treatment of the bladder are con train dicated in acute cystitis; irrigation is done only when 296 DISEASES OF THE URINARY TRACT the acute symptoms have passed. For relief of pain it is best to use codein suppositories \'2 grain and not hypodermics of morphin. If hypodermics are required the best are codein sulphate gr. 3^^ or hyoscin gr. Hoo or heroin gr. 3^^ 2- Chronic Cases. — (i) Any cause that can be found is removed; (2) descending infection from the kidney is excluded, by cystoscopy; (3) bland diet; (4) urinary antiseptics (helmitol, gr. 15 four times daily with benzoate of soda 10 grains if the urine is neutral or alkaline; (5) large amounts of water; (6) if there is much frequency of urination, a useful prescription is: I^. Tinct. belladonna 3i Potass, citratis 3 ii Liq. potass, citratis q. s. ad. 5 iii M. Sig. Two teaspoonsful in water four times daily. (7) bladder irrigation and instillation. Technic of Bladder Irrigation. — Apparatus : a four-ounce glass or metal funnel, to which eighteen inches of rubber tubing is attached. This is in turn attached by a glass connection to a number 17 F. (6 American) soft rubber catheter. The whole is boiled before use. 1. The patient is arranged in the dorsal position, the vesti- bule carefully cleaned by cotton pledgets and lysol solution, the labia separated by the fingers of one hand and the catheter passed into the urethra. 2. The urine in the bladder is drained off. 3. The funnel is filled with solution, which runs into the bladder. Four ounces at a time are poured in, until the pa- tient feels a strong desire to empty the bladder. The best solution is 10 grains to the ounce boric acid solution. Other good ones are nitrate of silver 1-6000; permanganate of potassium 1-5000. Any solution used should be at no F. 4. The funnel is lowered and the solution runs out. 5. The process is repeated three or four times, till the return- ing solution is perfectly clear. 6. After the bladder is clean, 2 ounces of 5 per cent, silvol CYSTITIS 297 solution, or 25 per cent, argyrol or i per cent, hegonon are introduced with the same funnel and catheter and the patient is told to retain it as long as possible (several hours if she can). 7. Irrigations are repeated daily, but not oftener than once a day. Usually a course of treatment will last two to four weeks. 8. Irrigation is useless in tubercular cystitis. 9. The criteria for cure are: (i) The patient's subjective Pig. 134. — Apparatus for irrigation of the bladder, consisting of a catheter, glass connection, rubber tube and a metal four-ounce funnel. A glass funnel is too liable to crack in boiling. symptoms; (2) the condition of the urine; (3) the appearance of the bladder wall through a cystoscope. Consequences of Chronic Cystitis, (i) Ulcers.- — Unless these disappear under the irrigation treatment described above, they can be treated by local treatment through an air disten- tion cystoscope, with the patient in the exaggerated Trendelen- 298 DISEASES or THE URINARY TRACT burg or knee-chest posture. Twenty grains to the ounce nitrate of silver is applied directly to the ulcer, on an applicator. (2) Contracted bladder is not uncommon from the cicatrices of ulceration or from habit of frequent urination. It is very annoying to the patient, due to frequent urination. Treatment. — (i) The patient and apparatus are prepared as for irrigation; (2) after the catheter is inserted in the bladder, sterile water is allowed to flow in, by gravity, until the patient complains of uncomfortable distention; (3) then 2 ounces more are inserted and the patient made to retain this for one- half hour if possible; (4) this procedure is repeated daily, gradually increasing the amount of water as it can be retained ; (5) the treatment should be kept up until 32 ounces can be introduced and retained; this process taking from three to six weeks; (6) the patient is told to empty the bladder only three times daily as a maximum, to avoid reforming the habit of frequent urination. In very severe cystitis, resisting other treatment, it may be necessary to secure constant drainage by artificial vesicovaginal fistula. The incision is made in the middle of the anterior vaginal wall, two-thirds of the way to the cervix. The inci- sion is three-quarters of an inch long and the bladder and vaginal mucosa are sewed together, to prevent premature closure. The bladder is irrigated through the fistula twice daily with boric-acid solution. A permanent fistula is not to be feared. The fistula has a strong tendency to close spon- taneously, and when the symptoms have subsided, the opera- tion of closure is always successful, as there has not been the sloughing seen in traumatic fistula. Cystitis Vetularum (old women) is a common affection, due to shrinking and gaping of the external orifice and direct invasion of bacteria through the urethra. There is great frequency of urination and often incontinence. The only relief is irrigation of the bladder with hot boric-acid solution, followed by §ss. of 25 per cent, argyrol or 5 per cent, silvol PAPILLOMA or THE BLADDER 299 solution repeated as infrequently as is compatible with reason- able comfort. TUBERCULOSIS OF THE BLADDER This is always secondary to some primary focus elsewhere, nearly always from the kidney. The affection in the bladder usually appears as ulcers of the trigone, especially around the ureter of the affected side. The corresponding kidney is searched for evidence of tuberculosis, as already described. Treatment.^ — Nephrectomy, provided the disease is uni- lateral. The bladder ulcers will disappear -spontaneously after nephrectomy, while no other treatment affects them. If the disease is bilateral, or if there is active tuberculosis elsewhere, operation is contraindicated. PAPILLOMA OF THE BLADDER Papilloma is the most frequent tumor of the bladder. They are pedunculated, vary in size from a pea to the clinched fist. They are usually multiple, three or four being the commonest number, and may be widely disseminated over the interior surface of the bladder. Structure. — A connective- tissue stalk, very vascular, covered with numerous layers of epithelium; hence their origin from the bladder epithelium. They are often partly or entirely encrusted with urinary salts, and for this reason, may be mistaken for stones in cystoscopic examination. They should be regarded as malignant, and should be re- moved as completely as possible. Symptoms. — (i) Hematuria; (2) all symptoms of chronic cystitis, frequency, tenesmus, etc. ; (3) if the papilloma is in the trigone, sudden interruptions of the stream of urine. Diagnosis is made by cystoscopic examination. Treatment. — (i) Fulguration, through a cystoscope. Several appHcations of the current, three or four days apart are required. This is the best method, except in very large papillomata. 300 DISEASES OF THE URINARY TRACT (2) Removal by a wire snare, through an operating cys- toscope. This is much more difficult and not as satisfactory as fulguration. (3) Vaginal cystotomy, in very large growths. (4) Suprapubic cystotomy, in very large growths. This is better than vaginal cystotomy, because of the greater room for dealing with hemorrhage which may be very profuse and re- quire packing of the bladder with gauze. (5) In large growths, necessitating vaginal or suprapubic cystotomy, the most satisfactory technic is to open the bladder, remove the papilloma with a heavy wire or chain snare, and then fulgurate the base. In this way the bleed- ing is minimized. Prognosis. — Papillomata often recur as carcinoma of the bladder wall, and patients should be regularly cystoscoped every two months over » a period of three years, so that any area can be fulgurated in the early stage. CANCER OF THE BLADDER • Cancer of the bladder is rare. It is of two kinds : (i) Primary; (2) secondary to cancer of the cervix. Primary cancer of the bladder occurs as (i) medullary; (2) scirrhous; (3) squamous epithelial; (4) papillary. It tends to perforate the bladder wall into the vagina, and gives metastasis to the deep pelvic lymphatics. Symptoms. — (i) Hematuria, at first intermittent, later con- stant, with severe secondary anemia; (2) Severe cystitis. Diagnosis is made by cystoscopic examination, when the ragged infiltrated area can be seen, if there is not so much bleeding that the fluid in the bladder is opaque. Treatment. — (i) Papillary masses may be fulgurated or removed by the suprapubic route; (2) if far advanced, it is inoperable; (3) secondary invasion from the cervix is always inoperable; (4) total extirpation of the bladder, with ureteral implantation in the bowel or vagina, has a very high primary mortality, and secondary pyonephrosis is almost inevitable. VESICO-URETHRAL FISSURE 301 STONE IN THE BLADDER Stone in the bladder is much less common in women, stone in men being two hundred times more frequent. This is due to the short, wide, dilatable urethra of the female, allowing small vesical or renal stones to escape before they have any chance to increase in size. Stones are formed by crystalHzation of urinary salts and are composed of phosphates, oxalates, ammonium urates, carbonates, uric acid, cystin and xanthin. Cystitis and ammoniacal urine are favorable etiologic fac- tors. They always form about any foreign body, such as hair- pins, nails, etc., which, introduced into the urethra for purposes of masturbation, have slipped into the bladder. Probably the commonest nucleus for stone is a suture of permanent material penetrating the bladder in an operation for cystocele. Site. — (i) Free in the bladder; (2) impacted in diverticula; (3) fixed in the urethra or ureteral orifice. Symptoms.^ — (i) Hematuria; (2) cystitis, usually severe. Diagnosis.^ — (i) May be felt by bimanual examination; (2) a sound in the bladder, will give the usual metallic click when it touches the stone; (3) :^;-ray; (4) cystoscopy, the most reliable of all. Treatment.^ — (i) If small, the stone can be drawn out through a cystoscope; (2) if impacted in the ureteral orifice it can be dislodged and removed; (3) large stones can be crushed by a lithotrite and washed out by the evacuating apparatus; (4) stones too hard or large to be crushed, or those so impacted in a diverticulum that they cannot be dis- lodged, may be removed by vaginal cystotomy, or by supra- pubic extraperitoneal cystotomy. VESICO-URETHRAL FISSURE Vesico-urethral fissure is a linear ulcer, beginning in the trigone and running through the vesical sphincter into the floor of the urethra, parallel with its long diameter. One- 302 DISEASES OF THE URINARY TRACT third of the length is in the bladder, two-thirds in the urethra. Cause. — (i) Gonorrheal urethritis; (2) cystitis; (3) passage of a stone with sharp edge; (4) injuries during cystoscopy. Symptoms.^ — (i) Frequency of urination; (2) burning on urination; (3) pus or blood in urine; (4) intense pain just at the end of urination, the stream being followed by one or two drops of blood. Diagnosis.- — The linear ulcer can be seen plainly through a cystoscope or urethral endoscope. Treatment. — (i) Injections of cocain solution, 4percent., into the urethra; (2) dilatation of the urethra up to a 42 sound; (3) repetition every other day for three or four treatments. - EXSTROPHY OF THE BLADDER This is due to a defect of development of the anterior abdom- inal and bladder walls and symphysis, so that the interior of the bladder is exposed. If the upper part of the bladder alone is exposed it is called superior vesical fissure. If the lower part of the bladder alone is exposed it is called inferior vesical fissure. If the urethra alone is involved it is called epispadias. Treatment is directed toward control of incontinence, and is accomplished by plastic surgery, flaps being taken from the abdominal wall, planned to meet the needs of the individual case. Repeated operations are the rule, and complete success is rare. OVERDISTENTION OF THE BLADDER Overdistention of the bladder is common in women. It is due to (i) Pelvic tumors; (2) neurosis; (3) pregnancy with backward displacement of the uterus; (4) pressure in labor. The distended bladder causes a cystic tumor in the lower abdo- men, easily mistaken for an ovarian cyst; there is often fre- quent urination or a constant dribbling. Treatment is catheterization with a silk or wax catheter, and not a glass one, which latter is too short and too easily broken. DISEASES OF THE URETHRA 303 No diagnosis as to the nature of a cystic tumor should ever be made until the bladder has been emptied by catheter and not voluntarily. IV. Diseases of the Urethra 1. Congenital defects as epispadias and hypospadias. The former is associated with exstrophy of the bladder. Hypo- spadias may be partial or complete. Incontinence always accompanies the complete, and in these cases there is a funnel- shaped opening, apparently communicating with the vagina, but really opening into the vestibule. The sphincter is absent. Treatment is plastic operation, the success of which is doubt- ful. Complete success can only be attained when there is a partial defect and the sphincter is, in part at least, present. 2. Stricture and Atresia. — Both are less common in women. The stricture is usually at the upper third, near the bladder. Causes. — (i) Injuries of childbirth; (2) caustics applied in treatment; (3) cicatricial bands; (4) disuse in fistulae; (5) congenital. Symptoms are (i) dysuria; (2) frequent urination. Diagnosis is made by catheterization or sounding, when the obstruction is obvious. Treatment is gradual dilatation by sounds, up to 42. Incision is rarely if ever necessary. 3. Acute Urethritis. — Acute urethritis is exclusively gonor- rheal, and is of short duration. Symptoms. — (i) First discomfort, then burning on urination; (2) meatus is swollen, hyper emic, everted; (3) orifices of Skene's glands are marked by erosion; (4) thick yellow purulent discharge. Prognosis. — (i) Heals quickly and spontaneously or (2) passes into the chronic stage. Treatment is given in Chapter XV, on gonorrhea. 4. Chronic Urethritis. Causes. — (i) Persistence after acute attack; (2) infection by other organism, notably colon bacillus or staphylococcus. 304 DISEASES OF THE URINARY TRACT Site. — It is localized, usually in Skene's glands, and does not involve the whole canal. Symptoms. — (i) Burning and pain during urination; (2) a thin scanty purulent discharge. Diagnosis. — (i) Meatus is everted and edematous; (2) orifices of Skene's glands are eroded; (3) pressure on or milking of urethra will yield a drop or two of pus. Treatment. — (i) Obliteration of Skene's glands, failing which a cure is unlikely; (2) applications of 30 grains to the ounce nitrate of silver solution to the canal, best by injection with a medicine dropper, every three days; (3) irrigation of the urethra, with boric acid solution, once daily through Skene's reflex catheter; (4) instillations into the urethra, every other day, of silvol ointment 5 per cent. ; argentide paste 20 per cent, or 25 per cent, argyrol or 3 per cent, protargol in glycerin. Treatment requires time and patience, as the disease is stubborn. Consequences. — (i) Peri-urethral or suburethral abscess (see Chapter IV); (2) granular erosion of urethra, where the mucosa is papillary, bright red and very sensitive. Treatment. — (i) As described in the treatment of chronic urethritis; (2) artificial vesicovaginal fistula, for drainage, hastens a cure. 5. Urethral caruncle, described in Chapter IV, number 16. 6. Prolapse of the mucosa, described in Chapter IV, number 17. CHAPTER XV GONORRHEA Gonorrhea is an acute contagious disease, caused by the gonococcus; a biscuit-shaped diploccccus, Gram negative, staining by the ordinary methods, and found in the purulent discharge both free and intracellular. I. Mode of Infection. — Except in the case of young children, where it is transferred indirectly, it is transmitted Fig. 135. — Diplococcus of Neisser, the gonorrhea germ, taken from the pus of the eye. The little dots are gonococci, the large masses are pus cells. {De Lee.) almost exclusively by sexual intercourse. Rarely it may be spread by towels, napkins, douche nozzles or other foreign bodies, used by an infected person. A common type of case is 20 305 3o6 GONORRHEA infection of the wife by a husband who has had gonorrhea, but who was supposed to be cured. The congestion and stimulus of intercourse will often light up an attack which under ordinary conditions gives no indication of its presence. It cannot be considered safe for a man to marry until at least one year after the disappearance of all symptoms. 2. Variations under Culture. — The gonococcus is purely a human organism. It is not found in other animals, and can- not be inoculated on other than human tissues. It will grow only in media made from human tissues; it will not grow on bouillon or other animal culture media. It can be cultured through numerous generations, gradually losing virulence, but when introduced into the human body, rapidly regains its lost virulence. It is infectious only in the moist state and grows only in the presence of moisture; if dried, it soon dies. 3. Habitat. — The gonococcus is particularly partial to columnar epithelium, where it dwells superficially and between the cells. It does not often involve the glands (of the cervix, uterus or Bartholin) but remains in their ducts. No abrasion of the surface is necessary for infection. Extragenitally, the commonest site of infection is M M «» S the eye. It rarely penetrates the w9 %9 «p «p blood- and lymph-channels, but Pig. 136.— Indicating the may do SO, and localize in the shape of the dipiococcus of gon- jq^j^^, ^^^ valves of the heart. It orrhea (gonococcus). {N orris.) ■' requires a moist surface, prefer- ably columnar epithelium, with good blood-supply. The incubation period, from inoculation to the appearance of symptoms, is four days to a week. 4. Growth. — No break in the epithelium is needed. The gonococcus is at first piled on the surface, then penetrates to the deeper layers through the interstices between the cells of the surface epithelium, and when once under the surface, it is extremely difficult to eradicate. 5. Latency. — When confined in a closed sac, like a pyosal- pinx, the gonococcus soon dies; when in gland ducts it remains DIAGNOSIS 307 active for very long periods. It may remain latent for years, so that the patient, though infected, shows no symptoms, and suddenly light up into active virulence, because of local hypere- mia from excessive intercourse, menstruation, childbirth, etc. The average period of latency is four or five years; longer periods are probably fresh inoculations, as the gonococcus does not confer immunity against successive attacks. 6. Order of Infection. — In the genitalia, the order of infec- tion is approximately as follows: (i) The urethra; (2) cervix, at about the same time; (3) Skene's and Bartholin's glands; (4) endometrium; (5) tubes; (6) peritoneum. 7. Lurking places of gonorrhea, in chronic cases are: (i) Skene's glands; (2) Bartholin's glands; (3) ducts of the cervical glands; (4) patches in the endometrium; (5) rugae in the folds of the tubal mucosa, provided there is no pyosalpinx. The annoying and persistent leukorrhea in a case of chronic gonorrhea is almost exclusively from the cervix. 8. Diagnosis. — If a patient presents herself with complaint of burning on micturition, with profuse purulent vaginal discharge and examination shows the skin of the vulva red and chafed, covered with a yellow, creamy, leukorrheal discbarge, the urethral orifice red and angry, exuding a few drops of pus when milked; the cervix eroded and the source of discharge, a presumptive diagnosis of gonorrhea is amply justified, and easily confirmed by the microscope. In cases past the acute stage, or of long standing, an accurate diagnosis may be extremely difficult, and depends finally upon microscopical examination of smears made from the discharge. Preparation of a Smear. — (i) The patient is arranged in the dorsal position, and, except in acute cases, has been told to take no douche for the twenty-four hours preceding the examination; (2) pressure is made along the urethra, from behind forward, and if a drop of pus appears in the orifice, it is taken up on a small pledget of cotton on an applicator, and transferred to the surface of a clean glass slide. A slide is better than a cover glass, unless permanent speci- 3o8 GONORRHEA mens are desired, because it gives a wider field for examination and is more easily handled. A second slide is placed upon the first and the two are then slid apart, to ensure an even, thin distribution of the discharge. 3. The cervix is exposed through a bivalve speculum, any discharge visible is caught and prepared in the same way. Staining is best done, except in doubtful cases, with i per cent, fresh aqueous methylene blue; (i) after the slide is dry, it is held in forceps and the surface flooded with the stain; (2) it is gently heated (so that it steams but does not boil) over a Bunsen flame or alcohol lamp for 8 minutes; (3) the stain is poured off, the slide washed and dried; (4) it is examined with a 3'l2"ii^ch oil-immersion lens. The nuclei of the pus cells are light blue, the gonococci very dark blue (almost black). Doubtful cases are stained by the Gram method, in which case the gonococci, being Gram-negative, are not stained. Technic (Tiedemann's Modification). — (i) The slides are prepared as usual. 2. The slide is flooded with 2 per cent, alcoholic solution of crystal violet, allowed to act for fifteen seconds. 3. The slide is slowly washed off by water dropping from a pipet (about ten seconds). 4. Flood slide with solution of iodin i gram, potassium iodid 2 grams, distilled water 100 mil and allow to act for fifteen seconds. 5. Wash thoroughly, dry and examine with H 2 -inch oil- immersion lens. Any diplococci appearing in a specimen stained in methylene blue and not appearing when a second slide is stained as above, are almost certainly gonococci. Doubtful Cases. — In old chronic cases, repeated examinations may fail to show positive evidence of gonococci. In such a case the diagnosis must rest upon the following: I. Tell patient to drink a bottle of beer at night, and present herself for examination the next morning, without douching. The irritating effect of alcohol may cause slight temporary GONORRHEA IN CHILDREN 309 activity in the discharge, sufficient to bring gonococci to the surface. 2. The complement-fixation test. 3. Search for the stigmata of gonorrhea: (i) Erosion of the orifices of Skene's glands; (2) erosion of the ducts of Barthohn's glands; (3) erosion of the cervix. History of previous infection in the husband; a point re- quiring considerable diplomacy. 9. Prognosis. — If infection has travelled above the internal OS, permanent cure is very rare; and in many cases infection of Skene's and Bartholin's glands and of the glands of the cervix resist treatment indefinitely. The acute stage of gonorrhea in women lasts for a short time only; the chronic stage lasts indefinitely. 10. Kinds of Gonorrhea. — (i) Acute — of short duration in women; (2) chronic — the type most commonly seen. The treatment of both will be described according to the region they affect. 11. Internal Treatment and General Hygienic Rules, Applicable to all Cases.^ — d) During the acute stage, rest off feet or in bed; (2) avoid all highly spiced foods, and alcohol in any form. Diet should be bland and easily digested ; (3) avoid- ance of anything causing pelvic congestion, particularly sexual intercourse; (4) copious amounts of water daily; (5) cleanliness of genitalia; (6) if the patient has burning on urination, give bland diuretics, such as potassium citrate 2 drams ; tincture of belladonna 2 drams; liq. potass, citratis q. s. ad. 3 ounces. Sig. Teaspoonful in water four times daily; (7) if nervous, give sodium bromid, 10 grains four times daily; (8) every patient, or person handling such a patient, should be warned of the danger of ophthalmia, and their hands should be kept scrupulously clean. 12. Gonorrhea in Children (Vulvovaginitis). — The modified squamous epithelium in children is soft, delicate, vascular and moist, hence very susceptible to gonorrheal infection, which in this type of case can be spread by indirect means. 310 GONORRHEA Method of Infection. — (i) Depraved sexual practices; (2) con- taminated linen, towels or diapers; (3) epidemics in institutions are often difficult to trace though a clue may be afforded by the fact that the gonococcus is infectious in the moist state only. Symptoms. — (i) Swolhn red labia; (2) severe chafing of perineum and inner side of thighs; (3) considerable pain and tenderness; (4) profuse purulent yellow discharge, in which gonococci are found microscopically. The disease is most often confined to the vulva, labia and external genitalia; it only rarely involves the uterus and tubes, though it may involve the vagina, causing ulceration and sub- sequent adhesion of the opposing surfaces. In a small percentage of cases the urethra is infected. Treatment is difficult and requires prolonged effort and patience. Prophylaxis is possible only in institutions and any suspected case should be rigidly isolated, until the vaginal discharge can be proven innocent. Nurses caring for suspected or actual cases should also be isolated, and all dressings burned. Special utensils must be kept for these patients. Treatment of Acute Stage. — During the acute stage there is so much tenderness that treatment can be directed only to- ward keeping the external genitalia as clean as possible, by external irrigation and sponging with boric acid solution or 1-5000 potassium permanganate. There is marked tendency to desquamation and adhesion of the labia; hence the inner margins of the labia should be kept covered with boric acid ointment, until the acute stage is past. Treatment of chronic stage is usually prolonged, and while the uncomfortable symptoms can be controlled quickly, a cure is a matter of months, and relapses are frequent. 1 . If the hymen is of such a character that it interferes with the necessary treatment, it must be sacrificed. 2. The vagina is dried out with a thin strip of gauze, and through a narrow speculum or endoscope, is painted with 5 per cent, nitrate of silver solution. GONORRHEAL URETHRITIS 311 3. A vaginal douche of 1-3000 permanganate solution is given twice daily, through a catheter. . 4. The external genitals are kept scrupulously clean. 5. Every other day, the vagina and labia are flooded with 25 per cent, argyrol solution, or 25 per cent, ichthyol in glycerin or ID per cent, silvol solution, injected with a medicine dropper. 6. The child is kept from active exercise, is given a bland diet with plenty of water; its underclothes are kept separate and boiled before washing, and all contaminated dressings are burned. 7. Vaccirtes are useful in shortening the duration of infection. Prognosis of Chronic Stage.— Th.t disease may last for years, in recurrent periods; three to six months are necessary for the disappearance of gonococci; very young children respond more quickly to treatment. Requisite for cure are four consecutive negative smears at weekly intervals. Complications of chronic stage are common, especially in neglected cases; (i) inguinal adenitis (rarely suppurative); (2) venereal warts; (3) arthritis (subacute form); (4) ophthal- mia, from hand infection; (5) peritonitis; (6) cystitis and pye- litis (rare). Recurrences are common, even after an interval of several years, and are treated like the original attack. 13. Gonorrheal urethritis is the commonest manifestation of primary infection in the adult, the epithelium of the meatus being a favorable medium for growth of the gonococcus. The disease is most commonly limited to the lower one-third of the urethra, and to Skene's glands. Symptoms. — (i) The vestibule is red and tender; (2) the mea- tus is pouting, edematous and exudes a thick yellow pus; (3) the orifices of Skene's glands are visible and eroded; (4) marked burning, with occasionally severe pain, during urination; (5) many cases produce negligible symptoms, so that the acute stage passes unnoticed. Prognosis. — (i) The duration is from three to six weeks, though the acute symptoms last only a few days. 312 GONORRHEA 2. There is slight danger of cystitis, unless the infection is carried in by injudicious use of a catheter. 3. Chronic urethritis may persist for years in Skene's glands, until the ducts are destroyed by cauterization. Treatment. — In addition to the general treatment described under section eleven in this chapter; (i) irrigation of the urethra with boric acid solution or 1-5000 potassium perman- ganate solution, using Skene's reflux catheter, and being careful not to push the catheter past the internal sphincter; (2) injection in the urethra of 5 per cent, argyrol cr protargol or silvol in glycerin, injecting only i mil to avoid entering the bladder. The patient should not urinate for at least an hour following the injection; (3) obliteration of Skene's glands, in chronic cases. Complications. — (i) Abscess of Skene's glands (see Chapter IV) ; (2) stricture, much less common in women. 14. Vulvovaginitis in the adult is rare, due to the tougher character of the epithelium. At the vulva, inflammation is usually secondary to inflammation of Skene's or Bartholin's glands; in the vaginal vaults, it is secondary to the cervix. Whatever form of treatment is instituted, it is essential that every care should be taken not to extend infection highei up in the genital canal, and that no instruments or solution should be used which would irritate or injure the epithelial surface. Treatment. — (i) Through a bivalve speculum, the cervix and vaginal vaults are sponged off with cotton pledgets soaked in salt solution (i dram to the pint; to dissolve mucus) and then by plain water to remove the salt. (2) The cervix and vaginal vaults are painted over with argyrol solution 25 per cent, or protargol 2 per cent, or silvol 10 per cent, or nitrate of silver 8 per cent, and the excess sponged out. (3) A large tampon, with 50 per cent, ichthyol in glycerin, or 25 per cent, boroglycerid, is packed rather firmly in the vaginal vault; two other dry tampons are packed in below it and the bivalve speculum removed. CERVICAL GONORRHEA 313 (4) If there is much discharge, the tampons are removed in twelve hours, otherwise in twenty-four. (5) The patient takes a douche of 1-3000 permanganate solution twice daily until the tampons are replaced. (6) The tampons are renewed every three days. ' Dry treatment consists of drying the cervix and vaginal vaults with gauze, through a bivalve speculum, and insufflating a powder (a satisfactory one is carboHc acid 2 drams, burnt alum I ounce, boric acid 3 ounces) with a Politzer bag. After the powder is blown in, a wool tampon heavily dusted with the same powder is inserted and left in place twenty-four to forty- eight hours, when it is removed and the treatment is repeated. It is satisfactory only when discharge is scanty. 15. Cervical gonorrhea (endocervicitis) is either primary or secondary. The cervix is involved in most cases of gonorrhea in the adult. As the cervix is quite insensitive, pain in the acute stage is absent. Symptoms. — i. Acute Stage: (i) The cervix is red and angry looking; (2) the external os is eroded; (3) the erosion bleeds easily to the touch; (4) there is a profuse yellow purulent discharge; (5) gonococci are found on' microscopic examination. Treatment. — It is not advisable to make any application to the cervical canal during the acute stage, because of the danger of carrying infection to the uterine cavity. The treat- ment as outlined in the previous section (14) of this chapter gives good results. 2. Chronic stage is one of the most stubborn conditions in gynecology. The gonococci have penetrated the ducts of the cervical glands, a mixed infection has taken place, and the irritation of this infection causes a profuse stringy mucopuru- lent discharge. Symptoms. — (i) The patient's chief complaint is a profuse, annoying leukorrhea; (2) the cervix is eroded; (3) the cervix and vaginal vaults are covered with stringy cloudy mucopus; (4) gonococci may be found with some difl&culty. 314 GONORRHEA Treatment: — In addition to the treatment described in sec- tion 14, the following will be found useful: . (i) Instillation into the cervix, T\dth an instillating syringe, of 25 per cent, argyrol, 10 per cent, silvol; 50 per cent, ichthyol all made up in ghxerin (watery solutions run out at once, while the thicker glycerin exudes slowly from the cervical canal), injections are given every other day. (2) Electrolysis with a copper electrode. The electrode is placed in the cervix, the positive pole attached to it, and a galvanic current of 25 to 40 milliamperes allowed to flow for thirty minutes every other day. (3) Amputation of the cervix, if there is hypertrophy and severe erosion. Douches are used for cleanliness only, as they do not reach the seat of the infection. Prognosis. — The condition is exceedingly stubborn. Treat- ment must be continued until the cervical mucus is clear, and then interrupted to watch results. Relapses are common. 16. Gonorrheal Endometritis. — The endometrium is fairly immune to a permanent gonorrheal infection. Invasion from the cervix takes place usually just before or just after a men- strual period. The endometrium seems to serve chiefly as a bridge for the gonococci to reach the tubes, and not as. a permanent home. The chief source of discharge is the cervix and not the corporeal endometrium. For these reasons gonor- rheal endometritis is not a disease for local or general treatment except as an incident in the treatment of complicating pyosalpinx. Curetment can do only harm and is absolutely contra- indicated except in connection with laparotomies for remov^al of the tubes for salpingitis, when there is usually a chronic endometritis existing with the tubal disease. Curetment of a case where the tubes are not diseased, is a sure way of producing an acute pyosalpinx or pelvic abscess. Many cases of pelvic inflammation are associated with menorrhagia or metrorrhagia, but this is not an indication for curetment, unless at the same time the tubes are removed. VACCINES AND SERUM 315 In operation for gonorrheal pyosalpinx, a preliminary curet- ment should always be done, followed by cauterization of the endometrium with tincture of iodin (7 per cent.) and pure carbolic acid equal parts, and the vagina then wiped out with 95 per cent, alcohol (but not the uterus). 17. Gonorrheal salpingitis and pelvic abscess have been described in Chapter VIII. 18. Complications of gonorrhea are (i) Abscess of Skene's glands (Chapter IV); (2) abscess of Bartholin's glands (Chapter IV); (3) condylomata acuminata (venereal warts) (Chapter IV); (4) arthritis; (5) general septicemia; (6) peri- tonitis; (7) pyelitis; (8) ophthalmia. Arthritis is rare in women, but may appear in any case. It is much more common after labor or miscarriage than at other times. The joints most commonly affected are the ankle, elbow, wrist, knee, in that order, and then the small joints. Suppuration is not the rule, but the risk of ankylosis is about 20 per cent. Treatment. — (i) Immobilization of the part; (2) application of saturated magnesium sulphate solution or equal parts of dilute leadwater and alcohol; (3) strapping after the acute stage is past; (4) massive doses of vaccines. Peritonitis is usually the result of general gonorrheal septi- cemia, and, if a diagnosis of its nature can be made, is best treated conservatively, as the prognosis is favorable. Ophthalmia is a serious risk to any patient or attendant, from hand infection. All persons should be warned of the danger and cleanliness enforced. 19. Vaccines and Serum. — Gonorrhea is as a rule not much influenced by vaccine or serum, with two important exceptions : (i) Vulvo-vaginitis in children; (2) gonorrheal arthritis. The serum is prepared from the blood of sheep who have been treated with virulent culture of gonococci. Dosage is 2 c.c. given daily in the thigh, for five successive days. There is considerable local reaction, due to the toxicity of the serum, and results have not been encouraging. 3l6 GONORRHEA Vaccines need not be autogenous. The commercial prepa- rations of mixed strains are satisfactory. The opsonic index should be taken, but even this is not essential. Dosage at first ten to twenty millions, given five days between doses, and increasing by ten or twenty millions to each dose. An average number of six injections will be required. Local and general reactions are often seen, but usually mild and of short duration. Anaphylaxis is not to be feared, except after small doses- with long intervals. Large doses are safer than small ones, and there is more danger of anaphylaxis in chronic than in acute cases. CHAPTER XVI NORMAL MENSTRUATION AND ITS ABNORMALITIES Menstruation appears usually about the fourteenth year, and continues until the forty-fifth. It may appear as early as the eleventh year or as late as the sixteenth, and still be within normal limits. When first established, periods are apt to be irregular, but when fully instituted, the average interval is twenty-eight days. The interval next in frequency is twenty- three days. Duration of the flow is three or four days. Amount of flowis, on the average, 50 grams (3 ounces). It is less in single women, and somewhat more in women who have had children. It is usually measured by the number of napkins used; a flow requiring, during its height, more than three napkins a day, can be regarded as excessive. Character of Menstrual Blood.- — It is more watery and' darker than normal blood. It is mixed with epithelium and mucus from the cervical and uterine glands. It does not clot, due to the alkaline cervical mucus with which it is mixed, or possibly to a local influence of ovarian secretion. Factors Influencing Menstruation. — (i) Climate, though to a less extent than formerly supposed. It affects the frequency of the periods rather than the age of puberty; the inter- menstrual interval being longer in colder regions; (2) changes of climate, causing amenorrhea or menorrhagia (in the tropics) ; (3) social conditions; the poorer classes beginning late and ending earlier than the well-to-do; (4) city dwellers come to puberty slightly earlier than those who live in the country; (5) nulliparous women and virgins reach the menopause earlier 317 3l8 NORMAL MENSTRUATION Fig. i37.^Premenstrual Endometrium. (Graves.) Low power. At the bottom is the muscle of the uterine wall, sharply demarcated from the endometrium. The glands in the deepest part of the endometrium are small, their epithelial cells low, for this part of the glands remains inactive. The stroma cells are small and lie close together. At the middle of the endometrium the glands are dilated, the epithelium > wavy, and the epithelial cells swollen and actively secreting mucus. The stroma cells are larger and lie further apart. On the right the -dilatation of the blood-vessels is well shown. Near the top the glands have the same characteristic as at the middle, but there is more edema of the stroma. Throughout there is a slight infiltration with round cells. ENDOMETRIUM DURING MENSTRUATION 319 than those who have had children; (6) those who reach puberty early tend to menstruate profusely and reach the menopause late. The uterus during menstruation is larger, softer, more com- pressible, and shows marked congestion, as do all the pelvic organs, both internal and external genitalia. Fig. 138. — Endometrium at Beginning of Menstruation. {Graves.) The glands, except for the one seen in the center, have collapsed, having discharged the material which was secreted during the premenstrual stage. The blood-vessels have been eroded by the ferment contained in the secretion, allowing the blood to exude into the tissue and on the sur- face of the endometrium. The surface epithelium in this section is still intact. Precocious menstruation, seen in very young subjects, two to four years old, usually associated with abnormally developed breasts and genitalia, and is due to abnormalities in the glands of internal secretion, especially the pineal. The Endometrium during Menstruation. — The uterine 320 NORMAL MENSTRUATION mucosa passes each month through three phases or cycles: (i) Premenstrual congestion; (2) period of menstruation; (3) postmenstrual involution. I. Premenstrual congestion begins about ten days before the period. The mucosa is thickened (6-7 mm. in depth). The Pig. 139. — Postmenstrual Endometrium. {Graves.) Low power. The surface epithelium is regenerated. The glands are still dilated, but the epithelium is low, the nuclei of the cells small and lying at the bases. There is some edema of the stroma near the top, but the cells are smaller, the blood-vessels collapsed. There is a slight infiltration with round cells and blood-corpuscles. cells are swollen and pale — like decidua cells. The endome- trium presents two layers — the deep spongy layer containing the glands and the superficial compact layer, formed of swollen stroma cells. The surface is irregular and furrowed, and the blood-vessels dilated and tortuous. ENDOMETRIUM DURING MENSTRUATION 321 2. Stage of Menstruation. — The blood escapes partly by ac- tual rupture of the vessels, but largely by diapedesis, and forms subepithehal hematomata. Uterine contractions force the blood through the mucosa into the uterine cavity, partly through the interstices of the cells of the gland lumina and partly by actual desquamation of the surface epithelium. 3. Postmenstrual involution or stage of quiescence. After the cessation of bleeding, the mucosa shrinks to its previous thickness of 2-3 mm. The blood-vessels contract, the ex- MenstruattOTi Pig. 140. — Goodman-von Ott wave. (Graves.) travasated blood is absorbed. The broken epithelial layers replaced by new cells. The glands resume their narrow and straight form. This stage lasts about fourteen days, and the cycle then begins anew. During the cycle of congestion there is a glycogen production from the mucosa, reaching its height during menstruation and disappearing during the stage of quiescence. The Goodman-von Ott curve or wave is a diagrammatic curve representing the energy of all functions of the female organism, with reference to the menstrual period. This energy 322 NORMAL MENSTRUATION is at its height three days before the flow, and at its lowest at the end of the period. The molimina of menstruation are the visible e\ddences of the process, affecting not only the genitalia but the entire organism. The breasts are often engorged and frequently secrete colostrum; there is usually a marked physical and mental depression; the nervous system is particularly unstable; mostly manifested by irritability, neuroses and headache; pelvic discomfort is the rule, varjdng from a sense of pressure to severe cramp-Hke pains; vasomotor disturbances are common — nose-bleed, edema of the throat and larynx, hot flushes, etc.; skin eruptions often appear only at this time. The sexual impulse is increased just before or after the period, and decreased or absent during the flow. Pain midway between periods is most commonly due to in- tramural fibroids, but often occurs without demonstrable cause. Relation of Menstruation to Ovulation. — The two processes can and often do occur independently. In a strictly normal case, o\nilation should precede 'menstruation by two or three days, but the occurrence of pregnancy during the amenorrhea of lactation is sufiicient proof that there is no absolutely fixed relationship. ABNORMALITIES OF MENSTRUATION L Amenorrhea (Absence of Flow) Causes. — ^I. Anatomical. — (i) lU development; (2) atresia of hymen, vagina or cervix; (3) congenital absence of uterus. II. Constitutional. — (i) Chronic systemic disease hke tuber- culosis, diabetes, nephritis ; (2) change of climate; (3) neurotic, as in cases of pseudocyesis; (4) disturbances of glands of in- ternal secretion. III. Physiological. — (i) Before puberty; (2) pregnancy; (3) lactation; (4) menopause. IV. Pathological. — (i) Inflammation destroying the ovary; (2) operations removing ovaries or uterus; (3) acquired atresia; (4) pelvic tumors (most commonly ovarian cysts). ABNORMALITIES OF MENSTRUATION 323 Under "functional amenorrhea" are classed cases not due to any definite pathological cause, such as fear or anger, climatic changes, obesity, exposure to cold, etc. Amenorrhea of Youth. — It is common for menstruation to be very irregular or scanty for one or two years from its first appearance. Periods of three to six months pass without a flow. If the patient retains good health, no treatment is re- quired. In nervous, anemic, ill-developed girls, great benefit can be derived from hypodermic administration of corpus luteum or whole ovarian extract. Dosage is one ampule (representing 20 mg. of the dried substance), given intra- muscularly daily in series of 24 doses. This is much better and more reHable than mouth administration of tablets or capsules of ovarian substance (5 grains four times daily). Treatment of amenorrhea depends largely on the cause, if one can be found. Absence of flow due to atresia is not true amenorrhea, as the flow occurs, but is dammed back. The treatment of these cases is described in Chapter III. Ill development can be helped by (i) hypodermic injections of i mil. (representing 20 mg. of dried gland) of corpus luteum or whole ovarian extract, daily in series of twenty-four doses, with an interval of several weeks between series; (2) electrical stimulation of the uterus, the negative pole in the uterus, using galvanic, slow faradic and sinusoidal currents, three times weekly for forty-five min- utes at each treatment. 3. In congenital absence of the uterus, nothing can be done. 4. Amenorrhea due to chronic systemic diseases will yield as a rule to treatment of the disease at fault. Anemia requires prolonged administration of iron, arsenic and strychnin, a very satisfactory capsule being the following : I^ Acid, arsenios gr. J-s Strychnin sulph gr. i Ferri pyrophosphat gr. 150 M. Ft. caps. No. 30 Sig. One three times daily. 324 NORMAL MENSTRUATION 5. None of the physiological causes require any treatment but it is worth remembering that prolonged nursing may give rise to such a degree of lactation atrophy as to cause permanent amenorrhea. These patients are treated hke those with ill development. 6. The pathological causes destroying the ovary or uterus are irremediable. The only chance is implan- tation of sections of ovary, with very small chance of success. Corpus luteum extract will banish the disagreeable symptoms of the menopause, but will not cause the flow to return. The commonest pelvic tumor to cause amenorrhea is the large ovarian cyst. After removal of the cyst, unless bilateral, regular menstruation will return. 7. Functional amenorrhea due to severe anger, fright, nervous shock, fear of pregnancy requires no treatment. That due to change of occupation or climate (as in domestic servants) requires good food, hy- giene, regular rest and exercise, and prolonged courses of iron, arsenic and strychnin. That due to cold is described under the heading "Acute Suppression." Emmenagogues. — Drugs to produce menstruation are of little value. Those most used are: (i) oxahc acid gr. 3^^ four times daily, given in 2 drams syrup of lemon; (2) dioxid of manganese gr. 2 four times daily; (3) permanganate of potas- sium gr. 2 four times daily; (4) aspirin gr. 5 four times a day. They all tend to upset the stomach and are not recommended. The best emmenagogue is the electrical current, galvanic, negative pole to the uterine electrode. Chlorosis is a disease occurring at puberty, having a tendency to recur at the menopause, characterized by a nearly normal red count and a low hemoglobin content. The coagulability of the blood is increased. Symptoms. — (i) The patient is pale, with a pecuhar greenish tint, and usually underdeveloped; (2) she complains of amenor- rhea, or very scanty flow associated with dysmenorrhea; (3) the blood count is as described above; (4) there is no leu- kocytosis; (5) marked dyspepsia due to hyperacidity. Treatment. — (i) Fresh air, open air exercise and nourishing ABNORMALITIES OF MENSTRUATION, 325 food; (2) alkalis (sod. bicarbonate) for the hyperacidity; (3) iron, in the form of Blaud's pills (three to nine a day) is the most valuable single drug; (4) mild saline laxatives; (5) very severe cases require complete rest in bed; those with a hemoglobin percentage of below thirty. Prognosis is good, though up to the twenty-fifth year relapses are common. Acute suppression of menses is most often due to cold. It is associated with severe, often agonizing, pelvic pain, simu- lating peritonitis, due to severe pelvic congestion. Treatment. — (i) Be sure the suppression is not due to normal or extra-uterine pregnancy; (2) rest in bed; (3) hot flaxseed poultice or hot water bag to lower abdomen constantly; (4) hot vaginal douches (i gallon at i2o°F., run in slowly with patient lying down) of sterile water four times daily. In young girls, hot enemata are substituted; (5) sahne purge (best flat magnesium citrate, 12 ounces); (6) for the reUef of pain give antipyrin gr. 2, ammonium carbonate gr. 3 every three hours; salol and phenacetin each gr. 23^^ every three hours ; tincture of aconite one drop every half hour until the sense of pelvic congestion is reHeved; codein sulphate gr. 3^^ hypodermically; heroin gr. K2 or morphin gr. }yi hypodermically only as a last resort. Scanty menstruation is due to many of the same causes that lead to amenorrhea and the treatment is the same. II, Dysmenorrhea or Painful Menstruation Causes. — (i) Mechanical obstruction due to congenital or acquired stenosis of the internal os; (2) malposition of the uterus (anteflexion, retroflexion and retroversion, in that order of frequency) ; (3) ill development of the uterus, usually associated with stenosis; (4) pelvic congestion, due most often to uterine displacement; (5) pelvic inflammation, of tubes and ovaries; (6) postoperative, due to Hgatures or adhesions; (7) cirrhosis of the ovaries. 326 NORMAL MENSTRUATION Dysmenorrhea is not a disease, but a symptom of many pelvic diseases. Sjnnptoms. — (i) Pain, cramp-like and often severe, either just before or during the first day of the period; (2) incapacity of varying degree; (3) the pain extends down the back of the legs, and is often associated with a sense of prolapse; (4) symptoms usually appear early in menstrual life and tend to grow worse; (5) headache, general malaise and vomiting are common; (6) the intermenstrual interval is usually free from pain. Intermenstrual pain (" mittelschmerz ") is due usually to an intramural fibroid, though it not infrequently occurs in patients in whom no cause can be found. Treatment of dysmenorrhea depends upon the cause. Medical treatment is unsatisfactory. A great number of drugs have been recommended, but all fail frequently. The best are: Antipyrin gr. 2, ammonium carbonate gr. 3 every four hours; (2) aspirin gr. 5 four times a day; (3) sodium bromid, gr. 20 four times daily; (4) alcohol (whiskey, or brandy oz. ^-^ in 4 ounces very hot water); (5)^ atropin, grain Moo by mouth three times daily, for two days before and the first two days of the period; (6) soluble ovarian extract or corpus luteum extract imil (20 mg.) hypodermically twice daily. (7) morphin, heroin and other habit-forming drugs are to be avoided. Their use in women with dysmenorrhea is one of the commonest causes of drug habit. Nasal Treatment. — In patients who have any nasal abnor- mality (deflected septa, hypertrophy of the middle turbinates, etc.) and those in whom the flow is preceded by headache and nausea, cocainization of the "genital spots" in the nose (the tuberculum septi and middle turbinate) has given good results. At present the galvanocautery or trichloracetic acid is used with more lasting effect, and if good results are obtained at the first trial, the procedure is repeated between the periods. After two or three treatments, the relief is said in many cases to be permanent. ABNORMALITIES OF MENSTRUATION 327 Operative Treatment. — (i) In cases of stenosis, forcible dilatation, followed by either Schatz's metranoikter or the Wylie drain (preferably the former) , will give most satisfactory results. The technic is described in Chapter VII. Dilatation alone, without some means of keeping the canal open for some time, is practically useless. 2. Dudley's operation of splitting the cervix and inserting stitches so as to eliminate the cervical canal, is mutilating and is often followed by a troublesome endocervicitis, which may require repair or amputation of the cervix. 3. In cases complicated by backward displacement of the uterus, the displacement must be corrected by pessary or operation. 4. Cases due to pelvic inflammation and adhesions require abdominal section.. 5. Cases due to ovarian cirrhosis (seen in elderly nulliparae, the pain being due to ovarian congestion causing the ovary to swell against its firm shrunken capsule) require abdominal section. This is the type called ovarian neuralgia and is sometimes seen in young women. Marriage and Sterility. — Many cases of essential dysmenor- rhea are sterile, due to anteflexion and stenosis or ill develop- ment. These cases are helped by marriage, and if they should become pregnant, the dysmenorrhea is permanently cured by the dilatation during delivery. Membranous dysmenorrhea is a condition characterized by intense pain at. the menstrual periods, accompanied by exfoliation and discharge of portions of the uterine mucosa varying from small pieces to complete casts of the uterine cavity. As this mucosa is the menstrual compact layer, its likeness to decidua is such that even in microscopic section there may be doubt as to the diagnosis. Cause is not definitely known. It is ascribed rather vaguely to an abnormal reaction between the ovarian secretion and the uterine mucosa. Some cases follow abortion and in these there can be demonstrated chronic interstitial endometritis. 328 NORMAL MENSTRUATION Symptoms are as given in the definition of the disease. Prognosis as to complete cure is not good, and treatment is often unsatisfactory. Treatment. — The best treatment is dilatation and curettage just before the period, during the stage of thickening of the mucosa, followed by cauterization of the endometrium by iodin (7 per cent, tincture) or carbolic acid or steam (atmokausis, see section on metrorrhagia). Repeated operations are re- quired, as a rule. Nervous symptoms vary from nervous dread of the pain of the approaching period up to epileptiform convulsions (hys- tero-epilepsy). They are treated by removing their primary cause (the pain), good hygiene and diet, regular exercise and occasionally mental therapy and suggestion. In hystero- epilepsy, oophorectomy is not indicated, as it does no good. in. Menorrhagia (Excessive Menstrual Flow) By this term is meant (i) an increased flow at the periods; (2) increased frequency of the periods (the interval being free from' any bleeding); (3) prolongation of the menstrual period. Amount of Flow. — If the period requires more than three or four napkins daily (a total of twelve to sixteen), or requires that the napkins be worn double, or if there are clots of con- siderable size, the flow is abnormal. Causes. — (i) Displacements of the uterus; (2) pelvic con- gestion from any cause especially with subinvolution of the uterus; (3) fibroid tumors; (4) chronic endometritis; (5) chronic pelvic inflammation; (6) excessive or abnormal coitus; (7) valvular heart disease; (8) high blood-pressure; (9) polyps (mucous or fibroid); (10) menorrhagia of youth; (11) approach- ing menopause (always suspicious); (12) ''functional" — in which no definite cause can be found. Treatment. — Menorrhagia is a symptom only, and if the causative conditions be found and removed, the menstrual flow returns to normal. In cases of valvular heart disease or ABNORMALITIES OF MENSTRUATION 329 abnormally high blood-pressure, the bleeding may be beneficial, and when checked, the patient is uncomfortable. For checking the bleeding at the time of the period, the following are indicated: (i) Rest in bed; (2) laxatives sufficient to secure one or two good movements a day; (3) sedatives (strontium bromid gr. 15 every three hours) if the patient is nervous and restless; (4) styptics; ergot gr. i, strychnin sulphat. gr. 3^^o in capsule four times daily; or fluid extract of ergot 20 drops four times daily; or stypticin gr. i, four times daily; or cotarnin hydrochlorid gr. i four times daily; or styptol gr. % five times a day; or hydrastinin gr. ]y^ four times daily. All these alkaloids are efiicient but very expensive; (4) if dys- menorrhea is also present (a common complication), and is severe, 3^^ grain opium suppository is given twice daily, but the patient is not told the nature of the drug; (5) calcium lac- tate or chlorid gr. 20 four times daily, to increase the coagu- latibility of the blood; (6) in severe bleeding, vaginal tampons of sterile gauze for twenty-four hours may be needed. Animal extracts (pituitrin; mammary extract; suprarenal extract) have given poor results in menstrual excess in the adult. The most reliable is pituitrin ^^ mil hypodermically twice daily. A point never to he forgotten is that a sudden ex- cessive menstrual How may be a very early abortion; the patient often not knowing she is pregnant. Menorrhagia of Youth.^ — In young girls, excessive men- strual flow is not uncommon. The loss of blood may be very severe and alarming, and has been fatal. The severe cases are probably hemophilic in origin. Some of the less severe cases are due to hypertrophic glandular endometritis, but in many no cause at all can be found. The cause is supposed to lie in loss of balance of the internal secretory glands, particularly the thyroid, but this has not yet been proven. Treatment should be as conservative as possible. (i) Pituitrin 3^^ mil hypodermically daily for eight or ten doses, though three or four are usually enough. This is the most valuable single drug; (2) calcium lactate gr. 20 four times 33© NORMAL MENSTRUATION a day, between the periods; (3) th)^roid extract 5 grains four times daily, between the periods. This routine treatment is ordinarily all that is required. Severe cases: (i) Normal horse serum, 50 c.c. subcutaneously and repeated daily for three or four doses; (2) transfusion, preferably from one of the parents, 250-500 c.c. of blood; (3) dilatation and curettage of value only in the cases of glandular endometritis; (4) atmokausis (see treatment of metror- rhagia) ; to be avoided if possible ; (5) a;-ray will stop nearly all cases, but is to be avoided except as a last resort, because of the damage done to the ripening ovarian follicles, and the danger of permanent menopause; (6) radium treatment is difficult of application, except under anesthesia. It is efficient but open to the same objections as the .v-ray; (7) only as a last resort, and very rarely if ever necessary, hysterectomy. IV. Metrorrhagia (Irregular Bleeding, Irrespective of Menses) All metrorrhagia is pathologic, and should be regarded as serious, especially as the patient nears the age of the meno- pause. The hemorrhages of pregnancy are included under this head, but their discussion belongs properly in works on obstetrics. Causes. — (i) Incomplete abortion; (2) extra-uterine preg- nancy; (3) laceration and erosion of cervix; (4) retroversion of uterus; (5) chronic endometritis; (6) fibroid or mucous polyps; (7) fibroid tumors; (8) ovarian cysts (though amenorrhea is commoner); (9) cancer of the uterus; (10) pyosalpinx; (11) valvular heart disease; (12) high blood-pressure; (13) any cause of acute or chronic pelvic congestion; (14) myopathic uterus (fibroid degeneration of the muscular wall); (15) infectious diseases, notably malaria. Diagnosis of the Source. — (i) Inspection of the cervix through a bivalve speculum. In this way erosion, laceration, polyps, or cancer can be seen; (2) bimanual examination, to detect gross pathological lesions; (3) dilatation and curettage. ABNORMALITIES OF MENSTRUATION 33 1 followed always by exploration of the uterine cavity with placental forceps, to extract if possible polyps that the curet might slip over. All the scrapings should always be examined microscopically; (4) uterine endoscopy, when with an instru- ment like a urethroscope, the uterine cavity can, after proper dilatation with Hegar's bougies, be inspected; (5) excision of a piece of the cervix, for microscopic examination for cancer; (6) anterior vaginal hysterotomy, when a submucous fibroid is suspected with reasonable certainty; (7) in all cases, the heart should be examined and blood-pressure taken. Treatment. — --Metrorrhagia, like menorrhagia, is a symptom, and the cause should be sought and removed. In sudden, severe bleeding, the possibility of pregnancy and miscarriage must never be forgotten. (i) Bleeding from incomplete abortion is quickly and easily controlled by cleaning out the uterine cavity with pla- cental forceps, usually without anesthesia; (2) small polyps in the cervical canal or protruding can be removed with- out anesthesia; (3) bleeding due to valvular heart dis- ease can be checked or at least diminished by oil of erigeron, tiex four times daily by mouth; (4) in high blood- pressure, the bleeding may be beneficial; (5) vaginal douch- ing, tampons, or intra-uterine application are of little use; (6) cancer, diagnosed by inspection of the cervix or by ex- ploratory curettage, requires prompt panhysterectomy. In Cases without Marked Local Lesion. — (i) Styptics, as de- scribed under menorrhagia; (2) electricity, positive pole to uterine electrode, with galvanic current of 40 milliamperes for forty-five minutes three times weekly; (3) animal extracts (pituitrin, thyroid, suprarenal extract) though these are not efficient as a rule, except in very young patients; (4) a;-ray, except in degenerated fibroid, where it is contraindicated; (5) radium, with the same limitations as the x-rsjy, with the additional one of the great expense of the supply required. Radium is indicated particularly in the bleeding due to the large, firm, myopathic uterus; (6) dilatation and curettage, 332 NORMAL MENSTRUATION followed by atmokausis; (7) hysterectomy when other means have failed. With the present status of x-ray and radium treatment and atmokausis, hysterectomy is rarely needed except in cancer and degenerated fibroids. Atmokausis is the cauterization of the endometrium by super- heated steam at a temperature of ii5°C. The apparatus consists of a boiler, with thermometer and safety valve; the outlet tube terminating in a uterine nozzle controlled by a three-way valve. Technic of Atmokausis. — (i) The patient is prepared as for any vaginal operation, is arranged in the dorsal position and anesthetized. 2. The cervix is dilated to one inch if the two-branched di- lator, or a circumference of 80 mm. if the four-branched Cleve- land dilator is used, and the uterus thoroughly curetted, explored with placental forceps, and washed out with sterile water through an intra-uterine catheter. 3. Thirty-one cubic centimeters of hot water is introduced into the boiler of the atmokausis apparatus and the alcohol flame is started under the boiler. 4. The intra-uterine nozzle of the apparatus, sterilized by soaking in 5 per cent, carbolic acid solution, is screwed on to the handle, all the joints being tightened, and as soon as steam is generated, the stop cock is turned slightly to test the tubes and make sure the lumen is free. 5. The nozzle is then inserted into the uterine cavity, the point being near, but not touching, the fundus. 6. When the thermometer on the boiler registers ii5°C. the steam is allowed to flow through the nozzle for ten, fifteen or twenty seconds, or as long as the individual case seems to require. 7. The uterus is then washed out again, and the patient returned to bed. 8. She should be left in bed ten days, and during her conva- lescence may require intra-uterine douches if a foul leukorrhea develops. ABNORMALITIES OF MENSTRUATION :^^:^ g. Repetition is rarely needed. lo. This form of treatrrient is absolutely contra-indicated in cancer or degenerated fibroids. Its field, like radium, is the myopathic uterus. Zestokansis is the same except that the uterine nozzle is closed, and the steam does not circulate free in the uterine cavity. It is not as efiicient. Hysterectomy may be supravaginal (as in fibroids) ; complete (either abdominal or vaginal panhysterectomy) as in cancer; Supravaginal extraperitoneal (a variation of vaginal hysterec- tomy in which the cervix is left); partial fundal, to diminish the bleeding endometrial surface. V. The Menopause (Climacteric, Change of Life) This is reached as a rule at about forty-five years of age. In less than i per cent, does it occur before thirty-five or after fifty-five. It is reached earlier in working women than in the leisure class. The date is influenced by early childbearing, fibroid tumors, chronic pelvic congestion, climate, occupation and many other factors. Mechanism.-^The periods at first become irregular, then scanty and then cease entirely. The entire process is prolonged over two or three years. Rarely the menses cease abruptly and never reappear. After the menopause is established, all the genital organs, external and internal, show a process of atrophy. Symptoms. — (i) Menses are irregular, then scanty and then cease; (2) hot flashes; (3) nervous irritability, dizziness and tendency to mental depression; (4) palpitation; (5) buzzing in ears; (6) often serious psychoses; (7) often marked increase in weight. Many patients pass through the menopause with few if any disagreeable symptoms, but the first three mentioned above occur in the majority. Just before the climacteric there is usually a marked increase of sexual impulse, which disappears after the process is complete. The loss of ovarian secretion is 334 NORMAL MENSTRUATION thought to be the cause of the menopause and its disagreeable symptoms. The surgical menopause, following double oophorectomy or hysterectomy is more severe in its manifestations than the normal, and the younger the patient the worse and more lasting the effects. Treatment. — Unless the disagreeable symptoms demand relief, often no treatment whatever is required. In patients who require treatment, the following can be depended upon: (i) Mental suggestion. Reassure the patient as to her safety and that any nervous depression is merely temporary; (2) strontium bromid, 15 grains four times a day, with periods of remission as the nervous symptoms are controlled; (3) hypodermic, intramuscular injections of soluble extract of corpus luteum, or whole ovarian extract, given in doses of I mil (20 mg.) daily for twenty-four doses, repeated in series of twelve doses at intervals of several weeks. This is the most efficient of all treatments, and rarely are more than two series of doses required. The effect is cumulative. The natural menopause requires least; the surgical menopause late in life the next and the surgical menopause in young women the largest number of doses; (4) valerianates are not as efficient as strontium bromid. When used, the ehxir of valerianate of ammonia, in teaspoonful doses, gives the most effect, but is objectionable as a rule because of its fearful smell. Bleeding at the menopause is always pathologic, whether it be menorrhagia or metrorrhagia, the commonest cause being cancer, fibroids and polj^s. Any abnormal discharge, whether blood, leukorrhea or a mixture of both, should be carefully investigated so that an early diagnosis of cancer may be established. The common belief that an excess of blood at the menopause is a normal feature is responsible for the large number of cancers that reach the physician too late for relief. This applies with equal force to bleeding or abnormal dis- charge after the menopause is established. ABNORMALITIES OF MENSTRUATION 335 Vicarious menstruation is the discharge of blood from other body canals, at the normal menstrual time, without any uter- ine flow. It is commonest from the nose, but may occur from any mucous surface, such as stomach, intestine, lungs or rectum. Very rarely skin areas are affected showing ecchy- moses. The vicarious periods are likely to be irregular and may alternate with periods of normal flow. The cause is unknown. Treatment. — Beyond correction of any pelvic disease or uterine displacement; iron arsenic and strychnin if anemic; the hypodermic injections of corpus luteum or whole ovarian extract, nothing can be done. CHAPTER XVII LEUKORRHEA (THE WHITES) Definition. — ^Leukorrhea is an abnormal discharge from the female genital tract, consisting as a rule of mucopus, but may be mucus, pus, serum or combinations of these. Sources. — i. Vulva: Gonorrheal infection of Skene's ducts, the urethra and Bartholin's glands account for most cases. It is common in children, and in the aged, in the latter especially with diabetes. 2. Vagina. — Vaginal leukorrhea is not common. The modi- fied skin with which the vagina is lined resists bacterial infec- tion. Many apparent cases of vaginal leukorrhea originate in Skene's ducts, urethra, or Bartholin's glands. Vaginal dis- charge in childhood is more common than in the adult, due to the susceptibility of the vaginal mucosa to gonorrheal infection. In the adult, the commonest causes are: (i) Saprophytic or fungus infections; (2) senile vaginitis (when the discharge is very white, due to degenerated epithelium); (3) neglected pes- saries, especially soft rubber ones; (4) neglected gonorrhea; (5) carcinoma. 3. Cervix. — This is the commonest source of leukorrheal discharge. The normal cervical discharge is a clear mucus and hardly appreciable. When the cervical glands are infected or irritated, they pour out large quantities of mucus, so that the patient must wear napkins for protection. The causes of cervical leukorrhea are: (i) Laceration of the cervix; (2) erosion; (3) eversion; (4) gonorrhea (of all the most stubborn to treat) ; (5) carcinoma; (6) non-bacterial hyper- secretion of the cervical glands (most often in virgins and often without obvious cause; though usually in neurotic pa- 336 BACTERIOLOGY 337 tients and those with displacement of the uterus; (7) cervical polyps. 4. Uterus. — The endometrium is not prone to infection and discharge. Causes of uterine leukorrhea are: (i) Chronic interstitial endometritis (after sepsis or gonorrhea); (2) chronic hyperplastic glandular endometritis (though bleeding is com- moner); (3) senile atrophic endometritis; (4) incomplete ab- ortion; (5) sloughing polyps; (6) cancer; (7) tubercular endo- metritis. There is a temporary leukorrhea just preceding or following menstruation and due to hypersecretion and hyper- emia; it is so common as to be physiologic. 5. Tubes. — Hydrosalpinx (hydrops tubse profiuens) and pyosalpinx (pyosalpinx profiuens) sometimes discharge through the uterine cavity, at intervals; but other than this the tubes play no part in leukorrheal discharge. Characteristics of Leukorrhea. — The normal vaginal reac- tion is acid; in leukorrhea the reaction is usually neutral or alkaline. The quantity of discharge is greatest from the cervix, and least (except in vulvovaginitis in children) from the vagina. The consistence varies from a thin watery discharge (as in early carcinoma of the cervix) to a profuse creamy ropy mucopus. The discharge varies in color, from clear mucus to white, yellow, red, green (sloughing fibroids) to dark brown or black. As a rule the thinner and more watery the discharge, the more persistent; the commonest exception to this is chronic gonorrheal endocervicitis. It is often blood-stained, most commonly in cancer, fibroid polyps or senile vaginitis. A foul discharge is rare in ordinary leukorrhea; it is the rule in: (i) retained products of conception; (2) cancer; (3) slough- ing polyps or fibroids; (4) neglected pessaries. Bacteriology. — By far the commonest organism is the gonococcus, especially in adults who have not borne children. In parous women, the injuries of childbirth, with non-gonor- rheal bacterial invasion, is the most common cause. Streptococci, both aerobic and anaerobic; staphylococci, colon bacilli, gram-negative anaerobes, tubercle bacilli, and 33^ LEUKORRHEA (tHE WHITEs) pneumococci are the commonest non-gonorrheal organisms. All these are of low virulence, except after miscarriage or labor at term. Diagnosis as to source is made as follows: i. Inspection of the vulva for (i) abscess of Skene's glands; (2) urethritis; (3) infection of Bartholin's glands. 2. Inspection of the en- tire vaginal wall, through a skeleton bivalve speculum made of wire, so that as little as possible of the vaginal walls is hidden from view. 3. Inspection of the cervix through the same, or a solid bladed bivalve speculum, for erosion or eversion, polyps or cancer. 4. Bimanual examination of the uterus, tubes and ovaries, to detect enlargement, tumors, fixation or pelvic iniiammation. 5. If no cause is found as above, and especially if the patient is nearing the menopause, exploratory dilatation and curettage, with microscopical examination of the scrapings. 6. Smears are always taken from the ureth- ral and cervical discharge. Treatment is best considered by sources. General Treatment. — The patient's general health should be considered, her mode of life, bowels and diet regulated, and iron, arsenic and strychnin given when she is anemic. 1. Vulvar Leukorrhea. — The vulvar lesions responsible for the discharge are nearly always gonorrheal in origin. In- fected Bartholin's glands are dissected out; infected Skene's tubules injected with nitrate of silver 8 per cent., or argyrol '25 per cent, or silvol 5 per cent, by a hypodermic syringe with a blunt needle; or much better destroyed by the electric cau- tery needle or slit up; an infected urethra is treated by local applications. Unless these lesions are removed, other local treatment is useless. A chronic urethritis is usually due to infected Skene's glands. 2. Vaginal Leukorrhea. — Vulvovaginitis in children has been considered in Chapter XV on gonorrhea. The treatment of neglected pessaries, tampons or other foreign bodies is ob- viously their removal, followed by douches of salt solution twice daily until the erosions caused by the foreign bodies have TREATMENT 339 healed over. If the patient is of uncleanly habits, and the discharge results from saprophytic or fungus infection, douches twice daily or mild antiseptics like lysol i dram to 2 pints, or boric acid gr. lo to oz. i, or permanganate of potassium i- 3000 are all that will be needed. Cancer is treated by surgical means if possible; if far advanced by :v-ray or radium. Senile vaginitis, associated with a white or yellow, often blood streaked discharge, and accompanied by intense itching resists all ordinary local applications or douches. In these cases, the following will help most cases: (i) Swabbing the entire vaginal mucosa, with 7 per cent, tincture of iodin. Care must be taken not to let any excess of solution run down over the perineum or anus, as it will then cause intense burning. This application must be repeated several times at intervals of a week, as the patient's condition indicates. (2) Eight per cent, nitrate of silver solution (gr. 40 to the ounce) used in the same way. (3) Implantation of lactic acid bacilli, as follows: {a) The patient is arranged in the dorsal position, the vagina thoroughly cleansed with salt solution, and dried; {b) the cervix is exposed with a bivalve speculum; (c) a lactic acid tablet, with lactose base, is moistened with sterile water (one or two drops only) and inserted in the posterior vaginal vault; {d) the speculum is half withdrawn, and after five minutes, withdrawn completely; {e) no douches are allowed; (/) fresh applications are made at weekly intervals for three or four weeks, until the vaginal secretion is acid, and then about once a month. This treatment is most efficient in senile vaginitis, next in ordinary mild vaginitis, next in chronic endometritis, and least of all in vulvovaginitis in children. (4) Routine douches, or local applications, except as noted above, are a waste of time. Mild vaginitis (not senile) responds to the following: (i) Hot douching twice daily of boric acid (gr. 10 to oz. i) or potassium permanganate 1-3000; (2) drying vagina with cotton and insertion of vaginal suppositories containing three grains 340 LEUKORRHEA (tHE WHITES) of Hydrastis; this is done nightly; (3) powder of aluminum acetate, one part; talcum two parts, boric acid three parts, applied on tampons or by insufHation. (3) Cervical leukorrhea is much the most stubborn to treat, especially if due to gonorrheal endocervicitis. The treatment naturally varies with the cause. A lacerated cervix must be repaired, and the erosion and eversion dependent upon the tear will disappear. Cancer requires cauterization, radium or panhysterectomy. Leukorrhea due to cervical polyps is easily checked by removal of the polyp. Erosion not due to laceration or gonorrhea, responds quickly to 8 per cent, nitrate of silver. The real problem is presented by chronic endocervicitis, particularly the gonorrheal type. Gonorrheal Type of Cervical Leukorrhea.' — (i) Dry treatment, by aluminium acetate, talcum and boric acid, applied thickly dusted on tampons. (2) Tampons of boroglycerid 25 per cent., or ichthyol 50 per cent, in glycerin, removed at forty-eight hour intervals. (3) Local applications, on cotton swabs through a bivalve speculum, of argyrol 25 per cent., protargol 5 per cent., silvol 5 per cent., all made up in glycerin; tincture of iodin 7 per cent.; pure formalin, 40 per cent, solution of formaldehyd; iodin 7 per cent., carbolic acid pure, equal parts. These applications are made with uterine applicators thinly wound with cotton, saturated with the solution to be used and carried up to the internal os The solution is then made by rotating the applicator, always in the direction the cotton has been wound on it. The last three are the most efficient, but likely to be painful, and a cotton pledget should be packed in the posterior vaginal vault to protect against leakage. These applications are made twice weekly, over periods of several weeks. (4) Electricity with copper uterine electrode, positive pole to the uterine sound, using a 40 milliampere galvanic current for forty-five minutes twice weekly. (5) Instillations into the cervical canal of 5 per cent, silvol or 25 per cent, argyrol or 50 per cent, ichthyol pastes, made with a slowly soluble base and injected by means of an instillating syringe. For technic TREATMENT 34I see Chapter VI. (6) Radium- — 50 mg. screened by i mm. plati- num or brass and encased in a finger-cot, inserted to the level of the internal os. The external os is closed by a suture, which includes the end of the finger-cot; the radium is removed after eighteen hours. (7) Vaccines — mixed autogenous, so as to be representative of the vaginal flora. (8) Brewer's yeast, 3^^ ounce poured in the vagina and held in by a large wool tampon for twenty-four hours sometimes works well, but is not to be depended upon. The same is true of lactic acid bacilli tablets, as described under senile vaginitis. (9) Vaginal douching, except for cleanliness, is useless. (10) Stubborn cases will require surgical relief, either Schroder's operation of excision of the mucosa (likely to be followed by a secondary dysmenorrhea from stenosis) or much better amputation of the cervix at the level of the internal os. This latter is efficient, but any future pregnancy is very liable to abort. (4) Uterine leukorrhea is uncommon. The treatment varies with the cause. Senile atrophy of the endometrium, if a cause of discharge requires dilatation and curettage and application to the uterine cavity of tincture of iodin 7 per cent, and pure carbolic acid equal parts, but this should rarely be needed. Incomplete abortion is cleaned out with placental forceps; cancer requires hysterectomy; sloughing fibroid polyps are removed by dilatation of the canal and placental forceps. Dilatation and curettage for gonorrheal infection is to be avoided as it is very likely to result in a pyosalpinx. The best treatment, locally, for uterine leukorrhea, except for cases due to cancer or tuberculosis, is instillation into the uterine cavity of 25 per cent, argyrol, 5 per cent, silvol or 5 per cent, protargol, prepared in glycerin. Vaginal douches are useless, except for cleanliness. (5) Tubal leukorrhea comes only from hydrosalpinx or pyo- salpinx, draining through the uterine cavity and requires abdominal section and removal of the affected tube. (6) Leukorrhea in virgins is most commonly due to displace- ment of the uterus or anemia (chlorosis) and on correction of 342 LEUKORRHEA (tHE WHITES) the primary cause will disappear. When it occurs without demonstrable cause, the treatment is: (i) Iron and arsenic tonics; (2) laxatives, to produce two soft movements a day; (3) ergotin gr. 3^^, pituitrin }-^ milhypo- dermically daily for five or six doses, to diminish uterine con- gestion; (4) in chronic cases, dilatation of the uterine canal and application of tincture of iodin and carbolic acid equal parts, to the uterine cavity. Prognosis. — Many cases of leukorrhea respond promptly to treatment; many are distressingly chronic, especially chronic gonorrheal endocervicitis. Relapses after apparent cure are common. - CHAPTER XVIII DISEASES OF THE BREAST I. ANOMALIES OF DEVELOPMENT Absence (Amazia). — The breasts are never microscopically- absent. While there may be no gross evidence of any gland tissue, it is said that traces may always be found, by micro- scopical examination. This is, of course, of no clinical impor- tance. Incomplete development is called micromazia. Supernumerary breasts (polymazia) are not uncommon. In the embryo of six weeks, there is a line of cells running from the axilla to the groin — the crista lactea. From the thoracic portion of this the breasts are developed. The extension of the crista lactea into the axilla is the most frequent site of accessory breasts, though they may be situated anywhere. Each gland may have its own nipple and secrete milk during lactation. The "swollen gland in the axilla" complained of by so many patients after delivery, is simply an accessory breast. Supernumerary nipples are known as polythelia. IL ABNORMALITIES OF THE NIPPLE Although many of the abnormalities mentioned in this chapter are met chiefly as complications after delivery, the author has thought it best to include them in this place, rather than limit the subject to those remote from child-birth. The most important of the abnormalities of the nipple are (i) Fissured or cracked nipple; (2) inverted; (3) stunted; (4) hollow; (5) mulberry; (6) conical; (7) mushroom. The inflammation of the nipple, associated with fissure, is called mammillitis. 343 344 DISEASES or THE BREAST Fissured nipple most often occurs in pregnancy, or the puerperium, from lack of cleanliness or rubbing of clothing. It is rare at other times. It is most common during lactation, in primiparae, in blonds or red-haired women rather than brunettes and in any deformity of the nipple itself. If the condition occurs in pregnancy, cleanliness and protection by a leaden nipple-shield will usually sufl&ce. V/i^/e/^: HROOMXr Fig. 141. — Faulty development of the nipple. {Dickinson.) Symptoms. — (i) Intense pain on nursing and (2) a visible crack in the skin. This fissure usually runs around the base of the nipple, at its lower border, but may occur as a vertical fissure dividing the nipple or as an ulcer anywhere on its surface. If not easily visible, a reading magnifying glass should be used to search for it. In any case of painful nursing, a fissure should be looked for, at once. The fissure often bleeds when the child is nursed, and if this blood is swallowed by the child, it will appear in the stools — meleua spuria. Treatment. — If the nipples are sore in pregnancy, and no ABNORMALITIES OF THE NIPPLE 345 actual fissure is visible, they should be kept scrupulously clean, protected by a leaden nipple-shield and witch-hazel applied to them twice daily. If the fissure appears during lactation, scrupulous cleanliness is imperative. The nipple is protected during nursing by a nipple-shield (either the Phoenix or Infantibus — the latter much the best). The nipple is washed off with boric acid solution before and after each nursing. After nursing dry and equal parts of subnitrate of bismuth and castor oil is applied. Fig. 142. — Leaden nipple- Fig. 143. — Nipple- shield. {B. C. Hirst.) shield. (Phoenix.) All these applications are made with sterile cotton pledgets. The nipples are then covered with sterile gauze and a Murphy breast binder applied. Alternative applications are com- pound tincture of benzoin, applied to the fissure itself; ichthyol I dram in i ounce each of glycerin and olive oil; solid stick nitrate of silver to the fissure. It is not safe for the child to nurse without the protection shield until forty-eight hours after the fissure has apparently healed. Should the fissure refuse to heal, or the child be unable to nurse from the shield, a tetrelle (or Phoenix number 3) should be used. This is a form of breast-pump in which the mother, by a rubber tube and mouth piece makes the necessary suction to draw the milk into the pump, and the child withdraws it by a separate orifice and tube. This instrument can be used over 346 DISEASES or THE BREAST Pig. 144. — Soft-rubber nipple- shield called "Infantibus" will be tolerated in cases of sensitive nipples when the "Phoenix" and others cannot be endured. {J. P. C. Griffith.) long periods, with little danger of causing pain, and for this reason is preferable to any other form. As the mother regulates the amount of suction, and can stop short of any degree that is uncomfortable, there is little chance of re- opening a fissure that is healing. If this will not work satisfactorily, the child must be weaned. Care of Nipple-shields. — Shields must be washed and scalded di- rectly after use, and kept in a closed jar of boracic acid solution (gr. 10 to oz. i) so that they are completely covered by the solution. The shield is removed from the solution with dressing forceps, and rinsed in cool sterile water just before use. Danger of fissured nipple is chiefly infection and breast ab- scess. Inverted nipple is an arrest of development. It is of impor- tance in lactation only. Long-continued use of the breast- pump in pregnancy, with moderate suction, will help somewhat, suction being appHed for fifteen to twenty minutes night and morning. The condition is usually obstinate. Massage with the fingers is somewhat dangerous, due to bruising and infection. The breast-pump is more efficient and safer. In- verted nipples are difficult to keep clean during lactation. They are hkely to fissure, and it is impossible for the child to nurse without a nipple-shield or a tetrelle. Stunted nipple is important only in that it is difficult for the child to nurse. Systematic use of moderate suction with a Fig. 145. — Breast-pump. {Phoenix.) NON-INFLAMMATORY DISEASES OF THE BREAST 347 breast-pump, throughout pregnancy, will often cause improve- ment, but the nipple-shield is usually required during the nursing period. Hollow nipples are merely a form of inverted, have the same disadvantages and are treated in the same way. Mulberry nipples are exceedingly hkely to fissure and re- quire care to prevent this complication. If a fissure occurs, it is treated as already described. Conical nipples make it somewhat difficult for the child to nurse, but the difficulty is not a serious one, and a nipple shield is rarely required. Mushroom nipples have the same disadvantages as mulberry — fissure — though to a less degree. All the above 'complications are those of pregnancy and lactation, and rarely if ever give trouble at other times. Abscess of the areola is most commonly seen in girls about puberty, though it can occur at any time. It arises from the sebaceous follicles, and requires incision and drainage. Paget's disease (Malignant Dermatitis), is a chronic, de- structive inflammation of the nipple, seen usually in women past forty-five. Cause is unknown. Symptoms. — ^(i) Moist desquamation, followed by yellow purulent discharge, with formation of crusts. (2) Under the crusts, the surface is red and raw. (3) The nipple is retracted or destroyed, and the condition often extends, like an eczema, to the skin of the breast. It is a precursor of carcinoma of the breast. Treatment is excision of the diseased area, and, if there are any indurated areas in the breast, removal of the breast and axillary glands. This operation, like those for known carci- noma, should be followed by x-ray treatment as a prophylactic. III. NON-INFLAMMATORY DISEASES OF THE BREAST I. Hypertrophy is rather rare. It is bilateral and usually asymmetrical, the condition is most often (80 per cent.) seen" 348 DISEASES OF THE BREAST in women under twenty-five years of age. The breasts may be very large — one of sixty-four pounds being reported. The enlargement is usually a fibrous tissue growth, and during lac- tation, a profuse flow of milk is not the rule. Nursing the child has been a cause of reduction in size of the glands, hence it is not contra-indicated. The process is benign, and if the weight is burdensome, a supporting binder or, failing this, amputation are the only remedies. 2. Neuralgia of the breast (mastodynia) is most common in young unmarried women, and is often associated with disturb- ance of ovarian secretion and menstrual irregularities. The skin is hyperesthetic, the breast is tender to the touch, but no organic change can be detected. Treatment is: (i) Iron, arsenic and strychnin as tonics; (2) hypodermic injections of whole ovarian extract, i mil daily for twenty-four doses, followed by series of twelve doses at intervals of several weeks. IV. INFLAMMATORY DISEASES OF THE BREAST Acute inflammation (mastitis) is most common in nursing mothers. It occurs occasionally in infancy (in both girls and boys) and at puberty in girls, as enlargement, induration and tenderness, persisting for several weeks and finally undergoing resolution, though suppuration sometimes takes place. Masti- tis is also seen as a metastatic process in mumps. The pus' may be in the areola, the subcutaneous connective tissue, the gland itself and the connective tissue under the breast. The commonest type is infection of the gland, with secondary involvement of the connective tissue. The bacteria responsible are Staphylococcus alhus or aureus, Streptococcus pyogenes, pneumococcus, colon bacillus, or O'idium albicans. Cause. — Dirt in handling, whether from hands, cloths, water, clothes or various applications, is the chief cause. The widespread superstition among the lower classes that saliva is the best application for fissured nipple is responsible for many INFLAMMATORY DISEASES OF THE BREAST 349 cases. The skin of the areola and nipple always contains pathogenic germs, and these may develop powers of invasion, through the ducts (this will explain the cases due to bruising in massage). The child may be the source of infection, if it has thrush or stomatitis. Symptoms. — A chill and moderate fever (103°) most com- monly from the tenth to twentieth day of the puerperium. The breast is painful, and one or more indurated areas can be felt. .- - dntramammari/ ahseess "" (pointing Superfic/allyJ yS lib cutaneous --" 'Suhtnammariy abscess ■^- -Subareolar ahseess jmramammari/ abscess '< - ^ \ / (Beep in the substance of /be breasfj Fig. 146 — Location of pus in a breast abscess. (After Deaver.) The commonest portion affected is the outer lower quadrant. The temperature and pain usually subside within thirty-six hours; if they continue, suppuration is to be expected. Treatment. — (i) If the breast is engorged, massage is indi- cated, otherwise not. In any case it must be gentle; (2) purgation with hydragogue cathartics; (3) breast-binder; (4) ice bag over affected area; (5) applications of saturated magnesium sulphate solution or dilute lead-water and alcohol (two ounces lead- water to three ounces of alcohol); (6) strap- 350 DISEASES OF THE BREAST ping with adhesive straps, if the extra pressure is not too pain- ful. This treatment is to be used only before suppuration is evident, and is often spoken of as the "abortive treatment." Bier's local hyperemia, by suction caps, is painful and ineffec- tual. It is used with suction for four-minute periods, with equal periods of rest, for forty-five minutes once daily. The results do not justify its use. Breast abscess is a common sequel of mastitis. As the area involved in the suppurative process is, at first, small, but tends rapidly to infiltrate the entire breast, it is important to recognize the presence of pus as soon as possible. A breast abscess is nearly always multilocular and fluctuation is not to be awaited. The pus is located above, usually in, or under the gland. Symptoms at first are indefinite. Pus may be expected with the following signs: (i) A dusky red or purple hue of the skin over the indurated area; (2) edema of the skin over the indu- rated area; (3) fever of an irregular septic type; (4) leukocytosis (18,000 to 22,000 on the average). Differential diagnosis may be needed, in rare instances, from carcinoma of the breast, tuberculosis of the breast or actino- mycosis. There is a type of carcinoma of rapid growth, first appearing in late pregnancy or early puerperium, called mastitis carcinosa. This, as well as tuberculosis or actino- mycosis, requires microscopic sections of an excised portion, for accurate diagnosis. Treatment. — Early opening of a breast abscess is imperative, before wide destruction of the gland has taken place. The technic is as follows: (i) General anesthesia. (2) Local surface cleansing as for any operation. (3) With a thin-bladed knife, make multiple stab wounds, about one-quarter inch long, opening every area where pus is suspected, and wiping off blade of the knife with an alcohol pad, after each incision. These incisions are to be made radiating from the nipple, so as not to cut across a milk-duct; they should be entirely within or without the areola, and not across the border (as in healing INFLAMMATORY DISEASES OF THE BREAST 35 1 the pigment will follow the scar); the incisions should be so planned that when the patient is out of bed, all drainage tubes will run down hill, and not straight across the breast; and it is desirable to confine all incisions, if possible, to the lower half of the breast. (4) A long hemostat is inserted through each opening, and the septa between the lobes of pus broken down, so as to make as nearly as possible a unilocular abscess. (5) Each opening is flushed out with sterile water, run from a fountain syringe by gravity. (6) Each pair of openings is then con- nected by fenestrated rubber drainage tubing, about the size of a lead pencil. The tubing is pulled from one opening to the other by the hemostat or clamp. Care is taken not to run the tubes superficially (as they will slough out and make ugly scars) or under the nipple. (7) Safety pins are passed through each end of each tube. (8) The tubes are flushed Fig. 147. — Pigment of the • ,i i •! J. i 1. J. I. areola following incisions. (Rich- witn sterile water, to be sure they ^^^^^^ ) are patent. (9) The breast is dressed with bunched gauze and a breast binder. Bandages or straps are a nuisance. The Bier hyperemia treatment is a failure in the ordinary breast abscess. It is fairly effective in small single abscesses, but a much easier, quicker and less painful way to cure a small unilocular abscess is to make a single small incision over the most prominent part of the swelling, wash out the pus, and inject a 2 per cent, solution of hegonon, or 25 per cent, argyrol, or 5 per cent, silvol. If the systemic symptoms of a breast abscess are severe, and the pus is streptococcic, intravenous injection of 80 to 100 c.c. of antistreptococcic serum is often of great value. The usual time of healing of a breast abscess, properly opened and drained, is five to six weeks. 352 DISEASES OF THE BREAST After-treatment. — The drainage tubes are flushed, once daily, with sterile water, run by gravity from a fountain syringe with a medicine dropper attached to the tube. Only if the tubes are blocked is a piston syringe used to force water through them, and as soon as they are clear, the gravity flow is substituted. No attempt is made to remove the tubes for at least two weeks, and then the shortest is removed first, and the others at two- or Fig. 148. -Drainage required in a case of mammary abscess. (5. C. Hirst.) three-day intervals; the sinuses are packed lightly with gauze, from each end, and flushed daily. Small secondary superficial collections frequently need opening during the convalescence. Unless the nipple ducts have been blocked, lactation in sub- sequent confinements is surprisingly little interfered with. INFLAMMATORY DISEASES OF THE BREAST 353 Postmammary abscess (submammary abscess) is a collec- tion of pus in the connective tissue under the breast, just over the pectoral muscles. It is rare, and serious. Symptoms. — One breast is more prominent than the other, the whole gland being lilted off the chest. There are no symptoms of inflammation in the breast itself, and very little pain on pressure. Systemic symptoms of sepsis are severe, fever high and leukocytosis 25,000 or more. Diagnosis is best made by aspiration with a hypodermic syringe. The needle should be of fairly large caliber, as the pus is usually thick. Treatment. — An opening is made at the most dependent portion, a counter-opening diametrically opposite, and through- and-through drainage established by a fenestrated rubber tube. The after-care is that of the ordinary breast abscess. Chronic mastitis occurs in two forms: 1. Lobar (or circumscribed), usually following trauma or pregnancy. It is most frequent in women near the menopause. The lobe involved is enlarged, indurated and tender, but there is no systemic disturbance. It is exceedingly chronic, but never suppurates. 2. Diffuse (lobular or interstitial) is most frequent after lactation or at the menopause. The intercanalicular connec- tive tissue increases very markedly, and later contracts, so that the breast is hard and shrunken, the seat of small cysts, and the nipple depressed. The breast is painful and there is a watery discharge from the nipple. The disease rarely disappears, but causes atrophy of the breast, with general cystic degeneration, and possibly carcinoma. Treatment of both forms of chronic mastitis is: (i) Removal of any source of chronic irritation, such as badly fitting corsets; (2) support by a breast-binder; (3) local inunction of unguent, hydrargyri and unguent, belladonnae equal parts; (4) potassium iodid 15 grains four times a day; (5) amputation of the breast if exceedingly painful or the seat of gross patho- logical changes. 354 DISEASES OF THE BREAST Chronic suppurative mastitis is distinguished by pus forma- tion without signs of inflammation. It follows lactation, syphihs, tuberculosis and actinomycosis. The abscess wall is very thick, and the tumor feels solid, without fluctuation. The diagnosis is made by aspiration. Treatment. — If small in extent, incision and drainage, if extensive, amputation of the breast. Tuberculosis is uncommon. It may be localized (cold abscess) or diffuse (miliary) . It is usually secondary. Sharply circumscribed areas can be excised, but as a rule amputation is required. Syphilis is seen as mucous patches or condylomata of the nipple, or as gummata. The local manifestations disappear on systemic treatment. V. TUMORS OF THE BREAST Tumors of the breast are benign or malignant. ' Method of Examination. — In palpating the breast for a tumor, the gland should not be picked up between the fingers, but pressed against the chest-wall with the flat of the hand. Benign Tumors of the Breast Fibro-adenomata are the most common benign tumors of the breast. Pure fibroma and pure adenoma are exceedingly rare. They occur between puberty and the thirtieth year. They are hard, nodular, freely movable, usually but not always painless and show no adherence of the skin, axillary involvement or effect upon the general health. They are subject to cystic degeneration, but rarely become malignant. They often grow rapidly in pregnancy. Treatment.- — (i) Semicircular incision along lower margin of breast; (2) breast is turned back and the growth removed by V-shaped excision; (3) the wound of excision is sutured, and if much tissue is lost, the gap can be filled in with fat trans- planted from the thigh or buttock; (4) the skin wound is TUMORS OF THE BREAST 355 sutured by subcuticular stitch, leaving provision for drainage of serum at one corner. Cysts of the breast are (i) Retention cysts caused by blocking of the ducts (galactocele); (2) involution cysts (in interstitial mastitis and often papillary), usually bilateral; (3) interacinous cysts (from lymph-spaces and lined with endothelium. They have no connection with the gland spaces. A galactocele is round, painless, near the nipple and usually fluctuating. The Pig. 149. — Removal of a breast tumor by elevation of the breast and wedge-shaped excision. (After Warren.) treatment required is incision and drainage. Involution cysts require amputation of the breast. Interacinous cysts are dissected out, entire if possible. Any cyst of the breast should be looked upon v/ith suspicion, even though the microscope shows no evidence of malignancy. They are often in the precancerous stage, and the patient should be kept under observation for several years. Cystadenoma is the dilatation of the acini into multiple cysts. It occurs between the thirtieth and fortieth years, is slow in 356 DISEASES OF THE BREAST growth, large in size, painless, and associated with bleeding from the nipple. It is nodular and encapsulated, hard, and in the later stages adheres to the skin even breaks through it. It does not as a rule involve the axillary glands. Treatment. — In the early stage, removal of the growth alone; in the late stages, amputation of the breast. Malignant Tumors of the Breast I. Carcinoma. — Frequency. — Over 80 per cent, of all breast tumors are carcinoma. It is more frequent in women who have borne children. Any lump in the breast must be regarded as potentially malignant, until proven otherwise. Cancer is more frequent in the left breast than the right. Age of Patient. — The majority are past thirty-five years of age. It may occur much earlier, but is unusual before thirty- five or past sixty-five. Causes. — (i) Preceding trauma or inflammation; (2) Paget's disease; (3) heredity influence is slight. The actual exciting cause is not known. Kinds. — (i) Acinous; (2) columnar celled or duct cancer; (3) squamous-celled epithelioma. Medullary or encephaloid cancer is soft, appears at an earlier age, grows rapidly, ulcerates early, gives early metastases, and the nipple is not retracted. This is the type which, owing to its often following pregnancy and being vascular, is mistaken for a breast abscess. Scirrhous or hard cancer appears later, grows slowly, is stony, hard and nodular, the skin is adherent and infiltrated and the whole breast is movable as one mass; in the early stages per- pendicularly to the milk ducts but not parallel to them; in the late stages, after the pectoral muscle has been in- volved, up and down but not transversely. As the fibrous septa of the breast contract, small depressions appear in the skin, giving it the appearance of orange rind or a pig's skin. This growth is most frequent in the outer segment of the TUMORS OF THE BREAST 357 breast. The nipple is higher on the affected side, and the areola shrunken. A scirrhous cancer is never large and in old women sometimes shrinks progressively and lasts for years (atrophied scirrhous). If the skin is extensively infiltrated, it is called cancer en cuirasse. Symptoms. — (i) A growth in the breast, answering one of the descriptions just given; (2) rapid growth if medullary, slow if scirrhous; (3) often a thin bloody discharge from the nipple; (4) pain is absent at first, but later is very severe, due to axillary involvement; (5) ulceration is preceded by a purple discolora- tion of the skin; (6) cachexia is a late symptom; (7) the axillary lymph-glands are involved early, and later, with the supra- clavicular, become palpable; (8) solid edema of the upper extremity, caused by pressure on the axillary vein and lymph- vessels. When ulceration takes place, the scirrhous ulcer has hard, uneven, everted margins, is deep and has an offensive bloody seropurulent discharge. Diagnosis. — Any suspicious lump in the breast should be excised and examined microscopically. This is vitally impor- tant in all women past thirty-five. By the time a diagnosis can be established by symptoms alone, it is usually too late for a successful operation. Metastasis takes place: (i) The axillary lymph-glands; (2) the supraclavicular lymph-glands; (3) the anterior and pos- terior mediastinum; (4) to the opposite breast and axilla. Treatment is early and complete removal of the breast, pectoral muscles, axillary glands and fat and supraclavicular glands. The huge wound is closed by undermining of the skin and bringing the flaps together with interrupted silkwormgut sutures. The axilla is drained for forty-eight hours, by rubber tissue or a tube through a stab wound. If the wound edges cannot be brought together, the gap is allowed to granulate and skin-grafted later if necessary. Inoperable cases are: (i) Those with extensive involvement of axillary or supraclavicular glands; (2) cancer en cuirasse; 35S DISEASES OF THE BREAST (3) those with visce.al involvement; (4) atrophic scirrhous cancer in old women. Treatment. — (i) Local cauterization; (2) fulguration, usually under chloroform and never ether, because ether vapor is inflammable; (3) a;- ray or radium, (4) morphin in doses sufficient to control the pain. The various cancer serums, cauterizing pastes; Coley's fluid, injection of drugs like pyok- tanin, thiosinamin, methyl-violet are useless. After-treatment. — Every case of cancer of the breast, should be treated, after operation, by .r-ray as a palliative measure. Prognosis. — In untreated scirrhous cancer, expectation of life is two or three years; in medullary cancer, eight to twelve months. After operation 20 per cent, remain well after three years. A^^ter operation, immediate edema of the arm on the same side is a favorable sign, showing complete removal of the lymphatics; late edema is uniavorable, due usually to recur- rence. Surprising muscular action in the arm is preserved or acquired, even after most extensive operations. The mortality of the operation itself is less than 3 per cent. 2. Sarcoma of the breast forms less than 5 per cent, of breast tumors. Sarcoma appears usually between the ages of twenty- five and thirty; it is encapsulated, grows rapidly; is usually softer than cancer, causes distention of the overlying veins, does not invade the axilla until ulceration has taken place, but does give early visceral metastasis. Kinds. — Equally divided between small round-celled and spindle-celled. Inflammation and suppuration are common. Differential Diagnosis. — (i) As given above; (2) is more movable than cancer; (3) does not retract the nipple; (4) does not infiltrate or thicken the skin; (5) causes profuse hemorrhage from ulceration. Treatment is the same as for cancer. Prognosis is very grave. The vast majority die from recur- rence or visceral metastasis. CHAPTER XIX DISEASES OF THE RECTUM Diseases of the rectum are very much the same in both sexes, but the frequency of rectal complications in pelvic diseases in women renders a short synopsis of the commoner ones advis- able in any work on gynecology. Methods of Examination. — Rectal examination is best made with the patient in the Sims or knee-chest position, the latter particularly for specular and proctoscopic examination. 1. Inspection of the external parts for fistula, fissure, hemor- rhoids bleeding or other discharge, and any other local con- dition. By having the patient strain, prolapse of the rectum becomes evident, as do internal hemorrhoids and some polyps. 2. Digital examination permits exploration of the rectum to the length of the finger only, about four inches. A rubber glove is essential. The index finger is anointed with vaselin, and gently inserted through the sphincter, at first forward and then back towards the sacrum. In this way, polyps, internal hemorrhoids, foreign bodies, stricture or any other internal abnormality may be felt. If pressure is made on the lower abdomen with the other hand, by pushing the bowel downward, the reach of the examining finger is slightly increased. 3. Specula for rectal examination are either cylindrical or bivalve. They are best used in the knee-chest position, but permit of a limited view only of the rectum. Light is reflected from a head mirror or headlight. 4. A proctoscope is merely a long cylindrical speculum (8 inches); a sigmoidoscope a still longer one (14 inches) both being provided with obturators and having an electric light at the distal end. 359 360 DISEASES OF THE RECTUM Technic. — i. The patient is arranged in the knee-chest or Sims position; anesthesia is unnecessary. 2. The instrument, with the light removed, is sterihzed by boihng. 3. The light is inserted and connected, the obturator in- serted, and the instrument greased with vaseHn. 4. The instrument is gently inserted past the internal sphincter, the obturator removed. 5. If the rectum does not distend under atmospheric pressure a plug with glass window is inserted in the proximal end and by means of a hand bulb, the rectum is distended with air and the instrument passed to its full length. 6. The whole rectum is carefully inspected as the instrument is withdrawn. 7. Applications may be made to the rectal mucosa by long applicators, through the barrel of the instrument. 5. If the rectum is filled with bismuth mixture, or a solution of 10 per cent, thorium nitrate, the size and shape of the rectum and the presence of fistulse or diverticula can be shown by :v-ray. I. CONGENITAL MALFORMATIONS During development, the gut and genito-urinary canal open into a common passage, the cloaca. Later the perineum is formed, by the growth of a posterior and two lateral folds, and the gut provided with its separate outlet. The proctodeum is a depression extending in from the perineum, until it meets the rectum, and marks the site of the anus. Errors in develop- ment cause the following: (i) Imperforate anus, where the rec- tum is complete but the proctodeum is absent; (2) imperforate rectum, where the rectum and proctodeum are both developed but do not meet; (3) absent rectum, where the rectum ends high up under the pelvic brim. All these must be corrected immediately after birth, as they are ^etal complications, and have no place in the adult; (4) an imperfect septum dividing the cloaca, results in the rectum opening into the bladder (anus vesicalis) ; urethra (anus urethraHs) ; or the vagina (anus PISTULA IN ANO 361 vaginalis or vestibularis). These abnormalities are usually- corrected during infancy or childhood and are rarely seen in adult life. IL FISSURES OF THE ANUS This is often a complication of hemorrhoids, fecal impaction and passage of hardened feces, or proctitis. Symptoms. — (i) Burning pain on defecation, and often on coughing or sneezing; (2) often a single "sentinel" pile at its outer extremity; (3) streaks of pus or blood on the fecal column when it is passed; (4) constipation encouraged because of the pain of a movement; (5) spasmodic contraction of the sphincter. Diagnosis. — By separating the folds of the anus the fissure can usually be seen. If not, the patient is examined with a bivalve rectal speculum. Prognosis. — May heal spontaneously. Some are chronic ulcers which persist for long periods. Treatment. — (i) As an office measure, cocamize the fis'Sure with 10 per cent, cocain solution and apply the solid stick nitrate of silver; repeated three times weekly until the pain on defecation disappears; (2) laxatives sufficient to give two soft movements daily; (3) if the above fails, the patient is anes- thetized and the sphincter forcibly dilated, with the thumbs. During the resulting paralysis for five or ten days, the ulcer usually heals; (4) coexisting piles should be removed at the same time. If there is any difficulty, in office treatment, in exposing the fissure, pressure by the forefinger in the vagina can be used to evert the rectum through the sphincter. For this the patient is in the right Sims' position, so that the left hand is used for everting and the right for application; (5) a large ulcerated fissure may require excision, but this is rare. IIL FISTULA IN ANO Fistula in ano is nearly always caused by the rupture of an abscess, the sinus refusing to heal because of poor drainage, tortuous course and constant reinfection from the bowel. About one-half the cases are tubercular. 362 DISEASES OF THE RECTUM There are three kinds of fistulcc: 1. Blind External. — A sinus, which opens externally but does not communicate with the bowel. It is short and near the anus when due to an anal abscess; deeper and further from the anus when due to an ischiorectal abscess. 2. Blind Internal. — Also a sinus, which opens into the bowel, but has no opening on the skin externally. It is the rarest, and is usually on the pos- terior or lateral wall of the rectum. 3. Complete. — With an opening both external and internal occurs in 75 per cent, of cases. It is usually due to an ischiorectal ab- scess, the internal opening being about one and one- half inches from the anus. Symptoms. — (i) Pain during defecation; (2) ten- esmus; (3) purulent dis- charge; (4) in complete cases, escape of gas and feces through the fistula; (5) often recurrent abscesses, due to blocking of the tract and re-infection. As these often rupture through new tracts, they cause branching of the sinus. Diagnosis is made by inspection and probing if the fistula has an external opening; by rectal speculum and digital explor- ation if it is blind internal. By digital examination can be felt spasm of the sphincter, the cord-like tract of the fistula and sometimes its orifice. Treatment. — (i) Always examine lungs for phthisis and if present and active, avoid operation if possible; (2) patient is arranged in the lithotomy position and anesthetized; (3) a grooved director is passed through the fistula into the rec- tum, between the two sphincters; (4) the overlying tissues are cut through, the external sphincter cut once at right angles to Pig. 150. — Forms of rectal and anal fistulae. Blind internal, blind external, and complete. HEMORRHOIDS (piLES) 363 its fibers. Incontinence need not be feared, provided the internal sphincter is not cut, and the external cut but once; (5) all branching sinuses are opened, and all hard cicatricial tissues cut away with scissors; (6) the bleeding is checked and the wound packed with iodoform gauze; (7) blind fistula are best converted into complete fistulse, and healed as described; the grooved director should always be brought out between the two sphincters; (8) the bowels are kept locked with opium suppositories for four days; (9) on the fourth day, the patient is given an ounce of castor oil, and when a desire for evacuation occurs, the packing is removed and she is given one-half pint of sweet oil by enema; (10) after each defecation the packing is removed, the wound irrigated, and the packing replaced; (11) time of convalescence is about three to four weeks. If the fistula is lined with mucous membrane, it must be com- pletely excised. The internal sphincter should never be cut, and if the fistula opens into the bowel above the internal sphincter, its lower portion only should be dissected out. IV. FOREIGN BODIES IN THE RECTUM Foreign bodies are occasionally found, having been inserted by degenerates or insane persons, or have been swallowed. Symptoms are tenesmus, bleeding (due to ulceration) and obstruction varying with the size of the foreign body. Diagnosis is made by digital examination, speculum or x-ray. Treatment. — Removal by finger or forceps, through a speculum, usually under anesthesia. Large bodies may require splitting of the anus. V. HEMORRHOIDS (PILES) Hemorrhoids are varicose veins about the lower end of the rectum. ' Kinds. — (i) External hemorrhoids at the margin of the anus are covered with skin. They originate from the inferior 364 DISEASES OF THE RECTUM hemorrhoidal plexus, and consist of varicose veins, surrounded by connective tissue. They are likely, especially in labor, to become inflamed, painful and thrombotic. 2. Internal hemorrhoids originate from the superior hemor- rhoidal plexus, are covered by mucous membrane, and consist of varicose veins, connective tissue and a few small arterial twigs. They are likely, under straining, to protrude through the sphincter, which then closes down and strangulates them. iternal emorrhoid Exferrfal ^&no- external Hemorr4iold Hemorrhoid Fig. 151. — -Location, of hemorrhoids. {After Peyuiington.) External and internal hemorrhoids often co-exist in the same case. •Causes. — ^(i) Chronic constipation, with its attendant straining at stool, is much the commonest cause; (2) laceration of the perineum, rectocele or prolapse of the uterus; (3) any cause (such as pelvic inflammation, obstruction to the portal circulation, rectal disorders) which produces chronic pelvic congestion; (4) they are the rule, though often temporary, in pregnancy. Histology. — The veins run longitudinally between the HEMORRHOIDS (piLES) 365 mucosa and the muscle, and form a complicated plexus above the anus. They have no valves, and are one of the principal communications between the portal and systemic circulations. Symptoms. — External hemorrhoids csiuse few symptoms, other than slight itching, unless they become inflamed. Then they are distended, tense, bluish masses, painful to the touch, and they cannot be emptied by pressure. Repeated attacks of inflammation cause permanent thickening of the pile. Internal hemorrhoids (bleeding piles) cause: (i) Pain, worse on defecation and in direct ratio to the degree of constipation; (2) sense of fulness in rectum at all times; (3) bleeding usually slight but may be very severe; (4) usually a mucous discharge; (5) when inflamed, they project through the sphincter and are intensely painful; (6) ulceration is common. Diagnosis. — External hemorrhoids are obvious on inspection. Internal piles are often made visible by straining, can be felt by digital examination or seen through a speculum. By placing the patient in the Sims position, the forefinger can exert sufficient pressure through the vagina to roll the entire anal canal out through the sphincter, into view, especially if the patient is asked to strain at the same time. Treatment. — External hemorrhoids, when not inflamed, re- quire: (i) Laxatives; (2) washing the anal region after each defecation; (3) the use of soft paper or cotton directly after defecation; (4) local application of witch-hazel and water equal parts. If they are inflamed and thrombotic, they must be incised, evacuated and packed, under anesthesia. Internal Hemorrhoids. Palliative Treatment. — (i) Laxatives. (2) Bland diet, with avoidance of highly spiced food or alcohol. (3) Cleanliness as described above. (4) Local applications, two very satisfactory examples of which are the following: Ext. hamamelis, fld. oz. i Ext. Hydrastis fld. Tinct. benzoin comp. aa oz. 3^^ Tinct. belladonnas dram i 01. olivse (carbol. 5 per cent.) q. s. ad. oz. 3 366 Diseases of the rectum Apply frequently, both externally and internally (Adler) Cocain hydrochlorat gr. 10 Unguent, galli (nutgall) Unguent, belladonnse aa oz. i Apply thickly, with finger protected by finger-cot, inside rectum, four times a day. The latter is the most useful, if there is much pain. (5) Whenever the piles prolapse, they should be replaced, with the finger protected by glove or finger-cot. Operative Treatment. — Is indicated when: (i) Excessive pain; (2) excessive or prolonged bleeding; (3) repeated strangu- lation; (4) ulceration; (5) repeated inflammation. Preparatory treatment for operation consists of: (i) Laxative — not purge, forty-eight hours before operation; (2) enemas thirty-six, twenty-four and twelve hours before operation; (3) paregoric drams 2, two hours before operation; (4) regular preparation for anesthesia. Operation. — (i) Injection of boiling water, done under local anesthesia (10 per cent, cocain), several drops being injected, by a hypodermic, into each pile at intervals of a week. (2) Injection of two drops of 10 per cent, carbolic acid solution, in the same way. These two can be used as office treatment, but are not routinely efficient. 3. Clamp and Cautery. — (i) The patient is arranged in the Sims or dorsal position and anesthetized; (2) the sphincter is thoroughly dilated; (3) a pile is caught with hemostatic forceps and pulled down; (4) a Smith's clamp, with ivory base next to the mucous membrane, is applied and screwed tight; (5) the top of the pile is removed with scissors and the base seared with a cautery at a dull red heat Ctoo much heat causes hemorrhage) ; (6) the clamp is removed and all other piles are treated in the same way. The Downes electrothermic angiotribe is a neat instrument for applying heat and pressure simultaneously. The pile is brought down in the same way, the clamp applied and the special guard underneath it. Wet gauze is then placed HEMORRHOIDS (PILES) 367 under the clamp and protector and the current turned on for thirty seconds, counted from the time audible sizzhng begins. The pile is cut away thirty seconds after the current has been turned of and the clamp and protector are then removed. 4. Ligature. — (i) The patient is treated like the clamp opera- tion until the pile is brought down; (2) a gutter is cut in the skin with scissors, around the base of the pile; (3) the pile is transfixed with a needle armed with number 3 chromic catgut, tied off in the gutter and emoved. Both these operations cause some sloughing or swelling, but the end results are satisfactory. 5. The Whitehead operation is useful only when the entire anus is surrounded by a mass of piles. A circular incision is made at the junction of the skin and mucosa, the pile-bearing area resected, and the mucosa stitched to the skin. The operation is rarely to be recommended. It is often followed by stricture and incontinence. After-treatment: — (i) At the end of the operation, insert a rectal suppository of extract of opium gr. i, iodoform gr. 5; (2) hypodermics of morphin or heroin will be required in most cases, for the first forty-eight hours; (3) swelling is controlled by hot applications; (4) a rectal tube left in the rectum pro- vides for the painless escape of flatus; (5) the patient wears a sterile pad, and the perineum is irrigated with lysol solution (one dram or two pints) four times daily; (6) the bowels are locked for four days and then moved with castor oil oz. i, followed by an oil enema when a movement is imminent; (7) catheterization is needed for several days, due to retention of urine from reflex pain, and should be done every eight hours. In patients who have perineal tears, any operation for hemorrhoids should be accompanied by perineorrhaphy, other- wise return of the hemorrhoids is certain. Rectal bleeding is usually neghgible, if proper technic has been followed. If it is excessive, it is best controlled by a rectal tube surrounded by gauze, or by packing the rectum 368 DISEASES OF THE RECTUM with gauze for twenty-four to thirty-six hours, the gauze being then very gently and slowly removed. VL PROCTiriS (INFLAMMATION OF THE RECTUM) This is not common. Causes. — (i) Polyps; (2) colitis; (3) infected syringe nozzle in giving enemas; (4) gonorrhea; (5) dysentery; (6) foreign bodies; (7) infected hemorrhoids. Symptoms are (i) tenesmus; (2) frequent defecation; (3) discharge of mucus, pus or blood; (4) fever, in acute cases. The rectal mucosa often prolapses and there is always danger of ulceration and stricture. Diagnosis. — By proctoscopy the red, swollen mucosa, covered with pus or mucus can be seen. Treatment is (i) removal of the cause; (2) rest in bed; (3) liquid diet; (4) suppositories of opium and belladonna; (5) hot sitz baths; (6) laxatives; (7) irrigation with nitrate of silver solution 1-5000. VIL INJURIES OF THE RECTUM Injuries of the rectum, other than those of childbirth, are due to falls on some sharp object, and are treated on general surgical principles. A curious feature is shock out of all proportion to the apparent injury. VIII. ISCHIORECTAL ABSCESS Ischiorectal abscess is due to infection from the rectum, and is a result of periproctitis. It tends to point (i) through the skin near the anus; (2) into the rectum between the sphinc- ters (forming a blind internal fistula) ; (3) occasionally burrow- ing across the midline into the opposite ischiorectal fossa. Symptoms. — (i) Intense throbbing pain in the perineum, made worse by sitting, defecation or any other exertion; (2) always constitutional symptoms of sepsis (fever, rapid pulse and leukocytosis). Diagnosis.- — (i) A bulging tumor, to one side of the anus, brawny, indurated and painful to touch; (2) redness of over- PROLAPSE OF THE RECTUM 369 lying skin; (3) on rectal examination, a tender elastic swelling is felt on the corresponding side. Treatment. — Early free evacuation, .with irrigation and drainage. Spontaneous rupture is to be avoided if possible, due to the danger of fistula. The pus is thick, very foul, and contains bubbles of gas. A chronic ischiorectal abscess is usually tubercular. The swelling is hard and painless, and then becomes softer as it degenerates. Acute infection is possible at any time, and the resultant fistula is stubborn and persistent. IX. PROLAPSE OF THE RECTUM Prolapse of the rectum, in the adult, is seen most often in elderly women, especially those with perineal tears, sphincter tears or prolapse of the ut- erus. It varies in degree from protrusion of. the mucosa to complete inversion of the rectum, with all its coats. Protrusion of the mucosa is limited in extent, more than one inch being rarely seen; in true prolapse of the rectum the mass is sometimes very large. At first the protru- sion is painless, but as ulcer- ation of the mucosa takes place, it later becomes a very painful affection. Diagnosis is obvious, the deep red protruding mass admitting of no mistake. Treatment is either pallia- tive or operative. Palliative. — (i) Reposition, in the knee-chest posture, after oiling the mass; (2) strapping the buttocks to prevent recur- rence, leaving room for defecation; (3) a vulcanite plug, held in 24 Fig. 152. — Prolapse of the rectum and uterus. {Author's case, Phila- delphia General Hospital.) 370 DISEASES or THE RECTUM place by a T bandage, in place of the strapping; (4) strychnin to the point of tolerance; (5) mildly astringent enemas, such as tannic acid two drams, water two pints; or zinc sulphate one dram to two pints of water; or alum two drams to one pint of water. Palliative treatment offers no chance of cure if there co-exists either a complete tear or prolapse of the uterus. Operative. — i. Linear Cauterization: Under general anes- thesia, a blunt pointed Paquelin or electric cautery at duU red heat is used to make six or eight linear burns, along the longitudinal axis of the bowel. Only the mucosa, and never the muscular coat, should be seared. The inflammatory re- action set up by this often causes sufficient cicatricial contrac- tion to prevent a recurrence. 2. The Moskowitz operation, in which, by abdominal section the rectum is suspended, by a series of purse-string sutures of number i chromic catgut or fine linen thread, to the back wall of the uterus, the posterior layers of the broad liga- ments and the peritoneum covering the sacrum. This operation is most efficient. 3, Afnputation of the prolapsed portion, with suture of the mucosa to the skin of the anus. This has the objections of occasional stricture and incontinence, and is indicated only in irreducible prolapse. An absolute essential, in both palliative and operative cases is the prevention of constipation and its consequent straining, as neglect of this precaution always means recurrence. X. PRURITUS ANI Pruritus ani is a symptom of many conditions, chief among which are: (i) Hemorrhoids; (2) proctitis; (3) worms; (4) pediculi or other results of lack of cleanliness; (5) chronic leukorrheal discharge; (6) chronic constipation; (7) diabetes; (8) neurosis. The itching is often severe, and in neurotic cases in pregnancy intolerable. Treatment is the same as given for pruritus vulvae, in Chapter TUMORS OP THE RECTUM 371 IV, except that the cause is usually more easily found and removed. XI. STRICTURE OF THE RECTUM Stricture of the rectum may be due to: (i) Congenital; (2) inflammation; (3) cicatrization of wounds or ulcers; (4) carcinoma; (5) syphilis; (6) tuberculosis. The bowel above the stricture is always greatly dilated. Symptoms.' — (i) Pain; (2) constipation; (3) ribbon-like stools; (4) discharge of mucus, pus or blood; (5) rarely diarrhea due to enteritis from irritation of the retained feces; (6) at times complete obstruction, especially if malignant. Diagnosis is made with the finger, if the stricture is not more than four inches from the anus; by proctoscope if higher up. Treatment. — (i) Gradual dilatation with bougies; (2) rapid avulsion with bougies or dilator, never safe unless the stricture can be reached with the finger. The lower two-thirds of the rectum are not covered by peritoneum, the upper one-third is, and the dividing line is approximately at the reach of the forefinger; (3) incision of the stricture posteriorly, with the same limitations as avulsion; (4) excision of the stricture, with end-to-end anastomosis; (5) routinely in malignant and fre- quently in syphilitic and tubercular ones, inguinal colostomy. XII. TUMORS OF THE RECTUM Tumors of the rectum are either benign or malignant. Benign Tumors Benign are (i) polyp, which is an adenoma with a long pedicle. It is most common in children but is seen at any age. It is usually single, but may be multiple and varies in size from a pea to a large orange. Symptoms. — (i) Rectal irritation; (2) discharge of mucus, pus or blood; (3) frequently protrusion of the polyp at defecation. Treatment is removal by ligature or snare. 372 DISEASES or THE RECTUM 2. Papillomata, usually benign but occasionally maKgnant; occur as cauliflower masses, with the same symptoms as polyps. They are removed with ligature or snare, and always examined microscopically. Malignant Tumors Cancer is usually tubular or cylindrical celled, and begins either as an ulcer, or as a nodule under the mucosa, with secondary ulceration. It frequently extends as a ring all around the rectal canal. The softer the cancer, the more malig- nant. Metastases occur late, in the liver, lumbar glands and peritoneum. The disease is commonest in middle life, but has been seen even in childhood. Symptoms are (i) Pain; (2) tenesmus; (3) rectal irritation; (4) difficulty in defecation; (5) passage of mucus, pus or blood; (6) in the late stages ribbon stools, cachexia and more or less complete obstruction, and sometimes rectovaginal fistula. Symptoms are often very slight, or absent, until the growth has reached a considerable size. Diagnosis is made by digital examination, which feels a soft, f ungating, friable mass, bleeding easily; or a hard firm one with ulcerated surface, with everted edges. Through a speculum, the growth can be seen and in cases of doubt a piece removed for microscopic examination. Prognosis is bad. Death results in from one to five years, from cachexia, obstruction, exhaustion or hemorrhage. Treatment is palliative or operative. Palliative treatment is only for those cases where the growth cannot be removed, (i) Opium for pain; (2) rectal irrigation; (3) colostomy, which diverts the fecal column and retards the progress of the disease; (4) both radium and .^•-ray have proven disappointing in rectal cancer. Operative treatment consists in the removal of the growth, possible when it has not involved the perirectal connective tissue or the sacrum or uterus, and there are no demonstrable metastases. ULCERS OF THE RECTUM 373 The primary mortality of operation is 25 per cent, and of the survivors only about 20 per cent, are well after three years. Methods of Operative Treatment. — (i) Vaginal route, when there is a small growth in the anterior rectal wall; (2) anal route, when the growth is very low; (3) perineal route, involving splitting of the perineum, when the growth is not more than three inches up; (4) sacral route (Kraske operation) for growths just beyond the reach of the finger; (5) abdominal perineal, in very extensive involvement. The last three operations are exceedingly difficult and to be attempted by experienced surgeons only. Sarcoma has the same symptoms as cancer, is much rarer, occurs at an earlier age and requires the same treatment. It occurs as a large fleshy mass, without primary ulceration. XIII. ULCERS OF THE RECTUM Ulcers of the rectum are (i) Simple — due to abrasive wounds, foreign bodies, etc.; (2) tubercular; (3) syphilitic; (4) malignant; (5) acute inflammation; (6) dysentery; (7) typhoid. Symptoms are (i) Rectal irritation; (2) pain; (3) discharge of pus, mucus, or blood; (4) tenesmus; (5) usually constipation, due to habit because of pain on defecation; (6) more rarely diarrhea (dysentery and typhoid). Diagnosis is best made through a proctoscope. Treatment. — (i) Hot enemata; (2) local application of nitrate of silver 40 grains to the ounce (8 per cent.) through a proctoscope; (3) iodoform suppositories 5 grains twice daily, especially in tubercular cases (but not if nitrate of silver has been used because of the irritating chemical reaction); (4) salvarsan in syphilis; (5) malignant ulcers treated as described under cancer; (6) in very stubborn cases, temporary inguinal colostomy, the artificial anus being closed after the ulcer has healed (three to four months usually); (7) nearly all cases require some arsenic and strychnin tonic. CHAPTER XX ELECTRICITY, X-RAY, RADIUM, MESOTHORIUM AND FINSEN LIGHT ELECTRICITY Electricity at one time exploited as a cure-all in gynecology, is very useful in its very limited field. Many exaggerated claims were made, which when exploded brought the entire method of treatment into disrepute. This chapter is designed to give an outline of what it and its allied methods of radiation may reasonably be expected to accomplish. Apparatus needed for gynecologic treatment consists of the following, as a minimum: (i) A source of current, preferably an apparatus which is connected with the street current and by rheostats, stops it down to a usable strength. A battery is unreliable and the constant recharging a nuisance. 2. A large (six by eight inches) abdominal pad electrode, covered by felt or other moisture containing covering. A small pad is not satisfactory as it does not give proper contact and does not allow enough current to pass. 3. Uterine electrodes, built like sounds, and capable of being sterilized by boiling. The best, and also much the most expensive, have platinum tips. Copper and aluminum are good substitutes, but the positive pole of the galvanic current causes rapid wear and disintegration, which is slowest in the platinum and most rapid in the copper tips. 4. Vaginal and rectal electrodes, though the vaginal may be used as rectal ones. Properties of Galvanic Current.- — The positive pole (anode) is hemostatic, promotes contraction of the uterus, and hence controls bleeding; acts as a cautery to the endometrium (mild 374 ELECTRICITY .375 but often painful), and contracts down the uterine vessels in the mucosa. The negative pole (cathode) causes hyperemia and congestion of the uterus, promotes relaxation of the muscle and vessels, and allays pain. Properties of Faradic Current.^ — (i) Primary faradic, causes contraction of the utecus and tends to act as a hemostatic. 2 Secondary faradic current is used as a sedative and allays pain. The action of the slow and rapid interruption is essentially the same. Properties of Sinusoidal Current.^ — This current flows in waves, from zero to maximum, with change of polarity at each zero. It is sedative and allays pain when used in the uterus; in the bowel it is an efficient treatment of obstinate constipation. In gynecologic treatments the active electrode is always the internal one — in the uterus vagina or rectum. The abdominal pad is the passive electrode, merely allowing the current to flow through. Indications for Intra-uterine Electrical Treatment. I. Galvanic Current. — i. Positive pole to uterine sound in (i) menorrhagia; (2) metrorrhagia (non-malignant); (3) inter- stitial fibroids (the current will have effect on the bleeding, but not on the size of the growth); (4) subinvolution of the uterus; (5) chronic gonorrheal endocervicitis (copper electrode). 2. Negative Pole to Uterine Sound. — (i) Infantile uterus; (2) amenorrhea from causes other than pregnancy or the artificial and natural menopause; (3) superinvolution; (4) lactation atrophy; (4) cervical stenosis with dysmenorrhea; (5) chronic endocervicitis (nongonorrheal). II. Faradic current is used in (i) subinvolution of the uterus; (2) amenorrhea; (3) to control muscles when weakened by long disuse such as relaxed sphincter ani or sphincter vesical. 376 ELECTRICITY, X-RAY, RADIUM, FINSEN LIGHT III. Sinusoidal current is used chiefly in the treatment of chronic constipation. It excites peristalsis and is most effec- tive when the lower bowel is filled with water before the rectal electrode is inserted. In the uterus, its uses are the same as the faradic. Contra-indication to intra-uterine electrical treatment is pehdc inflammation, unless acute symptoms have long subsided. Intra-uterine use of the electric current cannot be said to be entirely safe. With proper aseptic precautions, infection is unlikely, but severe pelvic inflammatory reaction sometimes follows its use, even though all precautions have been taken. When employed, it should be with appreciation of this possibility. Technic of Application. — i The patient is arranged in the dorsal position, and the cervix exposed through a bivalve speculum. 2. The abdominal pad is well soaked and applied so that there is firm broad contact to the skin. 3. The apparatus is examined to see that it is in working order, and that no current is turned on until all the electrodes are properly adjusted. 4. The uterine electrode is sterilized by boiling, or if the construction of its insulation does not permit of this, soaked in a solution of 1-20 carbolic acid for half an hour. It is absolutely essential that the electrode be properly sterilized. Neglect on this score may mean severe pelvic infection. Great care must also be taken not to abrade the surface mucosa, in the insertion of the electrode. 5. When ready, the current is turned on very slowly. If the patient complains of burning of the abdominal skin, the con- tact is poor and the pad too dry. Redness of the abdominal skin is due to too small a pad, but blistering is very rare. 6. At first a current of ten miUiamperes is used, and is gradually increased as the patient can stand it. Much lower amperage is used with the positive than with the negative pole. 7. For uterine bleeding a galvanic current of 10-50 miUi- ELECTRICITY 377 amperes is used for fifteen minutes twice weekly, positive pole to uterine sound. For amenorrhea, scanty menses, infantile uterus, or stimulation of the sphincter muscles, a galvanic current of 20-70 milliamperes for twenty minutes three times weekly, negative pole to uterine sound. For cervical stenosis, use galvanic current, negative pole to uterine sound, current 10-15 milliamperes for ten minutes, twice at a three-day interval, during the week preceding the menses. For dysmen- orrhea, use secondary faradic current, for twenty minutes at a time, every other day for the ten days preceding the period. 8. In all cases where the intra-uterine electrode is to be used, pregnancy must be excluded. 9. The length of treatment should not, except for special indications, exceed twenty minutes, to avoid fatigue. 10. The current is turned on very slowly, so as to be barely perceptible, and gradually increased as the patient becomes accustomed to it. 1 1 . The intra-uterine electrode must be constantly watched, as it has a tendency to slip out very easily. 12. The intra-uterine electrode should be sterilized directly after use, and resterilized before being used again. Cautery. — The electric cautery knife is very useful for excision of small growths, such as: (i) condylomata; (2) small cervical cysts; (3) small cervical polyps; (4) urethral caruncle; (5) persistent erosion of the cervix; (6) abscess of Skene's glands. For growths the knife is used; for erosion the dome-shaped spiral; for inflammation of Skene's glands the needle. A local anesthetic is best employed; 20 per cent, cocain applied to the surface, or 2 per cent, cocain injected into the base of the growth to be removed. The ethyl chlorid spray should never be used, as a preliminary to the cautery, as it is very inflammable. Fulguration (desiccation) is the process by which small growths or areas are cauterized by a spark of enormous voltage and very low amperage. It is most useful in removing surface blemishes, small warts or pedunculated growths; for cauteriza- 378 ELECTRICITY, X-RAY, RADIUM, FINSEN LIGHT tion of recurrent surface carcinoma, particularly of the mouth or breast or in the scar of the vaginal vault; it is the best of all methods for small papilloma of the bladder, used through the catheter channel of the cystoscope. High frequency, in gynecological work, is used chiefly in control of pelvic and sciatic pain, to reduce high blood-pressure, and particularly in pain caused by pelvic exudate persisting after pelvic peritonitis. The current has an enormous voltage but very low, amperage. The main electrode is a pad on which the patient sits;" the other electrode is held in the hands. X-RAY The uses of the :v--ray in gynecology are two-fold; (i) for diagnostic purposes; (2) for therapeutic purposes. The rays are capable of great damage, in inexpert hands, the greatest danger being that of burns, which are very slow to heal, resist all applications, are very painful and at times very deep and dangerous. They are most common in cases requir- ing prolonged treatment, as for cancer and fibroid; syphilitic patients are much more likely to be burned, hence a Wasser- mann test should always be made as a preliminary to .^-ray treatments, and if positive, the treatment should be avoided or at least the time of exposure materially shortened. Diagnostic use of the x-ray is chiefly for the following: (i) Gastro-intestinal tract, after a bismuth meal; (2) pyelog- raphy for the pelvis of the kidney and ureter, after they have been filled with collargol or 10 per cent, thorium nitrate solution; (3) the diagnosis of pregnancy, after the sixth month of gestation. Prior to this the fetal skeleton casts no appreci- able shadow, and often even at term the shadow is exceedingly faint and thin; (4) diagnosis of osseous deformity of the pelvis; (5) diagnosis of pelvic tumors; usually unsatisfactory, because they rarely cast sufficient shadow; (6) diagnosis of foreign bodies left in the abdomen at a previous operation, (7) Diag- nosis of kidney and ureteral stones. RADIUM 379 Uses of X-ray in Treatment.^ — (i) Bleeding from fibroid tumors; (2) metrorrhagia from myopathic uteri or other causes; (3) cancer of the uterus; of very doubtful value; (4) superficial cancers of the vulva or breast; (5) lupus vulvae; (6) kraurosis vulvae; (7) pruritus vulvae, (8) excessive sexual hyperesthesia (nymphomania); (9) for the production of artificial sterility, by causing loss of ovarian function. Disadvantages and Dangers.^ — (i) In fibroid tumors, the bleeding may be controlled, and the artificial menopause produced, but it has no effect on subsequent degeneration of the growth. If malignant degeneration has begun, the effect of the ray is often to stimulate the process to furious activity. (2) Burns are always a painful and distressing complication and often very dangerous one; the more anemic the patient, the more likely she is to be burned; (3) the artificial meno- pause induced by the rays is often complicated by very severe nervous symptoms, much more severe than the surgical menopause; (4) in patients in the childbearing period, the possibility of causing permanent amenorrhea and sterility, even with short exposures, must be borne in mind; (5) in deep- seated cancer, the rays often relieve pain, but do not influence the process in other ways; (6) many patients complain of severe digestive disturbances, of long duration. Treatment by a;-ray is a process involving considerable outlay in time, money and patience. It is a two-edged sword, capable of benefit in one direction often at the expense of harm in another, and is not a method adapted to amateur experimentation, but one to be used only by those thoroughly familiar with the apparatus they handle. RADIUM The physical properties are thus described by Burnam: "Radium is a metallic element belonging to the strontium- barium group. It readily forms salts with the mineral acids and is the leading member of the peculiar radio-active group of elements which are characterized by atomic instability. 380 ELECTRICITY, X-RAY, RADIUM, FINSEX LIGHT "Radium itself is formed by atomic reduction from uranium. It loses a portion of its atom to become a gas called radium emanation, and this, in turn, is the mother, grandmother, etc., of a series of solid elements. The so-called radium C, third in series from the emanation, is that member of the group which particularly concerns us, as it is from it that both the beta- and gamma-rays are derived. Radium emanation can be sepa- rated from radium as fast as it is formed. A given amount of radium is capable of producing a given amount of emanation. The emanation reaches a maximum and then disintegrates at the same rate that it is being formed. In about four days a given amount is reduced to one-half. If radium or radium emanation is sealed in a glass or metal container it begins to produce radium C. The maximum amount of radium C is obtained in a radium preparation so placed in a glass tube in thirty days. The maximum amount from emanation is produced in three hours and thirty minutes. Radium C itself can be isolated, but has such a short life, only two or three hours total, that it cannot be used effectually in practical treatment. "The essential characteristic of the radio-active substances is the giving off of in^dsible rays. These rays must not be confused with the emanation, which is an element just as radium itself is. The rays have been divided according to their physical characteristics into three kinds: the alpha, the beta, and the gamma. "The alpha-ray is a positively charged atom of helium. It has a very small power of penetration, being completely stopped by a thin sheet of writing paper. It acts very power- fully toward inducing chemical change in both inorganic and organic matter brought in contact with it. The beta-ray is a negatively electric ion which has about the velocity of light and will easily penetrate several centimeters of living tissue. It has also a marked capacity for inducing chemical changes in organic matter subjected to it. The gamma-ray is not par- ticulate matter, but a \dbration of ether similar to ordinary RADIUM 381 light and of x-ray. It differs from them in being of much shorter wave length and of much greater penetration. It has power also, but to a lesser degree than the alpha- and beta- rays, to produce chemical change in organic matter exposed to it. When radium is enclosed in a glass tube, alpha-, beta-, and gamma-rays are produced within the container. The alpha-rays are held in the tube, while the beta- and gamma- rays penetrate its walls, and pass out into the surrounding medium in radial lines, thus making a sphere of radiation. When the .glass tube is further surrounded by 2 mm. of lead, the hardest beta-rays can no longer penetrate this envelope. It is possible, therefore, in medical treatments to use all three kinds of rays together, the beta- and gamma-rays together, or the gamma-rays alone. It is impossible to use the alpha- rays alone, and it is difficult to use the beta-rays alone in anything except experimental work. "From the above it is evident that radium or one of its derivatives can be used in two essentially different ways: first, it can be taken into the body by mouth, hypodermically or intravenously as any other soluble drug; second, it can be applied from either outside or inside the body in sealed tubes or other containers in the same general way that an a;-ray tube is employed." As the alpha- and beta-rays are the ones that burn or act as unfavorable stimulants, they are filtered out by encapsulating the radium in a cylinder of some metal, like lead, silver, brass, platinum or aluminum. Of these brass seems to cause the smallest loss of the desirable gamma-rays, and hence is to be preferred, though the choice is not a matter of much moment, as the difference is small. Method of Use. — A minimum amount of 50-100 mg. of radium, in a glass tube, is enclosed in a brass filter and then in a finger-cot, and is inserted in the uterine canal and held in place by a temporary suture through the cervix, which grips the end of the finger-cot as well. It is left in place from three hours to five days, according to the judgment of the operator. 382 ELECTRICITY, X-RAY, RADIUM, FINSEN LIGHT eighteen hours being the average. About two weeks is allowed between treatments. The gamma-rays penetrate and kill cancer cells to a depth of 3-4 cm., and beyond this point have an inhibiting action on their growth. The gamma-rays and the hard beta-rays have a selective action on cancer cells, killing them without damage to the nor- mal cells surrounding the area of malignancy. Effect of radium depends upon: (i) The age of the growth; (2) the amount of radium used; (3) the amount of filtration; (4) the length of exposure; (5) the distance or depth of the growth; (6) the length of exposure and (7) the frequency of treatment. Favorable Effects. — (i) In metrorrhagia from a myopathic uterus, 100 per cent, of cures can be expected; (2) in cancer of the cervix the fetid discharge and bleeding cease; (3) the growth diminishes in size or even disappears; (4) pain is promptly reheved; (5) inoperable cases may be made operable; (6) the most favorable results are obtained in recurrence in the vaginal scar after hysterectomy; because the younger the cancer cell, the more destructive to it is radium. Dangers and Disadvantages. — (i) Overdosage, or too long exposure may result in excessive destruction of tissue; (2) under dosage or too short exposure, may stimulate the malig- nant growth to activity; (3) if pelvic infection is present, active pelvic peritonitis may result; (4) if cancer has involved the bladder or rectal wall, fistulae are very likely to result; (5) hysterectomy too soon after radium treatment is very likely to be followed by fatal postoperative sepsis; three weeks at least should elapse; (6) after treatment prior to hysterectomy, the parametrium is sclerosed and infiltrated, and this adds materially to the difi&culty of the operation. Reaction from use of radium is small as a rule, but may be evident as: (i) Headache; (2) abdominal pain; (3) pain in bladder; (4) diarrhea; (5) fever or moderate degree (101-102); (6) occasionally acute nephritis. These reactions are most common in elderly patients and in those with severe anemia. FINSEN LIGHT 383 The expense of a quantity of radium sufficient to carry out treatment is so great that it must necessarily remain a method for large institutions rather than the individual physician. MESOTHORIUM Mesothorium is like radium in its physical properties and effects, and what has been said about radium applies to meso- thorium as well. While radium continues giving out its emanations in undiminished volume for many centuries, mesothorium is exhausted and inert in about twelve years. FINSEN LIGHT Finsen light therapy is of use only in lupus vulvae, and does not even there give results comparable to the a;-ray, hence its use in gynecology is practically nil. CHAPTER XXI ENDOCRIN GLANDS AND THEIR EXTRACTS IN GYNECOLOGY The beginning of organotherapy was Brown-Sequard's experiments, in 1889, with injections of testicular juice. Since then a mass of Hterature and experimental work has been accumulating, though the surface has hardly as yet been scratched. For much of the material from which this chapter is compiled, the author is indebted to the articles by Hugo Ehrenfest in Crossen's gynecology and W. P. Graves. The term ductless gland (endocrin) is applied to a number of special glands or organs, producing biologic substances which when absorbed into the blood in normal amounts, maintain the organism at par, and exert definite effects on distant organs. They are: (i) Thyroid; (2) parathyroid; (3) thymus; (4) suprarenal; (5) pituitary gland or hypophysis cerebri; (6) pineal gland or epiphysis cerebri; these the true ductless glands; (7) pancreas; (8) ovary; (9) testicle; (10) mammary gland; these having external as well as internal secretory function; (11) the corpus luteum; (12) the placenta; from which animal extracts for therapeutic purposes are made and hence deserve inclusion in the list. The sex glands (testicle and ovary) are largely responsible for the development of male and female characteristics in the individual and their early removal exerts a profound influence on the development of these characteristics. Increased activity of a gland is hyp 67- function; diminished activity is hypofunction. The active materials of the endocrin glands are of a simpler chemical constitution than enzymes, and are not rendered 384 THYROID GLAND 385 inert even by prolonged boiling, and are known by the generic term of "hormones." Interglandular Relations. — While it is known that the action of most of the ductless glands is correlated and often recip- rocal, exact knowledge is wanting. Hypofunction in one gland is supposed to induce hyperfunction in another (as in the ovary and thyroid), if under normal conditions they are antagonistic. Perfect harmony and balance between all the endocrin glands results in normal development; abnormal development is often a result of disturbed balance. Our present knowledge is too meager to formulate deiinite state- ments as to the mechanism. In experimental work, hormones act differently on different species of animals; deductions drawn from animal experimenta- tion and applied to the human being are often absolutely in- correct. Of all the active principles, as yet only adrenalin has been isolated in pure form. I. The Thyroid. — At puberty the thyroid often takes on considerable enlargement, which is much more marked in girls than in boys. The nervous disturbances of puberty are ascribed to hypersecretion of the thyroid. The thyroid and ovary are antagonistic, and women with diseased thyroids usually have menstrual disorders; also patients in whom a goiter has been too completely removed often develop menor- rhagia, which yields to the administration of thyroid extract. The thyroid frequently swells in pregnancy, and while the enlargement is usually moderate, it is sometimes very great. It disappears, as a rule, during the period of lactation. Ex- ophthalmic goiter is eight times as common in women as in men. It is frequently a complication of pregnancy, which influences the goiter unfavorably. When associated with pelvic con- ditions requiring operation, it adds appreciably to the risk. Cretinism (myxedema) is due to absence or early atrophy of the thyroid, and the- adult type is much more frequent in women than in men; in these cases infantile genitalia and sterility are the rule. 386 ENDOCRIN GLANDS AND THEIR EXTRACTS 2. Parathyroid s.^ — When the parathyroids are removed, in animals, death follows from acute tetany; this tetany can be controlled by administration of parathyroid extract. Based upon this, the extract has been recommended in eclampsia in the human being, but clinically the results have been nil. 3. The Thymus.^ — The thymus, until puberty, has an unquestionable relation to the development of the sexual organs. At puberty there is a marked involution in the gland. If the genitals are infantile, involution takes place later than normal. No definite results, of value from a therapeutic standpoint, have yet been attained in experimental work. 4. Suprarenals (Adrenals).- — Animals with marked sexual powers are possessed of markedly developed adrenals also. Negroes show this more markedly than the white race. In individuals with hypoplastic genitalia, a diminution of the adrenals has been noted. Hypernephroma in children also produces precocious sexual development. Castration is fol- lowed by development of the adrenals, possibly as a compensa- tory process for the loss of ovarian secretion. Individuals with Addison's disease frequently have hypo- plastic genitalia, amenorrhea, and are sterile. If they become pregnant, the pregnancy has a deleterious effect upon the disease and abortion is common. Adrenalin is the only active principle of any of the ductless glands which has so far been isolated in pure form. 5. Pituitary (Hypophysis Cerebri). — This gland has a marked relation to the sexual organs. During pregnancy it is hyper- trophied, and to this is ascribed the acromegalic changes often seen in the faces of pregnant women. The hypertrophy is confined to the anterior lobe, and does not return to normal for several years after gestation. Removal of the anterior lobe causes in animals marked obes- ity, the genitalia of adult animals atrophy while those of young ones do not develop. The genital changes were much more marked in young than in adult animals. If the gland was removed in pregnant animals, they invariably aborted. If OVARY 387 hyperfunction of the pituitary occurs before puberty, gigantism results; after puberty, acromegaly. Hypof unction before puberty results in dwarfism; after puberty, in obesity associated with genital atrophy (dystrophia adiposogenitalis) . Organotherapy. — Preparations of the pituitary are: (i) Extracts of the whole gland, in powder or tablet form; (2) extract of the anterior lobe in tablet or as a liquid extract in ampules; (3) extract of the posterior lobe in tablet or as a liquid extract in ampules. Extract of the whole gland is used in obesity with genital atrophy, as is also exjtract of the anterior lobe. The anterior lobe limits carbohydrate absorption. It has been used, but with poor success, as a galactagogue. Extract of the posterior lobe is a very active and powerful stimulant to unstriped muscle, hence stimulates uterine contraction in labor. It is of great value in controlling disten- tion after abdominal section, and to stimulate the bladder in postoperative retention of urine. It raises blood-pressure, and hence combats postoperative shock. It controls bleeding in cases of uterine inertia and particularly in menorrhagia of youth. It is an active heart stimulant. 6. Pineal Gland (Epiphysis Cerebri) .^ — ^Hypof unction of this gland in early childhood, produces marked sexual pre- cocity; its hyperfunction causes marked obesity. 7. Pancreas.^ — No definite relation between the pancreas and genitalia has yet been established. True diabetes, induced in animals after conception, causes abortion. In human beings, pregnancy influences diabetes unfavorably, except under careful and rigid dietary control, and abortion is exceedingly common. 8. Ovary.^ — The ovary is a true organ of internal secre- tion as is proven by results from transplantation of ovarian tissue. Castration before puberty causes failure of genital development, while after puberty it causes atrophy similar to the menopause. Injection of ovarian substance relieves the 388 ENDOCRIN GLANDS AND THEIR EXTRACTS unpleasant symptoms of this condition, and if injected in virgin animals creates hyperemia of the internal and external genitalia. From what part of the ovary this secretion is manufactured is not known. But there is evidence to support the following conclusions: (i) The follicle apparatus controls the growth and nutrition of the genitalia. (2) The corpus luteum controls menstruation, and prepares and sensitizes the endometrium for the reception of the impregnated ovum. The destruction of the corpus luteum in animals results in abortion. (3) The part played by the interstitial gland is a matter of conjecture, but it is supposed that it shares with the follicle apparatus some power of control over development of the genitalia. Hypofunction of the ovary causes." (i) Lack of development; (2) because of the associated development of the anterior lobe of the hypophysis, adiposis and genital atrophy; (3) infantilism; (4) atrophy of the uterus and external genitalia; (5) fuctional amenorrhea; (6) after castration, and at normal menopause, hot flashes, dizziness, sweats and other vasomotor disturbances. Hyperfuncton of the ovary is not as well understood. It is supposed to cause menorrhagia; premature sexual development; overfertility; delay in coagulation time of the menstrual blood. All these are based upon theoretical grounds and are not well founded on scientific proven facts. Organotherapy. — Ovarian extract is prepared as: (i) Powder or tablets of Ovarian substance; (2) powder or tablets of corpus luteum; (3) hypodermic extract of corpus luteum; (4) hypo- dermic extract of whole ovarian substance; (5) hypodermic extract of ovarian substance with the corpus luteum removed (called ovarian residue). These preparations are from the pig, cow, or sheep. It is claimed that the corpus luteum of the pig approximates most closely, in the character and number of its lutein cells, that of the human being. Extracts of human corpus luteum, prepared from material secured during operations are MAMMARY GLAND 389 more active than those of the lower animals, but the supply is too limited and uncertain ever to make the human extract of practical value. Because the corpus luteum in pregnancy is supposed to be more stable, ovarian extracts are best made from ovaries of pregnant animals. Uses: — (i) Functional deficiency or absence of ovarian internal secretion, seen at the surgical or natural menopause. (2) Young women with fuctional amenorrhea or scanty men- struation. (3) Cases of pruritus, kraurosis or other vulvar affections in elderly women, dependent upon inadequate circulation. (4) Repeated abortions without demonstrable cause, but due presumably to the absorption or blighting of the corpus luteum. (5) The control of the nausea of pregnancy. The use of ovarian extracts is not dangerous. The only toxic effect of mouth administration is nausea. Hypodermic extracts cause, rarely, urticaria and, still more rarely, mild anaphylaxis, shown usually by depression of blood-pressure and headache. This is more common in corpus luteum ex- tracts than in those of the whole ovary. The dosage of the powder or tablets is five grains four times daily; one grain representing six or seven grains of the fresh substance. For hypodermic use, the dose is one ampule (i mil represent- ing 20 mg. of the fresh substance) daily in series of twenty- four doses, with an interval of six to eight weeks between series, as the effect is often cumulative. 9. The mammary gland has a definite, but little understood relation to the genitalia. At puberty the breasts develop; at each menstrual period, they enlarge in many cases; in preg- nancy they undergo marked hypertrophy and after the meno- pause they atrophy. Hypoplasia of the breasts following castration can often be prevented by ovarian transplantation. The nature of the hormone controlling the development and function of the breast is not known. 390 ENDOCRTN GLANDS AND THEIR EXTRACTS Extract of mammary gland is used in the control of func- tional menorrhagia or metrorrhagia, due to adnexal disease, fibroid tumors and metrorrhagia myopathica, but the results have not been brilliant, and the practical use is small. ID. The placenta is not an organ of internal secretion, but its extracts have certain influence of the maternal organism. The substance extracted from the placenta appears to be iden- tical with a similar substance from corpus luteum. In animals, placental extract induces hyperplasia of the uterus and breasts and acts as a galactogogue. In human beings extracts of the placenta of lower animals do not have routinely a similar effect, though such might and probably would be the case were the material of human origin. It was, in the middle ages, a common practice for midwives and physicians to feed finely chopped placenta to recently delivered women, as a galactogogue. Gynecological anomalies due to disturbed function of the endocrin glands are: (i) Failure of development of the genitalia; (2) infantilism (imperfect development) ; (3) delayed puberty; (4) precocious puberty; (5) menstrual abnormalities (oligo- menorrhea and menorrhagia); (6) uterine atrophy; (7) metror- rhagia; (8) obesity with genital hypoplasia and steriHty. Methods of Administration. — Mouth administration of extracts in powder or tablet form has been, till lately, the method employed. The average dose is 5 grains four times daily. The method has certain disadvantages; (i) Gastric disturbance (nausea) necessitating discontinuance of the drug; (2) the substance does not keep well and oxidizes easily on exposure to the air; (3) most important of all, the substance does not enter directly into the circulation, but is changed and in many cases destroyed by digestion. Hypodermic intramuscular administration is deservedly increasing in popularity and is much the better form of admin- istration. The average dose is one ampule daily. The best syringe is glass, boiled and cooled before the substance is drawn into it. Alcohol is not a good sterihzing medium and METHODS OF ADMINISTRATION 391 inhibits the activity of the extract. Injections are given deep intramusctdarly and never subcutaneously. Abscess, with proper technic, need not be feared, but local hyperemia is the rule for a few hours. If the site of injection is painful, a dressing of alcohol and water, equal parts, promptly relieves the discomfort. The site of injection should be massaged for a minute after the injection. Reaction after hypodermic administration is uncommon. Urticaria sometimes occurs in sensitive individuals as in any animal serum. Anaphylaxis is very rare, and mild when it does occur, and is shown by headache and lowered blood pressure. Pluriglandular therapy, or administration of extracts of several glands (thyroid, pituitary and ovary) is useful in all cases where ovarian extract or corpus luteum is indicated, except castration. It is most useful in functional amenorrhea or oligomenorrhea, and especially in cases with marked neuro- sis or neurasthenia and obesity. In disturbances of the menopause, to be effective, it must be given with corpus luteum extract, but is no more effective in these cases than the corpus luteum extract alone. CHAPTER XXII GENERAL TECHNIC OF GYNECOLOGIC SURGERY The author has attempted to described in this chapter a technic that has given him good results, and has emphasized certain points of importance which the student is liable to over- look. The chapter is designed to furnish the student a ground- work from which to develop a technic of his own. The equipment of a hospital operating room is designedly omitted. Hospitals are so well standardized that such a description is unnecessary in a book of this character. I. Preparation of Patient for Abdominal Section.^ — Day before Operation. — -Urine examination, blood count and full bath. 4 P.M. Scrub abdomen and upper one-third of thighs for ten minutes by the clock, using soft bristle brush (face brush) or gauze; after first two minutes shave completely. Rinse off soapsuds, and scrub for one minute in alcohol (95 per cent.) using fresh brush, rinse off again with sterile water, dry with sterile towel, and apply dry sterile gauze dressing with binder, covering abdomen and upper one-third of thighs, and fastened down by spica bandage so that it cannot ride up and expose the abdominal skin. 7 P.M. She is given a light supper. 9 P.M. Give one ounce of magnesium sulphate, or, if this is objectionable to her, eight ounces of flat magnesium citrate (without the gas). If she is nervous or sleepless, ten grains of veronal or trional are given. Day of Operation. — Early in morning, cup of beef tea, no other breakfast. Two hours before operation repeat scrubbing of day before, except that shaving is omitted, and after alcohol, 392 PREPARATION FOR VAGINAL OPERATION 393 apply dressing moist with i per cent, formalin solution, held in place by same kind of binder. An hour and a half before operation cleanse lower bowel by simple enemas so that last enema returns clear. Three-quarters of an hour before operation give hypodermic of morphin sulphate gr. )-^, atropin sulphate gr. 3''150- Catheterize just before etherization, and never trust to voiding. The nurse who does the scrubbing must prepare her hands and wear sterile gown and sterile gloves, as for an operation. No preparation on the table except wiping the abdomen with 70 per cent, alcohol, to take care of the surface infection due to perspiring under the dressing. In all abdominal sections, the abdomen is covered with rubber dam, through which the incision is made. Before the peritoneum is opened, the edges of the rubber dam are sewed into the wound, so that the skin is completely covered. In a wound of ordinary length, one stitch to each side is sufficient. The principle involved is the same that demands the wearing of rubber gloves; as the human skin cannot be sterilized, it should be covered as much as possible. In emergency cases, where time is limited, or where the abdomen is very sensitive, cover abdomen, after shaving, with gauze dripping wet with tincture of green soap, and cover with binder; after two hours, take off gauze, wipe off abdomen with alcohol 95 per cent., and apply wet dressing of i per cent, formalin for two hours, held on by binder. II. Preparation for any Vaginal Operation. Day before Operation. — 4 p.m. Shave pubes completely. 9 p.m. Mag- nesium sulphate 3^^ ounce. Day of Operation. — Early in morning, cup of beef tea, no other breakfast. Clear lower bowel out thoroughly by repeated enemas, so that last enema is given at least two hours before operation. Continue enemas until the water returns clear. Two hours before operation give paregoric one and one-half teaspoonfuls. Catheterize just before etherization. Do not give any hypodermic of morphin and atropin. The 394 GENERAL TECHNIC OP GYNECOLOGIC SURGERY paregoric takes its place. Paregoric inhibits peristalsis much better than morphin, and makes less likely the annoying accident of a bowel movement during the operation. Should the patient have much mucus in the throat during anesthesia, atropin may be given hypodermically, without morphin. Local preparation is done on the table, and consists of careful scrubbing of the external genitalia with tincture of green soap and hot water, using cotton pledgets, and not gauze. Then the vagina is cleansed with the same solution followed by a douche of lysol (i dram to 2 pints) solution, and followed in turn by 70 per cent, alcohol. In cases with intact hymen, the internal scrubbing is of course omitted and the douche alone used. III. Preparations for Operations in Private Houses. — It is perfectly feasible to arrange private houses for operations so that the lack of hospital facilities need not seriously be felt. An abdominal operation is, of course, more easily done and the patient more easily cared for in a hospital than at the patient's home, but even this type of operation can adequately be cared for at home, provided the preparation is sufficiently well made. Ordinary operations, especially plastics for the repair of the injuries of childbirth, are satisfactorily done in the patient's home. A trained nurse, or one at least accustomed to the care of surgical cases and with a working knowledge of asepsis, is most desirable, but not indispensable, provided the physician is willing to give minute instructions as to the care required and to attend to such details as catheterization himself. The Choice of a Room. — If possible, the room should be one adjoining the patient's bedroom, and preferably not the pa- tient's own room. The patient is thus spared the sight of the necessary preparation. The paramount question is one of light, and the operating table should be so placed as to get the maximum amount, hence, near the window. The window can be screened against outside observation by covering it with a single piece of gauze or by pinning together the curtains, provided they are of a material which will transmit the light OPERATIONS IN PRIVATE HOUSES 395 without too much diminution, or even by soaping or white- washing the panes of glass. Except for an abdominal opera- tion it is not necessary to strip the room or take up the carpets or rugs. The floor can be protected by newspapers, thickly laid, and over these a sheet, wrung out of a i-iooo bichlorid solution, should be spread and should be damp when the operation is begun. Any unnecessary hangings ought to be removed and the furniture moved to a part of the room where it will be out of the way and covered with sheets. The walls in the immediate vicinity of the operating table should be Fig. 153. — A room in a private home arranged for operation. In the center is the kitchen table with a Kelly pad made of newspapers, and cover- ed with a sheet. To the right is a table carrying a pile of sterile towels, a jar of pledgets, a bottle of sutures, and the instrument pan. On the left is a sewing-table with one bowl of i per cent, lysol, one bowl of i : 1000 bichlorid, each with pledgets, a pitcher of fresh hot lysol solution, and a saucer containing alcohol for the knives. {De Lee.) protected by sheets held up by the glass-headed pins known as Moore's push-pins, and not by tacks. The pins leave no scars, as tacks do, especially in wall-paper and plaster. ■ The Operating, Table. — This should preferably be one of the models of portable, collapsible operating tables, but this is by no means a necessity. A kitchen table with sufficient strength of legs answers every purpose. If this is used, the top must be thoroughly scrubbed and then thickly padded, as the thinly padded table is a prolific cause of backache after operations. In many operations, notably perineal operations, 396 GENERAL TECHNIC OF GYNECOLOGIC SURGERY a pad can be improvised by rolling up rubber sheeting at the sides and back, or even newspapers covered by towels or sheets. A Kelly pad is not a desirable feature. It is too easily infected and too hard to clean. The special tables are provided with stirrups and leg-holders for the lithotomy posi- tion, when this position is desired. The kitchen table can be equally well equipped with either Edebohls' portable leg sup- ports, which clamp on the edge of the table, or, much better. Fig. 154. — Diagram of room in private house arranged for operation. by a rolled sheet tied about one knee, passed back over one shoulder and out under the other (so that pressure does not come altogether on the patient's neck) and fastened above the other knee. The knots should be on the outside of the leg. This makes the best leg-holder I know. If the Edebohls' supports are used, it will be found necessary to tighten the screws with a wrench (no one's fingers are strong enough), for, if the patient should strain, the leverage is enormous. OPERATIONS IN PRIVATE HOUSES 397 If a chair or stool is needed, a piano-stool draped with a sheet is most satisfactory, but a plain chair (not too low) will answer. The end of the Kelly pad, or its substitute, should drain into a bucket or slop-jar which has been well scalded out. The special operating tables have apparatus for the Trendel- enburg position; the kitchen table can be equally well equipped Pig. 155. — Lithotomy position with limbs supported by a sheet- sling. {De Lee.) by raising the two legs on blocks or bricks, or even, if the extreme position is desired, on the seats of two chairs. The whole table is best draped in a sheet, although this is not essential. Instrument and Dressing Tables. — Two of these are required, one on either side of the operating table. As these tables often have pohshed tops, adequate protection must be pro- vided. This is best done by covering the top thickly with newspapers, placing on these a large tin tray and covering all 398 GENERAL TECHNIC OF GYNECOLOGIC SURGERY with a sheet, draped so that it will touch the floor on all sides. This to protect the legs and sides. Douche Bag. — This is needed in all perineal operations, and a more efficient means of splashing the wall paper than an improperly hung douche bag can hardly be devised. A suitable hook is provided, preferably in the mndow frame. An open towel is placed over this hook so that the center of the towel is over the hook. The bag is hung on the hook and the towel allowed to drape over it. This has proved an adequate protection. The douche bag and tube are, of course, prepared by boiling. Instruments. — It is best to boil these where the physician and nurse can keep an eye on them. A large alcohol lamp and a copper tray sterilizer or basin will be satisfactory. If an alcohol lamp is placed in the bath-tub, and the instru- ments are steriHzed there, it will guard against the danger of upsetting them and possibly a conflagration. If the instru- ments are sterilized over the kitchen stove, servants must be warned not to touch them. Dressings: — For all ordinary operations the commercially sterilized gauze and cotton are entirely satisfactory. For abdominal operations the dressings should preferably be steam sterilized either in an autoclave or even in a Rochester steam sterilizer. If the latter is used, the final sterilization should be completed just before the operation. It is not pos- sible adequately to dry dressings so sterilized, and it is better to have them warm and wet than cold and clammy. Sheets and towels can be adequately prepared by freshly laundering them and then ironing with an iron hot enough to come just short of scorching them. The time-honored custom of baking in the oven of the kitchen range is useless. Such dressings are not sterile unless so scorched as to be unfit for use. For gauze sponges, I have always found the commercially sterilized gauze safe. If sea sponges are used, they must be soaked over night in a 1-500 bichlorid or a 1-20 phenol (carbolic acid) solution. Boiling them destroys their absorptive quahties. OPERATIONS IN PRIVATE HOUSES 399 Basins. — Unless the physician carries his own nest of basins, he must depend on the household supply. Three at least are needed and they must be boiled. Rinsing or wiping them out with an antiseptic solution is not sufficient. Scrubbing. — The best arrangement for scrubbing up and sterilizing the hands can be made in the bath-room. Running water and previously boiled nail-brushes are used, and to obviate stooping over, the dishes of soap, alcohol, etc., can be arranged on a bread board placed over one end of the tub and resting on the sides of the tub. Rtibber Gloves.- — Steam sterilized and, hence, dry gloves are best, but this is not always practicable. Boiling is a method Pig. 156. — Rubber gloves, wrapped ^< in a towel or gauze and properly prepared for boiling. always available and satisfactory. The gloves must be boiled wrapped in gauze or a towel, and should always be boiled flat so that the water can enter them. The custom of boiling gloves rolled up in a ball is a pernicious one, as the inside of these gloves is never sterile and most of the outside is open to grave suspicion. Sterile Water. — The night before operation a clothes-boiler is filled with water. In it are placed three pitchers and a dipper with a hooked handle. These are boiled for half an hour. The pitchers are hooked out of the water with the handle 400 GENERAL TECHNIC OF GYNECOLOGIC SURGERY of the dipper and filled, and then towels are tied over their tops and they are set aside to cool over night The next morning the clothes-boiler full of water and the dipper are boiled again. Thus by mixing the cold water that has stood over night with the hot water boiled just before the operation a supply ample for most operations is secured. In emergencies, the bottled distilled water sold at all drug- stores is adequate for the cold sterile water, except in abdominal operations. The water in the pitchers can be Fig. 157. — Rubber gloves improperly prepared for boiling. They are not sterile as the boiling water cannot come in contact with every part of them. cooled in a reasonably short time by pouring cold water over the outside of the pitchers. Supplies Required. — The supplies needed for an ordinary operation are as follows: six sheets; twelve towels; 8 ounces of 95 per cent, alcohol; 8 ounces tincture of green soap; i pound of absorbent cotton (two half-pound rolls); one 5- yard roll of sterile gauze; one i-yard jar of iodoform gauze; one bottle of mercuric chlorid tablets; one 2-ounce bottle of glycerin (as a lubricant for putting on wet gloves); two 3^^ pound cans of ether, unopened; three small coarse (not silk) PREPARATION OP SURGEON AND ASSISTANTS 401 sponges, size of lemon; one i-yard package of sterile gauze (for the etherizer, to avoid opening the larger package). This list is best printed on cards, and one sent to the patient's house to guard against details being forgotten. Nurse's Kit. — It is useful to provide the nurse who attends to the preparing of houses with a bag equipped with what has been found needful. This bag is small and easily carried, but contains nine basins, twelve brushes, twelve pairs rubber gloves; all the catgut used in the operation (from eight to ten boxes being carried); a rubber sheet; douche bag; razor for shaving patients (especially in perineal operations) ; gown and uniform; the glass pins (three dozen) used for protective sheets, and a roll of safety pins. It is perhaps unnecessary to point out that all visible dis- turbances caused by these preparations should be cleared away, and all soiled linen and sponges and water disposed of as soon as possible. This is particularly desirable when every- thing has been prepared in the patient's room. No sign should be left for the patient to see on recovery from the anesthetic. IV. Choice of Time of Operation. — For operations of election one week after the menstrual period is best. The unexpected appearance of a period does not as a rule contra-indicate opera- tion, though rarely patients show evidence of shock thirty- six to forty-eight hours after operation if it has been done during a period. It is best to avoid operation at such a time, if possible. V. Preparation of the Surgeon, Assistants and Nurses. — Persons engaged in surgical work should not come in contact with infectious diseases. In all cases sterile operating suits, caps, gowns and gloves should be worn. In abdominal cases, face masks as well are essential. No one concerned with the operation should come in contact with suppurating wounds at any time unless protected by rubber gloves. No one with an infected wound or furuncle on hand or arm, or with acute throat infection should take part in an operation. 402 GENERAL TECHNIC OF GYNECOLOGIC SURGERY The technic of hand disinfection is described in paragraph VIII. For abdominal section, to secure the greatest efi&ciency, an assistant, a sterile nurse and two general nurses are required. For a plastic operation, one assistant, one sterile nurse and one general nurse. In addition, it adds much to the speed of an operation if an extra nurse can be provided for the sole purpose of threading needles. VI. Preparation of dressings, towels, sheets, etc., has been described on page 398. Wherever possible, autoclave steril- ized material should be used. Sponges, in surgery, are squares of gauze. Two kinds are required: (i) Large squares, six layers thick, 10 X 12 inches in size, with a piece of tape six inches long securely sewed in one corner; these are used in the abdomen to pack back the intestines, and a forceps is fastened to the tape. (2) Small squares three or four inches square, for mops. All sponges should have their edges sewed to prevent raveling. They are put in packages of a known number, are counted before the operation is begun, and in abdominal operations, must all be accounted for before the peritoneum is closed. Gowns should be long sleeved, reaching to the wrist, so that the cuff of the glove is turned up over the sleeve and all skin covered. VII. Suture material and ligatures are either permanent or absorbable. Permanent. — i. Silk, either braided or twisted, the former much the stronger, is sterilized either in the autoclave, or by boiling. It should not be used in the pelvis in infected cases, as it tends to cause a sinus which persists until the knot is discharged. 2. Silver wire is not much used at present. . It is sterilized by boiling with the instruments, tends to cut rather badly and is painful to remove. 3. Pagenstecher thread, or linen thread covered with celloidin, is better than silk. It is three times as strong, weight for weight, is non -capillary and can therefore be used -in finer sizes. SUTURE MATERIAL AND LIGATURES 403 It is chiefly used for intestinal, uterine suspension and skin stitches, and can with benefit be substituted for silk wherever the latter could be used. It is sterilized like silk, and with- stands repeated sterilization better. Barbour's linen thread. Fig. 158. — I. A "granny" knot; very liable to slip, especially in catgut. A knot to be avoided, always. 2. A square or reef knot; secure against slipping in silk or Pagenstecher thread; but not in catgut unless a third tie is added. 3. The double surgeon's knot. A very safe knot, very unlikely to slip, but too bulky to be used in the wound. 4. Three square knots; the ideal knot in wounds; gives a maximum of safety with a minimum of bulk. 5. Surgeon's and square knots; to be preferred in tying the broad ligaments, because the surgeon's knot prevents slipping until the second knot is tied. as sold in all department stores, is just as good as the much more expensive Pagenstecher, and is available everywhere. It is sterilized in the same way as Pagenstecher thread or silk. 404 GENERAL TECHNIC OF GYNECOLOGIC SURGERY 4. Horsehair, sterilized in the autoclave, is used for skin sutures only, has no advantage over Pagenstecher thread and is in many respects inferior. 5. Silkworm-gut is the best of the permanent suture materials, but it is never used for ligatures. It is the gut of the silkworm, and is best in strands ten to twelve inches long. Longer than this it is too thin for tension sutures. It is sterilized in the autoclave or by boiling in plain water, never in soda solution. It does not withstand repeated sterilization, but becomes brittle. Neither silk, hnen thread nor silkworm-gut should be boiled in soda solution, as they are all made brittle. Absorbable. — i. Catgut, prepared from the submucous layer of the intestine of the sheep. It is used in three forms chiefly: (i) Plain, not hardened to resist absorption; (2) iodized, hardened with iodin; (3) chromicized, hardened with bi- chromate of potassium solution. It is difficult to sterilize, hence it is best to use the commercial product, rather than attempt home manufacture. Commer- cially it is put up in tubes that can be resterilized by boiling, and which are much the best. The non-boilable tubes contain catgut which has not been dehydrated, is flexible and much inferior to the boilable kind. The latter is harsh and stiff, but can be made pliable if the strand is dropped in hot water for ten seconds only af '•^r the tube is broken. Longer immersion than this renders the gut elastic and slippery. Catgut sizes are 00, o, i, 2, 3, and 4. Sizes 00 and o are used for fine sutures and small ligatures; size i and all ordinary suturing; size 2 for ligation in pelvic operations. Size 3 is Ineorreef. Fig. 159. — The right and wrong waj^ to tie interrupted skin sutures. SUTURE MATERIAL AND LIGATURES 405 useful in perineal and cervical repair. Size 4 is too heavy for any ordinary use. Fig. 160. — Proper way to tie a knot when tying deep in the pelvis. The forefingers are close down on the knot, and the strand is never jerked. Pig. 161. — Proper way to tie a knot when tying near the surface, The thumbs are close to the knot, which is tied down by steady pressure and never jerked. In using catgut, use small sizes in preference to large, tie knots with the thumbs close to the knot, with a steady pull 4o6 GENERAL TECHNIC OF GYNECOLOGIC SURGERY and never a jerk. Tie the second knot just tight enough to hold the first and always a third knot on top of that. Never tie with the stitch crossed, so that it can break. Improper tying is the commonest cause of broken strands, especially when it breaks at the second knot. The knot is the hardest and last part to absorb, hence the value of small sizes. Durability of catgut is spoken of as its duration by days, Fig. 162. — Wrong way to tie a knot. The hands are far away from the knot, and the strain in the strand of Hgature material is excessive. buried in the fascia. Hence we speak of ten-day gut and so on. Plain catgut is quickly absorbed, five to six days at the latest. In the vagina, rectum and peritoneum, catgut will last only one-third of the time the same gut will last in fascia. Catgut is an almost ideal suture and ligature, provided it is not used in too large sizes, is not infected, and is not used unsupported by suitable permanent suture material where it is under heavy strain. Home Preparation of Catgut. — Bartlett's method is: (i) Catgut is wound in small coils, which are suspended by threads in a large beaker, the ends of the threads being brought through a pasteboard cover of the beaker. This covering has an open- ing, admitting a thermometer, the bulb of which is on a level with the topmost coil. The coils must not touch the sides of the beaker; (2) the catgut is covered with albolene and the DISINFECTION OF ABDOMINAL SKIN 407 whole gradually raised to 2i2°F. over a cumol bath and kept there twelve hours; (3) the temperature is then increased to 3oo°F. for one hour, and the oil allowed to cool; (4) the coils are picked up with sterile forceps, and kept in i per cent, solution of iodin in Columbian spirits. 2. Kangaroo tendon is obtained from the tail of the kangaroo. It is prepared in the same manner as catgut, it resists absorption longer than catgut, has greater tensile strength, but except in abdominal hernias, has no advantage over catgut. 3. Aluminum bronze wire differs from ordinary wire in that it is ultimately absorbed. It is flexible, ties easily and is used in large abdominal hernias, where tensile strength and durability are required. It is sterihzed by boiling. VIII. "Hand Disinfection.^ — There is no quick and easy method of hand disinfection. All methods depending upon antiseptics are unreliable and very hard on the skin. The following method is satisfactory: (i) Scrub hands and forearms, using tincture of green soap and hot running water, for ten minutes by the clock with a moderately stiff sterile brush. Particular attention is paid to the nails, which must be smooth and trimmed short; the spaces between the fingers, and to see that each hand, gets an equal amount of scrubbing. (2) Scrub for one minute, with a fresh sterile brush, in 70 per cent, alcohol. (3) Rinse hands in sterile water and dry on a sterile towel. Rubber gloves are always, worn, for every operation. They are sterilized by fractional method in the autoclave, or by boiling (flat and never rolled) wrapped in gauze or a towel. The hands should be just as carefully prepared as if gloves were not to be used. IX. Disinfection of the Abdominal Skin. — There is no quick and easy method. All rapidly antiseptic solutions are irritating and undependable. It is easy enough to secure favorable healing in any method of preparation, when it is remembered that the skin of persons with cleanly habits will in most cases heal kindly without any preparation at all. A reliable and safe method is that described in paragraph i. 4o8 GENERAL TECHNIC OF GYNECOLOGIC SURGERY Tincture of iodin particularly is objectionable for the follow- ing reasons: (i) In strengths of less than 12 per cent, it will not sterilize animal skin; (2) it is intensely irritating to the peri- toneum and is always carried in on the operator's gloves, dur- ing the operation; (3) wherever the intestines are brought out of the wound and come in contact with the skin, there are areas of intense irritation on the visceral peritoneum; (4) it is a prolific cause of postoperative adhesions and a not infrequent cause of intestinal obstruction; (5) tincture of iodin in strengths sufficient to have a real antiseptic action on the skin, will cause serious desquamation. At every section the abdominal skin should be protected with rubber dam, as the hands are with rubber gloves. X. Antiseptic Solution.^ — The best surgeon, in abdominal work, is one who leans away from antisepsis, toward asepsis. Hence the best solution is plain sterile water. For superficial use the best antiseptics are i per cent, formalin solution or 70 per cent, alcohol, or lysol solution (i per cent.). Bichlorid of mercury solutions are useless. Antiseptics of any kind are best kept out of the abdomen. XL Anesthesia for plastic operations is by gas and ether, chloroform or gas and oxygen. The latter is very satisfactory, especially for operations of short duration, but requires considerable skill in the handling of the apparatus. The safest t)f all inhalation anesthetics is unquestionably ether, though chloroform is very satisfactory provided it is pure, freshly opened, never given in the presence of an open iiame (because of chlorin degeneration) and never pushed or hurried. Fat persons do not stand chloroform well, as a rule, and are more liable to chloroform poisoning. For abdominal sections, gas and oxygen is not as a rule satis- factory, particularly in those requiring work deep in the pelvis. It is difficult or impossible to secure the necessary relaxation. In cases where general anesthesia is contra-indicated; age, bad kidneys, bad heart, diabetes, etc., various forms of local anesthesia are used. ANESTHESIA 409 In operations on the cervix the following is exceedingly use- ful, whether for repair or anterior vaginal hysterotomy : The solution used is 3^^ of i per cent, novocain (1-400) with fifteen drops of i-iooo adrenalin to each ounce. The in- jections are made: (i) Around the cervix, at the point of attachment of the vaginal mucosa, at 12, 3, 6, and 9 o'clock, considering the cervix as a clock face. (2) At 3 and 9 o'clock straight into the cervical muscle, parallel to the Fig. 163. — Safe position of the armij in anesthesia. {After Crossen.) cervical canal. The operation can be begun five minutes after injection. Perineal nerve blocking is rarely successful, and there is no satisfactory method of local anesthesia for plastic operations on the vagina and perineum. In abdominal sections, the skin and peritoneum are the two regions to be infiltrated. The same solution is used (1-400 novocain) and the length of incision in the skin is infiltrated with a succession of wheals; this is considerably simplified if a line is painted with tincture of iodin to represent the 4IO GENERAL TECHNIC OF GYNECOLOGIC SURGERY incision. Once through the skin, the layers can be incised until the peritoneum is reached. This is infiltrated, and then opened. The abdominal viscera can be handled with .im- punity, provided the mesentery and broad ligaments are not pulled upon. Quinin and urea-hydrochlorid is not a satisfactory solution for infiltration anesthesia. It causes considerable induration of the tissues and interferes with the healing of the wound. Position of the Arms in Anesthesia. — The arms should be arranged so that the palms of the hands lie flat on the pectoral Fig. 164. — Dangerous position of the arm in anesthesia, causing musculospiral paralysis. {After Crossen.) muscles, near the midline of the chest. They are secured by a six -inch bandage looped around one wrist going behind the neck and looped around the other wrist. Pinning the sleeves of the nightgown to hold the arms is not satisfactory as the pins are pulled out if the patient strains. The hands should not be placed under the patient's hips, nor should the arms hang down even for a short time over the edge of the table. This often results in a troublesome musculospiral paralysis. Also the arms should never be stretched up higher than the INSTRUMENTS 411 patient's shoulder level, thus causing strain on the brachial plexus. Spinal anesthesia is not a safe method. Infiltration anesthesia is much better. XII. Instruments in general are best sterilized by boiling for fifteen minutes in i per cent, sodium bicarbonate solution. Knives are sterilized by soaking in 10 per cent, carbolic acid in alcohol, as boiling destroys the edge. Instruments, like bougies, which cannot be boiled, are sterilized by soaking, Pig. 165. — Dangerous position of the arm in anesthesia, causing strain in the brachial plexus. {After Crossen.) wrapped in gauze, for at least an hour in cold 1-50 formalin solution, or i-ioo bichlorid. • The following instruments are those required, as a minimum, for plastic operation and for abdominal sections. ABDOMINAL SECTION 3 knives Plain and toothed tissue forceps Curved and straight scissors 412 GENERAL TECHNIC OF GYNECOLOGIC SURGERY i8 hemostats 12 curved hemostats or clamps Self • retaining abdominal retractor Hand retractors Sponge forceps Somers' clamp (for uterus) 2 curved ovariotom}- needles (pedicle needles) Sewing needles Intestinal needles with silk or linen thread Needle-holder Rubber- covered clamps for intestinal resection Cautery (for appendix, intestine or uterine stump) Catgut, silk, silkworm-gut, linen thread. PLASTIC OPERATION Weighted speculum (Auvard) 3 double tenacula / Small uterine dilator (Goodell) Heavy uterine dUator (Wathen) Sims' curet Martin curet Placental forceps (Emmet) Dressing forceps (Thomas) Uterine sound Bozemann intra-uterine douche Scissors curved and straight Tissue forceps, plain and toothed 1 8 hemostats 2 knives Gelpi perineal retractor 2 lion-jawed forceps (Jacobs) 2 lateral vaginal retractors Sutures (catgut and silkworm-gut) Shot and shot-compressor (if used) Needles and needle-holder. XIII. The Abdominal Wound. — In pelvic surgery, the straight central incision is much the best. There is no advantage in the right or left rectus incision. The curved incisions across the lower abdomen (Pfannenstiel or Barden- heuer) have the single questionable advantage of invisibility THE ABDOMINAL WOUND 413 of scar, as it is hidden in the pubic hair. They have the follow- ing disadvantages: (i) Danger of injury to the bladder; (2) traumatism to the abdominal muscles, as the fascia flap is dissected up; (3) limited room for work, unless a huge incision is made; (4) a badly adherent appendix is almost impossible to remove through them; {5) deep-seated hematomata, under the fascia, cause wound infection and drainage weeks after ap- parent satisfactory closure. The following points are to be remembered. (i) Make a small incision, to be increased later if needed; (2) open the peritoneum high up, to avoid the bladder, and then enlarge opening downward; (3) make sure no intestine is cut when peritoneum is opened; (4) keep fingers out of wound as much as possible, and handle, with forceps, but do not use forceps to pick up intestine or other viscera; (5) avoid bruising with retractors; (6) never bury catgut heavier than number I in the abdominal wound; disre- gard of this is the commonest cause of wound infection; (7) be sure of hemostasis, especially in the muscle (under it) and fat layers, otherwise a hematom.a will form. This is the second cause of wound infection; (8) handle tissues gently and do not tie sutures tight enough to strangulate. Accurate approximation is all that is needed. Closure of the Abdomen. — (i) Continuous number i chromic catgut of the peritoneum, everting the cut edges; (2) two (at least, more if wound is long) silkworm-gut stitches to but not through the peritoneum; (3) two or three interrupted number i chromic catgut stitches in fascia: (4) continuous number i chro- FiG. 166. — I. Central incision. 2. Right rectus incision. 3. Alexander operative incision. 4. Appendix incision. 414 GENERAL TECHNIC OF GYNECOLOGIC SURGERY mic catgut stitch for the fascia; (5) if no silkworm-gut stitches have been used, and they are unnecessary in very short wounds, the fat is closed with a continuous number o plain catgut stitch just tight enough for approximation. This stitch is unneces- sary when silkworm-gut stitches are used; (6) subcuticular stitch of Imen thread; (7) tie silkworm -gut stitches, so that the knot is to one side. Tying them over a gauze roll is not secure enough. Dressing of the Wound. — The wound, when closed, is washed Fig. 167. — The transverse abdominal incision. with 70 per cent, alcohol, and dried. Three strips of i inch gauze bandage are placed on it, and sealed down with collo- dion. This is in turn thickly dusted with sterile talcum powder, and covered with gauze and strips of adhesive plaster. The outer dressing is removed in six hours, leaving only the collodion strips. An ice bag is then placed on the strips, to allay pain. The cold does not interfere in the least with heal- ing and is most grateful to the patient. The collodion dressing is removed in two weeks, if there is no trouble in the wound. ROUTINE AFTER-CARE OF PLASTICS 415 The silkworm-gut and skin stitches are removed, and no further dressing is as a rule required. Iniected wounds are described under the complications. XIV. Routine After-care of Sections.^ — (i) Elevate head of bed on blocks twelve inches; (2) morphin sulph., gr. }-^, atropin sulph. gr. ^i^o — 6th hour p.r.n.; (3) cool water p. r.n. in ounce quantities as soon as nausea ceases; (4) catheterize 6th hour p.r.n.; (5) continuous enteroclysis, for first twenty- four hours, of glucose 1)2 ounces, sodium bicarbonate i^^ ounces, water 2 pints; run in at 110° F.^ — 40 to 60 drops to the minute. The enteroclysis must be given through a large tube, with ample provision for the escape of gas; otherwise the fluid is expelled from the rectum and the method is useless; (6) if wound is sealed, take off outer dressing after six hours and put ice-bag over wound; (7) after twenty-four hours feed by albu- min water, broth or milk and limewater equal parts, i to 2 ounces every hour; (8) after twenty-four hours give enema of milk of asafetida oz. 6, Hoffman's anodyne dram i, water q. s. ad. I pint; (g) if much nausea wash out stomach by giving 2 glasses of water with 5 grains of sodium bicarbonate to each glass. If this does not stop it, wash out with tube; (10) after forty-eight hours give calomel gr. 3^6 every hour for six doses, followed in two hours by flat magnesium citrate 6 ounces, divided into 3 doses, one hour apart; (11) after bowels move give soft diet, fifth day give light diet, seventh day give full diet; (12) if much distention, give eserin salicylate gr. 3^:40 hypodermically fourth hour, and pituitrin 3^^ mil twice daily hypodermically; (13) if urine output low, give spartein sulphate gr. I, hypodermically sixth hour and force water; (14) collo- dion dressing off fourteenth day, and wound dressed thereafter every other day with dry sterile gauze; (15) as a routine laxative use compound cathartic pills, one at bedtime. If too active give only half a pill. If griping, use A. B. S. & C. pill. Routine After-care of Plastics.^ — (i) Morphin sulph. gr. 3-^, atropin sulph. gr. 3-^50 — sixth hour p.r.n.; (2) water p.r.n. first twenty-four hours; (3) irrigate perineal stitches with 4i6 GENERAL TECHNIC OF GYNECOLOGIC SURGERY sterile water four times daily, and also after each urination or bowel movement, and keep sterile vulvar pad in place Name.. TEMPERATURE RECORD. Hospital ....Index File No Vol. 1 " 1 T«P«.TU«. 91 98 SB 100 101 102 103 104 105 103 107 -L <5' T, lM ,• ., (. Ify T, ,..,^ o i.^ 2k JL. ............ ..._...., -...1 i. ■IM j^.<^ io. E — ( ^ — f — ~E~ —J > — — — Sfe 2.3. E ..M.„ _ \ S; .'J ^ A,K *- ]' '^^ '?o >« M ^^5*— t 3iL if- E M -ipJ »=— - ^.. io ^ t .......... — , . . , Mil 1% E i - I ^ """- rd --M t= s M ^ 2a. to. 11 if M T. — ^ (__ n i -^ — /* <1j\. "i • k ..fS. ..M._ -. . S^ — ( — , > if A "f — T": -^ ::: . .... .... .... .... .... ■ 1 kl. .... .... .... 76 -1/' li. I 1 ^^.... 76 Ji ft- ..M. ^ 7k .M._ ?*— ' .M_ ..... H — z: ^ i: 1 — — T! ■ »M 'ZmL *" ^^ e a s 8 £ g 1 DO 1 91 1 )£ I D3 1 at, 1 06 I 38 >( n Pig. 1 68. — Average temperature and pulse chart after an abdominal section. after irrigation; (4) if stitches soiled, clean with cotton on STAY IN BED " 417 applicator and peroxid of hydrogen, especially around the knots; (5) vaginal douche sterile water every day after fifth day; (6) simple enema once or twice in second twenty-four hours; (7) end forty-eight hours, calomel gr. }^ every hour for six doses; (8) soft diet after first twelve hours, light diet fifth day, full diet seventh day; (9) catheterize eighth hour p.r.n.; (10) take out vaginal packing in twenty-four hours, and note its removal on the chart; (11) always note on chart the number of silkworm-gut stitches to be taken out, and whether they are vaginal, perineal, anal or rectal. The chief complaint after plastic operations, aside from the pain of the perineal stitches is backache. This occurs after any vaginal operation and is due to the dorsal position on the table, which strains the sacro-iliac joints and coccygeal and other pelvic ligaments. The greatest relief is change of position in bed. It is unnecessary to have plastic operation cases lie on the back. They may turn to either side, and it is entirely unnecessary to bandage or tie the knees together. It is desirable to leave the vaginal and perineal stitches in place for some days after the patient is out of bed, to avoid the spreading strain on the perineum when the patient sits down. XVI. Stay in Bed. — Cases with dilatation and curetment and repair of the cervix alone stay in bed for five days and leave the hospital on the seventh day. Ordinary plastics sit up on the fourteenth day and leave on the seventeenth. Cases of total prolapse stay in bed twenty-one days and leave in twenty- five. Ordinary sections stay in bed fourteen days and leave on the seventeenth. Cases of Alexander operation, abdominal or other hernia, Webster operation for diastasis of the recti and abdominal operation for retroversion of the uterus stay in bed twenty-one days and leave on the twenty-fifth. All these dates depend upon a smooth and uncomplicated con- valescence. Severe neuroses of long duration are liable to follow the too early getting up and getting about after abdominal opera- 4l8 GENERAL TECHNIC OF GYNECOLOGIC SURGERY tion, and the tendency unduly to shorten a patient's stay in bed — ^often strenuously urged by the patient herself — is to be avoided. Early getting up is said to prevent phlebitis, but this is most doubtful. XVII. Foreign bodies left in the abdomen are most often a sponge or hemostat. Constant watchfulness is needed to prevent this accident. Sponges are counted and accounted for before the peritoneum is closed. All instruments are counted and checked up in the same way. The symptoms are severe and sometimes fatal infection, usually with a most persistent sinus, and a palpable mass. A metal instrument will show on an a;-ray plate; the sponge will not. Either must be removed at the earliest date possible. Rarely a foreign body ulcerates into the rectum and is discharged spontaneously. XVIII. Reasons for leaving salt solution in the abdomen, the solution being heated to iio°F. and poured in just before the peritoneum is closed are: (i) Relieve thirst; (2) prevent shock; (3) supply the fluid that the patient needs but often cannot take because of postoperative nausea; (4) prevent reforming of adhesions, by giving the peritoneum a chance to glaze over. The plan is a good one and should be routine. XIX. Position in Bed after Operation.^ — An abdominal section case is best kept flat on her back for at least forty-eight hours, with the head of the bed elevated twelve inches. At the end of this time she can be turned to either side, avoiding all sudden movements. The Fowler position is most useful in all cases of abdominal infection, as it gravitates infectious fluids to the comparatively non-absorptive pelvis. The nearer the diaphragm, the more rapid is the absorption, hence the/00/ of the bed is never raised in peritonitis. In the Fowler position the patient is practically sitting up against a bed rest with the knees flexed over a pillow. The position is best secured on the Gatch folding bed. The foot of the bed is raised eighteen inches only in the treatment of shock and hemorrhage. TREATMENT OF COMPLICATIONS AFTER OPERATION 419 XX. Enteroclysis. — After every abdominal section and also prolonged plastic operation, continuous enteroclysis is desirable. The solution is glucose 1.5 ounces, sodium bicarbonate 1.5 ounces, sterile water 2 pints. It is run in at forty to sixty drops to the minute, at a temperature of iio°r. A faster flow than this makes it difficult for the patient to retain. If she does not retain it, it may be given high up, through a rectal tube, one pint twice daily. It relieves thirst, aids diuresis and is particularly desirable in drainage cases. Ample provision must be made for the escape of gas. XXI. The indications for and the treatment of drainage wounds is described in Chapter VIII. TREATMENT OF COMPLICATIONS AFTER OPERATION Complications after Abdominal Sections I. Shock is not common, after gynecologic operations, except those in which a very large amount of blood has been lost, such as extra-uterine pregnancy, very large tumors or operations in acute septic conditions. The symptoms are: (i) Subnormal temperature; (2) pulse rapid and weak (but occasionally slow and intermittent); (3) pallor; (4) leaky skin with cold clammy perspiration; (5) shallow and irregular breathing; (6) pinched expressionless face; (7) pupils dilated and reacting slowly to light; (8) restlessness and air hunger, only if the shock is due to hem- orrhage. Delayed shock, after abdominal operations, coming on six to thirty-six hours after operation is almost always due to internal hemorrhage, except in operations for densely adherent pus tubes with drainage, where it is not uncommon without hemorrhage. Differential diagnosis between internal hemorrhages and shock is often exceedingly difficult, as the symptoms are practically identical. The diagnosis can be made much more easily on paper than in practice. 420 GENERAL TECHNIC OP GYNECOLOGIC SURGERY Shock Internal Hemorrhage . I. No restlessness i. Restlessness marked 2. No air hunger 2. Air hunger marked 3. Patient apathetic 3. Patient anxious 4. No visual disturbance 4. Often loss of sight 5. Pulse rapid and small but not 5. Pulse rapid, but larger and easily compressible more easily compressible 6. Hemoglobin not lessened 6. Lessened, but not at first 7. No signs of fluid in flanks or 7. May be demonstrable Douglas' pouch Whatever value this differential diagnosis possesses is only in the recognition of shock not due to hemorrhage. In doubt- ful cases where the patient shows no sign of reaction under treatment, it is wiser to re-open the wound rather than over- look hemorrhage. Treatment.- — Most cases can be avoided by the following: (i) As rapid operation as is consistent with good work; (2) good hemostasis; (3) gentle handling of tissues; (4) expert anesthesia; (5) careful covering of patient during operation and avoiding chilling or wetting. Curative treatment can be summarized as external heat, stimulation, intravenous injection or transfusion: (i) Elevate foot of bed eighteen inches; (2) external heat by hot water bags or electric light frame; (3) bandage extremities, to drive blood to vital centers (autotransfusion) ; (4) hypodermic injection of digitalin gr. ^-so? strych. sulph., gr. 3^^'o every three hours, or digipuratum i ampule instead of the digitalin; (5) hypodermic injection of atropin sulph. gr. Moo re- peated every four hours or often enough to control the leaky skin; (6) hypodermic injection of morphin sulph. gr. 3^^ if very restless; (7) oxygen inhalation, if respiration labored; (8) enema of hot strong coffee i pint, brandy i ounce, given high up and not repeated; (9) if the shock is due to loss of blood, intravenous injection of salt solution 2000 c.c, given with a canula and not a needle (which is liable to perforate the vein) after exposure of the vein. Thirty drops of i-iooo adrenalin solution are added as the fluid is running TREATMENT OF COMPLICATIONS AFTER OPERATION 42 1 in; (10) intravenous transfusion of blood is better postponed until the patient has reacted, as when given in a hurry, satisfactory tests of the donor's blood are often impossible and hemolysis may result; (ii) artificial respiration, and oxygen especially if the shock appears suddenly during operation. II. Internal hemorrhage, may be either continuous or con- secutive. Continuous is a hemorrhage that never stopped at all; consecutive (the commonest) is one that comes on some time after the operation is completed, and due usually to a slipped ligature or breaking of adhesions following the withdrawal of a drain. It may come from any vessel, but is most often Pig. 169. — The arrow points to the commonest site of secondary hemorrhage after operations on the tubes, ovaries or broad ligaments. The edge of the broad Hgament pulls out of the grip of the ligature, and the bleeding is from the ovarian artery. from the ovarian artery, due to the outer edge of the broad ligament slipping out of the bite of the ligature. Symptoms are precisely those described under the previous heading of "shock." A fairly full, increasingly rapid and compressible pulse, with restlessness and air hunger, usually means hemorrhage. The temperature, due to peritoneal irri- tation from blood-clots is often elevated and falls.to subnormal 422 GENERAL TECHNIC OF GYNECOLOGIC SURGERY only when the case is desperate. The hemorrhage, unless from a small vessel, does not as a rule cease spontaneously. Treatment.- — Reopening of the abdominal wound and securing the vessel is the only treatment. The patient is put in the high Trendelenburg position, the intestines rapidly packed off, and the source of the bleeding sought at the outer edge of the broad ligament, where it will be found nine times out of ten. The broad ligament is retied, the clots and fluid blood sponged out and the abdomen rapidly closed. The after- treatment is the same as for shock. Regeneration of Blood After Hemorrhage. — The body fluids are absorbed, to make up the loss in volume of blood^ — hence the thirst and scanty urine output. The red cells regenerate more slowly, hence at first the reds show a low count; the next phase is the rapid increase of reds, which outstrips the increase in hemoglobin, and gives a picture similar to chlorosis. The leukocytes are also increased. The regeneration of blood after acute hemorrhage is very rapid, provided the hemorrhage is not repeated. III. Abdominal distention is seen most frequently in cases where there has been much handling of the intestines, as in pyosalpinx or extensive adhesions; in cases where there has been a sudden reduction in intra-abdominal pressure, as in large cysts, fibroids or in Cesarean section; in peritonitis; in intestinal paresis without peritonitis; and in intestinal obstruc- tion. It is much m.ore common in cases operated on without adequate preparation. It is often alarming in extent, but is not a serious complication unless the pulse is elevated, peris- talsis is absent, and vomiting is persistent. Treatment. — Prophylactic: (i) Proper cleansing of the bowel preparatory to operation; (2) gentle handling of the intestines as possible during the operation, and as little of it as possible ; (3) eserin salicylate gr. X'io hypodermically every four hours, pituitrin 3>^ mil hypodermically twice daily in all cases where it seems likely to occur (fibroids, pus tubes, large cysts and Cesarean sections). TREATMENT OF COMPLICATIONS AFTER OPERATION 423 Curative Treatment. — (i) Rectal tube left in situ for several hours at a time; (2) calomel gr. 3 dry on back of tongue, fol- lowed by Hat magnesium citrate solution 2 ounces every hour for four doses; (3) high enema of alum 3^^ ounce to sterile water 2 pints; (4) high enema quinin bisulphate 3^^ ounce to sterile water 2 pints; (5) high compound enema of magnesium sulphate }''2 ounce, turpentine 3^-^ ounce, glycerin i ounce, water enough to make i pint; (6) eserin salicylate gr. \^q with strychnin sulphate, gr. ^^^o every four hours hypodermically; (7) pituitrin )y'2 mil hypodermically twice daily; (8) if vomiting is persist- ent, wash out stomach and through tube give magnesium sul- phate I ounce in water, 2 ounces, or i ounce of castor oil (hot) . If the abdominal distention and vomiting do not yield to the above, they are due to peritonitis or intestinal obstruction, both of which are described later. IV. Acute dilatation of the stomach is a dangerous form of distention. It is most frequent in septic cases, but may occur in any case, nearly always in the first three days after operation. Symptoms.- — (i) The patient complains of pain in the epigas- trium; (2) the pulse is rapid and weak, without demonstrable cause; (3) there is a marked globular tympanitic swelling in the epigastrium. Treatment is prompt lavage, with the stomach tube, repeated as often as necessary to control the distention. In severe cases this may be every two or three hours. At the first wash- ing, the patient should be given, through the tube, one ounce of magnesium sulphate. She is given eserin and pituitrin as described under distention of the stomach. Prognosis. — This is always a serious complication, demands prompt treatment, and if neglected may be fatal. A variety due to thrombosis of the gastric veins, is always fatal. V. Postoperative Vomiting. — Kinds: i. Postanesthetic, con- sisting of mucus and swallowed saliva, sometimes bile tinged, and usually, unless complicated by some other factor, of short duration. 2. Acidosis characterized by persistent vomiting, usually 424 GENERAL TECHNIC OF GYNECOLOGIC SURGERY beginning twenty-four hours or more after operation but often continuous from the postanesthetic kind; severe epigastric pain and acetonuria. 3. Peritonitis, where there is exteme and constant retching, but at first only a frothy mucus is ejected; later bile colored and finally coffee ground. 4. Intestinal obstruction, vomiting without effort, and of large amounts, first stomach contents, then bile and then stercoraceous. As a prophylactic measure, it is a wise plan in any case where there has been considerable mucus in the air passages during operation, to wash out the stomach before the patient recovers from anesthesia. When the patient vomits after an abdominal operation, she is kept on her back, with the head turned to one side, to prevent inhalation of the vomited material. The vomit is best caught in a towel, rather than a basin. After plastic operations, the patient can be turned on her side, which makes her care easier. Treatment depends upon the cause. Moderate cases will yield to the following: (i) Absolute quiet, flat on back wdthout a pillow; (2) small amounts of hot water ( half an ounce at a time); (3) ice bag or spice plaster or mustard plaster to the epigastrium; (4) ii' persistent, give patient two glasses of water, with five grains of sodium bicarbonate to each glass, with the expectation that the water will be vomited promptly and hence wash the stomach out. If it is retained, i-t passes out through the pylorus and accompHshes the same purpose; (5) if still persistent , for- mal lavage with a tube, putting in one ounce of magnesium sulphate in strong solution before the tube is withdrawn. Morphin, heroin and codein as sedatives usually prolong and aggravate the vomiting, as does cold water or cracked ice taken by mouth. After the bowels move, the nausea usually disappears. Cases of the acidosis t}^e are promptly relieved by large doses of sodium bicarbonate, one dram to a dose, given every two or three hours. TREATMENT OF COMPLICATIONS AFTER OPERATION 425 Acidosis is a not infrequent complication after any operation, either plastic or section, where there has been prolonged anes- thesia. It is more common in patients past thirty-five years of age, but is not infrequently seen in the young. It is character- ized by severe vomiting, epigastric pain, considerable abdominal distention, marked stupor, and acetonuria. It is, except in very moderate cases, an alarming condition, often a very serious and sometimes a fatal one. The treatment consists in the ad- ministration of large doses of sodium bicarbonate by mouth, sixty grains every two hours being the minimum. The alkali can be given by bowel, in the proportion of one and one-half ounces of sodium bicarbonate to each quart of water, given by slow, continuous enteroclysis, forty drops to the minute. In very severe eases, time is a factor, and these cases can take nothing by mouth, nor retain anything by the bowel. Here the best results are gained by giving one pint of a five per- cent, solution of sodium bicarbonate solution intravenously, and repeating the dose once daily as long as the patient's symptoms demand it. This solution is sterilized as any other to be given intravenously, and the author has seen brilliant results from its use. Usually one dose is sufficient and three is the largest number he has had to employ. Cases of peritonitis vomiting, unless controlled by the methods described above, are usually uncontrollable wittiout operation. Intestinal obstruction requires operation. Rectal feeding is often required, to give the stomach an abso- lute rest. The best enemas are: liquid peptonoids or pre- digested beef 2 ounces and salt solution (0.7 per cent.) or sugar solution 2 ounces, given every four hours. A nutritive enema should never exceed 6 ounces, and 4 are better. Peptonized milk or peptonized beef tea or broth may be sub- stituted, but the predigestion should be carried to forty-five minutes. Twice daily a high enema of salt or sugar solution one pint should be given to relieve the thirst. The sugar solution is glucose 1.5 ounces, sodium bicarbonate 1.5 ounces, v/ater 2 pints. 426 GENERAL TECHNIC OF GYNECOLOGIC SURGERY VI. Retention of urine is common, due to a reflex nervous inhibition from pain. It is much more common in plastic operations than in sections. Prophylaxis. — (i) Place patient on bed pan and irrigate vulva and perineum with hot sterile water; (2) pituitrin i ampule (i mil) hypodermically and repeated in 3^^ mil doses twice daily for two days, if the inability to void persists for that long; (3) injection into the bladder of i ounce of 25 per cent, boroglycerid solution. Curative treatment is catheterization under strict aseptic precautions, every eight hours until the patient is able to void. Incontinence of urine is nearly always an overflow from reten- tion. The bladder can be palpated as distended, and the relief is catheterization, followed by hypodermics of pituitrin ^'2 mil twice daily for three days. VII. Fever. — The commonest cause of fever after abdominal section are: (i) Reaction, when the temperature occasionally reacts within twelve hours after operation to about 100°, and returns to normal line after about forty-eight hours; (2) ether pneumonia; (3) drainage cases, until the drain is removed; (4) peritonitis; (5) pelvic cellulitis, usually around a ligature in the broad ligament; (6) hematoma in Douglas' pouch, secondarily infected by colon bacilli; (7) phlebitis, (8) phleg- masia abla dolens, or milk-leg; (9) wound infection; (10) constipation. As a rule a persistently high pulse rate, or a pulse which is weak or irregular is a much more grave sign than an elevation of temperature, which often occurs from trivial causes. The rise in temperature following operation, often to 102° or 103°, is of no significance, as a rule, and requires no special treatment. Ether pneumonia is usually a misnomer, the ether not playing the chief role in causing pneumonia. Predisposing Causes. — (i) Elderly patients, who are particu- larly prone to the hypostatic type; (2) fat, short-necked TREATMENT OF COMPLICATIONS APTER OPERATION 427 patients; (3) choking and vomiting under the anesthetic; (4) exposure to cold during anesthesia; (5) inexpert anesthesia; (6) administration of anesthesia to a patient with a bronchial cold; (7) tuberculosis; (8) operations for pelvic infection. Lung complications are much more common after sections than plastics. Most cases are pleurisy or bronchopneumonia; lobar pneumonia is rarer and also more serious. The symptoms and treatment are those of bronchopneumonia, irrespective of the operation. Drainage cases, if gauze has been used, often show fever from blocking back of discharge by the gauze drain. If this drain is loosened slightly, slightly pulled out, a gush of fluid often follows it, but the temperature is unlikely to subside completely until all the gauze is removed. The fever is rarely sufficient to justify haste in this respect. Peritonitis is described under a separate head. Cellulitis occurs in the connective tissue in the bases of the broad ligaments or in Douglas' pouch or between the uterus and bladder. Its symptoms and treatment are described in Chapter X. Hematoma in Douglas' pouch is formed of blood that has oozed out slowly and collected here, in the most dependent portion of the peritoneal cavity. It is usually secondarily infected by colon bacilli and is detected by bimanual examination as a hard, globular mass behind the cervix. In the majority of cases it does not sup- purate, but undergoes resolution spontaneously, the process being hastened by four hot vaginal douches daily. If it sup- purates, the posterior vaginal vault becomes convex, and boggy, the fever is persistent and there is considerable leuko- cytosis. In this case, it is opened by puncture of the posterior vaginal vault, and T-tube drainage, as described under pelvic abscess in Chapter X. Phlebitis is discussed under a separate heading (11) in this chapter, together with its most common manifestation, milk-leg. 428 GENERAL TECHNIC OF GYNECOLOGIC SURGERY Wound infection is discussed on page 433. VIII. Constipation.- — The vast majority of patients require laxatives after operation, and usually in larger doses than they have been in the habit of using. Constipation is most common in patients with enteroptosis, weak and relaxed ab- dominal walls, and diastasis of the recti. In these the greatest difficulty is met in securing satisfactory movements. The laxative most likely to be satisfactory is that which the patient has been in the habit of using, giving, however, about double her usual dose. Mineral oil is not as a rule sufficient, by itself, though a valuable aid to other medication. Long- continued use of saline cathartics is liable to be followed by considerable gastro-intestinal irritation and discomfort, and hence it is undesirable. Enemata must not be depended upon alone, as they cleanse only the rectum. Glycerin supposi- tories are practically useless. In patients with weak abdominal muscles, enteroptosis or a long history of constipation can be benefited by strychnin sulph. gr. 3''20 four times daily by mouth, or by eserin and pituitrin as recommended for distention. If constipation after operation is complicated by vomiting, the only practicable way of giving a cathartic is through the stomach tube: either magnesium sulphate, i ounce in strong solution or castor oil 2 ounces hot (to thin it) being poured in through the tube after lavage of the stomach. IX. Peritonitis after operation is either local or diffuse. The symptoms begin on the second or third day, with persistent vomiting; rising temperature; rapid and thready pulse; steady abdominal pain, first in the lower abdomen and then diffuse; peristalsis is diminished, though there is usually passage of both gas and feces. Peristalsis is entirely absent only in diffuse peritonitis and late in the attack. Vaginal examination will reveal infiltration of the pelvic connective tissue, with its characteristic board-like hardness. The treatment of local and general peritonitis has been described in Chapter X. X. Intestinal obstruction is most often seen after operation TREATMENT OF COMPLICATIONS AFTER OPERATION 429 for acute pelvic infection, especially in those in which drainage has been used, but may occur as a result of infection, inflam- matory bands or improper technic of certain operations, notably ventrosuspension of the uterus. Symptoms.- — (i) Persistent vomiting; (2) increasing disten- tion of the abdomen; (3) severe cramp like abdominal pains; (4) increasing pulse-rate; (5) no passage of either gas or feces, and no results from enema; (6) vomiting at first mucus, then bile and then stercoraceous. Commonest Sites. — Obstruction occurs most in the rectum, at about the level of the pelvic brim; next in the sigmoid; next in the ascending colon; next in the eight inches of ileum nearest the caput coli, and next in any part of the small intes- tine, as a U trap. As these patients are usually very ill when re-operated on and as time is a very vital factor, it is worth while remembering these situations. Treatment: — Prompt re-opening of the abdomen, eventration of the intestines and search for constricting bands. It must be remembered that there is often more than one point of obstruc- tion, and the search should be thorough. Unless operation is promptly done, a secondary peritonitis develops, which is usually fatal. Prognosis. — The case is always a serious one, but a fair number will be saved by prompt operation. The later the operation the higher the mortality. XL Phlebitis, in gynecologic operations, is usually of the septic nonpyogenic type, affecting the uterine and ovarian veins, and from there extending into the pelvic trunks and to the iliac and femoral. It is most common after operations involving con- siderable handling and ligaturing of the broad ligaments, such as operations for pyosalpinx, but can occur during the most uncomplicated convalescence from clean and simple operations. Cause is obscure. It is probably a mild sepsis, due to non- virulent bacilli, like the colon group, lodging in the inner coat of a vein and causing a local lesion with development of a thrombus. The exact mechanism is not known. 430 GENERAL TECHNIC OF GYNECOLOGIC SURGERY Symptoms. — (i) Deep-seated pelvic pain, without demon- strable lesion by vaginal examination; (2) moderate fever 101° average; (3) leukocytosis 12,000-14,000. A constant moderate temperature, with moderate leukocy- tosis and no point of localization of infection points to a deep- seated pelvic thrombophlebitis. Treatment is rest in bed, until the temperature has been per- sistently normal for seven days. It is claimed that if patients are gotten out of bed at the end of a week after operation that the danger of thrombophlebitis is greatly lessened, but this is very doubtful. Nothing further than rest can be done for a deep-seated phlebitis, but it is uncommon to have such a con- dition alone. The phlebitis seen most commonly is phlegmasia alba dolens or milk-leg. The left leg is the more commonly affected — rarely the infection is bilateral. The name milk-leg comes from the milky white appearance of the skin or from the old belief that all localization of infection in puerperal cases was due to metastasis of the milk — lactation being usually interrupted by the fever. Kinds of Milk-leg. — (i) Cellulitic, due to infection of the connective tissue of the thigh; (2) thrombosis of the iliac and deep femoral veins — much the more common (98 per cent.). Symptoms of Milk-leg: — (i) On the tenth to thirtieth day after operation the patient complains of severe pain in the calf of one leg, usually the left, and also in the corresponding groin; (2) the leg is almost immovable, and any movement gives intense pain; (3) the leg swells rapidly, the skin is tense and milk white, and usually pits deeply on pressure; (4) there is moderate fever, lasting for a short time, and subsiding long before the swelling shows any signs of decrease; (5) there is usually tenderness along the whole course of the femoral vein, which can be felt as a tender cord; (6) the swelling may begin in the groin and extend to the labium majus on the affected side; (7) the patient shows the usual signs of sepsis- — depression, gastric disturbance, nausea and flushed cheeks. In the cellulitic variety, the infection extends to the connect- TREATMENT OF COMPLICATIONS AFTER OPERATION 43 1 ive tissue of the thigh from the pelvic connective tissue, through the obturator foramina. Treatment of Milk-leg: — (i) Absolute rest in bed; (2) eleva- tion of the leg, on pillows or in a fracture box, at an angle of forty-five degrees. This does more to relieve the pain than any single point in the treatment; (3) evaporating lotions (lead- water and laudanum; or saturated solution of magnesium sulphate) covering the whole leg; (4) paint course of vein with 5 per cent, tincture of iodin or 50 per cent, ichthyol in glycerin — of doubtful value; (5) full diet and moderate stimulation; (6) no local massage. The symptom urgently demanding relief is the pain in the groin. Ice bag to the groin, more rarely a hot water bottle, elevation of the leg and codein gr. j^^ or morphin sulph. gr. 3^^ hypodermically will give the greatest relief. When the patient is out of bed, after the temperature has been normal for ten days, the swelling of the leg will often increase. This should be controlled by an elastic stocking, and no massage should be given for three months at least, and then very cautiously. Dangers of Milk-leg. — (i) Pulmonary embolus; (2) pyemia; (3) gangrene. Prognosis of milk-leg is guardedly favorable. The patient must remain in bed until the temperature has been uninter- ruptedly normal for ten days, as the greatest danger is pul- monary embolus, from too early getting up. Recovery may be complete, but convalescence is often prolonged, and a tem- porary or permanent lameness may result, about which the patient should be warned. Gangrene will demand prompt amputation, and is a very serious complication, as it is prob- ably progressive. Extensive thromboses, even to the inferior vena cava, are not uncommon. In the cellulitic type, if long continued, elephantiasis is not unlikely, and suppuration is common. The most favorable termination is complete resolu- tion, but is rarely attained. The next most favorable, and the commonest, is organization of the thrombus, obliteration of the 432 GENERAL TECHNIC OF GYNECOLOGIC SURGERY vein, and compensatory collateral circulation through the epigastric and gluteal veins, with frequent slight disability. XII. Embolism is a constant danger of phlebitis, and also after operations for strangulated hernia. It is to be feared after operation for fibroid or any pelvic tumor with large dilated veins in the broad ligament, and is peculiarly frequent after appendectomy. The time of occurrence is usually late in convalescence, two or three weeks after operation, frequently after the patient is up and about. Postoperative emboli are most frequent in the lungs, but may occur in the brain, spleen, pleura, kidney and mesenteric vessels. As they frequently follow phlebitis, sepsis plays a part in their cause, and the risk of embolism is greatly increased if the patient, with phlebitis, is allowed to move about before her temperature has been persistently normal for a week. Pulmonary embolism is the greatest danger in phlegmasia. It is not likely to occur if the patient is kept quiet for a sufficient length of time. The clot may come from the femoral, iliac or uterine veins. A piece is broken off and carried by the cir- culation to the right auricle, right ventricle and pulmonary artery. Small emboli cause anemic infarcts and pleuro- pneumonia, and are not likely to be fatal, though a succession of them may be. The patient complains, without previous warning, of a severe pain in the chest and dyspnea. Her color is bad, she is obviously shocked, the heart is dilated and the pulse rapid, irregular and weak. If the embolus is a small one, active stimulation and oxygen will cause reaction in a short time. If the embolus is large the symptoms are all much more severe, and death is either instantaneous or so rapid that no time is given for any treatment. Mesenteric emboli are found most frequently in the mesenteric ' veins of the transverse colon or in the gastric veins. The symptoms are those of intestinal obstruction or acute gastric dilatation. If the diagnosis can be made before the gut is gangrenous, operation, with resection if not too extensive, offers a chance of cure, but the condition is nearly always fatal. TREATMENT OF COMPLICATIONS AFTER OPERATION 433 XIII. Infected abdominal wounds are rare, with good tech- nic, but will happen at times in spite of every precaution. Causes. — (i) Contamination at the time of operation. This can be due to poor preparation of the skin, imperfect cleansing of the hands of the surgeon or his assistants, imperfect sterili- zation of instruments, sponges or suture material, infected material from pelvis or appendix, or from hair follicle infection, especially in groin wounds. (2) Bruising of tissue from rough handling, especially from retractors. (3) Poor hemostasis with consequent hematoma, one of the commonest causes of wound infection. (4) Ligatures tied too tight, so that the tissue is strangulated, (5) Too heavy catgut. Nothing heavier than number i chromic catgut should ever be buried in abdominal wounds, with the possible exception of incisional hernia cases, where the tension is extreme. (6) Fat necrosis. (7) Post- operative infection, due to dressings or improper handling. It is common to speak of "catgut infection," but the gut is rarely to blame, unless it is home prepared. Tubes, put out by reliable manufacturers, which can be boiled with the instru- ments, are safe and sterile; those tubes which cannot be boiled but are "sterilized" by soaking in antiseptic solution are never safe, as the soaking will not sterilize them. Type of discharge is serum, oil (from fat necrosis), blood or pus. Only the latter means an infected wound, as the first three cause no systemic disturbance. Symptoms. — (i) Elevation of temperature; (2) leukocytosis; (3) throbbing pain in the wound; (4) brawny induration around the wound; (5) bulging under the skin; (6) as a late symptom, reddening of the skin. In any case of fever, beginning three days or more after operation, the wound should always be suspected and in- spected. Treatment. — The prophylactic treatment is expressed by the opposites of the conditions mentioned as causes. Care in these respects will eliminate all but a very small percentage of in- fected wounds. 434 GENERAL TECHNIC OF GYNECOLOGIC SURGERY in \ Curative consists in early opening, which should not be extensive. It is absolutely unnecessary to remove all stitches and allow the wound to gape. This only delays healing and ruins the appearance of the healed wound. A small opening, just sufficient to permit drainage and to allow the wound to be irrigated daily is all that is needed. The best solutions for irrigation are : hydrogen peroxid one part, sterile water three parts, injected with a small glass piston s}Tinge and washed out WT.th 1-3000 permanganate solution followed by sterile water; Dakin's solution injected but not washed out after the solution returns clear; dichloramin-T, used in the same way as Dakin's solution. The irrigations are done daily, the small sinus is drained wath a very small ^^^ck of rubber tissue, and the wound covered with gauze held by Montgomery straps. Un- der this the average wound will heal promptly and cleanly, in a week to ten days, and its appearance will be saved. Frequently the whole skin and fat layers will gape; such a wound is cleansed as described, covered by a thin strip of gauze, the edges pinched together and held in apposition by adhesive straps. The dressing is changed daily, the straps being removed by pulling always toward the wound. If the fascia is involved as well, the wound must be secondarily sutured after it is clean, otherwise a hernia is unavoidable. Suturing it is not necessary if the fascia is Intact. Sinuses are usually due to foreign material in the wound, such as heav}^ catgut knots or particularly the silk or linen thread used in ventrosuspension of the uterus. Per- sistent sinuses of this t}^e will not close until the offending Fig. 170. — The po- sition and compara- tive size of the open- ing for draining an infected abdominal wound. Removal of the stitches is un- necessary. TREATMENT OF COMPLICATIONS AFTER OPERATION 435 material is removed. It is not necessary to open the wound. A loop of silkworm-gut is passed down the tract to the bottom, is twisted around several times and withdrawn. A little per- sistence is usually rewarded by catching the stitch in the loop and withdrawing it. Tubercular and cancerous fistulae never close, and should not be operated upon. A fecal fistula should be given a year to close spontaneously; Fig. 171. Fig. 172. Pig. 171. — Separation of the skin and fat, as a result of superficial infection. The edges can be approximated neatly by adhesive straps. Fig. 172. — A wound strapped with adhesive strips, after separation of the skin. The line of the wound is covered with a thin layer of gauze, which, for the sake of clearness, is omitted. unless it is tubercular or cancerous, it may then be closed by operation, which is always serious, sometimes very extensive and to be attempted only after due consideration of its diffi- culties. Danger of hernia in infected wounds is small unless the fascia gapes. Then it is sure unless the fascia is repaired by second- ary suture. 436 GENERAL TECHNIC OF GYNECOLOGIC SURGERY XIV. Bursting open an abdominal wound sometimes occurs when only catgut has been used in suturing it. Causes are: (i) Infection; (2) premature absorption of the catgut; (3) severe or constant muscular effort. The wound gaps widely and intestines bulge out under the dressings. Fig 173. Fig. 174. Fig. 173. — A " stitch-fisher " made of a loop of silkworm-gut, tied on an ordinary wooden applicator. It is useful in extracting a buried stitch from the bottom of an infected sinus, as after ventrosuspension of the uterus. It must be boiled before use. Fig. 174. — A "stitch-fisher" in operation. The loop of silkworm- gut is passed down the fistula, is twisted rapidly and withdrawn, often bringing the buried stitch with it. The accident is not as serious as appearances would indicate, provided it is treated without delay. Treatment is: (i) Light anesthesia, (2) closure of the wound. TREATMENT OF COMPLICATIONS AFTER OPERATION 437 without freshening the edges, with close-set interrupted silk- worm-gut sutures; (3) insertion of a narrow rubber-dam drain to the peritoneum at the upper and lower angles; (4) the silk- worm-gut stitches should not be removed for three weeks. XV. Low urine output after operation is to be expected for the first forty-eight hours, the average being twelve to sixteen ounces in the first, twenty-four ounces in the second twenty- four hours. If it falls seriously below this the treatment is: (i) Continuous enteroclysis by Murphy drip, giving sodium bicarbonate 1.5 ounce, glucose 1.5 ounce to each quart of water; (2) free water by mouth unless the patient is seriously nau- seated; (3) spartein sulphate gr. i hypodermically every four hours. The Murphy drip is discontinued as soon as the patient can take the necessary water by mouth. XVI. Bed-sores are a constant danger in cases where there is continual vaginal, urine or fecal discharge. They should be prevented by proper care and cleansing. If they occur, the best dressing is zinc oxid ointment spread thickly on lint, covered by a larger square of lint thickly cov- ered with soap plaster. XVII. Incisional hernia occurs in about 25 per cent, of drainage wounds. In ordinary infected wounds it is not to be feared, unless the fascia is attacked. The diagnosis and treatment is described in Chapter XI. Complications After Plastic Operations These are not as common as after abdominal section, though some of them, as vomiting, intestinal paresis, phlebitis, reten- tion of urine, are seen in both kinds of cases. I. Vaginal hemorrhage is due to (i) Imperfect suturing; (2) imperfect hemostasis; (3) premature absorption of catgut. It is usually profuse, and accompanied by the passage of large clots. It may occur any time from a few minutes to four weeks after operation. On examination the vagina is found filled with clots, which are best removed by douching, rather than sponging, as the 43 8 GENERAL TECHNIC OF GYNECOLOGIC SURGERY latter Is exceedingly painful. When the vagina is distended by a wire bivalve speculum, under proper light, the source of the hemorrhage can be seen. It is most likely from (i) the angle of the cervical wound, in amputation of the cervix; (2) the angle of the perineal sulcus in perineorrhaphy; (3) the angle of the cervical wound in trachelorrhaphy; (4) the Fig. 175. — Uterine or vaginal packing; 5H yards of four thickness gauze; ij^ inches wide; put up in the ordinary i yard iodoform gauze jar and autoclave sterilized. anterior vaginal wall, in cystocele operation; (5) the uterine cavity. Treatment. — Unless a large vessel is obviously spurting, which must be caught and tied, the best method of controlling the bleeding is as follows: (i) With the patient on a table or bed, in the lithotomy posture, pull down the perineum gently with a narrow Sims speculum, or two fingers of one hand; (2) over the speculum or fingers, as a guide and protection to the perineal stitches, pack the vagina tight full of sterile gauze strip; using consider- able pressure, and packing against the vaginal vaults ; (3) put TREATMENT OF COMPLICATIONS AFTER OPERATION 439 a large vulvar pad of sterile gauze, held in place by a tight T-binder. The hemorrhage may be severe enough to require active stimulation, as described in the treatment of internal hemorrhage. II. Hematomata often occur, In the anterior vaginal wall and perineum, after plastic operations. They are globular swellings, attended by considerable pain and often elevation of temperature and pulse, and, in the perineum, with considerable discoloration of the skin of the perineum and buttocks. They should be opened early, in the line of the stitches, to avoid suppuration, and are irrigated daily through a small catheter, with sterile water. They do not as a rule affect the result of the repair. III. Retention of urine is common in all plastic operations, due to reflex action from pain. In interposition operations, the catheter may have to be used during the patient's entire stay in bed, as the obstruction is in these cases mechanical also. In all plastic operations, when a catheter has to be used re- peatedly, it is wise to give urotropin, ten grains four times a day, for the first three or four days. As a rule, the drug can then be discontinued, but if symptoms of cystitis appear, it ' must be continued. The treatment of cystitis is described in Chapter XIV. IV. Infection is not common after plastic operations. When it occurs it is usually in the perineum, and due to some gross error in technic, or to perforation into the rectum, by one or more sutures, or to neglect of proper after-care. Symptoms. — (i) Severe, throbbing perineal pain; (2) fever; (3) leukocytosis; (4) by palpation the hard globular indurated mass can be felt; (5) in severe cases there is profuse purulent discharge, gross edema of the labia and formation of false membrane. This latter in streptococcic infection only. Treatment. — (i) Ordinary cases require only opening of the abscess, in the suture line and irrigation. They do not as a rule affect the result of the repair. 440 GENERAL TECHNIC OF GYNECOLOGIC SURGERY Streptococcic infection demands the immediate removal of all sutures, thorough disinfection of the infected area with carbolic acid (pure) followed by alcohol, and frequent vaginal irrigation. This is a serious and occasionally fatal accident and always ruins the repair. V. Perforation of the rectum by suturing results in (i) Most commonly nothing at all; (2) infection and abscess localized around the puncture; (3) rectovaginal fistula. Perforation of the bladder may result in a troublesome small vesicovaginal fistula, or the stitch may serve as a nucleus for a vesical stone; the so-called "wandering stitch." Wounds of the bladder or rectum, made by accident in the course of an operation, are closed at once by chromic catgut sutures. The prognosis is favorable and fistula rarely results, unless the wound is infected. VI. Fistulas from stitch wounds or incised wounds in opera- tions vary in size from a pinhead to an opening admitting sev- eral fingers. The ver}^ small ones are the commoner, because more easily overlooked. The commonest fistula is rectovaginal, barely admitting a probe, annoying the patient by escape of gas, and fecal matter only when the bowels are loose. It does not as a rule close spontaneously. Vesicovaginal or rectovaginal fistulse, whatever their cause, are closed according to the methods described under the heading of Genital Fistula in Chapter XIII. INDEX Abdomen, foreign bodies in, after operation, 418 salt solution in, after operation, 418 skin of, disinfection of, 407 Abdominal distention after opera- tion, 422 drainage after operation in pelvic infection, 216 after-care, 218 contra-indications, 216 dangers, 216 indications, 216 methods, 216 technic, 217 through posterior vagi- nal vault, 218 examination, 26 diameters measured in, 26 in private house, 40 routine points in, 26 myomectomy in uterine fibroids, 141 panhysterectomy in cervical can- cer, 86 pregnancy, primary, 156 secondary, 156 section, abdominal distention after, 422 acidosis after, 425 bed-sores after, 437 closure of wound, 413 complications after, 419 treatment, 419 constipation after, 428 dilatation of stomach after, acute, 426 dressing wound, 414 embolism after, 432 enteroclysis after, 419 ether pneumonia after, 426 fever after, 426. See also Fever after operation. Fowler position after, 418 Abdominal section, incisional her- nia after, 224, 437 incisions for, 41 2 infiltration anesthesia in, 409 instruments for, 411 internal hemorrhage after, 420 intestinal obstruction after, 428 low output of urine after, 437 mesenteric emboli after, 432 phlebitis after, 429. See also Phlebitis after operation. position in bed after, 418 preparation of nurse for, 393 of patient for, 392 pulmonary embolism after, 432 retention of urine after, 426 routine after-care, 415 shock after, 4 1 9. See aXso Shock. supravaginal hysterectomy in uterine fibroids, 138 wall, abnormalities in, 220 tumors of, 226 wounds, bursting open of, 436 infected, 433 Abnormalities. See Anomalies. Abortion, tubal, 157 in extra-uterine pregnancy, 157 Abscess, ischiorectal, 368 treatment, 369 of areola, 347 of Bartholin's glands, 57 cause, 57 differential diagnosis, 58 pseudo-, 57 symptoms, 57 treatment, 58 true, 57 of breast, 350 Bier's hyperemia in, 351 of ovary, 201 of Skene's glands, 58 postmammary, 353 submammary, 353 441 442 INDEX Abscess, tubo-ovarian, 167 vulvovaginal, 57 Absence of breast, 343 of genital tract, 48 of menstruation, 322. See also Amenorrhea. of ovaries, 185 of rectum, 360 of vagina, 53, 69 Absorbable sutures, preparation of, 404 Accessory ovarj^, 185 Acetonuria in extra-uterine preg- nancy, 160 Acidosis after operation, 425 postoperative vomiting with, 423 treatment, 424 Acquired atresia of cervix, 79 Acromegaly, 387 Adams-Alquie-Edebohls operation in retroversion of uterus, 116 . technic, 117 Addison's disease, 386 Adenorna of cervix, malignant, 82 of rectum, 371 Adenomyoma of uterus, 143 of vagina, 72 Adherent prepuce of clitoris, 60 Adrenal glands, 386 Adrenalin, 386 Alexander operation in retrover- sion, 116 combined mth section, 119 technic, 120 with Pfannenstiel incision, 118 technic, 119 Alpha ray of radium, 380 Aluminum bronze wire sutures, preparation of, 407 Amazia, 343 Amenorrhea, 322 electricity in, 377 functional, 323 of j^outh, 323 symptoms, 326 treatment, 323 Ampulla of Fallopian tubes, 22 Amputation of cervix, 233 advantages, 233 disadvantages, 233 indications, 233 technic, 234 Anemia in fibroid tumors of uterus, 134 Anesthesia, 408 examination under, 32 infiltration, in abdominal sec- tion, 409 novocain-adrenalin, 409 position of arms in, 410 Angioneuroma of urethra, 67 Annular detachment of cervix, 230 Anomalies of abdominal wall, 220 of bladder, 50 of breast, 343 of cervix, 78, 79 of development, 48 of hymen, 48 of menstruation, 322 of nipple, 343 of ovaries, 185 of rectum, 50 of urethra, 50 of uterus, 103 congenital, 49 Anteflexion of uterus, 103 causes, 103 diagnosis, 103 Dudley's operation in, 106 dysmenorrhea in, 103 pessaries in, 106 symptoms, 103 tents in, 106 treatment, 104 alternate methods, 106 palliative, 106 Wylie drain in, 106 Anteposition of uterus, 107 Anteversion of uterus, 107 Antiseptic solutions, for operation, 408 Anus, atresia of, 50 fissures of, 361 imperforate, 360 urethralis, 360 vaginalis, 360 ^ vesicalis, 360 ' vestibularis, 50, 281, 361 Appendicitis, acute, extra-uterine pregnancy and, differentiation, 169 Applications, local, 43 indications for, 44 solutions for, 44 Applicator, uterine, 37 Apron, Hottentot, 53 INDEX 443 Arbor vltae, 21, 79 Areola, abscess of, 347 Arms, position of, in anesthesia, 410 Arteries of ovary, 182 Arthritis in gonorrhea, treatment, 3.^5. Artificial impregnation, 56 light for examination, 38 Assistants, preparation of, for operation, 401 Atmokausis for menorrhagia, 332 Atresia of anus, 50 of cervix, 79 of genital canal, 51 diagnosis, 52 prognosis, 52 symptoms, 51 treatment, 52 of Graafian follicles, 185 of urethra, 303 Atrophic endometritis, chronic, 127 Atrophy, genital, obesity associated with, 307 of cervix, 80 of ovary, 105 of uterus, lactation, 151 Backache in patient's history, 25 Backward displacement of uterus, 107 Bacteria in pyelitis, 289 Baldy operation in retroversion of uterus, 122 technic, 123 Bartholin's gland, 19 abscess of, 57 cause, 57 differential diagnosis, 58 pseudo-, 57 symptoms, 57 treatment, 58 true, 57 chronic infected, instillations for, 45 cysts of, 61 inflammation of, Saenger's macule in, 58 Battey's operation for uterine fibroids, 143 Bed, position in, after operation, 418 Bed-sores after operation, 437 Beta ray of radium, 380 Bier's hyperemia in abscess of breast, 351 Bimanual examination, 29 reposition in retroversion of uterus, no Birth canal, injuries of, 228 classification, 228 repair, 228 Bivalve speculum, 33 right method of removal, 35 of using, 34 skeleton, 36 Bladder, 283 anatomy, 283 blood-supply of, 283 cancer of, 300 contraction of, in cystitis, 298 defects of, 50 diseases of, 293 exstrophy of, 50, 22a:, 302 irrigations, 46 in cystitis, technic, 296 overdistention of, 302 papilloma of, 299 stone in, 301 trigone of, 283 tuberculosis of, 299 Bleeding at menopause, 334 in cervical polyps, 97 in fibroid tumors of uterus, 134 irregular, in cancer of cervix, irrespective of menstruation, 330 Blind fistula in ano, internal, 362 external, 362 Blood, regeneration of, after in- ternal hemorrhage, 422 Blood-letting, local, 46 Blood-vessels of uterus, 21 Boric acid tampons, 42 Boroglycerid tampons, 42 Breast, 343 abscess of, 350 Bier's hyperemia in, 351 absence of, 343 anomalies of development, 343 cancer of, 356. See also Cancer of breasts cystadenoma of, 355 cysts of, 355 diseases of, 343 inflammatory, 348 non-inflammatory, 347 444 INDEX Breast, fibro-adenoma of, 354 hormone of, 389 hypertrophy of, 347 inflammation of, acute, 348. See also Mastitis. method of examination, 354 neuralgia of, 348 sarcoma of, 358 supernumerary, 343 sjTjhiHs of, 354 tuberculosis of, 354 tumors of, 354 benign, 354 malignant, 356 Breast-pump, 346 Broad ligaments of uterus, 102 Bulbocavernosus muscles, 24 Bullet forceps, 36 Burns, .r-ray, 378 Bursting open of abdominal wound, 436 Byrne cautery method in cer\'ical cancer, 91 Cachexia in cancer of cervis, 83 Calculus, renal, 292 ureteral, 293 vesical, 301 Cancer en cuirasse, 357 of bladder, 300 of breast, 356 after-treatment, 358 age in, 356 causes, 356 diagnosis, 357 frequency, 356 hard, 356 inoperable, 357 treatment, 358 metastasis in, 357 prognosis, 358 scirrhous, 356 symptoms, 357 treatment, 357 varieties, 356 of cen.'ix, So abdominal panhj'sterectomv in, 86 age of occurrence, 80 cachexia in, 83 caulifloiver, 81 causes, 80 of death in, 83 Cancer of cervdx, cautery in, 89 classification, 81 clinical, 81 history, 83 diagnosis, 83 direction of metastasis, 82 foul discharge in, 83 frequency, 80 indications for operation, 85 indurating, 81 interstitial, 81 irregular bleeding in, 83 mesothorium in, 92 palliative treatment, length of life after, 92 methods, 89 pathologic, 81 tj'pes, 81 prognosis after operation, 89 radical operations in, 86 radium in, 382 recurrence, treatment, 92 squamous-cell, 81 symptoms, 83 vaginal hj'sterectomy in, 86 technic, 88 .r-ray in, 91 of Fallopian tubes, primary, 180 of ovary, 204 of rectum, 372 operative treatment, methods, 373 of uterus, 125 diagnosis, 126 prognosis, 126 symptoms, 125 syncytial, 126 treatment, 126 varieties, 126 of vagina, inoperable, treatment, 70 metastasis, 70 primary, 79 prognosis, 70 secondary, 69 sj^mptoms, 70 treatment, 70 of vulva, 62 Carcinoma. See Cancer. Cardinal ligaments of uterus, 21, 102 Caruncles, urethral, 67 myrtiform, 19, 48 Catarrh, chronic cervical, 93 INDEX 445 Catgut sutures, durability, 406 home preparation, '406 infection from, 433 preparation of, 404 sizes of, 404 Catheter, ureteral, uses, 288 Catheterization, technic, 284 Cauliflower cancer of cervix, 81 Cautery in cervical cancer, 89 knife, electric, uses of, 377 Cellulitis, pelvic, 208. See also Parametritis. fever from, after operation, 427 Cervical canal, hydatidiform sar- coma of, 149 Cervicitis, 93 Cervix, 78 abnormalities, 79 adenoma of, malignant, 82 amputation of, 233 annular detachment of, 230 atresia of, 79 atrophy of, 80 cancer of, 80 chronic catarrh of, 93 cicatricial bands of, 232 conical, 78 corpus mucosum of, 79 cylindrical, 78 ectropion of, 93 elongation of, hypertrophic, 95 endothelioma of, malignant, 82 erosion of, 94 simple, 85 symptoms, 94 treatment, 95 eversion of, 93 examination of, methods, 79 gonorrhea of, 313 hypertrophic elongation, 95 hypertrophy of, 95 instillations into, 45 colic from, 46 lacerations of, 229. See also Lacerations of cervix. leukorrhea from, 336 treatment, 340 gonorrheal type, 340 treatment, 340 mucosa of, 79 myoma of, 95 normal anatomy, 78 polyps of, 85, 96. See also Polyps, cervical. Cervix, relations of, 78 repair of, 232 sarcoma of, 85, 98 stenosis of, electricity in, 377 superinvolution of, 80 syphilis of, 85 tuberculosis of, 98 ulceration of, 98 Chancre of vulva, 60 Change of life, 333 Childbirth, pathological sequelae, 256 gonorrhea in, 309 Chlorosis, 324 Chorionepithelioma, 126 of vagina, 69 Cicatricial bands of cervix, 232 Cirrhosis of ovary, 185 dysmenorrhea from, 186 Clamp and cautery in hemorrhoids, 366 Climacteric, 333 Clitoris, 18 adherent prepuce of, 60 hypertrophy of, 53 Cloaca, 360 Coccygodynia, 260 Coccyx, fracture of, 260. See also Fractures of coccyx. pain in, causes, 260 painful mobility, causes, 260 rupture of, 229 Coffey's operation in retroversion of uterus, 124 Coitus, painful, 61 Colic, uterine, from instillations, .46 Collin's bivalve speculum, 2>2> Colpitis, 74. See also Vaginitis. Colpocleisis, in vesicovaginal fis- tula, 281 Condyloma, 60 flat, 60 pointed, 60 of vagina, 70 Congenital anomalies of uterus, 49 atresia of cervix, 79 malformations of rectum, 360 Congestion of ovary, 186 Conical cervix, 78 nipple, 347 Connective tissue, pelvic, anatomy, 207 Constipation after operation, 428 446 INDEX Corpus albicans, 185 luteum, 185 cysts, 187 symptoms, 189 mucosum of cervix, 79 Cortex of ovary, 23 Counter-irritation with iodin solu- tion, 44 Cretinism, 385 Cribriform hymen, 48 Crista lactea, 343 Curetforceps, 37, 38 Curettage in fibroids of uterus, 136 Cylindrical cervix, 78 Cystadenoma of breast, 355 of ovary, 187 diagnosis, 190 serous, 188 symptoms, 190 treatment, 193 Cystitis, 293 acute, course, 295 pathology, 294 treatment, 295 causes, 294 chronic, consequences, 297 course, 295 pathology, 294 symptoms, 295 treatment, 296 contraction of bladder in, 298 diagnosis, 295 irrigation of bladder in, 296 kinds, 294 of aged, 298 pathology, 294 prophylaxis, 295 routes of infection, 293 site of infection, 294 treatment, 295 ulcers in, 297 vetularum, 298 Cystocele, 263 causes, 264 diagnosis, 265 Goffe operation in, 269 Hirst's (B. C.) operation in, 269 JVlartin operation in, 268 mechanism, 264 operative treatment, 268 pessaries in, 265 Stoltz purse-string operation in, 268 symptoms, 265 Cystocele, treatment, 265 Watkins-Freund- W e r t h e i m operation in, 269 Cystoscopy, 285 by air distention, 285 by water distention, 285 Cysts, Nabothian, puncture of, 46 of Bartholin's gland, 61 of breast, 355 of corpus luteum, 187 symptoms, 189 of Gartner's duct, 71 of labia, 61 of Morgagni, 155, 180 of oophoron, 186 of ovary, 186 accidents to, 195 carcinomatous degenerations, 198 characteristics, 186 classification, 186 clinical classification, 186 degenerations, 198 dermoid, 188 symptoms, 190 diagnosis, 190 differential, 191 follicular, 186, 189 glandular, diagnosis, 190 symptoms, 190 hemorrhage in, 197 histologic classification, 186 implantation metastases in, i99_ infection and suppuration in, 199 intraligamentary, without pedicle, treatment, 194 marsupialization, 195 ovigenous, 186 papillary degeneration in, 198 pedicle, 189 twisted, 19s pregnancy and, differentia- tions, 191 prognosis, 199 proliferating, 186 pseudomucin, 187 rate of growth, 189 rupture of, 196 salpingitis and, differentiation, 169 symptoms, 189 tapping, 194 INDEX 447 Cysts of ovary, thrombosis of pelvic veins in, 196 treatment, 192 of paroophoron, 186 of parovarium, 186, 188 symptoms, 190 with pedicle, treatment, 193 of vagina, 71 Deciduoma malignum, 126 Defects of bladder, 50 Dentated hymen, 48 Dermatitis of labia and perineum, acute, 59 of nipple, malignant, 347 Dermoid cysts of labia, 61 of ovary, 188 symptoms, 190 Desiccation, 377 Detachment of cervix, annular, 230 Diabetes in fibroids of uterus, 134 Diagnosis, aids to, 33 Diastasis of recti, with viscerop- tosis, 220 Digital examination, 28 Dilatation in fibroids of uterus, 136 of stomach, acute, after opera- tion, 423 Diphtheritic vaginitis, 75 Discus proligerus, 184 Disinfection, hand, 407 of abdominal skin, 407 Displacements of ovary, diagnosis, 200 treatment, 201 of uterus, anterior, 103 backward, 107 Distention, abdominal, after opera- tion, 422 Dorsal position, 28 Douche bag for home operation, 398 intra-uterine, 47 vaginal, 44 directions for, 44 uses, 44 Douglas' pouch, hematoma in, fever from, after operation, 427 Dressing forceps, uterine, 37 table for home operation, 397 Dressings for home operation, 398 preparation of, for operation, 402 Duct, Gartner's, 49 Ducts, Mullerian, 49 Ductless glands, 384 Dudley's operation in anteflexion of uterus, 106 Duverney's glands, 19 Dwarfism, 387 Dysmenorrhea, 325 causes, 325 effect of marriage on, 327 electricity in, 377 from cirrhosis of ovary, 186 in anteflexion of uterus, 103 membranous, 327 nasal treatment, 326 operative treatment, 327 sterility from, 327 treatment, 326 Dyspareunia, 61 Dystopic kidney, 259 Dystrophia adiposogenitalis, 387 Ectopic gestation, 156. See also Extra-uterine pregnancy. Ectropion of cervix, 93 Edebohls' suspension in floating kidney, 258 Electric cautery knife, uses of, 377 treatment, 39 Electricity, 374 apparatus needed for, 374 faradic, for intra-uterine treat- ment, 375 properties, 375 for intra-uterine treatment, 375 contra-indications, 376 technic of application, 376 for uterine hemorrhage, 376 galvanic, for intra-uterine treat- ment, 375 properties, 374 high frequency current, uses of, 378 in amenorrhea, 377 in cervical stenosis, 377 in dysmenorrhea, 377 sinusoidal, for intra-uterine treat- ment, 376 properties, 375 Elephantiasis of vulva, 62 Elongation, hypertrophic, of cervix, 95 Embolism after abdominal section, 432 Emmenagogues, 324 448 INDEX Emmet's curet forceps, 37, 38 operation for delayed repair of perineum, 244 trachelorrliaphy in lacerations of cervix, 232 Emphysematous vaginitis, 74 treatment, 77 Endocervicitis, 93, 313 Endocrin glands, 384 active materials, 384 anomalies due to disturbed function of, 390 extracts, intramuscular admin- istration, 390 methods of administration, 390 interglandular relations, 384 Endometritis, 127 acute, causes, 127 causes, 128 chronic atrophic, 127 causes, 127 hyperplastic glandular, 127 interstitial, 127 curettage in, 129 examination' of material from, 130 perforation of uterus from, 130 regeneration of endometrium, after, 130 technic, 129 gonorrheal, 314 symptoms, 128 treatment, 128 palliative, 129 radical, 129 tuberculous, 128 varieties, 127 Endometrium, 102 during menstruation, 319 regeneration of, after curettage in endometritis, 130 Endosalpingitis, 179 Endothelioma of cervix, malignant, 82 of ovary, 205 Enteroclysis after operation, 419 Epiphysis cerebri, 387 Epispadias, 50 Epithelial cysts of vagina, 71 Epithelioma of vulva, 62 Epoophoron, 183 Erect position, 32 for examination, 32 Erosion of cervix, 94 simple, 85 symptoms, 94 treatment, 95 Ether pneumonia after operation, 426 Eversion of cervix, 93 Examination, 26 aids to diagnosis, 33 artificial light for, 38, 39 bimanual, 28 digital, 28 for tubes and ovaries, 29 in private house, 39 lubricants for, 29 methods, 25 of abdomen, 26 diameters measured in, 26 in private house, 40 routine points in, 26 of young girls, 32 pelvic, positions for, 28 preparation of patient, 28 rectal, 29 table for office, 38 under anesthesia, 32 Exophthalmic goiter, 385 Exstrophy of bladder, 50, 221, 302 External female genitalia, 17 Extra-uterine pregnancy, 156, 162 acetonuria in, 160 active stimulation in, 161 acute appendicitis and, differ- entiation, 169 causes, 156 classification, 156 clinical history, 159 development, 157 diagnosis, 159 dift'erential, 159 erosion of tubal wall in, 158 metrorrhagia after operation in, 162 pelvic hematocele in, 158 removal of both tubes in, 162 salpingitis and, differentiation, 169 symptoms, 159 terminations, 157 treatment, 160 tubal abortion in, 157 Fallopian tubes ampulla of, 22 22, 153 INDEX 449 Fallopian tubes, arteries of, 155 caliber, 23, 155 cancer of, primary, 180 congestion of, 155 diseases of, 153 divisions, 155 examination for, 29 fimbriae of, 22, 155 inflammation of, 164. See also Salpingitis. infundibulum, 155 interstitial portion, 155 isthmus, 22, 155 leukorrhea from, 337 treatment, 341 lymphatics of, 155 muscular coat, 23 nerves of, 155 normal anatomy, 153 proper, 155 structure, 153 tuberculosis of, 179 cause, 179 contra-indications to opera- tion in, 180 pathology, 179 progress, 180 symptoms, 179 treatment, 180 tumors of, 180 benign, 180 malignant, 180 uterine mouth, 155 uterine portion, 22 veins of, 155 Faradic electricity for intra-uterine treatment, 375 properties, 375 Female genitalia, external, 17 Femoral hernia, 225 Fever after operation, 426 from cellulitis, 427 from hematoma in Douglas' pouch, 427 in drainage cases, 427 predisposing causes, 426 Fibro-adenoma of breast, 354 Fibro-adenomatous cervical polyps, 96 Fibroid cervical polyps, 96 tumors of uterus, 131 abdominal myomectomy in, 141 anemia in, 134 29 Fibroid tumors of uterus, Battey's operation for, 143 bleeding in, 134 calcification in, 132 cause, 131 degenerations, 132 diabetes in, 134 dilatation and curettage in, 136 edematous degeneration in, 132 effect on pregnancy, 135 frequency, 131 heart lesion in, 134 hyaline degeneration, 132 hyperthyroidism in, 134 hysterectomy in, supravagi- nal abdominal, 138 vaginal, 137 in pregnancy, 143 interstitial, 131 intraligamentary, 131 intramural, 131 irritable nervous system in, 134 leukorrhea in, 135 life history, 132 ligation of arteries in, 143 malignant degeneration in, 132 morcellation in, 142 myxomatous degeneration, 132 pain in, 134 presence of tumor in, 134 radium in, 136 recurrent, 143 red degeneration in, 132 secondary symptoms, 134 site of development, 131 styptics in, 135 submucous, 131 subserous, 131 symptoms, 134 thrombosis in, 132 treatment, 135 palliative, 135 radical, 137 vaginal discharge in, 135 vaginal myomectomy in, 142 a;-ray in, 136 Fibro myoma of uterus, 131. See also Fibroid tumors. of vagina, 72 450 Index Fimbriated extremity of Fallopian tubes, 2 2 Finsen light, 383 Fissure, vesical, inferior, 50 superior, 50 vesico-urethral, 301 Fissured nipple, 344 symptoms, 344 treatment, 344 Fissures of anus, 361 Fistula after plastic operation, 440 Fistulae, genital, 278 varieties, 278 in ano, 361 blind external, 362 internal, 362 complete, 362 diagnosis, 362 symptoms, 362 treatment, 362 rectovaginal, diagnosis, 281 treatment, 281 uretero vaginal, diagnosis, 281 treatment, 282 vesicocervicovaginal, 282 vesicovaginal, 279 diagnosis, 278 Fixation, vaginal, in retroversion of uterus, 125 Flat condyloma, 60 Flexion of uterus, lateral, 107 Floating kidney, 256, 292 cause, 256 diagnosis, 257 Edebohls' suspension in, 258 symptoms, 256 treatment, 258 Floor, pelvic, 24 lymphatics of, 24 Follicles, Graafian, 23, 103 atresia of, 185 stages of maturity of, 184 Nabothian, 96 Follicular cysts of ovary, 186 symptoms, 189 Forceps, bullet, 36 curet, 37, 38 _ uterine dressing, 37 Foreign bodies in abdomen after operation, 418 in rectum, 363 in vagina, 71 Fossa, ovarian, 182 navicularis, 19 Fowler position after operation, 418 Fracture of coccyx, 260 diagnosis, 261 mechanism, 260 terminations, 260 treatment, 261 Fritsch-Bozemann intra-u t e r i n e douche, 47 Fulguration, 377 Functional amenorrhea, 323 Fundus of uterus, cancer of, 125. See also Cancer of uterus. Fungi in vaginitis, 75 Galactocele, 355 Galvanic electricity for intra- uterine treatment, 375 properties, 374 Gamma ray of radium, 380 Gartner's duct, 49, 183 cysts of, 71 Generative organs, external, 17 internal, 20 Genital atrophy, obesity associated with, 387 canal, atresia of, 51 diagnosis, 52 prognosis, 52 symptoms, 51 treatment, 52 fistulse, 278 varieties, 278 organs, hypertrophy of, 53 tract, absence of, 48 anomalies, 48 development, 48 Genupectoral position, 30 Gestation, ectopic, 156. See also Extra-uterine pregnancy. Gigantism, 387 Gilliam operation in retroversion of uterus, 123 Mayo's modification, 123 Girls, examination of, 32 menorrhagia in, 329 Glands, Bartholin's, 19 of Duverney, 19 endocrin, 384 Skene's, 19 vulvovaginal, 19 Glandular cysts of ovary, diag- nosis, 190 symptoms, 190 hyperfunction, 384 INDEX 451 Glandular hypofunction, 384 Glass jars, 39 Gloves, rubber, 39 Glycerin-ichthyol tampons, 42 Goffe operation in cystocele, 269 Goiter, exophthalmic, 385 Gonococcus, growth, 306 habitat, 306 latency, 306 preparation of smear, 307 staining, 308 in doubtful cases, 308 Tiedemann's modification, 308 variations under culture, 306 Gonorrhea, 305 arthritis in, treatment, 315 cervical, 313 complications, 315 diagnosis, 307 in children, 309 acute, treatment, 310 chronic, complications, 311 prognosis, 311 treatment, 310 method of infection, 309 recurrences, 311 symptoms, 310 treatment, 310 kinds, 309 latency, 307 lurking places, 307 mode of infection with, 305 ophthalmia in, treatment, 315 order of infection in, 307 peritonitis in, treatment, 315 prognosis, 309 serum treatment, 315 vaccines in, 315 vaginitis from, 75 treatment, 76 Gonorrheal endometritis, 314 pyosalpinx, streptococcic pyosal- pinx and, differentiation, 171 type of cervical leukorrhea, 340 urethritis, 311 complications, 312 prognosis, 311 symptoms, 311 treatment, 312 Goodman-von Ott curve in men- struation, 321 Graafian follicles, 23, 183 atresia of, 185 gtages of maturity of, 184 Granular vaginitis, diffuse, 74 Gubernaculum of Hunter, 183 Gynatresia, 51 diagnosis, 52 prognosis, 52 symptoms, 51 treatment, 52 Hand disinfection, 407 Heart, myoma, 134 Hematocele pelvic, 158, 213 in extra-uterine pregnancy, 158 Hematocolpometra, 51 Hematocolpos, 51 Hematoma after plastic operation, 439 in Douglas' pouch, fever from, after operation, 427 of ovary, tarry, 187 parametrial, 213 Hematometra, 51 Hematosalpinx, 51, 162 Hemelythrometra, 51 Hemorrhage from uterus, elec- tricity in, 376 in ovarian cysts, 197 internal, after operation, 421 shock after operation and, differentiation, 419 vaginal, after plastic operation, 437 treatment, 438 Hemorrhoids, 363 causes, 364 clamp and cautery in, 366 external, 363 symptoms, 365 treatment, 365 histology, 364 internal, 364 diagnosis, 365 symptoms, 365 treatment, 365 ligature in, 367 operation in, after treatment, 367 treatment, operative, 366 varieties, 363 Hermaphroditism, true, 54 Hernia, 221 femoral, 225 incisional, after abdominal opera- tion, 224, 437 inguinal, 224 452 INDEX Hernia, pudendal, 67 umbilical, 222. See also Um- bilical hernia. High frequency current, uses of, 378 Hilus of ovary, 23, 182 Hirst's (B. C.) double tenacula, 36 method of perineorrhaphy, 247 metranoikter, 56 operation in cystocele, 269 History taking, 25 Hodge pessary, 113 Home, operation in, 394 basins for, 399 care of instruments, 398 choice of room, 394 douche bag for, 398 dressing table for, 397 dressings for, 398 instrument table for, 397 leg-supports for, 396 nurse's kit for, 401 operating table for, 395 preparation of patient, 394 rubber gloves for, 399 scrubbing facilities needed, 399 sterile water for, 399 supplies required for, 400 Hormones, 384 Horsehair sutures, preparation of, 404 Hottentot apron, 53 Hunter, gubernaculum of, 183 Hydatid of Morgagni, 155 Hydatidiform sarcoma of cervical canal, 149 Hydrops tubse, 163 Hydrosalpinx, 163 Hymen, 19 abnormalities of, 48 Hyperemia treatment in breast abscess, 351 Hyperfunction, glandular, 384 of ovary, 388 Hypernephroma, 292 Hyperplastic glandular endome- tritis, chronic, 127 Hyperthyroidism in fibroid tumors of uterus, 134 Hypertrophy of breast, 347 of cervix, 95 of clitoris, 53 of genital organs, 53 of labia majora, 53 Hypertrophy of labia minora, 53 Hypofunction, glandular, 384 of ovary, 387 Hypophysis cerebri, 386 Hypospadias, 50 Hysteralgia, 144 Hysterectomy in menorrhagia, 333 in prolapse of uterus, 275 in salpingitis, 176 supravaginal abdominal, in uterine fibroids, 138 vaginal, in cervical cancer, 86 technic, 88 for uterine fibroids, 137 Hysteropexy in retroversion of uterus, 120 technic, 121 Hysterorrhaphy in retroversion of uterus, 120 technic, 121 ICHTHYOL-GLYCERIN tamponS, 42 Imperforate hymen, 48 anus, 360 rectum, 50, 360 Implantation of ovary, 204 Impregnation, artificial, 56 Incisional hernia after abdominal operation, 224, 437 Incisions for abdominal section, 412 Incontinence of urine, 277 after operation, 426 Indigo-carmin test for excretion of urine in pyelitis, 290 Indurating cancer of cervix, 81 Infantile uterus, 144 Infected abdominal wounds, 433 causes, 433 curative treatment, 434 from catgut ligatures, 433 sinuses in, 434 symptoms, 433 treatment, 433 type of discharge from, 433 Inferior vesical fissure, 50 Infiltration anesthesia in abdominal section, 409 Infundibulopehdc ligament, 24 Inguinal hernia, 224 Injuries of birth canal, 228 classification, 228 repair, 228 of rectum, 368 to pelvis, 229 INDEX 453 Instillations, 45 cervical and intra-uterine, 45 colic from, 46 solutions for, 45 Instruments for abdominal sec- tion, 411 for office use, 39 for plastic operation, 412 sterilization of, 38, 411 table for, in home operation, 397 Intermenstrual pain, 326 Internal generative organs, 20 hemorrhage after operation, 421 regeneration of blood after, 422 symptoms, 421 treatment, 422 shock and, differentiation, 419 secretion, glands of, 384 of ovary, 185 Interstitial cancer of cervix, 81 endometritis, chronic, 127 fibroid tumors of uterus, 131 mastitis, 353 Intestinal obstruction after opera- tion, 428 postoperative vomiting in, 424 Intraligamentary fibroids of uterus, 131 Intramural fibroids of uterus, 131 Intra-uterine instillations, 45 colic from, 46 douche, 47 Inverted nipple, 346 Inversion of uterus, 145 acute, 145 causes, 145 chronic, 145 complete, 145 complications, 145 differential diagnosis, 145 incomplete, 145 Spinelli operation in, 146 symptoms, 145 treatment, 146 operative, 146 lodin solution, counter-irritation with, 44 Irreducible prolapse of uterus, 274 operation in, 274 Irregular bleeding irrespective of menstruation, 330 Irrigations, 46 bladder, 46 Irrigations, syringe for, 46 urethral, 46 uterine, 47 Ischiorectal abscess, 368 treatment, 369 Isthmus of Fallopian tubes, 22 Jars, glass, 39 Kangaroo-tendon sutures, prepa- ration of, 407 Kidney, anatomy, 283 diseases of, 289 dystopic, 259 floating, 256, 292. See also Floating kidney. stone in, 292 tuberculosis of, 292 Knee-chest position, 30 reposition in, in retroversion, no Knife, electric cautery, uses of, 377 Knots, for sutures, varieties, 403 Kraurosis vulvae, 64 Labia, cysts of, 61 dermatitis of, acute, 59 lacerations of, 237 majora, 17 hypertrophy of, 53 minora, 18 hypertrophy of, 53 tumors of, solid, 61 Lacerations of anterior vaginal wall, 235 consequences, 236 diagnosis, 236 of cervix, 229 bilateral, 230 causes, 229 consequences, 231 diagnosis, 231 kinds, 229 repair of, 232 stellate, 230 symptoms, 231 terminations, 230 trachelorrhaphy in, 232 treatment, 232 unilateral, 230 of vulva and labia, 237 Lactation atrophy of uterus, 151 uterus during, 103 Lateral flexion of uterus, 107 454 INDEX Left lateral position, 30 Leg supports for home operation, 396 Leiomyoma uteri, 131 Leukorrhea, 336 bacteriology of, 337 characteristics, 337 color of discharge in, 337 consistence of discharge in, 337 definition, 336 diagnosis, 338 from cervical polj'ps, 97 from cervix, 336 gonorrheal type, treatment, 340 treatment, 340 from Fallopian tubes, 337 treatment, 341 from uterus, 337 treatment, 341 from vulva, 336 treatment, 338 in fibroird tumors of uterus, 135 in vaginitis, 75 in virgins, 341 mild vaginitis with, 339 prognosis, 342 quantity of discharge in, 337 radium in, 341 treatment, 338 with senile vaginitis, 339 Levator ani muscle, 24 tears of, 237 Ligament, infundibulopelvic, 24 utero-ovarian, 24 Ligaments of ovary, 182 of uterus, 21, 102 cardinal, 21 uterosacral, 102 uterovesical, 102 Ligatures, preparation of, 402 Light, artificial, for examination, .38, 39 Finsen, 383 Linear cauterization in prolapse of rectum, 370 Linen thread sutures, preparation of, 402 Liquor foUiculi, 23, 184 Lithotomy position, 28 Lobar mastitis, 353 Lobular mastitis, 353 Local applications, 43 in pruritus vulvae, 66 Local applications, indications for, 44. solutions for, 44 blood-letting, 46 treatment, methods, 41 Lubricants for examination, 29 Lupus of vulva, 64 treatment, 65 Lutein cells, 185 Lymphatic cysts of labia, 61 of vagina, 71 Lymphatics of ovar}^, 182 of pelvic floor, 24 of uterus, 21 Macule, Saenger's, in inflamma- tion of Bartholin's gland, 58 Malformations of rectum, con- genital, 360 Mammary gland. See Breast. Mammillitis, 343 Marriage, effect of, on dj-smenor- rhea, 327 Martin operation in cystocele, 268 Mastitis, 348 carcinosa, 350 cause, 348 chronic, 353 suppurative, 354 circumscribed, 353 diffuse, 353 interstitial, 353 lobar, 353 lobular, 353 symptoms, 349 treatment, 349 Mastodynia, 348 Mayo's modification of Gilliam's operation for retroversion. 123 Medulla of ovary, 23 Melena spuria, 344 Membrana granulosa, 23, 184 Membranous dysmenorrhea, 327 Menopause, 333 bleeding at, 334 mechanism, 333 surgical, 140, 334 _ after salpingitis, treatment, 178 sj-mptoms, 333 treatment during, 334 uterus after, 103 Menorrhagia, 328 amount of flow in, 328 INDEX 455 Menorrhagia, atmokausis for, 332 causes, 328 in young girls, 329 severe, treatment, 330 treatment, 328 zestokausis in, 333 Menstruation, 317 abnormalities of, 322 absence of, 322. See also Amen- orrhea. amount of flow, 317 blood in, character of, 317 congestion before, 320 drugs to produce, 324 duration of flow, 317 endometrium during, 319 excessive, 328. See also Menor- rhagia. factors influencing, 317 Goodman-von Ott curve in, 321 involution after, 321 irregular bleeding irrespective of, 330 mechanism of, 321 molimina of, 322 painful, 325. See also Dys- menorrhea. precocious, 319 scanty, 325 suppression of, acute, 325 uterus during, 319 vicarious, 335 Mesenteric emboli after operation, 432 Mesosalpinx, 155 Mesothorium, 383 in cervical cancer, 92 Mesovarium, 23, 182 Metranoikter, B. C. Hirst's, 56 in sterility, 55 Metritis, 147 symptoms, 147 treatment, 147, 331 Metrorrhagia, 330 after operation in extra-uterine pregnancy, 162 causes, 330 diagnosis of source, 330 radium in, 382 Micromazia, 343 Milk-leg, 430 dangers of, 431 prognosis, 431 symptoms, 430 Milk-leg, treatment, 431 varieties, 430 Mittelschmerz, 326 Mons veneris, 17 Morcellation in uterine fibroids, 142 Morgagni, cysts of, 155, 180 hydatid of, 155 Moskowitz'operation in prolapse of rectum, 370 Mucosa of cervix, 79 Mucous cervical polyps, 96 Mulberry nipple, 347 Miillerian ducts, 49 Muscle, bulbocavernosus, 24 deep transversus perinei, 24 levator ani, 24 Mushroom nipple, 347 Mycotic vaginitis, 74 treatment, 77 Myoma of cervix, 95 of heart, 134 of uterus, 131 of vagina, 72 Myomectomy, abdominal, m uterine fibroids, 141 vaginal, in uterine fibroids, 142 Myometrium, 21, 102 Myosarcoma of uterus, 149 Myrtiform caruncles, 19, 48 Myxedema, 385 Nabothian cysts, 96 puncture of, 46 Nerves of ovary, 182 of uterus, 21 Neuralgia of breast, 348 Nipple, abnormalities of, 343 conical, 347 fissured, 344 symptoms, 344 treatment, 344 hollow, 347 inverted, 346 malignant dermatitis of, 347 mulberry, 347 mushroom, 347 stunted, 346 supernumerary, 343 Nipple-shields, 345 care of, 346 Nitrate of silver tampons, 42 Non-gonorrheal vulvitis, 63 Novocain-adrenalin anesthesia, 409 456 Nulliparae, prolapse of uterus in, causes, 149 Nurse for office, 39 preparations of, for abdominal section,_ 393 for operation, 401 Nurse's lat for home operation, 401 Obesity associated with genital atrophy, 387 treatment, 225 Office, instruments for, 39 nurse for, 39 treatment, 25 Omophobia, 137 One-child sterility, 54 Oophoritis, 201 acute, 201 chronic, 202 Oophoron, 183 cysts of, 186 Operating table for home operation, 395 . Operation, abdominal. See Ab- dominal section. anesthesia for, 408 antiseptic solutions for, 408 choice of time for, 401 closure of abdomen after, 413 complications after, treatment, 419 disinfection of abdominal skin for, 407 foreign bodies in abdomen after, 418 hand disinfection for, 407 in private house, 394. See also Home operation. instruments for, 411 plastic. See Plastic operation. preparation of assistants for, 401 of dressings for, 402 of ligatures for, 402 of nurses for, 401 of sheets for, 402 of sponges for, 402 of surgeon for, 401 of towels for, 402 retention of urine after, 439 salt solution in abdomen after, 418 time in bed after, 417 Ophthalmia in gonorrhea, treat- ment, 315 INDEX Organotherapy, ovarian, 387 uses, 388 pituitary, 387 Ovary, 23 abnormalities of, 185 abscess of, 201 absence of, 185 accessory, 185 anatomy, 182 arteries of, 182 atrophy of, 185 carcinoma of, 204 cirrhosis of, 185 d3-smenorrhea from, 186 congestion of, 186 cortex of, 23 cystadenoma of, 187 diagnosis, 190 serous, 188 symptoms, 190 treatment, 193 cysts of, 186. See also Cysts of ovary. degenerations of, 186 descent of, 183 development of, 183 diseases of, 185 displacements of, 200 endothelioma of, 205 examination for, 29 external appearance, 23 extracts of, 388 uses, 389 fossa of, 182 hematoma of, tarry, 187 hilus, 23, 182 histologic divisions, 182 h3^erfunction of, 388 hj-pofunction of, 388 implantation of, 204 inflammation of, 201. See also Oophoritis. internal secretion of, 185, 387 ligaments of, 182 lymphatics of, 182 medulla of, 23 nerves of, 182 prolapse of, 200. See also Pro- lapse of ovary. relations of, 182 sarcoma of, 205 stigma of, 184 teratoma of, 189 symptoms, 191 INDEX 457 Ovary, transplantation of, 204 tuberculosis of, 206 tumors of, solid, 204 malignant, 204 Overdistention of bladder, 302 Ovigenous cysts of ovary, 186 Ovulation, normal, 184 Pagenstecher thread sutures, preparation of, 402 Paget's disease, 347 Pain, coccygeal, causes of, 260 in cervical cancer, 83 in vaginitis, 75 intermenstrual, 326 right-sided, causes, 290 Painful coitus, 61 menstruation, 325. See also Z)y5- menorrhea. Palmas plicatae, 79 Pampiniform plexus, 21 varicocele of, 181 Pancreas, internal secretion of, 387. Panhysterectomy, abdominal, in cervical cancer, 86 Papilloma of rectum, 372 Paracystium, 208 Parametrial hematoma, 213 Parametritis, 208 - causes, 208 chronic, 212 diagnosis, differential, 209 operative treatment, 209 palliative treatment, 209 pathology, 208 pelvic peritonitis and, differen- tiation, 209 pointing of abscess in, 210 posterior vaginal section in, 210 prognosis, 212 symptoms, 209 terminations, 209 treatment, 209 Parametrium, 102, 207 Paraproctiurn, 208 Parathyroid glands, 386 Paroophoron, 183 cysts of, 186 Parovarium, 49, 183 cysts of, 186, 188 symptoms, 190 with pedicle, treatment, 193 Patent urachus, 226 Patient, examination of, 26. See also Examination. preparation of, for abdominal section, 392 for operation at home, 394 for vaginal operation, 393 Pedunculated cervical polyps, 97 Pelvic anatomy, normal, 17 cellulitis, 208. See also Para- metritis. connective tissue, anatomy, 207 floor, 24 lymphatics of, 24 relaxation of, 237 tears of, 237 hematocele, 158, 213 in extra-uterine pregnancy, infection, abdominal drainage after operation in, 216 organs, examination of, 28. See also Examination, pelvic. peritonitis, 214 in acute salpingitis, 167 parametritis and, differentia- tion, 209 Pelvis, injuries to, 229 Percy low-heat cautery in cervical cancer, 91 Perforation of rectum by sutures in plastic operation, 440 Perimetrium, 102 Perineorrhaphy, Emmet's method, 243 Hegar's method, 243 B. C. Hirst's method, 247 Perineum, dermatitis of, acute, 59 tears of, 237. See also Tears of perineum. Perisalpingitis, 179 Peritoneal coat of uterus, 102 Peritoneum, anatomy, 207 diseases of, 207 Peritonitis, 214 after operation, 428 diagnosis, 215 diffuse, 214 in gonorrhea, treatment, 315 pelvic, 214 in acute salpingitis, 167 parametritis and, differentia- tion, 209 postoperative vomiting in, 424 treatment, 425 458 INDEX Peritonitis, tubercular, 215. See also Tubercular peritonitis. types, 214 Pessary, 112 action, 113 care of, 113 contra-indications to, 114 Hodge, 113 how retained, 113 in anteflexion of uterus, 106 in cystocele, 265 in retroversion, 112 after-treatment, 115 dangers from, 116 indications for, 113 insertion of, 114 qualifications of, 114 Smith, 113 stem, in sterility, 55 Thomas, 113 varieties, 113 Phenolsulphonphthalein test in pyelitis, 290 Phlebitis after operation, 429 cause, 429 symptoms, 430 treatment, 430 Phleboliths, 219 Phlegmasia alba dolens, 430. See also Milk-leg. Piles, 363. See also Hemorrhoids. Pineal gland, 387 Pituitary gland, 386 preparations of, uses, 387 Placenta, extracts of, 390 Plastic operation, complications after, 437 fistula after, 440 hematoma after, 439 infection after, 439 instruments for, 412 perforation of rectum by sutures in, 440 routine after-care, 415 vaginal hemorrhage after, 437 treatment, 438 Plexus, pampiniform, 21 varicocele of, 181 Plicae palmatae, 21 Pluriglandular therapy, 391 Pneumonia, ether, after operation, 426 Pointed condyloma, 60 Polymazia, 343 Polyp of cervix, 85, 96 attachments, 97 bleeding in, 97 degenerations in, 97 diagnosis, 97 fibro-adenomatous, 96 fibroid, 96 leukorrhea from, 97 mucous, 96 pedunculated, 97 sessile, 97 symptoms, 97 treatment, 97 of rectum, 371 of uterus, 148 Polythelia, 343 Position, dorsal, 28 genupectoral, 30 knee-chest, 30 left lateral, 30 lithotomy, 28 Sims', 30 Postanesthetic postoperative vomit- ing, 423 Postmammary abscess, 353 Postoperative vomiting, 423 in intestinal obstruction, 424 in peritonitis, 424 treatment, 425 postanesthetic, 423 rectal feeding in, 425 treatment, 424 with acidosis, 423 treatment, 424 Precocious menstruation, 319 Pregnancy, abdominal, primary, 156 secondary, 156 cysts of ovar}' and, differentia- tion, 191 effect of uterine fibroids on, 135 extra-uterine, 156. See also Ex- tra-uterine pregnancy. fibroid tumors of uterus in, 143 in horn of uterus unicornis or bicornis, 162 uterus during, 100 Preparation of nurse for abdominal section, 393 of patient for abdominal section, 392 for operation at home, 394 for vaginal operation, 393 Prepuce of clitoris, adherent, 60 INDEX 459 Private house, abdominal examina- tion in, 40 examination in, 39 operation in, 394. See also Home operation. Procidentia uteri, 271 Proctitis, 368 Proctodeum, 360 Proctoscope, 359 Prolapse of ovary, 200 causes, 200 symptoms, 200 of rectum, 369 amputation of prolapsed por- tion in, 370 diagnosis, 369 linear cauterization in, 370 Moskowitz operation in, 370 operative treatment, 370 palliative treatment, 369 of urethra, 68 of uterus, 148, 271 degrees, 271 diagnosis, 272 hysterectomy in, 276 in nulliparse, causes, 149 irreducible, 274 operation in, 274 mechanism, 271 operative treatment, 273 palliative treatment, 273 symptoms, 272 total, 271 treatment, 273 vaginitis in, 75 Prohf crating cysts of ovary, 186 Pruritus in vaginitis, 75 ani, 370 vulvas, 65 causes, 65 local applications in, 66 surgical treatment, 66 symptoms, 65 treatment, 65 Pseudo-abscess of Bartholin's gland 57 Pseudohermaphroditism, 54 Pseudomucin cysts of ovary, 187 Pseudomyxoma peritonei, 197, 199 Pseudovaginismus, 73 Pudendal hernia, 67 Puerperal vaginitis, 75 Pulmonary embolism after opera- tion, 432 Puncture of Nabothian cysts, 46 Purulent salpingitis, 167 Pus-tube, 165 Pyelitis, 289 antiseptic injections in, 288 bacteria in, 289 diagnosis, 290 examination of urine in, 290 functional tests in, 290 palliative treatment, 291 predisposing causes, 289 prognosis, 291 radical treatment, 291 site, 290 surgical treatment, 291 symptoms, 289 treatment, 291 vaccine treatment, 291 Pyelography, 288 Pyosalpinx, 165 gonorrheal and streptococcic, differentiation, 171 in salpingitis, 167 Radium, 379 alpha ray of, 380 beta ray, 380 C, 380 dangers and disadvantages, 382 effects of, 382 favorable effects, 382 gamma ray of, 380 in cervical cancer, 91, 92, 382 in fibroids of uterus, 136 in leukorrhea, 341 in metrorrhagia, 382 method of use, 381 physical properties, 379 reaction from, 382 Rectal examination, 29 in retroversion of uterus, 109 feeding for postoperative vomit- ing,_ 42s Recti, diastasis of, with visceropto- sis, 220 Rectocele, 262 diagnosis, 263 treatment, 263 Rectovaginal fistula, diagnosis, 281 treatment, 281 Rectum, 359 absent, 360 adenoma of, 371 anomalies of, 50 460 INDEX Rectum, cancer of, 372 operative treatment, methods, 373 digital examination, 359 diseases of, 359 examination of, methods, 359 technic, 360 foreign bodies in, 363 imperforate, 50, 360 injuries of, 368 inflammation of, 368 inspection, 359 malformations of, congenital, 360 papilloma of, 372 perforation of, by sutures in plastic operation, 440 polyp of, 371 proctoscopic examination, 359 prolapse of, 369 sarcoma of, 373 specular examination, 359 stricture of, 371 tumors of, 371 benign, 371 malignant, 372 Recurrent uterine fibroids, 143 Relaxation of sacro-iliac joints, 229, 262 of pelvic floor, 238 Renal calculus, 292 Repair of cervix, 232 Reposition, bimanual, in retrover- sion of uterus, no in knee-chest position in retro- version, no Repositor, uterine, 38 Retention of urine after operation, 426, 439 Retroflexion of uterus, 107 Retroversion of uterus, 107 adherent, reposition in, 112 Alexander operation in, 116 combined with section, 119 technic, 120 technic, 117 with Pfannenstiel incision, n8 technic, 119 Baldy operation in, 122 technic, 123 causes, 107 Coffey's operation in, 124 degrees, 108 diagnosis, 108 Retroversion of uterus, diagnosis, differential, 109 Gilliam operation in, 123 Mayo's modification, 123 hysteropexy in, 120 technic, 121 hysterorrhaphy in, 120 technic, 121 pathology, 109 pessaries in, 112 after treatment, 115 dangers from, 116 predisposing causes, 108 rectal examination in, 109 rectal manipulation in, 112 reposition, bimanual, no in knee-chest posture, no symptoms, 108 time of occurrence, 108 treatment, no operative, 116 palliative, no uterine sounds in, 112 vaginal fixation in, 125 ventrofixation in, 120 ventrosuspension in, 120 technic, 121 Webster operation in, 122 technic, 123 Right-sided pain, causes, 290 Rontgen ray. See X-ray. Round ligaments of uterus, 102 Rubber gloves, 39 for home operation, 399 Rudimentary vagina, 53 Rupture of coccyx, 229 Sacro-iliac joints, relaxation of, 229, 262 Sacrosalpinx serosa, 163 Saenger's macule in inflammation of Bartholin's gland, 58 Salpingectomy in salpingitis, 1 73 Salpingitis, 164 acute stage, 164 operative treatment, 173 palliative treatment, 171 pelvic peritonitis in, 167 symptoms, 168 bimanual examination in, 170 breaking up adhesions in, 173 chronic stage, 165 operative treatment, 173 palliative treatment, 172 INDEX 461 Salpingitis, chronic stage, symp- toms, 168, 169 closure of ends of tube in, 167 diagnosis, 170 differential, 169, 170 drainage in, 177 extra-uterine pregnancy and, dif- ferentiation, 169 hysterectomy in, 176 infections, bacteria in, 164 isthmica nodosa, 165 operations in, 173 indications for, 174 ligature material for, 178 conservatism in, 176 ovarian cyst and, differeniation, 169 pathology, 164 purulent, 167 pyosalpinx in, 167 removal of both tubes in, 178 routine curettage of uterus in, 178 salpingectomy in, 1 73 salpingo-oophorectomy in, 174 salpingo-oophorectomy in, dou- ble, sterility after, 177 salpingostomy in, 176 stages, 164 surgical menopause after, treat- ment, 178 symptoms, 168 treatment, 171 vaginal section and drainage in, 177 Salpingo-oophorectomy in salpingi- tis, 174 double, sterility after, 177 Salpingostomy in salpingitis, 176 Salt solution in abdomen after operation, 418 Sarcoma, hydatidiform, of cervical canal, 149 of breast, 358 of cervix, 85, 98 of ovary, 205 of rectum, 373 of uterus, 149 age of occurrence, 149 histology, 149 metastasis in, 150 point of origin, 149 prognosis, 150 symptoms, 150 Sarcoma of uterus, treatment, 150 of vulva, 63 Scanty menstruation, 325 Schatz metranoikter in sterility, 55 Scirrhous cancer of breast, 356 Sclerosis of skin of vulva, 64 Sebaceous cysts of labia, 61 Secretion, internal, glands of, 384 Segregation of urine, 288 Senile vaginitis, 75 treatment, 77 with leukorrhea, treatment, 339 Septate hymen, 48 Septic vaginitis, acute, 75 Septum formation in vagina, 72 Serous cystadenoma of ovary, 188 Serum treatment in gonorrhea, 315 Sessile cervical polyps, 97 Sex glands, 384 Sheets, preparation of, for opera- tion, 402 Shields, nipple-, 345 care of, 346 Shock after operation, 419 internal hemorrhage and, dif- ferentiation, 419 symptoms, 419 treatment, 420 Sigmoidoscope, 359 Silk sutures, preparation of, 402 Silkworm-gut sutures, preparation of, 404 Silver wire sutures, preparation of, 402 nitrate tampons, 42 Sims' position, 30 speculum, 33 Sinuses in infected abdominal wounds, 434 Sinusoidal current, properties, 375 for intra-uterine treatment, 376 Skeleton bivalve speculum, 36 Skene's glands, 19 abscess of, 58 chronic infected, instillations for, 45 Skin, abdominal, disinfection of, 407 Smith pessary, 113 Sound, uterine, 38 462 INDEX Speculum, bivalve, 33 right method of removal, 35 of using, 34 skeleton, 36 Sims', T,s Sphincter ani, tears through, sj'mp- toms, 240 Spinelli operation in inversion of uterus, 146 Sponge test, 56 Sponges, preparation of, 402 Squamous-cell cancer of cervix, 81 Stem pessary in sterility, 55 Sterility, 54 after double salpingo-oophorec- tom}^ in salpingitis, 177 artificial impregnation in, 56 causes, 54 from dysmenorrhea, 327 one-child, 54 primarj', 54 Schatz metranoikter in, 55 secondary, 54 stem pessary in, 55 treatment, 55 Wylie drain in, 55 Sterilization of instruments, 38, 411 Sterilizers, 39 Stigma of ovary, 184 Stitch, wandering, 440 Stitch-fisher, use of, 436 Stoltz purse-string operation in cystocele, 268 Stomach, dilatation of, acute, after operation, 423 Stone in bladder, 301 in kidney, 292 in ureter, 293 Streptococcic pyosalpinx, gonor- rheal pyosalpinx and, differentia- tion, 171 Stricture of rectum, 371 of urethra, 303 Struma ovarii, 189 Stunted nipple, 346 Subinvolution of uterus, 150 Submammary abscess, 353, Submucous fibroid tumors of uterus, 131 Subserous fibroids of uterus, 131 Superinvolution of cervix, 80 of uterus, 151 Superior vesical fissure, 50 Supernumerary breast, 343 nipples, 343 Suppression of menstruatioa acute, 325 Suppurative mastitis, chronic, 354 Suprarenal glands, 386 Supravaginal abdominal hj'sterec- tomy in uterine fibroids, 138. Surgeon, preparation of, for opera- tion, 401 Surgical menopause, 334 Suture materials, preparation of, 402 Sutures, knots for, varieties, 403 Syphilis- of breast, 354 of cervix, 85 Table, examination, for office, ;i8 Tampons, 41 chronologic arrangement for use, 43 . insertion of, 43 medicated, 42 method of making, 42 uses, 42 Tannic acid tampons, 42 Tarry hematoma of ovary, 187 Tears of levator ani, 237 of pelvic floor, 237 of perineum, 237 best time for repair, 240 causes, 238 central, 240 complete, operation for, 249- 253 after-treatment, 253 factors essential to success, 254. operation for, technic, 250 symptoms, 240 delaj'ed repair, choice of opera- tion, 243 Emmett operation for, 244 Hegar's method, 247 B. C. Hirst's method, 247 preparations for, 242 technic, 241 diagnosis, 238 immediate repair, technic, 241 incomplete, repair of, time in bed for, 254 preventive treatment, 241 repair of, routine after-care, 249 INDEX 463 Tears of perineum, results, 239 symptoms, 238 treatment, 241 of posterior vaginal wall, 237 of vagina, 237 . through sphincter ani, symp- toms, 240 Tenacula, double, 36 Tent, sponge, 56 tupelo, 56 Teratoma of ovary, 189 symptoms, 191 Tetrelle, 345 Theca folliculi, 23, 184 Thickened hymen, 48 Thomas' pessary, 113 uterine applicator, 37 Thymus gland, 386 Thyroid gland, 384 Tiedemann's modification for stain- ing gonococcus, 308 Towels, preparation of, for opera- tion, 402 Trachelorrhaphy, Emmet's, in lacerations of cervix, 232 Transplantation of ovary, 204 Transversus perinei muscle, deep, 24 Trigone of bladder, 283 Trigonum, urogenital, muscle of, , tear of, 235 True vaginismus, 73 Tubal abortion, 157 in extra-uterine pregnancy, 157 gestation, 156. See also Extra- uterine pregnancy. Tubercular ischiorectal abscess, 369 peritonitis, 215 diagnosis, 215 prognosis, 216 symptoms, 215 treatment, 216 Tuberculosis of bladder, 299 of breast, 354 of cervix, 85, 98 of Fallopian tubes, 179 cause, 179 contra-indications to opera- tion in, 180 pathology, 179 progress, 180 symptoms, 179 treatment, 180 of kidney, 292 Tuberculosis of ovary, 206 of uterus, 152 of vagina, 72 Tuberculous endometritis, 128 Tubes, Fallopian, 22 caliber, 23 examination for, 29 fimbriated extremity, 22 isthmus, 22 muscular coat, 23 uterine portion, 22 Tubo-ovarian abscess, 167 Tumors of abdominal wall, 226 of breast, 354 benign, 354 malignant, 356 of Fallopian tubes, 180 benign, 180 malignant, 180 of ovary, solid, 204 malignant, 204 of rectum, 371 benign, 371 malignant, 372 solid, of labia, 61 of uterus, fibroid, 131. See also Fibroid tumors of uterus. of vagina, 72 Tupelo tent, 56 Ulceration of cervix, 98 Umbilical hernia, 222 symptoms, 222 treatment, 222 operative, 223 palliative, 222 Urachus, patent, 226 Ureter, anatomy, 283 diseases of, 293 inflammation of, 293 stone in, 293 Ureteral calculus, 293 catheter, uses of, 288 Ureterovaginal fistula, diagnosis, 281 treatment, 282 Urethra, anatomy, 283 angioneuroma of, 67 atresia of, 303 blood-supply of, 283 caruncle of, 67 congenital defects, 303 defects of, 50 464 INDEX Urethra, diseases of, 303 irrigations of, 46 prolapse of, 68 stricture of, 303 Urethritis, acute, 303 chronic, 303 gonorrheal, 311 complications, 312 prognosis, 311 symptoms, 311 treatment, 312 Urethrocele, 264 Urinary tract, anatomy, 283 diseases of, 283, 289 lymphatics of, 284 nerves of, 284 technic of examination, 284 veins of, 284 Urine, examination of, in pyelitis, 290 incontinence of, 277 after operation, 426 low output after operation, 437 retention of, after operation, 426, 439 segregation of, 288 Urogenital trigonum, muscle of, tear of, 235 Uterine applicator, 37 colic from instillations, 46 dressing forceps, 37 irrigations, 47 repositor, 38 sound, 38 Utero-ovarian ligament, 24 Uterosacral ligaments, 102 Uterovesical ligaments, 102 Uterus, 20, 100 abnormalities, 103 of position, 100 adenomyomata of, 143 anteflexion of, 103. See also Anteflexion of uterus. anteposition of, 107 anterior displacement, 103 anteversion of, 107 at birth, 100 atrophy of, lactation, 151 bicornis, pregnancy in one horn, 162 unicollis, 49 biforis, 50 blood-vessels of. 21 Uterus, broad ligaments of, 102 cancer of fundus, 125. See also Cancer of uterus. cardinal ligaments, 102 congenital anomalies, 49 cordiformis, 49 curettage of, routine, in salpin- gitis, 178 didelphys, 49 diseases of, 100, 103 displacement of, backward, 107 double, 50 duplex bicornis, 49 during childhood, 100 lactation, 103 menstruation, 319 pregnancy, 100 excessive pain referred to, 144 fibro myoma of, 131 flexion of, lateral, 107 hemorrhage from, electricity in, 376 incudiformis, 49 infantile, 144 inversion of, 145. See also In- version of uterus. leiomyoma of, 131 leukorrhea from, 337 treatment, 341 ligaments of, 21, 102 cardinal, 21 lymphatics of, 21 means of support, 102 muscle of, 21 myoma of, 131 myosarcoma of, 149 nerves of, 21 normal position, 100 perforation of, from curettage in endometritis, 130 polyps of, 148 prolapse of, 148, 271. See also Prolapse of iiterus. retroflexion of, 107 retroversion of, 107. See also Retroversion of uterus. round ligaments of, 102 sarcoma of, 149. See also Sar- coma of uterus. septus, 49 subinvolution of, 150 ■ superinvolution of, 151 tuberculosis of, 152 INDEX 465 Uterus, tumors of, fibroid, 131. See also Fibroid tumors of uterus. unicornis, 49 pregnancy in one horn, 162 veins ot, 21 virgin, loi Vaccines in gonorrhea, treatment, 315 Vagina, 20 absence of, 53, 6g adenomyoma of, 72 cancer of, 69. See also Cancer of vagina. chorionepithelioma of, 69 condyloma of, 70 cysts of, 71 diseases of, 69 fibro myoma of, 72 foreign bodies in, 71 hemorrhage from, after plastic operation, 437 treatment, 438 inflammation of, 74. See also Vaginitis. leukorrhea from, treatment, 338 myoma of, 72 operation on, preparation of patient for, 393 rudimentary, 53 septum formation in, 72 tears of, 237 tuberculosis of, 72 tumors of, 72 varices of, 77 Vaginal douche, 44 directions for, 44 uses, 44 fixation in retroversion of uterus, 125 . hysterectomy for cervical cancer, 86 _ technic, 88 for uterine fibroids, 137 myomectomy in uterine fibroids, 142 section and drainage in salpin- gitis, 177 posterior, in parametritis, 210 wall, anterior, lacerations of, 235 consequences, 236 diagnosis, 236 posterior, tears of, 237 30 Vaginismus, 72 diagnosis, 73 pseudo-, 73 true, 73 treatment, 73 by gradual dilatation, 74 in obstinate cases, 74 Walthard's, 73 Vaginitis, 74 acute septic, 75 causes, 75 chronic, treatment, 76 diagnosis, 75 diffuse granular, 74 diphtheritic, 75 emphysematous, 74 treatment, 77 . from gonorrhea, 75 treatment, 76 fungi in, 75 in prolapse of uterus, 75 leukorrhea in, 75 mild, with leukorrhea, 339 mycotic, 74 treatment, 77 pain in, 75 prognosis, 77 pruritus in, 75 puerperal, 75 senile, 75 treatment, 77 with leukorrhea, treatment, 339 symptoms, 75 treatment, 76 Varices of vagina, 77 Varicocele of pampiniform plexus, 181 of vulva, 68 Varicose veins of vulva, 68 Veins of ovary, 182 of uterus, 21 Venereal warts, 60 fiat, 60 pointed, 60 Ventrofixation in retroversion of uterus, 120 Ventrosuspension in retroversion of uterus, 120 technic, 121 Vesical calculus, 301 fissure, inferior, 50 superior, 50 Vesicocervicovaginal fistula, 282 Vesico-urethral fissure, 301 466 INDEX Vesicovaginal fistula, 278 colpocleisis in, 281 diagnosis, 278 treatment, 279 Vestibule of vulva, 18 Vicarious menstruation, 335 Virgins, uterus in, loi leukorrhea in, 341 Visceroptosis, diastasis of recti with, 220 Vomiting, postoperative, 423. See also Postoperative vomiting. Vulva, 17 cancer of, 62 chancre of, 60 diseases of, 57 elephantiasis of, 62 epithelioma of, 62 inflammation of, 63 lacerations of, 237 leukorrhea from, 336 treatment, 338 lupus of, 64 treatment, 65 pruritus of, 65 sarcoma of, 63 sclerosis of skin of, 64 tubercular ulceration of, 64 treatment, 65 varicocele of, 68 varicose veins of, 68 vestibule of, 18 Vulvitis, 63 nongonorrheal, 63 Vulvovaginal abscess, 57 glands, 19 Vulvovaginitis, 312 Walthard treatment of vaginis- mus, 73 Wandering stitch, 440 Warts, venereal, 60 flat, 60 pointed, 60 Watkins-Freund-Wertheim opera- tion in cystocele, 269 Webster operation in retroversion of uterus, 122 technic, 123 Wertheim abdominal panhysterec- tomy in cervical cancer, 86 Whites, 336. See also Leukorrhea. Wound, abdominal, bursting open of, 436 infected, 433 Wylie drain in anteflexion of uterus, 106 in sterility, 55 X-RAY, 378 burns, 378 disadvantages and dangers of, 379 . in cervical cancer, 91 in fibroids of uterus, 136 uses of, in diagnosis, 379 in treatment, 379 Youth, amenorrhea of, 323 Zestokausis in menorrhagia, T)T,2, Zona pellucida, 184 Our books are revised frequently, lo that the editions you find here may not be the latest. Write us about any books in which you are interested GYNECOLOGY and OBSTETRICS W. B. SAUNDERS COMPANY West Washington Square PhUadelphia 9, Henrietta Street Covent Garden, London Our Handsome Complete Catalogue will be Sent on Request Graves* Gynecology Text=Book of Gynecology. By William P. Graves, M. D., Professor of Gynecology at Harvard Medical School. Large octavo of 770 pages, with 425 original illustrations, many in colors. Published June, 1918 JUST ISSUED— NEW (2d) EDITION This new work presents gynecology along new lines. An entire section is devoted exclusively to the physiology of the pelvic organs and to correlated gynecology — the relationship of gynecology to organs of tnienm I secretion, breast, skin, organs of sense, digestion and respiration, blood, circulatory apparatus, abdominal organs, nervous system, bones, and joints. A special section is de- voted to enteroptosis , intestinal bands, and movable kidney. The second portion of the book is devoted to special gynecologic disease and is arranged particularly for the convenience of medical students. The first two parts (covering 500 pages) are entirely non-surgical, giving only drug and mechanical therapy and material invaluable to the general practitioner. The third part is exclusively a treatise on surgical gynecology, and includes profusely illustrated descriptions of those gynecologic operations that to the author seem most feasible. A number of new operations are given. SAUNDERS' BOOKS ON DeLee*s New Obstetrics Text=Book of Obstetrics. By Joseph B. DeLee, M. D., Professor of Obstetrics at Northwestern University Medical School, Chicago. Large octavo of 1087 pages, with 938 illus- trations, 175 in colors. Cloth, ^8.00 net. Published August, 1915 SECOND EDITION You will pronounce this new book the most elaborate, the most superbly illustrated work on Obstetrics you have ever seen. Especially will you value the 938 illustrations, all, with but few exceptions, original, and the best work of leading medical artists. Some 175 of these illustrations are in color. Such a magnificent collection of obstetric pictures — and with really pracHcai yaiue — has never before appeared in one book. You will find the text extremely practical throughout Diagnosis is fea- tured, and the relations of obstetric conditions and accidents to general medi- cine, surgery, and the specialties are brought into prominence. Regarding Treatment: You get here the verj- latest advances in this field, and you can rest assured every method of treatment, every step in operative technic, is just right. Dr. DeLee' s twenty-one years' experience as a teacher and obstetrician guarantees this. Worthy of your particular attention are the descriptive legends under the illustrations. These are unusually full, and by studying the pictures serially with their detailed legends you are better able to follow the operations than by referring to the pictures from a distant text — the usual method. Prof. W. Stoeckel, Kiel, Germany " Dr. DeLee's Obstetrics deserves the greatest recognition. The whole work is of such sterling character through and through that it must be ranked with the best works of our literature." Norris' Gonorrhea in Women Gonorrhea in Women. By Charles C. Norris, M. D., Instructor in Gynecology, University of Pennsylvania. With an Introduction by John G. Clark, M. D., Professor of Gynecology, University of Pennsylvania. Large octavo of 520 pages, illustrated. Cloth, ^6.50 ngt PubUshed May, 1513 OBSTETRICS Davis' Manual of Obstetrics Manual of Obstetrics. By Edward P. Davis, M. D., Professor of Obstetrics in Jefferson Medical College. i2mo of 463 pages, with 171 original illustrations. Cloth, ^2.25 net. Published September, 1914 ORIGINAL ILLUSTRATIONS Dr. Davis' manual is a concise text-book of exceptional value. Dr. Davis, himself a teacher of many years' experience, knows the requirements of such a work and has here supplied them. You get anatomy of the normal and ab- normal bony pelvis, physiology of impregnation, anatomy of the birth canal in pregnancy, growth and development of the embryo. You get a full and clear discussion of pregnancy — its diagnosis, physiology, hygiene, pathology. You get the causes and treatment of labor, the physiology, conduct, pathology ; the puerperal period — care of the mother and child ; obstetric surgery, fetal pathology, mixed feeding, and medicolegal aspects of obstetric practice. Davis' Operative Obstetrics operative Obstetrics. By Edward P. Davis, M. D., Pro- fessor of Obstetrics at Jefferson Medical College, Philadelphia. Octavo of 483 pages, with 264 illustrations. Cloth, ^5.50 net. Published September, 1911 INCLUDING SURGERY OF NEWBORN Dr. Davis' new work on Operative Obstetrics is a most practical one, and no expense has been spared to make it the handsomest work on the subject as well. Every step in every operation is described minutely, and the technic shown by beautiful new illustrations. The section given over to surgery of the newborn you will find unusually valuable. It gives you much informa- tion you want to know — facts you can use in your work every day. There is an excellent chapter on anesthesia in obstetrics. The Lancet, London " The best and most interesting part of the book is the summary of results given at the end oi the chapters and compiled from the author's own experience and from the literature." SAUNDERS' BOOKS ON Ashton's Practice of Gynecology SIXTH EDITION— published October. 1916 The Practice of Gynecology. By W. Easterly Ashton, M.D., LL.D., Professor of Gynecology at the Medico-Chirurgical College, Graduate School of Medicine, University of Pennsyl- vania. Octavo of 1097 pages, containing 1052 original line- drawings. Cloth, ^6.50 net. Among the important new matter may be mentioned the De Keating-Harl fiilguration treatment, Coley's mixed toxins for sarcoma of the genito-urinarj organs, the cutireaction of von Pirquet in the diagnosis of tuberculosis, " 606 " for syphilis, the hormone theory, the Fowler-Murphy treatment of suppurative peritonitis, tincture of iodin in sterilization, and Baldy's new round ligament operation for retrodisplacement. Notliing is left to be taken for granted, the author not only telling his readers in eveiy instance what should be done, but also precisely how to do if. A distinctly original feature of the book is the illustrations, numbering 1058 line drawings made especially under the author's personal supervision. From its first appearance Dr. Ashton"s book set a standard in practical medical books ; that he lias produced a work of unusual value to the medical practitioner is shown by the demand for new editions. Howard A. Kelly, M. D., Professor of Gynecologic Surgery, Johns Hopkins University "It is different trom anything that has as yet appeared. The illustrations are particu- larly clear and satisfactory. One specially good feature is the pains with which you describe so many details so often left to the imagination." Cluo'les B. Penrose. M. D., Formerly Professor of Gyttecology, University of Pennsylvania. " I know of no book that goes so thoroughly and satisfactorily into all the details of everything connected with the subject. In this respect your book differs from the others." George M. Edebohls, M.D. Professor of Diseases of Women, Ne-ai York Post- Graduate Medical School. " I have looked it through and must congratulate you upon having produced a text- book most admirably adapted to teach gynecology to those who must get their knowledge, even to the minutest and most elementary details, from books." GYNECOLOGY. Bandler's Medical Gynecology Medical Gynecology. By S. Wyllis Bandler, M. D., Professor of Diseases of Women, New York Post-Graduate Med- ical School and Hospital. Octavo of 790 pages, with 150 original illustrations. Cloth, ;^5. 50 net. PubUshed February, 1914 THIRD EDITION— 60 PAGES ON INTERNAL SECRETIONS This new work by Dr. Bandler is just the book that the physician en- gaged in general practice has long needed. It is truly the practitiotier' s gyne- cology — planned for him, written for him, and illustrated for him. There are many gynecologic conditions that do not call for operative treatment ; yet, because of lack of that special knowledge required for their diagnosis and treatment, the general practitioner has been unable to treat them intelligently. This work gives just the information the practitioner needs. American Journal of Obstetrics " He has shown good judgment in the selection of his data. He has placed most emphasis on diagnostic and therapeutic aspects. He has presented his facts in a manner to be readily grasped by the general practitioner." Bandler's Vaginal Celiotomy Vaginal Celiotomy. By S. Wyllis Bandler, M. D. Octavo of 450 pages, with 148 illustrations. Cloth, I5.00 net. SUPERB ILLUSTRATIONS The vaginal route, because of its simplicity, ease of execution, absence of shock, more certain results, and the opportunity for conservative measures, constitutes a field which should appeal to all surgeons, gynecologists, and obstetricians. Posterior vaginal celiotomy is of great importance in the re- moval of small tubal and ovarian tumors and cysts, and is an important step in tlie performance of vaginal myomectomy, hysterectomy, and hystero- myomectomy. Anterior vaginal celiotomy with thorough separation of t'ie bladder is the only certain method of correcting cystocele. January, 1911 The Lancet, London " Dr. Bandler has done good service in writing this book, which gives a very clear description of all the operations which maj' be undertaken through the vagina. He makes »ut a strong case for these operations." SAUNDERS' BOOKS ON Hirst's Obtetrics New (8th) Edition A Text=Book of Obstetrics. By Barton Cooke Hirst, M. D., Professor of Obstetrics in the University of Pennsylania. Handsome octavo of 863 pages, with 715 illustrations. Cloth, I5.OO net. PubUshed January, 1918 The revision of the work for this edition was so thorough and complete that the book had to be entirely reset. Nothing has been omitted that could make this work a practical, valuable text-book embracing all the modern advances in the field. Among the new subjects included are the use of Dakin's solu- tion and of the sunlight and open-air treatment of puerperal infections, a new chapter on various anesthesias in obstetrics, and another on the repair of in- juries of the genital tract due to childbirth. The illustrations form one of the features of the book. They are numerous and most of them are original. British Medical Journal " The illustrations in Dr. Hirst's volume are far more numerous and far better exe« cuted, and therefore more instructive, than those commonly found in the works of writers on obstetrics in our own country." Hirst's Diseases of Women A Text=Book of Diseases of Women. By Barton Cooke Hirst, M. D. Octavo of 745 pages, 701 illustrations, many in colors. Cloth, ;^5.oo net. SECOND EDITION As diagnosis and treatment are of the greatest importance in considering diseases of women, particular attention has been devoted to tliese divisions. The palliative treatment, as well as the radical operation, is fully described, enabling the general practitioner to treat many of his own patients without referring them to a specialist. Published August, 1905 Medical Record, New York "Its merits can be appreciated only by a careful perusal. . . Nearly one hundred pages are devoted to technic, this chapter being in some respects superior to the descrip. tions in other text-books." GYNECOLOGY. Kelly and Noble's Gynecology and Abdominal Surgery Gynecology and Abdominal Surgery. Edited by Howard A.. Kelly, M. D., Professor of Gynecology in Johns Hopkins University; and Charles P. Noble, M.D., formerly Clinical Professor of Gynecology in the Woman's Medical College, Phila- delphia. Two imperial octavo volumes of 850 pages each, con- taining 880 illustrations, mostly original. Per volume : Cloth, |8.oonet; Halt Morocco, $9.50 net. Volume I published May, 1907; Volume- II published June, 1908. WITH 880 ORIGINAL ILLUSTRATIONS BY HERMANN BECKER AND MAX BRODEL In view of the intimate association of gynecology with abdominal surgery the editors have combined these two important subjects in one work. For this reason the work will be doubly valuable, for not only the gynecologist and general practitioner will find it an exhaustive treatise, but the surgeon also will find here the latest technic of the various abdominal operations. It possesses a number of valuable features not to be found in any other publication cover- ing the same fields. It contains a chapter upon the bacteriology and one upon the pathology of gynecology, dealing fully with the scientific basis of gyne- cology. In no other work can this information, prepared by specialists, be found as separate chapters. There is a large chapter devoted entirely to medical gynecology, written especially for the physician engaged in general practice. Heretofore the general practitioner was compelled to search through an entire work in order to obtain the information desired. Abdominal sur- gery proper, as distinct from gynecology, is fully treated, embracing operations upon the stomach, upon the intestines, upon the liver and bile-ducts, upon the pancreas and spleen, upon the kidney, ureter, bladder, and the peritoneum. Special attention has been given to modertt technic. The illustrations are the work of Mr. Hernia?in Becker and A'fr. Alax Br'odel. American Journal of the Medical Sciences " It is needless to say that the work has been thoroughly done : the names of the authors and editors would guarantee this ; but much may be said in praise of the method of presen- tation, and attention mav be called to the inclusion of matter not to be found elsewhere." SAUNDERS' BOOKS ON THE BEST ilLIIlCnCClIl STANDARD Illustrated Dictionary The New (9th) Edition, Reset The American Illustrated Medical Dictionary. A ne^v and complete dictionary of the terms used in Medicine, Surgery, Dentistry, Pharmacy, Chemistry, Veterinary Science, Nursing, and all kindred branches; with over loo new and elaborate tables and many handsome illustrations. By W. A. Newman DoRLAND, M.D., Editor of '' The American Pocket Medical Dictionary." Large octavo, 1179 pages, bound in full flexible leather. Price, ^5.00 net; with thumb index, $5.50 net. A KEY TO MEDICAL LITERATURE Gives a Maximum Amount of Matter in a Minimum Space ENTIRELY RESET— 2000 NEW WORDS This edition is not a makeshift revision. The editor and a corps of expert assistants have been working on it for two years. Result — a thoroughly down- to-the-minute dictionary, unequalled for completeness and usefulness by any other medical lexicon published. It meets your wants. It gives you all the new words, and in dictionary service new words are what you want. Then, it has two-score other features that make it really a Medical Encyclopedia. Published September, 1917 PERSONAL OPINIONS Howard A. Kelly, M. D.. Professor of Gy7iecologic Surgery, fohns Hopkins University , Baltimore. " Dr. Borland's dictionary is admirable. It is so well gotten up and of such conve- nient size. No errors have been found in my use of it." J. Collins Warren. M.D.. LL.D., F.R.C.S. (Hon.) Professor of Surgery, Harvard Medical School. " I regard it as a valuable aid to my medical literary work. It is very complete and of convenient size to handle comfortably. I use it in preference to any other." DISEASES OF WOMEN. Webster's Diseases qf Women Diseases of Women. By J. Clarence Webster, M. D. (Edin.), F. R. C. p. E., Professor of Gynecology and Obstetrics in Rush Medical College. Octavo of 712 pages, with 372 illus- trations. Cloth, ^7.00 net, FOR THE PRACTITIONER Dr. Webster has written this work especially for the general practitioner, discussing the clinical features of the subject in their widest relations tc general practice rather than from the standpoint of speciaHsm. The magni- ficent illustrations, three hundred and seventy-two in number, are nearly all original. Drawn by expert anatomic artists under Dr. Webster's direct super- vision, they portray the anatomy of the parts and the steps in the operations with rare clearness and exactness. Published January, 1907 Howard A. Kelly, '^.Yi,^ Professor 0/ Gynecologic Surgery, Johns HopkinsUniversity. " It is undoubtedly one of the best works which has been put on the market within recent years, showing from start to finish Dr. Webster's well-known thoroughness. The illustrations are also of the highest order." Webster's Obstetrics A Text=Book of Obstetrics. By J. Clarence Webster, M. D. (Edin.), Professor of Obstetrics and Gynecology in Rush Medical College. Octavo of 767 pages, illustrated. Cloth, ^5.00 net. Published July, 1903 Medical Record, New York " The author's remarks on asepsis and antisepsis are admirable, the chapter on eclamp- sia is full of good material, and ... the book can be cordially recommended as a safe guide." SAUNDERS' BOOKS ON Kelly and Cullen's Myomata of the Uterus Myomata of the Uterus. By Howard A. Kelly, M. D., Professor of Gynecologic Surgery at Johns Hopkins University; and Thomas S. Cullen, M. B., Associate in Gynecology at Johns Hopkins University. Large octavo of about 700 pages, with 388 original illustrations by August Horn and Hermann Becker. Cloth, ^7.50 net. A MASTER WORK ILLUSTRATED BY AUGUST HORN AND HERMANN BECKER This monumental work, the fruit of over ten years of untiring labors, will remain for many years the last word upon the subject. Written by those men who have brought, step by step, the operative treatment of uterine myoma to such perfection that the mortality is now less than one per cent., it stands out as the record of greatest achievement of recent times. The illustrations have been made with wonderful accuracy in detail by Mr. August Horn and Mr. Hermann Becker, whose superb work is so well known that comment is unnecessary. For painstakmg accuracy, for attention to every detail, and as an example of the practical results accruing from the associa- tion of the operating amphitheater with the pathologic laboratory, this work will stand as an enduring testimonial. Published May, 1909 Surgery, Gynecology, aaid Obstetrics •' It must be considered as the most comprehensive work of the kind yet published. It will always be a mine of wealth to future students." New York Medical Journal " Within the covers of this monograph every form, size, variety, and complication of uterine fibroids is discussed. It is a splendid example of the rapid progress of American professional thought." Bulletin Medical loid Chirurgical Faculty of Maryland " Few medical works in recent years have come to our notice so complete in detail, so well illustrated, so practical, and so far reaching in their teaching to general practitioner specialist, and student alike." GYNECOLOGY AND OBSTETRICS. Penrose's Diseases of Women Sixth Revised Edition A Text=Book of Diseases of Women. By Charles B. Penrose, M. D., Ph. D., formerly Professor of Gynecology iij the University of Pennsylvania ; Surgeon to the Gynecean Hos- pital, Philadelphia. Octavo volume of 550 pages, with 225 fine original illustrations. Cloth $3. 75 net. Published March, i908 ACCURATE Regularly every year a new edition of this excellent text-book is called for, and it appears to be in as great favor with physicians as with students. Indeed, this book has taken its place as the ideal work for the general prac- titioner. The author presents the best teaching of modern gynecology, un- trammeled by antiquated ideas and methods. In every case the most modern and progressive technique is adopted, and the main points are made clear by excellent illustrations. Howard A. Kelly, M.D., Projessor of Gynecologic Surgery, Johns Hopkins University, Baltimore. " I shall value very highly the copy of Penrose's ' Diseases of Women ' received. I have already recommended it to my class as the best book." Cullen's Uterine Adenomyoma Uterine Adenomyoma. By Thomas S. Cullen, M. D., Asso- ciate Professor of Gynecology, Johns Hopkins University. Octavo of 275 pages, with original illustrations by Hermann Becker and August Horn. Cloth, $5.00 net. Published May, 1908 Cullen's Cancer of Uterus Cancer of the Uterus. By Thomas S. Cullen, M. B., Asso- ciate Professor of Gynecology, Johns Hopkins University. Large octavo of 693 pages, with over 300 colored and half-tone text-cuts and eleven lithographs. Cloth, $7.50 net; Half Morocco, $8.50 net. Published 1900 SAUNDERS' BOOKS ON Davis' Obstetric and Gynecolog;ic Nursing' Obstetric and Gynecologic Nursing. By Edward P. Davis, A. M., M. D., Professor of Obstetrics in the Jefferson Medical College and Philadelphia Polyclinic; Obstetrician and Gynecologist, Philadelphia Hospital. i2mo of 498 pages, illus- trated. Buckram $2.00 net. PubUshed May, 1917 NEW (5th) EDITION This volume gives a vety clear and accurate idea of the maimer to meet the conditions arising during obstetric and gj-necologic nursing. The fifth edition has been thoroughly revised. " Not only nurses, but even newly qualified medical men, would learn a great deal by a perusal of this book. It is written in a clear and pleasant style, and is a work we can recommend." — The Lancet, London. American Pocket Dictionary New (loth) Edition The American Pocket Medical Dictionary. Edited by W. A. Newman Dorx,and, A. M., M. D. With 693 pages. Full leather, limp, $1.25 net; patent thumb index, $1.50 net. September, 1917 James W. Holland, M. D., Professor of Chemistry and Toxicology at the Jefferson Medical College, Philadelphia. "I am struck at once with admiration at the compact size and attractive exterior. I can recommend it to our students without reserve." Ashton*s Obstetrics Eighth Edition Essentials of Obstetrics. By W. Easterly Ashton, M. D., Pro- fessor of Gynecolog\s University of Pennsylvania. Cro\\Ti octavo, 290 pages, 125 illustrations. Cloth, $1.25 net. In Saunders' Qnestion- Compend Series. PubUshed January, 1917 Galbraith's Four Epochs of Woman's Life Edition The Four Epochs of Woman's Liee: A Study in Hygiene. Maidenhood, Marriage, Maternity, Menopause. By Anna M. Gal- BRAiTH, M.D. With an Introductory Note by John H. Musser, M.D . PubUshed March, 1917. i2mo of 296 pages. Cloth, $1.50 net. GYNECOLOGY AND OBSTETRICS 13 Bandler's The Expectant Mother The Expectant Mother. By Samuel Wyllis Bandler, M. D., Professor of Diseases of Women, New York Post-Graduate Medical School and Hospital. i2mo of 213 pages, illustrated. Cloth, $1.25 net. Published August, 1916 Montgomery's Care of Gynecologic Cases Care of Patients: Before, During, and After Operation. By E. E. Montgomery, M. D., LL.D., Professor of Gynecology in Jefferson Medical College. i2mo of 149 pages, illustrated. Cloth, $1.25 net. Published December, 1916 Macfarlane's Gynecology for Nurses Idwon A Reference Hand-Book of Gynecology for Nurses. By Cath- arine MacfarlANE, M. D., Gynecologist to the Woman's Hospital of Philadelphia, l6mo of 1 56 pages, with 70 illustrations. Flexible leather, ^1.25 net. Published May, 1913 A, M. Seabrook, M. D., IVoman's Medical College of Philadelphia. " It is a most admirable little book, covering in a concise but attractive way the sub- ject from the nurse's standpoint." Cragin's Gynecology Eighth EdWon Essentials of Gynecology. By Edwin B. Ceagin, M. D., Pro- fessor of Obstetrics, College of Physicians and Surgeons, New York. Crown octavo, 240 pages, 62 illustrations. Cloth, $1.25 net. In Saunders^ Question-Compend Series. Published October, 1913 Schaffer and Norris* Gynecology ^Ttfil Atlas and Epitome of Gynecology. By Dr. O. Schaffer, of Heidelberg. Edited, with additions, by Richard C. Norris, A. M., M. D., Assistant Professor of Obstetrics, University of Pennsylvania. 155 illustrations, 272 pages. Cloth, $3.50 net. Published 1900 Schaffer and Edgar's Obstetrics Atlas and Epitome of Obstetric Diagnosis and Treatment. By Dr. O. Schaffer, of Heidelberg. From the Second Revised German Edition. Edited, with additions, by J. Clifton Edgar, M. D., Pro- fessor of Obstetrics and Clinical Midwifery, Cornell University Medi- cal School, N. Y. With 122 colored figures on 56 plates, 38 text-cuts, and 315 pages of text. Cloth, $3.00 net. In Saunders' Hand-Atlas Series. Published January, 19u: 14 SAUNDERS' BOOKS ON Schaffer and Webster's Operative Gynecology Atlas and Epitome of Operative Gynecology. By Dr. O. Schaffer, of Heidelberg. Edited, with additions, by J. Clarence Webster, M. D. (Edin.), F. R. C. P. E., Professor of Obstetrics and Gynecology in Rush Medical College, in affili- ation with the University of Chicago. 42 colored lithographic plates, many text-cuts, a number in colors, and 138 pages of text. In Saunders' Hand- Atlas Series. Cloth, ^3.00 net. Much patient endeavor has been expended by the author, the artist, and the lithographer in the preparation of the plates for this Atlas. They are based on hundreds of photographs taken from nature, and illustrate most faithfully the various surgical situations. Dr. Schaffer has made a specialty of demon- strating by illustrations. Published 1904 Medical Record, New York "The volume should prove most helpful to students and others in gasping details usually to be acquired only in the amphitheater itself." De Lee's Obstetrics for Nurses Obstetrics for Nurses. By Joseph B. DeLee, M. D., Professor of Obstetrics in the Northwestern University Medical School, Chicago ; Lecturer in the Nurses' Training Schools of Mercy, Wesley, Provident, Cook County, and Chicago Lying-in Hospitals. i2mo of 550 pages, fully illustrated. Published July, 1917 Cloth, $2.75 net. FIFTH EDITION While Dr. DeLee has written his work especially for nurses, the practi- tioner will also find it useful and instructive, since the duties of a nurse often devolve upon him in the early years of his practice. The illustrations are nearly all original and represent photographs taken from actual scenes. The text is the result of the author's many years' experience in lecturing to the nurses of five different training schools. J. Clifton Edgar, M. D„ Professor of Obstetrics and Clinical Midwifery , Cornell University, New York. " It is far and away the best that has come to my notice, and I shall take great pleasure in recommending it to my nurses, and students as well." COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the library rules or by special arrangement with the Lib^-arian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE C28(S46)M25