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FROM THE LIBRARY OF 
 
 WILLIAM DUNCAN McKIM 
 
 GR-\DUATE OF 
 
 COLUMBLA. UNrVTERSITY 
 
 A. B., 1875; A. M., 1878; M. D., 1878 
 
 -Rfi/o/ 
 
 JB3Z 
 
 1897 
 
 College of 3^f}pskian& ani) burgeons: 
 
 Hibrarp 
 
A TREATISE 
 
 ON 
 
 GYNy^COLOGY 
 
 MEDICAL AND SURGICAL 
 
 S, POZZI, M.D. 
 
 Professeur Agrege a la Faculte de Medecine de Paris , Chirurgien de I'Hopital Broca ; 
 Membre de rAcademie de Medecine. 
 
 Second Hmerican iBMtfon 
 
 TRANSLATED FROM THE THIRD FRENCH EDITION UNDER THE SUPERVISION OF 
 
 BROOKS H. WELLS, M.D. 
 
 Editor of the American Journal of Obstetrics; Adjunct Professor of Gynsecology at the 
 
 New York Polyclinic ; Fellow of the New York Obstetrical Society, 
 
 and the New York Academy of Medicine. 
 
 WITH SIX HUNDRED ILLUSTRATION'S 
 
 NEW YORK 
 
 WILLIAM WOOD AND COMPANY 
 
 1897 
 
T?1 
 
 
 
 If '\1 
 
 C0P\TiIGHT, 1897, 
 
 By WILLIAM WOOD & COMPANY" 
 
 PRESS OF 
 
 THE PUBLISHERS' PRINTING COMPANY 
 
 82 AND 34 LAFAYETTE PLACE 
 
 NEW YORK 
 
PREFACE TO THE SECOND AMERICAN EDITION. 
 
 The treatise of which the second edition is here given to American 
 readers undoubtedly continues to hold the pre-eminence attained on its first 
 appearance, when ^t was at at once accepted as the best work of the time on 
 gynaecology. The cosmopolitan and scientific spirit of its author, shown in 
 his exhaustive research and judicious appreciation of the work of other na- 
 tions, together with his keen and mature judgment in utilizing the material 
 from his own rich clinical fields, make it a clear and reliable guide to the 
 best practice in this specialty. It has attained a phenomenal fame through- 
 out the world. It has been translated into the German, English, Spanish, 
 Italian, and Russian languages. It has received the prize of the Institute 
 and of the Academy of Medicine of Paris. 
 
 The third French edition, of which this is a translation, has been the 
 object of a careful and thorough revision, and of many additions. Certain 
 of the chapters have been completely rewritten. The most recent treatment 
 of uterine fibroids by abdominal and vaginal hysterectomy, the indications 
 for the latter operation in pelvic suppurations, the recent forms of interven- 
 tion in cases of retro-deviation of the uterus, are all discussed. Where the 
 author finds it difficult to present a dogmatic exposition of certain questions 
 still in process of evolution, he gives an exact idea of the different opinions, 
 but does not neglect clearly to formulate his own. He believes that in a 
 work like this, essentially didactic, it would be wrong to withhold from the 
 reader the possibility of forming a personal conviction, but that it is also 
 necessary that the author should never hesitate to express his own opinion. 
 
 The pathological anatomy has been subjected to many changes. The 
 numerous histological figures, borrowed in the first edition from other works, 
 have been replaced by new drawings, skilfully executed from specimens from 
 the author's service by his chief of laboratory, Dr. Latteux. 
 
 In preparing this second American edition the author has been followed 
 as closely as possible. Certain editorial notes have been added. They refer 
 mainly to minor points, and have been enclosed in brackets. I am indebted 
 to Drs. Aimee Raymond Schroeder and Hughes Dayton for assistance in 
 the translation, B. H. W. 
 
 71 West 45TH Street, New York, October ist, 1897. 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/treatiseongynaecOOpozz 
 
AUTHOR'S PREFACE TO FIRST FRENCH EDITION. 
 
 This work is tb\ result of .several years of practical experience as chief 
 of a hospital service at Lourcine, devoted especially to the diseases of 
 women. The materials for the works published by Huguier, Bernutz and 
 Goupil, Alph. Guerin, De Martineau, and their pupils were gathered from the 
 same field. Thanks to the increased facilities offered in gynaecological sur- 
 gery by the addition of the Pascal Annex, I have for six years been able to 
 give regular gynaecological instruction. Moreover, the kindness of the dean, 
 M. Brouardel, has permitted me to conduct a free supplementary course of 
 gynaecology at the Faculte de Medecine. The lessons there given have 
 served as an outline in the compilation of this book. Furthermore, I have, 
 in the course of several journeys abroad, studied the methods of the princi- 
 pal gynaecologists of England, Germany, and Austria, and compared their 
 instructions with those of the Faculte of Paris, where my own studies were 
 pursued. 
 
 It is impossible to ignore the great prominence which gynaecology has 
 everywhere assumed. The origin of its rapid progress is easy to trace. 
 By the introduction of antisepsis a new era was opened to gynaecology as 
 well as to general surgery. Active intervention has become almost free 
 from danger in many diseases which used to be abandoned to palliative or 
 disguised expectant treatment. Thanks to antisepsis, new operations have 
 been invented and old ones restored to favor. Some of the latter had been 
 boldly conceived and brilliantly performed by our predecessors, but the ter- 
 rific mortality due to surgical uncleanliness had caused their abandonment. 
 Such was the case with ovariotomy, vaginal hysterectomy, curetting, and 
 even shortening the round ligaments ; their present use is merely a revival. 
 
 Previous to Pasteur's great discovery, rendered fruitful by Lister, bold- 
 ness in operative medicine was sheer temerity. If an occasional success 
 raised hopes, they were at once destroyed by a series of mishaps. In 1822 
 Sauter (of Constance) obtained the first successful result in vaginal hyste- 
 rectomy for the cure of cancer. After this one isolated cure, eleven consec- 
 utive deaths followed the first eleven operations performed in imitation of 
 
Vi PREFACE. 
 
 his, and in all probability a complete list of the victims has never been pub- 
 lished. Scarcely twenty years ago, surgery had fallen into discouragement 
 and had renounced all active measures in a great part of the gynaecological 
 field. Accidents during labor or the co7isequences of labor were left in the 
 hands of accoucheurs, and the numerous forms of metritis, nearly all displace- 
 ments, and reflex nervous disorders, perimetritic inflammations, etc., to the 
 general practitioner. Thus dismembered and parcelled out among surgeons, 
 general physicians, and obstetricians, gynaecology was far from forming the 
 definite and distinct branch of the healing art that it does at the present day. 
 Not so very long ago a good operator was a good surgeon, the two terms 
 being almost synonymous. This is no longer the case. It has become of 
 even more importance to avoid infection of the wound than to operate bril- 
 liantly. 
 
 Antisepsis has now triumphantly overcome all oppositions; all our in- 
 structors teach it, and the younger generation practise it with the fervor 
 inspired by new religions. We are as well armed for the strife as our neigh- 
 bors. Let us profit by their experience, and avoid the operative excesses 
 into which they have too often fallen. 
 
 In view of these tendencies, which, it is to be feared, have sometimes 
 caused the sacrifice of a careful clinical study of the disease, and a patient 
 and exact determination of the diagnosis and prognosis to the eclat of imme- 
 diate results, it seems to me that a definite role falls naturally to the lot of 
 French gynaecology. Let it accept without qualification the bold and useful 
 inventions of foreign origin, but let it exercise a more solicitous sur\"eillance 
 over what is in reality the highest part of our art, an exact interpretation of 
 indications. There will then be no missing link in the chain of its records, 
 and its future will be worthy of its glorious past. 
 
 This past is too little remembered at the present day. We ourselves are 
 not proud enough of our long scientific lineage, which made us the teachers 
 of other nations, in gynaecology as well as in all the other branches of the 
 healing art. This is an opportune moment to recall it to the memory of 
 those among us who choose to neglect our works, and who were quick to an- 
 nounce our decline at a time our activity were temporarily retarded. Are 
 not modern methods of exploration, operations in use at the present day, new 
 departures in gynaecological nosology largely of French origin ? Bimanual 
 exploration, which has been said to be a more valuable aid to investigation 
 than even the speculum, was introduced in France by Puzos in 1753, and 
 adopted by Levret and Baudelocque long before Kiwisch, Veit, and Schultze 
 revived its use. The speculum, forgotten since the days of antiquity, of 
 
PREFACE. VU 
 
 Soranus and Paul of ^ginus, first reappears in the works of Ambroise Pare, 
 the illustrious Father of French Surgery, then in the surgical armamentarium 
 published by Gullet, and finally assumes definite importance in the hands of 
 Recamier, physician of I'Hotel-Dieu, who introduced it into general use. 
 Neither Lair nor Simpson nor Kiwisch were the ones to discover the diag- 
 nostic value of measuring the uterus with the uterine sound; the great 
 French obstetrician Levret, in 1771, was the discoverer, and Huguier, the 
 eminent surgeon of Lourcine, was the one who, after rescuing hysterometry 
 from the discredit into which it had fallen, formulated the indications for 
 its use. 
 
 Shall I speak of operations ? Curetting was invented by a Frenchman, 
 Recamier; the operation for vesico-vaginal fistula was first scientifically es- 
 tablished and successfully used, in a hitherto unknown degree, by a French- 
 man, Jobert de Lamballe. The surgeons who first attacked polypi, either by 
 ligature (Levret) or boldly with a cutting instrument " (Dupuytren) were 
 French. The one who first had the daring to enucleate fibromata in the 
 uterine tissue (Amussat) was French. In France, Recamier performed, if 
 not the first, at least the second, successful vaginal hysterectomy for cancer. 
 It was in France (in Strasburg), that our eminent compatriot Koeberle was 
 one of the first who of deliberate purpose (and not accidentally, like the 
 greater number or his predecessors) opened the abdomen to remove an in- 
 terstitial uterine fibroid. It was in Paris that Pean established a plan of 
 technique for abdominal hysterectomy which was classical for many years. 
 
 If we pass to nosology, to the anatomico-pathological and clinical study 
 of diseases, here again we meet a crowd of French leaders, and we have only 
 an embarras de cJioix : Huguier for diseases of the external genitals and 
 supravaginal hypertrophic elongation of the cervix; Nelaton for retro-uterine 
 hsematocele; Valleix, Aran, Bernutz and Goupil, Gallard, Alphonse Guerin, 
 for peri- and parametric inflammations ; Malassez and De Sinety, Cornil for 
 the pathological anatomy of ovarian cysts, endometritis, etc. 
 
 I will pause here lest this legitimate reclamation become a panegyric. I 
 merely wished to show that our patriotism has every cause to be at ease on 
 questions of bibliography, and that when we quote from a foreign author we 
 often do no more than to take back our own capital with the accumulated 
 interest thereon. 
 
 I have largely consulted foreign publications, and have quoted as many 
 English, American, and German, as French names. It is possible that I 
 may be criticised for so doing, but " For whoever thinks, there is neither 
 -French nor English," said Voltaire. 
 
Vlll PREFACE. 
 
 My endeavor has been as far as possible to present an exact statement of 
 the present condition of science in all countries, without giving a cumber- 
 some mass of detail. For that reason I have abstained from dwelling at any 
 length upon historical data preceding the antiseptic period, although I have 
 not neglected any occasion to assert any just claims of priority upon the part 
 of operators, without regard to nationality. 
 
 In respect to bibliography, I have thought it best not to make exhaustive 
 extracts from the enormous mass of documents which I could easily have 
 reached through special indexes — Reviie des Sciences Medicalcs, Index Cata- 
 logue, Index Medicus, Centralblatt, etc. This cheap form of erudition seems 
 to me of more ostentatious value to the compiler than of real use to the reader. 
 Those desirous of pursuing the subject farther can have ready access to these 
 publications. There was a time(not so very remote) when a complete bibli- 
 ography was essential to the compiling of any book. That time is past. At 
 the present day we are obliged to be incomplete, in view of the enormous 
 and constant accumulation of literary matter upon medical topics. It is 
 better frankly to acknowledge this inevitable necessity, and make a choice of 
 what we consider worthy of quotation. For my part, I have limited myself 
 to advising a consultation, upon each subject, of the most recent and best 
 works that I had been able to find. I have given the fullest list of refer- 
 ences in regard to the questions which excite the most interest at the day 
 present day, or about which there is the most dispute (Battey's operation, 
 hysteropexy, etc.). I have made very few quotations at second hand, and 
 those I have been careful to verify. 
 
 In a book designed for instruction, the author is always placed between 
 two horns of a dilemma. Either he is in danger of sacrificing everything 
 to perspicuity, dwelling upon outlines and leaving in the shade many details 
 which might interfere with the schematic clearness of his sketch, in which 
 case he is in danger of being incomplete and sometimes artificial ; or else 
 he tries to omit nothing from his picture, even though the addition of details, 
 and matter of secondary importance takes something from the prominence of 
 the chief topics ; he runs the risk in this case of being heavy and diffuse. 
 
 I have constantly endeavored to steer clear of this double danger, and, 
 although I cannot claim entire success, yet I can claim to have done my best 
 to that end. I deemed it essential to dwell at length upon the more recent 
 gynaecological operations, which were often incompletely reported by my 
 French predecessors, and somewhat obscurely described in the many existing 
 translations of foreign works. On the other hand, it seemed unnecessary to 
 give a detailed anatomical description of the female genital organs ; I con- 
 
PREFACE, IX 
 
 tented myself with a few indispensable general indications quite sufficient 
 for a work on pathology. The only details entered into are in reference to 
 the external organs of generation, where certain views had to be stated in 
 regard to their development and homology, which seemed to me to throw 
 light upon the origin of some interesting malformations. 
 
 Many of my illustrations are original ; they were drawn under my direc- 
 tion by M. Nicolet, who is both skilful and intelligent. I have also bor- 
 rowed largely from various treatises and monographs. In every case in which 
 these illustrations had any originality, I acknowledged their source, omitting 
 this formality only in the case of those which came from classical works 
 known by every one, and which have been so often reproduced as to be 
 almost public property. 
 
 Professor Cornil kindly gave me permission to reproduce the remarkable 
 histological illustrations of his lessons on endometritis, cancer, salpingitis, 
 and genital tuberculosis. Professor Wyder was good enough to allow me to 
 make reduced copies of the valuable plates in his atlas. M, Toupet, with 
 his well-known ability and courtesy, made several anatomical examinations 
 for me relative to salpingitis and follicular ovarian cysts. A few illustra- 
 tions were kindly lent by MM. L. le Fort, Tarnier, Doleris, Dumoret, Marcel 
 Baudouin, Poirier, Laroyenne, Collin, Mathieu, Aubry, Raynal, Dupont. 
 
 My good friend Professor Testut and my brother, Dr. Adrien Pozzi (of 
 Rheims), deserve my gratitude, the one for making out the indexes, the other 
 for correcting the proofs. 
 
 Finally, I wish to thank the publisher, my friend M. Georges Masson, 
 whose faithful co-operation has greatly facilitated the execution of my 
 laborious undertaking. 
 Paris, July 22d, 1890. 
 
CONTENTS. 
 
 CHAPTER I. 
 
 page; 
 Antisepsis in Gynaecology, . . . . ... , . , .r 
 
 CHAPTER II. 
 
 Anaesthesia in Gynsecology, . . . . . , , . , • 27- 
 
 CHAPTER III. 
 Methods of Suture and Haemostasis, . . . . , , , • 35 
 
 CHAPTER IV. 
 Methods of Gynaecological Examination, 68^ 
 
 CHAPTER V. 
 The Pathology and Etiology of Metritis, . . , , , , . log, 
 
 CHAPTER VI. 
 Symptoms, Course, and Diagnosis of Metritis, . . , . . • iSr 
 
 CHAPTER VII. 
 
 Treatment of Metritis, . . . . . . . . . . .163, 
 
 CHAPTER VIII. 
 Uterine Fibromata, . . . . . . . . . . .188 
 
 CHAPTER IX. 
 
 Symptoms, Diagnosis, and Etiology of Uterine Fibromata, .... 2or 
 
 CHAPTER X. 
 
 Medical Treatment of Fibroma — Surgical Treatment of Fibroma with a Vagi- 
 nal Evolution, . . . . . . . . . . .215 
 
 CHAPTER XL 
 
 Treatment of Fibrous Tumors of Abdominal Evolution — Myomectomy and 
 
 Hysterectomy, . . 238- 
 
Xii CONTENTS. 
 
 CHAPTER XII. 
 
 PAGE 
 
 Castration for Fibroma, . . . . . . . . , .276 
 
 CHAPTER XIII. • 
 Fibrous Tumors Complicating Pregnancy, 284 
 
 CHAPTER XIV. 
 Pathology, Symptoms, Diagnosis, and Etiology of Cancer of the Cervix Uteri, 290 
 
 CHAPTER XV. 
 Treatment of Cancer of the Cervix, ........ 308 
 
 CHAPTER XVI. 
 Cancer of the Body of the Uterus, ........ 339 
 
 CHAPTER XVII. 
 Displacements of the Uterus, ......... 360 
 
 CHAPTER XVIII. 
 Displacements of the Uterus — Continued, . . , , , . .374 
 
 CHAPTER XIX. 
 Prolapse of the Genital Organs, . . . . . . . , .414 
 
 CHAPTER XX. 
 Inversion of the Uterus, .......... 448 
 
 CHAPTER XXI. 
 
 Malformations of the Cervix — Atresia, Stenosis, Atrophy, Hypertrophy, . 456 
 
 CHAPTER XXII. 
 Disorders of Menstruation, . . . 468 
 
 CHAPTER XXIII. 
 Inflammation of the Uterine Appendages, . 481 
 
 CHAPTER XXIV. 
 Oophoro-salpingitis without Cystic Tumor, ....... 487 
 
 CHAPTER XXV. 
 Cystic Oophoro-salpingitis, 523 
 
 CHAPTER XXVI. 
 Perimetro-salpingitis, '552 
 
CONTENTS. Xlll 
 
 CHAPTER XXVII. 
 
 PAGE 
 
 Pathological Anatomy of Ovarian Cysts, 577 
 
 CHAPTER XXVIII. 
 
 Etiology, Symptoms, Course, and Diagnosis of Ovarian Cysts, . . . 608 
 
 CHAPTER XXIX. 
 Treatment of Ovarian Cysts, ......... 623 
 
 CHAPTER XXX. 
 Solid Tumors of the Ovary, 646 
 
 CHAPTER XXXI. 
 
 Tumors of the Fallopian Tubes, Broad and Round Ligaments, . . .653 
 
 CHAPTER XXXII. 
 Genital and Peritoneal Tuberculosis, . « 659 
 
 CHAPTER XXXIII. 
 Intra- and Extra-peritoneal Pelvic Hematocele, 685 
 
 CHAPTER XXXIV. 
 Extra-uterine Pregnancy, . . . . . . . . . . 697 
 
 CHAPTER XXXV. 
 Diseases of the Vagina, . . . . . . . . . '723 
 
 CHAPTER XXXVI. 
 Tumors of the Vagina, — Cysts, Fibrous Tumors, Polypi, Primary Cancer, . 733 
 
 CHAPTER XXXVII. 
 Cicatricial Fistulae of the Vagina, ....... '743 
 
 CHAPTER XXXVIII. 
 Vaginismus, . . ... . . . . . . . 794 
 
 CHAPTER XXXIX. 
 Laceration of the Perineum, 800 
 
 CHAPTER XL. 
 
 Inflammation, CEdema, Gangrene, Erysipelas, Eczema, and Herpes of the 
 
 Vulva, . .831 
 
Xiv CONTENTS. 
 
 CHAPTER XLI. 
 Lupus (Esthiomene) of the Vulva, • ' ^37 
 
 PAGE 
 
 CHAPTER XLH. 
 Tumors of the Vulva, 841 
 
 CHAPTER XLIII. 
 Inflammation and Cysts of Bartholin's Glands, 855 
 
 CHAPTER XLIV. 
 Pruritus Vulva — Coccygodynia, 85^ 
 
 CHAPTER XLV. 
 Wounds of the Vulva and Vagina— Atresia and Stenosis— Foreign Bodies, . 861 
 
 CHAPTER XLVI. 
 Malformations of the Vulva, and Hermaphrodism, . . . . . 867 
 
 CHAPTER XLVII. 
 Malformations of the Vagina and the Uterus, 892 
 
 CHAPTER XLVIII. 
 Retention Accidents from Genital Atresia, 9^2 
 
Clinical and Operative Gynecology. 
 
 CHAPTER I. 
 
 ANTISEPSIS IN GYNAECOLOGY. 
 
 The general laws of surgical antisepsis are applicable in the main to 
 gynaecology, but there are certain surgical details and technical processes 
 which it is necessary to emphasize and describe at length. These details 
 fall naturally into two divisions : the first relating to operations through the 
 natural passages upon the vagina, cervix uteri, and uterine cavity ; the sec- 
 ond to operations through artificial openings involving the peritoneum. 
 
 Antisepsis of Operations through Natural Openings. 
 
 A. Of the Operator. — Absolute cleanliness of the hands is of great im- 
 portance in general surgery, but is pre-eminently a matter of necessity where 
 there is to be manipulation of the vaginal or uterine cavities ; for in these 
 situations pathogenic germs find a culture medium essentially favorable to 
 their development, and infection is rapidly initiated. The nails must be 
 carefully cleaned with a smooth-pointed cleaner ; the hands and arms to the 
 elbow should be scrubbed for six minutes with soap and a stiff brush in hot 
 water. The towels used should have been rendered aseptic in a sterilizing 
 oven. 
 
 From researches carried on by von Eiselsberg in Billroth's clinic, upon 
 the various substances used in the hospitals for cleansing the hands, it would 
 seem that all soaps are good, except the ordinary hard (resin) soap; in this 
 Eiselsberg has found many pathogenic spores, whose presence is quite ac- 
 counted for by the processes of manufacture — the use of impure fats and the 
 low temperature of saponification. The scrubbing with soap and water should 
 be followed by washing in a bichloride solution of i : t,000. All assistants 
 and nurses should likewise cleanse hands and arms to the elbow in the same 
 thorough manner. Many operators consider this method of cleansing in- 
 sufficient, and prefer to immerse hands and arms in a saturated solution of 
 potassiifim permanganate, which stains the skin a violet-brown, then remov- 
 ing the color by a concentrated solution of oxalic acid, and finallv washing 
 in sterilized water. I believe that this method may be reserved for the 
 exceptional cases where there has been contact with material which is septic 
 
2 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 or suspected of being so. Fiirbringer advocates the use of alcohol at 90° 
 as a wash for the hands, in addition to the soap and bichloride. 
 
 Where one is obliged to handle fetid substances, as in uterine cancer, 
 etc., the use of deodorizers may well supplement but not replace antiseptics. 
 Without them, the hands become impregnated with a disagreeable odor which 
 clings in spite of thorough washings. Foulis, of Edinburgh, finds that 
 anointing them before the operation with spirits of turpentine is a sufficient 
 protection. 
 
 A vessel containing a i : 2,000 bichloride solution should be placed at the 
 side of the operator, so that he may from time to time dip his hands in it. 
 
 The operator and his assistants should wear over their ordinary garments 
 a blouse or linen frock, which must be changed, washed, and sterilized daily. 
 For operations where constant irrigation is used, the surgeon should further 
 be protected by a large apron of waterproof material. 
 
 B. Instfumcnts. — As far as practicable, the instruments used should be 
 of the simplest possible construction, easily taken apart if composed of sev- 
 eral pieces, without cavities or grooves from which impurities are removed 
 with difficulty. For this reason we should exclude slides on uterine sounds, 
 canulated suture needles, needle-holders with springs, and, in spite of their 
 convenience, the ingenious invention of Jacques Reverdin, needles with split 
 eyes. Instruments in one piece are the best. 
 
 The instruments, which immediately after a previous operation should 
 have been immersed for five minutes in boiling water containing a teaspoon- 
 ful of carbonate of soda to the quart and carefully wiped, must again be 
 boiled just before the next operation. Five minutes' immersion in boiling 
 water is sufficient to destroy all germs. The bichloride solution cannot be 
 used on account of its destructive action upon metals. Should the instru- 
 ments have been previously used upon septic material (fetid pus, sanious or 
 gangrenous matter, etc.), these precautions will be insufficient. They must 
 then be immersed for a half-hour in a strong (five-per-cent) carbolic solution 
 held at the boiling point, or kept for an hour in a sterilizing oven at 284° 
 F., or soaked for twelve hours in a strong -cold carbolic solution. These 
 processes have a deleterious effect upon the instruments, especially the bis- 
 touries, but they are nevertheless indispensable. 
 
 C. Surroundings. Operating Room. Furnitnre. — It is important that 
 the room used be perfectly clean, and free from curtains, hangings, mats, 
 carpets, etc., which might retain dust. In a private house, whatever room is 
 used for any important gynaecological operation should be emptied of its fur- 
 niture and thoroughly cleaned; in a hospital it is essential that the floor, 
 walls, and ceiling of the operating room should be so constructed that they 
 may be wa.shcd daily with the hose. Moreover, it is well to have sterilized 
 water and antiseptic solutions in jars with long tubes that may be easily 
 reached. It is advantageous to have, in addition to a high and wide window 
 at the side, free ingress of light from above. The furniture should l)e as 
 
ANTISEPSIS IN GYNECOLOGY, 3 
 
 scanty as practicable, and exclusively of glass or metal, easily movable and 
 easily cleaned. 
 
 D. The Patietit. Antisepsis of the External Genitals. — -The patient 
 should have had a complete bath with hot water and soap the evening before 
 or the morning of the operation. The rectum, however small a share it has 
 in the operation, should have been carefully emptied by an enema and after- 
 ward washed with a saturated solution of boric acid. The catheter should 
 be used by the surgeon or an assistant previous to the disinfection of his 
 hands. In all operations upon the vulva the pubic hairs must be shaved, to 
 add to the ease of the operation, as well as to remove a possible lodging- 
 place for septic material. 
 
 The external genitals and vagina should be cleansed first with hot water, 
 soap, and a brush, then washed with a i : i,ooo bichloride solution. 
 
 In my opinion, there is no objection to the i : i,ooo bichloride solution 
 as a vaginal injection, providing that it is administered under the conditions 
 and according to the directions to be given. The biniodide of mercury has 
 been recommended, but it does not seem to offer any great advantages. 
 Pinard and Bernardy use a solution of biniodide i : 4,000 instead of a sub- 
 limate solution I : 1,000. The use of bichloride in gynaecology and especially 
 in obstetrics has been much decried of late. Certainly at first it was used in 
 too strong solutions and with too little care, but the reaction has reached the 
 other extreme. The papers published upon this subject have not always 
 taken into account the radical difference between injections given imme- 
 diately after labor, and those administered under other conditions. In the 
 woman recently delivered, the vaginal and uterine cavities communicate 
 through a more or less gaping and softened cervix. Fluid injected into the 
 vagina, especially if one be not careful to separate its walls with the fingers, 
 flows readily into the uterus, accumulates and remains there, and is perhaps 
 absorbed by the relaxed mucosa, or its desquamated surface. Hence the 
 accidents noted after simple vaginal injections, which have been observed 
 not only after the use of bichloride, but after carbolic solutions. I would 
 here point out a danger attending the use of aqueous solutions prepared 
 upon the spot by diluting concentrated solutions of carbolic acid ; more es- 
 pecially if the preparation be impure, small oily drops may form w^hich dis- 
 solve with difficulty, and, as a consequence, the injection, instead of being a 
 perfect solution, is in reality a toxic mixture. This is the explanation of 
 cases observed by Briggs, serious accidents resulting from the administra- 
 tion of an injection of a teaspoonful of the alcoholic solution of carbolic acid 
 in a pint of water, to women recently delivered. It is equally certain that 
 the intra-uterine injection of a too powerful bichloride solution (i : 1,000) 
 may be dangerous even in non-puerperal patients, as in the case quoted by 
 Mijalieff, where such an injection, given daily for twenty-six days for sim- 
 ple metritis, resulted in a mercurial nephritis with haematuria. I purposely 
 omit allusion to the experiments upon the vaginae of female rabbits and 
 
4 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 giiinea-pigs, which do not seem to me conclusive. Moreover, one should 
 keep in mind the fact that the bichloride solutions commonly employed are 
 very rapidly neutralized by contact with abundant secretions, leucorrhoea, 
 cancerous ichor, etc., and lose both their toxic and disinfecting power. Er- 
 nest Laplace has recently shown the instability of this antiseptic, and has 
 investigated the cause and its remedies. The mercurial salt is precipitated 
 by albuminoid matter, forming albuminates, whence the rapid loss of anti- 
 septic power. The following are a few of his experiments : To an open 
 tube containing a little less than an ounce (25 c.c.) of natural serum is added 
 about a drachm (5 c.c.) of sublimate solution i : 1,000; the development of 
 germs is not prevented; with seven minims of serum bacteria are present. 
 In a tube containing a drachm of sublimate soluticn i : 1,000, with about 
 twelve minims of putrefied human blood containing bacteria, the microbes 
 multiply ; if a few drops of this mixture are cultivated on gelatin according 
 to Esmarch's method, at the end of five days we shall find large colonies of 
 the staphylococcus aureus. Laplace has found that the addition of 5 : 1,000 
 of tartaric acid to the solution is sufficient to prevent the formation of the 
 albuminates of mercury, without impairing its power to destroy every germ 
 present. This discovery, most valuable for general surgery, may also be 
 utilized in gynaecology. From my own experiments I have nothing but 
 praise to award it. 
 
 Creolin has been experimented with in gynaecology and obstetrics by 
 Baumm and Born in the Maternity and Obstetrical Clinic of Breslau. As 
 a result of their researches it would seem that creolin possesses certain de- 
 cided advantages, but also certain drawbacks which tend greatly to limit its 
 usefulness. It is extremely difficult to obtain a fixed product, its exact 
 chemical composition not having as yet been determined. It is used in 
 solution of I : 200 in treating ruptured perineum, fissured nipples, etc. If 
 more concentrated, it may produce erythema or eschars, so that as an anti- 
 septic it would seem to be inferior to a i : 8,000 bichloride solution (Baumm). 
 For intra-uterine injections Born has used a i : 100 solution, for vaginal irri- 
 gations 2 : 100, with no resulting accident due to absorption. Besides its 
 undoubted antiseptic power, creolin possesses the great advantage of leaving 
 the vagina soft and flexible, and even of imparting to it a degree of oiliness 
 which is of decided advantage in obstetrical operations, and in certain gynae- 
 cological manipulations when several fingers have to be introduced into 
 the vagina, or where a large tumor is to be extracted through it (enucleation 
 of fibroid bodies, vaginal hysterectomy). We know that solutions of the 
 bichloride of mercury and e\'cn those of carbolic acid have the opposite effect 
 of stiffening and roughening the vaginal mucosa, leading often to serious 
 inconvenience. This is, I believe, the only useful application of creolin. 
 The opacity of the solution renders it unfit for the immersion of instruments. 
 
 /J Naphthol, used by Bouchard for intestinal antisepsis, has been recently 
 extolled for surgical dressings, either in solution or as a saturated gauze. 
 
ANTISEPSIS IN C;YN.^.C0L0GY. 
 
 5 
 
 It has the advantage of being very slightly poisonous, and seems destined to 
 render real service. The aqueous solution contains only two parts in a 
 thousand. 
 
 Vaginal injections, to be truly cleansing, should be given according to 
 certain definite rules. A portable cylindrical can, to which is attached a 
 long tube ending in the nozzle (Figs, i and 2), .should be fixed at a slight 
 height above the operator, or held up by an assistant. The person who gives 
 the injection places the canula in the vagina, introducing by its side the 
 index and middle fingers, which are gently pushed up to the cul-de-sac, then 
 
 Fig. 
 
 -Vaginai, Ikri(;;ai 
 
 iR Srsi'ENSION. 
 
 Fig. 2. — PoRT.ABLE Vaginal Irrigator. 
 
 firmly rubbed about in every direction to open out the folds of the vagina 
 and insure their thorough cleansing. If this procedure be neglected, some 
 cause of infection will surely remain. The surgeon or his assistant should 
 himself give such an injection before an operation ; it is what I call rinsing 
 the A'agina. 
 
 All canulae to be used by the surgeon should be of strong glass with one 
 terminal orifice, fcr the water should be directed toward the cul-de-sac and 
 the cervix, cleaning the vagina upon its return only. For injections to be 
 administered by the patient herself it is best, to avoid all possibility of in- 
 troducing the tube into the os uteri, to have a canula with several openings 
 on the side of a terminal enlargement. It is also a convenience to use a 
 wire speculum, which accurately fits the canula, and which opens out the 
 vagina and permits of thorough irrigation (Fig. 3). The patient should lie 
 upon a pan, a Kelly pad, or a rubber sheet arranged to carry the fluids into 
 a pail (Figs. 4, 5, and 58). 
 
6 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 The accidents liable to occur from vaginal injections and the danger of 
 wounding the cervix or allowing liquid to enter through it, have been greatly- 
 exaggerated. Some physicians have even gone so far as to forbid the use of 
 the canula. This is, I think, a grave error. You should simply instruct 
 the patient to insert the instrument to a depth of six to eight centimetres 
 
 Fig. 3. — Fenestrated Speculi:.m for Vaginal Irrigation. 
 
 (three inches) only, or about a finger's length. Rubber canulse, which are 
 not easily cleaned and disinfected, should be discarded. Curved canulae 
 possess no advantage over straight ones. 
 
 During the week preceding the operation, the patient should take an anti- 
 septic injection (sublimate solution, i : 2,000) morning and evening, after 
 which a small pad of iodoform gauze is to be inserted in the vagina. On 
 
 Fig. 
 
 -French Bkij-tan with Exit-tube. 
 
 the day of the operation three injections are to be given, the first two at in- 
 tervals of an hour, the third at the very moment of the operation; I will 
 point out later the reason for this method of procedure. 
 
 After a vaginal injection, especially of corrosive sublimate, one should 
 be careful to press down upon the fourchette in such a manner as to insure 
 the escape of all the fluid. In many women the terminal portions of the 
 vagina and the vulva are of so firm a quality that much fluid may remain 
 imprisoned in the upper part of the canal, and give rise to the various acci- 
 dents due to absorption. I have myself witnessed several minor casualties 
 due to this cause. 
 
 There is a widespread opinion that an antiseptic injection should follow 
 
ANTISEPSIS IN GVN.-ECOLOGY. 7 
 
 and not precede minor gynaecological procedures — as examination, catheter- 
 ization, dilatation, etc. This is a grave error. Antisepsis is most needed 
 before any such manipulation. The observations of Kaltenbach upon the 
 auto-infection of parturient women might ha\'e caused a suspicion of the ex- 
 istence of a condition of latent infection, so to speak, of the female genital 
 organs, especially during the puerperal period. The researches of Winter 
 have recently placed this fact beyond dispute. The genital tract, vagina, 
 and cervix uteri of a healthy woman contain pathogenic germs ; the staphy- 
 lococcus pyogenes aureus, citreus, albus, and streptococci of three varieties 
 have beerr recognized by their several distinct characterisitcs and methods of 
 culture. But, and most important, their virulence seems to be attenuated 
 and latent, since the inoculation of animals with these germs and their cul- 
 tures has been without result. Notwithstanding this, they are a perpetual 
 
 Fig. 5.- Hospital Bed-pan (or Baker's Bed-pan). 
 
 menace, for these inert organisms may, at the slightest septic impulse from 
 without, germinate and fructify with the most terrible consequences. More- 
 over, there is no proof that these germs, innocuous so long as they remain 
 in their ordinary habitat below the orifice of the internal os uteri, may not 
 reacquire virulent properties if they are suddenly carried beyond this bound- 
 ary. That germs may be carried into the uterus by the use of the sound and 
 by manual touch has been proved beyond a doubt by Winter's examinations 
 of specimens removed by hysterectomy shortly after these operations. The 
 consequences of these remarkable experiments are important. As regards 
 the disinfection of the vagina prior to operation, they make its necessity 
 apparent. Is it possible, by means of the most carefully administered in- 
 jection, to get entirely rid of the micro-organisms quartered in the cervix.^ 
 Steffeck has made a particular study of this subject, from which he draws 
 the following instructive conclusions : 
 
 1. After a vaginal injection of one litre of a i : 3,000 sublimate solution, 
 as many germs as before are found in the cervix; only the vagina has been 
 cleansed. 
 
 2. After the same injection, in which the vaginal washing has been done 
 with the aid of one finger as described above, if some of the vaginal mucus 
 
8 CLINICAL AND OPERATIVE GVN.-ECOLOf;V. 
 
 be inoculated upon agar-agar, a number of colonies will develop, less numer- 
 ous, however, than in the first case. 
 
 3. After the same performance aided by two fingers, two of every three 
 cultures will remain sterile. 
 
 4. As a final experiment the injection of the vagina and the cleansing of 
 the cer\-ix are accomplished in the following manner : One finger is pushed 
 as deeply as possible into the cervix; another finger opens and permits a 
 thorough washing of the anterior cul-de-sac — then the two fingers are rubbed 
 about in such a way as to cleanse the posterior cul-de-sac; finally the stream 
 of water is sent directly into the os externum. After so thorough a washing 
 as this, all culture experiments have been without result, while before this 
 disinfection the tube cultures showed from fifty to one hundred colonies. 
 As might be expected, this disinfection is of short duration, as more germs 
 come from the supravaginal portion of the cervix through the os uteri, and 
 at the end of an hour may be found in the lower portion of the cervix. By 
 repeating the injection for a second and then a third time at intervals of an 
 hour, the germs may be destroyed for a longer time, Steffeck having found 
 that in such a case the mucus was free from germs for five days. 
 
 This process of successive sterilizations is somewhat tedious, but it re- 
 duces to a minimum the chances of auto-infection. This is the reason wh)- 
 I recommend the administration of three consecutive injections at intervals 
 of an hour, previous to every operation. No sound or dilator should ever be 
 introduced into the uterus without this thrice-repeated disinfection -of the 
 vagina and cervix. 
 
 To the omission of this precaution may be traced the numerous accidents 
 following these operations even when they are apparently done under strict 
 antisepsis. If we have to do with a disease causing a foul odor, as cancer, 
 sloughing fibroid, etc., the antiseptic should be preceded by a deodorizing 
 injection (which is at the same time in itself slightly antiseptic) of a quart 
 of hot water to which are added two or three teaspoonfuls of Labarraque's 
 solution of chlorinated lime or Pennes' vinegar. To wash the rectum and 
 the bladder, use either a solution of boric acid (30 : 1,000) or boiled water. 
 
 For dressings, iodoform gauze should be used almost exclusively. That 
 which we ordinarily obtain as an article of commerce is supposed to contain 
 from five to ten per cent of iodoform. When large amounts are needed, it 
 is more economical and better to have it ])reparcd by some one trustworthy 
 person. Ten yards of plain gauze sterilized by boiling are cut into pieces of 
 a yard each, soaked in a solution of iodoform (50), glycerin (100), and ether 
 iyoO), passed through a wringer, hung up in an isolated chamber which is 
 darkened and heated to 85° F., and dried, after which it is placed in tightl)' 
 closed tin boxes. I employ also for the first dressing strong iodoform gauze 
 which is prepared by rolling sterilized gauze or ten-per-cent iodoform gauze 
 in iodoform powder, shaking it lightly, and cutting it into small squares. 
 
 Some curious experiments made by von Eiselsberg in Killroth's clinic, 
 
ANTISEPSIS IN GYN^XOLOGY. 9 
 
 upon supposedly carefully prepared gauze, demonstrated the fact that it often 
 (eleven times out of thirty) contained germs whose presence was readily 
 shown by means of culture. If the gauze, before the addition of the iodo- 
 form, was subjected to a temperature of 212° F. (easily done by boiling it), 
 the cultures remained sterile in the proportion of eighteen out of twenty. 
 This preliminary precaution of sterilizing should ne\'cr be omitted. 
 
 It would be still better to heat the gauze to 250° F. in a steam sterilizer 
 in order to destroy both germs and spores. But this apparatus is not every- 
 where obtainable, and sterilization by means of boiling water, if not theoret- 
 ically perfect, certainly seems to produce sufficiently excellent practical 
 results. 
 
 It may seem surprising that iodoform alone does not suffice to destroy 
 all germs. As regards this point, we must refer to the researches of Heyn 
 and Rosving. They have proved that iodoform in itself is not a germicide, 
 is not even an obstacle to the development of germs. De Ruyter (of Berlin) 
 and Liibbert (of Wurzburg) have come to the same conclusions, which have 
 been further confirmed by the recent experiments of C. B. Tilanus. Shall 
 we conclude that iodoform in vivo is not an antiseptic in the presence of 
 pathogenic ferments .'' Certainly not. The researches of Behring (of Bonn) 
 will give the solution to this seeming contradiction. According to this 
 authority, iodoform acts upon and destroys leucomain sand ptomains as 
 fast as they are formed. It may be considered as an established fact 
 that it is not possible to have any dressings which will be absolutely 
 aseptic. You may keep them from all contact with the air in tightly 
 closed metal boxes ; but whenever the box is opened the germs may enter. 
 It is better, therefore, to use antiseptic gauze (iodoform) rather than aseptic 
 gauze which has simply been sterilized in a moist chamber. Nevertheless, 
 if sterilization were applicable on a large scale, not only to the dressings but 
 to all the bedding as well, it would no doubt be all-sufficient. In Berg- 
 mann's clinic, where everything is thus carefully purified, the effort is, as far 
 as possible, to replace antisepsis by asepsis, and for this reason gauze which 
 has simply been sterilized is used in many cases as a dressing. 
 
 If symptoms of absorption render necessary the substitution of some 
 other substance for iodoform, sterilized and sublimated gauze should be 
 used. This may be easily obtained by first boiling the gauze for an hour in 
 a solution of sodium carbonate, 20: 1,000, to remove all stiffening, then for 
 an hour in a i : 1,000 solution of bichloride. It is then dried in a sterilizing 
 oven and preserved in tightly closed boxes or jars. 
 
 I have used salol and iodol, and have found them very inferior to iodo- 
 form and sublimate. As to carbolized gauze, it so quickly loses its antisep- 
 tic properties that it is not to be depended on ; moreover, it is slightly 
 irritating. 
 
 A number of antiseptic substances have been recently extolled in gynas- 
 oology. Ichthyol, introduced into gynaecological practice by H. W. Freund, 
 
lO CLINICAL AND OPERATIVE GYN.-ECOLOGY. 
 
 has been the subject of many articles. These show that ichthyol, employed 
 with success in local applications for ulceration of the cervix and genital 
 pruritus, acts rather as an antiphlogistic and local analgesic than as an anti- 
 septic. It has been used internally in diseases of the genital organs depend- 
 ing upon the arthritic diathesis (chronic metritis, oophoritis). A resolvent 
 action upon exudates has been attributed to it, but this property has been 
 contested. Eschen has reported three cases of general erythema following 
 the use of ichthyol. 
 
 The aniline dyes have been recently recommended as powerful antiseptics 
 by J. Stilling, who uses a solution of from i : i,ooo to 5 : 1,000. Warmann 
 has employed with great success a i : 1,000 solution of pyoktanin or methyl 
 violet in cases of endometritis and of vaginitis and in gynaecological opera- 
 tions. He extols its antiphlogistic, analgesic, and antiseptic action. 
 
 Lysol, introduced into surgical and gynaecological practice by Cramer 
 and Wehmer, has a germicidal power at least equal to that of phenol. It is 
 much less toxic and its price is very moderate. It is said to lubricate the 
 hands of the surgeon and the instruments, a serious inconvenience during 
 operations, especially as regards hasmostasis, but advantageous in gynaeco- 
 logical examinations. Michelsen strongly urges its employment. 
 
 Dermatol has been presented as a substitute for iodoform. The obser- 
 vations of Sackur and Weissmuller show that while it is an excellent anti- 
 septic with a considerable drying power, it cannot supplant iodoform. Ac- 
 cording to Gloeser and Asch it renders great service in cases in which it is 
 desired to prevent an abundant secretion from a wound, or in which primary 
 union is desired in a place where an occlusive dressing is difficult to apply; 
 as the pedicles after hysterectomy, vesico-vaginal fistulae, operations upon 
 the cervix, perineorrhaphies, etc. 
 
 Among other antiseptics are aristol, whose good effects upon endometri- 
 tis, erosions of the cervix, perimetritis, and vulvar eczema have been appre- 
 ciated by von Swiecicki ; thiol, whose indications and antiseptic properties 
 are like those of ichthyol, of which it has not the disagreeable odor, though 
 its cost has prevented its general use; thiophane, employed in the form of 
 the biniodide either in powder or in gauze impregnated with a ten-per-cent 
 emulsion, and which may advantageously replace iodoform in many gynae- 
 cological operations; alumnol, which according to Heintz and Liebrecht is 
 of great service in gynaecology, either as an antiseptic for irrigating irregu- 
 lar wounds or as a mild caustic in the form of from two to five per cent 
 in cases of endometritis. Chotzen has used successfully in uterine irriga- 
 tion diaphtherin, or oxydinaseptol, recently discovered by Emmerich, and 
 which, according to Konrad, is one of the best antiseptics known, and di-iodo- 
 form, whose content of iodine is perhaps equal to that of iodoform and whose 
 therapeutic properties are analogous. 
 
 Antisepsis of the Cennx and Uterine Cavity. — After operations upon the 
 uterus or the cervix, it is well to leave some antiseptic in contact with the 
 
ANTISEPSIS IN GYN/ECOLOf;Y. I I 
 
 cenncal canal. I have used small crayons made according to this formula of 
 von Hacker : 
 
 ]ji Iodoform! pulv., .... 20.00 gm. ~ v. 
 
 Gum mi acaciae, 
 
 Glycerini, 
 
 Amyli, ..... aa 2.00 gm. gr. xxx. 
 
 M. S. To be made into sticks of the same calibre as the ordinary 
 sticks of nitrate of silver. 
 
 These crayons have the advantage of being very manageable, and they 
 can be inserted to quite a depth into the uterus ; but sometimes they dis- 
 solve incompletely, and their presence gives rise to colicky pains. I have 
 therefore abandoned their use, and content myself with dusting iodoform 
 upon the cervix or blowing it into the cavity, leavmg l^esides in contact 
 with the cervix a tampon of iodoform gauze. 
 
 The disinfection of the apparatus used in dilating the cervix is (^ne of 
 the most important points for our consideration. I do not use tupelo tents, 
 regarding them as much inferior to the laminaria. This even may be a 
 source of infection if we neglect certain precautionary measures. 
 
 It should be kept, for several weeks before using, in a saturated solution 
 of iodoform in ether, to which it is well to add one part of alcohol in ten. In 
 this way toxic effects, such as have been recently recorded after the use of 
 laminaria tents kept in a bichloride solution, are avoided. Konrad has ob- 
 served symptoms of poisoning by bichloride (tenesmus, severe pains, bloody 
 stools, metallic taste, etc.) five hours after the introduction of a laminaria 
 tent which had been kept in a i : 1,000 solution of mercuric chloride, the 
 symptoms disappearing rapidly after appropriate treatment. The anterior 
 and posterior vaginal walls showed small ulcerations produced by cauteriza- 
 tion. These as well as the toxic symptoms are believed by Konrad to have 
 been caused by small crystals of bichloride which had been deposited upon 
 the tent. 
 
 Intra-uterine injections in gynaecology are far from possessing the same 
 danger that they do in obstetrics, excepting where the uterine cavity is much 
 dilated and offers, after an operation, a large denuded surface (enucleation of 
 fibromata, curetting a cancer in the fundus, etc.). In a case like this, the 
 conditions are very similar to those of a uterus after delivery, so far as the 
 absorptive area is concerned. 
 
 When the uterine cavity is not specially dilated (as after curetting for 
 catarrhal or hemorrhagic endometritis), there is no objection to using a bi- 
 chloride solution I : 2,000, if one has a double-current catheter of hard rub- 
 ber, glass, or celluloid. But as most instruments are of metal, which is 
 attacked by the mercurial solution, it is better to use a one-per-cent carbolic 
 solution. This must be tepid and one may use a pint or more until from 
 the appearance of the fluid as it comes from the uterus it can be seen that 
 
12 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 the cleansing has been thoroughly accomplished. The number of tubes for 
 intra-uterine injections has greatly increased of late. When the uterine 
 cavity is not enlarged, I use the Bozemann-Fritsch instrument (Fig. 6), after 
 dilating the cervix, if that be necessary. If the uterus is much enlarged, no 
 
 I. Bozeman-Fritsch's. 
 
 2. Oliver's. 
 Fig. 6. — Recurrent Cathf.teks fuk iNTKA-rTERixE In'jections. 
 
 danger attends an injection given with an ordinary sound or canula, provid- 
 ing that the pressure of water be not too great, as the liquid can easily re- 
 turn around the canula. 
 
 Should the cavity of the uterus need powerful disinfection (as in certain 
 cases of gangrenous fibromata, intra-uterine cancer with putrid fungosities, 
 
 Fit;. 7. — Bldin's House-shoe Reci rrfnt Catheter kor Intra-I'terine Irrigation. 
 
 etc.), it would be well to use bichloride 1 : 2,000; after its prolonged appli- 
 cation, it must be followed by a second intra-uterine injection, simply to 
 wash away any of the poisonous antiseptic which might remain. For this 
 purpose I would recommend sterilized water, to which I would add 6: 1,000 
 of sea salt; this modifies its irritating and absorpti\-c powers by causing its 
 composition to approach more nearly that of the serum of the blood. I make 
 frec|ucnt use of this fluid for injections that are to be purely aseptic, when- 
 ever, for any reason, the use of antisei:)tics is contraindicatcd. 
 
 J^efore leaving the subject of the antisepsis of the external genitals, the 
 
ANTISEPSIS IN GYNECOLOGY. 
 
 13 
 
 vao'ina and the cervix, I would say a word in reference to a procedure which 
 is at the same time an adjuvant in an operation and a method of disinfection. 
 I refer to continuous irrigation. It may be accomplished by means of a 
 special speculum (Fig. 8), or more simply by the help of a long canula which 
 one of the assistants must grasp in his hand, supporting his wrist upon the 
 pubis, while in the same hand he holds another instrument (a retractor or 
 
 Fiii. 8. — Showing how Continuous Irrigation during Operation mav he Maintained bv Fkitsch's 
 Device, a. End of irrigatiri'jr canula to which rubber tube is to beattached. 
 
 a tenaculum, Fig. 9). I use for this irrigation carbolized water (10 : 1,000), 
 at 95° to 115° F. Its strength must be diminished to 5 : 1,000 if the irri- 
 gation lasts for any length of time, otherwise painful excoriations will be 
 the result. [The sterile normal salt solution is much to be preferred for 
 this purpose.] The slender stream of water which constantly flows upon 
 the operating field, and can be increased or diminished at will, has a two- 
 fold advantage : it washes away the blood, thus dispensing with the neces- 
 sity of sponges or their substitutes, and it keeps the wound bathed in an 
 antiseptic fluid which is a far better protection against the germs in the 
 atmosphere than even the spray. In all operations upon the vulva, vagina. 
 
14 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 and cervix, the use of continuous irrigation is to me a matter of routine 
 practice; I can scarcely praise it too highly. 
 
 I never use sponges except in vaginal h)'sterectomies, as I consider 
 pledgets of absorbent cotton, either dry or soaked in a solution of bichloride 
 and then wrung out thoroughly, to be superior in all other cases. When 
 
 Fig. 9. — CoNT7Nrors Ikrigation- witf^ "a Long Nozzle; also Shows Position ok Assistants. 
 
 these are used dry, it is well to wrap each in gauze in order to avoid the 
 detachment of portions which adhere to moist surfaces. 
 
 Laparatomy. 
 
 I will now take up the special antiseptic precautions which are to be 
 used in a laparatomy. 
 
 A serious preliminary point arises: How does it happen that operators 
 of great authority, as Lawson Tait and Bantock for example, disapprove 0/ 
 antisepsis, regarding it as useless and even dangerous, and, in spite of this 
 opinion, obtain the most superb results.? Does not this fact greatly impair 
 the value of the minute precautions which we are about to advise.-* 
 
 The contradiction is more apparent that real, and to convince yourself of 
 this it is only necessary to follow in detail the methods of procedure adopted 
 by these operators whom I have quoted. This will show that if they are not 
 antiseptic they are eminently aseptic, that is to say, they replace chemical 
 by physical antisepsis (the use of heat) and by the maintenance of strict 
 
ANTISEPSIS IN GYN/ECOLOGY. I 5 
 
 cleanliness. Now for a laparatomy and all intraperitoneal operations, asep- 
 sis is not only equal but far superior to antisepsis. In fact, considering the 
 delicacy of the endothelium lining serous cavities, an antiseptic solution 
 strong enough to exert any action would injure this tissue and perhaps be 
 followed by results which would endanger the success of the operation. 
 Rigid asepsis, then, should be the rule for the interior of the abdomen, anti- 
 sepsis being reserved for the exterior. If, moreover, you will note the fact 
 that after a laparatomy and the accurate fitting together and suture of the 
 abdominal walls, there is, so to speak, no longer any wound, you can under- 
 stand why the omission of antiseptics in the dressings may be unattended 
 by untoward results. Notwithstanding all this, I consider such omission to 
 be an error. 
 
 A. The operator and his assistants must be absolutely clean. For forty- 
 eight hours previous to the operation, none of them should have been in a 
 dissecting room, nor present at an autopsy, nor have handled an anatomical 
 specimen or septic wound. 
 
 On the other hand, they should have taken a full bath, using hot water 
 and soap over the whole body. 
 
 A long and perfectly clean sterilized linen garment should cover their 
 ordinary clothes. [It is better to remove the outer garments before putting 
 on the operating-room suit.] The hands and arms should be disinfected ac- 
 cording to directions given above. After these ablutions they must be care- 
 ful to touch nothing which has not been disinfected, nor to shake the hand 
 of any friend. If necessary, one may wear sterilized rubber gloves until the 
 very moment of the operation. 
 
 The number of assistants should be as restricted as possible in order to 
 diminish the chances of infection. One is usually sufficient for the opera- 
 tion itself ; a second to prepare and hand sutures and ligatures. The sur- 
 geon himself will take his instruments from the receptacles where they are 
 lying in an antiseptic solution. 
 
 No one should operate upon the abdomen if there be the smallest sore or 
 suppurating scratch upon the hands, for no rubber finger shield can fully 
 protect the peritoneum from possible infection. 
 
 B. The patient has on the previous evening been given a soap and sub- 
 limate bath. For several days she has had, night and morning, a vaginal 
 injection of bichloride i : 2,000, after which a pad of iodoform gauze has 
 been placed in the vagina. The bowels have been emptied by a purge the 
 day before, and by an injection in the morning. An assistant uses the cath- 
 eter, and immediately disinfects his hands. The hairs are shaved, the ab- 
 domen is scrubbed with soap and hot water with a brush, then with ether, 
 and finally with bichloride i : 1,000, taking especial care to clean the cutane- 
 ous folds of the umbilicus. The abdomen is then covered with compresses 
 saturated with sublimate solution, and these remain in place for the time, 
 however short, which elapses between the cleansing and the operation. 
 
i6 
 
 CLINICAL AND OPERATIVE GYNAECOLOGY 
 
 Kelly advises covering the abdomen, for two hours before the final cleansing, 
 with a poultice of soft potash soap in order to remove the epithelium. 
 
 C. In a hospital, a special room is reserved for laparatomies. It is as 
 far as possible from the wards in which are patients with suppurating or sep- 
 tic wounds, from the water-closets, and, in short, from all sources of infec- 
 tion. The corners should be rounded off ; there must be no recesses o~ 
 places not easily accessible for cleansing purposes. All the furniture should 
 be movable; seats, tables, stands, should all be of metal, enamelled or var- 
 
 FiG. lo. — Laparatomv Table of Mme. Horn, Emploved b>' Martin. 
 
 nished, or of glass. After each operation, the wall should be washed with a 
 hose attached to a pump, or to a faucet which admits the water with suffi- 
 cient force to send it to the most remote corners. 
 
 Should the operation not be performed in a hospital, the room chosen 
 should be carefully prepared at least two days in advance. The furniture 
 must be removed ; if the walls have not been newly whitewashed, they must 
 be carefully cleaned, as well as the ceiling, floor, and woodwork, with cloths 
 soaked in a carbolic solution 50: 1,000. If the house be old, or the room 
 under suspicion, this cleansing should be supplemented by a disinfection 
 with sulphurmis acid — placing some sulphur (two pounds to each one thou- 
 sand feet) upon a dish in the middle of the room, setting fire to it, and her- 
 metically sealing the openings to the chamber during twenty-four hours. 
 
 During the whole of the operation the temperature of the room should 
 be high, in order to avoid all chilling of the patient intns ct extra. From 
 'jy'^ F. at least, to 86° F. at most, is necessary. 
 
ANTISEPSIS IN GVN^XOLOGY 
 
 17 
 
 rustnimcnts.—ThQSQ should have been thoroughly cleaned and immersed 
 in boiling water for five or ten minutes after the preceding operation. On 
 the day appointed for the laparatomy they are to be placed for an hour in a 
 hot-air oven at 250° to 290° F., then plunged into the two-per-cent carbolic 
 solution. A sterilization less perfect, but sufficient for ordinary practice, 
 may be obtained by boiling (Figs, i i and 12) the instruments for a quarter 
 
 Fig. it.— Poktable Sterilizer. The cover serves as a second tray. 
 
 of an hour in a one-per-cent solution of carbonate of soda (Bergmann). This 
 solution possesses the advantage over pure water that it avoids oxidation. 
 Dressings must be sterilized, by means of steam under pressure, in auto- 
 claves. Of these I mention particularly those of Redard, Geneste-Herscher, 
 
 Fig. 12. —The Same, closed. 
 
 Wiesnegg (Fig. 17), Chamberland, Vaillard, and Besson. Chamberland's 
 autoclave is the type of apparatus intended for the sterilization of instru- 
 ments and dressings by steam under pressure, so a brief description of it, 
 borrowed almost verbatim from Terrier, follows : 
 
 This autoclave may be used also without pressure and at 212'' F., but it 
 is when under pressure that moist heat is most effective in surgical steriliza- 
 tion. In fact this pressure, which may be raised to two, three, or four atmos- 
 pheres, causes a rise of temperature to 248°, 273°, and 291° F. respectively. 
 
1 8 CLINICAL AND OPERATIVE GVN.^iCOLOGY. 
 
 This autoclave is formed of a cylinder of red copper, soldered, and sur- 
 rounded by a covering of sheet iron. The upper opening is closed by a 
 bronze cover which is fixed at its periphery by strong thumb-screws and 
 bolts. This cover presents three orifices : a safety-valve, a cock, and a man- 
 ometric tube. The manometer is graduated from o to 3 atmospheres and 
 gives at the same time, approximately, the tension of the steam contained in 
 
 Fk;. I!. — St him.mei.risch's Strrilizek. 
 
 Fig. 14. — Box for Stekilizin(; Dressings in 
 Schi.mmelbusch's Ai-iARATis. The openings 
 are closed after sterilization by a slidine: band. 
 
 the apparatus and its temperature. It should be remembered that the pres- 
 sure at zero is one atmosphere, so that at three four must be read. 
 
 Below the boiler, surrounded and supported by a chamber encased in 
 .sheet iron, is the gas-burner, which has two concentric circles of jets inde- 
 pendent of each other and capable of being lighted together or separately. 
 In the interior of the boiler is a basket of ordinary copper or brass wire 
 gauze, separated by an empty space from the lower part of the boiler. For 
 this basket are substituted metallic boxes, nickel plated or of pure nickel, 
 when compresses or gauze sponges are to be sterilized. These boxes are 
 clo.sed with a bayonet catch, and possess at their upper ends holes which per- 
 mit the entrance of steam to the interior of the boxes when the catch is not 
 entirely shut. 
 
ANTISEPSIS IN GYNAECOLOGY. 1 9 
 
 In using the sterilizer one to two litres of water, previously boiled, are 
 poured into the boiler, the metallic basket (;r boxes put in place, the cover 
 shut down, and the bolts raised and fixed by the thumb-screws. The cock 
 in the cover must be left open in order to allow the egress of the air within 
 the apparatus as it is displaced by the steam. When the water boils, a jet 
 of steam issues from the cock and the temperature is about 212° F. In 
 order to obtain a higher temperature the cock is closed when it gi\'es out a 
 full jet of steam and the screws of the bolts of the lid are tightened. The 
 pressure, indicated by the manometer, may rise to four atmospheres with a 
 temperature of 290° F. 
 
 It is well to regulate the gas and arrange the safety-valve so as to obtain 
 and maintain the desired pressure and temperature for some time. At the 
 beginning of the sterilization steam should be allowed to blow off once or 
 twice in order to remove the last portions of air which the apparatus con- 
 tains. When the temperature and pressure sought have been maintained for 
 the time wished, the gas is extinguished, and when the needle of the ma- 
 nometer has returned to zero, the cock is opened and air allowed to enter. 
 The lid is then raised and the objects sterilized or the boxes which contain 
 them are lifted out. Complete cooling must be waited for, or else the rub- 
 ber washer placed between the cover and the boiler may become adherent 
 and be easily torn. 
 
 The apparatus which I have long used, and which offers the advantage of 
 being light and portable in spite of its great size, is that which Lautenschla- 
 ger has constructed according to the indications of Schimmelbusch (Fig. 13). 
 It is formed of two copper cylinders placed one within the other and solidly 
 united. Being of unequal size these have between them a space which is 
 partially filled with a one-per-cent solution of carbonate of soda (up to the 
 point O). The dressings, enclosed in a metallic box pierced with holes 
 (F"ig. 14), are placed in the internal cylinder, and the cover of the apparatus 
 firmly closed by screw nuts, a rubber washer being placed beneath the lid to 
 assure perfect adhesion. A gas burner or several alcohol lamps may be used 
 for heating the apparatus. The steam formed by boiling the water between 
 the two cylinders can escape only into the internal cylinder through a line 
 of openings near its upper border. Entering here it passes through the dress- 
 ings, condenses at the bottom of the internal cylinder, and passes out of the 
 apparatus by a cock. In half an hour from the time when steam begins to 
 be formed the sterilization is sufficient. 
 
 This apparatus, though very convenient, does not give, theoretically, an 
 al)solute sterilization, as the temperature does not rise sensibly above 212° 
 F. ; spores must resist its action ; it is rather a pasteurization which takes 
 place. It seems sufficient in practice, and I have used it for several years 
 in my service with excellent results. It is for this reason that many Ameri- 
 can hospitals limit themselves to sterilizing dressings in simple and portable 
 apparatuses which are used for the pretended sterilization (pasteurization) of 
 
20 
 
 CLINICAL AND OPERATIVE GYN.-ECOLOGY. 
 
 milk (Fig. 15"). One may be easily improvised with any kind of vessel 
 (Fig. 16). 
 
 Cutting instruments and needles may also be sterilized in the direct 
 flame of an alcohol lamp or Bunsen burner. For bistouries and scissors this 
 method should be employed only when absolutely necessary, as it is uncer- 
 tain and injures the instruments. For needles it is very convenient and 
 more reliable on account of their small size, but in order to avoid ruining 
 their temper they should be plunged immediatel)- after being heated into a 
 cold antiseptic or aseptic solution. 
 
 I recommend the operator to use no instruments but his own and to ster- 
 ilize these himself, rather than rely upon the assistance of others. One can 
 
 Fig. 
 
 -Arxold's Stkrilizer. 
 
 ^-^-liSf.-i-T^m-s^w' 
 
 Fig. 16. — Extemporized Sterilizek. 
 
 never be sure, from an antiseptic point of view, of borrowed instruments. 
 Better a disinfected bistoury that is dull than a sharp bistoury capable of in- 
 fecting the patient. 
 
 I have completely given uj) sponges for the same reason. It is not 
 always easy to obtain them new and perfectly purified, and this does not 
 seem strange when we consider the number of processes to which they must 
 be submitted before they can be called clean. Schimmelbusch, though favor- 
 ing gauze sponges for ordinary operations, employs marine sponges for cer- 
 tain special operations, especially for making the toilet of the peritoneum. 
 The following method is recommended by him as furnishing a sufficient 
 guaranty of sterility of the sponges. They are first washed thoroughly in 
 cold water, then in hot, and next wrung out with great care in a cloth or 
 preferably in a bag. They are then plunged, still contained in the bag, into 
 a one-per-cent solution of sodium carl^onate, the solution having been 
 
ANTISEPSIS IN GYNy1<:COL()GY. 
 
 21 
 
 brought to a boil and being withdrawn from the fire just as the sponges are 
 put in, as the latter are injured by boiling. They are left in this solution 
 half an hour, then wrung out, washed in boiled water to remove the sodium 
 carbonate, and kept in a i : 2,000 solution of bichloride. Sponges which 
 have already been used require a still more scrupulous cleansing and are 
 always less reliable on account of the septic character of the fluids which 
 may have come into contact with them. They are both unreliable and ex- 
 
 Fin. 17. — Wiesnegg's Sterilizing Oven. A, Regulator; />, burners; C, thermometer. 
 
 pensive. One may be astonished that I mention the latter consideration, 
 but it should not be overlooked in a hospital. It also frequently happens, 
 especially in places distant from the great centres, that one can obtain only 
 sponges which are too hard or too easily torn, or of incofivenient size or 
 shape, and quite unmanageable. Having witnessed in Billroth's service in 
 Vienna the advantages which aseptic gauze sponges offer in laparatomies, 
 I use them exclusively. My method of preparing them is as follows : a 
 piece of gauze, a fine muslin known commercially as cheese-cloth, is folded 
 several times so as to make pads twelve inches square and consisting of 
 eight thicknesses of gauze. These compresses are carefully hemmed at the 
 edges with long stitches. They are then sterilized in the autoclave. If 
 this is not obtainable, they may be boiled for two hours at least in a one-per- 
 
22 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 cent solution of sodium carbonate. They are kept in a weak solution of 
 bichloride, and at the time of using are washed carefully in hot water which 
 has been sterilized by filtration and boiling, and wrung out. 
 
 These gauze sponges are a ver}- efficient and convenient absorbent 
 agent, which can be rapidly given any form or dimensions, can be introduced 
 upon the finger into cavities and interstices, and can be spread upon the in- 
 testines ; they offer in fact many advantages over sponges. During an oper- 
 ation the same compress may, if necessary, be used several times after 
 being w^ashed ; but those which have been soiled by septic fluids are imme- 
 diately thrown away, and after each operation all which have been used are 
 destroyed. Their insignificant cost justifies this sacrifice which often seems 
 extravagance in the case of sponges. In 1886 I first introduced in my hos- 
 pital ser\dce in Paris the exclusive use of gauze sponges for laparatomies, 
 and detailed their advantages in a report to the Societe de Chirurgie on 
 October 19th, 1887. 
 
 I shall confine myself to a simple enumeration of the antiseptic processes 
 which form part of the operation itself, and return to the subject under the 
 head of individual operations. I shall mention here only those which are of 
 especial importance. 
 
 The antiseptic spray, which has long been employed over the field of 
 operation, is more harmful than useful ; it chills and irritates the peritoneum 
 beyond measure. 
 
 Care of the Peritoneum. 
 
 Laparatomists have long pushed to an extreme the care taken to clear 
 away all discharges and clots of blood from the peritoneum. They have 
 greatly exaggerated the noxious action of these residua, which are very likely 
 to be reabsorbed if the absorptive powers of the serous membrane are not 
 destroyed by irritating solutions and unnecessary rubbings. One should be 
 very cautious in the care of the peritoneum and try to avoid the necessity for 
 much dressing by preventing the overflow of the contents of tumors. Where 
 this is not possible, the cleansing should be rapidly accomplished by means 
 of the gauze sponge. It has been demonstrated that some fluids which have 
 the reputation of being ver}' infectious, as the contents of cysts and the pus 
 from a pyosalpinx of long standing, are really less dangerous than has been 
 .supposed. 
 
 Flushing the peritoneum with warm sterilized salt solution was first ex- 
 tolled by Lawson Tait, and is chiefly of use where an irritating or infectious 
 fluid has come in contact with the serous membrane during the operation; 
 but it should not be used to wash away the blood, as this can be accom- 
 plished perfectly well by means of the gauze sponges. Although it is cer- 
 tainly a serious matter to leave the least drop of pus or the smallest septic 
 particle in the peritoneal cavity, the case is not the same with small clots 
 which are easily absorbed. There is another indication for these hot-water 
 
ANTISEPSIS IN GYNAECOLOGY. 23 
 
 flushings to which I will make only a passing allusion. They have been 
 much praised for the counteraction of shock following an operation. Polail- 
 lon has recently pointed out the danger attending the administration of wash- 
 ings of too high a temperature upon the supra-umbilical portion of the peri- 
 toneum in the vicinity of the solar plexus; they may cause an arrest of 
 respiration and syncope. As for pelvic washings, they are not harmful 
 when performed rapidly and with some harmless fluid which can be absorbed 
 without danger. However, the experiments of Delbet have proved that these 
 washings temporarily impair the absorbing powers of the peritoneum — a fact 
 which should be kept in mind if there is any fear of secondary oozing, as it 
 may render drainage necessary. 
 
 Water filtered through the Chamberland filter may still contain microbes, 
 as Tripier has shown, and we know that simply boiling it kills the germs 
 but not the spores. Certainly water which has been filtered and boiled is 
 fairly pure and may be used without much fear. But to insure absolute 
 security the temperature must have been raised to 250° F. 
 
 I Sterile normal salt solution is best prepared by adding one and a half 
 drachms of sodium chloride to the quart of water, filtering into clean flasks, 
 whose necks are then stopped with plugs of ordinary cotton batting, not 
 absorbent cotton, and disinfected by heating to the boiling point on three 
 successive days.] The cauterization of wounded surfaces, pedicles, and ad- 
 hesions has been done by means of antiseptics such as a concentrated so- 
 lution of carbolic acid, the tincture of iodine, iodoform, or with the actual 
 cautery. The last-named process was introduced by Baker Brown, and is 
 much in vogue in England and America. For my part, I often use it where 
 a cut surface has a suspicious appearance (as in some salpingotomies) or is 
 merely thick and moist. Be it understood, I speak in this connection only 
 of the antiseptic powers of cauterization, which it is important to keep sepa- 
 rate from its haemostatic properties, so valuable in parenchymatous oozing. 
 Paquelin's thermo-cautery has taken the place of the red-hot iron. A strip 
 of sterile gauze should be wrapped about the handle of the instrument in 
 order to prevent the hands from becoming soiled by contact with it. 
 
 Preparation and Preservation of Materials Used for Ligation" and 
 
 Suture. 
 
 The subject of antisepsis in gynaecology would be incomplete without a 
 section relating to the preparation and preservation of the various materials 
 used for ligatures and sutures. 
 
 Silk. — The strongest with the least bulk is the flat-braided silk, of which 
 twelve different numbers are made. It should be sterilized in the steam 
 chest or autoclave after being rolled in small quantities upon glass bobbins. 
 If one does not possess such an outfit the silk may be rolled in very loose 
 skeins (a precaution extremely important for securing equal and perfect ster- 
 
24 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 ilization), and then boiled for one hour in a five-per-cent solution of carbolic 
 acid. It is then to be rolled again upon glass reels and placed in a fresh 
 carbolic solution of the same strength, which should be changed every eight 
 days. It may also be kept dry, in small quantities superimposed and sepa- 
 rated by wool tampons, in a large sterilized glass tube. This method allows 
 the successive use of small quantities of silk without touching the whole 
 supply. 
 
 Schimmelbusch has had made a small box in which silk is sterilized and 
 kept. This box has a hinged cover and a side wall which can be drawn out. 
 The silk is rolled on small metallic drums, each formed of four parallel rods 
 united at their extremities by two metallic discs into which they are inserted. 
 In this way the steam is enabled to exert its sterilizing action upon all of 
 the silk. Each drum is movable around rods soldered to the box. A fixed 
 plate, pierced to allow the passage of the silk, protects it from all infection. 
 For purposes of sterilization the box is opened and placed in the steam ster- 
 ilizer. A similar box has been constructed by Forgues. 
 
 Catgut. Four numbers of catgut are manufactured. The method of 
 
 preparation which yields the best results is that by means of oil of juniper 
 wood (oleum ligni juniperi), which must not be confounded with oil of juni- 
 per berries (oleum juniperi). The oil of juniper wood was first recommended 
 by Thiersch and later adopted by Kiister, Schroder, Martin, Hofmeier, etc. 
 Kocher determined experimentally that this oil sterilizes violin string in 
 twenty-four hours (Troisfontaines : "Manuel d'Antisepsie Chirurg., p. lOo). 
 The same surgeon has, however, recently attacked catgut, which he holds 
 responsible for several septic cases which have occurred in his service, and 
 of which he has therefore given up the use. It seems probable that Kocher 
 had the misfortune to be supplied with a bad quality of catgut. His opinion 
 has been strongly combated by Zweifel and J. L. Championniere. In my 
 service the catgut is first carefully treated with ether to remove fat, then 
 sterilized in the hot-air oven at 230° F. for one hour. It is next soaked in 
 a 1 : 1,000 bichloride solution, then kept in the oil of juniper for several 
 weeks, and finally taken out of this and kept in rectified spirits to which is 
 added a tenth part of oil of juniper. Martin employs a slightly different 
 process. The catgut is rolled on glass reels, immersed for six hours in a 
 I : 1,000 solution of bichloride, withdrawn, dried by pressing in a towel, and 
 placed in a mixture of two parts of alcohol and one of oil of juniper. This 
 may be used after six days. During the operation the amount to be used is 
 kept in a basin in some kind of antiseptic fluid. In the Frauenklinik in 
 Berlin, the catgut is left twenty-four hours in oil of juniper, then for the 
 same length of time in glycerin, after which it is placed in absolute alcohol 
 t(j which has been added a small quantity of oil of juniper. 
 
 Tiie advantages posses.sed by catgut prepared in juniper oil are many: it 
 is far superior to that more commonly used which is disinfected in carbolized 
 oil; it possesses remarkable tenacity and flexibility; it may be used for 
 
ANTISEPSIS IN GYN.4£COLOGY. 2$ 
 
 buried sutures, as it is dissolved and absorbed in a length of time propor- 
 tionate to its bulk, which, by the way, should be carefully noted by the 
 operator. Jt is because of these qualities possessed by catgut that buried 
 sutures and sutures in layers have been undertaken with such success and 
 have given such excellent results. 
 
 Benckiser, who lias adopted the method of disinfection by heat, places 
 his rolls of catgut in envelopes, before putting them in the sterilizer — open- 
 ing the envelope only at the very moment of using the catgut. 
 
 Mikulicz has indicated a method of preparation which transforms the 
 catgut into a remarkably resistant and tenacious material for sutures, which 
 Leopold has adopted for Caesarean sections. The catgut is first put for 
 forty-eight hours in carbolized glycerin, lO parts to lOO, then for five hours 
 in a solution of chromic acid i : 200, and finally preserved in absolute 
 alcohol. 
 
 Doderlein recommends a slightly different method of preparation. He 
 plunges the catgut into a i : 1,000 chromic-acid solution for ten minutes, 
 dries it, and sterilizes it for two hours in an oven at 266° F. 
 
 We might mention also the methods of Braatz, Bunner, Partridge, Clin- 
 ton Gushing, and others, which are all processes of chemical disinfection. 
 Repin sterilizes catgut in the vapor of absolute alcohol at 250° F. for one 
 hour, and keeps it in tubes sealed in the flame, containing several cubic cen- 
 timetres of sterilized bouillon. This method of preservation serves as a 
 control, as unless the sterilization of the catgut is complete, the bouillon 
 quickly becomes cloudy. 
 
 [Probably the most certain method of sterilizing catgut is first to remove 
 all oil by soaking in ether and then to boil in ninety-five-per-cent alcohol, 
 the boiling being repeated on three successive days. This may be accom- 
 plished by using a still, as is done at some of the larger hospitals, or by put- 
 ting the gut into screw-topped bottles and heating in a water-bath, the 
 covers being left loose at first and screwed down when the bottle is taken 
 from the bath.] 
 
 Silvcj' Wiir, Si/kwonn Gut. — After heating to 250° Y. for one hour in 
 a sterilizer, these may be preserved in rectified spirit. 
 
 [Silkworm gut can be obtained in two sizes, coarse and fine. It may be 
 sterilized in tubes in the same manner as silk, or simply boiled in the soda 
 solution with the instruments. It should be soaked for twenty minutes 
 before using to render it more pliable and less liable to break. Silver wire 
 can be sterilized by moist or dry heat, and the metal itself is said to possess 
 definite antiseptic properties,. so that by its use stitch-hole abscesses may 
 be avoided.] 
 
 Elastic Ligatures. Drainage Tubes. — These may ho. made relatively 
 pure by boiling them for twenty minutes in a i : 1,000 bichloride solu- 
 tion ; they are then kept in a strong solution of carbolic acid or in I : 1,000 
 bichloride contained in bottles with tightly fitting corks. It is, how- 
 
26 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 ever, preferable to sterilize them in an autoclave or oven for one hour, 
 at 230° F. Rubber objects should be carefully isolated from each other 
 by gauze compresses, in order to avoid their agglutination. M. Baudouin 
 recommends the use of a i : 100 bichloride solution and several successive 
 boilings. 
 
CHAPTER n. 
 
 ANESTHESIA IN GYNECOLOGY. 
 
 Local anaesthesia may often be employed with good results, the method 
 differing' 'according to whether the operation be upon the skin or mucous 
 membrane. For an incision, or a rapid dissection, we may freeze the part 
 by means of a mixture of cracked ice and salt, operating the very moment 
 the skin becomes white, for an undue prolongation of the action of the cold 
 might result in a blister or even a slough. Richardson's ether spray is ex- 
 ceedingly convenient and too well known to need description. It possesses 
 the drawback of slow action and of preventing the use of the thermo-cautery ; 
 some foreign authorities, and Terrillon in France, have proposed replacing 
 it with a spray of bromide of ethyl, which is non-inflammable ; but this in 
 its turn possesses disadvantages which have interfered with its widespread 
 use. 
 
 Recently Redard has praised the effects of ethyl chloride employed as a 
 spray. This liquid, which vaporizes at 50° F., is convenient for use in prac- 
 tice. It is kept in small sealed glass bulbs with slender tips and containing 
 ten grams (two and one-half drachms) of ethyl chloride. In using it the 
 tip of the bulb is broken, and the heat of the hand is sufficient to vaporize 
 the ethyl chloride, which escapes in a fine jet. 
 
 Cocaine chlorhydrate can be used for anaesthesia of the skin. 
 
 Wolfier has demonstrated that if you inject hypodermatically, or prefer- 
 ably endermatically, fifteen minims of a five-per-cent solution, at the end of 
 one or two minutes a local anaesthesia will be produced which will last from 
 twenty to twenty-five minutes. The zone of anaesthesia will extend about 
 two to three centimetres around the point of entrance, and a second area of 
 semi-anaesthesia of the same extent surrounds the first — which gives us from 
 four to six square centimetres upon which we may operate painlessly for 
 from twenty to twenty-five minutes. This is more time than is needed to 
 open an abscess or remove a small tumor. If the operation is to be upon a 
 mucous surface, all that is required is to paint it over with a ten-per-cent 
 solution of the cocaine. This will produce an anaesthesia which may easily 
 be prolonged by repeated applications, so that, as I can bear testimony from 
 my own experience, an Emmet's amputation of the cervix may be done by 
 this means. The anaesthetized mucous surface seems, to use the patient's 
 own expression, to be " made of wood."" 
 
 I am convinced that the field of local anaesthesia in gynaecology would 
 be greatly increased, could we but overcome the timidity of those patients 
 
28 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 whose fears yield more readily to general anaesthesia. Daniel Lewis, of 
 New York, after the injection of cocaine, performed a painless amputation 
 of the breast upon a woman of sixty years, who, on account of a cardiac 
 murmur, was in dread of general anaesthesia. In the same way I amputated 
 the finger of a young woman who absolutely refused to be made unconscious. 
 
 Some surgeons, including Schleich, who uses a spray of cocaine in ether 
 I : lOO, Roux of Lausanne, and Reclus, have been able to perform laparato- 
 mies without employing general anaesthesia. They claim to have obtained a 
 sufificient insensibility by the simple injection of cocaine into the skin and 
 subcutaneous cellular tissue. I do not believe that their example should 
 be imitated. Largeau, of Niort, has gone still farther, having performed 
 three ovariotomies and one hysterectomy with absolutely no anaesthesia of 
 any sort. 
 
 We must not omit to mention and inquire into the statement made by 
 Hanks, namely, that applications of cocaine have an injurious effect upon 
 the union of wounds after plastic operations. In the cases quoted by the 
 American surgeon, may this result not be due to the use of a non-sterilized 
 cocaine solution ? The water for these solutions should be distilled and 
 then boiled, and it is well to add a few drops of Van Swieten's fluid. 
 Neverthless, we should bear in mind that accidents have sometimes occurred 
 as a result of these injections, and use them with moderation. Bousquet, of 
 Clermont-Ferrand, also claims to have seen two cases in which, in spite of 
 all antiseptic precautions, primary union entirely failed to take place. He 
 attributes this result to local trophic disturbances due to the cocaine. Dud- 
 ley reports to the Obstetrical Society of New York three cases in which the 
 hypodermatic injection of cocaine was followed by most alarming symptoms. 
 In two of the cases he had injected a solution into the cervix before curet- 
 ting the uterus ; in the third, at the margin of the anus before removing a 
 syphilitic growth. He used a ten-per-cent solution, of which he injected 
 about fifteen minims. One of the patients swooned; all were greatly de- 
 pressed. Emmet has noted similar untoward results. A loss of conscious- 
 ness has been observed after the hypodermatic injection of six drops of a 
 twenty-per-cent solution of the chlorhydrate of cocaine, which is equivalent 
 to six centigrams of the active principle. Very serious symptoms, such as 
 vomiting, extreme weakness, slowing of the respiration, and enormous in- 
 crease in the pulse rate, resulted from the hypodermatic injection of one 
 grain (sixty-five milligrams) with which Dr. B. J. Howel experimented 
 upon himself. 
 
 Lorenz has observed accidents with still smaller doses. Two, one, and 
 even three-quarters centigrams of cocaine injected into the cervix have 
 caused symptoms which, though not alarming, showed an evident intoxica- 
 tion. It would seem unsafe to use a larger dose than five centigrams or 
 twenty drops (about one gram) of a five-per-cent solution of cocaine. Re- 
 clus, who formerly employed as much as twenty centigrams, now never ex- 
 
AN.^iSTHESIA IN GYNECOLOGY. 29 
 
 ceeds ten to fifteen, and recommends the use in all cases of a very diluted 
 solution (1 : lOO). Roux opposes large doses, and insists upon the particular 
 susceptibility of certain persons; he has seen tetanoid symptoms develop 
 after the injection of five and one-half centigrams. Mannheim has collected 
 two hundred cases of accidents caused by cocaine. The largest dose which 
 was tolerated was one and one-fourth grams ; the smallest which caused 
 death, one-quarter of a gram. He advises the use of two centigrams as an 
 average dose. 
 
 It is difficult not to consider the accidents imputed to extremely weak 
 injections as exceptions resulting either from errors in dosage or to idio- 
 syncrasy. Thus Hallopeau has published a case of acute cocaine poisoning 
 of prolonged duration following the intragingival injection of about eight 
 milligrams. The acute symptoms were succeeded by functional disorders, 
 which reached their maximum intensity a month after the injection and did 
 not disappear until the expiration of two and a half months. Hallopeau has 
 gathered two other analogous cases. 
 
 Such facts should not be sufficient to lead us to dread or reject an excel- 
 lent means of securing local anaesthesia, but should simply teach prudence in 
 its use. 
 
 Continuous irrigation, which is so useful from the point of view of 
 convenience and antisepsis, has also a remarkable power of diminishing 
 pain, especially when even a weak solution of carbolic acid is used 
 (10 : 1,000). 
 
 Finally, in extremely nervous or hysterical women, we may obtain suffi- 
 cient anaesthesia by means of hypnotic suggestion. I call attention to this 
 as something of a pathological curiosity; nevertheless, at Lourcine-Pascal I 
 have several times been enabled to curette a patient without causing pain, 
 by simply suggesting that she was not suffering, and this without having to 
 put her to sleep. Very recently Geyl, of Dordrecht, was able to excise a 
 prolapsed rectum and amputate a cervix by complete anaesthesia from hyp- 
 notic influence alone, lasting two hours in the first case, one hour in the 
 second. Mesnet reports to the Academy of Medicine a case of vaginal 
 cystocele painlessly operated upon under the same conditions. 
 
 General anaesthesia is indispensable in major operations; it may even be 
 used in slight ones if administered with the proper precautions. I usually 
 employ it when curetting a uterus. 
 
 Finally, when an examination of the abdominal organs presents much 
 difficulty, anaesthesia is a necessity. The exploration is greatly facilitated 
 by the resulting flaccidity of the abdominal walls and the absence of reflex 
 movements caused by pain. This exploratory anaesthesia should be the 
 rule in many procedures, as without its help it is often impossible to ob- 
 tain an exact knowledge of the condition of the uterine appendages where 
 these are inflamed. Such exploration should preferably be made just before 
 operation. 
 
30 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Ether has been recommended by Lawson Tait, Keith, and a number of 
 other surgeons, inckiding Silex, who reports twenty-five hundred cases in 
 which it had been employed without a single death, and in France by the 
 school of Lyons. It has recently been the subject of study in Paris. It 
 has been claimed that ether exercises a destructive action upon the renal 
 epithelium, which renders its use dangerous when the kidneys are more or 
 less affected, as is often the case when abdominal tumors exist. Lee, Dud- 
 ley, Freeman, Talbot, etc., have cited cases of this character. For my part 
 I do not give up the use of chloroform, which seems to me the best of anaes- 
 thetics provided it is well administered. The two principal faults which I 
 find with ether are that it is irritating to the bronchi, and that it cannot be 
 used in the presence of an incandescent object [such as the actual cautery] ; 
 besides, it must always be given in such large amounts as to render its sup- 
 ply difficult. 
 
 Pental, or trimethylethylene, whose ansesthetic properties have recently 
 been revealed by von Mering, has been experimented with by several sur- 
 geons. Its action is extremely rapid, and it is held to have been of great 
 service in operations of short duration and in cases which took chloroform 
 badly. Breuer and Philip, however, have used it successfully in operations 
 which lasted over half an hour. No nausea or vomiting followed its admin- 
 istration, and accidents were extremely rare. They have nevertheless been 
 observed. 
 
 In Italy, several surgeons, among whom are Nanzetti, Morisani, and 
 Bianchi, extol the advantages of bichloride of methylene. 
 
 There has recently been an attempt, especially in Germany, to re-estab- 
 lish the use of bromide of ethyl. It has given satisfaction to those who 
 have employed it. Anaesthesia comes on very rapidly without a period of 
 excitement, and there are none of the after-effects which make the use of 
 chloroform so disagreeable for the patient. Unfortunately the anaesthesia 
 which this drug produces is of very brief duration, not exceeding five min- 
 utes, which materially limits its use in gynaecology. Its administration 
 is very simple. The whole quantity which is to be given (ten to fifteen 
 grams for an adult) is poured at once upon the inhaler or compress, and 
 this is applied to the patient's face r,o as to prevent entirely the access 
 of air. 
 
 In France chloroform is the anaesthetic preferred, and the rules for its 
 administration are so well known that I do not need to dwell upon them. 
 The purity of the drug should always be tested, especially when the anaes- 
 thesia is to be of long duration. Uubois-Reymond believed, as a result of 
 his experiments upon animals, that impurities in chloroform are in part re- 
 sponsible for the accidents which it causes. 
 
 When the operation is expected to be of long duration, and with patients 
 who are particularly nervous and excitable, I have long been in the habit, 
 before beginning the administration of chloroform, of giving a hypodermatic 
 
ANESTHESIA IN GYNAECOLOGY. 3 1 
 
 injection of one cubic centimetre (or twenty-five to thirty drops) of the fol- 
 lowing solution : 
 
 Gm. 
 
 Distilled water, . . . . .10. 3 iiss. 
 
 Morphine hydrochlorate, .' . . .10 gr. iss. 
 
 Atropine sulphate, .... .005 gr. yw^ 
 
 After one serious accident I gave up this method. 
 
 Kocher, Poitou-Duplessis, Terrier, and Segond recommend another method 
 of mixed anaesthesia which offers great advantages. In this bromide of 
 ethyl is first administered, and when insensibility is obtained it is con- 
 tinued by chloroform (Poitou-Duplessis, Terrier, Segond) or by ether 
 (Kocher). Complete insensibility is thus rapidly obtained, thus saving the 
 surgeon a considerable amount of time, avoiding the dangers of the period 
 of excitement at the beginning of anaesthesia by chloroform, and allowing 
 the use of small quantities of the latter drug even for the longest operations. 
 When it is necessary to prolong chloroform anaesthesia, the toxic and dan- 
 gerous dose is rapidly reached ; with ether this dose is attained much more 
 slowly. For this reason Kocher, who uses chloroform, replaces it by ether 
 when anaesthesia must be long continued. This process of mixed anaesthesia, 
 which we owe to Dastre and Morat, can scarcely be awarded too much praise 
 in operations of any considerable length. It is designed to avoid the symp- 
 toms due to chloroform which the surgeon is unable to combat — laryngo- 
 reflex syncope — especially secondary syncope. It prevents the initial excite- 
 ment, diminishes the nausea, limits the amount of chloroform used, and 
 consequently lessens the chances of chloroform poisoning in operations of 
 long duration. My learned friend. Professor Dastre, has assured me that in 
 his laboratory experiments, before he adopted this method, he lost one out 
 of every four dogs anaesthetized. For ten years he used it upon hundreds of 
 animals, and has not lost one. Safety and convenience are both gained by 
 the process. It has been adopted by practical surgeons. Aubert, head sur- 
 geon of the Antiquaille in Lyons, uses it to the exclusion of all other meth- 
 ods. This method has the following advantages: i. Safety. 2. I\Iore 
 rapidly induced unconsciousness. 3. Absolute calm on the part of the 
 patient. 4. An easy awakening. 5. Very little malaise or vomiting as 
 sequelas. Many of my colleagues in Lyons, especially Gayet and Leon 
 Tripier, have at my instigation used this method of anaesthesia. The num- 
 ber of cases experimented upon amounts to several thousands, with no result- 
 ing accident. y\lcohol has been combined with chloroform and with ether 
 more especially in alcoholic cases. The patient is anaesthetized in bed, and 
 taken to the amphitheatre in a ward-carriage, thus avoiding the disagreeable 
 impression produced by the sight of the surgical preparations, and facilitat- 
 ing the first steps in the administration of the chloroform. 
 
 We must bear in mind that if anaesthesia be unduly prolonged, it may 
 
32 CLINICAL AND OPERATIVE GYN^:COLOGY. 
 
 have a serious effect upon the nervous system and upon the kidneys. The 
 fatal results of many cases reported under the head of shock may be traced 
 to the depressing effects upon the nerve centres of an anaesthesia prolonged 
 to two or three hours. It is not impossible that many of the so-called reflex 
 symptoms occurring after utero-ovarian operations may be due to the same 
 cause ; more particularly what has been termed the guttural-reflex symptom, 
 characterized by incessant and painful expectoration. I have had the oppor- 
 tunity of observing this symptom after long operations other than abdominal, 
 and I feel convinced that it is due to real chloroform-poisoning. 
 
 Further, the absorption of a large quantity of chloroform or ether, and 
 its consequent elimination by the kidneys, may determine an intense renal 
 congestion with or without albuminuria. Chloroform absorbed in great 
 amount cannot fail to have an action upon the renal epithelium and thus in- 
 terfere with the elimination of the constituents of the urine; this action 
 may be the source of immediate danger when there is a pre-existing lesion 
 of the organ. It is especially after abdominal hysterectomies that cardio- 
 pulmonary symptoms have been observed, and we know that in these cases 
 the kidneys are peculiarly vulnerable, since abdominal tumors in general and 
 fibroids in particular are a predisposing cause of chronic nephritis. The 
 renal filter is then in a defective condition, and powerless to rid the circula- 
 tory current of the toxic agent introduced by a long pulmonary absorption. 
 Moreover, in patients with abdominal tumors, the heart, as well as the kid- 
 neys, is often affected, and it is easy to comprehend why, in these persons, 
 a prolonged anaesthesia is followed by certain fatal symptoms whose patho- 
 genesis has not heretofore been thoroughly understood. I have alluded to 
 heart lesions as frequently complicating abdominal surgery. Granted that 
 they call for especial precautions as to the duration of anaesthesia, do they 
 absolutely contraindicate the administration of chloroform ? In France the 
 prevalent opinion is that they do, but according to the greatest Fnglish 
 authorities on ovariotomy they do not. The latter claim that in chloroform 
 anaesthesia fatal results are due to a reflex inhibition of the cardiac centres 
 or of the respiratory and vasomotor centres; that this reflex inhibition is 
 most apt to occur where there is organic disease of the heart, and that, 
 therefore, paradoxical as it may seem, it is in reality logical to administer 
 chloroform in just such cases, and to push it to the point of complete abol- 
 ishment of reflexes. Ouenu and Terrier have recently made the same state- 
 ments at the Societe de Chirurgie. Guerin has expressed the opinion that 
 in chloroform anaesthesia the inhibition of the heart is due to stimulation of 
 the nasal nerves by the drug, and that consequently death from this cause 
 may l^e prevented l)y confining the respiration of chloroform to the mouth. 
 I^^atty degeneration of the heart, chronic renal disease, atheroma of the arter- 
 ies, and extreme weakness constitute absolute contraindications to the use 
 of chloroform. 
 
 It is quite unnecessary to give details upon the manner of administering 
 
ANESTHESIA IN GYNECOLOGY 
 
 33 
 
 an anaesthetic, and methods of resuscitation in case of accident. A few 
 words of counsel, however, may be to the point. 
 
 An important preliminary precaution is the removal of false teeth and 
 plates. The face should be anointed with oil of some kind, to prevent the 
 irritating effect of chloroform during prolonged anaesthesia. The chloro- 
 form itself should have been recently purified and kept away from the light ; 
 the required amount may be put, just before the operation, into a flask pro- 
 vided with a double tube, or else with a cork in which you can make a small 
 opening to limit the amount used. Junker's apparatus is much used in 
 other countries ; in France we prefer to use a folded piece of linen, a simple 
 procedure, which the English sometimes describe as the Scotch method, and 
 which allows of a close inspection of the patient's face. It should be held 
 a little way from the nose and mouth, and in order to prevent much loss of 
 
 Fig. i8. — Tongue Forceps. 
 
 chloroform by evaporation as well as to make the compress easier to handle, 
 it is well to cover it with a piece of oiled silk. 
 
 Wherever practicable, one assistant should devote himself to the admin- 
 istration of the chloroform, giving it in small but oft-repeated doses, closely 
 watching the pulse and respiration. 
 
 To prevent accidents, note the respiration and the pupils even more care- 
 fully than the pulse ; draw the tongue forward by pressing upon the lower 
 jaw, or by seizing it with the forceps. Spring forceps are to be avoided, as 
 they produce sloughing. I use forceps of my own devising; the spatulated 
 blade is slipped under the tongue, and the two sharp teeth of the upper blade 
 give a sure hold at the expense of very slight wounds. 
 
 Certain circumstances in gynaecological operations call for especial care. 
 Respiration is embarrassed, and the difficulties of anaesthesia increased, 
 when the patient lies upon her side or is kept in the genu-pectoral position. 
 There are also some processes connected with laparatomies during which the 
 dangers of anaesthesia are augmented ; the withdrawal of a great amount of 
 fluid or of a large tumor, traction upon the pedicle of a uterine tumor, or 
 upon the broad ligament may be the cause of reflex action upon the respira- 
 tory or circulatory apparatus. Interference with respiration due to a me- 
 chanical cause, such as the accumulation of mucus in the pharynx, is a mere 
 3 
 
34 CLINICAL AND OPERATIVE GYNiECOLOGY. 
 
 incident and not an accident, easily remedied by introducing a sponge upon 
 a holder, pressing it firmly and deeply and removing the obstruction. 
 
 If respiration becomes difficult or ceases, rhythmic tractions of the 
 tongue may be tried, and if an immediate result is not obtained, artifi- 
 cial respiration should at once be practised persistently, regularly, and not 
 too rapidly. If the pulse ceases suddenly and syncope occurs, the head 
 should be lowered, the surface of the body flagellated, cold water dashed on 
 the face and nape of the neck, electric stimulation applied to the phrenic 
 and pneumogastric nerves, and artificial respiration performed. The last 
 should be done by the assistants in turn, as I have seen a patient saved only 
 after it had been carried on for twenty minutes. If the room is very warm 
 or full of the fumes of carbolic acid, it should be well aired. Laborde has 
 recommended the use of apparatus for artificial respiration in case of chloro- 
 form syncope. It consists of an ordinary bellows and a facial mask, the air 
 from the bellows entering the mask and thence into the air passages. 
 
 I believe that the methods previously described are sufficient. The 
 benefits of tracheotomy also seem to me very doubtful. 
 
CHAPTER III. 
 
 METHODS OF SUTURE AND H^MOSTASIS. 
 
 Sutures. — Union by first intention, which, with a few exceptions for spe- 
 cial cases, has become the rule in modern surgery, is of prime importance 
 in gynaecology; upon it depend the success of plastic and the innocuousness 
 of other operations. I shall not dwell upon the local conditions necessary 
 to such union ; the cardinal principles are known to be these : that the wound 
 be clean cut, its surfaces smooth, accurately approximated, and without dead 
 spaces, that no traction be exerted, and but little pressure applied. The raw 
 surface should be thoroughly pared and all superfluous tissue removed by 
 
 Fig. 19.— Large Mounted Needles, i, blunt Deschamp's; 2, sharp Deschamp's. 
 
 means of curved scissors ; the sutures should then be so applied as best to 
 imitate the normal condition of the tissues. 
 
 Although all gynaecologists are doubtless familiar with the ordinary rules 
 -of surgery, it will be well in this connection to repeat certain points of espe- 
 -cial importance. 
 
 The needles may be used in one of several ways. ist. They may be 
 Tield in the fingers ; this is extremely inconvenient and should be done only 
 where absolutely necessary. 
 
 2d, Needles immovably attached to a handle are used in passing through 
 resistant tissues or parts difficult to reach. Deschamp's sharp-pointed 
 needle, which is of this description, may be used to advantage high up in 
 the vagina, upon the cervix uteri, or in the cul-de-sac, but where the needle 
 has to pass through relaxed tissues rich in blood-vessels (ovarian pedicles, 
 round ligaments, etc.), blunt needles with a rounded edge will push aside 
 the vascular tissues without wounding them. 
 
 I have already said that grooved needles or those with split eyes should 
 .be discarded on account of the difficulty of keeping them clean. 
 
36 
 
 CLIXICAL AND OPERATIVE GYNAECOLOGY. 
 
 3d. The needles may be inserted in a holder. This is the most usual 
 method. 
 
 Three kinds of needles are used : ordinary surgical needles, which are 
 
 Fig. 20. — Designed to Show the Superiority of the Flat over the Ordinary Needle, a, a, Skin 
 wounds made by ordinary surgical needle; d, i, enlargement of these orifices by suture; c, c, wounds made by Hage- 
 dorn needle (_d, d) which are not enlarged by the suture. 
 
 flat and slightly enlarged near the point, giving them a lanceolated appear- 
 ance. They penetrate the tissues with ease, but make a transverse incision 
 which is drawn upon and enlarged when the sutures are tied (Fig. 20). 
 Curv^ed needles, or those curv'ed near the point, are most in use. 
 
 Hagedorn's flat needles (Fig. 21), curved on the edge and bevelled at 
 
 Fig. 21. — Hagedorn Needles. 
 
 Fig. 22. — Ordinary Surgical Needles Made Strong 
 FOR Suturing the Abdominal Walls after Lapa- 
 ratomv. 
 
 the point, possess a greater cutting power than the old surgical needles. 
 They are of the greatest use in plastic operations. 
 
 One should have on hand a supply of needles of all sizes : very fine ones 
 are required for certain plastic operations, as in vesico-vaginal fistulas; while 
 
METHODS OF SUTURE AND H^MOSTASIS. 
 
 37 
 
 for suturing the abdominal walls after a laparatomy, it is well to have needles 
 of more than ordinary strength (Fig. 22). The choice of a needle-holder, of 
 which there are many varieties, depends upon whether the operation de- 
 mands chiefly great accuracy or strength. If the former, it may be found 
 more convenient to use a lock forceps, which obviates all necessity of keep- 
 ing the needle in place by pressure on the handle, and allows of concentra- 
 tion of attention upon the movements of the needle. Collin's forceps meet 
 
 Fig. 23. — I, Pozzi's needle-holder for small flat 
 needles. 2, Holder for small ordinary needles. 
 
 Fig. 24.— I, Holder for large round needles. 
 2, Holder for large flat needles (Pozzi). 
 
 this indication, and with my modification will hold the Hagedorn needle. 
 They can be taken apart and cleaned (Fig. 23). 
 
 If thick or resistant tissues are to be sutured, larger needles should be 
 used, and a strong holder without a lock will give greater leverage, with less 
 fatigue than any other. Grasp of the needle and forward pressure are made 
 simultaneously and are equal in force. The forceps used by A. Martin is 
 of unusual size, but I can testify from personal experience that it is not toe 
 large. Collin has made for me a needle-holder of this description for large 
 ordinary needles (Fig. 24, i) and one for Hagedorn's needles (Fig. 24, 2). 
 
38 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 The latter seems to me greatly superior to the spring forceps of the German 
 surgeon. For the intestinal sutures which may be required during a lapa- 
 ratomy, rovmd sewing needles will be found to make a smaller incision than 
 any of the foregoing. Figure 25 shows the most frequently used intestinal 
 sutures — those of Lembert, Czerny, and Gussenbauer. 
 
 I especially recommend an exact reunion of the mucous membrane irk 
 every case. In order to avoid threading the needle for each suture it is- 
 sometimes of advantage to use a needle furnished with a loop of silk in- 
 tended to draw upon the suture. 
 
 Suture Materials. — Formerly hemp, silk, and linen threads were used 
 for suturing ; the laws of antisepsis had not then been formulated, and the 
 necessity for aseptic suture materials was unknown ; the threads in use, by 
 their porous qualities, were veritable breeding-places for germs, and sup- 
 puration invariably followed their use. The introduction of wire sutures by- 
 the American gynaecologist Sims was a step in advance whose importance 
 at the time could scarcely be exaggerated. Silver wire was of all the most 
 
 1 2 3 
 
 Fig. 25. — Intestinal Sutures, i, Czerny's suture; 2, Lembert's suture; 3, Gussenbauer's suture. 
 
 aseptic, which no doubt accounts for the marvellous results obtained and the 
 enthusiasm aroused by its use. 
 
 Even at this date it is in general use, and it certainly possesses some 
 advantages. On the other hand it breaks easily ; when tied around a some- 
 what thick mass of tissue it cuts it more than other threads ; it requires more 
 time for its application. If it is cut off short, the ends wound the vagina 
 and the perineum ; if left long, they may be pulled upon. For these reasons 
 I have almost abandoned its use, replacing it with catgut or silk. Hegar 
 makes use of wire in cavities like the vagina, where silk easily becomes sep- 
 tic. In such cases I take pains to blunt the sharp ends of the twisted wire by 
 pressing upon them a piece of lead and cutting them off close to its level. 
 I never leave the ends more than two or three centimetres long, so as to 
 avoid pulling upon them. The piece of lead is of advantage also in aiding 
 the operator to find and remove the sutures, as without this precaution they 
 may often escape the sight and even touch, especially when they are placed 
 deeply. I have seen D^sormeaux use iron wire, while copper wire has been 
 recommended in America. Neither has anything in its favor except its 
 
METHODS OF SUTURE AND H^MOSTASIS. 39 
 
 cheapness, and they have the disadvantage of changing more rapidly than 
 silver wire. 
 
 Silkworm gut is as impermeable and non-absorbable as silver wire; it is 
 less easily broken, but less flexible, and applicable to all cases in which wire 
 is used ; it is given the preference by many authorities, as Bantock and San- 
 ger. I find that the knot does not hold as well as that of catgut or silk, so 
 that the stitches seem to me somewhat insecure. Moreover the ends be- 
 come stiff as they dry, which is a matter of some importance in plastic oper- 
 ations on the vulva and vagina. Nevertheless it is a good material for 
 sutures. It should be soaked in a carbolic or bichloride solution for about a 
 quarter of an hour before using, otherwise it will be inconveniently stiff. 
 
 The best silk is the braided, and not the twisted variety ; it comes in 
 very fine strands, and when rendered antiseptic is an excellent suture mate- 
 rial. It may even be used for buried sutures ; Billroth uses it exclusively. 
 Experimentation has shown that not only is it well borne by the tissues, but 
 that it is even absorbed by them, yet in these two particulars it is inferior to 
 good catgut. Therefore in cases in which there is no especial resistance to be 
 overcome, and where the suture need not remain for any great length of 
 time, I should use catgut, but in suturing the intestines, the stomach, or the 
 bladder, I give silk the preference. It is also desirable to insert silk sutures 
 at intervals to support a continuous catgut suture. 
 
 Owing to the porosity of silk, it possesses one serious drawback : that of 
 secondary infection. Buried silk sutures in any place where suppuration is 
 likely to occur may be the cause of fistulae, which will not close until the 
 septic piece of silk be eliminated. In such cases, it will be found best to 
 use catgut for ligatures and silkworm gut for the sutures ; being non-absorb- 
 ent they are less liable to infection. This applies with peculiar force to 
 operations for pyosalpinx and pelvic abscess, where the sutures come in 
 contact with suppurating matter, and in sutures of the abdominal walls, 
 where they are placed near drainage tubes or packing. Here silkworm gut 
 or silver wire should be employed. There is no material used for ligature 
 and suture, in either general surgery or gynaecology, to be compared to cat- 
 gut. Its property of disappearing by absorption in from eight to fifteen 
 days, according to its thickness and the method of its preparation, renders it 
 invaluable for sutures buried in the abdominal cavity, and for operations on 
 the cervix and vagina, where the removal of the stitches is attended by both 
 difficulty and pain. Catgut prepared in chromic acid is the only kind which 
 is not quickly absorbed. It is then even more durable than silk. I use it 
 exclusively in my operations, occasionally reinforcing it by a suppurating 
 suture of silk or of silver wire. Catgut loosens more readily than silk, and 
 should be tied in three knots to avoid mishaps. The commercial article is 
 unsatisfactory ; it should always be prepared by one's self or a competent 
 assistant. 
 
 Methods of StUitre. — The tendency of the present day is toward simplic- 
 
40 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 ity, and the reduction of the number of sutures in practical use for gynaeco- 
 logical operations to a few well-chosen methods, of which the following are 
 the chief : 
 
 I. Interrupted suture. 
 
 2 and 3. Simple continued suture and continued sutures in layers 
 (etages). 
 
 4. Mixed sutures. 
 
 5. Quilled suture. 
 
 I. Interrupted Suture. — Whatever the extent of the wound, its surface 
 must all be taken in by the suture, otherwise pocketing and an accumulation 
 of fluid may result which will distend the wound, preventing union, and 
 may increase the chances of sepsis. To meet this requirement Hegar, fol- 
 
 jy , 
 
 w,. 
 
 
 Fig. 26.— Covrse of Interrupted Sutures, a, a. Deep suture including whole surface of wound; b, 3, suture 
 including a part only of the denuded surface; c, c, superficial suture including edges only of wound. 
 
 lowing Simon's method, directs the needle deeply under the whole surface 
 of the wound, so that the suture is embedded in tissues. Occasionally the 
 thread may cross the wound at about half an inch or an inch above the de- 
 nuded surface (Fig. 26). The needles used in approximating surfaces (as in 
 colpoperineorrhaphy, etc.) should be both long and strong. After uniting 
 the deeper tissues by these concealed sutures, the lips of the wound should 
 be drawn together by superficial stitches, placed near the margin. These, 
 while applied last, are tied first; the deeper stitches are tied last. This 
 method insures a more exact approximation. The deeper the wound, the 
 farther from the edge should be the point of entrance and exit of the needle 
 (Fig. 26). Traction exerted upon one long strand certainly puckers the 
 edges of the wound ; to correct this defect the idea was conceived of using 
 buried sutures in layers of different depths. A layer of interrupted catgut 
 sutures brings together the deepest portion of the wound, successive layers 
 approximating the remainder of the surface. Werth, in 1879, applied this 
 method to perineorrhaphy; Schroder and his school at once adopted it. In 
 many cases it is an excellent procedure, but it possesses the disadvantage of 
 leaving knots of the catgut in the depths of the wound, materially interfer- 
 ing with the approximation of the surfaces. The continuous suture has 
 obviated this difficulty. When, at the instigation of a number of surgeons, 
 
METHODS OF SUTURE AND H^MOSTASIS. 
 
 41 
 
 this suture, so long in disuse, was again brought forward, Brose lost no time 
 in applying it to the plastic operations of gynaecology. Schroder and his 
 pupils likewise made extensive use of it. It is both efficacious and rapid in 
 its application, and is particularly useful where several operations have to be 
 done at one sitting; as, for example, amputation of the cervix with anterior 
 colporrhaphy, colpoperineorrhaphy, and Alexander's operation. 
 
 Simple ContiniLcd Suture. — This can be advantageously employed wher- 
 ever the surfaces to be approximated are neither extensive nor deep; it is 
 
 Fig. 27. — I, First step in a continued suture. /, /, Catgut. 2, Final steps in the continued suture. 
 
 also used in haemostasis, as I have already remarked. The needle is intro- 
 duced at one extremity of the wound, and the terminal end of the catgut tied 
 in three knots, leaving a short free end which is grasped by forceps. This 
 is held by an assistant, and serves to steady the suture (Figs. 27 and 28). 
 Introducing the needle a little from the edge, it is carried below the surface 
 of the wound and emerges at a corresponding point on the opposite side ; the 
 thread is gently pulled through, and an assistant holds the forceps while the 
 second stitch is taken. He must be cautioned not to let it go suddenly 
 when the second stitch is drawn through, but to follow the motion with his 
 hand to prevent relaxation of the first stitch. When the suture is about half 
 done, it is well to make light traction upon the opposite angle of the wound 
 
42 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 with a bullet forceps, in order to have the edges even. The thread may be 
 tied to the eye of the needle to prevent slipping. 
 
 3. Continuous Sutures in Layers. — These are used where one row of 
 sutures does not suffice to approximate the denuded surfaces. In this case 
 the needle, instead of being introduced through the skin outside of the 
 wound, is carried into the raw surface, the distance from the edge depending 
 upon the extent of the wound and the depth to which the needle can be car- 
 ried. When the deepest surfaces have been drawn together, the sutures are 
 taken through the skin, and the operation is terminated by a superficial spiral 
 
 Fig. 28. — I, Continuous suture in layers (one at tlie angle, two in the centre of the wound). 2, Continuous sutures 
 in layers (one at the extremities, three in the centre of the wound). 
 
 suture forward and then back (Fig. 28). It may be necessary to make three 
 layers of stitches. They should not be taken too closely together nor pulled 
 too tightly. 
 
 We may fasten the suture in several ways. If we have brought the 
 thread by a second layer back to the starting-point, we simply tie it three 
 times to the projecting end ; if the ends of the thread are not together, we 
 draw the last stitch out into a long loop and tie that to the end ; or we may 
 draw the end of the thread through the eye of the needle in such a way as 
 to leave a projecting end after the last stitch is taken — this wc tie to the 
 double loop of the stitch. 
 
 If, in suturing the upper part of the wound, the thread of the deeper 
 
METHODS OF SUTURE AND H/EMOSTASIS. 
 
 45 
 
 suture should accidentally be cut, or should it break, another stitch should 
 immediately be taken at the point of rupture and securely tied ; the suture 
 is continued with this second thread. Wherever the thread is liable to be 
 much pulled upon, as, for instance, at the point where the suture changes its 
 direction, I strongly recommend the insertion of supporting stitches of silk 
 or silver wire, to take off the strain from the catgut (Fig. 30). 
 
 In a perineorrhaphy I place one at each extremity of the perineum ; the 
 anterior one encircling the terminal point of the reconstructed recto-v^aginal 
 partition, the posterior uniting the extremities of the anal sphincter. In a 
 colpoperineorrhaphy, I put in one only at the fourchette. 
 
 4. Mixed Siitures. — It is often advisable to combine the interrupted and 
 continued sutures. To illustrate this point, I will describe my mode of pro- 
 cedure in closing the abdominal opening after a laparatomy. 
 
 As soon as the peritoneum has been cleansed, a protective gauze sponge 
 
 Fig. 29. — Suture in Layers. Shows method of fastening the thread in the middle of the suture by means of a 
 
 loop. 
 
 is spread like an omentum over the intestines, and an assistant draws the- 
 edges of the wound together and holds them in place. With a curved needle 
 and catgut of moderate thickness, a stitch is taken in the peritoneum at the 
 lower part of the wound, the end of the catgut being held with a forceps to 
 exert a certain amount of traction ; without cutting the thread, the operator 
 rapidly sutures the peritoneum with long, basting stitches (Fig. 31); when 
 the upper part of the wound is reached, the gauze sponge is withdrawn, and 
 the operator now returns to the starting-point by a somewhat closer row of 
 stitches on the aponeuroses, closing in any muscle sheath which may have 
 been opened (Fig. 32). The forceps are now removed and the two ends of 
 the catgut united. There now remains only the joining of the integument 
 and the subcutaneous tissue, which often, however, forms a very thick layer. 
 With a large curved needle, and silk of a strength proportioned to the thick- 
 ness of the parts to be traversed, separate stitches are placed at intervals of 
 about a half-inch. These sutures are introduced at about the same distance 
 from the edge of the wound, penetrate through the adipose tissue until the 
 
44 
 
 CLIXICAL AXD OPERATIVE GYNAECOLOGY. 
 
 aponeurosis is reached, and return in a similar manner through the second 
 lip of the wound. Both ends of each suture are held by forceps, the edges 
 are approximated, and with a small needle and fine catgut, or silkworm gut, 
 one or two superficial interrupted sutures are placed in each interval between 
 the deep sutures. They must be quite close to the edges and bring them 
 into exact juxtaposition. (I often replace these by a fine continued catgut 
 suture.) 
 
 It is not until they are all placed and tied that the deep sutures are fast- 
 ened over small rolls of iodoform gauze which obviate the production of 
 
 grooves in the skin by these sutures (Fig. 34 c). 
 It frequently happens that the superficial 
 cutaneous sutures leave their mark for several 
 months in the form of stripes, at first red, but 
 occasionally becoming pigmented later. This 
 may occur even when care has been taken to 
 make the tension slight, to include within the 
 sutures an equal amount of tissue on each side 
 of the wound, and to remove the stitches as soon 
 as union is obtained. 
 
 I have seen a new mode of suture, the in- 
 tradermic, employed successfully at the Johns 
 Hopkins Hospital of Baltimore, which obviated 
 this inconvenience. Kendal Franks appears to 
 have been its originator. I have modified his 
 technique considerably before adopting this 
 method of suture. 
 
 The intradermic suture may be either in- 
 terrupted or continuous. 
 
 In the interrupted intradermic suture the 
 lips of the wound are held firmly and are pierced 
 interrupted supporting suture; y, starting- succcssivcly with thc uecdlc, taking carc to pass 
 
 point of the continued suture in lavers. . ... 
 
 each time through the substance of the skin im- 
 mediately below the surface of the skin. Unless the suture lies as near as 
 possible to the surface the lips of the wound become everted after it is tied, 
 leaving the incision slightly open. The interrupted intradermic suture 
 seems to be of use only when very fine catgut is used and in exceptional 
 cases, such as to strengthen a continuous intradermic suture. If silk or any 
 other non-absorbable material were used, it would have to be left in place, 
 and on account of its proximity to the surface of the skin it might easily 
 protrude slightly and become infected eventually. 
 
 The continuous intradermic suture is much more serviceable. Kendal 
 Franks used catgut exclusively for it. I consider it safer to use silk, and 
 recommend a very fine suture and a small curved Hagedorn needle. The 
 upper angle of the wound must be kept steady, and each of its lips is succes- 
 
 FiG. 30. — Continuous Suture in 
 Layers in Operation for Ruptured 
 Perineum, i, 2, 3, Course taken by the 
 thread; a, b, simple continued suture; c. 
 
METHODS OF SUTURE AND H/EMOSTASIS. 
 
 45 
 
 sively held firmly and everted by two forceps, one of which is held by the 
 surgeon, the other by his assistant. The needle first enters a centimetre 
 abjve the angle of the wound, passes through the entire skin, and enters the 
 wound, drawing after it the suture until stopped by a knot which has been 
 made in the latter. It now enters one of the lips, where it runs intradermi- 
 cally for three or four millimetres, re-enters the wound and is passed into 
 the opposite lip at a level corresponding exactly to its point of emergence 
 
 Fig. 31. — Suture of Abdominal Walls after 
 Hysterectomy. First stage of the continuous su- 
 ture (peritoneum). 
 
 Fig. 32. — Second Stage of Continuous Suture 
 (Musculo-aponeurotic Layer). 
 
 from the first. The skin on either side is thus traversed alternately until 
 the lower angle of the incision is reached, where the needle is brought out 
 through the skin at a distance of one centimetre from the lower extremity of 
 the wound (Fig. 34, a). The course of the suture recalls a corset lace, the 
 eyelets being represented by the intradermic passages. 
 
 There remains now only to tighten the suture from above downward by 
 drawing on each loop successively with a hook, unless each stitch has been 
 tightened as it was placed (Fig. 34, b). When this has been done, the wound 
 
46 
 
 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 has been reduced to the Hne of incision and the suture is completely con- 
 cealed except at the two extremities. It is usually of no use to introduce 
 complementary intra- or extradermic interrupted sutures in order to prevent 
 gaping of the wound, but if it is considered necessary they may be resorted 
 to. A knot may be made in each end of the suture at the level of the skin 
 so as to prevent it from slipping and becoming relaxed. 
 
 To remove the intradermic suture (which is usually done on the eighth 
 day), the upper end is pulled upon until a portion is drawn out from within 
 
 Tig. 33. — Suture of Abiiominai, Walls after Hysterectomy. Interrupted suture of the integuments and sub- 
 cutaneous areolar tissues. 
 
 the skin ; it is cut close to the latter and the rest is removed by drawing 
 upon the lower end. During the next eight days I occasionally apply a 
 small strip of iodoformized diachylon to protect the cicatrix from tension. 
 I have in this way obtained cicatrices which were almost entirely invisible 
 a few weeks after laparatomies. 
 
 [In using the buried suture, whether continuous or interrupted, whether 
 of fine silk, of catgut, or of other material, the most important factor in 
 insuring 'success is the maintenance of an aseptic wound. With favorable 
 conditions it gives results attainable by no other method, bringing like tis- 
 
METHODS OF SUTURE AND H^MOSTASIS. 
 
 47 
 
 «ues together, leaving the minimum of scar with the maximum of strength. 
 An essential point is that all the sutures should be buried, so that there 
 are none above or in the skin when the wound is finally closed, the 
 superficial row being just beneath the skin. When it is thought necessary 
 to employ stay sutures they should be passed at such a distance that there 
 is no possibility of their coming in contact with any of the buried sutures 
 and so possibly infecting them. Other conditions favoring success are 
 that the wound shall not have been bruised by the unnecessary use of 
 hsemostatic forceps, by careless handling or rough sponging, and shall not 
 
 ah 
 
 Fig. 34. —Continuous Intradermic Suture. 
 
 have been soiled by pus or other septic material. If these conditions cannot 
 be attained, the buried suture should not be employed.] 
 
 5. Quilled Sttttires. — Small rolls of iodoform gauze are now substituted 
 for the quills and lead plates in former use. Lister's button suture, with 
 the heavy silver wire and piece of lead, has also been superseded by better 
 processes. It is no longer used in perineorrhaphies, but there are some ex- 
 ceptional cases in which it may be employed. For instance, when a large 
 abdominal tumor adheres anteriorly to the parietal peritoneum, its removal 
 will leave an extensive raw surface, caused by the stripping of the peritoneum 
 from the internal abdominal wall. The liability to septicaemia is increased 
 by the presence of this large and moist surface. It will then be found use- 
 ful, before closing the abdomen, to carry a long, deep suture from one side 
 to the other, supporting it at each end with a roll of iodoform gauze. This 
 
■.s 
 
 CLINICAL AND OPERATIVE GYNECOLOGY, 
 
 will fold the abdominal walls above and parallel to Poupart's ligament, will 
 exercise a beneficial pressure upon the raw surfaces, prevent hemorrhages 
 and serous exudation, and thus eliminate one source of infection. These 
 sutures can be withdrawn in from five to six days. 
 
 H(zmostasis. — We have compression for capillary hemorrhages, torsion 
 for small arteries, suture for the surface of wounds. But the two methods 
 to which I call especial attention are ligation and forcipressure. I shall 
 
 VZ 
 
 f IG. 35. — I, An improperly tied surgeon's knot; 2, properly tied surgeon's knot; 3, transfixion of the pedicle 
 with a needle and loop of silk; 4, crossing of ends of silk after transfixion of pedicle; 5, Bantock's knot for ligation of 
 small pedicles, 6, Lawson Tait's knot (Staffordshire knot) for ligation of small pedicles (the loop is to be thrown 
 over the tumor)-. 7, continuous ligature for a large pedicle; crossing of threads; 8, continuous ligature for large tumor; 
 threads tied (side view). 
 
 not touch upon ligation of the vessel alone, as it has no especial bearing 
 upon the subject in hand, but pass on to ligature in mass, which is of super- 
 lative interest in gynaecology, and by means of which we are able to control 
 the often formidable hemorrhages of the pedicles of abdominal tumors. 
 Wire, silk, catgut, elastic cords, and tubes have all been used in its applica- 
 tion. We shall take up the matter more in detail when we study the sub- 
 jects of ovariotomy and hysterectomy. 
 
 Silk is the most widely used agent for ligation in mass, as it offers the 
 greatest amount of resistance in the smallest bulk. Braided and not twisted 
 
METHODS OF SUTURE AND H/EMOSTASIS. 
 
 49 
 
 silk is always to be used. When, however, the ligatures are to be buried in 
 the abdomen it will be found disadvantageous to use a material which is 
 non-absorbable for a great length of time, and yet so absorptive as to in- 
 crease the liabilities of secondary infection. Since catgut prepared in oleum 
 juniperi does not possess these drawbacks, many gynaecologists do not hesi- 
 tate to substitute its use for that of silk in buried ligatures, notwithstanding 
 the fact that it is more difficult to tie it tightly than the silk. 
 
 In using the ligature in mass, if the part to be embraced is relatively 
 
 Fig. 36. — Continuous Ligature. Method of introduc- 
 ing threaded needle twice through the same opening (mem- 
 branous pedicle). 
 
 Fig. 37.— I, 2, Continuous Ligature. Method of 
 introducing threads of the second loop. The first loop 
 transfixes the pedicle and is then cut, which leaves a 
 protruding end; this is threaded into a blunt needle in 
 company with a new thread, and the two are again 
 carried through the pedicle. 
 
 thin, one loop of thread is passed around it and securely fastened with a 
 surgeon's knot (Fig. 35, i, 2), If the pedicle is thick and yet requires only 
 two loops, it must be transfixed in the centre by a needle threaded double 
 (Fig. 35, 3) ; the loop is cut, which leaves two ends on each side of the ped- 
 icle ; these are crossed and tied on either side (Fig. 35, 4) or, better yet, to 
 avoid having two knots (knots being less well tolerated by the tissues than 
 the rest of the thread) we may use Bantock's knot (Fig. 35, 5) or Lawson 
 Tait's Staffordshire knot (Fig. 35, 6). In a laminated pedicle, such as we 
 find in certain ovarian pedicles, membranous adhesions, or broad ligaments, 
 we pass a series of ligatures, so linked together that when they are tightened 
 4 
 
50 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 no laceration of the tissues results (Fig. 35, 7, 8). Figs. 36, 37, 38, 39 
 show with sul^cient clearness the methods generally used in applying these 
 ligatures, as well as the method which Wallich proposes to employ in their 
 stead. 
 
 I will merely allude to the kangaroo tendon proposed for use by Ameri- 
 can operators, and to the reindeer tendon recommended in Russia. They 
 
 Fig. 38. — Continuous Ligature (Wallich), i, Deschamp's blunt needle transfixing the pedicle; one thread of 
 the loop is to be seized at A and kept outside the pedicle, the other long end, J}, is held coiled in the hand of the 
 operator. 2, The loop is grasped by the forceps and held while the needle is withdrawn; it slides down the thread, B, 
 and then following the direction indicated by the arrows, pierces the pedicle again, leaving a second loop in place. 
 
 doubtless possess a remarkable power of resistance, and when deprived of 
 their fatty constituents by ether, and submitted to a process similar to that 
 used in the preparation of catgut, would be a better material for ligature in 
 mass. But the difficulty of obtaining them renders their general use impos- 
 sible. Ligature in mass upon the surface of the body causes death of the 
 strangulated tissues. When buried in the abdomen, with antiseptic precau- 
 tions, the constricted portions do not mortify, their vitality being preserved 
 
METHODS OF SUTURE AND H^MOSTASIS. 5 1 
 
 by vascular adhesions and by blood-vessels which pass like a bridge over the 
 groove of the ligature. After a while the stump shrivels and is absorbed. 
 This has been well shown by experiments on animals. 
 
 Hegar has witnessed the perfect absorption in a few weeks, by the peri- 
 toneum of a dog, of freshly extirpated bits of muscle ; and Czerny has seen 
 
 Fig. 39. — Steps in the Application of Wallich's Continuous Ligature, i. The threads in place, the loops 
 are to be cut at «, crossed and tied. 2, Threads crossed, tied, and ready to be tightened. 
 
 the same thing with portions of cancer, Ziegler with fragments of bone, and 
 Tillmans with pieces of liver, kidney, and lung. 
 
 Thomson has made a series of interesting experiments with the suture 
 materials most in use for laparatomies. Carbolized catgut is absorbed in 
 ten days ; chromic-acid catgut lasts for several months, as Sanger and Doder- 
 lein ascertained upon patients who survived Caesarean section. Silkworm 
 gut was intact at the end of two months. Silk is somewhat disorganized at 
 the end of fifty days. The silk threads are at first infiltrated with a new 
 cell growth, become encysted, and finally disappear, but this is a process 
 which it takes several months to accomplish, and before that time they may 
 
52 
 
 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 play the part of foreign bodies. The only explanation of this infection is 
 the passage of germs through the intestines or the Fallopian tubes ; unless, 
 indeed, we admit the existence of a species of latent microbism, called inta 
 activity by a vicious local or general condition. To avoid infection when 
 the cut surface of the pedicle may be septic (salpingitis, etc.) it is best to 
 use catgut, or to use both cauterization and ligature in mass. The aseptic 
 slough produced by the hot iron is rapidly absorbed. 
 
 Kaltenbach found in a subject who had died of tetanus eight days after 
 the operation that the cauterized surface was smooth, charred, and showed 
 
 Fig. 40. — Hegar's Forceps Temporarily Hold- 
 ing AN Elastic Ligature ix Place, while a Per- 
 .MAXEXT Ligature is beixg Adjusted. 
 
 Fig. 41. — Elastic Ligature Tied with Silk Thre.-m> 
 (Heg.a.r). 
 
 no trace of inflammation. Heppner, after an interv^al of two years, found 
 the merest trace of animal charcoal in the neighborhood of the pedicle. 
 
 Of elastic ligature, buried or on a free surface, I shall here mention only 
 a few general points, reserving technical details for the chapter on hysterec- 
 tomy. It has, however, been used in the ligation of other than uterine ped- 
 icles. Hegar uses it in profusely bleeding ovariotomies. To keep the 
 elastic cord in place, Olshausen ties it twice, and with a few additional silk 
 stitches fastens it to the pedicle. Thiersch draws the ends through a leaden 
 ring, which he then compresses. Hegar ties two silken ligatures around the 
 elastic, at a little distance from each other (Figs. 40, 41, 42). Since I first 
 introduced an instrument for placing ligatures many modifications have been 
 proposed, not only to facilitate the application of the cord, but also to keep 
 it in place. I consider this last precaution superfluous, as two threads of 
 silk fully accomplish the purpose without the intervention of any instrument.. 
 
METHODS OF SUTURE AND II^MOSTASIS. 
 
 53 
 
 Forcipjrssttrc. — The process of obtaining hsemostasis by the temporary 
 or permanent application of forceps is of ancient elate. For a long time 
 Charriere, the well-known manufacturer of instruments, attempted to induce 
 
 Fig. 42. — Hegar's Forceps for the Temporary Fixation of an Elastic Ligature. 
 
 surgeons to adopt forcipressure. In his catalogue, published the 15th of 
 April, 185 I, he shows forceps almost identical with the Koeberle-Pean forci- 
 pressure instrument. He then made them for the purpose of seizing insects 
 and reptiles in narrow spaces. In 1859 he pointed out their value in arrest- 
 ing arterial hemorrhage by pressure. 
 
 This method was, however, only occasionally used, until Koeberle and 
 Pean adopted it to save time in major abdominal operations. It is at the 
 present day used in. general surgery as well as in gynaecology. 
 
 The popularizing of this valuable method of haemostasis is due to Koe- 
 berle in the first place, to Pean, and finally to Verneuil. 
 
 In England, Spencer Wells has become an enthusiastic apostle of the 
 process, and its use is now general. 
 
 The use of forcipressure during an operation is of great value, not only 
 
 Fig. 43. — Pozzi's Licator Taken Apart. 
 
 for the immediate arrest of bleeding, but because the temporary haemostasis 
 effected by it nearly always becomes permanent. One may by its means 
 perform a laparatomy without once being interrupted to tie an artery. 
 
54 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 In plastic operations the use of this method must not be carried to excess, 
 for the pinching to which some portions of tissue are subjected by the for- 
 ceps is an obstacle to immediate union. 
 
 Forcipressure, as well as ligature, may be divided into that which com- 
 presses the vessels alone, and that which includes in its compression a large 
 amount of tissue. This temporary constriction is a great adjuvant to perma- 
 nent heemostasis. It is desirable to have on hand forceps of various kinds. 
 In the majority of cases forcipressure is resorted to as a temporary measure; 
 nevertheless, in cases of necessity, it has been utilized for the permanent 
 
 Fig. 44. — Application op Pozzi's Elastic Ligatvre. The elastic cord drawn under the clamp is held in place 
 by it; the lower part of the cord is disengaged from the furrow; the instrument is taken apart by unscrewing the lower 
 part of the shank on a level with the upper part of the groove. Only the head of the instrument remains temporarily 
 in place. 
 
 arrest of hemorrhage. Pean leaves the forceps in the peritoneal cavity after 
 abdominal hysterectomy, gathering the handles into a bundle at the lower 
 extremity of the wound ; this process is, however, inferior to the use of bur- 
 ied elastic ligatures. 
 
 Forcipressure has been used by many surgeons as a matter of necessity 
 in vaginal hysterectomy, but it remained for Spencer Wells and Jennings to 
 suggest its use as a matter of choice, and for Richelot to systematically 
 adopt it as such, even where ligature would be easier and, seemingly, prefer- 
 able. Many surgeons now do the same. I shall return to this subject in 
 the chapter upon vaginal hysterectomy. I would only observe in this con- 
 
METHODS OF SUTURE AND HyEMOSTASIS. 
 
 55 
 
 nection that hsemostasis by permanent forcipressure, when in mass, is always 
 followed by the death of a much greater amount of tissue than when applied 
 to isolated ligature. From the antiseptic point of view, it is inferior to 
 ligature. 
 
 Drainage. — This is not the place to discuss the indications for drainage 
 whether of reunited superficial wounds or of the peritoneal cavity. I would 
 simply establish a few general principles and point out the practical methods 
 for their application. 
 
 Draiuag-c of Wo?iiids. — In a suture in layers (etages) of the abdominal 
 cavity after laparatomy, it is usually not necessary to place a drainage tube 
 
 Figs. 45, 46, 47. — Koeberl^'s Hemostatic Forceps with Ratchet Catch Allowing Graduated Pres- 
 sure FOR Forcible Compression. «, Various forms of jaws for pressure forceps (Pean); b^ Lawson Tail's pressure 
 forceps; c, Pean's hsemostatic forceps witii Collin's joint. 
 
 between each series of stitches. Yet it is well to do so if the surface of the 
 cut has been exposed to infection, for instance, from pus ; for in this case, 
 notwithstanding the most energetic aseptic washings, a serous or sero-puru- 
 lent exudation may supervene, and unless it is promptly carried off by jDro- 
 phy lactic drainage may interfere with primary union. Under these circum- 
 stances it is advisable to place a small drainage tube between the aponeurotic 
 and cutaneous sutures ; this tube should be divided into three segments, and 
 a safety-pin transfixing the outer end will prevent its being lost in the wound. 
 In the hospital at Pesth, I have seen used, in place of the pin, a small flat 
 piece of hard rubber sewed to the end of the tube with two lateral stitches. 
 
56 
 
 CLINICAL AND OPERATIVE GYN.'ECOLOGY, 
 
 The best drainage tubes are of thick rubber, uniting elasticity, which 
 keeps them open, to a flexibility which permits of bending them as required. 
 It is not necessary to use glass or hard-rubber tubes if the soft ones at 
 hand are of sufficient thickness and good quality. 
 
 [With a presumably infected wound buried sutures should be discarded 
 in favor of plain through-and-through sutures of silver wire or silkworm 
 
 gut.] 
 
 Drainage of the Peritoneal Cavity. — From the earliest days of laparat- 
 omy this has been done to prevent the accumulation of liquids (blood, as- 
 citic fluid, more or less septic serum, etc.V Peaslee, in 1855, first pointed 
 out the necessity for it. He used an elastic catheter which penetrated into 
 
 Fig. 48. — «, Terrier's hcemostatic forceps; l\ Kocher's model; c, Pozzi's curved forceps. 
 
 the pouch of Douglas and emerged through the vagina. Koeberle, in 1867, 
 drained through the abdominal wound by means of a glass tube terminating 
 in a bulb, and perforated at intervals in its entire length with small open- 
 ings. The two directions to be taken in peritoneal drainage were from that 
 time determined. But the debatable ground, then and now, is the indication 
 for drainage. Sims, in 1872, recommended systematic drainage after every 
 ovariotomy. This exaggerated view at least showed the harmlessness of 
 drainage when attended with proper precautions. It is well to bear in mind 
 that, at the end of a few hours, the tube is surrounded and in a measure 
 isolated by a newly formed pseudo-membrane. Only a persistent oozing in 
 the abdomen will cause the formation of a cavity at the end of the tube in 
 which fluids accumulate. 
 
METHODS OF SUTURE AND H^MOSTASIS. 
 
 57 
 
 The problem has been further simplified by the recognition of the great 
 absorptive powers of the peritoneum when this physiological function is not 
 interfered with by extensive or ragged wounds, or by long exposure to the 
 air and paralysis of the intestines. Consequently in a laparatomy uncompli- 
 
 FiG. 4g. — Straight Forceps for Forcipressure in Mass. 
 
 cated by the above conditions a large amount of blood or serous fluid may 
 be rapidly absorbed without injury to the patient. 
 
 Chenieux asserts that this absorption is more beneficial than evacuation, 
 and we would scarcely wish to contradict him. The difficulty consists in 
 knowing when it will occur; if it does not occur at all, septicaemia is more 
 likely to follow. I have said in a preceding chapter that washing the peri- 
 toneum temporarily interferes with its absorptive powers. 
 
 (Wegener, basing his conclusions upon experiments with dogs and rab- 
 bits, estimates the absorptive powers of the peritoneum in man at two and a 
 half quarts an hour; toxic injections have as rapid action as if introduced 
 directly into the blood-vessels.) 
 
 The "toilet" of the peritoneum having been properly accomplished, after 
 a laparatomy, by means of gauze sponges introduced by the finger or long 
 forceps into all dependent portions, there is nothing to fear from what is 
 left in the abdomen but purely from what may come later and remain there. 
 Each and every surgeon must judge for himself what constitute indications 
 
 Fig. so. — Curved Forceps for Forcipressure in Mass (P£an and Richelot). 
 
 for drainage, it being manifestly impossible to lay down strict laws; yet we 
 may formulate the principal indications. 
 
 I. Abundant parenchymatous oozing of blood or serum after closure of 
 the abdominal walls, the absorbing power of the peritoneum being impaired 
 by special anatomical or clinical conditions. Drainage, in this case, serves 
 not only to carry off the fluid, but possesses haemostatic action as well. 
 
58 
 
 CLINICAL AND OPERATIVE GYX.-ECOLOGY. 
 
 2. The existence in the peritoneal cavity of a septic body (shred of a 
 cyst wall, suppurating surface) which would occasion the formation of fluid 
 whose absorption would be harmful ; lesions of the peritoneum. 
 
 3. Large tear of the peritoneum acting in two ways : (^7) as a source of 
 persistent oozing, {b) as an obstacle to normal absorption. 
 
 4. Long duration of the operation and manipulation compromising the 
 tonicity of the intestinal walls and the vitality of their serous covering. 
 
 Dj-amaore tJiroiis:h the Vas^ina. — The cul-de-sac of Douglas beino' the most 
 
 ! 1 
 
 Fig. 51. — Instruments of Several Sizes for Forcipressure in Mass (Adhesions) -with Collik's Joint. 
 
 Natural size. 
 
 dependent portion of the pelvic cavity, it seems reasonable to utilize it for the 
 purpose of draining. Moreover, by its use we avert the danger of weakening 
 the abdominal walls, and thus favoring the occurrence of a hernia by delay 
 in union at any point. The only objection to be raised against the vagina 
 as a canal for drainage is the fact that antisepsis is rendered more difficult 
 by the large number of micro-organisms always present in the genital tract. 
 
 Without dwelling upon inefficient or complicated methods of drainage, I 
 shall describe the one that seems to me of the most value. It consists in 
 the introduction of a cross-shaped tube formed of two rubber tubes firmly 
 
METHODS OF SUTURE AND H^MOSTASIS. 
 
 59 
 
 united. (This may be done with silk sutures, but there is danger of second- 
 ary infection.) After a laparatomy this tube may be inserted through an 
 incision in the posterior cul-de-sac, or directly by puncture with a large 
 trocar, or, better still, with Wolfler's forceps. 
 
 I have seen them inserted by A. Martin without previous puncture of the 
 
 Fig. 52. — I, Rubber cross-shaped drainage tube for draining cavities. 2, Method of seizing the tube in the forceps 
 for insertion in a cavity. 3, Wolfler's forceps for introducing tubes by transfixion. 
 
 tissue. The transverse arms of the tube were held folded in the teeth of the 
 forceps ; the surgeon placed two fingers in the pouch of Douglas, and, while 
 the cervix was held down by an assistant, the operator forcibly pushed the 
 forceps behind the cervix into the posterior cul-de-sac, bursting through its 
 walls and carrying the tube into the abdomen between the guiding and sup- 
 
'6o CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 porting fingers. The inventor of this process claims that rapidity of action 
 io secured and danger of hemorrhage or of wounding the rectum is averted. 
 For my part I prefer the cautious use of Wolfier's forceps (Fig. 52). The 
 transverse arm of the tube is held securely in place and yet in such a way 
 that it can be taken out when necessary, by strong traction. The vaginal 
 extremity should be wrapped in iodoform gauze. Unless special indications 
 call for longer drainage, it is left in place eight or ten days at most. A 
 feeling of discomfort in the abdomen warns us when the tube ceases to be 
 tolerated. As a matter of prudence, it is better to administer no injections 
 either through the tube or in the vagina while the tube is in place ; exuded 
 fluids can be absorbed by gently pushing iodoform gauze into the vagina. 
 
 Drainage through the abdominal walls has hitherto been done chiefly 
 with glass tubes. It is advisable to have an opening only at the inner end. 
 This is inserted into the cul-de-sac of Douglas and the upper extremity 
 emerges from the abdomen into an absorbent dressing. Lawson Tait uses a 
 special sort of cupping-glass to pump out fluid. [A slender forceps is better 
 
 
 2 
 
 Fig. 53. — Tubes for Peritoneal Drainage, i, Koeberle's tube. 2, Keith's tube. 
 
 and more easily kept aseptic than cupping-glass or syringe for removing 
 fluid from the tube. With it small pieces of sterile gauze or cotton can be 
 easily carried into the tube and the fluid entirely removed.] Koeberle, as 
 early as 1867, filled the canula with pledgets of carbolized cotton to absorb 
 the fluid. Hegar adopted this process, with improvements, bringing into 
 play the capillarity of the absorptive substances contained in the canula, 
 which were frequently renewed. He finally changed the canula into a large 
 abdominal speculum (Bauch speculum) of glass or hard rubber, one or two 
 inches in diameter and seven inches long, filled in his earlier experiments 
 with carloolized cotton, later with iodoform gauze. On the first day this is 
 renewed every hour, then every two hours, and finally every four hours. 
 Hegar has since abandoned this rpethod for that of capillary drainage by 
 means of iodoform gauze only. It is evident, then, that capillary drainage 
 has for some time been an auxiliary to tubular drainage through an abdomi- 
 nal opening; it counteracts the injurious effects of pressure far better than 
 Nussbaum's method of turning the patient upon the side or the abdomen. 
 The credit of reducing to a system what was previously a more or less em- 
 pirical process is due to Kehrer. He proposed the use of lamp-wick about 
 
METHODS OF SUTURE AND H^MOSTASIS. 
 
 6r 
 
 as thick as the little finger, thoroughly disinfected by boiling in a five-per- 
 cent carbolic solution ; in practice, however, it is usual to immerse the wick 
 in iodoform ether, and then thoroughly dry it. 
 
 Since the publication of Kehrer's article, antiseptic lamp-wick, iodo- 
 formed or carbolized, has been extensively used in Germany, both in gynae- 
 cological operations and in general surgery. Breisky has long used it for 
 drainage after vaginal hysterectomy for uterine cancer. Billroth used it for 
 several purposes, but seems now to prefer strips of iodoform gauze. Never- 
 theless the lamp-wick has recently come 
 into favor again. Gersuny considers its 
 absorptive powers greater than those of 
 gauze, and Chrobak took the trouble to 
 demonstrate its superiority by means of 
 comparative experiments. He used it in 
 draining after ovariotomy and supravagi- 
 nal hysterectomy. Yet operators of no 
 less authority than Hegar, Mikulicz, etc , 
 affirm that the absorptive powers of gauze 
 are all-sufficient, and that, other things 
 being equal, it is best to avoid multiplying 
 the number of materials used for dress- 
 ings. The indications for simple capillary 
 drainage of the peritoneum, as distin- 
 guished from the combination of it with 
 tamponing, to which I shall shortly al- p-,^ 
 lude, are, I believe, very few. For my 
 part, I use it only after vaginal hysterec- 
 tomy. Instead of inserting one or two 
 
 tubes into the peritoneal opening, or leaving it quite open as do many 
 surgeons, I prefer to reduce the size of the wound by a few lateral sut- 
 ures and push in, to the depth of about a finger, a large strip of iodoform 
 gauze doubled upon itself, its two ends tucked into the vagina and easily 
 recognized by a thread tied about them. At varying intervals, depending 
 upon the amount of exudation, the other pieces of iodoform gauze which 
 complete the intravaginal dressing are renewed, but the strip in Douglas' 
 pouch is left in place as a drain and only removed after a lapse of six or 
 eight days. 
 
 Antiseptic Tamponade of the Peritoncinn. — It was a bold step to stuff 
 antiseptic pledgets into a portion of the peritoneal cavity so as to isolate it 
 from the remainder of the serous membrane. This isolation is produced in 
 the first few hours by the tampon barrier alone, later by the adhesions formed 
 at its periphery. This audacious proceeding was suggested by the success 
 following the tamponade of wounds which replaced drainage in Kocher and 
 Bergmann's practice. The second step was Hegar's use, in the opening o^ 
 
 1 2 
 
 Abdominal Drainage, i, Glass tube, «, 
 surmounted by a sponge, i^, covered by rubber 
 tissue, c. 2, Syringe for aspirating fluid frortL 
 bottom of tube. 
 
62 
 
 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 pelvic abscess, of a process founded upon Volkmann's method of opening 
 hepatic abscess. Finally tamponade of the peritoneum itself was recom- 
 mended by Mikulicz. It has been used in Germany and in America, but I 
 can find no record of its use in England, and in France I was the first to 
 describe and make use of it. 
 
 AletJwd of Application. — Mikulicz advises the insertion, in the first place, 
 in the cavity to be tamponed, of a pocket formed by stuffing in a piece of ten- 
 
 FlG. 55. — Tamponade of the Peritoneal Cavity after Hysterectomy. a a, Pouch of iodoform gauze; 
 b, silk thread fastened to centre of pouch; c c, strips of iodoform gauze. 
 
 per-cent iodoform gauze. To the centre of this piece of gauze is attached an 
 antiseptic, double silk thread by means of which it may later be withdrawn. 
 To save time, this should be arranged before the operation ; the gauze when 
 in place looks like a tobacco pouch ; five or six long strips of iodoform gauze 
 are now stuffed in and spread over the whole surface of the cavity, their ends 
 project from the gauze pouch, and with it emerge from the lower extremity 
 of the abdominal wound (Fig. 55;. This process may be simplified by 
 merely pushing the strips of gauze directly into the cavity, if that cavity be 
 small or tortuous — but one must take care that the gauze has no loose threads 
 upon its edges. 
 
 It is well to insert a large drainage tube at the same time; this will give 
 
METHODS OF SUTURE AND H.^MOSTASIS. 63 
 
 central support to the tamponing and prevent the accumulation below of 
 fluids too dense to filter through the gauze. 
 
 I also advise that sterilized gauze or steamed iodoform gauze be used, for 
 I have occasionally seen signs of mild iodoform poisoning. It is well, also, 
 to attach threads of different color to the various strips of gauze, so as to 
 know which ones to take out first. 
 
 How long should the tampons be left in place? Mikulicz says the strips 
 of gauze should not be removed under forty-eight hours, and the bag itself 
 three or four days later. One should be guided by the amount of oozing, 
 and the condition of the parts to which tampons have been applied. At all 
 events, the pouch should not be taken out before the fifth day, so that the 
 peripheric adhesions may become firm enough to be safe from all danger of 
 tearing. It is easy enough to remove the strips of gauze, if you follow my 
 advice and put on some mark by which they may be distinguished and re- 
 moved in consecutive order. Otherwise their extraction may be difficult and 
 cause injury. Gluck has recently proposed the use of tampons which can 
 be absorbed, as catgut, etc. This seems to me a theoretical idea incapable 
 of practical application. Though it be necessary to leave the tampons in 
 place long enough to permit of the formation of plastic, aseptic inflammatory 
 adhesions surrounding and circumscribing it, it is self-evident that the ex- 
 ternal dressings should be changed as often as necessary — or about three 
 times a day. The serum secreted at the depth of the wound and transmitted 
 by capillary drainage through the tampons is very rapidly absorbed by this 
 external dressing. 
 
 It is no more possible to lay down an absolute rule in reference to cases 
 demanding the use of packing than it was in the case of drainage. Much is 
 necessarily left to the judgment of the operator. Tamponade should cer- 
 tainly be reserved for exceptional use, an ultima ratio, either for parenchy- 
 matous oozing (haemostatic tamponade) or in case of threatened septic infec- 
 tion (protective antiseptic tamponade). In the latter case, two different 
 conditions may exist. 
 
 A. A part of the wound is already septic at the time of operation, and 
 on account of the presence of septic tissue which cannot be removed without 
 danger, or of the large effusion of pus and septic fluid, irrigation and cleans- 
 ing seem to produce no effect. 
 
 B. The danger of infection occurs after closure of the abdominal wound, 
 and is due to the falling apart of a badly made suture, or to perforation of 
 some organ affected before or by the operation (intestines, bladder). In 
 either case, I have obtained good results from an antiseptic tamponade. 
 [This method is also valuable and most often used in cases in which, for any 
 reason, such as the presence of universal adhesions or because of anatomical 
 relations, it is impossible to complete the removal of any abdominal or pelvic 
 cyst. In these cases, after stripping off, if possible, the lining membrane of 
 the sac, the cavity is stuffed, as described, with an iodoform-gauze pouch 
 
64 CLINICAL AND OPERATIVE GYN.-ECOLOGY. 
 
 filled with plain gauze to lessen the risk of iodoform poisoning. This is 
 allowed to remain in situ for from forty-eight to sixty-four hours or longer if 
 there be no rise of temperature, when it is removed and the cavity repacked 
 if necessary. The cyst cavity rapidly shrinks and soon becomes a granulat- 
 ing surface, which after a time becomes obliterated.] 
 
 Intra- uterine Dminage. —C3.Y>iW^ry drainage of the uterus, by means of 
 thin strips of iodoform gauze successively pushed into place with a sound, is 
 used as a preventive of infection from uterine catarrh. These strips are 
 removed at the end of twenty-four hours and replaced with fresh gauze, a 
 procedure easily accomplished because of the increased dilatation of the cav- 
 ity. Should the uterine cavity need thorough disinfection, the drainage or 
 tamponing may be conducted in a very similar manner to that which I have 
 described for the peritoneal cavity. 
 
 Langenbuch, Theide, and Schede have used a drainage tube closed at 
 the upper extremity, but perforated with holes in the intra-uterine portion. 
 By its aid one can make frequent injections into the uterus, but it is a mis- 
 take to think that the mucus will be carried off. It is too thick to go 
 through the small apertures; the tube, moreover, is kept in place with diffi- 
 culty. It is a bad method, and may even cause intra-uterine infection 
 instead of preventing it. The case is altered when the uterus is sufficiently 
 dilated to allow of the insertion of a large cross-tube, which is a far better 
 instrument than the metallic ones which have been recommended but which 
 are likely to injure the uterus. It is both easier to introduce and keep in 
 place, and safer in its use ; and is of especial value when a permanent source 
 of infection exists in the dilated uterus, as a sloughing shred from a fibroid, 
 or a piece of foetal membrane which has evaded curetting. When necessary 
 this drainage can precede continuous irrigation, and in any case it facilitates 
 the evacuation of concealed fluids and the frequent administration of intra- 
 uterine injections. 
 
 Contimwns Irrigation. — The following is my method of applying it: 
 
 The arms of the crossed drainage tube are doubled up in the forceps and 
 inserted (PTg. 52, 2) into the uterine cavity, which, having already been 
 dilated, offers no obstruction. As a preliminary, you rapidly introduce two 
 or three pints of a strong antiseptic solution (3 : 1,000 of carbolic, 0.5 : 1,000 
 of bichloride), then begin the irrigation to the full capacity of the canal, and 
 finally, drop by drop, either by the use of an ordinary stopcock, or Schiick- 
 ing's minim-dropper. The solution used should now be weaker (one per 
 cent carbolic, one-fiftieth per cent bichloride), and should be maintained at 
 a temperature of 95'^ to 100° F. This drainage and irrigation may be con- 
 tinued for several days (F'ig. 56). 
 
 The patient is to be kept upon a rubber apparatus or sheet so arranged 
 as to carry the fluid into a receptacle placed upon the floor by the bedside 
 (Figs. 4 and 58). The buttocks and genital organs are to be anointed with 
 vaseline to prevent excoriation. 
 
METHODS OF SUTURE AND H.'EMOSTASIS. 
 
 65 
 
 Antiseptic tamponade of the uterine cavity was first used by Fritsch in 
 the dressing of certain cancers of the body of the uterus, and has proved of 
 use to me in similar cases. Long strips of iodoform gauze are prepared and 
 gently pushed into the uterus with some blunt instrument, as long and 
 slightly curved forceps, being packed in gradually, somewhat as a tooth 
 is filled (to use Fritsch's expression). The 
 gauze may be left in place from three to six 
 days, and renewed from time to time until the 
 disinfection is thoroughly accomplished. Intra- 
 uterine tamponade may be haemostatic as well 
 as antiseptic ; it is then well to use a gauze 
 which is prepared with resin as well as iodo- 
 form : this can be made upon the spot when 
 necessary by thoroughly dusting some Lister's 
 gauze with iodoform powder. Very exception- 
 ally one may add a few drops of the perchloride 
 of iron after curetting a cancer or enucleating 
 a fibroid. Such a tamponade, preceded by hot 
 injections, and followed by the administration 
 of ergot, may be of inestimable value. It has 
 recently been applied to post-abortum and post- 
 partum hemorrhages, and used in the treatment 
 of uterine atony. 
 
 Tamponade of the Vagina. — This must not be 
 confounded with the mere insertion of tampons. 
 To deserve the former appellation, the vagina 
 should be filled through its whole extent with a 
 column of a more or less elastic substance — 
 lint, cotton, gauze, or wool — rendered aseptic 
 and antiseptic by previous treatment. Various 
 medicinal agents may be incorporated with it, 
 but the tamponing is the chief object in view. 
 
 It may be used for two different purposes, 
 (i) Haemostatic; (2) antiphlogistic. 
 
 (I ) Hceniostatic Tamponade. — This is not a method adopted from choice, 
 but from urgent necessity, a profuse metrorrhagia calling for immediate in- 
 terference. To seek the cause and treat it directly is always best, but not 
 always possible, and to gain time we resort to vaginal tamponade, inserting 
 below the os uteri a large pledget of cotton which is permeated with great 
 difficulty, and causes coagulation of the blood in the uterus. Emmet, to 
 attain the same object, has had recourse to temporary suture of the external 
 OS. We must not forget that this is an expedient merely, and not treatment 
 properly so called ; danger would attend its protracted use, either from the 
 hemorrhage itself, or from reflex reactive action caused by the foreign body 
 
 1. 2. 
 
 Fig. 56. — I, Apparatus connected with 
 a cross-tube for continuous irrigation of the 
 uterine cavity or vagina. 2, Schiicking's 
 minim-dropper. 
 
66 CLINICAL AND CFERATIVE GYX/ECCLO'c^Y. 
 
 in the vagina. But, bearing in mind the possibility of such an occurrence, 
 the method is capable of rendering good service. 
 
 The old way of tamponing consisted in the introduction through a cylin- 
 drical or bivalve speculum of dry lint, arranged something like a kite-tail. 
 This lint, filled with germs, was often left in place long enough to initi- 
 ate infection. Since the era of antisepsis, lint has been replaced by cotton 
 or gauze saturated with carbolic, salicylic, or boric acid, bichloride or iodo- 
 form. These materials are not, however, of equal value ; dry absorbent cot- 
 ton is even injurious owing to its permeability; well-packed gauze is so in 
 a less degree, yet productive of harm unless previously well moistened. 
 
 That this little operation may be effective, I advise the following mode 
 of procedure, bidding you bear well in mind that its use is rarely called for ex- 
 cept in cases in which life is endangered. We fi.rst assure ourselves that the 
 rectum and bladder are empty. The best position for exposure of the whole 
 vagina without fatigue to the patient is the Sims or lateral semi-prone 
 position. The blade of a speculum depresses the posterior wall, and the 
 entrance of air brings the parts into view. Irrigation with carbolized one- 
 per-cent solution will clear out clots and accumulated blood. For the tam- 
 ponade I recommend the use of pledgets of cotton, a few of them saturated 
 with a concentrated solution of alum, the greater number with the weak car- 
 bolic solution which has been used for irrigation. Just before using them, 
 they are squeezed into the shape of fiat discs about the diameter of a silver 
 dollar and twice or three times as thick. With long forceps, five or six of 
 the alum discs are rapidly packed around the cervix in the culs-de-sac, down 
 to the level of the external os. When this is covered over, the tamponing 
 is continued with the carbolized discs, squeezed as dry as possible. 
 
 It will be necessary to have a large number of these cotton pledgets, 
 though they are not to be forcibly pressed into place, but simply inserted 
 one upon the other so as to form a homogeneous mass. The speculum is 
 gradually withdrawn as the discs are introduced, and will be entirely free 
 just before the completion of the tamponing. As this cotton column may 
 compress the neck of the bladder, it may be necessary to use the catheter 
 from time to time. The tampons should not be left in place more than 
 twenty-four hours; after their removal a hot douche is administered, and the 
 tamponade is only repeated if absolutely necessary. 
 
 (2) Antiphlogistic Tamponade. — The results aimed at by the inventors of 
 the process of columning the vagina are : the mechanical uplifting of the 
 uterus by relaxing the strain upon its ligaments, diminution of venous stasis 
 due to its prolapse, the slowing of the arterial current by eccentric pressure 
 on the parts ; combating thus congestion and inflammation and bringing the 
 tissues into a favorable condition for the reabsorption of exudations, and the 
 cessation of pathological reflex phenomena. Bozeman seems to have been 
 the first to use both the name of "columning" and the process. Taliaferro 
 was the one to introduce it into general yse. It is a popular method of treat- 
 
MKTHOUS OF SUIURE AND H^MOSTASIS. 6/ 
 
 ment in America, and the happy results obtained prove that it is XN^orthy of 
 serious consideration as a therapeutic measure, especially in the case of sub- 
 acute or chronic perimetritis, subinvolution, etc. The following is the cor- 
 rect method of procedure. The best position in which to place the patient 
 is the genu-pectoral ; this permits of free access to the vagina, which is 
 opened out by the inrushing aii". [This position is a disagreeable one for 
 the patient, and practically equally good results may be obtained in the 
 Sims position.] One should have at hand, (ist) small pledgets of antiseptic 
 absorbent cotton, soaked in glycerin and squeezed dry ; (2d) pieces of fine 
 wool, purified in a sterilizing oven, washed in a one-per-cent carbolic solution 
 and wiped dry; this substance is employed because of its elasticity. A 
 tamponade composed entirely of absorbent cotton would be too compact ; 
 cotton from which the oil has not been expressed, although less elastic than 
 wool, may con\eniently replace it if necessary. Tampons or discs to be 
 used are soaked in glycerin and squeezed out, then inserted in the posterior 
 cul-de-sac, surrounding the cervix, holding it firmly in place. The packing 
 of the vagina is completed by filling it with well-carded wool or non-absorb- 
 ent cotton almost to the vulvar opening. The patient should keep her bed 
 for one or two days after the first tamponing, which is always applied more 
 compactly than those which follow. Should an erythema supervene, it 
 would be well to use only dry substances well covered with vaseline. The 
 tamponade is renewed every two or three days, and to be effectual should be 
 persisted in for se\'eral consecutive weeks or months. 
 
 One may produce a topical effect upon the vaginal mucous membrane by 
 saturating the cotton or the wool with medicinal agents, as glycerole of tan- 
 nin, etc., but when this is done, tamponing ceases to be tamponade and be- 
 comes merely a collection of tampons. 
 
CHAPTER IV. 
 
 METHODS OF GYNAECOLOGICAL EXAMINATION. 
 
 The chief positions in which we are called upon to examine patients are 
 the erect, the dorsal, the lateral, and the genu-pectoral. 
 
 Erect Position. — The vaginal touch with the patient standing affords 
 only limited information, but is useful in cases of displacement of the pelvic 
 
 Fig. 57. — Metal Sheet for Continuous Irrigation (Lourcine). 
 
 organs and in abdominal tumors. It is not suitable for complete examina- 
 tion and deserves no further mention. [I cannot quite agree with the author 
 in his estimate of the value of the examination in the erect position. Very 
 many symptoms of pelvic disease are more marked or only noticed when the 
 patient is on her feet, and certain conditions of descent, prolapse, or displace- 
 ment may entirely disappear or change when the intra-abdominal pressure is 
 removed in the dorsal or Sims position. Further a pessary which seems to 
 support a displaced uterus perfectly while the patient is recumbent may be 
 found inadequate when she is erect. As these conditions cannot be cer- 
 
METHODS OF GYNECOLOGICAL EXAMINATION. 
 
 69 
 
 tainly determined in any other manner, the value and often necessity of ex- 
 amination in this position is evident.] The examiner, standing mostly in 
 front of the patient, places his left knee on the floor and the left arm back 
 of the patient's waist, while the right knee, semiflexed, supports the elbow 
 of the same side while the examination is progressing. 
 
 Dorsal Position. — For an examination of the abdomen or the simple 
 vaginal touch we may have the patient lie on her back, with her head on a 
 cushion, the legs a little flexed and the thighs abducted. In this position 
 she may be examined provisionally in bed ; but it does not produce sufficient 
 
 Fig. 58 (a and h). — Kelly's Ovariotomy and Perineal Pads. 
 
 relaxation of the abdominal muscles to allow satisfactory palpation, nor does 
 it permit the use of the speculum. 
 
 Modified Dorsal Position. (Semi-recumbent position). — This position 
 combines the advantages of relaxation of the abdominal muscles and easy 
 examination of the vagina by the finger or the speculum, and is to be pre- 
 ferred where we wish a complete exploration. The patient is placed at the 
 edge of a bed or table ; the upper part of the body is a little raised, as if the 
 woman were half sitting; the legs are flexed upon the thighs, and they in 
 turn upon the abdomen, and are held in this position by the assistants or 
 with the aid of foot-holders. 
 
 Dorso-sacral Position. — This is the most satisfactory position for all 
 operations on the external genitals, the vagina or the uterus per vias natit- 
 rales, since it renders all these parts most accessible to the surgeon. The 
 
70 
 
 CLINICAL AND OPERATIVE GYN.-ECOLOGY. 
 
 patient is placed at the edge of the bed or the table ; the head is elevated 
 by a pillow, the trunk is horizontal, the pelvis is flexed upon the vertebral 
 column so that the sacrum presents a marked obliquity both vertically and 
 from behind forward. The knees are bent and the thighs strongly flexed 
 over the abdomen and maintained in this position by supports, or, better, by 
 the assistants, each taking the flexed knee on his side under his axilla, thus 
 leaving the hand free to assist the operator. If one has no assistants, the 
 ingenious leg-holder of Fritsch may be employed, in combination with his 
 speculum-holder. Many forms of leg-holders have been invented ; the type 
 of such being Clover's crutch, which has been ingeniously modified by Ott 
 of St. Petersburg. [I have found a sheet folded diagonally like a cravat and 
 used in the same way as the device shown in Figs. 65 and 66, perfectly efficient 
 and convenient.] A very useful modification of this position is obtained by 
 a decided elevation of the pelvis above the rest of the body ; a position 
 which might be called the inclined dorso-sacral. This tipping of the pelvis 
 
 Fig. 50.— I, Triangular basin for dressings. 2, Basin with handle; to be placed under patient in dorso-sacral 
 
 position. 
 
 has the effect of allowing the abdominal contents to fall toward the concavity 
 of the diaphragm and renders examination of the true pelvis very easy. For 
 a simple examination this position is easily obtained by letting the patient lie 
 on a couch, the legs flexed over the head-board, which serves as their sup- 
 port. If one has assistants at his disposal, he may let them turn their backs 
 and take each a leg of the patient over their shoulders. This position is at 
 times of great assistance to the operator, in freeing the pelvis of its contents ; 
 as, for instance, in examining for small tumors of the uterine adnexa. It 
 has been recommended by Trendelenburg in searching for tumors of the 
 bladder, and by Pawlik in catheterizing the ureters ; and has lately been re- 
 introduced by Mendes de Leon. To render exploration easy and the organs 
 of the pelvis accessible during laparatomy, it has been found equally advan- 
 tageous to allow an assistant to elevate the uterus by two fingers in the 
 vagina, or to introduce into that canal an air pessary — a jiroccdure analogous 
 to Petersen's use of a balloon during lithotomy. 
 
 [This posture— the Trendelenburg position with the ])elvis elevated, the 
 body resting upon an inclined plane at various angles up to 45° from the 
 
METHODS OF GYNECOLOGICAL EXAMINATION. 
 
 71 
 
 horizontal — is now employed by many as a routine measure during the per- 
 formance of laparatomy ; it seems to possess few disadvantages, does not 
 interfere with the breathing, renders shock from acute anaemia less 
 liable, besides causing the intestines to gravitate toward the diaphragm 
 and rendering all parts of the pelvis readily accessible both to touch 
 and sight, thus lessening markedly the technical difficulties of intrapelvic 
 surgery.] 
 
 Latcro -abdominal o?- Scmi-pronc Positio7is. — This, the Sims position, is 
 particularly adapted to examinations and treatment with the duck-bill specu 
 lum, the weight of the abdominal viscera, drawing forward and upward, 
 neutralizes the intra-abdominal pressure and causes an easy and perfect sep- 
 aration of the vaginal walls. While of great use in many different circum- 
 stances, it is pai'ticularly desirable with 
 very modest patients. 
 
 The woman, with all bands about 
 the waist loosened, should lie upon her 
 left side, at the edge of the bed or the 
 table, flexing the legs at right angles 
 with the thighs and these at the same 
 angle with the bod)'. The lower ex- 
 tremities may be held by an assistant, 
 or by a support fastened to the table 
 (Fig. 6^). 
 
 The patient's body, instead of rest- 
 ing wholly on this side, is so turned 
 that her chest is directed obliquely 
 toward the table, and this is best ac- 
 complished by drawing the under arm 
 out behind and allowing it to hang over 
 the edge of the table. [" In this posi- 
 tion the woman lies partly on her side and partly on her chest and abdomen, 
 the abdominal viscera gravitate forward and downward away from the pelvic 
 cavity ; the pelvis has a lateral and downward inclination, so that a line 
 drawn from the coccyx through the rima vulvae will strike the left popliteal 
 space. The posterior vaginal wall is thus superior to the anterior and the 
 uterus sinks downward and forward. For ocular examination this position 
 is unrivalled and for many instrumental and operative procedures on the 
 vagina and cervix almost indispensable. While a hard table, covered with 
 a blanket or lightly upholstered, is undoubtedly the best couch for this posi- 
 tion, and the examination is facilitated by giving the table a lateral and 
 downward inclination toward the lower side and head of the patient, a tole- 
 rably satisfactory examination may be made on a firm, level sofa orbed, 
 which does not allow the hip to sink to the level of the vulva. The table 
 should be so placed that the light falls directly upon the vulva over the 
 
 Fig. 60. — Patient in Modified Doks.> 
 ON Chadwick's Table. 
 
72 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 right shoulder of the operator ; the table will, therefore, occupy a diagonal 
 position before the window."] 
 
 Geim-pectoral or Kiicc-cJicst Position. — In this position the body rests 
 on the upper chest and knees, the pelvis being the highest point. The 
 thighs are at right angles to the pelvis, the knees near the edge of the table 
 or bed, with the feet projecting over its edge; the head is turned and rests 
 upon the side of the face. [All clothing must be loose about the waist. In 
 this position the weight of the abdominal viscera draws strongly upward and 
 forward (in relation to the patient), tending to displace the contents of the 
 pelvis in the same direction, and as soon as air is allowed to enter the 
 vagina, to distend it to the maximum. For these reasons it is extremely 
 valuable in the reposition of certain retrodisplacements, particularly of the 
 
 Fig. 6i. — Ott's Leg-Hmi.iii;k. The long strap passes under the patient's back. 
 
 gravid uterus, or in freeing small incarcerated tumors.] Patients do not 
 readily assume this position, claiming that it is immodest, but in certain 
 cases, because of the reversal of intra-abdominal pressure and the vaginal 
 distention, it is indispensable. The position is irksome, cannot be long 
 maintained, and is not free from danger if used during ana:sthesia. 
 
 Genu-cjibital cr Knec-clboiu Position. — This, vulgarly known as the 
 " cow" position, is little used except in Bozeman's operation for vesico- 
 vaginal fistula. The patient rests on the elbows and knees and is supported 
 by special apparatus (see figure under Vesico-vaginal Fistula). Anaesthesia 
 in this position is somewhat dangerous because of the interference with 
 respiration. 
 
 Simple Abdominal Palpation.— T\\q patient is ]:)laccd in the dorsal posi- 
 tion with the knees a little bent, and advised to open the mouth, breathe 
 without effort, and avoid rigidity. The bladder and rectum should be empty, 
 
METHODS OF GYNECOLOGICAL EXAMINATION. 
 
 73 
 
 and it is well to completely clear the large intestine beforehand by a cathar- 
 tic and an enema. Both hands are used at the same time. They should be 
 warm, for when cold they excite reflex contractions. Beginning very gently, 
 the abdomen can be accustomed to the manipulation, and then the tips of the 
 fingers may be pressed in with more force for the purpose of deeper explora- 
 tion. A certain amount of massage disarms the abdominal muscles, prevents 
 reflex contractions, and permits the examiner to make a satisfactory palpa- 
 tion. It is advisable to proceed methodically, examining the hypogastric 
 reo-ion and then the iliac fossae, determining the amount of alteration in the 
 internal organs from their normal size or position ; then proceeding to the 
 
 Fig. 62. — ^Patient in Lithotomy Position (lateral view). 
 
 umbilical and lumbar regions, and finally to epigastric and hypochondriac. 
 The normal tension and consistence of the abdominal walls presents marked 
 extremes. The age of the patient, previous pregnancies or multiparity, lean- 
 ness or obesity, the distention to a greater or less extent of the stomach and 
 the intestine from gas in dyspeptics, etc., are all conditions which present 
 great diversities and may be the sources of error. I cannot pass them all in 
 revieAv, but will mention certain ones. 
 
 If the bladder and intestines have not been emptied, one is not safe 
 against the illusion that there is a tumor, really due to their contents ; and 
 at all times too great confidence must be avoided. The soft consistence of 
 faecal matter gathered in the caecum or the sigmoid flexure, its presence in 
 the lumbar regions, and the possibility of making a dent in it which shall 
 
74 
 
 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 persist, as in clay, are all characteristic qualities which will distinguish it 
 from other things. But even a vigorous cathartic may fail to remove scyba- 
 
 FiG. 63. — Cleveland's Lai'Akat(imv Table. 
 
 lous masses which may have accumulated, especially if there is any mechani- 
 cal cause for constipation. 
 
 An enormousl}' distended bladder, reaching to the umbilicus, has fre- 
 quently been mistaken for a cyst. This distention may be due to long 
 retention and incomplete urination, so that the bladder gradually assumes an 
 unusual size; or to pressure upon the vesical neck; or to nervous affections 
 which lessen sensibility. I was once summoned to an asylum for the insane 
 
 Fir,. 64.— Clrvkland's Laparato.mv Table Arkanged iok 'J'kendelrnbirg's Positiok, 
 
 to puncture an ovarian cyst, which proved to be nothing but extreme vesical 
 distention in a patient with general paralysis. Therefore always pass a 
 catheter before making such examinations. 
 
METHODS OF GYNAECOLOGICAL EXAMINATION. 
 
 75 
 
 Finally, catheterism if rapidly done may not empty the bladder wholly. 
 The/e are cases in which the organ is bilobed, wallet-shaped, from compres- 
 sion between a pelvic tumor and the pubis, and the 
 communication between the two portions may be 
 so restricted that the stream of urine ceases when 
 the lower compartment is emptied. If this condi- 
 tion be suspected, a long catheter, which should be 
 of stiffened rubber, will easily relieve the difficulty 
 and empty the upper portion. It thus seems, occa- 
 sionally, as if there were a pseudo-cyst overhanging 
 a veritable tumor, with some obscure connection 
 between them. The recti muscles of the abdomen 
 often simulate tumors by rigid contractions of their 
 mass and the sharpness of their borders. Espe- 
 cially is this true when there is a separation in the 
 linea alba with lateral displacement of the muscles. 
 It seems also that there may be partial contractions 
 between two tendinous intersections, which increases the 
 diagnosis. 
 
 Meteorism may be so developed that it resembles either a tumor or preg- 
 nancy. In this case percussion gives us great assistance but does not remove 
 
 Fig. 65. — Robe's Leg-holdek. 
 
 difficult\- of 
 
 Fig. 66.— Patient in Dorso-sacral Position; showing Application of Robb's Leg-holdek, or of the 
 
 Folded Sheet. 
 
 all doubt ; there have been cases of hysterical meteorism which have deceived 
 the most distinguished observers. 
 
 Extreme obesity, especially of the flanks, may render the examination 
 
76 
 
 CLINICAL AND OPERATIVE GYNECOLOGY 
 
 very uncertain. I have often observed a local excess of adipose deposit in 
 the hypogastric region on women who had some chronic disease of the geni- 
 
 FiG. 67. — Patient in Latero-abdominal (Sims') Position. 
 
 tal organs, as one often sees a like formation over the epigastrium of dys- 
 peptics. 
 
 Women who are hypersssthetic, or cowardly, and consequently become 
 rigid upon even the slightest touch, require to be put under an anaesthetic if 
 it is at all necessary to reach a decision by examination. It is possible to 
 obtain an insight into the patient's condition by bimanual palpation, which 
 far exceeds all others in precision, and in few cases (except where there is 
 
 Fig. 68.— Geni'-pectcral Position, showing the Dilatation of the Vagtoa and the Falling of the 
 
 ViSCEKA TOWARD THE DlAI'HRAGM. 
 
 unusual flaccidity or leanness) can the ovaries and tubes be reached by ab- 
 dominal palpation without anaesthesia. The various connections of a tumor 
 
METHODS OF GYN^XOLOGICAL EXAMINATION. "JJ 
 
 cannot usually be exactly determined without such aid. Often, for instance, 
 a tumor which appears to be connected with the uterus while the patient is 
 awake becomes easily separable under anaesthesia ; or a tumor which appears 
 hard is found to be plainly fluctuant. 
 
 \_Inspcction. — Before making a vaginal examination in a strange patient, 
 it is well to inspect the external genitals to detect the presence of any anom- 
 aly, of pediculi, of specific or other ulcerations or eruptions, etc.] 
 
 Vaginal ToiccJi. — The clean index finger is first covered with some anti- 
 septic lubricant as borated vaseline, or carbolized oil, and is then passed into 
 the vagina with a motion from behind forward, gliding over the fourchette. 
 Many gynaecologists advise the use of antiseptic injections after such exami- 
 nation ; in my opinion they are not less demanded beforehand. The finger 
 may gather and carry with it germs from the vagina and then go on to make 
 an erosion upon the cervix and so inoculate the patient. As a general rule, 
 then, v^aginal touch should be practised only between two antiseptic injec- 
 tions. To show the need of these precautions it is well to remember the 
 accidents which used to follow simple vaginal touch in the days before anti- 
 sepsis. Verneuil, for example, reports a case of death from extremely acute 
 peritonitis, the day after the examination, by touch and speculum, of a woman 
 with uterine polyp; he cites another of peritonitis which recovered in a 
 woman with polyp; and a third, of ulcerated polyp, where death occurred 
 after vaginal touch, the operation being postponed but one day. Howel cites 
 a similar case in his practice, and one in Broca's, whefe death followed light 
 cauterization with nitrate of silver. More recently, in Le Fort's service, 
 a woman with uterine polyp died after a vaginal examination by finger and 
 speculum. 
 
 The index finger is the most convenient for vaginal touch ; the thumb 
 should be kept straight, turned obliquely toward one or the other genito- 
 crural fold, and always avoiding the median line ; the other fingers are half - 
 flexed and make gentle pressure against the perineum and intergluteal space. 
 To reach the os the finger should follow the lateral or posterior wall, and 
 should it not be passed in the axis of the canal slight movements of rotation, 
 from behind forward and reversed, will show its position. The examiner 
 then considers, in regular order, the direction of the cervix, its size, its shape, 
 its consistence, the degree of its dilatation and the condition of the external 
 OS. Next the finger explores the posterior cul-de-sac, then the lateral, and 
 lastly the anterior. The examination is not complete, however, without the 
 aid of abdominal palpation; that is to say, bimanual exploration, which will 
 be treated farther on. On withdrawing the finger, the vaginal walls and 
 perineum are examined as to their condition. There are times when the 
 uterus is very high up and difficult to reach ; in such a case both index and 
 middle finger must be deeply introduced, at the same time the pressure 
 against the perineum is increased, if necessary, by allowing an assistant to 
 raise the elbow of the examining hand. Occasionally cases are met in which 
 
78 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 the cenax cannot be reached in any position except Sims or the knee-chest. 
 At times it may be necessary to practise the vaginal touch with the woman 
 erect, as in certain displacements and abdominal tumors. The hymen, if 
 present, may be an obstacle to the introduction of the index, but usually this 
 membrane is elastic enough to allow the touch, with some care, even upon 
 virgins, without fear of injuring it. If this manoeuvre is very painful, it is 
 better to anaesthetize the young woman unless the desired insensibility can 
 be obtained with cocaine. In such cases rectal touch does not take the place 
 of vaginal, although some authors have asserted it. 
 
 Rectal ToncJi. — It is necessary to introduce the finger into the rectum, 
 especially to examine the pouch of Douglas and the posterior aspect of the 
 uterus. Swellings and tumors of this neighborhood are not to be appreci- 
 ated at their just value by any other way. It is often very useful in deter- 
 mining whether the rectum is full or empty; the lumps of faeces felt by the 
 finger in the vagina might, perhaps, be mistaken for pathological products. 
 On the other hand, a novice may feel the cervix from the rectum and make 
 a similar error. One must especially accustom himself to the sensations 
 acquired by touch in the normal condition. The combination of rectal with 
 vaginal touch is particularly valuable in examining the condition of the recto- 
 vaginal septum. Schroeder strongly advises, in practising rectal touch, that 
 the thumb be passed into the vagina. 
 
 Manual exploration of the rectum, introduced by Simon, of Heidelberg, 
 is to be employed in certain exceptional cases. The patient is thoroughly 
 anaesthetized, the anus is dilated as for operation in fissure of the part, and 
 the fingers, gathered into a cone and well coated with vaseline, are gradually 
 pushed into the orifice as a wedge ; when the sphincter has been passed the 
 hand rests easily within the rectal ampulla and the fingers may be separated 
 for the examination. I have found this procedure of service on two occa- 
 sions and each time have introduced my hand to the wrist without any re- 
 .sulting accident, erosion, or incontinence. Nevertheless I consiiler it dan- 
 gerous, especially if the surgeon's hand is not unusually slender and pliable; 
 there have been serious accidents in certain cases. 
 
 Vesical Touch. — This method has only a restricted application, but in 
 view of the size and dilatability of the female urethra, it is generally easy to 
 carry out without recourse to incision as proposed by Simon. I have found 
 no difficulty in its performance without producing any disagreeable con- 
 sequences after previous dilatation of the urethra by graduated bougies. 
 This method has been recommended in cases of cancer of the cervix with 
 doubtful invasion of the vesical wall to determine the mobility of the mu- 
 cous membrane upon the cervix and the presence or absence of the com- 
 plication. 
 
 Noeggerath's combination of vesical and rectal touch renders excellent 
 service in atresia of the vagina and in practising palpation and bidigital ex- 
 ploration of the uterus and appendages. 
 
METHODS 0¥ CYN^:COL(J(;iCAL EXAMINATION. 
 
 79 
 
 Among combinations of methods we may further mention vesical cathe- 
 terism with vaginal or rectal touch. 
 
 Bimatiual Exploration. — I have described the vaginal and the rectal touch 
 singly for convenience' sake, but in practice one seldom examines without 
 adding abdominal palpation also, which supplements them admirably. Thus 
 arises the most valuable method of gynaecological in\'estigation, bimanual 
 exploration. 
 
 The glory of the discovery of bimanual palpation belongs wholly to 
 Puzos, the celebrated obstetrician of the eighteenth century, and to the 
 French school. 
 
 For the employment of the method the patient is placed in simple dorsal 
 
 Fig. 6q. — RiMwi \i Fxi'i oration. 
 
 decubitus, or, if that position offers any difficulty, as for lithotomy; while 
 the index of the right hand practises the touch, as described, the left hand is 
 laid above the pubis, and the fingers sunk inward with gentle, even pressure, 
 thus driving the pelvic contents toward the vaginal finger. To make clear 
 the exact position of the uterus, this procedure is carried out in the h}'po- 
 gastric region, then in the inguinal, and lastly the lumbar should be exam- 
 ined, the vaginal finger exploring the depths of the cul-de-sac toward the 
 other hand ; thus the bases of the broad ligaments and the uterine adne.xa 
 are easily examined for abnormal enlargements. At the same time account 
 should be taken of the sensitiveness of the parts ; in the healthy condition, 
 pressure over the adnexa, as also elevation and tossing (ballottement) of the 
 uterus, are free from pain. 
 
8o 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Bimanual palpation should then be performed by rectum and abdomen; 
 it is particularly advisable in disease of the adnexa. 
 
 By the combined method one can palpate the ovaries, with special facil- 
 ity if the patient is anaesthetized, but even without such aid. It is well, as 
 Hegar adv'ises, to have the uterus gently pulled down by an assistant, the 
 cervix being fixed with a bullet forceps while the surgeon palpates the ab- 
 domen and passes the index finger of the other hand by turns into vagina or 
 rectum ; the ovary is felt to glide between the fingers like a small testicle. The 
 left ovary is more easily reached than the right, which Olshausen attributes 
 CO its position in front of the rectum. With obese patients this method of 
 examination has many difficulties. Instead of adopting Noeggerath's vesico- 
 
 FiG. 70. — Bimanual Exploration. Sectional view (Davenport). 
 
 rectal method, I think it better to have recourse to the plan advised by Ul- 
 mann in difficult cases where ovarian palpation seems indispensable ; the 
 bladder being emptied, there is passed into the rectum a balloon filled with 
 200-250 gm. of water. Now bimanual palpation reveals the uterus and its 
 appendages strongly elevated and held in that position upon a resistant 
 body, which makes them very accessible. 
 
 Examination by Speculum. — After Recamier had reinvented the specu- 
 lum, this valuable instrument led to the neglect of all other exploring meth- 
 ods ; from this point of view, one may assert that the great service it has ren- 
 dered to gynaecology has been equalled by the temporary evil it has caused. 
 
 The form of the instrument has undergone endless changes ; but of 
 these, however ingenious, only a small lunnber are absolutely necessary. 
 
METHODS OF GYNECOLOGICAL EXAMINATION. 
 
 8i 
 
 There are three chief types, the cylindrical, the bivalve or the trivalve, 
 and the univalve. 
 
 TJic Cylindrical Speculum. — This form is particularly suited to topical 
 applications ; made of wood or ivory it protects the vaginal walls from heat 
 during the use of the actual cautery; made of silvered glass and covered 
 with hard rubber [or better of hard rubber or white celluloid] it cannot be 
 used for that purpose, but is valuable on account of the clear view it gives 
 and the ease with which it can be introduced, both for superficial examina- 
 tions and for the different dressings and applications which are required for 
 the cervix. These specula should not be too long and the end should be 
 
 Fig. 71. — Bimanual Exploration ix Retroversion (Davenport). 
 
 bevelled to correspond to the greater depth of the posterior vaginal cul-de- 
 sac. It is necessary to have at least three different sizes. 
 
 Before introducing the speculum it is well to dip it in warm watei- so 
 that its polished surfaces may not be dimmed by the vaginal moisture. It is 
 then coated with vaseline and presented obliquely to the vaginal orifice, 
 whose lips are separated by the fingers of the other hand. The point of its 
 bevelled end is then pressed backward against the perineum, and glides over 
 the groove of the fourchette, avoiding" friction against the urethra and ante- 
 rior vaginal wall as much as possible. When the vaginal orifice has been 
 passed, the instrument is tilted so that its axis corresponds with the direc- 
 tion of the cervix, previously ascertained by the finger, is pushed up gently, 
 aided by the sight, to embrace the external os, guarding against the tendency 
 to search for that structure too far behind and too deeply. [In certain cases 
 where the vagina is very voluminous, or the cervix in an unusual position, it 
 6 
 
82 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 may be difficult to engage the cervix in the lumen of the speculum. In 
 these instances the sound may be first introduced and the speculum passed 
 
 Fig. 72. — Cylindkical Specula. «, Ferguson's speculum, b^ Speculum with obturator, c, Ferguson's speculum 
 
 with rubber funnel for dressing, etc. 
 
 over it as a guide, or a tenaculum may be used for the same purpose.] 
 
 Miiltivalve Specula. — It is needless to describe the three- valve instru- 
 ment of Segalas, or the four-valve model of Charriere, in spite of their in- 
 teresting history; those of more recent invention appear to me but little 
 better. [The Nott speculum is the best of this class.] 
 
 Bivalve specula are the most useful to the general practitioner. 
 Cusco's or Brewer's speculum, the so-called " duck-bill," is an elegant 
 and simple instrument, especially adapted for use in examinations ; it has the 
 
 advantage of allowing inspection 
 of first the os, then, by gradual 
 withdrawal, of the culs-de-sac and 
 vaginal walls. Its small size and 
 readiness of introduction make it 
 valuable, and it may be kept asep- 
 tic by placing it a few minutes in 
 boiling water or strong carbolic- 
 a'cid solution. The introduction 
 of this instrument is accomplished 
 according to the rules laid down 
 for the use of the cylindrical. I 
 would merely remind students that 
 the axis of the vulva is perpendic- 
 ular to that of the vagina, and that while the end of the speculum should be 
 turned obliquely, at an angle of 45°, to open the vulvar orifice, it should be 
 
 Fig. 73. — Brrwrr's Si-eculum. 
 
METHODS OF GYNECOLOGICAL EXAMINATION. 
 
 83 
 
 restored to the horizontal position as soon as it has passed in. The blades 
 must not be separated until the instrument is wholly within the vagina, in 
 order that the vulva may not be unduly distended. In all of the bivalve 
 specula, it is necessary to have .a groove or slit in the upper blade to avoid 
 pressure upon the sensitive parts about the urethra and to render the intro- 
 duction of instruments (sound) less difficult. 
 
 One must not forget that the introitus is the narrowest part of the geni- 
 
 FiG. 74. — Simon's Spectlum. 
 
 Fig. 75. — Vagixal Retractor. 
 
 tal canal, and that just within it the vagina forms a kind of pouch compar- 
 able to the rectal ampulla ; the diverging of the blades in the bivalve specu- 
 lum is therefore seen to be essential. 
 
 Univalve Specula. — These instruments are chiefly intended for use in 
 operation. With only one it is easy to reach the vaginal wall opposite the 
 instrument, and so with the patient in the Sims or genu-pectoral position 
 one can easily reach the cervix. With two single blades, employed at the 
 same time, we have the best possible method of examining vagina and cervix, 
 but it has the inconvenience of requiring assistance. Long before Sims 
 made the use of the univalve speculum common such instruments had been 
 employed by certain skilled practitioners. 
 
84 
 
 CLINICAL AND OPERATIVE GYN.-ECvjLOCV. 
 
 Sims' speculum is to be employed in the semi-prone position which bears 
 his name. In his instrument two blades are joined end to end to lessen the 
 number of single instruments. In the semi-prone position this arrangement 
 presents no difficulty, but it is almost impossible to use the instrument in 
 
 Fig. 76. — Sims' Speculum. One blade is shown with the flange devi.-ied by Munde for supporting the upper 
 
 buttock. 
 
 the lithotomy position, ordinarily adopted in France. The blades are of 
 metal and their surface is bright to reflect the light. For my own part, I 
 prefer Simon's hollow blades. They are mounted on a handle and have a 
 strongly marked sweep. They come in sets and are made concave for de- 
 pression of the posterior vaginal wall (this shape augments the amount of 
 light), and flat for the anterior wall. Moreover, in the course of an operation 
 one can employ one or more retractors, which are narrow blades mounted on 
 handles long enough to keep them (jut of the surgeon's way. 
 
 One variety of Simon's blades is very short, reduced almost to its anterior 
 portion and widened at that place to increase the amount of reflecting sur- 
 face; this is particularly useful for operations on the cervix, where it is to 
 be drawn down to the entrance of the vagina. 
 
 [While the comfortable and efficient use of the Sims speculum usually 
 necessitates the presence and aid of a nurse, there is no other means by 
 
 < — = 
 
 Fro. 77. —ri, .Sims' depn-ssor for the anterior vai^inal wall, i. Tenaculum with stiff shank. 
 
 which the cervix and anterior vaginal wall can be so perfectly exposed with- 
 out interfering with the natural relations or mobility of the parts. In 
 manipulations requiring the use of one hand only, such as applications or 
 tamponade, the operator can, if necessary, hold the instrument with his left 
 
METHODS OF GVN.IXOLOCICAL EXAMINATION. 
 
 ^5 
 
 hand, tlie flanged modification of Mundc lacing" employed so as to support 
 the upper buttock. 
 
 . There arc nian\' modified forms of the Sims speculum, varying in curve 
 or breadth, but none are l^etter than those here shown, which can be procured 
 in several different sizes. Many attempts have been made to devise a perfect 
 self-retaining speculum of this class, but none have proven entirely satisfac- 
 tory. That devised by Cleveland is good and efficient in most cases. It can 
 also be used with the patient in the lithotomy position, being held in place 
 by a piece of rubber tubing laid under the patient's hips, and retained by her 
 weight. There are two instruments, the depressor and tenaculum, which 
 are indispensable in using the Sims; the first to press forward the anterior 
 vaginal wall and to bring the cervix forward into the a.xis of the speculum, 
 and the latter to steady it or draw it slightly downward or forward. To in- 
 sert the speculum, the patient being in the Sims position already described, 
 
 l'"ii;. 7S. — Fkalick's Self-retaining Perineal Retkactor. 
 
 the warmed and lubricated instrument is taken firmly by the external blade 
 in the left hand, and the point of the blade to be used passed into the vagi- 
 nal orifice with the concavity directed upward (ov downward), the upper but- 
 tock and labium being lifted out of the way by the right hand or by the 
 nurse. As soon as the point of the blade is fairly in the vagina, the concav- 
 it)' is turned forward and the point backward when it glides along the posterior 
 vaginal wall until completely inserted, when on retracting the perineum back- 
 ward and slightly upward the cervix will be exposed. A slight upward tilt 
 of the outer end of the speculum allows a better light. The cerA'ix being 
 exposed, the speculum is handed to the nurse, who, standing at the patient's 
 sacrum, grasps the blade firmly with the full hand and continues the trac- 
 tion in the same direction, her arm resting against her side. This holding 
 of the instrument is at first very irksome and difficult, but it is an accom- 
 plishment soon acquired after a little practice. The traction must be even 
 and steady so as not to cause pain to the patient, and must be made so as not 
 to tip the point of the blade too far forward or Imckward. Tf the posterior 
 wall is closely folhnved in inserting the blade and it is passed behind tlie 
 
86 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 cervix, the latter will come into view easily, and it is not necessary to pass 
 in the blade on the finger as was formerly taught. There is sometimes diffi- 
 culty in exposing the cervix where the vagina is long and voluminous, and in 
 these instances it is very necessary to have the patient in good position and 
 all clothing loose. Ver}^ rarely it may be necessary to put the patient in the 
 knee-chest position.] 
 
 Uterine So?iuds. — Levret appears to have been the first who explored the 
 uterine cavity by introducing an instrument, but it was only after the writings 
 of Huguier in France, Simpson in England, and Kiwisch in Germany, that 
 its use became general. As it first became known it was much abused, and 
 Scanzoni complained with reason against such excess. The forms of the 
 hysterometer have been multiplied, without real advantage ; the simplest is 
 the best. It is a single graduated metallic stem, ending in a small button 
 above, and below in a broad spatula-shaped handle, which facilitates the ope- 
 ration of holding and guiding it. The instrument should have some rigidity, 
 and yet be flexible enough to take and preserve the different curvatures which 
 it may be necessary to give it ; silver and pure copper are the best materials 
 
 G€oT/EMANN&:Co. 
 
 Fig. 7g. — Uterine Sound. 
 
 for this purpose ; the inflexible hysterometers of German silver should be re- 
 jected. The little slides which are made to be pushed along till flush with 
 the cervix, and so mark the depth of the uterus, should also be proscribed ; 
 it is sufficient for this purpose to seize the sound with dressing forceps at the 
 desired point [or to place the finger against the sound at the os as it is with- 
 drawn] and read the degree marked on the scale. The sound should never 
 be used without having previously ascertained the position, shape, and size of 
 the uterus [and the absence of peri-uterine inflammations or the possibility 
 of pregnancy] by means of bimanual palpation ; otherwise one gropes in the 
 dark and may produce serious injuries. It is enough to bend the tip of the 
 instrument in the desired curve and to carry the handle in the opposite direc- 
 tion, to introduce it with ease, even in flexions of the uterus. 
 
 Flexible sounds have been invented, furnished or not with dials, which 
 seem to me better than simple rubber bougies, when a rigid sound will not 
 enter on account of the sinuous curves of the cavity. [These are practically 
 never required. ] The best position for sounding is the dorso-sacral. It can 
 be done without the aid of a speculum, by slipping the instrument along the 
 palmar aspect of the index finger held at the orifice of the cervix. The pres- 
 sure applied must be very gentle, and one must bear in mind that there is al- 
 most always a feeling of constriction at the upper part of the cervix. The fin- 
 ger applied to the stem, at the margin of the external os, .shows how deeply it 
 
METHODS OF GYNECOLOGICAL EXAMINATION. 87 
 
 has penetrated. It is probably better to employ the speculum that there may 
 be no difficulty in the procedure and because of the aid to diagnosis ; the 
 cervix should be drawn down and fixed by a pair of hooked forceps. This 
 is at times the only way of reaching the cer\'ix if it is displaced into one 
 or the other of the vaginal culs-de-sac as in malpositions of the uterus. 
 I have found gentle traction upon the cervix of value, from its effect of 
 straightening the uterine canal. 
 
 [It must be remembered that the passage of the sound is to be accom- 
 plished with the utmost gentleness, the instrument being held delicately be- 
 tween the thumb and forefinger, and that skill must take the place of force. 
 The conditions under which it may be employed have been mentioned and 
 necessitate a practical knowledge of bimanual palpation. The physician will 
 find that the more skilful he becomes in pelvic examination, the less often 
 he will need the information given by the sound. I prefer to use the instru- 
 ment with the patient in the dorsal position and without the speculum, as 
 much more information as to the mobility and position can be obtained. The 
 beginner usually finds difficulty in passing the internal os when the uterus is 
 in a normal position or anteflexed. This obstruction is usually overcome by 
 markedly depressing the handle of the sound when its tip reaches this point. 
 In a few cases this manoeuvre may fail and it may be necessary to put the 
 patient on the side and pass it through the Sims speculum, steadying and 
 straightening the cervix by means of a tenaculum.] 
 
 The most vigorous asepsis is indispensable when passing the uterine 
 sound, the instrument being disinfected as already described, and after each 
 examination heated in the flame of an alcohol lamp. A vaginal injection 
 and a thorough antiseptic cleansing of the cervix, by means of a stick wrapped 
 with absorbent cotton, are necessary preliminaries. The researches of Win- 
 ter have demonstrated that in the majority of cases the cervix contains path- 
 ogenic germs, dormant and inactive, possessed of a very slight virulence as 
 inoculation proves ; but these germs have never been found by him within 
 the cavity of the uterus unless the sound had previously been used. The 
 sound, therefore, can without any doubt transport these germs to the upper 
 portions of the genital tract, where normally they are not present, and this is 
 the cause of the accidents — -metritis, salpingitis, and perimetritis — which one 
 may observe after the use of a proper sound which has passed through a 
 cervical cavity not previously cleansed. 
 
 I would consequently recommend with emphasis that the young doctor 
 should never use the uterine sound without being assured of two chief points : 
 1st. The fact that the uterus is empty, ascertained by careful questions and 
 bimanual palpation ; in the case of any doubt, indicated by delay in menstru- 
 ation for several days, the procedure must be given up, for numerous abor- 
 tions were produced during the time when the sound was used with too great 
 frequency. 2d. The strict asepsis of the instrument. The notches mark- 
 ing its graduation are difficult to clean thoroughly, and it would be better to 
 
8b CLINICAL AND OPERATIVE GYNAECOLOGY. , 
 
 use instruments which are not so marked at the price of making measure- 
 ments a little less conveniently. 
 
 The sound must be held in the flame, after having been washed with car- 
 bolic-acid solution, immediately before its introduction. I have known sev- 
 eral cases of metritis and salpingitis after the use of the sound in the hands 
 of well-known physicians, which are to be attributed to the lack of minute 
 antiseptic precautions. 
 
 The uterine sound affords us an exact idea of the permeability of the cer- 
 vical canal, of the two diameters of the uterus, longitudinal and transverse, 
 and also of the organ's general direction. In the normal state the sound 
 passes without difficulty, except for a slight resistance at the le^•el of the 
 isthmus, to the depth of five or six centimetres in nulliparse, and six or seven 
 (two and one-half inches) in those who have borne children. 
 
 The extent of lateral movement which it can make is very limited ; it is, 
 so to sav, immobilized between the anterior and the posterior wall. If, how- 
 ever, the point of the instrument is freely movable and can be turned in 
 different directions, it is because the antero-posterior and transverse diame- 
 ters are increased and the cavity is of unusual size. 
 
 Is it possible to pass the sound into the Fallopian tubes .•' This is the ex- 
 planation of some authors in those cases in which the instrument penetrates 
 deeply into the abdomen and can be detected through its wall. That this 
 may occur tliere must be a combination of very unusual circumstances : a 
 latero- version of the uterus which brings the orifice of the tube into the long 
 axis of the cen'ix and an exceptional wideness of its opening. This con- 
 dition actually existed in a case obser\-ed by Bischoff, and was verified after 
 death following ovariotomy. But in almost every one of the published cases 
 of pretended sounding of the tubes, it is far more likely that there was a per- 
 foration of the uterus — a condition which is easily produced without exag- 
 gerated efforts when the uterus is softened and thinned from pregnancy or 
 recent abortion, or when it is displaced : the benign character of such wounds 
 has surprised mo.st of those who have witnessed their production and has in- 
 duced them to seek an explanation which appears more plausible. This is 
 without doubt the significance which must be given to two cases recently re- 
 ported by Conner, of Basel. Finally we may note the possibility of estab- 
 lishing permanent false passages and the introduction of the sound by the 
 same route into the abdominal cavity. But these are, in truth, but patholog- 
 ical curiosities, with which we have little to do. 
 
 Fixation and Donnnuard Traction of tJic Uterus. — This procedure should 
 be classed among exploratory methods, not that it is employed by itself, but 
 because it renders immense .service, associated with other means, in facilitat- 
 ing examination. 
 
 Hegar has shown that it is possible by his method to examine the entire 
 posterior aspect of the uterus, and even to reach beyond the fundus b)- rectal 
 touch, simply by seizing the cer\-ix with a pair of forceps and gently drawing 
 
METHODS OF GYNyECOr.OGICAL EXAMINATION, 
 
 89 
 
 it downward. I have already indicated all the advantages procured by the 
 passag-e of the sound with fixation of the cervix and without infratraction. 
 We will see also that direct exploration of the uterine cavity demands the 
 same auxiliary. 
 
 Many practitioners dread to employ this method of drawing down the 
 uterus. Before the antiseptic era many accidents /T^ 
 
 were attributed to it which were due to infection. 
 The profession was urged to contend against such 
 fatal practices. But nothing is less dangerous than 
 infratraction of the uterus when antiseptic precau- 
 tions are observed ; even when the procedure is car- 
 ried out with force, as in bringing the external os to 
 the vulva in certain operations, there is no danger 
 with strict antisepsis. For my part .1 daily practise 
 the one or the other method in my service and have 
 never met with an accident which could be attributed 
 to it. It is only necessary to remember that there is 
 danger so long as there is the least sign of acute or 
 subacute peri -uterine inflammation. 
 
 It seems advisable to me to establish a distinction 
 between fixation and downward traction. The first 
 denotes merely holding the uterus steady with as 
 little traction as possible upon its ligaments ; the 
 other actually pulls the organ downward, with a per- 
 ceptible effort, below its normal level. Now, in ex- 
 amining it is rarely necessary to go beyond simple 
 fixation, and if the organ is at all drawn downward, 
 the degree of such traction is very moderate. 
 
 The method employed is very simple. The pa- 
 tient being placed in the dorso-sacral position, the 
 operator grasps the anterior lip of the cervix, guided 
 to it by his index finger, or through a speculum. A 
 hooked forceps (which is merely an American bullet 
 extractor) is the best instrument for the purpose 
 (Fig. 80) ; it makes only two trifling punctures, 
 which cause no discomfort and bleed but little. It 
 is only when the force employed needs to be great, or the position main- 
 tained a long time, that Museux's forceps are required ; we must then take 
 care that they are constructed according to the model I have recomm.ended, 
 where the blades meet exactly without the over-riding which is found in the 
 form most commonly used. With this small matter correct, the wound made 
 is very slight, and the surgeon need run no risk of injury to his finger as he 
 passes it over the part seized. 
 
 Artificial Dilatation of the Uterus, and Intra- n ferine Touch. — There are 
 
 Fixation Forceps. 
 
90 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 certain rare cases in which it is necessary to explore the uterine cavity with 
 the finger, either to confirm a diagnosis or as a preliminary to operation. This 
 bold plan originated with Simpson; to accomplish it several methods have 
 been proposed. Before discussing them it is necessary to establish a distinc- 
 tion ; the cervix presents a narrow canal, not a simple orifice, which has an 
 upper, supravaginal, and a lower, or external mouth. The points requiring 
 especial consideration are the condition of the internal os and of that part of 
 the cervical canal which lies above the vagina. In certain cases the patency 
 and greater or less degree of softening of the internal os present no obstacle 
 to exploration, except below at the os externum ; for instance, in certain 
 intra-uterine fibromata and polypi, just after abortion, etc. Such cases are 
 essentially different from those in which the whole extent of the canal is 
 rigid, and the same measures will not produce equivalent effects in these two 
 classes. Let us pass the principal procedures in review. 
 
 The principal methods of dilatation may be divided into two classes : 
 
 1. Bloodless methods, comprising: (A) Gentle dilatation by tents ; (B) 
 divulsion ; (C) immediate progressive dilatation. 
 
 2. Those accompanied with bleeding, consisting of two important opera- 
 tions of diverse character, viz. : (A) Opening of the external os by incision; 
 (B) entire bilateral division of the cervix. 
 
 No one of these procedures should be adopted in practice unless abso- 
 lutely necessary, and every dilatation of the uterus should be regarded as dan- 
 gerous, particularly if there is the least reason to suspect recent inflammation 
 about the uterus or its appendages. 
 
 Bloodless Methods. — (A) Gentle dilatation by means of absorbent expan- 
 sive materials is accomplished by introducing into the cervical canal cylin- 
 ders of different material, among which prepared sponge, laminaria, tupelo, 
 slippery elm, decalcified ivory, and gentian root are advocated. I will not 
 stop to discuss the relative merits of these various tents ; the matter seems 
 to me decided in favor of laminaria, and although I do not wholly reject pre- 
 pared sponge, rendered aseptic, I still believe that it has only a limited appli- 
 cation. Laminaria, used in fagots, that is, several tents at once, if neces- 
 sary, suffices for nearly all our needs. This excellent therapeutic agent was 
 introduced to surgeons by Sloan. 
 
 After thorough disinfection by laying them in iodoform-ether, tents are 
 employed in the following manner : The vagina is carefully irrigated; the 
 patient then being put in the dorso-sacral position, the cervix is exposed by 
 the bivalve speculum or two of Simon's blades ; it is then advisable to grasp 
 the anterior lip of the cervix with a tenaculum forceps and thus hold it firm 
 during the introduction of the tent; the position of the uterus must have 
 been ascertained beforehand by the use of bimanual palpation and the sound. 
 The tent should be slightly curved to adapt it to the natural curve of the 
 canal which is to receive it ; then, well covered with vaseline, it is grasped 
 by a forceps and gently introduced. The end, to which a small thread is 
 
METHODS OF GYNECOLOGICAL EXAMINATION. 
 
 91 
 
 attached, must be left outside the cervix. Two or three tents may thus 
 be inserted within the canal if the introduction of one of sufficient size is too 
 difficult, for violence must never be employed. The fixation forceps being 
 removed, a tampon of iodoform gauze is placed over the cervix and then the 
 speculum is withdrawn. 
 
 About ten hours are required for the laminaria tent to become thor- 
 oughly dilated ; then it is removed by gentle traction upon the thread passed 
 through its lower end. Sometimes, however, there is some difficulty, as the 
 tent may have assumed an hourglass shape, from constriction at the internal 
 OS. Then the extremity must be seized with a forceps, and withdrawn by 
 
 Fig. 81. — (a) Ti'pelo and (i) Laiiinari.\ Texts before and after Dilatation bv Soaking for Eight 
 
 HofRS. 
 
 combined traction and rotation, while the finger offers a point of support at 
 the external os. 
 
 Despite all antiseptic precautions, we must not regard dilatation by tents 
 d.§, an inoffensive operation ; for one sometimes encounters symptoms of acute 
 metritis after their use, with severe pain and marked febrile movement. 
 They should, therefore, be employed with more moderation than is usually 
 advised. 
 
 [While no other tent dilates so rapidly or produces so great a degree of 
 softening of the uterine tissues as one of compressed sponge, their use is en- 
 tirely abandoned in America, because of the difficulty of rendering and keep- 
 ing them sterile and the great danger from septic accidents following their 
 employment. Their place is very satisfactorily taken by the compressed 
 
92 CLINICAL AND OPERATIVE GVN.-ECOLOGY. 
 
 tupelo ( made from the strongly compressed root-wood of the Nyssa uniflora, 
 Wang.) which can be procured of any necessar}' dimensions, has little ten- 
 dency to become septic, dilates rapidly and gently, causes only moderate 
 pain, and does not irritate the uterus excessively. While, as I have said, 
 these tents have little tendency to become septic, we can easily render their 
 sterility absolute by enclosing each one in a small sealed paper envelope and 
 baking them at a temperature of 250° F. for three hours; the envelope being 
 opened only at the moment when they are to be inserted. These tents are 
 especially valuable when considerable dilatation is required, as in cases of 
 incomplete abortion with contracted os or before the removal of submucous 
 fibroids, etc. 
 
 Tents may be introduced in the Sims or in the dorsal position, and at the 
 patient's home where she can be kept quiet in bed during the period of their 
 retention. No anaesthetic is required for their introduction or removal, but 
 in many instances pretty severe pain is felt during their dilatation. This 
 can best be relieved by a powder of phenacetin (gr. iv.) and codeine (gr. JA), 
 which I prefer, or by morphine. The tent selected should be one which can 
 be readily passed through the internal os ; its inner extremity should not 
 reach much above this point, while its base should project somewhat into the 
 vagina to facilitate its removal.] 
 
 (B) Divjilsion. — The advantage at times of immediate dilatation by force 
 has given birth to many instruments of different shapes and powers. The 
 dilator of Ellinger, with two parallel branches, is the one I prefer ; Schultze, 
 Sims, and others have invented special forms of instruments. But they are 
 all objectionable, since they take their point of support from portions which 
 are liable to yield and tear under the strain, and by themselves they do not 
 suffice to make a passage admitting the index finger. The Ellinger dilator 
 is very serviceable and convenient for facilitating the passage of the sound or 
 the curette in cases of cen'ical constriction. 
 
 [Palmer's dilator, with the intra-uterine portion of the blades two and a 
 quarter inches long and capable of dilatation to one inch, is most convenient 
 and efficient for general use. Where a more powerful instrument is needed, 
 Goodell's modification of Ellinger, with blades two inches long, corrugated 
 to prevent slipping, and opening to a width of one and a half inches, is one 
 of the best. For slight degrees of dilatation an anaesthetic is not neces.sary. 
 To avoid tearing or unnecessar}- injury to the parts, dilatation should always 
 be done slowly, occupying from ten to twenty minutes, with the least possi- 
 ble degree of force and preferably without the use of the screw attachment. 
 It -should be done through the speculum, with the patient either on the back 
 or the side, the vagina being filled with a pool of antiseptic fluid in which 
 the cer\'ix is kept immersed.] 
 
 {C) Immediate Progressive Dilatation. — This method is well known to sur- 
 geons, who apply it in dilating urethral strictures by means of graduated 
 sounds. Of these there are many devised for the use of the gynaecologist ; 
 
METHODS OF GVN.-ECOLOGICAL EXAMINATION. 
 
 93 
 
 Peaslee's; Tail's, of conical form; Hanks', ovoid; Fritsch's, and lastly, 
 Hegar's, which are the most practical. They are cylindrical metal bougies 
 with conical ends, and measure tv/elve to fourteen centimetres (four and one- 
 half to five inches) in length, exclusive of the flat handle (about two inches). 
 The diameter of No. i is two millimetres and they increase by one milli- 
 metre per bougie (three millimetres in circumference) ; this increase is a 
 little t(K; rapid for the higher numbers, and, according to Hegar's own advice, 
 
 Fig. 82. — Uterine Dil.ators. 
 
 it is well to have some bougies for difficult cases, which increase only by 
 half-millimetres. 
 
 To use them, the patient is anaesthetized and placed in the dorso-sacral 
 position, the fourchette is depressed with a short blade, the anterior cervdcal 
 lip is seized and fixed with a hooked forceps, the position of the uterus hav- 
 ing been previously determined by the aid of bimanual palpation and the 
 sound. Then the first bougie is covered with vaseline and passed in, and 
 should be of a calibre which enters with but little resistance. Immediately 
 afterward a second, and then a third are introduced, and, if any difficulty is 
 encountered, the bougie is allowed to remain from one to three minutes or 
 the previous one is introduced a second time. 
 
 When the cen-ix is naturally or artificially softened, it is possible to reach 
 in fifteen minutes a sufficient dilatation to admit the index finger. When 
 the cervix is dense, an hour or even more is necessary. Th .- procedure must 
 
94 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 be abandoned, if there is risk of laceration, as soon as a sufficient dilatation is 
 reached. Hegar's bougies are extremely useful if the cen-ix is already soft 
 and dilatable, as it is directly after abortion or parturition ; when, however, 
 the cer\-ix is rigid throughout its whole length, I recommend the insertion of 
 a laminaria tent for ten to twelve hours to produce a certain degree of dilata- 
 
 FiG. 83. — Hegae's Dilator. 
 
 tion, softness, and dilatability, and, at the time of its removal, the rapid com- 
 pletion of the process with Hegar's bougies. 
 
 Operation for Rapidly Dilating the Cei"inx by Incision. — Rapid dilatation 
 of the cer\dx with a cutting instrument may be indicated when the obstacle 
 to be overcome in passing the index finger within the cervix is at the exter- 
 nal OS alone ; when there is a special urgency and no time can be lost, the 
 cer\^ix not being obliterated ; or when the surgeon does not have the special 
 apparatus needed for the bloodless method. 
 
 {A) bicision of the External Os. — When the external orifice has sponta- 
 neously enlarged from the pressure of an intra-uterine polyp, abortion, etc., a 
 simple cut in either side of the os will suffice for the introduction of the fin- 
 ger; then the bloody method is both most simple and rapid. Scissors with 
 long handles are used, guided by the finger, after depression of the fourchette 
 with a short Simon's blade and fixation of the cervix. The blades of ordi- 
 nary scissors are apt to slip, and therefore Kiichenmeister's, though not in- 
 dispensable, are to be preferred. 
 
 An incision of i to 1.5 cm. on either side is enough for the passage of 
 the index finger, which will accomplish the required dilatation itself. After 
 
 Fir,, 84. — Kuchenmeister's Scissors. 
 
 the exploration is complete, the uterus should be irrigated and the cuts closed 
 with catgut. 
 
 (/>') Complete Bilateral Divisioi of the Cervix. — This procedure is so truly 
 an operation that one should not undertake it if he has not already a large 
 experience in uterine surgery. A neces.sary preliminary is ligation of the 
 uterine artery. The patient being anaesthetized and placed in the dorso- 
 
METHODS OF GYNECOLOGICAL EXAMINATION. 95 
 
 sacral position, the vagina is strongly retracted upon one side, while the cer- 
 vix is drawn with a tenaculum toward the opposite side ; in this manner one 
 of the lateral vaginal pouches will be exposed. Then a long and strongly- 
 curved needle, or better a Ueschamp's needle, threaded with silk, is passed 
 through the cul-de-sac across the finger outside of the cervix, taking care 
 anteriorly not to go beyond a line tangent to the circumference of the cervix 
 at that level in order to avoid the ureter. The surgeon must include the 
 greatest possible thickness of tissue and must bring his needle out in the 
 vagina posteriorly, as nearly as possible to the point of entrance and always 
 at the same distance from the os. In thus keeping the points of the needle's 
 entrance and exit close together, the surgeon endeavors to include as little as 
 possible of the vaginal mucous membrane within the loop of his ligature. 
 The silk is then firmly tied and the process repeated on the opposite side. 
 
 I have had occasion to make use of this preliminary ligation and can 
 state that it is very efficacious. I think that it is not the main trunk of the 
 artery which is included in the ligature, but probably its inferior branches; 
 however that may be, the surgical result is excellent. One can then take 
 up his bistoury with no fear of hemorrhage. The cervix being drawn down 
 is incised on either side to the vaginal insertion, and then an attempt is 
 made to introduce the finger; should this still be difficult, a probe-pointed bis- 
 toury is passed in along the index finger and, in withdravnng it, the cervix is 
 scored on its internal aspect on either side, until the finger has room enough 
 to pass. As soon as the exploration has been finished, and the uterus irri- 
 gated, the cervix must be restored with great care. For this purpose a 
 needle armed with catgut is passed through the cervix at the level of the 
 vaginal insertion, so deeply that, with the finger as guide, the loop of the 
 ligature lies at the highest point of incision within the cervical canal. It is 
 well to make all the stitches on both sides, and have them symmetrical, be- 
 fore drawing the first tight ; otherwise the orifice is narrowed at once and 
 the finger no longer serves as a guide. The first two superior stitches being 
 placed and tightened, a sufficient number are taken below to adapt the mu- 
 cous membranes accurately, both within the canal and without. 
 
 It is needless to leave the ligature of the artery indefinitely in place; it 
 may ulcerate and injure the vaginal mucous membrane; it should, there- 
 fore, be removed, unless there are special indications to the contrary, at the 
 end of three or four hours. Of course its removal must be far more speedy 
 if there is reason to fear that the ureter has been tied, but this accident may 
 always be avoided if the directions given are minutely observed. 
 
 Permanent Dilatation. — The dilatation obtained in one of these ways 
 may be maintained by tamponing the uterine and cervical cavities. The 
 idea has lately been current that continued dilatation favors diagnosis and 
 treatment in certain uterine affections, since it exposes the parts to view. 
 
 Vulliet, who proposed this tempting procedure, thus describes it : The 
 patient is placed in the genu-pectoral position, the cervix is exposed by a 
 
96 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Simon's speculum, and its canal explored. If constricted or misplaced, its 
 natural direction and calibre are restored by preliminary treatment ; if it is 
 normal, a small tampon of cotton is passed into its cavity with a metal 
 sound. These tampons vary in size from that of a pea to that of an almond, 
 and are each furnished with a thread. They are first plunged into a mixture 
 of ether and iodoform (i : 10 ), then dried and kept in a well-stoppered bottle. 
 Williet introduces tampons until the cervix is full to the external os. These 
 he removes at the end of forty-eight hours. If it has been well stuffed, the 
 cervdcal walls have become soft and have so far yielded that there is free 
 space for the operator, who at once takes advantage of it and packs in a 
 much greater number of tampons than before. In proceeding thus with 
 gradual increasing tamponade, there are at least eight or ten repetitions of 
 the method before the canal is so wide that it may be seen in all its extent. 
 To save time and regulate the calibre of the cavity, Vulliet advises that the 
 tamponing be alternated with laminaria tents. 
 
 This procedure is not always applicable in the conditions indicated by its 
 author. There are a certain number of cases in which the requisite calibre 
 cannot be obtained, as the obser\^ations of Porak and Sabail demonstrate; 
 and there are other cases in which the repetition of the tamponade must be 
 given up, either because of the pain produced, or because of nervous acci- 
 dents; these latter symptoms appear to be due to the nature of the operation 
 itself, not to the absorption of iodoform from poorly made tampons. More- 
 over, I do not think that vision furnishes more satisfactory information about 
 the uterine cavity than can be gained by the different exploratory methods 
 already described. Nor do I think that therapeutics have been greatly ad- 
 vanced by this plan, or that it will survive, ingenious as it may be, a legiti- 
 mate interest, mixed with some astonishment, provoked at the moment of its 
 appearance. 
 
 These remarks do not apply to haemostatic or antiseptic tamponade of 
 the uterine cavity, for I believe that this procedure will be retained in prac- 
 tice and more frequently employed. 
 
 The touch, by the introduction of the index finger into the uterine cav- 
 ity, takes note of the softness or villosity of the mucous membrane, of vege- 
 tations, tumors, or abnormal projections which may exist there, and the 
 manoeuvre .should be always combined with hypogastric palpation. It must 
 be very rapidly carried out, and followed by an intra-uterine injection of car- 
 bolic solution (I : 100), an iodoform tampon, and absolute rest in the horizon- 
 tal position for two days. If the hemorrhage occasionally produced does not 
 yield to very hot injections (115° to 120° F.), there should be no delay in 
 filling the cavity with iodoform gau/.e tampons for a few hours. 
 
 Exploratory Incision and Curetting. — Diagnosis between malignant and 
 benign growths is so important from an operative point of view that we 
 should not hesitate to make an exploratory incision in doubtful cases. There 
 may be alterations in the cervix when a doubt as to their nature could be 
 
METHODS OF GYNECOLOGICAL EXAMINATION. 97 
 
 settled only by an operation dangerous to the patient. I remember an ex- 
 cellent instance : My regretted master, Gaillard, suspecting cancer, sent me 
 for operation a woman who had a hard, irregular cervix and a bloody dis- 
 charge. Though inclined to accept the diagnosis, it was with some reserva- 
 'tion, and so I removed a small section from the cervix ; the microscope 
 showed simple chronic inflammation. She had escaped another surgeon 
 who was just about to operate. 
 
 This mode of exploration has been praised by clinicians as of great value. 
 The technique is very simple; fixation of the cervix, excision of a wedge- 
 shaped piece with sharp scissors or a bistoury, thermo-cautery if necessary 
 for the bleeding, since an antiseptic tampon may allow the flow to continue. 
 
 When it is necessary to determine the state of the uterine mucous mem- 
 brane, scraping it with a cutting curette furnishes us with shreds enough for 
 examination. Martin, who is a great partisan of this method, advises not to 
 stop with partial curettage, but to make it complete and follow it with anti- 
 septic irrigation and the injection of (2 or 3 gm.) perchloride of iron. The 
 technique of the process will be described in the chapter on Metritis. 
 
 Exploration of the Ureters. — This entire subject is of recent date. In 
 1874 Tuchmann collected the urine from one ureter by compressing the 
 other; Hegar, at the same time, proposed tying the ureter per vaginam for 
 this purpose. But it is not until recently that Simon (1875) was able 
 to catheterize the ureter by the guide of the finger placed in the bladder 
 after urethral dilatation. For the same purpose Griinfeld employed the en- 
 doscope. Rut Pawlik, in 1880, discovered a method which cannot be called 
 easy and yet is more or less practicable, by which to enter the ureter directly 
 without previous operation, guided by external anatomical landmarks. Later 
 labors of Newman, Kelly, and Byford have not added anything important 
 to Pawlik's method. More recently Sanger (1886), more clearly defining 
 the indications already sketched by Hegar, Chrobak, and Pawlik, attempted 
 to introduce into practice vaginal palpation of the ureters ; I have seen Paw- 
 lik and Sanger demonstrate their method. Without attempting to give his- 
 torical details, which will be found complete in their works and which have 
 been summed up by Schultz in a recent review, I will simply try to give an 
 idea of the technique of these two skilled gynaecologists. 
 
 Reversing the chronological order for the logical, I will describe Sanger's 
 method. 
 
 A. Palpation of the Ureters. — The anatomical relations of these ducts 
 to the cervix and vagina have been studied with especial care of late be- 
 cause of their importance to the success of certain operations which have 
 become the order of the day. As is well known, it is possible to feel through 
 the vagina the anterior pelvic portion of the ureters, if injected, in the cada- 
 ver, just where they open into the bladder at the base of the broad ligaments ; 
 this is equal to a length of 6 or 7 cm. (2J.4 in.), that is, the greater part of 
 the ureters within the pelvis and about one-fourth of their whole length. In 
 7 
 
9B 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 pregnant women we can feel as much as lo cm. (4 in.), owing to the general 
 muscular hypertrophy which all the pelvic organs undergo at that time. 
 Moreover, one can take his supporting point from the head of the foetus and 
 feel the ureter against that structure. 
 
 In some cases of gonorrhceal and calculous inflammation of the ureters, 
 Sanger was able to diagnose by touch that they were remarkably enlarged. 
 When there is a chronic inflammation of the broad ligament the ureter is 
 found to be very large and palpable upon the other side, as if from hyper- 
 trophy. Under Sanger's direction I have been able to palpate the ureters in 
 
 Fig. 85. — The Portion of the Ureters Accessible to Toich. (Figure diagrammatic; the posterior vaginal 
 wall supposed to be removed and the ureters visible through the anterior wall.) rt, Base of broad ligament; b^ ureter; 
 c, cervix; d, ligament between the ureters; e, trigonum; /, urethra; jg-, vagina. 
 
 pregnant women, but on attempting to repeat it at several different times 
 the result has always seemed uncertain to me. Probably by reason of the 
 great difficulty, and the doubtfulness of its results, as well as the rarity of 
 practical conclusions furnished, the manoeuvre is not likely to become general. 
 To employ the method, several anatomical points must be held clearly in 
 mind. The field of investigation is limited to the upper portion of the 
 anterior vaginal wall. Diagrammatically the surface is a trapezium with 
 oblique and divergent sides corresponding to the union of the ureters and 
 the junction of the anterior with the lateral vaginal wall. The small base 
 of this trapezium, which is really the truncated apex of a triangle, is 
 placed below and horizontally, corresponding to the ligament between the 
 
METHODS OF GYNAECOLOGICAL EXAMINATION. 99 
 
 ureters ; the larger base is above, formed by the point of exit of the ureters 
 from the broad ligaments and a line joining them. In this space the finger 
 encounters, in certain circumstances, i or 2 cm. (yi to 3,/( in.) behind the os 
 externum-, in the depth of the vaginal pouch, two hard, longitudinal cords, 
 one on each side, directed from without inward and from below upward, 
 making a curve which is concave inward (Fig. 85, d). One cannot ordi- 
 narily trace them through their whole accessible length, which is 6 or 7 cm. 
 (2>2 in.) to the base of the trigonum; about 2 cm. is all that can be usually 
 palpated. 
 
 The ureters are normally symmetrical, but they cease to be so after dif- 
 ferent lesions, and then their direction may vary from cicatricial contraction 
 so much that the ureter of one side may be found upon the other ; or their 
 •concavity may be directed upward instead of inward; or, finally, but one 
 ureter may be palpable. 
 
 The average normal diameter of the ureter is i mm., but diseased, it 
 may reach the volume of a goosequill or even a large crayon. They are 
 more or less movable under the finger, or fixed in place by inflammation, and 
 normally they are not sensitive to pressure, though they may become so if 
 diseased. 
 
 To palpate them by the vagina one must proceed in the following way: 
 With the index finger, trace up the urethra to its exit from the bladder, which 
 brings the finger into the anterior vaginal pouch; there notice the direction 
 of the cervix. To find the ureter we must seek in that portion of the an- 
 terior vaginal wall which is comprised between the internal orifice of the 
 urethra and the anterior vaginal cul-de-sac. This region has an extent of 
 not more than 2}i cm. (i in.) and is remarkable for its loose attachments. 
 With the lateral surface of the tip of the finger the vaginal wall is palpated 
 to the front and side in the direction of the broad ligament, using the finger 
 corresponding to the ureter sought. The left index finger can be used for the 
 right ureter and I'zce versa, but in that case it is the palmar surface which 
 palpates. It is necessary to work gently, with a gliding motion, and not by 
 frequently applying and removing the finger. Delicate palpation demon- 
 strates whether the ureters are normal or a little hypertrophied ; they have 
 the feel of an artery deprived of its pulsation. When one can compress 
 them against a hard body, like the pelvic bones or the foetal head, they roll 
 about within their sheaths. Palpation is more readily accomplished when 
 the vaginal wall is very flaccid. 
 
 The ureters must not be confounded with arteries, cicatricial bands about 
 the uterus, or, according to Sanger, with the levator and sphincter ani. 
 These errors may be avoided if one takes strict account of both their ana- 
 tomical and their abnormal positions. It is none the less very difficult, 
 without special training, to employ with profit this ncAv exploratory method 
 of the eminent Leipsic gynsecologist. 
 
 Cathctcrism of the Ureters. — Pawlik's method. It was during his stay 
 
lOO 
 
 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 in Vienna as privat-docent that Pawlik, now professor at the University of 
 Prague, made his first experiments toward his ingenious method in a case of 
 doubtful diagnosis occurring in Billroth' s clinic. I had an opportunity at 
 the time of seeing and verifying the marvellous dexterity with which he ac- 
 complished the delicate manoeuvre. There are cases in which it is of the 
 greatest importance to determine whether both kidneys are diseased or only 
 one ; Pawlik made the matter perfectly clear on one memorable occasion, and 
 
 Fig. 86. — The Vaginal Trigone (Pawlik). Z, L^ Labia minora; O, urethral orifice; 0\ 0\ urethral cushion;- 
 V, OS e.xternum; B, fold of mucous membrane, behind interureteral ligament, forming base of triangle; 5, 5, lateral 
 fold, converging and corresponding to the sides of the triaii:;le. 
 
 on another diagnosed a hydronephrosis and allowed the ureteral sound to re- 
 main in position. For this latter procedure, he constructed a special instru- 
 ment (Fig. 87), but it is not free from all danger; for the metal piece which, 
 in this instrument, is fastened to the long rubber sound, could not be re- 
 moved, if separated, without an unusually fortunate combination of circum- 
 stances. 
 
 Certain anatomical points must be clearly understood beforehand in 
 order to use Pawlik's method. In front of the lowest part of the bladder, on 
 the posterior portion of the antero- inferior wall, the ureters are found at the 
 posterior angles of the trigone, and the anterior is occupied by the urethra. 
 Each of the three orifices is at the top of a papilla, which is more or less. 
 
METHODS OF GYNAECOLOGICAL EXAMINATION. lOI 
 
 prominent, of an irregular cylindrical form, made by a thickening of the 
 muscular coat and invested by mucous membrane. These papillae serve as 
 landmarks. They are, moreover, connected by a marked band of the same 
 formation, convex forward, thick and resistant enough to hold the point of a 
 sound at its middle, where it is somewhat thinned, and to be appreciated by 
 direct palpation. This fold is called the interureteral ligament, the pad or 
 muscle of the ureter; it forms the curved base of Lieutaud's triangle, the 
 other sides being indicated by less marked folds which point toward the 
 urethra and become thinner. The dimensions of this triangle are naturally 
 inconstant, but it is usually almost equilateral. Its base is estimated at 2 
 cm. 6 mm. to 4 cm. (7q to 1)4 in.), its sides, at 2 cm. 7 mm., 2 cm., and 2 
 cm. 8 mm. or at 4 cm. (i to i)4 in.). The distance between the urethral 
 opening and the middle of the base is given as i cm. to 2 cm. to 3 cm. (3-^ 
 to ly^ in.). 
 
 Pawlik has the patient put in the genu-pectoral position, but one can 
 quite as well do the operation in the dorso-sacral ; it is only necessary in the 
 latter position to have the head well lowered and the buttocks strongly 
 raised, that the viscera may fall toward the diaphragm. A Simon's specu- 
 lum, as large as possible, is put into the vagina and the posterior wall de- 
 pressed ; the anterior wall is thus perfectly stretched. 
 
 This tension of the anterior vaginal wall allowed Pawlik to note certain 
 permanent folds of great importance topographically. He mentions near 
 the external orifice of the urethra a pad or cushion elongated from before 
 backward in the median line, folded or furrowed transversely and well 
 marked, which corresponds to the course of the urethra within the wall 
 (tubercle and anterior column of the vagina). This fold terminates at the 
 internal meatus. Next there follows a triangular space corresponding to the 
 base of the bladder or the trigone of Lieutaud. This space is bounded pos- 
 teriorly by the interureteral ligament, slightly convex forward, having the 
 orifice of a ureter at each end of it. The lateral folds diverge from before 
 backward and end about i cm. ( 5 8 in.) behind the internal meatus, thus 
 forming the truncated apex of the triangle (Fig. 88). 
 
 It can be demonstrated upon the cadaver that the vaginal triangle thus 
 bounded corresponds line for line with the intravesical trigone of Lieutaud, 
 and should therefore be called Pawlik's vaginal trigone. 
 
 Pawlik uses a catheter which has a probe-pointed extremity, about 25 
 cm. in length with a tip of 1.5 mm. diameter; the eye of the catheter is 
 very much elongated, with bevelled edges, and is situated on the base of the 
 point of the instrument on a slight curve continuous with the main stem, 
 which tapers a little. At 1.5 cm. from the other end of the catheter is at- 
 tached a holder, of octahedral shape, which carries a mark corresponding to 
 the curve of the instrument, and beyond this handle the tube projects for 
 about 1.5 cm, more. 
 
 To render the instrument aseptic the stylet is withdrawn and the instru- 
 
I02 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 merit washed out with water; then it is filled several times with ether, and 
 finally passed through an alcohol flame. Before intro- 
 ducing the catheter, there should be a certain degree 
 of vesical distention, and the shortest and surest way 
 to obtain this is to empty the bladder completely and 
 then inject (200 c.c — 6 oz.) of water, which is plenty 
 for moderate distention. The urethral catheter is 
 then removed and the ureteral passed in. 
 
 As soon as this instrument has passed within the 
 internal meatus the other end of it should be raised 
 so that the tip shall be brought toward the rectovagi- 
 nal pouch at the level of the trigone. As the instru- 
 ment is pushed gently in, its beak makes a slight 
 prominence on the anterior vaginal wall, and as it 
 passes onward, this prominence changes its place ; 
 thus the catheter can be guided, following the sides- 
 of the vaginal trigone and moving from within out- 
 ward and behind forward, toward the orifice of the 
 ureter. In this direction it meets the interureteral 
 ligament or fold at its most projecting outer part; 
 while, if it is held in the median line, it may pass 
 over the middle of the fold, where it is flattest, and 
 so miss it entirely. Arriving at the ureteral orifice, 
 it is held there while small movements of gliding,, 
 rotation, elevation, and depression are made, until it 
 has passed in ; but always without leaving the angle 
 of the trigone, which is kept constantly before the 
 eye. Once within the ureter, the instrument is. 
 pushed I or 2 cm. {% in.) toward the posterior \'esi- 
 cal wall. The entrance of the catheter is appreciated 
 by the sudden removal of all resistance ; it advances 
 as into an empty space; while, on the contrary,, 
 lateral and downward movements of the handle are 
 resisted more and more as the instrument advances. 
 At the end of a certain time the urine flows in a 
 jerky stream, while, as is well known, from the blad- 
 der it would be continuous. If the catheter is passed 
 still farther in, it changes its direction at the superior 
 strait, and then it is time to arrest the procedure on 
 account of its difficulty, which is especially great 
 where the urethra is tightly fastened to the os 
 pubis and but little dilatal)le, as in nulliparae; if, 
 however, the urethra is large and soft-walled, the cath- 
 eter may be passed still farther. It should be pushed on with the great- 
 
 
 Fig. 87.— Pawlik's Ureteral 
 Catheters, a. With stylet; d, 
 permanent form with rubber 
 tube which is passed through a 
 metal sheath. 
 
METHODS OF GYNECOLOGICAL EXAMINATION. 
 
 103 
 
 est gentleness as the other end is depressed as far as possible. On the 
 other hand, this latter half of the process is as easy as the first, when 
 one has entered a fistula in the bladder or urethra. I once was able to pass 
 Pawlik's sound to the pelvis of the kidney, but it was not per urethram. I 
 had introduced it into a vesicovaginal fistula which I had reason to suspect 
 was connected with the ureter, and I was able to confirm the diagnosis. 
 
 Thus one may reach the pelvis of the kidney; the ureter is then dragged 
 into a straight line. Ordinarily in contact with the pelvic wall, it is then 
 pulled away to a distance of about 4.5 cm. (i^ in.), but the cellular tissue 
 which surrounds it will permit this degree of displacement if it is in normal 
 
 Fig. SS. — Ureteral Catheterism by Simon's Method. The instrument is slid along the finger whose tip 
 rests upon the interureteral ligament, «,«,«, Base of the bladder; (5/, orifices of the ureters; 7VZ., Lieutaud's 
 triangle. 
 
 condition; ureteral catheterism should therefore be carried out with the 
 utmost gentleness, especially if there is reason to suspect any inflammation 
 about these tubes. 
 
 The only troublesome results which I have been able to verify are fever, 
 abdominal pain, which does not last more than twenty-four hours, or a slight 
 degree of peritonitis (in a case in which it had already been present) ; in the 
 urine, furthermore, we may find blood, epithelial debris, products of trauma- 
 tism of the ureter. It seems possible that there might be a ureteral fever, 
 similar to the urethral, which would be a serious accident to follow such 
 catheterism. We must wait till the procedure has been more frequently 
 employed before observations become numerous. 
 
 Simons Method. — If exploration of the ureter is considered necessary 
 
I04 
 
 CLINICAL AND OPERATIVE GYNECOLOGY 
 
 and Pawlik's method cannot be carried out after several attempts, then 
 Simon's method may be employed; which comprises anaesthesia, urethral 
 dilatation, introduction of the catheter along the finger, which immediately 
 feels the interureteral ligament. Incontinence of urine need not deter, for 
 it seldom lasts long. This older form should be adopted where the operator 
 has had no special training in Pawlik's method, as being the more certain of 
 the two. Different plans have been proposed for compressing or tying the 
 ureter from the vagina for diagnostic purposes. Narkalla has recently lauded 
 exploratory compression by a thread passed over the ureter from the vagina. 
 He succeeded in doing this on the cadaver ten times in thirty. According 
 to this author the operation offers no danger, since instead of tying the 
 
 thread, he merely used gentle traction upon 
 it, to shut off the ureter temporarily. I 
 prefer catheterism to this manosuvTC. 
 
 Endoscopy. MetJiods of Griinfeld, Bren- 
 ner, and Howard A. Kelly. — Catheterization 
 of the ureters has recently been attempted 
 under the control of sight, an undertaking which has been 
 made successful by the new illuminating apparatuses which 
 the progress of cystoscopy has put at our disposal. 
 
 The first surgeon to attempt endoscopic catheterization 
 was Griinfeld, of Vienna, who utilized for this purpose his 
 system of endoscopy by external light. 
 
 The vesical endoscope of Griinfeld is composed of a 
 simple metallic tube blackened internally and furnished 
 with a plane mirror at its extremity. A head-mirror, with 
 a small electric light, is the means of illumination. This 
 arrangement gives an admirable view in natural position 
 and size of a small portion of the vesical surface which is sufficient for the 
 examination and catheterization of the ureters. 
 
 To point the instrument at the ureteral orifice it must be held at an 
 angle of fifty to fifty-five degrees to the right of the median line for the left 
 ureter and correspondingly to the left for that of the right side. The point 
 of the instrument must also be depressed three to four centimetres in the 
 bladder and the other end raised gently toward the pubis. This exposes to 
 view the little orifice of the ureter from which flows an intermittent jet of 
 urine, normal in color or colored with blood or pus according to the condition 
 of the kidneys. 
 
 The exploration of the ureter by Griinfeld' s method is done with a fine 
 catheter whose tip is movable, at the will of the operator, by an arrangement 
 similar to that of the curette of Leroy d'Etiolles. This catheter is intro- 
 duced into the bladder parallel to the endoscopic tube. Its movable extrem- 
 ity is placed at a right angle and is engaged in the ureteral opening under 
 control of the eye. As soon as it has been introduced the catheter is 
 
 Fig. S5. — Kelly's 
 
 CVSTOSCOPE. 
 
METHODS OF GYNECOLOGICAL EXAMINATION. 
 
 105 
 
 Straightened, the cystoscope withdrawn, and the catheter pushed in as far as 
 desired. 
 
 The ureter may be emptied by catheterization in the same way with a 
 small sound whose end is directed toward the ureteral orifice with the index 
 finger previously introduced into the vagina. 
 
 Since the invention of Nitze's cystoscope, all authors who have used this 
 or similar instruments observed the ureteral orifices and drew useful conclu- 
 sions concerning diseases of the bladder and kidneys ; but it was not until 
 1889 that it was made applicable for catheterization of the ureters, by an 
 important modification which he made in the c}stoscope of Seiter. This 
 
 Fig. 90. — Hips in Extreme Elevation for Cvstoscopic Examination and Catheterization of Ureters. 
 
 modification consists in adding to the tube of the cystoscope a small canal 
 which opens directly below the objective and in which is made to glide a fine 
 sound whose tip is clearly seen in the field of the instrument. This arrange- 
 ment makes the catheterization of the ureters very easy, even in man. 
 
 Howard A. Kelly, of Baltimore, practises catheterization of the ureters in 
 the following manner : The patient is placed in the dorso-sacral position, 
 with the hips preferably raised by pads (Fig. 90) or better, in the genu- 
 pectoral position. The cystoscope (Fig. 89) is introduced into the illumi- 
 nated vesical cavity, and tipped toward the vesical orifice of the ureter 
 which is to be examined, and into this is introduced either a metallic ex- 
 plorer or a sound. 
 
 [None of the methods other than Kelly's are entirely satisfactory for 
 
io6 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 general use, but by means of his simple plnn of direct inspection any gynae- 
 cologist possessing ordinary skill should after a little practice be able to- 
 locate and catheterize either ureter with ease. 
 
 The instruments required are a catheter, conical urethral dilators, spec- 
 ula, head-mirror, a good lamp or electric light, long slender forceps, suction 
 apparatus for completely emptying the bladder, and ureteral catheter. The 
 dilators and specula are numbered from 5 to 20, according to their calibre in 
 millimetres. For general purposes four specula, Nos. 8, 10, 12, and 14,, 
 and dilators from 7 to 14 are sufficient. A good light is indispensable. An. 
 
 r Insi'ECTIon of Bladder by Rfflected Light. Hips in niodurati; cK-vation. 
 
 Argand burner suffices, but the electric light is best because of the small' 
 angle at which it can be used. 
 
 The method is as follows : The vulvar orifice, especially the urethra, is- 
 carefully cleansed with a warm boric-acid solution and cotton, to obviate risk 
 of infection of the urinary tract, which might easily be brought about by 
 successively introducing instruments through an unclean urethral orifice into 
 the bladder. The conical dilator is then introduced until the urethral meatus 
 is dilated up to No. 10 or 12. This can l)c accomplished in nearly all cases- 
 with but little pain by applying .a cotton-wrapped applicator saturated with 
 five-per-cent solution of cocaine to the urethra for five minutes before dilat- 
 ing. The bladder is now catheterizcd, a pledget of sterilized cotton placed 
 over the urethra to protect it from contamination during the change in posi- 
 tion, and the patient placed in the knee-chest posture. The speculum with 
 
METHODS OF GYNAECOLOGICAL EXAMINATION. 
 
 107- 
 
 the obturator held firmly in place is then introduced into the urethra by a. 
 motion describing a slight curve around the under surface of the symphysis.. 
 Upon withdrawing the obturator the bladder becomes distended with air and. 
 by properly directing the reflected light all parts of its interior are accessible: 
 to direct inspection. By slightly depressing the handle of the speculum the 
 region of the interureteric ligament comes into view, often marked by sl 
 
 Fig. 92. — Speculum Inclined 30° to Left, Exposing Ri hi I ft: 
 
 slightly elevated transverse fold or a slight difference in color. By then 
 turning the speculum thirty degrees to one side and looking carefully, the 
 urethral orifice may usually be seen. Sometimes it appears as a dimple, or 
 a little pit, or, in inflammatory cases, as a round hole in a cushioned emi- 
 nence; at other times as a y\ with the point directed outward, or as a fine 
 crack in the mucosa, or may be found only by noting the escape of a jet of 
 urine or by a slight difference in color, the mucosa being usually of a slightly 
 deeper rose around the ureter. As a result of the foreshortening of the base 
 of the bladder the ureteral orifice always appears to lie much nearer the ure- 
 
I08 CLINICAL AND OPERATIVE GYX.^COLOGY. 
 
 thra than one expects. When the orifice is found, the catheter can easily be 
 passed in from two to six centimetres and the urine collected, or a bougie 
 may be passed for purposes of diagnosis or to define the position of the ure- 
 ter during a hysterectomy or other operation. 
 
 Instead of employing the knee- chest position the patient may be on her 
 back with the hips sharply elevated, residual urine being removed with the 
 suction apparatus or cotton pledgets. Ureteral catheterization may also be 
 satisfactorily performed in some cases with the patient in the left semiprone 
 position, the pelvis being elevated by a pillow, or by an expert even, in the 
 dorsal position without pelvic elevation. 
 
 By this examination with distended bladder, diagnosis and treatment of 
 vesical disorders is very greatly facilitated. Direct applications to localized 
 areas can be made with the same certainty and ease as on the surface of the 
 body and various instruments can be used through the larger specula. Un- 
 pleasant after-effects may be avoided by careful attention to an aseptic tech- 
 nique, and by a gentle touch that avoids unnecessary traumatism.] 
 
CHAPTER V. 
 
 THE PATHOLOGY AND ETIOLOGY OF METRITIS. 
 
 Dcfinitio7i. — According to its etymology, metritis is inflammation of the 
 uterus, and I shall hold to this general definition although it might call for 
 a long commentary. But it is enough that I am understood, and the word 
 has a decided clinical value. The generic term inflammation is applicable to 
 all morbid states in which the anatomical substratum is reduced by irritative 
 lesions without resulting in the formation of specific neoplasms. How nu- 
 merous and varied these lesions may be we shall soon discover. But they are 
 all to be grouped under the same head because of the infectious nature of 
 their origin as well as by their defensive character and limited evolution. 
 When there is mucous or parenchymatous proliferation, the entire process 
 takes place as circumscribed local irritation, coming to a focus either exter- 
 nally or internally, with no tendency to pass certain bounds ; this distin- 
 guishes inflammation from neoplasms properly so called. Do there exist, 
 aside from metritis, " morbid states without neoplasm" which need to be 
 distinguished .-* Basing their opinion upon dogmatic ideas and a narrow con- 
 ception of inflammation, the ancient authors did not hesitate to reject from 
 the class of metritis all states which did not fall under the fourfold division 
 of "tumor, rubor, calor, dolor." Granulations, ulcerations, and leucorrhoea 
 belonged in consequence to other diseases. There are traces of this scholas- 
 tic prejudice to be found even up to the modern writers, Alph. Guerin and 
 Courty. Does not the latter author devote separate chapters to fluxion (in- 
 flammation), congestion, engorgement, oedema, hypertrophy, subinvolution, 
 and granulation and ulceration of the cervix .'' It is only necessary to run 
 the eye along his tables, so laboriously prepared with the view of differential 
 diagnosis of the various morbid entities, to be at once convinced of the folly 
 of parallel tabulations. 
 
 A very necessary distinction is the following: the idea of the lesion must 
 not be confounded with the disease. This is what the various authors wish 
 to indicate by the use of the terms idiopathic and symptomatic metritis ; ill- 
 chosen language which we will not adopt. The word metritis should remain 
 a clinical and not a pathological term. It is thus that we shall study the 
 malady, and its pathology is but the supplement thereto. Because there are 
 lesions of endometritis with a fibroma, or of metritis with carcinoma, shall 
 we therefore describe a myomatous and a carcinomatous metritis .' That 
 would have but one effect — confusion. 
 
 Our distinctions are certainly somewhat artificial, because they must be 
 
no CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 sharply defined and there is nothing absolute in nature; they are none the 
 less indispensable, and quite justifiable if one is careful to explain upon what 
 criterion they are founded. I have already said that ours is clinical ; it is 
 the only one which gi\-es personality to a disease. I cannot leave the sub- 
 ject without a few words on pseudometritis, the so-called s}"mptomatic me- 
 tritis. Inflammatory changes in the uterine mucous membrane are almost 
 constant with fibromata, and to this fact we may undoubtedly ascribe the 
 bleeding. Wyder's monograph on the subject is very complete. The irrita- 
 tion in these cases travels by continuity step by step. In the same manner, 
 but in a reverse direction, it can follow reflex congestions, which predispose 
 to infection, after disease of the adnexa. This pseudometritis, as I have 
 termed it, has been classified by Czempin under different heads according to 
 the point of origin as follows : 
 
 1. Chronic oophoritis, of one or both sides, with or without participation 
 of the tubes. 
 
 2. Exudative parametritis with exacerbations. 
 
 3. Pelvic peritonitis after removal of ovaries or tubes, starting in cica- 
 trices of the broad ligaments. 
 
 4. Tumors of slow growth in the adnexa (pyosalpinx, sarcoma, and car- 
 cinoma of the ovary). 
 
 The peculiar characteristic of pseudometritis is, that the inflammation 
 of the uterine mucous membrane is merely an epiphenomenon of tardy de- 
 velopment and not appearing at the first onset, which becomes evident only 
 after the appearance of disease in the adnexa or the pelvic peritoneum. 
 
 Brennecke, even before Czempin, had described a hyperplastic ovarian 
 metritis, occurring chiefly at the menopause, marked by continued or typical 
 hemorrhages, and equivalent to the hyperplastic form upon which Olshausen 
 insisted. 
 
 Doderlein and Pfannenstiel have recently held that fungous endometri- 
 tis is not of infectious origin and that it is always connected with trouble of 
 the ovarian functions. Treub and Lehmal also deny the inflammatory char- 
 acter of this variety of endometritis, and propose to remove it from the group 
 of metritis and to describe it separately under the name of hypertrophy of 
 the uterine mucosa. 
 
 Classification. — ^Turning now to the study of metritis proper, and its va- 
 rious forms, if we consult the authors we shall find the most widely different 
 starting-points for classification ; they take the progress of the disease and 
 term it acute and chronic ; or its location, and describe cervical and corporeal 
 endometritis, parenchymatous and idiometritis ; or from its cause, it is puer- 
 peral, post-puerperal, gonorrhoeal, traumatic, etc. ; or from its pathology, it 
 is styled granular, fungous, ulcerating, etc. For our purpose these schemes 
 all have the defect of being as systematic and artificial as Linnzeus' classifi- 
 cation of plants. They are founded upon some character, arbitrarily chosen, 
 whose value is not so great that all authors should be fairly dominated by 
 
THE PATHOLOGY AND ETIOX^OGY OF METRITIS. 
 
 Ill 
 
 it. But in order to reach a classification as natural as possible, following 
 in disease the definite rules propounded by Jussieu for botany, we have a 
 guide that we can follow — the clinic. Truly, if lesions were always circum- 
 scribed, and if to such definite lesions a particular group of symptoms always 
 corresponded, then we should have in the anatomical method the most logical 
 
 Fig. 93. — KoRMAL Mlxous Membrane of the Body of the Uterus, * slightly Enlarged, 
 
 To the naked eye the uterine mucous membrane differs from the cer\'ical in being smoother. Under the micro- 
 scope it is seen to consist of collections of embrj'onal cells and tubular glands. These embryonic connective tissues 
 are essentially homogeneous, rich in round and fusiform cells, which are found scattered through the muscular base of 
 the membrane, along the vessels and glands, and here and there in the thickness of the tissues; both forms, especially 
 the round cells, are characterized by their single large nucleus surrounded by a thin layer of protoplasm. The tubu- 
 lar glands cross the interglandular tissue almost perpendicularly, and at the muscular layer are branched, piercing the 
 thin layer between the connective-tissue bands which separate the muscular bundles. The limit between muscle and 
 membrane is sharply cut throughout. The surface of the mucous membrane is covered with a single layer of ciliated 
 cylindrical epithelium. The mucous membrane of the body is further distinguished by the wealth of its arterial supply 
 and the poverty of its venous. The arterioles pierce the layer perpendicularly, give off many little branches which 
 enter the glands, then recur\-e and cross immediately below the epithelial investment, forming an irregular plexus of 
 large capillaries, whence the veins originate. 
 
 I, Intraglandular tissue composed of round cells with large nuclei; 2, surface epithelium with vibrating cilise; 
 3, tubular glands slightly sinuous; 4, a bifurcated gland; 5, transverse sections of same glands. 
 
 system possible; but while this condition does not exist, the anatomical 
 basis lacks all precision and serves but for illusions. 
 
 I propose, therefore, to classify metritis according to the prevailing clin- 
 ical symptom which may be deduced from its course, or may stand in marked 
 
 * In order to estimate tissue chano:es correctly, we must know the normal histolog}- of the 
 part, and I have therefore prefixed to figures of morbid tissues one which presents the healthy con- 
 dition; this is indispensable for com.parison. 
 
.112 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 predominance in the order of its symptoms, 
 lowing varieties : 
 
 1. Acute inflammatory, 
 
 2. Hemorrhagic, 
 
 3. Catarrhal, 
 
 4. Chronic painful. 
 
 We have, accordingly, the fol- 
 
 These epithets shall have only a taxonomic or 
 classifying value henceforth, and any other adjec- 
 tive will be used, when necessary, to give them a 
 purely descriptive force. 
 Pathology. — For the methodical description of the lesions found in me- 
 tritis, it is necessary to depart from the clinical arrangement and follow the 
 
 Fig. 94. — Normal Mucous Membrane of the Cervix. X 100 diameters. 
 
 The mucous membrane of the cervix is very firm and presents a number of branching folds (arbor vitae). The" 
 interglandular tissue, which has in the body of the organ the nature of granulation tissue, is here of a connective- 
 tissue type, the fusiform and stellate cells predominating. There is not the same clear limit between membrane and 
 muscular coat; and one can follow the glands deeply inward among the connective-tissue bands which separate the 
 muscular bundles. Consequently the mucous membrane in section has a partly reticulated, partly fasciculated ap- 
 pearance. The cervical membrane possesses, moreover, many vascular papillae. Cylindrical ciliated epithelium in- 
 vests the glands in the adult, and in the child extends to the e.xternalos. In the adult, especially after pregnancy, the 
 flat vaginal epithelium rises higher and lies more or less within the cervix. Between the superficial cylindrical epi- 
 thelium and the glands, cup-shaped and colloid cells are here and there present. 
 
 The vessels (Moericke) pass into the mucous membrane perpendicularly and have very thick walls, dividing pro- 
 gressively into a capillary plexus, which is less developed than in the body. Sometimes the capillaries lie very super- 
 ficially under the epithelium, reuniting to form veins, which at once leave the mucous membrane. The glands and 
 ovula Xabothi are surrounded by the vessels. 
 
 I, Layer of ciliated columnar epithelium; 2, mucus secreted upon the surface; 3, mouth of a gland; 4, glands 
 slightly dilated; 5, vessels; 6, tissue forming papillary projections composed of small cells; 7, deeper tissue in denser 
 bundles. 
 
 topographical order, first considering lesions of the body and then those of 
 the cervix. 
 
 In most of the treatises on metritis the division is still maintained of 
 acute and chronic parenchymatous, and internal (or mucous, i.e., endometri- 
 tis), and both the pathology and clinical study of the disease are arranged 
 accordingly. I have said that I do not adopt this plan clinically, but yet I 
 
THE PATHOLOGY AND ETIOLOGY OF METRITIS. 
 
 113 
 
 take advantage of it for the study of the lesions. As de Sinetyso justly re- 
 marks: "How shall we imagine that the mucous membrane presents the 
 lesions of an acute disease without participation of the tissues below ? Or 
 how shall we suppose that the glands are involved without observing at the 
 same time that there is an alteration in their lymphatic sheaths which com- 
 municate freely with the lymph spaces of the parenchyma?" 
 
 I shall first describe the lesions of acute metritis throughout all the ute- 
 rine tissues and then those of the chronic form. 
 
 Acute Metritis. — The descriptions which have been given of the paren- 
 chymatous lesions of acute metritis all suffer from one defect : non-puerperal 
 
 U^^ 
 
 Fig. 95. — Normal Mucous Membrane of the Cervix. Portion of preceding figure X 300. i, Verj' embrj-onal 
 connective tissue, composed of round cells with large nuclei; 2, vessels (specimen injected); 3, ciliated epithelium of 
 the surface; 4, glands cut transversely, showing lining of ciliated epithelium. 
 
 metritis is not fatal and does not justify hysterectomy, and hence descrip- 
 tions of lesions of the uterine mucous membrane and parenchyma, based on 
 the autopsy of women dying in the puerperal state, are not comparable to 
 those which should be found in acute inflammation of the non-gravid uterus. 
 We ought to free our minds of this ancient idea of Chomel's, who described 
 all the accidents of septicaemia after parturition as puerperal metritis. When 
 a woman succumbs to such accidents, there is certainly present a septic in- 
 flammation of the entire uterine tissue, but this is merely an additional cir- 
 cumstance which defines the general septic condition which proves fatal. 
 The pathologist alone has the right to speak of a septic puerperal metritis, 
 
114 
 
 CLINICAL AND OPERATIVE GYX.ECOLOGY. 
 
 marked in life by vague resemblance to acute metritis. This transposition 
 of terms has been so often repeated since Aran that it has become trite. 
 
 These authors note the increase in volume, the softening of the tissue, 
 the red color mottled with yellow, the vascular dilatation, and the shedding 
 of the mucous membrane. Finally, to complete the cycle of acute inflamma- 
 tion with pus formation, most authors blindly repeat a number of ancient 
 obser\-ations which are all exposed to hostile criticism. Their pretended 
 
 
 
 ■'<k 
 
 Fig. q5. — Normal Mrcors ^Membrane of the Uterus during JMexstruation. 
 
 A preparation of the layer removed by curette during menstruation. The figure reproduces the upper third of 
 the membrane. There are small extravasations here and there ; in the deeper parts is almost normal interglandular 
 tissue, the glands being somewhat more sinuous than usual. The blood-vessels are full; the upper layers are partly 
 normal, partly infiltrated with blood cells; the epithelium, for the most part preserved, is here and there raised from 
 its seat and covered with altered blood cells; hemorrhage into the glands in places; no appearance anywhere of the 
 fatty degeneration described by certain authors (Williams, Kundrat, Engelmann). It is very likely that sometimes 
 during menstruation part of the mucous membrane is destroyed (Leopold, Wyder), and that there is no such desquama- 
 tion at other times (Moericke). This figure shows that the different changes may be simultaneous, and that there is 
 great diversity in the process. 
 
 I, Normal uterine tissue formed of numerous rounded embryonal cells; 2, same, infiltrated with blood corpuscles to 
 a considerable depth; 3, dilated vessels, full of blood; 4, intact uterine mucosa; 5, place where it has become de- 
 tached; 6, longitudinal section of a gland; the epithelium near its mouth has disappeared; 7, dilated glands; 8, gland 
 whose lining epithelium has become detached; 9, normal deep glands; 10, mucous membrane raised by infiltration of 
 blood. 
 
 uterine abscesses are either collections of pus in the neighborhood, as in 
 pyosalpinx, or suppuration m a degenerated myoma, neither of which bear 
 any relation to metritis. r)f the two cases reported by Schroder, one, post 
 partum, seems to be a simple parametritis ; the other, opened by the rectum 
 after uterine sounding, was probably suppuration of the tubes. This latter 
 explanation must be given also to the case of Hervey de Chegoin, so often 
 cited. 
 
 A. Martin has related a case which was suppuration of a myoma but 
 
THE PATHOLOGY AND ETIOLOGY OF METRITIS. 
 
 115 
 
 which exactly simulated uterine abscess, J. B. Kirkpatrick has lately pub- 
 lished a case under the name of uterine abscess in which the cavity of Retzius 
 was invaded and the pus appeared at the umbilicus — probably a parametritis. 
 
 C. 2oi7a ce//aiara/n / 
 
 
 .D Za/2a exfo/iatioms. 
 
 S Zona g^a/rdularam . / 
 
 Fig. 97.— Normal Placenta (Friedlander, Wvdf.r). 
 
 The figure is largely diagrammatic, for the sake of clearness. It represents the placenta at the end of pregnancy. 
 This membrane is the product of two factors, viz., proliferation of the uterine mucous membrane in all its elements, 
 and compression of this hypertrophied mass by the enlarging ovum. There are thus two layers, the cellular (zona 
 cellularum) and the glandular (zona glandularum). The former lies close to the foetal membranes (amnion and cho- 
 rion), and is made up of cells which measure 2 fi. to 61 /u. in diameter, superiorly they are round, but below they be- 
 come fusiform. Intercellular tissue is altogether lacking, or present as a trace merely The glandular layer shows a 
 plexus of flattened alveoli, not very long or wide, not communicating with each other freely, empty or filled with 
 granular matter. The layers which separate these alveoli are formed of connective tissue, richly supplied with 
 vessels and infiltrated with lymph cells. They are covered on the internal surface by epithelium; in places pave- 
 ment, in others cylindrical. 
 
 The zona e.xfoliationis, or separating line between the two layers, is produced almost always in the cellular layer 
 (Friedlander) and but seldom in the glandular; the opposite is the case according to Langhaus, Hiistner, and Leo" 
 pold. The above figure, after Friedlander, is modified according to the views of his opponents, who seem to be cor- 
 rect. The glandular cavities thus opened by placental separation furnish the regenerated epithelium of gland and 
 mucous membrane after parturition. 
 
 Surely, if one would assert that suppuration of the uterine wall is possi- 
 ble, we should agree with him ; but that it occurs as part of the clinical 
 picture we call metritis — that we deny. 
 
 Our most trustworthy source of information as to the acute lesions of 
 
ii6 
 
 CLINICAL AND OPERATIVE GYNECOLOGY, 
 
 the mucous membrane is found in examination of the membrane of mem- 
 branous dysmenorrhoea. The mucous membrane is abnormal both in soft- 
 ness and thickness ; the microscope shows no change in the glands but a 
 peculiar alteration in the interglandular tissue; the cells being far more 
 numerous than usual and so tightly packed against each other that there is 
 almost none of the homogeneous intercellular substance left. They preserve 
 their normal volume, and differ in that respect, and in the small amount of 
 
 ^^•■€ 
 
 
 ?s^^!^;j*..,^^. 
 
 
 
 •»* 
 
 « t 
 
 :^^-.^;' Q <^;.'.f,« V^'^:ci:''.Ci^'^?!?--^ri^> , b 
 
 
 
 
 Fig. q8. — Acute Endometritis. Slightly enlarged view of entire mucosa, i, Superficial layer formed of more or 
 less altered tissue, infiltrated with coagulated blood; 2, round-celled embryonal tissue; 3, zone in which these cells are 
 especially numerous; 4, large dilated and varicose vessels gorged with blood; 5, lymph spaces; 6, transverse sections 
 of glands; 7, glandular cul-de-sac. 
 
 their protoplasm, from the cells of the placenta. In other words, we have to 
 do (Fig. 99) with an acute interstitial inflammation. 
 
 Massin has examined the uterine mucosa of women who have died of 
 acute infectious diseases (typhoid fever, recurrent typhus, pneumonia, dys- 
 entery). The lesions which he found were those of a parenchymatous and 
 interstitial inflammation of the mucous membrane and of an interstitial 
 inflammation of the muscular layer. The glands showed a cloudy swelling, 
 granular disintegration and desquamation of the epithelium, and the presence 
 of blood corpuscles within their cavities. The interglandular tissue was 
 infiltrated with small round cells, the vessels gorged with blood; here and 
 there were seen hemorrhagic foci of varying size. 
 
THE PATHOLOGY AND ETIOLOGY OF METRITIS. 
 
 117 
 
 Oironic Metritis. — The parenchymatous lesions of chronic metritis are 
 particularly characterized by a hypertrophy of the connective tissue, causing 
 a general enlargement of the organ, which, however, does not exceed the size 
 of a fist. This increase in volume may be absent altogether, and then we 
 have a decrease in the size of the organ. Theoretically there are two stages, 
 according to Scanzoni : the one of infiltration and the other of induration. 
 The first of these corresponds to an active or passive congestion of the 
 uterus, where the vessels are so dilated that the wall of the organ has an al- 
 most areolar aspect. There are great numbers of embryonal nuclei through- 
 out the thickness of the tissue. The predominating change is h3'pertrophy of 
 the connective tissue, but authors are not agreed as to the participation of 
 the muscular tissue in this hypertrophy. Finn, of St. Petersburg, admits the 
 
 Fig. 99.— Acute ENDOiMETRiTis; Membranous Dysmenorrhcea. Highly magnified. Fragment of membrane 
 corresponding to surface of mucosa, i, Cylindrical epithelium which has become slightly vesicular and has lost its 
 cilia;; 2, point showing change and proliferation of epithelial cells; 3, tissue of mucosa infiltrated with many 
 rounded embryonal elements in process of multiplication; 4, diffuse hemorrhagic foci. 
 
 hypertrophy but denies the importance of the fatty degeneration described 
 by others. De Sinetyhas discovered in one case a considerable dilatation of 
 the normal lymph spaces, and hyperplasia of the perivascular connective tis- 
 sue which diminishes the calibre of the vessels and gives rise to a special 
 form of sclerosis. The muscular tissue does not seem to be involved. 
 
 When the uterine parenchyma has thus been the seat of profound and 
 lasting inflammatory processes, it is unusual not to have with it evidences of 
 perimetritis, adhesions in Douglas' pouch with displacement of the organ, 
 and traces of salpingitis and inflammation about the tubes and ovaries. The 
 uterine mucous membrane is always involved to a greater or less extent. 
 • In many cases of endometritis of the uterus and the cervix, independent 
 of parturition or occurring in aged women who have had children long before, 
 Cornil has found hypertrophy of the uterine wall due entirely to a new for- 
 mation of adult connective tissue between the muscular trabeculae. To the 
 
ii8 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 naked eye the muscular tissue is then of a pale red color, presenting a se:ies 
 of opaque lines which are thickeneci and sclerotic arterioles in a state of 
 atheromatous degeneration. Under the microscope this thickening of the 
 vessel wall is found to be considerable, the elastic elements are increased 
 and present also numerous cells in fatty degeneration. The connective- 
 tissue sclerosis corresponds to that of the arterial and venous coats, and is 
 not so much a cicatricial contraction of the connective tissue as a permanent 
 
 3 
 
 Fig. ioo. — Slight Chronic Endometritis. The interglandular vessels are dilated and appear varicose. Photo- 
 graph of a section injected with gelatin and stained with soluble Prussian blue, i, Nearly normal glands; 2, same 
 deformed, and of corkscrew shape; 3, dilated and varicose vessels; 4, fine capillary network. 
 
 augmentation of its volume. The microscopic and histological lesions of 
 the mucous membrane under chronic inflammation are to-day perfectly under- 
 stood, thanks to the operations which permit the study of so many fresh 
 specimens of this disorder. 
 
 I cannot better describe the usual appearance of a uterine mucous mem- 
 brane thus altered than by reproducing the words of Cornil in his recently 
 published " Lemons" ; his description applies especially to chronic glandular 
 endometritis, the more common form : 
 
 " The mucous membrane does not present its normal whitish color, smooth 
 surface, and peculiar rigidity; it is bloated, pulpy, soft, and both in aspect 
 and consistence resembles currant jelly; the discoloration is in places very 
 
THE PATHOLOGY AND ETIOLOGY OF METRITIS. 
 
 119 
 
 marked and may have the appearance of a layer of blood interspersed with 
 dark clots. This softened layer, formed by the inflamed mucous membrane, 
 is easily displaced by the scalpel, readily elevated or torn by gentle traction. 
 There is present an intense congestion throughout the organ, between the 
 muscular fibres, but this is most pronounced on the deep surface of the 
 mucous membrane. On a section of the organ, if made with a very sharp 
 knife, it is difficult to distinguish muscle from mucous membrane, the two 
 having a similar appearance. However, the mucous membrane is easily 
 
 Fig. ioi.--Chronic Interstitial Endometritis. Hypertrophy and sclerosis of the perivascular connective tis- 
 sue. I, Smooth muscle fibres in longitudinal bundles; 2, same in transverse section; 3, vessels diminished in calibre and 
 with thick walls; 4, dilated lymphatics; 5, hypertrophied connective tissue around blood-vessels. 
 
 scraped off with the curette, which cannot penetrate the muscular layer 
 unless it is much softened by inflammation, which is very unusual. 
 
 "Hardened in alcohol, to fix the different elements, and cut in microscopic 
 section, it is easily seen that the mucous layer is abnormally thick. When 
 stained by picrocarmine this thickening is very plain to the naked eye. 
 The mucous membrane then has a slightly yellow tinge, which distinguishes 
 it from the redder muscular tissue. It is, moreover, more transparent, espe- 
 cially in its deeper portions, where the microscope reveals the presence of 
 glands. To appreciate these details by the naked eye it is enough to exam- 
 ine a section stained by picrocarmine, holding it against the light ; the 
 mucous membrane is seen to be 2 to 5 mm., even i cm. thick at times, 
 whereas its usual thickness is but i mm. Its surface, instead of being 
 
120 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 smooth, is fungous, presenting alternate projections and depressions of a 
 flabby appearance. These fungosities have received the name of villi, vege- 
 tations, etc., and the disease has been therefore termed villous, fungous, 
 granulating, or vegetating metritis. These vegetations are at times very 
 large, of a round and elongated form, and may become veritable polypi, ses- 
 sile or pedicled. In other cases there are small cysts, of the size of a pin's 
 head, resembling the ovules of Naboth, so common in the cervix and about 
 the OS externum, and having the same glandular origin ; but they differ from 
 these in the quality of the fluid contained. It is more thin and serous, less 
 
 
 Vf7 :^ f %%^v >s> 
 
 Fig. I02. — Chronic Ixterstitial Endemetritis; Partial Atrophy of Glands. Section perpendicular to sur- 
 face of mucous membrane of body of uterus, i, Surface of raucous membrane denuded of epithelium and covered with 
 a layer of coagulated blood; 2, atrophied gland which almost projects; 3, fibrous tissue with long parallel nuclei; 4, 
 glands undergoing atrophy, very long and contracted; 5, glands of normal size, more deeply situated; 6, tissue consist- 
 ing of rounded and ovoid cellular elements embedded in a homogeneous substance. 
 
 consistent and colloid, than the contents of the Nabothian ovules of the cer- 
 vix. These small cysts of the body of the uterus are seen more often in 
 aged patients than in the young. 
 
 " Such is the macroscopic appearance of the uterine mucous membrane 
 after chronic inflammation." 
 
 In the histology of the subject there are three distinct types, often clearly 
 presented in different subjects or at times combined in one. In this de- 
 scription I follow Wyder's recent work. 
 
 Chronic Interstitial Metritis. — The interglandular tissue which we have 
 seen gorged with cells in the acute form so that it resembles granulation 
 tissue, is transformed into true cicatricial tissue in which the number of cel- 
 lular elements steadily increases. The glands undergo the opposite altera- 
 tion, being strangled in places and transformed into cysts, or so compressed 
 
THE PATHOLOGY AND ETIOLOGY OF METRITIS. 
 
 121 
 
 in their whole extent that they atrophy, and thus we may have a few glands 
 scattered through the connective tissue (Fig. loi), altered into cysts in 
 places (Fig. 104, A) or totally destroyed (Fig. 104, />'). 
 
 In cases in which the atrophy is very marked the muscular layer is covered 
 by only a very thin layer of sclerosed connective tissue and this in turn by 
 epithelium. Under the surface still covered by pavement epithelium one 
 sees the mucous membrane traversed by these fibrous layers, which frequently 
 interlace to form a meshwork, generally filled with a homogeneous substance, 
 thouo-h the deeper portion of the tissue may be full of round cells packed 
 close together. Nearer the surface the interglandular tissue has a more 
 
 Fig. 103. — Chronic Interstitial Endometritis. Varying degrees of atrophy of glands (X 500). i. Tissue com- 
 posed of fusiform cells, corresponding to the surface of the uterine mucous membrane; 2, tissue composed of smaller 
 'Ovoid cells; 3, very long gland undergoing atrophy — the epithelium has become cuboidal; 5, slit near surface, the 
 site of a gland which has disappeared; 6, large lymphatic cavity. 
 
 regular arrangement, being composed of a series of layers of cells and their 
 parallel prolongations. The section may contain only very few glands. 
 
 At many points (Fig. 104) there are cystic cavities, lined with cuboidal 
 ^epithelium and surrounded by bands of connective tissue with fusiform cells. 
 At places there are evidently no glands present, and the mucous membrane 
 is represented by a homogeneous connective tissue which possesses no cells 
 and is arranged in many bundles, the whole being clearly marked off by a 
 sharp line from the muscular tissue. Near the surface this formation is 
 smooth in places and at others arranged in large flat villous projections. 
 There are present, therefore, all the signs of advanced connective-tissue 
 sclerosis. 
 
 ■Chronic Glandjtla7'- Metritis. — Ruge, and after him Wyder, recognized 
 two forms of glandular endometritis, the hypertrophic and the hyperplastic. 
 In the first, the epithelial proliferation takes place without multiplication of 
 :the glands themselves. Instead of being a series of straight tubes, the 
 
122 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 glands are then of irregular form, frequently twisted and arranged spirally. 
 In the hyperplastic form there is an increase in the number of the glands. 
 Cornil has discovered karyokinetic figures in the epithelium lining the glands 
 (Fig. 107) in such cases. He is of opinion that this may be normally pres- 
 ent after menstruation, as it is a feature of physiological repair in gland 
 cells. 
 
 Fig. 109 presents a form of combined hypertrophy and hyperplasia which 
 is more common than is usually supposed. The glandular tissue is abso- 
 
 Fig. 104. — Interstitial Endometritis with Complete Atrophy of the Glands (Wyder). 
 tion, last trace of glands. B, All vestige of gland tissue disappeared. 
 
 Cystic fontia- 
 
 lutely normal in structure, but the glands themselves are much distorted and 
 have lateral prolongations. 
 
 Chronic Polypoid Endometritis. — This form is marked by an enormous 
 development of the mucous membrane, which has a fungous appearance and 
 may be bristling with small and soft polypi. Recamier was the first to give 
 a good description of the macroscopic appearance in this form, and Olshaa- 
 sen has lately studied the subject anew. It is a mixture, histologically, of 
 interstitial and glandular changes with marked cystic degeneration. On the 
 surface the naked eye discovers small vesicles of i mm. diameter, transpar 
 ent and a little elevated ; and these under the microscope (Fig. 114) are 
 plainly degenerated glands lined with cuboidal epithelium. They are sepa- 
 rated by bands of connective tissue; in the superficial layers the glands are 
 widely dilated, and more deeply they appear normal but are bent aside, par- 
 allel or oblique to the muscular fibres. 
 
THE PATHOLOGY AND ETIOLOGY OF METRITIS. 
 
 123 
 
 The glandular culs-de-sac pass beyond their usual limit in the depth of 
 the mucous membrane and sink in between the subjacent muscular fibres ac- 
 cording to Cornil. This is a remarkable instance of what the older anat- 
 omists called "glandular heterotopy" occurring with a simple inflammation 
 having no tendency to become malignant. In this invasion of the muscular 
 tissue a certain amount of their investing connective tissue accompanies the 
 glands. The interglandular structure is very rich in vessels. 
 
 At the points which correspond to glandular dilatations there are en- 
 closed numbers of spindle-shaped cells, whose prolongations give the part a 
 
 
 Fig. 105. — Interstitial Endo.metritis. Detachment of the epithelial lining in rings. X 100. i, Periglandu- 
 lar tissue of small elongated fusiform cells; 2, contracted glandular cavity; 3, shred of epithe'um bent upon itself; 4, 
 glandular cavity whose epithelium has disappeared, lined by small, flat cells; 5, large dilated and winding glandular 
 cavity containing fragments of detached epithelium. 
 
 Striated appearance, or, at other times, the tissue has very few cellular ele- 
 ments ; this latter arrangement is especially noticed about the blood-vessels. 
 Lying deeply about the intact glands among the cysts there is found a homo- 
 geneous substance, replacing the proper interglandular tissue, which is full 
 of round cells pressed closely together (Fig. 114). De Sin^ty has given an 
 excellent description of the lesions of endometritis, although a post-mortem 
 examination was made on but one case. He specially studied the vegeta- 
 tions and excrescences which are to be observed upon the mucous membrane, 
 and which he removed for the purpose by a Recamier's curette ; but he laid 
 less emphasis upon alterations in the membrane itself. He describes three 
 kinds of vegetation : the glandular, formed by enlarged and distorted glands, 
 
324 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 with thickening of the connective tissue ; the embryonal, formed of embry- 
 onic tissue and a few dilated vessels ; and the vascular, composed of vessels 
 often widely dilated. 
 
 Certain authors discuss a diphtheritic metritis, which it were better to 
 call gangrenous, since the false membrane is merely the product of a partial 
 mortification. This is a simple nosological error which has crept into the 
 
 group, so well-defined clinically, 
 
 C&S.'i 
 
 
 of inflammations of the uterus ; 
 whereas it is but a simple acci- 
 dent which may happen in the 
 uterus or elsewhere, in certain 
 peculiar conditions either general 
 or local. Thus diphtheritic metri- 
 tis has been seen to follow tam- 
 ponade with perchloride of iron, 
 and to occur after enucleation of a 
 fibroma, or in the course of a 
 septicaemia in an old woman 
 who had a phlegmon upon the 
 lower extremity. Cornil has also 
 
 £ 
 
 ./ 
 
 fUllf' 
 
 mm 
 
 Fig. 107. 
 
 Fig. 106. — Interstitial Exdo.metritis; Detachme.nt of the Epithelial Linings. (Part of Fig. 116 X 500.) 
 I, Periglandular tissue containing a large number of rounded embryonal cells; 2, cavities produced by the contraction 
 of the epithelial rings and lined by flat cells; 3, epithelial layer separated from the wall and formed of cylindrical cells ; 
 4, glandular wall cut obliquely; s, white corpuscles which have passed by diapedesis into the cavity of the gland. 
 
 Fig. 107. — Epithelial Investment of a Gland from the Body of the Uterus (Cornil). X 350. Reich- 
 ert's apochromat. with 00.4. /, Nucleus with enlarging granules and filaments of nuclein; ^, nucleus showing the be- 
 ginning karyokinesis, with "star" arrangement of nuclein; ?«, small, round wandering cell between the cvlindrical cells. 
 
 observed certain details of high interest in which the only change visible is 
 extreme enlargem.ent, and the glands in longitudinal or cross section present 
 a single flat layer of cylindrical cells, usually on their internal aspect. 
 Where there are many layers superimposed the details are difficult to grasp, 
 "but sections sufficiently thin, if well examined, disclose only a single series 
 of cells. The vibratilc cilia which are found upon normial glandular epithe- 
 lium are in great part preserved, and this retention of cilia in a gland so 
 modified by chronic inflammation is a remarkable fact. At the same time, 
 
THE PATHOLOGY AND ETIOLOGY OF METRITIS. 
 
 125 
 
 it is not always easy to find these cilia ; it is necessary to use for that pur- 
 pose excellent objectives and tissue absolutely fresh. To demonstrate them 
 the material must be taken as it comes from. the surgeon's hands at the ope- 
 
 FiG. loS. — Glandular Endometritis. (Section perpendicular to the surface of the mucous membrane. X 60.)' 
 I, Free surface of the mucosa still covered by its epithelium; 2, blood clot projecting from the surface at a point where 
 the epithelium has disappeared; 3, mouth of gland; 4, surface glands slightly enlarged; 5, longitudinal sections of 
 deeper glands, tortuous and dilated; 6, transverse sections of glands; 7, glands projecting into the muscular layer; 8, 
 tissue of the superficial layer of the mucous membrane, formed of small elongated cells; 9, deeper tissue, formed of 
 rounded embryonal cells; 10, vessels cut longitudinally and transversely; it, blood extra vasated into the deep tissue 
 and around the glandular cul-de-sacs; 12, smooth uterine muscle fibres. 
 
 ration and placed directly in some hardening fluid, preferably ninety per 
 cent alcohol. In preparations even of irreproachable freshness the cilia may 
 seem to have disappeared ; then there is seen upon the surface of the cell a 
 delicate layer of mucus, sometimes clear and homogeneous, at others as if 
 formed of little spheroid bodies, or somev.-hat striated, composed of an ag- 
 
126 
 
 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 glomeration of the cilia. The cells which fill the alveoli, often completely, 
 are identical with those found normally in the uterine glands, cylindrical or 
 modified, ovoid or even mucous. 
 
 The only difference presented by portions of tissue scraped off with the 
 curette and entire sections of the viterus, is found in the difficulty of recog- 
 nizing the relations of the first; and therefore it is better to study sections 
 made perpendicularly to the surface in material provided by hysterectomy. 
 
 Finally, there is a histological variety 
 of endometritis which does not deserve 
 the dignity of being placed in a separate 
 class, and yet should be mentioned, and 
 that is post-abortum endometritis. Ac- 
 cording to Schroder it is almost always an 
 interstitial form of metritis which occurs 
 after abortion, the glands taking part only 
 very late in the disease. But the feature 
 which distinguishes such metritis anatom- 
 
 FiG. 109. — Glandular E.vdometritis of the Utekine 
 Body (Wyder). Slightly enlarged. 
 
 Fig. iio. — Glandular Endometritis. Cork- 
 screw deformity of glands. 1, Embryonal peri- 
 glandular tissue; 2, gland which is very long and 
 which has become tortuous throughout its entire 
 length; 3, dilatation of certain glands; 4, gland 
 which has preser\-ed its normal calibre. 
 
 ically is the persistence of the decidua (vera or serotina) which undergoes a 
 partial retrograde metamorphosis ; if this persistence is partial, we find little 
 islands of decidua, more or less prominent, about which there is a very 
 active proliferation of small cells (Fig. 115). This inflammatory modifica- 
 tion of the mucous membrane, adds Schroder, differs essentially from reten- 
 tion of the placenta, which is often described under the inappropriate name 
 of endometritis post abortum, and which is only a hemorrhage post abortum 
 due to incomplete contraction of the uterus and its vessels. 
 
 Lesions of the Cervix. — Anatomically it is incorrect to speak of metritis 
 of the body as distinct from metritis of the cervix, for these two portions of 
 
THE PATHOLOGY AXD ETIOLOGY OF METRITIS. 
 
 127 
 
 the uterus are never completely independent ; most frequently the lesions 
 are synchronous and undergo a parallel evolution. However, there is often 
 a more decided localization of the disease in one or the other of these differ- 
 ent parts ; and as the cervix is the more exposed to traumatism, cervical 
 
 
 Fig. III. — Polypoid Endometritis. Section of fungosities of surface of mucosa, i, Tissue of small, rounded 
 granular cells; 2, deeper tissue of cells which are usually elongated; 3, surface villosities hanging loosely in the 
 uterine cavity and denuded of epithelium; 4, atrophied glands; s, gland maintaining its normal dimensions; 6, glands 
 which are lengthened and with hardly visible lumen. 
 
 metritis predominates. If the mucous membrane of the cervix is thoroughly 
 diseased, the process is carried step bv step into the fibrous and muscular 
 portions, and thus a veritable parenchymatous metritis occurs with every in- 
 flammation of the cervix if of long duration. Cornil expressly describes a 
 parenchymatous metritis which may be partial. For example, the lesions 
 
128 
 
 CLINICAL AND OPERATIVE CxYX.^COLOGY. 
 
 are at times restricted to the cervix in the ectropion of the part caused both 
 by thickening of the mucous membrane, turned outward into the vagina, and 
 by thickening of the connective tissue beneath the mucous membrane and 
 between the muscular fibres. In this connective tissue lesions of recent in- 
 
 'W^^. 
 
 
 
 
 
 4J-L » ■ " ■« • ^Z'^ ■ ^ V^ifc^ 
 
 .M'^^>J*^^&^0 ^.J^'^'^'^ ^^*fe 
 
 
 
 
 Fig. 112. — Polypoid Endometritis with Hemorrhages. Transverse section of a fragment of mucous mem- 
 brane. 1, Tissue infiltrated with embryonal cells and e.xtravasated blood corpuscles; 2, large dilated capillaries filled 
 with blood; 3, embryonal papilla; corresponding to the surface of the mucosa and denuded of their epithelial layer; 4, 
 layer of coagulated blood upon the surface; 5, fragments of detached epithelium surrounded by the blood clot; 6, 
 complete ring of epithelium; 7, remains of glands; 8, fragments of epithelium surrounded by embryonal cells. 
 
 flammation can often be demonstrated, by thickness of the trabeculse and of 
 the interposed flat cells. 
 
 The neck of the uterus may present special and very diverse lesions in 
 metritis ; there may be lacerations, ectropion, hypertrophy, congestion, varix, 
 granulations, folliculitis, erosions, ulcerations, cysts, and ovules of Naboth, 
 
THE PATHOLOGY AND ETIOLOGY OK METRITIS. 
 
 129 
 
 etc., etc. When this part of the uterus is accessible to the view, the macro- 
 scopic description should enter into the clinical demonstration ; but it is nec- 
 essary also to make the exact nature of the disease clear by the resources 
 of histology. 
 
 Ovules of NabotJi, Gramdations, Folliculitis. — The Nabothian glands, so 
 called, are small cysts ; granulations and folliculitis are small ulcerations (I 
 will explain the value of the word farther on), scattered over the surface of 
 the uterine neck. The one or the other of these resemble an eruption, and 
 authors have been led to identify them with those of the external integu- 
 
 FlG. 113. — PoL^■pOID Endometkitis. X 500. I, Connective tissue rich in elonjjated or rounded cellular elements; 
 2, hypertrophied glandular cavities lined with cylindrical epithelium; 3, point at which this epithelium has proliferated, 
 4, lining- with oval nuclei; 5, cuboid cells with large rounded nuclei. 
 
 ment, erythema, eczema, herpes, acne, pemphigus, etc., but the parallel is 
 purely arbitrary, built upon theoretical views and lacking all serious founda- 
 tion. 
 
 Erosions, Ulcerations. — The cervix may present, near the external os, a 
 red and rough aspect without protuberances or depressions ; this is erosion, 
 properly so termed. It may be observed in acute vaginitis with abundant 
 secretion, or after contact with a foreign body (pessaries) ; under the micro- 
 scope it is seen that there is a simple substitution of flat normal vaginal epi- 
 thelium for the proper cylindrical. Fischel has shown that there is often, 
 9 
 
I^iO 
 
 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 in the infant at birth, a pseudo-erosion of the external os, the epitlielium 
 being then cylindrical over a certain zone externally. Later on this epithe- 
 
 
 '^^. 
 
 ^-~ > \-^^ 
 
 Fig. -114. — Polypoid Endometritis (Wvdek). 
 
 Hum is invested by stratified pavement cells ; but when these desquamate, 
 the original appearance is restored. Should there thus be a congenital pre- 
 disposition to erosions it would be a curious fact. The observations of 
 Klotz seem to favor this view. According to him there are patients who 
 
 
 - \ 
 
 !'i 
 
 
 Fig. 115. — Endometritis Post Abohtum, showing Islands of Decidua aboi't which is .\n Active Prolifer- 
 ation OF Cells. 
 
 suffer from erosion or ulceration under the influence of the lightest inflam- 
 mation, while others, though there be a severe cervical catarrh, never pre- 
 sent such changes. 
 
THE PATHOLOGY AND ETIOLOGY OF METRITIS 
 
 131 
 
 Fig. 116. — Ovules of Naboth. Section perpendicular to the surface of the cervix near the outer border, i, 
 Layer of stratified squamous epithelium; 2, mucous membrane; 3, vessels cut longitudinally; 4, vessels cut transversely; 
 5, connective tissue with numerous cellular elements; 6, small centre of accumulation of embryonal cells around a blood- 
 vessel; 7, interior of a cyst (ovule of Naboth) formed from a dilated gland whose lining epithelium is partially de- 
 tached; 8, colloid material poured out into its interior and containing masses of white corpuscles and of epithelial cells. 
 
 ^^^1^ 
 
 Fig. 117. — a, 3, Simple papillary erosion; c, follicular. Slightly enlarged. 
 
132 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 This author, moreover, insists on the anatomical differences of the indi- 
 vidual as regards the adult and the virginal conditions of the cervix and the 
 line of demarcation between the two kinds of epithelium. It would seem, 
 
 ^^ N 
 
 X j2 & 
 
 then, that certain women are especially exposed, by a congenital idiosyn- 
 crasy, to cervical metritis. 
 
 Ulceration [erosion] is a term applied to still another kind of appearance, 
 namely, where the entire circumference of the os, or only a part of it, seems 
 to be depressed over a circumscribed area, presenting a circular edge and a 
 smooth, red surface or one covered with villi. Gynaecologists have always 
 
THE PATHOLOGY AND KTIOLOCV OF METRITIS. 
 
 U3 
 
 regarded this condition as an actual loss of substance with destruction of the 
 tissue, giving it the name of ulceration of the cervix, and some of them sin- 
 gularly magnify its importance. 
 
 
 t % 
 
 
 
 Fig. 119. — Section of the Mucous Membrane of the Vaginal Portion in a Case of Chronic Inflam- 
 mation (Cornil). X 40 diam. e. Papillae covered with a single layer of cylindrical epithelium; l\ epithelium begins 
 to be squamous; d, thickening of the squamous epithelium; ,f, superficial corneous layer; w, mucous membrane 
 much thickened; /, papillse; i, t, connective tissue; 7', vessels. 
 
 Tyler Smith, and more recently Roser, see in this lesion only a kind of 
 hernia of the mucous membrane within the cervi.x, which is comparable, 
 according to Roser, with the similar condition observed in the lids during 
 
 '"^^S^^^'iH^^ 
 
 5.'[i ■' 'A'•*"'"^'>■• 
 
 Fig. 120. — A Portion of the Mucous Membrane op the Previous Figure more Highly Magnified 
 (Cornil). X 200 diam. «, Thickness of the superficial epithelial layer, formed of cylindrical cells much elongated; 
 e, interpapillary depression; /, connective tissue. 
 
 conjunctivitis. This author distinguishes a traumatic or cicatricial ectro- 
 pion, due to laceration of the cervix, and an inflammatory, due to hernia of 
 
134 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 the mucous membrane. Assuredly a certain portion of the intracervical 
 mucous membrane does make such a descent when it is swollen so that it 
 passes out of the external os and appears upon the external surface of the 
 part. It would thus form the greater portion of the exposed ulcerated sur- 
 fa.'ce in deep laceration. But in the majority of cases the external os is 
 closed and does not allow more than a very thin edge of the internal mucous 
 membrane to protrude, and when the ulceration has invaded a large part of 
 the convexity of the cervix we absolutely must recognize that the ulceration 
 has taken place in situ, upon that particular surface. 
 
 What is the exact nature of the alteration ? Does the ancient notion of 
 ulceration correspond exactly to an anatomical reality or only to an appear- 
 
 FiG. 121. — Cervical Metritis, Hypertrophy of the corneous epithelial layer, i, Corneous layer of flat cells; 2, 
 mucous membrane doubled in thickness; 3, papilla; 4, connective tissue rich in cells; 5, embryonal inflammatory centre; 
 6, vessel surrounded by a zone of proliferating cells; 7, large branching capillary; 8, dilated lymph space. 
 
 ance.'' The authoritative work of Ruge and Veit, verified in France by De 
 Sinety, clears up this question. These authors affirm that there is no 
 destruction of tissue, but a new formation ; that while the cylindrical epi- 
 thelium replaces, at the level of the external ulcerated surface, the pavement 
 epithelium, it is the product of the adjacent glands, and the interglandular 
 substance between the depressions assumes the appearance of stakes in a 
 palisade, whence the papillary aspect of the surface. So that when a bilat- 
 eral laceration permits, by this new glandular formation, a large display ex- 
 ternally, the mucosa projects like a lining of crimson velvet in a sleeve. It 
 is certain that laceration forms ulceration, but it is exaggeration to say, with 
 Bouilly, that there is no true ulceration without laceration due to childbirth. 
 At other times the glands become cystic and form little projections on the 
 
THE PATHOLOGY AND ETIOLOGY OF METRITIS. 
 
 135 
 
 bottom of the ulcerated [eroded] surface, which thus has the so-called follic- 
 ular appearance (more evident in section than to direct inspection) (Fig. 
 117, c). These cysts may form a semi-detached mass on the surface of the 
 part, as mucous polypi (Fig. 124). They are small, of a red color, semi- 
 transparent or purplish, hanging by pedicles more or less free in the cavity, 
 and projecting from the external os ; in general resembling the mucous 
 polypi of the nose, only far more vascular. (It is a mistake to describe 
 mucous polypi of the uterus in a separate chapter, since pathologically, 
 clinically, and therapeutically they belong to hemorrhagic metritis.) When 
 
 Fig. 122. — Cervical Metritis. Dilated gland filled with colloid material. X 500. i, Connective Issue with 
 
 altered cells; 2, cylindrical epithelium still adherent to the gland wall; (2 bis.), detached fragment of epithelium; 
 
 3, modification of epithelium, which is proliferating and becoming polyhedral in the deep layer; 4, colloid material 
 surrounding lymphatic elements; 5, small lymph space. 
 
 this cystic transformation of the glands takes place throughout the cervix, 
 it can produce, by penetrating and dilating its substance, an elongation by 
 follicular hypertrophy (Fig. 123, a). Finally, the glandular vegetation and 
 the cystic formation may produce within the cavity of a partly opened cervix 
 small vesicular projections which I compare to an almond (Fig. 123, b). 
 The theory of Ruge and Veit, true in most of these cases, is not, however, 
 so absolute as its authors have declared, Fischel has objected to their 
 exclusiveness and shown that there is at times an actual loss of substance, 
 an ulceration in the proper sense of the word. 
 
 The epithelium in such cases is desquamated, and the mucous mem- 
 
136 
 
 CLINICAL AND OPERATIVE GYNAECOLOGY 
 
 brane is renewed by inflammatory granulations which start from the papillae. 
 Doderlein has verified the reality of these t\yo processes, that of pseudo- 
 ulceration and that of the real form. 
 
 Laceration of the cervix is an accident of common occurrence after par- 
 turition. It has been observed after abortion at the second month, when 
 the elasticity of the foetus would seem to make it unlikely on a priori 
 grounds ; but that the cervix should be lacerated, it is enough that it should 
 be insufliciently softened and dilated. According to Munde's statistics, 
 cervical tears occur most frequently at the first delivery, though it is 
 possible that both cervix and perineum, left intact by former childbirths, 
 should ultimately tear. There may not be the least notch in the cervix of a 
 
 Fig. 123. — Follicular Hypertrophy of the Cervix, a, Anterior lip, internal surface displayed by an incision; ^, 
 
 same, anterior hp, front view. 
 
 woman who has had children, and yet a considerable laceration may occur. 
 The pathological importance of cervical laceration has been brought into 
 relief, and certainly exaggerated, by Emmet, who goes so far as to say : 
 " The half of all uterine affections in women who have had children depend 
 upon laceration of the cervix." 
 
 Fallen estimates the proportionate frequency of the accident as 40 per 
 100; while according to Goodell it is i in 6. Munde, in 2,500 women 
 who had been delivered, found 612 lacerations (25 per cent), but only 280 
 (11.02 per cent) were sufficiently deep to have any pathological importance; 
 the others cicatrized or gave rise to but little complaint. The degrees and 
 varieties of laceration are very variable ; we can distinguish unilateral, bilat- 
 eral, anterior, posterior, and stellate lacerations. The bilateral form is the 
 most frequent ; then comes the unilateral, then the stellate, the multiple, 
 
THE PATHOLOGY AND ETIOLOGY OF METRITIS. 
 
 137 
 
 the posterior, and, finally, at the end of the series, the anterior. The uni- 
 lateral has been most often observed on the left side; due without doubt to 
 the frequency of the left anterior occipito-iliac presentation, the tear being 
 made by the occiput. When the laceration is deep and partly healed over, 
 there is a feeling of a smooth line along the cervix, sloping toward its sur- 
 face; sometimes, in the vaginal cul-de-sac, at the base of the broad ligament, 
 there is felt a small hard nodule, probably due to the same traumatism. 
 
 In the stellate form the clefts are usually less deep. Finally, one ob- 
 tains the impression of a laceration in some cases in which I believe noth- 
 ing of the kind has occurred ; I mean those cases in which the cervix is gap- 
 ing and the finger finds no rent whatever in its circumference. Defenders 
 
 Fig. 124. — Mucous Polypi from the Interior of the Cervix and upon the Surface, from 
 
 Follicular Hypertrophy. 
 
 of the pathogenic influence of lacerations have not been wanting who have 
 seen in such cases a tear in the internal mucous coat — an endotrachelian 
 laceration — which has produced a subinvolution of the part and consequent 
 patency of the cervical canal. According to Munde this variety should be 
 considered as a subinvolution of the cervix with paralysis of its muscular 
 fibres. For ease of description it has been proposed to divide lacerations 
 according to their depth in three degrees; the first, but slightly cleaving 
 the cervix ; the second, dividing it through most of its length ; and the 
 third, which goes down to the vaginal cul-de-sac or even beyond. It is pos- 
 sible for the laceration to be free from any accompanying ulceration, and for 
 its whole surface to be covered with squamous epithelium like the rest of 
 the cervix. This cicatrizing of the torn portion without reunion of the lips 
 
138 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 is particularly observed after surgical division of the cervix followed by vig- 
 orous antisepsis. When it occurs after parturition, we can therefore con- 
 clude that the wound has wholly escaped infection. In the opposite case 
 ulceration is produced; and then, the deeper the laceration and the more 
 the lips are everted the greater is the ectropion. This exposes the mucous 
 membrane to all causes of vaginal irritation, friction, secretions, contact of 
 air, etc., and is doubtless an efficient cause of the morbid processes styled 
 
 
 Fig. 125. — Mlcols PoLvi-f s of the Cekvix. Transverse section perpendicular to the surface; slightly enlarged. 
 I, Layer of squamous epithelium; 2, fibrous tissue with smooth muscle elements; 3, glands more or less dilated, and 
 cystic in some places; 4, colloid contents of the dilated cavities. 
 
 ulceration. The cystic and papilliform changes may then be so far developed 
 and so largely displayed that the everted lips have the appearance of a 
 fungus of malignant character. 
 
 At the same time there are important histological alterations in the torn 
 cervix. In the first place the work of cicatrization itself, and its consequent 
 contraction, may have troublesome results ; it compresses the glands, hasten- 
 ing their cystic degeneration and the hypertrophy of the tissue (cystic hyper- 
 plasia i. This dense cicatricial tissue, by compressing the nerve termina- 
 
THE PATHOLOGY AND ETIOI.OflY OF METRITIS. 
 
 139 
 
 tions, can give rise to various nerve disorders, according t(j lunmet and his 
 disciples. 
 
 It is especially the pressure excited by the superior angle of the lacera- 
 tion, according to this gynaecologist (who has so magnified the importance 
 of this little accidentj — it is in the pressure in the .superior angle, which 
 he calls "the cicatricial plug," that the trouble has its root; and he sees a 
 frequent cause of nervous disease in this, even in cases in which but little 
 complaint is made of the cervical deformity. Doleris follows Emmet, insi.sts 
 upon the cicatricial plug, and attributes part of its formation to a parame- 
 tritis following infection of the tear. 
 
 Fig. 126.— Glandular Polypus. Stroma of fibrous tissue with elastic and smooth muscle fibres; proliferated 
 glands cut in different directions and lined with an epithelium of poorly defined cells, and filled with granular colloid 
 material. 
 
 Another early change in the cervix is the eversion of its lips, caused by 
 traction of the vaginal insertion upon the divided cervix ; this may reach 
 extreme ectropion of the mucous membrane, which becomes more marked as 
 the disease advances. Finally a third result of laceration may be arrest of 
 post-partum involution, or passive congestion, catarrh, etc. 
 
 Pathogeny. — The majority of classic authors describe the different forms 
 of metritis, one after the other, in complete form, and the study of causes is 
 found distributed among many sections, as if each type differed in all parts. 
 It seems to me that there is no interest in following this tradition. While 
 
I40 
 
 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 I have presented the anatomical and pathological studies in one paragraph, I 
 have given in one section all the causes, and so avoid useless repetitions. 
 
 From the point of view of pathogeny one may say that all inflammations 
 of the uterus are due to microbes ; that is, of infectious origin. 
 
 The knowledge of the general bacteriology of woman dates from the 
 work of Hausmann. Many articles have since appeared, thanks to the 
 numerous operations which have been performed upon the uterus and ap- 
 
 
 
 "■ --mm 
 
 Fig. 127. — Partitions of Cystic Cavities ■whose Walls Give Origin to Papillary Elevations. Portion 
 of the preceding figure strongly magnified, i, Fibromuscular tissue; 2, cylindrical non-ciliated epithelium, swollen and 
 with ill-defined cellular outlines; 3, colloid material containing cellular debris; 4, papillae orojecting into the interior of 
 the cyst; 5, point at which the proliferated cells are changed in form. 
 
 pendages. The microbic origin of uterine inflammations has been directly 
 demonstrated, so that there now remains no doubt on the subject. This 
 opinion, now commonly held, was long ago very categorically stated by 
 Schroder. The most recent researches confirm this presumption, which ex- 
 plains without doubt the gonorrhoeal origin. 
 
 The important part played by the gonococcus in the pathogenesis of 
 the genital affections of woman has been shown by Schwarz, Steinschneider, 
 and especially by Bumm and Wertheim. In an important set of statistics 
 
THE PATHOLOGY AND ETIOLOGY OF METRITIS. I4I 
 
 based upon 1,000 patients in A. Martin's service, Witte found 288 cases of 
 blennorrhagia, 65 of which were endometritis and 56 pelveoperitonitis. 
 
 Steinschneider, in his interesting studies on the seat of gonorrhoeal in- 
 
 FiG. 128. — Normal Cervix in Multipara. 
 
 fectioii in females, demonstrated long ago that after the gonococcus had dis- 
 appeared from the urethra it could still be found in the cervix or body of 
 the uterus, as the mucous membrane there is better fitted for its culture 
 
 Fig. 129. — Lacerations of the Cervix. First, second, and third degrees. 
 
 than that of the vagina because of the unfavorable circumstances dependent 
 upon the pavement of squamous epithelium of the latter and the acidity of 
 its secretion, together with the coexistence of the numerous bacteria which 
 dwell normally within the cavity. 
 
142 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 The same direct demonstration is not so easily obtained for the micro- 
 organisms of post-puerperal endometritis. 
 
 Goenner, of Basle, has found in cases of puerperal fever streptococci 
 
 Fig. 130. — Lacerations of the Cervix. Stellate and unilateral. 
 
 which are very easily cultivated. Doderlein has recently collected the lochia 
 of a parturient woman from within the uterus itself. These lochia were 
 examined by the microscope, and by cultures on gelatin and agar-agar. The 
 result was that following normal labor, with a temperature not beyond ^8° 
 C. (98.4° F.), there were no germs ; but, when there was fever, bacilli and 
 cocci were found until the temperature fell, they being then eliminated by 
 the very abundant secretion, especially when it was purulent. The results 
 
 A B 
 
 Fig. 131. — Lacerations ok the Cervix. A^ Submucous laceration producing gaping; B^ follicular and papillary 
 hypertrophy following a laceration and simulating epithelioma. 
 
 of the pathological labor, and also, without doubt, of the consecutive metri- 
 tis, are thus due to the pathogenic influence of the streptococcus pyogenes. 
 Doderlein thought that these germs were carried from the vagina into the 
 uterus by the exploratory finger or instrument. 
 
THE PATHOLOGY AND ETIOLOGY OF METRITLS. I43 
 
 According to Doleris, Pasteur was the first to demonstrate by the study 
 of the lochia of parturient women that those of healthy women are germ- 
 free, though bacteria swarm in the discharges of those who are sick. 
 
 Straus and Sanchez Toledo have published confirmatory experiments, 
 but their attempts to infect the uteri of rabbits with septic lochia have 
 failed, because of the different form of placenta and the absence in these 
 animals of a decidua. 
 
 Peraire observed, and was able to cultivate, both bacteria and cocci found 
 in the secretions of metritis ; and the inoculation of rabbits with these pro- 
 duced both fever and vaginitis. 
 
 It is, then, well established that in septic metritis, or, better, in the in- 
 fection of the uterine mucous membrane following labor or abortion, the 
 cause of the accident is a proliferation of the pathogenic microbes, and the 
 actual metritis which persists after the puerperal state is due to the persist- 
 ence of these germs. 
 
 A much-discussed question is. What is the point of invasion of these 
 microbes ? Do they always come from the exterior, or may they come from 
 within ? Are they, in other words, a hetero-infection or an auto-infection ? 
 I will not enter into the long discussions recently provoked by this subject ; 
 it is enough to give briefly the conclusions which seem to me to be trust- 
 worthy. 
 
 The majority of microbes, even those which invade the internal genital 
 organs, are normally found in the vagina. Winter has found twenty-seven 
 different species in the genital canal. The greater number were not injuri- 
 ous to the woman or to animals into which they were inoculated. Witte, 
 however, claims to have isolated five species, not before described, which 
 were distinguished by their fatal action upon white mice ; he has named 
 them collectively bacillus murisepticus. 
 
 The presence of these microbes in the new-born several hours after birth 
 has been proven. Their development depends upon the medium in which 
 they are placed. Doderlein has taught that in a vagina whose secretion 
 has the normal acid reaction no pyogenic bacteria are found, but only inof- 
 fensive micro-organisms. In vaginae with an alkaline reaction, on the con- 
 trary, streptococci and staphylococci occur in the proportion of 9.2 in 100. 
 The ordinary microbe of the normal vagina is a rod-shaped bacillus 
 whose function, according to Doderlein and Stroganoff, is the secretion of 
 lactic acid. It is to this acid that the transformation of alkaline pathologi- 
 cal vaginal secretions to a neutral and then acid reaction is due, as the quan- 
 tity of normal vaginal bacteria increases and they outnumber the pathogenic 
 micro-organisms. The acidity of the vaginal secretion has not only a favor- 
 able influence in causing the disappearance of the pathogenic microbes, but 
 greatly diminishes the virulence of bacteria carried from without into the 
 vagina. 
 
 Witte has given the explanation of these facts observed by Doderlein. 
 
144 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 According to his researches, the streptococcus cannot develop in an acid 
 medium containing 0.07 per cent of lactic acid; the various staphylococci 
 (aureus, citreus, albus) die in a medium whose acidity exceeds 0.5 percent. 
 For this reason, in order that the streptococcus or staphylococcus may de- 
 velop in the vagina, it is necessary that the normal coefficient of acidity of 
 this canal should be greatly diminished, and even then these microbes find a 
 sufficiently acid medium to attenuate their virulence to a great extent. 
 
 New researches upon the microbic flora of the utero-vaginal canal have 
 recently been made by Kronig and Menge, by the former in pregnant women, 
 by the latter in those not pregnant. Their studies demonstrate that the 
 vaginal secretions possess bactericidal properties. 
 
 Kronig inoculated the bacillus pyocyaneus in 20 pregnant women, whose 
 vaginal secretions contained vaginal bacilli in 9 cases, short bacilli in 4, 
 and micrococci in 7. In the first 9, no bacilli pyocyanei were found after 
 10 to 24 hours, or an average of I4;^2 hours; in the 4 women of the second 
 class the bacillus pyocyaneus was absent from the vaginal secretions after 
 16 hours, and had disappeared after an average time of 20 hours in the 
 third group. Similar experiments with the staphylococcus and the strepto- 
 coccus have given analogous results ; the staphylococcus had disappeared 
 after 11 to 14 hours, the streptococcus after 6 hours on the average. 
 
 Menge has made like experiments upon non- pregnant women with the 
 same results. He inoculated 35 women in the vagina, 23 times with pure 
 cultures of the bacillus pyocyaneus, 30 times with pure cultures of staphylo- 
 coccus aureus, 27 times with streptococcus cultures. After a longer or 
 shorter interval the micro-organisms which had been introduced were en- 
 tirely absent ; the auto-asepticization of the vagina was complete in from 
 2^ to 70 hours after inoculation. 
 
 Menge has also made a bacteriological examination of the vaginal secre- 
 tions of 50 healthy women : in 44 cases the cultures remained sterile, in 5 
 non-pathogenic micrococci were found, in i the streptococcus. 
 
 Hetero-infection, or infection by contact, or exogenous infection, is by 
 far the more frequent ; it is indeed the rule. Leopold found an enormous 
 diminution of the death-rate in his service after he had forbidden the exam- 
 ination of pregnant women ; that is, in spite of all antiseptic precautions the 
 exploratory finger may be the vehicle for germs. In a normal labor the 
 vagina should be considered as a.septic. There are no germs, as I have 
 stated, in the lochia of a normal labor; they are not to be found in the 
 upper portion of the vagina immediately after parturition according to Ott ; 
 and he attributes this fact to the cleansing action of the waters and the fric- 
 tion of the foetal body upon the vaginal walls. Thus, if everything is favor- 
 able, with no retention of foetal debris, with no accumulation of clots from 
 atony of the uterus, and with no premature rupture of the membranes pre- 
 venting the physiological cleansing of the genital canal, there is no chance 
 whatever of infection. This is the explanation of the happy issue of so 
 
THE PATHOLOGY AND ETIOLOGY OF METRITIS. 145 
 
 many labors where no precautions have been taken, for Nature, we are ac- 
 customed to say, has provided for her own asepsis. We must, therefore, 
 beware of useless interference or manipulation in simple cases, and abstain 
 from meddling with antiseptic injections which may be useless, and there- 
 fore dangerous. 
 
 There is nothing specific in a bacterial infection of the uterus. It is an 
 error long since laid aside to think that each special infection corresponds 
 to a special pathogenic element. It is known perfectly to-day that but one 
 and the same microbe, the streptococcus pyogenes, causes all the septic 
 lesions of parturition, and is also produced in erysipelas and furunculosis. 
 
 Puerperal infection of the uterus, the starting-point of consecutive metri- 
 tis, may then be the product of a pathogenic germ coming from various 
 sources. It is demonstrated to-day, not only by clinical experience, but also 
 by bacteriological observation, that the germs which cause surgical infec- 
 tions, boils, and erysipelas may infect the parturient woman, and be found 
 then in her genital secretions. While I was interne at the hospital during 
 Broca's service I had many opportunities to see small epidemics of erysip- 
 elas in the surgical wards following puerperal fever in the obstetrical wards 
 near by. This mixed infection has been made the subject, during the last 
 years, of very interesting works from the pathogenic point of view. Pfan- 
 nenstiel studied a little epidemic in the Breslau Frauenklinic, following a 
 general attack of tonsillar angina, and perfectly demonstrated their bacterial 
 relationship. The streptococci of erysipelas and of suppuration are at 
 present considered identical. 
 
 Winter's researches on this subject are very valuable, because of the 
 ability of the author and the rich material at his disposal, thanks to the 
 numerous hysterectomies and salpingotomies of the Berlin clinic. This 
 fresh material removed many of the causes of error of former researches, 
 and led him to the conclusion that in the genital canal of the female there 
 is a zone rich in micro-organisms which I call "the dangerous zone." 
 
 The opinion of Winter that even in virgins bacteria are always found in 
 the cervical canal has recently been strongly opposed by Stroganoff and by 
 Witte. Stroganoff has found bacteria only in women who had submitted 
 to some gynaecological intervention. Witte also determined that of eight 
 women in whom he found microbes in the uterus, seven had previously un- 
 dergone a local examination. It should not, therefore, be said, as Winter 
 and so many other authors hold, that the normal limit of the bacterial region 
 of the cervix is the os internum. This limit is the os externum. Not only 
 does the vagina contain an abundance of germs, as Hausmann, Kiistner, 
 Lomer, and Bumm have stated, but in half the cases, according to Winter, 
 pathogenic organisms are found ; three species of staphylococci (staphylo- 
 coccus pyogenes albus, aureus, citreus) and the streptococcus. The normal 
 uterine cavity contains no microbes. This is due, according to Winter, to 
 the fact that it lacks liquid necessary for their development; also, when once 
 10 
 
146 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 introduced into the cavity of the uterus, the micro-organisms become fixed 
 upon the mucous membrane as on a solid culture medium, and are probably 
 destroyed by phagocytosis. The bacteria found in the uterus either enter 
 from without, being introduced by copulation or by gynaecological manoeu- 
 vres, or come from an endogenous infection. Witte has examined fifteen 
 diseased uteri removed by hysterectomy, and in thirteen cases proved the 
 presence in their cavities of pathogenic organisms (streptococci and staphy- 
 lococci), either alone or associated with other bacteria; in two cases the 
 micro-organisms had entered the tubes. This is of the utmost importance, 
 for it proves the possibility of self-infection. It would not be easy to un- 
 derstand why such infection does not occur more often, in every labor ni 
 fact, during the period of rapid multiplication of the germs, but that Winter 
 has shown by his inoculations with cultures obtained at that time that the 
 staphylococci have lost their virulence, being domesticated, as it were, in 
 the genital passages. We have thus an example of spontaneous attenuation 
 which is equally remarkable and fortunate. But it is quite probable that 
 this virulence might be rapidly regained under favoring circumstances, e.g., 
 the presence of organic debris. Thus we can understand why abortions are 
 so dangerous from bits of retained foetal structure, the uterine infection ad- 
 vancing step by step. It is equally plain how great is the risk of making 
 uterine exploration without previous cleansing of the genital canal ; even 
 though the finger and the sound may be rendered aseptic, they may still be- 
 come the vehicles of infection, for they may transport germs from the cervix 
 into the body of the uterus. It is at the level of the internal os that the 
 dangerous zone is found. 
 
 Certain mechanical conditions may aid in producing uterine infection. 
 Thus Schultze thinks that in women with a patulous vulva, as is the case in 
 many multiparae even without perineal rupture, a slight leucorrhoeal discharge 
 may carry atmospheric germs ; and in a similar way the menstrual discharge 
 may act in women with a closed vulva. Hence the necessity, according to 
 Schultze, of protecting the part by a pad which will filter the air. 
 
 Other germs than those usually found in the vagina or cervix may be 
 carried by the sound into the uterine cavity. In large towns we live in the 
 midst of bacteria. Eiselsberg has found staphylococcus pyogenes aureus 
 in the wards of a hospital ; Fiirbringer demonstrated them in matter scraped 
 from the nails ; Passet found them in dish-water, and the same author en- 
 countered staphylococcus pyogenes albus in some slightly damaged beef, 
 etc. Biondi found the same germ in normal saliva. These observations 
 prove the many chances of infection which would indeed be almost inevita- 
 ble but for the vital force of living tissue which fights against it ; whatever 
 lessens this force, therefore, opens the door to infection. 
 
 Some of the most curious examples of such action is found in what 
 Verneuil calls latent microbism, for we do not have to do with an extin- 
 guished danger, but with an infection which does not yet exist, depending 
 
THE PATHOLOGY AXD ETIOLOGY OF METRITIS. 1 47 
 
 for its development upon a transformation of its medium from physiological 
 to pathological conditions. Auto-infection, or, as Fehling styles it, endog- 
 enous infection, is thus reduced to a cjuestion of culture media, producing 
 virulence in an organism before inactive. Thus Chauveau restored the 
 powers of charbon (anthrax) bacilli by cultivating them in rarefied air in 
 blood plasma and bouillon. If this faculty of increasing the noxious powers 
 of germs residing in the female genitalia belongs to organic debris, may it 
 not be called forth by other means .' Could not general debility of all the 
 tissues, which reduces cellular vitality, or traumatism, with its inhibitory 
 action (Brown-Sequard), raise the barrier of phagocytism which keeps all 
 germs out of the body or renders them inoffensive ? Perhaps we may thus 
 explain the effect of certain diseases, as eruptive fevers, and also of venereal 
 excess. 
 
 Gottschalk was the first to report a case of hemorrhagic metritis occur- 
 ring with influenza, and two cases of non-suppurative parametritis following 
 the same disease. Goldberg has observed the same inflammatory attack in 
 a woman affected with scorbutus. I have seen four cases in which acute 
 attacks of suppurative perimetro-salpingitis occurred, under the influence of 
 an attack of grippe, in women whose appendages presented chronic lesions. 
 
 Moreover, it has been shown that the presence of one germ aids the 
 development of another species. Thus women with gonorrhoeal metritis are 
 easily infected with septic material more or less attenuated, as staphylo- 
 cocci and streptococci or even tubercle bacilli. Such may be termed mixed 
 infection. Thus the lesions of pneumonia prepare the lung for the inva- 
 sion of the tubercle bacillus. 
 
 Etiologv. — Passing now to the direct causes of metritis we find them as- 
 sociated with ( I St) menstruation; (2d) copulation ; (3d) parturition; (4th) 
 traumatism. 
 
 1. Menstruation. — The establishment of the catamenia maybe the signal 
 for metritis to manifest itself, because of the intense congestion of a pecu- 
 liarly vulnerable organ. There is generally present in such a case some 
 malformation of the uterus which induces venous stasis ; incomplete devel- 
 opment, congenital anteflexion, a conical cervix, stenosis of the os, exposure 
 to cold, and masturbation may be some of these primary or secondary causes. 
 To this virginal metritis, there is, at the other pole of the woman's genital 
 career, a corresponding metritis of the menopause, for at that time again 
 there may be a predisposing active congestion. 
 
 Between these two extremes every menstrual period favors the develop- 
 ment of metritis, and every extra fatigue or exposure to cold may bring it 
 on if the uterus is malposed, if the cervix is contracted, or if there is a deep 
 laceration from previous labor. 
 
 2. r^/'7//«//^;^. —Excessive coitus, whether during menstruation or coin- 
 cident with great fatigue, may provoke uterine inflammation independently 
 of all contamination ; but far more often it is a gonorrhceal infection, m.ore 
 
148 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 or less disregarded, which is so efficient a cause of metritis and which plays 
 this role in the case of newly married women. Husbands who consider 
 themselves cured and pay no attention to a trifling urethral discharge may 
 thus infect the urethra, the vagina, the cervical and uterine cavities, and the 
 tubes of the young wife. 
 
 Such a gonorrhoeal infection may remain a long time latent within the 
 cervix ; then under the irritation of a rough examination, or after abortion 
 or labor, the infection gains entrance to the body of the uterus. Noeggerath 
 asserts that in women with gonorrhoea abortion and labor are followed by 
 metritis and perimetritis as often as seventy-five per cent ; substituting sal- 
 pingitis for perimetritis, the statement is not exaggerated. It is doubtless 
 to this cause, also, rather than to the traumatism of too frequent coitus, that 
 we must refer the metritis of prostitutes. Abortions are frequent and un- 
 heeded among women who are beginning a debauched life, and later the 
 inflammation of the uterus rises high enough to involve the tubes, obliterat- 
 ing them and causing sterility. 
 
 3. Parturition. — This is by far the most frequent cause. Normal labor, 
 spontaneous and induced abortion, leave the uterus in a peculiar condition 
 of hyperplasia and congestion which demand special hygienic conditions for 
 their gradual removal ; but these conditions are often neglected, from care- 
 lessness among the well-to-do, from necessity among the laboring classes. 
 It is not so very long ago that celebrated obstetricians considered fifteen to 
 twenty days' rest sufficient. Guerin justly opposed this fixed rule, advising 
 that the patient should not be permitted to leave her bed till a week after 
 the first menstrual period ; for only by that time has the uterus regained its 
 normal size. Without such care we see a post-puerperal engorgement in- 
 tervening, which is Chomel's "post-puerperal metritis" and Simpson's "ar- 
 rested involution" ; the chronic metritis, uterine infarction, chronic and 
 painful metritis of other authors. 
 
 When parturition has been abnormal, by reason of difficult delivery, and 
 when pieces of placental detritus have remained a long time in the uterine 
 cavity, then the organ is specially liable to inflammation. At such a time 
 there can be no doubt that we have a local infection, and if a rigorous anti- 
 septic treatment is not at once begun, there is reason to fear that the disease 
 may persist in chronic form. The same is true of abortion, where, as is so 
 frequently seen, small portions of the decidua graft themselves upon the 
 mucous membrane and become centres of infection for it. 
 
 One condition in particular has recently been insisted upon as of great 
 influence in establishing and prolonging metritis, and that is cervical lacera- 
 tion, as Emmet styles it. This American gynaecologist was the first to rec- 
 ognize its importance (in 1869), though Bennet had dimly foreseen it some 
 time before. But in America there has been a disposition to exaggerate the 
 influence of this lesion. 
 
 It seems to me that the role of laceration has been alternately too much 
 
THE PATHOLOGY AND ETIOLOGY OF METRITIS. 149 
 
 exalted and belittled. It is false to suppose that no other cause for uterine 
 malpositions exists, or to attribute all inflammations of the organ and its 
 adnexa to laceration alone. At present it is generally agreed that uterine 
 displacements may give rise to nervous phenomena, but they cannot be said 
 to cause metritis, however much they predispose thereto. This then is the 
 limit of the influence of laceration — it may cause morbid reflexes, and pre- 
 dispose to cervical catarrh and prolong it. But there are many cases of 
 retroversion without symptoms, and as many of laceration without metritis ; 
 at the same time there are lacerations which extend to the cellular tissue of 
 the cul-de-sac, and bilateral forms with marked ectropion, which have a 
 pathological importance that cannot be neglected. 
 
 Traumatism. — Chronic contusions, produced by a pessary that is too 
 large or badly placed, so that it exerts strong pressure upon the uterus, may 
 give rise to acute symptoms of metritis which disappear as soon as the in- 
 strument is removed ; and of all pessaries, those with an intra-uterine stem 
 are the most dangerous, unless carefully watched by the surgeon. 
 
 Finally, any operation whatever within the genital canal may be the 
 starting-point of metritis (with or without parametritis and perimetritis) if 
 strict antisepsis has not been maintained. Such accidents, so frequent that 
 gynaecologists were justly timorous, exist no longer in the practice of those 
 who observe the rules — which might almost be called sacred — of modern 
 surgery ; for to-day even if inflammation do occur after operations within 
 the uterine cavity, it may, to a certain point, be kept from becoming septic, 
 and permanent results prevented. 
 
 Very hot or cold vaginal injections have been accused of causing metri- 
 tis ; for my part, I lay but little stress upon them as a cause; an injection 
 may do harm if the tube is ill-fitting or if force enough be used to injure 
 the cervix. In prolapse, for instance, the injection tube has been passed 
 into the cervix and serious accidents have followed ; but this has nothing to 
 do with metritis. 
 
 Other Causes. — Ought we to regard the exanthemata as a cause of metritis, 
 as certain authors have done .-* It seems to me that new observations are 
 needed upon this point. It must, however, be acknowledged that the recent 
 work of Massin is of a nature to awaken serious attention. We cannot 
 deny that the female genital tract may be more exposed to disease after a 
 general affection which has enfeebled the entire organism. Certain mala- 
 dies (icterus) and some poisons (phosphorus) may produce an acute fatty 
 degeneration of the uterus ; but that is a lesion, not a disease, and it is a 
 mistake to insist upon it in connection with metritis. 
 
 The influence of diathesis has been very much exaggerated. Martineau 
 has even classified metritis into constitutional and traumatic. According to 
 him, constitutional metritis is partly protopathic and partly deuteropathic, 
 arising from scrofula, arthritis, herpes, chlorosis, syphilis, or tuberculosis. 
 
 I consider it a misuse of language to describe a scrofulous or herpetic 
 
150 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 metritis, as if they possessed clear-cut boundaries. I willingly grant that 
 general conditions and place involved play a great role, if not in the produc- 
 tion, at least in the permanence of local inflammation, particularly of metri- 
 tis ; and that we must carefully examine the general state of a patient before 
 attempting treatment. But this is all that I can concede to diathesis. 
 
CHAPTER VI. 
 
 SYMPTOMS, COURSE, AND DIAGNOSIS OF METRITIS. 
 
 After studying the diseases of the internal genital organs of the female, 
 it is impossible not to be struck by the similarity of the rational signs 
 obtained by questioning the patient. The symptom complex differs but 
 little whether the case is one of chronic metritis, catarrhal endometritis, 
 fibroma, cancer, or salpingitis. Of course I do not go so far as to say that 
 they are identical, for if the questions are sufficiently precise, sensible dif- 
 ferences are found in the intensity of special symptoms. But although a 
 certain part of the picture may be particularly clear — as the hemorrhage in 
 fibroma, leucorrhcea in cancer, nervous troubles in displacements or disease 
 of the adnexa — it is not the less true that the chief features are the same ; 
 different states of the same plate, often retouched. 
 
 By the term " uterine syndroma" I would express the common sympto- 
 matic basis which I have found — as Beau grouped in his asystolic syndroma 
 all the phenomena of cardiac disease when the heart arrives at its period of 
 fatigue, whether the lesion be mitral, tricuspid, or aortic. I think I have 
 found the same interest in the clinical synthesis which I propose ; for I be- 
 lieve that with this sketch it will be enough for the special cases to fill in 
 the necessary touches, so avoiding useless repetitions. 
 
 This study of the uterine syndroma naturally has its place here, as it so 
 closely corresponds to the rational signs of metritis. The principal features 
 of the uterine syndroma are : 
 
 Pain, leucorrhcea, dysmenorrhoea, metrorrhagia, symptoms from neigh- 
 boring organs (bladder, rectum), symptoms from distant organs (digestive 
 canal, nerves, etc.). 
 
 The pain is spontaneous ; its seat is in the smaller pelvic cavity, but its 
 focus is not always at the same level as the uterus ; it is not in the hypogas- 
 tric region that the patient suffers the most, but frequently in the iliac 
 fossa, especially the left near the ovary. To explain this fact it seems rea- 
 sonable to admit the presence of a slight catarrhal salpingitis with uterine 
 inflammation. The tubes are simply prolongations of the uterus ; anatomi- 
 cally and pathologically the two organs are the same. The term metritis 
 should include almost always metrosalpingitis, with unequal distribution of 
 the inflammation ; that of the uterus predominating, that of the tube being 
 not less real ; as to the predominance of the left side, it is as difficult to 
 explain as epididymitis on the same side. Another focus of pain is found 
 in the lumbar region. 
 
152 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 This pain is increased by all fatigue, such as the jolting of a carriage; 
 but such mechanical influences may not produce an immediate increase ; the 
 exacerbation may come on only after the lapse of some time. Riding in the 
 horse-cars is usually well borne, but railroad travelling is injurious be- 
 cause of the peculiar shaking endured. The pain is dull, persistent, giving 
 a feeling of weight and fulness in the perineum and lower pelvis ; seeming 
 to the patient as if there were a foreign body there, tending to escape — that 
 is, she feels her own uterus. The bent position in walking in acute cases 
 is characteristic; instead of seating herself hurriedly, the patient does it 
 with great care, helping herself with the support of a piece of furniture near 
 by, like the arm of a sofa, lest she reawaken the slumbering pain. The 
 distress is increased by pressure, especially in bimanual palpation; but one 
 can assure himself that it is not so much the direct pressure upon the cervix 
 which is painful, as the part is not sensitive (except in lumbo-abdominal 
 neuralgia), but the transmitted shock to the uterus itself. Gosselin has long- 
 insisted upon this distinction. 
 
 Lcucorrhcea. — This is a constant symptom. It may be more or less 
 masked by the blood or pus present in the discharges, but it is always pres- 
 ent ; singly or in combination. 
 
 Leucorrhoea (whites, etc.) is a phenomenon so important in g3maecology 
 that some of the older authors made it the principal disease of the uterus 
 and grouped all the others about it. Even Courty makes leucorrhoea an 
 entity, an idiopathic affection, in certain cases. 
 
 Leucorrhoea is a morbid alteration and exaggeration of the physiological 
 uterine and vaginal secretions. In a state of health these parts secrete in 
 small quantity a mucous liquid which always contains a few leucocytes, due 
 to the destruction of the local epithelium. As soon as this has become 
 abundant and purulent, it is morbid and constitutes a leucorrhoea. 
 
 This may be from two sources — the uterus or the vagina. 
 
 Vaginal leucorrhoea may often be found alone; it maybe a discharge 
 of very thin fluid of a milky appearance, which does not stain the linen 
 much, or it may be charged with pus and be of a greenish-yellow color ; 
 its reaction is acid. 
 
 Leucorrhoea from the body of the uterus is of a somewhat viscid nature ; 
 that from the cervix is jelly-like and in the normal state is transparent, 
 like the unboiled white of &%g, staining the linen strongly; in disease it is 
 of a greenish-yellow color. Its reaction is alkaline. 
 
 O. Klistner has made precise researches upon the uterine secretion, both 
 normal and diseased. He introduced glass tubes into the uterus and then care- 
 fully closed the external os with collodion and diachylon. In this way he 
 examined six women who were free from uterine catarrh, and found that 
 the secretion of the uterine neck and body had the characters I have indi- 
 cated. Afterward he examined women with uterine catarrh, with or without 
 purulence, and demonstrated that most often the inflammation was present 
 
SYMPTOMS, COURSE, AND DIAGNOSIS OF METRITIS. 1 53 
 
 in both cervix and body ; and that isolated catarrh of the cervix was more 
 frequent than isolated catarrh of the body of the organ. In all his cases 
 Kiistner, by the microscope, demonstrated the presence of micro-organisms 
 in great quantity, having for the most part an o\-al form, and presenting four 
 or five distinct types. The recent researches of Winter, as stated above, 
 show that these germs are identical in form with pathogenic varieties. 
 
 The leucorrhoeal secretion is seldom voided by steady flow, not that its 
 production is not constant, but that it accumulates in the vagina and escapes 
 a little at a time. In some cases there appear to be secretory crises, when 
 a great quantity of fluid is discharged all at once after a strong pain ; this 
 suggests the intermitting discharge of a dropsical tube (hydrops tubse pro- 
 fluens). But I have observed in many cases that this flow by jets may be 
 present where there is no tubal collection ; properly speaking, it is a phe- 
 nomenon of reflex pathological hypersecretion. 
 
 Certain authors have sought for a method of diagnosis between leucor- 
 rhoea of the vagina and that from the uterus. Schultze has proposed to in- 
 troduce a tampon of cotton into the vagina and leave it in contact with the 
 cervix during twenty-four hours; then, on removing it, one can judge from 
 the quality of the absorbed fluid whether it is from the body or the cervix. 
 
 Leucorrhoea may depend simply on a general debilitated condition, as 
 anjemia, chlorosis, etc. This symptomatic form is so frequent that Marc 
 d'Espine has claimed to find it in two-thirds of all women. Many work- 
 women in Paris have a leucorrhoeal discharge, and explain it by the fact that 
 they are accustomed to drink cafc-an-Iait, and there are physicians who are 
 able to gravely accept this grotesque explanation. Perhaps it is true that 
 because they are able to take no better nourishment, certain women have 
 the whites. 
 
 MctrorrJiagia, Dysmcnoi'rJioea. — Menstrual troubles may occur with uter- 
 ine disease, but it must not be supposed that they are constant. Dysmenor- 
 rhoea, or painful menstruation, is often observed in metritis from the same 
 mechanical obstacle to the flow which induces the inflammation (flexion, 
 narrowness of the cervix, etc.). Amenorrhoea is chiefly due to anaemia; for 
 though metritis which has lasted a long time may debilitate the patient, 
 still its influence is indirect. 
 
 Metrorrhagia, on the contrary, is directly dependent on the uterine in- 
 flammation, and is most often seen when the mucous membrane of the body 
 is affected in interstitial metritis (either primarily or following fibroma and 
 carcinoma), the loss occurring during the regular periods or at other times. 
 In the first case we speak of it as menorrhagia, in the second as metror- 
 rhagia. 
 
 Most of the uterine diseases are an obstacle to conception ; but the ste- 
 rility is not absolute, for pregnancy may occur with cancer and fibroma, and 
 the same is true of metritis. But abortion is frequent in these diseases. 
 
 Symptoms from Adjacent Organs and Reflexes. — Apart from pressure 
 
154 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 effects, which do not enter into this general description, or properly belong 
 to metritis, there are always symptoms from adjacent organs in all affections 
 of the uterus. Patients complain of pain in urination, frequent micturition, 
 or it may be of vesical tenesmus. Every disease of the uterus affects the 
 bladder more or less, and yet the patient may not call the attention of the 
 physician to the vesical disturbance. When it is necessary to use a cathe- 
 ter, cystitis may follow if antiseptic precautions are not observed. 
 
 Since patients av'oid going to the water-closet, on account of the efforts 
 involved and consequent pressure on the uterus, they defecate as little as 
 possible and become habitually constipated. 
 
 Uterine Dyspepsia. — There is no function upon which uterine disease 
 reflects more constantly than on the digestive, and ignorance of this fact 
 may cause grave errors of diagnosis. Such a dyspepsia is explained by 
 reflex action from the nervous system ; to understand it, the peculiar rich- 
 ness of the sympathetic innervation of the uterus and stomach need only be 
 recalled to mind. Dilatation of the stomach is very common in metritis of 
 long duration, with all its train of symptoms so well described by Bouchard 
 and his pupils. The subject deserves renewed study, for dilatation from uter- 
 ine cause has not as yet been thoroughly described ; I have already collected 
 a number of observ^ations upon it. But to dyspepsia, or inactive digestion, 
 the attention of gynaecologists has for a long time been directed, though 
 their descriptions are but brief; Bennet and Courty have mentioned it 
 without insisting upon it. More recently important memoirs have appeared 
 upon the subject. These patients suffer from loss of appetite, nausea, and 
 a peculiar form of flatulence, which occurs as a chronic tympanites, so that 
 the abdomen enlarges till the end of the disease, however much the patient 
 may have lost flesh. This meteorism is very troublesome and interferes 
 with abdominal palpation and bimanual exploration. 
 
 Respiratory Reflexes, Uterine CougJi. — Patients with uterine disease very 
 frequently have a dry cough, occurring singly or five at a time, even though 
 there may be no trace of disease in the respiratory tract and the hysterical 
 element can be eliminated. It is generally a small choking cough, but may 
 be so metallic and sonorous that both the patient and her friends are 
 alarmed. Aran has described this briefly; one of my pupils has devoted to 
 it a more complete study. Its peculiarity is that there is no auscultatory 
 symptom, that it disappears with the uterine lesion — displacement, metritis, 
 etc. 
 
 Symptoms Referable to the Central and Peripheral 
 Nervous System. 
 
 Neuroses and Neitralgias of Genital Origin. — We can explain the pathog- 
 eny of these reflexes by the richness of the innervation of the genital organs, 
 which are supplied from the great sympathetic through the hypogastric 
 olexus, and from the cord through the internal pudic (Fig. 132). Neuralgia 
 
SYMPTOMS, COURSE, AND DIAGNOSIS OF METRITIS. 
 
 '55 
 
 is very common. Intercostal neuralgia is so constant that Bassereau 
 claimed that it was always connected with metritis. We find also facial 
 neuralgia, and lumbo-abdominal with radiation of the pain along the cuta- 
 neous femoral branches, particularly down the left thigh. 
 
 Simpson and Scanzoni have insisted upon sacral neuralgia, which they 
 have made the subject of monographs under the name of coccygodynia. An 
 attempt has been made to refer peripheral neuroses to the sensory nerves. 
 Clifton. S. Morse describes a form of asthenopia dependent upon uterine 
 disease. 
 
 Fig. 132. — Genital Nerves of the Infant. Risrht side, a. Right coeliac ganglion; ^, first, second, and third 
 lumbar ganglia; c, sacral ganglion; d, cer\'ical ganglion; t', renal ganglia; _/", hypogastric plexus. 
 
 Lastly I may mention cardiac palpitation, both reflex and due to anaemia. 
 
 I will not insist upon the general nervous troubles, which are of great 
 diversity. The nervous symptoms cover all the forms of hysteria ; not that 
 we have a veritable hysteria, though it may rarely be present, but that alter- 
 ations of the nervous system, in women, almost always take this form, 
 especially where the uterus is the point of departure. 
 
 It is certain also that any genital disease in a woman predisposed to 
 hysteria will produce a development of that neurosis ; thus we can explain 
 both the intensity of the symptoms caused by slight ailments, like Emmet's 
 "cicatricial plug," and the marvellous success of certain operations. How 
 can we defend the dia£:nosis of hysteria when we read observations like that 
 
156 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 of Munde, of an attack of sciatica or catalepsy produced simply by pressure 
 upon the cicatrix of a laceration, all such attacks disappearing after opera- 
 tion ? One might almost believe in a special pathology for the hysterical, 
 and special chances of successful treatment, and expect unhoped-for results 
 with means which remain useless where the nervous system is not hyper- 
 sensitive. 
 
 There is another consequence of uterine disease which is often seen with 
 metritis, displacement, etc., which may last through many years. This is a 
 peculiar asthenia, an excessive depression of the nervous system which ren- 
 ders the patient incapable of all effort, although there is no loss of muscular 
 strength or other deviation from health corresponding to this languor. This 
 must certainly be attributed to morbid reflex action. 
 
 Finally we shall see, in studying displacements of the uterus and dis- 
 eases of the adnexa, that there are grave nervous troubles present at times, 
 like chorea, epilepsy, etc., which depend directly upon them and which are 
 curable at the same time. 
 
 General Condition.— The pain which prevents exercise, the dyspepsia 
 which impairs alimentation, the condition of the nervous system which has 
 a depressing influence upon nutrition, all combine to alter the patient's gen- 
 eral health rapidly, to give her an habitual chloro-anaemic color, a muddy 
 complexion, dark circles under the eyes, and the air of suffering, which to- 
 gether complete the picture of the facies uterina. 
 
 It is this combination of rational signs which makes up the syndroma 
 common to all diseases of the internal genital organs, but which is most 
 marked in cases of metritis. The study of the physical signs, revealed by 
 direct examination, permits now the precise statement of the characters 
 proper to uterine inflammation. 
 
 Physical Signs. — By touch, which should always be practised with bi- 
 manual palpation, we find the cervix increased in volume and altered in con- 
 sistence, except in those rare cases in which the body alone is involved. It 
 is larger and more open than normal, with a velvety or greasy feel when its 
 surface is ulcerated ; and in places there is the sensation of a number of 
 little hard grains, which are glandular cysts. The finger discovers, more- 
 over, the lacerations upon which I have dwelt in the section on pathology. 
 If this examination is not painful, the ballottement of the uterus, performed 
 by giving a rocking motion to the cervix, hurts severely, and Gosselin lays 
 much stress upon the clinical importance of the fact. Touch also informs 
 us whether the cul-de-sac is free; the uterus being then perfectly movable. 
 
 The first examination with the speculum should be made by preference 
 with Brewer's bivalve or with two single blades of Simon, in the lithotomy 
 position. It discloses a very large cervix, of altered form, which at times 
 fills the depths of the vagina : in nulliparae, instead of being conical, as it 
 should be, it is cylindrical ; in a woman who has had children, it is often 
 Svvollen, and if there has been a laceration, it may be peculiarly figured and 
 
SYMPTOMS, COURSE, AND DIAGNOSIS OF METRITIS. 1 57 
 
 of various forms. The color varies between bright red and violet. A dis- 
 charge of viscid mucus, at times very purulent or mixed with bloody threads^ 
 escapes from the cervix ; by the repeated gentle pressure of the speculum it 
 seems to be milked from the organ. The surface of the part presents an 
 eroded aspect, the apparent loss of substance being at times small and dis- 
 seminated over the surface (the folliculitis of authors), resembling a slight 
 vesication (erosion), or deep, smooth and polished, or granular (ulceration) ; 
 at times yellowish grains indicate the superficial cysts called Naboth's 
 ovules. Lacerations are often less perceptible to the sight at the bottom of 
 the speculum than to the touch, and the ulcerated surface is far less dis- 
 played by a cylindrical speculum than by a bivalve. 
 
 To separate the lips and see into the cavity of the cervix, one can use 
 Courty's forceps or two tenacula. Rectal is a useful addition to vaginal 
 touch, but it may be negative in simple metritis. 
 
 The use of the uterine sound demonstrates in most cases an increase in 
 the depth of the uterine cavity which may reach as high as 8 cm. (3^' in.). 
 When the sound passes deeply in, there may be another explanation for it 
 than metritis. When the uterus is displaced to one side (which often hap- 
 pens in deep laceration, where it is bent toward the torn side), the sound 
 does not measure the exact height of the organ, but that of a line obliquely 
 directed toward the cornu opposite the side to which the uterus is bent — 
 thus there is an apparent elongation which does not really exist. To rectify 
 the error when there is reason to suspect its presence, the uterus can be 
 raised by bimanual palpation or the patient may be placed in the genu- 
 pectoral position, which straightens the uterus considerably. 
 
 The sound often causes pain, but it is an exaggeration to say with Veit 
 that one can thus determine the exact point where the inflammation is most 
 marked. In reality it is often the movement of the organ as a whole, rather 
 than the friction of the mucous membrane, that causes the pain. The 
 escape of blood as soon as the sound has passed is a sure indication of al- 
 tered mucous membrane : if there are fungosities present they can usually 
 be felt by the sound. 
 
 The Different Forms of Metritis. 
 
 Acjtte Form. — At the beginning of a metritis there is often a chill with 
 fever. Such acute phenomena are at times present in the course of a chronic 
 metritis as the result of some special fatigue or at the menstrual epoch. 
 However, it may be, when the metritis takes this form either acutely or 
 gradually, direct exploration reveals the peculiar sensitiveness of the organ, 
 the heat of the vagina, where the finger perceives a throbbing at times, the 
 redness and swelling of the external os — in one word, all the classic signs 
 of inflammation. They usually disappear very quickly, but may return if 
 there is a renewal of the cause. 
 
138 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Catarrhal Form. — In this form two features predominate, namely, the 
 erosion of the cervix and the leucorrhoeal discharge. I have already de- 
 scribed the appearance of the eroded cervix and do not need to repeat it. 
 
 This form is observed most often in young women and is accompanied 
 with reflex nervous symptoms (palpitation, dyspepsia, etc.) which I have al- 
 ready enumerated. The principal portion involved is the region of the 
 cervix; it is the cervical catarrh of authors. I believe it a mistake to 
 describe it as a circumscribed lesion, for there is always a concomitant al- 
 teration ':i the mucous membrane of the uterine body, and in therapeutics of 
 the part this must not be neglected, or our treatment will disappoint us. 
 
 HemorrJiagic Form. — Here, to the contrary, it is the uterine body which 
 especially suffers, while the cervix may remain comparatively healthy. We 
 meet with this form chiefly in young girls at the establishment of menstru- 
 ation and in women near the menopause; it is also the form most common 
 after abortion, when the almost invisible particles of the decidua graft them- 
 selves on the mucosa and set up a lasting inflammation. Early abortions ai'e 
 often unrecognized and their pathogenic influence is felt more frequently 
 than is supposed. 
 
 In the catarrhal and hemorrhagic forms which have lasted a long time, 
 we observe those profound alterations of the mucous membrane of a vegetat- 
 ing, fungous nature which we call polypi. This exuberant proliferation 
 of the interstitial and glandular elements may also be found on the cervix ; 
 it then appears externally and constitutes a new symptom, but that fact 
 does not warrant us in giving the affection a new name. Mucous polypi and 
 follicular hypertrophy of the cervix are lesions of metritis and should be de- 
 scribed with it both anatomically and clinically. I have already described 
 their histological nature above. The appearance of these polypi recalls that 
 of the nasal variety : they are red or violet in color, of the size of a hazel- 
 nut, sometimes furnished with a pedicle, sometimes sessile. It is easy to 
 recog lize them by touch or speculum. 
 
 Follicular hypertrophy of the cervix is due to a glandular vegetation in 
 the thickness of one of the lips, which thus presents a hypertrophic elonga- 
 tion and a soft consistence, is marked by many fissures, and can be brought 
 down to the vulvar orifice or even lower. 
 
 The polypi give rise to frequent serious bleeding; the elongation is an 
 accompaniment of the catarrh. 
 
 The hemorrhagic form may cause almost continual losses through many 
 months, with very short intervals ; some women are thus brought to an ex- 
 treme degree of anaemia. The discharge of the blood occurs most often 
 without colic; the patients complain only of more or less intense lumbar 
 pain, and present various neuralgic points. 
 
 CJu'onic Painful Form {CJironic Metritis, Engorgement, Uterine Infarc- 
 tion). — T have called this the painful form, for the pain and its consequent 
 weakness arc the chief features. 
 
SYMPTOMS, COURSE, AND DIAGNOSIS OF METRITIS. 1 59 
 
 It is absolutely false to represent chronic metritis as the sequel and resi- 
 due of an acute attack. It is far more correct to say that it is the result of 
 an infection which has developed slowly, slumbering a long time after the 
 infecting cause has disappeared; a state of things which Verneuil has de- 
 scribed as latent microbism. Such a case has an insidious course, de- 
 ceiving respites, and unnoticed exacerbations ; so that there are many points 
 in an old focus of osteitis which clinically resemble a case of chronic me- 
 itis, for in the intervals between exacerbations, both the one and the 
 other are more of an infirmity than a disease. 
 
 Sometimes the case is one of localized puerperal infection, of a very slow 
 course. The delay in the normal involution, the engorgement as certain 
 authors say, is characterized by an abnormal volume of the uterus, a feeling 
 of weight, pain in the loins, discomfort in standing or walking, and dysmen- 
 orrhoea. These first symptoms may be unnoticed during the early months ; 
 the woman feels ill after some unusual fatigue, attributes to this cause all 
 her trouble, and forgets the already distant labor or abortion. Later on the 
 pain becomes more severe, and enforces more or less complete repose. The 
 local examination reveals a different condition according as it is made during 
 the exacerbations or at other times. In the former case we have the signs 
 already described with acute metritis. At other times we find the cerv'ix 
 somewhat swollen, hard, perhaps sclerosed, often of very irregular form, due 
 to old lacerations, of an almost wooden consistence in places, and at other 
 points feeling as if covered with small nodosities like grains of shot (gland- 
 ular cysts). The speculum discloses this granular appearance and a vari- 
 able congestion which often has a very characteristic coppery look. If there 
 are lacerations, one can observe the ectropion of the mucous membrane, but 
 there is seldom any such fungosity of the ulcerated surface as in the catarrhal 
 form ; it is far more likely to be smooth as in a cicatrizing ulcer. Touch 
 often reveals an accompanying displacement ; but the sound does not give 
 any marked increase in the depth of the organ. 
 
 There is one variety of chronic painful metritis which deserves a special 
 description ; it is that which passes under the name of membranous dysmen- 
 orrhoea, exfoliating endometritis, or decidua menstrualis. The capital symp- 
 tom is the painful extrusion at the menstrual period of all or a part of the 
 uterine mucous membrane; this presents the histological alterations of acute 
 inflammation (acute endometritis. Fig. 99). These patients may suffer very 
 little between their periods, though indubitable signs of metritis are present, 
 such as leucorrhoea. Many authors, however, have overlooked this source 
 of the disease and made it a distinct variety of metritis. Others, as Schro- 
 der, have seen the relation : he says in one place, " Chronic catarrh is found 
 so often that it may be considered as the cause of the disease." If the ori- 
 gin of the affection be sought, we find almost always that it followed labor 
 or abortion, more rarely that it appeared at the establishment of menstrua- 
 tion (the importance of these phases of the genital life in the development 
 
l6o CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 of metritis is well known). This disease may then be described as a chronic 
 metritis with acute exacerbations and inflammatory desquamation of the mu- 
 cous membrane at the time of the regular period. Therefore it enters clin- 
 ically into the chronic form, and anatomically belongs to the acute. At 
 times the membrane is passed in shreds ; at other times the sac is complete, 
 and the form of the uterine cavity can be recognized, the internal surface 
 being grooved in little furrows, the external being irregular and jagged. 
 This membrane must not be confounded with the product of an abortion, 
 where an attentive examination (especially after short immersion in picric 
 acid) reveals the chorionic villi. On the other hand, the presence or ab- 
 sence of cells of the decidua is not pathognomonic. 
 
 This special manifestation of chronic metritis lasts until the menopause, 
 unless energetic treatment is begun ; it may accompany menorrhagia. Al- 
 though it usually produces sterility, pregnancy may occur, with a return of 
 the disease after labor. 
 
 Course, Prognosis. — All the forms of metritis are rebellious; the mucous 
 membrane, the muscular tissue, the parenchyma, become involved in turn ; 
 then follow uterine sclerosis, cyst formation, etc. Sometimes the sequel is 
 the morbid condition which we know as chronic metritis, for every case 
 which is not rapidly cured tends to become chronic. Scanzoni asserts that 
 he has never seen a case of chronic metritis cured, but he does not distin- 
 guish clearly enough between that and salpingitis. 
 
 Does metritis predispose to cancer ? We have seen that a number of for- 
 eign authors do not hesitate to say that the combination of cervical catarrh 
 and a laceration offers favorable conditions for the appearance of carcinoma 
 (epithelioma). An inflammation of the mucous membrane of long duration, 
 when it takes the glandular form, may lead to the formation of adenoma; 
 now, when the epithelial vegetation passes the limit of the cul-de-sac, the 
 typical adenoma becomes atypical, and by a progressive transition an actual 
 cancer of the cervix is produced. 
 
 Diagnosis. — The causes of error may come from exaggeration of one 
 symptom, or from neglect of concomitant signs. 
 
 The increase in size alone, or with the dyspeptic symptoms, may sim- 
 ulate beginning pregnancy, especially if there is amenorrhoea ; the question 
 can be determined by waiting or by careful examination, avoiding the use of 
 the sound. 
 
 The abundance of the leucorrhoea with the cervical laceration may give 
 the idea of cancer ; the characters of the one and the other are, however, 
 very different. In cancer the discharge is not muco-purulent and viscid, but 
 serous, of a reddish color, having a peculiar stale smell : the ulceration is 
 seamed, sown with yellow points, and bounded by hard borders when it is 
 not of a cauliflower form ; it destroys the supporting tissues so that there 
 is a marked loss of substance, which is never found in the pseudo-ulceration 
 of metritis. The hard and nodular swelling of the cervix, due to the devel- 
 
SYMPTOMS, COURSE, AND DIAGNOSIS OF METRITIS. l6l 
 
 opment of sclerosis and cysts together, gives to the finger the feeling of can- 
 cer, it is true; but puncture of the cysts and incision of the cervix to re- 
 move the congestion will make the diagnosis very clear. If necessary, a 
 small section may be cut from the part and examined by the microscope. 
 
 Strong regular pains, a very tenacious discharge of fetid muco-pus mixed 
 with blood, a great increase in the size of the organ, and the examination of 
 pieces removed by the curette, confirm the diagnosis of carcinoma of the 
 uterine body. 
 
 The metrorrhagia produced by an early abortion must not be confounded 
 with hemorrhagic metritis ; the study of the matters expelled and the pa- 
 tient's antecedents should enable us to decide. 
 
 Fibrinous polypi, or better placental, are nothing but the debris of the 
 placenta or chorionic villi which have remained planted upon the uterine 
 mucous membrane, and which may continue their obscure life there through 
 many weeks or even months after labor or abortion. The patient's own 
 story, and the examination of pieces scraped away with the blunt curette, 
 will soon show what is the origin of the little tumor. 
 
 Fibrous polypi, if intra-uterine, may give rise to a symptom-complex like 
 that of metritis with abundant hemorrhage. Examination by bimanual pal- 
 pation, the uterine sound, and, if necessary, dilatation of the cervix, should 
 prevent error here. 
 
 Salpingitis, as I have said, often coexists with metritis. The diagnosis 
 consists in deciding which of the two lesions predominates, and gives, there- 
 fore, its character to the malady. Bimanual palpation, perhaps with the 
 aid of anaesthesia, should be employed to discover the condition of the ad- 
 nexa. If they are not augmented in volume but only a little painful on pal- 
 pation, while the uterus presents the objective signs which have described, 
 the diagnosis is clearly metritis. 
 
 I have described the existence of metritis symptomatic of primitive and 
 non-inflammatory disease of the adnexa ; by that I mean that a lesion of a 
 tube, an ovary, or a broad ligament may be reflected in the uterus. It is 
 difficult to say in what way the uterine mucous membrane becomes affected, 
 but we cannot deny that it does alter. A small ovarian tumor has been the 
 starting-point for profuse bleeding, with hyperplastic endometritis which was 
 confirmed by autopsy. Brennecke and Lohlein, who reported cases of 
 this kind, thought that reflex hyperaemia caused by the ovarian irritation 
 was sufficient to produce the mucous hyperplasia. It nj.ist be acknowledged 
 that this state of permanent congestion creates a peculiar morbid receptivity, 
 owing to which the numerous causes of infection — germs dwelling within 
 the vagina and germs from without — are able to exercise their evil influence 
 and overcome an organization already enfeebled by inflammation. 
 
 As regards diagnosis, there are two well-established facts which the clin- 
 ician must not forget : 
 
 I. There is but a narrow limit between inflammations of the uterus and 
 II 
 
l62 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 of the adnexa; we should always seek for the latter, therefore, because 
 whether it be protopathic or deuteropathic, its existence may become very 
 important in consideration of operative interference. 
 
 2. Alterations in the ovaries, whether inflammatory or not, may simu- 
 late metritis by their reflection upon the uterine mucous membrane ; the al- 
 teration, at first simply congestive, tends to transform itself into a veritable 
 inflammatory lesion. 
 
 Cystitis may occur with inflammation of the uterus or resemble it by the 
 pain which it causes. The same is true of proctitis with tenesmus and a 
 glairy secretion (anal leucorrhoea), which we see at times appearing with an 
 acute metritis with which it is connected. In such a case we must be care- 
 ful not to see the effect and overlook the cause. I have seen a sphincteralgia 
 in one case, which yielded to the cure of a catarrhal metritis. Very excep- 
 tionally a rectal disease provokes symptoms of pseudo-metritis. I have pub- 
 lished a case of rectal polypus which for a long time gave rise to signs 
 which were thought to be due to metritis. Rectal touch enabled me to dis- 
 cover the cause of the disease and cure it by removal of the polypus ; the 
 patient had mistaken for metrorrhagia a bloody discharge which really came 
 from the rectum. 
 
 The disturbance of the general health is often so severe that it entirely 
 masks the local lesion. The patient may complain of persistent cough, or 
 loss of breath, or progressive emaciation, and say little about her leucorrhoea 
 and abdominal pain. One is often inclined to think of pulmonary tubercu- 
 losis until auscultation reveals the error. With other cases it is the symp- 
 toms referable to the stomach which predominate ; loss of appetite, flatulence, 
 gurgling, with percussion and succussion, demonstrate the existence of dila- 
 tation of the stomach. It is present, but is only symptomatic of a metritis 
 of which it is a sequence. Finally the number of young women who suffer 
 from precordial anxiety, palpitation, and in whom the stethoscope reveals car- 
 diac and vascular murmurs, is very large. On examining the uterus also, we 
 very quickly recognize that we have to deal with a metritis, or, less probably, 
 with a lesion of the adnexa. 
 
 The rule should be, therefore, to carefully examine the uterus in every 
 woman with a chronic disease. 
 
CHAPTER VII. 
 
 TREATMENT OF METRITIS. 
 
 The prophylaxis of uterine inflammation made a great step forward when 
 antisepsis was first followed in obstetrics. It is to a more or less localized 
 and attenuated puerperal infection that the majority of cases of metritis are 
 due. 
 
 The complete cleansing of the uterine cavity after labor and abortion of 
 all debris of membranes and placenta has a capital importance here. In my 
 opinion, the discussion whether expectance accomplishes more than active 
 interference is all wrong. Budin has raised his voice too loudly against 
 what I call the exaggerated fear of accident from the expectant plan. He 
 bases his ideas upon statistics of all cases treated in the maternity service of 
 la Charite during a period of three years, comprising forty-six retentions in 
 two hundred and ten cases of abortion : did he notice that septicaemia 
 occurred but four times, and only once with a fatal issue .-' 
 
 Budin combats hemorrhage by tampons, septic accidents by vaginal and 
 intra-uterine injections of sublimate (i : 2,000 or i : 3,000) or carbolic (20 or 
 30: 1,000), with quinine internally. Surely one can, no doubt, thus remove 
 the immediate trouble, but is it the same with the sequels, metritis and sal- 
 pingitis ? As surely not ! Are the patients really cured who have escaped 
 from death ? For my part I cannot combat this therapeutic cowardice 
 enough. If there is reason to fear that a portion of the foetal structures has 
 been left within the uterine cavity, no time must be lost before making ex- 
 ploration, thorough cleansing, and disinfecting; do not await the appearance 
 of hemorrhages, for by that time the mucous membrane is already infected. 
 The dull curette of Recamier, and weak injections of sublimate, are the best 
 means at hand. 
 
 After thorough use of the curette, followed by a haemostatic injection of 
 perchloride of iron and antiseptic irrigation, the temperature is seen to fall 
 one or two degrees if it has been high before ; one can prevent fever and in- 
 sure rapid recovery where the decomposition of the debris has not yet begun. 
 The " ecouvillon" (or scraper) which has been advocated for this purpose, is 
 an altogether unsuitable instrument, as is shown by a case ending in death 
 published by one of its partisans. It is evident, a priori, that it has not 
 sufficient force to detach by scraping the often firmly adherent debris. 
 
 Before mentioning the special treatment suited to each case I will describe 
 the therapy which is applicable to all alike. 
 
 It has been recommended to immobilize the abdomen with a bandage 
 
164 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 of ticking, elastic tissue, or a band of flannel making two turns round the 
 body, a little obliquely from above downward; this affords much comfort 
 in walking. 
 
 All fatigue and all violent efforts must be forbidden, and the sexual rela- 
 tion given up. 
 
 The constipation is best combated by means of proper food (vegetables, 
 Graham bread, prunes, etc.), mild laxatives (mineral waters, rhubarb and 
 magnesia, etc.) and enemata, to which we can add a spoonful of glycerin. 
 Certain patients find it well to take at meals a spoonful of white mustard in 
 
 Fig. 133. — Abdominal Bandages. A, Of elastic stocking tissue; ^, of webbing for stout women who do not 
 
 stand compression well. 
 
 water ; this mechanically provokes hypersecretion and contraction of the in- 
 testine. Long-continued use of drastic purgatives, like aloes, podophyllin, 
 etc., has its own inconveniences, but we have to employ them at times. It 
 is very important to unload the large intestine and thus relieve the pelvic 
 viscera. 
 
 The patient's general condition must be kept up by tonics which are 
 suited to her ; for women who are of a 13'mphatic temperament, cod-liver oil 
 and phosphates ; for the arthritic, preparations of arsenic ; for almost all, 
 iron, with quinine and rhubarb, may be administered with success. Lastly 
 hydrotherapy is a powerful auxiliary, especially where the metritis has pro- 
 duced anasmia and nervous symptoms, as it so often does. 
 
 There is no other disease in which mineral waters have been so strongly 
 recommended. They certainly have a good effect on the general state, and 
 indirectly on the local. I think that the chief indication is to take care of 
 the patient's general condition and of the reflex disturbances of the chief or- 
 gans which may be produced by the uterine disease. If the patient is very 
 anaemic, we prescribe in preference ferruginous waters, or sulphur and arsen- 
 ical with sea-bathing ; for dyspeptics, alkaline waters and gentle purgatives ; 
 for the nervous, indifferent waters, but a spa which is pleasantly situated 
 and on high ground. Finally, springs charged with chloride of sodium have 
 an incontestable action, not only on the scrofulous and lymphatic constitu- 
 tions, but also on all visceral congestion, and may be of real benefit in the 
 beginning of certain forms of chronic metritis^ in which the engorgement of 
 the body predominates without great alteration in the cervix. 
 
TREATMENT OF METRITIS. 165 
 
 Special Treatment of each Form, 
 
 In acute metritis the rest in bed must be absolute: sitz baths are pre- 
 scribed with the introduction, while in the bath, of a small speculum, which 
 allows the water to reach the cervix; and repeated mild purgatives should be 
 given. If the pain is very severe, it may be calmed by laudanum in the 
 vaginal douche or by opium suppositories. The 
 daily application of a glycerin tampon, which is 
 left in place twelve hours, is an excellent anti- 
 phlogistic ; the glycerin, having an affinity for 
 water, causes considerable flow of serum. The 
 patient can be taught how to introduce the tam- ^''^^ 134-— bath Speci-loi. 
 pon herself, with thQ aid of a cylindrical speculum which she guides by a 
 long handle; the speculum is then withdrawn, leaving the tampon in place. 
 
 Hot vaginal douches (45° to 50° C.) kept up for a long time are of great 
 service. This therapeutic measure, advised by Sedillot and Trousseau, gen- 
 eralized anew by Emmet and other American and English gynaecologists, 
 is capable of many applications, but it is well to give precise directions for 
 its employment. 
 
 The injection, or better the irrigation or hot douche, should be taken by 
 the patient lying at the edge of the bed, her legs supported on either side 
 by a table or chair, and the pelvis a little elevated. For greater convenience 
 a basin or a piece of rubber tissue should be placed under the buttocks, 
 folded along the edge into a gutter and leading into a pail below (Fig. 58). 
 The vessel containing the water should hold not less than three litres (Fig. 
 2) ; it is filled with water at 45° C. (115^ F.) (there is always a loss of two 
 degrees in passing through the apparatus), and raised about one meter above 
 the patient. The vaginal tube is then gently pushed up as far as the cer- 
 vix. It is well before beginning the injection to cover the vulva and peri- 
 neum with vaselin ; the action of the hot water is then less disagreeable. 
 From three to ten litres may be used at one time and the douche repeated 
 twice a day ; after each, it is well to pass two fingers into the vagina and de- 
 press the fourchette strongly to allow the escape of the accumulated water ; 
 then a glycerin tampon may be introduced and the patient ordered to rest an 
 hour in bed. That the acute stage may not be too prolonged, we may have 
 recourse to scarification — local blood-letting. The scarificator (Fig. 135) 
 can be used for this purpose, but there is no need for a special instrument. 
 An ordinary bistoury, round which is rolled a band of diachylon that leaves 
 only about one centimetre of the blade free, will do as well. 
 
 After the vagina has been well irrigated, a cylindrical speculum is passed 
 in and the cervix displayed ; then it is pierced in a dozen different points 
 without going far beyond the external os. To render the little operation 
 antiseptic and aid the flow of blood, a continuous irrigation of warm carbolic 
 
i66 
 
 CLINICAL AND OPERATIVE GYNAECOLOGY 
 
 solution (i : lOo) is kept up. This is very easy to do with the little funnel 
 which I have adapted to the speculum (Fig. 72). When the blood has 
 flowed long enough, the speculum is removed, the vagina emptied, and a 
 tampon of iodoform gauze placed upon the cervix, which stops the bleeding. 
 
 This method is much better than the use of leeches, does not require an- 
 aesthesia, being painless, and may be repeated as often (every other day) as 
 deemed necessary. 
 
 Exfoliative metritis or membranous dysmenorrhoea is both anatomically 
 and clinically an acute metritis, or better the acute stage of a chronic metri- 
 tis. Generally every other treatment than curetting fails. This means, on 
 the other hand, gives excellent results. It should be followed by an injec- 
 
 t,.U5B^^^j*sse&-WHfeg^- 
 
 Fig. 135. — Cervical Scarificators. 
 
 tion of tincture of iodine. If there is at the same time stenosis of the cer- 
 vix, both that and the pain are treated at once by dilatation with laminaria 
 tents or the steel dilator. 
 
 Landowski has published cases successfully treated by the galvano- 
 cautery ; the method is a good one, but I consider the curette more expedi- 
 tious. 
 
 Acute gonorrhceal metritis should be energetically treated by antiseptic 
 and slightly caustic vaginal and intra-uterine injections. Alph. Guerin has 
 described the good effects of an intra-uterine injection of a weak solution 
 of nitrate of silver (gm. 0.05 to gm. 30 of water). Fritsch has recently 
 recommended the use of chloride of zinc, i : 100, for the vagina; more 
 concentrated for intra-uterine cauterization. Both the vaginitis and the 
 endometritis, which depend upon each other, may be treated together. We 
 may find in any case that the inflammation has already disappeared from the 
 vagina and taken refuge in the uterine cavity or the urethra ; it is in this lat- 
 ter place that we seek the last traces by which to characterize the nature of 
 the uterine affection. For the vaginitis and the urethritis injections of bi- 
 chloride have always given excellent results, joined with the use of crayons 
 of iodoform. Acute gonorrhoeal metritis should not be treated by curet- 
 tage, which is liable to increase the infection ; it is better to employ intra- 
 uterine cauterization with nitrate of silver or chloride of zinc (i : 20), and to 
 
TREATMENT OF METRITIS. 1 67 
 
 use intra-uterine injections of potassium permanganate (2 : 1,000) by means 
 of a double-current catheter. 
 
 Catarrhal Metritis. — The general treatment already described should be 
 most carefully followed ; this is the form in which chloro-ansemia very rapidly 
 appears, and the general treatment must aid the local as much as possible. 
 
 This is also the form in which it is most necessary to maintain entire 
 cleanliness and rigorous antisepsis of the vagina ; thus one acts indirectly, it 
 is true, but very efficaciously, upon the cervix, which is often the part most 
 deeply affected. By advising the patient to rest in bed after the morning 
 injection, and to take the evening one in bed without rising afterward, a cer- 
 tain quantity of the medicated liquid is kept in the upper part of the canal, 
 making a kind of local bath which is of excellent effect. The i : 3,000 solu- 
 tion of sublimate is the best for injecting, but it must not be continued for 
 too long a time, because of the danger of mercurial poisoning. Other good 
 injections may be made by adding to a pint of water a tablespoonful of pow- 
 dered tannin, or two of boric acid, or a dessertspoonful of alum in powder. 
 
 To cure metritis completely it is necessary to attack the interior of the 
 organ. The three principal procedures of intra-uterine medication are : an- 
 tisepsis, cauterization, and curetting, employed together or singly. To these 
 it is often necessary to add surgical treatment for the cervical erosions and 
 lacerations which play so important a part in the catarrhal form of the disease. 
 
 I will follow this order in the description of the different therapeutic 
 measures. 
 
 Cleansing of the Uterus, 
 
 {a) bitra-uterine Irrigation. — Large injections of some feeble antiseptic 
 must not be confounded with the use in smaller quantity of agents which are 
 more powerfully caustic. Schultze has especially praised this method. He 
 dilates the cervix with laminaria, introduces a uterine catheter, and w^ashes 
 the cavity with a copious injection of weak carbolic solution (i : 50). This 
 treatment is not enough in obstinate cases, and I think it should be reserved 
 for those light attacks in which there is no great change in the mucous mem- 
 brane, for there it is useful. The injection may be given every day through 
 a two-way catheter ; if there is any difficulty in introducing it, the cervix 
 should be dilated by tent or instrument ; a half-litre is used at a time. When 
 the patient does not soon recover after the employment of these simple meas- 
 ures, W'C must have recourse to cauterization and the curette. 
 
 {b) Drainage. — Fehling employs glass drains pierced with holes ; Ahlfeld, 
 hollow cylinders of rubber ; and Schwartz wicks of spun glass which act by 
 capillarity. It does not seem as if these devices had given as good results 
 in the hands of others as their authors and their pupils have obtained. I be- 
 lieve that the presence of a foreign body in the uterus would be more likely 
 to keep up the metritis than to cure it. It is otherwise with the capillary 
 drainage of a piece of iodoform gauze described in the next paragraph. 
 
i68 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 (c) Tampons. — Fritsch, since 1882, has employed the following measure 
 in gonorrhoea! metritis : he passes into the uterus a strip of iodoform gauze 
 75 cm. in length and 2 to 3 cm. broad, packing it into the cavity "as one 
 fills a hollow tooth" ; then he removes it and repeats the manoeuvre, thus 
 thoroughly cleaning the uterus. After this he introduces another, allows 
 it to remain twenty-four to forty- eight hours, and if it produces colic it is 
 removed by pulling the end which hangs out of the vulva. As is easily 
 seen, this procedure has for its object both the cleansing and the antisepsis 
 of the uterine cavity. But it seems to me much less active than curetting 
 
 Fig. 136. — Slide Applicator. 
 
 followed by cauterization, and I reserve the uterine tampon for energetic dis- 
 infection when it is necessary (as in cancer of the body, sloughing fibroma, 
 etc.), or I employ it as a haemostatic after enucleation of fibromata. 
 
 (d) Stveeping zvith a Tampon ajtd Scraping. — Many gynaecologists con- 
 tent themselves with dilating the cervix and cleansing the uterine cavity by 
 means of a pledget of absorbent cotton rolled on a handle. This is very 
 simple, and the cotton will be securely held on the handle if the end of 
 it is a little irregular ; a sound with no terminal enlargement is all that is 
 required {Fig. 1 36). It is easy to make pledgets of tapering form, so that 
 they can be passed into a cervix but little dilated. It is well to soak these 
 in a I : 1,000 solution of bichloride, or carbolic i : 50, to gently squeeze the 
 excess out before introducing them, and then to turn them about within the 
 uterine cavity so that the walls of the organ shall be thoroughly wiped clean. 
 The last tampon may carry the caustic. 
 
 Doleris prefers to this simple means the employment of a scraper like 
 that used in cleaning bottles (Fig. 137); the instrument, designed to brush 
 the interior of the uterine cavity, is rendered aseptic by immersion in i : 100 
 sublimate solution, and then introduced by a spiral motion, which is kept 
 up in different directions until it is removed. Both the scraper and the 
 tampon may be charged with various medicating solutions. Dol6ris thinks 
 that by using scrapers with harder or softer bristles, he can effect both a 
 cleansing and a scraping of the mucous membrane, with destruction of it if 
 necessary. That this is an illusion will be clear to all those who are accus- 
 
TREATMENT OF METRITIS. 169 
 
 tomed to use the blunt curette, and know the amount of force necessary to 
 remove the membrane with a dull instrument ; it seems to me impossible by 
 simple friction of the mucous membrane with a brush to destroy its 
 elements. 
 
 The instrument is, therefore, illusory, and, like the tampon, cannot be 
 successful as a means of either cleansing or medicating the uterus. From 
 this double point of view, it is not much superior to the tampon, which I 
 employ almost wholly for the cervical cavity, preferring to clean the uterus 
 by irrigation. 
 
 There are cases, especially in nulliparae, in which the cervix is full of muco- 
 pus, but the external os is narrow and prevents the escape of the secretion. 
 It is better then, instead of dilating, which would require to be repeated, 
 
 MATHrEU 
 
 FlG. 137. — DoLf RIS' ECOUVILLON. 
 
 .to make a small crucial incision of the orifice ; this may be done with scissors 
 curved on the flat or a probe-pointed bistoury, and the cut should be about 
 I cm. in depth. This will make applications to the interior of the cervix 
 easy, as well as complete examination of the part and the decision of the 
 question whether a more energetic treatment is necessary : the small inci- 
 sions heal very quickly. 
 
 Intra-iiterine Cauterisation. — The employment of solid caustics — such as 
 Becquerel and Rodier's medicated crayons, Courty's pencils of nitrate of 
 silver left in the uterine cavity, which Spiegelberg removes with a catheter 
 and a metallic thread : the uterine pistol of E. Martin (senior), imitated by 
 Storer ; and the porte-caustic of Dittel — all have the common defect that 
 they blindly leave in the uterus a caustic with an action either too strong or 
 too feeble. The direct momentary application of the agent by a porte-caustic 
 is preferable : but beforehand the cavity should be thoroughly cleaned by 
 irrigations or tampons. 
 
 Dumontpallier, as Polaillon had already done, introduces into the cavity 
 a pencil of Canquoin's paste (chloride of zinc i gr. to 2 or 3 grs. of rye meal). 
 He produces thus a destruction of the tissues which certainly may pass be- 
 yond the mucous membrane and, I think, obliterate the orifice of the Fallo- 
 pian tube and cause contraction of the cervical canal. I have twice been 
 obliged to remove the appendages and once to perform vaginal hysterectomy 
 for accidents following this treatment. 
 
 Galvano-cautery has been used by Spiegelberg for a long time, and 
 advised anew by Apostoli. It seems both less easy and less sure to me ; 
 for it may cause sterility by lining the interior of the uterus with cicatricial 
 tissue. 
 
 Liquid or sirupy caustics are easily applied with a thin pledget of cotton 
 
I/O CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 wrapped on a handle or special sound. The method has been employed by- 
 many authors since Miller and Playfair recommended it. 
 
 Rheinstadter and Broese have recently advised anew the use of chloride 
 of zinc, dissolved in its own weight of water, as an intra-uterine caustic, ap- 
 plied with the cotton-wrapped applicator. This method, according to Broese, 
 never produces contraction of the cervix, and may be repeated every week 
 or twice a week, without confining the patient to the house. The uterus 
 does not need to be held, and the caustic is rapidly passed in through a cer- 
 vix dilated enough beforehand to prevent any difficulty in penetrating into 
 the cavity. The contact is prolonged only one minute, and any drops which 
 might attack the vagina are to be carefully wiped off. [In using any strong 
 intra-uterine caustic it is advisable to protect the vagina by thin tampons 
 soaked in a strong solution of sodium bicarbonate squeezed dry and packed 
 about the cervix.] 
 
 Caustics much employed in America are weak nitric and concentrated 
 carbolic acids. The cervix must be previously dilated, and certain precau- 
 tions taken, or the applicator reaches the uterine cavity after most of the 
 caustic has been squeezed out, or its strong action at the level of the cervix 
 mav cause subsequent stenosis. After such a cauterization it is necessary 
 to cleanse the uterine cavity with great care. 
 
 Peaslee has invented a speculum designed to protect the cervix from the 
 action of the caustic, but it is not convenient in use ; a simple tube of glass, 
 such as Woodberry of Washington employs, would be better. For the same 
 purpose, Joseph Hoffmann wraps the end of a slender syringe tube, pierced 
 with many holes, with cotton, and then, introducing it to the fundus, forces 
 the fluid out by the gentle play of the piston, thus affecting only the mucosa 
 of the cavity. 
 
 I do not employ these methods. In spite of all precautions, it is diffi- 
 cult, whatever may be said, to avoid contraction of the cervix after cauteriz- 
 ing the entire extent of its orifice. But this is not the principal objection 
 which could be made; for unless each cauterization is preceded by a dilata- 
 tion, or the intervals are employed in tamponing to retain the dilatation, one 
 cannot be sure of penetrating well into the cavity and reaching the fundus. 
 Thus there is a part of the diseased membrane which is never touched ; while 
 the cervical portion is too strongly cauterized, the action is nil above. The 
 first cauterizations by means of injections were made a long time ago by 
 Lisfranc and Vidal. Then followed much discussion as to the possibility of 
 the fluid passing into the Fallopian tubes. This possibility is easily de- 
 monstrated upon the cadaver, under conditions not found in the living, but 
 practically is very rare if two things are provided for : the canula must not 
 fill the cervical canal, so that there may be plenty of room left about it for 
 the fluid to pass out again ; and no great force must be used, nor should the 
 jet be directed in the axis of the uterus. With these precautions the injec- 
 tion may be made in safety ; both arc realized in syringes of different models. 
 
TREATMENT OF METRITIS. 171 
 
 particularly Braun's, which is made of hard rubber and may be used, there- 
 fore, with any fluid, as it does not become altered. The operation is a be- 
 nign one; though we must not forget certain unfortunate cases, in some of 
 whom there have been abnormal anatomical conditions (dilated tubes), and 
 in others an imperfect operative technique. 
 
 Many fluids are used ; the best being tincture of iodine, glycerin and 
 creosote, and perchloride of iron. It is enough to inject about three grams, 
 which equals the contents of Braun's syringe (Fig. 138). I use the tinc- 
 
 FiG. 138. — Braun's Intra-uterine Syringe. 
 
 ture of iodine a great deal, but only after a preliminary curetting several 
 days before, followed by injection of perchloride of iron. I begin the iodine 
 injections five days after the operation, and in very intense cases of catarrh 
 I have done it every second day through two weeks. 
 
 I prefer the tincture of iodine in a solution of creosote (from the beech) 
 in glycerin, i : 3 and 1:10, as Doleris recommends. The canula is introduced 
 through a speculum, the axis of the uterus having been ascertained before- 
 hand. If there is any difficulty, the cervix should be held firm with a bullet 
 forceps, and gentle traction made on the lip opposite to the flexion, the vag- 
 inal walls being kept apart by the valves of the speculum. As the canula is 
 slowly withdrawn from the fundus toward the cervix, the injection is per- 
 formed with but little force. There is ordinarily no need to dilate the cer- 
 vix, unless the canula cannot be freely moved about so as to effect the rapid 
 outflow of the fluid. During the intra-uterine injection, the vagina is to be 
 copiously irrigated to prevent cauterization of its walls. 
 
 I have seen acute pain, vomiting, and fainting follow such an injection, 
 but never any serious accident. 
 
 The objection has been made to tincture of iodine that it causes precipi- 
 tation of albumin, and the formation of coagula within the cavity of the 
 uterus. This is an error which Nott's experience has refuted. The iodine 
 simply makes a layer of very fine precipitation upon the mucous membrane, 
 and its antiseptic action is thus prolonged for some time. The essential oils 
 and aromatics, like creosote, etc., have a very fugitive action; and iodoform 
 would be dangerous from the effects due to its absorption. 
 
 The uterine curette, which was invented by Recamier and fell into dis- 
 credit, has again come into favor since the use of antiseptics in gynaecology. 
 To-day, in France as well as in other countries, it occupies an important 
 place in the treatment of metritis. 
 
 The choice of a curette is not a matter of indifference. There are many 
 varieties, of which the principal are — the cutting spoon of Simon (which 
 should be reserved for excision of cancer of the cervix and uterine fungosities 
 
172 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 very far advanced) ; the sharp ring curette of Sims (excellent for detaching 
 polypi) ; the flexible dull curette of Thomas, much used in America ; and 
 the dull instrument of Recamier-Roux, which Martin has adopted and which 
 I also prefer. It presents the advantage over the ring form, that it removes 
 with it from the cavity the greater part of what has been detached (Fig. 139). 
 
 a b c d 
 
 Fig. 139. — Curettes, a, Simon's sharp curette; i, Thomas' dull curette and a hooked curette for removing debris 
 from the uterus; c, Sims' sharp curette; c/, curette of Recamier-Roux. (All these curettes should be made with metal 
 handles.) 
 
 Curettes are made with a hollow handle and a perforated top, to permit irri- 
 gation during their use. I do not find that this simplifies the technique, 
 and they are hard to keep clean. I am a resolute partisan of the dull (by 
 dull I mean that the edges are thin but not cutting, like a knife blade which 
 has not been filed) curette in endometritis. We have not here, as in cancer, 
 to remove a resistant tissue ; but simply to scrape a hard muscular wall, 
 covered by a soft investment which is still further softened from inflamma- 
 tion. As is easily understood, it is enough to scrape the interior of the 
 uterus with a narrow blade to be sure of detaching all that is not strongly 
 
TREATMENT OF METRITIS. 173 
 
 adherent — and that is precisely the mucous membrane. Dull curettes have 
 the further advantage that with them there is the least risk of doing injury 
 to the parenchyma of the organ, for if the force used is never too great and 
 is always directed obliquely, it is impossible to perforate the wall of the 
 uterus (except in the post-puerperal state). 
 
 By the curette the whole thickness of the membrane is never removed; 
 the glands penetrate to the muscular layer, and the terminal culs-de-sac re- 
 main attached to the parenchyma in spite of all scraping, however energetic, 
 and serve to start a very rapid reconstruction of the membrane. It is this 
 fact which has led me to divide curetting, both in my course and in the 
 thesis of Despreaux, my pupil, into " modifying" for metritis, " destructive" 
 for malignant neoplasm, and "exploratory" where the purpose is to secure 
 a small piece for diagnosis. In the two latter cases the cutting instrument 
 is to be preferred. 
 
 The mucous membrane of the uterus is unique in its special power of re- 
 generation. What occurs in menstruation and pregnancy demonstrates that 
 a layer equal almost to its whole thickness may be expelled and rapidly 
 replaced. The curette produces artificially, and for a therapeutic object, a 
 moulting of the membrane similar to that of the decidua ; it substitutes, so 
 to speak, in an antiseptic way, a regenerated mucous membrane for one in- 
 fected by germs which has already suffered such changes that its repair 
 would be very long and tedious. After curetting, the fecundity of the wom- 
 an is no more compromised than after abortion or labor. One may, how- 
 ever, expect the next menstruation to default, and sometimes the second or 
 the third ; I have in one case seen amenorrhoea for four months. 
 
 Technique of Curettage. — The operation should be done by preference in 
 the first days after menstruation. Though but slightly painful, I prefer to 
 anaesthetize the patient. The preliminary antisepsis of the vagina and vulva 
 should be carried out according to the rules laid down in Chapter I. The 
 patient is placed in the dorso-sacral position, and the thighs supported by two 
 assistants ; the one upon the left of the operator draws down the short, flat 
 valve which depresses the fourchette, the other holds the fixing forceps and 
 the canula for continuous irrigation. The patient's knees being held in the 
 axilla, each assistant has the left hand free and can at need hold one of the 
 vaginal retractors (Fig. 9). The cervix is drawn down to the vulva by a 
 Museux's forceps, with teeth opposite, not over-riding (Fig. 140) which is 
 fixed in the anterior lip. The uterine sound is first passed to determine anew 
 the direction and depth of the canal, and then the curette is presented at 
 the external os. Nine times out of ten it passes without difficulty ; if any 
 is encountered, the cervix is at once opened with an Ellinger's dilator or 
 by passing one or two of Hegar's bougies. The curette is then directed tow- 
 ard the fundus of the uterus and the scraping is done by bringing it first 
 over the anterior face, then the posterior, and the fundus, the angles, and 
 the sides in turn. After a few strokes with the curette, for which some 
 
174 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 force is necessary, the instrument is withdrawn, and at once plunged into 
 a vessel filled with strong carbolic solution which is ready at the right of 
 the operator. One can always pass twice over the same place and make a 
 second curetting, supplementary to the first, following the same order along 
 the internal surface of the uterus. The operation should be done rapidly ; not 
 more than three minutes are required. Then a double-current catheter of 
 Bozeman-Fritsch is introduced (Fig. 8), and the surgeon, seizing the canula 
 from which a stream has not ceased to flow gently over the cervix, fits it to 
 the catheter and washes the uterine cavity copiously with the same hot car- 
 bolic solution which has served for the continuous, irrigation (i : lOo). A 
 
 Fig. 140. — Toothed Forceps. 
 
 quarter or a half litre should be injected, until the water, at first bloody, 
 returns but little tinted ; the effects of this are haemostatic, antiseptic, and 
 by it the clots and shreds of membrane are removed. 
 
 The catheter is taken out and replaced by a Braun's syringe (full of per- 
 chloride of iron at 35° C, or of tincture of iodine), which is passed up to 
 the fundus. As this is retracted, its contents are driven out little by little, 
 scattering them through the cavity from fundus to os externum. During 
 this time continuous irrigation is kept up with a small jet against the cervix 
 to wash away any caustic which might escape and irritate the vagina or vulva. 
 
 The Bozeman-Fritsch catheter is again introduced and for the second 
 time the cavity of the uterus is thoroughly washed out ; this removes the 
 excess of the caustic, whose action should be rapid, and also the last remain- 
 ing clots. If there is any difficulty in passing the double-current catheter, 
 one can, without danger, practise the injection in small intermittent jets, 
 by the aid of the long, fine canula which has served for the continuous irri- 
 gation, taking care only that the uterus is not distended or the cervix oc- 
 cluded by passing the canula too deeply. 
 
 When the operation is finished, a tampon of iodoform gauze is laid over 
 the OS, which may be taken out on the second day. Every morning and even- 
 ing the vagina is thoroughly irrigated with i : 2,000 bichloride, and, if the 
 catarrhal metritis has been very stubborn, if the uterine vegetations have been 
 very plentiful, or if there are signs of salpingitis, we begin to make intra- 
 uterine injections of iodine every second day; four to eight of which con- 
 stitute a complete treatment. William M. Polk advises the following 
 method of performing curettage : after dilatation of the cervix, a small uter- 
 
TREATMENT OF METRITIS. I75 
 
 ine speculum is introduced and the cavity of the uterus is freely irrigated 
 with a I : 1,000 bichloride solution. The speculum is then withdrawn and 
 the uterus is curetted. The uterine speculum is reintroduced, the cavity of 
 the uterus again irrigated and very carefully packed with gauze soaked in 
 bichloride, the introduction of the gauze being greatly facilitated by the uter- 
 ine speculum and special dressing forceps. The operation is finished by 
 loosely tamponing the vagina. This tampon is removed after forty-eight 
 hours, and after that time a vaginal injection is given morning and evening. 
 On the sixth day the intra-uterine tampon is removed unless it has already 
 been expelled. Several vaginal injections are then given. Finally, the 
 author recommends operating during the premenstrual period, that is, six or 
 seven days before menstruation. [A curetting may be easily done without 
 assistance other than the anaesthetizer if an anaesthetic is employed, by plac- 
 ing the patient in the dorso-sacral position on a Kelly pad with the legs 
 held in place by the folded sheet described on pages 70, 75. Then with the 
 perineum retracted by an Edebohl's self-retaining speculum the cervix is 
 easily exposed and the operation completed. I prefer the irrigating curette, 
 as during its use all blood and debris is washed away at once before clotting 
 can occur, and the cavity of the uterus is left clean with more certainty than 
 when an intra-uterine catheter is employed.] 
 
 For the first caustic injection which immediately follows the curetting, 
 I use tincture of iodine when it is a case of recent catarrhal metritis ; in an 
 older case, or where the oozing demands it, I employ perchloride of iron. 
 
 Except in cases of pronounced flexion or stenosis, the previous dilatation 
 may be omitted in women who have had children. It is not needed for the 
 introduction of the instrument, it is illusory as regards the escape of the se- 
 cretions, for artificial dilatation lasts but a few hours, and as to the debris 
 and clots they should be washed out by the irrigation. Now, this omission 
 is not of trifling importance the first time; even slight dilatation is often 
 very painful, the patient who has agreed to the operation has probably passed 
 a sleepless night, she is in a state of great nervous excitement, and to this 
 may be joined some fever due to the increase in the inflammation caused by 
 the dilatation. Therefore I have given up dilatation after employing it three 
 years, unless there is special indication for it ; following in this respect the 
 example of Martin, Fritsch, and others. The first of these observers has 
 seen it cause serious trouble in a case of intracervical polypus which be- 
 came gangrenous by its action. 
 
 To surgeons not familiar with the curette, perforation of the uterus by 
 it seems a horrible possibility, but there is no danger of it if we operate 
 with a dull curette and always obliquely as regards the uterine tissue, after 
 clearly determining the direction of the organ. It must, however, be feared 
 after labor and recent abortion, for then the uterine wall is very soft, thin, 
 and perforable by very slight force. The patient's own statements, the size 
 of the uterus, and the softness of the cervix should prevent any such acci 
 
1/6 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 dent. In one case of this kind I think that I made a perforation, because 
 of the great depth to which my curette suddenly passed in the direction of 
 the umbilicus ; but I simply did not give the intra-uterine injection, and the 
 patient recovered with no other accident than bilious vomiting the day after 
 the operation. Doleris has thought it possible to explain these cases as a 
 false perforation, the illusion being produced by atony of the uterine wall 
 which allows the curette to depress it into a funnel shape ; this seems to 
 me an error. The reported observ^ations on this point prove to me the com- 
 parative harmlessness of such punctures under antisepsis. 
 
 As a possible accident with curetting one may mention bleeding. In 
 many hundred cases I have never met with it; the astringent injection 
 which ends the operation permits nothing more than an insignificant oozing. 
 
 Subacute and localized peritonitis need only be mentioned ; I have never 
 seen a single case; exact antisepsis prevents it completely. Curetting the 
 uterus is the rational treatment for catarrhal metritis. If simple measures 
 have failed, general treatment, injections, local applications, etc., it will not 
 do to hesitate. By waiting too long, time will be given for the alteration 
 of the mucous membrane to become more advanced, the parenchyma of the 
 organ is exposed to sclerotic changes and follicular degeneration, especially 
 in the cervix, and, lastly, we must not forget the possible extension of the 
 inflammation to the tubes, so frequent in old cases of catarrhal metritis. 
 
 Mucous polypi may be removed by seizing them with a flat forceps and 
 twisting off their pedicle. If numerous and sessile, the cutting curette of 
 Sims or Simon should be used and the bleeding surface touched with per- 
 chloride of iron or the actual cautery. If the cervix is very much altered, if 
 there is follicular hypertrophy, we have recourse to the operation of Schro- 
 der described below. 
 
 Cervical " ulcerations" are only a new growth of glands, more or less hy- 
 pertrophied, and are found only with deep inflammation of the mucous mem- 
 brane of the body of the uterus, as was shown a long time ago by Gosselin 
 in the reaction from the narrow doctrine which dissociated the two. Usual- 
 ly, to cure the ulcers it is enough to cure the endometritis. After curet- 
 ting v/e see the ulcers disappear as does the coating from the tongue after 
 vomiting, but this is true only of cases taken at the start. Later on, the 
 glandular proliferation becomes a settled lesion and requires for its cure 
 topical modification or removal by the bistoury. 
 
 As the first treatment of the ulceration, we must employ the curette; in 
 the second place come applications of nitrate of silver or tincture of iodine, 
 practised every second day. In America, weak nitric acid (not fuming) has 
 been much used, applied with a very small tampon of cotton on the end of a 
 handle; this caustic is preferred to chromic acid which has caused intoxica- 
 tion ; but all such energetic caustics may produce contraction of the cervix, 
 and I avoid them. The good effects of chloride of zinc have also been much 
 praised. Rheinstadter advises the hastening of the action of this caustic in 
 
TREATMENT OF METRITIS. 
 
 177 
 
 deep ulceration by making small punctures in the cervix. Hofmeier strongly 
 advocates acetic or pyroligneous acid. He encloses the cervix in a Fergus- 
 son's cylindrical speculum, pours in a certain quantity of the acid, and lets 
 the part soak for a few minutes, the gentle action of the caustic attacking 
 almost entirely the cylindrical epithelium and the ulceration. At the end of 
 a number of these seances the epithelium has become pavement, stratified, 
 and the ulceration is healed. The trouble may persist or reappear if it pen- 
 
 FiG. 141. — Uterine Dressing Forceps, Straight and Elbowed, for Removal of Polypi. 
 
 etrate within the cervical canal and the os be narrow. In such a case it is 
 advised to introduce the caustic into the interior of the cervix by tampons, 
 which I consider dangerous from the stenosis that may result ; in any case, 
 only the weakest caustics should be employed, and they but for a short time. 
 It is dangerous to attempt the cure of an old ulceration by caustics ; for thus 
 sclerosis of the cervix is produced, and cysts by the obliteration of the glan- 
 dular orifices. But when the ulcer is recent, cervical cauterization following 
 the use of the curette for the endometritis is excellent therapy, capable of 
 giving rapid and lasting success. This distinction is important. It has not 
 been made by Doleris and Mangin, who condemn every attempt at " epider- 
 mization," even for the purpose of hastening" the cure of a recent lesion. 
 
 When other means fail, or when the patient will not follow a treatment 
 which demands months, asking to be rapidly cured, even by operation, then 
 the surgical treatment is of great service. Excision of the affected mucous 
 membrane by Schroder's operation has given excellent results ; it substi- 
 tutes a healthy for a diseased membrane and permits the removal of parts 
 which have undergone cystic degeneration. It make no large scar and hence 
 is no obstacle to labor, as many observations prove. My practice is to do it 
 after curetting, in the same session. The operation is especially indicated 
 in the following conditions : in old ulcers of the cervix, with hypertrophy ; 
 in ulceration with stenosis of the canal ; in ulceration with deep laceration. 
 It is far superior to Emmet's operation, all of whose indications it fulfils. 
 
178 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Erosion Complicated by Laceration. — We know the capital role which this 
 condition plays in uterine pathology according to Emmet. His enthusiasm 
 has had the good effect of showing that the element of laceration, before neg- 
 ■ lected, is not, however, to be disregarded. Is it the previous inflammation 
 of the cervix which prevents the laceration from healing, as Schroder thinks, 
 or is it the laceration which provokes the catarrh and maintains the ulcera- 
 tion, as Emmet believes .-' I am inclined to fear that we have here one of 
 those vicious circles that are so frequent in general pathology. At any rate, 
 Emmet's operation, to which Dudley, of Philadelphia, has given the name 
 of "trachelorrhaphy," cannot be performed on an ulcerated cervix until it is 
 healed, or else we shut the wolf up in the sheepfold. Emmet lays down a 
 preparatory treatment which lasts months ; there is hence no comparison 
 between his and Schroder's operation: the latter is designed especially for 
 cervical catarrh, the former for nodular tissue due to laceration. For Em- 
 met the ulceration is only accessory, the main lesion being the sclerosis 
 which compresses vessels, nerves, and glands. For this reason I will de- 
 scribe trachelorrhaphy in the section on chronic metritis, since it is not a 
 question so much of the ulcers seen in catarrhal metritis as of the cicatrices 
 met with in the chronic form of the disease. 
 
 Lacerations, then, with extensive ulceration, demand excision of the 
 mucous membrane, or Schroder's operation, which insures prompt healing 
 and at the same time restores the external os better than trachelorrhaphy. 
 
 When the surface involved is not large, it may be caused to cicatrize by 
 the application of the actual cautery or simple caustic ; but this means, good 
 enough in mild cases, should not be used where the ulceration is extensive. 
 The granulation tissue so produced is in itself a pathological element- — a 
 fact which does not seem to have been grasped by those gynaecologists who 
 use and abuse the hot iron. 
 
 Hemorrhagic Metritis. — The treatment may be divided into two parts — • 
 for the bleeding, which is palliative but must be at once carried out ; and for 
 the disease itself, which should be curative. 
 
 Palliative Treatment for the HemorrJiage. — The patient is kept in the hori- 
 zontal position, and prolonged vaginal injections of very hot water should 
 at first be tried ; ergot is of very little use. Gallard has strongly advocated 
 digitalis, which he says influences the symptom and the inflammatory state 
 at the same time. He advises the infusion of the leaves (0.03-0.05 in 125 
 gm. of water), of which the woman drinks during the day by the tablespoon- 
 ful. A remedy which I have tried with good results is fluid extract of hy- 
 drastis canadensis, in thirty-drop doses thrice a day ; the medicine is also an 
 excellent stomachic. 
 
 E, Falk recommends hydrastinine as preferable ; it may be administered 
 by subcutaneous injections, which are less painful than those of ergotin. 
 This author reports twenty-eight cases in which he obtained satisfactory re- 
 sults. The drug should be given hypodermatically, employing half the con- 
 
TREATMENT OF METRITIS. 1 79 
 
 tents of a Pravaz syringe of a ten-per-cent solution (5 to 10 cgm. of hydras- 
 tinine). 
 
 Dilatation of the cervix or the introduction of a tent of laminaria wiii 
 sometimes stop the bleeding temporarily, but the respite obtained is short. 
 The action is due, no doubt, to contraction of the uterine body and to vaso- 
 motor reflex. 
 
 As to injection of perchloride of iron, the amelioration is only temporary, 
 whatever may have been published of cures from its use; the patients were 
 not followed long enough to prove any such assertions. 
 
 In case of persistent bleeding we may try vaginal tampons. I have re- 
 cently used successfull)^ a new mode of haemostatic tamponade, which I be- 
 lieve was first employed methodically by me. I use sterilized silk, either in 
 free strips or enclosed in a bag of silk. This material has appeared to me 
 to possess remarkable haemostatic properties, comparable to those of amadou. 
 
 I will next describe a palliative measure which has given good results 
 under Fritsch, and which I have seen Martin emplo}', viz., ligature of the uter- 
 ine arteries. It is done without incision into the vagina, by tying in mass 
 across the cul-de-sac (see p. 95). Fritsch recommends, for greater surety, 
 to make an incision on each side of the cervix, about 3 cm. long ; the first 
 branches met are two vaginal twigs, then more deeply the trunk of the uter- 
 ine ; both are tied. I do not hesitate to proceed thus in an urgent case. 
 
 The best haemostatic, and at the same time the curative treatment, is 
 curetting. It should be practised as soon as possible, according to the rules 
 already given, and be followed by an injection of perchloride of iron at 30° C. 
 The operation may be done while the bleeding is free; I have often seen it 
 at once arrested after the curettage, which I attribute not only to the de- 
 struction of the bleeding tissue, but also to the contraction of the muscular 
 fibres in the vessel wall provoked by the scraping. A single injection is 
 usually sufficient ; the cure is rapidly obtained. 
 
 There are certain rare forms called by the name of hemorrhagic metritis 
 in which all means fail and the bleeding persists, threatening the life of the 
 patient. In such a case the last resort is either castration, to produce an 
 artificial menopause, or vaginal hysterectomy, to remove the very source of 
 the hemorrhage. The exciting cause may be an unrecognized alteration of 
 the adnexa with a symptomatic pseudo-metritis. At any rate, this is our 
 only refuge when all other means remain powerless and it is a question of 
 the life of the patient. 
 
 Chronic Painful Metritis. — Local bleedings by scarification of the cervix 
 find here a frequent application ; not only is the immediate antiphlogistic 
 effect desired, but also the evacuation of the cysts, superficial and deep, which 
 are scattered over the surface of the neck of the uterus. As regards cau- 
 teri/ition with the hot iron and thermo-cautery, especially ignipuncture so 
 praised by certain authors, but the usefulness of which I doubt, I consider 
 them all inferior to puncture and scarification with the bistoury; the scars 
 
l8o CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 which follow their use tend to favor cystic degeneration, by adding to the 
 sclerosis and also to cause contraction of the canal, and compression of the 
 nerves, with the accompanying morbid reflexes. 
 
 It is very advisable to employ antiphlogistic dressings, consisting of a 
 coat of tincture of iodine, to the cervix, followed by a glycerin tampon to 
 which is added a very little iodoform. Some authors use a glycerin solution 
 of iodide of potash (5 : 100), but I see no real advantage in this. Ten per 
 cent of ichthyol may be added to the glycerin with great advantage, the drug 
 certainly having a marked analgesic effect. 
 
 The application of a simple glycerin tampon must not be confounded with 
 complete tamponing of the vagina, or its " columnization," as the Americans 
 say (page 66). I refer to the method recommended by Bozeman, and extolled 
 afterward by Taliaferro, which is in general use ; with many of the Ameri- 
 can gynaecologists it is the sovereign remedy for chronic metritis and the ex- 
 udations of perimetritis. The column of cotton (ordinary) which fills the 
 vagina is for the viscera what an elastic bandage is to a relaxed part (Engel- 
 mann). It gives a support to the uterus and ovaries, removes traction from 
 the ligaments, and provokes the absorption of plastic products. 
 
 Fallen, thinking that the cotton was insufficient, did not hesitate to fill 
 the vagina with clay. Reeves Jackson rejected the cotton, which was apt to 
 settle, and employed wool from which the grease had been removed, as being 
 more elastic. I am content, unless there is a uterine deviation, to place a 
 series of small pieces of glycerinated cotton carefully about the cervix in the 
 cul-de-sac, packing them lightly so that they form a ring like a pessary. The 
 best position in which to put the patient is the genu-pectoral, which permits 
 the ascent of the viscera and assures their final support. The tampons may 
 be left in place four or five days, if to the glycerin a little iodoform has been 
 added. The latter, it is true, may give rise to accidents if too long used ; 
 with the first signs of its absorption, such as malaise, headache, loss of ap- 
 petite, and alteration of the urine, it should be discontinued. But these evil 
 effects are never observed if it is used at intervals, with precautions against 
 constipation, which seems to me to play an indisputable role in predisposing 
 to its absorption. 
 
 Hot injections are often of great aid, in two conditions : in a chronic 
 metritis in which there is a complicating perimetritis, more or less pro- 
 nounced; and with very sensitive patients who complain of acute pain, as in 
 the case of what Lisfranc calls hysteralgia, chronic metritis without hyper- 
 trophy, and which Routh has termed the irritable uterus. In such cases I 
 have had excellent results, and cannot too strongly recommend this special 
 hot irrigation. 
 
 Good effects have been obtained with electricity; from this a bipolar ex- 
 citer is introduced into the uterus. 
 
 Massage has been much recommended in chronic metritis, as well as for 
 prolapse, displacement, and chronic perimetritis. There is a clear distinc- 
 
TREATMENT OF METRITIS. l8l 
 
 tion to be made between general massage, a kind of passive gymnastics, 
 which favors nutrition and can only be useful if practised with method; and 
 local massage, which claims to diminish congestion and volume by manipu- 
 lation of the diseased organ. This latter form consists in passing two fin- 
 gers into vagina or rectum, supporting the posterior face of the uterus, and 
 Avith the other hand above the pubis making gentle progressive pressure, like 
 a kind of kneading. In spite of the favor which this method enjoys in 
 Sweden, in spite of the good results published by Reeves Jackson, Runge, 
 Prochownik, etc., I have hesitated to employ this two-edged tool, which might 
 so easily cause some accident to the uterus or its adnexa. I will not, how- 
 ever, condemn a therapeutic measure which is espoused by prominent gynae- 
 cologists, and which I have not employed ; I merely reserve my decision. 
 There remain certain cases of chronic painful metritis, a great number of 
 them, for which all measures are powerless ; the cervix continues to be large, 
 swollen, hard, and mammillated in spite of all scarification, topical applica- 
 tions, and thermal cures ; the body is increased in size, heavy and painful on 
 ballottement ; the patients are so weak that the least walking tires them, all 
 exercise is troublesome. It is in these cases that surgery renders great ser- 
 vice by means of an operation which acts upon the cervix and reacts upon 
 the uterine body^ — namely, amputation. 
 
 Amputation of the cervix is always to be held as our last resort in all 
 cases of chronic metritis with hyperplasia. However, in cases of sclerosis 
 of the cervix it restores the calibre and suppleness of the external orifice and 
 stops the dysmenorrhoea caused by its rigidity and irregularity. 
 
 A complete contra-indication to the operation would be coexisting acute 
 perimetritis ; but I do not hold the same opinion where the inflammation is 
 old, with sequelae like adhesions, etc. There is always a fear that the ancient 
 focus will become active after even a perfectly antiseptic operation upon the 
 uterus, whether it be amputation of the cervix, curettage, or simply infra- 
 traction. We must then, if we do not altogether refrain from surgical in- 
 terference in such Cases, be on our guard, and search out beforehand any 
 focus in the adnexa or adhesions which may be present whence accidents may 
 result. 
 
 The operative technique has been perfected and at the same time simpli- 
 fied by the use of a cutting instrument. The fear of hemorrhage was natural 
 at a time when the operation was done laboriously at the bottom of the vagina. 
 Moreover, the fashion was to employ various haemostatic measures, like ex- 
 temporaneous ligature, the linear ecraseur, galvano- and thermo-cautery. 
 Previous compression with a ring of rubber, which many operators advise, 
 shows the same exaggerated prudence. When the operation is rapid, there 
 is but little bleeding, which the sutures arrest at once and completely; we 
 need, however, to tie them tightly and securely. 
 
 Every amputation by the ecraseur or the galvano-cautery has the fatal dis- 
 advantage of leaving a harsh cicatrix, with concentric contraction, ending in 
 
l82 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Stenosis. Other circular amputations with bistoury or guillotine have the 
 same defect, though to a less degree, and the bleeding is hard to stop. 
 
 The only amputations which are to be commended are those which allow 
 perfect coaptation and suture of the divided mucous membrane, with the for- 
 mation of an orifice not liable to contract. Two procedures of this kind 
 may be adopted according to special indications: (i) amputation with two 
 flaps for each lip, or (2) with but one which may be so graduated as to become 
 only an excision of the internal mucous membrane. 
 
 Amputation of the Cervix zvitk Double Flaps — Conical Excision. — This 
 procedure, suggested by Simon, generally bears the name of Marckwald, who 
 
 was the first to describe it methodically. It 
 is to be preferred when the internal mem- 
 brane of the part is not affected and does not 
 need to be removed. 
 
 The following is a short description of the 
 technique : Anaesthesia ; lithotomy position ; 
 fourchette depressed by an assistant with a 
 short speculum; continuous irrigation made 
 with small stream by the assistant who holds 
 the fixing forceps, either with Fritsch's irriga- 
 tion speculum or a long canula. Division of 
 the cervical commissures with a convex bis- 
 toury of large size or strong scissors. The 
 
 Fig. 142. — Amputation of the Cervix with Double Flaps (Simon). A , Sectional view showing lines of inci- 
 sion for formation of flaps and method of suture. B^ Front view of cervix, operation complete. 
 
 incision of the anterior lip goes deeply through the internal surface, 
 obliquely from below upward; the second, through the anterior mucous 
 membrane, joins the other so as to form a conical segment of the an- 
 terior lip, its base below, its apex above. Suture of the two lips thus 
 formed with a sharp needle, threaded with wormgut, taking care to pass it 
 under the whole bleeding surface ; five or six points are necessary. The 
 same mancijuvre on the posterior cervical lip, after removal of the fixing for- 
 ceps, using the first sutures to depress the organ. Suture of the commis- 
 sures by one or two points. Cutting of the threads, vaginal irrigation, uterus 
 restored to its place, iodoform tampon (Fig. 142, A, B). 
 
TREATMENT OF METRITIS. 
 
 183 
 
 At the end of three days the tampon may be withdrawn, and antiseptic 
 irrigation practised morning and evening (i : 2,000 bichloride). It is neces- 
 sary to keep the patient in bed during at least fifteen days. The sutures are 
 then removed. 
 
 This operation is easier of execution than Hegar's, which differs in the 
 absence of the first step, the incision of the commissures ; as to the method 
 of Sims, in which the vaginal mucous membrane alone is sutured above the 
 wound, that was considered an improvement when it appeared, but it is now 
 superseded. 
 
 Ampittatiou of the Cervix with Single Flap. Excision of the Mucous 
 Membrane. ScJiroder s Operation. — .This is especially applicable to the ca- 
 
 FiG. 143. — Amputation of the Cervix by one Flap or Excision of the Mucosa (Schroder's Operation). 
 A^ Showing method of placing the sutures; i and 2 are those uniting the commissures. B, Section showing shape of in- 
 cisions and (b c) line of suture. C, Shows position of lips after suturing. 
 
 tarrhal form, in which there is rebellious ulceration and follicular de- 
 generation more or less deep; but it may be adopted in any chronic 
 metritis in which from the shape or consistence of the cervix it is more 
 convenient. 
 
 This operation of Schroder's is coming rapidly into favor elsewhere, and 
 is beginning to be adopted in France, where I was one of the first to prac- 
 tise it. 
 
 Its execution is a little more difficult than the preceding. The cervix is 
 made accessible and the bilateral incision made as above ; from that we pro- 
 ceed as follows : Transverse incision of the internal mucosa and semicircular 
 incision of the external, forming thus a layer of tissue which is dissected 
 from without till the internal transverse incision is reached and the layer 
 is wholly detached ; the thickness of this varies according to the alteration 
 of the tissue. Infolding, entropion, of the lip thus formed and suture in- 
 
1 84 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 ternally by five or six points with catgut, the needle being passed below the 
 whole bleeding surface ; two or three auxiliary sutures superficially placed. 
 The same dissection and suture of the posterior lip, the cervix being held 
 firm by the threads already passed. Suture of the commissures, etc., as above 
 
 (Fig. 143). 
 
 At times there may be an advantage in making the twofold incision on 
 one of the cervical lips and the single one on the other. Bouilly extols an 
 operation which has given him thirty-nine successes in forty cases of inveter- 
 ate glandular cervical metritis. He dilates the cervix and cavity of the 
 body of the uterus with a laminaria tent ; then, after having curetted the 
 body, he removes from each lip of the cervix, by means of a long straight 
 bistoury, a strip of mucous membrane 2, 3, or 4 mm. thick according to cir- 
 cumstances. In order to prevent contraction these grooves do not join lat- 
 erally, a little normal mucosa being left at each side. A wide opening and 
 a dilated canal are in this way obtained. The canal is packed with iodoform 
 gauze soaked in creosote in glycerin, i to 3. 
 
 The cases of cervical endometritis to which Bouilly applies this operation 
 seem to me to be usually the result of a true mucous obstruction of the cer- 
 vix caused by the contraction. I prefer to treat these cases by a free bilat- 
 eral incision, which gives easy access to the mucous membrane and facilitates 
 its treatment by ordinary means. It is well also to precede the operation by 
 a curetting of the body where the mucous membrane is always somewhat 
 altered. I prefer to do this after the amputation, so as not to be disturbed 
 by the bleeding, and to operate on the part while it is not shrivelled by the 
 perchloride. 
 
 Emmefs Operation. Trachelorrhaphy. — As I have said, this should yield 
 to Schroder's operation whenever with cervical laceration there is also cervi- 
 cal catarrh. Emmet's operation, then, should be saved for chronic metritis 
 without erosion of the cervix. One might then hope, by removing cicatricial 
 tissue and restoring the normal shape of the part, to cause the disappear- 
 ance of the pains and irritation; all the more, because the trauma of the cer- 
 vix usually promotes involution of the body of the uterus, an important fac- 
 tor in the success obtained. 
 
 The patient is anaesthetized and the assistants are disposed as before; 
 the cervix is seized with forceps; one forceps catches the anterior lip close 
 to the laceration, the other is placed opposite, symmetrically ; then the bor- 
 ders of the laceration are dissected out in a single piece, being careful to 
 reach the depth of the angle and to remove all the cicatricial tissue (Emmet), 
 The wound is then equalized, if necessary, by curved scissors. The first 
 suture is then passed with a strong curved needle near the angle of the 
 wound, piercing the thickness of both sides 2 mm. from the external sur- 
 face and I mm. from the internal, and each suture is tied at once to secure 
 perfect coaptation of the parts. Four to eight sutures are thus passed. I 
 use silkworm-gut for the sutures. I have long employed catgut, but have 
 
TREATMENT OF METRITIS. 185 
 
 abandoned it, for it often becomes softened and gives way, allowing separa- 
 tion of the flaps. 
 
 Lately, under the influence of Lawson Tait, there has been a reaction 
 against any loss of substance in plastic operations. Applying the principle 
 of the flap-splitting operations to trachelorrhaphy, Sanger and Fritsch ad- 
 vise the following : Excision of the superior angle, then partial splitting of 
 the lips of the laceration by an incision from above downward, and suture at 
 the external surface alone. I consider this procedure defective, as it does 
 not remove the cicatricial tissue, which it is especially important to excise 
 
 Fig. 144. — Emmet's Operation. This cut shows the common fault of insufficient denudation at the angle of the 
 
 laceration. ] 
 
 with great care. An iodoform tampon left in place three days is all the 
 dressing needed. After this, antiseptic vaginal irrigation morning and even- 
 ing, and rest in bed for two weeks. 
 
 When the laceration is bilateral it is almost impossible, in doing a 
 trachelorrhaphy on both sides, to avoid narrowing the cervical canal. I there- 
 fore prefer Schroder's operation, which is in these conditions more expedi- 
 tious and permits thorough removal of the sclerosed tissue. 
 
 After any procedure of this kind it is well to explore the cavity of the 
 uterus with a curette, and, if anything soft and friable is found, to do a com- 
 plementary curettage, which does not complicate the principal operation. 
 
 There are fevv^ operations which have had such passionate partisans and 
 detractors as trachelorrhaphy. While certain authors have accused it of pro- 
 ducing sterility and of complicating labor, others have extolled it as a rem- 
 edy against this very sterility, while some have not hesitated to do it on 
 pregnant women, demonstrating at least by their boldness the harmless na- 
 ture of the procedure. 
 
 To me it seems certain that the operation, well done, need have no bad 
 
1 86 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 results, though it has no advantages ; it is probably often done unneces- 
 sarily. 
 
 [I cannot wholly agree with the author in his statements concerning Em- 
 met's operation, which has the manifest advantage of restoring the cervix 
 to its natural ante-partum condition instead of removing it by an amputation. 
 Each method has its own indications, and trachelorrhaphy is to be reserved 
 for cases with deep cervical tears with slight glandular or parenchymatous 
 hyperplasia and endometritis, or with symptoms dependent on nervous re- 
 flexes. Then the operation as shown in Fig. 145 will be sufficient; care 
 
 being taken to denude thoroughly, 
 removing all the diseased tissue, 
 and to unite the surfaces accurately;, 
 denudation and union of the edges 
 only, as shown in the author's dia- 
 gram (Fig. 144), being carefully 
 avoided. 
 
 Denudation may be accomplished 
 by scissors or scalpel, the patient 
 being in the Sims or lithotomy po- 
 sition, the cervix being steadied by 
 
 [Fig. 145. — DiAGR.\M Showing Area of Denudation 
 AND Arrangement of Sutlres in Emmet's Operation 
 (Trachelorrhaphy).! 
 
 [Fig. 146. — Appearance of Cervix .\fter 
 Sl'tures are Tied.] 
 
 tenaculum, and excessive downward traction being avoided. Sutures may 
 be of silver wire (No. 27), or of silkworm-gut, silk, or chromicized or 
 juniper catgut. They may be removed in ten days, the patient getting up 
 about the fourteenth. Careful antisepsis.] 
 
 The various plastic operations on the cervix, amputation, resection, su- 
 ture of lacerations, do not diminish the dilatability of the part, for they heal 
 by primary cicatrization without the formation of inelastic tissue. Many ob- 
 servers agree on this theoretic point, and prove that there is no need to fear 
 sterility or dystocia. 
 
 Is castration a legitimate operation in metritis.' I do not hesitate to an- 
 swer in the negative. Castration owes its unquestionable success, not so 
 much to the fact that it was done for disease of the uterus as for character- 
 istic alterations in the adnexa (peri-oophoritis, perisalpingitis), in cases of 
 
TREATMENT OF METRITIS. 18/ 
 
 old or badly treated metritis. In such cases the metritis occupies the second 
 place, and the treatment relates more especially to the complication which 
 has become the principal disease. But to practise a castration with removal 
 of both ovaries and tubes on the sole indication of excessive pain during the 
 menses, to establish thus an artificial menopause, seems to be too extended 
 an application of the operation. In a number of the reported cases all the 
 measures of conservative surgery do not appear to have been exhausted be- 
 fore reaching an operation which, if legitimate, is hardly indispensable. 
 
 Pean has often performed vaginal hysterectomy, which he calls uterine 
 castration, for painful metritis accompanied, as he says, by the morbid state 
 described as utero-ovarian neuralgia, which has resisted all medication. In 
 such cases he has seen ovarian castration by itself permit the pains to con- 
 tinue, as if the uterus were a centre from which reflexes started independent 
 of those which take their birth in the adnexa. On the contrary, where he 
 has removed the uterus and left the adnexa, the results have been more sat- 
 isfactory. Pean, then, desires to substitute vaginal hysterectomy for Battey's 
 operation in cases of chronic and painful inflammation of the utero-ovarian 
 apparatus ; he recognizes that after ablation of the uterus, however, one may 
 be obliged to open the abdomen to remove the altered adnexa, which are 
 difficult to reach by way of the vagina. It does not seem to me proven that 
 the secondary operation has not a right to precede the principal one, which 
 it has often rendered needless. Vaginal hysterectomy has been performed 
 many times by other surgeons for rebellious hemorrhagic or painful metritis; 
 and it has certainly been abused. The most recent researches demonstrate 
 that every hypertrophic glandular metritis which has resisted curetting for 
 many months ^hows thereby its tendency to become an epithelioma. These 
 growths are styled adenoma in Germany, and form the transition between 
 hyperplasia (benign adenoma) and cancer (malignant adenoma). Exploration 
 by the curette is not always sufficient to remove doubt, for we are not able 
 thus to examine the glands in all their depth. We must in such a case give 
 the most weight to the clinical signs ; in any case we may well be cautious 
 about operating for a cancerous tendency in metritis when there is no actual 
 degeneration present. 
 
CHAPTER VIII. 
 
 UTERINE FIBROMATA. 
 
 Pathology. — To those tumors of the uterus which have the same structure 
 as the uterus itself, the narnes of fibrous body, fibrous tumor, myoma, fibroma 
 fibro-leiomyoma, fibroid, and hysteroma have been given. They are usually 
 benign, that is to say, incapable of becoming general and infecting the or- 
 ganism ; but, while the greater number of them may exist unnoticed, causing 
 
 Fig. 147. — Small Interstitial Fibkoid. «, Hyper- 
 trophied uterine wall; it, fibroid; c, uterine mucosa show- 
 ing the lesions of endometritis with polypoid vegetations. 
 
 Fig. 148. — Submucous Pediculated 
 Fibroid. 
 
 only a hidden deformity or a slight infirmity, there are many which are of 
 more serious import, and which may lead to conditions resulting in death, 
 
 Histogeny. — Velpeau, and after him a number of others, attributed the 
 development of fibromata to the presence of a "drop of blood, plastic lymph, 
 or even pus" in the uterine tissue. The spontaneous organization of coagula 
 after ligation of arteries suggested the idea that the same process might re- 
 sult in the formation of these neoplasms. But experimental study has de- 
 monstrated that this organization of coagula is nothing but an ingrowth of 
 the elements of the vessel wall, and thus this edifice of theory, founded on 
 lack of observation, collapses altogether. 
 
 Klebs asserts that these fibrous tumors have their origin in a prolifera- 
 tion of the connective tissue and the muscular layers of certain vessels; the 
 different nodules thus formed become aggregated to make one tumor. Klein- 
 
UTERINE FIBROMATA. 
 
 189 
 
 wachter describes the evolution of fibromata as due to a round cell which is 
 found along the capillaries and produces a partial obliteration of them ; these 
 cells then become fusiform and produce the nodules. Gottschalk, as the 
 result of the examination of small fibroid nodules, thinks that all fibromata 
 originate by an endarterial proliferation rapidly followed by an increase of the 
 
 Fig. 140. — Submucous CEdematous Fibroid with Hypertrophy of Uterine Wall. 
 
 cellular elements surrounding the artery. Local irritation and circulatory 
 disturbances would be the principal agents in this pathological process. Our 
 knowledge of this subject is very limited. 
 
 These neoplasms are very frequent ; according to Bayle, who described 
 certain anatomical features of them in 1813, a fifth of all women over thirty- 
 five have fibromata. 
 
 The number is very variable ; certain uteri present an enormous number 
 of interstitial or pediculated nodules. Most frequently there are three or 
 four distinct tumors ; at other times there is but one. Though clinically 
 there may appear to be but one, not rarely there is another in the thickness 
 or on the surface of the organ, which either may remain latent indefinitely 
 or may finally develop ; this fact is often demonstrated at laparatomies. 
 
 These tumors may reach very large proportions, and then often become 
 fibro-cysts. Stockard found one, in a negress, that was colossal, weighing 
 one hundred and thirty-five pounds. Even the solid tumors may be as large. 
 Hunter, of New York, recently observed one that weighed one hundred an4 
 forty pounds, while the cadaver after its removal weighed but ninety-five. 
 
190 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 The body of the uterus is more often affected than the cervix. The tu- 
 mor's position relative to the unterine tissues permit us to distinguish the 
 followina: varieties : 
 
 Fig. 150. — Subperitoneal and Ixterstitiai, Fibroids of the Fundus of the Uterus. (The incisions are to 
 
 show the multiple nodules.) 
 
 1. Interstitial, in the thickness of the (usually hypertrophied) muscular 
 parenchyma. 
 
 2. Submucous, immediately or nearly below the mucous membrane. 
 
 Fig. 151. — Intf.rstttial Fibroid of the Body of the Uterus. 
 
 3. Polypoid, or pediculated, hanging from the mucous membrane by a 
 stem or fold of the mucosa, with muscular fibres and vessels. 
 
 4. Subperitoneal, external to the muscular tissue, with a broad base or 
 
UTERINE FIBROMATA. 
 
 191 
 
 with a narrow pedicle; it is well not to speak of these as polyps, even though 
 the}' may resemble them, but keep that name for those which are found within 
 the cavity of the organ. An important sub-variety is the intraligamentous, 
 developing in the thickness of the broad ligament, which will be described 
 with tumors of the cervix. 
 
 Whatever may be the seat of the fibroma, it provokes a constant but vary- 
 ing degree of uterine hypertrophy. 
 
 The muscular wall increases in such a way as to encapsulate a number of 
 tumors as a single mass ; the muscular layers then resemble those of the 
 
 Fig. 152. — Uterine Poi.vp F.xpelled ixto the Vagina bct Preserving the Triangular Form of the 
 
 Uterine Cavitv. 
 
 gravid uterus, often being continued far into the broad ligaments, which be- 
 come thickened and fleshy. A large vascular development generally accom- 
 panies this hypertrophy. 
 
 The increase in the volume of the uterus, caused by the continual con- 
 gestion of which the neoplasm is the focus, might be compared to that which 
 occurs in the first n.onths after fecundation ; for which reason the name fib- 
 rous pregnancy (grossesse fibreuse) has been proposed by Guyon to designate 
 the fact. Even small fibromata are sufficient to produce the condition (Fig. 
 147). The uterine cavity is found much enlarged by the eccentric hyper- 
 trophy, and also, in part, by the traction of the mass which hangs from the 
 fundus of the organ. 
 
 Fibroviata of the Cervix. — Fibrous tumors of the ceiwix deserve a special 
 paragraph ; they are found in the same positions and could be classified as 
 other fibroids; but the division of the cervix into two distinct regions, the 
 supra- and the subvaginal, makes another classification necessary. 
 
 A. Fibromata of the External Os. — Whether submucous or interstitial. 
 
192 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 they give to the lip involved a cylindrical and elongated form (Fig. 154). 
 The submucous tumors of the cervical canal occasionally take on a peculiar 
 polypoid form, of which I have observed examples. They descend into the 
 vaginal canal in the form of slender stalactites or like the drops from a torch, 
 forming a kind of sheaf which appears at the external os and is attached by 
 a circular or semicircular base at the level of the isthmus or often much 
 lower. I have seen a submucous cervical fibroma make a projection in the 
 
 interior of the dilated cervix like a 
 plaited collar round the internal ori- 
 fice. At other times these little 
 polypi contain a layer of glandular 
 tissue, newly formed, and have a 
 papillary or mulberry appearance: 
 
 (Fig. 155)- 
 
 Exceptionally a fibroma within, 
 the uterine wall may descend intO' 
 one of the lips of the cervix by a 
 kind of splitting process. 
 
 B. Fibromata of the Siibvaginal 
 Portion. — The only forms in this 
 class which deserve special mention 
 are those which are developed from 
 the external surface of the region,, 
 and so find themselves at once between the layers of the pelvic floor. 
 They usually develop behind the cervix, raise the pouch of Douglas, 
 and come into contact with the posterior wall of the vagina and the 
 rectum. They often pass between the layers of the broad ligament, con- 
 stituting one of the most dangerous of the intraligamentous varieties. They 
 may even exceed these limits, crowding in anteriorly between the bladder 
 and the uterus, and pushing prolongations as far as the iliac mesocolon. Im- 
 prisoned by their attachments in the narrow enclosure of the bony pelvis, 
 which is itself inextensible, they give rise to the most serious symptoms by 
 compression. I have proposed to name them " pelvic fibromata." 
 
 Connection of Fibro2is Tumo7's zvith the Uterine Tissue. — Fibrous tumors 
 have usually an investment of loose cellular tissue which forms a capsule, 
 out of which they can be shelled without much effort. This arrangement is 
 sometimes so well marked that, as soon as the capsule is incised, the tumor 
 projects strongly, under the influence of the muscular contraction; but more 
 often the fibroma, instead of being encased in the uterine parenchyma like 
 a foreign body, is held in place by the fibrous bands, more or less dense, by 
 .which its vascular connections are established. There are also rare cases 
 in which there is no more demarcation between tumor and uterus than a local 
 thickening at its periphery. In general, the softer the tumor the fewer its 
 connections with the neighboring tissues. 
 
 Fig. 153. — Subperitoneal Pediculated Fibroid. 
 
UTERINE FIBROMATA. 
 
 193 
 
 Stnuttcre and Texture. — To the naked eye, uterine fibromata are formed 
 of dense tissue, shiny or rosy white, elastic, giving a very clean surface on 
 section, sometimes unequally convex, as if the middle portions were com- 
 
 FiG. 154. — Interstitial Fibroid of the Posterior Lip of the Cervix. 
 
 pressed by the superficial layers, generally more closely packed. One can 
 at times distinguish on the surface, with the aid of a glass, the intercrossing 
 loops of fibres and the vortices, which look 
 as if the fibres were rolled about many differ- 
 ent axes (Fig, 157). 
 
 The vessels are relatively few; but in 
 tumors of great size we do see them, su- 
 perficially, under the peritoneum or in the 
 capsule, and I have observed in one case a 
 vessel of the broad ligament which was as 
 large as the brachial and had given a loud 
 bruit with a thrill. The peripheral veins 
 then are of the size of the jugular, adherent 
 on all sides to the muscular bundles, which 
 hold them wide open. When this arrange- 
 ment is very well marked and the tumor is 
 hollowed by vascular lacunae, due to the 
 dilatation of the capillaries, we have the 
 form which Virchow calls " teleangiectatic 
 nosum" ; the portions thus degenerated resemble a sponge soaked in blood. 
 
 In polypi the pedicle sometimes contains large arteries. They present, 
 however, a thickness of their walls and a contractility which, joined to the 
 elasticity of the pedicle itself, secure a rapid, spontaneous haemostatic action 
 
 Fig. 155. — Small Muriform Polyp of 
 THE Cervix. (Papillary fibroma with glandu- 
 lar hypertrophy. Ackermann.) 
 
 myoma," or " myoma caver- 
 
.194 
 
 CLINICAL AND OPERATIVE GYNECOLOGY, 
 
 as soon as they are cut off. The spaces which separate the different layers 
 are considered by Klebs to be lymph channels. 
 
 Ners'es have been followed into these tumors by Astruc and Dupuytren ; 
 Bidder has demonstrated them anew, and Hertz has described their mode of 
 termination in the nuclei of the smooth muscular fibres. On microscopic 
 section fibromata present smooth muscular fibres and connective tissue in 
 varying proportion. According to Ch. Robin, the muscular fibres are always 
 in the minority, perhaps as high as half and at times as low as one-tenth. 
 
 Fig. 156. — Intraligamentous Fibroma. ^4, Abdominal variety. j5. Pelvic variety. 
 
 As one or the other predominates, the tumor is called a fibroma, a myoma, 
 or a fibromyoma. These terms are not exact but relative, for almost always 
 the two elements are mixed. Gusserow proposes to distinguish them as 
 hard, where the connective tissue is in excess, and soft, composed chiefly of 
 muscular fibres ; the latter form is seldom entirely encapsuled and is more 
 vascular. On section we see the fibres cut transversely, obliquely, or longi- 
 tudinally. The first are easily distinguished by the fusiform aspect of their 
 elements and the characteristic nuclei which look on cross section like a mo- 
 saic ; this appearance must not be confounded with that of round cells. Be- 
 tween the bundles there are fibrous layers of unequal thickness which cross 
 in all directions ; they are partly connective tissue, poor in cells, and partly 
 fusiform bodies prolonged longitudinally (Fig. 158). 
 
 Connections with Neighboring Organs. — When a fibroma with a broad 
 base grows from some free portion of the uterus (fundus, anterior or poste- 
 rior surface), it extends into the abdominal cavity above the superior strait 
 and floats among the intestines ; the uterus is then drawn upward, the cervdx 
 is thinned and elonfrated. 
 
UTERINE FIBROMATA. 
 
 195 
 
 If its point of attachment is narrow, the tumor may fall backward into 
 the pouch of Douglas and become fixed. When it is of large size and not 
 bound down by adhesions, it jolts about in the abdomen, irritating the peri- 
 toneum till it provokes an exudation, at times liquid, at times plastic, which 
 forms adhesions. This ascites is generally abundant and of a yellow color, 
 rarely tinged with blood, except with malig- 
 nant tumors. A form of ascites has been 
 observed to which the name " chylous" has 
 been given ; it is probably due to a trans- 
 formation to fatty granules of a fibrinous 
 exudation. 
 
 Adhesions when present are usually with 
 the great omentum or the intestine ; a loop 
 of the gut may be so fused with the surface 
 of a fibroma as to defy all dissection. These 
 adhesions become then the principal source 
 of derangement of nutrition, and the pedicle 
 may become so thin that the tumor ceases 
 to grow. It may even break off and lea\-e 
 
 . r 1 ^"^- ^57- — Uterink Fibroid. Section 
 
 the fibroma independent or the uterus and showing the disposition of the fibres to the 
 grafted on some part of the pelvic circum- "^^^'^^y<^- 
 
 ference. Huguier and Nelaton have reported cases of this kind. Depaul 
 found a fibroma entirely free in the cul-de-sac of Douglas ; such a case 
 may be explained by the rupture of the pedicle with absence of adhesions. 
 
 Elongation or torsion of the pedicle may cause various changes in the 
 nutrition of the tumor, with consecutive degenerations. 
 
 Alterations and Degenerations. — At the menopause most of the fibromata 
 undergo a progressive induration ; at the same time they diminish in volume 
 and the uterus may present a senile involution and atrophy; the tumor still 
 persists, but without causing any morbid reaction : this is the condition of 
 most of these tumors, not recognized during life and found for the first time 
 at the autopsy of aged women. 
 
 Calcification is an unusual change. It is not an ossification, as the older 
 authors thought; the deposits of carbonate of lime are foundtoward the mid- 
 dle of the tumor, sometimes partially, sometimes completely converting it 
 into a uterine stone. We observed this but rarely in the pedicled subserous 
 form or in polypi, which may then become free and be expelled spontaneously. 
 This fact has been known since the days of Hippocrates, and the Academy 
 of Surgery has collected a number of such cases. 
 
 Softening may result from various causes. During pregnancy the tu- 
 mors acquire a considerable volume, sharing in the exaggerated nutrition of 
 the uterus. Thus swollen with juices they are usually very soft; after labor 
 and by a process attributed a little hypothetically to a fatty degeneration, 
 they may gradually disappear, taking part in the uterine involution. Differ- 
 
196 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 ent authors have cited many cases of this regression and I have observed 
 it in one very remarkable instance ; the pregnancy, intervening during a ther- 
 mal treatment for a large fibroma, had doubled the size of the tumor; the 
 labor took place without accident, and the fibroma disappeared completely, 
 leaving no traces. 
 
 The fatty degeneration, as so justly remarked by Gusserow, has never 
 been proven by the microscope, except in two cases, in which there was no 
 diminution in the size of the tumor as the result. Amyloid degeneration 
 has been found in one instance by Stratz, a unique case up 'to the present. 
 CEdema, which is often the first stage of gangrene, may be the cause of the 
 softening. 
 
 Colloid or myxomatous degeneration, according to Virchow, is character- 
 ized by the effusion of a mucous fluid between the muscular bands. It is. 
 
 mm 
 
 mm 
 
 Fig. 158. — Uterine Fibromyoma. ^Microscopic view. 
 
 distinguished from simple oedema by the presence of the mucin and the 
 proliferation of nuclei and small round cells in the interstitial tissue. The 
 formation of fibrocystic tumors may succeed these degenerations when the 
 bands which separate the small cells from the oedema are destroyed. There 
 are no distinct walls in these cysts, as they are formed simply from the 
 lacunae of the tumor tissue. 
 
 Other fibrocystic tumors have a very different origin and belong in a 
 special pathological class. These cysts are formed in pre-existing cavities, 
 in dilated lymph spaces comparable to the similar dilatations which the 
 blood-vessels may present. The fluid which they contain is limpid and 
 coagulates on contact with the air. Leopold has termed these tumors " lym- 
 phangiectatic myomata." It must be noted that this lymphatic origin of 
 certain cystic tumors of the uterus had already been clearly formulated by 
 Koeberle. Their formation seems to be due to the development of part of 
 the tumor along the path of the lymph-vessels contained in the broad liga- 
 ment. On the internal surface of such tumors we can demonstrate an epi- 
 thelial investment which distinguishes them from simple cavities formed 
 
UTERINE FIBROMATA. I97 
 
 from softening of the neoplasm or apoplexy into its substance. There are 
 also mixed forms in part vascular and in part lymphatic. 
 
 We must be careful not to confound these tumors of the uterus with either 
 the intraligamentous ovarian cysts, which are very adherent to that organ, 
 or with the serous accumulations found at times in foci of peritonitis about 
 the uterus ; the mistake seems to have been more than once committed. 
 •Certain forms of pseudo-cysts are produced in the foci of molecular fatty dis- 
 integration at the centres of large tumors where the nutrition is impeded. 
 There can be no gangrene because of the absence of germs ; it is then a 
 necrobiosis, with the formation of soft masses, which later may fall into 
 <ieliquescence and fill the cavity with more or less dense fluid. Hemorrhages 
 are often added to dilute the contents of the cyst and increase their size. 
 These have been known to rupture into the uterus. In certain of these rare 
 cases, the uterine orifice may be obliterated by the elongation of the cervix, 
 the partial rotation of the organ, and a certain degree of inflammation, and 
 thus is formed a peculiar form of haematometra. W. A. Meredith has re- 
 ported a remarkable case of this condition which was cured by supravaginal 
 hysterectomy; the morbid mass weighed fifteen pounds and contained five 
 pounds of blood. Dubreuil has punctured and drained, in a woman of sixty- 
 five years, an haematometra that simulat'ed a fibrocyst, due to obliteration of 
 the neck of the uterus containing a fibroma ; this incomplete operation was 
 followed by death. Tillaux has published under the name " cystic uterus" an 
 analogous case, which was cured by abdominal hysterectomy. These cases 
 are usually found in aged patients, in whom the cervix has a tendency to 
 become retracted and obliterated under the influence of senile atrophy. 
 
 It is evident, then, that from an anatomical point of view these tumors 
 do not form a natural group of myo- and fibrocysts ; for they may take their 
 origin from : (ist) closed spaces, resulting in dilatation of the lymphatics, or 
 lymphangiectasis ; (2d) oedematous or myxomatous infiltrations, in their high- 
 ■est development ; (3d) lacunae (geodes) formed at the centre of myomatous or 
 sarcomatous tumors by disintegration of their tissue. Apoplectic foci may 
 ■complicate either of these different varieties. 
 
 Injlaimnatioji; Siippiimtion; Gangrene. — It is probable that the starting- 
 point for inflammation in fibrous tumors is always a mortification, more or 
 less extended, which infects the capsule and sets up a suppuration in the zone 
 where the tissue is both more lax and more vascular. This initial mortifica- 
 tion may be due to surgical interference, which has opened the seat of the 
 fibroma with a therapeutic object, or to an infection from outside following 
 septic exploration (dilatation, sounding, etc). ; or, finally, it may come from 
 compression and obliteration of the nutritive vessels of the tumor, with chaf- 
 ing of the mucous membrane which covers and protects it against the en- 
 trance of germs. The latter mode of origin is especially frequent in polypi. 
 Finally it may occur suddenly through torsion of the uterus on its axis below 
 the insertion of the tumor. If it is true that a mortification of a small part 
 
198 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 of the tumor, interstitial or submucous, precedes inflammation and suppur- 
 ation, it is due, on the other hand, to the agency of this, in its turn, that the 
 whole mass becomes gangrenous, and separates, by an actual dissection, from 
 the adjacent tissues. 
 
 The sphacelated portions are eliminated spontaneously or by the aid of 
 art ; or they may produce a putrid infection. The pus may spread itself out 
 in the pelvic cellular tissue. G. Braun reports a case in which the pus^ after 
 
 Fig. 159. — Pedici:lated Firkoid \vith Aidominal Evolution (Schroder). .MS, Fibroid lobe; .l/C, Fibro- 
 cystic lobe. 
 
 distending the uterine cavity, discharged by the external os and also through 
 the inguinal region. Orthmann performed an unsuccessful laparatomy on a 
 woman in whom a suppurating fibroma had perforated the posterior uterine 
 wall and caused peritonitis. 
 
 Cancerous Degeneration. — Can a carcinoma arise from a fibroma .'' Simp- 
 son maintained that the irritation produced by a fibroma invited the forma- 
 tion of malignant neoplasm ; to-day we express the same idea by saying that 
 its presence constitutes a locus minoris resisientics, producing the local de- 
 termination of the diathesis. Recent researches allow us to form a definite 
 idea of the process. It is probable that in certain cases it is the chronic in- 
 
UTERINE FIBROMATA, I99 
 
 flammation which involves the mucous membrane and is the constant accom- 
 paniment of fibromata, which first causes a proliferation of the glands; this, 
 at the beginning of a typical form (adenoma), passes to the atypical and be- 
 comes epitheliomatous. E. Wahrendorff collected in Schroder's clinic four 
 such cases which seem conclusive. A second way in which cancer may 
 arise from a fibroma is by sarcomatous degeneration of the framework of the 
 tumor, which is little by little infiltrated with round cells until the muscular 
 fibres disappear. It is also possible that these myosarcomata undergo a cys- 
 tic transformation either by softening and hemorrhages or by distention of 
 the lymph spaces. There is then a sarcomatous variety of fibrocyst. [Wil- 
 liams states that fibromyomata may be transformed into sarcomata either by 
 the proliferation of the connective-tissue cells between the muscle bundles, 
 or by the proliferation of the muscle cells themselves, or possibly by a com- 
 bination of both processes, the first giving rise to ordinary sarcomata and the 
 second to muscle-cell sarcomata.] 
 
 As to the degeneration of a fibroma into carcinoma Virchow admits it 
 in principle, but it is evident from Gusserow's inquiry into the subject that 
 it is far from being demonstrated. The observations cited to prove the point 
 have to do generally with cancer invading the uterus by the side of a fibroma, 
 which is a very different thing from the pathological and pathogenic stand- 
 point, however much like it it may be clinically. C. Liebmann has lately 
 published a case in which it seems certain; there was also cancer of both 
 ovaries. 
 
 Ehrendorfer has operated upon a woman of fifty-four for a polypus of the 
 cervix, which presented, besides the classical characteristics of a fibromyoma, 
 a carcinomatous degeneration. No other carcinomatous focus existed in 
 the uterus. 
 
 The association of cancer of the cervdx with fibroma of the body is not 
 infrequent. 
 
 Adjacent and Distant Lesions. — Wyder and von Campe have shown that 
 in almost all cases of fibroma there is present also an endometritis : the mu- 
 cous membrane of the uterus suffers a glandular or interstitial hyperplasia. 
 Wyder has observed that the former is found almost exclusively where the 
 tumor is at a distance from the uterine cavity, and the interstitial occurs 
 with those but little removed from the mucous membrane; occasionally we 
 encounter a mixed form, which Olshausen calls " endometritis fungosa." 
 These lesions explain the symptomatic hemorrhages of fibromata. 
 
 According to O. Semb, certain secondary changes" (pressure occasioned 
 by the neoplasm, concomitant inflammations) may cause a complete disap- 
 pearance of the initial hypertrophy at an advanced period in the evolution 
 of a myoma. 
 
 It is certain also that there exists in some cases an endosalpingitis by 
 propagation ; for a times, in hysterectomies and castration for fibroma, the 
 tubes are found flexuous and full of blood. Complicating abscess of the 
 
200 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 ovary and also chronic salpingitis have been noted. Rose, in the course of 
 a myomotomy, discovered one of these hsematomata of the tube, which was so 
 thinned that rupture seemed imminent, and he cites this condition among 
 the indications for operation. 
 
 Bantock finds that in patients with uterine fibroma the liver is fatty, and 
 attributes the lesion to the presence of the tumor; he believes it to be a 
 frequent cause of unsuccessful operation. Fibrous uterine tumors, by pres- 
 sure on the ureters, may produce grave kidney disorders — pyelitis, pyelone- 
 phritis, hydronephrosis. These accidents are especially frequent when the 
 tumor has a pelvic development ; I will describe them with cancer. 
 
 Lesions of the heart, which may be found in all cases of large abdominal 
 tumor, are very often a complication of uterine fibroma. They seem at times 
 dependent upon renal changes, as Traube has indicated, but often we cannot 
 find any such correlation. The hypertrophy, with or without dilatation of 
 the cavities or consecutive change in the cardiac tissue, produces itself, no 
 doubt, by a pathogeny similar to that which causes the hypertrophy in preg- 
 nancy. As to the final degeneration of the heart, it is strongly favored by 
 the ansemic and cachectic condition of certain subjects; two such forms of 
 degeneration are described, the fatty and brown atrophy of the myocardium. 
 Sebileau has recently called attention to the troubles caused by hypertrophy 
 and dilatation of the left side of the heart, more rarely of the right, in volu- 
 minous tumors of the abdomen. 
 
CHAPTER IX. 
 
 SYMPTOMS, DIAGNOSIS, AND ETIOLOGY OF UTERINE 
 
 FIBROMATA. 
 
 The symptoms of fibroma of the uterus are of two kinds : ( i st) Lhe ra- 
 tional signs which reproduce the uterine syndroma described in Chapter 
 VI., with certain special differences and a predominance of the hemorrhage; 
 (2d) the physical signs proper to the tumor. 
 
 I. Rational Signs. — The completeness of my description of the uterine 
 syndroma permits me to abridge this section. The hemorrhages appear in 
 a peculiar form and become the chief symptom in themajority of these cases. 
 They occur either as metrorrhagia or as menorrhagia; that is, they come at 
 the regular period of menstruation or during the intervals. They are inti- 
 mately connected with the lesion of interstitial metritis, which always ac- 
 companies fibroma situated at but little distance from the mucous membrane; 
 the glandular metritis which is found with tumors farther removed from the 
 uterine cavity gives rise only to leucorrhcea. In general the symptom of 
 bleeding is more complained of the more the neoplasm invades the cavity 
 and reaches its highest grade in polypi. The loss of blood is very enfeebling 
 to the patient, but death by hemorrhage is exceptional : Duncan has reported 
 one such case in which at the autopsy a rupture of a large uterine sinus was 
 found. 
 
 The leucorrhoea is not distinctive; at times there may be very abundant 
 serous discharges, a hydrorrhoea, which differs from that of cancer in having 
 no odor and in being intermittent. 
 
 The pains are various. There is usually only a sensation of dragging 
 and weight, with reflex neuralgias in the lumbar region and abdomen, as is 
 so common in any uterine affection. To these are joined, when the tumor 
 projects into the uterine cavity, colic and expulsive pains occurring at the 
 time of the hemorrhages. When the tumor is very large, it may press upon 
 the sacral plexus and cause extreme sciatic pain, which is apt to be more 
 violent at the menstrual period. Jude Hue observed one case of this kind 
 in which the support of an air pessary caused the sciatica to disappear. 
 
 The symptoms of vesical compression are very frequent. West found 
 dysuria in thirty-five cases out of eighty-six, but Gallard did not regard this 
 as simply a mechanical trouble, although he gave no explanation of its pro- 
 duction. It is probable that this dysuria is due to small tumors on the an- 
 terior face of the uterus in direct relation with the neck of the bladder. All 
 
■202 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 these visceral symptoms are more pronounced during tiie periodical conges- 
 tion of menstruation, and they may at times acquire the importance of a cys- 
 titis from the permanent presence of residual urine or from infection intro- 
 duced by the catheter when proper precautions are not observed. The com- 
 pression of the vesical neck may produce a chronic distention which simulates 
 ovarian cyst. 
 
 The compression of the rectum, more rare than the preceding, may at 
 times cause hemorrhoids, and with the dyspepsia will produce constipation. 
 Barnes attributes great importance to the absorption of excrementitious mat- 
 ters which follows this obstinate constipation, and considers it a veritable 
 toxaemia, which he proposes to call copraemia; recent researches on the pto- 
 maines and leucomaines give a certain weight to this opinion, which seemed 
 a very bold one when it was first formulated. 
 
 Fibromata which are contained within the lesser pelvis may cause inter- 
 nal strangulation and death. 
 
 Compression of the ureters and grave renal troubles have been known 
 since Murphy's description of them ; since which time there have been nu- 
 merous observations of this kind scattered through the literature of the sub- 
 ject. I have collected some of these and shown that the risk of this serious, 
 complication, wrongly considered rare by Gallard as by most other authors, 
 should on the contrary be one of the most serious indications for operation. 
 
 A very great number of the deaths following hysterectomy or castration 
 must be attributed to renal degeneration, by reason of which the surgical 
 interference and the long inhalation of the anaesthetic are invested with great 
 and sudden gravity. (Lee reported a case of pregnancy at four and one-half 
 months with three fibromata, of the size of an apple, compressing the blad- 
 der; the fundus imprisoned, the cervix above the symphysis; unsuccessful 
 attempts to disengage ; death ; and at the autopsy, pyelonephritis. Skene, 
 on this occasion, said that it was the third fatal case of pyelonephritis which 
 he had seen from pressure on the vesical neck, and that such cases were prob- 
 ably more frequent than was supposed. Salin and VVallis report a case of 
 castration with death, from double hydronephrosis, due to a large uterine 
 myoma in a woman of forty years, who had always suffered great pain in the 
 dorsal decubitus. The castration was followed by suppression and death in 
 seven days, with the symptoms of uraemia and a little albumin in the urine. 
 At the autopsy the ureters were found compressed and thickened, their pelves 
 dilated). On the other hand, symptoms of pyelitis, and of albuminuria with 
 threatening uraemia, have been seen to disappear after the removal of a 
 fibroma which compressed the ureters. We must never neglect to examine 
 the urine both chemically and by the microscope, and determine the propor- 
 tion of urea, the presence of albumin or pus, and the characteristic hyaline 
 and granular casts. 
 
 Every abdominal tumor causes an increased vascular pressure, and so 
 reacts upon the cardiac muscle. It is not therefore astonishing that any 
 
SYMPTOMS OF UTERINE FIBROMATA. 203 
 
 heart lesion, although slight, may be aggravated by the presence of a fibroid; 
 for a similar effect is produced by pregnancy. A part of the cardiac trouble 
 observed in patients with voluminous tumors of this kind has often no other 
 origin. ' Only a few isolated observations have been published, since Hof- 
 meier, in 18S4, in an article remarkable for its physiological and pathological 
 explanation of shock, insisted on the frequency of cardiac disease in cases of 
 abdominal tumor, and especially with fibromata of large size. He collected 
 a series of eighteen cases in which sudden death was caused by cardiac failure 
 provoked by the presence of a large abdominal tumor, either physiological or 
 pathological ; in three of these there was advanced fatty degeneration of the 
 heart muscle (two myomata and one ovarian cyst) and in fifteen brown 
 atrophy of it (five ovarian tumors, five myomata, and five pregnancies). Five 
 deaths occurred before any operation, nine after operation, and five following 
 labor. 
 
 This interesting question has been studied by other authors also. Feh- 
 ling, in a series of fourteen hysterectomies, studied all the patients from this 
 point of view, and found in four of them manifest signs of cardiac altera- 
 tion. He also observed at the same time three cases of fibroma of middle 
 size, with symptoms of heart disease ; two of these patients died afterward, 
 one of them suddenly. In America, Dower published an observation of this 
 kind ; and in England, B. Fenwick presented to the Gynaecological Society 
 of London a memoir upon the subject. In France, Sebileau collected con- 
 firmatory cases. Among eighteen cases of tumor of the abdomen which he 
 observed in reference to this point, seventeen had cardiac trouble indicated 
 by a murmur ; but in the three cases of myoma which he cites there was no 
 autopsy. We should, then, auscultate carefully every patient with a tumor 
 of any considerable size ; the dull character of the heart sounds, the dyspnoea 
 and the general debility may lead us to fear a fatty degeneration of the myo- 
 cardium. Brown atrophy may not give any special symptoms ; it is found 
 chiefly in individuals who are much weakened by hemorrhages. 
 
 I share in the opinion of those surgeons who see in this lesion a new in- 
 dication for operation and at the same time a grave addition to the prognosis. 
 
 Among the signs furnished by local examination, that which is common 
 to all tumors, whether large or small, should be given the first place, namely, 
 elongation of the uterine cavity. This is constant in all tumors during their 
 evolution — that is, all giving rise to morbid phenomena. The uterus is di- 
 lated both wdth a small interstitial fibroma and with a small polyp, since it is 
 hypertrophied under the influence of what Guyon has called the " fibrous 
 pregnancy." With a large fibroma the uterus is also elongated by the ec- 
 centric development of the tumor, and the traction which it causes upon the 
 cervix ; the sound may pass as far as twenty centimetres (eight inches). 
 
 This passage of the uterine sound should always be done with the great- 
 est care ; it is generally possible to use a silver instrument which one can 
 curve as is necessary. But for fear of meeting difficulties we may employ a 
 
204 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 urethral bougie which is moderately flexible, seizing it close to the cervix to 
 determine how far it has penetrated. 
 
 The uterine cavity may be effaced by a tumor which projects into it, and 
 the sound may not pass. 
 
 The search for the tumor should be made by bimanual palpation, aided 
 by rectal touch ; and in difficult cases it may be well to administer an anaes- 
 thetic, to relax the abdominal walls. One general remark is applicable to all 
 these examinations — they furnish very variable information, according as 
 they are made during or after a fluxionary or hemorrhagic period. In the 
 .second case we often find a great diminution in the size of the tumor, which 
 misfht cause mistakes as to the internal treatment to be followed. We must 
 be on our guard as to the contractions which some have claimed to feel in cer- 
 tain of these tumors; a fibrillary movement of the abdominal walls, the glid- 
 ing of a loop of the intestine, might easily give rise to this illusion. 
 
 When the tumor has effaced or passed beyond the cervix it is accessible 
 to vaginal touch. 
 
 Diagjtosis. — From a clinical point of view we may divide these fibrous 
 bodies into three great classes, according as the tumor (i) is very small and 
 interstitial or (2 and 3) is well characterized and pursues its evolution toward 
 the peritoneal or the uterine cavity. In the first case the chief symptoms 
 are those of the complicating metritis, the metritic type. 
 
 In the second form, with a vaginal evolution, we must distinguish the 
 varieties caused by (A) submucous fibroma of the body ; (B) pediculated fib- 
 roma of the body, or polypi ; (C) fibroma of the external os, or of the subvag- 
 inal portion of the cervix. 
 
 In the third case, with an abdominal evolution, we must distinguish : (A) 
 pediculated fibroma; (B) those developed at the fundus above the attachment 
 of the broad ligaments ; (C) those from the body of the organ below the attach- 
 ment of the broad ligaments ; and, among these last (D) those of the sub- 
 vaginal portion of the cervix below the peritoneum which have a pelvic de- 
 velopment in the tissues of the lesser pelvis. The following table renders 
 this clear : 
 
 I. Metritic type — small interstitial fibroma. 
 II. Type of vaginal evolution : 
 
 A. Fibroma of the external os — sessile or pedicled. 
 
 B. Submucous fibroma of the body. 
 
 C. Fibroma of the body, pedicled or polypi. 
 
 a. Intra-uterine. 
 
 b. With intermittent signs. 
 
 c. Intravaginal — var. enormous polypi. 
 
 III. Type of abdominal evolution — subperitoneal or interstitial : 
 
 A. Pedicled fibroma. 
 
 B. Sessile fibroma, not in the broad ligament. 
 
DIAGNOSIS OF UTERINE FIBROMATA. 205. 
 
 C. Sessile fibroma, in the broad ligament : 
 
 a. Abdominal. 
 
 b. Pelvic. 
 
 I. Diagnosis of Ffbroma of the Metritic Type. 
 
 Small Litcrstitial Fibroina. — When the tumor is not very large and has a 
 tendency to project from the uterine wall (Fig. 147) it is at times very diffi- 
 cult to recognize the real source of the morbid phenomena observed, the 
 chief of which would be : persistent hemorrhage coincident with enlargement 
 of the uterine cavity, and finally the discovery of a tumor. 
 
 We must eliminate hemorrhagic metritis. Early pregnancy is accom- 
 panied by cessation of the menses, but we should remember that in excep- 
 tional cases they have persisted. Abortion with delay in the involution of 
 the uterus caused by retention of placental fragments, is distinguished by its 
 special course and by the study of the material furnished by the curette. 
 Cancer of the uterus is also accompanied by hemorrhage, but with this there 
 is fetid leucorrhoea, and the curette will remove fragments which under the 
 microscope determine the nature of the tumor. Inflammations of the tubes. 
 and ovaries are a frequent source of error, for there may be repeated hemor- 
 rhages, and a tumor (hydro-, haemato-, or pyosalpinx) which appears to form 
 part of the uterus, attached either to the sides of the organ or to the posterior 
 surface in Douglas' pouch. We cannot always in our search determine the 
 presence of fluctuation, and it is dangerous to examine for it with too much 
 zeal ; in the small, tense tumors it is generally absent. The very great rap- 
 idity of the formation, the patient's own story, the rational signs, careful 
 local examination under the influence of anaesthetics, and the absence of in- 
 crease in the size of the uterus are all valuable means for recognizing dis- 
 ease of the adnexa. 
 
 Anteflexion and retroflexion, although accompanied by bleeding, do not 
 deceive us for very long; the nature of the tumor which we feel in the cul- 
 de-sac on one side or the other of the vagina should be quickly recognized by 
 the sound and bimanual palpation. The small collections of faeces which are 
 found in the rectum and felt by vaginal touch need only be called to mind in 
 order to dismiss them ; they could deceive no one but a novice. The finger 
 indents them and a purgative causes them to disappear. 
 
 II. Diagnosis of Fibroma with a Vaginal Evolution. 
 
 A. Of the External Os. — The existence of a tumor hanging from the lip 
 of the cervix is here the capital symptom. Ordinarily it is not ulcerated, 
 but is smooth and elastic. Passing the index along it to the base, we feel 
 the OS in front or behind, according to the lip from which it hangs ; the other 
 lip is usually thinned and partially effaced. This circumstance has caused 
 
•206 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 the error of supposing the uterus everted or that the tumor came from the in- 
 terior of the organ. Attentive examination of both lips by touch, of the 
 cavity by the sound, and of the position of the organ by bim.anual palpation 
 will furnish the needed corrections. A fibroma of the external os may itseli 
 be pedicled, and the fact should not be forgotten. Finally, when they grow 
 at the level of the vaginal insertion they may split the rectovaginal septum 
 and then simulate a tumor of that situation, or they may develop toward the 
 uterine cavity. 
 
 B. SubniiLcoiis Fibroma. — The hemorrhages and the increase in the size 
 of the uterine cavity are here especially marked, and the presence of the 
 tumor is readily ascertained. For this purpose, touch should be practised 
 during the bleeding, since at that time the uterus is softened and the os patu- 
 lous. If necessary, we may increase the cervical dilatation by the means 
 already described, and confirm the diagnosis by intra-uterine touch. On the 
 level face of the uterus there is then to be felt a tumor which projects into 
 the cavity and reduces it to a mere linear cleft, laterally distorted. The sur- 
 face of the tumor is covered by hypertrophied mucous membrane, which is 
 smooth and downy. There is no pedicle, but a large base of attachment, 
 which excludes the idea of a polyp. 
 
 Externally the uterus has a globular form which would resemble that of 
 the first months of pregnancy, were not hemorrhages exceptional at that time. 
 
 When the surface of the tumor has become gangrenous, the possibility of 
 a mistaken diagnosis is much increased; the sanious discharge, the irregular 
 ■ and putrid surface, and the patient's cachexia make us think of malignant 
 tumor, or of cancer of the body of the uterus. 
 
 C. Pedicled or Polypoid Fibroma of the Body. — We can divide the evo- 
 lution of a polyp into three stages, and each one of these corresponds to a 
 variety of fibroma. In the first, the pedicled fibroma is still far from the 
 uterine cavity, which is often very much dilated; that is, it is intra-uterine. 
 In the second period there is a tendency to pass beyond the cervix, after di- 
 lating it, which is far more marked at the moment of the monthly discharge 
 and disappears between-while; this is the variety with intermittent symp- 
 toms. Finally, in the third period of their evolution, these polypi protrude 
 completely from the uterus, have become intravaginal, and may take on an 
 enormous size, thus forming a new variety from the point of view of the 
 
 •symptoms and possible operation. 
 
 These intra-uterine polypi may be distinguished from sessile submucous 
 tumors by direct examination after dilatation of the cervix, the presence of 
 the pedicle being characteristic. 
 
 A polyp with intermittent symptom.s, occurring at the menstrual periods, 
 ■may pass unrecognized unless we see the patient at the favorable time, and 
 ^here again the cervix will require to be dilated, both for diagnosis and to 
 permit removal. 
 
 -An iatravaginal polyp of the vagina, coming from the body of the or- 
 
DIAGNOSIS OF UTERINE FIBROMATA. 207 
 
 gan, would seldom be confounded with a sessile or pedicled fibroma of the 
 cervix; touch alone should reveal its relations. W'c might think of an in- 
 verted uterus, especially if the organ itself contained a fibroma; and this 
 error is very easy to make, as is shown by the fact that more than one distin- 
 guished surgeon has committed it. This inversion may be unrecognized in 
 two conditions — if there is a complicating polyp or submucous tumor which 
 alone attracts attention ; and when it is the only alteration, and the con- 
 striction at the level of the internal os makes the upper part of the everted 
 organ seem like a pedicle. The operator may especially note, as an aid in 
 guarding against mistake, the extreme sensitiveness of a tumor formed by the 
 uterus, though this symptom is very inconstant. But the sound and rectal 
 touch, combined with vesical catheterism and bimanual palpation under an- 
 sesthesia, will make it evident that the uterus is not in its usual place — that 
 we have to do with a case of uterine prolapse. 
 
 This examination is at all times difficult with polypi which are of great 
 size, for they fill the vagina and even project from the vulva, causing a dis- 
 placement of the uterus. They may also form adhesions with the vaginal 
 walls, provoke ulcerations, or themselves slough in places ; and, more than 
 that, by retention of decomposing fluids above them in the occluded vagina, 
 they may cause the absorption of these putrid products, and thus seriously 
 disturb the general condition. Though the statements of the patient and 
 the local signs might lead us to suspect cancer, a careful examination will 
 quickly correct the error. 
 
 III. Fibroma with an Abdominal Evolution, 
 
 A. Subper-itoneal : Pedicled. — The uterus is here entirely distinct from 
 the tumor, whose movements cannot be transmitted to the finger placed in 
 the vagina (Fig. 153). The cervix is generally raised ; there is usually no 
 metrorrhagia ; and the cavity of the uterus is not enlarged. Ovarian cysts 
 are the most difficult things from which to differentiate these fibromata. 
 The fluctuation in the cyst would be pathognomonic, but it might be con- 
 founded with the softness of an oedematous fibroma ; and if the cyst were 
 small and tense or multilocular, with small areolar cavities, it would be very 
 hard to appreciate. Examination under anaesthesia would then be necessary 
 to remove all doubt. In the case of fibrocystic tumor the fluctuant parts 
 alternate with harder portions. 
 
 Another point for consideration is that the fibroma develops very slowly 
 and the ovarian cyst rapidly. As Thornton has remarked, " there are certain 
 pedicled fibromata which run so rapid a course that confusion is easy, as 
 they also react but little upon the uterus ; and thus in every ovariotomy we 
 should be prepared to do a hysterectomy." 
 
 Exploratory puncture, which has been abused in former years, should be 
 completely given up; it may cause serious accidents, as dischargeof the cyst 
 
208 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 within the abdomen, internal hemorrhage, thrombosis or embolism in case 
 of a fibroma, or even more or less extended peritonitis. Harsha observed, 
 in the case of a fibrocystic tumor, that he could clearly perceive contrac- 
 tions in the muscular wall, and proposed to anaesthetize the patient at the 
 menstrual period — a time most propitious for the examination — and verify 
 the existence of contractions in the tumor by percussion. 
 
 H. Jones has described an exceptional condition of the gravid uterus which 
 simulates pedicled fibroma. In four observations which form the basis of 
 his paper, the uterus formed a hard, round tumor, movable, and of the size 
 of the fist, between the symphysis and the umbilicus, and appeared to be a 
 mass connected by a long pedicle to some pelvic organ. Pressure upon the 
 tumor moved the cervix but little, there was no fluctuation, and the sound 
 (before the pregnancy was recognized) gave a depth of the uterine cavity of 
 12 cm. The author attributed this peculiar state of the organ to the absence 
 of liquor amnii ; the fundus, the point where the ovum is commonly attached, 
 would then become globular, while the lower segment would remain lax ; 
 hence there would be a false sensation of a pedicle. It is very probable that 
 the case occurred in a woman with hypertrophy of the supravaginal portion 
 of the cer\dx. A short delay is all that is needed to make the matter clear.. 
 
 Floating kidneys may be recognized by their contour and the entire ab- 
 sence of any connection with the uterus. 
 
 The large cancerous cakes formed in peritoneal carcinoma by the degen- 
 eration of the omentum may be mistaken for fibroma if there are adhesions, 
 to the uterus ; but the sanguinolent ascites, the shape and situation of the 
 tumors, the cachexia, and other symptoms, with the freedom of the uterus as 
 disclosed by the sound and bimanual palpation, are sufficient to distinguish 
 the two diseases. 
 
 B. Subperitoneal Fibrotna, Sessile and Free : Not in the Broad Ligament. 
 — The differential diagnosis is here the same as in the preceding cases. Oc- 
 casionally it is very difficult to diagnose pregnancy complicated by such a 
 tumor, for even exact analysis of the symptoms, with careful attention to 
 those characteristic of the foetus, may be without result during the first 
 months. 
 
 Fibroma of this variety may be discovered by its solid union with the 
 uterus, for the two constitute but a single mass on bimanual palpation. At 
 the same time the examination reveals how much the lower portion of the 
 organ is involved ; for if the tumor has developed above the insertion of the 
 adnexa this part will be intact, but in the contrary condition it will become 
 a part of the tumor's circumference. The mass is then immobilized by the 
 walls of the lower pelvis, and permits no lateral movements; but on biman- 
 ual palpation we feel that the iliac fossae are free, which distinguishes it 
 from the next form, 
 
 C. (a) Intraligamentous Fibroma — Abdominal Variety. — Here the devel- 
 opment of the tumor is altogether lateral, splitting up the layers of the broad 
 
DIAGNOSIS OF UTERINE FIBROMATA. 2O9 
 
 ligaments, and ordinarily the tumor lies in one of the iliac fossse, and fills 
 it up. By touch and palpation we can determine its connections with the 
 uterus, and we find usually that but one of the lobes of the tumor is actually 
 in the ligament, the other being above it; but that which gives the tumor 
 its name and importance is its very grave nature and the special therapeutic 
 measures required. Jt is only exceptional that there is any doubt as to the 
 existence of a fibroma, though before complete examination we might sup- 
 pose that there was present a tumor of the iliac bone. 
 
 Parovarian cysts within the broad ligament may be recognized by their 
 fluctuation. 
 
 Encysted tumors of the tubes, especially hydro- and haematosalpinx, may 
 be difficult of diagnosis from their adhesion to the posterior surface of the 
 uterus and the difficulty of appreciating any fluctuation ; but here the pa- 
 tient's history, the use of the sound, and the determination of the grossesse 
 fibreiise are valuable diagnostic measures. 
 
 C. {b) Intraligamentojts Fibroma — Pelvic Variety. — The chief charac- 
 teristic of this variety is found in the development of the neoplasm within 
 the pelvic floor between the organs attached there, and its tendency to fill 
 up all places between them and raise the body of the uterus into the ab- 
 domen (Fig. 156, B). Clinically we have, as the result of this, the m.ost 
 serious compression symptoms, and for the operator there are extreme diffi- 
 culties. 
 
 The starting-point of these tumors is always in the subserous portion of 
 the uterus ; that is, the supravaginal part of the cervix. If their attachment 
 is anterior, while their volume is still very small, they may cause grave dis- 
 turbance of the bladder, dysuria, and retention of the urine. And it is in this 
 variety also that we observe especially the intense pain caused by pressure 
 on the nerves, as well as the accidents of intestinal obstruction. 
 
 Vaginal and rectal touch, combined palpation, determine the close con- 
 nection of these tumors with the organs of the pelvis; the culs-de-sac are 
 found to be depressed or obliterated, and the cervix may have wholly retract- 
 ed to form part of the tumor. About its orifice, of which only the exter- 
 nal OS may remain, there are felt hard nodular masses which are connected 
 with the uterus and which pressure does not displace ; it is in the latter re- 
 spect especially that these tumors differ from those of the body of the uter- 
 us, which invade the pelvis only as there is a retroflexion developed. These 
 latter, which become pelvic by immigration, may produce the same symptoms 
 from compression and give the same sensations to the examining finger, but 
 they are not tightly bound down unless there are adhesions of inflammatory 
 origin ; and pressure made through rectum and vagina upon the morbid mass, 
 with the woman in the genu-pectoral position, will change the tumor's place 
 if it does not return it above the superior strait. 
 
 Hasmatocele, inflammatory foci about the uterus, and encysted collections 
 in the tubes are at times difficult of diagnosis, and have been the cause of 
 14 
 
2 10 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 numberless errors ; no doubt the so-called medical treatment of fibrous tu- 
 mors owes much of its success to this fact. Before finishing the clinical de- 
 scription, I may mention certain symptoms which are occasionally observed. 
 
 It is common to all tumors which compress the great vessels to present 
 an intermittent murmur, called the uterine souffle in pregnancy. It has lit- 
 tle diagnostic worth. If it is absent in a case of ovarian tumor, we may 
 then be sure of finding fluctuation ; with solid tumors, on the contrary, it is 
 present. 
 
 With telangiectatic fibroma there is often a distinct area over one of the 
 broad ligaments where we find a continuous murmur which resembles that of 
 an arterio-venous aneurism, and, like it, is accompanied by a thrill ; I have 
 observed one such case. 
 
 Ascites is uncommon with fibroma, but it may develop when the tumor 
 is very movable or when it has undergone a degeneration from torsion of its 
 pedicle. In cachectic subjects, also, it will at times appear with tumors which 
 in another patient would certainly not have caused it. I have observed it 
 in these conditions in a patient who suffered from mental disease, in which 
 hysterectomy was successfully performed and ameliorated the mental condi- 
 tion. Hemorrhagic ascites is an almost constant symptom with malignant 
 tumor, and its presence warrants a very guarded diagnosis. I have already 
 spoken of chylous ascites as a great rarity. 
 
 Serous cysts of the broad ligament coexist quite frequently with fibroma 
 of abdominal development, and are more than merely fortuitous, since the 
 exaggerated nutrition caused by the tumor favors their development in the 
 vestiges of the Wolffian body which constitute the parametrium. Some large 
 tumors of the uterus drag the organ downward and cause a genital prolapse 
 as do also some of the ovarian tumors. Inversion of the uterus may be found 
 with polypi, and, exceptionally, with subserous fibroma. 
 
 A rare accident, of which I have seen one case and which has been made 
 the subject of a thesis by Diill, of which Schroder has given an analysis, is 
 the separation of the linea alba and consequent eventration with the formation 
 of a hernial sac, in which the large fibroma, usually pedicled, is found lodged. 
 In my case the patient was an old woman who had carried this singular hernia 
 many years. Its size was larger than her head, there was so small a ring 
 that reduction was impossible, and the sac was thinned and rested upon her 
 knees. In a case mentioned by Diill death followed mortification of 
 the sac. 
 
 Course and Pivgiwsis. —T\\q great majority of these cases present noth- 
 ing during life beyond a few vague symptoms which are often unrecognized. 
 But there are others which cause serious disturbance throughout the entire 
 period of sexual activity until the menopause, when most of these tumors 
 atrophy and diminish in volume by induration and involution. This effect 
 is at times hastened by a pregnancy, but the rule is not absolute. A certain 
 number of these tumors have a veritable " galloping" course, as I have termed 
 
DIAGNOSIS OF UTERINE FIBROMATA. 2 I I 
 
 It, causing death not so much by the hemorrhage, as by the exaggerated 
 development of the morbid mass and the phenomena of compression and de- 
 nutrition which result from it ; of this number are fibrocysts in general and 
 some simple fibromyomas. On the other hand, there are certain tumors of a 
 less rapid course which continue to grow indefinitely after the critical age ; 
 but most frequently there is a distinct retardation at that epoch. 
 
 The natural evolution of a fibroma tends toward its expulsion from the 
 uterine walls, either externally or into the peritoneal cavity, and this effort 
 is shown by the pedicles which are produced in these two directions. Al- 
 though such cases are rare, still at times we observe the accouchement of a 
 polyp under the influence of strong uterine contractions with rupture of the 
 pedicle ; or the same thing may occur from the weight of the tumor alone 
 and the thinning of the pedicle. In these conditions an effort of defecation 
 or of vomiting suffices to expel the polyp. The rupture of the capsule of a 
 submucous fibroma may produce its spontaneous enucleation, preceded by a 
 period of pains and hemorrhage, or suddenly after some effort or while under 
 examination ; it has sometimes followed labor and the consecutive contraction 
 of the uterus. 
 
 An analogous process to that which causes the rupture of the pedicle of 
 a submucous polyp may also liberate a fibroma which is subserous and pedi- 
 cled. The tumor then remains grafted to some point where it has formed 
 adhesions, or lies free in the peritoneum and undergoes a kind of mummifi- 
 cation. 
 
 Another and more serious mode of spontaneous extrusion is produced by 
 the mortification of the tumor, the sphacelated portions tending to escape 
 outwardly; at times this takes place toward the uterine ""avity and all may 
 go well, despite the danger of infection. Or there may be perforation of 
 some neighboring organ, as the bladder, the rectovaginal pouch, or the ab- 
 dominal wall; the two former almost always causing death, the latter some- 
 times ending in recovery. Finally, the tumor may undergo absorption, as 
 I have said above, after pregnancy, or at the menopause ; but in the latter 
 case there is more truly an induration and diminution than complete disap- 
 pearance. Although fibromata are an undoubted cause of sterility, fecunda- 
 tion may take place and pursue its normal course. 
 
 The cause of death may be the gradual exhaustion produced by the pro- 
 found anaemia which follows repeated hemorrhages, or it may occur from suc- 
 cessive attacks of chronic peritonitis, from disease of the kidneys and uraemia, 
 or from cardiac complication and heart failure. Rupture of a cyst, or in- 
 flammation and gangrene of the tumor, propagated with or without perfora- 
 tion to the neighboring serous membrane, may set up an acute peritonitis, 
 with a rapidly fatal termination. Or gangrene of a submucous tumor may 
 be the origin of a fatal septicaemia. Ghastly, sudden death has been ob- 
 served after embolism, especially in the case of fibrocysts of telangiectatic 
 nature; exploratory puncture seems to favor the production of thrombi in 
 
212 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 the large venous sinuses. Almost immediate death by shock has been ob- 
 served after intra-abdominal rupture of a fibrocystic tumor. 
 
 Etiology. — In spite of the patient researches which have been made upon 
 this subject, we still know nothing positive about the exciting causes of uter- 
 ine fibroma. We can only give certain predisposing conditions, among which 
 are race (the negro being more subject to such tumors than the white) and 
 advanced age ; in the white races the most susceptible age is from thirty to 
 forty years. Sterility is not so much a cause as a consequence. All the local 
 exciting causes which have been advanced are without proof. On the other 
 hand, it has been supposed that a celibate life disposed to their formation, 
 but Gusserow's statistics disprove the idea. Fehling has attributed great 
 importance to incomplete involution after labor and abortion where a suffi- 
 cient period of repose was not enjoyed. Prochownik thinks that the specific 
 irritations due to syphilis, malaria, and typhoidal infections may have a 
 pathogenic action in the development of uterine fibromyomata. 
 
CHAPTER X. 
 
 MEDICAL TREATMENT OF FIBROMA— SURGICAL TREAT- 
 MENT OF FIBROMA WITH A VAGINAL EVOLUTION. 
 
 The treatment of fibroma may be divided into medical and surgical. 
 
 Medical treatment of these cases is often only the treatment of the symp- 
 toms. The various substances which have been advocated for the purpose 
 of acting directly upon the tumor itself, either to cause contraction of the 
 nutritive vessels (as ergot) or to set up a fatty degeneration (as arsenic and 
 phosphorus), appear to produce a good effect by far other means; the first 
 ■contracting the uterine vessels and thus decreasing the hemorrhage, the sec- 
 ond relieving the general malnutrition. As specific agents, electricity, to 
 which certain authors attribute considerable importance in the absorption of 
 iibrous tumors, and mineral waters charged with sodium chloride, of which 
 the action is incontestable, may be mentioned. 
 
 Ergot injections have been practised since the writings of Hildebrandt, 
 who gave his name to the method. The treatment must be used persistently 
 for months ; for which purpose the following formula may be employed : 
 
 ]^ Ergotini, 
 
 Chloral, hydrat. , .... 
 
 AqucC destill., 
 
 M. 
 
 and twelve minims injected daily. If it is desired to preserve the solution 
 for a long time, it is well to add, besides the chloral, which is intended to 
 accomplish the same object, a few drops of Van Swieten's fluid. A wire 
 must be kept in the needle to insure its being permeable, and it must be 
 passed through the flame of an alcohol lamp after each injection to dry it, 
 and beforehand to sterilize it, so that abscess may be avoided. The injec- 
 tion is best made in a fleshy part, like the deltoid or the buttock, the needle 
 being inserted perpendicularly from a half to three fourths of an inch. To 
 prevent pain, Bumm advises that the solution be neutralized with soda and 
 filtered. The patient may be taught to give herself these injections ; Winckel 
 speaks of a woman who had thus done it fifteen hundred times. 
 
 In spite of the so-called demonstrative cases which have been published, 
 the effect of this method upon the development of fibrous tumors is still con- 
 tested. Schroder asserts that he has seen no diminution in the size of the 
 tumor after four hundred injections, although the dose employed was stronger 
 than the one I have indicated; but he has noticed that the tumor remained 
 
 5 gm. 
 
 gr. 
 
 Ixxv. 
 
 I " 
 
 gr. 
 
 XV. 
 
 lOO " 
 
 ad 3 
 
 iij. 
 
2 14 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Stationary, though it had been increasing up to that time. Leopold recom- 
 mends the method, and Byford, in America, is its warm partisan. On the 
 other hand, many others declare that they never obtained any good effect 
 from. it. In the use of this treatment, if the prescribed dose is much ex- 
 ceeded, it may produce cramps of the extremities, vomiting and fever, or 
 even suppuration of the tumor. [It is well to remember that this long con- 
 tinued use of ergot often produces degeneration of the heart muscle and 
 that cases so treated are apt to die of "heart failure" after operation.] 
 
 One of the good effects attributed to the ergot treatment is that it favors 
 the spontaneous expulsion of fibroma; but it is doubtful if it will cause the 
 formation of a pedicle in a tumor which is submucous, and those which are 
 already polypoid require more than medical treatment. 
 
 Churchill and MacClintock strongly advise the administration of tincture 
 of cannabis indica in six-drop doses, given three times a day, to arrest the 
 hemorrhage. Antipyrine has been tried with the same object. 
 
 A drug, which I have used with good results, introduced into European 
 practice from America by Freund, is the fluid extract of hydrastis cana- 
 densis. This acts as a haemostatic by contracting the vessels, while its 
 bitter taste makes it a good stomachic ; the dose is forty drops three or 
 four times a day. Schatz praises the drug highly, claiming to have seen a 
 fibroma, which had reached the umbilicus, return to the pelvic cavity after 
 two years' use of hydrastis. Lack of success, according to him, may be due 
 to the difficulty of procuring a pure form of the medicine. 
 
 Bromide of potassium, given in small doses for a long time, has been ad- 
 vocated by Simpson ; but it seems to act only as a sedative against the pain, 
 and its prolonged use may impair the digestive function, which it is so 
 important to preserve. 
 
 Arsenic, advised by Gueniot, does not display the selective action which 
 had been hoped from it, but, as a tonic, may be of benefit. 
 
 Baths of mineral waters containing sodium chloride have an undoubted 
 beneficial action on fibrous tumors, doing more than simply improving the 
 general condition, and the cases in which I have obtained good results from 
 them are very numerous. Many of these bitter waters contain alkaline 
 bromides and iodides which impart to them a peculiar sedative action, those 
 of Salies-de-Bearn, for instance, containing lo gm. of bromide of sodium to 
 the quart. 
 
 As the result of Apostoli's work, who has followed with rare patience 
 the way opened by his master Tripier, electricity has been much employed, 
 especially in America and England. The application of electrolysis to 
 fibromata was made in 1871 by Cutter, in America, and in 1876 by Ciniselli 
 and his pupil Omboni in Italy. 
 
 As is well known, the effect of a strong current of electricity is to pro- 
 duce chemical decomposition of the tissues, the positive electrode attracting 
 the acid elements and the negative the basic; if then we put the positive 
 
MEDICAL AND SURGICAL TREATMENT OF FIBROMA. 215 
 
 (acid) pole in contact with the tissues, either on the surface of the mucous 
 membrane or in the depth of the tumor, we produce an eschar similar to that 
 which follows the application of acids, ending in a cicatrix which is fibrous 
 and retractile. If the contact has been made with the negative pole, the re- 
 sult is a soft non-retractile eschar, like that caused by potassium hydrate. 
 This excessive chemical action can be prevented at one or the other pole by 
 largely increasing its area and covering it with some good conducting sub- 
 stance (clay, gelosin, gelatin, wet cotton or chamois leather, etc.), which 
 spreads it over so large a surface that its action is not felt. 
 
 The first who employed electricity used feeble currents which had a 
 catalytic effect without actual destruction of the tissues, and many authors 
 still hold to this method as least dangerous. But the great majority fol- 
 low the example of Apostoli and Engelmann, employing currents of 
 high intensity from a battery of Leclanche cells. Apostoli, in 1884, did 
 not use more than 100 milliamperes; he now reaches 250 at times. The 
 strength of the current is measured by a galvanometer. [The "ampere" is 
 the current developed by an electromotive force of one " volt" in a circuit in 
 which the total resistance is one "ohm." The "volt" is an electromotive 
 force which differs but little from that of one " Daniell" cell; the "ohm" is 
 the resistance of a column of mercury i mm. square, 106 cm. long.] His 
 technique is as follows : 
 
 One of the poles is applied to the abdomen by means of a large moist 
 clay electrode or other appropriate medium, and the other pole is introduced 
 into the uterine cavity in the form of a platinum or carbon sound, which is 
 insulated with celluloid or rubber over the part which does not enter the 
 uterine cavity. The electrode is pushed into the substance of the organ 
 " after preliminary puncture where we desire to hasten the denutrition of 
 the neoplasm, or where the cervix is impermeable or inaccessible." Thus an 
 intra-uterine eschar is produced, the positive pole being used when the tumor 
 is hemorrhagic, the negative in the opposite case. 
 
 Apostoli asserts that " if well applied and continued long enough (from 
 three to nine months), this method is very successful, leading in ninety-five 
 per cent of the cases to the reduction of the tumor from one-fifth to one-third 
 of its former size, and sometimes to one-half and producing rapid and lasting 
 control of the hemorrhage and disappearance of compression symptoms." 
 
 Engelmann describes a similar technique, with the employment of 50 to 
 250 milliamperes during three to six minutes; exceptionally with double 
 puncture of the tumor through the vagina. 
 
 The mode of action seems to be a double one. In the first place the 
 mucous membrane is cauterized, producing", as Apostoli expresses it, an 
 actual electric curettage ; and, as well known, the curette will often control 
 hemorrhage by destroying the diseased mucosa; both curette and electricity 
 may thus cause a superficial mortification of a submucous fibroma. Brose 
 especially insists upon this mode of action for electricity, and Nicaise agrees 
 
2l6 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 with him in considering the destruction of the mucous membrane as the 
 chief benefit derived from it; this destruction is never more than an incom- 
 plete one, in a straight line corresponding to the sound in the uterus. It 
 should not be compared with that obtained by the curette, which works 
 effectively in all directions, penetrating all the corners. Danion, in his ex- 
 periments with animals, demonstrated that, with a sound introduced into the 
 
 \ 
 
 Fig. i6o.— Apostoli's Uterine Electrode, i, Natural size of the instrument ; A , ordinary hysterometer ; B, 
 trocar for puncture ; F^ notch marking average depth of uterus. 2 and 3, Entire instrument, reduced to one-third size, 
 in C, celluloid handle to protect the vagina ; E, electrode ; D, thumb screw, to regulate length of exposed sound. 4, 
 Carbon electrode for galvanocheraical cautery ; one-third size. Apostoli now replaces the platinum trocar by one of 
 gold or steel, which has the advantage of being more readily sharpened. 
 
 Uterine cornu of a rabbit, the current used by Apostoli caused but very 
 slight cauterization. 
 
 Still another mode of action is claimed by all partisans of the method, 
 whether they use feeble or strong currents, namely, the so-called " inter- 
 polar" action. Unfortunately this is pure theory; is it a chemical change 
 in the living elements of the tumor, or a vasomotor effect with electrotonic 
 action on the muscular fibres ? Danion has even spoken of galvanic massage, 
 insisting that the current be reversed for the purpose. All these ideas are 
 
MEDICAL AND SURGICAL TREATMENT OF FIBROMA. 
 
 217 
 
 hypothetical and rest upon imagination only. The method is not altogether 
 safe, for several fatal cases have been already recorded. 
 
 Far more dangerous yet is the method of Cutter, who employs a battery 
 of great strength and pierces the tumor in two places, either through vagina, 
 rectum, or abdominal wall; he has had four deaths in his first fifty cases. 
 His results are as follows : arrest of the tumor, 25 cases ; tumor not arrested, 
 7 cases ; improvement, 3 cases ; cure, 1 1 cases. Cutter, in seeking the elec- 
 
 FiG. 161.— I, Tripier's Unipolar Uterine Electrode. 2, Apostoli's Bipolar Uterine Electrode. 
 
 trolytic destruction of the tumor, follows other theoretical views than those 
 of Apostoli, though the latter seems to have made certain attempts in the 
 same direction, when in exceptional cases he buried the electrode deeply in 
 the centre of the tumor. One of the inconveniences of this method is that 
 it gives rise to protracted suppuration. 
 
 Reacting against these violent measures, Danion and Championniere ad- 
 vise the employment of feeble currents of from 45 to 65 milliamperes, or 
 very rarely up to 90, claiming that these weaker currents are quite as satis- 
 factory as the stronger. Danion attaches much importance to frequent re- 
 versal of the current. He introduces the electrode into the cervix, but 
 
2l8 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 claims that he can obtain the same effects by placing it in the vagina if he 
 takes the necessary precautions. 
 
 It is very difficult, even now, to pass judgment upon the value of elec- 
 trolysis as applied to uterine fibromata. Diverse opinions are held in New 
 York, in London, in Berlin, and in France. Doleris, who has employed the 
 method in a series of twenty cases, thinks that he is often the victim of an 
 illusion, mistaking for a diminution in the size of the tumor what is really 
 only its subsiding into the lesser pelvic cavity. One must further be on 
 his guard not to mistake for the tumor the perimetritic exudations which 
 often become absorbed as the result of the rest and good care. The value 
 of this treatment has been overestimated as regards the diminution in the 
 size of the tumor, for when this effect is produced it is only temporary and 
 ceases when the electricity is discontinued ; but the majority recognize that 
 it does lessen the hemorrhages and the pain and improve the general con- 
 dition. 
 
 Without accepting the exaggerations of Keith, who has declared it crim- 
 inal to practise hysterectomy unless electricity had been first employed, we 
 should remember that in it we have a therapeutic resource which should not 
 be neglected in those cases in which operation cannot promise a radical cure. 
 
 I will mention only the use of the interrupted constant current, of which 
 Aime Martin and Cheron have spoken warmly; its employment is no more 
 useful or general than is the use of faradization. 
 
 [While ultra-enthusiasm and too great expectations have undoubtedly led 
 to failure or disappointment in the use of electricity, there can be no ques- 
 tion of its importance as a palliative therapeutic agent. When carefully 
 employed, the treatment is generally considered to be free from any danger 
 to life, unless electro-puncture be the method. Most of the unsatisfactory 
 results have been in the case of tumors which have proved cystic — a condi- 
 tion which absolutely contraindicates the use of electricity — or in cases 
 in which the proper precautions in regard to cleanliness or asepsis were not 
 employed. Treatment by electricity is indicated in inoperable cases or 
 where operation is refused ; in fibroids of the smooth interstitial variety, 
 especially when near the menopause ; and in incipient fibroids in women 
 over forty. It is absolutely contraindicated when there is pus in the pel- 
 vis, or where there is a suspicion of cystic degeneration. 
 
 Some knowledge of electrophysics, carefulness in manipulation, and 
 exactness in dose are necessary to the effective employment of galvanism, 
 together with a proper selection of the cases and accurate knowledge of the 
 tumors to be treated. The current must be localized and its effcc > 
 confined as closely as possible to the neoplasm. One pole must ser\"e 
 as the active agent for the application of the electricity, and upon 
 this its entire effect is concentrated. This is termed the active pole. 
 The current at the opposite pole is to be dispersed over as large a 
 surface as possible, so that its effects will be least perceptible. The 
 
MEDICAL AND SURGICAL TREATMENT OF FIBROMA. 219 
 
 poles should be placed on opposite sides of the diseased part, and as 
 near to it as possible, the indifferent pole being placed on the largest 
 and least sensitive surface. The current should be of sufficient strength 
 to accomplish the object desired in the shortest possible time without 
 detriment to the patient. This strength will usually be from 80 to 250 
 milliamperes. The first instrument required is a battery of sufficient con- 
 stancy and strength. One which has been found most serviceable is com- 
 posed of fifty or sixty improved Law or Leclanche cells. These can be 
 stored in any closet, or even in the cellar, connected in series with wires 
 leading to any convenient spot in the office. Here we need a rheostat for 
 the purpose of controlling the current strength, and an amperemeter for 
 measuring the amount used. In addition to these, there are the connecting 
 cords, the abdominal and the internal electrodes. The abdominal electrode 
 may be the original one of clay, first devised by Apostoli, or a thin plate 
 of lead or tin as large as can be used upon the abdomen, covered with a 
 thin layer of soft clay, held in place by gauze ; or it may be made of gauze 
 covered with wet canton flannel or thin, soft buckskin, held in place on 
 the abdomen by a quilted sand-bag. The internal electrode is either a 
 gold or platinum-plated sound, or a curved rod of carbon. 
 
 If the patient is hyperaesthetic or nerv^ous, anaesthesia may be neces- 
 sary ; but, ordinarily, if skilfully and carefully used, the current may be 
 passed without an ansesthetic. The patient is to be put upon the 
 operating table or chair in the dorsal decubitus, the clothing loosened about 
 the waist, the corset removed ; the abdominal electrode, previously 
 soaked in warm water, is then snugly adapted to the abdomen, so that 
 the epidermal layers of the skin may have a chance to become thoroughly 
 moistened, the current then passing with much less resistance and con- 
 sequently less pain. Before placing this electrode, any scratches, pim- 
 ples, or excrescences should be covered with bits of plaster or oiled silk, 
 as otherwise the passage of the current will cause much pain at these points. 
 Warm, dry towels should be placed over and above the electrode to protect 
 other portions of the patient's body, as well as her garments, from any excess 
 of moisture. The vagina should now be cleansed by an antiseptic douche 
 and the uterine electrode carefully introduced. Being certain that the 
 rheostat is at its greatest point of resistance, the connecting cords are 
 now attached to the electrodes and the current turned on very slowly 
 and evenly, so that in the course of a minute we have increased it from 
 nothing up to 50 or 100 milliamperes or more. The first sitting should not 
 be for a longer time than six minutes, the current remaining at its strongest 
 for half of this time, and then being slowly reduced. During the passage of 
 the current the operator must constantly observe both his galvanometer and 
 the patient. The needle should remain perfectly steady, with no oscillations 
 which would indicate jar or shock. The operator must be particularly care- 
 ful to avoid any accident which might produce a sudden change in the inten- 
 
220 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 sity of the current, as the shocks thus produced are exceedingly trying. At 
 the end of the sitting the vagina should be again douched and the patient 
 kept in bed for the rest of the day. If there are evidences of pain or re- 
 action, and in susceptible individuals, it is well to insist on rest in bed for 
 several days, together with the use of the ice-bag over the region of the 
 tumor. Should there be any bleeding, it may be necessary to tampon the 
 vagina with styptic cotton. The necessity for this, however, is rare. We 
 must atways warn the patient of what is coming; we must first apply 
 the moistened, warm, dispersing electrode to the abdomen; we must have 
 the intra-pelvic electrode aseptic, and introduce it with the greatest possible 
 gentleness ; we must thoroughly insulate all but the active portions of the 
 instrument, avoiding metallic contact with vagina, vulva, or speculum, and 
 never establish the current until intra-pelvic disturbance has ceased; always 
 increase the current verv gradually, bearing in mind that the intra-uterine 
 or intra-pelvic pole must never cause pain. All shock must be avoided, the 
 connections made before the current is established, and not broken until it 
 is entirely turned off.] 
 
 Treatmcjit of Tumors Incarcerated in the Pelvis. — Certain fibrous tumors, 
 either developing in the lesser pelvis or retroflexed into it, may cause serious 
 compression of the rectum, bladder, or nerves, even producing ileus, uraemia, 
 or paraplegia. At times all these symptoms may be relieved by replacing 
 the tumor above the promontory. The patient is put in Sims' position, or, 
 better, in the genu-pectoral, and the tumor is elevated by pressure from the 
 vagina or the rectum ; if there is much muscular contraction, chloroform 
 should be used. This procedure may be adopted also in cases of pregnancy 
 complicated with fibroma at the time of parturition. 
 
 Minor Hcemostatic Operations. — Before the description of the major oper- 
 ations for the relief of fibroma, a few words may be said about the more 
 simple surgical measures which are employed against the often very serious 
 hemorrhage. 
 
 Curettage and Intra-utei'ine Injection. — This measure has frequently 
 been adopted, often, without doubt, from an erroneous diagnosis of hemor- 
 rhagic endometritis. Recent researches demonstrate that it is nevertheless 
 the correct thing to do. It may be successful when the uterine cavity is not 
 much deformed and the curette can be employed efficaciously. The injec- 
 tion of perchloride of iron with Braun's syringe, and copious washing after- 
 ward with the double-current catheter, as described under the head of 
 metritis, may then f(;llow. Such injections must always be made with the 
 greatest care, remembering that the tubes may be markedly dilated and 
 permeable. 
 
 Dilatation of the Cervix. — This operation, advised by Baker Brown, Mac- 
 Clintock, and Nelaton, has been recently advocated by Kaltenbach, who uses 
 Hegar's bougies, from i6 to i8 mm., and in certain cases has obtained re- 
 markable success. He attributes great importance to thd narrowness of the 
 
MEDICAL AND SURGICAL TREATMENT OF FIBROMA. 22 1 
 
 cervical canal in the causation of both pain and bleeding with myomata, and 
 especially recommends this palliative measure in women with a small tumor 
 who are near the menopause or when it is desirable to gain time. I have 
 seen good results from it. 
 
 Bilateral Section of the Cervix. — This operation was done first by Nela- 
 ton, then by Baker Brown, and recently has been recommended anew ; but 
 as the incision must be carried down to the chief branches of the uterine 
 artery, it amounts to nothing more than ligation of these vessels. It is of 
 benefit only when the neoplasm occupies the lower segment of the uterus, 
 and is thus of restricted application. 
 
 Intra-iitcriiic Scarification. — In cases of obstinate bleeding depending 
 upon an intra-uterine fibroma, Martin claims to have had good results from a 
 measure formerly employed by Simpson, pamely, the division of the capsule 
 by scarification upon the projecting part of the submucous tumor, the sev- 
 ered vessels undergoing retraction. 
 
 Surgical Treatment of Fibrous Tumors. 
 
 The operations applicable to fibromata differ according as the tumors are 
 accessible by the natural passages or only by laparatomy. The progress of 
 operative gynaecology permits us to-day to avoid in most cases the division 
 of the abdominal walls. 
 
 I shall treat in this chapter of those tumors only which by their evolu- 
 tion toward the vagina may be reached by that passage. 
 
 A. Fibroma of the Vaginal Portion of the Cervix. — In the cervix, 
 owing to the small size of the part, we do not distinguish between submucous 
 and interstitial tumors. They are ordinarily not difficult to detach from the 
 surrounding tissues, and we may then, as Lisfranc and all other surgeons 
 have done, attempt to enucleate them by the aid of finger and spatula after 
 removal of their lower portion and a section of the tissue, or making a coni- 
 cal excision, in order to facilitate the manoeuvre. 
 
 It is always useless to complicate the operation by the employment of 
 the ecraseur or the galvano-caustic loop ; the latter is dangerous to the sur- 
 rounding parts and of too delicate an action, and should be used only in 
 exceptional cases. The ecraseur, which many surgeons still advise for the 
 ablation of tumors by the vagina, has several defects — it may break on tis- 
 sues of great resistance, it cuts very slowly and causes a loss of time during 
 which the uterus may be bleeding above the tumor, and it has a tendency to 
 rise upward by a climbing motion on very hard tissues, which has caused 
 the peritoneum to be opened. To avoid loss of blood, the best way is to 
 proceed as quickly as may be with the bistoury; fibrous tumors are not very 
 vascular, and, if certain vessels bleed, it is easy to arrest the hemorrhage by 
 means of forceps. If the cervical tumor, as in one of Schauta's cases, is 
 prolonged above into the uterus, it should be attacked by morcellation so as 
 
222 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 to remove it completely. If the tumor has no capsule, we may amputate it 
 as high as possible, saving two lips, which should then be reunited. When 
 there is a clean wound after enucleation, we may equalize its edges and 
 suture them ; but if primary union seems improbable, it is better to remove 
 the debris of the capsule and pack the cavity with iodoform gauze. 
 
 B. Pcdicled Fibroma of the Body or Polyp. — When the tumor is intra- 
 uterine, it is necessary to do a preliminary operation to render it accessible; 
 
 Fig. 162. — MusEux Forceps. 
 
 this is best accomplished by the bilateral division of the cervix with strong 
 scissors up to the vaginal insertion. The upper portion of the canal is 
 usually dilated b}^ the tumor itself ; if otherwise, the part is softened by 
 laminaria tents, and then dilated by Hegar's bougies; or we may make a 
 bilateral incision (pages 90 to 94). The ablation of the polyp is ordinarily 
 very simple. The patient is placed in the dorso-sacral position ; the vagina 
 is dilated with a speculum or retractors ; and the polyp, being seized with 
 toothed forceps (Figs. 162 .and'i63), is drawn downward as much as possible 
 Avhile the hand above the pubes examines that the uterus is not inverted. 
 Then the pedicle is twisted by imparting to the polyp a movement of rota- 
 tion on its axis, and after two or three turns a pair of strong scissors, curved 
 
 Fig. 163. — Collin's Tumor Forceps. 
 
 on the flat, is slid up to the attachment of the pedicle, which is then divided 
 by small cuts while the torsion continues; this has the double effect of aid- 
 ing the extraction of the tumor and lessening the hemorrhage. 
 
 The usual advice is to cut the pedicle as high as possible ; but by a 
 lower section I think that there is less risk of secondary hemorrhage, and 
 the stump retracts within the cavity of the uterus and is rapidly obliterated. 
 
 All the measures devised with a view to prevent bleeding should be reso- 
 lutely abandoned; they have resulted in more victims than cures. Galvano- 
 
MEDICAL AND SURGICAL TREATMENT OF FIBROMA, 
 
 223 
 
 cautery, ligature, and ecraseur all prolong and complicate an operation which, 
 to be safe, should be rapid. Even Dupuytren contended against the chimer- 
 ical fear of hemorrhage, and advised the cutting instrument ; it is time to 
 return to his practice. In the very rare cases, of which Trelat has cited an 
 example, in which the pedicle contains large vessels, the condition may be 
 recognized by palpation, and before operating a pressure forceps should be 
 placed on the part and allowed to remain for several hours. If there is much 
 loss of blood, hot injections, ergot, and tamponade wdth iodoform gauze will 
 easily check the hemorrhage. 
 
 I have proposed the name " enormous polyps" for those which fill the 
 vagina, do not permit the finger to reach the pedicle, and cannot be easily 
 removed through the vulva; these peculiar polyps offer special operative 
 indications. The pedicle should not be treated until the volume of the 
 
 Fig. 164. — Forceps for Removal of Large Tumors, a, With adjustable joint ; 1^, pickerel toothed. 
 
 tumor has been diminished — a result easily obtained by combining certain 
 measures which have been advised at different times. Simon's method con- 
 sists in making a series of transverse deep incisions one above another until 
 the pedicle is reached. Hegar attains the same object by a series of spiral 
 incisions on the capsule of the tumor, which is always the most resistant 
 part. Lastly, the fragmentary removal of the polyp by a number of conoidal 
 excisions seems to me the best method. It is better to attack the tumor at 
 the fourchette and make our incisions at that level, as advised by Dupuytren. 
 When the volume of the tumor has been sufficiently diminished, it is seized 
 between the branches of wide-jawed forceps (Fig. 164) ; this compression 
 reduces its size still more ; and by small incisions with the scissors, and tor- 
 sion, the section of the pedicle is completed. 
 
 When the patient is cachectic or enfeebled, it is especially important to 
 employ the most rapid methods and avoid prolonging the anaesthesia or the 
 operation. 
 
224 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 After the removal of the tumor it is well to do a supplementary curet- 
 tage, either at the same sitting or at the end of a few hours, and follow it 
 with cauterization, to cure the metritis, which is constant, and to hasten the 
 involution of tlie enlarged uterus resulting from the presence of the neoplasm. 
 
 Submucous Fibroma of the Uteriue Body. — Clinically, we must include 
 under this head those tumors which are separated from the mucosa by a layer 
 of muscular tissue, for they are more closely related to this surface than to 
 the peritoneum, and cause a decided projection into the cavity of the organ. 
 At certain times, during menstruation, or metrorrhagia accompanied by colic, 
 the cervix is more or less obliterated and opens enough to allow the finger to 
 pass upward to the projection of the tumor. Artificial dilatation, in default 
 of the natural, permits us to appreciate the conditions present. An urgent 
 indication for immediate interference is the commencement of gangrene. 
 
 The loose connection of the tumor with the uterus, and the many times 
 repeated example of spontaneous expulsion by natural effort alone, should 
 lead the surgeon to attempt enucleation. This idea was first advanced by 
 Velpeau, but it was Amussat who did the first operation, and made it his own 
 by the zeal and talent with which he defended it; since then it has been 
 performed by Boyer, Berard, Alaisonneuve, Lisfranc, and others. But after a 
 momentary favor it fell into discredit and was done only here and there in 
 isolated cases ; the criticisms of Jarjavay and Guyon contributed powerfully to 
 this result. But while its fortune declined in France, it improved elsewhere. 
 Atlee recommended it in America as a means of curing " tumors till then 
 considered beyond the resources of art." In England and Germany also 
 Amussat's operation was practised for a long time, though it continued to 
 have its warmest partisans in America. It was but little practised in 
 France, when my fellowship thesis called attention to it anew, and brought 
 out new observations, but the progress of laparatomy has almost entirely 
 directed surgeons to the intraperitoneal methods (hysterotomy, castration), 
 up to the recent reaction in favor of the vaginal operation of Pean and his 
 admirers. 
 
 This reaction has caused a nearly complete disappearance of the opera- 
 tion of enucleation in France, it being in that country almost always replaced 
 by vaginal hysterectomy with or without morcellation. The latter operation 
 is in fact more rapid and consequently less serious. 
 
 We shall see, however, that morcellation of the tumors permits us to 
 reach much higher up the vagina ; and it is only when the tumors are very 
 small that we practise enucleation alone. 
 
 Narrowness and rigidity of the vagina do not constitute an absolute con- 
 tra-indication. One may attempt to overcome them by a preliminary tampon- 
 ade; but it is preferable to diminish the size of the tumor by morcellation. 
 
 In the absence of spontaneous dilatation of the cervix, we use laminaria 
 tents or Hegar's bougies with preliminary bilateral incision. Chrobak pre- 
 fers multiple incisions, which he carefully sutures after the operation. If 
 
MEDICAL AND SURGICAL TREATMENT OF FIBROMA. 
 
 225 
 
 the tumor surpasses the size of the fist, we do not attempt to enucleate it 
 entire, but remove it preferably in small portions. 
 
 The operation varies considerably with the volume, the consistence, and 
 the connections of the fibrous tumor. 
 
 The most convenient position is the dorso-sacral, but certain operators 
 prefer that of Sims. Anzesthesia is necessary. Two assistants hold the 
 legs of the patient, the one depressing the uterus from above the 
 pubes, the other keeping up continuous irrigation, each of them 
 holding one of the retractors. It is well to have another assis- 
 tant, as the operation is particularly fatiguing. 
 
 When the cervix is not sufficiently dilated, there should be no 
 hesitation in splitting it up to the vaginal insertion, after having 
 ligated the lower branches of the uterine artery (page 94) ; this is 
 the preliminary step. 
 
 If the tumor is small and the cervix is not too much thinned 
 to sustain the traction, forceps in one or the other lip render valu- 
 able service in drawing the organ down and furnishing a point of 
 support for the enucleation. 
 
 The first step consists in opening the capsule. The project- 
 ing part of the tumor is seized by a Museux forceps, and at the 
 point where the mucous membrane is reflected on to the uterus an 
 incision is made with a bistoury or scissors to as great an extent 
 as possible. 
 
 The second step consists of peeling the capsule from the 
 tumor with the fingers; a spatula is sometimes necessary for this 
 purpose. It should be dull and slightly concave ; I have devised 
 an enucleator in the form of a large spoon with which I have 
 obtained good results (Fig. 165). I prefer the enucleator of Sims 
 to the toothed spoon of Thomas. 
 
 When the adhesions of the fibroma have been destroyed over 
 a certain area, the Museux forceps are re-applied, and with these 
 or double hooks the tumor is rotated on its axis ; if it is necessary, 
 curved scissors may be used to divide the fibrous bands which do 
 not yield to the enucleator. 
 
 The third step, or removal of the tumor, is not so laborious 
 as it is extensive. I have removed in mass an intra-uterine fib- 
 roma larger than the fist, which was not in a capsule, but free in 'p'ozz^i' 
 the uterine cavity, where it had formed adhesions. It was in a 
 very curious case of polyp with intermittent symptoms, which had 
 not been removed though frequently coming down into the vagina, and which 
 finally was retracted into the uterus, where it became secondarily fixed. 
 
 Frankenhauser has invented for the extraction of large tumors a special 
 instrument resembling the cephalotribe, and Martin a kind of tongs with a 
 forceps point. P. Segond has an instrument which permits the extraction 
 
 ESTCLEA- 
 TOK. 
 
226 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 of part of the tumor as a core. C. Braun uses a cranioclast to reduce the 
 size of voluminous tumors. 
 
 When the fatigue of the operator or the debility of the patient has made 
 it necessary to arrest the operation before it is completed, the spontaneous 
 elimination of the tumor has been observed at the end of a few days, and 
 sometimes a second operation is far less difficult, owing to the infiltration 
 of the capsule and the relaxed adhesions. This latter fact has given the 
 idea to certain operators of spreading the operation over different sessions. 
 But this is to make a matter of choice of what should be only a condition of 
 necessity, and expose the patient to the septic accidents which have so often 
 followed such treatment. There is another variety of operation in two ses- 
 sions, where the first consists merely of a deep incision of the capsule, after 
 the example of Atlee; then after some days, when we may suppose that the 
 uterine contractions have produced a partial separation of the tumor, we 
 may proceed to enucleation. Vulliet has recently perfected this procedure 
 of Atlee. He attempts, a little theoretically, to direct the fibroma at its first 
 appearance toward the uterine cavity, rather than toward the abdominal, by 
 the aid of a galvanic current; then, when it has become submucous, the 
 capsule is incised and ergot and electricity are employed to increase its 
 tendency toward self-enucleation, and to this are added intra-uterine tam- 
 pons of iodoform gauze, renewed every fort3'-eight hours. 
 
 The objections to this method are its extreme slowness, the many dan- 
 gers to which it exposes the uterus, and the uselessness of long temporiza- 
 tion with a tumor which has become accessible to operation. 
 
 If it is impossible to remove the whole of the tumor without dangerous 
 violence, we may leave a portion of it, hoping that by antiseptic treatment 
 (iodoform tampons and intra-uterine injections, etc.) we may prevent the 
 septicaemia which might be caused by gangrene of the portion left in place; 
 but incomplete removal has given rise to serious disaster when antiseptic 
 precautions have not been observed. Although the result may at any time 
 be disappointing, we may still hope to realize one of the following effects : 
 either the spontaneous expulsion, more or less tardy, or the retraction and 
 atrophy of the intra-uterine portion. I consider, however, that it is best to 
 end the operation by vaginal hysterectomy. After the enucleation of intra- 
 uterine fibroma, there is left a large bleeding cavity containing loosely at- 
 tached portions of capsule of tumor, in a more or less completely relaxed 
 uterus. All loose pieces should be removed from the wound, and hot anti- 
 septic injections employed. On account of the large absorbing surface, 
 it is better to use a solution of carbolic acid, i 150, rather than bichloride 
 which may cause toxic symptoms. If there is much oozing, the temperature 
 of the injections should be raised to 120° F., and the cavity may be packed 
 with iodoform gauze. A hypodermic of ergotin, with massage over the 
 hypogastrium, will bring on uterine contractions. Then several layers of 
 cotton and a bandage are applied, and the patient ordered absolute rest. 
 
MEDICAL AND SURGICAL TREATMENT OF FIBROMA. 227 
 
 The principal accidents of enucleation are hemorrhage, wounds of the 
 uterine wall, inversion of the uterus, and septicaemia. 
 
 For the hemorrhage the best remedy is rapid completion of the opera- 
 tion, for the retraction of the uterine walls will stop the bleeding. If nec- 
 essary we may compress the abdominal aorta and tampon the uterus. 
 
 Perforation is not very serious unless there is septic infection of the 
 cavity, without which an adhesive peritonitis closes the wound as after vagi- 
 nal hysterectomy. 
 
 Inversion of the uterus may be produced during the operation from ex- 
 cessive traction. It renders the tumor more accessible to the manipulations 
 of the surgeon, but is dangerous if unrecognized, for it may lead our efforts 
 in a false direction. After the operation, the thinness of the uterine wall 
 where the tumor was situated may produce a consecutive inversion ; Bis- 
 choff in such a case produced a gradual reposition by tamponade. 
 
 Septicsemia, with its different local manifestations, metroperitonitis, 
 thrombosis, etc., may follow when there is a large cavity without much re- 
 traction of the uterine wall ; it is then necessary to employ repeated anti- 
 septic injections. A permanent drainage tube of rubber made in the shape 
 of a cross may be left in the cavity, where it is retained without exercising 
 pressure (Fig. 52). 
 
 Where the secretion is very abundant and putrid, continuous irrigation 
 may be employed, the flow being only drop by drop. This weak current 
 may be regulated with the aid of Schiicking's ingenious apparatus fitted to 
 the discharge tube of a container full of carbolic-acid solution (i :5o), and 
 attached to the drainage tube (Fig. 56). 
 
 As West and Gillette have remarked, it is impossible to obtain an exact 
 idea of the gravity of this operation from statistics ; for some concern only 
 successful cases, others include very different kinds of operation, complete 
 and incomplete enucleations, those divided over different sessions with 
 tumors gangrenous or otherwise, with or without antiseptics, etc. 
 
 Moreover, the word enucleation does not have the same meaning with 
 different authors. To judge correctly of this operation, as of all others, 
 we should have a series of individual cases from surgeons of an average 
 skill, established by homologous observations. If such information is lack- 
 ing, we must content ourselves with the scattered notices, some of them in- 
 complete, accumulated in the medical periodicals. Thus, in 1875 I pub- 
 lished 64 cases, with 16 deaths, that is, 25 per cent; Gusserow collected 
 154 cases since Amussat's, up to 1877, with 51 deaths, that is, 33 per cent; 
 Lomer, who restricted his inquiries to the antiseptic period (from 1873 to 
 1883), found in 112 cases 18 deaths, that is, 16 per cent. Adding to Lo- 
 mer's statistics several more recent cases, Gusserow collected 153 cases, 
 with 23 deaths, or 14.6 per cent; Ascher has observed only i death in 10 
 cases, or 10 per cent; Leopold has recently obtained 28 cures in 28 opera- 
 tions, and C. Braun 1 5 successes in 1 5 cases. From this it appears how 
 
228 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 greatly the fatality of the operation has been lessened by antisepsis. A. 
 Martin has published personal statistics which have an unusual value be- 
 cause of his skill, and the opportunity he has had in a large practice to 
 compare this operation with others done through the abdomen for analogous 
 cases. In 27 operations he had but 5 deaths, of which 2 were from 
 wounds of the peritoneum and peritonitis, 2 from septicaemia (before the 
 antiseptic era), and i from collapse. Martin declares that he has entirely 
 abandoned vaginal enucleation for tumors of the body of the uterus, even 
 though they are in partial expulsion; preferring extraction through the 
 abdomen, where he makes an actual enucleation, as far as the integrity of 
 the uterus is concerned, as we shall see farther on. 
 
 Transvaginal Emccleation. — If the myoma starts from the supravaginal 
 portion of the cervix or the posterior surface of the uterus, it may make the 
 posterior wall of the vagina prominent to such a degree that the most direct 
 way to reach it is by incision of that wall ; less often the incision may be 
 made through the anterior vaginal pouch. In these cases the most rational 
 operation is free incision of the vagina. This procedure may be relatively 
 simple when the tumor is posterior, for it is then developed in the. pelvic 
 connective tissue outside of the peritoneum. Czerny reports many success- 
 ful cases with this method; Ljocis and Olshausen have published similar 
 cases. Le Fort reported a curious case in which the rectovaginal septum was 
 split from above, simulating rectocele, by a pedicled fibroma whose enuclea- 
 tion through the perineum was followed by cure. Marc See on this occa- 
 sion cited a similar case without a pedicle. Eugene Bockel, in a case in 
 which the fibroma was accessible through the vagina, made a median in- 
 cision through that canal and the cervix, posteriorly, and successfully enu- 
 cleated the tumor. 
 
 When the tumor is very large, both morcellation and enucleation may 
 be required. In a case in which a large fibroma partially separated the 
 rectovaginal septum, I easily removed the tumor by morcellation after 
 opening this septum by an incision extending between the ischial tuber- 
 osities (transverse perineotomy). When the fibroid projects toward both 
 vagina and peritoneal cavity, the latter is liable to be opened. One may 
 also open it intentionally, in cases of small tumors of the anterior wall of 
 the fundus, by anterior colpotomy, incise the uterus, enucleate the tumor, 
 and after the operation is finished suture the uterus and fix it to the vagina. 
 
 Morcellation or Vaginal Myomotomy. — The difficulty of enucleating the 
 tumor when it is of large size or is closely connected with the uterine tissue 
 on the one hand, and the gravity of opening the abdomen compared with the 
 vaginal method on the other, have led surgeons to remove large tumors in 
 successive fragments by the vagina through the partly effaced cervix, either 
 by natural dilatation or by incision. This operation, which I have described 
 because of its historical interest, has been entirely replaced by vaginal hys- 
 terectomy by morcellation, which is more rapidly performed and less serious. 
 
MEDICAL AND SURGICAL TREATMENT OF FIBROMA. 229 
 
 Emmet, in America, has devised, under the name of "extraction of 
 fibroma by traction," a procedure which he has practised since 1884. His 
 object is to produce a pedicle by traction on the tumor, which he then re- 
 moves by a combination of morcellation and enucleation, but he describes 
 his technique in so incomplete a manner that it is difficult to form precise 
 ideas about it. The isolated cases of Czerny and other German surgeons 
 lack quite as much definite synthesis and method. 
 
 On the other hand, this criticism cannot be made of the technique which 
 Pean has made known even in the smallest details by a series of publications 
 which have been collated by Secheyron. The fundamental idea of this 
 method is the employment of morcellation from the first, without the ad- 
 dition of enucleation. Instead of attacking the tumor at its periphery, the 
 surgeon begins immediately upon the central portion, and, after that is fully 
 excised, finally reaches the fibrous shell ; moreover, Pean's method includes 
 a special preliminary operation of splitting, and, at the same time, excising 
 the cervix to obtain easy access to the fibroma. 
 
 The cases to which morcellation by the vagina may be applied comprise 
 not only submucous tumors of the size of the infant or adult head, but also 
 cases of interstitial and subperitoneal tumors for which laparatomy might 
 be fatal because of the large opening made in the serous membrane. In 
 certain cases, moreover, Pean has completed the operation by total ablation 
 of the uterus either by the vagina or through the abdominal walls. That 
 seems to me an exaggerated extension of the operation. It would be pref- 
 erable, in such a case, to perform vaginal hysterectomy at the outset and 
 intentionally, instead of' being forced to do so after other laborious ma- 
 noeuvres. 
 
 The operation is divided into three steps: i. Freeing the cervix from 
 its vaginal attachments. 2. Section of the cervix and a segment of the 
 uterus at the level of the tumor. 3. Removal of the tumor by small pieces, 
 with or without enucleation ; and excision and suture of the lips of the cer- 
 vix. 
 
 For this operation, Pean uses a series of forceps either straight or curved, 
 with long jaws, flat, toothed or not, without points, round or blunt, espe- 
 cially designed for morcellation (Fig. 166), and, lastly, he is provided with 
 long or short-handled forcipressure forceps. The preliminary steps are the 
 same as those of all gynaecological operations. 
 
 The patient is placed in the left lateral or dorsal position. Besides the 
 two assistants at right and left of the operator, a fourth is placed on a foot- 
 stool on a little lower plane, to help in holding the retractors. 
 
 First Step — Liberation of the Cervix. — Two or three elbowed retractors 
 display the cervix at the bottom of the vagina ; this is immobilized with 
 strong Museux forceps; a circular incision is made with a bistoury at the 
 level of the vaginal insertion, haemostatic forceps being placed upon the 
 bleeding vessels as necessary. It is at this point in the operation that the 
 
230 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 forceps are the most necessary, for, before completing it, it is necessary to 
 stop the bleeding entirely. When the cervix is free enough above, it is 
 cut almost through with a bistoury in order not to wound either bladder or 
 ureters ; it is then very movable, swinging as freely as the pendulum ot a 
 clock. 
 
 In this part of the operation we must take care not to wound the peri- 
 toneum, though that accident has not the gravity which has been attributed 
 to it ; in some cases even, according to Pean, it is advised to make this 
 perforation in order to reach a fibroma projecting into the cul-de-sac. 
 
 Second Step — Incision of Cervix and Segment of litems below Fibroma. — 
 Long, straight scissors with blunt points are introduced into the cervical 
 cavity, and a clean bilateral incision is made. A Museux forceps is then 
 placed on each one of the lips, anterior and posterior. The finger intro- 
 duced into the cavity determines the exact seat of the tumor and the point 
 where it is most easily accessible, which is distinguished from the uterine 
 wall by its white or violet color and its density. During this examination 
 the organ should be drawn well downward. 
 
 Third Step — Fractional Excision of the Tumor. — The tumor projects tow- 
 ard the cavity of the uterus, the peritoneum, or the vagina ; it is drawn 
 downward by steady traction with a Museux forceps, or by long forceps with 
 flat teeth fenestrated or furnished with points (Fig. 166). The elbowed 
 retractors are then introduced, the large ones into the vagina, and smaller 
 ones into the uterus, displaying the operative field as widely as possible. 
 These retractors not only make the part accessible, but also form a valuable 
 means of controlling the hemorrhage by the pressure and traction which 
 they exert. If necessary, an electric light may be used to illumine the part 
 operated on. 
 
 The fibroma is fixed by the finger, seized with the forceps, and drawn 
 strongly down. A piece of it is then grasped by a strong-toothed forceps, 
 and a deep incision perpendicular to the long axis of the tumor is made ; 
 each of the lips of the section, or perhaps but one of them, is grasped as 
 high as possible with a strong-toothed or pointed forceps and the subjacent 
 parts excised. Before the first forceps is removed, a second pair is passed 
 above it, grasping a new portion of the myoma, and the scissors or the bis- 
 toury cut out the part below; thus by the aid of the forceps, bistoury, and 
 scissors the tumor is excised portion by portion. 
 
 The bistouries which Pean uses are of special make and very strong, 
 resembling metacarpal knives, either straight or curved on the flat, and with 
 long handles. 
 
 Very often the procedure is simpler; the tumor may not bleed, and then 
 the forceps are used only to draw down different parts of it, the portions be- 
 tween its jaws being cut out in turn. This excision is practised alternately 
 first on one side of the tumor, then on the other ; and as the operation pro- 
 gresses the traction allows us to remove larger fragments, which may be as 
 
MEDICAL AND SURGICAL TREATMENT OF FIBROMA. 23 1 
 
 large as a nut, or even as an apple. Thus successive fragments are removed, 
 the operation lasting perhaps an hour. 
 
 When the lower part of the tumor has thus been removed, it is often 
 possible by reaction and rotation to produce spontaneous expulsion of the 
 upper portion, which will shorten the time of operation considerably. The 
 volume of the mass enucleated by traction alone may exceed that of the por- 
 tion excised. 
 
 When the fibroma is of large size, the intra-muscular cavity which held 
 it is almost always widely opened, communicating with the interior of the 
 uterus and the peritoneum, and bleeding so freely that the important vessels 
 require ligation. This step of the operation demands the dissection of 
 almost the whole lower portion of the uterus, and its infra-traction almost 
 to the vulva ; to facilitate this, Pean excises the two cervical lips, and su- 
 tures them afterward to the lips of the vaginal wound with metallic sutures. 
 
 Fig. 166. — Plan's Forceps, Serrated and with Teeth, for Morcellation of Fibromata. 
 
 As to any communication with the peritoneal cavity, Pean leaves it open if 
 its edges are much contused, though he narrows it by a few sutures at sepa- 
 rate points. 
 
 It is easy to determine when the myoma has been completely extracted, 
 for the last portions present a convex, smooth, and red surface, covered with 
 cellular debris. The operation is not complete until the state of the ad- 
 jacent uterine tissue has been examined by the finger. If another myoma 
 is found near the first, it should beat once removed; for this purpose a 
 larger incision of the uterus may be made with a bistoury if necessary. The 
 second tumor is then strongly grasped with forceps and removed as before. 
 Thus the operator may be obliged to extract a series of small tumors hidden 
 away in the parenchyma. 
 
 FonrtJi Step — -TJic Uterine Toilet and Sutnre of tJie Cervix. — As the 
 tumor is removed it leaves a large pocket which communicates freely with 
 the uterine cavity ; from this hang the haemostatic forceps with long handles 
 to the number of twelve to twenty. During the operation Pean uses small 
 sponges provided with long handles to cleanse the walls of the part and find 
 the bleeding points ; I replace these with pledgets of absorbent cotton. 
 
232 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 The last step of the operation is the thorough cleansing of the wound; 
 the smaller clots are removed, and between the forceps left to control the 
 bleeding (from ten to fifteen) it is well to pack strips of iodoform gauze. 
 Intra-uterine irrigation with hot antiseptic fluid should precede the appli- 
 cation of these tampons, and after thirty-six to forty-eight hours the forceps 
 
 Fig. 167.— HAEMOSTATIC Forceps for Vaginal Hysterectomy. >}, Long curved forceps of Pozzi. • ^, Ordinary 
 long forceps. C, Forceps with short jaws. £>, Pryor's forceps with removable handles. 
 
 are removed. When the tumor is small the operation may be finished by 
 suturing the lips of the cervix. During the first days after the operation 
 it is well to give small doses of ergot. 
 
 The enucleation of fibroids by this method of morcellation is an operation 
 of but slight gravity, as is shown by the publications of Pean, Terrillon (five 
 successes in five operations), and Bouilly (four successes in five cases). In the 
 single case in which I performed it I obtained a cure. It seems to me certain 
 that this bold procedure ought to give excellent results whenever the tumor, 
 
MEDICAL AND SURGICAL TREATMENT OF FIBROMA. 
 
 233 
 
 though of large size, is submucous or interstitial and furnished with a cap- 
 sule which permits us to limit the operation by a clean extraction of the 
 upper part of the fibrous sphere. But if one attacks a subperitoneal tumor, 
 either at the outset or secondarily, which is intimately fused with the uter- 
 ine parenchyma, so that nothing marks the boundary between the patho- 
 logical and the normal tissue, one may be led to complete the removal of 
 the fibroid by a hysterectomy. I believe the latter is much less serious than 
 the procedure of Mikulicz, who after inverting 
 the uterus at an operation, resected a portion of 
 its wall to remove a tumor of this kind, then su- 
 tured the peritoneal wound with catgut for a 
 distance of 10 cm. and finally returned the organ 
 to its place ; the patient recovered. 
 
 Vaginal Hysterectomy. — Total ablation of 
 
 Fig. 168.— Plan's Retractors. 
 
 FtG. i6g. — Forceps for Morcellation'. 
 
 the Uterus for fibrous tumors has been advised in two different conditions : 
 I. In case of small simple or multiple tumors, which are the cause of grave 
 symptoms. 2. In the case of large tumors when, at the end of an operation 
 for their fractional removal, it becomes evident that a portion of the uterine 
 wall requires excision. In the latter case it is an operation of necessity. 
 I have long preferred to this operation (which Pean terms uterine castration) 
 ovarian castration, which I considered much less serious. Now that I under- 
 stand more fully all the resources and the benignity of vaginal morcellation, 
 I am more completely abandoning ovarian castration, which I regard as a 
 
234 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 makeshift. It is almost as grave a procedure, and certainly less efficacious, 
 than vaginal hysterectomy, and above all it does not relieve the pressure 
 symptoms due to the presence of the fibroid, particularly those of compression 
 
 Fig. 170. — LoN'G, Strong Curved Scissors. 
 
 of the rectum and of the ureters. I have, therefore, come to consider, as 
 Segond does, that all uterine, or peri-uterine fibroids, whose upper borders 
 do not extend above the level of the umbilicus, are amenable to vaginal 
 hysterectomy by morcellation. 
 
 Although colpohysterectomy had already been done by Kottmann, Pean 
 was the first to perform it in France systematically. Demons has also ad- 
 vocated it. Successful cases have been published by Sanger, Orthmann, 
 Richelot, Terrier, Spath, and Leopold. Leopold, in 21 operations, had 
 only 3 deaths, or 14.3 per cent. Martin has been less fortunate: in 9 
 operations he has had 2 deaths, or 22 per cent. Since then the operation 
 has been generally practised, and its results have been greatly improved. 
 Pean, from 1890 to 1895, performed 248 vaginal hysterectomies for fibroids 
 
 Fio. 171. — Vaginal Hysterectomy; Anterior Hemisection op the Uteres. .4, First pair of forceps which 
 remain until uterus is removed ; B, second pair for seizing progressively higher on the median incision to antevert the 
 fundus toward the operator ; C, opening into peritoneal cavity through the vcsico-uterine cul-de-sac. 
 
 with four deaths, or 1.6 per cent. Richelot has had 3 deaths in jG cases, 
 or 3.9 per cent. P"inally, Segond has had 7 deaths in 66 cases of large 
 fibroids reaching the umbilicus. 
 
MEDICAL AND SURGICAL TREATMENT OF FIBROMA. 
 
 235 
 
 The operation of vaginal hysterectomy for fibroids, as performed by 
 Pean and the French surgeons who have followed him, includes four steps : 
 (i) Liberation of the cervix from its vaginal attachments; (2) division of the 
 cervix after placing forceps upon the uterine arteries; (3) morcellation of the 
 body; (4) haemostasis of the broad ligaments. 
 
 First Step. — The cervix is seized with two toothed forceps at the level of 
 the vaginal insertion. By means of a bistoury and then with scissors the 
 
 Fig. 172. — Diagram, a, Forceps first 
 applied ; b, c, rf, successive positions of 
 second pair of forceps ; f, peritoneal border. 
 
 Fig. 173. — Diagram Showing Method for Re- 
 moving A Fibromatous Uterus throigh the Vagina 
 BY Morcellation. i-6, Successive portions removed 
 from anterior wall ; b to ?', position of forceps. 
 
 cervix is circumscribed by an incision, and its anterior and posterior faces 
 liberated as far as into the peritoneal cavity. 
 
 Second Step. — The bladder and rectum being held away from the opera- 
 tive field by two retractors, the operator places at the base of the broad lig- 
 aments, upon each uterine artery, a haemostatic forceps with short and strong 
 jaws, and divides the ligaments at the level of these forceps. The cervix, 
 after being freed in this manner, is divided into two flaps, an anterior and 
 a posterior; a strong clamp is placed upon the base of each of these flaps 
 and all the portion of uterine tissue situated below this flap is removed. 
 
 Third Step. — The morcellation proper now begins. This manoeuvre 
 consists in removing by resection of successive fragments and without pre- 
 liminary haemostasis the portions of the two uterine walls which tips forward 
 most easily, sometimes the two walls alternately. The most important 
 point in this operation is never to resect the slightest fragment without 
 
236 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 having first seized its base with a new forceps. During this process the 
 fibroids are enucleated by means of a hook, if they are sufficiently small, 
 or are morcellated in the same manner as the uterus itself. According to 
 whether curved scissors or a curved bistoury is employed, the fragments 
 removed resemble more or less closely a V or a cone. In either case one 
 performs morcellation. It is also morcellation to cut out a large V-shaped 
 portion, from the anterior uterine wall, with its base above near the fundus, 
 in order to diminish the volume of the fibroid uterus sufficiently to permit 
 its removal by the process which Doyen has revived. All these procedures 
 had been employed and described by Pean. Doyen's merit consists chiefly 
 in having insisted in a more systematic manner than his predecessors upon 
 the great utility of the preliminary incision of the anterior wall of the 
 uterus. This eventration of the uterine body facilitates to a considerable 
 extent the descent of the organ. A point of support is taken higher and 
 
 Fig. 174. — Self-retaining Catheter and Mandrii.i. for Facilitating Introduction. 
 
 higher with the forceps upon the lips of this median incision (Figs. 172, 
 
 173)- 
 
 Fourth Step. — When the fundus of the uterus appears at the vulva, draw- 
 ing down the broad ligaments, but not until then, haemostatic precautions 
 must again be taken. Clamps are placed upon the broad ligaments from 
 above downward, and the uterus is detached. Each clamp falls down caus- 
 ing a torsion of 1 80° of the portion of broad ligament which it includes. 
 Doyen places only one large clamp upon each ligament. As he leaves the 
 cervix until the end of the operation, he does not find it necessary I0 secure 
 preliminary haemostasis of the uterine arteries. I believe this practice offers 
 little security. 
 
 When the uterus has been detached the appendages are found and re- 
 moved if this can be done easily, otherwise they are left. In some cases it 
 has been possible to place the forceps upon the broad ligaments below the 
 appendages and thus to remove them with the fundus of the uterus. When 
 the operation is terminated the clamps are gathered into two lateral bundles, 
 allowing inspection of the deep parts of the wound, and if oozing is 
 found, this is checked by long-handled forceps. A thick strip of steril- 
 ized or weak iodoform gauze is placed in Douglas' cul-de-sac to secure 
 drainage. The forceps are arranged in two lateral bundles, and the vagina 
 is packed with strips of iodoform gauze whose ends form a cushion, above 
 the clamps, upon which the intestines rest. The vaginal walls are pro- 
 tected from injury by the forceps by wrapping each bundle with gauze. 
 
MEDICAL AND SURGICAL TREATMENT OF FIBROMA. 237 
 
 Finally, a self-retaining catheter, like that of Mal6cot (Fig. 174) is inserted 
 into the bladder. 
 
 After-treatment. — The broad-ligament clamps and catheter are removed 
 after forty-eight hours. The gauze drainage of the vagina is renewed daily 
 after the fourth day, or twice daily if the condition of the wovmd appears to 
 demand it. Weak antiseptic vaginal douches should be employed only after 
 the eighth day, and then should be given with great care, in order to avoid 
 breaking up the adhesions which protect the peritoneal cavity above. 
 
 Destruction of the Fibroma tJirougJi the Vagina. — I include under this title 
 several operations which do not belong in the previous categories, but which 
 should nevertheless be described, though only as a matter of history : 
 
 Partial Destj'uction by Incisions. — Baker Brown has attempted to copy 
 the natural processes which at times cure the fibroma by gangrene and con- 
 secutive elimination. His method is as follows: Incision of the capsule; 
 introduction into the depths of the tumor of special scissors cutting on their 
 outer edge, and dilaceration of the morbid mass or ablation of a conical frag- 
 ment ; or perforation by a kind of trephine. 
 
 Partial Destruction by Cauterization. — Greenhalgh, with the same ob- 
 ject, opened the capsule with a hot iron, establishing suppuration, removing 
 debris by the hand; in case of retrovaginal tumor he pierced it in different 
 places with the hot iron over the projecting portions ; in two cases out of 
 three death followed from peritonitis. 
 
 In the case of tumors which seemed inaccessible, above the pubes, Koe- 
 berle has dilated the cervix and made a series of parallel incisions into the 
 tumor, filling them with enough perchloride of iron to determine the mor- 
 tification of the intervening portions. 
 
CHAPTER XL 
 
 TREATMENT OF FIBROUS TUMORS OF ABDOMINAL EVO- 
 LUTION— MYOMECTOMY AND HYSTERECTOMY. 
 
 Hysterectomy, or removal of fibromata by way of the abdomen, is not 
 an operation that was deliberately premeditated, but is the product of diag- 
 nostic error. After opening the abdomen to remove a tumor presumably 
 ovarian, it has occurred that the surgeon found himself confronted by a 
 fibrous tumor of the uterus. The first who committed this mistake recoiled 
 from the terrors of an unknown operation, and hastily closed the abdomen 
 without finishing. These were the cases of Lizars in 1825, of Dieffenbach 
 in 1826, and more recently of Atlee (1849-51), Baker Brown, Cutter, Deane, 
 Mussey, and Smith. Fourteen cases of this kind were published during this 
 period, of which five were followed by death. Then certain bold surgeons 
 ventured to extirpate subserous pedicled tumors, Granville in 1837 being 
 imsuccessful, and the cases of Atlee and Lane recovering. Clay and Heath 
 in 1843 and Burnham in 1853 were the first to undertake the partial extir- 
 pation of the uterus ; G. Kimball was the first to propose hysterectomy for 
 an interstitial fibroma which was the cause of violent hemorrhages; the 
 patient recovered. Koeberle was the second to do the operation, but the 
 exact determination of the diagnosis, the rational choice of an operative tech- 
 nique, and the absolute novelty of the subject in Europe gave exceptional 
 value to his case. The report which he published on this occasion made 
 the operation the fashion of the day, 
 
 Koeberle was the first to employ the metallic loop and ligature-tightener 
 for ligating the pedicle. This was a great advance over the former practice 
 of ligating the tumor in mass, a method which exposed the patient to great 
 risk of hemorrhage ; the first step was thus taken, and from that time the 
 cases multiplied. In the year 1866, Caternault, a pupil of Koeberle, pub- 
 lished a series of forty-two cases of amputation of the uterus and twenty 
 cases of gastrotomy for the extirpation of pedicled tumors. Many of the 
 operators replaced Koeberle' s ligature-tightener by a clamp, which they 
 allowed to remain like a vice about the pedicle — an inferior method. After 
 the operation was made known, Pean obtained great success with it in Paris 
 in cases which were considered unfit for major abdominal operations, and 
 where even 'ovariotomy appeared bold. The presentation of a successful 
 case at the Academy of Medicine (August, 1870), and three years later the 
 publication of an important work, where the rules for operation were estab- 
 lished with a precision up to that time unknown, bound the name of P6an 
 
TREATMENT OF FIBROUS TUMORS OF ABDOMINAL EVOLUTION. 239 
 
 to hysterotomy with extraperitoneal treatment of the pedicle. The tech- 
 nique consisted chiefly in the employment of forcipressure, which Koeberle 
 was the only one to use freely at that time ; in fractional excision of large 
 tumors, after the application of a metallic ligature, to avoid opening the 
 abdomen too freely; and in transfixing the pedicle with sharp needles placed 
 crosswise below a steel-wire ligature applied by Cintrat's ingenious tight- 
 ener. This technique, of which the latest improvements have still retained 
 the general features, was for a long time adopted by all operators in France 
 and elsewhere. It is, then, to these two French surgeons that the merit 
 belongs of having established the operation upon a scientific basis. 
 
 After this first stage in the progress of abdominal hysterotomy, marked 
 by metallic constriction of the pedicle, and followed by many arguments 
 and disputes, there was a second stage characterized by the application of 
 antisepsis to the operation as to all others in surgery. 
 
 A third phase was inaugurated by perfection of the technique, and es- 
 pecially by the introduction of the elastic ligature for temporary or final 
 haemostasis. The most marked feature of the time was the strife between 
 partisans of extraperitoneal and intraperitoneal methods, and the substitu- 
 tion of castration for hysterotomy in a large number of cases. Finally a 
 fourth stage has been reached ; at present all surgeons attempt to substitute 
 total abdominal hysterectomy for methods with formation of a pedicle; ac- 
 cording to individual preference, some advise the abdominal route, others 
 the combination of abdominal and vaginal routes. 
 
 Synonyms. — The term hysterotomy, which means, from its etymology, 
 section of the uterus, is essentially comprehensive; with the adjective 
 abdominal, it may be applied to every operation where the uterine tissue 
 is removed after opening the abdomen. Still another word may be em- 
 ployed for the sake of precision; thus, supravaginal hysterotomy means 
 section or ablation of the uterus above the vagina. Tillaux, in a commu- 
 nication to the Academic in 1889, proposed the word hysterectomy, which 
 conveys the idea of excision, for those cases in which a part or the whole of 
 the organ is removed. This more exact term has rapidly prevailed, although 
 the older form is still met with. The Germans employ the word myomot- 
 omy or myomectomy for removal of a myoma with all or a part of the uterus, 
 thus including both hysterotomy for pedicled fibroma and partial hysterec- 
 tomy for interstitial fibroma. Lastly, by intraperitoneal enucleation is 
 meant simply incision into the uterine wall to remove a tumor, with pres- 
 ervation of the uterus itself. 
 
 General Indications for Abdominal Hysterectomy. — We shall see further 
 on that the possibility of substituting for this always serious operation an- 
 other which is less grave, namely, castration, reduces in certain definite 
 circumstances the field of hysterectomy. We may thus formulate the indi- 
 cations for the operation : 
 
 Rapid growth of the tumor; grave hemorrhage which does not yield to 
 
240 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 any palliative; ascites produced by the irritation of a very movable fibroma; 
 compression of important organs ; very large tumor, and especially its cystic, 
 oedematous, or suppurative degeneration ; symptomatic prolapsus of the 
 uterus; pregnancy, when the fibroma will manifestly be a serious cause 
 of dystocia. 
 
 The classification which may be established for the abdominal operation 
 is as follows : 
 
 I. Pedicled fibroma. 
 
 II. Fibroma with a single nucleus. 
 
 III. Fibroma with many nuclei. 
 
 IV. Fibroma within the pelvis or the ligaments. 
 
 In the first class the removal of the tumor is extremely simple and differs 
 but little from ovariotomy ; it is here only that the term myomectomy is ap- 
 plicable. 
 
 For the second and third varieties we may generally perform partial 
 hysterotomy or supravaginal hysterectomy, according to the location of 
 the tumor ; in certain special cases we may practise intraperitoneal enu- 
 cleation or total abdominal hysterectomy. 
 
 In the fourth class, if it is not possible to employ the pallative operation 
 of castration, we should attempt an intraligamentous decortication or a 
 vaginal morcellation. 
 
 Finally, total extirpation of the organ by the abdominal method has been 
 practised for certain multiple tumors which involved the cervix, with hyper- 
 trophy of the tissues and no opportunity of saving a pedicle. 
 
 Before passing these different operations and their varieties in review, I 
 wish to say a few words concerning an operative manoeu\Te which is appli- 
 cable to them all, and which has completely changed their technical conditions 
 since its introduction into abdominal surgery. 
 
 Provisional Hceinostasis during the Operation of Hysterotomy. — What- 
 ever may be the nature of the operation done in the abdominal cavity, it is 
 of the greatest importance to be able to perform it without much bleeding. 
 To obtain this end the older operators employed the compression of the 
 ecraseur; Billroth invented an enormous forceps which might be used in 
 such cases. A most valuable means of controlling the hemorrhage is the 
 temporary elastic ligature, which must not be confounded with the permanent 
 ligature to be described further on. Kleeberg, of Odessa, first used the 
 elasticity and steadiness of rubber to procure a constant constriction of the 
 uterine pedicle. He replaced the metallic ligature of Koeberle and Pean 
 with an elastic tube, leaving it in place permanently, and the patient was 
 cured. But it was Hegar who raised it to its present rank, and Martin 
 who gave a general application to the procedure, so that it now fills in 
 gynaecological practice the place of Esmarch's bandage in general surgery. 
 
 For the permanent elastic ligature a thick rubber tube of about 5 mm. 
 diameter is employed in Germany. I prefer a solid cord of the same size. 
 
TREATMENT OF FIBROUS TUMORS OF ABDOMINAL EVOLUTION. 24 1 
 
 and, after my communication which made it known, it has been generally 
 adopted in France. It has the advantage of being more easily sterilized 
 and, with the same volume, is more resistant. The temporary ligation is 
 best obtained by the same elastic cord. After stretching it and making two 
 or three turns round the part, the crossed ends are secured by a strong pres- 
 sure forceps ; for this purpose Hegar has a special form of forceps, with short- 
 elbowed jaws which are quite convenient. I have invented an elastic con- 
 strictor which renders good service when the surgeon is obliged to work in 
 a narrow cavity, and which is far less cumbrous than forceps. Certain 
 operators, forgetting the real object of this instrument, have used it for the 
 purpose of permanently securing the ligature, but this end is best attained 
 by a double thread of silk ; the ligator being only employed for tightening 
 the rubber cord. (For the technique see p. 46 and Fig. 44, p. 54.) 
 
 I. Pediclcd Fibroma — Myomectomy. — After the provisional ligature has 
 been applied as low down on the uterus as possible, the pedicle, if thin, is 
 pierced with a needle armed with double silk, whose ends are secured by Ban- 
 tock's or Tait's knot (Fig. 35, Nos. 5 and 6, p. 48). If the operator is not 
 familiar with this special knot, he simply cuts the loop and ties the ends 
 right and left after crossing them by a half-turn (Fig. 35, 3 and 4) ; to make 
 the surgical knot, the thread must always be passed twice (Fig. 35, 2). 
 
 If the pedicle is thick, it is well to seize and compress it with large 
 clamp forceps while the tumor is cut transversely, taking care to leave a col- 
 lar of peritoneum and capsule about the margin of the wound. The clamp 
 is then removed, and in the furrow which it has traced around the foot of 
 the pedicle a series of silk sutures are placed. The excess of tissue left 
 above the seat of the clamp is then cut away, leaving only enough to cover 
 the wounded surface, that being secured by the sutures already passed and 
 a few superficial points. The provisional elastic ligature is then removed, 
 and if there is much oozing by the sutures a few deeper ones are added. If, 
 at the moment of section, it is possible to see any of the large vessels, they 
 are separately tied. 
 
 The pedicle is returned to the cavity of the abdomen only when all ooz- 
 ing is completely arrested; if there is still any fear of further bleeding, 
 tamponing of the pedicle is practised by the method of Wolfler- Hacker 
 described below. With large pedicled fibromata wide adhesions to the in- 
 testines may be found with adventitious vascular connections more impor- 
 tant than those of the pedicle itself. To detach these adhesions when they 
 are intimate we make use of the procedure recommended by Schroder, leav- 
 ing adherent to the intestine a superficial portion of the fibroma with 
 its peritoneum, and passing one or more catgut sutures so as to secure 
 the coaptation of the bleeding surface (Fig. 175). A more expeditious 
 procedure which I have employed is the superficial and rapid cauterization 
 with the thermo-cautery, of the layer of the fibroid left adherent to the 
 intestine. 
 
 16 
 
242 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 II. Encapsuled Fibroma, ivith One Nodule. Intraperitoneal Enucleation. 
 Cases of this variety are relatively rare, the most common form being mul- 
 tiple fibromata, distorting a large segment of the uterus, which seems to be 
 stuffed full of them (Figs. 150 and 151, p. 190). To treat each one of these 
 nuclei separately would not be possible, but when the tumor is single, 
 whether formed by a simple or a compound mass, whether interstitial or 
 submucous, it is possible to carry out the plan of removal by enucleation 
 of the neoplasm alone, preserving the integrity of the uterus and its adnexa, 
 and not interrupting the genital life of the woman. This consideration will 
 have some weight when the patient is not near the menopause, but it rarely 
 needs to be considered. Enucleation, then, may often be considered only a 
 simplification of the operative technique applicable to certain definite cases. 
 
 Spiegelberg seems to be the first who employed it ; Spencer Wells has 
 
 Fig. 175. — Suture of the Thin Fold of Peritoneum and Fibrous Tissue Left after the Detachment or a 
 Firm Adhesion. /, Intestine ; P^ peritoneal fold covering the fibroid ; 5', suture. 
 
 practised it for a long while ; but it is A. Martin who has especially advo- 
 cated it. 
 
 We begin by drawing the uterus outside of the abdomen upon a layer Oi. 
 gauze sponge, and placing about the cervix an elastic cord with its ends 
 crossed and held in place by forceps or my ligator. Having thus provided 
 for control of the bleeding, the uterus is incised over the most projecting 
 part of the tumor, and this is removed, care being taken not to open the 
 uterine cavity. 
 
 As this operation has often been performed for submucous fibroma, which 
 most surgeons prefer to remove by the vagina, the viterine canal has some- 
 times been opened (ten cases out of sixteen : Martin) ; in these cases Martin 
 closed the mucous wound with a continuous catgut suture. 
 
 The incision in the uterine wall is closed by a series of deep sutures 
 taking in the whole extent of the wound. Martin uses for this purpose 
 catgut prepared in oil of juniper, which he has substituted for carbolized 
 silk (Fig. 176). 
 
 When the cavity left after the removal of the tumor is very large, Martin 
 uses a cross-drain passed through the cervix into the vagina. Freund, in 
 a remarkable case which was followed by success, where the fibroma was 
 
TREATMENT OF FIBROUS TUMORS OF ABDOMINAL EVOLUTION. 243 
 
 inflamed, replaced the rubber drain by an iodoformized wick, and then tam- 
 poned the uterus with iodoform gauze. We may also diminish the tumor 
 cavity by removing portions of its wall. 
 
 Martin, in one case, also removed both the degenerated ovaries, and once 
 a single ovary. He recommends castration in all cases in which we suspect 
 the presence in the uterine tissue of another fibrous nodule beyond our 
 reach. 
 
 In sixteen cases he had three deaths ; and once he had to do a secondary 
 vaginal amputation of the uterus because of the appearance of a new fibroma 
 whose origin had been unforeseen at the time of the first operation. The 
 possibility of this second operation is the weak point in the whole method, 
 and for that reason it should always be combined with castration. In this 
 
 Fig. 176. — A, Enucleation of an Interstitial Myoma. B, Disposition of Sutures after Enucleation. 
 
 case, however, enucleation fails of its initial object, which is to maintain the 
 genital functions, and becomes simply a particular case of partial hysterec- 
 tomy with the pedicle left within the peritoneum. 
 
 III. Fibroma tvitJi Mitltiple Nodules. Supravaginal Hysterectomy. — Ac- 
 cording to Schroder we must distinguish two different classes : the first, 
 where the tumor is above the adnexa at its lower level, the body of the uter- 
 us being intact ; and the second where the body is invaded in such a way 
 that the adnexa form a more or less sessile appendix to the tumor. 
 
 In the first class the rule is not to detach the broad ligaments, which 
 would render the operation more serious ; but as we are never sure that there 
 are no small nodules remaining in the uterus which may develop later, it is 
 prudent to remove the ovaries as the last step. In this way we do not usu- 
 ally obtain as narrow a pedicle as by complete ablation of the body of the 
 uterus, which will be reason enough to reject partial hysterectomy; it is 
 
244 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 possible, however, to do the operation without opening the uterine cavity, 
 which diminishes the chances of infection. 
 
 Partial hysterectomy presents no essential difference from supravaginal 
 amputation, with the exception that it does not include the detachment of 
 the broad ligament. The temporary elastic ligature is placed below the 
 tumor, which is removed with its capsule, saving only a portion of the latter 
 to make, with the peritoneum and subserous tissues, a collar about the 
 wound. This operation is distinguished from enucleation by the removal of 
 the mass as a whole, and by excising it with the knife. I advise that the 
 operator should always assure himself beforehand by a vertical cut that enu- 
 cleation is not possible; for when it is, it is preferable. 
 
 Supra-vaginal amputation, or hysterectomy, is a typical operation, which 
 we adopt in the majority of cases, either at once or after trying enucleation 
 
 A. 
 
 Fig. 177. — Chain Ligature. 
 
 or partial hysterectomy. Two methods divide the preferences of surgeons; 
 the first, in which the pedicle is treated exterior to the peritoneum, to which 
 are attached the names of Koeberle, Pean, and Hegar; the second, the meth- 
 od in which the pedicle is abandoned within the peritoneum, or Schroder's 
 operation, which has been modified by many different authors. Lastly, I 
 shall describe a procedure which unites the advantages of both the preced- 
 ing with ablation of both uterus and cer\ax, or the mixed method of total 
 hysterectomy. 
 
 TecJiJiique of Supra-vaginal Hysterectomy. — The first steps of the opera- 
 tion are identical whether Hegar's or Schroder's operation is performed. 
 The abdomen is rapidly opened through the linea alba without stopping to 
 put forceps upon the little bleeding points. If the tumor is small and chiefly 
 within the lower pelvis, the incision is prolonged nearly to the pubes, but 
 with the precaution of keeping a sound in the bladder. We have always 
 reason to fear a wound of this organ from elongation of it in front of the 
 tumor. To give a little more room below, the muscular insertion on one 
 side or the other may be divided, though I do not advise it. 
 
 If the tumor is very large and soft, we should see whether it may be 
 diminished by puncture of a cystic cavity ; if not, it is better to prolong the 
 incision rather than to attempt the long, difficult, and perilous procedure of 
 fractional excision advocated bv Pean. 
 
TREATMENT OF FIBROUS TUMORS OF ABDOMINAL EVOLUTION. 245 
 
 The uterus must then be disengaged so that the elastic ligature may be 
 put in place, the connections of the bladder with the tumor having been 
 determined by exploration with a male sound. It has happened to good sur- 
 geons that a portion of the bladder has been included in the ligature and 
 removed. To avoid such an accident in difficult cases Albert transfixes the 
 tumor immediately above the bladder with a pin to prevent the ligature from 
 slipping and including part of it. 
 
 The broad ligaments are cut between a double series of ligatures which 
 are passed by a blunt, mounted needle (Fig. 19, i and 2) either straight and 
 curved a little at the point or similar in form to a Deschamps needle (for 
 technique see pages 46 to 54); the tube and round ligaments should be sepa- 
 
 FiG. 178.— Schroder's Intraperitoneal Suture of the Pedicle. 5", Deep suture, passed at once under 
 the whole bleeding surface ; C, continuous suture of catgut in different terraces, bringing together the whole wounded 
 surface whose lower portion is marked by the heavy line aa, formed by the cauterized uterine cavity ; P, peritoneal 
 investment. 
 
 rately tied. As soon as the upper part of the cervix is free, the elastic lig- 
 ature is put in place. Some authors advise to go immediately below and 
 search for the uterine arteries by feeling their pulsation or their projection 
 upon the sides of the uterus. For this purpose it is necessary to descend 
 to the folds of Douglas, which bound the cul-de-sac of that name, including a 
 certain portion of the adjacent soft tissues within the ligature. One of the 
 great advantages of the extra-peritoneal method is that it dispense swith this 
 dangerous step. 
 
 It is always better to remove the adnexa, though certain operators attach 
 but little importance to neglect of this extirpation, thinking that the tissues 
 will atrophy. Where there are no difficulties caused by extensive adhesions, 
 castration should be performed at the same time, on account of the accidents 
 which have been described, such as pelvic hasmatocele and extra-uterine 
 pregnancy. When the uterus is sufficiently freed from its peripheral attach- 
 
246 
 
 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 ments, the elastic ligature is applied to the cervix, and then an antero-pos- 
 terior incision made a finger's breadth above it, and the fibroma removed as 
 soon as possible by section and enucleation. From this moment, according 
 to the treatment of the pedicle, the operation varies. 
 
 Intra-peritoncal Treatment of the Pedicle. — I will describe Schroder's 
 technique as it is given by Hofmeier. In proceeding with the removal of 
 the tumor we should be careful to finish by a circular conoidal incision at 
 least 3 cm. from the ligature and not going more deeply beneath the peri- 
 toneum than to slightly pare off this membrane, so that the rim of tissue left 
 is partly serous ; with the scissors it is then trimmed so that with slight 
 
 Fig. 179. — Vaginal Drainage ■with a Cross Tube after Abdominal Hysterectomy (Martin). 
 
 traction it just covers the whole of the wound; all gaping vessels that may 
 be found are tied with catgut. 
 
 An important feature of the operation is the destruction and disinfection 
 of the mucous membrane of the uterine cavity, which is found in the bottom 
 of the wound. There is no doubt that this opening of the uterus forms one 
 of the unfavorable elements in the intra-peritoneal treatment, since it may 
 be a source of infection ; though certain authors, as Martin for example, as- 
 cribe but little importance to it. But Hofmeier, in his analysis of Schro- 
 der's operations, has clearly demonstrated this influence (21 cases without 
 opening, 2 deaths; 59 with opening, 18 deaths). It is important, then, to 
 reduce this danger to a minimum both by securing rapid cicatrization by 
 exact coaptation and by completely modifying the membrane adjacent to the 
 wound. For this purpose Olshausen recommends the free excision of the 
 
TREATMENT OF FIBROUS TUMORS OF ABDOMINAL EVOLUTION. 247 
 
 bottom of the wound in the shape of a funnel, dissecting out as much as pos- 
 sible of the mucous membrane. It is well also to cauterize the bottom of the 
 wound with strong carbolic acid (i : 20), or better with the Paquelin thermo- 
 cautery, which should be buried perpendicularly in the cervical canal. We 
 must not, however, cauterize the superficial portions of the wound for fear 
 of preventing primary union. 
 
 The next step consists in the application of the suture. Veit and Martin 
 employ juniper catgut; Schroder and Hofmeier use both catgut and silk. If 
 the bleeding surface is not extensive, it is sufficient to pass deep sutures with 
 a strong needle under the whole wounded surface, forming thus a series of 
 separate points, which are firmly tied, and completing the junction of the 
 peritoneum by a superficial suture. It must always be kept in mind that 
 exact coaptation is indispensable for complete primary union ; the difficulty 
 is to tie tightly enough to obtain it without compromising the nutrition of 
 the tissues. 
 
 If the wounded surface is extensive, perfect union of the sides is obtained 
 by the employment of the continuous catgut suture in tiers, or with separate 
 silk sutures, which Schroder originally used. For fear, however, that the 
 catgut will be too quickly absorbed, especially if the tissues are very dense, 
 certain sustaining sutures of silk are placed at equal distances through the 
 whole thickness of the wound before beginning the continuous suture. 
 These are tied after the continuous suture is finished, but they are put in 
 position beforehand in order not to cut the catgut in passing them. They 
 .should be inserted a little obliquely, and not perpendicular to the axis of the 
 wound, that they may not be parallel to the vessels which they are meant to 
 constrict (Fig. 178, Hofmeier). The wound should be closed longitudinally, 
 that is, parallel with the abdominal opening (Gersuny, Fritsch, etc.). 
 
 When the suture of the pedicle has been completed by Schroder's meth- 
 od, if a few drops of blood ooze by the side of the suture, after the elastic 
 band has been removed, Martin does not hesitate to pass through the pedicle 
 from before backward a strong needle with quadruple thread, and thus tie it 
 in two portions; in autopsies which he has had occasion to make, he has 
 never seen any trace of mortification from this complementary ligature, which 
 Leopold also employs at times. 
 
 After hysterectomy, no matter how simple the operation has been, Mar- 
 tin always practises drainage through the vagina (page 58). The lower end 
 of the tube is always folded in the vagina and covered with antiseptic gauze 
 to prevent the entrance of germs from the air ; it is withdrawn on the third 
 or fourth day, when the patient begins to feel a peculiar uneasiness in the 
 lower part of the abdomen (Fig. 179). This drainage, after simple opera- 
 tions, without destruction of the peritoneum or septic infection, is not gene- 
 rally employed, and seems to me unnecessary. 
 
 Extraperitoneal Treatment of tJic Pedicle — Hegar s Method. — The ab- 
 dominal cavity is closed as tightly as possible about the tumor, and this is 
 
248 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 surrounded by gauze sponges to receive the blood ; the incision is then made 
 transversely, two fingers' breadth above the elastic ligature. At this mo- 
 ment the fibrous nodules which penetrate the pedicle appear upon the cut 
 surface ; they may be enucleated without danger of bleeding, the elastic 
 band compressing the pocket left empty by the small tumor. Bleeding ves- 
 sels should be separately tied. The surface of the stump is then smoothed 
 and held strongly drawn out with Museux forceps. We then proceed with 
 the toilet of the peritoneum, keeping the pedicle fixed in the lower part of 
 the wound. The temporary elastic ligature may often be permanently re- 
 tained if it is properly placed, but, if too far down to permit the drawing out 
 
 Fig. i8o. — Suture of the Abdominal Walls after Sui'ra-\aginal Hysterectomy with Extra-peritoneal 
 Treatment of the Pedicle. Suture of the peritoneum in a collar about the pedicle. Suture begun. (Pedicle is 
 shown drawn strongly upwards, exaggerating its distance from the symphysis.) 
 
 of the pedicle, a new one is placed above it and tied before the first is re- 
 moved. When the pedicle is very large, it is well, according to Hegar, to 
 tie it in two portions after transfixing it with a double elastic band by means 
 of a special instrument, Kaltenbach's needle. This complication, it seems 
 to me, might be avoided by taking an additional turn of the elastic ligature 
 as Tauffer has lately advised. 
 
 In applying the permanent ligature, the greatest care must be taken to 
 avoid the inclusion of intestinal coils or bladder and to see that nothing but 
 the pedicle is constricted. It is applied in the following manner : While an 
 assistant holds the pedicle in place with the Museux forceps, we make two 
 turns about it with the elastic cord in such a way that it is tightly con- 
 stricted. The ends are crossed and the cord stretched a little. Between 
 the cross and the cervix a ligature of strong silk is applied with the double 
 surgical knot (Fig. 35, 2) ; then, after gentle traction on the instrument to 
 
TREATMENT OF FIBROUS TUMORS OF ABDOMINAL EVOLUTION. 249 
 
 stretch the elastic cord a Uttle more and give room, a second ligature is ap- 
 plied for security a few millimetres in front of the first. After removing 
 the forceps or the clamp (Figs. 41 and 44), the ends of the silk are then cut 
 short, leaving those on the elastic cord a little the longer. 
 
 One of the most important points in Hegar's method is the complete iso- 
 lation of the pedicle outside of the abdominal cavity. By suturing the peri- 
 toneum below the elastic ligature and by non-suture of the immediately ad- 
 jacent abdominal planes he forms a gutter which surrounds the pedicle so 
 that it remains isolated like a pistil in the centre of a flower. This gutter 
 prevents the pedicle, which is meant to slough off, from being imprisoned 
 
 Fig. 181. — Suture of the Abdominal Walls after Supra-vaginal Hysterectomy with Extra-peritoneal 
 Treatment of the Pedicle. Suture of the peritoneum in a collar about the pedicle. Suture continued. 
 
 within the soft parts and infecting them, and about it we can make topical 
 applications destined to mummify it and keep it aseptic. It is especially in 
 very stout patients that this peculiarity of the technique is of the greatest 
 value. 
 
 To suture the peritoneum about the pedicle, Tauffer fixes in the lower 
 part of the abdominal incision a long thread with two ends ; each is provided 
 with a needle, and is used to attach the peritoneum to the surface of the 
 pedicle immediately below the ligature, right and left ; I prefer to accom- 
 plish this with catgut and a single needle (Figs. 180 and 181). 
 
 Great care must be taken that only the serous surface is included in this 
 suture, using a very fine curved needle that the punctures may not bleed. 
 It is well in the same suture to attach the stump of the broad ligament on 
 each side to the stump of the uterus as closely as possible. When this peri- 
 toneal collar has been applied to the pedicle, we may continue the suture of 
 
250 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 the peritoneum through the whole length of the abdominal opening with the 
 same needle and catgut, adding, if necessary, a few supplementary points. 
 The suture of the other abdominal planes is begun about 4 cm. above the 
 pedicle (Fig. 182). At present I use a continuous catgut suture for this 
 purpose. 
 
 To prevent the pedicle from descending too far into the pelvis under the 
 influence of movement, etc., two strong pins, crossing like the letter X, are 
 
 {-^ 
 
 Fig. 182. — SuTiKE of the Abdominal Wa'lls after Supra-vaginal Hvstekectomv with Extra-pekitoneal 
 Treatment of the Pedicle. A, Continuous suture of the peritoneum with catgut after finishing the collar about 
 the pedicle, f}, Continuous suture with catgut of the musculo-aponeurotic planes. 
 
 passed through just above the ligature, and their pointed ends cut off. These 
 pins have the additional advantage of preventing the elastic ligature from 
 slipping. Below their ends small pads of iodoform gauze are placed to pre- 
 vent their wounding the integument (Fig. 184). Then, with the scissors, 
 the pedicle is trimmed to the shape in which it is to be left, and after sur- 
 rounding it with wet antiseptic compresses its surface is cauterized with the 
 thermo-cautery. 
 
 Hegar, Kaltenbach, and Tauffer dress the wound as follows : A tampon 
 
TREATMENT OF FIBROUS TUMORS OF ABDOMINAL EVOLUTION. 25 I 
 
 of cotton moistened with a solution of zinc chloride (i : 10) is placed over the 
 centre of the pedicle, which is surrounded with cotton which has been dipped 
 in a zinc solution (i : 20) and carefully squeezed dry. Over and about this 
 is placed iodoform gauze covered with several layers of cotton and held in 
 place by a flannel body bandage. This first dressing is usually left in place 
 for from five days to a week, and is then found dry and hard. The tampons 
 of zinc cotton about the pedicle are now replaced by iodoform gauze and the 
 pedicle itself is touched anew with the caustic solution to mummify the 
 eschar and prevent its becoming soft and fetid. This dressing is repeated 
 every day, and if the pedicle is very large the mortified parts are removed 
 little by little with the scissors. 
 
 Kaltenbach has recently substituted for the chloride of zinc, which has 
 the disadvantage of making too extensive an eschar and giving rise to capil- 
 lary bleeding, a dressing of iodoform gauze ; but in very fat or very anaemic 
 patients this exposes to the risk of poisoning from rapid absorption in the 
 deep gutter which surrounds the pedicle. Kaltenbach and Hegar have had 
 good results with the mixture of three parts tannin and one part salicylic 
 acid which Freund recommends for use for operation in extra-uterine preg- 
 
 FiG. 183. — Holder for Passim; Pedicle Needles. 
 
 nancy; I substitute, for the salicylic acid, iodoform in the proportion of i : 5 
 of the tannin, and find the mixture very serviceable. After the operation, 
 as soon as the interior of the pedicle has been cauterized, the gutter about 
 the pedicle is filled with the powder, and then the dressings applied; thus 
 the part is tanned, so to speak, with no danger of cauterizing the adjacent 
 healthy tissue. The first dressing is left in place from eight to ten days. 
 
 This modification is a great improvement, permitting the patient to. rest 
 quietly instead of fatiguing her with repeated dressings, and producing the 
 drying up of the entire pedicle, without the need of removing portions of it 
 from time to time with the scissors. 
 
 On the third or fourth day after the operation it is not imcommon to see, 
 as after salpingectomy, a slight sanguineous discharge from the vagina ; this 
 is of no serious importance. 
 
 The elastic ligature and the pedicle with its pins usually fall on the fif- 
 teenth to twentieth day, leaving a granulating funnel which should be lightly 
 packed with iodoform gauze ; it is sometimes very deep, for the mortification 
 of the pedicle is seldom arrested at the level of the elastic ligature. This 
 cicatrix formed at a weak part often makes it necessary for the patient to 
 wear an abdominal supporter. If the ovaries have ndt been removed, there 
 is observed at each menstrual period a discharge of blood from the scar. 
 There may even be a persistent cervico-abdominal fistula. 
 
2 52 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Dropped Elastic Ligature. — Whatever may have been done in this direc- 
 tion by Czerny and Kaltenbach, it was Olshausen who first recommended re- 
 tention of the elastic ligature. It is applied as for the external method and 
 then sutured about the pedicle with silk thread to prevent its slipping. Ols- 
 hausen employed this procedure occasionally where the hemorrhage was 
 very difficult to control, yet, though very successful, he has to-day relin- 
 quished it. The pedicle thus ligated does not mortify but continues to de- 
 
 Fig. 184. — Suture of the Abdominal Walls after Supra-vaginal Hvsterectojiv with Extra-peritc 
 NEAL Treatment of the Pedicle. Skin and deep sutures placed above the pedicle (pedicle is drawn down to 
 show upper part of peritoneal collar), but not yet placed below. 
 
 rive nourishment, either through the base or through adjacent adhesions; 
 its nutrition is, however, very scant, and it undergoes a granulo-fatty degen- 
 eration. There have also been cases in which it has suppurated and caused 
 serious symptoms with the elimination of the ligature or fatal peritonitis. 
 At other times the ligature has been expelled without inconvenience to the 
 patient. Ahlfeld cites an instance which the surgeon complicated by fasten- 
 ing the ligature, after having taken two turns about the pedicle, with a ring 
 of lead 5 mm. in diameter, which he crushed about the rubber with strong 
 forceps. This mode of fixing the ligature had already been employed by 
 Thiersch, but only for extra-peritoneal treatment, and was then adopted by 
 
TREATMENT OF FIBROUS TUMORS OF ABDOMINAL EVOLUTION. 253 
 
 Sanger, who later abandoned it for his mixed method after obtaining nine 
 successes without a single failure. 
 
 The following procedures are cited only because of their originality : 
 
 Schwarz has proposed to cover the elastic ligature with a fold of peri- 
 toneum cut from the pedicle after preliminary hasmostasis. 
 
 Albert isolates the stump completely by means of an antericjr and a pos- 
 terior peritoneal flap which he sutures carefully to each other. 
 
 Meinert has proposed to open Douglas' pouch and pass the pedicle into 
 the vagina; he made the experiment once, but the patient died. 
 
 Hysterectomy has been performed in two stages ; the first consisting in 
 opening the peritoneum and the production of adhesions ; the second, of the 
 
 Fig. 185. — Ligature of the Pedicle by Zweifel's Method. Chain suture of the broad ligaments. 
 
 removal of the tumor. Nussbaum has employed this dangerous method in 
 the case of a suppurating myoma ; the patient died. Vulliet has recently 
 adopted it, but his patient, when he published his case, had not recovered. 
 
 Continuous Fractional Ligature {Fortlaufetide P artienligatw^ . — Under 
 this name Zweifel has described a method of suturing the pedicle which 
 certainly assures better haemostasis than Schroder's, but seems, a priori, 
 inferior in technique as regards primary union of the stump and its chances 
 of sloughing; however, the good results published by Zweifel demand at- 
 tention. 
 
 In ten cases with his method there was but one death when he pub- 
 lished his book {1888), and in April, 1894, he announced a series of ninety- 
 two cases with three deaths. His technique is as follows : For all his liga- 
 tures he employs sterilized silk and a needle furnished with a groove which 
 resembles Reverdin's ; the point is blunt. He first ties the broad ligaments 
 with chain sutures. He then divides them. He previously takes care to 
 
254 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 leave the ends of the two silk ligatures of the broad ligaments, which are 
 nearest to the uterus, sufficiently long to be able to utilize them for a chain 
 ligature of the stump. 
 
 In the excision of the tumor a small musculo-peritoneal lip is preserved 
 in front (Fig. i86) A sharp needle is then threaded and a series of partial 
 ligatures passed, of which the figure (185) gives a sufficient explanation. The 
 peritoneum is closed by a series of superficial sutures (Fig. 187). Drainage 
 
 Fig. 186. — Ligature ok the Pedicle bv Zweifel's Method. Shows the manner of cutting the peritoneal flap for 
 covering the pedicle. The needle is carrying a suture through the pedicle. 
 
 through the vagina by the cross-tube is necessary only when there is per- 
 sistent oozing. 
 
 Mixed Method {It might also be called juxtaparietal). — Owing to the 
 difficulty which some surgeons have found in fixing a short pedicle in the 
 abdominal wound, it has been abandoned within the cavity of the abdomen 
 as in the successful case of Kleeberg, of Odessa, whom I have cited as the 
 inventor of the elastic ligature, and who in 1887 allowed a thick and short 
 stump to drop back into the peritoneal cavity, bringing out the ends of the 
 constricting ligature through the lower angle of the abdominal wound. Pean 
 
TREATMENT OF FIBROUS TUMORS OF ABDOMINAL EVOLUTION. 255 
 
 has at times left a bundle of forceps projecting from the abdomen, with suc- 
 cess. But these were all procedures of necessity. Fixation of the pedicle 
 immediately below or in the thickness of the abdominal walls, with perma- 
 nent communication exteriorly at this level, has been lately proposed and 
 carried out as a procedure of choice, with the intention of permitting exam- 
 ination where the haemostasis has been difficult, and to insure the external 
 discharge of products which could infect the peritoneum. The first to apply 
 a mixed method was probably Freund, who, after amputation of a voluminous 
 uterine tumor, made one bundle of stump and broad ligaments, passed an 
 elastic cord about them, and covered their extremities with a condom whose 
 lower shut extremity he cut off; into this he passed a glass tube to the ped- 
 icle, brought the extremities of the elastic ligature out of it, and packed with 
 
 Fig. 187. — Ligature of the Pedicle by Zweifel's Method. A, Pedicle finished (one sees in a dotted line the 
 course of the subperitoneal suture). B, Antero-posterior view of the pedicle. 
 
 iodoform gauze. The patient recovered. It is very evident that the rapid 
 formation of protecting adhesions, and not the condom, made the barrier 
 against infection of the peritoneum ; tamponing with iodoform gauze above 
 the pedicle would have been both more simple and more sure. 
 
 Two surgeons of Vienna, pupils of Billroth, Wolfler and von Hacker, 
 and Sanger, of Leipsic, have lately proposed a mixed method which deserves 
 to be described in detail. Hacker conceived the method, inspired by a case 
 of Billroth's, and first performed it August 31st, 1884. 
 
 Wolflcr- Hacker s Method. — The pedicle is sutured according to Schro- 
 der's method and is then dropped back, so that its summit lies against the 
 deeper surface of the abdominal wall ; it is fixed there, close to the peritoneal 
 incision, by passing through it on each side a carbolized silk suture which 
 traverses its superficial layers and then the abdominal walls. The ends of 
 the silk are looped over small rolls of iodoform gauze and tied so that the 
 surface of the stump is held between the lips of the peritoneal wound. The 
 
2;6 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 edges of the parietal peritoneum are not sutured together at this point, but 
 are carefully stitched around the top of the pedicle so that it, as regards the 
 abdominal cavity, is extraperitoneal, and yet juxtaparietal. The abdominal 
 ^valls are then sutured, leaving only room for a band of iodoform gauze and 
 the drain which is passed down to the pedicle (Figs. i88, 189). 
 
 The first two cases of Wolfler and Hacker recovered with but little sup- 
 puration or sloughing ; both would probably have died of septic peritonitis 
 if the pedicle had been abandoned within the abdominal cavity ; then fol- 
 lowed a number of cures by first intention. Fritsch adopted the method, and 
 obtained nineteen successive successes, while Olshausen's and Schroder's 
 
 Fig. 
 
 -Wulflek-Hacker's Mixed Treatment of the Pedicle, c. Skin ; ?«, muscular layers ; //, parietal 
 peritoneum ; d, drain ; ut, pedicle. Median section ; diagrammatic. 
 
 methods had given twelve deaths in thirty-nine cases. Although I have not 
 adopted it exclusively, it is certain that the method is a very useful one, for 
 it is applicable both to large and to short pedicles, which could not be drawn 
 out of the abdominal wound without too much effort, and where the abun- 
 dance of the vessels and the number of the ligatures would render abandon- 
 ment in the abdomen dangerous, because of the probability of secondary 
 hemorrhage, mortification, and septicaemia. 
 
 Sanger s MetJiod. — Intra-peritoneal sequestration : Sanger thus desig- 
 nates an operative procedure which consists of suturing the peritoneum 
 closely about the pedicle, drawing upon the parietal peritoneum for this pur- 
 pose, and fixing it along the posterior face of the stump. The abdominal 
 cavity is thus separated from its lower division, in which lies the seques- 
 trated pedicle. 
 
 Sanger distinguishes two modifications of this procedure: 
 
TREATMENT OF FIBROUS TUMORS OF ABDOMINAL EVOLUTION. 257 
 
 1. The pedicle is sutured by Schroder's method, but, hemorrhage being 
 probable, it is sequestrated by suturing to it the parietal peritoneum, with 
 drainage (Fig. 190). 
 
 2. The pedicle is too short to be drawn out of the abdomen. The trans- 
 fixing pins are placed some distance above the elastic ligature, which is dis- 
 posed as in Hegar's method. The peritoneum is then sutured to the upper 
 part of the pedicle in front of the elastic ligature, to sequestrate it from the 
 abdominal cavity. A barrier is thus formed above, making the elastic lig- 
 ature extra-peritoneal and yet intra-abdominal (Fig. 191). Sanger has thus 
 
 Fig. i8g. — Wolfler-Hacker's Mixed Treatment of 
 THE Pedicle, c, Skin ; «z, muscles ; //, parietal peritoneum ; 
 pVy visceral peritoneum ; ut, pedicle ; «, cutaneous suture ; b, 
 muscular suture ; r, peritoneal suture with catgut ; r, pedicle 
 supports on rolls of iodoform gauze. Transverse section ; dia- 
 grammatic. 
 
 Fig. 190. — Sanger's Mixed Treatment of the 
 Pedicle ; Intra-peritoxeal Sequestration of 
 a Pedicle Sutured by Schroder's Method. 
 //, Parietal peritoneum sutured to posterior sur- 
 face of stump; u, uterine pedicle; t', vagina ; (/, 
 drainage. 
 
 obtained great success with a stump which was very short, thick, and hem- 
 orrhagic. 
 
 A careful study of these two methods demonstrates that the first of San- 
 ger's does not differ materially from Wolfler-Hacker's, for the two lateral 
 sutures for the suspension of the uterus are replaced by the suture of the 
 peritoneum to the posterior face of the stump. As to the second, it is prac- 
 tically Hegar's method applied to a very short stump, in which the suture 
 around the pedicle is replaced by the suture above it of the peritoneum ; but 
 it presents this originality, that the peritoneum is sutured (with catgut) above 
 the elastic ligature to the part which is intended to slough. Sanger powders 
 the stump with a mixture of salicylic acid, iodoform, and tannin ; to this I 
 add a covering of iodoform gauze. 
 
 Total Abdominal Hysterectomy. — Pean was the first to perform total ab- 
 dominal hysterectomy, doing this operation in 1 869 upon a patient who re- 
 covered. In 1873 he again advised this procedure for all cases in which 
 17 
 
258 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 "the cervix itself is the seat of the neoplasm." Much later (1881), Barden- 
 heuer recommended the liberation of the cervix by a first step termed vagi- 
 nal, and then the extirpation, by the abdominal route, of the uterus with its 
 fibroids. Bardenheuer obtained six successes in seven operations, but these 
 were very simple cases which could have been cured by any other method. 
 For a long time few cases were published, which shows the opposition in- 
 spired by this application to fibroids of Freund's operation for cancer, which 
 is to-day condemned. 
 
 Martin was one of the first to advise total extirpation, fie performed 
 supra-vaginal hysterectomy through the abdomen with a preliminary elastic 
 
 JPlG. 191.— Treatment of the Pedicle by Sanger's Mixed Method. Intraperitoneal sequestration of the ped- 
 icle, with elastic ligature. /, Elastic ligature ; ui^ posterior surface of the uterus ; /, pedicle (section) ; b^ pins. 
 
 ligature ; then an assistant freed the cervix through the vagina. Finally, 
 the surgeon completed the operation through the abdomen by tying the broad 
 ligaments and separating the bladder. 
 
 The great multiplication of publications at the present day shows incon- 
 testably that this method, revived with an improved technique, is tending 
 to replace the procedures of Hegar and Olshausen. Personally I am not far 
 from considering it a matter of election, much more benign and more rational 
 than that with the buried elastic ligature, much more in conformity with 
 modern surgical principles than the extraperitoneal treatment of the pedicle. 
 Is it then to be supposed that the latter method will completely disappear.? 
 I think not ; but from the rank of the operation of election it must descend 
 
TREATMENT OF FIBROUS TUMORS OF ABDOMINAL EVOLUTION. 259 
 
 to that of one of necessity ; being applicable, for example, in cases which 
 are too anaemic and too much enfeebled by severe hemorrhages or by an 
 early cachexia. 
 
 Total abdominal hysterectomy is now practised according to two well- 
 defined techniques. In the first, called total ab domino -vaginal hysterectomy, 
 the surgeon works successively through the abdomen and the vagina ; in the 
 
 Fig. 192. — Reverdin's Apparatus for Raising Fibroid Tumors. A, Pulley. B^ Forceps to grasp tumor and then 
 
 be attached to pulley. 
 
 second, or total abdominal hysterectom.y proper, the entire operation is per- 
 formed through the abdomen. 
 
 Total Abdominal Hysterectomy P^'oper. — This operation, first practised 
 by P6an, has been well systematized by Martin, whose technique is as fol- 
 lows : The tumor being brought out through the abdominal incision, the 
 uterus is drawn upon in such a way as to exert strong tension upon the floor 
 of the pelvis. If the tumor is very large, it may be held up by means of 
 Reverdin's ingenious apparatus (Fig. 192). Ligatures are then applied to 
 the infundibulo-pelvic ligaments, which are divided. The broad ligaments 
 are tied in sections from above downward ; if bleeding occurs from the por- 
 tion which is attached to the uterus, they should be compressed with a long 
 clamp. When the broad ligaments have been ligatured down to the level of 
 the cervix and in immediate contact with the vaginal vault, the posterior 
 cul-de-sac is opened by a horizontal incision extending between the two 
 
26o 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 ligaments. Through the lips of this incision are then passed a number of 
 sutures which unite the peritoneum to the vaginal mucous membrane. The 
 cervix is now held in place by only its attachments to the bladder. The 
 vesico-uterine cul-de-sac is incised horizontally and the bladder is dissected 
 off with the fingers or a blunt instrument. The anterior cvd-de-sac being 
 open, the same procedure is carried out as in the posterior, uniting succes- 
 sively the vaginal mucosa, the bladder wall, and the edge of the peritoneal 
 incision by interrupted or continuous suture. When the tumor has been re- 
 moved the ends of all the catgut sutures are united into one bundle and brought 
 into the vagina by means of a forceps introduced through the vulva. This 
 simple manoeuvre sen-es to approximate the edges of the gap made in the 
 
 pelvic floor, and a complete closure 
 of the peritoneal cavity is obtained 
 by several catgut sutures passing 
 from the vesical peritoneum to that 
 of Douglas' cul-de-sac. 
 
 Martin considers this occlusion 
 of the peritoneum most important. 
 In a first series of total hysterec- 
 tomies in which he left the perito- 
 neum open he had 13 deaths in 43 
 cases, or 30.23 per cent. Since he 
 has carefully closed the peritoneal 
 cavity he has operated 54 times with 
 but 5 deaths, or 9. 5 per cent. 
 
 The retro-peritoneal method of 
 Chi'obak should, I believe, be de- 
 scribed with total extirpation, al- 
 though it leaves the cervdx ; but the entire intra-abdominal portion of the 
 uterus is removed and the cer\^ical stump is covered with peritoneum, for 
 which reason he has termed the procedure retro-peritoneal. The broad lig- 
 aments are first tied as for a total extirpation, and two peritoneal flaps 
 are marked out upon the tumor, one larger than the other. These flaps are 
 dissected off as far as the level of the insertion of the vagina upon the 
 cer\-ix. The entire uterus is then removed with the exception of a ring of 
 cer\-ix from one-half to one centimetre thick. The cervical canal and the 
 cut surface of the cer\'ix are thoroughly cauterized with the Paquelin 
 cautery, and the cervdcal canal is drained with a strip of iodoform gauze. 
 If the stump bleeds several sutures are passed through it from before back- 
 ward. The broad Hgaments are fixed above the stump by sero-serous 
 sutures, and abov^e all the peritoneal flaps are carefully brought together. 
 The stump is thus covered by an intact peritoneal surface, and the unequal 
 size of the flaps brings their line of suture beyond the limits of the cervical 
 stump. The abdomen is completely closed. 
 
 Fig. 193. — Abdominal Hysterectomy by Doyen's 
 Method. A^ B, Longitudinal section of peritoneum ; C, Z*, 
 E, circular section ; L^ point where ligature is passed after 
 decortication of the tumor. 
 
TREATMENT OF FIBfiOUS TUMORS OF ABDOMINAL EVOLUTION. 26 1 
 
 Baers method, which is much used in America, must be compared with 
 that of Chrobak. F. Baer ties the upper part of the broad ligaments with 
 silk, and divides the part tied between the ligature and a clamp placed close 
 to the uterus. This done, he makes a circular incision through the perito- 
 neum above the vesico-uterine fold. The peritoneum being separated from 
 the anterior and posterior surfaces of the uterus down to the level of the 
 cervix, he ties the uterine arteries included in the broad ligaments. Hasmo- 
 stasis being thus assured, he resects the tumor as low as possible, and the 
 two peritoneal flaps, anterior and posterior, immediately fall over the uterine 
 stump. When they are sutured perfect coaptation is obtained and the peri- 
 toneal cavity is hermetically sealed. This procedure resembles in its 
 principal points that of Chrobak, from which it differs especially in the 
 greater size of the uterine pedicle. 
 
 Doyen s method is really only an ingenious combination of the technique 
 of Martin with that of Chrobak, differing from them only in the absence of 
 preliminary hsemostasis. Doyen ties separately the utero-ovarian (Fig. 193) 
 and the uterine arteries, and re-enforces this ligature by placing two forceps 
 upon the flaps of the broad ligaments inverted from above downward. These 
 are thus carried outside of the peritoneal cavity and the serous membrane is 
 carefully united above them by several sutures, completely closing the peri- 
 toneal cavity without drainage. 
 
 Total Abdom.ino -vaginal Hysterectomy. — Two methods are at present in 
 favor. That of Pean, first applied in 1886, consists in removing the body of 
 the uterus through the abdomen and the cervix by the vagina; the other, 
 that of Bardenheuer, in removing the entire uterus through the abdomen, 
 "but securing haemostasis of the broad ligaments either through the vagina or 
 the abdomen alone, or combined. 
 
 {a) Sticcessive Removal of the Cervix and Uterine Body. — When the 
 abdomen has been opened and the fibroid tumor drawn out, Pean applies an 
 elastic ligature below it and resects it. When only the lower portion of the 
 body and the cervix are left, he binds the pedicle with a wire placed, accord- 
 ing to circumstances, above or below the elastic ligature and fastened by 
 means of a special ligator, that of Cintrat. He resects the stump as near 
 as possible to the metallic loop after having carefully removed the mucosa, 
 and reduces it into the abdomen, the incision in which he sutures. He im- 
 mediately removes the stump by the vagina by morcellation and clamping 
 the broad ligaments. 
 
 Pean claims a mortality of 2 per cent (i death in 50 cases) for this 
 operation, in a first series; and in a second series (1890 to 1894) 5.8 per 
 cent (7 deaths in 120 cases). 
 
 Since 1890 Boldt had obtained three successes by the abdomino-vaginal 
 method. 
 
 In France, the same technique has been employed by Bouilly in a case of 
 fibroma with cancer of the cervix, and by Goullioud in a simple case of fibroids. 
 
262 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 In 1888 Martin also combined the vaginal and abdominal routes for the 
 removal of fibroid uteri. His technique differed from that of Pean only in. 
 the substitution of ligatures for forceps and in the removal of the tumor 
 without morcellation of the pedicle. 
 
 Chaput takes out first the cervix through the vagina and the rest of the 
 uterus through the abdomen. Guermonprez describes as probably new the 
 following method of hysterectomy: i. Section of the two broad ligaments 
 stopping a short distance from the uterine arteries. 2. Transverse section 
 of the vesico-uterine peritoneum, and separation of the bladder and uterus 
 with the fingers as far as the anterior lip of the cervix. 3. Opening the 
 vagina by a buttonhole incision running longitudinally in the median line 
 and in its anterior wall. 4. Transfixion of the vagina, keeping in the antero- 
 posterior plane, by means of a tunnelled sound which emerges in Douglas' 
 cul-de-sac. 5. Haemostasis assured before removal, by means of two large 
 clamps. 
 
 {b) Total Removal of the Uterus tJiroiigJi the Abdomen. — In 1881 Barden- 
 heuer recommended first liberating the cervix by a step which he termed 
 vaginal, followed by the extirpation of the uterus and its fibroids by the 
 abdominal route. 
 
 Rouffart, like Bardenheuer, liberates the cervix by a preliminary vaginal 
 step, and places haemostatic forceps on the base of the broad ligaments which 
 he divides ; he then opens the abdomen and ties the portion of the liga- 
 ments which has escaped the clamps. 
 
 Jacobs proceeds in the same manner as Rouffart, but clamps the upper 
 portion of the broad ligaments instead of tying them. When the tumor has 
 been extirpated he replaces the clamp placed through the abdomen, by others 
 introduced through the vagina. ^ In order to avoid this manoeuvre he has 
 invented forceps with detachable handles which can be applied through the 
 vagina to the jaws which are left in place. 
 
 Lanphear, after opening the abdomen, ligatures and divides the appen- 
 dages ; next, tipping the fundus of the uterus backward, he makes a transverse 
 incision through the peritoneum and methodically detaches the bladder from 
 the uterus ; then he passes a finger into the vagina and perforates the an- 
 terior cul-de-sac with scissors. The uterus is now drawn strongly forward 
 and the posterior cul-de-sac similarly treated. When this has been opened 
 the uterus is left in charge of an assistant, who draws it upward and laterally ; 
 a clamp is then introduced through the vagina, leaving one hand in the 
 abdomen to guide the jaws of the instrument, which are made to include all 
 the soft parts attached to the side of the uterus. The clamp is then locked. 
 The opposite side is treated in the same manner, and the uterus removed 
 after dividing the soft parts close to the clamps. 
 
 Richelot has recently devised a method which he applies to all cases and 
 which resembles those just described. He relies entirely upon the use of 
 permanent forceps without ligatures and without closure of the vagina. By 
 
TREATMENT OF FIBROUS TUMORS OF ABDOMINAL EVOLUTION. 263 
 
 this he seeks rapidity of execution and absolute exclusion of foreign bodies 
 from the abdomen. 
 
 The first essential point, when the uterus has been brought out through 
 the abdominal wound, is to perform a preliminary enucleation, if circum- 
 stances demand it, of all the fibroids which interfere with the beginning of 
 the operation, by concealing the true pehis, immobilizing the uterus, and 
 distorting the broad ligaments. Large tumors in the lower uterine segment 
 and filling the pelvic cavity are boldly attached by a median incision in their 
 capsule, and are removed entire or by morcellation. The emptied uterus 
 becomes flaccid ; the upper border of the broad ligaments, which before 
 reached the umbilicus, is lowered sufficiently in all cases to be seized with 
 the forceps. An anterior peritoneal flap is then cut out to bring the bladder 
 and ureters toward the pubis. Then the anterior cul-de-sac alone is opened 
 with scissors close to the anterior surface of the cervix, so as not to be 
 obliged to pull the uterus forward and dissect behind it, and thus early 
 cause bleeding from the posterior vaginal incision. 
 
 After opening the cul-de-sac the broad ligament is held with the left 
 hand and the end of a blunt-pointed scissors is pushed through its base, mak- 
 ing a small opening close to the cervix, immediately above the vaginal 
 insertion, internal to the uterine artery and well above the ureter with which 
 it cannot interfere. The clamp curved on the flat, with jaws 9 or 10 cm. 
 long and a great deal of " bow" in order to lock at the end as well as at the 
 base, is introduced through the vagina, its posterior jaw passing through the 
 small opening just made, and the whole ligament is easily seized after push- 
 ing the clamp upward. 
 
 The opening of the anterior cul-de-sac alone, the perforation of the liga- 
 ment at its base, and the manner of applying the clamp are the characteristic 
 points of this method. 
 
 When the two ligaments are clamped, the uterus is rapidly detached 
 laterally, and the posterior cul-de-sac is finally opened. Richelot never leaves 
 a drain or tampon in the supra-pubic wound, but carefully arrests the inevitable 
 hemorrhage from the posterior vaginal incision by seizing bleeding points 
 with two or three long-handled forceps introduced through the vagina. He 
 then places in the vagina an anterior retractor and slides between it and the 
 forceps a tampon of iodoform gauze exactly as far as the vaginal wound, then 
 a second and a third below the first. When the abdominal wound is closed 
 the immediate result is that of a vaginal hysterectomy, and the operation 
 has lasted from thirty-five to fifty minutes. 
 
 IV. Intra-ligamentous and Pelvic Fibroma — Decortication. — Fibromata 
 from the supravaginal portion of the cervix and the lower part of the body of 
 the uterus grow below the peritoneum, which they elevate and unfold and are 
 seldom covered by it completely, having a tendency to insinuate themselves 
 into the cellular spaces of the pelvic floor. They may thus split the meso- 
 rectum up to the superior strait, or lift up the utero- vesical pouch and com- 
 
264 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 press the bladder against the pubic bone ; or, as in the great majority of cases, 
 they may spread into the broad ligaments, whose folds they entirely efface. 
 From the surgical point of view all these varieties belong in one natural 
 group, characterized by extreme difficulty in forming a pedicle and intimate 
 and extended connections with the walls and viscera of the lesser pelvic 
 cavity. 
 
 When these tumors do not extend above the umbilicus, I believe that they 
 
 Fig. 194.— Total Abdominal Hysterectomy by Richelot's Method, i. Fibroid ; 2, tube ; 3, round liga- 
 ment ; 4, broad ligament ; 5, orifice made at the base of the broad ligament ; 6, ureter ; 7, uterine artery ; 8, bladder 
 drawn toward the pehis ; 9, denuded surface of the inferior segment of the uterus ; 10, 10', anterior vaginal insertion ; 
 II, vagina ; 12, section of anterior peritoneal flap ; 13, ovary. 
 
 should be removed through the vagina by morcellation. According to their 
 connections with the uterus, vaginal hysterectomy should be performed si- 
 multaneously with the extirpation of the fibroid, either as a preliminary step 
 (to allow access to the tumor) or as a complementary procedure. In all 
 cases the technique should be that which I have described. When, how- 
 ever, intra-ligamentous fibroids extend above the umbilicus, their surgical 
 treatment is attended by the greatest difficulties. After opening the abdo- 
 men, if they appear too large for extirpation to offer real chance of recovery, 
 we may perform castration (palliative) in place of extirpation (curative).' 
 
TREATMENT OF FIBROUS TUMORS OF ABDOMINAL EVOLUTION. 265 
 
 We must, however, recognize that in these cases it is not the hemorrhage 
 which is the most important symptom, but the compression, and that there- 
 fore castration has but an uncertain vakie ; if performed, it is only as a 
 makeshift. 
 
 I propose to reserve the term "decortication" for the extraction of the 
 tumor from its cellular bed, and the term " enucleation" for its removal from 
 the uterine tissue ; the use of the latter word for the two operations, so dif- 
 ferent in their natures, has given rise to great confusion. It is impossible 
 
 Fig. 195. — Hysterectojiy by Richelot's Method, Operation Finished. 14, Line of section of the broad liga- 
 ments ; 15, haemostatic forceps on posterior vaginal wall, 
 
 to give a typical description to cases which are beyond all rules and hence 
 termed " atypical." 
 
 The application of the provisional elastic ligature is seldom possible, and 
 then only on a part of the tumor. Redoubled care must be employed not to 
 include the portion of the bladder which is generally elongated upon the 
 anterior face of the uterus. If part of the tumor projects far into the peri- 
 toneal cavity, the ligature is placed as deeply as possible about this lobe, 
 which may then be removed without fear. An attempt is made to enucleate 
 the deeper parts by strong traction, the elastic cord following the diminution 
 of the tumor and keeping up a steady and sufficient constriction upon the 
 capsule as it is emptied. Very often it is necessary to begin the operation 
 by ligation and section of the adnexa on the side where we are operating, at 
 the same time placing a deep ligature on the corresponding trunk of the 
 uterine artery. 
 
266 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 It may occur that these manoeuvres are impossible, and that we must pro- 
 ceed at once to the important step of the operation, namely, the free incision 
 of the tumor's intra-ligamentous seat, whose lips are then seized by strong 
 forceps, and the decortication accomplished with fingers and spatula. The 
 operator keeps up strong traction with toothed forceps, carefully dissects out 
 the neoplasm and applies clamps to bleeding points, without forgetting the 
 position of the ureters ; the tumor once removed, he sees the veins of the 
 broad ligaments, which are at times enormous, and is surprised to require 
 more ligatures than he had thought necessary. 
 
 When the connections of the tumor to the uterus are not extensive, it is 
 sufficient to apply haemostatic ligatures or sutures as necessary, and leave the 
 organ in place ; but if they are close and the bleeding is hard to stop, it is 
 better to decide on supravaginal hysterectomy without further hesitation. It 
 may occur that this happens almost without our knowledge, for at the end of 
 
 3 V 
 
 Fig. ig6. — Intralig-amentous Fibroma. A , Horizontal section to show the connections of the tumor ; weight 14 lbs. 
 By Suture of the cavity resulting from enucleation of the preceding ; drainage by the vagina ; cure (Kaltenbach). 
 
 a laborious decortication we may reach, in a tumor which fills the pelvis, a 
 pedicle which is at once recognized as the cervix. 
 
 The resulting cavity may be very large, with prolongations toward the 
 rectum, bladder, or on each side of the vagina; its treatment may be accord- 
 ing to one of the following plans : 
 
 If we feel perfectly sure that the operation has been aseptic, we may 
 try for primary union without drainage. If the peritoneum has not been 
 torn or contused, as is the case with small tumors and where the adhesions 
 are loose, a few points of suture are placed in the membrane to unite it, the 
 peritoneal toilet is then completed and the abdomen closed. If the pocket 
 is very deep and the bleeding is free, we may make a continuous suture 
 in terraces, which both unites the parts and stops the hemorrhage. Debris 
 which may mortify should be excised. 
 
 This bold procedure is justified only in exceptional cases; if the cavity 
 is extensive and we fear oozing, drainage is more prudent. It may be per- 
 formed in two ways; Martin and Kaltenbach recommend the use of a cross 
 tube through the vagina, passed through the cul-de-sac. Sanger, after drop- 
 ping the pedicle left by the removal of a tumor from just above the cervix. 
 
TREATMENT OF FIBROUS TUMORS OF ABDOMINAL EVOLUTION. 267 
 
 closed the abdominal walls and immediately opened by the vagina and 
 packed with gauze the capsule filled with blood which projected into it; his 
 patient recovered. 
 
 Drainage through the inferior angle of the abdominal wound is prefer- 
 able in some cases, according to the situation of the cavity; it has the 
 advantage of exposing less to infection. Terrier has recently treated in this 
 way the cavity of a myoma cf the broad ligament ; recovery, with permanent 
 fistula. H. A. Kelly decorticated a pelvic fibroma which had compressed the 
 bladder, left open and drained the cavity, and then used weak carbolic injec- 
 
 FiG. 197. — Fibroma in the Broad Ligament ; Decortication and Suture of the Cavity, and Drainage by 
 
 THE Vagina (Martin). 
 
 tions through the drain without fear of effusion into the peritoneum, which 
 was closed off during the first days by adhesions. I prefer to employ iodo- 
 form gauze, as it is at once a haemostatic and a capillary drain, and I have 
 used it with success in one case of intraligamentous tumor which weighed 
 fifteen pounds. Kuster has also packed the cavity and united its edges to 
 the lower part of the abdominal wound. The gauze should be withdrawn a 
 little at a time and replaced by a drain at the end of a few days. 
 
 Tauffer has had curious success by partially resecting large fibromata of 
 the ligaments, fixing the stump in the abdominal wound, and then treating it 
 by strong cauterization with chloride of zinc. 
 
 Operative Accidents. — Hemorrhage is one of the most serious dangers, 
 and has caused many deaths upon the operating table, but it may be avoided 
 by the judicious use of the temporary elastic ligature. It must be noted 
 
268 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 that we do not produce here, as in the application of the Esmarch bandage 
 to a limb, an ischaemia of the tumor; this idea of L. Labbe's, though in- 
 genious, is still pure hypothesis ; and beside the almost insurmountable diffi- 
 culties in application, it exposes to excessive manipulation, and without 
 doubt to embolism. We must not be surprised, therefore, on cutting the 
 tumor above the ligature, to see a large discharge of residual blood which 
 has been imprisoned by it. If the case is one of telangiectatic tumor or if 
 the broad ligaments are traversed by dilated veins (tubo-ovarian varicocele), 
 the ligaments must be tied with the greatest care and cut only between two 
 ligatures. The threads should be passed with a dull needle to avoid punc- 
 ture of the vessels — an accident which has often caused large subserous 
 hemorrhages, and to sare time the ligatures may be replaced by long forceps. 
 
 In cutting the tumor above the ligature, the greatest care must be exer- 
 cised to prevent the section from going too near the elastic band and thus 
 allowing the escape through it of any part of the tumor's pedicle from the 
 constriction of its circumference. The extra-peritoneal treatment of the 
 pedicle, with the use of the elastic ligature, permits us to avoid all secondary 
 hemorrhage, but with the intra-peritoneal method (suturing the stump with 
 catgut or" silk), this is not the case even though the uterine arteries be 
 strongly ligated to right and left of the pedicle by passing a stout needle 
 through a certain thickness of the organ. In spite of this precaution, we 
 often see fatal hemorrhage from shrinking of the tissues and relaxation of 
 the ligature a few hours or days later. 
 
 The possibility of wounding the bladder should always be remembered. 
 The cases are numerous in which it has been lacerated, or partly included in 
 the permanent ligature. If the viscus is elongated in front of the tumor it 
 must be dissected off sufficiently to allow the ligature to be placed below it. 
 
 When the bladder is extensively wounded, it should be closed imme- 
 diately by a continuous catgut suture on two or three planes. Catgut is 
 preferable when the stump has been treated by the extra-peritoneal method, 
 for silk is porous and may cause infection by absorbing the secretions from 
 the furrow around the pedicle. When the stump is abandoned within the 
 peritoneum, as in myomectomy, silk may be used. A soft catheter furnished 
 with a tube forming a siphon should be left in the bladder for ten days after 
 the operation. Leopold has had complete success with this method, and I 
 have employed it in a case of bladder wound 12 cm. in length, which was 
 perfectly cured although the patient removed the catheter after six days and 
 caused a partial temporary disunion of the vesical suture, which was rendered 
 aseptic by iodoform gauze placed in front of it. In a former case, which 
 occurred in the course of an ovariotomy, in which the wound was enormous 
 (20 cm.), I sutured its intra-peritoneal portion and maintained a small hole 
 unsutured as a safety-valve ; the patient recovered after a period of tem- 
 porary fistula, which was easily effaced by freshening its edge. 
 
 .Sanger adopted a different procedure in a case in which the elongated 
 
TREATMENT OF FIBROUS TUMORS OF ABDOMINAL EVOLUTION. 269 
 
 bladder was taken for the pedicle of an ovarian tumor and included in the 
 sutures, retaining these and losing the peritoneum around and above the 
 vesical stump by sequestration similar to that employed for the uterine 
 pedicle : cure without fistula. A permeable urachus, divided during the 
 operation, has rarely caused fistula; these have, however, a tendency to heal 
 spontaneously. It is well to carry the incision of the abdomen outside of 
 this cord when it is encountered, and if slightly wounded, it should be sewn 
 into the abdominal wall by one or two deep sutures. If the wound in it is 
 very extensive, it may be closed by a few sutures and the patient catheterized 
 every three hours to prevent distention of the bladder. 
 
 I am inclined to think that the ureter has often been ligated during 
 haemostasis of the stump which is returned to the abdomen, and in decorti- 
 cation of intraligamentous fibromata, and that' many of the deaths attributed 
 to shock are really due to this accident. The relations of these ducts should 
 never be forgotten in placing deep ligatures on the sides of the uterine neck. 
 
 The intestines may be simply applied to the surface of a fibroma which 
 splits the mesocolon, and it is then easy to separate them by the finger, or 
 there may be firm union between them when the tumor derives its nutrient 
 vessels from such adhesions, as I have observed in the case of a large sub- 
 peritoneal fibroma with a narrow and small vascular pedicle. A thin layer 
 of the tumor is then to be left adherent to the intestine, which if not too 
 extensive may be folded upon itself and sutured (Fig. 175). If, however, a 
 large surface of the intestine has thus been wounded, we take the risk of 
 contracting the digestive tube by coaptation of the bleeding part; it is then 
 better to touch it lightly with the thermo-cautery and fix it to the parietal 
 peritoneum by a few catgut sutures, as near as possible to the abdominal 
 drain. To simply abandon it within the abdomen would be to produce con- 
 ditions that would favor an attack of ileus. 
 
 Causes of Death after Abdominal Hysterectomy. — Hemorrhage, septi- 
 caemia, and the complex syndroma called shock are the chief causes of death 
 after operation ; less often it is due to embolism, ileus, or tetanus. 
 
 I have already spoken of primary hemorrhage at the time of operation. 
 In Schroder's method secondary bleeding is always to be feared and is 
 announced by the extreme agitation of the patient, the accelerated, irregular, 
 small pulse, and pallor of the integument and mucous surfaces. In other 
 cases we may find a serous fluid oozing out between the sutures, or the 
 patient describes a pleasant sensation as of a jet of hot water flowing through 
 the abdomen. The blood may escape in great amount below the peritoneum 
 between the broad ligaments, forming enormous retroperitoneal hasmatoceles, 
 or it may accumulate in the seat of the enucleated tumor, projecting through 
 the ecchymosed vagina and pressing it strongly downward. 
 
 If there is reason to suspect an internal hemorrhage, there should be no 
 delay in opening the abdomen, both to tie the bleeding vessels and to remove 
 the clots which form an excellent culture medium for the microbes which 
 
270 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 enter from without, by the tubes, or from within, through the wall of the 
 paralyzed intestine. O. Kiistner reports a remarkable case which he saved 
 in this manner, in which the bleeding came from the pedicle in the abdomen 
 after ovariotomy. If the state of the circulation permits and the heart's 
 action is not too much compromised, a litre of sterilized water at 38° C. 
 (100° F.), containing chloride of sodium (6: 1,000) may be injected by the 
 cephalic vein. For this purpose we may use a small canula, passed through 
 an alcohol flame, and a funnel of glass furnished with a rubber tube a yard 
 in length, sterilized with boiling water. If the pulse is weak, and it seems 
 dangerous suddenly to increase the contents of the vessels, injections of 
 water and chloride of sodium, 100 to 200 gm. at a time, may be given into 
 the subcutaneous cellular tissue ; the fluid is very quickly absorbed. 
 
 Septicaemia may occur in several ways — either from defective asepsis 
 during the operation or, more frequently, from germs introduced from with- 
 out through the pedicle ; hence the precautions recommended for destruction 
 of the mucous membrane, careful junction of the surfaces to obtain complete 
 occlusion, and the other methods of treating the pedicle. 
 
 The constriction of the suture does not account for the sloughing of the 
 pedicle after it has been returned to the abdomen ; to produce mortification, 
 the action of germs is indispensable. If kept aseptic, the tissues deprived 
 of their circulation undergo a granulo-fatty degeneration. The circulation 
 may be re-established by the formation of adhesions or bridges of tissue 
 above the pedicle, which is thus little by little encapsuled. There are 
 records of a slow or secondary infection of the dropped stump by means of 
 the sutures when they are of silk, or by the elastic cord. The germs may 
 then come through the tubes or the intestine, following a temporary stasis 
 of its contents ; and in certain cases we must suppose a latent microbism. 
 Whatever the origin may be, cases of death from pelvic inflammation and 
 suppuration are not very uncommon. 
 
 Abroad, and also in France, death has been ascribed, after grave and 
 protracted operations, to a combination of depression symptoms called 
 "shock." There is no doubt that a number of such cases are to be attrib- 
 uted to hemorrhage, of which some surgeons are too unwilling to allow the 
 importance ; others may be due to septicaemia or acute uraemia from acci- 
 dental ligation of the ureters or abolition of the function of kidneys already 
 seriously impaired by the influence of traumatism and absorption of the 
 anaesthetic. Degeneration of the heart (Hofmeier) may also be the cause in 
 many cases (page 202), such myocarditis being more frequent than is sup- 
 posed. Cohnheim has shown that persistent hemorrhage alone is enough to 
 produce a fatty change in the cardiac muscle. Ungar and Strassmann have 
 called attention to the action of the chloroform in these cases ; and many 
 authors have proved that the antiseptics act strongly on the heart. Some of 
 these depression phenomena are due to the exposure of the viscera and the 
 handling which they receive, as is evident from the experiments of Goltz on 
 
TREATMENT OF FIBROUS TUMORS OF ABDOMINAL EVOLUTION. 27 1 
 
 abdominal shock and of Olshausen on evisceration. To these numerous 
 causes of depression Landau has added chronic intoxication from ergot, pro- 
 ducing enfeeblement of the heart, and a similar condition from iodine. These 
 substances have at times been taken in very large quantity by hypodermic 
 and intra-uterine injection, and their absorption may account for some of 
 these symptoms. 
 
 To prevent shock I would recommend rapidity of operation, for the 
 depressing effect in every laparatomy which lasts more than an hour is 
 increased in high proportion. Contact of the intestines with the air must 
 also be carefully avoided by protecting them with hot gauze compresses and 
 closing the abdominal wound as soon as the tumor is drawn out of it. The 
 incision should be as small as possible, passing the tumor as through an 
 elastic buttonhole, and aiding its issue from the abdomen by movements of 
 rotation upon its axis and by elevation through the vagina by the fingers of 
 an assistant. For the depression and lowered temperature, we employ hot 
 friction and hypodermic injection of ether, alternating every quarter of an 
 hour with caffeine. If acute anaemia has helped to cause the accident, 100 
 to 200 gm. of the salt solution may be injected into the subclavicular dorsal 
 region. 
 
 As embolism has produced death even during convalescence, we cannot 
 insist too much on absolute rest, especially if the tumor was very vascular 
 or the broad ligaments largely varicose. 
 
 Intestinal occlusion has been observed after hysterectomy, as after all 
 other abdominal operations, but it must not be forgotten that some of the 
 cases published under this head were only pseudo-strangulation from paraly- 
 sis of the intestine, announcing a septic peritonitis which was unrecognized. 
 
 To prevent this terrible complication, we should be sparing of antiseptics 
 within the abdominal cavity, if we do not abstain from them altogether; for 
 they exert an extremely intense action upon the delicate epithelium, and 
 predispose to plastic exudation. As little bleeding surface should be left in 
 the peritoneal cavity as possible. The wound surface of the stump should 
 be carefully covered with peritoneum ; and the broad ligaments, if torn or 
 divided in the process of decortication, must be secured with catgut sutures. 
 
 As regards the treatment of ileus, before reopening the abdomen we 
 should try the method proposed by Bode and Leopold, of placing the patient 
 upon her side and giving forced enemata of hot chamomile infusion, with the 
 addition of oil and soap. 
 
 Mortality of Hysterectomy. Comparison of Results by Dijferent Methods. 
 — It is difficult to decide as to the gravity of the operation, as the majority 
 of authors do not divide their cases according to systems which permit com- 
 parison. Thus supra-vaginal amputation should not be compared with decor- 
 tication of a large fibroma; there is more difference between them than 
 betv/een amputation of the leg and the same operation on the thigh. But in 
 default of anything better we must have recourse to statistics. 
 
2/2 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 In my earlier editions I have given statistics compiled by Paul Wehmer 
 and by Zweifel. Their results were almost identical. Wehmer gave a mor- 
 tality of 24 'per cent by the extra-peritoneal method; Zweifel found it to be 
 22.3 per cent. By the intra-peritoneal method, the mortality was stated by 
 Wehmer to be 28.2 per cent ; by Zweifel, a little higher, 32.7 per cent. The 
 relative benignity of the first method seems to be strikingly shown by these 
 figures. 
 
 The following objection has been made to these figures : Avowed par- 
 tisans of the extra-peritoneal method, like Kaltenbach, Thornton, and S. 
 Keith, are found also among those who perform the intra-peritoneal ; and it 
 is evident that the two methods cannot be equally favored in both the series, 
 and, very probably, where the pedicle was abandoned within the abdomen, 
 the case was more serious than those in which the favored method was 
 employed. 
 
 In order to obtain statistics free from this objectionable feature I have 
 taken the figures of surgeons (A. Martin, Schroder, Olshausen, etc.), who 
 confine themselves exclusively to the intra-peritoneal treatment of the pedicle. 
 I have done the same in the series relating to the extra-peritoneal method and 
 have obtained the following figures, which demonstrate clearly the superior- 
 ity of the latter method. 
 
 Extra-peritoneal method, mortality, . . 21.6 percent. 
 
 Intra-peritoneal method, mortality, . . 25.79 
 
 This superiority is also confirmed by the latest statistics. A. Biichel 
 gives the following figures : Fehling reported a mortality of 7.14 per cent in 
 14 cases with extra-peritoneal treatment of the pedicle. In 132 operations 
 by the same method, by Hegar, Kaltenbach, Keith, Bantock, Fehling, and 
 Fritsch the mortality was 12.9 per cent. Schroder, Ohlshausen, Martin, 
 and Gusserow have employed the intra-peritoneal method in 133 cases, with 
 a mortality of 30.8 per cent. Frommel, Landau, and Hofmeier, in 57 cases, 
 by this method had a mortality of 14 per cent. 
 
 The following statistics are published by Price : 
 
 Extra-peritoneal Method. 
 
 Number of ^^^^^^, 
 operations. 
 
 Chrobak 55 5 
 
 Ascher 5 2 
 
 Kaltenbach 22 i 
 
 Hegar 31 10 
 
 Schroder 34 7 
 
 Albert 50 3 
 
 Fritsch 33 6 
 
 Terrillon 26 3 
 
 Lauwers 13 o 
 
 Keith 38 2 
 
 Lawson Tait 88 ic 
 
 Number of j^^^^j^ 
 operations. 
 
 Bantock 56 19 
 
 Spencer Wells 20 10 
 
 Thornton 54 20 
 
 J. Price 91 6 
 
 Gushing 25 5 
 
 Boldt 6 2 
 
 J.-B. Irisch 19 5 
 
 Mann 12 i 
 
 Munde 12 4 
 
 690 121 
 
 Mortality, 16 per cent. 
 
TREATMENT OF FIBROUS TUMORS OF ABDOMINAL EVOLUTION. 2/3 
 
 Intra-peritoneal Method. 
 
 Number of 
 operations. 
 
 50 
 
 10 
 
 Zweifel 
 
 Ascher 
 
 Kaltenbach 8 
 
 Leopold 22 
 
 Schroder 164 
 
 Martin I35 
 
 Brennecke 22 
 
 R. Dick II 
 
 Deaths. 
 6 
 
 4 
 
 8 
 
 5 
 43 
 43 
 
 I 
 
 2 
 
 Number of t, ... 
 
 operations. I^^^'^^- 
 
 Fritsch 27 11 
 
 Terrillon 32 3 
 
 Lauwers 3 2 
 
 Spencer Wells 26 10 
 
 Gushing 3 3 
 
 Boldt 3 o 
 
 516 144 
 Mortality, 28 per cent. 
 
 Tauffer in 51 hysterectomies had 12 deaths — 22.5 percent (extra-peri- 
 toneal) ; Fritsch in the operations in which he employed the extra-peritoneal 
 method, a little modified to resemble W5lfler-H acker's, had 23 cases, 5 
 deaths, and, by Schroder's method, 27 cases and 11 deaths; Albert in 30 
 cases had but i death by the extra-peritoneal method. C. Braun, in a series 
 (1887 to 1890) of 38 hysterectomies with extra-peritoneal treatment, lost 
 only 4 patients, or 10.5 per cent; in 2 hysterectomies with intra-peritoneal 
 treatment he had 2 deaths; and Hegar, in his series from June, 1887, to 
 May, 1889, comprises, besides 2 myomectomies for pedicled fibroma with 
 cure, also 18 supravaginal hysterectomies for interstitial tumors with cure, 
 and 12 hysterectomies for intra-ligamentous tumors with 2 deaths, one at 
 the end of four months and the other at the end of five. 
 
 Terrier, in a series of 38 hysterectomies, with extra-peritoneal treatment 
 of the pedicle, lost 15 patients, or 39.4 per cent. In 8 cases in which the 
 pedicle was returned he had 4 deaths, or 50 per cent. 
 
 P. Segond has observed 9 deaths, or 45 per cent, in 20 cases in which 
 he performed abdominal hysterectomy by the extra-peritoneal method. 
 
 Treub had only 5 deaths, or 8. 7 per cent, in 57 cases in which he treated 
 the pedicle by the intra-peritoneal method. The same method has given 
 Richelot 3 deaths in 16 cases, or 18 per cent. 
 
 Leopold, employing bofh methods, has had 7 deaths in 34 cases, or 20.5 
 per cent, for the extra-peritoneal treatment of the pedicle, and 5 deaths in 
 22 cases, or 22.7 per cent, for the intra-peritoneal treatment. 
 
 Finally, at the Surgical Congress of 1891, Terrillon gave the statistics 
 of his abdominal hysterectomies. In 54 cases he had had 6 deaths; the 54 
 cases were divided as follows : 28 in which the pedicle was returned (3 
 deaths) ; 26 by the extra-peritoneal method (3 deaths). 
 
 Personally, I have long remained a partisan of the extra-peritoneal 
 method. At present I am inclined to favor total hysterectomy, which I be- 
 lieve to be the method of the future. We must not forget that each one of 
 these methods has its own dangers. The presence at the bottom of the 
 abdominal wound of a stump destined to slough is at the outset a decided 
 disadvantage for the extra-peritoneal method, although the new dressing of 
 
274 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 powder adopted by Kaltenbach lessens the inconvenience which might 
 result from the mortification of the pedicle. It should also be noted of this 
 method that the cure is slow and leaves a weak point in the abdominal 
 wall. 
 
 But these disadvantages are more than equalled by the greater security. 
 The certain hasmostasis by the constriction of the elastic ligature, and the 
 free escape of secretions from the pedicle, remove the twofold danger of 
 internal hemorrhage and peritoneal infection which always exists when the 
 stump is abandoned in the abdomen, especially when the uterine cavity has 
 been opened. 
 
 Neither of these methods should be absolutely proscribed, but one or the 
 other should be selected according to the case. 
 
 The dangers of the intra-peritoneal method, which is evidently ideal in 
 theory, are : Extreme vascularity, which renders control of the bleeding im- 
 possible without the application of so many sutures that they might cause 
 mortification and septicaemia; opening of the uterine cavity, which would 
 give access to germs from^ the vagina ; in other words, there is danger with 
 bleeding and with hollow pedicles : they are to be treated by the simple or 
 the mixed extra-peritoneal method, which is designed specially to guard 
 against such dangers. 
 
 For other cases the intra-peritoneal method may be chosen. In case of 
 suppurating or gangrenous inflammation of the tumor, the extra-peritoneal 
 method is the only one to be employed. 
 
 One may reasonably ask to-day whether these two methods which have 
 so far divided the preferences of surgeons should not be replaced by total 
 extirpation, not, however, that certain disadvantages of the latter procedure 
 cannot be alleged, among others the greater duration of the operation and 
 the danger of infection through the vagina. However this may be, in an 
 important set of statistics embracing 434 cases borrowed from surgeons of 
 all countries, one of my pupils has found a mortality of 15. per cent for the 
 method of total extirpation by the combined route, and of 14.32 per cent by 
 the abdominal alone. Delageniere has practised total abdominal hysterec- 
 tomy 20 times with i death, or a mortality of 5 per cent. These figures, 
 though notably inferior to those of the intra- and extra-peritoneal methods, 
 should at least cause us to make great reservations in our present judg- 
 ment. 
 
 The following table seems to me to condense the precepts which should 
 regulate the choice of methods for the surgical treatment of uterine fibroids : 
 
 A. Fibroids with Vaginal Evolution. 
 
 _., . . f I. Pediculated; removal with assistance of vagrinal morcellation. 
 
 Fibroids erowingf if, , • , • r • , ,^ ■ ^ 
 
 ° ° I 2. bubmucous; removal with assistance of vaginal morcellation; comple- 
 
 j mentary vaginal hysterectomy, if the uterus is perforated during mor- 
 
 ■'' cellation, or if other interstitial fibroids exist. 
 
TREATMENT OF FIBROUS TUMORS OF ABDOMINAL EVOLUTION. 2/5 
 
 B. Fibroids with Abdominal Evolution. 
 
 umbilicus. 
 
 3. Pediculated; removal by laparatomy. 
 
 Interstitial — General condition bad (heart and 
 kidney lesions); supravaginal ^ 
 hysterectomy. 
 
 a. Fibroids not c i. Interstitial; vaginal hysterectomy by morcellation. 
 
 reaching t h e -| 2. Developed into broad ligament; vaginal hysterectomy by morcellation. 
 
 Long pedicle; He- 
 gar's method. 
 Short pedicle ; Wolfler- 
 [^ Hacker method. 
 
 General condition good; total abdominal hysterectomy. 
 
 Suture of capsule without drainage, if little bleed- 
 ing. 
 Suture and vaginal drainage or abdominal tam- 
 ponnade of capsule, if bleeding. 
 Decortication and complementary hysterectomy, if the uterus is closely 
 L adherent to the tumor. 
 
 .^. Fibroids extend 
 
 ing above the ■< 
 umbilicus. 
 
 2. Intraligamentous ; 
 decortication. 
 
CHAPTER XII. 
 
 CASTRATION FOR FIBROMA. 
 
 Clinical experience has long demonstrated that the cessation of the 
 sexual life in women is usually followed by a remarkable diminution in the 
 symptoms caused by fibrous tumors ; the bleeding stops and the tumor atro- 
 phies. To hasten the appearance of this favorable period we may produce 
 an artificial menopause by removal of the ovaries. 
 
 The term castration has given rise to much discussion ; it should be 
 reserved for ablation of healthy ovaries to secure a functional modification., 
 Hegar applies the term to any removal of ovaries, normal or diseased, which 
 do not "form a notable tumor." This definition is insufficient, for then the 
 operation would be called castration when performed for a cyst of the size 
 of the fist, and ovariotomy when it was of the size of the head. Battey and 
 the Americans call castration " normal ovariotomy" and " oophorectomy." It 
 is not well thus to confound operations in which the adnexa are removed, as. 
 the centres of morbid reflexes, hemorrhagic or painful, with those in which it 
 is done for a pathological condition diagnosed before the abdomen is opened, 
 as in salpingo-oophorectomy, generalized by Lawson Tait. The term cas- 
 tration is then to be used for the ablation of adnexa reputed normal, and it 
 may be haemostatic or analgesic. Oophorectomy designates, like salpingo- 
 oophorectomy, extirpation of inflamed adnexa in salpingitis or ovaritis. 
 Thus confusion is avoided. 
 
 Castration for painful dysmenorrhoea was done in 1872 at almost the 
 same time by Hegar and Battey, and surgeons had begun to familiarize them- 
 selves with the operation when Trenholme published, in 1876, the first 
 known case of castration for uterine myoma; a month after, Hegar per- 
 formed it with the same object. There is no doubt that Hegar did not 
 know of the operations of Battey and Trenholme when he conceived and exe- 
 cuted his, although they had already been published, and it is largely due tO' 
 his writings and to those of his pupil Wiedow that the operation has become' 
 general. In England Lawson Tait, and in France Duplay, Tissier, and 
 Segond have promoted it. 
 
 It is not easy to formulate exactly the indications for this operation. 
 Hegar recommends it in nearly every case in preference to hysterectomy, 
 the graver operation, holding himself ready to perform the second if the 
 first is not sufficient; he mentions the different forms of fibrous tumor for 
 which he has successively practised it, and finds that there are no excep- 
 tions. Thornton has also had good results in cases of fibro-cyst. There is. 
 
CASTRATION FOR FIBROMA. 277 
 
 no doubt, however, that there are cases in which the operation, though easy of 
 performance, is dangerous from its consequences, and there are others in 
 which the danger arises from the inherent difficulties of its accomplishment. 
 
 In the first class belongs castration for large solid or fibro-cystic tumors; 
 for by the obliteration of the vessels, both blood and lymphatic, which it 
 causes it may produce formidable and rapid changes in the fibrous mass. 
 There may be oedema, as the result of the venous stasis or as the first stage 
 of mortification, or embolism following thrombosis when the broad ligaments 
 contain large vessels. The operation may also be dangerous from the risk 
 of immediate hemorrhage when there are very vascular adhesions or when 
 the alse of the broad ligaments are effaced, as is the case with some intra- 
 ligamentous tumors. 
 
 These considerations govern the operative indications, which may be thus 
 stated: Castration should be employed in every case in which its perform- 
 ance is less grave than hysterectomy, and in which the latter is not specially 
 indicated by compression phenomena. 
 
 With pedicled fibroma myomectomy is to be preferred for two reasons : 
 first, because it is the less dangerous operation ; and, second, because with 
 this form of the tumor the bleeding is not the most important symptom, and 
 it is against hemorrhage that castration is chiefly directed. 
 
 Interstitial fibroma with abdominal evolution and of small or medium 
 size may be treated by castration if the only troublesome symptom is the loss 
 of blood ; and the same is true of pelvic and intra-ligamentous tumors at the 
 beginning of their evolution. 
 
 Profound anaemia would be a strong indication for removal of the ovaries 
 rather than of the uterus. 
 
 Castration is therefore contra-indicated with very large tumors, from the 
 danger of oedema and mortification ; with tumors of small size which give 
 rise to compression symptoms ; with fibro-cystic tumors, from the relative 
 benignancy of hysterectomy and the rapid course of the neoplasm ; and, 
 lastly, with telangiectatic tumors, from the danger of thrombosis. These are 
 the elements which direct the choice of the operation, but it is difficult to 
 formulate them in a definite manner before the abdomen is opened. As 
 certain authors have truly said, castration always begins as an exploratory 
 incision, after which the connections of the tumor may be exactly defined 
 and the dangers of operation settled. 
 
 It is then either an operation of choice, decided upon before the first in- 
 cision is made, or one of necessity, undertaken during the operation, when 
 the opening of the abdomen has demonstrated that the risk of the premedi- 
 tated hysterectomy would be too great or that extirpation of the ovaries is 
 both possijjle and of evident advantage. 
 
 Operative TccJiniqiic. — The best time to perform the operation is during 
 the week after the menses. The preparation for it and the rules for the 
 .abdominal incision are the same as in every laparatomy. Hegar advises 
 
278 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 always to palpate the ovaries and make sure of their exact position before- 
 making the incision, but, while a useful precaution, it is not always possible 
 to acquire positive ideas upon this point before opening the abdomen. 
 
 There are three ways of reaching the ovaries : by the median line, the 
 lateral aspect of the abdomen, and the posterior cul-de-sac of the vagina; 
 the first is the only really practical method in the great majority of castrations 
 for myoma. 
 
 The lateral incision presents theoretic advantages, because we come 
 directly upon the ovary which is often thrust outward by the projecting 
 tumor ; Hegar has employed it, following the example of veterinary surgeons. 
 But it seems to have been abandoned owing to the real disadvantages which 
 it possesses — the necessity of a double wound, the strong retraction of the 
 lips, the great vascularity of the tissues in this region, etc. It would be 
 only in the case of a tumor of great size with much lateral displacement 
 that this incision would be necessary, and it is in just those cases that cas- 
 tration is a dangerous operation, not to be deliberately proposed. 
 
 The vaginal incision finds its proper indication in the case of the opera- 
 tion which I have called the analgesic, performed in the absence of tumor 
 and when we can determine the prolapse of the ovary into the pouch of 
 Douglas ; but it is altogether unsuitable when there is a fibroma which has 
 lifted the pelvic tissues above the level of the superior strait. Moreover, 
 there is danger by vaginal touch, of confounding a small lobulated fibroma 
 with a prolapsed ovary, and, lastly, there is the danger of hemorrhage from 
 dilated vessels of the broad ligaments — a danger which is here of especial 
 importance owing to the depth at which we are obliged to operate. 
 
 Oophorectomy by a Median Incision. First Step — Opening of the Abdo- 
 men. — The incision is made at a greater or less distance from the umbilicus 
 according to the height to which we suppose that the tumor has carried the 
 adnexa, and should not extend more than about 8 cm., giving just room 
 enough to pass one or two fingers. As soon as the peritoneum is reached, 
 great caution is needed ; a small incision is made in it with a bistoury held 
 flat, and into this is passed a grooved director, and the incision is finished; 
 thus we avoid wounding the intestine or the surface of the tumor, on which 
 any scratch might cause copious bleeding. 
 
 Second Step. Fijtding and Removing the Ovary. — While the mesentery 
 and intestine are held out of the way by a flat gauze sponge, the index and 
 middle fingers of the right hand are passed deeply through the wound and 
 down upon the fundus of the uterus to search for the ovary ; as soon as it is 
 found it is drawn with the end of the tube out of the wound between the 
 two fingers; at the same time an assistant holds the lips of the incision 
 together. To insure a stronger hold upon the ovary, a pair of forceps may 
 be used instead of the fingers, and special forms of the instrument have been 
 devised for this purpose, but a long and somewhat curved pair is all that is 
 needed, passed beneath the ovary and the pavilion of the tube. A blunt 
 
CASTRATION FOR FIBROMA. 2/9 
 
 needle with a double thread is then used to tie off these parts, and for this 
 purpose I am accustomed to employ Lawson Tait's knot (p. 48, Figs. 35 to 
 37), which is quickly tied and leaves but one knot within the peritoneum; 
 but if the pedicle is very large, it is better to tie it with two crossed liga- 
 tures. It is well to include the tube in this ligature, for it is frequently the 
 seat of chronic inflammation, and its complete removal contributes much to 
 the cure of both pain and hemorrhage. 
 
 If the pedicle is very short, it is advisable to add to this ligature in mass 
 (which may slip) separate ligatures for the vessels, which are to be carefully 
 sought upon the surface of the section. We should also assure ourselves 
 that the ligature has been placed below the ovary, and that no portion of the 
 organ has escaped. The crushed and flattened form of the ovary is very 
 remarkable in certain cases of fibroma. As an additional measure of safety, 
 I prefer, with Hegar, to cauterize the pedicle with the thermo-cautery, pro- 
 ducing a thorough destruction of the tissues ; if there remains any vestige of 
 the ovary, it will thus be sufficiently modified to insure its absorption. The 
 operation is not successful if the least part of the organ is left to become, as 
 P. Miiller has shown, the seat of new cystic formations. 
 
 This cauterization may be performed on the flat surface of a forceps 
 furnished with an non-conducting plate of ivory; Hegar has given to this 
 instrument a double curvature, which is very convenient when the pedicle is 
 deeply situated. Instead of cutting the parts away with the cautery, which 
 is very slow, I prefer to use it only when the section is completed with the 
 scissors, leaving a small stump, which I gradually dry up with successive ap- 
 plications of the cautery carried to a dull-red heat. This cauterization is at 
 the same time antiseptic, hgemostatic, and destructive of the last portions of 
 the ovary. When the ovary can be readily seized, I do not use the forceps, 
 but grasp the organ with the left hand, cut off about three-quarters of the 
 pedicle with the scissors, at the distance of i cm. from the ligature ; then, 
 holding the pedicle by the uncut portion, I cauterize the surface of the sec- 
 tion with the thermo-cautery, and as the last thing complete the division of 
 the pedicle with it. 
 
 The ends of the ligatures should not be cut until it is sure that there is 
 no more oozing and that the threads are well placed ; but if they are left to 
 the end of the operation, with the idea of a final supervision, they may do 
 harm by the traction which is exerted upon them. 
 
 The second ovary is removed in the same manner. 
 
 If the small incision which I have recommended is not large enough, it 
 would be better to enlarge it either above or below rather than to use much 
 force ; but it is dangerous to carry this increase too far, or to divide the in- 
 sertion of the rectus muscle, as has been advised. If the intestines are much 
 in the way the patient should be put in Trendelenburg's position, which 
 causes them to fall toward the diaphragm. 
 
 Tamponing the vagina or rectum to bring the ovaries out of the lower 
 
280 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 pelvis IS a procedure which is rarely needed in the removal of abnormal organs, 
 for they are then more often found above than below the superior strait. 
 
 Evisceration, or the temporary extraction of the mass of intestines, which 
 are wrapped in warm aseptic compresses, certainly gives a great deal of 
 space ; it is an unusual manoeuvre but sometimes necessary. I shall refer to 
 it more fully when considering the treatment of inflammatory lesions of the 
 appendages by laparatomy. 
 
 In any case we should not imprudently bring the tumor out of the abdo- 
 men ; it becomes congested and swollen and very difficult of re-introduction, 
 which exposes to the risk of thrombosis and embolism ; but there is no 
 danger in turning it upon its axis in the abdomen to make the adnexa more 
 accessible. 
 
 Adhesions between the ovary and tube and adjacent parts should, on 
 account of the large development of the venous circulation which occasionally 
 accompanies fibromata, be detached only with the greatest caution and as 
 much as possible under the control of the sight. 
 
 When the broad ligament, especially the portion attached to the ovary, 
 is very short, it forms an insurmountable obstacle to the success of the 
 operation ; the ligatures slip and it is impossible to form a pedicle. In one 
 such case Hegar terminated the operation by hysterectomy in order not to 
 lose the patient by hemorrhage. The bleeding may be arrested by a strong 
 suture made like a hem in sewing, or, after the example of Hegar, an elastic 
 ligature may be applied to the ovarian pedicle. 
 
 Some surgeons attribute great importance to ligature of the tubo-ovarian 
 vessels even without removal of the ovary, believing that it causes fatty de- 
 generation of the ovary or directly modifies the vitality of the uterus and 
 favors atrophy of the tumor. Although such an " atrophy ligature" may be 
 employed as a necessity when removal offers great difficulties or dangers, it 
 would certainly be a mistake to advocate it as a matter of choice. Terrier 
 is its avowed partisan, and Segond accepts it as an expedient to diminish 
 the number of merely exploratory laparatomies ; but this " expedient" does 
 not appeal to me, and, while its usefulness is questionable, it does not seem 
 to me harmless. 
 
 It seems to me much better to remove both ovaries, close the abdomen as 
 soon as possible, and not wait to perform ligation of a vessel which shall 
 produce a theoretical atrophy by lessening the afflux of blood. It has been 
 claimed, however, that by this method unilateral castration has in certain 
 cases an influence upon the development of a myoma which is on one side of 
 the uterus. Removal of the ovaries is rational only when performed on both 
 sides to produce an artificial menopause. 
 
 Unilateral castration appears to have had its rise from the necessities of 
 operation rather than from theoretic conceptions ; the latter have come after- 
 ward to make it legitimate. Sims, Battey, and their imitators are plainly 
 following a mistaken path in praising it. 
 
CASTRATION FOR FIBROMA. 28 1 
 
 Third Step. Toilet of the Peritoneum a7id Suture. — This toilet is usually 
 very rapidly made, except when there has been a rupture of a coexisting cyst 
 in the tube or broad ligament. The threads passed through the abdominal 
 walls at the beginning of the operation are removed, a continuous catgut 
 suture of the peritoneum is made, and then of the muscular planes, ending 
 with interrupted suture of the integuments by strong silk and a few supple- 
 mentary sutures of fine catgut. If the lips of the wound are contused, it is 
 well to leave a drainage tube between the muscles and the skin, which may 
 be withdrawn at the end of twenty-four hours. Drainage of the abdominal 
 cavity is not employed unless there has been an effusion of pus (pyosalpinx) 
 or unless the operation has been very long and laborious ; in the first case 
 the peritoneum should be washed out with hot water. 
 
 After-treatment. — If there is a metrorrhagia a short time after the opera- 
 tion, hot vaginal douches and hypodermics of ergotin are to be employed. 
 Strong compression of the abdominal wall must be kept up, on account of 
 the presence of the tumor and the intestinal paresis which always follows 
 a laparatomy. It is well also to keep the patient in a slanting position, by 
 raising the pelvis, so as to cause the intestines to occupy the upper part of 
 the abdomen. The second day a laxative enema should be administered to 
 evacuate the gas. 
 
 Mortality and Results of the Operation. — Conforming to the method 
 which I have adopted, I give the results obtained by surgeons of the greatest 
 authority on this special subject. Hegar in 55 cases had 6 deaths (11 per 
 cent), of which number 5 were from septicaemia (one case due to infection 
 before operation), and 16 cases, or 29 per cent, presented complications of 
 greater or less gravity, such as 3 mild cases of peritonitis, 7 of abscess, 4 of 
 thrombosis of the lower extremity, i of pneumonia, and i of vesical catarrh : 
 complete success in 33 cases. Deducting from these 55 cases the 6 deaths, 
 and also 12 which were still too recent and 9 in which there was a simultane- 
 ous extirpation of a large pedicled fibroma, there remain 28 cases of castration 
 operated on more than a year and a half. The following are the results as 
 regards cure : 
 
 {a) HemorrJiage. — In 20 cases there was immediate cessation of the 
 bleeding; in 4 cases cessation after certain irregular losses; in i case per- 
 sistence of irregular metrorrhagia; in i case temporary menopause, then 
 hemorrhage and fibrocystic development of the tumor ; and in i case meno- 
 pause, then hemorrhage with beginning enucleation of the tumor, which was 
 finally extirpated by Fehling. 
 
 (b) Timor. — In the same series of 28 cases there were 22 cases with 
 diminution of the tumor ; 3 cases with no change ; i case, diminution doubt- 
 ful ; I case, appearance of a fibrocystic tumor ; i case, secondary enucleation. 
 
 Thus it is plain that the menopause and atrophy of the tumor are not 
 necessarily correlative ; the bleeding may cease without any diminution in 
 the size of the fibroma, but this is the exception. Two of Hegar's cases 
 
282 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 became obese ; another presented five years after the operation, which had 
 been followed by the menopause and retraction of the tumor, a focus of 
 parametritis coming from a blow upon the pedicle ; and another was cured of 
 a reflex chronic cough. 
 
 The care with which these cases have been observed, the absolute secur- 
 ity of the name of Hegar, give to these figures a peculiar interest; it is 
 necessary, however, to know the collected statistics of different authors. 
 The following are taken from Tissier's recent series : 
 
 In 171 operations, 25 deaths — 14.6 per cent. The causes of death were : 
 In 12 cases septicaemia; in i case, embolism of pulmonary artery; in i 
 case, cardiac debility, with death eleven days after the operation ; in 9 the 
 result was undetermined. 
 
 {a) Results as to JiemorrJiage in 146 cases : In 89, complete cessation; in 
 21, menopause after a period of irregular losses ; in 10, return of the menses 
 after a short respite. In this list are included i case of unilateral opera- 
 tion and I of ligature of one ovary; in 3, the statement is simply that the 
 patient was cured. 
 
 {b) As regards the tumor (146 cases) : Nine times, no change; 66 times, 
 rapid diminution : 71 times, no note on the point. 
 
 Wiedow has published statistics, made with great care, in which no patient 
 is reported under a year after operation. There are 56 cases, which agree 
 pretty well with those of Hegar just given. In 39 there was a menopause 
 with atrophy of the tumor; in 5 the menopause alone is noted; in 5 there 
 were small irregular losses ; in i there was menopause for three months, 
 then partial enucleation of the tumor which was finished by the surgeon ; in 
 I, amenorrhoea followed, then return of the menses with atrophy of the 
 tumor ; in i there were small losses lasting a day after amenorrhoeal inter- 
 vals of three months (no note as to the tumor) ; in 3 after menopause and 
 atrophy for two years there was return of the hemorrhage and development 
 of the tumor, which became fibrocystic in i case. 
 
 Lawson Tait has perform.ed castration for fibroma 262 times, with a mor- 
 tality which he puts at 1.23 per cent; but we have no precise information 
 as to the curative effects of his operations. Fehling has a series of 8 cases 
 with no death ; in 5 the menopause was permanent ; in 2, there were irregular 
 hemorrhages at the end of one and two years ; in all, the tumor diminished 
 in size. Prochownik in 12 cases had no deaths; the tumors atrophied, and 
 the return of irregular hemorrhages was exceptional. In 68 cases of uterine 
 myomata treated by castration, Fehling and Kaltenbach had 4 deaths. Fifty 
 times, that is to say in 78 per cent of the cases, the menopause occurred 
 after the operation; 14 times menstruation persisted. In 94 per cent of 
 the cases a notable diminution of the tumor was observed. In 4 women, the 
 tumor continued to increase. Castration seemed to fail in the cases of sub- 
 mucous fibroids, and to give good results in the cases of interstitial fibroids 
 growing toward the abdominal cavity. Segond has had 4 successes, without 
 
CASTRATION FOR FIBROMA. 285 
 
 a death; in 2 cases with immediate menopause and rapid atrophy. In i 
 case the operation was unilateral, the menses became normal and painless, 
 and the tumor remained stationary. In i case of eight months' standing 
 there was haematemesis. Terrillon in 5 castrations for fibroma had i 
 death at the end of two months from continued intestinal compression. It 
 is very evident that in this case the castration was performed as a makeshift, 
 on account of the great dangers of hysterectomy. The fatal termination 
 cannot be attributed to the operation, but merely shows how powerless is 
 castration to cause rapid diminution of large tumors in any case. In 4 other 
 cases violent hemorrhages were arrested. 
 
 Bouilly has performed castration for fibroid tumors 26 times ; he has had 
 6 deaths. In 18 cases he has obtained suppression of the hemorrhages and 
 pains, and diminution of the tumor; in 3 cases the patients were only im- 
 proved ; in I case failure was complete. 
 
 As I have said above, I am abandoning castration more and more in 
 favor of vaginal hysterectomy by morcellation in the conditions which I have 
 pointed out, as I consider castration a last resort. 
 
CHAPTER XIII. 
 
 FIBROUS TUMORS COMPLICATING PREGNANCY. 
 
 As is well known, pregnancy gives a lively impulse to the development 
 of fibrous tumors, and often causes their cedematous softening. This phe- 
 nomenon is the more marked as the connections of the tumor with the uterus 
 are more intimate, and attains its maximum in the case of interstitial fibro- 
 mata, single or multiple, with great increase in the uterine wall, as in those 
 cases which have improperly been described as hypertrophy of the uterus. 
 This sudden augmentation in the size of the tumor exaggerates any symp- 
 toms to which it may have given rise, the pain resulting from pressure on 
 the sacral plexus becoming at times intolerable. Retroflexion of a gravid 
 uterus with a fibroma causes symptoms of internal strangulation. When the 
 tumor is pelvic, taKing its origin from the supravaginal portion of the cervix, 
 and developing below the superior strait, the compression signs are rapid 
 and extreme ; they may appear in connection with the bladder, the ureters, 
 the rectum, the nerves or the vessels, and peritonitis may coexist. The 
 most common and not the least grave result is abortion ; and as involution 
 is so much interfered with, immediate hemorrhage and septicaemia are both 
 very likely to occur. Lefour in 307 cases found 39 abortions, ending fatally 
 to the mother 14 times; Xaus in 241 cases observed 47 abortions. 
 
 The treatment depends upon the nature of the symptoms caused and the 
 seat of the tumor. If it is a pedicled or sessile subserous fibroma of the 
 fundus we may hope that it will not interfere with the course of the preg- 
 nancy. If there is danger of inflammation or the transformation of the 
 tumor into a fibrocyst, there is also a hope that it will disappear during the 
 uterine involution, and we may therefore pursue the expectant treatment. In 
 the case of pelvic fibroids, however, delay seems more dangerous ; if they 
 cause no very serious symptoms we may wait in the hope that they will 
 either precede the foetal head at the time of parturition, as has been ob- 
 served, or else will ascend above the superior strait after the rupture of the 
 membranes. All these results have been observed, and by the aid of the 
 forceps and of version labor has been successfully terminated, even in 
 desperate conditions. In such a case one should attempt to reduce the 
 tumor by pressing it back with the hand in the vagina. Often the labor is 
 accomplished only after a duration which results in a fatal exhaustion, if the 
 woman does not die at once of the hemorrhage. These risks decidedly limit 
 the advisability of the expectant method. When the fibroma is accessible its 
 extirpation presents less danger than waiting. 
 
FIBROUS TUMORS COMPLICATING PREGNANCY. 285 
 
 Fibrous tumors of the cervix are of this class, and may often be enu- 
 cleated either before or after parturition. Danyau removed one that weighed 
 650 gm. and measured 15 cm. in diameter. Braxton Hicks followed enu- 
 cleation by the immediate use of the forceps and ended the labor without 
 difficulty. J. F. Fry reports the curious case of a woman who had been de- 
 livered of nine children and in whom a fibroma of the anterior lip compli- 
 cated each pregnancy. At the eighth, a portion of the tumor was removed 
 with the ecraseur ; on the ninth, premature labor was produced and, imme- 
 diately after the extraction of a living child, almost at term, the fibroma,, 
 whose base measured about 6 cm. in diameter, was enucleated. 
 
 Munde advocates enucleation by the vagina in any case in which it can be: 
 accomplished; in sixteen cases which he cites the mothers died in only two,, 
 and the children were for the most part living ; one of these was his own- 
 personal case. 
 
 When the operation is performed late in pregnancy, there may be no in- 
 terruption of its course; Mayo Robson removed at the seventh month a 
 fibroma of the cervix of the size of a cocoanut. The operation, performed 
 with the galvano-cautery, was followed by such copious bleeding that many 
 ligatures were required, but there were no complications and the patient: 
 went on to a normal delivery at term. 
 
 Polypi may be expelled before the foetal head when their pedicle has. 
 been torn ; of this Dubois and Dupaul have cited cases. To facilitate the: 
 delivery the pedicle may be cut. Fergusson's error, of placing the forceps, 
 on a large tumor, thinking that it was the foetal head, should not be com- 
 mitted ; his patient died from rupture of the uterus. If the polyp is recog- 
 nized before term, it may be extirpated without interrupting the pregnancy;, 
 Felsenreich has recently published such a case in which the tumor was as. 
 large as a lemon. 
 
 Interstitial fibromata with an abdominal development are so nearly inacces- 
 sible that any operation for their extraction would be too grave, and we ask: 
 ourselves whether it would not be better to produce abortion. The feelings-, 
 of the surgeon and his operative habits enter largely into the solution of the 
 problem, though it must not be forgotten that even induced abortion is not 
 free from dangers. If the placental insertion is at the seat of the tumor, the? 
 uterine tissue may not be able to contract after delivery, and thus formidable 
 hemorrhage can occur. The patient is also exposed to the risk of puerperal; 
 septicaemia. Lefour, in a series of 23 induced abortions, observed 3 deaths;. 
 Tarnier, in 7 cases in which the labor was normal, has seen death of the mother- 
 once, of the child three times. In 6 cases terminated by the forceps, it wa» 
 fatal to 4 mothers and 4 children. In 6 versions, 3 were fatal to the mother 
 and 3 to the child. And 5 women who had fibromata died before parturi- 
 tion ; once induced abortion was followed by success, and once embryotom)r 
 caused the death of the woman. Siisserott, in 147 cases of pregnancy com- 
 plicated with fibroma, which he collected, describes 20 in which the forceps, 
 
286 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 were applied, with death of the woman 8 times and of the child 13 ; in 20 
 versions, death of the woman 1 2 times and of the child 1 7 ; artificial extrac- 
 tion of the placenta 2 1 times, death of the mother 1 3 times ; in all 78 women, 
 or 53 per cent, and 66 per cent of the children died. 
 
 It must be remembered that induced labor may cause the expulsion of a 
 non-viable child, that it does not relieve the compression very much, and 
 that, if we have to perform hysterectomy afterward, we have exposed the 
 life of the patient twice instead of once ; these are the reasons why most 
 surgeons prefer early interference. Supravaginal amputation is evidently 
 "better than the Csesarean operation, which Cazin has performed with suc- 
 cess in the seventh month. This author has collected 28 cases of Caesarean 
 section which were rendered necessary by the presence of a fibroma of the 
 uterus; only 4 of the women were saved, 15 children were born alive, 8 were 
 •extracted dead ; of the other 5 no information is given. Sanger has recently 
 ■collected 43 cases of this operation for fibroma, in which 7 women were 
 saved, or 83.7 per cent. Tufiier has published one fatal case. 
 
 When it is decided to practise hysterectomy, if the fibroma is situated in 
 the middle of the fundus or is pedicled, the partial operation of myomec- 
 tomy, which does not interfere with the pregnancy, should be attempted. 
 When it is sessile and there is need of cutting away the uterine tissue in 
 the neighborhood of the tubes, myomectomy is attended by great danger of 
 hemorrhage, while the supravaginal operation (Porro's) is rendered easy by 
 the relaxation of the ligaments caused by the pregnancy. 
 
 Synopsis of Published Results. 
 I. — Simple Myomectomy; Uterus Not Removed. 
 
 Author. 
 
 Date of Operation or 
 Publication. 
 
 Month of the 
 Pregnancy. 
 
 Anatomical Condition. 
 
 Result. 
 
 Pean 
 
 Clin. Chir., Dec. 15. 
 1874, vol. i., p. 679. 
 
 Obst. Trans., June 4, 
 
 1879. 
 Nov. 16, 1879, cited 
 
 by Hegar, loc. cit. 
 Jan., 1880; Operat. 
 
 Gynak., 3d edition, 
 
 P- 475- 
 Dec. 19, 1882, cited 
 by Hegar, loc. cit. 
 
 MUnch. med. Woch., 
 1882, No. 52. 
 
 Ber. klin. Wochen., 
 1885, No. 3. 
 
 Ber. klin. Wochen., 
 1885. No. 3. 
 
 Fifth. 
 
 Seventh. 
 Fourth. 
 Third. 
 
 Three . and a 
 half. 
 
 Fifth. 
 Sixth. 
 
 Fibrocystic tumor. 
 
 Tumor pedicled. 
 
 Tumor pedicled; mul- 
 tiple. 
 
 Tumor pedicled; soft; 
 peritonitis. 
 
 Tumor pedicled. 
 
 Fibroma s i z e f a 
 child's head. 
 
 Myomectomy, with 
 conoid e.xcision of 
 fundus alone. 
 
 Myoma, on right side 
 as large as infant's 
 head; on left, as an 
 
 Recovered; abortion 
 
 Thornton 
 
 :Schr6der 
 
 the day after oper- 
 ation. 
 Death, seventh day. 
 
 Recovered; normal 
 
 Hep'ar 
 
 labor. 
 Death, third day. 
 
 Studgaard 
 
 Frommel 
 
 IMartin 
 
 Recovered; preg- 
 nancy not d i s - 
 turbed. 
 
 Recovered ; p r e g - 
 nancy not d i s - 
 turbed . 
 
 Death, seventh day. 
 
 
 of hemorrhage af- 
 ter abortion. 
 Recovered ; normal 
 
 
 
 labor. 
 
 
 
 
 egg- 
 
 
FIBROUS TUMORS COMPLICATING PREGNANCY 
 
 287 
 
 Author. 
 
 Date of Operation or Month of the 
 Publication. Pregnancy. 
 
 Anatomical Condition. 
 
 Result. 
 
 Ogden 
 
 Can. Pract., April, Not given. 
 1885; cited by Van 
 
 Interstitial myoma, 
 removed by enucle- 
 
 Recovered; abortion 
 
 
 twelve days later. 
 
 
 d e r Veer, Amer. 
 
 
 a t i n ; pregnancy 
 
 
 
 Journ. Obst, 1889, 
 
 
 not diagnosed. 
 
 
 
 vol. xxii. , p. 1138. 
 
 
 
 
 Barnes 
 
 1885 (cited by Routier, 
 Ann. de Gyn., 
 
 Third. 
 
 Pedicled niyoma. 
 
 Death. 
 
 
 
 
 March, 1890). 
 
 
 
 
 Martin 
 
 Ber. klin. Wochen., 
 1886, No. 29. 
 
 
 Large tumor with 
 large pedicle. 
 
 Recovered; delivery 
 at term. 
 
 
 
 Martin 
 
 Ibid. 
 
 Fourth. 
 
 Large tumor on an- 
 terior face and 
 
 Recovered ; a b r- 
 
 
 tion. 
 
 
 
 
 smaller tumor. 
 
 
 Martin 
 
 Ibid. 
 
 Three and a 
 half. 
 
 Tumor at fundus of Recovered' deliverv 
 
 
 Uterus; large pedi- 
 cle. 
 Fibroma. 
 
 at term. 
 
 Gordon 
 
 Bost. Med. and Surg. 
 Journ., Oct., 1889. 
 
 Third. 
 
 Recovered; preg- 
 nancy continued. 
 
 
 Routier 
 
 Bull. Soc. Chirurg., 
 Nov., 1889. 
 
 Third. 
 
 Subserous myoma 
 with large base. 
 
 Recovered. 
 
 
 
 Homan 
 
 Bost. Soc. for Med. 
 I mpro vement, in 
 
 Third. 
 
 Fifteen-pound fibroma 
 
 Recovered' aborted. 
 
 
 
 
 Bull. Med., Dec. 
 
 
 
 
 
 30, 1889. 
 
 
 
 
 A. Bergh 
 
 Hygeia, 1889, Bd. li., 
 
 Fourth. 
 
 Two tumors, the 
 
 Recovered ; normal 
 
 
 No. 5, p. 292. 
 
 
 larger size of two 
 fists; enucleation. 
 
 labor. 
 
 Frommel 
 
 Verh. der deutsch. 
 
 Sixth. 
 
 Interstitial myoma re- 
 
 Death on the third 
 
 
 Gesellsch. f. Gyn., 
 
 
 moved by enuclea- 
 
 day from hemor- 
 
 
 1894, p. 325- 
 
 
 tion. 
 
 rhage. 
 
 Flaischlen 
 
 Cent, fiir Gyn., 1892, 
 
 Third. 
 
 Pediculated myoma. Recovered ; d e 1 i v - 
 
 
 p. 185. 
 
 
 ered at term. 
 
 Rosner 
 
 Przeghad Leka r s k i , 
 1892, Nos. 39-41. 
 
 (?) 
 
 
 
 
 moved by enuclea- 
 
 
 
 
 
 tion. 
 
 
 V. Strauch 
 
 St. Petersb. med. 
 
 Fourth. 
 
 Interstitial myoma 
 
 Recovered; preg- 
 
 
 Woch.,i892,No.io. 
 
 
 enucleated. 
 
 nancy continued. 
 
 Frommel 
 
 Munch, med. Woch. , 
 1893, No. 24. 
 
 (?) 
 
 Fibroma in broad lig- 
 ament enucleated. 
 
 Recovered; preg- 
 nancy continued. 
 
 
 Mackenrodt 
 
 Cent, fur Gyn., 1893, 
 p. 211. 
 
 Third. 
 
 Pediculated fibroma. 
 
 Recovered; preg- 
 nancy continued. 
 
 II. — Supravaginal Amputation of Gravid Uterus. 
 
 Author. 
 
 Date of Operation or 
 Publication. 
 
 Month of the 
 Pregnancy . 
 
 Anatomical Condition. 
 
 Result. 
 
 R. Barnes 
 
 St. George's Hosp. 
 Rep., 1S74-76, vol. 
 
 Third. 
 
 Fibroma concealing 
 pregnancy. 
 
 Death. 
 
 Kaltenbach 
 
 viii., pp. 91-95. 
 Mar. 2, 1S80; cited by 
 Hegar, loc. cit., p. 
 
 Fifth. 
 
 Interstitial myoma at 
 fundus ; weight 
 
 Recovered. 
 
 Wasseige 
 
 475- 
 March 18, 1S80. 
 
 Fifth. 
 
 3,500 gm. 
 Interstitial myoma of 
 fundus; weight 
 
 Death, sixth day. 
 
 Nieberding 
 
 Feb. 10, 1S82. 
 
 Fourth. 
 
 4,500 gm. 
 
 Death in forty-nine 
 hours. 
 
 
 Schroder 
 
 Jan. 10, 1883. 
 
 Third. 
 
 Interstitial myoma of 
 size of adult head. 
 
 Recovered. 
 
 Schroeder 
 
 June 29, 1884. 
 Brit. Med. Assoc, 
 Liverpool, 1883. 
 
 Third. 
 Fourth. 
 
 
 Recovered. 
 
 Waiter 
 
 Colossal tumor. 
 
 Death, ninth day. 
 
 
288 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Author. 
 
 Date of Operation or 
 Publication. 
 
 Month of the 
 Pregnancy. 
 
 Anatomical Condition. 
 
 Result. 
 
 
 Bristol Med. Joum., 
 June, 18S2, vol. ii., 
 
 Fourth 
 
 Interstitial myoma, 
 nine pounds. 
 
 Recovered. 
 
 
 
 H. Agnew 
 
 P- 423- 
 Brit. Med. Journ . , June 
 1884, vol. i.,p. 45S. 
 
 Sixth. 
 
 Pelvic fibroma. 
 
 Death on the third 
 day. 
 
 Alex. Patterson. . . 
 
 Glasgow Med. Journ., 
 April, 1SS5. " 
 
 Fourth. 
 
 Fibroma concealing 
 pregnancy. 
 
 Recovered. 
 
 Etheridge 
 
 Am. Joum. Obst., 
 
 Third (useless 
 
 Fibrocystic tumor. 
 
 Death on eleventh 
 
 
 1S87, vol. XX., p. 69. 
 
 attempts to 
 i n d u c e 
 abortion 
 had been 
 made). 
 
 
 day of peritonitis. 
 
 Karstrom 
 
 Hygeia, April, 1887; 
 analysis in Cent. f. 
 G3'n., 1SS7, No. 34. 
 
 Fifth. 
 
 I n t r aligamentous; 
 pedicle lost; drain- 
 age. 
 
 Recovered. 
 
 
 Unpublished case 
 cited by Van der 
 
 Eighth. 
 
 Fibroma concealing 
 pregnancy. 
 
 Recovered. 
 
 
 
 
 Veer, loc. cit. 
 
 
 
 
 G. G. Bantock . . . 
 
 Brit. Gyn. Journ. , vol. 
 ii., p'. 63. 
 
 Third. 
 
 Fibroma concea ling 
 pregnancy. 
 
 Recovered. 
 
 G. G. Bantock . . . 
 
 Am. Gyn. Soc. Trans., 
 1S87, p. 211. 
 
 Fourth. 
 
 Interstitial fibroma. 
 
 Recovered. 
 
 G. G. Bantock 
 
 Brit. Med. Journ. , 
 1888, p. 1331. 
 
 (?) 
 
 Multiple fibromata. 
 
 Recovered. 
 
 Hofmeier 
 
 Die Myomotomie, p. 
 76. 
 
 Third. 
 
 Fibroma; pregnancy 
 suspected. 
 
 Recovered. 
 
 Tauffer 
 
 Cent. f. Gyn., 1887, 
 p. 119. 
 
 Second. 
 
 Fibroma; fcetus dead 
 and macerated. 
 
 Recovered. 
 
 
 
 Kaltenbach 
 
 Cent. f. Gyn., 1887, 
 P- 435- 
 
 Second. 
 
 Fibroma disintegrat- 
 ing; foetus mace- 
 rated. 
 
 Recovered. 
 
 K. Thornton 
 
 Brit. Med. Journ., 
 June, 18S8, p. 1331. 
 
 Fifth. 
 
 Sixteen-pound myoma. 
 
 Recovered. 
 
 Meredith 
 
 Ibid. 
 
 Fifth. 
 
 Enormous fibroid; 
 twin pregnancy. 
 
 Death on the third 
 day. 
 
 Meredith 
 
 Ibid. 
 
 Second. 
 
 Fibroma size of adult 
 head. 
 
 Death on the sixth 
 day. 
 
 Fritsch 
 
 Volk. Samml. klin. 
 Vort., 1889, No. 
 
 (?) 
 
 Fibroma of rapid 
 growth. 
 
 Recovered. 
 
 
 
 
 339- 
 
 
 
 
 More Madden. . . . 
 
 Lancet, i88g, p. 271. 
 
 Fourth. 
 
 Very large pediculated 
 fibroma. 
 
 Death. 
 
 F. Barnes 
 
 Brit. Gyn. Journ., 
 T889, p. 315. 
 
 Fifth. 
 
 Enormous fibroid. 
 
 Recovered. 
 
 D. Van Ott 
 
 Arch. f. Gyn., Bd. 
 
 Ninth; 263 
 
 Large fibroma of su- 
 
 Recovered; living 
 
 
 xxvii., p. 88, 1890. 
 
 days. 
 
 pravaginal portion 
 of cervix; intraperi- 
 toneal treatment of 
 pedicle. 
 
 child. 
 
 A. Martin 
 
 Naturf . Versamml. , 
 Heidelberg, 1889; 
 Cent. f. Gyn., 1890, 
 p. 67. 
 
 Cent. f. Gyn., 1890, 
 
 Fourth. 
 
 Tumor of lower part 
 of uterus. 
 
 Recovered. 
 
 Kaschkaroff 
 
 Third. 
 
 Subserous fibroma; 
 
 Recovered. 
 
 
 No. 49, p. 890. 
 
 
 hydramnion. 
 
 
 Wyder 
 
 Arch, fiir Gyn., 1891, 
 t. xli., p. 922. 
 
 Third. 
 
 Multiple fibroid. 
 
 Recovered. 
 
 
 
 F. Chrobak 
 
 Cent, fiir Gyn.. 1893, 
 ?• 345- 
 
 Sixth. 
 
 Enormous fibroid. 
 
 Recovered. 
 
 Most of these cases relate to operations done before the ninth month ; if 
 Porro's operation is attempted, the prognosis is very grave, but, as an im- 
 
FIBROUS TUMORS COMPLICATING PREGNANCY. 289 
 
 portant consideration, there is tiie chance of saving both mother and child. 
 This operation should be undertaken a few days before the expected time of 
 parturition, never just at term, for fear of being surprised by labor. The 
 operative procedure which seems to promise the greatest immunity from 
 hemorrhage and septicaemia, which are much to be feared when the uterus is 
 gravid, is the extraperitoneal ligature of the pedicle. 
 
 Guermonprez recently performed a total abdominal hysterectomy for a 
 uterine fibroid at the ninth month of pregnancy with successful results to 
 mother and child. 
 19 
 
CHAPTER XIV. 
 
 PATHOLOGY, SYMPTOMS, DIAGNOSIS, AND ETIOLOGY 
 OF CANCER OF THE CERVIX UTERL 
 
 The word cancer should have clinically a meaning synonymous with 
 malignant neoplasm. A malignant character, displayed by uncontrollable 
 invasion, reproduction, and generalization, is encountered in many species of 
 tumor which are anatomically distinct, whose profound study interests the 
 pathologist more than the surgeon, but yet furnishes certain indications 
 which are useful in the matter of prognosis. 
 
 PatJiological Anatomy. — The great predisposition of the cervix to the 
 development of cancer has been noticed by all observers. Is there anything 
 in general anatomy which will explain the fact.'' Cohnheim has supposed 
 that the embryonal cells (embryoplastic cells of Ch. Robin) which have not 
 been absorbed in the formation of the organs, and which are found scattered 
 through the connective tissue or gathered in islands at certain points, may 
 be the matrix tissue of carcinoma. These tumors are found most frequently 
 in the nests of embryonal cells which define the natural orifices, where there 
 is a more or less irregular involution of the blastodermic layers ; the cervix 
 uteri, developed relatively late, at the expense of the Miillerian ducts, be- 
 longs in this class of congenitally vulnerable points. The presence of two 
 varieties of epithelium at the external os and the consequent plastic poly- 
 morphism which results may also be a factor in their production. There 
 remains unexplained, however, the exciting cause of the neoplasm; the 
 repeated afflux of blood upon which Cohnheim lays so much stress does not 
 account for it. 
 
 In epithelioma of the mucous membrane it is evident that the heterol- 
 ogous formation proceeds from the epithelial cells, either of the rete Mal- 
 pighii or from the cylindrical cells within the cervix which have passed the 
 external os, or from the glandular cells. In cancer of the uterine paren- 
 chyma, the histogenic origin of the cells of the neoplasm is very obscure. 
 Virchow derives them solely from the connective-tissue cells, which accords 
 with Cohnheim's hypothesis, and the latest researches of Ruge and Veit go 
 to support the idea. According to these observers, cancer is usually a 
 transformation of these connective-tissue cells, sometimes into a papillary 
 or cauliflower form. The connective tissue becomes vascular and returns to 
 the embryonic condition, and the cells take on an epithelial character; 
 exceptionally an adenoma, also the product of these epithelial elements, may 
 become cancerous. 
 
PATHOLOGY OF CANCER OF THE CERVIX UTERI. 
 
 291 
 
 Anatomical Forms. — From the clinical point of view, when these tumors 
 are seen at the start, and before they have altered the primitive aspect of the 
 parts by their spread to adjacent structures, we can distinguish four classes : 
 
 Fig. 
 
 . — Papillary Cancer of the Cervix ; Pavement Epithelioma of the External Os. Section, 
 
 natural size. 
 
 (i) the papillary, (2) the nodular, (3) of the cervical cavity, and (4) the 
 vaginal. 
 
 I . Papillary Form (Syn. : Superficial cancer of the cervix, vegetating or 
 cauliflower cancer). — This form begins on that part of the cervix which is 
 below the vaginal insertion, and may remain for a long time limited to it. 
 Often it starts from cylindrical epithelium which has invaded the external 
 surface, as we have seen in the case of metritis; this, without ulceration, 
 though at first benign, is transformed into an epithelioma. It may take on 
 a fungous appearance, the os and the healthy lip being hidden beneath it, 
 
 Fig. igg. — Cancer of the Cervix, Nodular 
 Form. /, Zone of intact pavement epithelium ; y", 
 cancerous nodule; a^ external os ; <-, cervix. 
 
 Fig. 200. — Beginning Cancer of the Cervix, Ulcera- 
 tive Form. 
 
 and for a long time show no tendency to spread ; but there comes a time 
 when it attacks the cul-de-sac, involves it both superficially and deeply, and 
 passes on to the peri-uterine tissues ; or the extension may take place along 
 the cervical canal. 
 
 There is always an accompanying lesion of the mucous membrane of the 
 
292 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 body of the organ; Abel in seven cases from Landau's clinic found in three 
 a sarcomatous degeneration, and in two others an interstitial endometritis 
 which appeared to be developing toward sarcoma. He states that the malig- 
 nant degeneration is produced concomitantly, though under a different his- 
 tological form, in the two regions. These assertions of Abel are strongly 
 disputed and are not generally admitted. 
 
 2. Nodular Form (Syn. : Parenchymatous cancer, cancerous nodosities, 
 circumscribed or infiltrated cancer). — This form starts as one or several 
 nodules in the mucous membrane of the cervix, on either the external or the 
 internal surface, with ulcerations only late in the disease. By its progress 
 it destroys the mucosa, and thus a cancerous ulceration results. Then nodules 
 
 m. 
 
 Fig. 201. — Cylindrical Epithelioma from the Upper Part of the Cervix, Invading the Fundus (X 150). 
 ;«, e^ Hypertrophied glands of the body of the uterus, like those of chronic metritis ; t, enlarged glandular cavity, the 
 walls showing many layers of epithelium ; £% adjacent gland wall, in a similar state ; 7', vessels ; <r, connective 
 tissue (Cornil). 
 
 in the cervix and body fuse with the first, and soon the whole organ and the 
 adjacent tissues are involved. 
 
 3. Cancer of the Cavity (Syn. : Cancer of the cervical mucous membrane, 
 boring or eating cancer). — This form develops at first in the cervical mucous 
 membrane, or just below it, by an infiltration which soon ulcerates and causes 
 a slow destruction of the part by erosion ; there are cases of this kind in 
 which the cervix becomes a mere shell, and, with the retraction which is 
 noticed as in the case of cancer of the breast, it may nearly disappear. The 
 body of the uterus is early involved, then the peri-uterine connective tissue, 
 and the vagina last or not at all. 
 
 4. Vaginal Form. — This is far more unusual than the others. It begins 
 in the posterior cul-de-sac as certain cancers of the tongue start from the 
 floor of the mouth, and invades equally the cervix and the adjacent portions of 
 the vagina, producing extensive ulcerations. 
 
 Histological Varieties. — The three kinds which are most often found are : 
 (i) Pavement epithelioma; (2) cylindrical epithelioma; (3) carcinoma or 
 
PATHOLOGY OF CANCER OF THE CERVIX UTERI, 
 
 293 
 
 atypical epithelioma. In France since the writings of Ch. Robin, Cornil, 
 and Malassez, the epithelial origin of cancer is the most favored doctrine, 
 
 
 
 Fig. 202. — Cylindrical Epithelioma of the Body, Extended from the Cervix (X 150). c, f, Connective 
 tissue ; a, cavity full of cells, the e.xternal layer being cylindrical. These cells have a tendency to become detached 
 from the wall, well seen at ; y, cavity with mucous cells, and large cells in mucous degeneration (Cornil). 
 
 and carcinoma is considered as an alveolar epithelioma, a particular kind, an 
 evolutionary stage of epithelioma, and not as a neoplasm developed from the 
 first at the expense of the connective-tissue cells. 
 
 Pavement epithelioma, lobulated or tubulated, is seldom general, though 
 Virchow has observed it. The cylindrical form has the most frequent 
 metastasis. 
 
 Pavement epithelioma is often found in the superficial forms, capillary 
 
 Fig. 203. — Cylindrical Epithelioma of the Body, Extended from the Cervix (X 400). 1?, Single layer of 
 epithelium ; k, cells showing karyokinesis ; k, free degenerating cell ; d, adjacent alveolus (Cornil). 
 
 and vaginal ; the variety called lobulated is formed by cellular masses which 
 separate the still evident muscular bundles, and which may undergo either 
 
294 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 a mucous or corneous change. Tubulated cancers are formed of cylinders 
 stuffed full of epithelial cells which anastomose and penetrate between the 
 muscular trabeculse that still resist the invasion, and on section we see in the 
 lumen of such tubes pavement cells becoming cubical and others deformed 
 by pressure. 
 
 Cylindrical epithelioma is usually the form which begins in the cervix 
 and spreads along its cavity, and resembles that of the uterine body (Figs. 
 20 1, 202, 203). It begins by a typical glandular proliferation (adenoma) 
 and ends as an atypical (malignant adenoma), which is simply an epithe- 
 
 FiG. 204. — Carcinoma, or Atypical Epithelioma. Section of one of the nodules of Fig. 199. On the median 
 edge of the section the pavement epithelium ceases and is replaced by an erosion presenting a structure almost papillary 
 and more or less ramified glands. The stroma is formed of fibrous bands which divide the alveoli of different sizes, and 
 these again are subdivided by smaller bands. The alveoli are filled with polymorphic cell elements ; the exact origin 
 of the cell nests is difficult to determine ; they are apparently from glandular cavities, of which some are covered with 
 a single layer of cylindrical epithelium. These cavities are transformed to solid cords by the proliferation of the cells ; 
 the normal glands can be followed from the surface up to the middle of the cancerous nodule (Wyder). 
 
 lioma. Cornil insists on the great histological resemblance between glan- 
 dular endometritis and certain developmental stages of cylindrical epithelioma. 
 
 The atypical epithelioma, or carcinoma of most German authors, is not 
 clearly distinguished from certain forms of tubulated pavement epithelioma; 
 it is characterized by polymorphism of its cells, which correspond to those 
 of the alveolar wall or to those of the gland, and by their disposition in 
 masses within the alveoli, whose walls are formed by anastomosing bands of 
 connective tissue (Fig. 204). When the fibrous stroma is small in amount 
 and the cells are swollen and predominant, the tumor is called encephaloid 
 (Fig. 207); when they are hard and dry, it is called scirrhus (Fig. 199). 
 
 Extension. — At an advanced period of the disease the characteristics 
 peculiar to each form are lost in the destruction and grave symptoms caused 
 by this extension, either to the vagina, the body, the connecti\'e tissue of the 
 
PATHOLOGY OF CANCER OF THE CERVIX UTERI. 
 
 295 
 
 pelvis and the broad ligaments, the ureters and bladder, the rectum, the peri- 
 toneum or lymph nodes. 
 
 Extension to the vagina may be found at the outset, may occur rapidly 
 in the papillary form, and may reach the vulva (Fig. 205). 
 
 Invasion of the body occurs late in the papillary form, but it should not 
 be forgotten that the mucous membrane of the part may also undergo a de- 
 generation of an intensely inflammatory nature by vi^hich it is made very 
 liable to invasion. The body of the organ is very soon involved in the case 
 of tumor of the cervical cavity, and 
 in the nodular form may be infected 
 from the first. 
 
 Czempin has seen, during a total 
 hysterectomy for a cancer of the an- 
 terior lip of the cervix, a circum- 
 scribed carcinomatous nodule in the 
 
 Fig. 205. — Epithelioma of the Cervix Extending 
 TO THE Vagina ; Papillary Form. 
 
 Fig. 206. — Epithelioma op the Cavity of the Cer- 
 vix. On the left is an extension toward the fundus 
 of the uterus. 
 
 posterior vaginal wall at the exact point where the cervix rested upon it. 
 It was evidently a case of infection by contact. 
 
 In a uterus which I removed by the vaginal route, a cylindrical epithe- 
 lioma of the body coexisted with a squamous epithelioma of the cervix (Fig. 
 206). A distinct band of healthy tissue could be seen, by the naked eye, 
 separating the two neoplasms. 
 
 The pelvic connective tissue may be invaded from the cul-de-sac, the 
 cervix, or the fundus; the uterus is then imprisoned, as if glue had been 
 poured about it and had hardened. The broad ligaments become thick and 
 shortened, and toward the end the vessels and nerves of the lower pelvis, 
 especially the branches of the sacral plexus, may be involved, when we 
 observe oedema and intense pain. 
 
296 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 The ureters are often involved, for instead of merely pushing them out 
 of the way, as does a fibroma, the neoplasm assimilates them little by little ; 
 occasionally the walls of these ducts may be ulcerated through, and thus a 
 fistula produced. Most frequently the ureter is constricted; its calibre 
 being diminished at the lower end, the duct is dilated up to the pelvis of the 
 kidney by the constant accumulation of urine under high pressure. The 
 great frequence of renal disease in cancer of the uterus has been known for 
 a long time, and recently made the subject of special study. Lancereaux 
 
 Fig. 207. — Encephaloid Ei-ithelioma of the Cekvix I.wading the Bodv of the Uterus. 
 
 asserts that this ascending nephritis is constant when the disease is at all 
 advanced, and during twenty-five years I have never seen it absent at autopsy, 
 unless the patient had died prematurely from metrorrhagia. 
 
 The experiments of Straus and Germont on the effects of ligation of the 
 ureters in animals, which confirm and explain the older observations of 
 Aufrecht in Germany and Charcot and Gombault in France, clearly explain 
 these lesions. They found that ligation produced a progressive atrophy of 
 the kidney which destroyed the distinction of cortical and medullary por- 
 tions, and that the papillae and pyramids disappeared. These lesions closely 
 resemble those found at the autopsy of women dead of cervical cancer. The 
 ureters are dilated to the size of the external iliac artery, or even to that of 
 the small intestine; their walls are thickened and at times tortuous; the 
 
PATHOLOGY OF CANCER OF THE CERVIX UTERI. 
 
 297 
 
 pelvis of the kidney is distended, especially at the lower part, and of a coni- 
 cal or pyriform shape. When its dimensions are very large, it forms a 
 tumor which, according to Rayer's comparison, is covered by the remaining 
 portions of the kidney as with a helmet. 
 
 The characteristic lesion is in the modifications of the pyramids and 
 papillae; the papillae become flattened and their apices depressed, so that 
 where there was a projection a hollow is formed. Later there is no trace of 
 secreting tissue left, but in its place a fibrous membrane limiting a cavity 
 crossed by the columns of Bertini, which persist for some time, so that the 
 kidney has a multilobed and cystic aspect. 
 
 The cellular tissue which unites bladder and cervix may be invaded, then 
 the bladder. Soon after there is a catarrhal inflammation produced ; small 
 
 Fig. 208. — Pavement Epithelioma of the Cervix and Cylindrical of the Body Separated kv a Zone of 
 Normal Tissue. «, Point from which tissue was taken for histological examination. 
 
 sections of the bladder wall may slough or be eaten through by the morbid 
 tissue, which penetrates the vesical cavity and establishes a fistula. 
 
 Ureteritis and septic pyelonephritis are some of the first and gravest 
 consequences of the bladder invasion; its result may be miliary abscess of 
 the kidney, but this is less common than interstitial nephritis. In their 
 statistics, which cover 51 cases, Caron and Fere found suppurative pyelitis 
 and miliary abscess 7 times ; in all the others there were only mechanical 
 lesions, such as dilatation of the ureters, hydronephrosis, and nephritis. 
 Lancereaux, in 23 cases, has not described suppuration of the kidney even 
 once. 
 
 We would expect that the heart would be influenced by this kidney lesion, 
 and in certain cases there is found hypertrophy of the left ventricle, as 
 Traube's theory requires. This theory is that the kidney lesion destroys a 
 certain number of arterioles and lessens the circulatory domain, augmenting 
 thus the inter-arterial pressure; to this is added the functional insufficienc}" 
 
298 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 of the kidney, which causes the retention in the blood of an abnormal 
 amount of water besides the excrementitious matters; the cardiac hyper- 
 trophy is the direct necessary consequence of these two factors. In a work 
 intended to support this theory, Straus cites two cases of cervicpl cancer with 
 secondary nephritis and great hypertrophy of the heart ; four similar cases are 
 published by Artaud, and still others by Weill and Thouvenet in their theses. 
 But in 1884 Lancereaux published a memoir based on twenty-three cases of 
 his own obser^-ation, in which he reaches the opposite conclusion. In these 
 
 Fig. 209. — XoDiLE ok Pavement-celled Epithelioma (Fragment from cervLx, Fig. 208) A, Normal pavement 
 epithelium ; 5, bud of pavement-celled epithelioma. 
 
 twenty-three autopsies the heart was weighed and all its details carefully 
 examined, and in twenty-one it was either normal or small and atrophied. 
 Often it was soft and covered with fat on its anterior and basal surfaces. 
 In only two cases was there any increase in weight and volume, and then 
 there was also an arterial lesion (aortic endarteritis or insufficiency) to 
 explain the h}'pertrophy. This important series seems to be demonstrative. 
 It is thus probable that the cardiac lesion accompanies the nephritis of can- 
 cer only exceptionally, in cases in which the latter is of very rapid develop- 
 ment. There is still another lesion of the heart which is at times found 
 at the autopsy of cancer of the uterus, which Lancereaux calls " verrucous" 
 endocarditis, and which he found twice among his twenty-three cases. Under 
 this name he describes a special vegetating form of endocarditis which differs 
 entirely from the ordinary inflammation which is present in cases of cachec- 
 
DIAGNOSIS OF CANCER OF THE CERVIX UTERI. 
 
 299 
 
 tic disease like tuberculosis; but the exact nature of the vegetations is not 
 decided ; probably they are of microbic origin. 
 
 The rectum is seldom involved and fistula of it is rare. 
 
 The peritoneum resists the ingrowth of the neoplasm by the production 
 of adhesions which limit the disease to a small focus ; thus it occurs that the 
 rectovaginal pouch appears to be so far from the vaginal cul-de-sac when we 
 perform hysterectomy. 
 
 In very advanced cases we find the vagina transftrmed into a cloaca, 
 opening both into the bladder and into the rectum ; above, the lower peh'is 
 
 Yu:. 
 
 
 -Portion Marked A in Fig. 209, Highlv 
 Magnified. 
 
 Fig. 211. — Portion Marked B in Fig. 209, Highi.\' 
 Magnified, a, Flat cells of the superficial layer; i, 
 mucous cells with large amount of protoplasm ; c, indiffer- 
 ent cells ; (/, connective tissue. 
 
 is filled with a cancerous mass in which the fundus and adnexa can be recog- 
 nized only with difficulty, being covered by adherent coils of intestine, which 
 may also be perforated. 
 
 Lastly, there may be metastasis to distant organs, as the liver, kidney, 
 stomach, and lungs. 
 
 The iliac, prevertebral, and inguinal ganglia are often involved. The 
 inguinal ganglia, contrary to the general opinion, may be involved without 
 disease of the vagina. The lymphatics of the cervix communicate with those 
 of the body, and these again with the inguinal ganglia through the lymph 
 vessels which accompany the round ligaments. This was described first by 
 Mascagni and rediscovered by Poirier. Troisier has recently called atten- 
 tion to the adenopathy of the left subclavicular region which is at times pro- 
 duced, independently of the invasion of the lung and the prevertebral ganglia, 
 in general or abdominal cancer, but especially in uterine. It is probable, 
 
300 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 as Troisier supposes, that this isolated manifestation is due to direct infec- 
 tion of the ganglia by reflux of the lymph from the thoracic duct where the 
 ganglia empty into it by short trunks. This curious anatomical fact is at the 
 same time a valuable contraindication to operation. 
 
 Among the deuteropathic and distant lesions may be noted fatty degener- 
 
 FiG. 212. — Cylindrical-celled Epithelioma of the Body (from Fig. 208). 
 
 ation of the liver as described by Leca. It appears that the septic material 
 absorbed by the organism from the ulcerating surfaces acts like a steatogenic 
 poison on the liver, as do alcohol and phosphorus. This fatty degeneration 
 
 of the liver was long ago described among 
 other surgical septicaemias by Verneuil. 
 
 Symptoms. — The onset of the disease is in- 
 sidious, and there may be a long period during 
 which it is latent and the patient preserves 
 every appearance of health with a lesion al- 
 ready far advanced ; for this reason it is un- 
 usual to observe the initial symptoms. The 
 attention is first attracted by a small loss of 
 Fig. 213-Cvl.ndkical-celled v.vi- blood at souic Other time than the regular 
 
 period, after some exertion, especially coitus. 
 But this accident, often happening in women 
 who are approaching the menopause, is taken 
 for an unimportant irregularity and passes unnoticed until by its repetition 
 it becomes alarming. At other times these hemorrhao:es occur with some 
 
 THELIOMA OF THE Hf)I>Y OF THE UteRCS 
 
 (a point in Fig. 212 highly magnified). 
 a, Connective tissue ; ^, cylindrical cells ; 
 Cy central polymorphous cells. 
 
SYMPTOMS OF CANCER OF THE CERVIX UTERI. 30I 
 
 regularity every month and are viewed with satisfaction as a return uf men- 
 struation and the index of renewed youth. 
 
 The early bleeding does not come from an ulcerated surface, but is due 
 to the complicating metritis, or simply to the congestion caused by the pres- 
 ence of the tumor; the process may be compared to the haemoptysis of the 
 first months of pulmonary tuberculosis. 
 
 At the same time leucorrhoea without any special characters appears ; 
 then the pain, the reflex phenomena from the digestive tract, the circulation 
 and the nervous system, produce the pathological cycle which I ha\'e de- 
 scribed in the chapter on metritis as the uterine syndroma. But the diag- 
 nosis must not be made without local examination, in which the touch 
 recognizes the induration, or papillary and ulcerated condition, of the cer\'ix, 
 and the speculum demonstrates the livid aspect of the tumor, the yellowish 
 surface of the ulcerations, and the cauliflower or fungous vegetations. 
 
 Soon after follows the second stage, which may be called the period of 
 acme, when all the symptoms are present ; the hemorrhage becomes more 
 frequent, there is a reddish discharge with a stale odor, or fetid and disgust- 
 ing, and so copious and acrid that it causes erythema of the thighs and 
 pruritus vulvae, which are very distressing. At the same time the pain, 
 chiefly lumbar, is very severe, and with it there are neuralgic radiations in 
 different directions. By touch the vaginal pouches may be found free, but 
 they are often already invaded, the uterus remaining movable or becoming 
 more or less fixed by extension of the morbid process to the peh-ic cellular 
 tissue. The results of the local examination by touch are far more trust- 
 worthy than by the speculum ; it is surprising, if the usual order is reversed, 
 to see how the finger discovers alterations incomparably more extensive than 
 those which can be seen. A cervix which seems to be a little swollen and 
 ulcerated by the speculum is felt by the finger as a large tumor deeply 
 changed by an already advanced process. 
 
 The digestive symptoms, anorexia, constipation, meteorism, etc., have 
 by this time become of great importance and interfere with the general 
 nutrition. With this condition begins the third stage, or the cancerous 
 cachexia; the skin having a pale yellow tint which Barnes attributed to the 
 absorption of fecal matters retained by the obstinate constipation (copraemia). 
 The skin is also peculiarly harsh and dry. At this time also there may be 
 present painful cystitis, intolerable neuralgia from compression or invasion 
 of the nerves, phlegmasia alba dolens, and fistulas ; local examination reveal- 
 ing wide extension of the neoplasm to the adjacent parts. There may 
 coexist with all this successive attacks of subacute uraemia, and on analysis 
 of the urine the excretion of urea is found to be subnormal, due not so much 
 to the general enfeeblement as to insufficiency of the renal filter; the sign 
 of these attacks is an exaggeration of the stomach disorder with vomiting. 
 
 The uraemia gradually becomes chronic and constitutes an actual source 
 of comfort to the patient, as it blunts both intelligence and sensibility. 
 
302 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 After a few days in this condition, indifferent to all surroundings, semi- 
 comatose and hardly responding to questions, the patient quietly dies ; this 
 is the usual history, convulsions of an eclamptic form being rare. I have 
 seen one case of uraemia with dyspnoea. Peritonitis by extension or per- 
 foration, or embolism may cause a speedily fatal termination. It is evident 
 that septicaemia may enter largely into the production of the later effects ; and 
 if there is no proper treatment of it, this alone may be the cause of death. 
 
 Coviplicating Pregnancy. — Conception may occur with cancer of the cer- 
 vix, as is proved by many cases, although the conditions are very unfavorable 
 to fecundation. It often happens that women return to their physician with 
 a new pregnancy in whom a cancer had complicated the previous one. 
 Cancer predisposes to abortion. In one hundred and twenty women with 
 cancer of the cervix treated during pregnancy by Lever at Guy's Hospital, 
 forty per, cent aborted. Hanks thinks that the abortion occurs most often 
 in the third month, and that if the patient passes this period in safety the 
 chances are that labor will take place at full term. 
 
 Chantreuil cites three cases of prolonged pregnancy, the most interesting 
 being a case of Menzies of Glasgow. At times there is a series of ineffec- 
 tual efforts at expulsion occurring at intervals and exhausting the patient, 
 and in one of these the uterus may be ruptured. 
 
 The prognosis for a woman with cancer is always aggravated by preg- 
 nancy, for abortion may cause a fatal hemorrhage or septicaemia, and when 
 the case goes on to full term the labor is dangerous ; Herman found 40 
 cases of death in labor in 137 of this kind. The older statistics show an 
 even higher mortality, Chantreuil giving 25 deaths for 60 labors, and West 
 41 in 75. Among 128 children of cancerous mothers only a few were born 
 alive. 
 
 Diagnosis. — I have already given the differential diagnosis between cancer 
 before the ulcerative period and chronic metritis, and between cancer after 
 ulceration and catarrhal metritis of the cervix (page 300). Stratz lays much 
 stress upon the yellow color and the brilliant granular aspect of non-ulcerated 
 cancer. In all doubtful cases a section should be cut and examined micro- 
 scopically. If we are forced to wait, the course of the disease will remove 
 the doubt ; almost always where the nature of the disease is uncertain, it is 
 not cancer. 
 
 The benign vegetations observed in vaginitis with mucous patches and 
 papilloma could not be confounded with cancer; their multiplicity, their dis- 
 semination, and the characteristic cock's-comb aspect will prevent error, 
 while the purulent excretion of vaginitis is very different from the reddish, 
 fetid discharge characteristic of cancer. 
 
 A circumscribed, cancerous nodule in the cervix may be difficult to dis- 
 tinguish from a small myoma, though the latter is more clearly defined and 
 there is no sign of infiltration or inflammation about it; the mucous mem- 
 brane is not adherent to the fibrous tumor, as it is to the cancerous. 
 
DIAGNOSIS OF CANCER OF THE CERVIX UTERI. 303 
 
 Certain cylindrical epitheliomata of the cervix present a polypoid appear- 
 ance which might be confounded with benign mucous polypi ; in such cases 
 the cancerous nodules of the uterine body and neck begin to project toward 
 the exterior. A decision may be reached by dilatation and intra-uterine 
 touch, or, if necessary, by exploratory curetting. 
 
 All these considerations apply to cancer at the very first ; later on in the 
 course of the disease, the invasion of adjacent parts, the progress of the 
 ulceration, the frequent hemorrhage, and the abundant fetid discharge render 
 the diagnosis easy. There is, however, an affection with which it may be 
 confounded, namely, sloughing fibroma of the cervix, or polyp of the body 
 arrested by strangulation or adhesions at the external os, which is dilated 
 and partially effaced when the fibroma has been altered by spontaneous de- 
 composition or by the application of caustics. Hemorrhage, fetid discharge, 
 and a fungous or sphacelated appearance of the neoplasm all concur in mak- 
 ing the case uncertain ; the patient, exhausted by profound anaemia, seems 
 to present the cancerous cachexia. There is but one symptom which removes 
 the doubt, but it is pathognomonic ; we should always seek for the external 
 OS, and in the case of a fibroma it will be found as a thin continuous collar 
 about the tumor, and the tip of the finger may be introduced between the 
 morbid mass and this diaphragm ; frequently, also, the tumor is firm and free 
 from ulceration along its margin. In one case of this kind I operated suc- 
 cessfully and enucleated a sphacelated intracervical fibroma in a patient who 
 had been sent away by a distinguished physician as afflicted with incurable 
 cancer. 
 
 The following are exceptional forms of malignant disease of the cervix : 
 Hegar found a very rare form in an old woman, the hypertrophied cervix 
 projecting beyond the vulva, with no ulceration. Eckhardt observed in a 
 young woman of nineteen years a considerable hypertrophy of the cervix 
 which seemed to immediately precede its cancerous degeneration. Schroder 
 found on autopsy a cancer of the upper part of the cervix, intracervical, of 
 which there was nothing to be discovered externally. Sarcoma of the cervix 
 has been exceptionally observed, but so rarely that it cannot be considered a 
 clinical entity; its variable manifestations might render diagnosis difficult. 
 
 Spiegelberg described in 1878 a curious case which he called sarcoma 
 colli hydropicum papillare (dropsical papillary sarcoma of the cervix) in a 
 young woman of seventeen years. There was a papillary tumor of the 
 anterior lip which returned six months after ablation and filled the whole 
 vagina like a hydatid chorionic mole ; the microscope demonstrated that it 
 was a sarcoma with oedematous infiltration of its stroma. The same author 
 observed a similar case in a woman thirty-one years old in 1878; and 
 Winckler cites a case of Sanger's which resembles it. 
 
 Ludwig Pernice has given a description of a striocellular myosarcoma of 
 the uterus, in the form of a bunch of grapes, in a nullipara who had suffered 
 from hemorrhage for six months. The tumor started from the external os 
 
304 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 and was of the volume of about lo cm. in all diameters, with lobules of a 
 violet color filled with a gelatinous fluid ; it was removed by the bistoury. 
 On examination it proved to be a sarcoma mixed with striated muscular 
 fibres of an embryonic appearance. Two months afterward it returned and 
 was removed again, this time being nearly half as large as at first ; and in 
 nine months more the patient returned with a tumor which reached almost 
 to the epigastrium. Exploratory laparatomy was performed and death fol- 
 
 FiG. 214. — Myxo-sarcoma of the Cervix (Pernice). 
 Z, Line of excision ; a, b, lobules of the tumor ; c, shreds of 
 an enveloping membrane. 
 
 Fig. 215. — FiBRO-ADENO.MA OF THE CeRVIX 
 
 (Thojias). 
 
 lowed from pneumonia ; the microscope showing that both the second and 
 the third tumors were sarcomatous, but without any sign of myxomatous 
 degeneration. 
 
 Munde has described a tumor which was evidently malignant and which 
 he considered a myxo-adenoma transformed into a myxo-sarcoma, in a patient 
 of nineteen years who had suffered from intense leucorrhoea and complete 
 amenorrhoea for two years. The vagina was filled and the hymen protruded 
 by a friable tumor composed of lobules of the size of a muscatel grape ; on 
 removal by the snare its centre was found to be fibrous, and it proved to 
 have started from the cervix, in places showing a myxomatous degeneration 
 of the vaginal cul-de-sac. One month and a half later it returned. Histo- 
 logically it was composed of a multitude of myxomatous cysts, in whose 
 fibrous stroma there were many lymph corpuscles and sarcomatous cells. It 
 seemed to Munde that it was a case of malignant degeneration of a tumor 
 which was at first benign. 
 
DIAGNOSIS OF CANXER OF THE CERVIX UTERI. 
 
 305 
 
 Thiede has described under the name of fibroma papillare cartilaginescens 
 a tumor observed in a woman of forty years, lobulated and spongy in appear- 
 ance, taking origin from the mucous membrane of the cervix. Its ablation 
 was followed by recurrence and death. On section there were found islands 
 of hyaline cartilage in a stroma rich in dilated vessels, but none of the char- 
 acters of a sarcoma. To this may be compared Rein's case of what he calls 
 an arborescent enchondromatous myxoma of the cervix, found in a patient 
 of twenty-one years, the tumor being A 
 
 lobulated and soft. It was removed 
 entire, but rapidly returned, and caused 
 death. On section the soft tissue was 
 found to be subdivided by bands of 
 fibrous structure surrounding masses of 
 aspect and structure like Wharton's 
 jelly, and in the middle of these myxo- 
 matous portions there were nodules of 
 hyaline cartilage. 
 
 Lastly, Winckel describes a myxo- 
 matous adenoma of the cervix which he 
 removed from the anterior lip of the 
 uterus of a woman forty years old, with 
 rapid recurrence and invasion of the va- 
 ginal pouches, when the patient passed 
 out of his observation. On section the 
 tumor was full of alveoli containing 
 mucus, and, the microscope proved that 
 it, had probably been at first an adenoma 
 which then became transformed into a 
 sarcoma and then underwent myxomatous 
 degeneration. This singular hybrid neoplasm established, according to this 
 author, a transition between epithelioma and sarcoma. 
 
 All of these rare cases deserve mention, but their differences interest the 
 pathologist more than the clinician ; they are all malignant tumors and may 
 be called cancer. The racemose polypus of the cervix, which I observed in 
 a young girl suffering from intractable hemorrhages, and for which I success- 
 fully performed hysterectomy, is very different histologically, though of very 
 similar appearance. Histological examination showed the neoplasm to be a 
 glandular hypertrophy of benign character (adenoma). A similar growth 
 existed at the fundus of the uterus (Fig. 216). 
 
 An important part of the diagnosis is the determination of the tumor's 
 extension. Bimanual palpation, with systematic infra-traction of the uterus, 
 will furnish the needed information on this point, and, if necessary, anaes- 
 thesia may be employed to facilitate the examination, which is so important 
 from the operative point of view. 
 
 Fig. 216. — Racemose Polyp of the Cervix. A, 
 Glandular hypertrophy of the fundus of the uterus 
 of the same benign nature as the polyp, B. 
 
3o6 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Prognosis. — Cancer in all its forms runs a fatal course, but some forms 
 develop more slowly than others ; for example, scirrhus cancer of the cavity. 
 
 The average duration of the disease is from sixteen or seventeen months, 
 according to Courty, to twelve months ; but Simpson says two or two and 
 a half years, and Fordyce Barker up to three years and eight months. 
 Arnott, who has published scanty but well-studied statistics, assigns to car- 
 cinoma (of the cavity .?) a duration of fifty-three to fifty-four weeks, and to 
 epithelioma (papillary) eighty-two to eighty-three weeks; cases of longer 
 duration have been cited. Courty speaks of a woman who lived seven to 
 eight years, Fordyce Barker of one who lived eleven years, after the first 
 signs were discovered, and Emmet asserts that he has seen life prolonged 
 from five to eight years ; these cases may be compared to certain forms of 
 atrophic scirrhus of the breast. 
 
 The age of the patient is of great importance. Generally, cancer at the 
 age of twenty or thirty develops more rapidly than at the time of the meno- 
 pause; with tumors of a galloping course, where there is rapid return even 
 after hysterectomy performed under the most favorable conditions, the patient 
 is generally young. 
 
 The form of the tumor should also be considered in the prognosis. It 
 may take years to develop those of the cavity and the hard variety with but 
 little bleeding or vegetation^ especially if the patient is of advanced age. 
 
 Etiology. — Women are more subject to cancer than men, and it is the 
 uterus which is most frequently attacked. This fact has been proved be- 
 yond doubt by Sir J. Y, Simpson's statistics in the "Annual Report of 
 the Registrar-General for England" of the years 1847-61. 
 
 During the period which may be called the uterine life of the woman 
 this frequency is most manifest ; that is, from puberty to the menopause, 
 when it attains its maximum. After the uterus, the breast is most often 
 attacked. 
 
 Race, heredity, age, and environment are general predisposing causes : 
 the influence of race in the United States, where it can be well studied, is 
 to the benefit of the negress, in whom cancer of the uterus is so rare while 
 fibroma is so common. According to Chisholm's statistics, nearly one in 
 every hundred whites die of cancer and only one in three hundred blacks, 
 both sexes included. 
 
 The force of heredity has been disputed. In collecting the statistics 
 which he first published, Schroder found in 948 cases that this factor could 
 be determined in only 78. I have seen many incontestable cases. 
 
 The period at which it most frequently develops is between the ages of 
 forty to fifty years. Examples are known of very early development of 
 cancer of the cervix. Ganghoffer records the case of a child of nine who for 
 two years had had losses of blood together with an ulcerating tumor which 
 filled the vagina. The child died of variola a few days after its excision and 
 cauterization. Microscopic examination by Chiari proved it to be a medul- 
 
ETIOLOGY OF CANCER OF THE CERVIX UTERI. 307 
 
 lary carcinoma, probably from the glands. The principal statistics are com- 
 bined in the following table by Gusserow, who has added to his own results 
 those of Lever, Kiwisch, Chiari, Scanzoni, Saxinger, Tanner, Hough, Blau, 
 Ditrich, L. Meyer, Lebert, Clatter, Beigel, Schroder, Schatz, Winckel, and 
 Champneys — in all 3,385 cases: 
 
 Age at which Cancerous Disease Began. 
 
 17 years i case (Clatter). 
 
 19 " .... I " (Beigel). 
 
 20 to 30 years 114 " 
 
 30 " 40 " 770 " 
 
 40 to 50 years 1,196 cases. 
 
 50 " 60 " 856 " 
 
 60 " 70 " 340 " 
 
 Above 70 " 193 " 
 
 Insanitary environment, with privations leading to poor nutrition, favor 
 the development of cancer, so that it is most often observed in the lower 
 classes of society ; the opposite is true of myoma. 
 
 Schroder has drawn up comparative statistics of the cases he has seen in 
 hospital and private practice, which are of great interest : 
 
 Myoma. Cancer. 
 
 In 14,000 hospital cases 2S5 (2.0 per cent). 
 
 "16,800 " " 603 (3.6 per cent). 
 
 " 9,400 of private practice 537(5-7 " ) 209(2.2 " ) 
 
 Martin has made a similar list, and finds that three per cent of his hos- 
 pital cases were cancerous, and a slightly larger proportion myomatous ; in 
 his private practice the results were like Schroder's. 
 
 Local predisposing causes which have been mentioned are laceration and 
 metritis of the cervix. 
 
CHAPTER XV. 
 
 TREATMENT OF CANCER OF THE CERVIX. 
 
 The treatment of cancer may be divided into two sections, according as 
 it is palliative or radical ; the latter is possible only when the tumor is 
 limited to the uterus itself without invasion of other parts. Palliative treat- 
 ment is addressed to cancers which have passed beyond the limits of the 
 organ in which complete ablation would be either impossible, too dangerous,, 
 or useless. 
 
 I. Cancer of the External Os Not Involving the Vaginal 
 
 Culs-de-Sac. 
 
 Until recently no attempt was made toward a radical cure of uterine 
 cancer vmless the neoplasm was limited to the vaginal portion of the cervix, 
 and in such cases intra-vaginal amputation was performed. The operation 
 has given good results in the hands of Verneuil, who uses the ecraseur ; C. 
 Braun, who employs the galvano-caustic loop ; Byrne, who advises the gal- 
 vano-cautery ; and Schroder, who advises a cutting instrument, which I con- 
 sider both quicker and safer. Very brilliant results have been credited to 
 both these methods, but in many of the older cases there is an uncertainty 
 of diagnosis. Pawlik's statistics from Braun's clinic cover about twenty 
 years : In 1 36 intra-vaginal amputations of the cervix by the galvano-caustic 
 loop, 9 died from the operation (6.6 per cent); 33 cases were followed more 
 than one year (24 per cent) ; 26 more than two years (19 per cent) ; 2 were 
 still exempt at the end of twelve years, i at the end of nineteen and one- 
 half. Verneuil in October, 1888, reported 22 operations by his method,, 
 with I death. Polaillon, who used the galvano-caustic loop, had i death (from 
 chloroform) in 200 cases. Marchand, in 12 cases, 4 by the ecraseur and 8 
 by the galvanic loop, had i death from opening the peritoneum and peri- 
 tonitis. Terrillon had 7 cures. Adding one case of Schwartz's we obtain 
 60 amputations of the cervix, with 2 deaths from operation (3.33 per cent). 
 Among these Verneuil has i case of cure of seven years' standing, i of 
 five years, and i of three years ; 2 of six years and three years, respectively, 
 presented a return of the disease in the pelvic ganglia. Polaillon gives i 
 case of cure after seven and i case after five years ; Marchand, i case after 
 seven and i after five years ; Schwartz i after four years. 
 
 I consider the employment of the bistoury superior to all other methods 
 of excision, for it jDcrmits an operation which is throughout intelligent and 
 not mechanical, and by it the ablation may be carried as far upward as may 
 
TREATMENT OF CANCER OF THE CERVIX. 
 
 309 
 
 be necessary. I therefore use the cutting instrument according to the rules 
 already given under the treatment of metritis. As I have said before, when 
 the lesion is cancerous, no matter how small, I perform total hysterectomy. 
 
 I consider it preferable to amputation of the cervix even iii very circum- 
 scribed cases of cancer, as it alone assures the removal of the entire affec- 
 tion. Furthermore, the mortality of hysterectomy has been so greatly re- 
 duced that it differs but slightly from that of amputation of the cervix. T 
 shall return to this subject in greater detail in the succeeding paragraph. 
 
 II. Cancer of the Entire Cervix, without Extension tc the 
 
 Culs-de-Sac. 
 
 In this condition intravaginal amputation will not suffice, for it does not 
 include the whole of the disease. We therefore practise the supra-vaginal 
 excision, a conical excision similar to that which Huguier long since applied 
 
 Fig. 217. — Byrne's Method of Supra-vaginal 
 Amputation of the Cervix. «, Body of the 
 uterus ; ^, cancerous ceri'ix ; c^ galvano-caustic knife ; 
 ■d^ forceps with divergent jaws for fixing the uterus. 
 
 Fig. 218. — Supra-vaginal Amputation of the 
 Cervix, showing the Extent of the Excision 
 AND the Ligature of the Lower Branch of 
 THE Uterine Artery. 
 
 to another affection, and which many surgeons independently of each other 
 have practised under different names. Koeberle has " for nearly twent}' 
 years" performed a conical excision with the bistoury, using a sound in the 
 cervix as a guide, and " roasting" the stump with the thermo-cautery. Baker, 
 of Boston, also employs the " high amputation," followed by the hot iron, 
 and Ely van de VVarker does the same, cauterizing with chloride of zinc. J. 
 Byrne amputates the cervix by means of a galvano-caustic loop which he 
 handles as a bistoury (Fig. 217), 
 
 Schroder has made the operation general, and best described the indica- 
 tions and technique under the name of supra-vaginal amputation of the cervix. 
 
3IO CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 According to him there is a fundamental difference between cancroid (epi- 
 thelioma) of the cer\'ix and all other forms of cancer. He believes it to be 
 a local affection, with no tendency toward propagation to the body of the 
 organ if the cer\-ix is freely excised, the limits of the disease being passed 
 by from i to i-J- cm. 
 
 The technique is as follows : The diseased cervix is brought down to the 
 vulva by Museux forceps and a strong loop of thread is passed through and 
 above each of the lateral culs-de-sac (Fig. 218). These loops serve to draw 
 the parts down, and to compress the uterine artery. 
 
 A transverse incision is then made across the anterior cervico-vaginal 
 junction, at least i cm. from the diseased part, extending into the con- 
 nective tissue. The bladder is then easily separated over a large extent 
 by tearing the loose connective tissue between it and the cervix. The for- 
 ceps are then elevated so that the posterior cul-de-sac is exposed, and a 
 transverse incision made through the vagina as before, with usually some 
 difficulty in separating the peritoneum from the posterior vaginal wall. If 
 from the extent of the disease we are obliged to make this latter incision 
 high up on the vaginal wall, the peritoneum is likely to be opened, and if 
 this is avoided, there is still the danger of wounding it in several points during 
 the separation of the vaginal tissues. The serous membrane is easily recog- 
 nized, even when not wounded, from its bluish and transparent appearance; 
 but opening it is a matter of indifference when the operation is antiseptic, 
 and it is only necessary to close it with a few sutures and cut the ends short. 
 When the vagina is thus divided in front and behind, the incisions are pro- 
 longed laterally till they meet, and the separated cen-ix detached from its 
 connections by the finger. It is difficult to do this on the sides, for there 
 the connective tissue is dense and the vessels enter the uterus. Before the 
 latter are cut they should be tied, a second ligature being applied if neces- 
 sar}'. Then when the cen'ix is free enough, its anterior wall is incised with 
 the bistoury as far as the canal, and sutures are passed through the anterior 
 cul-de-sac and along the posterior wall of the bladder, traversing the uterine 
 w^all and coming out in the cervical canal (Fig. 219). These are then tied, 
 embracing the parts deeply and closing the wound in the connective tissue 
 so that the cut surface of the anterior vaginal wall is applied to the cut sur- 
 face of the cervical mucous membrane. Then the posterior lip of the cervix 
 is divided, the sutures preventing the stump from escaping upward, and 
 sutured in the same manner. The union of the parts is then completed by 
 lateral sutures, and the entire bleeding surface closed by ligatures placed as 
 deeply as possible. 
 
 This operation permits the complete removal of most of the vaginal cul- 
 de-sac, the entire cervix, and a part of the uterine body; Schroder has also 
 excised at the same time the upper portion of the vagina. 
 
 Hofmeier has published the results of Schroder and some of his assistants 
 from the beginning of 1879 to the end of 1884; in 105 partial extirpations 
 
TREATMENT OF CANCER OF THE CERVIX. 
 
 311 
 
 there were but 10 deaths, or 9.5 per cent, and the final results were excel- 
 lent. This series has been completed up to 1891 by Winter; it includes all 
 the supra- vaginal 'amputations for cancer performed at the gynaecological 
 clinic of the University of Berlin under the direction of Schroder and of 
 Olshausen. One hundred and fifty-five such operations have given 10 
 deaths, a mortality of 6.5 per cent; none of the last 64 cases died. The 
 remote results were: 80 recurrences, 57 during the first year, 10 during the 
 second, 5 during the third, 5 during the fourth, and 3 during the fifth; 52 
 were reported as free from recurrence, and of these, 49 had been operated 
 
 Fig. 2ig. — Amputation of the Cervix. «, Intra-vaginal operation ; h, supra-vaginal operation, showing line of in- 
 cision and suture ; oi^ internal os. 
 
 upon more than two years before. In Germany this operation has been per- 
 formed by Gusserow; in America by Baker and Reamy; in England by 
 Spencer Wells and Wallace ; and in France by Koeberle, Marchand, Buffet, 
 Tedenat, etc. 
 
 Combining the statistics of Hofmeier and Winter, Gusserow, Baker, 
 Reamy, Wells, and Wallace, we obtain 287 cases, with 18 deaths, or 6.2 per 
 cent ; those of Hofmeier and Baker, which alone are complete from this point 
 of view, show more than 50 per cent of cures after two years. I find, with 
 Barraud, that this proportion is " truly too fine," completely disagreeing with 
 the general prognosis of cancer. It seems to me that it affords the best 
 demonstration of the numerous errors of diagnosis which lie hidden in this 
 extraordinary series, upon which many of the arguments against early hyster- 
 ectomy have been based. 
 
 In spite of the ardent discussions in France and elsewhere, surgeons are 
 not agreed in the choice between total and partial excision, and it is prob- 
 able that the opinion of the majority of the partisans of the latter operation 
 would be modified if it were demonstrated that the mortality of hysterectomy 
 
312 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 is not sensibly higher than that of excision of the cendx; however, this 
 demonstration is to-day complete. The gloominess of the early statistics 
 was due in part to the inexperience of many of the operators, the perform- 
 ance of radical operations in unsuitable cases, and the absence of a perfect 
 technique. Since these causes of failure have disappeared, the mortality has 
 fallen to 5.88 per cent in France. Leopold from 1883 to 1889 did 80 
 vaginal hysterectomies for cancer, with only 4 deaths, or 5 per cent ; the 
 last 52 of this series were followed by cure. Dmitri Ott, of St. Petersburg, 
 had 30 cases without a death. Schauta has performed 65 of these opera- 
 tions with 5 deaths, or y.6 per cent. Fritsch had had 7 deaths, or 1 1.6 per 
 cent in a first series of 60 cases (1883 to 1887) ; his new statistics (1887 to 
 November, 1889) include 41 cases with 2 deaths, or only 4.9 per cent. 
 These examples are eloquent. They prove that by attacking cancer at the 
 first and performing hysterectomy in cases which used to be treated by 
 partial excision, we obtain a mortality which does not surpass that of cervical 
 amputations. I cannot repress the thought that haemostasis and antisepsis 
 are far easier in total hysterectomy than in supra-vaginal amputation ; and in 
 fact the last operations of this kind, both in and out of France, have not 
 given more than eleven per cent of deaths. The great argument against early 
 hysterectomy is thus ruined and the indications for speedy interference 
 strengthened. The chief of these appears to me, to be the impossibility, in 
 the majority of the cases, of knowing whether the disease is circumscribed 
 or whether it is travelling by the mucous membrane toward the body of the 
 uterus. Examinations by touch and speculum are always uncertain on this 
 point and expose us to cruel mistake. I have recently seen a case of this 
 anatomical condition which escaped clinical examination where, after per- 
 forming total hysterectomy for an epithelioma which seemed confined to the 
 lower part of the cervix and for which either the high or the low. amputation 
 appeared suitable, it was easy to determine on the extirpated tissues the 
 presence of a band of neoplasm reaching up toward the fundus. 
 
 A second, more unusual mode of hidden propagation where there is a 
 small cancer in the cervix, is by the formation in the body of the organ of a 
 series of metastatic nodules not admitting diagnosis upon the living patient. 
 Cases of this kind have been cited by Ruge, Binswanger, Diivelius, Terrier, 
 Strotz, Abel, Flaischlen and others. Let me also call to mind the observa- 
 tions of Abel and Landau on serious changes in the uterine mucosa with 
 epithelioma of the cervix; for while it is not proved that these alterations 
 are sarcomatous, yet they undoubtedly produce a Iocils minoris rcsistcnticB 
 and favor recurrence. 
 
TREATMENT OF CANCER OF THE CERVIX. 
 
 313 
 
 III. Cancer of the Cervix, with Extension to the Body of the 
 Uterus, without Invasion of the Adjacent Tissues. 
 
 In cases of this character there is but little discussion concerning the 
 best method of treatment, the majority of gynaecologists favoring the per- 
 formance of total hysterectomy by the vagina. 
 
 This operation is not of recent origin, having been known for nearly half 
 a century under the name of colpo-hysterectomy. It fell into disfavor on 
 
 BOA F 
 
 Fig. 220. — Various Models of Prehension Forceps for Grasping the Cervix Uteri in Hysterectomy. 
 A, £, Hook forceps ; £, D, flat with internal teeth ; C, with blunt hooks (Collin); F, F, with gliding hooks (Collin). 
 
 account of its excessive mortality until recently, when Czerny prepared the 
 way for its revival, after the greater dangers of total extirpation by the 
 abdominal method (Freund, 1878) had made it necessary to seek othei 
 means of relief. 
 
 Colpo-Jiystcrcctomy or Vaginal Hysterectomy — Method by Forcipress2ire. — 
 Before operating it is necessary to make certain, by careful examination of 
 the patient, that the uterus is movable and the broad ligaments free from 
 disease; for this purpose bimanual palpation, rectal touch, and downward 
 traction with fixation forceps are indispensable. At times, in doubtful 
 cases, to overcome the contractions of the abdominal muscles and render the 
 
314 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 tissues lax, or to eliminate timidity in a nervous patient, it is well to make 
 a preliminary examination under chloroform. 
 
 Another preliminary precaution consists in as complete disinfection as 
 possible of the vagina for several days before the operation by free irrigation 
 with sublimate solution (i : 5,000) twice a day, and the application of iodo- 
 form tampons in the interval. 
 
 Three hours before the operation the patient should take a large, simple 
 enema, and immediately beforehand an assistant who is not to have any part 
 
 Fig. 221. — Vessels of the Uterus ; Uterine and Utero-ovarian Arteries. 
 
 in the hysterectomy should determine by rectal touch that the large intestine 
 is entirely empty; if it still contains fecal matter, an injection of hot water 
 is at once given and the faeces removed with the aid of the finger; then the 
 rectum is cleansed by an injection of a saturated boric-acid solution. The 
 bladder is to be emptied at the beginning of the operation by one of the 
 assistants. 
 
 The patient in anaesthetized and placed in the dorso-sacral position, an 
 assistant on each side taking one of the flexed thighs under his arm while 
 his other remains free to assist. The fourchette is depressed by a univalve 
 speculum and the lateral parts held aside by retractors. The cervix is seized 
 with Museux or other fixation forceps (Fig. 220) and continuous irrigation of 
 the field of operation gently begun (Fig. 9, p. 14). 
 
 By means of a sharp curette, all fungosities are removed, in order to 
 diminish as much as possible the chance of infection. The cervix thus 
 cleansed is seized firmly with tenaculum forceps and drawn down to the 
 vulva. 
 
TREATMENT OF CANCER OF THE CERVIX. 315 
 
 First Step. Vaginal Incision. — The surgeon incises the cervix circular- 
 ly, as far as possible from diseased tissue, and if necessary, completes this 
 circular incision by two lateral, extending from the base of the broad liga- 
 ments to the circular incision. 
 
 Second Step. Liberation of the Bladder and Rectum. — The bladder is 
 carefully separated from the cervix by means of the thumb-nail, aided by 
 scissors if necessary, but using these prudently and keeping close to the 
 uterus. This separation should be carried as far as possible. In the same 
 way the posterior vaginal mucosa is freed with the fingers, and the perito- 
 neum of Douglas's cul-de-sac is broken through with a retractor, or cut with 
 scissors if it protrudes freely between the borders of the wound. 
 
 TJiird Step. Liberatioji of the Cervix and Preliminary Clamping of the 
 Uterine Arteries. — The hemorrhage from the vaginal incision usually bleeds 
 little, and is never sufficient to necessitate special haemostasis. The oozing 
 ceases spontaneously when the two uterine arteries have been clamped. To 
 do this without danger of injuring the ureter the operative field is freely ex- 
 posed by two retractors, one protecting the rectum behind, the other the 
 bladder in front. A clamp with short jaws is then placed upon the base of 
 each broad ligament, close to the uterus, and a single incision with the scis- 
 sors, on each side, severs the portions of the ligaments they enclose. The 
 cervix is thus liberated, and two lateral incisions transformed into an anterior 
 and a posterior valve, which are successively resected. 
 
 Fourth Step. Hemisection and Tipping of the Uterine Body. — When 
 the cervix has been removed, the body tends, when drawn upon, to tip into 
 one of the culs-de-sac, generally the anterior. No positive rule should be fol- 
 lowed in regard to this, but the uterus should be brought into the cul-de-sac 
 toward which it naturally inclines. This tipping is greatly facilitated either 
 by Doyen's hemisection if the body of the uterus is small, or by diminishing 
 it if the uterus is of large size. Personally I avoid as far as possible an 
 extensive morcellation in cases of cancer, from fear of infecting the perito- 
 neum with fragments of the neoplasm. During hemisection or morcellation 
 the anterior cul-de-sac is opened, and the fundus of the uterus appears, with 
 the upper border of the broad ligaments. 
 
 Fifth Step. Haemostasis of Bi'oad Ligaments. — The healthy or but slight- 
 ly diseased appendages are easily brought into the operative field. Clamps 
 with short jaws are placed external to them upon the upper border of each 
 broad ligament, whose final haemostasis is thus accomplished in successive 
 stages by short forceps applied from above downward. 
 
 If removal of the appendages offered great difficulties, on account of ad- 
 hesions, etc., one should not delay for this complementary step, for it is 
 better to run the risk of some subsequent accidents, usually not serious, 
 than to complicate the operation. Brennecke has reached the conclusion 
 that removal of the appendages is of but slight importance, as they will soon 
 atrophy. The experiences of Grammatikati and the observations of Glae- 
 
3l6 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 vecke, however, seem to indicate that ovulation continues, but that it is 
 tolerated by the peritoneum. 
 
 The completeness of haemostasis should then be ascertained. The forceps 
 placed upon the broad ligaments are united in a right and left lateral bundle. 
 A strip of sterilized or iodoform gauze is passed beyond the jaws of the for- 
 ceps into Douglas' cul-de-sac and gently packed. The vagina is tamponed 
 with strips of gauze, and the vulva is closed with a pad of absorbent cotton 
 held in place by a T bandage. 
 
 The final treatment is very simple. If the iodoform tampons are not sat- 
 urated with blood, they are left in place four days; then they are removed. 
 The strip which acts as a drain is withdrawn at the end of the first week, for 
 the peritoneal wound has then long been closed by exudation. It is none 
 the less necessary to be very careful in the use of vaginal injections — not to 
 employ them under eight days and then with but little pressure, keeping the 
 fourchette depressed (sublimate i : 5,000). The patient may leave her bed at 
 the end of three weeks. For the first twenty-four hours the patient takes 
 nothing but a little ice, to control vomiting from the chloroform. At the 
 end of the third day I gave a laxative enema. Convalescence should be 
 without any elevation of temperature. 
 
 I have described the technique which I have adopted and which I recom- 
 mend. I will now describe the method of hysterectomy with ligatures which 
 is still generally employed abroad ; and will then indicate, in the form of an 
 appendix, the principal modifications in the operative technique to which the 
 names of their originators give weight. 
 
 Operation by Ligature {J\lartiii s Method). First Step. Opening Dong- 
 las PoncJi and Vaginoperitoneal Sntnre. — The cer\nx is drawn strongly for- 
 ward so as to stretch the posterior vaginal pouch as much as possible, which 
 is then incised transversely down to the peritoneum, across its whole width. 
 The index finger of the left hand is passed into this opening, and with a 
 strongly curved needle a series of sutures is inserted throughout the whole 
 extent of the section, taking in the entire thickness of the tissues up to the 
 peritoneum and including it. By this procedure we obtain a perfect haemo- 
 stasis of the vaginal vessels, which are often the source of bleeding trouble- 
 some by itc persistence, and the cellular interstices are closed and protected 
 from laceration during the subsequent manoeuvres (Fig. 222). 
 
 It may happen that the posterior vaginal insertion is very thick, or that 
 the cul-de-sac of Douglas is partially closed by adhesions; in these instances, 
 where the dissection must be carried very high, it is well to insert two su- 
 perimposed planes of suture. 
 
 Second Step. Hceniostatic Sntnre of tJic Pelvic Floor [Ligation of the 
 uterine artery]. — The needles are now changed for those which are less el- 
 liptical, stronger, and of greater length; Deschamps' pointed needles are the 
 best for this special step. With them two large sutures are placed on each 
 side of the opening, which include the posterior part of the lateral vaginal 
 
TREATMENT OF CANCER OF THE CERVIX. 
 
 317 
 
 pouches in mass, going deeply to seize the inferior branches or the trunk of 
 the uterine artery, at the base of the broad ligament. During this manoeu- 
 vre it is best to place the index finger in the opening, and press the base of 
 the ligament strongly forward so that it is carried in front of the needle (Fig. 
 223). 
 
 The needle enters two centimetres from the angle of the wound, while the 
 finger feels for its point, and it emerges about one centimetre from its point 
 
 Fig. 222. — Vaginal Hysterectomy. 
 
 ng the posterior cul-de-sac and suture of the peritoneum to the 
 vaginal mucosa (Martin). 
 
 of entry. Very strong silk is used for this suture, and tightly tied. One or 
 two other points are then sutured in a similar way, the first being anterior and 
 very near the cervix; and thus all the vessels are obliterated before the early 
 steps of the operation are completed. There is no danger of including the 
 ureter, as it is situated more in advance, and also is strongly drawn upward 
 by the traction upon the cervix. 
 
 Third Step. Complete Circumcision of the Cervix and Liberation of the 
 Bladder. — The cervix is carried backward to stretch the anterior cul-de-sac, 
 and the incision of the vagina completed in front, using great care to keep 
 as near the uterus as possible, so as not to injure the bladder, and yet to avoid 
 the diseased tissues. For the same reasons the edge of the knife is to be 
 directed obliquely toward the cervix. When the vaginal incision is accom- 
 plished, the knife is laid aside and the part dissected from the bladder with 
 the finger ; occasionally the scissors will be needed for this part of the oper- 
 ation. We need to remember that the extent and strength of these connec- 
 tions vary much in different subjects. At the end of a short interv^al the 
 
3i8 
 
 CLINICAL AND OPERATIVE GYNAECOLOGY 
 
 finger appreciates the lack of resistance before it, which indicates that the 
 peritoneum has been reached and the Hmit of the attachment of the bladder; 
 the serous membrane may sometimes be seen at the bottom of the wound, 
 recognized by its bluish appearance. Many surgeons incise it at this mo- 
 ment. The dissection should not be carried farther fonvard without arresting 
 the hemorrhage, which is very slight, by points of suture placed on the cut 
 surface of the tissues. 
 
 FojLvtJi Step. Displacement Backzuard of the Uterus and Ligation of tJie 
 Broad Ligaments. — The cervdx is now free to its upper limit. It should be 
 
 Fig. 223. — Vaginal Hysterectomy. Second step, ligation of the uterine artery (Martin). 
 
 drawn well fonvard, while the posterior portion of the wound is depressed 
 with a single blade or retractor, and then the uterus is seized behind with a 
 cur\'ed Museux forceps and made to turn over within the wound, the forceps 
 on the cervix being first removed. 
 
 At times there is some difficulty in effecting this mancemTC, most often 
 because the cervix is not entirely freed from its connections — a procedure 
 which must be completed as soon as the ligation of the pelvic floor has ren- 
 dered the parts exsanguine. 
 
 Different instruments have been invented for this inversion of the uter- 
 us; Martin employs a sound introduced into the cavity; Ouenu uses a 
 double-branched hook. These instruments have become absolutely useless on 
 account of the adoption of morcellation. 
 
 When the uterus has been inverted, the superior portion of the broad lig- 
 aments is found below and their base above. They should be ligated in three 
 
TREATMENT OF CANCER OF THE CERVIX. 319 
 
 parts unless there is any need of intercrossing the threads for a chain suture. 
 The left ligament is first tied and cut. Before detaching the uterus com- 
 pletely the last portion of the ligament is to be united by single sutures to 
 the commissure of the vaginal wound. The right side is then treated in a 
 similar manner, and the operation is terminated by sex-ering the last bands 
 which retain the uterus, particularly the peritoneum of the anterior cul-de- 
 sac, which has been so far retained as a barrier against possible infection 
 from the inverted cervix. The wound is then cleansed with great care by 
 small tampons of antiseptic cotton. 
 
 FiftJi Step. Drainage and Dressing. — One point of suture in each com- 
 missure of the vaginal wound diminishes it enough without closing it en- 
 tirely. Before tying the sutures Martin places in Douglas' cul-de-sac a rubber 
 tube in the form of a cross and packs the vagina loosely with iodoform gauze. 
 Complete occlusion of the wound, as recommended by Mikulicz at the Ber- 
 lin Surgical Congress in 188 1, has justly few partisans to-day. 
 
 Modifications of the First, Second, and Third Steps. — Fritsch begins by 
 a dissection of the lateral cul-de-sac, searching for the uterine artery and 
 tying it ; then he proceeds to the dissection of the bladder, and ends by the 
 incision of the rectovaginal pouch. Olshausen defers the opening of the 
 cul-de-sac as long as possible, for fear of infecting the peritoneum. Schatz 
 reserves the separation from the bladder for the final step. Sanger and 
 other authors advise the operator to open the vaginal pouches by means of 
 the actual cautery, but this makes subsequent dissection difficult, and is 
 without real advantage. To prevent hemorrhage from the ulcerated surface 
 of the cervix, Fritsch places an elastic ligature at its base before dissecting. 
 Miiller compresses the abdominal aorta during the operation. 
 
 It is sometimes necessary in cases with very narrow vagina or introitus, 
 as from the presence of the hymen, from senile atrophy or circular bridles, 
 to obtain greater working room by incising the perineum and afterward su- 
 turing it. I have obtained great assistance from this procedure. 
 
 For fixation of the cervix, which is so easily torn, many different forms 
 of forceps have been invented. Brennecke's model is introduced into the 
 cavity of the cervix, and then the hooks are made to project and implant them- 
 selves in the healthy tissue, so that there is no fear of their tearing out. 
 The Museux forceps which are exactly apposed, and the bullet forceps seem 
 to me to be sufficient. Miiller, after ligation of the broad ligaments in mass, 
 divides the uterus into halves, and extracts each separately. 
 
 Modifications of the Fourth Step. — Billroth, Leopold, and Olshausen do 
 not employ the inversion of the uterus, but by strong traction pull down the 
 organ and detach it by degrees, carefully ligating each portion of tissue be- 
 fore dividing it, thinking that the inversion leads to infection of the wound; 
 but this danger is almost wholly prevented if the cervix has been curetted 
 and disinfected at the beginning of the operation. Czerny, Fritsch, and 
 Demons revolve the uterus forward — a procedure which is rendered easy by 
 
320 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 the frequent presence of anteflexion and the fact that the resistance of the 
 round ligaments does not have to be overcome. Martin and Schroder re- 
 verse the uterus posteriorly, but, as I have already said, no formal rule can 
 be adopted. 
 
 For hsemostasis of the broad ligaments, Olshausen employs the elastic 
 ligature, making an opening in the peritoneum with a blunt bistoury and pass- 
 ing the elastic band with a Deschamps [Peaslee's] needle. Hegar and Kal- 
 tenbach also recommend provisional elastic ligature of the ligaments in mass, 
 securing permanent hasmostasis by partial silk ligatures as soon as the uter- 
 us is detached. This I consider a useless complication. C. E. Jennings 
 has made a provisional ligature of the ligaments in mass with a loop of car- 
 bolized silk, fastened with the aid of a perforated shot which is crushed ; he 
 then uses either ligatures or permanent forceps. 
 
 Modifications of the Fifth Step. — With the object of preventing recur- 
 rence by free excision of the adjacent tissues, it has been proposed to termi- 
 nate the hysterectomy by cutting away a part of the vagina or of the broad 
 
 Fig. 224. — Bowed Forceps for Compression of the Broad Ligaments in Vaginal Hysterectomy (Doyen). 
 
 ligaments. Richelot advises the first, even when the vaginal wall is healthy, 
 as a complementary step which is easily executed at the end of the opera- 
 tion. Pawlik still more boldly extirpates the parametrium, after placing 
 sounds in the ureters so that they may be recognized and avoided ; he has 
 operated three times in this manner, but his final results are not published. 
 It is doubtful whether these modifications are really useful, and it is certain 
 that they are more or less dangerous. 
 
 The question of drainage is not definitely settled. In France the ma- 
 jority of operators leave the wound open and introduce one or two rubber 
 tubes. In England glass tubes are more used. Martin employs a rubber 
 tube made in the form of a cross, which has the advantage of being easily 
 retained in place, and removes it on the third or fourth day. But in Ger- 
 many most surgeons close the peritoneal wound ; Kaltenbach, Mikulicz, 
 Tauffer, v. Teuffel, Schede, etc., declare in favor of this method, while 
 Czerny and Fritsch reject the suture. I think with Demons, Bouilly, Ter- 
 rier, and almost all French surgeons that it is more prudent not to close the 
 wound completely, but to diminish it. The discharge of serum and blood 
 which is so frequent in the first few hours shows that this is not an unnec- 
 essary precaution, for in spite of all our care the wound may be infected with, 
 cancerous material. 
 
TREATMENT OF CANCER OF THE CERVIX. 32 I 
 
 Decortication of the uterus, the old method of Langenbeck, who operated 
 thus on a prolapsed uterus in i 813, has been revived by certain authors, 
 among whom are Lane and Franck. It is only a useless complication. 
 
 Operative Accidents. — I have already spoken of hemorrhage and the means 
 of avoiding it. 
 
 The ureter may be wounded by the bistoury, a ligature, or the grasp of 
 a forceps ; it is also in great danger from forcipressure. It has been included 
 in the forceps of very distinguished operators. When the accident is not 
 mortal, it usually ends in the establishment of a ureteral fistula. 
 
 To avoid such injury to the ureter we must keep very near to the cervix, 
 the uterus should not be inverted until it is freed from its attachments up to 
 the peritoneum, and, lastly, no long forceps should be deeply placed on the 
 broad ligament. 
 
 The bladder has been opened by the bistoury and torn through by the 
 finger, the accident being almost unavoidable if the operation is performed 
 for cancer with large extension anteriorly (which should contraindicate any 
 operation). We must never forget to catheterize the patient at the begin- 
 ning of the operation and so make certain that the bladder is empty and least 
 liable to injury. 
 
 When the bladder has been cut or torn, it must be immediately closed 
 with sutures. Such cases have recovered without fistula, and, if not, they 
 are easily treated later. In every case a soft catheter is to be retained in 
 the bladder for several days. 
 
 The rectum should not be opened except by an actual fault of the opera- 
 tor, unless it is invaded by the disease, in which case the radical operation 
 would be more injurious than useful. It has been Avounded by the forceps, 
 both by being seized in their jaws and from simple pressure effects. 
 
 Mortality. — The mortality has fallen considerably during the last few 
 years. In 1884 F. Brunner collected in his inaugural dissertation all the 
 cases then published and found, before 1877, 33 cases with 82 per cent of 
 deaths, and, after 1877 till February, 1884, 146 cases with 32.9 per cent 
 of deaths. Munde, in 255 cases from both continents since 1879 (the time 
 when Czerny made known his operation) up to 1884, found 72 deaths, or 
 28 per cent. W. A. Duncan, in 276 cases since the beginning of 1885, 
 found 28.6 per cent; and Hache, who used the excellent tables of S. Post 
 with good effect, and added other cases, bringing the record up to the be- 
 ginning of 1887, gives for this period a mortality of 24.47 P^J" cent. 
 
 These figures have only a historical interest, for, in order to appreciate 
 the gravity of colpohysterectomy, we must eliminate the older cases and 
 confine ourselves to those of later years, in which the technique was perfected 
 and the operators had acquired a large experience. It is just, also, in an ex- 
 act estimate, not to include isolated cases by surgeons more or less incompe- 
 tent. In the statistics of Duncan (1885) there were 276 cases of seventy- 
 one operators, and thirty-five of these surgeons had performed the operation 
 
322 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 but a single time. \Mth such elements we are likely to obtain the in- 
 herent mortality of the operators and not of the operation. The rule es- 
 tablished by Tait seems reasonable ; it consists in adopting as the criterion 
 the results of surgeons of average ability and experience, and thus all new 
 operations should be judged. 
 
 Following this rule, ^Martin obtained the list given below of operations 
 up to the end of 1886 : 
 
 Fritsch 60 operations with 7 deaths, 10. i per cent. 
 
 Leopold 42 
 
 Olshausen 47 
 
 Schroder and Hofmeier 74 
 
 Staude 22 
 
 A. Martin 66 
 
 4 
 12 
 
 I 
 II 
 
 47, about 15 per cent. 
 
 But, as I have said above, these results, though recent, are still too an- 
 cient for our purpose. The latest statistics which I have examined give 5 per 
 cent as about the correct mortality; the last series of 80 operations which 
 Leopold had gave 4 deaths, or 5 per cent ; Kaltenbach, in 5 3 cases, had 2 
 deaths, or 4 per cent ; D. de Ott is still more fortunate, having operated 
 30 times without a single death; and the same is true of 25 consecutive 
 cases of Pean's which were successful. After these figures, there is no need, 
 it seems to me, of further discussion as to whether this operation is appli- 
 cable to every case in which cancer has been diagnosed. It cannot be denied 
 that we may thus perform a radical operation ; why, therefore, should it not 
 be adopted, since it is as benign as the partial operation .'' Consequently 
 there is to-day, on the part of many surgeons, a reaction against amputations 
 of the cer\dx in cancer : Schatz, Gusserow, Martin, Kaltenbach, Sanger, 
 Fritsch, C. Fenger, Bouilly, Terrier, etc., have thus expressed themselves 
 categorically. I also believe that hysterectomy is the operation of election 
 when the diagnosis of cancer is certain. Therefore I have written (with- 
 out always having been understood), " the more limited the disease, the 
 more extensive should be the operation." In thus removing the whole of 
 the uterus the result is certain, there is no opportunity for the disease to 
 recur locally, and we avoid also ganglionic engorgement and invasion of the 
 adjacent tissues, both of which have occurred where the treatment has 
 been palliative and only partial destruction attempted. In other words, 
 we simply apply here the rules which are accepted for external or general 
 cancer. 
 
 Causes of Death after Vaginal Hysterectomy. — These may be arranged 
 under three principal heads — hemorrhage, shock, and septicaemia. 
 
 Hemorrhage may occur during or after operation. Primary hemorrhage 
 is always the result of an operative fault, and may be certainly avoided by 
 clamping the tissues in small sections before dividing them. By using 
 
TREATMENT OF CANCER OF THE CERVIX. 323 
 
 clamps with short jaws, the hemorrhages, which were formerly frequent 
 when the operation was performed with very long-jawed forceps, have be- 
 come quite unusual. 
 
 Secondary or rather continuous hemorrhage has been observed in cases 
 of excision for cancer in which the parts adjacent to the uterus were involved 
 and all of the disease could not be removed. 
 
 In case of secondary bleeding, which is a comparatively rare accident, the 
 vagina should be packed with tampons of resin-iodoform gauze if the hemor- 
 rhage is not alarming. If, however, it is dangerously free, the bleeding 
 vessel should be found and tied or controlled with forceps. 
 
 Shock. — Under this vague and general name are grouped factors the most 
 diverse. In the first place, exhaustion from a hemorrhage whose importance 
 has escaped the attention of the operator may be one of the causes of the 
 accident, for, unless the haemostasis has been carefully performed step by 
 step, certain vessels may bleed continuously during the whole of the opera- 
 tion, and this condition is the more serious when the patient has been already 
 exhausted, or when it continues for a long time. 
 
 Another cause of shock is acute uraemia, depending upon alteration of 
 the kidneys. It is well known how frequently compression of the ureters 
 causes disease of these organs. Many cancerous patients live with the min- 
 imum of uropoietic function in a kind of unstable equilibrium, and, if this 
 precarious condition is overbalanced by some disturbance, the uraemia which 
 has been threatening develops with great rapidity. Thus the chloroform 
 [or especially ether] absorbed during the time of anaesthesia may during its 
 elimination by the kidney cause a fatal congestion of these organs ; hence 
 the mortality of prolonged narcosis. The uraemia may be due to absorption 
 of the wound secretions, whose elimination encumbers the renal filter and 
 monopolizes the small portion of healthy tissue which sufficed for the nor- 
 mal requirements of the economy. Many cases of death from so-called 
 shock are plainly due to uraemia, generally of the comatose form, as appears 
 both from the clinical details and from the autopsy records. It may also 
 have been caused by the unfortunate application of a ligature to an unrecog- 
 nized ureter. To avoid such accidents, we should never perform hysterec- 
 tomy on a patient who presents symptoms of albuminuria or whose urine 
 contains a largely diminished quantity of solids. If, however, in spite of 
 unfavorable conditions, we decide to operate, the gravity of the prognosis 
 should be recognized and the operation be performed as quickly as possible 
 with the shortest convenient duration of the anaesthesia. I keep my patients 
 on a milk diet for the first few days after the operation, quite as much to 
 facilitate diuresis as to supply aliment. 
 
 SepticcBmia. — One of the chief causes of this accident is the infection of 
 the wound in its deeper portions by either the fluids or, the debris of the 
 cancer. This condition may be escaped by following the rules which I have 
 described and advised — preliminary curetting, scraping the fungous portions, 
 
324 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 continuous irrigation during the operation, and avoidance of morcellation as 
 much as possible. 
 
 Survival after Hysterectomy. — Although the operation is of very recent 
 date, a number of reports have been collected upon, the subject, the most 
 extensive of which is that furnished by Hache. A resume is given in the 
 following table, which I cannot reproduce without remarking that it unfor- 
 tunately refers to a series of relatively ancient cases of operation in which it 
 was performed too late, with no real chance of permanent success. It gives, 
 therefore, too gloomy an idea of the actual results, but it is a valuable doc- 
 ument by which to appreciate the progress accomplished since 1866. 
 
 Ultimate Result in 150 Cases after Hysterectomy. 
 
 Time since operation. 
 
 Three months . 
 
 Six " 
 
 Nine " 
 
 Twelve " 
 
 Eighteen " 
 
 Two years 
 
 Three " 
 
 Four " 
 
 view before 
 rrence. 
 
 Dead, or with return. 
 
 With no recurrence. 
 
 5 
 
 23 
 
 122 
 
 6 
 
 20 
 
 96 
 
 5 
 
 10 
 
 81 
 
 2 
 
 9 
 
 70 
 
 10 
 
 S 
 
 52 
 
 14 
 
 
 
 38 
 
 21 
 
 
 
 17 
 
 10 
 
 I 
 
 6 
 
 By these figures we may appreciate approximately the proportion of sur- 
 vivals and recurrences in one hundred operations during what may be called 
 the initial period of hysterectomy (up to 1886). To determine this propor- 
 tion, it is necessary, as Hache asserts, to consider all patients lost to view 
 less than a year after operation as having had a return of the disease imme- 
 diately after their last examination. For those who were observed more 
 than a year, Hache includes among recurrences a majority of those who 
 have been consequently lost to view. The following results, therefore, may 
 be considered a very pessimistic interpretation of the preceding statistics : 
 
 In 100 Cases. — Twenty-three succumbed to operation ; in 1 5 the disease 
 returned in the first three months ; in 1 3 between three and six months — 
 which is 28 in the first half-year; in 13 between six and twelve months, 
 that is, 13 in the second semester; in 10 between one and two years; in 10 
 in the second year ; 26 were still in good health at the end of two years. 
 
 In determining what percentage of the patients had a recurrence in the 
 number of those who survived at the end of each of these periods, Hache 
 found that the chances of return were about equal during the first two 
 periods of nine months, with a gradual decrease thereafter. This result is 
 evidently due to incomplete operation and the immediate return of a neo- 
 plasm which has been simply resected. There is still another factor, which 
 is the very rapid course of certain cancers, especially in young women. As 
 a striking example of this, two patients of Tillaux and one of Tedenat had a 
 return of the disease at the end of six weeks, three months, and five months. 
 
TREATMENT OF CANCER OF THE CERVIX. 
 
 325 
 
 I have observed a case of rapid return in a woman of thirty-eight years with 
 a tubular epithelioma of the cervical cavity; the origin of the disease seemed 
 to have been only five months before the operation, and, although the dis- 
 eased portions were entirely removed, the return was very rapid, and the 
 patient succumbed five months after the hysterectomy. 
 
 A valuable report is given by A. Martin in the memoir which I have 
 cited. In the series which he reports is included the practice of certain 
 German gynaecologists up to the end of 1886, with the following results as 
 regards survival without return : 
 
 Recurrence. 
 
 Leopold, 56 cases. 
 
 Schroder, 62 cases. 
 
 Fritsch, 53 cases. 
 
 Martin, s6 cases. 
 
 In one year 
 
 16 
 
 9 
 5 
 2 
 
 20 
 
 ID 
 
 7 
 
 4 
 
 17 
 
 7 
 2 
 
 35 
 32 
 
 25 
 20 
 
 In one and a half years. 
 
 In two years 
 
 In three " 
 
 In four " 
 
 In live " 
 
 5 
 3 
 2 
 
 In six '■ 
 
 
 
 Percentages derived from the above table : 
 
 Recurrence at end of one year 42.5 per cent. 
 
 " " " one and a half years 33. i ' ' 
 
 " " " two years 21.2 " 
 
 " " " three " 13.5 " 
 
 " " " four " 2.4 " 
 
 The first observations of vaginal hysterectomies performed in France 
 were discussed at the Societe de Chirurgie in October, 1888, and are too 
 recent to form a satisfactory analytical table. The last statistics communi- 
 cated to that society at the end of 1891 furnish valuable data. 
 
 P. Segond has operated upon 25 cancers of the cervix, with 7 deaths 
 from operation; 4 patients died at the end of first year; 3 were living with 
 a recurrence; 2 had been operated upon more than one year before; 3 
 were living without recurrence, i since November, 1888, the 2 others since 
 October, 1889, and April, 1890. The last 6 operations were of recent date 
 (August, 1 891). 
 
 Terrier had performed hysterectomy in 29 cases of cancer of the cervix 
 from June, 1885, to September, 1891 ; he had observed 6 deaths from oper- 
 ation. One patient had had no return after more than six years and five 
 months, 2 had lived four and a half years, 2 others three years and three 
 and a half years, 3 two to two and a half years; all others died within from 
 one month to one year. In 3 cases cancer of the body and of the cervix 
 coexisted. Terrier had observed i death from operation among these ; the 
 2 others lived eight and thirteen and a half months respectively. 
 
 In 1888 Bouilly had practised 20 hysterectomies with 7 deaths. From 
 1888 to 1892 he performed this operation for cancer of the cervix 19 times 
 with 7 deaths ; 3 of his patients remained cured after four and a half years. 
 
326 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 the others after nearly four and more than three and a half years respec- 
 tively. 
 
 Richelot in 47 operations had 3 deaths from operation; i occurred after 
 two months from the repair of a urinary fistula. In 2 cases the diagnosis 
 was doubtful ; 3 patients had disappeared. Ten times hysterectomy was 
 of value only as a palliative measure directed against the rapid spread 
 of the disease; 28 patients remained: 11 had had recurrences, i at the end 
 of five and a half years, the others after an average of one year; 17 remained 
 cured : 2 after seven years, i after four years, 2 after three and a half years, 
 4 after from two to three and a half years, i after seventeen months, 7 
 others after less than one year. 
 
 I have had one cure lasting two and a half years, and one of three years' 
 duration, but recurrence then took place in each. 
 
 Kaltenbach has had 2 deaths from operation in 49 patients surgically 
 treated during a period of four and a half years; 25 had a return of the 
 growth within between three and a half to sixteen months ; i after one and 
 a half years ; in 7 no recurrence was noted at the end of one year. 
 
 Tannen reports 43 new cases operated upon by Fritsch between 1887 
 and 1889, with 3 deaths, or 6.9 per cent. Recurrence had not taken place 
 in 48.7 per cent at the end of three years ; in 45 per cent after four years; 
 in 36 per cent after five years. 
 
 Gusserow has had 7 deaths from operation in dj vaginal hysterectomies ; 
 56 patients w^ere seen again; 16 who had been operated upon between eight 
 years and ten months previously were free from recurrence; 10 were still 
 free after less than six months; 23 cases had recurred. 
 
 One of the most important sets of statistics is that of Leopold, who had 
 treated 80 cases of cancer by vaginal hysterectomy, only 4 dying as a result 
 of the operation. It includes his cases for five and a half years. At the 
 time of Miinchmeyer's publication, 14 of the ^^ women cured had died, 10 
 of these from a recurrence of the neoplasm. Since then ij others had died, 
 leaving 45, 37 of whom were seen by Leopold and 8 of whom had written to 
 him. These 45 cases are classified as follows : 
 
 Free from recurrence more than : 
 
 Two weeks after operation, 45 of So patients 56.25 per cent. 
 
 Three " " •• 34 " 58 " 58.6 
 
 Four " " " 25 " 42 " 59-5 
 
 Five " " " iS " 30 " 60. 
 
 Six " " " 6 " 9 " 66.6 
 
 Seven " " '' 2 " 2 " 100. 
 
 Hofmeier, Schauta, and Olshausen, who consider freedom from recurrence 
 at the end of the second year as establishing the therapeutic value of total 
 extirpation, have given the following figures as representing the proportion 
 of complete cures : Hofmeier places it at 24 per cent according to 
 Schroder's operations, and at 47.3 per cent from his own statistics. Ols- 
 
TREATMENT OF CANCER OF THE CERVIX. 327 
 
 hausen has been able to follow 155 of 235 cases operated upon in four and a 
 half years, with a mortality from operation of 12.8 per cent. More than two 
 years after the surgical treatment, no recurrence had taken place in 41 of 
 these, or 26.4 per cent. 
 
 Kriikenberg has published the results of 217 vaginal hysterectomies by 
 Schroder, Olshausen, and Hofmeier for cancer of the cervix. Twenty-five, 
 or 12.7 per cent, died as a result of the operation; 188 patients were seen 
 again and freedom from recurrence was noted : 
 
 At the end of one year in no of 188 cases, or 58.5 per cent. 
 
 " " two years " 63 " 141 " " 44.7 " 
 
 " " three " " 42 " 112 " " 37 " 
 
 " " four " " 26 " 88 " " 29.5 " 
 
 " " five " " 9 " 51 " " 17.6 " 
 
 Zweifel published in 1892 a series of 'j'j vaginal hysterectomies for can- 
 cer with 4 deaths from operation, or 5.5 per cent. Of 12 patients operated 
 upon in 1887 and 1888 all had recurrences; of 13 operated upon in 1889, 7 
 were free from recurrence; of 12 treated in 1890, 7 had not had a return ; in 
 the 14 patients operated upon in 1891 the growth had not yet reappeared. 
 
 Martin has performed 'j'j new vaginal hysterectomies for cancer since 
 1887, with 10 deaths, or 13 per cent. 
 
 I consider it better to use the term durable than that of final cure as 
 recurrence is still to be feared. It would seem illusory to speak of an abso- 
 lute cure of cancer of the uterus more than of other malignant neoplasms. 
 I believe one must mistrust the original diagnosis in patients who remain 
 free from recurrence. To me, hysterectomy is merely a palliative treatment 
 whose results are of greater or less duration ; the average being, in my ex- 
 perience, hardly more than one year, after which time the disease reappears 
 and leads to death within a year at the latest. In young patients and those 
 with the papillary or proliferating form, recurrence is often extremely rapid. 
 One is, however, none the less authorized to perform hysterectomy as to am- 
 putate the breast and dissect the axilla, an operation whose prognosis is cer- 
 tainly more serious. Recurrence is always to be feared in either case ; but a 
 cure, though temporary, is still a cure. 
 
 It is interesting to examine the reports of survival after partial operation 
 (supra- and intra-vaginal), and to compare them with those of total ablation 
 of the uterus. But before reporting on the principal documents which we 
 possess on the subject, I must remark that this unequal parallel should not be 
 made the basis of conclusions without some reservation. In what cases do 
 we always amputate the cervix } For cancer at its beginning. In what cases 
 do we ordinarily perform hysterectomy.-* For cancers which are well ad- 
 vanced, having already reached the body of the organ. In the first case, 
 there are many chances that the disease has not infected the lymphatics, but 
 very few in the second. Why should we then be surprised if return is less 
 rapid where amputation of the cervix has been so fortunate as to remove all 
 
328 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 of the disease ? But who shall say that all the cases of permanent cure would 
 not have been increased in number if those treated by partial operation had 
 been submitted to total ablation of the organ ? May not those cases be un- 
 recognized in which, with appearance of the disease limited to the cervix, the 
 mucous membrane of the body is invaded by propagation, and also those 
 in which the uterine parenchyma contains distant secondary nodules ? 
 
 The comparison which we would like to establish between the results of 
 partial and total ablation, as regards permanence of cure, would not be a just 
 one unless it were derived from two series of patients in exactly similar con- 
 ditions, with affections of equal development. But how shall we construct 
 such a parallel with the aid of published series of total hysterectomies which 
 refer in the great majority of cases to disease which has passed freely beyond 
 the cervix, which appear in the list of the less serious cases, and yet which 
 render the final table discouraging.^ For this reason I have thought that the 
 value of the actual statistics on this special point should be contested. 
 
 The most important papers on the subject are those of Schroder, Winter, 
 Verneuil, and of Byrne. 
 
 The first in date, and not the least curious, is the former, which gives all 
 the total hysterectomies and partial amputations of Schroder's clinic from 
 1878 to 1886. The following table gives the comparative number perma- 
 nently cured by the two methods : 
 
 At the end of first year, partial operation, 114 cases, 49 cures 51 per cent. 
 
 total hysterectomy, 46 cases, 20 cures 63.6 " 
 
 " " second ' ' partial operation, 102 cases, 38 cures 46 " 
 
 total hysterectomy, 40 cases, 7 cures 34 " 
 
 "' " third " partial operation, 76 cases, 24 cures 42 " 
 
 total hysterectomy, 31 cases, 6 cures 26 " 
 
 ■' " fourth ' ■ partial operation, 59 cases, ig cures 41.3 " 
 
 total hysterectomy, 18 cases, o cures o " 
 
 It is evident that an enormous advantage lies with the second year after 
 amputation (supra- and intra-vaginal taken together). At the end of three 
 years 24 patients out of y6 had no return of the disease, and at the end of 
 four years 19 out of 39: but may that not be due simply to the fact that 
 they were operated upon before the lymphatics were infected ? 
 
 The results of Verneuil are no less remarkable. The intra-vaginal oper- 
 ation with the ecraseur, in his hands, gave the following proportion of re- 
 currence and periods of respite: In 21 operations there were 10 cases of 
 rapid return ; in more than 9 of these Verneuil recognized by immediate ex- 
 amination that the ablation had not been complete. In 6 other cases there 
 was no return up to the time when the patient was lost to observation in 
 perfect health, three years and more after the operation. Two cases, which 
 are still alive but afflicted with a return in a distant part, presented an ap- 
 parent recovery after three years. Lastly, in 3 cases the patients were actu- 
 ally in good health after five years, seventeen months, and three months. 
 
 Winter has lately published the immediate results of partial amputation, 
 
TREATMENT OF CANCER OF THE CERVIX. 329 
 
 according to Schroder, in 155 cases; there were 10 deaths from operation, 
 or 6.5 per cent; after two years 38 per cent remained cured; 26.5 per cent 
 had had no recurrence after five years. 
 
 J. Byrne has published, in a recent paper, the results of his own experi- 
 ence for more than twenty years. He has operated upon 81 cases of 
 cancer of the cervix and has always performed partial removals with the 
 galvano-cautery. He has noted that the neoplasm had not recurred after 
 more than 17 years in i patient, after 13 years in another, 11 years in 2, 7 
 years in 6, 5 years in 8, 4 years in 6, and after more than 3 years in 1 1 cases. 
 
 In contrast to this series, which appears to prove the therapeutic superi- 
 ority of the partial operation, the results of Martin's experience should be 
 cited. A pupil of the school of Schroder, he began to perform supra-vaginal 
 amputation of the cervix in cases of epithelioma in which it was theoretically 
 indicated, but his results were deplorable : Among twenty-eight patients, 
 two alone remained without recurrence. He then adopted early hysterec- 
 tomy, with decided improvement in his ultimate results. 
 
 In the presence of such contradictions, and the absence of rigorous 
 means of comparison, I must persist in considering the value of these statis- 
 tics as very slight, for the conclusion appears to me paradoxical that partial 
 excision of the tissue about the neoplasm is as efficacious as ablation made 
 as free as possible. 
 
 Recently, surgeons have devised several new methods of penetrating the 
 lower pelvis. Otto Zuckerkandl has proposed division of the recto-vaginal 
 septum, making a transverse incision which will comprise all the space be- 
 tween the sciatic tuberosities, instead of being limited by the vaginal walls 
 Frommel has adopted this procedure with success, and claims that it allow;; 
 the surgeon considerably to exceed the usual bounds of hysterectomy. San- 
 ger, on the contrary, who performed the operation only on a cadaver, rejects 
 it completely. 
 
 The para-sacral or para-rectal incision of E. Zuckerkandl and Wolfier 
 furnishes a method of hysterectomy for difficult cases. It consists of a deep 
 incision, either on the left side or upon the right. The latter surgeon makes 
 his incision from a little higher than the articulation of the sacrum with the 
 coccyx, beginning from i to 2 cm. outside of that point and cutting down- 
 ward with a slight external concavity which corresponds to the tuberosity of 
 the ischium, to a point 2 to 3 cm. from the fourchette. In this way the 
 ischio-rectal fossa is opened from below ; then a part of the gluteus maximus 
 is resected (Wolfier then extirpates the coccyx, which E. Zuckerkandl pre- 
 serves), the sacro-sciatic ligaments and the levator ani are incised, and the 
 rectum detached from the vagina. The culs-de-sac of the latter canal are then 
 incised and the hysterectomy is performed according to the rules already 
 given. The operation is terminated by exact occlusion of peritoneum and 
 vagina and drainage of the para-sacral wound, which is partly closed by su- 
 tures. Wolffer has employed this method upon the living subject, for ex- 
 
330 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 tirpation of the rectum and also the uterus, while E. Zuckerkandl has limited 
 his researches to the cadaver. 
 
 It seems to me bolder and yet more rational to employ the preliminary 
 operation devised by Kraske for reaching the cancerous rectum deeply within 
 the pelvis. It consists not only in resection of the coccyx, as Verneuil and 
 Kocher have done, but also of the lowering of the sacrum, thus creating a. 
 very large opening where one can manoeuvre with ease. 
 
 The patient is placed in right lateral decubitus, and starting from the 
 point of the coccyx an incision is made bythe side of that bone for about ten 
 centimetres, curving outward to end at the middle of the sacro-iliac symphy- 
 sis (Fig. 225). The coccyx is cleared of the periosteum and extirpated, and 
 at the same time the lower portion of the sacrum is detached and removed 
 
 %M^M 
 
 Fig. 225. — Hysterectomy by the Sacral Method. 
 Line of incision. (The dotted line shows the central 
 
 Fig. 226. — Lines of Resection of the 
 Sacri'm. 
 
 axis of the body.) 
 
 with a Strong cutting forceps, first laterally, and then, if necessary, by a trans- 
 verse section. To procure space enough without injuring any important 
 nervous branch it is sufficient to carry this section just below the third sacral 
 foramen (Fig. 226). The rectum, which it is well to pack with iodoform 
 gauze, is then displaced laterally, and the peritoneum incised in Douglas' 
 pouch. An enormous opening is thus produced (Fig. 227), through which 
 can be seen a large portion of the anterior abdominal wall between symphy- 
 sis and umbilicus above the bladder. 
 
 The first anatomical experiments in the application of this method of 
 Kraske' s to hysterectomy were m^ade by C. A. Herzfeld, of Vienna, but 
 Hochenegg recorded the first operations upon the living subject. One of 
 these was by Gersuny, who was thus able to extirpate a very large uterus 
 with a cancerous ganglion buried in the subperitoneal cellular tissue ; the 
 f)ther was by Hochenegg himself, who removed both the uterus and a cyst 
 of the ovary as large as the fist, which was adherent. Both cases recovered,, 
 but the second developed an intestinal fistula. 
 
TREATMENT OF CANCER OF THE CERVIX. 
 
 331 
 
 A modification of the preceding method was adopted almost at once by 
 Hegar. It consists in making only a temporary section of the coccyx and 
 lower portion of the sacrum, and laying them to one side, without complete 
 extirpation. When the hysterectomy has been performed, the flap containing 
 the bone is returned to its place. Hegar had in one case a necrosis of the 
 displaced bone, and in another it remained movable. Roux and Terrier 
 followed Hegar's example for the extirpation of a voluminous cancer which 
 could not be removed through the vagina. In his second case, as the vagina 
 was very narrow and there were reasons to fear adhesions between it and the 
 bladder, Roux elevated the osteo-cutaneous flap as one opens a door, by trans- 
 verse section of the sacrum with a cutting forceps, and sutured it for the 
 time to the buttock. After ablation of the uterus the vagina was sutured. 
 
 Fig. 227. — Hysterectomy Through the Sacrum ; Open- 
 ing Obtained by Preliminary Operation. 
 
 Fig. 228. — Hysterectomy Through the Sacrum; 
 Closure and Drainage of the Wound. 
 
 the flap replaced, and the wound tamponed with iodoform gauze and closed at 
 its extremities. Both patients recovered. 
 
 Hochenegg advises not to proceed to detachment of the vaginal culs-de- 
 sac until the peritoneal wound has been closed by sutures ; in this way we 
 avoid as completely as possible infection of the serous membrane by the tu- 
 mor. With the same object, and to render the occlusion more complete, von 
 Beck dissects a layer of peritoneum from the anterior face of the uterus. 
 
 Zinsmeister has described a certain difficulty in finding the peritoneal 
 pouch at the bottom of the wound, but this seems to depend upon the fault, 
 in the operation, of not carrying the incision far enough downward ; it should 
 be prolonged almost to the anus. 
 
 The relations of the rectum make it preferable to operate upon the left 
 side, for then that organ is more readily seen, and consequently there is less 
 risk of injury if it has been moderately filled with tampons. Rectal wounds, 
 however, constitute one of the dangers of the operation and require immedi- 
 ate suture {suture a etage). The ureter may also be cut; if that happens, 
 it is made to empty into the rectum or the vagina. If into the latter, its 
 lower portion is to be closed after establishing free communication with the 
 
332 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 bladder. This is better than establishing a urinary fistula through the 
 wound. 
 
 After having carefully sutured the base of the wound itself, then the peri- 
 toneum (before extirpation of the uterus), then the vagina (when the extir- 
 pation has been accomplished), the externa] wound is partly closed, leaving 
 an opening large enough to permit drainage and antiseptic tamponing of its 
 cavity — that is, of the "dead space" which always remains. The tampons 
 should be left in place from six to eight days, then renewed and gradually 
 decreased in quantity as the cavity fills up. It would be dangerous to make 
 complete occlusion without some certain means of issue for the wound secre- 
 tions. 
 
 There is no doubt that preliminary resection of the coccyx and sacrum 
 greatly facilitates excision of cancer, which, without that, could be removed 
 only through the abdomen. I consider, however, that the vaginal route, 
 aided by forcipressure and morcellation, amply suffices for the removal of all 
 cancerous uteri which demand radical treatment, and I believe it may be 
 boldly stated as a principle that no cancer of the uterus, whose extirpation 
 through the vagina is impossible, should be submitted to any other than pal- 
 liative treatment. 
 
 IV. Canxer of the Cervix, with Suspicion or Certainty of Deep 
 
 Extension. 
 
 When the mobility of the uterus is lessened, and bimanual palpation dis- 
 closes a tumefaction and pufiiness at the sides of the organ, two hypotheses 
 are possible : perimetritis with adhesions, or extension of the cancer to the 
 pelvic cellular tissue and broad ligaments. In the first case operation would 
 be difficult and possibly dangerous, especially if there were purulent foci as 
 in an unfortunate case of Le Bee; in the second case it would be both dan- 
 gerous and useless. It would be better to refrain from interference, however 
 great may be the resources offered by the sacral method. 
 
 The operative prognosis is doubly aggravated in cancer with extension. 
 Martin had 32 per cent of deaths in such cases instead of the 16.92 per 
 cent which he obtained in cancer limited to the cervix. The cases which 
 increase the mortality of our statistics are very frequently of this kind. Re- 
 moval of the uterus from the midst of a deep cancerous focus has been im- 
 properly described under the name of palliative hysterectomy, just as the 
 name of irregular supra-vaginal amputation has been given to hysterectomy 
 which it becomes necessary to leave incomplete after an exploratory dissec- 
 tion. This is an abuse of scientific language which is much to be regretted, 
 for it seems to justify the operation where it is formally contra-indicated. An 
 operation of this kind, when it does not kill the patient, which is often the 
 case, is far less palliative than simple curetting followed by cauterization. 
 
TREATMENT OF CANCER OF THE CERVIX. 333 
 
 V. Cancer of the Cervix Invadtng the Vagina Primarily or Consec- 
 utively. 
 
 This invasion is an absolute contra-indication to any radical operation ; 
 for it is either an indication of the extension of an advanced cancer, which 
 has probably already infected the lymphatics, or it is the result of the so- 
 called vaginal form of cancer of the cervix, for which I have proposed the 
 name " liminaire," and which has an invincible tendency to extend to the 
 vagina and recur fatally in that situation. It is then rationally the whole of 
 the vagina rather than the whole of the uterus which should be removed. 
 Here the curette and cauterization are the best palliatives. 
 
 VI. Cancer of the Cervix Extending to Vagina and Bladder 
 
 OR Rectum. 
 
 In spite of advice to the contrary from distinguished surgeons, to attempt 
 a radical operation under these conditions, and for this purpose to remove the 
 uterus and invaded portions of rectum or bladder, seems to me a fatal delu- 
 sion. The operation certainly is feasible, but the recurrence, or, better, 
 the immediate local multiplication, is fatal after a brief delay, for a cancer so 
 far advanced has certainly infected the lymphatics. Moreover, the gravity 
 of hysterectomy is much increased in such cases, and we may therefore de- 
 mand whether it is well to expose the patient to dangers so great for benefits 
 so precarious. 
 
 In the last three categories which I have passed in review I have described 
 only a palliative operation capable of removing the two great causes of exhaus- 
 tion of the patient, namely, the hemorrhage and the fetid discharge. For 
 this purpose it is necessary rapidly to break down and remove the ulcerating 
 masses which cause these symptoms. The best instrument for this is the 
 curette, and beyond all others the cutting spoon of Simon (Fig. 229). With 
 this instrument the largest mass of fungous growth may be rapidly removed ; 
 the smaller vegetations being followed into the crevices with smaller sizes of 
 the curette. The position of the bladder and ureter must be noted before- 
 hand and the greatest caution observed in extensive lesions. If we penetrate 
 into the cavity of an invaded uterus we must, to avoid perforation, be careful 
 to attack its surfaces obliquely and not perpendicularly. 
 
 As soon as the surfaces have been cleaned, Martin, after freshening their 
 edges, reunites them to produce primary union, though it seems to me that 
 the cases which permit the application of this ingenious method are very rare 
 and that it is very inconvenient. I much prefer to follow the curettage with 
 the energetic application of the rose- or olive-shaped actual cautery, by which 
 the neoplastic processes are followed up and destroyed in the midst of the 
 healthy, more resistant tissue. This procedure is practically that which has 
 
334 
 
 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 given such good results in the hands of Koeberle and Baker, and which 
 Schroder also recommends ; I have obtained great benefit from it. 
 
 This method of treatment may be repeated at intervals of a few weeks or 
 months. If we operate rapidly, after application of cocaine to the vagina, 
 and under continuous cold irrigation, anaesthesia may be omitted, which is 
 desirable, as the patients are usually much exhausted and have more or less 
 
 Fig. 22g. — Cutting Curettes. A, B, and C, cutting spoons of Simon ; D. Recamier's cutting curette; £, Sims' 
 model ; J^, fenestrated curette with malleable handle ; G, Thomas' serrated curette. 
 
 advanced kidney lesions. The operation causes but little pain, and only the 
 preparation for it is somewhat appalling. 
 
 After the curettage a tampon of iodoform gauze is placed in the cavity 
 produced by the excision, and renewed at the end of two days. Injections 
 of sublimate i : 5,000, which appears to me the best, may also be employed. 
 As soon as the granulations at the base of the vagina begin to secrete with 
 some abundance I apply a small disc-shaped tampon wet with chloride of 
 zinc (i : 10), kept solidly in place and isolated by a large tampon of iodoform 
 gauze saturated with bicarbonate of soda, the vagina being carefully tam- 
 poned with cotton so as to avoid any displacement. This dressing should be 
 
TREATMENT OF CANCER OF THE CERVIX. 335 
 
 renewed every second day, and each time preceded by abundant irrigation 
 with sublimate. 
 
 Chemical Cautcrirjation. — Various agents have been employed for this 
 purpose, such as nitric or chromic acid, a i : 5 alcoholic solution of bromine, 
 etc. The vagina must always be protected by tampons wet with a saturated 
 solution of bicarbonate of soda. Ganquoin paste has its ardent defenders, 
 but numerous accidents, such as perforation, peritonitis, etc., due chiefly to 
 the employment of caustic arrows {flechcs), have caused these to be almost 
 entirely abandoned; chloride of zinc, however, managed with care, may ren- 
 der real service. The first to apply this caustic to the treatment of cancer 
 of the cervix were Maisonneuve and Demarquay. Marion Sims, to whom 
 many authors give the credit of the procedure, really came after them, and 
 Van de Warker imitated the latter in his special technique without citing 
 him; more recently, Frankel has recommended this agent again. Its appli- 
 cation is as follows : The diseased surface is scraped with the curette, and 
 the bleeding stopped with the cautery, though its action is not carried very far. 
 Then a small tampon of cotton is placed on the cervix after being wet with a 
 solution of chloride of zinc (^3), and this is left in place from twelve to 
 twenty-four hours. To neutralize the effects of this acid caustic on the va- 
 gina, Frankel, following the example of Sims, superposes a tampon wet with 
 bicarbonate of soda, and anoints the vulva with vaseline containing the same 
 ( V3). The eschar is detached in about ten days. 
 
 [I have seen very satisfactory palliative results from chloride of zinc used 
 as follows : A sufficient number of very thin discs of cotton about one inch 
 in diameter are soaked in a saturated solution of the zinc chloride, squeezed 
 flat and dried. A number of larger tampons are prepared in the same manner 
 from a saturated soda solution. The cancerous growth is rapidly and vigor- 
 ously curetted until firm tissue is reached, when hemorrhage, until then pro- 
 fuse, usually ceases. The thin caustic discs are then carefully packed over 
 the whole of the raw surface and the vagina carefully and firmly tamponed 
 with the soda cotton. If the zinc cotton is used wet, it is difficult to prevent 
 the caustic from running on to the vaginal walls and causing disagreeable 
 sloughing. The slough caused by this treatment is deep and follows up the 
 diseased tissue; it is dry and leathery and usually separates in from seven to 
 ten days, leaving a very clean granulating surface. 
 
 The first tampons are to be removed on the second day, and the parts 
 dressed with iodoform gauze until the separation of the slough is completed.] 
 
 As an injection for disinfection in cases of very fetid discharge we may 
 use a solution of permanganate of potash, about 10 to 20: 1,000 (a solution 
 which should have a cherry-red color) or a dilute Labarraque's solution, and 
 besides employ the curette followed by the cautery, or chloride of zinc, for 
 destruction of the fungosities. 
 
 Against the hemorrhage, which will be diminished by the foregoing meas- 
 ures, we may apply tampons wet with perchloride of iron and then dried, after 
 
336 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 having dusted them with iodoform ; but the hot iron energetically employed 
 is the best means. Ergot is almost without effect, but something may be 
 done with digitalis. 
 
 Erythema of the vulva may usually be prevented by extreme personal 
 cleanliness, bathing with white wash (liq. plumbi subacetatis), and inunction 
 of borated vaseline as a protection from the vaginal discharge. 
 
 Gastric symptoms are to be treated b}^ tonics and bitters, such as wine 
 of quinine, wine of Colombo, bitter tincture (Baume's) in doses of two or 
 three drops before each meal, tincture of nux vomica in ten or fifteen drop 
 doses in the same way, or amorphous quassin in pills of i cgm. twice a day. 
 If the kidneys are affected, milk diet should be ordered. Against repeated 
 vomiting of uraemic origin. Winker has obtained good results from tincture 
 of iodine in drop doses in water before each meal. 
 
 Constipation must be combated with great care, for the straining which 
 it causes is a potent element in the production of the metrorrhagia. The 
 best means of regulating the bowels is to give the patient a diet with plenty 
 of vegetables and fruit, green peas, prunes, etc. A large enema every day, 
 with the addition of two tablespoonfuls of glycerin, usually suffices so that 
 we avoid the constant and injurious employment of purgatives, but, if neces- 
 sary, the following may be given : 
 
 I^ Pulv. rhei, .......... gr. viiss 
 
 Pulv. belladonnae, ......... gr. )4- 
 
 M. ft. caps. No. i. 
 
 If these measures are not successful, we must have recourse to drastic 
 purgatives, of which the best is podophyllin : 
 
 I^ Podophyllin, . . ....... gr. ss. 
 
 Ext. belladonnse, ......... gr. %. 
 
 M. ft. pil. No. i. 
 
 The pains are seldom benefited by surgical interference, but frequent in- 
 jections and dressings diminish them sensibly. Morphine by hypodermic 
 injection could hardly be refused without cruelty to patients whose condi- 
 tion is hopeless. It is only necessary to enforce the limits within which it 
 may be employed, and so avoid such abuse of the drug as would alter the 
 digestive function and depress the bodily powers. 
 
 [In many cases the most satisfactory results in relieving pain are ob- 
 tained by the employment of — 
 
 I^ Phenacetine, ......... 3 i.-iss. 
 
 Codeinse, .......... gr. vi.-xij. 
 
 M. ft. chart, (vel caps.) No. vi. Sig. One powder to be taken three times a day for pain.] 
 
 The following have been recommended as specifics : Hemlock, which 
 merely aggravates the stomach disturbance; condurango in decoction (15 
 gm. to 200 gm. water"), which acts only as a stomachic; and Chian turpen- 
 tine (0.5 to i.ogm. in pill), which seems to have no injurious action, al- 
 though its therapeutic value has not been demonstrated. [Methylene blue 
 
TREATMENT OF CANCER OF THE CERVIX. 33/ 
 
 (pyoktanin), in two cases in which I have employed it locally, seemed to 
 lessen the amount of hemorrhage, pain, and foetor, but had no perceptible 
 effect in checking the progress of the disease.] 
 
 VII. — Cancer of the Cervix Complicating Pregnancy. 
 
 It is impossible to recognize a pregnancy, in a woman with cancer of the 
 cervix, before the fourth month, for the volume of the uterus may be 
 legitimately attributed to the presence of the neoplasm. If, however, the 
 diagnosis should be made at that early period, ought the fact to modify the 
 treatment ? I think not. What we know of the accelerating influence of 
 pregnancy on uterine cancer on the one hand and the great probability of 
 abortion on the other make vaginal hysterectomy perfectly legitimate when- 
 ever it is applicable to the gravid uterus. For this operation the disease 
 must be limited, and the volume of the uterus must permit extraction by the 
 vagina. It is then remarkably easy on account of the laxity of the tissues, 
 and is infinitely preferable to intra- or supra-vaginal amputation of the cer- 
 vix, which is a frequent cause of abortion and has often been followed by 
 rapid recurrence. [The primary mortality seems to be even lessened by the 
 presence of early pregnancy ; fourteen cases, all successful, where the can- 
 cerous uterus with a pregnancy advanced from two to four months, has been 
 removed by vaginal hysterectomy having been recorded in 189 1. If the neo- 
 plasm has extended to the adjacent tissues we must distinguish between the 
 very hard cervix, when abortion should be induced and followed by palliative 
 treatment of the cancer (curette and cauterization), and the fungous cer- 
 vix, all of whose circumference is not invaded, when it is best to wait and 
 not induce abortion until feebleness of the foetal heart renders it probable 
 that its death is imminent. 
 
 When the labor is difficult, we should employ, according to circumstan- 
 ces, version or the forceps, and as a final resource the Caesarean operation, 
 for it seems to me that we should not sacrifice by craniotomy the living child 
 of a mother who is beyond hope. 
 
 Finally we must consider the rare cases in which the cancer is still limited, 
 but the uterus is too far developed for extraction by the vagina without evac- 
 uation of its contents. It is impossible to give rules which shall apply to 
 all cases ; the study of each patient must be the surgeon's guide. The fol- 
 lowing operations may be adopted, according to the special conditions of 
 each case : 
 
 A. Induced labor, with hysterectomy after a few days. 
 
 B. Caesarean operation, with colpo-hysterectomy later. 
 
 C. Supra-vaginal hysterectomy (Porro) followed at once bv vaginal re- 
 moval of the remainder of the uterus. 
 
 D. Total extirpation of the gravid uterus, with dissection of the vagina, 
 by laparatomy, according to the procedure adopted for the first time with full 
 success by Spencer Wells on October 21st, 1 88 1. 
 
 22 
 
338 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 VIII. Cancer of the Cervix Complicating Fibroma. 
 
 If the fibrous tumor is large enough to form an absolute obstacle to the 
 accomplishment of vaginal hysterectomy, there is only the choice between 
 the abdominal operation of Freund, extirpation through the pelvis (sacral), 
 and curetting followed by cauterization. One or the other of these last two 
 is the method which I should adopt, for the dangers of abdominal hysterec- 
 tomy are very serious in such cases. If, however, the fibroid is within the 
 limits which I have indicated above (p. 233), vaginal hysterectomy by mor- 
 cellation should be done. 
 
 IX. Cancer of the Cervix, with Complicating Cyst of the Ovary. 
 
 Should hysterectomy be performed, if it is legitimate, before the ovari- 
 otomy or after it, or both in one session .-* I consider that the affection 
 whose course is the more menacing should be first treated, namely, the can- 
 cer. If the radical operation is justifiable, we should first perform total ex- 
 tirpation by the vagina and try, after puncture, to remove the cyst wall 
 through the vaginal wound. If this manoeuvre should prove too difficult it 
 would be better to give up the attempt, and perform ovariotomy after the 
 patient had recovered; if, on the contrary, palliative treatment of the cancer 
 alone is possible on account of its extension, we should not attempt ovari- 
 otomy, as the patient will survive but a very short time. Asch records a case 
 in which he performed total extirpation of the cancerous uterus and ovariotomy 
 at the same time. The uterus was first removed by the vagina, then the cyst 
 by laparatomy. In beginning the second operation, bubbles of air were no- 
 ticed in the peritoneum, evidently introduced by the vaginal opening. On 
 the eighth day, after removal of the sutures, there was gaping of the wound, 
 and escape of the intestines, which displaced the bandage and rested on the 
 thighs for two hours. These loops of intestine were cleansed with carbolic 
 compresses and returned to the abdomen and a second suture made. The 
 patient recovered. It is difficult to think that this serious accident could 
 have occurred if the operation had been performed in two sessions. 
 
CHAPTER XVI. 
 
 CANCER OF THE BODY OF THE UTERUS. 
 
 Adenoma of the Uterus. — There is, except among French authors, a cer- 
 tain amount of confusion regarding adenoma of the uterus. Some authors 
 apply the name of typical or benign adenoma to what I have described as 
 glandular endometritis in a preceding chapter, while atypical or malignant 
 adenoma is the same as the first stages of degeneration of the mucous mem- 
 brane in epithelioma. This difference they derive from the anatomical con- 
 ditions entirely, depending upon the distinctions and refinements of histol- 
 ogy, while I, with all other French authorities, have adopted the nosology 
 to the clinical aspect. The conception of adenoma plays no part at the bed- 
 side of the patient. I refer to the chapter on Metritis for whatever con- 
 cerns benign adenoma, having described its pathology with glandular metritis 
 and its symptoms with catarrhal and hemorrhagic metritis and mucous polypi. 
 
 Malignant adenoma is then only the initial stage of cancer of the mu- 
 cous membrane. If there is any need of further distinction it may be de- 
 scribed histologically as glandular epithelioma, adeno-carcinoma, or glandular 
 carcinoma. 
 
 It suffices to glance at the two following figures to see the enormous 
 difference which separates these conditions, and to grasp at the same time the 
 transitions which permit the transformation of the one into the other; for a 
 lesion begun as a slight glandular endometritis may become, if inveterate, a 
 glandular endometritis of the most pronounced type (typical benign adenoma), 
 may then degenerate into an atypical malignant adenoma, and this is the first 
 stage of cancer. 
 
 In the case of the so-called benign adenoma (Fig. 230) the proliferation 
 "is absolutely typical, there are no solid epithelial tubes, and the cylindrical 
 epithelium is in one layer only. Between the glandular tubes there is still 
 •a certain quantity of normal interglandular tissue. The glandular and the 
 muscular layers are clearly defined, and the glands have no tendency to pene- 
 trate into the muscular parenchyma and destroy it. 
 
 In malignant adenoma (Fig. 231), on the contrary, the proliferation of 
 the glands is atypical; furnished with a single layer of cylindrical epithe- 
 lial cells, they are folded upon themselves and rolled up into glomeruli ; the 
 fibrous substratum has almost disappeared and the glands touch each other at 
 many points; and there is no boundary between the glands and the uterine 
 tissue. 
 
 The figure, borrowed from Ruge and Veit, reproduces the initial lesions 
 
340 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 of cancer derived from malignant adenoma, forming thus the last stage 
 which I have described in the pathological progression. The lumen of the 
 glands is enlarged at the expense of the interglandular substance, the beau- 
 
 FiG. 230. — Benign Adenoma of the Uterine Mucous Membrane (Compare ^vith Fij;. 100, Glandular Endome- 
 tritis), Wyder. 
 
 tiful epithelium with vibratile cilia has changed its form and become strati- 
 fied, flattened, and enlarged with an epidermoid aspect, following the greater 
 
 Fig. 231. — Malignant Adenoma of the Uterine Mucous Membrane. Beginning glandular epithelioma 
 
 (Ruge and Veit). 
 
 or less rapidity of the proliferation, and the gland cells also stain with more 
 difficulty. The space which the gland occupies by its increase may be fifty 
 
CANCER OF THE BODY OF THE UTERUS. 34I 
 
 times that of its original volume. The epithelial proliferation may begin 
 upon one of the walls and fill the cavity little by little, so that at last there 
 remains but an insignificant portion still covered with a single layer of epi- 
 thelium; or it may start from the whole circumference of the gland at once 
 and leave the cavity persisting. In other cases the glandular canal disap- 
 pears so that there is only a solid mass of cells. Finally the proliferation 
 of the cells may begin from many points at once and form b}^ their junction 
 a series of bridges which dividethecavity into several compartments. These 
 glands, in part degenerated, form the last term between those which are 
 still normal and those which are transformed into solid cylinders, stuffed full 
 of cancerous cells. 
 
 As regards symptoms, prognosis, and treatment, malignant adenoma is 
 identical with cancer of the uterine body. 
 
 Cancer of the Body of the Uterus. 
 
 Cancer of the body of the uterus presents various anatomical forms which 
 •correspond to distinct clinical types, as follows : 
 
 1. Cancer of the mucous membrane: 
 
 A. Epithelioma (French authors). 
 
 Carcinoma (German authors). 
 
 B. Sarcoma. 
 
 2. Cancer of the parenchyma (fibro-sarcoma, sarcomatous fibroma). 
 
 3. Deciduoma malign uni. 
 
 Primary cancer of the body of the uterus has until recently been regarded 
 as very rare. Gallard found but two cases in his long career, and Pichot in 
 1876 could collect only forty-four cases among French and English authors. 
 
 This apparent rarity depends upon the fact that the older gynaecologists 
 ■seldom employed exploratory dilatation, and almost never exploratory cu- 
 rettage. Thanks to the modern means of investigation we now know that 
 primary cancer of the uterine mucous membrane is far more frequent than 
 had been thought to be the case; thus Gusserow has published 122 cases. 
 The relative frequency of cancer of the body and of the cervix is, according 
 to Szukits, in the proportion of i to 420. More recently, Schroder in 812 
 cases found 28 of primary cancer of the body, and Schatz among 80 cases 
 found 2. 
 
 I. Epithelioma or Carcinoma of the Mucous Mem.brane. 
 
 The German school ordinairly applies the term carcinoma to the form 
 which the French school now designates as epithelioma. I shall consider 
 these two terms, which suggest but one and the same lesion, as synonymous. 
 One might almost describe this lesion as cancer of the menopause, in view 
 •of its great frequency at that epoch of the genital life. It originates in a 
 
342 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 transformation from the conditions of glandular metritis, such as I have de^- 
 
 scribed, which may be followed step by step in the same patient by repeated 
 
 curettings. 
 
 P^;'/^(?/(?^.— -Macroscopically we may distinguish two varieties. In the 
 
 one there is a diffuse growth of villi throughout the whole uterine cavity,, 
 
 which gives to its section-, 
 the aspect of a ripe fig 
 (Figs. 233 and 234); in 
 the other there is an iso- 
 lated fungoid growth with 
 a large or small base^ 
 which at times has the 
 form of a polyp (Fig. 232). 
 It is worthy of note 
 
 Fig. 232. — Epithelioma of the Uterine Mucous 
 Membrane, Circumscribed Form. 
 
 Fig. 233. — Epithelioma of the Uterine Mucous 
 Membrane, Diffuse Form. 
 
 that the neoplasm has little tendency to invade the mucous membrane of 
 the cervix. This peculiarity is both an added difficulty in diagnosis and an 
 advantage in the matter of treatment. The uterine wall, on the contrary, 
 is little by little eroded and destroyed. Metastatic nodules form in vari- 
 ous points of the parenchyma, and even under the peritoneum, causing pro- 
 tective adhesions of that membrane between the uterus, the bladder, and 
 the intestines. Occasionally fatal peritonitis has been caused by perfora- 
 tion. Frequently these metastatic nodules are found superficially in the 
 vagina and deeply in the ovaries, tubes, etc. 
 
 Histologically these tumors are tubular or lobulated epitheliomata pro- 
 vided with tubes which for the most part are very large and form anastomo- 
 ses with each other, with the peculiarity that the first layer of cells implanted 
 
CANCER OF THE BODY OF THE UTERUS. 
 
 343 
 
 upon the wall is regularly cylindrical. These cells are of long shape, and 
 have nuclei which stain strongly. The successive layers are formed by poly- 
 hedral cells which are at times of the pavement variety. The most internal 
 become mucous, cover the granulations, and often present complete atrophy 
 of their nuclei. 
 
 When a section is examined under a low power to obtain a comprehen- 
 sive view of the neoplasm, a number of alveoli may be discerned, whose thin 
 walls are carpeted by cylindrical epithelial cells in one or two layers only. 
 
 j^-'^S^:^'?^;^ 
 
 A /<af;jjau5Ai 
 
 Fig. 234. — Epithelioma of the Uterus ; Diffuse Form, with Circumscribed Thickening, a. Muscular wall 
 of the uterus ; b, <?, section of neoplasm ; <r, surface of neoplasm ; d, cervix, not involved. 
 
 In the fresh state, large cavities are also found which contain a mucous 
 liquid holding cells in suspension (Fig. 235). It is easy to understand the 
 method of formation of these cavities. The fibrous wall which circumscribes 
 them contains capillary vessels penetrating into the epithelial layer, and cov- 
 ered by it. These vessels present vegetations under the form of papillae, 
 which are seen sometimes cut longitudinally, sometimes transversely, in 
 which latter case they appear to be surrounded by cylindrical cells. There 
 are also mucous cavities in the midst of the epithelial investment, so that 
 certain tubes, originally narrow, are transformed into large cavities. 
 
 With the higher powers the conditions are more easily understood (Figs. 
 236 and 237). Besides the lesions, which are wholly epitheliomatous, the 
 alterations of chronic metritis are almost constantly found. To avoid errors 
 many sections should be examined, and not merely a few small fragments. 
 
 The great quantity of cylindrical cells in these tubular or lobulated for- 
 mations distinguishes these epitheliomata of the uterus from ordinary tubu- 
 
344 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 lar pavement epitheliomata, such as are found in the integument. They are 
 in reality a special form, peculiar to the mucous membrane where they are 
 developed. 
 
 At an advanced stage of evolution, cancer of the body of the uterus may 
 ulcerate, or, as Cornil has found, the mucous membrane may be preserved 
 and merely elevated by the epithelial lobules. 
 
 The mucous membrane of the body of the uterus is usually easily recog- 
 nized, for its epithelial cells are preserved although covered by certain wan- 
 dering cells, but its glands are atrophied and their cylindrical cells are very 
 
 Fig. 235. —Epithelioma of the Uterus. X 120. 3, 3, Lobules of the epithelioma; »«, lobules showing empty 
 spaces, which are either transverse sections of vessels or cavities filled with cells in mucous degeneration ; «, smaller 
 alveoli of the epithelioma. Nearly all of these epithelial cells have a tendency toward isolation by the walls of the 
 spaces that inclose them. 
 
 small, the connective tissue being thin and compressed. In other places the 
 mucous membrane is reduced to a very thin layer of connective tissue lined 
 by one simple layer of cylindrical cells (Fig. 238). 
 
 At a later period the muscular layers are infiltrated by the neoplasm, and 
 there may also be extension to the tubes and ovaries. 
 
 I have described as a unique anatomical curiosity a case of primary pave- 
 ment epithelioma of the body of the uterus, observed by O. Piering and 
 others. 
 
 Symptoms. — Hemorrhage is the primary symptom, and, as in cancer of 
 the cervix, it is usually accompanied by a serous discharge of a reddish 
 color and a stale, disagreeable odor; with this there is often a discharge of 
 small shreds of tissue from the broken fungosities. 
 
 The pains and the other functional and reflex symptoms are, for a long 
 
CANCER OF THE BODY OF THE UTERUS. 
 
 345 
 
 time, those which I have described under the head of the uterine syndroma 
 {I'ide metritis) ; but according as the disease becomes more advanced the 
 pain takes on a paroxysmal character which is remarkable and almost pathog- 
 nomonic. These crises of excruciating pain described by Simpson are 
 wrongly attributed, I think, by Schroder to contractions of the uterus caused 
 by the effort to expel its abnormal contents. They have none of the char- 
 acters of colic, and their appearance at regular hours once or twice a day, 
 even after the tumor has been destroyed by the curette, as I have observed. 
 
 
 Fig. 236.— Epithelioma of the Body of the Uterus. High power, c, Connective tissue ; d, glandular cul- 
 de-sac, but little altered ; _/, g, ;«, dilated and modified glands. Their investment is formed of cylindrical cells, _/", but 
 their cavity is full of cells, ?«, g^ and the glandular membrane is wanting, a. Large cavity in the middle of an island 
 of epithelioma. The epithelial mass is pierced by vessels which belong to the adjacent connective tissue, as seen at 
 ^, 7', w, oblique sections of the same vessels (Cornil). 
 
 proves clearly that they are due to a veritable neuritis propagated along the 
 nerves of the disorganized uterus. 
 
 Bimanual palpation determines that the organ is much increased in vol- 
 ume, being as large at times as the pregnant uterus at the fourth month. It 
 remains movable for a long time, but finally becomes imprisoned by adhe- 
 sions in the pelvis. By touch, the cervix is found to be free from the disease, 
 but often much softened and partly open, as in the case of the gravid uterus. 
 
 The sound, which should be used with much precaution, reveals an 
 increase in the capacity of the uterus, and the presence of irregular masses. 
 At times the cervix may be sufficiently dilated for the finger to feel these 
 fungosities within the uterus; if not, an artificial rapid dilatation will con- 
 iirra the diagnosis. 
 
346 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 The condition of the general health fails as the neoplasm develops and 
 terminates in cachexia. 
 
 Diagnosis. — The hemorrhage, the serous discharge, the increase in the 
 volume of the uterus, and the results of intra-uterine exploration constitute 
 the clinical elements of the case, while the examination of portions removed 
 by the curette clearly differentiate between cancer and metritis without ma- 
 lignant neoplasm, or between carcinoma and sarcoma. This examination is 
 particularly necessary in order to differentiate cancer of the uterus from 
 certain cases of fetid endometritis which occur in aged women. 
 
 It is in these cases, however, that we encounter the greatest difficulties in 
 the differential diagnosis between cancer and metritis. With all the com- 
 
 FlG. 237. — Primary Epithelioma of the Uterine Body. X 300. a, Numerous layers of stratified epithelium- 
 the deepest being cylindrical ; ^, e, cells with karyokinesis ; /, muscular tissue of the uterus, on which the cylindrical 
 cells are directly implanted (Cornil). 
 
 mon rational signs, and especially persistent hemorrhage which has resisted 
 the curette, we have only the resistance of the disease to therapeutic meas- 
 ures and the examination of small particles removed by the curette to enable 
 us to decide the nature of the lesion. As Cornil has justly remarked, al- 
 though histological diagnosis is easy when we have the whole uterus to exam- 
 ine, it is otherwise when we can secure only small fragments of the mucous 
 membrane. The simple glandular hypertrophy of metritis may then be very 
 difficult to distinguish from carcinoma, especially when the mucous mem- 
 brane of the glands cannot be examined in the deeper parts. In the simple 
 glandular hypertrophies there often exists between the culs-de-sac and the 
 connective tissue a very regular layer of fiat cells, which serve as the mem- 
 brane of implantation for the epithelium. The vibratile cilia are almost al- 
 ways preserved and are found to the bottom of the gland. The mucous 
 transformation of the cells is never complete, but occupies only their free 
 extremities. The inter-glandular tissue is less charged with lymph cells, but 
 in the epithelioma and the layers of young connective tissue they are arranged 
 in regular lines which follow parallel to the excretory ducts. In the epi- 
 
CANCER OF THE BODY OF THE UTERUS. 34/ 
 
 theliomata, on the contrary, there is at the same time a hypertrophic elonga- 
 tion of the glands and a multiplication of cells which rapidly lose the type 
 of ciliated epithelium. As a result of this proliferation the lower part of the 
 gland is filled full with an epithelial mass. The cells may either undergo 
 a mucous transformation or take on the polyhedral or cuboid form. As soon 
 as the walls of these glands are ruptured, the tumor presents the general dis- 
 position of epithelioma or carcinoma. 
 
 It may happen then, that as a last resort against the persistent hemor- 
 rhage which threatens the life of the patient, we are obliged to perform vaginal 
 hysterectomy with only a diagnosis of probable cancer, but beforehand we 
 must carefully assure ourselves by examination of the adnexa that they are 
 not the cause of a reflex hemorrhage. Occasionally we can determine upon 
 the organ so removed the presence of the characteristic lesions of epitheli-^ 
 
 Fig. 238. — Mucous Membrane of the Cervix Compressed and Atrophied by a Cancer Developed in the- 
 Deeper Layers. X 300. e^ e. Mucous cells of the clear epithelial investment, no longer having cilia ; a, wandering 
 cell on the surface of the epithelium ; b, a desquamated epithelial cell ; t, connective tissue of the mucous membrane 
 compressed by the tumor ; v, vessels ; g; glandular tube (Cornil). 
 
 oma which were not demonstrable from the fragments obtained by the cu- 
 rette. Martin and Lohlein have published cases of this nature which are very 
 instructive to the clinician. 
 
 A fibroma which is undergoing cancerous degeneration may be recog- 
 nized by the aid of the microscope. The presence of metastatic nodules of 
 a cancerous nature in the vagina will render the diagnosis clear. 
 
 The prognosis is grave; nevertheless an early operation has been fol- 
 lowed by a long survival. 
 
 Etiology. — This form of primary cancer of the uterus is found chiefly in 
 women who have reached the menopause, the average age according to Hof- 
 meier being fifty-four years. Among thirty-one cases of malignant tumor, 
 comprising many varieties which Pichot removed, only nine were below the 
 age of fifty; in but one case was the influence of heredity manifestly pres- 
 ent; nulliparae were far more frequently attacked than in the case of cervi- 
 cal cancer. Only twenty-one per cent of Hofmeier's cases had never had 
 children. 
 
348 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 II. Diffuse Sarcoma of the Mucous Membrane. 
 
 Following Virchow, the name of diffuse sarcoma is given to thickening 
 of the mucous membrane by proliferation of round or fusiform cells which 
 infiltrate it and produce the type of young connective tissue, producing soft 
 villous or lobulated tumors of an encephaloid aspect. This form of cancer 
 is found most frequently in young women. 
 
 Pathology, — There is no need of dwelling upon the microscopic charac- 
 
 FiG. 239. — Sarcoma of the Uterine Mucous Membrane. 
 
 ters of sarcoma, which here present nothing of special interest (Fig. 240), 
 except to notice that the histological elements of sarcoma and cancer have 
 occasionally been united in the same tumor, thus constituting a mixed form 
 or carcino-sarcoma. 
 
 When the sarcoma forms a pedicled tumor it may present in the cervix 
 like a polyp. Its ulceration and disintegration are more rapid than in the 
 case of epithelioma, and when the process has begun it may destroy the 
 uterine parenchyma. 
 
 Abel, as I have already mentioned, affirms that diffuse sarcoma of the body 
 of the uterus often coexists with cirumscribed epithelioma of the cervix, but 
 he seems to have taken a purely inflammatory lesion for a sarcomatous 
 growth. 
 
 Symptoms and Diagnosis. — The symptoms resemble in many particulars 
 those of the preceding form. There is hemorrhage, a serous discharge, and 
 
CANCER OF THE BODY OF THE UTERUS. 
 
 349 
 
 increase in the size of the uterus. The introduction of the finger discovers 
 the neoplasm. Tlie cervix is not involved. But sarcoma is distinguished 
 from epithelioma by the following clinical characters. The discharge is less 
 fetid during the early stages, the ulceration appears later, and the cervix is 
 not so much dilated; possibly also a polypoid tumor may be found opening 
 the cervix and descending into the vagina, at times causing inversion of the 
 uterus. For the diagnosis from other diseases I refer to the preceding form. 
 
 Prognosis. — This is very grave, fatal recurrence being observed even 
 when an early operation has been performed. 
 
 Etiology. — One of the most remarkable characters which separate this. 
 
 Fig. 240. — Diffuse Sarcoma of the Uterine Mucous Membrane. The neoplasm is separated from the peri- 
 toneum on the left by a well-marked layer of healthy muscular tissue several miUimetres thick ; the superficial portions 
 toward the cavity of the uterus, on the right, are beginning to disintegrate. In the deeper parts are seen the connec- 
 tive-tissue fibrils, rich in fusiform cells with long and short processes. Between them is an amorphous basement sub- 
 stance with a large accumulation of round cells whose nuclei appear to resemble those of the others. In the superficial 
 portions the bands of connective and muscular tissue have entirely disappeared, being replaced by round cells. The 
 tumor is very rich in vessels, about which are foci of hemorrhage. In no part of the tumor can we find any trace of 
 either mucous membrane or gland (Wyder). 
 
 neoplasm from epithelioma is the age at which it occurs, there being many 
 cases of it among women of less than twenty years. Zweifel has reported 
 one case of hysterectomy performed for uterine sarcoma in a child of thir- 
 teen. It especially attacks nulliparce. The first histogenetic stage seems 
 to be an interstitial endometritis. As this has so often been observed in the 
 body of the uterus when the cervix is the seat of epithelioma, it is conceiv- 
 able that the metritis may transform itself into sarcoma, according to the still 
 disputed opinion of Abel, whence the frequent coexistence of these two dif- 
 ferent neoplasms in the same uterus. 
 
 III. Fibrosarcoma. 
 
 Synonyms : Sarcoma fibrosum seu nodosum, circumscribed fibro-sarcoma, 
 sarcoma of the uterine parenchyma. 
 
 Pathology. — From a clinical point -of view this form might be called ma- 
 lignant fibroma; like its benign homologues, it occurs as a submucous, in- 
 
350 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 terstitial, or subserous tumor. Like them also it takes its origin in the 
 parenchyma of the uterus ; but instead of being limited by a loose capsule, 
 it is, as a distinctive characteristic, deeply rooted. On section its surface is 
 pale and its consistence homogeneous and soft. When it has a pedicle it is 
 apt to be fibrous, showing that it has come from a degenerated fibro-muscu- 
 lar polyp. The vestiges of a structure which was at first benign may at times 
 be recognized in the sessile tumors, but in others the characteristic tissue 
 of sarcoma — namely, the accumulation of round cells, in places fusiform — is 
 traversed by a few bands of connective tissue. It is very probable that a 
 ifibro-sarcoma always originates in a fibro-myoma; this degeneration may 
 often be detected, as the remarkable observations of Chrobak, M tiller, Simp- 
 son, Frankenhauser, and Kurz demonstrate. 
 
 Metastatic nodules have been observed in the vagina, the peritoneum, the 
 lung, the liver, and the vertebras. 
 
 Transformation of fibro-sarcoma into myxo-sarcoma, cysto-sarcoma, and 
 other mixed forms is exceedingly rare, of which a remarkable case of Gus- 
 :serow's of a myxo-sarcoma with metastasis to the peritoneum, and another 
 of Rabl-Riickhardt's, where there was a combination of carcinoma and fibro- 
 :sarcoma, are noteworthy examples ; the partisans of the proposition defended 
 by R. Maier might even see here a proof of the direct transformation of sar- 
 •coma into carcinoma. 
 
 Symptoms. — At first nothing distinguishes fibro-sarcoma from a benign 
 iibroma, the signs being hemorrhage under the form of menorrhagia or me- 
 trorrhagia, with a serous discharge, a non-odorous hydrorrhoea, moderate pain, 
 and increase in the size of the uterus. The physical phenomena are those 
 of a non-ulcerated tumor which may be reached by the finger if the cervix is 
 -dilated and the tumor submucous. 
 
 Later on, ulceration of the neoplasm alters the scene ; the bleeding be- 
 'comes an almost continuous oozing; the leucorrhoea has a fetid odor and 
 contains debris which under the microscope is found to be made up of sar- 
 comatous tissue; the pain increases and takes on a regular paroxysmal char- 
 acter, as already described under carcinoma of the mucous membrane. Local 
 examination by the finger in the intact but dilated cervix permits us to feel 
 the tumor which projects between the lips of the organ. The uterus maybe 
 greatly increased in size and is often retroverted and rendered immovable 
 'during the later periods of the disease. Inversion of the uterus has also 
 been observed as a consequence of sarcoma. The cachexia becomes progres- 
 sively more pronounced. 
 
 Frequently this second phase is preceded by a temporary improvement 
 due to the removal of the tumor under the idea that it is a simple fibroma, 
 but even during the operation there is a suspicion that it may be of a more 
 serious character because of the intimate fusion with the adjacent tissues 
 which renders enucleation impossible. A rapid recurrence leaves no room 
 ior doubt; this character is so pronounced that English authors have termed 
 
CANCER OF THE BODY OF THE UTERUS. 35 I 
 
 it "recurrent fibroid." Freund has observed one very curious case of fibro- 
 sarcoma in an atresic uterus which had caused hydrometra. 
 
 Diagnosis. — The suspicions to which the rational and general symptoms 
 give rise are confirmed by the finger introduced deeply into the uterus, 
 after dilatation if necessary. The only condition with which it might be 
 confounded at the outset would be hemorrhagic metritis or fibroma. Later 
 in the course of its development it might resemble a sloughing fibroma, an 
 epithelioma, or a sarcoma of the mucous membrane. The examination by 
 the microscope of fragments by the curette would be of valuable assistance 
 in deciding the question. 
 
 The duration of the disease varies from four months to ten years; the 
 average is three years. 
 
 The prognosis varies, but is always serious ; the disease recurs most 
 quickly in young patients and with tumors of a very rapid development. 
 
 Etiology .—Yxox^ all the cases published up to 1885, Gusserow derived 
 the following table, which shows the influence of age : 
 
 Before twenty 4 cases. 
 
 From twenty to thirty 5 
 
 ' ' thirty to thirty-nine 15 
 
 ' ' forty to forty-nine 28 
 
 ' ' fifty to sixty i S 
 
 Above sixty (of which one case was at seventy-two) 3 
 
 This table demonstrates the predisposition created by the menopause as 
 in the case of other malignant growths. In seventy-four cases analyzed by 
 the same author in regard to fecundity and sterility, there were twenty-three 
 women sterile, of whom four were virgins. This proportion seems very 
 high and forms a contrast with that which I have said as to the predisposi- 
 tion of multiparae to cancer of the cervix. 
 
 III. Decidtioma Maligmmi. 
 
 The malignant tumors which follow pregnancy, and which are termed 
 deciduoma malignum, have but recently been known. R. Maier, who orig- 
 inated the name, had suspected their connection with the decidua, but to 
 Sanger belongs the merit of having distinctly defined their clinical charac- 
 teristics and of having called attention to the special nature of these neo- 
 plasms. They have since then been the subject of many articles and dis- 
 cussions. 
 
 Pathology. — Macroscopically, the deciduoma malignum presents no fea- 
 tures which distinguish it from ordinary cancer of the body of the uterus, 
 with which it has undoubtedly often been confused by the older writers. It 
 occurs habitually in the form of nodules, often multiple ; rapidly invading 
 the entire thickness of the uterine wall and projecting both into the uterine 
 cavity and toward the peritoneum (Fig. 241). These nodules are generally 
 
352 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 soft and friable, easily penetrated by the finger. Their tissue is of low vi- 
 tality, and their surface ulcerates very rapidly, causing severe hemorrhages 
 which are one of their most marked clinical characteristics. They become 
 
 Fig. 241. — Deciduoma Malignum of the Uterus (Saenger). 
 Uterus divided through its anterior wall and opened, i, 2, 3, 4, 
 Tumors ; G:, uterine cavity ; Oi, os internum ; C, cavity of 
 cervix ; SO, peritoneum of uterus ; 1', vagina. 
 
 Fig. 242. — Section of Portion of Deciduoma 
 (Fig. 241). a, Decidu?.i cells ; b, leucocytes; 
 c, blood corpuscles ; fl', intermuscular cellular 
 tissue ; e, fusiform cells ; _/, reticulum. 
 
 generalized with great rapidity and give rise to metastatic nodules which 
 have been observed principally in the lungs, vagina, ovary, broad ligaments, 
 and diaphragm. 
 
 Histologically the deciduoma malignum is characterized by the presence 
 
 a. ^ 
 
 Fig. 243. — Very Small Section of Fragment of Deciduoma (Fig. 241). a. Decidual cells with thirteen 
 nuclei ; b, same with four nuclei ; c, giant cell in process of formation, with three nuclei ; d, uninuclear decidual cell 
 enclosed in a reticulated stroma ; e, reticulated stroma. 
 
 of large cells (Figs. 242 and 243) concerning whose origin authors are far from 
 agreeing. According to Lacroix these cells are essentially polymorphous. 
 A large number of them are round or polygonal with rounded angles ; in this 
 case their epithelioid appearance is very marked. When these cells are 
 crowded together they become polygonal with sharp angles, fusiform and 
 more or less elongated. Their protoplasm is most often granular; some- 
 times, however, it appears more homogeneous and stains more deeply with the 
 
CANCER OF THE BODY OF THE UTERUS. 
 
 353 
 
 ordinary reagents. These large cells of the decicluoma contain one or metre 
 nuclei. The cells occur in different parts of the tumor, either singly, or in 
 small groups (Figs. 244 and 245), or in masses of considerable size. In the 
 
 
 
 
 Fig. 244. — Section of Another Fragment of Deciduoma (Fig. 241). a. Group of decidual cells resembling 
 cancer nest ; i, b, groups apparently in process of formation ; <r, intermuscular cellular tissue ; d^ muscular fibres ; 
 t\ extravasation nf blood. 
 
 first case they grow into the interstices of the connective tissue, push aside 
 fixed cells and fibres, and penetrate ev^en into the interior of muscular bun- 
 
 Fk;. 245. — Section of Another Fragment of Deciduoma (Fig. 241). a, Venous capillaries; /5, ^, nests of dis- 
 integrating decidual cells ; c, extravasations of blood ; d, muscle. 
 
 dies. When, from their rapid multiplication, these cells become united into 
 groups, the connective and muscular tissues between them atrophy. 
 
 Without following the discussions upon the nature and origin of these 
 cells, we content ourselves with stating that some believe them to originate 
 23 
 
354 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 from special cells of the decidua by simple proliferation; others consider 
 them as epithelial in nature, an. opinion which has tended to become com- 
 mon since Marchand's important article, but differ as to their point of origin, 
 which some believe to be the decidua serotina, others the chorionic villi. 
 Ruge thinks that they are sarcomatous cells existing before pregnancy, and 
 assuming during that period an appearance of decidual cells. This diver- 
 gence of interpretations has given rise to a confusing nomenclature : sarcoma 
 
 Fig. 246. — Section at Point of Transition of Tumor into Uterine Tissue (Fig. 241). a, a, Section of 
 veins of muscular tissue ; /', i, sarcomatous proliferations along internal wall of veins ; c, muscle tissue which has be- 
 come entirely sarcomatous : ^, necrotic portion of muscular tissue infiltrated with leucocytes ; e, e, extravasations 
 of blood. 
 
 deciduo-cellulare, sarcoma chorio-deciduo-cellulare, blastoma deciduo-chorio- 
 cellulare, sarcoma of the chorionic villi, deciduo-sarcoma uteri giganto-cellu- 
 lare, decidual tumors, carcinoma syncytiale uteri. 
 
 Two things show clearly that the large cells of the deciduoma, whatever 
 may be their origin, constitute a characteristic elem.ent which justifies the 
 separate place assigned to this affection in the classification of tumors. These 
 are: the exclusive presence of cellular elements of this type in these uterine 
 neoplasms, and their constant presence in the secondary nodules observed in 
 the lungs (Fig. 248), vagina, or ovary. 
 
 Symptoms. — The onset is generally insidious, and it is difficult to say 
 how long after the delivery or abortion the tumor appeared. It usually an- 
 nounces its presence by metrorrhagia, but this may be absent throughout 
 the entire course of the affection. The hemorrhages are characteristically 
 profuse and persistent, and reappear quite abundantly and at a short interval 
 after curettage of the uterus; exceptionally, they cease entirely after curet 
 
CANCER OF THE BODY OF TTIE UTERUS. 
 
 355 
 
 tage. These hemorrhages are the essential symptom ; the others are sec- 
 ondary. The fetid discharges come on only later, generally after an exam- 
 ination or an intra-uterine treatment ; they are accompanied by fever and 
 indicate a secondary infection. 
 
 The uterus increases progressively in size, as is easily appreciated by bi- 
 manual examination. Irregularities of its wall may be noted. The finger 
 introduced into the uterine cavity after preliminary dilatation ascertains the 
 existence of the tumor, notes its special consistence, and can if necessary 
 remove a fragment for microscopic examination. 
 
 As Nove-Josserand and Lacroix have stated, the very circumscribed spot 
 of softening produced by the deciduoma malignum, through which the finger 
 may be passed often close to the peritoneum, is limited by well-marked bor- 
 
 \ww~^ 
 
 Fig. 247. — Point at which Sec- 
 tion SHOWN IN Fig. 246 was Made. 
 a, Uterine wall ; &, nodule of tumor. 
 
 Fig. 248. — Section of Metastatic Nodule in Lung, a, Small pul- 
 monary vein ; 6, b, pulmonary endothelium ; c, c, decidual cells in interior 
 of alveoli ; </, «', intra-alveolar cellular tissue infiltrated with leucocytes ; 
 <?, e", alveoli with fibrinous exudate. 
 
 ders having the normal consistence of uterine muscle. This softening has 
 only a very distant resemblance to the rather uniform friability of the entire 
 uterus after an abortion. 
 
 The affection rapidly proceeds to a fatal termination. Gradually a pro- 
 gressive anaemia is established, which in a short time ends in cachexia. The 
 metastases, which are rather constant, are visible when occurring in the va- 
 gina, or give rise to special symptoms when they are situated in the lungs 
 (dyspnoea, cough, blood-stained expectoration, physical signs of consolida- 
 tion of the lungs, or a pleuritic effusion). They have in several instances 
 confirmed the diagnosis, which was doubtful before their appearance. They 
 shortly precede the fatal termination. The entire duration of the affection 
 is not more than six or seven months. 
 
 Prognosis. — -This is exactly the same as that of common cancer of the 
 uterus. In the observations collected by Cazin it is seen that death rapidly 
 occurred in all patients who were not surgically treated, or who did not sub- 
 mit to a palliative treatment of one or more curettages. Recurrence has 
 
356 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 been observed in three cases in which vaginal hysterectomy had been per- 
 formed ; in three, who had undergone this operation a longer or shorter time 
 before, recurrence had not yet taken place. One of them, operated upon by 
 Segond in September, 1893, is now in perfect health, locally and generally; 
 she had, however, an extension already to one of the ovaries, as Cazin discov- 
 ered by the histological examination of the uterus and appendages. 
 
 Etiology. — From an etiological point of view, the only certainly known 
 fact is that deciduoma malignum follows a pregnancy. In quite a number 
 of cases the appearance of these tumors has been preceded by the expulsion 
 of a hydatidiform mole. At what moment do these tumors develop .'' Is it 
 during pregnancy or after labor or abortion .'' Are they simply, as Veit and 
 Ruge hold, sarcomata in existence before pregnancy and undergoing certain 
 cellular modifications as a result of this condition.'' These questions can 
 be answered only by hypotheses. We possess no information as to the orig- 
 inal cause of the affection. 
 
 Treatment of Cancer of the Body of the Uterns. 
 
 There is no great difference in the treatment of the various forms of can- 
 cer of the uterus ; that which follows applies as well to epithelioma as to 
 sarcoma and deciduoma. 
 
 The indications are the same as for cancer of the cervix. Perform a rad- 
 ical operation whenever there is reason to hope that the disease may be re- 
 moved entire, and the gravity of the operation is justified by the great benefits 
 which are to be derived from it ; in other cases limit the interference to pal- 
 liative treatment. 
 
 The method of choice is vaginal hysterectomy performed as early as pos- 
 sible, before there is much enlargement of the uterus. Schroder advises us 
 to remove by the vagina a. tumor which does not exceed the volume of the 
 fist. This limit is purely theoretical, and by the aid of morcellation can be 
 markedly exceeded. I know that morcellation in cases of cancer of the uter- 
 us submits the woman to the risk of infection, but this consideration should 
 be relegated to second place on account of the facilities for operation which 
 this method gives. It is to be noted that the immediate success of the vag- 
 inal operation is much facilitated by the fact that the cervix is normal, so 
 that there is but little risk of infecting the wound. 
 
 When the lesions are very extensive, some surgeons (especially in Ger- 
 many) have had recourse to hysterectomy by the sacral route, which I have 
 described in the preceding chapter, instead of relying, as I advise, upon a 
 series of curettages and energetic cauterizations. Up to the present time, 
 when the uterus has been too large for vaginal extraction the custom has 
 been to remove it through an abdominal incision. Two methods may be 
 needed : 
 
 I. If the cervix has remained healthy, we may excise the fundus and use 
 
CANCER OF THE BODY OF THE UTERUS. 357 
 
 the cervix for a pedicle ; in other words, perform a supra- vaginal hysterec- 
 tomy (which should not be confounded with total hysterectomyj. But unfor- 
 tunately the cervix will furnish a stump which is far too short to be fixed 
 externally, and it must therefore be abandoned within the peritoneal cavity, 
 sutured by Schroder's method as described under the head of myoma. We 
 must determine beforehand that it is healthy, and curette its interior and 
 cauterize it with the thermo-cautery. 
 
 Abdominal hysterectomy for cancer of the uterus in Schroder's hands has 
 given four deaths in thirteen cases, or thirty-one per cent. 
 
 Rapid return of the disease is a priori to be feared from the fact that the 
 section of the cervix necessarily goes so near to the altered tissues. How- 
 ever, in eleven cases of cure by Schroder three only succumbed to a recur- 
 rence during the first year, four were still in good health after two years, 
 and two after five years. In the tenth edition of his book, Schroder speaks 
 of one cure dating from five and one from seven years before, which evi- 
 dently belonged to the same series. 
 
 2. If the uterus is very large and the cervix is involved, we can no longer 
 do the supra-vaginal operation, but must perform total extirpation by the ab- 
 dominal method. This operation was formerly employed for all cancers of 
 the cervix and body, but by reason of its alarming mortality there was a re- 
 turn to the vaginal method as far less dangerous. The operation of Freund 
 as actually performed is only a return to a method proposed by Delpech in 
 1830 (combining the hypogastric with the vaginal method). The typical 
 operation of Freund as described in his first writings is no longer practised 
 without the modification which was suggested by Rydigier, and which consists 
 in freeing the cervix completely by the vagina before opening the abdomen. 
 The perfected operation is performed as follows : 
 
 The patient is placed in Trendelenburg's position after the preparation 
 which I have described for vaginal hysterectomy. 
 
 After the first and the second steps are executed, a tampon of iodoform 
 gauze is placed in the vagina. 
 
 Third Step. Openijig the Abdomen. — The incision begins at the umbilicus 
 and extends to a finger's breadth above the pubes. It is well to suture the 
 abdominal wall in mass at each side of the lower angle of the wound to 
 avoid laceration or stripping of the peritoneum. If the abdominal wall is 
 very rigid, one or both of the recti muscles may be severed near their inser- 
 tion. Crede has proposed a very bold plan for the purpose of gaining more 
 room, namely, the resection of a part of the pelvic wall. The intestines, 
 which have a tendency to fall toward the diaphragm from the position of the 
 patient, are held in that place by gauze compresses; but if there is no other 
 way of obtaining room enough, a portion of the intestine may be drawn out 
 of the wound and kept warm and moist by frequently renewed gauze com- 
 presses. 
 
 Fourth Step. Ligation and Section of the Broad Ligaments. — The uterus 
 
358 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 is seized with a Museux forceps and drawn strongly out of the abdomen. 
 Freund then ties the broad ligaments in three portions. In passing the 
 lowest thread which is to include the uterine artery, he uses a needle trocar 
 whose point can be pushed out of a canula and then retracted within it. 
 When the operation has been begun by the vagina, this step is much sim- 
 plified, for the uterine artery has already been tied from below. This pre- 
 liminary has also the enormous advantage of enabling us to avoid the ureters 
 more certainly, though it is also possible to see them after the abdomen has 
 been opened. The vessels having been ligated, the broad ligaments are 
 divided and the uterus removed. The separation from the bladder should 
 be conducted with the greatest care after incision of the peritoneal pouch. 
 If the patient is young, the ovaries and tubes should be removed with the 
 uterus. 
 
 FiftJi Step. Dressing. — The toilet of the peritoneum is to be carried out, 
 the abdominal wound closed, and iodoform gauze placed in Douglas' pouch 
 and in the vagina. 
 
 Freund prefers to close the vaginal wound by carefully suturing its edges 
 to the peritoneum above, passing the sutures by the vagina and exercising 
 strong traction on the ligatures of the superior portion of the ligaments, 
 causing their inversion, so that there shall be a large cicatricial mass in the 
 place of the uterus between the bladder and the rectum. 
 
 Bardenheuer employs a very complicated method of drainage. 
 
 Martin advises that the order which I have given be reversed, first re- 
 moving the fundus by laparatomy and then the cervix by the vagina. He 
 has performed this operation three times with two deaths, while the third 
 patient died of a return of the tumor within the first year. 
 
 The statistics which Hegar and Kaltenbach have given in 1881 comprise 
 93 cases, with 63 deaths, or 68 per cent. In the third edition of their work 
 (1886) they have presented the following figures: in 119 cases there were 
 80 deaths, or 67.2 per cent; also 4 operations which were not completed and 
 I whose result is unknown, that is, 5 which maybe counted as among the fa- 
 tal cases. The tumors recur very rapidly and in almost every case. The 
 preceding authors do not know of more than a single case of permanent cure, 
 namely, a patient operated upon by Freund in 1878. Whenever they could 
 follow the case long enough they always saw a return of the disease after a 
 short respite. Total extirpation by the abdomen is then an operation of 
 gravity and of doubtful benefit ; and for my part I prefer the sacral method 
 when vaginal hysterectomy seems to be impossible. 
 
 When the limits of the uterus have been passed by the growth of the tu- 
 mor, we are confined in our efforts to merely palliative treatment, the cu- 
 rette and cauterization (see chapter on treatment of cancer of the cervix). 
 
 Strict antisepsis of the vagina and uterine cavities is hereof great impor- 
 tance, for the products of the disintegration of the neoplasm have but one 
 means of exit — by the cervical canal — and by their presence in these cavities 
 
CANCER OF THE BODY OF THE UTERUS. 359 
 
 they may produce the symptoms of putrid intoxication. I have seen patients 
 who appeared absolutely septicaemic return to life, so to speak, after the use 
 of the curette, antiseptic tampons of iodoform, and persevering intra-uterine 
 irrigation. Many of these cases are described in the thesis of my brother, 
 Adrien Pozzi. The sublimate solution i : 5,000 is here more or less danger- 
 ous on account of the large absorbing surface. It must therefore always be 
 followed by the use of filtered and boiled water, which is simply aseptic. 
 For a more energetic disinfectant I am accustomed to employ injections of 
 a cherry-red solution of permanganate of potash (one to two per cent) and as 
 a deodorant one to two tablespoonfuls to the litre of Labarraque's solution. 
 
 In the case of acute septicaemic intoxication great benefit may be ob- 
 tained from free intra-uterine irrigation followed by the introduction of small 
 strips of iodoform gauze into the uterine cavity, leaving them in place twenty- 
 four hours as a rapid and energetic means of disinfection. Antiseptic tam- 
 poning of the uterus has been recommended by Fritsch after curetting for 
 cancer, both as an antiseptic and as a haemostatic. 
 
CHAPTER XVIL 
 
 DISPLACEMENTS OF THE UTERUS. 
 
 The uterus is connected posteriorly to the sacrum by the utero-sacral 
 ligaments, whose inextensible and resistant fibres are attached to the organ at 
 the level of the cervix. Its connections with the bladder in front and the 
 round and broad ligaments at the sides preserve its normal position of slight 
 anteflexion, which it retains as a vestige of its foetal condition. The tonic- 
 ity of the pelvic floor, of which the only weak point is occluded by the nor- 
 mal contraction of the vagina, prevents the abdominal contents from acting 
 in the direction of their weight ; the pressure is distributed over the whole 
 surface and the uterus floats as if it were suspended in the midst of the 
 organs of the lower pelvis which act as cushions for it. When the uterus 
 is artificially drawn downward, this state of the pelvic contents becomes 
 very apparent, for up to the moment when the utero-sacral ligaments are 
 stretched and oppose any farther descent, the organ yields with but gentle 
 resistance, as of a floating body which is slowly drawn under. 
 
 When the bladder is full, it pushes the uterus backward, so that its 
 slight curve of anteflexion is obliterated, to be restored and exaggerated 
 when the organ is again emptied. The rectum, when full, pushes the uterus 
 forward and upward in a corresponding manner, though in the physiological 
 condition this motion is seldom so pronounced that its action is noticeable. 
 In the case of the bladder, however, it is important, especially as social 
 customs, which very quickly become organic habits, exaggerate it consid- 
 erably. 
 
 There is then but one point of attachment where the uterus is at all firm- 
 ly fixed, namely, that of the posterior ligaments, and, as they are inserted 
 where the organ is thinnest, evidently its position may be compared to that 
 of a pyramid balanced upon its point. This paradoxical condition does not 
 exist in the lower animals but is an anomaly in the animal kingdom, explained 
 by the upright position of the human species. 
 
 When we consider the extensive changes of volume, form, and consis- 
 tence which the uterus undergoes at each pregnancy; the alterations and 
 lesions which may be produced by parturition on the adjacent organs, lig- 
 ament.s, muscles, and serous membrane; and finally the influence which 
 efforts of all sorts may exert on an equilibrium so unstable — we are surprised 
 that uterine displacements are not more frequent. 
 
 In the description of displacements I shall treat first of those which art- 
 produced in the vertical planes, comprising flexions and versions, for which 
 
DISPLACEMENTS OF THE UTERUS. 
 
 \6l 
 
 I reserve the name deviations, and next of those which follow horizontal 
 planes, z'.r., elevation, prolapse, and inversion. 
 
 Classification. — The displacements in the vertical planes are commonly 
 divided into versions or flexions according as the uterus as a whole is in- 
 volved or only the body flexed on the cervix. There may be therefore ante- 
 and retro-flexion, and ante- and retro-version, and latero-version and flexion. 
 The latter are rare in the simple form, but they exist in combination with 
 the others. When the uterus is displaced en masse backward or forward, it is 
 called ante-or retro-position, two words which have only a descriptive value. 
 
 Fig. 249. — Position of the Uterus, with the Bi.ADnRK Emttv. 
 
 Historical Reviezo. — The history of uterine deviations has passed through 
 several phases. They were unknown at the time, before Recamier, when 
 all uterine maladies without neoplasm were attributed to prolapse ; by Re- 
 camier and Lisfranc they were relegated to the second place by the promi- 
 nence which these authors gave to ulceration ; with Velpeau, on the contrary, 
 their role in uterine pathology was much exaggerated. This latter belief, 
 by which displacements were made the chief factor in gynaecology, endured 
 till Gosselin produced a reaction in favor of metritis. The science becom- 
 ing more analytic and more eclectic at the same time, the tendenc)- was 
 then to refer each disease to its proper place. There were also new elements 
 introduced, up to that time almost ignored, which resulted from pathological 
 conditions of the adnexa. 
 
362 
 
 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 As is well known, displacement by itself does not constitute a ' disease, 
 but is only a factor, or the coefficient in a morbid complex into which the 
 deviation enters only as a variable. There is no gynaecologist who has not 
 seen marked displacement in women who presented no symptom of disease, 
 and certain authors, basing their statements on this fact, have not hesitated 
 to deny the pathological importance of deviations completely. They go 
 from the one excess to the other. If the displacement does not constitute 
 a disease by itself, it creates for the displaced organ a peculiar vulnerability 
 which results from alterations in the circulation produced by the increase of 
 the venous tension and the nutritive changes which may be the consequences 
 of this condition ; it favors and preserves inflammation of the uterus both in 
 
 Fig. 250.— Position of the Utekus, with -ihe Bladper Half Filled (Wai.deyer). 
 
 its cavity and on its surface. Prolapse of the adnexa, moreover, which fre- 
 quently accompanied the inflammation of the uterus, may be the source ot 
 reflex nervous troubles whose importance, especially in the posterior dis- 
 placements, should not be neglected. And the adhesions of peri-salpingitis, 
 when that is added, may fix the uterus in the vicious position, and thus ren- 
 der all resulting phenomena the more distressing. 
 
 From the preceding it is evident that the conception of uterine displace- 
 ment, which was formerly so simple and referred to one point of pathology 
 alone, comprehends for us, under the same clinical term, complex elements 
 whose treatment should be considered of the first importance, even before 
 that of the actual change in the axis of the organ; of these the chief are: 
 metritis; prolapse of the adnexa, either healthy or inflamed; peri-salpingi- 
 tis.; and, especially at the beginning of the treatment, excessive mobility 
 of the uterus due to laxity of the ligaments. 
 
DISPLACEMENTS OF THE UTERUS. 
 
 363 
 
 Displacements Forward — Anteversion. 
 
 Pathology and Etiology. — The normal curvature of the uterus coincides 
 fairly well with the curvilinear axis of the pelvis. In anteversion this curve 
 becomes straight, as the uterus falls forward and the organ lies just behind 
 the pubes upon the bladder, the cervix presenting directly backward (Fig. 
 251). The uterus is usually somewhat increased in size by a certain degree 
 of metritis, and there often exists a perimetritic exudation toward one of the 
 poles of the organ, sometimes in front at the level of the fundus, sometimes 
 behind at the level of the cervix, which tends to fasten the uterus in its ab- 
 normal position. 
 
 The great cause of anteversion is to be found in the structural changes 
 which occur after labor and abor- 
 tion, or in the course of an abnor- 
 mal involution, caused by a slight 
 degree of infection. The organ 
 takes the position while it is still 
 soft and yielding, and maintains 
 it because its normal tonicity fails 
 to return. Then there are adhe- 
 sions formed and the uterus be- 
 comes fixed. The presence of a 
 tumor which by its weight causes 
 the deviation is only of secondary 
 importance. 
 
 [Anteversion being but an 
 exaggeration of the normal posi- 
 tion, but rarely causes symptoms or needs treatment except when complicated 
 by parametritic adhesions or contraction of the utero-sacral bands, which 
 markedly limit its mobility. In a limited number of cases of anteversion, 
 with marked relaxation of the uterine supports and " descent" when in the 
 erect position, the ring pessary may be needed as advised below.] 
 
 Symptoms. — The uterine syndrome which I have described in discussing 
 metritis reappears here in all its characters. The rectal and vesical tenesmus 
 are especially noteworthy, are exaggerated by the pressure of Ihe uterine 
 body and neck, but yet may be absent or may exist with simple metritis. 
 The nervous reflexes which result are due to the uterine mobility and the 
 enteroptosis which it causes more than to the mere displacement, which is 
 demonstrated by the effectiveness of immobilization by means of the pessary. 
 
 Diagnosis. — The diagnosis is easily made clear by bimanual palpation. 
 The finger in the vagina seeks for the cervix far in the rear, then, carried 
 forward, feels the body of the organ through the anterior cul-de-sac and may 
 follow its anterior surface, while the hand placed above the pubes examines 
 
 Fig. 251.— Axte^'ersion. 
 
364 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 the posterior, placed horizontally. The passage of the uterine sound is usu- 
 ally difficult and is seldom necessary. It should be employed only when 
 there is any doubt as to the nature of the tumor felt in the anterior vaginal 
 pouch, or if the fundus cannot be differentiated from a tumor above it, such 
 as a fibroma or an inflammatory or hemorrhagic exudation. Anteflexion may 
 be recognized by the curve which exists at the junction of the cervix with 
 the body. To facilitate the passage of the sound into the cervix, the ante- 
 rior lip may be seized with a tenaculum and drawn gently downward. Rec- 
 tal touch in such cases is often of great service in determining whether the 
 fundus is in its normal position. 
 
 Treatment. — -As it is the metritis which causes the anteversion and keeps 
 it up, we must address our efforts in the first place to that disease ; but be- 
 fore beginning a vigorous treatment of the uterine mucous membrane, we 
 must assure ourselves that there is no acute inflammation about either 
 uterus or tubes. Should there be acute perimetritis or salpingitis, they 
 should first be treated by appropriate means, among which I include very hot 
 vaginal douches [110° F. and for twenty to thirty minutes], tampons of gly- 
 cerin, frequent sitz baths, and vesication over the hypogastrium ; then when 
 every acute symptom has disappeared, we perform curettage and follow it by 
 the injection of tincture of iodine or perchloride of iron as already described. 
 
 There is no need here to replace the organ, for its position is only an ex- 
 aggeration of the normal condition. If the pain persist after the metritis 
 has been cured, it can be due only to reflexes which take their origin from the 
 relaxed ligaments and the enteroptosis ; it is then that the organ should be 
 immobilized and sustained, and this may be accomplished either through 
 the abdominal walls or by way of the vagina. 
 
 The best abdominal supporter in the case of forward deviation is that 
 which carries a movable cushion, which may be managed by a strap or a 
 channel and screw after its application above the pubes (see Fig. 252). 
 
 The most serviceable form of pessary in anteversion is that which I term 
 "the indifferent," because its sole function is to distend the vaginal pouches 
 and thus immobilize the uterus and maintain the cervix. The pessary 
 which is called Dumontpallier's in France and Mayer's elsewhere, in the 
 form of an elastic ring, is the best example of this indifferent class of in- 
 strument, easy to apply, withdraw, and clean. Special forceps have been 
 invented for its introduction into the vagina without pain (Fig. 254), but 
 with a little experience the same result is obtained by holding it between 
 the index and the thumb. It is convenient to place the patient in the lateral 
 or genu-pectoral position ; then it is necessary merely to place the upper part 
 of the pessary in the posterior pouch, push the anterior portion a little up- 
 ward, and it adapts itself automatically to the parts. Its size should be de- 
 termined according to the dimensions of the vagina. A pessary which does 
 not overstretch the canal or cause the patient inconvenience may be left in 
 place two or three months ; it does not interfere with either coitus or fecun- 
 
DISPLACEMENTS OF THE UTERUS. 
 
 36s 
 
 dation. [While a well-fitting, polished, hard-rubber pessary may often be left 
 in place this length of time, any soft-rubber instrument should be frequently 
 removed and cleansed, as otherwise it soon becomes extremely offensive.] 
 At the end of that time it should be taken out and cleansed in carbolic solu- 
 
 FiG. 252. — I, Elastic Abdominal Girdle (Payot). 2, Oikdi.e having a 
 Movable Plate with Double Motion. 
 
 Fig. 253.— Dumontpallier's or Mayer's Soft-Rubber Ring Pessary. Fig. 254. — Forceps for Intro- 
 
 DiCTioN OF Ring Pessary. 
 
 tion and the patient advised to go without it for a few days to see whetheV 
 it is still necessary. 
 
 Many special forms of pessary have been invented and advocated for 
 anteversion, but I have never found them of the least advantage. The 
 above cut shows the method of application of Hewitt's pessary. The use of 
 
Z^6 
 
 CLINICAL AND OPERATIVE GYNECOLOGY 
 
 Thomas' form will be more easily understood when we consider the figures 
 relating to Hodge's pessary for retroversion, for it is like the Hodge, but 
 with the difference that it has a movable piece shaped like a horseshoe which 
 
 Fig. 255. — Grailv Hewitt's Cradle Pessarv for Anteversion". 
 
 passes in front of the cervix to sustain the uterine body. Galabin's model 
 has its anterior portion much thickened for the same purpose. 
 
 As regards general treatment, the anaemia and the nervous excitability 
 should be controlled. Preparations of iron and quinine, and hydrotherapy 
 will be beneficial in many cases. 
 
 Anteflexion. 
 
 Pathology and Etiologv. — Anteflexion is an exaggeration of the normal 
 forward curvature of the uterus. Before it was well understood it was fre- 
 quently the case that a uterus in perfect position was taken for one in a 
 state of pathological deviation. It is difficult to draw a clear distinction be- 
 tween the physiological and the abnormal positions ; but it might be said 
 that the abnormal begins when the examining finger perceives the angle as a 
 sharp bend in the axis of the organ. 
 
 [Schultze holds that this distinction is not an invariable one. He states 
 that, as contrasted with the great mutability of normal anteflexion, stabilitv 
 is the characteristic most typical of pathological. Pathological anteflexion 
 
 Fig. 256. — Thomas' Anteversion- Pessary. Fig. 257. — Galabin's Anteversion Pessary. 
 
 is then that position in which the uterus lies with its fundus permanently 
 flexed over its anterior surface and more than normally stabile.] 
 T. Gaillard Thomas distinguishes three varieties: 
 
DISPLACEMENTS OF THE UTERUS. 
 
 367 
 
 1. Corporeal flexion, where the body is bent upon the cervix which is 
 normally placed; this is the usual type. 
 
 2. Cervical flexion, where the cervix is bent upon the body. 
 
 [Fig. 258. — Various Foriis of the Cervix, Natural Size (Schultze). a. Fully developed normal cen'i.x, 
 normally inserted into the vaginal vault ; i, an approximation to the condition in childhood often found in virgins and 
 usually accompanied by flexion ; c, cervix and mode of insertion normal during childhood ; when found in the adult it 
 is nearly invariably associated with sharp fie.xion.] 
 
 3. Cervico-corporeal, where the segments of the organ are bent the one 
 upon the other. 
 
 Etiologically there are two forms, the congenital and the acquired. 
 
 In the foetus and in early infancy the cervix is relatively much developed 
 while the body is still small, and there is an exaggerated curve between 
 them ; if at the time of puberty the growth of the uterus is irregular and the 
 anterior wall is retarded in its development while the posterior increases in 
 size, the congenital form of anteflexion manifests itself. As a second mark 
 of arrested growth, the cervix may be very long and conical (Fig. 258), with 
 
 Fig. 239. — Anteflexion of Infantile Origin. The angle is acute and the fundus globular. 
 
 the vaginal portion tapering and the external os very narrow. At other 
 times atrophy of the anterior lip may be pronounced and thus furnish an 
 indication of the condition of the corresponding uterine wall. This congen- 
 
368 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Fig. 260. — Very Acute Anteflexion with HvpERTRorHv 
 OF THE Vaginal Portion of the Cervix. 
 
 ital anteflexion has been observed with hypoplasia of all the genital organs 
 and a narrow pelvis. 
 
 The congenital forms do not present so acute an angle of flexion as the 
 
 acquired forms, but correspond 
 generally to the first two varieties 
 of Thomas. 
 
 The anteflexion may be ac- 
 quired at the time of the estab- 
 lishment of puberty if, when the 
 uterus is engorged and softened 
 during the first menstrual periods, 
 the hygiene of the young woman 
 is improper. Any overstrain or 
 great fatigue, masturbation, and 
 all the causes of virginal metritis 
 may here play their part in devel- 
 oping both an inflammation and a. 
 deviation. It is readily seen that 
 the general softness of the organ 
 permits it to bend at the isthmus as upon a hinge, and to become flexed to 
 the side or to increase its infantile forward curve. Cases have been ob- 
 served in which a fall was the starting-point of this condition. 
 
 Metritis of puerperal origin may be counted among the causes of acquired 
 anteflexion, though it more commonly produces a retroflexion. It has been 
 attributed with much reason to absence of sufficient involution of the poste- 
 rior wall after labor and abor- 
 tion, and this may be due to 
 the persistence of portions of 
 the membranes or placenta caus- 
 ing a very intense local infec- 
 tion at the place of their ad- 
 hesion. Schultze, after E. 
 Martin, has attributed great 
 importance to parametritis 
 situated posteriorly, involving 
 the utero-sacral ligaments and 
 causing their contraction (Fig. 
 261). He also asserts that in 
 such cases the cervix is placed 
 much higher than normal in 
 the pelvis, and the vagina thus 
 undergoes elongation. The origin of the posterior parametritis he finds 
 in puerperal or gonorrhoeal infection. 
 
 I am of the opinion that this is most frequently due to peri-salpingitis. 
 
 Fig. 261.— Anteflexion from Contraction of the Utero- 
 Sacral Ligaments. 
 
DISPLACEMENTS OF THE UTERUS, 
 
 369 
 
 about the diseased adnexa. The adhesions which result and which fix the 
 cervix strongly from behind cause the uterus to fall forward and flex it at 
 the isthmus, which is weakened by the accompanying metritis, while the cer- 
 vix, hypertrophied and sclerosed 
 by an old inflammation, remains 
 rigid (Fig. 262). The subvagi- 
 nal elongation of the cervix re- 
 sults in inveterate catarrh, which 
 often coexists with anteflexion, 
 as has been well described by A. 
 Martin; this author considers 
 the congenital lesions of but 
 little importance. 
 
 Symptoms. — Congenital an- 
 teflexion is accompanied by 
 amenorrhoea, or delay in the ap- 
 pearance of the menses, when it 
 
 K.G. 262.-Anteflex:on Combined with Retro-Position and coiucidcS with an infantile COn- 
 
 PnsTERiOK Adhesions. 
 
 dition of all the genital organs. 
 If the periods begin at the normal time, they are apt to be at long intervals 
 and irregular. At other times, with a normal flow of blood, there appear 
 the symptoms of dysmenorrhoea. Violent pains in the loins occur while the 
 blood distends the uterus above the point of flexion, then suddenly the ob- 
 stacle is overcome and the blood is expelled in a clotted flow, which may 
 have a very strong odor, due to its long stagnation. The mechanical theory 
 of the pain of dysmenorrhoea de- 
 pending upon anteflexion has been 
 generally received since it was 
 made known by Simpson and 
 Sims. It is not, however, accepted 
 by Fritsch, who explains the pain 
 as due to irritation of the nerves \ 
 
 from congestion by the abnormal 
 vascular tension produced by cur- 
 vature of the vessels at the point 
 of the flexion. It is difficult not to 
 attribute great importance to the 
 obstacle, in view of the paroxysmal 
 character of both pains and dis- 
 charge. We may also ask whether 
 the posterior perimetritis noted by 
 
 Schultze is not as often the result of the anteflexion as its cause, when every 
 month there are a few drops of blood forced through the tubes into Douglas' 
 pouch, producing thus a kind of miniature and periodic haematocele. Thus 
 24 
 
 Fig. 263. — Anteflexion Simulated by a Fibroma in the 
 
 Anterior Uterine Wall. 
 
370 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 we might explain the acute and febrile phenomena with which these crises 
 of dysmenorrhoea sometimes terminate. 
 
 These patients present all the symptoms of the uterine syndroma. The 
 dysuria is ordinarily very marked, and the reflex nervous symptoms are bit- 
 terly complained of. 
 
 Pain often occurs in sexual intercourse. Sterility is the rule, and should 
 conception take place, abortion is probable. 
 
 Diao-jiosis. — If the case is one of the frequent acquired antefiexions, the 
 so-called corporeal, the finger feels the fundus in the anterior vaginal pouch, 
 curved like a pistol handle and almost on the same plane as the cervix. By 
 pressing the organ down in bimanual palpation, the body of it is rendered 
 accessible and the finger can appreciate its curve and angle of flexion, while 
 the cervix is found in the normal axis. 
 
 In the cervical variety of the affection the cervix is, on the contrary, 
 oblique from above downward and from before backward ; by touch alone we 
 
 Fig. 264. — Sagittal Discission of the Cervix in Cervical Anteflexion (Sims), a, ^, c, Portion of the 
 cervix divided by the scissors ; c, a., d, triangular portion which escapes the scissors and which is divided by the probe- 
 pointed bistoury ; e,f, supravaginal portion of the cer\-ix where the flexion occurs. 
 
 might then think of retroversion, but bimanual palpation discovers the fundus 
 in the normal situation. 
 
 In the cervico-corporeal variety the direction of the cervix is the same as 
 in the preceding form, but the fundus is also curved and hidden behind the 
 pubes; Vy exploring the anterior cul-de-sac in front of the cervix it may be 
 felt. At times, when the uterus is thus rolled on itself, there is nothing to 
 be felt but the angle of flexion ; and above it a rounded mass which might 
 very easily be taken for a fibroma or an inflammatory exudation. The oppo- 
 site mistake has also been made (Fig. 263). The uterine sound is of great 
 service in these cases. Its introduction may be rendered easy by seizing the 
 cervix with tenaculum forceps and drawing it down and back, when the sound, 
 properly curved, is passed in with great care and gentleness in the supposed 
 direction of the uterine cavity, while one finger presses on the fundus through 
 the anterior vaginal pouch to straighten it a little. When the sound is in 
 the uterus the organ may be restored to its normal shape by merely carrying 
 the handle of the instrument forward. Then the two surfaces of the organ 
 may be examined by rectal touch and bimanual palpation to discover the 
 presence of any tumor which may coexist and to estimate the uterine mo- 
 
DISPT.ACEMENTS OF THE UTERUS. 
 
 37^ 
 
 bility. To avoid all danger of interrupting a beginning pregnancy, this ex- 
 amination should be made only shortly after a menstrual period. 
 
 A calculus in the bladder, pressing upon the anterior cul-de-sac, could 
 only be mistaken for anteflexion when the examination of the uterus and 
 vesical catheterism were not combined. 
 
 Treatment. — The indications are to relieve symptoms, to cure the patho- 
 logical conditions of the mucosa, to induce a return to the normal in the 
 muscular tissue, and to restore the normal uterine position. Acquired ante- 
 flexion causes but little disturbance except when there is coincident inflam- 
 mation or when it presses upon the bladder or with a very movable uterus. 
 Relief may be obtained by either a girdle or a pessary without the need of 
 previous reduction {vide supra, Anteversion). 
 
 The treatment should be directed chiefly against the coexisting metritis. 
 In simple cases curetting followed by iodine injections will be found suffi- 
 
 FiG. 265. — Stem Pessaries, a and b^ Common forms; c^ Fehling's. 
 
 cient. With marked cervical hypertrophy Schroder's biconical amputation 
 or excision of the mucous membrane will be required. This causes a rapid 
 and progressive involution of the hypertrophied cervix, which much exceeds 
 the immediate results obtained by the bistoury, and which with the ameli- 
 oration of the metritis causes the disappearance of the morbid symptoms 
 which are attributable to the deviation. The displacement corrects itself 
 little by little. It seems probable to me that the good effects of Sims' 
 "sagittal discission" (Fig. 264), which has enjoyed such favor and been so 
 much abused, should be referred to the indirect action of the operation 
 upon the involution of the uterus and its influence on the metritis, rather 
 than to the mere re-establishment of the normal calibre of the cervix. 
 
 Congenital anteflexion claims our interference only because of the very 
 painful dysmenorrhoea or the sterility which it causes. If we decide to 
 straighten and dilate the organ as has been recommended, it is well to pre- 
 cede every attempt at straightening by the use of laminaria tents, after de- 
 termining the extent and direction of the uterine cavity by the sound. The 
 laminaria tents, treated with iodoform and sufificiently thin, are supple enough 
 to permit a good deal of curvature. It is useless to attempt too great a dila- 
 tation ; the principal office of the tents is to soften the tissues and make them 
 
372 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 more supple in view of the final restoration of the form of the organ. This 
 is begun with the dilatation itself. After dilating, enlarging, and somewhat 
 correcting the axis by the use of a few tents, we may continue by passing 
 Hegar's bougies once or twice a week, aiding the manoeuvre by fixing the 
 cervix with tenaculum forceps and by pressure on the fundus by the finger 
 in the anterior vaginal pouch ; the process should be completed with sizes 
 No. lO or 12. Rapidly straightening the uterus with a sound, returning it 
 to its position by a " /<?z/r rt'^ mditre,'' which temporarily carries the organ 
 backward, is here always out of place. 
 
 Since the case is almost always one of incomplete development, the pro- 
 gressive dilatation and the frequent passage of sounds will produce a fluxion 
 to the part and an increase in its nutritive activity, which are probably the 
 chief advantages of the method. 
 
 In addition to the pessaries which I have described, which are applicable 
 to both anteflexion and anteversion alike, special forms have been invented 
 for anteflexion. That of Fancourt Barnes is a combination of the Hodge 
 model with the Hewitt. Thomas has invented a complicated form composed 
 of a Smith pessary supporting a cup with an intra-uterine stem. I much 
 prefer abdominal girdles to vaginal pessaries in both anteversion and ante- 
 flexion, but among the latter I consider Dumontpallier's ring sufficient. 
 
 The stem, or intra-uterine, pessary so warmly advocated in England by 
 Simpson and in France by Valleix, which has caused so many accidents be- 
 fore the days of antiseptic surgery, should be employed only in exceptional 
 cases. When the patient is a weak and timid young woman who is very ner- 
 vous, and for whom the repeated manoeuvres of progressive dilatation would 
 be torture or at least present a real difficulty every time, we are authorized 
 to leave an agent within the uterus which shall gradually straighten and 
 dilate it. The older forms of pessary had a stem which was perfectly 
 straight, which is erroneous, as the normal uterus has an anterior curvature. 
 They were often composed of two metals, copper and zinc, whose galvanic 
 action was thought to aid the salutary action of the dilatation. Fehling con- 
 structed a far more rational instrument consisting of a tube of thick glass, 
 fenestrated, provided with a bell mouth, and slightly curved ; this curve could 
 be altered by heat. This tube was to be filled with powdered iodoform and 
 introduced into the uterine cavity, with care that the tube be about one-half 
 centimetre shorter than the canal, previously measured. The patient is kept 
 in bed and under observation for eight days ; then she is allowed to rise, 
 but the stem is not removed, according to this author, before eight or ten 
 months. It is kept in place by the projection of the mucous membrane into 
 the fenestrse of the tube, and, being light, has but little tendency to fall out 
 (Fig. 265, c). I think that this delay of eight months is too long, and that 
 the good effects should be produced within one or two. It is claimed that 
 massage has given good results. [ Vide Dysmenorrhoea. ] 
 
 The chief cause of the dysmenorrhoea in congenital anteflexion is in 
 
DISPLACEMENTS OF THE UTERUS. 373 
 
 the conical cervix witii its stenotic external os. To relieve this stenosis, 
 crucial incision with the bistoury has been practised for a longtime. Simp- 
 son's metrotome, Collin's hysterotome, or Kiichenmeister's scissors may be 
 employed. 
 
 The results so obtained are not permanent, for the cicatrization re-estab- 
 lishes the original conditions ; a stomatoplastic operation by biconical ampu- 
 tation of the cervix is far preferable. ( Vide Cervical stenosis.) 
 
 The operation of discission in cervical anteflexion is sometimes performed 
 for the relief of sterility. Marion Sims (Fig. 264) incised the posterior lip 
 of the cervix with his short and curved bistoury. Emmet practised the 
 sam^e incision with elbowed scissors, which are preferable ; he straightened 
 the canal by making an incision on its anterior face with a short tenotome a 
 
 Fir.. 266. — Collin's Hysterotome. 
 
 certain depth into the tissues and kept the cut open by means of a glass tube. 
 He thus removed a triangular piece or the whole of the posterior lip. More 
 complicated plastic operations have been proposed, like Kiistner's or Reed's, 
 but I reject them all. If there is any deformity of the cervix, amputation 
 of the part is preferable (according to the rules given under Metritis), tak- 
 ing care to leave a sufficiently large os. 
 
 Thiriar has more recently attempted to cure anteflexion by an operation 
 which he calls cuneihysterectomy. He performs a coeliotomy, and after the 
 intestines have been pushed up from the pelvic cavity, draws upon the 
 uterus as forcibly as possible by means of tenaculum forceps. Upon the 
 posterior projecting angle of the flexion he denudes a surface of about two 
 centimetres in height and extending entirely across the uterus. The portion 
 removed includes the entire thickness of the uterine wall except the mucosa. 
 The edges of the denuded area are united by separated catgut sutures, and 
 the abdomen is closed without drainage. This ingenious operation is claimed 
 by its originator to be easy in execution, but in spite of one complete success 
 obtained by Thiriar, it should be accepted with great reserve. 
 
CHAPTER XVIII. 
 
 DISPLACEMENTS OF THE UTERUS— Continued. 
 
 Posterior Deviations. 
 
 Displacement of the uterus backward is far more frequent than any 
 other variety. Sanger, among 700 gynaecological patients, found 108 cases 
 of retro-deviation, or 15.43 per cent. Winckel obtained 19.10 percent, 
 and Lohlein 17 or 18 per cent. 
 
 I. Retroversion. 
 
 Pathology ; Etiology. — Every time that the bladder becomes filled the 
 uterus is placed physiologically in a temporary position of retroversion. The 
 
 Fig. 267. — Retroversion with Posterior Adhesions of Large Extent. 
 
 tonicity of the broad, round, and utero-sacral ligaments, which, it must not 
 be forgotten, contain much muscular tissue, ordinarily sustain the uterus in 
 its normal position ; but when it has become increased in weight by inflam- 
 mation and especially by retarded involution after parturition, the ligaments 
 themselves undergo a relaxation, while the uterus is rendered turgid by me- 
 tritis, and the abnormal position may become permanent under the influence 
 of prolonged dorsal decubitus. 
 
 Then the uterus often becomes fixed in the new and abnormal situation, 
 by adhesions, the result of a local pelvic peritonitis originating from an in- 
 flamed tube which ma}-- be the antecedent and chief cause of the whole dis- 
 
DISPLACEMENTS OF THE UTERUS. 
 
 375 
 
 turbance. A sudden effort or a fall is often the determining cause of the 
 deviation; retroversion is not so common as retroflexion. 
 
 Symptoms. — When the displacement has occurred suddenly, it is often 
 accompanied by acute pain and various nervous phenomena; when it is ac- 
 quired slowly, its symptoms are often not to be disti.:guished from those of 
 a metritis or of a circumscribed perimetritis which may have preceded it, 
 and with these we find the uterine syndrome. Sterility is the rule. Vesical 
 and rectal tenesmus may either be very marked or absent altogether Palpa- 
 
 FiG. 268. — Retroflexion of the Uterus from Subinvolution of the Anterior Wall, on -which m.' 
 Seen the Site of Placental Insertion (E. Martin, Sr.). 
 
 tion and touch recognize the position of the cervix forward and that of the 
 fundus posteriorly toward the concavity of the sacrum, where it is more or 
 less immobilized. The two segments of the uterus are found in the same 
 straight line. 
 
 Diagnosis. — Bimanual palpation with rectal touch, and the use of the 
 uterine sound if necessary, are the means by which this form of displacement 
 may be recognized. The distinction from retroflexion is found in the fact 
 that there is no angle in the organ between cervix and fundus. It should 
 not be confounded with fibroma of the posterior wall, with a retro- uterine 
 hasmatocele, tumor of the ovary or tube prolapsed into the cul-de-sac of Doug- 
 las, with a focus of parametritis or with a scybalous accumulation. Almost 
 all cases in which any doubt could exist are easily made clear by the uterine 
 
376 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 sound combined with other means of exploration ; this instrument being es- 
 pecially useful where we must differentiate the condition from anterior cer- 
 vico- corporeal displacement, which, in view of the direction of its antero- 
 posterior axis, is almost necessarily a source of error if we confine our ex- 
 amination to touching the cer\dx alone. 
 
 Treatment , — This is similar to that for retroflexion. 
 
 II. Retroflexion. ■ 
 
 Pathology ; Etiology. — Contrary to the forward deviations, retroflexion 
 seldom exists from childhood or puberty, although it may follow virginal me- 
 tritis, habitual constipation, and masturbation (Fritsch). In the immense 
 majority of cases the retroflexion succeeds to a metritis of puerperal origin; 
 the subinvolution of the anterior face where the placenta is inserted plays 
 
 Fig. 269. — Extreme Retroflexion of the 
 Uterus. 
 
 Fig. 270. — Retroflexion of the Uteri's in a Nullipara. 
 The cervix is movable, the os has preserved nearly its normal 
 position. 
 
 here, according to Y^. Martin, a role similar to that which I have indicated 
 for anteflexion. 
 
 Considerable importance must also be attributed to the weight of the con- 
 gested organ, and to relaxation of the broad and round ligaments, which 
 cease to hold the uterus in place anteriorly, while the cervix remains fixed 
 by the more resistant utero-sacral ligaments. The fiaccidity of its own sup- 
 ports thus allows the uterus to bend backward at the level of the isthmus, 
 impelled by the weight and pressure of the intestines. Retroflexion has been 
 observed to follow simple retroversion and even anteversion; in the latter 
 case this is possible when the seat of the flexion remains soft and movable 
 like a hinge. The cervix is directed downward and forward, ordinarily ap 
 preaching the vulva, for it is usually a little lowered. The external os is 
 somewhat patent and its lips are swollen, owing to the disturbance of the 
 venous circulation which results from the curvature of the vessels. It must 
 
DISPLACEMENTS OF THE U TERUS. 
 
 377 
 
 not be forgotten that the displacement ahiiost always happens in a woman 
 who has had at some time metritis of puerperal origin. The body of the organ 
 occupies the pouch of Douglas. On one or the other of its walls there has 
 been found a marked thinning, anteriorly by Ruge, posteriorly by Fritsch. 
 
 Adhesions are often present, either perimetritic from exudation into 
 Douglas' pouch, or parametritic from similar conditions about the utero- 
 sacral ligaments. According to the opinion oi Schultze, relaxation of the 
 folds or ligaments of Douglas under the influence of posterior parametritis 
 plays a great part in the production of all the uterine displacements. In or- 
 der to comprehend the production of retroflexion, we must suppose that dur- 
 ing a first stage of acute inflammation the ligaments preserve all their resili- 
 ence in such a way that the cervix 
 becomes fixed ; soon after, in the 
 stage where tlie exudation retreats, 
 the denutrition of the ligaments 
 causes their flaccidity ; then, accord- 
 ing as the cervix has resisted or be- 
 come flexed in the first stage, we 
 have a retroversion or flexion. In 
 other words, version presupposes al- 
 teration in the ligaments ; flexion, 
 an altered condition of both ligaments 
 and uterine parenchyma together. 
 
 The peritoneal adhesions fix the 
 uterus to the bottom of the recto- 
 uterine pouch, by bands often loose, 
 filamentous, and easily torn. At 
 other times they are funicular, lamel- 
 lated, and firm. The ovaries and 
 tubes are often drawn by the devia- 
 tion into the cul-de-sac. It is probable that a part of the nervous reflexes, 
 often grave even to the production of paraplegia, which have been noted in 
 cases of retroflexion, are due to the dragging upon the nerves, and not to the 
 problematical compression of the sacral plexus. 
 
 Salpingitis often coexists, and is the rule in the irreducible cases, the 
 fact that the organ cannot be reduced very frequently depending upon the 
 presence of adhesions between the adnexa and the wall of the pelvis. Ex- 
 acerbations of the salpingitis are the cause of these adhesions, and also of 
 the hard, often painful nodules that so rapidly appear and disappear about 
 the lateral and posterior surfaces of the retroflexed organ. 
 
 Symptoms. — The uterine syndrome is present, the reflex nervous phe- 
 nomena are very well marked, and there is sterility. Constipation, with or 
 without tenesmus, is peculiarly obstinate, and Barnes attributes to this the 
 coprajmia which so often debilitates the patient. 
 
 Fig. 271.— Retroflexion of the Uterus, Very 
 Pronounced. Compression of the rectum, whose lumen 
 is effaced ; hypertrophy of the cervix ; atrophy of the angle 
 of flexion ; thickening of the posterior lip ; thinning of the 
 anterior lip, which is hidden in the bottom of the cul-de-sac. 
 
378 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 The nervous reflexes appear most often as difficult)^ in walking markedly 
 out of proportion with that caused by simple muscular fatigue and simulating 
 paraplegia, as multiple neuralgias, hysteriform excitability, fitful cough, dys- 
 pepsia, etc. Schroder has observed chorea ; Chrobak, very intense asthma ; 
 Kehrer, aphonia; Sielki, hystero-epilepsy ; Kidderlen, incessant vomiting. 
 Simple straightening of the uterus has caused all these symptoms to disap- 
 pear rapidly. 
 
 Sterility is usually the sequence of retroflexion, though at any time fe- 
 cundation may take place and the uterus return to its proper position. If it 
 remains flexed and incarcerates the foetus in the lower pelvis, it produces 
 serious compression symptoms or abortion. If involution proceeds under the 
 most favorable conditions after labor, the uterus may correct its own malpo- 
 sition spontaneously. That pregnancy in such cases may be a valuable thera- 
 peutic measure cannot be denied, and yet its importance has been much 
 overestimated. 
 
 Certain authors describe a post-puerperal retroflexion in which the dis- 
 placement occurs immediately after confinement. This is often only one of 
 the symptoms of a post-puerperal metritis with retarded involution, and dis- 
 appears with the latter under appropriate treatment. 
 
 Diagnosis. — The tumor occupying the posterior cul-de-sac ma}', by means 
 of bimanual palpation, be easily recognized as the fundus from the absence 
 of resistance in the anterior pouch where the organ is normally placed, and 
 the possibility of feeling the angle of junction between the cervix and the 
 fundus. Le Dentu attributes great diagnostic value to the presence of a 
 longitudinal median ridge easily felt on the posterior surface of the uterus. 
 Sanger has noticed, in cases of congenital retroversion, the presence of 
 a median protrusion of the anterior vaginal cul-de-sac, a fraenum i to 
 I Vo cm. high, dividing the cul-de-sac into two portions. It seemed to 
 be the remains of delayed fusion of Miiller's ducts. Rectal touch is 
 here often indispensable. Exploration with the sound removes the last 
 doubts ; it should be curved to suit the axis of the uterus, and the cervix 
 seized with tenaculum forceps and drawn downward. Further details of 
 diagnosis will be found under the head of retroversion, to which I refer (see 
 page 375). 
 
 It is necessary to determine clearly the degree of mobility of the uterus 
 before entering upon any treatment, and from this point of view Trelat di- 
 vides retroflexions into three classes: (i) reducible; (2) resistant; (3) ad- 
 herent. These different grades may be appreciated after efforts of reduction, 
 either by the bimanual procedure or by the sound, by estimating the resist- 
 ance encountered and by the permanence of the reposition. 
 
 Tiratmcnt. — Whether the complicating metritis should first be treated or 
 the displacement reduced is a disputed question. I think it is well to treat 
 the inflammation first, and for this purpose to employ the curette followed 
 by injections, and, in case of metritis which is chronic and painful [with 
 
DISPLACEMENTS OF THE UTERUS. 
 
 379 
 
 cervical laceration and hyperplasia], to amputate the cervix [or perform Em- 
 met's operation] (page 184 et seq.). It is not unusual to see the pains of re- 
 troflexion cease when the metritis has been cured, and also a certain degree of 
 reduction may result from the subesquent involution. It is well in special 
 cases to dilate the cervix, before curetting, with laminaria tents, which effec- 
 tually begin the work of straightening the canal. 
 
 If with the metritis there is also an acute perimetritis, with peri-salpingi- 
 tis, this should be treated by appropriate means (hot injections, baths, appli- 
 cation of iodine, glycerin tampons of the cervix, etc.), and only when all in- 
 flammatory symptoms have ceased should we make an effort to reduce the 
 
 Fig. 272. — Reduction of Retroflexion in the Genu-pectokal Position. 
 
 uterus and maintain it in place ; the contrary practice advised by Poullet ap- 
 pears to me unwise. 
 
 Reduction of Retroflexion. — This may be accomplished in many ways : 
 I. By the Genu-Pectoral Position. — -When the woman has been pat in the 
 genu-pectoral position with the legs a little separated, and the fourchette 
 retracted so as to allow the entrance of air into the vagina, the viscera fall 
 toward the concavity of the diaphragm (Fig. 272) and the retroverted or 
 retroflexed uterus, if freely movable, is restored to its normal position. This 
 reduction may be aided by keeping the vaginal walls separated and apply- 
 ing traction to the posterior cul-de-sac with a speculum blade which depresses 
 the fourchette. This "spontaneous reposition by air," as Courty terms it, 
 is a valuable exercise which the patient may every day repeat, morning and 
 evening, for a few moments, placing herself in the attitude of a praying Ma- 
 hometan. Tarnier advises the patient, when she takes this position, to in- 
 troduce a small speculum of wire or simply an injection nozzle into the va- 
 gina to facilitate the entrance of air and the upward movement of the uterus. 
 E. Mosher recommends his patients to pass the finger into the vagina and 
 press upon the anterior face of the cervix, which has the effect of making 
 the uterus revolve forward. If this procedure is not sufficient for many 
 
38o 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 cases, it is still a valuable auxiliary where the trouble is not inveterate. 
 Patients should also be advised to sleep on the face or side, 
 
 [In using the genu-pectoral position it is necessary to see that there are 
 no constricting bands or corsets about the waist to interfere with the free 
 forward and upward falling of the abdominal viscera. If after the perineum 
 is retracted and the vagina allowed to " balloon" (an effect caused by the 
 traction of the inverted abdominal contents) the fundus remains fixed behind 
 the sacral promontory, it may often be dislodged by drawing the cervix down 
 
 Fig. 273. — Bimanual Reduction uk a Retkoversihn or Flkxion. First step. Elevation of the uterus. 
 
 toward the vulvar opening and backward by a tenaculum forceps, and, if this 
 is not sufficient, by pressure at the same time against the fundus by the 
 fingers, or a wad of gauze held in a dressing forceps. Occasionally, espe- 
 cially where we have to do with an incarcerated retroflexed gravid uterus, it 
 may be necessary to employ manual pressure, or a colpeurynter, through the 
 rectum. 1 
 
 2. Binianiial Reduction. — The patient maybe put in Sims' position, or 
 even in the genu-])ect()ral if necessary ; two or three fingers of the left hand 
 are then placed in the rectum or the vagina, and the cervix is pressed back- 
 ward, while the right hand on the abdominal surface endeavors to seize the 
 fundus and bring it into the position of anteversion ; the new position of the 
 organ must be exaggerated to successfully combat the tendency to return to 
 
DISPLACEMENTS OF THE UTERUS. 
 
 38r 
 
 the displacement. This manceuvre may be much simplified by seizinj^ the 
 cervix with tenaculum forceps and drawing it gently downward. 
 
 Schultze has advised in difficult cases to introduce the finger into the 
 previously dilated cavity of the uterus ; and by energetic traction thus ex- 
 erted directly upon the uterine tissues, break up any adhesions which ha\'e 
 formed between the organ and other structures which oppose the reduction. 
 He describes minutely the method of freeing the uterus from pseudo-liga- 
 
 Fir,. 274. — KiMANUAi. Redaction of a Retroversion or Flexion. Second step. Placing the reduced uterus in a 
 
 position of anteversion. 
 
 ments and adhesions which fix it behind or laterally or on its surface to the 
 rectum. Under anaesthesia he claims that he can feel the ovaries and de- 
 stroy their adhesions. This bold practice has found imitators, but it has 
 also been condemned (Schroder). It is true that Schultze has obtained verv 
 remarkable success in this way, but if the tubes should be inflamed, the 
 method, it seems to me, would be very dangerous. 
 
 3. RediLctioji by the Sound. — This is the method which is generally em- 
 ployed, and which even Schultze advises whenever it is necessary to over- 
 come resistance of unusual degree. Either the genu-pectoral or Sims' posi- 
 tion may be adopted. A large smooth metallic sound is selected and intro- 
 
^82 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 duced many times consecutively to reduce the deformity to a retroversion; 
 then the sound is made to describe an arc of a circle, and the beak of the 
 instrument within the uterine cavity performs a rotation which carries its 
 concavity forward. The uterus is thus straightened but is still in the retro- 
 position ; to bring it forward, the handle of the sound is depressed toward 
 the fourchette (Fig. 275). 
 
 In all these manoeuvres no sudden, rough movements should be performed, 
 but the pressure should be gentle and continuous. It is well to precede 
 
 Fig. 275. — Replacement of a Retroflexed Uterus nv the Sound. 
 
 the reposition of the organ by dilatation with laminaria tents, which gives 
 suppleness to the tissues, and the mucous membrane which is so often dis- 
 eased at the isthmus shovild be curetted ; the reduction may then be com- 
 pleted in one session. At other times it is of advantage to divide the treat- 
 ment over several sittings, repeating them every two or three days : after each 
 one the amount of improvement obtained may be preserved by carefully fill- 
 ing the posterior vaginal pouch with iodoform gauze ; finally the pessary 
 may be introduced. The most simple instrument for reducing the uterus is 
 the sound; I prefer it to all the various repositors which have been invented. 
 [It is to be remembered that this method of instrumental reposition is 
 
DISPLACEMENTS OF THE UTERUS. 
 
 383 
 
 only to be employed after a most careful examination has shown the probable 
 absence of any recent parametritric trouble or of marked disease of the uterine 
 appendages, and that in its employment the most scrupulous asepsis is to be 
 maintained. With these precautions, and remembering that to avoid me- 
 chanical injury to the uterine tissue the sound should be inserted only to 
 within a quarter of an inch of the fundus and the finger tip in the vagina 
 and not the cervix used as a fulcrum, the method is comparatively safe.] 
 
 Fixation of the Reduced Uterus. — For this purpose v/e may employ either 
 prothetic measures (pessaries) or various operations. 
 
 Pessaries. — A simple tampon of cotton in the posterior pouch is a means 
 of maintaining the uterus and is easily renewed, but it is better to employ 
 
 an indifferent pessary, like Du- 
 montpallier's ring, which has at 
 times caused the reposition of 
 the organ without the surgeon's 
 efforts by the steady pressure 
 which it exerts (Fig. 276). 
 [Ring pessaries of either hard or 
 
 Fig. 276. — Annular Pessary of Dumontpallier in Place, 
 IN A Case ok Retroflexion which it is Changing to Re- 
 troversion ; Reduction may Follow Spontaneously. 
 
 Fig. 277. — Hodge Pessary w^ith Anterior 
 Depression to Avoid Comi'ressing the Ure- 
 thra. 
 
 soft rubber, while often effective, are objectionable because of the stretching 
 of the vagina which they cause.] A better instrument is the Hodge pessary 
 with a double curve (Figs. 277, 278, and 279). 
 
 The pessary should be chosen to fit each case. If too small it is of no 
 value, if too large it becomes intolerable. If the perineum is resLstant, the 
 pessary may be a little narrowed below (Albert Smith's) ; this would be an 
 inconvenience in the contrary condition. It is well to have a small depres- 
 sion in the anterior portion to avoid injury to the urethra (Fig. 277). The 
 most convenient kind of pessary is that formed of one thickness of strong 
 copper wire and covered with rubber ; they may be instantaneously modified, 
 and yet they are resistant enough. As a matter of fact, the surgeon should 
 know how to adapt his instrument to each case by giving more or less sweep 
 to its curves. Hard-rubber pessaries are also very good, unalterable, and can 
 be softened in hot water so that their form can be changed. In diffictdt cases 
 I model a pessary of flexible tin, and when I am certain that it is of the 
 
384 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 shape exactly adapted to the case I copy it in aluminum, which is both light 
 and resistant, though the vaginal secretions alter it and it has to be fre- 
 quently renewed. The lower extremity of a pessary should always rest a 
 little above the meatus. 
 
 Gaillard Thomas has devised a pessary which resembles the Smith, ex- 
 cept that it has its posterior bar thickened [and Munde has still further mod- 
 ified this by making it shorter and broader (Fig. 281)]. 
 
 The Hodge or Smith pessary should be introduced with the patient Iving 
 
 Fig. 278. — Introdlxtion- 
 
 A Hodge Pessary :n a Case of Retroflexion Ovhich Should First bb 
 Redixed). 
 
 on the side; it is covered with vaselin and presented at the vulva in such a 
 manner that it shall glide flatwise along one of the lateral vaginal walls. 
 While the labia are separated, the perineum is strongly depressed (Fig. 
 278) ; then when the pessary has passed the introitus, it is easily turned 
 about in the larger superior portion of the canal. It then glides upward and 
 backward, describing a spiral along the posterior wall. A slight pressure on 
 its posterior bar carries it beyond the cervix into the posterior vaginal pouch, 
 and it thus occupies an oblique position from above downward and from 
 behind forward. The abdominal pressure acting upon the pelvic floor, con- 
 stantly but with increased force in all efforts, tends to make the pessary take 
 
DISPLACEMENTS OF THE UTERUS. 
 
 385 
 
 a horizontal position, and it thus oscillates about an imaginary axis which 
 passes through the middle of its transverse diameter, so that while the infe- 
 rior arc is depressed the superior is lifted, owing to the obliquity of the wall. 
 The posterior cul-de-sac is therefore stretched, the cervix drawn backward 
 according to the degree of the abdominal pressure, and the uterus as a whole 
 
 Fig. 279. — Hodge or Smith Pessary in Place after Reduction of Retrodeviation. 
 
 carried forward if the retroflexion has been reduced previously. It is not 
 unimportant to remark that, even when this reduction has been incomplete, 
 some benefit may often be obtained by either the ring or the Hodge pes- 
 sary ; the instrument then acting simply by diminishing the mobility of the 
 uterus. 
 
 The cradle pessary with a simple curve has the advantage of not descend- 
 ing so far as the Hodge, and also of sustaining the anterior vaginal wall; 
 
 Fig. 280. — Albert Smith Pessary for Retroversion. 
 
 Fig. 281. — MuNofi Pessary with Thickened Poste- 
 rior Bar for Use in Retroflexion. 
 
 but it is not so powerful as the doubly curved lever form (Figs. 280 and 
 282) ; it is specially adapted to cases in which there is some relaxation of 
 the anterior wall. 
 
 If the patient takes a douche twice a day, the pessary may be left in 
 place for two or three months; at the end of this time it should be with- 
 25 
 
386 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 drawn and careful account taken of the position of the uterus ; if it remains 
 in the position of anteversion, the pessary is given up, otherwise its use 
 must be continued. The accidents which have been described as the effect 
 
 Fig. 282. — Mund^-Thomas' Pessary in Place after Reduction of a Retrodeviation. 
 
 of forgotten pessaries are due to their complete neglect for years, with no 
 attempt toward cleanliness. 
 
 [The Albert Smith type of pessary, both with and without the thickened 
 
 Fig. 283.— Cradle Pessary in Place after Reduction of a Retrodeviation. 
 
 posterior bar, is the most generally useful, and it is seldom that any other 
 form will be required in the treatment of retro-displacements. This is em- 
 ployed with a posterior bar having a gentle sweep in simple retroversion, and 
 
DISPLACEMENTS OF THE UTERUS. 
 
 387 
 
 ■with a more pronounced curve, up to 90°, when a flexion is to be over- 
 come. 
 
 It is to be remembered that this pessary does not act by a general over- 
 distention of the vagina, but by pushing up the posterior cul-de-sac and thus 
 drawing the cervix backward and upward. When properly fitted, it should 
 cause no pain, should not project from the vagina or be felt by the patient, 
 should be movable and small enough so that the finger can be swept between 
 it and the vagina at every accessible point without tension. It should never 
 be introduced until the uterus has been replaced, never when there is any 
 jnarked tenderness or inflammation present in any part of the pelvis. The 
 
 Fig. 284. — Schultze's Figure-of-Eight Pessary in Place after the Reduction of a Retrodeviation. 
 
 patient must always be told that she is wearing a pessary, and that she must 
 remove it by hooking her finger over the anterior bar and pulling downward 
 if it causes pain at any time. She must keep the parts clean by a daily 
 cleansing warm injection, with a little sodium bicarbonate added. Injections 
 ■of alum or any sulphate are to be avoided, as they soon cause the pessary to 
 become roughened by incrustations. The pessary should be removed at least 
 once in three months, to be cleaned and polished. So far, no better mate- 
 rial has been found than polished hard rubber of good quality. While it is 
 truly said that very few permanent cures result from the use of these instru- 
 ments, they are most valuable as a palliative and adjunct to other treatment, 
 and when properly and intelligently used do not cause harm, 
 
 A properly fitting bar pessary does not interfere with coitus or impreg- 
 nation; and should the latter occur the pessary should be worn until the 
 uterus has become so large that there is no longer danger of its possible re- 
 'troversion and incarceration. ] 
 
388 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 The preceding pessaries act indirectly upon the cervix by the tension of 
 adjacent parts; other forms of the instrument have a direct action upon the 
 organ. Schultze uses pessaries of the form of the numeral 8, which encircle 
 the cervix and lift it backward; they are made of copper covered with rub- 
 ber. An instrument is chosen whose upper curves embrace the cervix with- 
 out strangling it, and the lower ring is adapted to the size of the vagina and. 
 the angle of the pubic arch. These pessaries are best for nulliparae, in whom 
 the vagina is resistant and there is no need of seeking a point of support 
 from the pubis ; in the latter case they are intolerable. 
 
 When the perineum is very flaccid and the vagina large and relaxed,. 
 Schultze employs a pessary with a cervical rest (Fig. 285), which resembles- 
 the instrument proposed lately by Vulliet. Fritsch combines Schultze's. 
 pessary with the Hodge made of hard rubber, especially in the first daya 
 
 Fig. 285. — Schultze's Pessary with Cervical Rest, Fig. 286. — Fritsch's Pessary. 
 
 OR Sleigh Pessary. 
 
 after reduction, following it with a Hodge pessary strongly curved (Fig. 286). 
 All these pessaries are best inserted in Sims' position (lateral semiprone). 
 
 Pessaries have been devised which have their point of support externally, 
 like the hysterophores used in prolapse ; they are all inconvenient and un- 
 trustworthy. [The Thomas-Cutter is sometimes temporarily useful when, 
 the posterior vaginal cul-de-sac is too shallow to permit the use of an intra- 
 vaginal pessary, its action tending to stretch and deepen this pouch.] 
 
 Pessaries with an intra-uterine stem may be of service in maintaining a 
 reduction for a few days, especially as an auxiliary to other methods. 
 Courty replaces the uterus with the sound once or twice a week, introducing 
 a galvanic uterine stem for a few hours after each session. Alexander also 
 maintains the organ in anteversion with a stem pessary after shortening the 
 round ligaments. These are the only advisable applications of these instru- 
 ments in retroflexion. 
 
 Whatever the form adopted, there are many cases in which it is absolutely 
 impossible to maintain the reduction. Sanger, from careful statistics of 57 
 cases treated by pessaries in his practice, obtained but 7 cures, or 12.2 per 
 cent; 27 were improved, or 47 per cent; in 15 cases there was no result 
 (24.7 per cent) beyond moderation of the subjective symptoms. 
 
 The causes of failure with pessaries may be either extreme mobility of 
 
DISPLACEMENTS OF THE UTERUS. 389 
 
 the uterus or relaxation of the vagina and perineum ; in the latter condition 
 they may be combined with the use of a perineal cushion, which often 
 affords much relief. If there is at the same time procidentia uteri or vagi- 
 nas, plastic operations are of great service in providing a point of support 
 for the pessary. 
 
 Patients are always relieved, especially when the abdomen is very large, 
 by an abdominal supporter which takes off the weight of the viscera. 
 
 Whatever the prothetic measures adopted, there are many patients who 
 cannot be cured by them ; in such cases we must have recourse to operation. 
 There are two of these which merit special mention, viz., shortening the 
 round ligaments and abdominal hysteropexy. 
 
 TJie Operation of Alqtde- Alexander- Adams . — The idea of restoring or 
 elevating the uterus by shortening the round ligaments, which are easily 
 accessible to the surgeon at their termination, belongs to Alquie, of Montpel- 
 lier. Two English surgeons reinvented the operation and performed it at 
 about the same time, and it is only just to connect their names with that of 
 our compatriot. 
 
 The operation is performed to maintain the reduction in retroflexion and 
 for prolapse; I will return to it in considering the latter subject. It was 
 very coldly received in England, Germany, and France. It was asserted, 
 after insufficient and unfortunate investigation, that the round ligaments 
 were not to be found outside the inguinal ring. A reaction then followed, 
 and the operation to-day has many partisans, although its precise indications 
 and its advantages are far from being correctly appreciated. 
 
 In my description of the technique I base my remarks on Alexander's 
 paper and on my own experience. The operation should always be preceded 
 by curettage as a preliminary step. 
 
 First and Second Steps. Discovery of the Ligaments. — Having found the 
 pubic spine, an inch and a half incision is made over it in the line of the in- 
 guinal canal down to the muscles. With the finger the non-resistant point 
 of the external inguinal ring is found and laid bare, avoiding the intercol- 
 umnar fibres which limit the ring above and externally. The cellular layer 
 which stretches between the pillars of the ring is then cut and a cushion of 
 fine yellow fat, upon which Imlach insists, pouts out of the wound. The 
 genital branch of the genito-crural nerve is then drawn aside, and wdth a 
 grooved director the round ligament is sought. It may be recognized by its 
 reddish cord-like aspect, a little striped at its lower extremity (Fig. 287); 
 it is then seized with forceps and isolated with a blunt instrument. The 
 wound is then covered with an antiseptic pad and the same manoeuvre re- 
 peated on the other side. 
 
 [The ligament is more easily found toward the upper limit of the external 
 ring. If a nick is made in the intercolumnar fascia and the opening made 
 to gape by drawing it back with a strabismus hook, while another is passed 
 down on the outside of the grayish mass seen through the opening, and its 
 
390 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 point turned inward, a mass of tissue is easily secured which when freedi 
 from the accompanying nerve is easily recognized as the round ligament. 
 Fibres are found which do not draw on the borders of the ring, and by steady- 
 traction on these the glistening, smooth cord of the ligament emerges.] 
 
 Third Step. Reposition of the litems. — Alexander prefers to replace the 
 uterus with a sound which an assistant passes into the organ, aiding the re- 
 duction by means of bimanual palpation, while the surgeon uncovers the 
 wounds, seizes the ligaments, and isolates them with the spatula or by cut- 
 ting the fibrous bands which hold them 
 with the scissors. They are drawn out a. 
 distance of about ten centimetres. Four 
 or five centimetres, which some operators- 
 have considered enough, does not accom- 
 plish a satisfactory reduction. To avoid 
 wounding the serous membrane, Duplay 
 has proposed to put a ligature round that 
 portion of the ligament which is farthest 
 up the canal; thus if the infundibuliform 
 process of the peritoneum has been drawn 
 down, it is tied off by the ligature. I do 
 not practise this manoeuvre. 
 
 The two ligaments must be treated 
 with the same traction and they should 
 
 Fig. 287.— The Round Ligament at the Ex- comC with but little forCC, especially whcu. 
 TERNAL Abdominal Ring. . . , , . . , , 
 
 the assistant aids the reduction by the 
 sound ; this easy extraction need not cause any fear that they have been torn 
 within the abdomen. Resistance is felt when the uterus is replaced, and 
 movements of the sound in the organ will be transmitted to the ligaments. 
 
 Fourth Step, Suture of the Shortened Ligaments; Closure of the Wound. 
 — The surgeon confides to an assistant the charge of keeping the ligaments, 
 moderately tense while he prepares to suture them. A curved needle with 
 silk is passed through the external pillar and the ligament toward its upper 
 border and lastly through the internal pillar, so that the stump of the liga- 
 ment is firmly united to the margin of the external orifice of the inguinal 
 canal. A second suture is passed through the lower portion of the ligament;, 
 then all that part of the fibrous cord which is beyond these sutures is cut 
 off. If it has been necessary to open the canal and divide the intercolumnar 
 fascia, the incision should be closed with catgut ; even when these parts 
 have not been cut, I am accustomed to close the ring by a deep catgut su- 
 ture, which thus forms the lowest of the different planes of superimposed 
 sutures which I employ for the closure of the wound. It is useless to drain 
 if the wound is clean and the search for the ligament has not been dif^cult. 
 Antiseptic dressing, with slight compression. 
 
 Casati, of Rome, has proposed a modification of the technique, making a 
 
DISPLACEMENTS OF THE UTERUS. 39I 
 
 curved incision from one ring to the other, crossing the extremities of the 
 excised ligaments, and fixing them with a deep, continuous catgut suture. 
 Doret employs the same cutaneous incision as Casati, opens the entire length 
 of the inguinal canal, liberates the two round ligaments, and ties them to- 
 gether in a triple knot which is fixed in the fibrous tissue in front of the 
 symphysis. The rest of the ligament is then sutured to the inguinal canal. 
 Dol6ris, in cases in which the ligaments are thin, adopts a procedure similar 
 to the above, with the difference that the crossing and suturing of the liga- 
 ments is made under the skin and not exposed. The free end of the right 
 ligament cut at its pubic insertion is seized by forceps introduced from the 
 opposite side, and carried under the skin above the pubes to meet the end of 
 the other. The left ligament is sutured to its pillars, the free portion is 
 resected, and its free extremity placed in contact with that of the opposite 
 ligament ; the two trunks are freshened and sutured with catgut ; drainage. 
 Segond fastens the round ligament in the superior angle of the ring by a 
 suture of silk; then, in the middle of the two pillars on their free borders 
 and parallel to them, he makes a short incision like that which Reverdin has 
 advised in the radical operation for hernia ; he thus obtains two small but- 
 tonholes which he uses in tying the ligament round the pillars. Seizing 
 the end of the ligament, it is passed from behind forward through one of the 
 openings, then through the other from before backward, and finally made to 
 emerge in the superior angle of the ring, which thus forms an actual knot 
 and is then fastened with one or two sutures which diminish the ring and 
 give more solidity to the fixation of the ligament. I consider the procedure 
 which I have given more simple and equally effectual. 
 
 Fifth Step. — Alexander considers it of great importance to maintain the 
 uterus in a good position during convalescence, with a stem pessary to keep 
 it straight and a Hodge to insure anteversion. The ligaments are thus re- 
 lieved from the traction which the uterus does not fail to exert upon them by 
 its tendency to reproduce the displacement. The pessary should be retained 
 during the first month, which the patient spends in bed [and for several 
 months after]. I have abandoned the stem, but it is well, I think, to main- 
 tain the uterus and thus relieve the ligaments either with the Hodge or by 
 means of antiseptic tampons frequently renewed. 
 
 Gravity of the Operation ; Results ; Indications. — At the end of the work 
 which I have cited, Alexander mentions twenty-six cases of retroversion and 
 retroflexion upon which he had operated up to June, 1885, with permanent 
 success. It is evidently, then, a benign operation. But Alexander states 
 that death may occur in exceptional circumstances, as after every surgical 
 procedure, however small, having known three cases, in his own experience, 
 from pyaemia due to contagion. Man)*" cases have been recently published 
 in France and elsewhere by Trelat, Doleris, Schwartz, Terrillon, who have 
 obtained great advantages from the operation in retroflexions which were 
 easily reduced, with no accidents. Fatal cases have been described by for- 
 
392 CLINICAL AND OPER-\TIVE GYNECOLOGY. 
 
 eign writers, Harrington having collected one hundred and forty cases, 
 with one death, from twenty-one operators. The operation is now general- 
 ized and is practised everywhere, with variable success, which appears to 
 depend upon the degree of clearness with which the indications are appreci- 
 ated. Besides the important discussion at the Paris Surgical Society, I 
 would mention those of the Congress of Gynecology at ^Munich, and at the 
 Congress at Halle. 
 
 Trelat has performed Alexander's operation forty times, of which five 
 were for movable or adherent retroversion, which were previously reduced in 
 repeated sessions, and obtained excellent results. He clearly formulates 
 the rule that shortening of the round ligaments seems to be the operation 
 directly indicated to maintain in anteversion a uterus which was previously 
 fixed by adhesions in retroflexions, mobilized by treatment, but unable to 
 preser^-e the position itself or by pessary. Moreover, since retrodeviations 
 seemed to him to constitute an actual menace to the patient, in view of the 
 almost constant complication of metritis and salpingitis provoking adhesions, 
 he considered it good practice to intervene in retroversions which were ab- 
 solutely indolent, and thus to guard against possible accidents. This prin- 
 ciple seems to me to extend the field of operation far too widely. I am in- 
 clined rather to accept Munde's advice, who, although a great partisan of the 
 operation, reserves it for painful deviations which are easily reducible. 
 
 It seems, then, that the operation of A Iquie- Alexander is susceptible of 
 giving excellent and permanent results in retroflexions of the uterus. In 
 simple cases a pessary ma.y be preferable ; but where it is difficult to apply 
 and is not well borne, shortening of the round ligaments is a valuable re- 
 source ; we should thus be able to cure even bedridden patients ; but it is 
 well to know that cases which are rebellious to the pessary sometimes bring 
 disappointment, even after operation; Kiistner and Keith have published 
 instructive cases of this variety. 
 
 It has been fully demonstrated that shortening of the round ligaments 
 does not hamper the course of pregnancy in any way, and does not compli- 
 cate labor; it also appears that the malposition has no tendency to recur 
 after confinement. Several cases of pregnancy and delivery at term have 
 been reported. Alexander has seen seven of his patients out of eight success- 
 fully delivered. Polk has noted the occurrence of pregnancy in a woman 
 operated upon for retroversion with adhesions ; she miscarried at the fourth 
 month. Doleris has observed pregnancy seven times ; Imlach, four times. 
 
 [Nearly all those who have had practical experience with Alexander's 
 operation have declared in its favor, and it will undoubtedly continue to be 
 done successfully in properly selected cases and with accessory operations 
 for lessening the weight of the uterus, narrowing the vaginal walls, and re- 
 pairing the torn perineum. 
 
 The greatest value of the operation is in old cases of retroversion and 
 flexion, especially when associated with descent or prolapse and with more 
 
DISPLACEMENTS OF THE UTERUS. 393 
 
 or less anterior or posterior colpocele ; that is, when the pelvic floor is in- 
 jured beyond non-operative restoration. To these indications may be added 
 displacement accompanied by prolapse of the ovaries, so that the wearing of 
 a pessary is not practicable. The presence of adhesions is an absolute con- 
 tra-indication, except where they can be broken by gentle manipulation. 
 When Alexander's operation is contra-indicated or inefficient, other methods 
 are to be employed. These fall into two distinct categories, one utilizing 
 the natural supports, the other creating new supports, and each having its 
 own sphere of usefulness.] 
 
 Co Ipo -hysteropexy and Vaginal Hysteropexy. — The first attempts to fix the 
 uterus by way of the vagina, after it had been reduced to a good position, 
 date from the time of Amussat, who in case of version, either forward or 
 backward, employed the hot iron and cauterized the side opposite to the dis- 
 placement to produce a cicatricial bridle which would restore the organ. 
 Courty claimed to have obtained very good results from this singular treat- 
 ment in cases of anteversion, and, although he did not reject it in retrover- 
 sion, declared that there was here some danger to the adjacent peritoneum. 
 
 With the same object a transverse fold of the vagina has been sutured 
 in such a way as to shorten one or the other wall of the canal; Sims per- 
 formed this three times for anteversion. 
 
 Richelot, Sr., has proposed to consolidate the cervix with the posterior 
 wall of the vagina. Bossi has recently described a similar procedure under 
 the name of vaginal fixation of the cervix. Byford has performed an analo- 
 gous metro-elytrorrhaphy in patients who had passed the menopause, uniting 
 the anterior vaginal wall on the anterior surface of the cervix with the pos- 
 terior wall of the vagina. Doleris practised pre- or retro-cervical colpor- 
 rhaphy in similar cases, after having reduced the displacement. 
 
 When the anterior vaginal wall appears too short, Skutsch proposes to 
 lengthen it by a transverse incision, which is then sutured longitudinally. 
 
 Schiicking fixes the fundus of the uterus to the vesico-uterine cul-de-sac 
 by means of a double-threaded, strongly curved needle cachec, introduced into 
 the replaced and dilated uterus, with which he pierces the vaginal fundus 
 and vaginal pouch below the bladder, tying the suture so as to have the 
 uterus in an exaggerated position of anteflexion. The suture is removed 
 from the tenth to the fourteenth day, when the exaggerated anteflexion 
 disappears. Zweifel opens the anterior cul-de-sac as a preliminary meas- 
 ure, in order to avoid with certainty injuring the bladder, intestine, or 
 urethra, accidents which are to be feared. In spite of this modification, of 
 which Schiicking strongly approves, and notwithstanding reported successes, 
 this adventurous procedure does not seem to me w^orthy of recommendation. 
 
 Von Rabenau has proposed to incise the cervix, then to open the ante- 
 rior vaginal pouch and separate the bladder from the uterus by a dull instru- 
 ment ; the anterior wall of the uterus is then excised for a distance of four 
 centimetres and the wound sutured. This operation has been imitated by 
 
394 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Schmid, of Cologne. Fraenkel has justly observed that the cervix is so 
 strongly drawn forward by the cicatricial process that the body of the uterus 
 tends to fall backward. 
 
 Sanger has theoretically adopted the idea of Schiicking, but his operation 
 of suturing the fundus to the anterior vaginal cul-de-sac is different. After 
 transverse section of the anterior cul-de-sac of the vagina and of the perito- 
 neum behind the bladder, he sutures the uterine body to the vagina with sil- 
 ver, uniting the vaginal wound on a vertical line to elongate the anterior 
 
 wall of the canal and permit the cervix to 
 retire backward. 
 
 Another method which is suggested by 
 the same author is dilatation of the uterus, 
 introduction of the finger into its cavity, 
 and, using the finger as a guide, the direct 
 insertion of a metallic suture into the uterus 
 through the anterior vaginal cul-de-sac which 
 is left intact. 
 
 These methods of vagino-fixation are not 
 satisfactory and have been but little used. 
 The recent methods of Mackenrodt and of 
 Diihrssen, however, are now commonly em- 
 ployed, especially in Germany, and have 
 been adopted by Le Dentu, with slight modi- 
 fications. In these two procedures the op- 
 eration includes three steps: (i) Incision of 
 the anterior vaginal wall ; (2) dissection of the bladder, which is drawn for- 
 ward and upward; (3) suture of the body of the uterus to the denuded 
 borders of the vaginal incision, with or without opening the peritoneal 
 cul-de-sac. The body of the uterus is in this way fixed to the anterior 
 vaginal wall for a greater or less distance, and unless relaxation of the wall 
 of the vagina occurs, the uterus is maintained in the position of anteversion 
 in which this procedure has placed it. 
 
 Both Mackenrodt and Diihrssen begin by forcibly drawing the cervix 
 downward and backward in order to expose the anterior vaginal wall. The 
 bladder is emptied and its lower limit carefully ascertained. A sound is used 
 to replace the uterus and carry it very far forward, and this instrument is 
 then left in the care of an assistant; it is better to employ a special forceps 
 constructed by Orthmann, one of its jaws, which is elongated in the form of 
 a sound, being passed into the uterus, while the teeth of the other grasp the 
 cervix. After this point Mackenrodt's and Duhrssen's methods differ. 
 
 At first Mackenrodt made a curved transverse incision convex anterior- 
 ly, a little below the lower limit of the bladder, extending as far as the tis- 
 sue of the cervix. He then incised the anterior vaginal wall in the median 
 line, from a point one centimetre behind the sub-urethral tubercle to the 
 
 Fig. 288. — Vaginal Hysteropexy, 
 ing's Operation. 
 
 SCHUCK- 
 
DISPLACEMENTS OF THE UTERUS. 
 
 39S 
 
 preceding transverse incision, and dissected the two triangular flaps thus 
 formed. After having completely separated the bladder from the uterus as. 
 far as the vesico-uterine cul-de-sac, he drew the uterus forward (Fig. 289) and 
 
 Fig. 289. — Mackenrodt's Vagino-fixation According to Arrizabalaga. Anterior median incision and sepa- 
 ration of vaginal flaps, i, Forceps placed below tubercle of anterior vaginal column ; 2, deep surface of vaginal flap : 
 3, hooked retractor showing internal surface of flap ; 4, dotted line showing limits of subsequent colporrhaphy ; 5, 
 bladder wall ; 6, suture in cellular tissue between bladder, vagina, and cer\'ix, raising lower portion of bladder; below 
 is part of anterior surface of cervix ; 7, combined sound and forceps drawing cervix toward vulva. 
 
 attached it to the two vaginal flaps by silkworm-gut sutures passed a little 
 above the upper portion of the cervix ; be then fastened the two triangular 
 flaps in their original position. 
 
 This primitive procedure gave several failures in the hands of its origi- 
 nator and of others. Mackenrodt has modified it several times. Being con- 
 vinced that the recurrences were due to the persistence of the vesico-uterine 
 cul de-sac, he obliterated this by an important special step in the operation:. 
 
\g6 
 
 CLINICAL AND OPERATIVE GYN-ECOLOGY. 
 
 -for this purpose he passed several catgut sutures transversely across the cul- 
 de-sac to unite its anterior and posterior walls. The entire anterior face of 
 the uterus from cervix to fundus was then fixed to the vagina across the ob- 
 literated cul-ds-sac. 
 
 Later, Mackenrodt deliberately opened the peritoneal cul-de-sac, drew the 
 uterus outside of the peritoneum and fixed it so throughout its entire length, 
 accepting the modification proposed by Schauta. 
 
 Quite recently he has abandoned vagino-fixation in favor of vesico-fixation. 
 
 Fig. 290. — Vagino-fixation — Placing the Si"tures (Duhrssen). 
 
 •on account of the unfavorable results of the former operation in subsequent 
 -confinements. After opening the peritoneal cul-de-sac he sutures the vesi- 
 cal flap of peritoneum to the fundus of the uterus, and then fixes the bladder 
 to the anterior wall of the uterus as far as the os internum. The sutures are 
 removed after three or four weeks. 
 
 Diihrssen makes a transverse incision in the anterior vaginal wall near 
 its insertion into the cervix and separates the bladder so as to denude as 
 large a portion of the anterior face of the uterus as possible. The uterus 
 is replaced by a sound in the hand of an assistant, and a silk suture, intended 
 to draw down the body of the uterus, is passed transversely through its an- 
 
DISPLACEMENTS OF THE UTERUS. 
 
 397' 
 
 terior wall (Fig. 290). If necessary a second and a third suture may be 
 passed above the first. The three sutures which fix the uterus are passed in 
 the. following manner: The suture penetrates the raw surface of the upper 
 vaginal flap, near its free border, passes through its entire length, then tra- 
 verses the uterine wall at the level of the fundus (Fig. 291). Each suture 
 runs vertically; they are tied and left in the wound. The sutures used ta 
 draw down the uterus are then removed and the vaginal wound is closed bya. 
 continuous catgut suture (Fig. 292). 
 
 Fig. 201. — Vagino-fixatiox — the Sutures ix Place (Duhrssen). 
 
 Pregnancy after Vagino-fixation of the Body of the Uterus. — The important- 
 communications made by Strassman and Mackenrodtto the Berlin Obstetrical 
 and Gynaecological Society show the influence which vagino-fixation may 
 exert upon subsequent pregnancies. 
 
 When pregnancy occurs in a uterus fixed to the anterior vaginal wall, 
 traction is exerted upon the adhesions, sometimes destroying them and lead-^ 
 ing to a recurrence after delivery. This occurred frequently after Rlacken- 
 rodt's earlier operations when fixation was accomplished without opening the 
 peritoneal cavity. 
 
 When the peritoneum is opened (that is to say, in Duhrssen's method. 
 
39^ 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 and in the modified procedure of Mackenrodt) the adhesions are much stronger. 
 They do not yield to the traction and furnish an insurmountable obstacla to 
 the regular development of the uterus, resulting in frequent abortions. 
 Diihrssen has counted six abortions in twenty-four pregnancies under these 
 conditions, and Weberstedt reports six abortions in twenty-four pregnancies 
 obsen-ed at Gusserow's clinic in patients operated upon by Diihrssen's method. 
 When pregnancy continues to term, serious complications may arise at 
 the time of delivery. Strassman has shown clearly that when the adhesions 
 
 Fig. 202. — Vagino-fixation — Final Sutures of the Vagina (DOhrssen;. 
 
 do not yield, the development of the gravid uterus takes place especially at 
 the expense of the posterior wall ; the anterior wall hypertrophies, but does 
 not rise out of the true pelvis where it is imprisoned. The cervix is drawn 
 high up and backwards by the posterior wall. Strassman reports two cases 
 in which normal delivery was impossible. In the first, version was required 
 and the patient died of post-partum hemorrhage. In the second, Porro's 
 operation was performed and death followed. Mackenrodt adds a similar case. 
 Richelot has warmly recommended a procedure of Nicoletis for the pur- 
 pose of elevating the uterus, which takes its point of support upon the poste- 
 rior vaginal wall and peritoneum. The intra-vaginal portion of the cervix is 
 "first amputated, then on its posterior aspect three catgut ligatures are passed 
 
DISPLACEMENTS OF THE UTERUS. 
 
 399 
 
 through the uterine stump and vagina in such a way that they reappear at the 
 internal uterine os. These three threads are median ; to the right and left 
 two others are passed, taking in the posterior wall of the vagina and emerging 
 on the anterior border of the stump so that the posterior vaginal wall is thus 
 suspended from this border of the uterine section; coaptation is completed 
 by superficial sutures. The entire vaginal insertion is carried forward, and 
 the wall drags upon the fundus of the uterus and rotates it forward even at 
 the moment of operation (Fig. 288). This, I think, is to expect a mechan- 
 
 FiG. 293. — Vagino-fixation. Theoretical correc- 
 tion of action of posterior adhesions of uterus fixed by 
 Mackenrodt's method, a. Cicatrix of uterine fixation; 
 «!, direction of its action; i, direction of traction force 
 exerted by adhtsion at fundus of uterus; c, c'^, situa' 
 tions into which the fundus c is successively drawn by 
 traction forced; r, resultant of traction forces a^ and d. 
 
 Fig. 294. — Vagino-fixation. Theoretical correc- 
 tion of action of posterior adhesions of uterus fixed 
 by Diihrssen's method, a, Cicatrix of uterine fixation; 
 rt', direction of its action; i, direction of traction force 
 exerted upon fundus of uterus by adhesion at that 
 point; r, resultant of traction forces a^ and i. 
 
 ical effect to be permanent, which is really only an illusion, for the constant 
 extensibility of the vagina and the frequent fiaccidity of the perineum reduce 
 the procedure to an ingenious theoretic conception. The good results ob- 
 tained have been due only to cer/ical amputation and its effect upon the 
 metritis. 
 
 A new method of fixation of the uterus has recently been recommended 
 by Pryor, who fixes the uterus to the bladder in cases of movable retrover- 
 sion. He opens the anterior cul-de-sac, denudes a small surface on the an- 
 terior surface of the uterus, and a corresponding area on the posterior surface 
 of the bladder, and unites the two organs in these regions by several inter- 
 rupted sutures. 
 
 When the uterus is retroverted and bound down by adhesions Pryor 
 opens the posterior cul-de-sac, breaks up adhesions, and makes the uterus 
 completely movable. He then places in Douglas' cul-de-sac a tampon of 
 iodoform gauze which pushes the body of the uterus forward. A second 
 
40 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 tampon, in the vagina, presses the cervix backward, aiding the first in main- 
 taining the uterus in its proper situation. The pelvic tampon is removed 
 in a few days ; the vaginal is left longer in position. 
 
 Pelvic Colpo-hysteropery. — This is the name which might be given to the 
 operation of Freund in cases of prolapse or serious retroflexion with a largely 
 developed Douglas' pouch. He thinks that both of these displacements may 
 be due to persistence of the great extent of this cul-de-sac in the foetus, for 
 up to the seventh month of intra-uterine life the peritoneum descends to the 
 middle of the vagina. Freund made a large opening in the posterior vaginal 
 pouch, entered the peritoneum, and sutured the posterior surface of the supra- 
 vaginal portion of the cervix to the serous membrane above the promontory 
 near the utero-sacral ligaments, taking care not to wound the rectum ; then 
 he packed the cavity with iodoform gauze and partly closed the vaginal 
 wound; afterward he restored the perineum if it was necessary. This oper- 
 ation, which furnishes a radical cure for congenital hernia into Douglas' cul- 
 de-sac, has been applied by Freund in two cases of retroflexion complicated 
 with hernia of this cavity. It does not seem more benign or more effica- 
 cious than abdominal hysteropexy. 
 
 The germ of Freund's conception was found in the propositions of 
 Schultze and Sanger. Schultze proposed a transverse section of the poste- 
 rior cul-de-sac of the vagina, freeing uterus and adnexa, reposition of uterus, 
 and obliteration of Douglas' pouch by sutures in such a way that the cervix 
 would be drawn backward. Sanger inquired whether curative adhesions 
 could be produced by opening the recto-uterine pouch and tamponing with 
 iodoform gauze. Freund thought of alcohol injections in the neighborhood 
 of the utero-sacral ligaments and into the retro-cervical cellular tissue,, 
 in the hope of thus producing anteversion by the contraction of these liga- 
 ments. This was assuredly a great risk, exposing the parts to inflammation 
 which would exceed therapeutic limits. 
 
 Most of these procedures of vaginal hysteropexy are open to two objec- 
 tions : they act directly upon the fundus, and fix the uterus to tissues which 
 are movable and extensible, which is not the case in suture of the uterus to 
 the abdominal wall. 
 
 Gastro-Jiysteropexy or Fixation to the Abdominal Wall (ventro-fixation,, 
 gastro-hysterorrhaphy, gastro-hysterosynaphy) : 
 
 Historical Review. — When the pedice of an ovarian cyst has been fixed 
 in the abdominal wound, it is quite common to find that a previous uterine 
 displacement has disappeared. From this originated the idea of purposely 
 fixing the uterus to the abdominal wall by means of the broad ligaments, with 
 or without removal of the ovaries. The first operation of this kind was per- 
 formed by Koeberld. On March 27th, 1869, in a difficult case of retroflexion 
 which had caused symptoms of chronic intestinal obstruction, he incised the 
 abdominal walls, brought the uterus forward, removed a healthy ovary, and 
 sutured the pedicle to the lower border of the wound. Sims (February 22d, 
 
DISPLACEMENTS OF THE UTERUS. 4O I 
 
 1875) performed laparatomy on a woman of thirty-two years who suffered 
 from an extremely painful retroflexion, removed the left ovary, which was of 
 the size of a nut and in cystic degeneration, and sutured the pedicle in the 
 lower angle of the wound in such a way that the uterus was held in its nor- 
 mal position ; the patient was perfectly cured. Schroder, a little later, had 
 a patient who suffered from retroflexion and choreic symptoms, and also had 
 a small cyst of the ovary, upon whom he performed laparatomy and fixed the 
 pedicle to the abdomen, curing the displacement and the chorea. Lawson 
 Tait, on February 20th, 1880, practised laparatomy for oophoritis and retro- 
 flexion upon a woman whom nothing had benefited. He found the ovaries 
 large and soft but not cystic, and removed them; then on closing the abdom- 
 inal wound he passed a suture through the fundus and fastened the uterus to 
 the wall. A second operation was done April 9th, 1880. Both cases 
 remained cured in 1883. Hennig in 1881, in a case of rebellious retro- 
 flexion, performed castration and sutured the ovarian ligament on the right 
 side and the broad ligament on the left into the abdominal wound. 
 
 After these scattered cases without definite system, Olshausen, in an ar- 
 ticle which was the beginning of a new era, published an improved method 
 including three remarkable cases, one of retroflexion and two of prolapse. 
 He united with many sutures of silkworm gut that portion of both round and 
 broad ligaments which is adjacent to the uterine cornua with the abdominal 
 wall, taking great care to avoid the epigastric artery. In one case he extir- 
 pated the ovaries in a patient who was near the menopause, but remarks that 
 this contingent to the operation was purely accidental. 
 
 At the congress where Olshausen's communication was made, a memoir 
 of Fraenkel's was followed by a discussion, and a number of new cases were 
 cited by Bardenheuer (reported by Frank) and Czerny. Soon afterward Kel- 
 ly, in Philadelphia, published an interesting case of retroflexion cured by 
 ablation of one ovary and fixation of the pedicle to the abdomen, together 
 with a partial analysis of preceding papers; the other ovary had been extir- 
 pated some time before by the vagina. Kelly published at the same time 
 two cases of castration and suture of the broad ligaments to the abdomen by 
 Sanger. Soon after the latter author prepared a more complete study of 
 the subject with seven personal cases. Since then he has performed ventro- 
 fixation twelve times ; in nine cases he removed the appendages. Klotz, in 
 October, 1887, had already reported to the Gynaecological Society of Dresden 
 seventeen cases of fixation of a retroflexed uterus to the abdominal wall by 
 means of a pedicle formed of the tube. Leopold, one month later, presented 
 three successful cases after fixation of the fundus in the abdominal wound. 
 In 1888 Kelly, in America, published a new paper on the subject with sev- 
 eral new cases ; four of P. Zweifel's for retroflexion (hysterorrhaphy without 
 castration) and one of Staude's for retroflexion (hysterorrhaphy witli ablation 
 of one ovary, the other being so adherent that it could not be extirpated). 
 Phillips published one case of ventro-fixation for prolapse in Fngland. 
 26 
 
402 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Schauta has reported four cases from his practice. Czerny has given four 
 cases of gastro-hysteropexy and described his method in an important memoir 
 which appeared in October, 1888, In France, Terrier, and Picque were the 
 first to perform the operation. Terrier in August, 1888, for prolapse, and 
 
 - 
 
 Fu-,. 
 
 -Gastro-hvsteropf.xv (Olshai'sex and Saenger). Profile view to show the path of the sutures_ 
 7", Tube ; /\, round ligament ; (', o\-arian lig-ament. 
 
 Picque in September for retroflexion. Since that time the cases have multi- 
 plied in France and elsewhere, and their description offers nothing peculiar. 
 It is probable that many gynaecologists have practised occasional comple- 
 mentary fixation of the uterus after ablation of an ovarian cyst or a fibroma 
 or to remedy a retroflexion or a prolapse, without publishing : thus, in April, 
 
 Fig. 296. — Gastro-hystkroi'EXY (Olshaiisen and Saenger). Front view. Two" of the sutures for closings the 
 al)dominal wall are represented as cut away so as to show clearly the uterine sutures on either side which have already 
 been tied. 
 
 1882, I fixed the pedicle of an ovarian c}'st and cured a prolapse. The case 
 was mentioned for the first time at a discussion on hysteropexy and published 
 entire by Dumoret. Czerny practised an analogous suture of the pedicle of 
 the ovary for retroflexion June 15th, 1886, but did not publish the case till 
 the )-car 1 888. At that time he had done the complementary operation three 
 or four times in forty-six ovariotomies. 
 
DISPLACEMENTS OF THE UTERUS. 4O3 
 
 With these complementary hysteropexies it is convenient to include nec- 
 essary fixation of the pedicle after supra-vaginal amputation and fixation of 
 the uterus after extirpation of a subperitoneal fibroma. Brennecke, of Mag- 
 deburg, has sutured the uterine cornu of the right side to the abdomen in the 
 course of an ovariotomy to remedy a prolapse; success; 1883. In a second 
 operation of ovariotomy he sutured both cornua for prolapse; failure; new 
 operation on the same patient ; suture of ovarian pedicle; 1885. With the 
 exception, perhaps, of this last case, these operations have nothing in common 
 with hysteropexies deliberately proposed. Werth, of Kiel, performed castra- 
 tion for hemorrhage in 1887, sutured the pedicle to the wall, with cure at the 
 same time of extreme retroflexion. In 1884, in another operation for der- 
 moid cyst, he sutured the retroflexed uterus to the vesical peritoneum with 
 silk ; this is not ventro-, but vesico-hysteropexy, or cysto-hysteropexy. A 
 case of Weist's, cited by Kelly, in which he was said to have attached the 
 ovarian pedicle to the abdomen for prolapse, belongs in the class of fortui- 
 tous operations and is very different from veritable gastro-hysteroptrc}- 
 
 Operative Technique. — Three chief and several secondary procedures may 
 be distinguished : 
 
 1. Indirect Fixation. — The ovary or tube being first removed, the ped- 
 icle is fixed in the abdominal wound. Klotz, who has employed his method 
 in thirty-eight cases, attaches much importance to the use of a glass tube be- 
 hind the uterus in Douglas' pouch, which may be withdrawn after a short 
 time, and which has for its purpose the production of adhesions. This 
 method has the defect that it sacrifices the ovary, twists the uterus, and 
 produces only a temporary union ; it has often failed. 
 
 2. Direct Lateral Fixation of the Fundus. — Silkworm-gut sutures are 
 placed on each side, at the edges of the fundus, as shown in Figs. 295 and 
 296. They are inserted with care to include only the anterior serous layer 
 and not to pierce the tube or the epigastric artery. This procedure has the 
 disadvantage of leaving a cleft or buttonhole between the uterus and the ab- 
 dominal wall which may cause internal strangulation. Kelly's method re- 
 sembles Olshausen's and does not need special description. 
 
 3. Direct Media?!. Fixation. — Leopold also fixes the fundus of the uterus 
 to the abdominal wall. The abdomen is opened, the uterus replaced after 
 rupture of adhesions, and then a strong needle, armed with silk, is passed 
 from before backward, a little outside of the border of the wound, through the 
 whole abdominal wall at the level of the fundus. The uterine tissue is 
 pierced on the elevated surface of the anterior aspect of the organ in a line 
 with the insertion of the two round ligaments. The needle is passed under 
 the serous membrane and the superficial layer of the muscle for a distance of 
 one centimetre, and then through the other lip of the wound, but this time 
 from behind forward. A second suture is then inserted above in a line with 
 the insertion of the tubes for about two centimetres, and a third a little above 
 this one in the same manner (Fig. 297). 
 
404 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 To facilitate the adhesion, Leopold gently scrapes the surface of the peri- 
 toneum with the back of the bistoury over that portion of the uterus which 
 is circumscribed by the sutures, making a superficial freshening which does 
 not bleed and simply removes the epithelium. Then he unites the lips of 
 
 ,^{ 
 
 Fig. 297. — Gastro-h^stekopf.xv ; I.kopoi.p's TiIethod. 
 
 the abdominal wound at that level, tying the three sutures above the abdom- 
 inal wall (Fig. 297) so that the anterior surface of the uterus is exactly ap- 
 plied to the parietal peritoneum at this point. The rest of the wound is 
 then closed below and above. The uterine sutures are removed at the erd 
 
 Yll,. 298. — OA.STIiO-HVSTKK()I•HX^■ ; CZKRNV'S MkTHOD. 
 
 of about twelve days. None of the sutures are hidden. Leopold thinks 
 that he thus produces lax adhesions, with little risk to the bladder. It is 
 well to insert a Hodge or Smith pessary for the first month to prevent strain 
 on the sutures and maintain the good position gained. 
 
 Czerny pierces the abdominal wall near the fundus with a very strong 
 needle furnished with bichloride catgut (he first used chromic catgut). The 
 needle passes through the muscles and the peritoneum and then the opposite 
 
DISPLACEMENTS OF THE UTERUS. 
 
 405 
 
 side, but does not include che integument, which is a capital difference be- 
 tween this and Leopold's method. One or two threads are thus placed with 
 care not to exert traction upon the uterus, a point being selected where the 
 organ may be easily applied to the abdominal wall ; they are then tied, the 
 ends cut and the w^ound closed (Fig. 298). 
 
 Terrier's procedure is a variation of the preceding". He begins by plac- 
 ing a provisional suture of silk in the fundus, through but little of the tis- 
 sue, for the purpose of drawing the organ upward. Large catgut is used for 
 the three permanent sutures on the anterior surface of the uterus. The first 
 is passed at the junction of cervix and body, the next at the middle of the 
 body, and the last near the fundus. The threads pass through the superficial 
 
 Fig. 299. — GASTRo-HVSTEKOrEXv ; Tekkiek's Method. 
 
 layers of the uterus, and the w^hole thickness of the abdominal wall, with the 
 exception of the cellular tissue and the skin. This is the real difference 
 between Leopold's and Terrier's procedures; the latter being distinguished 
 from Czerny's by the care which is taken to pass the sutures like basting 
 stitches so that they are not wholly hidden in the tissues of the uterus, but a 
 portion is interposed between the organ and the abdominal wall ; he thinks 
 that the production of adhesions is thus better assured (Fig. 299). The 
 threads are tied and form a " suture perdu," above which the integimients are 
 brought together, superiorly by three silver sutures through the peritoneum 
 and below by three strands of silkworm gut. 
 
 I have long employed the continuous hem suture, no matter how great 
 the extent of the wound. At present I have returned to the method of 01s- 
 hausen, Sanger, and Kelly, and use silkworm-gut. 
 
 On many secondary points of technique surgeons are not agreed. Should 
 
406 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 the suture be one which cannot be absorbed (silk or silkworm gut) as Leo- 
 pold, Olshausen, Sanger, and Phillips propose, or silver as Olshausen advises 
 for support in prolapse, or large catgut which is absorbed, as Terrier and 
 Czerny suggest ? Should we employ a Hodge pessary immediately after the 
 operation, tampon the vagina when the case is one of retroversion, or keep 
 the patient on a bed which is inclined toward the head to prevent intestinal 
 pressure when the operation has been done for prolapse ? These are points 
 of detail which I will not discuss. 
 
 Immediate Abdominal Hysteropexy, tvithoitt Laparatomy. — The old fear of 
 the peritoneum formerly caused many surgeons to avoid opening it ; and, on 
 the other hand, the possibility of replacing a retroflexed uterus in such a way 
 that its fundus came in contact with the anterior abdominal wall a long time 
 ago gave rise to the idea of direct anterior fixation without laparatomy. Ac- 
 cording to Emmet, Marion Sims first conceived this idea, in 1859, and con- 
 structed a special hollow needle to pass a silver suture, with this object ; but 
 having one day begun the operation, he had not the audacity to finish it. 
 Caneva, more than twenty years afterward, proposed abdominal hysteropexy 
 for prolapse by piercing the serous membrane through a small exposed sur- 
 face, but he does not seem to have performed it. Kaltenbach, however, has 
 employed it five times, using silver sutures. Kelly, still more boldly but 
 without permanent success, has three times sutured the uterus to the abdo- 
 men by passing two or three horsehair sutures deeply through the fundus of 
 the organ without preliminary incision ; the sutures are fastened by a shot, 
 and removed on the fifteenth day. Assaky proposed this operation and fur- 
 nished Roux, of Lausanne, the opportunity of showing its dangers by a per- 
 sonal case. Having begun to perform the operation, before suturing the 
 peritoneum, which nothing seemed to separate from the uterus, he suddenlv 
 decided to make an incision, and found under the serous membrane a loop of 
 very thin intestine which he must have punctured. This demonstrated the 
 dangers of this brilliant but blind procedure. 
 
 Prognosis of Gastro-hystcropexy . — The published results give but \'ery few 
 deaths. The operation is not more fatal than an uncomplicated laparatomy. 
 There is no doubt, however, that the prognosis may be aggravated b}- intra- 
 abdominal laceration of great extent (as in a case of Klotz), when the uterus 
 must be freed from strong adhesions, and in particular from adhesion of its 
 surface to the rectum. It is only in these cases that drainage is indicated. 
 Experience has proved that the bladder is not often involved and that there 
 is seldom much urinary trouble. The results appear to be permanent. 
 Leopold has had cures lasting three years and Korn sixteen months, in retro- 
 versions ; but Olshausen has had one striking failure after ventro-fixation 
 for prolapse. In one of Sanger's patients three months after operation there 
 was already a tendency toward return. 
 
 A question which it is very important to answer otherwise than b}- theo- 
 retical considerations is concerning the influence which pregnancy might 
 
DISPLACEMENTS OF THE UTERUS. 4O7 
 
 have on a uterus sutured to the abdominal wall. Would the adhesion be 
 ruptured ? Would the course of the pregnancy be interfered with by the 
 obstacle produced to its increase in size, or would such increase go on very 
 easily above and outside of the small surface immobilized? One of the rea- 
 sons why Olshausen, Sanger, etc., have adopted the suture of the uterus 
 along its edges rather than on its anterior surface seems to be just this fear 
 of obstructing the development of the organ during gestation. But their 
 procedures assure insufficient adherence ; and the cleft which Olshausen 
 leaves between the bladder and the uterus is, in spite of all precautions, a 
 dangerous point for the production of internal strangulation. Experience 
 has sustained some of the theoretical objections on this point. It has now 
 been demonstrated that pregnancy and delivery at term are not rare after 
 hysteropexy, and recently many cases of pregnancy terminating normally 
 have been reported. 
 
 Sanger has performed hysteropexy upon two women in whom pregnancy 
 occurred and ended normally. One of them aborted the first time, but car- 
 ried the second to term ; the other was delivered at term. Olshausen re- 
 ports a case of labor at term, following an operation by Kaltenbach. Frai- 
 pont found, in 6 cases in which hysteropexy had been performed by von 
 Winiwarter, i delivery at term, i premature labor (traumatism), and i deliv- 
 ery at the eighth month (child living). Jacobs has seen i of his patients 
 confined at term. Klotz has observed 4 pregnancies — 4 deliveries at term. 
 Leopold has noted 3 normal pregnancies in 19 cases of ventro-fixation for 
 retroflexion. Gottschalk has seen pregnancy in i of his patients, with abor- 
 tion at the third month. Flaischlen has published a case of confinement at 
 term from the practice of Carstens ; i of his patients, four months pregnant, 
 was under observation. Howitz has observed pregnancy in i of his cases 
 some weeks after operation ; the labor was normal. Routier has seen i of 
 his patients successfully delivered ; 2 of mine have been confined without 
 accidents ; a second patient of Routier, i of Michaux, and 2 of Terrier have 
 also had normal labors at the Baudelocque Clinic. 
 
 Goubaroff has recently recorded a case in which he was obliged to per- 
 form Caesarean section upon a woman who had submitted to an abdominal 
 hysteropexy four years before. 
 
 J. Milander has collected 74 cases of pregnancy in women upon whom 
 gastro-hysteropexy has been performed; 65 times pregnancy terminated by 
 a normal labor, 3 times by premature labor, and 6 times by an abortion. 
 Eight women had had two pregnancies and 3 had been pregnant 3 times 
 after the operation. The uterus had been maintained in anteversion in all 
 cases except 2 ; of which one belonged to Fraipont, the other to Olshausen. 
 In these the retroversion had returned. 
 
 Generally speaking, it may be said that the cases of pregnancy and labor 
 which have been enumerated have not been followed by a recurrence of the 
 retro-deviation ; neither in von W^iniwarter's 3 cases, Sanger's 5, Klotz's 4, 
 
408 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 nor in those of Leopold nor of Howitz. Six weeks after delivery the uterus 
 of Kaltenbach's patient was still anteverted. Jacobs has presented his pa- 
 tient, completely cured, to the Gynaecological Society of Brussels. Routier 
 has noted that in his patient the adhesions were not destroyed. Carstens' 
 patient was not seen again ; Flaischlen's had the uterus in anteflexion at the 
 fourth month of pregnancy. As a irs?ime of the most recent works, gastro- 
 hysteropexy seems to give durable therapeutic results and not to create ob- 
 stacles to subsequent pregnancies and labors. Observations show, however, 
 that fixation of the uterus by the fundus predisposes to malpresentations by 
 causing an exaggerated anteversion. 
 
 Indicatio7is for Gastro-hysteropcxy in Retroversion. — Should the operation 
 be performed for cases in which the uterus is movable, that is to say, the 
 displacement reducible, trusting to the benign character of antiseptic laparat- 
 omy, when a properly selected pessary, with perseverance on the part of the 
 physician and with patience on the part of the woman, has demonstrated 
 that the case is not to be cured by the employment of such an instrument 
 and that the symptoms persist .■' It seems to me, it should not be. Short- 
 ening of the round ligaments is too valuable a resource to be neglected in 
 such a case. It is so also with vagino-fixation (Mackenrodt), at least in pa- 
 tients who are near, or have passed, the menopause. It is better not to per- 
 form it in young women, as subsequent pregnancies may expose them to real 
 dangers. If I reject gastro-hysteropexy at the outset of the treatment as an 
 exaggeration of its province, yet when we have tried Alexander's operation 
 or vaginal fixation without success, I think that the first operation is legiti- 
 mate. 
 
 The principal indication for abdominal hysteropexy seems then to be 
 ftnmd in those cases of retroflexion which are irreducible, where there are 
 adhesions which can be destroyed only under chloroform, which keep the 
 fundus always in Douglas' pouch, except possibly after a false reduction 
 where the uterus is replaced by drawling with it the anterior wall of the rec- 
 tum. When, with the patient under an anaesthetic, we are convinced that 
 the uterus cannot be reduced by the use of external means aided by the 
 sounder the repositor within tlie organ; when, especially after dilatation, 
 the finger in tlie uterus, as Schultze adA'ises, is not able to effect the reduc- 
 tion — in such cases there are but two things to do: either abstain from new 
 attempts to reduce the organ, which cause serious accident to the adnexa and 
 the pL']\ ic peritoneum, or, if the intensity of the symptoms demand it, per- 
 form lajxiratomy, liberate the uteru.s, and then fix it. 
 
 So far I have considered hysteropexy only as a principal procedure, de- 
 cided upon from the outset as applicable to retroversion. If its advisability 
 in this case is doubtful, the same is not true as regards its performance sec- 
 ondarily, as the complement of another operation. When, in the course of a 
 la])aratoniy for another lesion, fibroma, ovarian cyst, inflammation of the ad- 
 nexa, etc., the uterus is found to be displaced backward, as so often happens, 
 
DISPLACEMENTS OF THE UTERUS. 
 
 409 
 
 the indication is to profit by the occasion and replace it. If there is a pedi- 
 cle at one's disposal, it may be sutured into the wound. I think, however, 
 that it is not well to stop here, but to render the proper position of the organ 
 certain by passing a few sutures through the superficial layers of the fundus 
 or its anterior face, in the median line. 
 
 Another indication for hysteropexy, secondarily performed, is found in 
 those cases in which there are severe pains or painful reflexes dependent upon 
 
 ^Z^l?!^. 
 
 Fig. 300. — CoiRSE of the Rolnd Ligaments as Seen throigh n he Transparent Peritoneim (Wvlie). 
 
 the State of the adnexa, which may be simply prolapsed (movable retroflex- 
 ion), or adherent (resistant or irreducible retroflexion"), or involved in inflam- 
 mation. Sanger and Leopold have combined castration with hysteropexv in 
 
 Fig. 301. — Hysteroi'EX\ ; \\'\ lie's Method. Shortening- the round liiranients by intra-peritoneal fold. 
 
 the latter case. Hysteropexy alone suffices in simple prolapse of the ovary, 
 thus becoming a conservative operation, for, as the pains disappear after the 
 uterus is fixed, Battey's operation is unnecessary. 
 
 The following modifications of abdominal hysteropexy are of considerable 
 interest, although they seem to me inferior to those already mentioned. 
 
 SJiortcning tJie Vtero-sacral Ligaments by the Abdominal Method. — This 
 procedure, proposed by Kelly, consists in passing a suture on each side of 
 the rectum at the bottom of Douglas' pouch from within out, and then 
 
4IO CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 deeply into the cervix at the insertion of the iitero-sacral ligaments. From- 
 mel has performed it once. 
 
 Intra-abdominal Shortening of the Round Ligaine^its. — First Gill Wylie, 
 then Ruggi and Emile Bode have proposed a method of shortening the 
 round ligaments by folding them. 
 
 Ruggi, having opened the abdomen and reduced the displacement, pierces 
 the round ligament with a curved needle carrying strong catgut, a very short 
 distance from its entrance into the inguinal canal and on the peritoneal fold 
 which surrounds it. A knot is made in the end of the catgut distant from 
 the needle ; the latter is passed through the round ligament of the same side 
 near its uterine extremity, and the two halves of that ligament are brought 
 together by folding, and united by a double continuous suture. The same 
 steps are carried out on the opposite side. 
 
 Gill Wylie has successfully employed a very similar method in a large 
 number of cases. He seizes one of the round ligaments at an equal dis- 
 tance from the uterine cornu and the pubis, and draws it out through the 
 abdominal wound ; he then denudes the internal surface of the fold formed 
 by raising the ligament. This denudation, which consists in scraping the 
 peritoneum from the surface of the ligament, should assure the solid union 
 of the folded portions (Fig. 301 ). For this purpose he passes three 
 strong silk ligatures around the fold formed, including as much as pos- 
 sible of the round ligament. He does the same upon the other side, 
 closes the abdominal wound, and inserts an Albert Smith pessary in the 
 vagina. 
 
 Bode sutures rather differently. Beginning at the uterus he takes as 
 much of the broad ligament as is needed to shorten it to the extent which he 
 deems necessary. Raising the ligament, he folds it, and passes a suture 
 which surrounds it almost entirely at the point of traction. This suture is 
 knotted once, then passes through the adjacent uterine cornu. Its two ends 
 are easily tied after having shortened the round ligament until it is 
 stretched. 
 
 Polk employs a method of shortening by stitching the round ligaments 
 in front of the uterus. He denudes them near their uterine end at the level 
 of their internal surface, brings them in front of the uterus, and sews them 
 together inside; at the apex of the loop he unites them with a strong suture 
 at the denuded portion. By this method the loop formed is internal, not 
 external, as in the operations previously described, and the ligaments are 
 united in the form of an X behind the bladder. 
 
 Dudley, of New York, has proposed a much more complicated method 
 than the preceding. He shortens the round ligaments by making a loop at 
 the uterine extremity of the ligament and sewing it to the anterior surface of 
 the uterus. He applies it to cases in which peri-uterine adhesions exist, 
 without serious complicating affections of the appendages and with perme- 
 able tubes. 
 
DISPLACEMENTS OF THE UTERUS. 4I I 
 
 Vaginal Hysterectomy. — This operation has been performed by certain 
 surgeons for painful and rebellious retroversions, but it cannot be considered 
 justifiable except where other radical means have been exhausted, including 
 abdominal hysteropexy. 
 
 Choice of Operation for Retroflexion. — The first indication in every case 
 of painful retroflexion is to find the exact seat of the inflammation and the 
 mobility of the uterus. 
 
 If the uterus is easily replaceable, it is probable that there is only a mild 
 degree of metritis. If bimanual examination confirms this diagnosis, the 
 inflammation must be cured before everything else; and therefore the treat- 
 ment of catarrhal or chronic painful metritis should be at once begun. The 
 curette should be employed, and if there is hyperplasia the cervix resected. 
 I have many times observed that intra-vaginal amputation (Simon, Schroder) 
 has been followed by spontaneous reposition of the uterus, owing, without 
 doubt, to the involution which succeeds and imparts new tone to the organ. 
 The same fact has been noted by others, and it explains the cases falsely 
 attributed to complicated procedures of excision and suture which act, not 
 upon the deviation, but the metritis. 
 
 When the uterus has been replaced, any tenderness about the adnexa 
 should be treated. Then a pessary may be fitted, or preferably, a perma- 
 nent reposition secured by Alexander's operation or by \'agino-fixation. 
 Shortening the round ligaments, however, even with the latest improve- 
 ments, gives results of a questionable durability ; vagino-fixation should be 
 employed only in women who have passed the menopause, on account of the 
 serious danger to which subsequent pregnancy subjects patients operated 
 upon by this method. If these measures fail, and if at the end of several 
 months the deviation has been reproduced and the pains have returned, 
 we are then authorized to perform laparatomy. Keith followed the 
 above plan in one of the first hysteropexies deliberately proposed and 
 performed. 
 
 There is a class of movable retro-deviations to which, after failure of the 
 pessary, Alexander's operation is especially adapted. In the higher ranks 
 of society we often observe women with a delicate nervous organization, 
 who have an easily reducible displacement with no inflammation, but where 
 too great mobility of the uterus seems to be the cause of all the symptoms. 
 The uterus takes a new abnormal position after it has been replaced, and is 
 found in latero-version or flexion or even in anteversion. There is a condi- 
 tion of abnormal mobility of the organ, similar to that of certain joints, with 
 great laxity of the ligaments, as described by Gerdy. The pathological 
 state which results is characterized by nervous reflexes and neurasthenia, 
 and approaches without being easily confounded with that synthetized by 
 Glenard under the name of entero-ptosis. In such patients the application 
 of a pessary gives immense benefit. These patients should also wear an 
 abdominal supporter. 
 
412 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 There remain now only the adherent retroflexions. Here the diagnosis 
 appears to me to be of the greatest importance. I can ahnost agree with 
 Wylie that in nine cases out of ten the adhesions have resulted from a co- 
 existent salpingitis. It is dangerous, therefore, to make repeated attempts 
 at reduction, either with the finger introduced into the dilated organ or with 
 sound and repositor. If, after a moderately thorough trial under chloroform, 
 reduction cannot be accomplished, I abandon it. If there is metritis, I limit 
 myself to the surgical treatment of this (curette and amputation of the cer- 
 vix », with the hope that the pains will disappear with the cure of the inflam- 
 mation. If there is serious disease of the tubes, old and persistent, I per- 
 form laparatomy. 
 
 If there is severe and persistent pain with no appreciable tubal disease, 
 laparatomy, which is always exploratory to a certain degree in such cases, 
 may be performed, when, if any developing lesion of the adnexa (pyo-sal- 
 pinx, parenchymatous salpingitis, oophoritis, sclerocystic degeneration of 
 the ovary, etc."), is found, the diseased organ should be removed. 
 
 After castration on both sides and destruction of the adhesions, the 
 uterus will frequently return to a normal position. Strictly speaking, the 
 operation of hysteropexy could then be dispensed with, but for fear that it 
 may again be displaced posteriorly it is well to suture it to the abdominal 
 Avail. 
 
 In cases in which the retroversion coincides with a certain degree of gen- 
 eral enfeeblement of the pelvic floor and of the supports of the uterus, marked 
 by relaxation of the vagina and the gaping vulva, the patient is usually a 
 multipara in whom the retroposition constitutes the first stage of prolapse. 
 In these complex cases the various contributing factors must be eliminated 
 by a combination of operative measures; the metritis, by curetting and am- 
 putation of the cervix ; the uterine deviation, by shortening the round liga- 
 ments if the uterus is movable, and by abdominal hysteropexy if it is adhe- 
 rent ; the perineal weakness, by colpo-perineorrhaphy. Plastic operations on 
 the perineum and vagina should be deferred until the uterus has been fixed, 
 that we may better appreciate the amount of surface which needs to be de- 
 nuded. 
 
 As it seems to me unadvisable to devote a whole chapter to the consider- 
 ation of the less important displacements of the uterus, I will simply enume- 
 rate them. 
 
 The uterus, from the pressure of a tumor posterior to it, may be pushed 
 directly forward — anteposition ; retro-uterine hsematocele offers a striking 
 example of this displacement, which is invariably an epiphenomenon. 
 
 Retroposition is a posterior displacement of the entire organ without any 
 change in the long axis. This follows posterior para- or peri-metritis, and 
 may occasionally be observed in its typical and uncomplicated form ; though 
 as a general thing it is usually complicated by an anteflexion. The symp- 
 
DISPLACEMENTS OF THE UTERUS. 4T3 
 
 toms observable are due to the inflammatory adhesions, and treatment should 
 be directed to these alone. 
 
 Upzvani Displacement of the Uterus is also merely a symptom. Tumors 
 in the pouch of Douglas, in the ligaments, or those imprisoned in the pelvis 
 may lift the organ out of place; in some cases it seems to be upheld and 
 prevented from returning to its normal position oy adhesions formed during 
 pregnancy. In all cases the cervix is elongated. 
 
CHAPTER XIX. 
 
 PROLAPSE OF THE GENITAL ORGANS. 
 
 Following Trelat's example, I include under one head prolapse of the 
 uterus, that of the anterior vaginal wall pulling upon the bladder (cystocelei 
 and of the posterior wall dragging forward the rectum (rectocelei. These 
 several displacements have been artificially classified as separate, but in 
 reality should be described together, since the cases when they occur inde- 
 pendently of each other are quite exceptional. The etiolog}^ and the treat- 
 ment of these lesions also ser\'e to give them absolute clinical identity. 
 Moreover, hypertrophy and elongation of the cervix should be included in 
 the anatomy and symptomatology of these displacements. 
 
 Etiology. — Hart very wisely compares these displacements to hernia. 
 But there is this difference between them : in an ordinary hernia, the parts 
 pushed outward by intra-abdominal pressure are freely movable (intestines, 
 omentum), while in a uterine prolapse we have to do with organs fixed or 
 limited in situation by their firm attachments, and which consequently when 
 displaced are likewise distorted. This is the chief reason for the hypertro- 
 phic elongation of the cervix. As in herniae, hoAvever, we recognize dis- 
 placements due to violence and those due to weakness. The first follow a 
 violent effort of some kind, which is either sufficient in itself to cause the 
 injury, or which is injurious because of predisposing conditions. A fall 
 upon the back, an epileptic seizure, a violent attack of coughing have all 
 been the direct cause even in virgins of what some authorities term acute 
 prolapsus. In the majority of cases, however, the uterine supports have 
 been enfeebled by one or more labors, and some violent strain is merely the 
 determining factor of the prolapse. Pregnancy is often a predisposing cause 
 of this displacement, a fact which can be readily understood when we con- 
 sider the changes which have taken place in the parts surrounding the gravid 
 uterus. All the ligaments are elongated and at the same time softened ; 
 intra-abdominal pressure is increased, and bears with more than the usual 
 force upon the weak points of the pelvic floor, where the vagina forms a line 
 of cleavage which seems always ready to give way under increased strain. 
 
 Whatever may have been said to the contrary, rupture of the perineum 
 is a predisposing cause of prolapsus uteri. It permits of a gaping condition 
 of the vulva which admits air into the vagina, separating its walls, and 
 diminishing the support offered by the perineal floor. It has been asserted 
 [and truly] that the transversus perinasi and the levator ani may have sus- 
 
PROLAPSE OF THE fiENITAL ORGANS. 415 
 
 tained a subcutaneous laceration, or may have l^ccn paralyzed during labor, 
 without giving any external evidence of the injury. The relaxed condition 
 of the peritoneum, which has been stretched by the gravid uterus, also tends 
 to favor the prolapsus induced by parturition. 
 
 Shall we go further and admit the existence of an hereditary congenital 
 predisposition to prolapse, or consider the predisposition to be simply an 
 individual peculiarity due to the weakness of the supporting genital appa- 
 ratus ? The latter view certainly seems reasonable, and would account for the 
 fact that the same cause is productive of varying results in different individ- 
 uals. It is the same in the case of hernia. 
 
 Pathological Anatomy. 
 
 In this connection it is absolutely essential to observe a certain classifi 
 cation of the disorders under consideration. 
 
 I. Prolapse of tJie Vagina Alone {Cystocele and Rectocelc). — In the great 
 majority of cases, prolapse of the vagina precedes that of the uterus, the 
 uterine displacement following in the course of time as a result of the down- 
 Avard dragging. The anterior vaginal wall is the more easily displaced. In 
 Avomen who have borne many children it is not unusual to observe a small 
 cystocele when the bladder is full. This is, however, in no sense a patho- 
 logical phenomenon; the anterior vaginal wall simply exceeds the posterior 
 in length, and, providing that the perineum possess a sufficient degree of 
 tonicity to support it, the results are of little consequence. If, however, the 
 perineum be deficient in tone, a form of vesical hernia follows, as the poste- 
 rior wall of the bladder is intimately associated with the vagina and cannot 
 be separated from it. This vesical protrusion is sometimes more apparent 
 than real, the protuberance (compare Figs. 302 and 304) being mainly the 
 subinvoluted and thickened vaginal wall. The posterior vaginal wall soon 
 follows the anterior and the dilated rectal pouch becomes insinuated be- 
 tween its folds ; though as the intestinal and vaginal walls are only loosely 
 connected, rectocele occurs less frequently than cystocele. When both are 
 present, a finger introduced through the anus can be hooked into the poste- 
 rior part of what appears at the vulva as a vaginal protrusion, while a curved 
 catheter can easily be inserted into the cavity of the cystocele. We have 
 then a double-lobed protrusion into the vagina (the lobes being usually of 
 unequal development ), which enlarges and becomes tense upon straining, 
 and the surfaces of which still retain the folds and the color of the vagina. 
 Under the influence of the air and friction it thickens, hardens, and some- 
 times ulcerates. If there be no prolapse of the bladder (which is rare) or of 
 the rectum (less rare), the peritoneum may insinuate itself into, and greatly 
 deepen, the anterior and posterior culs-de-sac. This condition presupposes 
 immobility of the uterus and flaccidity of the serous membrane, or eLse fac- 
 cording to Freund) lack of development, for in the foetus the folds of peri- 
 
4i6 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 toneum are relatively much lower down. A porrion of the small intestines 
 may now fall to the front or back, pushing down the vaginal wall, and form- 
 ing what have been called herniae or vaginal enteroceles. These lesions are 
 
 Fig. 302. — Pko'lai-se ok Genital Organs. Procidentia of thickened anterior vaginal wall; slight cystocele ; 
 persistence of posterior cul-de-sac ; hypertrophy of middle portion of cervix. 
 
 exceedingly rare in their occurrence, there being on record but few cases of 
 vaginal prolapse with anterior enterocele, and still fewer of vaginal prolapse 
 with posterior enterocele. 
 
 Fig. 303. — Prolap.se of Genital Organs. Pro- 
 cidentia of anterior vaginal wall with cystocele, and 
 hypertrophic elongation of the middle portion of the 
 cervi.v (Schroder). The posterior cul-de-sac is intact. 
 
 Fig. 304. — Prolapsb of Genital Organs. Com- 
 plete procidentia of vagina, with cystocele ; no rectocele; 
 hypertrophic elongation of the supra-vaginal portion of 
 the cervix ; the posterior cul-de-sac is inverted. 
 
 2. Vaginal and Uterine Prolapse with Secondary Hypertrophic Elongatioti 
 of the Cervix. — The constant dragging of a prolapsed vagina upon its attach- 
 ments to the cervix soon affects the uterus itself. These attachments are 
 loosened by degrees, and finally slip down in such a way that the projection 
 
PROLAPSE OF THE GENITAL ORGANS. 
 
 417 
 
 of the cervix completely disappears, being covered by the portion of vaginal 
 wall which formerly constituted the culs-de-sac. The uterus being still im- 
 movable, and the vagina continuing to drag downward, the cervix, which is 
 now entirely supra-vaginal, gradually elongates. Occasionally it is length- 
 ened without any hypertrophy, but more often the passive congestion and 
 the inflammation in the prolapsed organs bring about a hypertrophic condi- 
 tion — this hypertrophy being entirely a secondary process. The preliminary 
 disappearance of the cervical projection is what marks the beginning of this 
 process, the cervix then being perceptible to palpation as a cylindrical col- 
 vmin in the centre of the inverted vagina.. 
 
 If, as not infrequently occurs, the posterior vaginal wall gives way later 
 and less completely than the anterior, the vaginal procidentia will be in front 
 
 Fig. 305.— Prolapse of Genital Organs.— Complete procidentia of thickened vagina ; slight cystocele ; posterior 
 cul-de-sac obliterated ; hypertrophy of supra-vaginal portion of cervix. 
 
 only, and the posterior cavity of the vagina will still remain ; a finger intro- 
 duced into the posterior cul-de-sac (Figs. 302 and 303) will be able to ap- 
 preciate the fact that the posterior portion of the cervix is hypertrophied. 
 
 This somewhat singular condition of things is quite accounted for by the 
 preceding considerations, although Schroder gives a more elaborate explana- 
 tion. He thinks it due to the fact that the hypertrophy begins in the mid- 
 dle portion of the cervix, intra-vaginal posteriorly, supra-vaginal anteriorly 
 (Fig. 308, b, h). 
 
 3. Prolapse of Vagina and Uterus Resulting from a Primary Hypertro- 
 phic Elongation of the Snpra-vaginal Portion of the Cervix. — This condition 
 was for a long time unrecognized and is still disputed by some authori- 
 ties ; it nevertheless exists, although it is of less frequent occurrence 
 than Huguier supposed. In some virgins with firm vagina and perineum, 
 and no prolapse of the uterus, an inversion of the upper part of the vagina 
 may be observed, coexistent with a supra-vaginal hypertrophy of the cervix. 
 I operated upon such a case when with my lamented preceptor Gallard. We 
 27 
 
4i: 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 are forced to admit that the initial elongation of the cervix drags upon the 
 vaginal attachments, yet, although the starting-point of the process is always 
 the cervical hypertrophy, later the roles may be reversed, and the vaginal 
 procidentia become of chief importance, in its turn causing elongation of the 
 cervix. The position of the intra-vaginal cervix will aid in determining 
 whether this condition of things exists ; it is so often lengthened by hyper- 
 trophy that if we find it in normal position we may be quite sure that the 
 
 Fig. 306. — Prolapse of the Uterus, with considerable hypertrophic elongation of the cervix ; cystocele. 
 
 vaginal attachments are not dragging upon it. This influence exerted upon 
 prolapse of the genitalia by hypertrophy and elongation of the cervix above 
 the vaginal attachment had been observed and remarked upon by several 
 authorities, but was given no special prominence until Huguier published 
 his celebrated treatise upon the subject. With sovereign ability he demon- 
 strated, by the aid of clinical and anatomical material, the fact that in the 
 great majority of cases downward displacement of the uterus has been 
 wrongly interpreted ; there has not been prolapsus or falling or precipitation 
 of the uterus in its entirety out of the abdominal cavity through the vulvar 
 opening, hernia-fa.shion, but rather a lengthening of the supra-vaginal por- 
 tion of the cervix which, undergoing hypertrophy and being unable to ex- 
 
PROLAPSE OF THE GENITAL ORGANS. 4I9 
 
 tend into the abdomen, pushes downward into the vaginal aperture, dragging 
 after it the vagina and neighboring viscera, which are more or less closely 
 adherent. This theory advanced by Huguier was revolutionary to the ideas 
 previously entertained, which held that the prolapse of the uterus was the 
 last step in its downward displacement, this being divided into three de- 
 grees : 1st. Simple downward displacement. 2d. Descent, the cervix ap- 
 pearing between the labia. 3d. Prolapse or precipitation, where the fundus 
 has followed the cervix and is entirely outside of the vulva. According to 
 Huguier, this order of progression without a preceding cervical hypertrophy 
 
 Fig. 307. — Prolapse of the Uterus. Hypertrophic elongation of the cervix; rectocele. 
 
 is very exceptional, the cervical changes constituting the initial lesion and 
 causing the real displacement of the vagina and the apparent displacement 
 of the uterus. It forms the point of chief importance in the condition, and 
 to it should the treatment be directed. Huguier performed conoidal ampu- 
 tation of the cervix; he first dissected it out from the vesical and rectal 
 attachments, and then amputated as high as possible (Fig. 309). I have 
 frequently performed this operation and found it valuable. But if done 
 according to Huguier's method, without approximating and fastening the 
 mucous membrane by sutures, it will lead to contractions, of small impor- 
 tance in women who have passed the menopause, but of great inconvenience 
 to those still menstruating. A proper appreciation of the value of Huguier's 
 theories upon this point will give it a high position, without, however, rush- 
 ing to the extreme of Gallard and others who undoubtedly overestimated it. 
 From an anatomico-pathological point of view, he established the fact of 
 
420 
 
 CLINICAL AND OPERATIVE GYNAECOLOGY, 
 
 the frequent occurrence of a hypertrophic elongation of the supra-vaginal 
 portion of the cer\'ix, in prolapse of the genital organs. 
 
 It is true that this hypertrophy is not invariably the primary manifesta- 
 tion that he supposed. It is, in fact, usually the secondary elongation due- 
 
 FiG. 308. — SrBDmsiOKs of the Cervix 
 (Schroder). P, peritoneum ; V, bladder ; a, 
 intra-vaginal portion ; b, middle portion (intra- 
 vaginal posteriorly, supra-vaginal anteriorly); 
 c, supra-vaginal portion. 
 
 Fig. 309. — CoKoiDAL Amputation of the Cervix (Hu- 
 guier's method). Portion of ceri-ix thus obtained (trans- 
 fixed by a sound). Natural size. 
 
 to the traction exercised by the prolapsed vagina ; while the hypertrophy is- 
 the result of venous stasis favoring a parenchymatous cervical endometritis. 
 Yet the fact remains, that it had been unrecognized, and to him belongs the 
 
 Fig. 310. — Prolapse of the Uterus, following a retroversion ; no ii\pertrophy of the cer\-ix. 
 
 credit of bringing it into notice, and of calling attention to and causing the 
 adoption of amputation of the hypertrophied cervix as a method of treat- 
 ment. That it is of less value than he at first supposed scarcely detracts 
 from the merits of his discover}-, when we recall the almost constant failure 
 of all plastic operations before the introduction of antisepsis. Amputation 
 
PROLAPSE OF THE GENITAL ORGANS. 42 I 
 
 of the cervix still holds its own in therapeutics as an important preliminary 
 step in operation for prolapsus. 
 
 What is the nature of this hypertrophy of the cervix.^ When it follows 
 the continuous traction of a prolapsed vagina, it is undoubtedly an inflamma- 
 tory process. But when it constitutes the first step in the process, what is 
 its origin ? Is it the result of a congenital predisposition to malformations, 
 manifested only when the organ is completely developed either at puberty 
 •or from the nutritive activity called into play by pregnancy? Is it the 
 indication even, in the latter case, of a localized cervical endometritis, as 
 Gallard supposes ? Each of these factors may operate singly or together. 
 The histological examination does not give any very satisfactory result. 
 Olivier has given a resume oi such examinations upon cervices which I had 
 removed, according to Huguier's process, when in Gallard's service. He 
 found no hypertrophy, but he did find a localized arterio-sclerosis. The 
 sections examined were similar in structure to those of a uterus with endo- 
 metritis. Moreover, the distinction was not carefully observed between 
 sections taken from a cervix where the hypertrophic elongation was a secon- 
 dary process and those where it was primary. Inflammatory lesions may 
 often be secondary, for every prolapsed uterus is almost certain to become 
 infected. 
 
 4. Prolapse of Uterus and Vagina witJiout Hypej'tropJiy of the Cervix. — A 
 slight sinking of the uterus, rendering it more easily accessible to the exam- 
 ining finger, and deepening the vaginal culs-de-sac, is frequently observed. 
 But complete prolapse is rare, because of the resistance to be overcome. 
 (Bastien and Legendre certainly exaggerated the amount of resistance en- 
 countered. According to their statements, it takes a force of from twenty 
 to twenty-five kilograms [forty-four to fifty-five pounds] to pull the cervix to 
 the vulva upon the cadaver, and of over fifty kilograms [one hundred pounds] 
 to draw it below this opening. Daily clinical experience proves that upon 
 the living subject this same thing can be done without any violent exertion, 
 but owing to the elasticity of the tissues the organ returns to its normal po- 
 sition as soon as released. In a pathological condition this elasticity is lost, 
 and the organ remains out of position.) 
 
 It may be termed a hernia from violence, since so great an effort is 
 required to produce it. In this case the uterus usually drags the vagina 
 after it ; the organ itself is usually retroverted, this displacement rendering 
 the occurrence of prolapse more probable under strain (Fig. 310). After 
 the uterus has emerged beyond the vulvar opening, it may undergo devia- 
 tions from its normal axis, and, suspended in its hernial sac, become ante- or 
 retroflexed (Figs. 311, 312). Inversion combined with prolapsus has also 
 been observed. 
 
 The relations of the neighboring organs vary according to the kind and 
 degree of the displacement ; as a general rule, the greater the cervical hy- 
 pertrophy (and by cervix we here mean exclusively the supra-vaginal portion) 
 
422 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 the farther are the folds of peritoneum from the uterine orifice ; on the other 
 hand, in the variety shown in Fig. 310 they would be very near to it. 
 
 With a marked rectocele (Fig. 312) faecal matters tend to accumulate 
 and harden in the pouch. 
 
 A cystocele usually results in the formation of a wallet-shaped bladder, 
 whose lower pocket is situated below the internal urethral opening, this fre- 
 
 FiG. 311. — Prolapse of the Uterus ^VITH Anteflexion; it is no longer connected with bladder and rectum; 
 
 these organs meet above the uterus. 
 
 quently giving rise to stagnation of the urine (Figs. 303 and 310). There 
 is often dilatation of the bladder, and even of the ureters and the pelvis and 
 
 Fig. 312. — Prolapse of the Uterus with RETKnri.iJxmx ; rectocele. 
 
 calyces of the kidney, owing to the strain upon or compression of the lower 
 end of the ureters. Calculi are said to have been found in the cystocele, 
 but there are fewer cases reported than the theories advanced would lead one 
 to expect. 
 
PROLAPSE OF THE GENITAL ORGANS. 423 
 
 The vaginal mucous membrane is thickened, often resembling skin or 
 leather, and becomes blanched or violet-colored. The prolapsed portions are 
 oedematous, and we frequently notice ulceration of the cervix, ectropion of 
 the OS, or excoriations and ulcerations due to friction of the surface of the 
 tumor. Endometritis almost always occurs in a prolapsed uterus, and sal- 
 pingitis is not infrequent. 
 
 Symptoms. — Acute prolapsus, as it has been termed, meaning that 
 which immediately follows some violent strain, is rare, yet cases have been 
 reported. Immediately after the accident, a tumor formed by the anterior 
 wall of the vagina alone, or by the uterus as well, is seen hanging out of the 
 vulva. Intense pain, sometimes syncope and peritonitis, accompany the 
 lesion. Usually, however, the prolapse is gradual, and gives rise to no well- 
 marked symptoms ; a feeling of heaviness referred to the perineum, a drag- 
 ging sensation in the loins and abdomen, fatigue upon walking, are the chief, 
 accompanied by the ordinary symptoms of endometritis, besides troubles 
 connected with micturition, dysuria, polyuria, incontinence, or retention, 
 with or without cystitis. If there be a very large cystocele, the patient may 
 be obliged to assist micturition by external pressure upon the protruding 
 bladder. Menstruation is unaffected. Fecundation is rare, though possi- 
 ble, in complete prolapsus. Abortion may follow, but, again, the gravid 
 uterus may develop normally in the abdomicn, causing a temporary disap- 
 pearance of the displacement. 
 
 In prolapsus, as in hernia, the severity of the rational symptoms does 
 not always depend upon the gravity of the lesion. Often women apply for 
 admission to the hospital, with a uterus suspended between the thighs, who 
 have, in despite of this condition, continued to perform hard manual labor 
 with apparent ease, until some accident obliges them to stop and undergo 
 treatment. On the other hand, some patients whose uterus is only slightly 
 fallen, and is not even near the vulvar opening, complain of intense pain 
 when walking, and are reduced to a state of invalidism. It would seem as 
 if, in the former case, a new and definite static condition of the uterus had 
 been developed, giving tolerance to a well-marked lesion, while in the latter 
 case this species of compensation had not been acquired; the unstable con- 
 dition of the uterus giving rise to numberless twinges of pain and nervous 
 reflex phenomena, which make a prolapsus uteri one of the manifestations 
 of " enteroptosis," that group of symptoms so ably classified by Glenard. 
 
 The physical signs are very characteristic. In the early stages of a pro- 
 lapse, the vaginal mucous membrane, though very flaccid, does not appear 
 beyond the vulvar opening unless the patient strains. By placing her in 
 the dorsal position and bidding her bear down, one may see the anterior 
 vaginal wall bulge outward by a sort of rotary motion, forming a soft, pink- 
 ish tumor, which returns in place with the cessation of the downward strain- 
 ing. 
 
 It is well to bear in mind that the anterior and posterior vaginal walls 
 
424 CLINICAL AND OPERATIVE GYN^COLOGv. 
 
 are normally in apposition, so that a section of the canal in a state of rest 
 would be well represented by the letter H, The procidentia of the vagina 
 could scarcely be cylindrical, as in the case of the rectum ; the anterior or 
 posterior walls simply slip down, either singly or together. This first de- 
 gree of cystocele soon gives place to the permanent and more severe form, 
 and later the os uteri appears just behind it, discharging the mucus pro- 
 duced by the cerv'ical catarrh. If the posterior vaginal wall be involved, the 
 OS seems to be in the centre of a pyriform tumor which opens out the labia 
 minora, and whose surface is dry, wrinkled, darkened by exposure to the air, 
 and occasionally, in addition to ulcerations around the os, suffers a loss of 
 substance from friction and lack of cleanliness. A furrow surrounds the 
 tumor at the base, especially near the fourchette. The size of the tumor 
 varies from that of an egg to that of two doubled fists (Figs. 306 and 307), 
 
 Palpation will give different results according to whether the uterus 
 shares in the prolapse or not. Everything included in the vaginal proci- 
 dentia is soft and flabby. Tension and elasticity of the cystocele increase 
 when the bladder is full. The existence of an enterocele ('which is of rare 
 occurrence) is shown by gurgling. \\'hen the uterus is prolapsed without 
 any cen^'ical hypertrophy, the body even of '.he organ may be felt in the 
 interior of the presenting tumor (Figs. 310, 311, 312). But in the typical 
 cases described of prolapsus either preceded or followed by hypertrophy of 
 the cerv'ix, only this portion of the uterus is to be found in the tumor (Figs. 
 302, 303, 304, 305) of which it forms the axis. It is more or less thick and 
 rigid according to circumstances, imparting to the hand the sensation of a 
 cord, or of an elastic cylinder ; by bimanual palpation it is found to be con- 
 tinuous with the body of the uterus, which is behind the pubic bone. 
 
 The insertion of the uterine sound will reveal pathognomonic signs in 
 the case of cervical elongation ; it passes for a length of from four to eight 
 inches. [A curious fact often noted in these cases of cervical hypertrophy 
 is the apparent "ductility" of the tissues, a uterus which when prolapsed is 
 seven or eight inches in depth measuring only about four when fully re- 
 placed.] We must remember that in aged women there may be obliteration 
 of the cervical canal. The tumor is perfectly reducible when the uterus 
 has not participated in the prolapse; even if it has done so, it may be re- 
 duced, but is with great difficulty kept in position. A permanent cure is 
 almost always impossible; the firm column in the midst of the tumor formed 
 by the hypertrophied cervix could only be pushed into place by a degree of 
 violence that might be the cause of injury. 
 
 The exact position of the bladder may be determined by the use of a 
 male catheter, which is introduced with the tip turned downward. The 
 bladder often reaches the immediate neighborhood of the uterine orifice (case 
 of secondary elongation of the cervix from traction) (Fig. 304); in other 
 cases the os uteri, which has remained normal, causes another and sometimes 
 large bulging below the lower extremity of the bladder (primary hypertro- 
 
PROLAPSE OF THE GENITAL ORGANS. 425 
 
 phic elongation of the supra-vaginal portion of the cervix) (Figs. 305 and 
 306 ) . 
 
 Course and Prognosis. — The course of the disease is chronic in its 
 nature, and, if untreated, results in a complete prolapsus. In some patients 
 this descent of the genital organs is coexistent with other large herniae, and 
 forms a pelvic condition quite as incurable as the abdominal disembowelling. 
 Cases have been referred to in which a spontaneous cure followed the tempo- 
 rary reduction of a prolapsus, when the uterus was bound down by adhesions 
 formed by peritonitis. These cases seem to me to need confirmation. 
 
 Diagnosis. — By bimanual palpation, rectal touch, and the use of the 
 uterine sound and the catheter, we may distinguish the tumor which emerges 
 through the vulvar opening, from a polypus or an inverted uterus. The 
 chief difficulty consists in determining precisely what parts have shared in 
 the prolapsus, and to what extent they have altered, whether in position, 
 form, or size. A male catheter introduced into the bladder will determine 
 the boundaries of the displacement ; a finger hooked into the rectum will 
 appreciate any folds of intestine anteriorly ; while the hypertrophied condi- 
 tion of the cervix may be felt by means of palpation and the uterine sound. 
 The condition of the peritoneal culs-de-sac it is impossible to tell, except 
 when efforts at reduction result in a gurgling sound and give rise to the sup- 
 position that loops of intestine are to the front and behind the prolapsed 
 uterus. As I have before observed, these enteroceles are of rare occur- 
 rence, and are never found where there is supra-vaginal hypertrophy of the 
 cervix. In this case the peritoneum is farther away from the vagina than in 
 the normal condition ; in simple descent without cervical hypertrophy it is, 
 on the contrary, nearer to the vagina (Fig. 310). 
 
 Urethrocele is an interesting variety of vaginal prolapse, which may 
 almost be considered a special form of cystocele ; Duplay has published 
 an important treatise upon the subject. The tumor is formed by the 
 dilatation of the urethra, or by a cavity opening into this canal, the bladder 
 not being implicated. A tumor, rarely larger than a walnut, appears at the 
 vulva, and is situated immediately beneath the urethra, apparently in the 
 meatus ; straining brings it more into view. It is only by a careful exami- 
 nation that we are able to distinguish it from cystocele ; we then see that it 
 extends only a little way upward and is not connected with the bladder, 
 which has no tendency to prolapse. The catheter passes into the pouch of 
 the urethrocele and then into the bladder ; the inferior wall of the urethra, 
 which is deflected, is much longer than the anterior wall, which has retained 
 its normal position. The urethro-vaginal wall is sometimes greatly thick- 
 ened and sometimes much thinned. It is doubtful whether a urethrocele, 
 by continuing to dilate, can ever pass into the bladder and become a cysto- 
 cele. 
 
 Treatment. — The prophylaxis of prolapse of the genital organs consists 
 in the careful conduct of labor and subsequent rigid observance of hygienic 
 
426 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 laws. Belts and pessaries give little help ; yet we must not neglect to sup- 
 port the abdomen by a well-constructed bandage, which will keep the intes- 
 tines from bearing down with their full weight upon the pelvic organs. 
 
 Pessaries are of use only when the perineum has preserved a degree of 
 tonicity; their action is often aided by a perineal pad (Figs. 313 and 314). 
 Breisky claims good results from an egg-shaped pessary, which is held suffi- 
 
 FiG. 313. — Perineal Air-Cushion. 
 
 ciently in place by the narrow vaginae of aged women, Dumontpallier's 
 ring pessary, Hodge's pessary, Schultze's sled-runner pessary, the "gim- 
 blette" pessary, Gariel's air pessary, should all be given a trial. Zwanck- 
 Schilling's winged pessary is well known, but of little value [and so danger- 
 ous that it should be mentioned only that it may be avoided]. 
 
 In order that any kind of pessary be of use, I repeat that a certain degree 
 of tonicity in the perineum is essential, and a somewhat small vulvar open- 
 ing. They are valuable in cases of cystocele, but fail when the uterus takes 
 
 Fig. 314. — Belt with Perineal Pad. 
 
 Fig. 315.- 
 
 -Basin-Shaped Pessary. 
 
 part in the prolapse. In any case, they should never be used except as a 
 palliative measure, trusting to a radical operation for cure. 
 
 Nevertheless if the patient positively refuses surgical aid, or if it offer 
 but small chance of relief, as in the case of complete prolapse in enormously 
 stout women, with pendulous abdomen, whose vagina and uterus seem to 
 have lost all connection with the pelvic cavity, the only resource seemj; to be 
 a stem pessary supported by a belt. Very similar varieties have been c':- 
 vised by Scanzoni, Courty, and Grandcollot (Figs. 315 and 316). The 
 Dumontpallier pessary may be fixed to a stem which has an abdominal sup- 
 port, but the ring must be very unyielding to be of use. Borgnet's cork 
 pessary recommends itself, especially for hospital use, by its simplicity of 
 construction, its solidity, and its cheapness (Fig. 317). Whatever the pes- 
 
PROLAPSE OF THE GENITAL ORGANS. 
 
 427 
 
 sary used, its insertion should be preceded by a reduction of the proLpse, 
 and treatment tending to diminish the congestion of the parts. If there be 
 oedema or inflammation, the patient should be kept in bed ; frequent baths 
 and prolonged tepid vaginal injections are to be given, tampons applied, and 
 massage administered. As soon as the tissues have lost some of their rigid- 
 ity, reduction of the prolapse is attempted, the patient being in the Sims or 
 
 Fig. -516. — The Roser-Scanzoni Pessary. 
 
 else the genu-pectoral position, both of which favor the entrance of air into 
 the vagina. The bladder and rectum must be empty. If much difficulty 
 be experienced in restoring the prolapsed organs to place, it is better to wait 
 patiently and not use force. 
 
 [Much may be accomplished in the prophylaxis of these displacements 
 by the avoidance of any exertion during the puerperium ; confinement to 
 bed until involution is well under way ; the avoidance of constipation or the 
 use of clothing which compresses the waist, and the immediate suture of 
 perineal lacerations. Any relaxation of the vaginal tissue should be treated 
 
 Fig. 317. — Borgnet's Pessary. 
 
 by hot astringent injections. Chronic cases of slight degree are benefited 
 by the tonic effect of the hot douche and by astringent tamponade, and ac- 
 cording to many writers by elevation of the uterus and massage by Thure 
 Brandt's method. Pessaries in general are. unsatisfactory, as stated above, 
 though many cases of cystocele receive great benefit and relief from the pes- 
 sary devised by Gehrung (Fig. 318). This instrument, while most efficient, 
 needs to be carefully fitted, and is difficult to adjust unless fully understood. 
 As it sustains a considerable weight, it must be watched to see that its su- 
 perior bar does not cut into the vaginal wall. It is inserted as follows: 
 Place the pessary on a table, with the superior arch [S) below and the in- 
 
42 8 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 ferior (/) above, the curves R and L pointing toward you. Take the pes- 
 sary by curve L with the right hand and insert curve R into the vagina to 
 the right of the patient, until three-fourths of the instrument is buried 
 within. Then push curve L toward the fourchette and the left side of the 
 
 patient, so that it slips into the vagina at the 
 ime time that vS" turns upward in front of the 
 uterus and / under the pubic arch. The 
 t irves R and L should rest squarely on the pos- 
 terior vaginal wall, while .S and / support the 
 rectocele between the uterus and symphysis.] 
 
 Sicrgical Treatment. — This offers so much 
 chance of relief, and is attended by so little 
 danger, that it ought to be much preferred to 
 the use of pessaries. 
 
 The various methods used may be thus 
 classified : 
 
 1. Support derived from the vagina, vulva, or perineum. 
 
 2. Uterus raised by shortening the round ligaments. 
 
 3. Uterus sutured to neighboring structures (hysteropexy) through the 
 vagina or by means of a laparatomy. 
 
 4. Hysterectomy. 
 
 Before going into the details of these various operations, we must devote 
 a few moments to the consideration of a valuable preliminary operation, de- 
 
 FiG. 318. — Gehrung's Pessary for 
 Cystocele. 
 
 1 2 
 
 Fig. 319. — Uterine Prolapse; Amputation of the Vaginal Portion of the Cervix. 
 2, After the suture, n, Bladder. /', Douglas' cul-de-sac. 
 
 I, Before the suture. 
 
 signed to favor the replacing of the uterus when the cervix is hypertrophied, 
 viz., amputation of the cervix. Instead, however, of following Huguier's 
 method without reference to subsequent reunion, we should always try to 
 bring the mucous lining together, after the excision of a conoidal portion of 
 each lip (Fig. 319). 
 
 We may avoid wounding the bladder by introducing a male catheter into 
 it, which is to be held by an assistant, and which will serve as a guide; the 
 peritoneum posteriorly and the rectum may be preserved from injury by 
 
PROLAPSE OF THE GENITAL ORGANS. 429 
 
 keeping the cutting edge of the bistoury constantly turned toward the part 
 to be excised. The vaginal mucous membrane may be sutured to that of the 
 cervix, but in order to accomplish this it is necessary that the segment of 
 the cervix removed be not too large ; indeed, it is not needful to remove 
 more than a small portion to insure the result aimed at. 
 
 I. S?ipport DciHvcd from Iiitra-vaginal Parts. — The great majority of 
 operations for the cure of prolapsus come under this head. I shall merely 
 enumerate those no longer used, reserving a detailed description for those 
 whose use I recommend. 
 
 Among the old methods, I will name episiorrhaphy, or suture of the 
 labia majora, to contract the vulvar opening; freshening the surface and 
 suturing of the vulvar opening ; infibulation by means of a metallic ring; 
 cauterization of the vaginal walls with various caustic agents, or with the 
 actual cautery — all detestable methods, that have recently been recalled to 
 our notice. I have the same opinion of treatment by ligation. Franck per- 
 forms an operation whose object is the formation in the vagina of a vertical 
 fold, projecting anteriorly like a tampon. He dissects up the vagina almost 
 to the posterior cul-de-sac, and, with buried catgut sutures forms the spur- 
 like projection. This is, however, not the only result of this operation, 
 which is a species of colpo-perineorrhaphy. 
 
 Elytrorrhaphy or colporrhaphy, the excision and suturing of a portion of 
 the vaginal wall, was first introduced by Marshall Hall, His operation, al- 
 though incomplete, served as the starting-point for the perfected operations 
 of colpo-perineorrhaphy and perineauxesis of the present day, which follow 
 the plan of procedure initiated by Simon, who was the first to realize the 
 importance of freshening a large surface of the perineum as well as of the 
 vagina. His denudation was in the form of a trapeze. Colporrhaphy, or 
 anterior elytrorrhaphy, was first done by Sims. Since Simon's day, the size 
 and shape of the denudation in this operation have been indefinitely varied. 
 I shall describe only the methods of Hegar and A. Martin, and Doleris' 
 for perineoplasty, besides Le Fort's operation for closure of the vagina. 
 The modified procedure of Lawson Tait, which I employ exclusively in 
 these cases, will be described later (see Laceration of the Perineum) in 
 detail. 
 
 Colpo-perineorrhaphy (Hegar's method). — The patient's bowels and blad- 
 der are to be evacuated, and she is to be thoroughly washed, after which she 
 is anaesthetized and placed in the dorsal position. The extent of surface to 
 be denuded is determined by grasping the posterior wall of the vagina with 
 the forceps and drawing it into view. In cases of minor importance, it will 
 be quite sufficient to make a denudation in the shape of an isosceles triangle 
 — about two inches broad at the base (which is at the fourchette) and about 
 two inches long. When the prolapsus is very great, we may add from a 
 quarter to half an inch to these measurements. During the operation, con- 
 tinuous irrigation should be practised; the stream of tepid water should be 
 
430 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 slow, and should consist of either a weak antiseptic solution (carbolic acid, 
 one per cent), or of filtered water with salt, 6 : i,ooo. 
 
 One assistant will administer the chloroform, two will hold the thighs 
 and the forceps, while a fourth will hand the instruments. 
 
 Retractors are of small use in bringing the parts to be denuded into view. 
 A blade of a speculum temporarily pushes up the anterior wall of the va- 
 gina, and the surgeon grasps the posterior wall with tenaculum forceps, about 
 two inches above the fourchette, at a point which is to constitute the apex 
 
 ^^:>^/ ^>i''^>•;)iS:i'^' 
 
 
 Fig. 320. — Colpo-Perineorrhaphv by Hegar's Method. 
 
 of the freshened surface. The labia are separated and two forceps placed at 
 the ends of the base of the triangle at the lower extreme inferior limit of the 
 vagina and about two inches apart. 
 
 Two additional forceps mark the middle of the sides of the triangle. 
 When the assistants hold out all these forceps, the operating field is conven- 
 iently spread before the surgeon. With a sharp-curved bistoury he outlines 
 the triangle, making the base slightly concave, and the sides very slightly 
 convex to the centre. The mucous membrane is now grasped at the apex 
 with mouse-toothed forceps, and dissected sufficiently to allow of the finger 
 replacing the instrument, strong traction being at the same time exerted 
 upon the detached membrane to facilitate its dissection. If the recto-vaginal 
 septum be very thin, it is well to avoid the danger of puncturing it, by in- 
 
PROLAPSE OF THE GENITAL ORGANS. 43 1 
 
 troducing a finger through the anus. In view of the possibility of this pro- 
 cedure, the rectum should have been previously subjected to a thorough 
 cleansing with boric or salicylic acid solutions ; the assistant who attends to 
 this preparatory measure must thoroughly disinfect himself after its applica- 
 tion. If there be hemorrhage, the bleeding points are to be seized with for- 
 ceps. The whole thickness of the mucous membrane, which has often 
 undergone hyperplasia, is to be stripped off, and the surface of the wound is 
 
 Fig. 321.' — Colpo-Perineorrhaphy by Martin's Method. Bilateral denudation of posterior vaginal -wall. Con- 
 tinuous suture in layers. 
 
 to be made thoroughly smooth with curved scissors. Perforation of Douglas' 
 cul-de-sac has not infrequently occurred during this operation. Schauta 
 seized the opportunity offered by this accidental opening to draw down and 
 resect the peritoneal cul-de-sac. This manoeuvre is somewhat similar to 
 Freund's operation, which I have described on page 458. 
 
 For the suture, Hegar uses silver wire, which he introduces under as 
 much of the surface of the wound as possible, adding a few superficial 
 sutures between these deeper stitches. 
 
 It seems to me preferable to use the continuous buried catgut suture. 
 
 Colpo-perineoiTJiapJiy or PcrineaiLxesis. — Martin's chief object in this 
 operation is to save the posterior column of the vagina, which is the most 
 resistant portion, and which Freund first pointed out as a part to be care- 
 
432 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 fully handled in all plastic operations. Besides this, the denuded portion, 
 while quite as extensive as in Hegar's operation, instead of forming one con- 
 tinuous surface, consists of several segments in close juxtaposition, which 
 allows of more accurate suturing and more perfect union. 
 
 Having taken the same preliminary measures as in the former operation, 
 Martin grasps the posterior wall of the vagina, just below the cul-de-sac, 
 with two pairs of tenaculum forceps, which forcibly stretch it so that the 
 
 Fig. 322. — Colpo-Perineorrhaphv bv Martin's Method, SHO^vlNG Denuded Surface, i, 2, Incisions by- 
 the side of the posterior vaginal column ; 3, 4, incision upon the lateral wall of the vagina ; J, extremity of denuded 
 surface, at the level of the vulvar opening ; A-A, £-B, a-a, b-b, c-c, d-d, /8-a-^, 5-5, y-y, indicate the points which will 
 be in contact after the suture. 
 
 vaginal column (columna rugarumi has the appearance of a long, projecting 
 fold. An incision is made with the bistoury on either side and two narrow 
 lateral strips are dissected off as far as a finger's breadth above the four- 
 chette. Tenaculum forceps are applied to both extremities of these fresh- 
 ened surfaces to keep the operating field as tense as possible. These two 
 small wounds are now sewed up by a continuous suture in layers (Fig. 321 ), 
 the forceps are removed, and the first step in the operation, double lateral 
 elytrorrhaphy, is now completed. The second step, perineorrhaphy, remains 
 to be done. 
 
 A transverse incision is made at the muco-cutaneous junction, which in- 
 
PROLAPSE OF THE GENITAL ORGANS. 
 
 433 
 
 tersects the column of the vagina, and ascends on either side to about half 
 the extent of the vaginal opening [to the inferior caruncles]. From the ex- 
 tremities of this incision a second concentric incision, forming an acute angle 
 with it, intersects the lower part of the vertical incisions made in the elytror- 
 rhaphy. The result is a semilunar transverse strip whose concavity is 
 turned upward in a condition of rest (Fig. 322), but which, when pulled 
 
 Fig. 323. — Colpo-Perineorrhaphy by Martin's Method. Continuous suture in layers of the denuded perineal 
 
 surface (deep layer of stitches). 
 
 upon at its end, becomes lozenge-shaped. This strip is now denuded, and 
 the surface reunited by a continuous catgut suture in layers as in Fig. 323. 
 
 Martin uses a trowel-shaped bistoury for the dissection of these strips of 
 membrane, rolling them up on a slender staff with lateral teeth {I'dteait). It 
 seems to me that an ordinary curved bistoury and long forcep.s are equally 
 good. Bischoff has adopted a method which, like Martin's, preserves the 
 normal condition of the vaginal column (Fig. 324). Winckel denudes the 
 lower third of the vagina for about an inch above the remains of the hymen, 
 and laterally to 1.5 inches from the meatus, making first a vertical median 
 incision and separating the mucosa so as to form lateral flaps. He then 
 brings the freshened surfaces into apposition vertically, as in Martin's oper- 
 
434 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 ation, and after shortening the two flaps one half, sutures them so that they 
 form a bridge across the remainder of the denudation. 
 
 Colpo-periiieoplasty by Flap-splitting. — This is an ingenious combination 
 of Lawson Tait's flap-splitting, Schroder's removal of the mucous membrane, 
 and Emmet's suture, and is chiefly applicable where the uterine prolapse 
 is only slightly marked, but where the vulva gapes so widely that there is 
 danger of vaginal prolapse, with or without partial laceration of the peri- 
 neum. It strengthens the perineum by increasing its length and thickness, 
 without any vaginal suture, and is rapidly performed. The weak point of 
 the process is the shortening of the posterior vaginal wall, which interferes 
 
 Fig. 324. — Coli-o-Perineorrhaphv bv Bischoff's Method. 
 
 with any ascent of the uterus and thus renders it of doubtful utility in cases 
 of marked prolapse. It cannot be combined with Alexander's operation, as 
 can Hegar's and Martin's methods. Moreover, it does not contract the va- 
 gina itself, but only the vulvar orifice, and is in fact merely a perineoplasty, 
 since the portion of vagina removed is very small. With a bistoury, Doleris 
 makes a deep curved incision at the juncture of skin and mucous membrane. 
 Forceps are inserted at the two ends of the incision, to stretch the tissues. 
 The upper, mucous lip of the wound is dissected slightly from the submu- 
 cous tissue, and then uplifted by forceps. The operator, now using the 
 index finger of the left hand instead of an instrument, gently pushes the 
 tissues apart, separating the vaginal and rectal walls as far as necessary. 
 The vaginal flap is now drawn outside of the vulva and resected, and its 
 edge then united to the edge of the first incision with curved needles and 
 three strands of heavy silkworm gut. The first stitch is in the centre ; it is 
 inserted just to the left of the anus, goes deeply through the tissues, and 
 
PROLAPSE OF THE GENITAL ORGANS. 
 
 435 
 
 into the vaginal flap close to the wall, entering the vagina or not as the 
 operator prefers ; it is then brought back in the same manner to the right 
 side. This first suture brings the vaginal wall near the vulvar commissure, 
 also serving to unite the cutaneous lips of the wound. The second and third 
 sutures are inserted in the same way, each slightly outside the other. The 
 portion of the flap in excess of the reconstructed fourchette is now cut off, 
 and the mucous and cutaneous lips united (see Fig. 325). 
 
 While colpo-perineorrhapJiy is the chief operation for prolapse of the geni- 
 tal organs, it needs often to be supplemented by other operations, as ampu- 
 tation of the cervix, already described, and anterior colporrhaphy or elytror- 
 
 ^^^^aJ^'^.S 
 
 Fig. 325. — Colpo-Perineoplasty by Flap-Split- 
 ting (Glissement). Doleris' method. Semicircular 
 incision following the outline of the posterior vulvar 
 ■commissure, at the point of union of skin and mucous 
 membrane, from A to B. 
 
 Fig. 326. — Colpo-Perineoplasty by Flap-Split- 
 ting. Dissection of vaginal flap, A, B, D, by bistoury 
 and fingers. Insertion of three stitches which are to 
 bring the under surface of the flap into apposition with 
 the cutaneous lip of the wound. 
 
 rhaphy. The object of the first is to facilitate the restoration of the uterus, 
 while the latter acts directly upon the procidentia of the anterior wall. An- 
 terior elytrorrhaphy was performed by Sims, whose denudation was in the 
 shape of a horseshoe, with its convexity toward the urethra. Emmet made 
 it trowel-shaped. Hegar advises an ellipse, with as blunt an upper end as 
 possible. As a rule, it is folly to waste time in trying to obtain a flap of 
 any special shape : the exuberant portion of the vagina is simply to be 
 excised. 
 
 Hegar unites the two lips of the wound with sih'er sutures. I prefer a 
 continuous suture in layers. I cut off the mucous fold, stretch the tissues 
 
436 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 b\" means of forceps < Fig. 330;, and insert the sutures according to the 
 method described on page 42. 
 
 Stolz has devised a very ingenious method of suturing in anterior colpor- 
 
 FiG. 327. — CoLrO-PERTN-EOPLASTY BY Flap-Splitting. Stitches drawn. The &a.p A, B, £>, liited • to be resected 
 
 on the line A to B. 
 
 Fig, 328.— Colpo-Pkrikeoplasty by Flap-Split- Fig. 329. — Colpo-Perineoplasty by Flap-Splitting. 
 
 IXG. The flap has been excised ; two lateral openings Suture completed. Stitches all on external surface. 
 are still unsutured. 
 
 rhaphy. After freshening an oval surface similar to that shown in Fig. 330, 
 two curved needles are threaded on a silk suture, one needle at each end, and 
 
PROLAPSE OF THE GENITAL ORGANS. 
 
 437 
 
 beginning near the cervix the suture is passed in and out of the whole cir- 
 cumference of the wound, about half an inch from the edge, something like 
 the draw-string of a tobacco pouch (Fig. 331). The denuded surface is 
 pushed inward toward the bladder and the ends of the silk closely drawn and 
 tied. This was the most expeditious procedure known before the use of the 
 
 Fig, 330. — Anterior Elytrorrhaphy. Flap removed. The raw surface, stretched out by forceps, is to be 
 united by a continuous suture in layers. At the lower part of the picture is the bundle of stitches from the suture of 
 the amputated cervix. 
 
 continuous suture in layers, which should be given the preference. Stolz 
 freshens the anterior vaginal wall with curved scissors, after rendering it 
 prominent by the pressure of a thick sound introduced into the bladder. 
 
 Closure of the Vagina. — Le Fort calls attention to the fact that the pro- 
 lapse of the uterus is almost always preceded by that of the vagina, the walls 
 of which fall, as it were, from a straightening out of their folds. If, he 
 reasoned, these walls which face each other could be joined together, 
 all prolapse would be prevented. The next step was the uniting of the 
 
438 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 walls by suture after freshening a longitudinal strip on each (Figs. 332 
 and 333). 
 
 Sometimes the prolapsed uterus becomes so enlarged that it is difficult 
 to restore it to place at once. That the reduction of the displacement may 
 be effected by degrees, the patient is kept in bed from eight to fifteen days, 
 after which the passive congestion has subsided in whole or in part, and the 
 uterus is diminished in size. By straining, it is made to emerge again from 
 the vulva. 
 
 The freshened surface should begin as near to the vulva as possible, 
 since it is in this situation that the anterior and posterior walls tend to sepa- 
 
 U 
 
 Fig. 331. — Stoltz's " Tobacco Pouch " Operation for Cystocele (Mun-d£). C, Cer\-ix ; Z/, urethra. 
 
 rate most widely and thus permit of a prolapse. If one operates too near the 
 cer\-ix, it may be difficult to approximate the surfaces on account of the size 
 of the uterus. As a usual thing, the surgeon first replaces the uterus, opens 
 out the vulva, and with a bistoury makes two transverse incisions, one upon 
 the anterior and the other upon the posterior wall of the vagina, at the lowest 
 point where these two walls meet (the uterus being in place). These two 
 incisions form the lower borders of the two denuded surfaces. 
 
 The vertical length of the freshened surface is from 2.1 to 2.5 inches, 
 the vaginal walls having been unfolded and stretched by the prolapse of the 
 uterus, which was induced by straining just before the operation. The 
 breadth of the freshened surface first advised by Le Fort was from half 
 an inch to three-quarters of an inch. At the present time he makes it about 
 an inch wide. If the surface be too large, it will interfere with perfect 
 union. The tissue taken off should be as thin as is compatible with the 
 exposure of a raw surface. The removal of the whole thickness of the vag- 
 inal portion of the posterior wall would endanger the cul-de-sac. Tillaux 
 
PROLAPSE OF THE GENITAL ORGANS. 
 
 439 
 
 perforated it once, and the patient died of peritonitis, but Le Fort thinks 
 tiiis the only time that such an accident has occurred. He usually begins 
 by making four incisions to outline the flaps and thus facilitate their dissec 
 tion. In the early days of the operation, Le Fort used silver wire for the 
 suture; and although it is difficult to find the stitches afterward, even when 
 the ends are long enough to hang outside the vulva, he still uses them, for 
 he had two failures with silk which irritated and inflamed the tissues. He 
 several times tried the experiment of passing the sutures only through the 
 edges of the wound, but met with small success; in such a caso, if the 
 freshened surface be of any size, the central portion does not unite, blood 
 
 t^effA/i'Aj-/. S'T 
 
 Fig. 332. — Le Fort's Operation for Closure 
 OF Vagina. R^ Rectum ; 6', uterus ; VR^ urethra ; 
 A , anterior denudation ; B, posterior denudation. 
 
 Fig 333- — Le F jri s Operation F( p Ci osi re of 
 THE A AoiNA. A, Denuded surface upon the anterior 
 wall of the vagina ; B, denuded surface upon the pos- 
 terior wall of the vagina; C, C, a suture on the left side; 
 Z>, D\ suture on the right side. 
 
 collects in it, and the operation is a failure. It is now his custom to pass 
 the sutures to the very centre of the denudation. The first one is inserted 
 at the middle portion of the end of the denuded surface nearest to the uterus, 
 this stitch serving as the support to the prolapsed uterus. When the sur- 
 faces A B are once in apposition from the return of the uterus to its normal 
 position, all that remains to be done is to suture the edges. The needle is 
 inserted into the mucous membrane of one of the vaginal walls, traverses 
 the wound, and enters in the other denuded surface, emerging at the mucous 
 membrane of the opposite vaginal wall. The sutures are left in place two 
 weeks, or even three weeks at times, and no attempt is made to remove them 
 until certain perfect union has been secured. No dressings are necessary. 
 
 Out of forty operations, Andr6 records thirty-five successful results, of 
 which thirty-one were successful immediately. It is an interesting fact that 
 
440 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 this operation does not interfere with coition, fecundation, or labor. One of 
 the first patients upon whom Le Fort performed this operation went through 
 a perfectly normal labor. To deliver the child, it was only necessary to cut 
 the artificial frenum with the scissors. 
 
 After-treatment of Colpo-perijieorrhaphy. — The care of the patients, after 
 these plastic operations for strengthening the perineum and narrowing the 
 vagina, has an important bearing upon primary union ; should this primary 
 union fail, the success of the operation will be endangered, in spite of cases 
 quoted to prove that granulation or immediate secondary union have given 
 excellent results. 
 
 The line of suture is to be dusted with iodoform and covered with iodo- 
 form gauze. The catheter should not be left in the bladder, as there is dan- 
 ger of its causing cystitis, but, if the patient be unable to pass her urine 
 spontaneously, an aseptic catheter may be introduced every six hours. Shall 
 the bowels be rendered constipated or loose.'* I consider it best to prevent 
 defecation until the fourth day, and then to give an enema. The patient 
 will of course have been thoroughly purged, and the rectum washed, before 
 the operation. Two tablets of opium daily, one-third of a grain each, will 
 be quite sufficient to prevent premature evacuations if the diet be light. 
 Should the patient still feel a desire to defecate, a suppository containing 
 1-4 grains of the extract of opium may be used. On the tenth day it 
 is my custom to administer an ounce of castor oil, and two hours later an 
 enema of four teaspoonfuls of the oil of sweet almonds with two of glycerin. 
 After this, the bowels are closely watched to insure regular daily movements. 
 The patient is to keep her bed for a month. 
 
 Immediate and Remote Results of the Operatio7i of Colpo-perineorrJiaphy . 
 — Those gynaecologists who have the most frequently performed this opera- 
 tion are unanimous in testifying to its safety and efficacy. In what follows, 
 I refer more especially to the operation of Hegar, which seems to me the 
 most practical, and to that of Martin, which is of the greatest use where the 
 vaginal walls are exceptionally loose and flabby ; in this latter case Hegar's 
 method, if used, would have to be preceded by an elliptical posterior elytror- 
 rhaphy, as he himself admits. 
 
 The accidents to be feared are : Puncture of the peritoneum, which, if 
 the operation be conducted under strict antisepsis, is not of grave import ; 
 wounding the rectum, which a well-applied suture will remedy ; suppuration 
 and destruction of the suture, which may be avoided by a careful prepara- 
 tion of the catgut and the minutest precautions against possible infection. 
 Out of 400 cases operated upon in his clinic, Hegar has seen but 2 deaths 
 from septica;mia, and in both cases it was ascertained that the infection was 
 carried from cases previously operated upon. Dorff, who is Hegar's as- 
 sistant, has published an interesting series of statistics upon the re- 
 mote results of 136 operations. He was able to secure positive informa- 
 tion in only 63 of the cases; of this number 53 reported a perfect cure 
 
PROLAPSE OF THE GENITAL ORGANS. 44I 
 
 (some after a lapse of ten years), 9 reported successful parturition with- 
 out subsequent relapse; in 10 patients the operation had failed, either in 
 the first place or at a later date, in 2 of them after labor. The immediate 
 results are even more gratifying : For a period of three years and a half, 
 during which he has performed this operation 150 times, Hegar has not had 
 one failure. P>nest Cohn^ in a scholarly treatise upon the cases in Schroder's 
 clinical and private practice, reports that of 74 women whom it was 
 possible to keep under observation after the operation, 46 were perma- 
 nently cured; that is, 62.2 per cent. Hospital cases alone give 56 per 
 cent, and clinical cases report ^G.y per cent. (These are all cases in 
 which Hegar's method was employed with a continuous suture in layers, 
 using catgut prepared in oil of juniper.) Three of the patients went suc- 
 cessfully through labor. 
 
 II. SJiortening the Roimd Ligamejits for Prolapse of the Uterus. — This 
 is the Alquie-Alexander- Adams operation. For a detailed description the 
 reader is referred to the chapter on Retroflexion (page 389). The success 
 of this operation alone, when performed for the relief of prolapsus, is not in 
 the main brilliant, although some good results have been reported. But it 
 is of undoubted usefulness when combined with plastic operations upon the 
 perineum and vagina, especially in thin women whose abdominal walls are 
 not too lax. It seems to me that its chief action is the correction of the 
 retroversion which accompanies and is a prominent feature of prolapsus. 
 
 III. Suture of the Uterus to tJie Abdominal Wall — Ventro-fixation. — The 
 history and description of this operation are given in the preceding chapter 
 (page 400). 
 
 If an abdominal tumor, fibroid or cystic, complicate the case, it will be 
 an excellent procedure after laparatomy to fix the pedicle into the wound. 
 
 It is important to remember that ventro-fixation is not adapted to the 
 cure of prolapse of the genital organs in toto, but only to prolapse of the 
 uterus itself. Unless this have fallen, it would not be justifiable to fix it to 
 the abdominal walls simply because of the existence of a cystocele and rec- 
 tocele. Neither would ventro-fixation alone suffice to cure a prolapse of the 
 uterus if it were accompanied by prolapse and distention of the v^aginal walls 
 and a supra-vaginal hypertrophy of the cervix. From a theoretical as well as a 
 practical point of view, this operation is adequate only in those relatively rare 
 cases in which an unenlarged uterus alone is prolapsed. In all other cases, 
 supplementary operations upon the cervix, vagina, or perineum will be found 
 necessary ; the conoidal amputation of Huguier, or biconical amputation of 
 Simon ; anterior and posterior elytrorrhaphy, the various forms of colpo- 
 perineorrhaphy, Le Fort's closure of the vagina, etc. 
 
 It would seem then that ventro-fixation possesses no advantages over 
 Alexander's operation, which is also rarely adequate in complicated cases, 
 but a very valuable auxiliary. It is really between these two operations that 
 a comparison should be instituted, from the point of view of both danger and 
 
442 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 efficacy It is unnecessary to dwell upon the first point, the relative safety 
 of Alexander's operation being well known. This fact does not by any 
 means settle the question of a choice, but it should influence the conscien- 
 tious surgeon not to resort to the more serious operation before having 
 tried the less serious one. As to the question of efficacy, experience 
 will not as yet justify a judgment in favor of gastro-fixation, as the op- 
 eration has too recently come into prominence and has been too seldom 
 performed. 
 
 The first patient operated upon by Olshausen had a speedy return of the 
 displacement, but it would seem that in her case the sutures were insuffi- 
 cient (two stitches of silkworm gut at the insertion of each round ligament). 
 The second operation by the same surgeon, where fixation was superadded 
 to an ovariotomy, was successful, the patient reporting a complete cure in 
 1886, a year and a half after the operation. Phillips reports a case in which 
 the cure had lasted for six months, the last observation being taken at the 
 moment of publishing the report; in this case, also, the pedicle of a removed 
 ovary was fastened to the abdominal wall. Dumoret reports eight success- 
 ful cases out of eleven such operations. Terrier's three cases and those of 
 Tuffier are of too recent date to add much to our knowledge of results. Two 
 failures and one death are facts not to be overlooked, and scarcely justify the 
 enthusiasm displayed by some surgeons over this operation. Foreign oper- 
 ators do not seem to favor ventro-fixation for prolapsus. Kelly disputes its 
 value. Mliller has performed it from twelve to fifteen times without good 
 result, the prolapse of both uterus and vagina soon recurring. In some 
 cases the adhesions to the abdominal walls have given way; in others they 
 have remained, but the walls have been dragged down out of place. Hof- 
 meier has seen no good results from Schroder's operations; Freund, to ex- 
 plain these failures, calls attention to the fact that even after a myomotomy 
 with extra-peritoneal fixation of the pedicle, the latter often becomes de- 
 tached from the abdominal wall. Fehling, out of three cases, had one 
 successful result. 
 
 Moreover, if there be much hypertrophy of the cervix and vaginal pro- 
 lapse, though the uterus be firmly fixed in place or even removed, the vaginal 
 prolapse will return. This has happened when vaginal hysterectomy had 
 been performed. Mliller has met with this deplorable result after the seri- 
 ous operation of abdominal supra-vaginal hysterectomy, with fixation of the 
 pedicle in the abdominal wound. The woman was thirty-eight years of age, 
 had had one child, and suffered from complete prolapsus of the uterus. 
 Miiller had performed Bischoff's operation of colpo-perineorrhaphy upon her 
 in December, 1878, but without good results. June i6th, 1879, he made 
 an incision -n the linea alba about 2.5 inches in length, and by means of a 
 sound in the uterus brought this organ into the abdominal opening, placed 
 a clamp upon it and excised the upper portion, suturing the lower portion to 
 the lips of the external wound. The patient left her bed on the i6th of July, 
 
PROLAPSE OF THE GENITAL ORGANS. 443 
 
 cured. In November of the same year her menses had returned twice, as a 
 sanguineous oozing through the vulvar and the abdominal cicatrix. The lat- 
 ter was much depressed, or rather was at the base of a narrow infundibulum 
 — formed by the abdominal walls. The uterine prolapse had returned in full 
 force, the cervix protruding from the vulva about 3.5 inches. Its lips were 
 swollen and admitted the first phalanx of the index finger. It seems to me 
 that this case proves conclusively that support from above does not suffice to 
 keep the uterus, or even a stump of the uterus, in place when a hypertro- 
 phied cervix and prolapsed vagina are continually pulling upon it from below, 
 Ventro-fixation, like Alexander's operation, unless the case be one of simple 
 uterine prolapse, should always be combined with an operation upon cervix, 
 vagina, or perineum if durable results are to be obtained. 
 
 We might rank with ventro-fixation a new procedure described and per- 
 formed by H. T. Byford for the cure of cystocele, and which he proposes to 
 use as a complement to Alexander's operation, utilizing the same incision 
 and carrying it more deeply into the cellular tissue in order to suture the 
 vagina. Byford carries the incision through the inguinal canal to the retro- 
 pubic cellular tissue (cavity of Retzius), which he separates from the pubis, 
 being careful to ascertain the exact situation of the ureter by bimanual ex- 
 amination. He next passes a needle threaded with silkworm gut from above 
 downward through the vaginal wall into the left lateral cul-de-sac. The 
 needle is then carried from below upward through the vagina about a quarter 
 of an inch from the point of entrance and emerges through the inguinal 
 wound. A loop of silkworm gut thus holds a small portion of the anterior 
 vaginal wall ; another suture is firmly embedded in the cellular tissue, the 
 threads are drawn taut and tied over the inguinal canal, and the incision upon 
 the posterior wall of this canal is closed. The same operation is repeated 
 upon the other side, and the vaginal wall is drawn up to the middle of the 
 pubic bone, uplifting and supporting the bladder. Byford claims that it is 
 of the utmost importance to include in the suture some of the vaginal mu- 
 cous membrane in which the thread sinks and is gradually buried, thus im- 
 parting additional strength. When operating upon both sides, especial care 
 must be taken not to bring the sutures too near the urethra, for fear of di- 
 minishing its calibre. The ureter also is to be avoided. Byford has twice 
 performed this operation. The first time it resulted in a failure, which he 
 attributes to a lack of experience in the details. The second operation w^as 
 a success, although he inserted one suture only, on the left side. This sec- 
 ond case, however, proves little or nothing. The patient had already had a 
 vaginal hysterectomy performed on her ; and at the same time that he did 
 the ventro-fixation, Byford also did a double elytrorrhaphy, besides Martin's 
 colpo-perineorrhaphy. It is very probable that this last operation alone 
 would have sufficed; at all events, it is difficult to decide how much of the 
 credit belongs to the first operation. Byford calls his process colpo-cystor- 
 rhaphy, which seems to me a misnomer, since, although the bladder is up- 
 
444 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 lifted, it is the abdominal wall, and not that organ, which is sutured to the 
 vagina. Either laparo- or ventro-fixation is a better term. 
 
 IV. Vaginal Hysterectomy. — Except in case of fibromata, I consider ab- 
 dominal hysterectomy unjustifiable. As to vaginal hysterectomy, though less 
 severe than this, it is more serious than plastic operations, and should onl} 
 be resorted to as an extreme measure. 
 
 Leopold has performed this operation, but does not recommend it. Mul- 
 ler performed it three times, and in two of the cases had to supplement it 
 with a colporrhaphy. Baumgarten has witnessed the occurrence of vaginal 
 hernia as a sequel. On the other hand, Kehrer has used it successfully in 
 the cure of a uterus prolapsed for the second time, and Robert Asch reports 
 no less than eight cases of hysterectomy for prolapsus in Fritsch's clinic. 
 This surgeon combines an extensive resection of the vagina with this opera- 
 tion. 
 
 Braun has also removed the entire uterus, in a case in which recurrence 
 took place in spite of plastic operations. 
 
 In France, vaginal hysterectomy has been performed a number of times 
 for complete prolapse. I have used it successfully in many cases. I con- 
 sider hysterectomy only a complementary step, though initial, in the complex 
 treatment of complete genital prolapse. Removal of the everted portion 
 of the vagina, colpectomy, and colpo-perineorrhaphy should always follow ex- 
 tirpation of the uterus. The capital point in the treatment of all cases of 
 prolapsus is the reenforcement of the pelvic floor, the correction of the 
 gaping, the physiological if not anatomical occlusion of the \-ulva. 
 
 I employ the following technique : 
 
 I first mark out, with a bistoury, on the anterior vaginal wall, a large 
 triangular flap, whose apex is not more than two or three centim.etres from 
 the meatus urinarius. Its base includes the cervix, along whose sides it ex- 
 tends. A small similar triangular flap is marked out with the bistoury on 
 the posterior wall. These two triangles of unequal size are united by their 
 bases (Fig. 335). I then dissect off v/ith scissors the two lips of vaginal mu- 
 cous membrane. This manoeuvre is aided by inserting a male sound into 
 the bladder and keeping its point under the region where the dissection is 
 being done. The parts should also be kept tense by forceps applied within 
 the limits of the operative field. When the two vaginal flaps have been dis- 
 sected, and remain in front of and behind the cervix, the conditions arc the 
 same as in ordinary vaginal hysterectomy, except that the bladder is in this 
 instance more closely connected with the elongated cervix and more stretched 
 out by it. I dissect off the bladder with scissors ; as the cer\'ix is freed I 
 incise its anterior face from below upward and attach forceps to the divided 
 surface, so as to draw the organ progressively lower If this proves too 
 difficult, one may proceed at once to the following step of opening Douglas' 
 cul-desac with scissors. Through this incision the fingers may be hooked 
 around the uterus, depressing the vesico-uterine cul-de-sac, so as to allow it 
 
PROLAPSE OF THE GENITAL ORGANS. 445 
 
 to be incised. Both faces of the uterus being" thus completely liberated, the 
 broad ligaments are ligatured with silk and divided. A ligature is first 
 passed through the lower part of each ligament, allowing the uterus to be 
 freed sufficiently to seize its posterior face, and tip it backward in order to 
 tie the broad ligaments from above downward. No special manoeuvre is 
 needed to attach the upper end of the vagina to the pedicles of the broad 
 ligaments; this is accomplished by the process of cicatrization. The vagi- 
 nal wound, which leaves a large portion of the surface of the bladder ex- 
 posed, is closed by three tiers of continuous catgut sutures. The wound at 
 the back, resulting from the removal of the small posterior flap, is united 
 by several interrupted stitches of catgut. Before tying them, a strip of 
 iodoform gauze is placed in the region formerly occupied by the uterus. 
 
 The final step is a perineorrhaphy by flap-splitting, according to a modi- 
 fication of Lawson Tait's method. This is, as I have said, the essential part 
 of the operation, though the short time which it requires and its simplicity 
 make it appear merely an accessory step. 
 
 The indications for vaginal hysterectomy for complete prolapse are lim- 
 ited. It should be employed only when palpation and use of the sound show 
 that the uterus is elongated or hypertrophied, so that its reduction would 
 evidently interfere with restoration of the perineum. In such a case the 
 everted vagina is also so large that a segment requires removal. The vaginal 
 hysterectomy should be under these circumstances a colpo-hysterectomy, in 
 the full etymological meaning of the term. I recognize three contra-indica- 
 tions to this chief indication : relative youth, that is to say, the possibility 
 of future child-bearing, senile debility, and poor vitality from an organic 
 lesion of her heart, lungs, kidneys, or any other cause. If the patient has 
 passed the menopause it may be sufficient to remove the cervix, after having 
 dissected it off as high as possible, without opening the peritoneum. After 
 this high amputation of the cervix, like that of Huguier, a stenosis or even 
 a cicatricial atresia of the canal occurs, but this is to be dreaded only in a 
 woman who is still menstruating. 
 
 The therapeutic indications of the various types of prolapse of the genital 
 organs riray be thus grouped : We may employ pessaries or palliatives {page 
 426) after reducing the displacement by rest, baths, and tampons, and if 
 necessary amputation of the hypertrophied cervix. Massage has been much 
 extolled of late as a remedy in most of the uterine affections, especially pro- 
 lapsus. I think it destined to render real aid, when combined with baths 
 and rest, in diminishing the size of the prolapsed parts and facilitating their 
 replacement. Brandt recommends massage with two operators ; one of them 
 lifts the uterus by means of two fingers introduced into the vagina ; the other 
 places both hands between the uterus and the symphysis, and slowly presses 
 the ends of the fingers as deeply as possible, lifts them and presses them 
 down again about a dozen times. A daily application for about eight days 
 will be sufficient. It would be useless to expect a permanent cure from this 
 
446 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 treatment. It will give only a temporary relief, and cannot replace a plastic 
 operation. 
 
 In the consideration of curative treatment we must divide the cases into 
 several classes. 
 
 I. Simple Prolapse of the V^agijia without Hypertr^opJiy of the Cervix or 
 Marked Sinking of the litems. — Anterior elytrorrhaphy and colpo-perineor- 
 
 -A 
 
 Fig. 334. — Vaginal Hysterectomy and Colpec- 
 TOMY FOR Prolapsus Uteri. Shows the Une of in- 
 cision on the anterior vaginal wall. 
 
 Fig. 335. — Uterus and Portion of Vagina 
 Removed by the Operation. Ay Anterior 
 vaginal flap ; /", posterior vaginal flap. 
 
 rhaphy if the vagina be much enlarged ; when the cystocele is small, anterior 
 elytrorrhaphy followed by colpo-perineoplasty by flap-splitting to increase 
 the perineal resistance. 
 
 2. Vaginal and Uterijie Prolapse with Hypei'tropJiic Elongation of the 
 Cervix. — Amputation of the cervix, anterior elytrorrhaphy, and colpo-perine- 
 orrhaphy. I use exclusively for this last operation a modification of Lawson 
 Tait's operation. 
 
 If the body of the uterus be much prolapsed, it will be better to shorten 
 the round ligaments at once, after amputating the cervix, before attempting 
 a plastic operation upon the vagina. This combination of several processes 
 for the cure of prolapse of the genital organs, and in especial the union of 
 Alexander's operation to colpo-perineorrhaphy, was first suggested by Alex- 
 ander himself. Munde and Doleris warmly praise this mixed method. It 
 seems to me that shortening the round ligaments is of especial value in cor- 
 recting the retroversion which frequently accompanies a prolapsus and is so 
 powerful a cause of relapse. It may sometimes be necessary to do as many 
 as five operations upon the same patient ; but they are all simple and rapid 
 of performance, as all may be acccomplished within an hour, thanks to the 
 time gained by the use of the continuous suture in layers. 
 
 When the prolapse of uterus and vagina is complete, and the fallen or- 
 gans hypertrophied and replaced and maintained in position with great 
 difficulty, when they have in fact apparently lost their connection with the 
 
PROLAPSE OF THE GENITAL ORGANS. 447 
 
 pelvis, it will be quite justifiable to perform a vaginal hysterectomy, with 
 extended excision of the vagina, followed by colpo-perineorrhaphy to diminish 
 the vulvar opening. 
 
 3. Prolapse of Uterus and Vagina zvitJiont Hypertrophy of the Cervix. — 
 Shortening the round ligaments, then colpo-perineorrhaphy. As every case 
 of prolapsus is accompanied by endometritis, one will always begin by curet- 
 tine-. 
 
CHAPTER XX. 
 
 INVERSION OF THE UTERUS. 
 
 Inversion of the uterus may be defined as the turning in of the organ 
 upon itself, so that the fundus, which is pushed down like the end of a glove 
 finger, protrudes either into the uterine cavity or the vagina. 
 
 The first stage of that process usually escapes notice, and may indeed 
 be only temporary in its duration. To attract the attention of the physician, 
 the fundus must protrude through the cervix and form a tumor which touch 
 or sight can appreciate. The various degrees into which the classic author- 
 ities divided inversion (Fig. 336) have merely a theoretical interest. The 
 
 Fig. 336.— Inversion of Uterus. Schematic representation of the three degrees. a, Fundus inverted ; /', in 
 uterine cavity • r, in vagina ; d^ upper edge of the depression formed by the inverted fundus. 
 
 division into complete and incomplete has not much more value ; complete 
 inversion, where any projection of the cervix is entirely obliterated, is so rare 
 that the existence of even the few cases quoted is a matter of dispute. 
 
 The only classification of any clinical importance is that of simple inver- 
 sion and of inversion with prolapsus. 
 
 Pathology and Etiology. — For the production of inversion, there must be 
 a loss of tone of some portion of the uterus which excites the contraction 
 of the uterine muscles just above it. These conditions are found after 
 labor, or as the result of a fibroma growing into the cavity. In both of these 
 conditions the uterus is hypertrophied and dilated; in both a zone of its 
 surface is inert and depressed. After labor, this zone is at the placental 
 site, so that Rokitansky has described the affection as a "paralysis of the 
 placental zone." In the case of fibroma it is at the site of the implantation 
 of the tumor. Traction exerted from below upon the umbilical cord, or an 
 impulse from above produced by exaggerated action of the abdominal walls 
 
INVERSION OF THE UTERUS. 
 
 449 
 
 when there is uterine inertia, may in this case depress the fundus. It the 
 rest of the organ is then about to contract, the depressed portion is seized 
 upon, as it were, and, by an automatic motion which may be compared to 
 deglutition, carried down through the cervix. A light inversion will give 
 rise to contractions in a direction opposite to their usual one. 
 
 Among the more frequent causes we may mention : shortness of the 
 umbilical cord with excessive dragging upon the placenta; abnormal adhe- 
 
 FiG. 337. — Inversion of the Uterus Without Prolapse. 
 
 sion of the placenta or its insertion upon the fundus ; labor in an erect posi- 
 tion. Partial inversion often occurs without the knowledge of the attending 
 physician, and the fundus, which is cupped like the bottom of a bottle, to use 
 Mauriceau's expression, continues to descend in the first few days following 
 parturition, and the inversion which occurred in the first moment is noticed 
 only after a lapse of several days. Sometimes it becomes slowly appreci- 
 able, sometimes very suddenly. Its origin at the puerperal period is the 
 most frequent. Cross out of four hundred cases of inversion found that 
 three hundred and fifty were due to labor and fifty to polypus. Fibrous 
 bodies, fibro-sarcomata in the fundus, especially if they have been subjected 
 to traction, may cause an inversion even in nulliparae. The existence of 
 these tumors leads to a condition of hypertrophy and vascularity bearing a 
 close resemblance to the gravid uterus {grosscssc fibreuse). 
 29 
 
450 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Inversion is a rare affection. According to Beigel's statistics, it occurs 
 only once in one hundred and ninety thousand cases of labor. 
 
 P at Jwlogical Anatomy. — A marked distinction should be made between 
 recent inversions in the puerperal state and chronic inversions in the same 
 condition. The peculiar condition of the uterus at the moment of delivery 
 establishes a radical difference between the two. Under the first head there 
 is one variety which may be called acute and which is so formidable an 
 
 Fig. 338. — Inxersion and Prolapse of the Utekus Caused dv a Fibroid Tumor. 
 
 occurrence that it may cause death from profuse hemorrhage. It is fortu- 
 nately so rare that I need not dwell upon it, but leave its description to the 
 obstetrician. 
 
 Puerperal inversions occurring during the death struggle have also been 
 reported. A knowledge of this fact is important on account of medico-legal 
 errors to which such accidents might giv^e rise. 
 
 By recent inversion I mean cases in which the inversion constitutes the 
 chief symptom to be treated, and may be made manifest to the surgeon at 
 any time not too far removed from delivery (usually a month and a half) 
 when the involution of the uterus is still incomplete. By chronic inversion 
 I mean cases of much longer standing. In the recent cases the cup-shaped 
 deprcssioKi of the fundus is usually pronounced and contains the Fallopian 
 tubes, the ovaries, and sometimes loops of intestine (Fig. 339). At a later 
 stage this cavity disappears, leaving only a slit. The uterine tumor is large, 
 
INVERSION OF THE UTERUS. 
 
 451 
 
 its tissue spongy and vascular. The surface, which is soft and downy, is in 
 contact with the vaginal mucous membrane. J^y careful observation we find 
 two small lateral openings about an inch apart, into which we can sometimes 
 pass a hog's bristle; these are the openings of the Fallopian tubes. The 
 upper part of this pyriform tumor is set into the cervical ring. When the 
 cervix shares in the process of inversion, it does so in an irregular manner 
 — the anterior cul-de-sac being of a greater depth than the posterior. Upon 
 the uterine mucous membrane can be seen, both macroscopically and micro- 
 scopically, the lesions of glandular endometritis. 
 
 Chronic inversion without prolapsus forms a tumor which in aspect and 
 consistence is much like a fibrous polypus, the pedicle being represented by 
 
 Fig. 339. — Inversion of thk Uteris, a, Vagina ; l>, fundus ; c, c, upper borders of the inversion ; c; d, portion 
 ■of cervix not inverted ; y", cul-de-sac formed by the inversion of the fundus ; ^, ^^ Fallopian tubes dragged downward 
 by the inversion ; /^, X-, round ligaments ; A, /;, ovaries ; /, i, broad ligaments. 
 
 that part of the body which is compressed by the cervix. The cervix re- 
 mains in its normal position, though in some rare cases of complete pro- 
 lapsus the cervical ring disappears and the uterine and vaginal mucous mem- 
 branes are directly continuous. In a chronic inversion the mucosa of the 
 uterus often takes on the external characteristics of the vaginal mucosa, its 
 glands disappearing in great measure. 
 
 Chronic inversion with prolapsus is rare ; it may be accompanied by 
 ulceration due to friction and irritation. The mucous membrane becomes 
 skin-like in its nature by the formation of layers of pavement epithelium 
 upon its surface. 
 
 Cases have been reported of a species of spontaneous cure in which the 
 inverted uterus was eliminated by sloughing. 
 
 Sympto7ns.—-\ shall make no reference to the acute inversion at the time 
 of delivery, as it is a condition which cannot escape the notice of a careful 
 physician. If this inversion is only partial, the accompanying hemorrhage 
 may not be alarming in its nature. 
 
 Inversion in the puerperal state may occur suddenly and be accompanied 
 b)y sharp pain with grave reflex phenomena, even to syncope. In a few 
 
45- CLINICAL AXD OPERATIVE GYX.ECOLOGY. 
 
 cases pain has been absent ; hemorrhage may or may not be present. If the 
 inversion has taken place slowly and by degrees, as is usually the case when 
 polypi are the cause, the symptoms may in no wise differ from those of sim- 
 ple prolapsus : metrorrhagia, however, is the rule, and should call for careful 
 attention. All the group of uterine symptoms have been noted : pain, leu- 
 corrhoea, reflex symptoms in the digestive tract and nervous system, and 
 sometimes phenomena of compression of the rectum and bladder. The 
 tumor formed by the uterus resembles a polypus, but bimanual palpation will 
 convince us that the uterus is not behind the pubis but filling the vagina. 
 The signs of inversion may be combined with those of prolapsus, but this is 
 rare. 
 
 Diagnosis. — There are two mistakes possible : A simple inversion may 
 be taken for a tumor (polypus), or an inversion complicated by a tumor may 
 not be recognized. Whenever a supposed polypus has a large pedicle, we 
 must be on our guard against falling into these errors. Certain positive 
 signs will enable us to avoid them; the absence of the rounded mass of the 
 uterus behind the pubis, demonstrated by rectal touch, hypogastric palpa- 
 tion, and a catheter in the bladder; a circular, padlike constriction all 
 around the tumor behind which the sound cannot be inserted; the recogni- 
 tion of the openings of the Fallopian tubes — all these are the signs of a 
 simple inversion. 
 
 Inversion accoinpa7iying a polyptis is more difficult of recognition, and it 
 is often hard to determine to which cause the symptoms are due. As a 
 diagnostic sign, some authorities have mentioned the sensitiveness of the 
 uterine mucous membrane in contradistinction to the lack of sensitiveness 
 of the surface of a fibroid. The \'alue of this sign has been disputed, and it 
 is evidently not pathognomonic. 
 
 The greater flexibility and deeper color of the uterine tissues indicate 
 ver}^ little, nor does the consistence of the tissue as shown by thrusting in a 
 pin reveal much more. If a thorough examination during anaesthesia does 
 not decide the matter, I think it would be advisable to tie an elastic ligature 
 about the pedicle, and incise the surface of the tumor in one place after an- 
 other to a sufficient depth to ascertain whether or not a fibroid be present ; 
 if a capsule be found, the tumor may be enucleated with blunt instruments, 
 after which iodoform tampons may be inserted and the inxersion reduced. If 
 the incision give a negative result, it can be carefully closed, by a suture in 
 layers, before removing the haemostatic ligature. Such an exploration would 
 not be dangerous, and would prevent the disagreeable surprises which some 
 surgeons have experienced who have undertaken complete extirpation of the 
 tumor without preliminary precautions. 
 
 Simple prolapsus of the uterus can not long interfere with a diagnosis. 
 The disappearance of the vaginal cul-de-sac, the presence of the os uteri 
 through which the sound can be inserted usually to more than the normal 
 depth, will permit of its ready recognition. Obliteration of the os and the 
 
INVERSION OF THE UTERUS. 453 
 
 coexistence of a fibroid tumor might cause difficulty and is a complication 
 for which one should be prepared. 
 
 Prognosis. — Once acquired, inversion tends to increase. Moreover, the 
 patients are exhausted by hemorrhages, leucorrhoea, and pain. It is useless 
 to build any hopes upon the few cases reported of a spontaneous reduction 
 of the displacement, or of those still more exceptional cases of gangrene, 
 which, while effecting a cure, is by no means free from danger. We must, 
 however, not ignore the fact that a remarkable tolerance may be acquired for 
 even the most serious lesions. 
 
 Treatment. — Reduction is most easily accomplished immediately after 
 the occurrence of the inversion. As soon as possible after delivery, having 
 assured himself that no fragments of the placenta are left behind, the phy- 
 sician will introduce one hand into the uterine cavity and push the depressed 
 fundus into place, which the other hand, strongly pressing upon the abdomen, 
 will seize and hold. 
 
 In a chronic case, the reduction is accomplished with far more difficulty, 
 and yet some apparently permanent inversions have been cured. Audige 
 reports a successful reduction in a case of thirty years' standing. 
 
 The methods of reduction employed may be divided into forcible and 
 gradual reposition. 
 
 Forcible Reposition. — ^I shall merely enumerate these methods, without 
 dwelling upon them, for I believe that they will fall into disuse; the great 
 majority of inversions can be reduced by the gradual method, and the ex- 
 ceptional cases which will not yeld to this treatment are better treated by 
 extirpation of the organ than by forced taxis. 
 
 For manual reduction the patient is anaesthetized; three fingers are in- 
 troduced into the vagina and seize the tumor; the other hand grasps the 
 uterus through the abdominal walls and serves to direct the pressure. Two 
 methods have been suggested. One the reduction in mass, by grasping the 
 whole of the inverted uterus; the other a gradual reduction, replacing first 
 one horn of the uterus and then the other (Noeggerath). Emmet recom- 
 mends dilatation of the cervix with the fingers of one hand, while the palm 
 of the other presses upon the fundus. Courty draws down the uterus with 
 Museux's forceps, fixes the cervnx in place b}' two fingers hooked into the 
 rectum, and with the thumb and index of the other hand presses upon the 
 pedicle so as gradually to diminish the utero-cervical groove. Courty some- 
 times lessens the constriction by two or three longitudinal incisions 
 which start from the os and extend upon the cervix, dividing its cir- 
 cular fibres. Barnes also uses this method. Emmet advises, when the 
 fundus has been replaced within the cervix but not completely reduced, 
 the suture of the os for a few days to prevent a possible return of the 
 inversion. 
 
 Instrumental taxis by means of Viardel's drumstick repositor or White's 
 instrument, which has a sort of cup to hold the tumor and an elastic spring 
 
454 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 at the other end which is held against the chest of the operator, possesses 
 for us only an historic interest. 
 
 Gaillard Thomas, on account of the difificulties encountered in operating- 
 through the vagina, because of the cervical constriction, performed a laparat- 
 omy, dilated the cervical ring with an instrument shaped like a glove- 
 stretcher, and with great difficulty pushed the uterus upward through the 
 vagina. The vagina was perforated, and the patient had a severe hemor- 
 rhage but recovered; a second one died. In view of these risks, I cannot 
 agree with a recent writer who considers this operation as one to be highly 
 recommended, for even in patients young enough to have children hyste- 
 rectomy seems to me safer. 
 
 Gradtial Reductioji. — Rest in bed, hot vaginal injections, and massage 
 should all be used to diminish congestion and reduce the size of the uterus. 
 With these aids continuous pressure u^on the tumor is the chief curative 
 method and, if persisted in, it is almost sure to succeed. Hofmeier has 
 never seen it fail. There are many ways of applying it. Tyler Smith, who 
 was soon followed by Teale, West, Bokenthal, Courty, etc., was the first to 
 reduce an inversion of twelve years' duration, by the continuous pressure 
 exerted by an air pessary. One of these can be introduced empty, and then 
 distended as much as possible. Its action seems to be exerted in many 
 ways : by direct pressure upon the tumor it diminishes its volume ; its pro- 
 longed contact with the cervix serves to loosen it ; and finally the presence 
 of the pessary may excite uterine contractions which work from below up- 
 ward and help in the reduction. In other countries, a colpeurynter, a rub- 
 ber bag filled with water, is often used. It may take a month or more to 
 accomplish the reposition, which is usually preceded by sharp pain. Thomas, 
 Barnes, Duncan, Aveling, etc., speak in praise of a cup and stern pessary 
 which is fastened to a belt by elastic bands. I consider it a dangerous 
 instrument and one likely to cause sloughing. 
 
 Tamponade with iodoform gauze is far preferable to these methods, as it 
 is simple, easy of application, and requires no especial instruments. It is 
 to be renewed every two or three days, and to be done with the utmost care, 
 using long strips of gauze about two fingers' breadth wide, which is packed 
 around and above the tumor, being pressed in place with some force. The 
 patient is to be kept in a horizontal position, the bowels to be kept open by 
 enemata, and, should micturition be difficult, the catheter is to be regularly 
 passed. 
 
 Removal. — A few cases will resist even a long-continued pressure treat- 
 ment. The removal of the inverted portion of the uterus is then justifiable, 
 for the accidents caused by inversion often threaten life itself. The history 
 of the methods used for excision of the inverted uterus before the days of 
 antisepsis is as long as it is wearisome, and contains the oldest records of 
 hysterectomy. Amputation by means of a straight ecraseur is not to be 
 tolerated. It is a very slow procedure, gives rise to agonizing pain, does 
 
INVERSION OF THE UTERUS. 455 
 
 not prevent hemorrhage, and may wound neighboring organs. Incision im- 
 mediately preceded by the application of a ligature or a clamp ; section by 
 the galvano-cautery ; slow ligature with iron wire or rubber tubes frequently 
 tightened, preceded by the formation ot a groove with the thermo-cautery 
 (Courty), are ancient methods which should be obsolete, although, used 
 properly, they are capable of giving good results. 
 
 Perier has greatly facilitated the application of the slow ligature by in- 
 vention of his process of elastic ligation with traction, in which he uses a 
 toothed ligature tightener. Those practitioners who are not familiar with 
 the operation of vaginal hysterectomy could utilize this method with profit. 
 
 Kaltenbach advises the immediate amputation of the inverted portion of 
 the uterus, after the application of a temporary elastic ligature. 
 
 The technical details of total extirpation of the uterus through the 
 vagina have been so accurately tested, and the operation has given such 
 excellent results (page 313), that, for my part, if reduction were not pos- 
 sible, I should not hesitate to perform it rather than an amputation limited 
 to the inverted portion. 
 
CHAPTER XXI. 
 
 MALFORMATIONS OF THE CERVIX— ATRESIA. STENOSIS. 
 ATROPHY. HYPERTROPHY. 
 
 Atresia. 
 
 By atresia of the cennx we mean that the os uteri is imperforate or 
 occluded. 
 
 Congenital atresia is in the great majority of cases found only as accom- 
 panying other and graver malformations, as double uterus and vagina, whose 
 description belongs to the general history of malformations of the genital 
 organs. Theoretically we should here include a description of those rare but 
 incontestably existing cases in which the only congenital lesion has seemed 
 to be an imperforate cervix, the occlusion being either at the internal or the 
 external os, but as the clinical results of this anomaly are identical with 
 those of absence of development of the upper portion of the vagina, its de- 
 scription would involve needless repetition. 
 
 Acquired atresia follows sloughing after labor, cicatrices resulting from 
 excessive cauterization of the whole periphery of the cervix, amputations 
 which have not resulted in lining the circumference of the cer\'ical opening 
 with mucous membrane but have permitted a concentric retraction of the 
 inodular tissue. It may also follow the cicatrization of ulcers of the cen.-ix 
 coincident with senile atrophy of the uterus; finally it may, in old women, 
 be due to a tumor in the cervix or lower portion of the body of the uterus. 
 Atresia also occurs, in prolapsus uteri, as a result of the friction of a pes- 
 sary or of the thighs upon the os if there be complete prolapse. It may 
 occur spontaneously in old age; and some cases, to my mind of doubtful 
 occurrence, have been reported of atresia appearing during pregnancy 
 
 The results of this obliteration vary as the patient has or has not reached 
 the menopause. If not, we must be on our guard against haematometra 
 and haemato-salpinx (see chapter on ^Malformations). If she have ceased 
 menstruating, the lesion usually causes no distin-bance unless some cause of 
 septic infection exist in the uterine cavity causing an accumulation of pus 
 (pyometra) or gas (physometra). I have seen two cases of pyometra from 
 cancer of the body of the uterus and fibroma in aged women. The treat- 
 ment in such a case consists in incising or puncturing the cervix if it be 
 necessary to disinfect the uterine cavity, and then in meeting the indications 
 called for by an existing fibroma or cancer. 
 
MALFORMATIONS OF THE CERVIX. 
 
 457 
 
 Stenosis. 
 
 Stenosis is a narrowing of the cervical canal, which may be congenital 
 or acquired. When congenital, it is usually accompanied by a conical cer- 
 vi.x, often hypertrophied in inverse proportion to the development of the body 
 of the uterus. The conical or sugar-loaf cervix is firm in consistence and 
 has at its apex a pinhole os {Fig 342). The anterior lip may protrude a 
 little, giving the appearance of hypospadias of the canal, or it may resemble 
 the trumpet-shaped snout of a tapir, in which case the stenosis is usually 
 
 KiG. 340. Cervical Stenosis — Various Forms of Conical Cervix. 
 
 accompanied by congenital hypertrophy of the cervix (Fig. 340). Congenital 
 stenosis may be the result of an anteflexion of the uterus, pronounced 
 enough to obliterate the cervical canal. Acquired stenosis is due to the 
 same causes as atresia. One of the consequences of the narrowing is the 
 retention of the cervical mucus, which accumulates, and dilates the ca\ity of 
 the cervix. Catarrhal inflammation of the mucous membrane follows, caus- 
 ing an increased secretion of discolored, tenacious, viscid mucus (Fig. 341). 
 The use of speculum and uterine sound will speedily decide the question of 
 the existence of this condition ; when the sound has passed the os it enters 
 an ampulla-like dilatation of the cervical cavity. 
 
 Dysmenorrhoea and sterility are the two more prominent symptoms, 
 though is some cases dysmenorrhoea is absent. 
 
 The pain experienced during menstruation, the obstructive dysmenor- 
 rhoea of Fnglish writers, is usually situated in the lumbo-iliac and sacral 
 regions ; it is colicky in its nature, coming on spasmodically, when the 
 amount of blood exuded is too great to be immediatel}- carried through the 
 
45! 
 
 CLINICAL AND OPERATIVE GYNAECOLOGY 
 
 narrowed canal, or when the cervix is obstructed by a clot. Relief follows 
 a breaking of the clot. The pain is frequently so intense that the patients 
 develop marked nervous reflexes, as syncope or uncontrollable vomiting, 
 which leave them in a condition of extreme prostration. These patients are 
 usually chlorotic, anaemic, dyspeptic, and neuropathic. Endometritis fre- 
 quently results from the imperfect evacuation of the mucus and blood from 
 the uterine cavity, and the group of uterine symptoms then persists in the 
 intervals between the menstrual periods. This is a frequent form of the 
 endometritis of virgins. 
 
 Stenosis oftentimes causes sterility, although its influence in this par- 
 ticular has been exaggerated since the days of Sims. The mechanical ob- 
 
 FiG. 341. — Cervical Stenosis. Dilatation of the 
 cavity of the cervix by retention of mucus, in a case 
 of cervical endometritis with narrowing of the ex- 
 ternal OS. 
 
 Fig. 342. — Cervical Stenosis. Uterus with nar- 
 row cervical canal, without flexion. (Typical case for 
 Simpson's operation.) 
 
 struction to the entrance of the spermatic fluid is a less important factor than 
 the mucous congestion of the cervical canal. Normally, during coition, the 
 cervix, by a species of erethism which Rouget has compared to true erec- 
 tion, expels the mucus which it contains. From aspiration succeeding the 
 cessation of the venereal orgasm, or simply from capillarity, the alkaline vag- 
 inal mucus mixed with spermatic fluid enters the cervix in its place. This 
 exchange is prevented by the narrowness of the external aperture, which is 
 completely stopped up by a plug of acid mucus. 
 
 Diagnosis. — The most interesting and delicate point of diagnosis consists 
 in localizing the exact point of maximum of constriction. Where there is a 
 conical cervix with a pinhole os hidden by a drop of viscid mucus not unlike 
 the small concrete masses of sputum from the larynx, the external os is with- 
 out doubt one of the points at fault. But it may not be the only one; for, 
 as Bennett justly remarks, there is normally another narrow opening at the 
 upper end of the cervix which may be constricted (Fig. 342 K 
 
 Stenosis of the internal os has been said to be due to contracture, but I 
 
MALFORMATIONS OF THE CERVIX. 459 
 
 consider this doubtful. It seems to me to be the result of incomplete de- 
 velopment, with or without congenital anteflexion. Acquired stenosis from 
 excessive cauterization is more rare at the internal than the external os, and 
 worthy of passing mention only. 
 
 If difficulty is experienced in passing the sound through the internal os, 
 we must not jump to the conclusion that there is necessarily a constriction 
 at this point. We must iirst be certain that the tip of the sound has not 
 come against a fold of mucous membrane or the angle of a flexion; and to 
 ascertain if this be so, we bend the sound in accordance with the presumed 
 direction of the cervico-uterine canal, press down the handle toward the 
 fourchette, and draw down the posterior lip of the cervix in the case of an 
 anteflexion, and the anterior lip in case of a retroflexion. We must grope 
 gently with the sound a great many times before the diagnosis can be estab- 
 lished w^ith certainty. 
 
 Pj-ognosis. — Congenital cervical stenosis, which is the most frequent 
 form, disappears after fecundation and labor, not so much from the exces- 
 
 FiG. 343. — Cervical Stenosis. Normal and pinhole os. 
 
 sive dilatation as from the structural changes undergone by the uterus in 
 pregnancy. The efforts of the surgeon should be directed toward favoring 
 fecundation, and the various methods of artificial dilatation are to be regarded 
 as merely temporary and palliative. 
 
 Treatment. — Slow dilatation with laminaria tents, or rapid progressive 
 dilatation with graduated bougies, gives merely ephemeral results, yet it may 
 be used to advantage before each menstrual period. I prefer Hegar's dilat- 
 ing bougies, and believe that their frequent use may stimulate the vitality 
 of a more or less incompletely developed uterus (for details, see page 90 
 et seq.). 
 
 This operation, although a minor one, must be considered worthy of an- 
 tiseptic precautions. Some serious accidents have been known to follow it, 
 and doubtless a greater number still have not been reported. 
 
 Division of the external os may be done with a bistoury, with strong- 
 scissors, with Kiichenmeister's scissors (which have hooked ends to prevent 
 slipping), or with some one of the many forms of hysterotome which have been 
 invented since Simpson first recommended this operation. Marion Sims 
 made great use of this method of treatment, and brought it into a promi- 
 nence which is at this day hard to understand from an exclusivelv scientific 
 point of view. Since his time gynaecology has passed through a period 
 
460 
 
 CLINICAL AND OPERATIVE GYNECOLOGY 
 
 when discission of the cervix was carried to an extreme. Any young wife 
 in whom pregnancy was a trifle delayed, any young girl or woman suffering 
 during menstruation, was considered a fit subject for this operation. Now, 
 however unimportant it may seem to be, it has most certainly led to fatal 
 results, especially before the days of antisepsis. 
 
 We must distinguish between section of the external os (which may be 
 median, posterior, bilateral, or crucial) and an incision which is carried into 
 the cervdcal canal and to the mtenial os (Fig. 345). The incision may be 
 made with a probe-pointed bistoury, after drawing the cervix down and 
 steadying it. This operation is far more serious than the one first men- 
 tioned. To arrest hemorrhage, the wound may be loosely tamponed with 
 
 Fu;. 344. — Discission of the Cervical Canal, i. Di- 
 vision by Kiichenraeisters scissors. 2, Division with a 
 double hysterotome. The dotted line A, B, C, indi- 
 cates the segment incised by the separation of the blades. 
 
 Fig. 345. — Stenosis of the Cervical Canal. 
 Line of incision at the internal os. a, Incision of the 
 e.xternal os on a level with the posterior lip ; />, incision 
 of the internal os on a level with the anterior wall. 
 
 small pledgets of cotton soaked in perchloride of iron, which are to be taken 
 out on the following day. The patient should be kept three days in bed. 
 Barnes' small elastic-stem pessary or Thomas' glass stem may be worn for 
 several days in the cervix. 
 
 I do not describe these operations in detail, because I consider them bad 
 practice. Incisions of the external os either by cicatrization cause stenosis 
 again, or by gaping cause an eversion of the mucous membrane and conse- 
 quent cervical catarrh. The deeper incisions are not unattended by danger, 
 for, howev^er carefully one may use the hysterotome, the instrument with 
 which we are working in the dark may easily slip and cause serious accidents. 
 I much prefer the probe-pointed bistoury, which is more manageable. 
 
 Dilatation of the cervix by either the bloodless or bloody operations may 
 give excellent results in those cases in which the stenosis is slight and accom- 
 panied by quite disproportionate nervous reflex phenomena. However, two 
 opposite theories have been advanced in regard to this subject. Schauta, 
 who advocates incision, claims to have cured hysterical neuroses by the sec- 
 
MALFORMATIONS OF THE CERVIX. 46 1 
 
 tion of nerve filaments ; he states that in such cases dilatation by the blood- 
 less method is of no avail. On the other hand, Doleris recommends forced 
 dilatation of the cervix under the same circumstances, claiming that it acts 
 in the same way as nerve-stretching. It seems to me that the relief afforded 
 by both of these methods may be fully explained by the ready flow of pre- 
 viously retained mucus, which removes a source of continual reflex action. 
 Gastric troubles as well as pain are rapidly relieved. 
 
 Electrolysis has been highly praised. The advantages claimed for it are, 
 its harmlessness and painlessness and its efficacy, due to the fact that the 
 slough produced by the negative pole leaves a cicatrix as soft and disten- 
 sible as that produced by alkaline caustics. Currents of feeble strength 
 but long duration are recommended. 
 
 In cases of slight stenosis I prefer the simpler method of gradual dilata- 
 tion with Hegar's bougies (after softening the cervix with laminaria). I 
 sometimes combine this treatment with very small incisions upon the cir- 
 cumference of the OS with a probe-pointed tenotome to facilitate the inser- 
 tion of the laminaria. 
 
 In cases of marked stenosis, the only rational operation seems to me to 
 be a plastic operation for the production of an external orifice of sufficient 
 size. The operation of stomatoplasty does not affect the external os only, 
 as one might imagine. By the functional changes which it induces in the 
 cervix, the upper portion of the canal becomes more permeable. There are 
 cases in which a flexion of the uterus gives the impression of a constriction 
 situated high in the cervix. This flexion often disappears after the opera- 
 tion, so that I consider it advisable to wait a while before attempting to treat 
 a suspected stenosis of the upper portion of the canal which has been diag- 
 nosed by anterior palpation. Later, should the stenosis persist, gradual dil- 
 atation with Hegar's bougies is preferable to incision, though a few slight 
 scarifications may be made to facilitate the passage of the first bougies, but 
 these do not in the least resemble the deep discission of Simpson, Sims, etc. 
 
 Stomatoplasty is in reality nothing more nor less than amputation of the 
 cervix. I have minutely described it in the chapter upon the Treatment of 
 Metritis (page 182). According to the case, one may choose one or the 
 other process described. If the cervix is thick and fleshy, the biconical ex- 
 cision is to be preferred. If the mucous membrane has undergone pro- 
 found alteration, the single flap operation of Schroder is the better. I 
 have sometimes combined the two methods where the cervix was conical, 
 taking a wedge-shaped piece from the anterior lip, but paring only one 
 surface on the posterior lip. Whatever method be adopted, the result 
 aimed at is the formation of a transverse opening of ample size, with the 
 mucous membrane lining it to the very edge in such a way that it will not 
 contract after the operation. 
 
 I have for some time preferred to treat conical cervices by a new opera- 
 tion to which I have given the name of commissural excision of the cervix. 
 
462 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 The cervix is first divided laterally, so as to form two long flaps, one an- 
 terior, the other posterior. By separating these, nearly the whole cervical 
 cavity is exposed and the mucous membrane is seen divided into halves 
 corresponding to the flaps, and on each side of this mucosa is a raw surface 
 extending from above downward (Fig. 346, I, 2, 3, 4). From each of these 
 long, narrow surfaces a long wedge-shaped piece of tissue is excised, by 
 means of two longitudinal incisions, starting from the ends of a transverse 
 incision parallel to the angle of junction of the two flaps, and terminating to- 
 gether at the divided external os. One longitudinal 
 incision is parallel to the cervical mucous membrane, 
 the other follows the course of the vaginal mucosa of 
 the cervix (Fig. 346, 2), and the two extend into 
 the substance of that organ, meeting each other (Fig. 
 346, 3) in such a manner as to remove a triangular 
 
 pyramidal portion (Fig. 346, 3"). 
 
 When the wedge- 
 
 KiG. 346. — Commissural Excision of the Cervix. — 
 I, Cut surface after incision ; 2, line of excision ; 3, 
 prismatic section removed. 
 
 Fig. 347. — Di.\GRAM Showing the Immediate Re- 
 sult OF the Operation. 
 
 shaped fragments have been removed, a groove with flattened sides is left in 
 each of the original raw surfaces. The borders of each groove are sutured to- 
 gether transversely from the angle of junction of the two flaps to the divided 
 external os (Fig. 346, 4). Silver wire is employed and each suture is shotted 
 after being tied (Fig. 347). The internal or intra-cervical mucous membrane 
 is thus united to the external or vaginal mucosa of the cervix, perfect appo- 
 sition is secured, and there is no subsequent tendency to union of the orig- 
 inal raw surfaces. The immediate result is to form an elliptical external 
 opening for the cervical canal, the lips of the cervix resembling a duck's 
 bill (Fig. 347) ; but later, by gradual retraction, the orifice is represented by 
 a horizontal line bounded by rectilinear lips. 
 
 This operation has always given excellent results. One of my patients 
 
MALFORMATIONS OF THE CERVIX. 463 
 
 who had been sterile and suffered with dysmenorrhoea for four years of mar- 
 ried life, became pregnant four months after the operation. Another, who 
 had been married, but sterile, ten years, became pregnant one and one-half 
 years after this treatment. The dysmenorrhea had entirely disappeared. 
 Both women had normal labors. 
 
 Congenital AtropJiy of t/ic Cervix and Utenis. 
 
 There is a so-called congenital atrophy to which it would be better to 
 apply the term congenital predisposition to atrophy, for after birth the uterus 
 may experience a general retardation of growth which cannot properly be 
 called an arrest of development like that which occurs in prenatal life — an 
 arrest which would produce a malformation either by the excess or absence 
 of some portion of the organ — this general retardation resulting in an adult 
 uterus of infantile proportions but unaltered in its type. The whole organ 
 is small and its walls thin, but the relative proportions of body and cervix 
 are normal, thus differing from the foetal uterus. This type Puech calls a 
 uterus pubescens, to show that it preserves the proportions found at puberty. 
 Virchow calls it hypoplasia of the uterus. As a usual thing, it is accom- 
 panied by atrophy of the other internal and external organs of generation. 
 According to Puech, the uterus pubescens weighs about 405 grains instead 
 of 675. 
 
 This infantile condition of the genital organs is often accompanied in the 
 female (as in the male) by a general lack of development, a young woman of 
 twenty years and more having the appearance of a child who has not yet 
 reached puberty. In other cases the atrophy is limited to the sexual ap- 
 paratus, and there are no external signs of it visible except a narrowness of 
 the pelvis. There is, in fact, with rare exceptions, an intimate relation be- 
 tween this part of the bony framework and the internal genital organs. At- 
 rophy is to be attributed to a congenital predisposition of unknown origin. 
 It has been supposed to be due to chlorosis or tuberculosis, but it seems to 
 me that cause and effect have been reversed, the woman with this malforma- 
 tion possessing a defective nervous system and general innutrition because 
 of the genital lesion. 
 
 Symptoms and Diagnosis. — Complete or partial amenorrhoea is the first 
 thing noticed by the patient. The menses may fail to appear and the pa- 
 tient be sexless from a physiological standpoint. If they do appear, they 
 are usually accompanied by dysmenorrhoea and serious nervous symptoms. 
 Some of the patients inherit a defective nervous system,' and belong to the 
 neurotic class called deg^neres by the alienists ; they possess a feeble intel- 
 lect, and have hysterical or epileptic seizures. This is not, however, a gen- 
 eral rule, for another class of patients with a uterus pubescens have a vig- 
 orous constitution in every other respect. Local examination reveals a small 
 cervix with a narrow os ; bimanual palpation, rectal touch, the passage of the 
 
464 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 sound, all show atrophy of the uterus itself; the external genitals are usu- 
 ally incompletely developed ; the vagina is shorter than usual. The normal 
 proportion of the cervix in uterus pubescens distinguishes it from the foetal 
 or infantile uterus - where the cervix is large and the body atrophied. 
 
 Treatment should be at first directed to the general condition. Tonics, 
 nourishment, hydrotherapy, sea air, all tend to improve the health and favor 
 development. As to local treatment, there is scarcely any of value. It has 
 been suggested that pessaries with galvanic stems of iron and copper might 
 induce feeble electric currents and act as local stimulants, but this method 
 is not without difificulties and dangers, and a good result is by no means cer- 
 tain. It would be far more rational to apply electricity directly, using a con- 
 tinuous current. Symptomatic treatment should be directed to the dys- 
 menorrhoea. If this be very severe and the nervous symptoms marked, it 
 would be reasonable to suppose that the development of the ovaries was 
 out of proportion to that of the uterus ; if an examination under chloroform 
 established this fact, ovariotomy might be indicated. 
 
 Acquired Atrophy, or SiiperinvoL'tion of the Cervix mid Body of 
 
 the Uterus. 
 
 Pathological Anatomy and Etiology. — Normally, the termination of sex- 
 ual functions in the female is marked by a shrinking in size of the uterus, 
 which is progressive, so that in aged women the uterus is extremely small, 
 unless, as frequently occurs, it contain a fibroid body. 
 
 Senile atrophy dSi^oX?, both body and cervix, the latter being often only a 
 shapeless stump, or even disappearing entirely with the exception of the os, 
 which is seen at the end of the vagina. This occurs most often in women 
 who have borne many children. Atrophy sometimes begins before the 
 menopause, after a labor which seems suddenly to exhaust the vitality of the 
 uterus, the normal involution being carried beyond physiological limits. 
 James Simpson estimates the occurrence of this atrophy at about 1.5 per 
 cent, and Frommel at one per cent. But these superinvolutions are some- 
 times only temporary in duration. Frommel considers prolonged lactation 
 as one of the principal causes of atrophy. Profuse hemorrhages during labor 
 seem to exert a predisposing influence, as do all debilitating diseases — tu- 
 berculosis, chlorosis, syphilis, diabetes, Bright's disease, morphinism, Base- 
 dow's disease, etc. Diseases of the genital organs, as prolonged endome- 
 tritis, and oophoro-salpingitis, often terminate by atrophy. 
 
 Pelvic peritonitis during the puerperal period, or rather the septic peri- 
 oophoro-.salpingitis which sometimes follows labor or abortion, may, by caus- 
 ing sclerosis of the ovary, bring on a premature menopause and superinvolu- 
 
 * This second term must not be misunderstood. It is derived from iu/atis, and means properly 
 a foetus at term. The name puerile or childish might be applied to the uterus pubescens, indicat- 
 ing that it is analogous to that of a child (before ^->uberty). 
 
MALFORMATIO^^S OF THE CERVIX. 465 
 
 tion. Finally, I have noted that the diminution in volume of the body of 
 the uterus, which Braun observed to follow amputation of the cervix, may 
 go on to atrophy of the uterus. In an old woman upon whom four years ago 
 I performed a conoidal amputation of the cervix, according to Huguier's 
 method, for prolapsus, the uterus had become reduced to the size of a wal- 
 nut. In the case of a young woman in whom I excised a portion of the cer- 
 vical mucous membrane for severe endometritis, the uterus was for a time 
 greatly diminished in size, but finally returned to its normal condition. 
 
 [Hardon has noted nine cases and Hawkins two in which superinvolution 
 occurred after the closure of a lacerated cervix by Emmet's operation. In 
 eight of these eleven cases which were treated by intra-uterine faradization 
 the menses returned, while in three which received no treatment the condi- 
 tion persisted.] 
 
 Removal of the ovaries is a cause of uterine atrophy, and some authori- 
 ties have not hesitated to perform an ovariotomy for the cure of persistent, 
 painful endometritis. 
 
 In senile atrophy, the uterine tissue is sclerotic; in post-puerperal 
 superinvolution it may be soft and friable from incomplete absorption of the 
 fatty substances produced by the disintegration of the muscular fibres. 
 
 Symptoms and Diagnosis. — The cessation of the menses and the diminu- 
 tion in volume of the cervix and body of the uterus, as proved by the various 
 methods of exploration, establish the diagnosis. The greatest caution should 
 be exercised in the use of the sound in post-puerperal atrophy, as the walls 
 may be thinned. In cases of senile atrophy, the sound can penetrate only 
 to the depth of about two to two and a quarter inches, while in puerperal 
 superinvolution the cavity is usually normal, but may seem to be deepened 
 from the yielding nature of the uterine tissues. 
 
 Prognosis and Treatm,ent. — This post-puerperal superinvolution may be 
 only temporary in its nature ; and the observation of many cases has gone to 
 prove that fecundation and pregnancy may afterward take place. A return 
 of the functional activity of the uterus should be aided by general tonics, 
 hydrotherapy, salt baths, the intra-uterine application of electricity, and local 
 stimulation produced by hot injections and the often-repeated passing of the 
 sound into the uterine cavity. I prefer these methods to the use of a gal- 
 vanic or elastic stem pessary, which seem to me to play the harmful part of 
 a foreign body rather than to benefit. 
 
 HypertropJiy of the Siipra-vaginal Portion of the Cervix. 
 
 Hypertrophy may affect the supra- or the intra-vaginal portion of the 
 cervix. I have already described the first lesion under the head of Prolapse 
 of the Genital Organs, which it so frequently accompanies, Polaillon records 
 a case in which both the supra-vaginal portion of the cervix and the body 
 of the uterus had undergone a gigantic hypertrophy ; the uterus, which was 
 not altered in shape and in which there was no tumor, filled the whole ab- 
 
 30 
 
466 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 domen. The patient was thirty years old ; etiology unknown ; symptoms of 
 endometritis present. Polaillon advised injections of ergotin into the sub- 
 stance of the uterus, the continuous electric current, and, as a last resort, 
 ovariotomy. These exceptional cases of a gigantic uterus could not be mis- 
 taken for hypertrophy of the supra-vaginal portion of the cervix. The hy- 
 pertrophy following upon the presence of fibrous body or '' grossesse fibreiise'' 
 could also be easily recognized by the special symptoms caused. The only 
 
 symptom common to all of these 
 conditions is the unwonted depth to 
 which the sound may be carried. 
 
 Hyperh'ophy of the Intra-vagmal 
 Portion of the Cervix. 
 
 Etiology and Pathological Ana- 
 tomy. — I shall not dwell upon 
 acquired hypertrophy, following en- 
 dometritis, having already fully de- 
 scribed it (page 126). I would 
 simply recall the fact that there are 
 two varieties : Follicular hypertro- 
 phy, which especially affects the 
 mucous membrane, which is filled 
 with newly formed glands that 
 have undergone cystic degenera- 
 tion; and sclero-cystic hypertro- 
 phy, where the substance of the 
 cervix is distended by the produc- 
 tion of connective tissue and small cysts or glands of Naboth. 
 
 The first of these varieties is fungoid and soft to the touch ; the second 
 nodulated (tubereuse) and firm. They both often give the cervix the ap- 
 pearance of a club or of a bell-clapper (Figs. 349 and 350). Very different 
 in form and structure are the congenital and developmental hypertrophies 
 which appear at puberty and subsequently progress more or less. In this 
 case the change of size is not due to inflammation. The whole structure of 
 the uterus seems to undergo hyperplasia simultaneously, without deviation 
 from the normal type; the mucous membrane is in a healthy condition. 
 The cervix is elongated, conoid or cylindrical in shape, sometimes like a 
 tapir's snout because of the prominence of the anterior lip. It may fill the 
 vagina and project from the vulva, leading the patient to suppose that there 
 is uterine prolapse. Stenosis of the external os frequently accompanies this 
 affection, as I have already stated (Fig. 340 ). 
 
 Symptoms and Diagnosis. — Dysmenorrhoea often precedes the appearance 
 of the cervix at the vulva; in young girls this is what usually first calls at- 
 
 FiG. 348.— Hypertrophy of the Supra- Vaginal Portion 
 OF THE Cervix. 
 
MALFORMATIONS OF THE CERVIX. 
 
 467 
 
 tention to the affection. Married women suffer from dyspareunia. If tlie 
 hypertrophy is not very marked, the male organ pushes it to the front, and 
 forms a species of false vaginal passage by depressing the posterior cul-de- 
 sac, which is found to be of increased depth. Pain, leucorrhoea, and metror- 
 rhagia complete the group of uterine symptoms. The vaginal touch and use 
 ■of the speculum will reveal the nature of the tumor ; the location of the fun- 
 dus in its normal position will prevent a diagnosis of prolapsus or inversion; 
 the connection of the cervix with the body of the uterus, and the perception 
 4)f the external orifice, will exclude a polypus. Careful bimanual palpation, 
 
 Fig. 349. — Hypertrophy of the Intra-Vaginal with 
 'Elongation of the Supra-Vaginal Portion of the Cervix. 
 
 Fig. 350. — Hypertrophy of the Intra 
 Vaginal Cervix with a Deep Bilateral 
 
 Laceration. 
 
 and the use of the sound, will show whether there be also any hypertrophy 
 of the supra-vaginal portion of the cervix. 
 
 Prognosis and Treatment. — There is no tendency to retrogression. Op- 
 erative procedures alone will remove this source of continual pain and 
 discomfort. 
 
 Biconical amputation of the cervix is the best of all operations (page 
 182). If hemorrhage be feared, or if the operator be not sufficiently expe- 
 rienced to perform the operation rapidly, temporary hsemostasis may be se- 
 cured by tying an elastic cord above a strong needle which is thrust through 
 the cervix just below the vaginal attachment and which will prevent the cord 
 from slipping. This manoeuvre is rendered very easy of accomplishment by 
 the use of my elastic-ligature carrier. 
 
 After amputation of the intra-vaginal portion of the cer\-ix, the sujora- 
 vaginal portion, if hypertrophied, may undergo a retrogressive process and 
 become normal in size. 
 
CHAPTER XXII. 
 
 DISORDERS OF MEXSTRUATION. 
 Precocious ajid Protracted Moistniation. 
 
 In our temperate climate, menstruation usually begins in the fifteenth 
 year, and ends in the forty- seventh, giving a menstrual life of about thirty- 
 two years. Those who menstruate early usually continue to do so longer 
 than usual. 
 
 Puberty occasionally occurs at a very early age. The pubes become 
 covered with hair, the breasts and external genitals undergo rapid develop- 
 ment, and the menses finally appear and either continue with great regu- 
 larity or cease in a few years. Campbell has recorded an excessive devel- 
 opment of the generative organs in a child of four years, who had regularly 
 menstruated every three weeks since birth ; Prochownick had the opportunity 
 of performing an autopsy upon a little girl of three years who had begun to 
 menstruate at one year, and found upon the ovaries all the signs of both old 
 and recent ovulation. Young girls have become pregnant at the incredibl}" 
 early age of eight, ten, eleven, and twelve years. These cases of precocious 
 puberty in the female have their analogues in the male. 
 
 A report of protracted menstruation is to be received with some reserva- 
 tion. Women not far from the menopause are apt to consider any intermit- 
 tent or irregular hemorrhage as a continuation of the menses, especially if 
 the inter\'al between them and the last period has not been long. 
 
 The flow, however, may be caused by some uterine affection whose ex- 
 istence had not been suspected, as endometritis, mucous polypi, fibromata,, 
 and especially cancer. It is true, however, that some indisputably authentic 
 cases have been reported of menstruation lasting until the fifty-sixth or 
 fifty-seventh year. 
 
 AmcnorrJicea. 
 
 By amenorrhoea we mean the absence of menstruation, and not simply 
 the lack of a periodical discharge through the genital tract. ^Menstruation 
 may in fact exist, but in a latent form, as in the case of retention of the 
 menstrual flow from atresia, etc. We must carefully distinguish between 
 these two classes of cases. In the second, the amenorrhcea which might 
 appropriately be called obstructive, is merel)' a secondary symptom ; it is 
 considered in the chapter upon Malformations of the Genital Organs. 
 
 Primary or permanent amenorrhoea is the term used where menstruatiori 
 
DISORDERS OF MENSTRUATION. 469 
 
 has never occurred ; it has also been called emansio mensium. The amenor- 
 rhoea which is called transitory or secondary, or accidental, has been called 
 suppressio mensium. 
 
 Pathology and Etiology. — The female organism between puberty and the 
 menopause may be said to live simultaneously two lives — that of the indi- 
 \-idual, and that of the species; that of the organs in general, and that of 
 the generative apparatus in particular. This dual existence, whose physio- 
 logical and psychological effects are so important, may be interrupted by 
 the influence of sickness, as it is by that of age. Amenorrhoea is simply 
 the absence or suspension of sexual life, produced either by organic im- 
 potence or by a profound disturbance of the general nutrition of the indi- 
 vidual. We must look at the matter from this point of view^ in order to 
 fully understand the unexpected and excessive disorders caused by the dis- 
 turbance of this equilibrium. The sexual apparatus is not, so to speak, an 
 ■accessory wheel in the female mechanism : it is, on the contrary, the chief 
 wheel, and it is to secure its proper action that constant economies and re- 
 serves are made by nature. The whole economy of nutritive receipts and 
 expenditures bears directly upon the fact that a woman is, according to na- 
 ture's plan, liable at any time to conception. The Hindoos, not without 
 some show of reason, consider all menstruation which has not been preceded 
 by intercourse to be infanticide; hence young girls are married just before 
 puberty, to prevent their committing the crime even once. We might say, 
 with paradoxical conciseness, that a woman's normal condition is pregnancy 
 or lactation. During these periods menstruation ceases ; it returns only 
 when the excess of nutritive material is no longer required for these pur- 
 poses. Menstruation may then be considered a safety-valve ; its absence 
 indicates a lowering of nutrition, when it is not the normal result of the 
 utilization of the nutritive materials for the reproduction of the species. 
 
 There are no well-authenticated exceptions to the general rule that men- 
 struation is suspended during pregnancy; there are many exceptions, how- 
 ever, for the period of lactation, but the milk is usually more or less altered 
 in quality during the menstrual flow-. 
 
 The conditions necessary to a normal and regular menstruation may be 
 ■enumerated as follows : 
 
 a. Integrity of the genital apparatus. 
 
 b. Normal condition of the blood. 
 
 c. Normal state of the nervous system. 
 
 Any disturbing influence originating in one of these systems may pre- 
 vent the maturing of the ovum, or disturb ovulation, or, by an inhibitory 
 influence upon the sympathetic or vasomotor ner\'es, interfere with the in- 
 tense congestion which is the necessary precursor of the menstrual flow. 
 Anything impairing the integrity of the ovaries — cysts, sclerosis, periovaritis 
 — acts directly upon the starting-point of the reflex action, and at a suffi- 
 ciently advanced state may abolish it entirely. It is, however, more usual 
 
470 CLINICAL AND OPERATIVE GYN.'ECOLOGY. 
 
 for these injurious agents, which have not completely destroyed the organ, 
 to play the opposite part of excitants, and produce menorrhagia with dys- 
 menorrhoea, instead of amenorrhoea. 
 
 Does removal of both ovaries absolutely cause a cessation of menstrua- 
 tion ? This question, the answer to which at one time seemed positive, has of 
 late been asked by surgeons after a vast number of experiments whose results 
 were contradictory. In considering the matter one great distinction must be- 
 observed. The same importance should not be given to cases in which cys- 
 tic or papillary tumors have been removed, as to those in which ovariotomy 
 is performed for slight changes, as sclero-cystic degeneration, which have 
 modified but little the size and connections of the organ, or even when it 
 is performed upon perfectly healthy ovaries (Battey's operation). Cases of 
 the first class should be carefully inquired into, for in the case of a large 
 tumor it is often impossible to affirm positively that a small fragment of 
 ovarian tissue has not been left in the pedicle, and that would in itself be 
 quite sufficient to allow of the continuation of menstruation. There remain. 
 a large number of well-authenticated cases belonging to the second class, in_ 
 which, in spite of a double ovariotomy, menstruation continues with more or 
 less regularity. But if the cases are attentively followed for any length of 
 time, it will be found that this postlnmions menstruation, so to speak, inva- 
 riably ceases after a few months. It is quite unnecessary to suppose the 
 existence of a supplementary ovary : the well-known law of the persistence 
 of habit will sufficiently account for the phenomenon. The ner\-ous system, 
 automatically reproduces congestion of the generative apparatus. The proc- 
 ess seems to continue from its own momentum for a while, and finally be- 
 comes slowed and ceases because of the lack of further impulse. Another 
 factor which may cause the temporary prolongation of the menstrual moli- 
 men is the existence of any impairment of the mucous membrane or sub- 
 stance of the uterus, such as always remains after the performance of ovari- 
 otomy for a fibroid tumor, and is apt to be present after removal of the 
 appendages for obstinate cases of oophoro-salpingitis. Therefore I consider- 
 it essential in such cases to follow the principal operation by a complemen- 
 tary curetting of the uterus. Czempin attaches some value, as a factor in the 
 process, to the passive congestion due to the compression of veins by the 
 cicatricial tissue resulting from the operation. The amenorrhoea following 
 ovariotomy is accompanied by certain general physical changes : an increase- 
 of embonpoint, atrophy of the mammary glands, and sometimes a marked 
 change in the disposition, which often becomes more placid. Removal of 
 the Fallopian tubes alone does not seem to influence menstruation, provid- 
 ing that the ovaries be healthy, which fact upsets Lawson Tait's theory of 
 the paramount influence of these organs upon this function. 
 
 Primary amenorrJicea may be due to malnutrition, which causes a delay 
 in general development. Over-.stimulation of the intellectual faculties, with 
 too little physical exercise, a condition of things found in certain convents. 
 
DISORDERS OF MENSTRUATION. 47 1 
 
 and schools, may cause amenorrhoea as well as chlorosis. Weakly young 
 girls with a strumous taint are especially predisposed to it. On the other 
 hand, the change of regimen, the rapid substitution of an abundant and 
 stimulating diet, and the absence of their accustomed exercise in the open 
 air in young girls who are transplanted from a country to a city home, while 
 causing sudden plethora, often causes a delay in the appearance of the 
 menses. 
 
 Secondary amenorrJicca may follow impoverishment of the blood, and the 
 profound debility resulting from a chronic disease or following an acute ill- 
 ness. Anaemia, chlorosis, Bright's disease, diabetes, alcoholism, morphin- 
 ism, cancerous or malarial cachexia, pulmonary tuberculosis, convalescence 
 from fevers, are all potent in producing amenorrhoea; acute or chronic sur- 
 gical affections may act in the same way. These facts, which have recently 
 elicited much study, were observed and commented on by Dupuytren, It is 
 to the profound anaemia accompanying the onset of the diathesis to which we 
 must attribute the amenorrhoea of syphilitic women upon which A. Fournier 
 lays such stress, and that of young women who are the victims of obesity, 
 often a most debilitating dystrophia. The condition of the nervous system 
 has a decided influence upon the production of amenorrhoea. Fright may 
 cause a temporary suspension of the menses. On the other hand, there are 
 cases on record in which amenorrhoea has been cured by some sudden emo- 
 tion. The amenorrhoea of prisoners and of insane women confined to asylums 
 is due as much to the mental depression as to the anaemia consequent upon 
 seclusion. Chlorosis, which causes amenorrhoea, seems to be a disease of 
 the nervous system. Absence of menstruation is often noted in the hys- 
 terical. Sudden chilling, which is often given as a cause of amenorrhoea, 
 probably acts through the vasomotor tract. The emotional amenorrhoea of 
 the newly married, or of women who are very desirous of having children, is 
 probably to be referred to the inhibitory power of the nervous system ; its oc- 
 currence simultaneously with tympanites has often been the cause of bitter 
 disappointment. Anxiety may induce amenorrhoea in women who, because 
 of the irregularity of their lives or from some other reason, dread pregnancy 
 (Raciborski). I have seen several instances of this. The last two forms 
 may be due in part to auto-suggestion. Atrophy of the uterus from su- 
 perinvolution after repeated pregnancies, prolonged lactation, etc., causes 
 amenorrhoea. 
 
 Symptoms. — The chief sign is of course the absence of the periodical 
 flow through the genital tract. But we should not overlook the accompany- 
 ing nervous symptoms, which may be very serious, and which occur in the 
 form of chlorosis or of hysteria. Sensory disturbances, such as impairment 
 of vision and of hearing, and paraplegia, seem to depend as much upon 
 anaemia as upon hysteria. 
 
 Amenorrhoea is some patients is accompained by the cutaneous eruptions 
 which in other women occur during menstruation — acne, eczema, herpes. 
 
472 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 urticaria, pemphigus, erysipelas. Hyperidrosis and a swelling of the hands 
 and feet have been known to occur, doubtless from angio-neuroses. 
 
 These curious facts lead naturally to the study of vicarious menstruation, 
 as they demonstrate the harmony existing between different parts of the or- 
 ganism, and the possibilities of an interchange of function between the ex- 
 ternal integument and the uterine mucous membrane. Science has on record 
 some curious examples of what may be called substituted secretions. Jones 
 reports the case of a young woman in whom menstruation was checked ap- 
 parently from sudden chilling, w^ho then suffered from amenorrhoea, and for 
 five years had, instead of the menstrual flow, an abundant flow of milk from 
 the breasts, which lasted thirty-six hours. In another woman, who had borne 
 several children, the catamenial period was characterized by a profuse diar- 
 rhoea for three days, accompanied by leucorrhoea, with a subsequent scanty 
 discharge of blood. He also mentions a case in which periodical leucorrhoea 
 replaced the normal flow. 
 
 Vicarious or ectopic menstruation is met with in the most extraordi- 
 nar}^ and unexpected forms. The discharge most frequently occurs from the 
 bronchial or pulmonary mucous membrane, the patient having hsemoptyses, 
 which may lead to a diagnosis of incipient phthisis. Haematemesis has been 
 obser\'ed, and epistaxis, rectal hemorrhages, especially in plethoric patients 
 with hemorrhoids — and otorrhagia — either where a pre-existing purulent 
 otorrhoea had made this portion of the frame a locus minoris resistenticB, or 
 when the tympanum was intact. Of rarer occurrence are cutaneous hemor- 
 rhages in the form of ecchymoses and petechial spots, or a flow of blood from 
 the surface of some one special point where the skin is unbroken or from the 
 surface of an ulcer. In the hospital of Saint-Louis I saw a patient, suffering 
 from lupus of the face, who had an abundant flow of blood in this situation 
 at each menstrual period. 
 
 Treatmejit. — It is a mistake to suppose that amenorrhoea calls for special 
 medication supposed to have an elective action upon the uterine mucous 
 membrane. Emmenagogues — rue, savine, saffron, apiol — are of use only in 
 a few limited cases, in which some decided influence (as cold or violent emo- 
 tion) has caused a suspension of the menses, and should be administered 
 with moderation at the time the flow is expected. The same maybe said of 
 hot baths (104° to 113° F.). Drastic and saline purgatives may then be 
 given for the purpose of causing a certain amount of pelvic congestion. Of 
 late, permanganate of potash has been recommended as almost a specific. 
 As a rule, we should try to reach the cause of the disease, and, amenorrhoea 
 depending usually upon poverty of the blood or upon some nervous trouble, 
 we must have recourse to nutrition, tonics, and alteratives, especially iron 
 or manganese or hydrotherapy. I depend much more upon this general 
 treatment than upon such measures as scarification of the cervix, application 
 of a galvanic pessary, etc. Electricity (faradic or continuous) may give good 
 results, and should not be omitted. Bigelow recommends static electricity 
 
DISORDERS OF MENSTRUATION. 473 
 
 (franklinization) for the amenorrhoea of chloro-anaemic girls, as a general tonic. 
 In the intermittent form of amenorrhoea found in plethoric patients we may 
 use the continuous current, placing the positive pole in the uterine cavity. 
 In the unmarried, one electrode may be placed upon the lumbar region, and 
 the other externally over the site of the uterus ; in the married it is better 
 to place one electrode in the uterus and the other on the hypogastrium. 
 Bigelow also advocates general electricity for amenorrhoea, one electrode 
 being placed on the back of the neck, and the other in a foot-bath of salt 
 water. He finds this particularly useful in the case of young girls who are 
 irritable, nervous, and chlorotic. The treatment should be started a few days 
 before the period is due, and be taken daily until that time. Physical exer- 
 cise, walks in the open air, gymnastics, sea or mountain air, amusements, 
 and distraction from all anxiety are to be prescribed as well. 
 
 Where amenorrhoea occurs in young women who are obese or threatened 
 with obesity, I have often caused a return of the menses by treating the 
 obesity, prescribing a diet free from fluids and starchy foods, exercise, ther- 
 mal baths (Brides, Salies de Beam), and finally by stimulation of the uterine 
 mucous membrane by curetting, followed by iodine injections at the date 
 that menstruation should occur. 
 
 In women in whom amenorrhoea follows an ovariotomy, it is not unusual 
 in the first few months to observe periodical disturbances [practically iden- 
 tical with those which occur at the physiological menopause] — lumbar pains, 
 flashes of heat, vertigo, and a special form of irritability ; in short, a moli- 
 men which is all the more painful because it is longer in duration than the 
 normal crisis. In these cases I have obtained good results from scarifying 
 the cervdx and obtaining a slight local bleeding every month at the time of 
 the disturbance. I also use saline purgatives. One of my patients came to 
 me regularly for a year to obtain the relief afforded by this treatment. In 
 the end these phenomena disappear spontaneously. 
 
 Menorrhagia. 
 
 A notable increase in the menstrual flow constitutes menorrhagia ; a dis- 
 charge of blood in the interval between the periods is called metrorrhagia. 
 
 Symptoms. — A profuse and prolonged flow, the formation of clots, and 
 general debility are the symptoms of what is not in itself a disease, but a 
 symptom of several diseases. 
 
 Etiology and Pathology. — The cause may be general or local. 
 
 1. General causes act by altering the composition of the blood; to this 
 class belong the various dyscrasise, haemophilia, purpura, scorbutus, severe 
 icterus, phosphorus poisoning, Bright's disease, Werlhof's disease, obesity, 
 and cachexia. Sometimes in these cases amenorrhoea alternates with menor- 
 rhagia. Finally, uterine epistaxis (Gubler) may mark the onset of fevers. 
 
 2. The local causes are : 
 
 A. Reflex stimulus from the genital organs (especially the appendages) 
 
474 CLINICAL AND OPERATIVE GYN.-ECOLOGY. 
 
 without any existing lesion, simply from nervous derangement, as at pu- 
 berty, first intercourse, or the menopause. We must include in this class the 
 metrorrhagia caused by lactation, which is no doubt due to reflex stimulation 
 from the mammary glands. 
 
 B. Nearly every disease of the uterus and its appendages ; endometritis, 
 fibromata, cancer, ovarian tumors, especially those situated near the uterus, 
 as intra-ligamentous cysts, and affections of the Fallopian tubes. As in this 
 chapter I do not pretend to do more than outline the diseases causing menor- 
 rhagia, I shall content myself with this enumeration, without going into de- 
 scriptive details ; each affection will be found described at length under its 
 appropriate heading. 
 
 Trcatvunit. — Unless this symptom threaten serious danger it need not be 
 treated by itself, but the cause should always be sought for. A mere men- 
 tion of the haemostatic measures at our command will suffice. The local 
 means are: prolonged irrigations of very hot water (iio° to 120° F.) and 
 tamponade of the vagina. Emmet was the first to use temporary suture of 
 the cervix, which may be done if all other measures fail. I have seen Mar- 
 tin ligate e7i masse the inferior branches of the uterine artery through the 
 vaginal culs-de-sac (page 95), with successful result. 
 
 General measures are to be simultaneously employed ; rest in bed, with 
 sight elevation of the pelvis; opium in the form of laudanum; rectal injec- 
 tions ; ergot, by the stomach and hypodermatically. Gallard places a high 
 value upon the infusion of digitalis leaves given to the point of toxic effect. 
 
 [In many cases fluid extract of hydrastis, given in half-drachm to drachm 
 doses every four hours during the time of the flow, and in twenty-drop doses 
 before meals in the intervals, is very efficient. 
 
 All of these measures are only palliative and of very slight importance 
 compared with the treatment of the causal factor of the bleeding.] 
 
 If menorrhagia becomes threateningly severe, would it be justifiable, in 
 the absence of an exact diagnosis, to perform a radical operation .? Vaginal 
 hysterectomy has in some cases seemed justifiable for a hemorrhagic en- 
 dometritis which resisted all other treatment (page 187). Some operators 
 have performed ovariotomy. 
 
 Olshausen mentions the case of a woman of thirty-nine years who suffered 
 from such severe menorrhagia, with no discoverable cause, that he performed 
 an ovariotomy, with the greatest success. Yet we should beware of creat- 
 ing a therapeutic law out of such exceptional cases, and Walton has quite 
 justly protested against the OA-er zeal for operation of some surgeons. 
 
 Dysnioiorrhcea ajid Menstrual Disorders of Neii'oiis Origin. 
 
 At the menstrual period, women normally feel unwell, as they express it ; 
 that is to say, they experience a general malaise, a few vague pains in the 
 loins, and a certain irritability of temper. These symptoms are, however, 
 
DISORDERS OF MENSTRUATION. 475 
 
 not at all pronounced. If menstruation becomes painful it is called dys- 
 menorrhoea, which has been divided and subdivided into: (ist) Neuralgic or 
 sympathetic dysmenorrhoea ; (2d) congestive or inflammatory; (3d) mechanical 
 or obstructive ; (4th) membranous ; (5th) ovarian. This classification may be 
 simplified by grouping the pains under two heads, according to whether they 
 occur during the ovarian-tubal period (ripening of the follicle) or during the 
 uterine period (expulsion of the menstrual blood). 
 
 DysmenorrJicca of Ovarian Origin. 
 
 This may be the result of incomplete development of the genital organs,, 
 the ovaries and uterus being of the pubescent variety ; or this may be the 
 case with the uterus alone, the ovaries having attained an adult development. 
 A want of regularity in the function of menstruation will of course result 
 from the difficulty of ovulation, or from the disproportion existing between 
 the intensity of the congestive phenomena in the ovaries and that in the uter- 
 us ; which produces an exaggerated erethism in the ovaries, with consequent 
 suffering. 
 
 Disease of the appendages is another frequent cause. I do not refer to- 
 acute inflammations only, or to serious affections, as salpingitis, hydro-, 
 hsemato-, and pyo-salpinx. But the remains of old lesions (often limited in 
 extent), adhesions, false membranes compressing the uterine appendages or 
 binding them down in an abnormal position (producing sclerosis of the ova- 
 ries and obstruction of the tubes), are the frequent but unrecognized cause of 
 intense pain at the menstrual period. Tubo-ovarian varicocele (Richet), or 
 varicose dilatation of the pampiniform plexus and the veins of the broad liga- 
 ment, seems to have some causative influence; a varicose condition is, more- 
 over, usually accompanied by chronic ovaritis and ovarian atrophy, just as, in 
 the male, it may be followed by atrophy of the testicle. 
 
 DysnienorrJicea of Uteidne Origin. 
 
 The principal factor is the existence of any mechanical obstacle to the 
 expulsion of the blood ; stenosis of the cervix with or without hypertrophy ; 
 displacements of the uterus, especially flexions ; endometritis (causing swell- 
 ing of the mucous membrane, and salpingitis) ; the various forms of tumors, 
 fibroids, mucous polypi, cancers, etc. I have described, under the head of 
 acute endometritis, the special form which is accompanied by complete des- 
 quamation of the mucous membrane, and which many authorities have de- 
 scribed as a separate disease, membranous dysmenorrhoea. 
 
 Can we recognize a dysmenorrhoea due to the rheumatic or gouty diathesis ? 
 I think not, and that we are only justified in saying that patients suffering 
 from these complaints are liable to every form of neuralgia. 
 
 Symptoms and Diagnosis. — The pain of dysmenorrhoea differs widely ac- 
 
476 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 cording to its origin. At the onset of menstruation the ovarian pains pre- 
 dominate ; the uterine pains are the most pronounced when the flow becomes 
 fully established. 
 
 biter-mejistmal Dysmenorrhoea (Mittelschmerz of the German authori- 
 ties), is erroneously so called. The name has been applied to spasmodic 
 pains in the ovarian region, occurring in the intervals between the menses, 
 and hypothetically attributed to ovulation. These are really symptoms of 
 inflammation of the uterus or the appendages. 
 
 I have already described the character of dysmenorrhoeal pain, and shall 
 not here dwell upon it at length. 
 
 As a rule, the pain makes its appearance with the flow, and is especially 
 severe on the first two days. Sometimes, even when there is no mechanical 
 obstacle and no narrowing of the cervical canal, the blood is discharged drop 
 by drop (like the urine in strangury), a phenomenon which Aetius called stil- 
 licidium uteri. Small clots indicate a stagnation of blood in the uterine cav- 
 ity, and their expulsion may cause spasms of colicky pain so intense as to 
 produce hysterical attacks and even syncope. 
 
 The menstrual period may for a long time be a period of actual relief to 
 the patient, and then become exceedingly painful; this is specially noted in 
 cases in which salpingitis passes from the acute to the chronic state. 
 
 The differential diagnosis consists in distinguishing dysmenorrhoea from 
 lumbo-abdominal neuralgia, which is increased at the menstrual period ; the 
 coexistence of neuralgia in other localities and the identification of Valleix's 
 painful points will facilitate the diagnosis. To determine whether the pain 
 is of ovarian or uterine origin, a careful study of local conditions will be nec- 
 essar)\ The phenomena preceding menstruation will assist us in forming 
 an opinion. This question of diagnosis occurs in regard to the various 
 uterine diseases of which I have spoken. 
 
 I would call especial attention to the dysmenorrhoea and the grave reflex 
 phenomena which may be produced by prolapse of the ovary. By vaginal or 
 rectal touch we shall be able to find a tumor in the pouch of Douglas, pres- 
 sure upon which causes a peculiar and characteristic nauseating pain. Two 
 accompanying symptoms are, pain during defecation and coition, dyschezia 
 and dyspareunia, 
 
 Battey, and many other gynaecologists following his teachings, especially 
 in America, attach much importance to the coexistence of menstrual disor- 
 ders, amenorrhoea and dysmenorrhoea, with grave nervous disorders, hysteria, 
 epilepsy, mania ; they have even created the terms oophoralgia, oophoro-epi- 
 lepsy, oophoro-mania. Beyond doubt, many of these affections are of re- 
 flex origin, and proceed from undeveloped or diseased ovaries. But an exact 
 diagnosis is difficult to reach, and the surgeon should be more guarded in his 
 opinions than many have been on the other side of the Atlantic. There are 
 a few clearly defined cases in which the preponderating influence of the men- 
 strual epoch is recognized beyond question, and the congested ovary is the 
 
DISORDERS OF MENSTRUATION. 
 
 477' 
 
 cause of the aura of epilepsy for instance ; there are many more in which 
 the menstrual disorders merely coincide, without being causative. 
 
 As palliative treatment for the pain, we may use potassium bromide, 
 chloral, valerianate of ammonia, asafoetida, musk, tincture of cannabis indica, 
 belladonna, and hyoscyamus. Antipyrine hypodermatically injected is a 
 valuable resource; intense spasms of pain may be relieved by the careful ad- 
 ministration of a few whiffs of ether. Oxalate of cerium has been extolled. 
 Wylie praises electricity ; he inserts the positive pole in the cervix. 
 
 Laudanum and valerian douches often afford relief when all other reme- 
 dies fail. General treatment will attempt to reach the anaemic or nervous 
 condition of the patient. 
 
 [Routh, in an excellent re'simt^ oi the subject, writes : " Successful treat- 
 ment depends upon finding and removing the cause. As a rule it is irra- 
 tional to mask the symptom of pain by giving opiates, though during a 
 severe paroxysm it may be necessary ; but even then we should add atropine, 
 belladonna, or hyoscyamus, to relax muscular spasm, to avert constipation, 
 and to enable us to use smaller doses of the opiate. The main objection to- 
 opium, chloral, or alcohol is that their repetition tends to their abuse. Ni- 
 troglycerin and amyl nitrite are excellent for spasmodic cases. The bro- 
 mides are indicated in those cases in which the dysmenorrhoea is supposedly 
 ovarian. Cannabis indica is valuable when menorrhagia coexists. A favo- 
 rite prescription, both in congestive and spasmodic dysmenorrhoea, is : 
 
 I^ Tr. cardamomi comp. , 
 Spir. chloroformi, 
 Liq. ammonii acetat. , 
 Tr. belladonnse 
 Aq. cinnamomi, 
 
 M. Sig. For one dose. 
 
 q. s 
 
 3 ss. 
 
 2.0 
 
 Ill XX. 
 
 1-3 
 
 Iss. 
 
 15-5 
 
 TTl, X. 
 
 0.65 
 
 .ad 3 i. 
 
 31- 
 
 gm. 
 
 I have found the tincture of pulsatilla, given for some days before the 
 period in five-drop doses three times daily, quite efficient in the neuralgic 
 form common in young women. In congestive dysmenorrhoea saline laxa- 
 tives, hot sitz-baths, and fifteen to twenty grain doses of phenacetin every 
 six to eight hours are effectual. For obstructive dysmenorrhoea thorough 
 dilatation of the uterine canal gives the best results. All internal medica- 
 tion is uncertain. ] 
 
 No general rule can be given about curative treatment, which will vary- 
 according to the cause of the dysmenorrhoea. The initial lesion, whether 
 it be in the uterus or the appendages, is the one to be treated. Where 
 there is doubt about the existence of this lesion, or where the trouble is 
 functional and its origin not well determined, the therapeusis is difficult. In 
 many cases in which the trouble is due to a delay in the perfect development 
 of the internal genital organs, with or without cervical stenosis, it will often- 
 disappear spontaneously with age, marriage, and conception. In some cases, 
 however, the ovaries and uterus whose functions are unequally performed da 
 
478 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 not become restored to a normal condition ; in other cases, acquired lesions 
 (adhesions, displacements) permanently impair the functional powers of the 
 ovary. The periodical pain becomes unbearable and the general health de- 
 teriorates. Moreover, it has been supposed that grave nerA^ous disorders, epi- 
 lepsy and mania, were of reflex origin, due to the dysmenorrhoea ; it is in 
 these cases that removal of healthy ovaries has been performed in order to 
 stop the pain by abolishing the function which caused it. The special indi- 
 cation for oophorectomy, castration, or normal ovariotomy (a term signifying 
 that the ovary is of normal size), was first pointed out by Battey in America, 
 then by Hegar in Germany, and Lawson Tait in England. According to 
 Battey, whose name the operation bears, the surgeon, before performing an 
 ovariotomy in such cases, should ask himself: ist. Is the case a serious one? 
 2d. Is it curable by any other medical or surgical means.'' 3d. Can it be 
 cured by the menopause .-* 
 
 The last question is, in truth, the all-important one. Ovarian pain in 
 itself is not enough to prove that the ovary is the starting-point of the trou- 
 ble : there is an ovarian congestion accompanying hysteria; moreover, neu- 
 ralgic pains of central origin may radiate centrifugally. Sound teeth are 
 frequently rendered sensitive by neuralgia of the trigeminal ; no one would 
 dream of extracting them. This very appropriate comparison of Olshausen 
 has been met by the reply that, normal ovariotomy being a benign operation 
 and the pain suffered of an excruciating nature, many patients would be will- 
 ing to submit to the operation for the uncertain chance of a cure. It would 
 at least put a stop to the exacerbation of pain at the menstrual period. 
 
 Lawson Tait has had encouraging results with ovariotomy in the cure of 
 menstrual epilepsy. Yet G. Willers, a pupil of Hegar, has proved that there 
 is more chance of cure if the ovary be diseased than if it be healthy. The 
 same is true of hysteria and hystero-epilepsy with acute exacerbation at the 
 menstrual period. 
 
 Castration has given some good results — it has also resulted in many fail- 
 ures. Some of the cures are quite remarkable, but they may be only tem- 
 porary in their effect, and often no cure follows. We must also ask our- 
 selves whether the cures may not oftentimes be due to the deep psychical 
 impression produced by the operation — to a species of suggestion, in short. 
 As a proof of this being possible, we would instance the good effect pro- 
 duced in a few cases by a pretended ovariotomy. As to ovariotomy for 
 mania or psychoses apparently influenced by menstruation, I believe- that it 
 should be prohibited. In some cases of this kind the trouble has been ag- 
 gravated instead of cured by the procedure. It is difficult to appreciate the 
 point of view of those surgeons who practise ovariotomy for the purpose of 
 producing sterility and preventing the transmission of hereditary insanity. 
 I have as yet said nothing as to the anatomical condition of the ovaries. In 
 spite of Hegar's praiseworthy efforts to restrict ovariotomy to cases in which 
 lesions of the ovary can be demonstrated, and to give this operation an ana- 
 
DISORDERS OF MENSTRUATION. 479 
 
 tomical basis, even when it is performed for nervous conditions only, it is an 
 undoubted fact that in the great majority of cases such positive diagnosis 
 cannot be made. 
 
 Sclero-cystic degeneration, cirrhosis, and hyperplasia of the stroma are 
 rarely recognizable by bimanual palpation ; and as for the symptoms produced 
 by these lesions, they differ in nowise from those of purely nervous origin. 
 
 It seems to me beyond doubt that removal of even healthy ovaries has 
 often modified the condition of the nervous system so as to cause a disap- 
 pearance of the grave reflex disturbances accompanying menstruation. Con- 
 sequently the operator should be less anxious to know whether the ovary to 
 be removed presents an anatomical lesion, than to know whether it be the 
 physiological starting-point of the trouble ; rational symptoms will in this 
 case tell him more than physical examination. But an absolute diagnosis is 
 difficult to establish ; and unless he be very positive as to the cause, a con- 
 scientious surgeon will hesitate to perform an operation which, when it does 
 not cure the disease, constitutes a mutilation of the patient, which, from a 
 social point of view, is more serious than the amputation of a limb. 
 
 Pean prefers vaginal hysterectomy, which he calls uterine castration, to 
 ovariotomy; he finds it more efficacious, even in overcoming the nervous 
 troubles, than removal of the ovary. I hold rather the same opinion. 
 Uterine castration acts by radically removing the point from which ab- 
 normal reflexes arise. In some exceptional cases I have performed this 
 operation and have obtained remarkable cures. 
 
 Technique of Castration. — I have already described this operation when 
 speaking of the indirect treatment for fibroids (page 276) : a few special 
 points are worthy of notice in this connection. 
 
 The abdominal incision should be as small as possible, since only the 
 ovary and tubes are to be withdrawn through it, and there is no great 
 amount of groping necessary, nor is there anything to remove that offers 
 any great difficulty ; moreover, it is always an easy matter to enlarge the 
 wound if necessary. From two and a half to three inches is large enough ; 
 the centre of the incision should be placed directly over the fundus of the 
 uterus, which can be exactly located by bimanual palpation; the inferior end 
 of the wound will usually be about two fingers' breadth from the pubes. 
 Battey, at least in his first operations, removed the ovary only. Hegar, in 
 the very beginning, realized the value of removing the tubes as well — a pro- 
 cedure which facilitates, rather than adds any difficulty to, the operation. 
 Lawson Tait also considers it of paramount importance, and his opinion has 
 had great influence in transforming oophorectomy into salpingo-oophorec- 
 tomy. 
 
 The cicatrix left by so small an incision as that made by Lawson Tait is 
 unimportant, especially if my advice be followed in regard to uniting the ab- 
 dominal walls by three successive layers of buried catgut suture, to which 
 may be added an intra-dermic suture of the skin. 
 
48o CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Vaginal incision possesses no particular advantages. Yet if the patients 
 object decidedly to an abdominal cicatrix, it may be used, especially if the 
 ovaries are prolapsed and easily reached. The prolapse of the ovaries may 
 be recognized by vaginal touch, in Douglas' cul-de-sac ; and by the twa 
 characteristic symptoms, pain during defecation and coition. 
 
 If the uterus be freely movable, the operation is of extreme simplicity. 
 The patient is placed in the dorso-sacral position, a short Simon speculum 
 presses down the f ourchette, the cervix is brought into view by a tenaculum, 
 and an assistant keeps down the uterus by pressing upon the hypogastrium. 
 A transverse incision about two inches long is made in the posterior cul-de- 
 sac as near as possible to the uterus. The index and middle fingers are in- 
 troduced into the pouch of Douglas and bring down the ovary and tube,, 
 about which a ligature is carried with a blunt needle, and tied with a Tait's 
 knot. If the nervous symptoms are very marked, it is better to remove the 
 appendages of both sides, even if one ovary only be prolapsed; for the in- 
 duced menopause has a greater therapeutic value than removal of the dis- 
 placed organ. Should there be no complication and no special indication for 
 drainage, the wound can be completely closed by catgut sutures. 
 
CHAPTER XXIII. 
 
 INFLAMMATION OF THE UTERINE APPENDAGES. 
 
 General Consideratioxs. 
 
 The important position taken in gynsecology by inflammation of the uter- 
 ine appendages, the ovaries and tubes, has but recently been generally ad- 
 
 A B 
 
 Fig. 351. — Fallopian Tubes, Normal Condition. A, Transverse section of tube near the uterus. B, Section 
 from the ampulla (Wyder;. Layers cf the Fallopian tube : i, Upper and outermost layer, serous coat ; 2, layer of loose 
 connective tissue, richly supplied with blood-vessels ; 3, muscular coat, much thicker near the uterus Cuterine seg- 
 ment) than near the ampulla (abdominal segment). It is principally made up of circular fibres. Above and within it 
 is reinforced by longitudinal fibres, some of which spread into the mucous layer, others {the most external) penetrate 
 between the layers of the broad ligament ; still others go to the hilum of the ovary or are prolonged to the fundus of 
 the uterus ; a few fibres penetrate to the inner layer ; 4, mucous coat. The framework of this layer is embryonic con- 
 nective tissue, rich in fusiform cells ; it projects into the lumen of the tube in longitudinal folds which have been cut 
 through obliquely m the section shown above. Near the uterus these folds are radiating and give a star-shaped ap, 
 pearance to the lumen in the section. Near the ampulla they are longer and reduplicated, which gives the lumen a 
 jagged and toothed appearance on section. The whole surface of the mucous membrane is lined with simple columnar 
 ciliated epithelium ; the movement of the cilia is in the direction of the uterus. 
 
 mitted. Aran and his pupil Siredey clearly recognized the fact ; but in spite 
 of the appreciation of its importance by these physicians, it was for a long 
 
 31 
 
482 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 time condemned to oblivion because not indorsed by the surgeons. The 
 fame of Lawson Tait's operations has done more to popularize this truth than 
 all the reasonings of physiology and pathological anatomy ; it has thrown a 
 great light upon the controversy waged over perimetritic inflammations. 
 
 The interminable and wearisome discussion over the question as to wheth- 
 er inflammation began in the cellular tissue about the uterus or in the 
 neighboring peritoneum — of a perimetritic phlegmon or a pelvic peritonitis — 
 a discussion which fatigued a whole generation, is now only a memory. The 
 
 Fig. 352. — Lymphatics of the Uterus (Poirier). i, Lymphatics from the body and fundus of the uterus ; 2, 
 ovary ; 3, vagina ; 4, Fallopian tube ; 5, lymphatics from the cervix ; 6, lymphatic vessels from the cervix going to the 
 iliac ganglia ; 7, lymphatic vessels from the body and fundus going to the lumbar ganglia ; S, anastomosis of cervical 
 and uterine vessels ; g, small lymphatic vessel in the round ligament going to the inguinal glands ; 10, 11, lymphatic 
 vessels of the tubes which empty into the large lymphatic vessels from the body of the uterus ; 12, ovarian ligament. 
 
 ardent controversy upon this subject between Nonat, Bernutz, Goupil, and 
 Gallard seems as superannuated as the discussions between Gendrin and Lis- 
 franc concerning uterine engorgement and chronic partial endometritis in 
 explanation of the same symptoms. Even the distinction between para- and 
 perimetritis still made by modern authorities seems unnecessary in clinical 
 practice. It is a vestige of old theories. To understand the close connec- 
 tion of the uterus and the tubes, we must bear in mind the fact of their com- 
 mon embryonic origin. At the end of the second month of intra-uterine 
 existence, the ducts of Miiller become fused together at the lower portion to 
 form the uterus and vagina, while above they remain separate and form the 
 tubes, which are in reality a slender prolongation of the horns of the uterus ; 
 the various coats of both are directly continuous with each other — a fact 
 
INFLAMMATION OF THE UTERINE APPENDAGES. 
 
 483 
 
 which explains the possibility of ascending salpingitis following endometritis, 
 just as an ascending pyelitis may follow chronic cystitis. The ovary, which 
 is connected with the tube by the tubo-ovarian ligament and is almost di- 
 rectly in contact with the ampulla, may also be easily infected by continuity. 
 Moreover, these organs are bound together by important vascular and 
 lymphatic vessels. I will remind you of the anastomoses of the utero-ova- 
 rian arteries and veins with the uterine vessels. More important still are 
 
 Fig. 353. — Lymphatics of the Cer\tx- and Upper Third of Vagina (Poirier). 
 
 the lymphatic connections. To Lucas Championniere, after Cruikshank and 
 Cruveilhier, belongs the credit of having called attention to it. 
 
 He described with especial care the superficial lymphatics, at the angles 
 of the uterus, which are lost in the broad ligaments behind and below the 
 tubes, between the tube and the round ligament, and especially below the 
 ovary and tube. There are also deep lymphatics which can be demonstrated 
 only by making a longitudinal section of the uterine angle ; here a group of 
 lymphatics is situated in the hollow between the tube and the ovarian liga- 
 ment. Thus important lymphatic communications are established between 
 the ovaries and tubes, which have such a close anatomical connection. 
 There is scarcely ever an ovaritis uncomplicated by salpingitis, or a salpin- 
 gitis unaccompanied by ovaritis. 
 
 As a rule, inflammation passes by direct contact and adhesion from the 
 tube to the ovary. Sometimes, however, there is suppuration of the ovary 
 without continuity of the inflammatory condition of the tube; this is ex- 
 plained by the lymphatic supply. The vessels from the ampulla follow the 
 
484 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 broad ligament to the outer side of the ovary, and join the larger lymphatic 
 network called the subovarian plexus. It is not hard to understand that an 
 abscess of the ovary may coincide with relatively unimportant lesions of the 
 oviduct. Adhesions, which are rich in lymphatics, as Poirier has shown, 
 may also transmit inflammation.* 
 
 Again, the network of lymphatics which covers the surface of the ovary 
 communicates with the lymphatics of the peritoneum. According to Wald- 
 eyer, if a lymphatic injection tube is inserted into the ovary, the whole net- 
 
 Fig. 354. — Vertical Section of the Pelvis, Showing the Superior Pelvi-rectal Space and the Ischio- 
 rectal Fossa. (On the left the section is on a level with the broad ligament ; on the right it is a little in front.) 
 
 work of lymphatics in the abdominal serous membrane may be filled from it.. 
 The fact that peritonitis following inflammation of these organs usually re- 
 mains circumscribed in extent is probably because the first stage of the proc- 
 ess consists in a plastic obliteration, a sort of adhesive lymphatic throm- 
 bosis. Finally, the subperitoneal cellular tissue in the fimbriae of the tube 
 and in the ovary is a sort of appendage to that of the broad ligament, which 
 is continued below on to the pelvic floor, and on the sides is continuous with 
 the laminated tissue more or less infiltrated with fat, which lines the perito- 
 neum, and which is especially loose in front of the bladder in the pseudo- 
 cavity of Retzius (Fig, 354). A knowledge of these details is absolutely 
 necessary in explanation of the deep and superficial transmission of inflam- 
 mation. 
 
 *I shall use the X^rms pcri-ttteritie, peri-ovaritis, perisalpingitis, which usage has sanctioned, 
 although they are of defective composition, since they are formed by the union of a Greek and a 
 Latin word. The correct terms would be: circum-uterine, circum-ovarian, tubo-ovaritis, or else 
 peri-metritis, peri-oophoritis, oophoro-salpingitis. 
 
INFLAMMATION OF THE UTERINE APPENDAGES. 
 
 485 
 
 Various widely differing classifications of salpingitis have been made. 
 Cornil and Terrillon give the following : 
 
 1. Catarrhal vegetative salpingitis. 
 
 2. Purulent salpingitis (pyo-salpinx). 
 
 3. Hemorrhagic salpingitis (haematoma of the tube; haemato-salpinx). 
 
 4. Blennorrhagic salpingitis. 
 
 5. Tubercular salpingitis. 
 
 This division is incomplete, for it ignores certain forms of diffuse in- 
 terstitial inflammation found in chronic disease. It is a little defective in 
 
 Fig. 355. — Superficial Subserous Layer from a Non-gravid Uterus, Slightly Enlarged (Wallich). 
 I, Peritoneal epithelium ; 2, clear bands ; 3, star-like spaces ; 4, dentate cells from the walls of the clear bands ; 5, 
 capillary blood-vessel with its elongated wall cells ; 6, large lymph capillaries with the dentate cells of their walls. 
 (Wallich gives the name of clear bands to the spaces which are brought into evidence by nitration, which at certain 
 points during their course have dentated cells, and which are very probably a system of lymphatic spaces situated be- 
 yond the blood-vessels.) 
 
 that it separates purulent from tubercular and blennorhagic salpingitis, which 
 are merely varieties of the first. Orthman makes this division : 
 
 1. Catarrhal salpingitis with its varieties: simple, diffuse, interstitial, 
 hemorrhagic, follicular. 
 
 2. Purulent salpingitis, which may be septic, blennorrhagic, or tubercular. 
 
 3. Haemato-salpinx. 
 
 4. Hydro-salpinx. 
 
 5. Pyo-salpinx (or purulent cystic salpingitis). From both a clinical and 
 an anatomical standpoint, I think it of importance to classify the inflamma- 
 tions of the tubes according to whether they terminate or not in the forma- 
 tion of an encysted tumor. We should thus have : 
 
486 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 II. 
 
 r a. Acute catarrhal. 
 
 Non-cystic sal- J b. Acute purulent. 
 
 ] c. Chronic parenchymatous ( p a c h y 
 
 i salpingitis) . 
 
 t a. Hydro-salpinx, or serous. 
 
 -| /'. Hremato-salpinx, or hjematic. 
 
 ( c. Pyo-salpinx, or purulent. 
 
 pingitis. 
 
 Cystic salpin 
 gitis. 
 
 Hypertrophic or vegetative variety. 
 Atrophic or sclerous variety. 
 
 I do not bring in the factor of etiology; for a blennorrhagic salpingitis, 
 for example, may develop in one of several widely differing ways into a pur- 
 ulent non-cystic, or purulent cystic salpingitis or pyo-salpinx, which may be 
 converted into hydro-salpinx or form a parenchymatous salpingitis. 
 
 Lesions of the ovary are, as a rule, coexistent with those of the tubes. 
 From a clinical standpoint, it would be difficult to describe an ovaritis which 
 was not also a tubo-o\^aritis. This will explain why I have thought it best 
 to subordinate inflammation of the ovary to that of the tube from a nosolog- 
 ical and clinical point of view. As we shall see later, an exception may be 
 made in the case of sclero-cystic ovaritis which sometimes exists indepen- 
 dently of salpingitis, originating in special nutritive disorders either func- 
 tional or due to diathesis. 
 
 According to Paul Petit, who has made a special study of this subject, 
 we might, from ?. purely histological standpoint, make the following classifi- 
 cation of ovaritis : 
 
 Acute. 
 
 Non-cystic ovaritis J 
 
 Chronic. 
 
 Serous cysts, -j 
 
 Cystic ovaritis ^ -qiq^^ ^ 
 
 ysts. 
 
 Cortical. 
 Diffuse. 
 
 Cortical. 
 Disseminated. 
 Hypertrophic. 
 I Sclero-cystic. 
 By follicular hydropsy. 
 By interstitial hydropsy. 
 Of follicles . 
 Of corpus luteum. 
 Of stroma. 
 
 Purulent cysts. 
 
 Cysts due to lymphatic dilatation. 
 
CHAPTER XXIV. 
 
 OOPHORO-SALPIXGITIS WITHOUT CYSTIC TUMOR. 
 
 {Acute Catarrhal and Puniloit Salpingitis, Xo)i-cjstic. Chronic Parcnchy- 
 
 niatoiis Salpingitis. 
 
 Pathology and Etiology. — Is there such a thing as primary ovaritis, an idio- 
 pathic lesion connected with menstrual disorders and venereal excesses, and 
 quite independent of all infection or preceding lesion of the uterus and 
 tubes ? Dalche and Prochownick have recently upheld this view, but scarcely 
 with convincing proofs. It seems to me very doubtful. I do not think that 
 there are any cases of ovaritis, properly so called, that are not preceded by 
 endometritis and salpingitis, with the exception of some rare cases of sclero- 
 cystic ovaritis, of functional and diathetic origin. As predisposing causes of 
 such ovaritis, I am inclined to attach great importance to the rheumatic diath- 
 esis, to chilling during menstruation, to venereal excesses, and also to the 
 dilatation of the pelvic veins known as tubo-ovarian varicocele. In the great 
 majority of cases, however, ovaritis is due to pre-existing endometritis or 
 salpingitis. It is true that one or the other of these conditions may have 
 existed without leaving any permanent anatomical traces, but a study of pre- 
 vious symptoms will prove that they did exist. 
 
 I shall therefore use the terms tubo-ovaritis or oophoro-salpingitis, and 
 if for the sake of brevity I say salpingitis or ovaritis it will be understood 
 that the word signifies a mixed lesion. Inflammator}^ conditions of the 
 uterus are, without doubt, the chief cause of inflammations of the appen- 
 dages. Postello long ago compared the extremity of the tube to the epi- 
 didymis, and Bernutz clearly defined the analogy between tubo-ovaritis of 
 blennorrhceal origin in the female and epididymo-orchitis in the male. In 
 specific and other inflammations, the infection is carried from one place to 
 another by means of the continuity of the mucous tissues. Schroder con- 
 siders this the only method of infection, and in a discussion at the Surgical 
 Society the majority of speakers held the same opinion. J. L. Champion- 
 niere was almost the only one to advance the view that the lymphatics car- 
 ried infection, although he himself formerly considered this the case only in 
 the puerperal condition. He lays special stress upon the relative integrity 
 of the uterine extremitv of the tubes, even when two-thirds of the external 
 portion are much affected. We may say in reply that the integrity is only 
 apparent ; the microscope reveals an inflamed condition of the tube when the 
 
488 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 naked eye is unable to perceive any trace of it. Moreover, analogous inter- 
 ruptions in the continuity of inflammations occur in the series of lesions car- 
 ried from the bladder to the ureters and kidneys. Yet the part played by 
 the lymphatics must not be ignored. Adhesions very often bind the fundus 
 of the uterus to the appendages. As Poirier has shown, these adhesions are 
 almost entirely composed of lymphatics which connect the sub-endothelial 
 uterine plexus with the lymphatics of the appendages. These adhesions are 
 without doubt the result of the action of a previously existing endometritis 
 upon the deep lymphatic plexus of which the sub-endothelial plexus is merely 
 a continuation. Inflammation from the body of the uterus may be carried 
 along this channel to the tubes and ovaries, especially if some new patholo- 
 gical influence comes to accelerate the process. 
 
 However this may be, if a catarrhal endometritis last any time, the tubes 
 are always affected, but the symptoms caused are so slight that this epiphe- 
 nomenon does not attract the attention of the clinician. In aggravated cases 
 of endometritis with slight salpingitis, only the former condition is recog- 
 nized and treated. On the other hand, in marked salpingitis a slight endo- 
 metritis, though it may be the cause of the tubal affection, may easily be 
 overlooked. 
 
 The frequency of endometritis quite explains that of salpingitis, the 
 more so that a temporary endometritis is usually followed by a permanent 
 lesion in the tubes. Winckel found, upon 575 female cadavers, 182 more 
 or less pronounced lesions of the appendages. Arthur Lewers, in 100 au- 
 topsies at the London Hospital, found 1 7 times lesions of hydro-, pyo-, or 
 hsemato-salpinx. Galabin, from the year 1883 to 1886, in Guy's Hospital, 
 found 1 2 cases out of 302 autopsies, or 4 per cent. As Lawson Tait re- 
 marked, patients in this hospital come from a class more well-to-do than 
 those of the London Hospital, and gonorrhoeal and puerperal infections are 
 consequently less frequent. Out of 20,605 gynaecological affections ob- 
 served in Martin's clinic from September 15th, 1886, to December 31st, 
 1894, there were 1,363 cases of lesions of theadnexa; out of 2,078 cases 
 279 were due to gonorrhoea. 
 
 Gonorrhccal Infection is the most usual cause of inflammation of the 
 tubes, if one is to believe Noeggerath, who took up the study of this sub- 
 ject after Ricord, Requin, Bernutz, Zweifel, and Rosthorn. Westermark 
 was the first to find the gonococcus in the pus from a blennorrhagic salpin- 
 gitis. Since then the researches have greatly multiplied in number, especially 
 in Germany, where Schmidt, Carstens, Zweifel, Witte, Wertheim, Schauta, 
 and Prochownick have reported the most conclusive observations. Martin, 
 from his own statistics, joined to those of Wertheim, Charrier, Prochownick, 
 and Schauta, found 'j6 cases of purulent salpingitis in which the gonococcus 
 was present. In France, Hartmann and Morax found the gonococcus 1 3 
 times in 33 cases of suppurative salpingitis; Jayle 4 times out of 30 cases. 
 
 The finding of the micro-organism has been attended with more difficulty 
 
OOPHORO-SALPINGITIS WITHOUT CYSTIC TUMOR. 489 
 
 in the various tissue layers of the tubes. Wertheim, however, found it in 
 the mucosa and in the muscular layer. According to Reymond, it is most 
 abundant upon the surface of the mucosa in a purulent layer composed of a 
 larger number of leucocytes and of some desquamated epithelial cells. It is 
 found within these cells, in the leucocytes, and sometimes between the cells. 
 These authors lay especial stress upon inoculation with the gonorrhoeal 
 virus, which is, so to speak, attenuated in strength, a vestige of an old gonor- 
 rhoea, Avhich is often neglected because considered at the same time incur- 
 able and harmless (gleet). Many newly married women may be infected in 
 this way, and the fatigues of the wedding journey thus accounted for. 
 Slight endometritis and intense catarrhal salpingitis are often caused; abor- 
 tion follows and aggravates the condition of the patient, who may long re- 
 main an invalid and sterile. 
 
 Gonorrhoeal infection often leads to graver diseases, causing a sudden 
 suppuration of the tubes, which becomes encysted or extends to the pelvis. 
 This is the form described by Bernutz, and that I have also frequently seen 
 at Lourcine. In one case I witnessed an overwhelming onset of gonorrhoeal 
 pyaemia, with multiple foci of suppuration scattered about in the subperi- 
 toneal cellular tissue and in the substance of the mesentery. There was in- 
 tense vaginitis and pyo-salpinx. Neisser's gonococcus cannot always be 
 identified, even when the gonorrhoeal origin of the affection is undisputed. 
 It has, however, often been found. 
 
 Puerperal infection following labor, and especially abortion under septic 
 conditions, should be placed among the chief causes of inflammation of the 
 appendages. In Martin's statistics, already quotea, three hundred and se- 
 venty-four cases were of puerperal origin. Lesions of the tube are espe- 
 cially to be feared in post-abortum endometrits with retention of placental 
 debris, which is a strong argument in favor of energetic interference (cleans- 
 ing with a blunt curette, and irrigation) instead of the expectant treatment 
 or timid interference recommended by some authorities. The cures obtained 
 by these last methods are only apparent. Any patient in whose uterine 
 cavity gangrenous placental debris remains for several days is sure to de- 
 velop a metro-salpingitis. The streptococcus is the infection agent in this 
 form of salpingitis, and the cases in which it has been found are numberless. 
 It is situated chiefly in the pus, free between the epithelial cells, more rarely 
 within the leucocytes or the epithelial cells. It has been found in the mu- 
 cosa, and in thrombosed vessels. Nearly all women suffering from salpin- 
 gitis due to the streptococcus have at some time or another had some puer- 
 peral affection. Yet Kaltenbach observed a case of streptococcal ovaritis in 
 a virgin. During the course of a puerperal infection the staphylococcus 
 may act in the same manner as the streptococcus, but its presence in the 
 pus of the tubes is decidedly the exception. The authorities who have met 
 with it there have invariably found it associated with the streptococcus. 
 
 In women who are suffering from gonorrhoea at the time of parturition, a 
 
490 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 mixed infection is produced, puerpero-gonorrhoeal, which explains the fre- 
 quency of metro-salpingitis in these cases. Gertheim, VVertheim, and Witte 
 have determined the amount of influence exercised by the gonococcus upon 
 the development of the streptococcus. In my opinion, the elevation of tem- 
 perature which occurs so frequently after delivery in women suffering from 
 gonorrhcea is due to the streptococcus, whose development has been favored 
 by the gonococcus. 
 
 Contamination from Obstetvico-snrgical Exploration and Interference. — I 
 refer the reader to what has already been said upon this subject in the chap- 
 ter on Endometritis. 
 
 The uterine sound has had many victims, and also discission of the cer- 
 vix, before the days of antisepsis. Even at the present day, we must bear in 
 mind that, in order to secure intra-uterine exploration from danger, not only 
 must the instrument and the finger be free from germs, but the cervical ca- 
 nal must, by repeated washings, have been freed from the organisms which it 
 normally contains. The presence of a constant source of infection in the 
 cervical canal (Winter) may account for the existence of some cases of en- 
 dometritis and salpingitis which have no other apparent cause than a diffi- 
 culty experienced in the evacuation of the cervical secretions, from some 
 displacement or stenosis ;. the normal drainage of this mucus filled with 
 microbes that are virtually pathogenic being interfered with, auto-infection 
 might thus be produced. It is very certain that inflammation of the uterus 
 and adnexa is rarely absent in this condition. 
 
 Tubercular salpingitis may coexist with other affections of the genital 
 apparatus of the same nature, and be lost, so to speak, among the graver 
 lesions. But tubercular salpingitis has often been observed as an isolated 
 lesion. Are these cases of tubercular salpingitis, which are of more frequent 
 occurrence than is generally supposed, to be attributed to auto-infection or 
 to hetero-infection (by the introduction of tubercular semen into the genital 
 tract) } The point of entrance of Koch's bacillus seems in many cases to 
 have been the genital tract (Cohnheim, Verneuil). But there are frequent 
 instances of tuberculosis of the appendages in virgins which are quite unac- 
 counted for by this explanation ; it is very likely that they are in the first 
 place due to an ordinary auto-infection caused by cervical stenosis, and that 
 the bacilli introduced into the circulation through the pulmonary or diges- 
 tive tract fix upon the inflamed tubes as the point of least resistance. This 
 hypothesis harmonizes with the prevalent ideas of general pathology upon 
 what is called pre-tubercular inflammations. Malformations or congenital 
 atrophy of the tubes would also cause a morbid predisposition of these or- 
 gans, as Lawson Tait has pointed out, and to which Freund has called es- 
 pecial attention. 
 
 I will merely mention as of passing interest the rare causative influence 
 of eruptive fevers, especially scarlatina or variola, which Lawson Tait has de- 
 monstrated, and the very problematic influence of genital papillomata men- 
 
OOPHORO-SALPINGITIS WITHOUT CYSTIC TUMOR. 49I 
 
 tioned by Alban Doran to explain a papillomatous salpingitis whose exact 
 nature was undetermined. « 
 
 The cases of syphilitic salpingitis which have been reported will not 
 bear investigation. Further observations upon this subject are needed. The 
 salpingitis due to actinomycosis is a mere anatomical curiosity. 
 
 I was the first to call attention to the intestinal origin of certain cases of 
 oophoro-salpingitis. I have seen three cases in which, all other etiological 
 factors being absent, the infection of the tubes seemed to be absolutely trace- 
 able to an old intestinal lesion (enteritis, typhoid). Propagation would seem 
 to be carried by means of adhesions which unite the appendages to an inflamed 
 coecal appendix, or through the lymphatic communications between this or- 
 gan and the ovary, to which Clado called attention. 
 
 In connection with these cases of purely intestinal origin, we must not 
 fail to mention the possibility of infection of gonorrhoeal or puerperal 
 pyo-salpinx through the digestive tract. Schauta (once), Hartmann and 
 Morax (twice), Reymond (six times), Girode (twice), and Jayle (six times) 
 found the bacteri?iin coli coninmne in suppurative salpingitis of distinctly 
 gonorrhoeal or puerperal origin, adhesions having been formed with various 
 portions of the intestines. 
 
 According to Reymond, in the presence of the bacterium coli commune 
 the micro-organisms previously existent in the tubes seem to acquire increased 
 virulence. A certain number of cases of salpingitis with pneumococci have 
 been reported, but in no case was pneumonia found in the histor}^ of the 
 patients. Frommel and Witte found the pneumococcus in puerperal sal- 
 pingitis, Zweifel and Girode in gonorrhoeal salpingitis. It is an interesting 
 circumstance that salpingitis with pneumococci is always unilateral. 
 
 Pathological Anatomy. I. Lesions of the Tubes. — These are in the acute 
 variety at least more constant and more characteristic than those of the 
 ovaries, the mucous lining being more vulnerable than the serous mem- 
 brane surrounding the uterus. 
 
 The comprehensive term catarrhal salpingitis has been much abused. 
 A glance at the records published on the subject will show that it has been 
 applied to the most varied pathological conditions. Every non-purulent in- 
 flammation of the tubes, from a simple and slight salpingitis accompanying 
 an endometritis and simultaneously cured with it, to a hypertrophic pachy- 
 salpingitis with abundant vegetations on the folds of the mucous membrane, 
 and excessive thickening of the walls has been placed pellmell in this class. 
 This confused classification makes it extremely difficult properly to estimate 
 the therapeutic value of the various operations recently performed in France 
 and other countries. The knowledge that a slight increase in size and a 
 trifling congestion of the Fallopian tubes constitute a salpingitis in the eyes 
 of some surgeons, and call for removal by operation, causes one to hesitate 
 before indorsing the value of the brilliant series of operations, which really 
 demonstrate only the incontestable simplicity and innocuousness of ovari- 
 
492 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 otomy performed with aseptic precautions. To form an exact opinion it 
 would be necessary to have eacli report of extirpation of the appendages ac- 
 companied by a condensed but accurate description of the lesion, instead of 
 being labelled as vaguely as it is at present. I believe, moreover, that acute 
 catarrhal salpingitis should be carefully distinguished from chronic parenchy- 
 matous salpingitis with acute exacerbations ; they have often been con- 
 founded under the common name of catarrhal vegetative salpingitis, because 
 a sufficiently detailed clinical history has not been secured in regard to the 
 patients from whom the histological specimens were obtained. This confu- 
 sion is made easier by the fact that many women are operated upon for a le- 
 sion of long standing after an acute exacerbation, which puts one on the 
 wrong track as to its exact duration. 
 
 In acute catarrhal salpingitis we find in the first place a hypertrophy of 
 the organ, which is swollen cylindrically from about the size of the little 
 finger to that of the thumb, this being due as much to an infiltration of the 
 walls as to that of the subserous tissue. As the lower border of the tube is 
 bound to the broad ligament, it is obliged to twist and bend until it presents 
 a lumpy and moniliform appearance. The fimbriated extremity is sometimes 
 patulous and turgescent, more often folded up like an unopened daisy. The 
 agglutination of its fimbriae does not go on to complete obliteration, as in 
 the case of chronic lesions. This permeability of the fimbriated extremity 
 I consider, to be pathognomonic of inflammations, which are simply catarrhal, 
 or in other words superficial and curable, not calling for extirpation of the 
 organ. False membranes, which are usually fine, soft, lamellated, or filamen- 
 tous, and transparent enough to show the blood-vessels in their substance, 
 often bind the tubes to the ovaries and adjacent structures. 
 
 The external surface of the tube is of a pinkish tint, somewhat deeper in 
 color near the outer extremity. On section, the cavity is seen to b2 filled 
 with the normal but hypertrophied folds of mucous membrane, which are 
 pinkish or silvery gray in color, giving the appearance of vegetations ; mu- 
 cus sometimes is seen on the surface. 
 
 A histological examination shows that the lesions are especially marked 
 in the mucous membrane ; the folds are covered with lateral, newly formed 
 vegetations ; instead of being thin they are thick and club-shaped. Many 
 of them anastomose at the internal extremity, which gives a reticulated ap- 
 pearance to the section. The framework of these vegetations is cellulo-vas- 
 cular, infiltrated with the embryonic cells ; they are lined in some places by 
 a layer of columnar, ciliated epithelial cells. The fibro-muscular coat is, as a 
 rule, but slightly affected, there being only a hyperplasia of its substance. 
 
 Acute puj'ulcnt, non-cj'stic salpingitis is more rarel}^ met with than the 
 encysted form, pyo-salpinx, in which, however, it invariably terminates if it 
 lasts long and if the pus cannot be evacuated through the uterine cavity. 
 According to Freund, this unfavorable result is largely dependent upon in- 
 complete development of the ovdduct. He claims that two forms of Fallo- 
 
oOphoro-salpingitis without cystic tumor. 
 
 493 
 
 pian tube exist normally — one almost straight and of normal calibre; the 
 other much twisted and with diminished calibre in some spots, this being the 
 remains of an infantile condition. In the first class of cases, tubular affec- 
 tions develop rapidly and tend to a spontaneous cure. In the second, from 
 the atresia of the oviduct, suppuratve inflammations necessarily result in en- 
 cysted collections of pus. This condition of things is to be looked for in 
 persons of delicate constitution in whom dysmenorrhcea accompanies the 
 onset of menstruation. This view of the case may be correct, but, as a rule, 
 
 
 
 ? — 
 
 
 
 
 
 4i 
 
 .m^ 
 
 
 Fig. 356. — AcvTE Catarrhal Salplxgitis. (Transverse section of tube ; enlarged 350 diameters.) i, Fibro-mus- 
 cular tissue infiltrated with some embryonal cells ; 2, vascular spaces ; 3, muscular bundles ; 4, opening formed by 
 union of two adjoming villosities ; 5, tissue of villosities, hypertrophied and completely infiltrated with embryonal cells; 
 6, lining of ciliated epithelium ; 7, point at which development of embryonal cells has caused desquamation of 
 epithelium. 
 
 it is only necessary that the inflammation be very intense in its nature, to 
 produce, in addition to the protective occlusion of the ostium abdominale, a 
 swelling and infiltration of the walls so marked chat the lumen is obliterated, 
 or ceases to be permeable at the uterine orifice. This is what often occurs 
 in gonorrhoea} affections. However that may be, the transformation into a 
 pyo-salpinx is always preceded by an acute purulent, profluent salpingitis, if 
 the term be permitted, which means that the ostium uterinum is permeable 
 and permits of free evacuation of the purulent secretion. If an operation 
 be performed at this stage, we shall observe all the external signs of intense 
 inflammation of the tubes; swelling, a twisted, knotty, lumpy condition of 
 
494 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 the oviduct, with the fimbriae so agglutinated as to close the abdominal 
 orifice. On section the tube is found to be filled with pus, the cavity often 
 resembling a string of beads, owing to the contractions. 
 
 The pus, which is creamy like all pus of recent formation, can easily be 
 evacuated through the uterine cavity, as the ostium uterinum is not occluded 
 like the ostium abdominale. The mucous membrane is downy and of a 
 grayish tint. Under the microscope a transverse section shows very thick 
 reduplications covered with anastomosing vegetations, forming a system of 
 primary and secondary folds, enclosing irregular cavities that look like 
 glands. This thickening is due to the infiltration of migratory cells in the 
 connective tissue. 
 
 The ciliated cells are destroyed, and the epithelial cells are changed in 
 shape, becoming cubical or flat, and preserving their normal shape only in 
 
 Fig. 357. — AccTE Purulent Gonorrhceal Salpingitis. 7", Thickened tube ; /", fimbriae swollen and incompletely 
 agglutinated ; O, cystic and adherent ovary. 
 
 the sinuses, whose pouch-like endings are lined with a basement membrane 
 of columnar cells which still further increases their resemblance to glands 
 (Fig. 358). The whole thickness of the wall is also infiltrated with these 
 round migratory cells, and the blood-vessels are dilated (Cornil). 
 
 If purulent salpingitis does not go on to the formation of pyo-salpinx it 
 may, as clinical experience has demonstrated, be spontaneously cured. 
 
 This retrogressive process is rare, however, and during its progress the 
 patient is at any moment liable to a return of the acute phenomena. When 
 it does occur, the cure takes place by induration, as it used to be called ; 
 that is, by the formation of embryonic connective tissue which, temporarily 
 at least, results in a hypertrophy of the organ, a pachy-salpingitis. Fig. 
 359 gives an excellent representation of purulent salpingitis, which seems 
 to be in process of development. The vegetations which were at first iso- 
 lated are now united and form an embryonic tissue which at first sight 
 seems to be homogeneous. This new layer of tissue lines the walls of the 
 tube and diminishes its calibre by projecting into the lumen in the form of 
 
oOphoro-salpingitis without cystic tumor. 
 
 495 
 
 papillomata formed of embryonic tissue. If the pus disappears and these 
 perishable vegetations become organized, a chronic salpingitis will be estab- 
 lished. In chronic parenchymatous salpingitis it is usual to find both tubes 
 involved, whereas acute and unimportant lesions may be unilateral. This 
 circumstance has given rise to Lawson Tait's rule of always removing the 
 adnexa of both sides, as, if left, the sound side usually succumbs later. The 
 ovary is usually implicated as well, being affected with sclerosis or peri-ova- 
 
 FiG. 358.— Acute Purulent Salpingitis. Transverse section (magnified 12 diameters). f,f. Thickened vegeta- 
 tions, for the most part joined to each other in such a way as to form narrow openings of glandular appearance ; /, 
 wall of tube ; ?', blood-vessel (Cornil). 
 
 ritis. Strong adhesions, as a rule, bind the appendages to the pelvic walls 
 or to Douglas' cul-de-sac. These adhesions may even become so tough that 
 the ovary and tubes, which have become quite friable, cannot be detached 
 without being torn to pieces. The thickened tube is often hard and cordlike. 
 The lesions, instead of being limited to the mucous membrane as in 
 the preceding forms of salpingitis, include the whole thickness of the walls. 
 The middle layer, the parenchyma, is even more altered than the other coats ; 
 so that chronic salpingitis, even more than chronic endometritis, may be 
 called parenchymatous. On section we recognize the great thickness of all 
 the walls. The mucous membrane is slate-colored. The external orifice is 
 always obliterated and sometimes adheres to the ovary. The uterine orifice, 
 on the contrary, is usually permeable, but the tube has often become im- 
 
[g6 
 
 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 permeable in some places. The lesion has also been called pachy-salpingitis, 
 or interstitial salpingitis because of the increase in connective tissue as shown 
 
 Fig. 359. — AcvTE Purulent S.^ipingitis. Transverse section (magnified 12 diameters), i. Connective tissue of 
 the walls. Above the connective tissue is a thiclc layer of erabrj'onic tissue i, l>, filled with cavities «, a, a, covered 
 with epithelial ceUs and narrow creWces/", _/, which also contain epithelial cells ; <i, similar cavities nearer to the waUs 
 (Cornil). 
 
 by the microscope. It is analogous to chronic epididymitis with sclerotic 
 degeneration of the spermatic cord. Two anatomical varieties of this affec- 
 
 FiG. 360. — Hypertrophic P.achy-salpikgitis and Sclerosed Ovary, i, Small parovarian cyst of the broad liga- 
 ment ; 2, thickened tube ; 3, sclerotic ovary fused with the fimbriated end of the tube. (Specimen removed by 
 laparatomy.) 
 
 tion may be recognized, which correspond with those of parenchymatous en- 
 dometritis. In the first, which was ably described by Kaltenbach, and then 
 by Schauta and Sawinoff, and of which I have seen examples, there is a 
 
OOPHORO-SALPINGITIS WITHOUT CYSTIC TUMOR. 
 
 497 
 
 chronic hypertrophic salpingitis. The tube, about as large as the little 
 finger or the index, is the color of wine-dregs, purple, and of fleshy consist- 
 ency. Upon cutting it, we find a thick shell of hypertrophied muscular tis- 
 
 
 
 ^' 
 
 
 
 
 ^m}^ 
 
 
 m 
 
 
 
 \,vn:x, 
 
 :^\ 
 
 
 'I. ir 
 
 E 9 
 
 o 
 
 
 
 1 s 
 
 - ^ 
 
 t > 
 
 '/^ • 
 
 
 "/ 
 
 
 .'/ 
 
 
 5 i< 
 E .a 
 
 J J3 
 
 H 4) 
 W ■" 
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 t 
 
 u > 
 
 £ o 
 
 sue, or of newly formed connective tissue ; and beneath, filling the interior 
 of the obliterated lumen, as the marrow fills bone, is a pulpy substance of 
 brilliant silvery appearance, formed by the mucous membrane whose epithe- 
 32 
 
498 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 lium is greatly altered. In Kaltenbach's case the vessels were much dilated, 
 and there were a number of hemorrhagic spots on the walls. The abdominal 
 end of the tube was obliterated, the uterine extremity merely narrowed. 
 These cases seem to me to point to the previous existence of a purulent sal- 
 pingitis, which was saved from cystic dilatation by the permeability of the 
 ostium uterinum. In the cases observed by me, and by Kaltenbach and 
 Schauta, there was every proof of previously existing gonorrhoea. 
 
 These authorities attribute too much importance to the muscular hyper- 
 trophy in the production of the colicky pains of salpingitis ; the same pains are 
 noticed when the hypertrophy is confined to the connective tissue, and seem 
 
 
 Fig. 362.— Chronic Hypertrophic Salpingitis. Tissue from the wall of the tube shown- in Fig. 360 (X 250 
 diameters), i, Fibro-muscular tissue in longitudinal bundles ; :?, the same cut transversely ; 3, infiltration of embry- 
 onal cells ; 4, large mass of the same elements ; 5, lymphatic ; 6, hypertrophied blood-vessel with thickened walls. 
 
 to be due to compression of the nerve filaments, to a perineuritis which 
 Sawinoff has conclusively demonstrated. There is another variety of chronic 
 salpingitis which may be called atrophic. The cellular infiltration of the 
 walls of the tube, instead of giving rise to a permanent product, is reab- 
 sorbed, and by a formation of cicatricial tissue causes contraction. This is 
 probably a more advanced state of the iiypertrophic pachy-salpingitis which 
 has gone on to cirrhosis of the Fallopian tubes. The muscular tissue disap- 
 pears before the fibrous tissue, the whole organ contracts, and in extreme 
 cases is changed to a hard and impermeable cord. Boldt has carefully 
 studied and described these lesions. He has often seen the lumen of the 
 tube completely obliterated by agglutination of the walls. He compares the 
 destruction of the epithelium which occurs under those circumstances to 
 cirrhosis of the liver and kidneys. Orthmann describes, under the name of 
 follicular salpingitis, an anatomical lesion which scarcely merits a special 
 classification. It is distinguished by cystic cavities in the walls, giving it 
 
OOPHORO-SALPINGITIS WITHOUT CYSTIC TUMOR. 
 
 499 
 
 an areolar appearance, but this pseudo-glandular character is common to all 
 the varieties of tubal inflammation (Figs. 358 and 359). There are also 
 small nodular bodies, resembling myomata, which have been obser\'ed in the 
 
 ,iSi>^iijjmp^i''rJ'^''fiff(0 
 
 'A'/ ^«-^---=>=i-=-^ 
 
 M- 
 
 11^, i 
 
 ^ ' iii^ 
 
 
 -R 
 
 
 -H 
 
 Fig. 363. — Atrophic Form of Chronic Salpingitis (Boldt). Slight enlargement. Remains of mucous folds 
 and obliterated lumen. //, Hypertrophy of submucous connective tissue and of the middle coat ; .1/, scattered muscu- 
 lar fibres cut transversely ; A, arterioles near the peritoneal surface. 
 
 walls of an inflamed or cystic tube, but their presence does not justify the 
 classification of a special form of nodular salpingitis. 
 
 A ll 
 
 Fig. 364.— Chron'ic Sclerotic Ovaritis without Lesion of the Tube. 
 
 In all the varieties that I have described, the tube may continue to form 
 a canal open at both ends, and the permeability of the ostium uterinum al- 
 
500 
 
 CLINICAL AND OPERATIVE GYN^-ECOLOGY 
 
 lows of an evacuation of the mucus as soon as it is formed. This of course 
 prevents ampullar or cystic dilatation. 
 
 II. Lesions of the Ovary. — The ovary, which often presences its integrity 
 in catarrhal salpingitis, is usually affected in acute purulent and in chronic 
 salpingitis. It is generally displaced, fixed, by adhesions in Douglas' cul-de 
 sac or to the sides of the pelvis. It may suppurate independently of the 
 
 Fig. 365. — Chronic Sclerotic Ovaritis. Section perpendicular to surface of shrivelled ovarj' (Fig. 364. a) showing 
 convolutions similar to those of the brain. Entire surface composed of dense lissue, more or less sclerotic, i. Cortical 
 layer rich in compressed cellular elements ; 2, superficial sclerotic zone ; 3, vessels with sclerotic walls ; 4, lymphatics ; 
 5, subcortical micro-cyst ; 6, layer of compressed peripheral cells ; 7, zone of loose o:dematous connective tissue, infil- 
 trated with fibrinous granular matter ; 8, convolutions of surface ; q, follicle which has persisted. 
 
 tube, but quite exceptionally. As a rule, ovarian lesions follow, rather than 
 precede, those of the tubes; when they do exist alone, it is under the form 
 of chronic sclero-cystic ovaritis. 
 
 In the majority of cases ovaritis is caused by a localized peritonitis, a 
 peri-oophoritis, which progresses from the periphery to the centre. This 
 peri-oophoritis may, however, be absent, and the starting-point of the proc- 
 ess be in the interstitial tissue of the ovary itself, near the vessels and the 
 ovisacs. 
 
 However that may be, little is known in regard to the initial lesions of acute 
 ovaritis. Paul Petit describes the following forms based upon thoroughly 
 accurate data. 
 
 a. Cortical Ovaritis.- -T\\\'s> is secondary to peri-oophoritis. According to 
 
OOPHORO-SALPINGITIS WITHOUT CYSTIC TUMOR. 
 
 501 
 
 Cornil and Terrillon, in many cases this form, which is analogous to vagi- 
 nalitis in the male (Bernutz), can exist alone, the ovarian parenchyma remain- 
 ing intact, and the lesions being limited to more or less resistant false 
 membranes. Lavvson Tait does not agree with this opinion, and believ^es 
 that when the serous covering of the ovary is affected, some lesion will in- 
 variably be found at a certain distance from the capsule, the whole organ 
 being greatly increased in size. 
 
 b. Dijfnse Ovaritis. — In this variety the enlarged ovary is increased in 
 size, infiltrated with fluid, and studded with follicular cysts containing serum 
 
 p. 
 
 Fig. 366. — Chronic Sclerotic Ovaritis. Sclerotic vessels showing extremely contracted lumina. i, Connective 
 tissue of cortical layer, very rich in cells ; 2, very thick-walled vessels ; 3, remains of lumen of vessel ; 4, smaller ves- 
 sels ; 5, lymph space. 
 
 or blood. The stroma is the seat of an embryonal infiltration scattered in 
 every direction, but more pronounced around the follicles and the vessels 
 which are undergoing plastic obliteration. 
 
 c. Suppurative Ovaritis follows the two preceding varieties unless they 
 undergo sclerosis. It begins in the form of miliary gatherings within the 
 follicles. 
 
 Chronic Ovaritls. — From a purely histological standpoint, we may, 
 with Paul Petit, distinguish several subdivisions under this head. Unfortu- 
 nately they do not correspond to any well-marked clinical types, notwith- 
 standing which it will be of value to enumerate them. 
 
 {a) Cortical Sclerosis. — The ovary is surrounded by false membranes, 
 among which are occasionally found blood foci analogous to those of pachy- 
 meningitis. The sclerosis either invades the organ to a great extent, or else 
 
502 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 in distinct and uniform fashion remains within a few millimetres of its sur- 
 face. The subjacent tissues are none the less destined to destruction ; the 
 obstruction to expulsion of the ovum and to the venous circulation of the 
 hilum determines a follicular hydropsy and hemorrhagic infarct around 
 which are grouped the secondary foci of sclerosis. 
 
 {b) Chronic Disseminated Ovaritis. — This is characterized by plaques of 
 sclerotic tissue which have originated around the vessels and follicles ; the 
 result is the same, for the ovisac is the most richly vascularized part of the 
 ovary. The process is probably slow and chronic from the outset. It is 
 usually observed with or without vascular dilatation in the ovaries of pa- 
 tients who have large uterine fibromata. 
 
 {c) CJironic Hypertrophic Ovaritis. — Sclerous hypertrophy of the ovary is 
 characterized by the hypergenesis of fibrous tissue, with destruction of the 
 follicles. As Lawson Tait well observes, it is merely a second stage of 
 sclerosis preceding that of retraction. " I have had the opportunity," he 
 says, " of observing one of these cases for several years. At present it ap- 
 pears to have reached the stage of sclerosis." The hypertrophy is either 
 complete or limited to the periphery. In either case the surface of the 
 ovary, from the exaggeration of its furrows, resembles the cerebrum with its 
 convolutions. 
 
 Independently of sclerous hypertrophy, Lawson Tait and Slavjansky ad- 
 mit of a true hypertrophy caused by hypergenesis of the normal gland ele- 
 ments and capable of increasing the weight of the organ to more than two 
 ounces. 
 
 id) Fatty Degeneration. — -In suppurating or sclerotic ovaries we often find 
 small foci of fat. In certain exceptional cases the fat may invade the or- 
 gan to such an extent that its tissue becomes analogous to that of a fibro- 
 lipoma. 
 
 Micro-cystic Degeneration. — This name, or that of chronic follicular 
 oophoritis, has been given to a lesion characterized by the presence of a great 
 number of small cavities, varying in size from that of a millet seed to a pea, 
 which are scattered over the surface of the ovary, and which have often been 
 found when castration was performed merely to relieve pain (Battey's opera- 
 tion). These cavities contain a clear, serous fluid and occasionally clots. 
 
 Some authorities consider that this constitutes a pathological condition, 
 but the majority believe there is nothing morbid about it. It is certainly 
 reasonable to suppose that these small follicular dropsies are in themselves 
 non-inflammatory, and they are often met with when no symptoms pointed 
 to their existence. Nevertheless they may by their number impair the integ- 
 rity of the organ ; interstitial sclerosis, as a matter of fact, is often met with 
 in ovaries thus affected. In some cases it would seem as though we had to 
 do not with follicular dropsy, but with hydrops of the ovules. When this 
 is the case, according to Toupet we can clearly distinguish the following 
 layers from the periphery to the centre of the cyst : first the layer of cubical 
 
OOPHORO-SALPINGITIS WITHOUT CYSTIC TUMOR. 
 
 503 
 
 cells of the wall, then a narrow granular zone formed probably of the detritus 
 of cells, a second epithelial peri-ovular layer, a more or less distinct hyaline 
 membrane corresponding to the vitelline membrane, a granular mass repre- 
 senting the vitellus which has become dropsical, and showing in its centre a 
 nucleus with nucleolus. 
 
 The term sclero-cystic degeneration has certainly been misapplied in 
 order to justify the removal of organs which should have been left undis- 
 turbed. It should be exclusively reserved for those cases in which follicular 
 cysts exist in large number throughout the whole extent of the organ, trans- 
 forming it into a veritable areolar tissue. 
 
 Total Sclerosis. — The whole organ may be invaded by the interstitial 
 inflammation which produces the hypertrophy of the connective tissue. 
 
 Fig. 367. — Chronic Sclerotic Ovaritis. Small nodules at base of ovary (Fig. 364, B). A, Section perpendicular 
 to surface of ovary and passing through pedicle of growth (50 diameters), diagrammatic, i, Body of tumor ; 2, fibrous 
 pedicle ; 3, Graafian follicle ; 4, vessel ; 5, lymph spaces; 6, surface of ovary ; 7, Graafian follicle in cortical layer; 8, 
 vessels ; g, lining epithelium of small subjacent cyst. B, Region 3-4 of Fig. A (300 diameters). i, Connective-tissue 
 bundles running in all directions, with elongated slightly flexous nuclei; 2, vessel; 3, follicle and ovum. C. Section 
 perpendicular to surface of one of the small tumors (500 diameters), i, Fibrous tissue with long nuclei ; 2, endothelial 
 cells. 
 
 In the early stages it is compatible with ovulation, but, if it be at all ad- 
 vanced, the follicles are compressed and choked. The compression of 
 the nerve filaments, which is due to the same cause, has been considered 
 the chief reason of the nervous symptoms for which Battey's operation 
 is performed. In the majority of cases the immediate cause of the cir- 
 rhosis seems to be a localized peritonitis, a peri-oophoritis which progresses 
 from the periphery to the centre. This peri-oophoritis may, however, be 
 absent and the starting-point of the process be in the interstitial tissue 
 of the ovary itself. In these cases the hypertrophied ovary may attain 
 the size of a hen's egg, and show the mammillated, mulberry-like surface 
 of a cirrhotic ovary (Fig. 360). Usually, however, the ovary is shrivelled 
 and diminished in volume from retraction of the newly formed fibrous tissue. 
 
504 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Jones found a most interesting lesion in such an ovary, which was of the size 
 of an egg, granular on the surface, which was prolapsed and had been re- 
 moved by operation. The lesion (to which I have already referred under the 
 head of chronic endometritis) consisted in a dilatation of the lymphatics. 
 The lacunae were filled with a nearly homogeneous lymph containing a few 
 lymph corpuscles ; an elastic coat and a thick endothelial lining could be 
 clearly seen. 
 
 Cirrhosis of the ovary usually accompanies micro-cystic degeneration, 
 thus forming a mi.xed lesion, sclero-cystic ovaritis, which is more frequent in 
 occurrence than either lesion alone. This lesion is sometimes accompanied 
 
 Z 
 
 vifer 
 
 -1 
 
 
 W¥' 
 
 C^\>1C^N- ...i: Al! yp) ^ -ev ,.y ■ (^ ^' 
 
 
 Fig. 368. — Chronic Sclerotic Ovaritis. Central portion of ovary in state of fatty dejjeneration (500 diameters). 
 I, CEdematous fibrous connective tissue; 2, large granular cells with thin protoplasmic limiting layer • 3, same changing- 
 to fat drops ; 4, free fat droplets ; 5, capillary blood-vessel filled with red and white corpuscles. 
 
 by oedema of the ovary, to which I shall refer later {c]u'onic ccdcmatous ova- 
 ritis). I Avill add a new form to the preceding ones. Chronic ovarian and 
 peri-ovarian inflammation frequently is reduced by the normal development 
 of the follicles which become transformed into cysts varying in size from a 
 ])ea to a walnut. This form, which macroscopically has- a distinct type, may 
 be classified as cystic ovaritis from abnormal ovulation. 
 
 Paul Petit states that the stroma, which is normally composed of connec- 
 tive-tissue cells with multiple prolongations pressed closely against each other, 
 which gives them a fusiform appearance, are gradually converted into fibrous 
 tissue with dense wavy bundles, poor in cells and containing few blood-ves- 
 sels, many of the arteries and veins having been obliterated by the plastic 
 process. The connective-tissue bundles are thickest where they surround 
 
OOPHORO-SALPINC.ITIS WITHOUT CYSTIC TUMOR. 
 
 505 
 
 the blood-vessels, follicles, and corpora lutea, the latter being for the most 
 part increased in amount but reduced to a debris, and are recognized alone 
 by their folds and hyaline appearance. This increase of corpora lutea is 
 evidently the result of a species of morbid maturation of the follicles during 
 the course of acute attacks of the disease. In the newly formed tissue, when 
 the sclerotic process is far advanced, we see long ovular or star-shaped fis- 
 sures, vestiges of the blood and lymphatic vessels of the ovisacs. They are, 
 however, diminished in number and often altogether absent, according to the 
 stage of the disease; some undergo modifications which result in the forma- 
 tion of serous or bloody microcysts. 
 
 Follicular Cysts from Abnormal Ovulation and Cystic Disease of the Ovary. 
 — Dropsy of the Graafian follicle has long been considered the only or 
 
 A 
 
 Fk;. 369.— Chronic Micro-cystic Ovakitis with Apoplectic Areas. A, A, Cystic corpus Iiiteum ; />, />, apoplec- 
 tic areas ; C, C, small folliculai' cysts. 
 
 the chief cause of the development of large ovarian cysts. Some English 
 authors still cling to this theory, which should, however, be abandoned. 
 Cysts due to this origin are always small, and if they provoke morbid s}mp- 
 toms, that is rather because of the chronic inflammation of the adnexa than 
 to the ovarian cysts themselves. We might almost say, by a juggling of 
 terms, that the operations they call for are castrations rather than ovari- 
 otomies. I must therefore place them here among the cases of ovaritis. 
 
 Rokitansky's observations have established the fact of the existence of 
 cystic dilatation of the follicle, and some writers describe this anatomical 
 form by his name. 
 
 Follicular cyst (Fig. 369), or follicular dropsy, forms a small unilocular 
 pouch, as small as a hempseed or as large as a walnut ; this is the miniature 
 cyst of Cruveilhier. The agglomeration of several of these pockets may 
 exceptionally increase the size of the ovary to that of a fist or of a foetal 
 head. The wall is smooth, and lined with only one layer of epithelium ; 
 
5o6 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 the fluid is not thick. The ovule can often be seen, even in the larger 
 cavities. In the new-born infant we sometimes find well-developed fol- 
 licles towards the centre of the ovary : they seem to be due to special 
 
 
 Fig. 370. — Chronic Micro-cystic Ovaritis. Section perpendicular to the surface of a dilated follicle. A Cyst 
 wall. 1, Dense connective tissue containing many large granular cells with brilliant nuclei ; 2, epithelial layer com- 
 posed of a single layer of cells ; 3, homogeneous intermediate layer. B, A flake of the same epithelium detached and 
 seen on the flat. 
 
 local developmental activity at the moment of birth. It would be incorrect 
 to call them cysts. The hr^g-e conglomerated cysts which transform the 
 
 Fig. 371.— Chronic Micko-cvstic 0\'aritis. Section from an ovary containing a large number of small cysts, 
 slightly enlarged, i, Fibrous layer ; 2, cortical layer ; 3, 3, 3, cystic cavities deformed by mutual pressure ; 4, layer of 
 epithelium from one of the many superimposed cell walls; 5, point deprived of epithelium ; 6, granular mucoid material; 
 7, small cyst filled with blood ; 8, blood-vessel ; 9, follicles in process of evolution. 
 
 whole ovary into a multilocular mass from a definite anatomical type which 
 corresponds to an equally well-marked clinical variety. I think we might 
 
OOPHORO-SALPINGITIS WITHOUT CYSTIC TUMOR. 
 
 507 
 
 well distinguish them from other small cysts, under the name of cystic 
 disease of the ovary (Figs. 371, 372). These conglomerated cysts, which 
 are rarely larger than a head, are usually the size of a man's fist, but are not, 
 
 Fig. 372. — Chkonic Micro-cvstic Ovaritis. A point, showing the wall separating two cavities, from Fig. 371, 
 highly magnified, i. Epithelial layer consisting of one or two tiers of small rounded cells, corresponding to granular 
 layer of follicle ; 2, small flat cells (basement membrane) ; 3, reticulated lymphatic layer ; 4, fibrous layer ; 5, prolif- 
 erated epithelium, deeper layer cylindrical ; 6, point where desquamation of epithelium has occurred ; 7, effusion of 
 blood corpuscles ; 8, detached epithelial cells ; o, thick contents of cyst. 
 
 as used to be supposed, the first stage of a more voluminous tumor. The}' 
 retain for an indefinite period their small size, a fact which from a surgical 
 point of view separates them from glandular proligerous cysts, which are 
 moreover histologically different. 
 
 Fig. 373.— Total Chronic Sclerotic Ovaritis.—^. Ovary (natural size) shrivelled and showing grooves and 
 projections of its surface, resembling cerebral convolutions, i, Grooves penetrating more or less deeply. B. Section. 
 of the same, i. Sharply defined cortical layer; 2, place where this is more or less sclerotic; 3, micro-cyst; 4, corpora lutca. 
 
 In cystic disease of the ovaries, the liquid contents are serous or bloody. 
 Yet I once extirpated a polycystic ovary in which a certain number of the 
 sacs, varying in size from a pin's head to a walnut, were filled with a serous 
 fluid, the rest containins; a caseous or lardaceous substance in which a mi- 
 croscopic examination by Toupet, in Professor Cornil's laboratory, revealed 
 
;o8 
 
 CLINICAL AND OPERATIVE GYNECOLOGY 
 
 myxomatous tissue. The lesion was unilateral, the other oxary being sclero- 
 cystic. This species of secondary degeneration of the follicular cysts has 
 not, I believe, been described before. 
 
 Cysts of the Corpiis Liiteum. — To Rokitansky, again, we owe the first de- 
 scription of this affection. He believed that 
 the corp7is hitcimi of pregnancy alone was 
 capable of cystic degeneration, but this 
 opinion was too absolute ; Gottschalk found 
 them in a nulliparous woman. As a rule, 
 these cysts are not larger than a walnut, but 
 the two described by Gottschalk were of the 
 size of an orange and a small apple respect- 
 ively. Schroder saw one which was the size 
 of a pigeon's &gg, and Nagel reports them as 
 large as an apple, or even of an adult's head. 
 A microscopic examination of the walls 
 shows the papillary granulations peculiar 
 to the corpus luteum. This will prevent 
 confusion of cysts of the corpus luteum (Figs. 379, 380, 381) with follicular 
 cysts, the walls of which are thickened and stained by deposits of blood, or 
 
 Fig. 374. — ScLER>>-CYSTic Ovaritis with 
 A Large Follicvlar Cvst. O, Ovary sur- 
 mounted by a large transparent follicular 
 cvst. 
 
 Fig. 375. — CvsTic Disease of the Ovaries. Multiple serous follicular cysts. The tumors are seen opened CKarnes). 
 
 with suppurative ovaritis with inspissated pus when the cysts are inflamed 
 under the influence of a coexisting salpingitis. 
 
 To a right understanding of the genesis of cysts at the expense of what 
 is usually considered a cicatricial process, we must bear in mind that the 
 
OOPHORO-SALPINGITIS WITHOUT CYSTIC TUMCJR. 
 
 509 
 
 theory of a retraction of tissue for the formation of the corpus luteum is 
 quite erroneous. It should be replaced by the view that there is prolif- 
 
 Fir,. 376. — Cystic Disease 01 'lllL Ovaries. (Serous and myxomatous multiple follicular cysts.) /, Tube ; ^7. 
 
 ovary ; a, /', follicular myxomatous cysts. 
 
 eration and neo-formation of the ovarian tissue. Toupct's recently ad- 
 vanced theory attributes the formation of the corpus luteum to the granu- 
 
 FiG. 377. — Cystic Disease of the Ovaries. (Serous and myxomatous multiple follicular cysts.) (Section of tu- 
 mor shown in preceding cut natural size.) «, «', Small myxomatous cysts ; i, i\ large my.xomatous cysts ; t', e\ fol- 
 licular cysts with fluid conten s ; c\ .?, g\ follicular cysts with caseous contents ; o,J'^ /', ovarian tissue containing small 
 follicular cysts, 
 
 lar membrane, as does Waldeyer, from whom he differs in believing that the 
 vitelline membrane is of the nature of connective tissue, or at least in holding 
 that it is lined by a fibrous layer which serves as a support to the cells of the 
 
5IO 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 ovular granular layer. This fact once admitted, the formation of the corpus 
 luteum is explained as follows : when the ovisac is ruptured, the ovular gran- 
 ular layer and the subjacent connective-tissue layer remain in place as does 
 the parietal granular layer, the germinal vesicle and the vitellus alone be- 
 ing expelled ; the two sub-epithelial internal and external connective-tissue 
 layers then begin to proliferate and form the papillary prolongations which 
 penetrate into the cells of the granular layer, some being directed towards 
 the centre and some to the periphery. By this theory, the formation of the 
 corpus luteum would come under the general law of the development of tis- 
 
 Fig. 378. — Follicular Cyst of the Ovary, with Myxomatous Degeneration. (Magnified 50 diameters.) 
 A, A, Loose myxomatous tissue toward the interior of tVie cyst; B, B, dense myxomatous tissue toward tiie external 
 surface. 
 
 sues, by attributing to them a process identical to that observed upon the 
 mucosa when undergoing development or when subject to inflammation. 
 
 With these lesions of the tubes and ovaries, we often find lesions of the 
 folds of the broad ligament which must be attributed to the same inflamma- 
 tory origin. In fact, they are only exceptionally found due to any other 
 cause. 
 
 Residual Wolffian and Milllerian Cysts. — In the case of uterine fibroids or 
 of beginning tumor of the ovaries especially, we frequently find in the broad 
 ligament or the tube small transparent vesicles which possess no surgical 
 interest, but whose anatomical significance deserves mention. They occur in 
 three varieties. 
 
OOPHORO-SALPINGITIS WITHOUT CYSTIC TUMOR. 
 
 UI 
 
 (i) Hydatid cyst of Morgagni, attached to the fimbriated extremity of the 
 tube, varying in size from a pea to a cherry, transparent, and lined with only 
 one layer of endothelium. We know that the hydatid of Morgagni is the 
 remains of the extremity of Miiller's duct. 
 
 (2) Snpra-tidml cyst of the same size, structure, and general appearance 
 as the foregoing. It would seem to be a micro-cyst of the broad ligament 
 which has pushed its way under the serous membrane and slipped into this 
 
 
 Fig. 379. — XoRiiAL Corpus Luteuh. Section through its centre C30 diameters), i, Corpus luteum (substance 
 formed of closely united cells); 2, mucus on surface ; 3, grooves between the lobules ; 4, connective-tissue layer; 5, 
 prolongations into interior of lobules ; 6, ovary, cortical portion riddled with vascular spaces ; 7, extravasation of blood. 
 
 unusual position. Paul Petit is of opinion that these little cysts are due to 
 the inclusion of peritoneal endothelium near the folds of the tube, from an 
 adhesive and circumscribed peritonitis. 
 
 (3) Micro-Cysts of the Broad Ligamcjit. — Some of these are dependent 
 from Rosenmiiller's body, and others are independent and of undetermined 
 origin. According to Doran, only those which take origin from the vertical 
 tubes of the parovarium contain ciliated epithelium, and become papillary 
 from later development ; the other cysts, those which originate outside of 
 the parovarium, or even the cyst in the horizontal tube, which may be at- 
 tached to the broad ligament by a slender pedicle, are lined with ordinary 
 endothelium. We cannot positively affirm that the micro-cysts of this third 
 variety have so distinctly limited a form of development as those of the 
 
512 
 
 CLINICAL AND OPERATIVE GYX.^COLOGY. 
 
 
 Fig. 3S0. — Cnst of Corpus Liteim, from a Photograph (slightly magnified), i, Large vegetating mass pro- 
 jecting'^ into the cyst ; 2, distorted pedicle ; 3, tissue of hypertrophied corpus luteum'; 4, layer of corpus luteum lining 
 cavity of cyst ; 5, fibrous wall of c\-st ; 6, peripheral extravasation of blood. 
 
 
 Fig. 381. — CvsT of Corpis Llteu.m. Cells separated by alcohol (1,000 diameters), i, Fragment from preceding 
 figure showing grouping of cells ; 2, isolated cells of various forms. 
 
OOPHORO-SALPINGITIS WITHOUT CYSTIC TUMOR. 
 
 513 
 
 first. It even seems probable that although some of them may be of no im- 
 portance at any time, others, under the influence of some unknown irritative 
 process, may form the starting-point of large cysts of the broad ligament 
 with purely liquid or else papillary contents. 
 
 Fig. 382. — Micro-cyst of the Broad Ligament Developed between the Tube and Ovary (Pozzi). 
 A', Cyst with transparent walls and contents ; O, ovary ; T, sclerotic tube showing small fibrous nodules and contain- 
 ing sound to demonstrate its permeability. 
 
 In this connection, it is interesting to read the data of the comparative 
 anatomy of lesions of the uterus and ovaries in animals, given by Bland 
 Sutton. These lesions are much more 
 frequent in domestic than in wild ani- 
 mals. Cysts originating from the ves- 
 tiges of the Wolffian bodies are fairly 
 frequent among batrachians. Sutton 
 found ten cases in two hundred and 
 fifty frogs and toads. In birds and in 
 batrachians we know that only the left 
 canal of Miiller persists, to form the 
 oviduct. The right one disappears, and 
 opens like a little coecum in the cloaca. 
 This small rudiment of a canal is a fre- 
 quent starting-point for cystic forma- 
 tions. The following is a curious fact : 
 when a female bird in the poultry yard 
 possesses plumage or characteristics 
 which resemble the male bird, its 
 ovaries are usually found to be altered. 
 In old mares, cysts of the tubes and 
 ovaries frequently occur. Two-thirds 
 of them are thus affected. They have 
 been found in cats, goats, etc. 
 
 Suppuration of tJie ovary, as a rule, 
 coexists with that of the Fallopian tube; the two are, so to speak, amal- 
 gamated, and sometimes form the wall of the same purulent pouch, so that 
 pyo-salpinx is in reality a pyo-oophoro-salpingitis. 
 Z2> 
 
 Fig. 383. — SuB-TUBAL Micro-cyst of the Broad 
 Ligament (Pozzi). G/v', Cyst, size of a mandarin, 
 with transparent walls and contents ; PK, accessory 
 cyst, size of a nut, with transparent walls and con- 
 tents ; T', tube affected with parenchymatous salpin- 
 gitis superimposed upon the ovary and adherent to it. 
 
514 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Symptoms. — It is rare to find an acute salpingitis without coincident in- 
 flammation of the uterus, so that it is difficult to decide with precision to 
 which lesion the symptoms are due. The uterine symptoms (uterine syn- 
 
 FiG. 384. — SuB-TUBAL MiCRO-CYST. Section perpendicular to inner surface. A. Loosely arranged and interlacing 
 bundles of connective-tissue fibres with elongated cells ; 2, single layer of epithelial cells ; 3, coagulated granular mat- 
 ter ; 4, vessels. B. Fragment of epithelium seen on the flat. 
 
 droma) which I have fully described are usually most marked, yet there are a 
 few special signs by which we may know that the tubes and ovaries have 
 become inflamed. 
 
 Fig. 385. — SuB-TUBAL Micro-cyst. Section perpendicular to the wall (slightly magnified), i, Fibrous tissue of 
 der.su, parallel, wavy fibres ; 2, mass of small embryonal cells ; 3, layer of cylindrical ciliated epithelium ; 4, denuded 
 portion of cyst wall ; 5, portion where epithelium has become squamous ; 6, mucus on internal surface of cyst ; 7, lymph 
 spaces ; 8, vessels. 
 
 Pain is characterized by pseudo-neuralgic crises situated in the neigh- 
 borhood of the appendages or in the lumbar region ; it radiates upward to 
 the epigastrium and downward to the thighs. Sometimes, but not always, 
 
OOPHORO-SALPINGITIS WITHOUT CYSTIC TUMOR. 
 
 515 
 
 s. 
 
 the pain is of a colicky nature, called salpingeal, and its cessation is charac- 
 terized by the evacuation of muco-pus, which comes not so much from the 
 tubes as from the cavity of the uterus which has been reflexly stimulated to 
 contract. 
 
 Pressure, whether it be abdominal or vaginal, near the appendages causes 
 pain. If the inflamed ovary be pressed between the two hands, the pain is 
 exquisite, especially on the left side, for the left ovary is the one most often 
 affected, just as in the male the left testicle is the one most liable to disease 
 (varicocele, epididymitis, etc.). This may be due to the greater frequency 
 of laceration of the cervix on the 
 
 left side with direct propagation _/^, 
 
 of inflammation either by an as- . ., j. ;-v-.-'- J^l ■■,■ .■-• 
 
 cending endometritis or through 
 the lymphatics. 
 
 The pain in the sides and in 
 the lumbar region is often ac- 
 companied by gastralgia and vo- 
 miting; it is most marked at the 
 menstrual period. Quite excep- 
 tionally we may see a case in 
 which there is relief from pain 
 ■during the menstrual period, 
 and crises in the intervals 
 (inter-menstrual dysmenorrhoea). 
 Menorrhagia is an almost con- 
 stant symptom, but there may. 
 also be long periods of amen- 
 orrhoea ; thus we may have great 
 irregularity in menstruation. 
 
 An examination of the in- 
 flamed organs is difficult in acute 
 tubo-ovaritis, because of the 
 pain which it causes. If there 
 be any doubt as to the' diagnosis, 
 
 and a decision be imperative, the patient should be anaesthetized. I 
 hardly know how to protest with sufficient energy against the system- 
 atic neglect of this valuable auxiliary to investigation, and against the 
 substitution for it of an inquiry into the anatomical condition of the parts 
 by one means of diagnosis only, namely, localized pain. This neglect is 
 an excellent method of multiplying exploratory laparatomies. 
 
 Palpation of the appendage may be done according to the excellent rules 
 laid down by Schultze. To examine the right side, the index and middle 
 fingers of the right hand are introduced into the vagina, and the left hand is 
 placed on the abdomen ; for an examination of the left ovary, exactly the re- 
 
 FiG. 386. — SuB-TUBAL Micro-cyst. A. Section at point 3 in 
 Fig. 385 C500 diameters), i, Layer of vibrating cilia; ; 2, col- 
 umnar epithelial cells with large nuclei ; 3, long ovoid cells ; 
 4, rounded cells of deep layer ; 5, mucus ; 6, rather dense con- 
 nective tissue with fusiform cells. B. Section at point 5 of Fig. 
 385 (500 diameters), i, Polyhedral squamous cells ; 2, layer of 
 connective tissue. 
 
5l6 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 verse is done. The patient is upon her back, the knees elevated and the 
 thighs rotated outward, to put the psoas muscles on the stretch. The inner 
 border of these muscles is to be followed as far as the superior strait, after 
 which the exploring fingers are directed more inward toward the horns of the 
 uterus, A small ovoid body, about the size of an almond, is met with and 
 grasped bimanually. An exploration thus conducted can scarcely fail, under 
 ansesthesia, to reveal any existing lesion of the appendages. Noeggerath has 
 suggested that examination of the tubes be made by vesico-rectal touch, and 
 he has by this means appreciated conditions which could not otherwise have 
 been recognized; but as this method is open to some objections, it should be 
 used only as a last resource. Although Hegar claims to have appreciated 
 by touch alone micro-cystic degeneration of the ovary and catarrhal salpin- 
 gitis, it is very certain that such tactile sensibility will never be possessed 
 by any larger number of clinical physicians. Nevertheless, in acute salpin- 
 gitis, some lesions may be more easily recognized than would seem possible 
 from their limited nature, because of the existence of peripheric oedema 
 which doubles or triples the volume of the inflamed tubes. In chronic sal- 
 pingitis the tube feels like a resistant cord which is immobilized by adhe 
 sions to the sides of the pelvis. When, in addition to these physical signs, 
 and to the proofs of a pre-existing endometritis, we find constant localized 
 pain in the neighborhood of the appendages, of the character already de- 
 scribed, and from time to time accompanied by acute attacks of peri-salpin 
 gitis which I shall describe later on, we may with certainty affirm the pres 
 ence of salpingitis. We may suspect a purulent condition if the rational' 
 symptoms are extremely marked, and if there has been recent gonorrhoea, or 
 gonorrhoea called into activity by septic post-abortum infection. 
 
 Differential Diagnosis. — The pain of salpingitis must not be mistaken 
 for that of ovarian neuralgia, ovaralgia, or painful ovary due to hysteria. 
 This is situated on the left side as a rule, but may be bilateral. Charcot 
 has shown that it is often accompanied by ancesthesia of the same side and by- 
 hystero-epileptiform attacks. This pain is manifested during serious and 
 slight hysterical attacks ; pressure brings it back ; and as it is frequently as-- 
 sociated with dysmenorrhoea of nervous origin, one may be tempted to attrib- 
 ute this symptom to inflammation of the ovary. According to Charcot, the 
 pain really is situated in the ovary. In a pregnant woman wlio was a hyste- 
 ro-epileptic and suffered from hyperaesthetic ovary, he was able to follow the 
 ascension of the painful zone as the ovary was drawn higher and higher in 
 the abdomen by the enlarged uterus. The characters of the pain are such 
 that it cannot be mistaken for anything else. Graduated pressure causes the 
 appearance of a more or less marked hysterical attack, beginning with con- 
 striction in the epigastrium, nausea, cardiac palpitation, accelerated pulse, 
 and globus hystericus ; then follow ringing in the ears, sharp pain in the 
 temples, and obscuration of sight, all more marked upon the same side as the 
 affected ovary ; finally there may be partial or complete loss of consciousr- 
 
OOPHORO-SALPINGITIS WITHOUT CYSTIC TUMOR. 517 
 
 ness. On the other hand, firm pressure upon the ovarian region may abort 
 or delay the attack ; but it must be firm enough to overcome the contractions 
 of the abdominal muscles, which may require the exertion of all one's 
 strength for several minutes. With such a group of symptoms as we have 
 here described, it would be difficult to mistake the purely neuralgic nature 
 of the attack ; the presence of other neuralgic pains, paralyses, contractures, 
 and hystero-epileptic seizures will re-enforce the diagnosis. Moreover, 
 hysterical stigmata may be found — hysterogenic zones (sub-mammillary, dor- 
 sal), anaesthetic regions, narrowing of the field of vision, etc. The way in 
 which the patient tries to avoid the pain caused by pressure is in itself 
 characteristic of hysteria; when the appendages are really inflamed, the pa- 
 tient groans and instinctively tries to push away the hands of the examining 
 physician; in the case of hyperaesthetic ovary, the movements lack co-ordi- 
 nation, and are of an irregularly convulsive type. 
 
 Lumbo-abdominal neuralgia, which may exist alone, and which so often 
 accompanies endometritis, is recognized by its location in the abdominal 
 walls, and by the fact that it is awakened by superficial pressure, especially 
 upon the points of emergence of the cutaneous nerve filaments. Pressure 
 over the appendages may give pain, because at the same time the abdominal 
 walls are pressed upon ; we can readily ascertain where the pain is actually 
 situated by trying both methods of exploration. 
 
 Inflammation of the uterus is recognized by special symptoms already 
 described ; it is seldom, indeed, that we do not find at least a trace of it 
 where there is marked inflammation of the tubes. I have in fact already 
 stated that the two affections are rarely separated. Even when the endome- 
 tritis is the more serious trouble, it is often accompanied by slight ascending 
 salpingitis, too trivial perhaps to cause any appreciable physical signs to be 
 included in the diagnosis, or to modify the treatment in any way, and yet 
 quite sufficient to cause sensitiveness of the appendages. 
 
 Is it possible to determine from physical examination alone, without the 
 rational signs, the exact part played by the tube or the ovary in an oophoro- 
 salpingitis .? In the majority of cases this distinction cannot be made, nor 
 is it usually necessary as regards the indications for operation. 
 
 Sclero-cystic degeneration of the ovary may exist without any marked 
 tubal lesion; yet, as a rule, lesions of the two organs are rarely dissociated. 
 The ovary is, as a general thing, so closely bound to the tube by adhesions 
 that the tumor met with is tubo-ovarian. Still in a few cases we may, by 
 means of bimanual palpation, distinguish the thickened cord-like Fallopian 
 tube from the oblong ovarian tumor, which is by far the more movable of 
 the two, and more detached from the edge of the uterus. It is not easy to 
 find, and it may often be necessary to introduce both the middle and fourth 
 fingers into the posterior and lateral culs-de-sac of the vagina; in some 
 cases bimanual palpation with rectal touch will be better. Besides the 
 changes in shape and mobility, an inflamed ovary is so sensitive that the 
 
5l8 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 lightest touch will cause the patient to cry out with pain and draw herself 
 away. Finally, it is when ovaritis is pronounced, and especially when it is 
 bilateral, that dysmenorrhoea is the most intense, and that one may perceive 
 a sensible increase in the size of the tumor at the menstrual period, either 
 because of congestion or because there is an extrav^asation of blood into the 
 micro-cystic cavities. 
 
 Cystic salpingitis and peri-salpingitis will be recognized by the great vol- 
 ume and the character and connections of the tumor which they cause. Yet 
 it is well to know that we may meet successively, at inten^als of a few days, 
 either the elongated and cord-like tumor of acute or chronic salpingitis or 
 the rounded and more or less diffused tumefaction produced by an acute 
 peri-salpingitis of short duration. 
 
 Course and Prognosis. — Inflammation of the mucous membrane of the 
 tubes is less amenable to treatment than that of the uterus. Let septic in- 
 fection find a foothold in one of the many folds of the external third of the 
 organ, and it will be inaccessible to direct therapeutic measures ; if the pa- 
 tient recover, the cure will be spontaneous, the microbes having been de- 
 stroyed. It is well known that such a result may occur in other localities ; 
 it is therefore reasonable to believe that it may occur here, especially if care- 
 ful treatment be given to the uterine mucous membrane (anatomically 
 and physiologically so closely connected with that of the tubes), placing 
 a barrier about the tubal inflammation, and constantly re-enforcing the ana- 
 tomical tissue elements in their struggle against the microbes. Is it 
 possible for the cure to be complete with rcstitiUio ad integnivi ? i\Iost 
 assuredly, and yet it is of rare occurrence. As a usual thing the Fallopian 
 tube is more or less permanently impaired as a result of acute inflamma- 
 tion. There may be atrophy of the parts involved, as Boldt has shown ; 
 on the other hand, clinical experience demonstrates, by the persistence of 
 the morbid symptoms when once the appendages have been subject to in- 
 flammation, how little amenable to treatment is this affection, and how 
 serious are the after-results. The chief danger in either acute or chronic 
 salpingitis comes from the perpetual liability to sudden attacks of peri- 
 salpingitis (pelvic peritonitis). 
 
 The least over-exertion or change of regimen may cause an increase in 
 severity of all the symptoms, and a decided change for the worse in the con- 
 dition of the patient. Lawson Tait believes that this is caused by the en- 
 trance of a few drops of muco-pus into the peritoneum. Whether this 
 theory be true or not, we find a peripheric puffiness due to infiltration or 
 acute oedema of the subperitoneal cellular tissue. As a rule, rest and care 
 bring about resolution, but relapses are frequent, may occur at inten-als of 
 months or years, and be characterized by the rapid appearance and no less 
 rapid disappearance of circumscribed inflammatory nodules in the culs-de-sac. 
 The feeling imparted to the hand by the senodules has caused certain author- 
 ities, who did not sufficiently examine into the anatomical conditions pres- 
 
OOPHORO-SALPINGITIS WITHOUT CYSTIC TUMOR. 519 
 
 ent, to consider them inflamed ganglia, and the names peri-uterine adenitis 
 and lymph-adenitis have incorrectly been given to this affection. There are 
 no ganglia in this situation, consequently no adenitis ; yet the oedema is 
 doubtless found around lymphatic vessels and constitutes a peri-lymphan- 
 gitis. It is found just above the vaginal cul-de-sac, upon the sides of 
 the cervix, in the exact spot where Poirier has found and described a sort 
 of network of lymphatic vessels which go from the cervix to the iliac 
 ganglia. 
 
 Sterility is not an invariable consequence of salpingitis, which may re- 
 solve without obliteration of the ampulla ; but when an old salpingitis has 
 closed both tubes, fecundation is impossible. This, no doubt, accounts in 
 great measure for the sterility of prostitutes. 
 
 Treatment. — Whatever may have been said to the contrary, a laparatomy 
 or even an exploratory incision is not justified for the mere relief of per- 
 sistent pain in the vicinity of the appendages. After an era of surgical ex- 
 cesses, especially in foreign countries, where, according to Emmet, " re- 
 moval of the uterine appendages has been lightly undertaken by both com- 
 petent and incompetent persons," we have at last reached a point where the 
 fruitfulness of patients is not so readily sacrificed, and where we attempt to 
 cure rather than to extirpate. 
 
 The treatment of catarrhal tubo-ovaritis is identical with that of endo- 
 metritis, as that of ascending pyelo-nephritis is similar to that of the cysti- 
 tis which causes it. Absolute rest, mild aperients, careful antisepsis of the 
 vagina, prolonged and hot vaginal irrigations are the first things to be pre- 
 scribed. When necessary, bleeding, if not contra-indicated, may be produced 
 by scarifying the cervix or by leeches applied to the iliac fossa, and will 
 greatly relieve the pain. Small blisters followed by the application of one- 
 sixth of a grain of the chlorhydrate of morphine to the denuded surface, 
 cauterization of the iliac region, prolonged tepid baths, injections of lauda- 
 num, valerian, chloral, may all be used for the relief of pain. As I said 
 above, we may hope to cure salpingitis along with the endometritis provid- 
 ing that the lesions do not have time to become permanent. Curetting the 
 uterus and then injecting tincture of iodine, as described at length in the 
 chapter on Endometritis, has often done me good service in curing an in- 
 cipient salpingitis. Trelat has obtained excellent results by following cu- 
 retting with injections of creosote and glycerin. The cures reported by 
 Walton, Gottschalk, and Doleris are doubtless due more to the antiseptic 
 treatment of endometritis than to any problematical mechanical action, and 
 the very indirect dilatation of the ostium uterinum. 
 
 Should curetting be done when salpingitis is accompanied by acute peri- 
 salpingitis characterized by the painful nodules in the vaginal cul-de-sac "i 
 I think not, and that it is better to wait until rest and antiphlogistic treat- 
 ment have caused a disappearance of these nodules, which occurs very rapidly 
 when they are not encysted tumors of the Fallopian tubes, A little delay 
 
520 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 will often help in settling the question of diagnosis. To extol forced dilata- 
 tion and curetting as a cure for perimetritic exudations, as Walton of Brus- 
 sels and Poullet of Lyons have done, is to formulate a dangerous precept, 
 since it presupposes that there can be no error of diagnosis. Undoubtedly 
 curetting for endometritis may in many cases relieve or cure a serous peri- 
 salpingitis as well as the salpingitis ; but in other cases it may result fatally 
 by causing the rupture of a cyst where a pyo-salpinx exists but has not been 
 suspected. In view of this danger, and of the fact that an exact diagnosis is 
 often impossible, would it not be better to delay curetting until the acute 
 manifestations have subsided and we can assure ourselves that they did not 
 mask a collection of pus .'' 
 
 It is under the head of indirect treatment that we must consider the 
 question of the value of elect7'icity in some cases of salpingitis. 
 
 I think the extent of its applicability has been overestimated. Encysted 
 matter in the tubes can only be reached by puncture, which would be as dan- 
 gerous with the negative pole as with a trocar. In hydro- or hsemato-sal- 
 pinx suppuration may be induced ; in pyo-salpinx this incomplete opening 
 may entail, not only a fistula, but septic accidents. Galvano-puncture 
 through the vagina, if it does not penetrate into collections of pus, is very 
 apt to produce adhesions which cause pain and complicate further operative 
 procedures. Apart from the cases just mentioned, I see no reason why the 
 application of the intra-uterine galvano-cautery may not cure catarrhal sal- 
 pingitis by its good effects upon the endometritis. But I consider curetting 
 with intra-uterine injections preferable on account of its greater simplicity 
 and the greater certainty of its good results. In very nervous patients, con- 
 tinuous faradic currents carried into the uterus by means of the bipolar ex- 
 citor may give relief. But we must proceed with great caution, and bear in 
 mind the possible presence of pus ; electrization of the uterine cavity has 
 been known to cause the rupture of a pyo-salpinx. 
 
 Massage has in the past few years been greatly praised as a method of 
 treatment for inflammation of the uterus and appendages, and like all new 
 measures has aroused more enthusiasm than it deserves. This method is by 
 no means free from disadvantages. I think it should be used exclusively in 
 cases of chronic salpingitis in which there is no suspicion of the existence of 
 encysted collections of pus, for the cysts might easily be ruptured acciden- 
 tally into the peritoneal cavity instead of being emptied through the ostium 
 uterinum as the masseur desires. In acute inflammatory processes, massage 
 does more harm than good. By friction of tissues which are friable and 
 filled with blood, it may cause rupture and dangerous hemorrhages. Yet I 
 would advise the use of this method of treatment in the case of residues of 
 inflammations long passed, adhesions and cicatricial contractions, which all 
 cause pain, for the relief of which many a laparatomy has been too hastily 
 undertaken. 
 
 Antiphlogistic massage should follow, in gynaecology, the same laws 
 
OOPHORO-SALPINGITIS WITHOUT CYSTIC TUMOR. 52 I 
 
 which general surgery have created for it, as, for example, in the treatment 
 of arthritis. 
 
 If all therapeutic measures fail, after a sufficient delay we are justified in 
 having recourse to the radical operation of oophoro-salpingotomy. 
 
 We must not hesitate to perform it without delay when the severity of 
 the symptoms leads us to suspect a purulent salpingitis which might rapidly 
 threaten life. And although we should be a little more conservative in the 
 case of chronic non-purulent tubo-ovaritis, yet the operation is not to be 
 proscribed. These lesions, while not endangering life, render it unbearable 
 by the almost incessant pain they cause, and the deterioration of the general 
 health. At least six months' careful and patient treatment by the methods 
 which I have already indicated should precede an ovariotomy for non-puru- 
 lent salpingitis. 
 
 Removal of the appendages by abdominal incision, except in very excep- 
 tional cases, is a safe operation. It really includes two distinct procedures : 
 (ist) rupture of peripheric adhesions and replacing the uterus, which is 
 usually retroverted or retrofiexed ; (2d) removal of the tube and ovary as close 
 as possible to the uterus. 
 
 Their removal by vaginal incision has been praised by Byford in 
 America, by Gottschalk in Germany, and by Picque in France. This 
 operation has recently been restored to favor by Dlihrssen under the name 
 of vaginal coeliotomy, and by Martin as anterior colpotomy. Martin prac- 
 tised it one hundred and seventy-nine times without one fatal result, 
 fifty-four of the cases being lesions of the adnexa. No doubt this opera- 
 tion is of use in certain cases, but it seems to me that here it possesses 
 no special advantages, and may be of serious disadvantage should the slight- 
 est operatory complication arise. The ovary must always be removed with 
 the tube, even if it seem to be unaffected. Can we, in certain cases, limit 
 ourselves to the first part of the operation, breaking down of the adhe- 
 sions, liberation and replacement of the uterus and appendages ? Hadra 
 was the first to observe that the morbid symptoms, especially sharp ab- 
 dominal pains, for the relief of which healthy ovaries have often been 
 removed, may be relieved by merely destroying the adhesions, often filament- 
 ous, which bind together the various abdominal viscera. He therefore sug- 
 gests that whenever a laparatomy is performed under these conditions, 
 we should carefully examine the abdominal organs for adhesions, slip- 
 ping the hand carefully between the loops of intestine, under the omen- 
 tum, and above it. If the appendages are in a healthy condition, he 
 contents himself with this performance ; if they are diseased, he removes 
 them. 
 
 Polk goes farther than this. Having removed only one tube after going 
 through the procedure just described, although the oviduct which was left 
 in place showed evident signs of inflammation, he proposed the plan of sim- 
 ply expressing the muco-pus contained in the diseased tube, washing the 
 
522 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 peritoneum, and closing the abdomen, after having, if necessary, performed 
 a hysteropexy to prevent a return of the retroflexion. 
 
 Munde theoretically approves of this treatment, and in addition to ex- 
 pressing the contents of the tubes proposes that a catheter be introduced 
 into them and that they be washed from the abdominal end with a hot bi- 
 chloride solution I : 5,000. F. Howitz has also in some cases substituted the 
 breaking down of adhesions for an ovariotomy. He reports a remarkable 
 case in which all the symptoms of chronic salpingitis were cured without a sal- 
 pingotomy, although the right tube seemed to be inflamed and swollen. He 
 lays much stress upon the pathological influence exercised by adhesions ex- 
 tending from the epiploon to the pubis. Many other authorities are begin- 
 ning to show the same conservative tendency. J. L. Championniere recently 
 expressed himself in favor of these views at the surgical society. Terrillon 
 has performed the exploratory method once ; Martin did not stop with break- 
 ing down the adhesions, but opened the obliterated extremity of the tube 
 and reconstructed the ampulla. Out of thirty-one cases of laparatomy for 
 lesions of the appendages, Polk in twenty-four of them simply destroyed the 
 adhesions. 
 
 It is impossible as yet to give a definite opinion as to the value of these 
 procedures. There is perhaps a danger of going from one extreme to the 
 other, and, after having been too ready to operate, we may be in too great 
 haste to try procedures of great ingenuity but of doubtful value. Yet the good 
 results following simple hysteropexy after breaking down adhesions, in cases 
 in which salpingitis and peri-salpingitis undoubtedly existed, plainly show 
 that many tubes and ovaries have been needlessly sacrificed. The replacing 
 of the uterus into position, the liberation of the appendages, and the anti- 
 septic cleansing of the pelvis, which necessarily attends this operation, will 
 certainly tend to diminish the number of oophoro-salpingotomies. We may 
 probably reserv^e extirpation of the appendages for three classes of cases : 
 
 1. Ovaritis and salpingitis where there is every reason to suspect the 
 presence of pus, and to fear the consequences. 
 
 2. Painful sclero-cystic ovaritis. 
 
 3. Chronic parenchymatous salpingitis and cystic (serous or haemic) 
 salpingitis, where, in spite of the lesions being apparently slight, menor- 
 rhagia, dysmenorrhoea, or nervous reflex phenomena call for an operation. 
 Removal of inflamed appendages, which contain a small quantity only of 
 mucus or muco-pus without the formation of a pouch or pyo-salpinx, is not a 
 severe operation. Conservatism is enjoined, less because of the gravity of 
 the operation than because of the sterility which follows it. 
 
CHAPTER XXV. 
 
 CYSTIC OOPHORO-SALPINGITIS. 
 
 iyPyo-salpinx, Hydro- salpinx, Hczmato-salpinx.^ 
 
 Among the cystic dilatations of the Fallopian tubes, that due to accumu- 
 lations of pus should have the first place. Pyo-salpinx often becomes trans- 
 formed into serous or bloody cysts. When (probably from spontaneous de- 
 struction of the germs) the phlegmonous process comes to an end, an abscess 
 in the tube may, like a cold abscess, 
 become changed to a collection of se- 
 rous matter by a clarification of the 
 pus, the solid constituents of which 
 are deposited upon the walls while 
 the serum increases in amount. This 
 seems to be the origin of the majority 
 of cases of hydro-salpinx. The rup- 
 ture of newly formed blood-vessels in 
 the walls of the cavity of a chronic 
 pyo-salpinx often fills it with blood. 
 
 Pathological Anatomy. — P y o - s a 1- 
 pinx, or purulent cyst of the Fallopian 
 tube, is a sequel of purulent salpingitis, 
 especially that caused by gonorrhoea or 
 by septicaemia — the latter usually oc- 
 curring post abortum. 
 
 As I have already remarked. Law- 
 son Tait and Freund attach much im- 
 portance to an incomplete development 
 of the oviduct, which predisposes it 
 to obliteration and cystic degeneration, 
 is closed by an agglutination and a species of intussusception of the fimbriae, 
 is dilated for about two-thirds of its extent externally ; more rarely the whole 
 length is dilated. As a usual thing the portion nearest the uterus remains 
 of normal size for about half an inch or an inch, but is at the same time 
 much hardened. In this situation we may observe a torsion of the uterine 
 pedicle of the tube. The ampulla often adheres to the ovary, which is more 
 or less fused in with the cyst ; very rarely we may find the ampulla intact 
 and free and projecting beyond the collection of pus, which is limited by the 
 
 Fig. 387. — Pyo-salpinx Adherent to a Sclero- 
 CYSTic Ovary. T, Dilated tube ; C, ovary. 
 
 The tube, whose external extremity 
 
•524 
 
 CLINICAL AND OPERATIVE GYNECOLOGY 
 
 obliteration of the tube nearer to the uterus. Adventitious membranes ad- 
 here to the tube and ovary, which they usually bind down to the cul-de-sac 
 
 Fig. 388. — Pyo-salpinx. i. Dilated portion of the tube formed by the obliterated distal end ; no trace of the fim- 
 tria: to be seen ; 2, middle portion of tube thickened and bent ; 3, proximal end of tube ; below is seen the remains of 
 an adhesion. 
 
 of Douglas. The uterus itself is consequently frequently displaced. The 
 left tube is, as a usual thing, the larger. 
 
 Fig. 389. — Pvo-SALPINX. i, Fibro-muscular tissue of tube ; 2, villosities infiltrated with embryonal cells and de- 
 nuded of epithelium ; 3, points where epitheHum still remains ; 4, dilated vessels full of blood ; 5, lacunae formed by 
 •consolidation of adjoining villosities. 
 
 Cysts vary much in size ; some have been reported to be as large as a 
 foetal head or a cocoanut. 
 
CYSTIC OUPHORO-SALPINGITIS. 
 
 525 
 
 As a rule, however, they are about the size and shape of a small pear; 
 often they are slightly curved upon themselves, like a hunter's horn (Fig. 
 388), and are yellowish-white in color. The wall of the cavity varies in 
 thickness ; usually there is a weak spot corresponding to the posterior ad- 
 hesions ; it is difficult to avoid bursting the sac in this place when detaching 
 it. The internal surface is velvety to the touch, the pus creamy and yel- 
 lowish ; it has a fetid odor when the sac is intimately connected to the rec- 
 tum. Sometimes a cyst of the broad ligament, or of the ovary situated just 
 
 Fig. 39o.^Pyo-salp!NX. Section perpendicular to inner surface of tube (350 diameters), i, Fibro-muscular tissue;-. 
 2, vessels ; 3, villosities composed of loose connective tissue infiltrated with innumerable cells and showing no epithe- 
 lial cells upon their surface ; 4, granular mass of coagulated fibrin containing blood corpuscles ; 5, spaces between . 
 
 villositiea 
 
 below the inflamed tube, may also suppurate, and even open into it. I have' 
 myself seen an example of the first-named variety. 
 
 Under the microscope, we find the internal surface covered with branch- 
 ing vegetations like those of acute catarrhal salpingitis, but two or three 
 times as thick, because of the more abundant infiltration with embryonic 
 cells. They are covered with a single layer of columnar cells, which is also 
 found in the bottom of the sulci which separate them. 
 
 The deep layers of the mucosa are rich in fusiform cells. Nearer to the 
 surface is a zone of such abundant cellular infiltration that it looks like 
 granulation tissue. The walls of the undilated portion of the tube, which 
 to the naked eye look perfectly normal, are also infiltrated with embryonic 
 cells. The blood-vessels are everywhere seen to be dilated. 
 
 In pyo-salpinx the uterine end of the tube may be still slightly perme- 
 able. It is said that the walls are thickened in this variety, when there is- 
 free evacuation. In all probability they seem so, because they are not ex- 
 cessively distended. It has also been asserted that the hypertrophy of- ths: 
 
526 
 
 CLINICAL AND OPERATIVE GYNECOLOGY, 
 
 muscular fibres would then cause an evacuation of the cavity ; but this is 
 improbable ; evacuation is probably caused by an overflow. 
 
 The tube being more or less affected and showing signs of a chronic in- 
 terstitial inflammation, it may happen that the ovary alone is transformed 
 into a purulent cavity, or that circumscribed abscesses occur within it. In 
 such cases the source of the inflammatory process has usually been the tube. 
 
 Fro. 3gi. — Tubercular Salpingitis, Section perpendicular to wall of tube (diagrammatic), i, Villosities of tube 
 TOore or less united, leaving between them irregular cavities of varying size ; 2, cylindrical ciliated epithelium ; 3, 
 mucus ; 4, tubercle with giant cells ; 5, tubercle without giant cell ; 6, obliterated vessel ; 7, wall of tube ; 8, large 
 vessel filled with coagulated blood ; 9, tissue of villosities infiltrated with numerous embryonal cells especially near 
 tubercles. 
 
 which after evacuating its contents into the uterus has gone on to the stage 
 of chronic inflammation, while the suppurative process still continued in the 
 ovary. 
 
 In other cases in which the two organs have remained widely separated, 
 the infection of the ovary must have been indirect and by means of the lym- 
 phatics. However that may be, it is probable that the formation of abscess- 
 es within the ovary, from contagion derived from the tube, is usually favored 
 by a small pre-existent cyst, either follicular or of the corpus luteum, or else 
 by micro-cystic degeneration. 
 
CYSTIC OCJPHORO-SALPINGITIS. 
 
 527 
 
 Pyo-salpinx may coexist with uterine tumors, fibroid or cancerous. 
 
 Cold abscess of the tube, or tubercular pyo-salpinx, is recognized with 
 difficulty when there is no similar lesion of the ovary or uterus. We may, 
 however, find characteristic tubercular granulations upon the neighboring 
 peritoneum ; as to the caseous masses found in the tube, they might be 
 caused simply by inspissation of pus, and we know now that these apparent 
 tubercles, to which so much importance was attached of old, are of small im- 
 portance. The microscope alone can decide whether they are really tuber- 
 cular, by showing the characteristic cellular features of a tuberculous follicle, 
 with its zone of nucleated cells surrounding the giant cells, and showing, 
 
 
 ^^f;^ 
 
 Fig. 3Q2. — Tubercular Salpingitis. Portion of Fig. 391 highly magnified, i, Tissue of villosities with numer- 
 ous round embryonal cells ; 2, villosities cut transversely ; 3, epithelium arranged in several layers, the deeper being 
 cylmdrical ; 4, giant cells; 5, proliferated cells. 
 
 above all, the Koch bacillus. Hegar and Orthmann have met with the lat- 
 ter, but, like Neisser's gonococcus in gonorrhoea, it may be absent ^^because 
 it has disappeared) without invalidating a diagnosis of specific lesion. 
 
 Hydrosalpinx, or tubal dropsy, is, from an anatomical point of view, the 
 oldest known of the tubal affections. But, beyond doubt, many a case of 
 tubo-ovarian cyst when the tube was not dilated but only lengthened, hyper- 
 trophied, and adherent to an ovarian cyst which opened into it, has been 
 mistaken for hydro-salpinx. This may account for the colossal dimensions 
 attributed to it by ancient and even modern authors. It is very doubtful 
 if these tumors ever attain a greater size than that of a foetal head. As 
 a usual thing they are only as large as a small pear. They are smooth 
 and bluish-white in color; the walls are transparent in places and papyra- 
 ceous. In a few cases the tube is not equally distended throughout, and the 
 
52 8 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 hydro-salpinx presents sigmoid curvatures (Fig. 393). There are few periph- 
 eric adventitious membranes, or, if they exist, they are thin and distended — 
 for dropsy of the tubes always indicates an inflammation which has sub- 
 sided. 
 
 Froriep, who studied this lesion profoundly, divided hydrops tubae into 
 two varieties : aperta and occlusa, according to whether the uterine end were 
 open or occluded. The fluid is yellowish, and sometimes contains blood or 
 a little purulent matter. 
 
 Tubo-ovarian Cysts. — In this connection I will give a few details in 
 regard to a variety of cyst which by a structural peculiarity due to its ac- 
 quired connection with the tube, deserves a special classification. In these 
 cases the cystic ovary is engrafted upon the dilated tube with which it com- 
 municates, so that the cavity (which is usually curved in the shape of a re- 
 tt)rt) in this case consists partly of a tubal and partly of an ovarian portion. 
 Richard was the first to give an accurate description of this variety. As a 
 rule it consists of small tumors of the ovary (cysts of the Graafian follicle 
 joined to the dilated tube, their volume being inconsiderable). But Hilde- 
 brandt and Olshausen have seen tubo-ovarian cysts formed by proliferous 
 cysts, and consequently of enormous size ; the latter authority reports two 
 cases which were apparently in relation with cysts of the broad ligament. It 
 is therefore evident that this variety may be superadded to any kind of cyst. 
 As a usual thing the tube remains permeable, which allows the fluid to flow 
 into the uterus so soon as the pressure within the sac becomes great enough. 
 In this way we have the formation of z. profliient ovarian hydrops, similar to 
 what has been described in connection with hydro-salpinx, under the name 
 of projliieiit tubal hydrops. This open communication plays the part of a 
 safety-valve, which prevents exaggerated distention of the cyst and tends to 
 limit its growth. In one case Hennig was able to follow the diminution in 
 size which occurred in bilateral tumors after their evacuation. In regard to 
 the origin of these compound cysts, the question occurs as to whether the 
 adhesion of the tube to the ovary precedes or follows the cyst formation, 
 whether in the beginning there is not an inflammation of the appendages 
 leading to their adhesion, or else a precedent co-existence of hydro-salpinx 
 and ovarian cyst which by resorption of the wall become fused into one. 
 For my part, I am inclined to believe that this is usually the case, so that 
 the lesion might equally well be described in the chapter of ovarian dis- 
 eases as in this one upon the pathology of the tube. Out of three hundred 
 ovariotomies Olshausen found three cases of tubo-ovarian cyst, one of which 
 was bilateral. 
 
 Hcsmato- salpinx must be distinguished from the small hemorrhages or 
 haematomata of the tube which distend its inflamed walls ; these effusions of 
 blood, which tend to reabsorption, are mere accidents rather than disease. 
 Haematocele of the tube, or true haemato-salpinx, implies a profound altera- 
 tion in its walls which have assumed a definitely cystic formation, and a mod- 
 
CYSTIC oOphoro-salpingitis. 529 
 
 ification of the blood analogous to that undergone by it in hasmatocele. In 
 one word, there is a permanent lesion, instead of the transitory pathological 
 incident which is the real significance of an extravasation of blood into an 
 inflamed organ. This distinction, however, not having been made by most 
 authorities, I shall be obliged to conform to the general usage. 
 
 Leaving aside the cases of retention of the menstrual blood by atresia of 
 the genital tract, which will be treated of in the chapter on Malformations, 
 there remain two chief varieties of hsemato-salpinx. 
 
 I St. The first and more frequent, of which I have just been speaking, is 
 an apoplexy of the tube, which may occur incidentally in the course of a 
 catarrhal inflammation, or even during an irregular menstruation affected by 
 
 Fig. 393. — Hydrosalpinx with Sigmoid Flexures of the Tube. C, C, Flexures of the dilated tube ; (9, ovary ; 
 P, fimbriated extremity obliterated and distended. 
 
 change of regime, by great fatigue, or by the effect of cold in neuropathic 
 or plethoric patients. It is not impossible that the symptoms attributed by 
 some to a congestion of the uterus or to pelvic congestion have this origin 
 only. The lesion is usually only temporary, the clot is reabsorbed, and the 
 symptoms may gradually subside, unless, as is often the case, they have been 
 grafted upon the symptoms of a chronic parenchymatous salpingitis. 
 
 (There is no doubt that the mucosa of the tubes is the seat of an exuda- 
 tion of blood during menstruation. There is then a physiological hemor- 
 rhage into the tubal cavity as into the uterine cavity. After an ovariotomy, 
 when the stump of the tube is fixed to the abdominal walls, either by means 
 of a clamp or by extra-peritoneal ligature, it is not unusual to see an oozing 
 of blood from the cut surface at the menstrual period. This physiological 
 hemorrhage, if not constant, is certainly frequent, and is probably easily in- 
 duced by anything which increases the active or passive congestion of the 
 genital apparatus. If the hemorrhage occurs when the extremities of the 
 tube are free, the blood will probably pass into the uterus without causing 
 34 
 
530 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 any disturbance — the physiological condition. If very abundant, it may give 
 rise to clots in the tube, with consequent indefinite morbid phenomena, un- 
 til thev are reabsorbed : if still more excessive, retro-uterine hasmatocele 
 may result.) 
 
 2d. The second variety of hasmato-salpinx, the only one which possesses 
 a real anatomical individuality, is especially characterized by the presence 
 of a sac like that of pyo-salpinx. For the formation of the sac I think we 
 must presuppose a tubal pregnancy arrested in its development by the death 
 of the foetus, which is reabsorbed, or a previous pyo-salpinx which has ob- 
 
 U 
 
 Fig. 394. — Double Hvdro-salpinx. Showing tossing backward of the right appendages. 
 
 literated the uterine opening and thickened the walls at the same time that 
 they became dilated. Sometimes there is a direct transformation from the 
 pyo- to the haemato-salpinx ; again, there seems to be an intermediate condi- 
 tion of hydro-salpinx ; it is in these latter' cases that the fluid is the clearest 
 and the walls the thinnest. 
 
 Inversely, it may happen that a secondary suppuration of the haemato- 
 salpinx occurs ; the infection is in this case probably carried by the lym- 
 phatics rather than through the uterine cavity, with which, indeed, all direct 
 connection is cut off. The size of these sacs rarely exceeds that of a pear ; 
 yet Lawson Tait reports a case in which one reached above the umbilicus 
 and contained several litres. It seems to me that there must have been a 
 co-existing encysted intra-peritoneal haematocele which was bound to the 
 h?emato-salpinx. 
 
 Haemato-salpinx is often associated with fibromata; it is not to be attrib- 
 
CYSTIC Or)PIIORO-SALPINGrnS. 
 
 531 
 
 uted to the pressure of these tumors upon the ostium uterinum, but rather 
 to the hemorrhagic metro-salpingitis which accompanies the development of 
 myomata. 
 
 The sac of haemato-salpinx is thin in some places and thick in others. 
 Hypertrophy of the muscular fibres is met with, as in pyo-salpinx. The 
 communication with the uterus may persist. As to the contents there may 
 be a syrupy, chocolate-colored blood (in cases in which the lesion is due to a 
 retention of the menstrual flow from genital malformation) or, more often, a 
 
 Fig. 395. — Suppurating H,«mato-salpinx. The pouch is opened, the mammillated inner surface is seen, and a 
 small kidney-shaped body (clot or embryo?). A canula a is inserted in an opening which existed between the pouch 
 and the rectum ; b, ligature around the uterine extremity. 
 
 clearer liquid formed of a watery fluid and blood or of pus and blood. Clots 
 may form in layers on the walls, or in little fibrous masses which are free 
 (Fig. 395). A microscopical examination of the sac shows an irritative proc- 
 ess less severe than in pyo-salpinx. But there is an unusual abundance of 
 the fusiform cells in the mucous membrane, which in some of the folds seem 
 to rise perpendicularly from the deeper layer. The top of these folds has 
 usually lost its epithelial coating; the intervals between them may contain 
 a dense network of capillaries filled with blood, that can be traced almost to 
 the surface of the mucous membrane. In places small parenchymatous 
 hemorrhages hide the structure of the tissues (Fig, 396). 
 
 Cystic Ovaritis. — Microcysts, or slightly developed cysts of the ovary, are 
 
532 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 described in their proper place in the study of the inflammatory processes 
 by which they are caused. 
 
 A. Serous Cysts. — Upon the surface of a normal ovary it is usual to find 
 a certain number of follicles filled and swollen by fluid ; this is probably a 
 purely physiological condition, a simultaneous development of several ovules, 
 in order to secure the expulsion of an ovum. Moreover the most competent 
 authorities assert that even in cases in which the peripheric tissues are dis- 
 tinctly altered, the existing" follicles do not differ histologically from normal 
 follicles in process of growth or of regression. In order to judge whether 
 the condition is a morbid one, we must base our conclusions upon concomi- 
 
 FiG. 396. — H^MATO-SALPiNX. Section slightly magnified (Wyi^r). 
 
 tant lesions, upon the number of these follicles, and more especially upon 
 their size, which normally should not exceed from four-fifths of an inch to 
 one inch. 
 
 Follicular cysts occur in the form of spherical, unilocular sacs, varying m 
 size from that of a small cherry to that of a walnut, but sometimes attaining" 
 greater dimensions. Though usually scattered about or agglomerated upon 
 the surface of the ovary, they may also be found within its tissues. Upon 
 section they show a smooth wall with double outlines, and limpid, colorless 
 contents. According to Ritchie and Webb the ovule is not to be found in 
 cysts which are larger than a cherry; upon the proliferation of the granular 
 cells which surround them they seem to disappear. The parietal epithelium 
 first proliferates and then undergoes colloid or granular degeneration. As 
 to the so-called lymphoid layer it gradually becomes lost in the cellulo-vas- 
 cular layer, both undergoing the sclerotic process. In some cases, accord- 
 ing to Toupet, there would appear to be hydropsy of the ovule itself, and 
 not of the follicle. 
 
 I removed a polycystic ovary in which a certain number of the sacs, rang- 
 ing in size from a pin's head to a walnut, were filled with a serous fluid, 
 while the rest contained cheesy or lardaceous matter which was examined 
 microscopically by Toupet in Professor Cornil's laboratory, and found to 
 
CYSTIC 0()PHORO-SALPINGITIS. 
 
 533 
 
 consist of myxomatous tissue. The process was probably analogous to that 
 of cicatrization in normal follicles. 
 
 From a clinical standpoint, I believe that it is advisable to distinguish 
 between microcystic degeneration accompanied by sclerosis, and the large 
 conglomerated follicular cysts which transform the whole ovary into a mul- 
 tilocular mass reaching the size of a fist or even of the head. This type of 
 lesion I call cystic disease of the ovary. 
 
 Chronic oedematons ovaritis, to which I have already referred, is found 
 more especially in cases of tubo-ovarian varicocele. The first succinct de- 
 
 FiG. 397. — Chronic CEdematous Ovaritis without Lesion of the Tube (Pozzi). 
 
 scription of them was given by me in the theses of two of my pupils. Since 
 then, histological researches have completed our knowledge of the subject. 
 The appearance of an oedematous ovary is characteristic ; it is twice or 
 three times its usual size, its surface is smooth and lustrous, its consistence 
 soft and elastic. Upon section its stroma is found to be infiltrated, ge- 
 latinous, and dotted with small serous cysts which project from the softened 
 tissue like transparent stones (Fig. 397). The microscope reveals a pro- 
 found sclerosis of both arterial and venous vessels around the hilum (Fig. 
 398) ; an active inflammatory process affecting the blood and lymph capil- 
 laries (with dilatation of the lymphatic spaces), a dilatation of the ovarian 
 stroma from oedema (Figs. 399 and 400), and transformation of the follicles 
 into interstitial cavities by the granulation of their connective-tissue walls 
 and destruction of their epithelium. There is therefore in oedema of the 
 
534 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 ovary, either diffuse, acute, or subacute ovaritis. This process may advance 
 sufficiently to the formation of the pseudo-cysts recently described by Paul 
 Petit from a specimen furnished in my practice. These pseudo-cysts, analo- 
 gous to physiological bullae of oedema, might at first be confounded with fol- 
 licular cysts, but are distinguished from them by the absence of a wall and 
 by their disappearance as soon as opened. 
 
 B. Blood-Cysts. — Blood cysts of the follicles occur under varying as- 
 pects, according to their causation. When multiple and of small size, and 
 riddled often throughout the whole extent of the organ, they result from in- 
 fectious ovaritis of internal origin. Larger cysts, varying from the size of 
 an almond to that of the fist, contain a sero-sanguineous fluid, and appear to 
 be due to hemorrhages into the dropsical follicles, or to be formed of blood 
 
 Fig. 398. — Chronic CEdematous Ovaritis. Sclerosis of the hilum (75 diameters) (¥. Petit). 
 
 which is almost pure. The latter are an especial accompaniment of cortical 
 sclerosis, and it has been stated that they were capable of growth to the point 
 of rupture by a species of intra-cystic process of expulsion of the ovum in the 
 neighboring follicles (ineiiorrJiagic cysts of Boeckel). These cysts have a 
 fibrous wall, which is sometimes extremely thin ; their investing layer of 
 epithelium is degenerated or destroyed. 
 
 Blood cysts within the corpora lutea result from an exaggeration of the 
 physiological hemorrhage after the expulsion of the ovum, or from a hemor- 
 rhagic raptiis within cicatrized corpora lutea. Cysts of the first-named va- 
 riety have a nearly uniform enveloping membrane within which is found the 
 more or less altered elements characteristic of corpora lutea, vitreous masses 
 of degenerated epithelium supported upon papillae. The other must be con- 
 sidered simply as a variety of interstitial hemorrhage. Sometimes they are 
 disseminated, sometimes diffused throughout the whole stroma of the ovary, 
 which they transform into a pulpy mass like the splenic pulp. Between in- 
 
CYSTIC OOPHORO-SALPINGITIS. 535 
 
 tra-vesicular hemorrhage and apoplexy of the stroma there would seem to be 
 a mixed variety (Besnier), consisting of a veritable intra-ovarian hcematocele, 
 from abnormal ovulation. 
 
 C. Purulent Cysts. — Suppuration of the ovaries at the outset occurs in 
 the form of small, multiple abscesses, strictly limited, and for the most part 
 
 Fig. 39g. — Chronic CEdematous Ovaritis. First degree of a;dema in medullary portion (150 diameters) (P. Petit). 
 
 situated in the ovisacs, if we are to judge by their form and the debris of 
 epithelial cells found upon their walls. Little by little these cavities be- 
 come fused by the purulent melting away of the interposed cellular tissue. 
 
 Fig. 400. — Chronic CEdematous Ovaritis. Third degree of cedema. Vacuolation of stroma (90 diameters) 
 
 (P. Petit). 
 
 and finally form several large sacs, or one sac only. The wall of this large 
 abscess is formed from within outward of a layer of embryonal tissue, a 
 dense fibrous layer, and finally a vascular layer within which are found the 
 
536 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 more or less altered elements of the organ. To purulent cysts probably be- 
 long the cysts from circumscribed softening, described by Rindfleisch and 
 JMayweg. 
 
 Abscess of the ovar}' is nearly always unilateral (twenty-eight out of 
 trsventy-nine cases). As infection of the ovary (when the tube is normal, 
 or when it is diseased, but not adherent to it) always occurs through the 
 lymphatic or blood channels, the pus of suppurating ovaritis should con- 
 tain only streptococci ; in one case Etheridge reports having found pneu- 
 mococci ; Zweifel found the gonococcus. 
 
 D. Lymphatic Cysts. — These pseudo-cysts which are probably always de- 
 pendent upon ovarian varicocele may attain to the dimensions of small fol- 
 
 FiG. 401 . — Suppurative Ovaritis. Ovary size of hen's egg, containing purulent collection. Section perpendicular 
 to surface of sac (diagrammatic), i, Very loose connective tissue infiltrated with large number of cellular elements ; 
 2, vessels dilated and filled with blood ; 3, extravasation of blood on surface ; 4, large lymphatics ; 5, papillse on inner 
 surface of sac ; 6, spaces separating papillse. 
 
 licular cysts. They occur in the form of starry masses, covered with flat 
 cells and enclosing a small number of white corpuscles. 
 
 All these microcysts, which are so varied in character, with serous, bloody, 
 and purulent contents, and which are for the most part associated, possess a 
 common property in that they are usually the result of an inflammatory or 
 irritative process, and that they are restricted in development. It seems to 
 be absolutely established that they cannot be transformed into proliferous 
 cysts. At a given time they empty either into the abdominal cavity (blood 
 cysts) or the neighboring viscera (purulent cysts), or else become atrophied 
 after reabsorption of their contents. 
 
 Syviptovis. — It may seem singular, a priori, to attempt to give at the 
 
CYSTIC 0(3phoru-salpingitis. 
 
 537' 
 
 same time the clinical picture of collections of pus and of collections of se- 
 rum and blood of the tubes and ovaries. If one had not verified the fact by 
 actual observation, it would be difficult to believe that a patient might be 
 carrying about in her abdomen two sacs filled with pus without exhibiting 
 any serious phenomena or even seeming to suffer from their presence. Be- 
 tween the initial period of formation and the final period of inflammation of 
 surrounding parts, and efforts at spontaneous evacuation, pyo-salpinx passes 
 through a torpid and latent phase, so to speak, during which the economy 
 which is perfectly protected by the encysting of the septic fluid seems to ac- 
 quire tolerance for its presence ; the rational symptoms then seem to be ex- 
 
 FiG. 402. — Suppurative Ovaritis. Portion of preceding figure (500 diameters), i, Fine network of connective- 
 tissue fibres ; 2, round cells with large nuclei surrounded by thin protoplasmic layer ; 3, transverse sections of vessel 
 filled with blood corpuscles ; 4, longitudinal section, same ; 5, white blood corpuscles ; 6, fine molecular granulations 
 of exuded fibrin. 
 
 actly similar to those of chronic salpingitis, and the physical signs are in no- 
 wise different from those of hydro- or hasmato-salpinx. We are thus justified 
 in treating of the symptoms under one head, only adding a few special ones 
 which characterize the acute stage of tubal abscess. 
 
 This clinical picture does not materially differ from the one which I drew 
 for non-cystic salpingitis. There are the same pains and the same men- 
 strual disorders (amenorrhoea, dysmenorrhoea, menorrhagia) ; the latter, how- 
 ever, may not occur, and menstruation be perfectly normal. In haemato-sal- 
 pinx, Puech has sometimes noticed a constant dribbling of small quantities 
 of blood instead of real menses ; this is what some call amenorrJicca distilane; 
 it is not pathognomonic, and is met with in endometritis as well. 
 
 I must not fail to mention another accessory symptom, to which alto- 
 
538 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 gether too much importance has been attributed ; I mean the sudden flow of 
 a certain amount of serous, bloody, or purulent fluid following an attack of 
 colicky pain ; this may occur at irregular intervals of a month or six months. 
 Has it anything to do with the permeability of the uterine orifice, now and 
 then forced open by the overflowing of the overfilled cyst ? Or is there 
 merely an expulsion of the contents of the uterus, which is itself inflamed, 
 caused by reflex contraction of its walls? We shall be tempted to accept 
 the latter explanation if we remember how frequently the cystic tubes are 
 obliterated at the uterine extremity. However that may be, the fact has 
 long been noticed; it constitutes the hydrops tubae profluens of Froriep. 
 Klob, having examined and studied many aged patients, thinks that this may 
 account for certain cases claimed to be a return of the menstrual function 
 after the menopause. Sometimes by pressing upon the tumor from above, 
 its contents are expelled into the vagina. This flow of pus caused by abdom- 
 inal pressure, or pyo-metrorrhagia, has often been considered a sure symp- 
 tom of pyo-salpinx. 
 
 Two groups of symptoms only are really characteristic : the pains which 
 direct attention to the uterine appendages ; and a local examination which 
 results in the finding of a tumor at the side of the uterus. 
 
 The physical examination will be made by means of bimanual palpation 
 and rectal touch. It is to be undertaken with great precaution ; serious and 
 even fatal accidents have been caused by rupture of a pyo-salpinx from too 
 rough an examination. Cystic tumor of the tubes varies greatly in its 
 character, according to whether it is free and to a certain extent movable by 
 the side of the uterus, or whether it has fallen into the cul-de-sac of Douglas 
 and become fixed there by adhesions. 
 
 The first case is the typical one ; with both hands we can grasp a small 
 pear-shaped body, which hangs upon the side of the uterus, to which it is 
 connected by a slender pedicle which we. can scarcely reach. When the 
 tumor is bilateral, it seems as if a wallet had been thrown over the uterus, 
 saddle-bag fashion. Fluctuation is rarely felt, but pain is always caused by 
 the examination if the patient be not anaesthetized. In some cases we find 
 the cyst upon one side, while the cul-de-sac of the other side and Douglas' 
 pouch are filled by an elastic or fluctuating globular mass which seems in- 
 corporated with the posterior surface of the uterus. This is one of the tubes, 
 dilated to the shape of a retort, which has fallen into the cul-de-sac, uplifts 
 the uterus, and presses down the rectum. It is usually purulent and non- 
 movable ; at first it is free, but gradually becomes so adherent to surround- 
 ing parts that it becomes transformed into a veritable pelvic abscess which 
 cannot be enucleated. 
 
 Diagnosis — Can we always distinguish pyo-salpinx from serous or hae- 
 matic tubal cysts ? I have already spoken of the extreme caution to be 
 observed in this diagnosis, and of the tolerance acquired by the system for 
 the presence of a sharply limited collection of pus. 
 
CYSTIC OOPHORO-SALPIXGITIS. 
 
 539 
 
 ^W:- 
 
 
 tJMMmm 
 
 mmmm 
 
 f 
 
 Pyo-salpinx is to be suspected if the dilatation of the oviduct follow 
 gonorrhoeal or puerpero-gonorrhaal infection, and if the tumor be very 
 closely adherent. If temporary or permanent purulent fistulae are found, 
 there is no room for doubt. There only remains the question of exact loca- 
 tion to decide, and the possibility of a transformation into a pelvic abscess. 
 In doubtful cases only abdominal section can give the answer. 
 
 Hydro-salpinx and pyo-salpinx are usually double, while haemato-salpinx 
 is unilateral. It would be pertinent to inquire whether this be not due to 
 the fact that it is caused by an arrested tubal pregnancy. 
 
 There may be a purulent mass upon one side and a fluid mass upon the 
 other. If the tubal mass be of large size and there be no extensive adhe- 
 sions, we probably have to do with a hydro- 
 salpinx; pressure is less painful than in the 
 case of a purulent cyst. 
 
 While the tumor is still movable, we may 
 mistake it for a small ovarian cyst, and es- 
 pecially for an intra-ligamentous cyst. The 
 latter, however, is more decidedly lateral, and 
 is not usually separated from the uterus by 
 the space corresponding to the pedicle of the 
 tubal cyst. 
 
 The differential diagnosis from tubal preg- 
 nancy in the first four months is almost im- 
 possible to make with certainty. In the 
 majority of cases in which these foetal cysts 
 have been extirpated, the operation had been 
 undertaken for a supposed salpingitis. Hy- 
 pertrophy of the uterus and expulsion of a 
 decidual membrane are the only diagnostic 
 symptoms. Menstruation may continue to be 
 normal. 
 
 An inexperienced examiner is very apt to mistake large serous or bloody 
 cysts for uterine fibromata, and it is indeed often very difficult at first to 
 distinguish the one from the other. But the uterine sound, carefully used, 
 will show a great increase in the uterine cavity when there is a fibroid, and a 
 normal cavity in the case of the tubal affection. Moreover, we may always 
 perceive fluctuation in hydro- and haematp-salpinx if they be of any size, or 
 if the patient be anaesthetized : it is surprising how different the sensation 
 imparted is from that felt before the anaesthetic was administered. Pyo-sal- 
 pinx with adhesions projecting into the cul-de-sac of Douglas often give the 
 sensation of a pasteboard vagina. 
 
 Is it permissible to make an exploratory puncture for the sake of clearing 
 up a diagnosis ? It seems to me a dangerous procedure, however far the tu- 
 mor may be from the point of puncture; whether it be abdominal or vaginal. 
 
 Fig. 403. — Suppurative Ovaritis. Sec- 
 tion stained by Weigert's method (800 diam- 
 eters). I, Fine connective-tissue network ; 
 2, molecular granular exudate ; 3, round 
 cells with large nuclei ; 4, small masses of 
 micrococci ; 5, same in chains. 
 
540 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 There is danger of wounding the intestines ; especial danger of an effusion 
 of septic fluid in the peritoneum, either primarily if in spite of aspiration 
 the evacuation has not been thoroughly accomplished, or, secondarily, if the 
 cyst is again filled and forces open the lips of the small wound. This ex- 
 ploration, which seems so trifling to the patient and her friends, is in reality 
 much more serious than an incision under antiseptic conditions. Certainly 
 the latter is not to be lightly undertaken ; still, we should not forget that it 
 constitutes one of the most valuable of surgical resources. 
 
 The differential diagnosis between a large cyst of the tube and fibro- 
 cystic tumor of the uterus is in some cases almost impossible ; yet the in- 
 creased size of the uterine cavity, as demonstrated by the use of the sound, 
 will determine the question. In this case exploratory puncture would be 
 especially dangerous. 
 
 Pelvic adenitis, which is of rare occurrence and of obscure origin, may 
 occasion errors of diagnosis. The rational symptoms to which it gives rise, 
 and the tumor which it forms, resemble pyo-salpinx with adhesions. Tenier 
 mentions an interesting case of this kind. L. Championniere and I have 
 also seen similar ones. Pregnancy complicated with a bilateral pyo-salpinx 
 has been observed, and the peculiar condition caused was understood only 
 after an exploratorj^ laparatomy. 
 
 Doleris mentions two interesting cases of adherent enterocele in Doug- 
 las' cul-de-sac, where the pain and the physical signs pointed to an inflam- 
 matory tumor of the appendages. The mass felt behind the uterus was 
 formed of loops of intestines agglutinated together by false membranes. 
 The tubes and ovaries were in an almost normal condition. These seem to 
 be examples of pelvic peritonitis of intestinal origin, very seldom met with, 
 and only possible to diagnose by laparatomy. Removal of the appendages 
 gave no relief. 
 
 I obser\^ed a case which was similar, except that the symptoms appeared 
 to be subacute and to be due to a peri-salpingitis, although the tubes were 
 but slightly affected. Laparatomy followed by rupture of the adhesions, 
 irrigation of the peritoneum, and drainage resulted in a rapid recovery. 
 
 Course, Duration, Termijiation, Prognosis. — We may assert that these 
 cysts of the tube constitute a definite disease, which is incurable except by 
 extirpation. The patients become chronic invalids, in whom the least over- 
 exertion brings on acute attacks of peri-salpingitis; so that the course of the 
 disease is marked by contant relapses, just as in peri-uterine phlegmon and 
 pelvic peritonitis. In fact, until recently tubal lesions were indiscriminately 
 classified with the inflammatory processes of which they are the cause. The 
 acute attacks in the case of non-purulent tumors are characterized by an ex- 
 acerbation of the pain and the nervous symptoms and by a remittent type of 
 fever. Tait attributes these repeated attacks to the exit of a few drops of 
 irritating fluid through small openings in the tube. However that may be, 
 it is certain that there are constantly recurring attacks of peri-salpingitis, 
 
. CYSTIC OOPHORO-SALPINGITIS. 54I 
 
 which may finally result in rupture. If this occur to a serous or a blood 
 cyst, the result may be comparatively harmless (as in the case of rupture of 
 the ovary). 
 
 But if a pyo-salpinx opens and discharges into the peritoneal cavity, the 
 most formidable results follow, of which the cause is often not recognized. 
 The medico-legal adviser should be informed of the possibility of these sud- 
 den deaths which may carry off patients in apparently good health ; in their 
 unexpected severity these cases are comparable to the rupture of extra-uter- 
 ine pregnancy. When the evacuation of pus is prevented by the oblitera- 
 tion of the uterine opening, and its formation still continues, the pus dis- 
 tends the cavity so enormously that it comes into contact with neighboring 
 cavities, rectal or vaginal, and adheres to them ; perforation follows, with 
 evacuation of the pus. The opening tends to become permanent, and fistulae 
 are thus formed which usually communicate with the rectum, as the pyo- 
 salpinx usually prolapses into the cul-de-sac of Douglas ; but it may also be 
 observed in the intestines higher up than the rectum, so that the evacua- 
 tion of an abscess by the anus does not mean the opening of an abscess 
 into the rectum. More rarely the pus finds its way into the vagina or 
 bladder or ureter. Shooting pains, tenesmus, and glairy diarrhoea (Nonat) 
 precede the opening into the rectum ; signs of cystitis announce the opening 
 into the bladder. Recto-vesical communication may be established by a 
 double perforation. 
 
 These fistulae are usually intermittent. After a febrile stage and pre- 
 monitory pains, the pus is suddenly evacuated. Instantaneous relief fol- 
 lows ; the patient, who often seemed at the last gasp, comes to life again, and 
 seems almost to be cured, until the advent of another sharp attack exhausts 
 her again. These alternations of pain and relief may last for a long time 
 without greatly impairing the general health. In some cases the attacks as- 
 sume a septicasmic character, the temperature rises to 106° F., violent chills, 
 delirium, a pronounced alteration of the facies indicate the intensity of the 
 infection. After a few of these attacks the patient is much enfeebled, and 
 subject to an exhausting though slight hectic fever. Unconquerable ano- 
 rexia is one of the most striking features of this morbid state ; some patients 
 cannot take the slightest nourishment; everything is rejected, and they 
 finally die of inanition. 
 
 Another clinical type exists, in which the fistula, whether permanent or 
 intermittent, causes scarcely any reaction, but brings about a gradual dete- 
 rioration of the system. 
 
 The suppurating Fallopian tube may open laterally into the iliac fossa, 
 giving rise to abscess in this region, or, in front, into the prevesical cellular 
 tissue, causing a special form of suppuration in the cavity of Retzius. 
 These lesions, which will be carefully considered in the following chapter, 
 belong more to the category of pelvic abscesses than of circumscribed inflam- 
 mations. 
 
542 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 When a partial cure is spontaneously effected, the plastic residues which 
 bind down and displace the uterus and its appendages are a constant source 
 of pain, and continually menace a return of acute inflammation. Moreover, 
 the tubes, even after the evacuation of their contents, are subject to an in- 
 terstitial salpingitis, at first hypertrophic and finally atrophic, which causes 
 persistence of the pain. 
 
 Treatment. — " Many diseases which are the despair of medical practice 
 are easily cured by the help of surgery," wrote Louis more than a century 
 ago. These words were never more strikingly illustrated than in tubal affec- 
 tions. Only a few years ago women thus diseased were treated upon the 
 expectant plan, and condemned to a perpetual state of invalidism or to a lin- 
 gering and painful death. Now surgery affords an almost certain means of 
 cure. 
 
 Can we in these cases employ the indirect treatment which I recom- 
 mended in the case of non-cystic salpingitis } Many good authorities thought 
 it well to expel the fluid in the tubal cavity by reopening the uterine orifice 
 by curetting and dilating the uterus. If we remember the pathological anat- 
 omy of these lesions, the complete and permanent obliteration of the calibre 
 of the tubes in the majority of cases, we shall see how illusory are the hopes 
 of success in this direction. The relief and cure obtained after this treat- 
 ment must certainly belong to serous peri-salpingitis, which has been mis- 
 taken for pyo-salpinx. It is scarcely worth while even to mention the plan 
 of evacuating the tubes by means of a catheter. There is danger in penetrat- 
 ing into a healthy tube, and in the case of a diseased organ it would cer- 
 tainly be dangerous. 
 
 As soon as the diagnosis of a cyst of the tube is established, we must 
 remove the diseased parts, choosing the best moment for the operation. If 
 possible we should not operate during an acute attack. Yet if it be of so 
 serious a character as to threaten general peritonitis, or if there be danger 
 of rupture of the pyo-salpinx, the abdomen must be opened without delay, as 
 it is the only way to save the patient. Two methods of surgical treatment 
 share the approval of operators : these are laparatomy and vaginal hysterec- 
 tomy. 
 
 The operation of oophoro-salpingotomy for cystic lesions is far more 
 difficult than when done for simple catarrhal salpingitis. The great number 
 of adhesions and the danger of perforating a cavity full of fluid that may 
 infect the peritoneal cavity call for the utmost precautions. The incision is 
 usually larger than is ordinarily the case for ovariotomies. We often find 
 the omentum adhering to the pubis and covered with bullae (acute oedema) 
 which completely change its appearance. This is to be detached by the 
 fingers covered with gauze compresses, and if it be much altered, resected, 
 in small sections after a careful application of catgut ligatures. With the 
 fingers we then find the fundus of the uterus, and follow its upper surface 
 outward to the tubes and ovaries. As soon as we have found which tube is 
 
CYSTIC oOphoro-salpingitis. 
 
 543 
 
 the more diseased, we try to pass our fingers around the tumor, detaching it 
 if it be adherent, and insinuating the finger between it and the adjacent 
 organs. If the sac be very large and its walls thin, we must avert all danger 
 of rupturing it by aspirating its contents w^ith Potain's or Dieulafoy's ap- 
 paratus, closing the small opening made by the needle with one or two forci- 
 pressure forceps. If the tumor be small, firm, and resistant, w-e would better 
 carefully detach it without emptying it; this gives a better grasp to the 
 fingers. When the tumor is freed, and is no longer fastened to the broad 
 lio-ament except by the alas of the tube and ovary, we transfix this mem- 
 
 FiG. 404. — Patient in Trendelenburg's Position on Table. 
 
 branous pedicle by means of a blunt needle threaded with silk, and we tie it 
 with a Lawson Tait knot, or, if the pedicle be too large for this, with two 
 crossed threads, or a series of linked ligatures. If adhesions interfere with 
 the first loosening of a cystic tube fixed to the cul-de-sac of Douglas, we 
 may facilitate matters by cutting the tube between two ligatures at about 
 half an inch from the uterus, which is a situation where the tube is usually 
 but slightly affected and not at all dilated, and forms a real pedicle. We 
 then detach the adhesions from within outward instead of from without in- 
 ward. I must call attention to the fact that there may be an adhesion of 
 the tumor to the vermiform appendix. If the latter be mistaken for the 
 pedicle, it might be a dangerous error. 
 
 The surface of the cut section of the tube should be cauterized wdth the 
 thermo-cautery as an antiseptic precaution, for there is always a small 
 hernia of diseased mucosa in the centre of the stump. 
 
544 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 When much difficulty is experienced in isolating the adherent tube, there 
 is a natural desire to enlarge the wound in order to be able to see as well as 
 to feel. Lawson Tait, who has an unparalleled experience in operations, 
 strongly condemns this procedure. He advises an absolute reliance upon 
 the sense of touch, and decries a further complicating of the operation by 
 the necessity of replacing the intestine and drawing together the often resist- 
 ant lips of a lax abdominal wound. If, when we come to ligate the pedicle, 
 we find that it is large, stretched, and inelastic, and is in danger of being 
 torn by the traction necessary to bring it within reach of the instruments, or 
 of being cut by the constricting threads, Lawson Tait recommends the fol- 
 lowing procedure to relax it somewhat : he slips his fingers along the broad 
 ligament as far as its attachment to the pelvis, then by scratching with his 
 nails he produces some small wounds of the serous fibres of the ligament. 
 These scratches do not affect the blood-vessels, which escape because of 
 their elasticity and mobility. The broad ligament is thus given more free- 
 dom of motion, and the pedicle can be more readily drawn to the wound, and 
 tied without tearing or cutting it. 
 
 In exceptional cases, where digital examination does not give sufficient 
 information, or where it is deemed unsafe to trust to this alone, it may be 
 necessary to bring the parts into view either by putting the patient in the 
 Trendelenburg position, or by evisceration, or temporary extraction of one or 
 several loops of intestine, to be covered with warm aseptic compresses. In 
 this way I have been enabled easily to separate appendages that were very 
 adherent to the sigmoid flexure in a case of pyo-salpinx, by means of scissors 
 and the thermo-cautery. 
 
 The best method of arresting hemorrhages during these operations is by 
 compression. I accomplish it exclusively by means of the gauze compresses. 
 The operation is suspended for a moment, and with both hands we press 
 firmly down upon the mass of compresses which fills in the wound. Hem- 
 orrhage caused by detaching a tumor fixed in the cul-de-sac of Douglas can 
 readily be stopped by this means. That due to a tear of the edges of the 
 uterus may persist; but a row of catgut stitches will control it. Irrigation 
 with hot water, or the application of the thermo-cautery, may be tried when 
 necessary. Only in case of absolute necessity should we have recourse to 
 haemostatic tamponade of the peritoneal cavity with iodoform gauze, or even 
 to permanent forcipressure, which is the ultima ratio. In the later case, 
 capillary drainage should be employed by covering the forceps with pieces 
 of iodoform gauze. Some surgeons have even had to resort to hysterectomy 
 to obtain haemostasis in cases in which the hemorrhage was caused by uterine 
 adhesions. 
 
 If there has been an effusion of pus or of irritating fluid into the abdo- 
 men, the cavity should be washed out, and if the manoeuvres have been very 
 painful, and there is any reason to fear much oozing from extensive lacera- 
 tions, drainage or antiseptic tamponade of the peritoneal cavity should be 
 
CYSTIC OOPHORO-SAI.PINGITIS. 545 
 
 resorted to. I make it a rule to observe this last precaution whenever there 
 is a fistula ; the latter usually closes soon after the operation, without infect- 
 ing the peritoneum. If there should be delay in the closure, the tamponade 
 will sufficiently protect the serous cavity. 
 
 Shall we, as a matter of routine, remo\'e both tubes, even when only one 
 is diseased, because of predisposition to disease on the part of the other .^ 
 This seems to be a needless sacrifice of the possible fruitfulness of the 
 patient, and it would be better to let her run the chance of a second opera- 
 tion. Few surgeons are as radical upon this point as Tait. Surgery of the 
 tubes, having passed through a period of absolute temerity, would seem to 
 be entering upon one of conservatism. I have already noted the practice 
 of some operators who content themselves with breaking down the adhe- 
 sions, and treating the pelvic cavity antiseptically in cases in which a 
 laparatomy has shown only a small amount of disease of the appendages. 
 Martin has at times simply opened the ampulla by pushing apart the agglu- 
 tinated fimbriae or has made an artificial opening by partial resection of the 
 tube. He performed resection of the tube sixty-five times without one fatal 
 result. In two women in whom after ablation of the appendages of one side 
 he had partially resected the other tubes, he later noted pregnancy. In 
 some cases of hydro-salpinx he went farther, and resected a portion of the 
 sac, and sutured the internal to the external wall in such a way as to make a 
 permanent opening, an artificial ampulla which made fecundation possible. 
 Skutsch reports an operation of this nature, to which he proposes giving the 
 name of salpingostomy. Instead of extirpating the tube, which is trans- 
 formed into a serous cyst, he ascertains the nature of the contents by aspira- 
 tory puncture, opens the abdominal extremity, excises an oval piece about 
 half an inch wide, and by means of silk sutures unites the mucous and 
 serous membranes around the opening. The permeability of the tube is 
 ascertained by passing a sound through it. Skutsch wonders whether in 
 such cases it would not be better to suture the new ampulla to the ovary. 
 It seems to me to be preferable. In a recent case Gersuny did this in a 
 woman whose appendages of the left side he had removed. The right ovary 
 was normal, but there was a hydro-salpinx. Gersuny performed salpingos- 
 tomy, and attached the ovary to the new tubal ampulla. Seven months later 
 the patient, whose health was completely restored, became pregnant. I have, 
 however, but little confidence in the value of this so-called conservative oper- 
 ation ; I believe that whenever we find upon the tube signs of an old in- 
 flammatory process of sufficient intensity to have converted it into a serous 
 cyst or even to have merely obliterated the fimbriated extremity, its struc- 
 ture and physiological functions are necessarily greatly impaired. On the 
 other hand, I heartily believe in the value of really conservative operations, 
 partial resection of the ovary, ignipuncture whenever a portion of the ovary 
 is found to be diseased, the tube being healthy, as is sometimes the 
 case in sclero-cystic degeneration. Resection of the ovary has been per- 
 
546 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 formed in such cases by Martin, Zweifel, Gusserow, Wiedow, etc. 1 
 reser\*e it for the large follicular cysts (serous or blood-cysts) and for 
 those cysts of the corpus luteum which are about the size of a wal- 
 nut. A cone-shaped piece is removed from the diseased ovary, and the 
 two lips are united by means of catgut sutures. In the more common 
 cases of diffuse oedematous ovaritis, or of micro-cystic degeneration, I per- 
 form ignipuncture of the ovary, inserting the point of the thermo-cautery 
 into the little cysts. Their whole internal surface must be well cauterized. 
 Should the cyst be somewhat large (large follicular cyst), the wall must be 
 resected with the scissors, so as to remove a flap which might mortify. Cau- 
 terized surfaces of sufficient extent are united by a catgut stitch or series of 
 stitches ; all persistent oozing of blood should be stopped in the same way. 
 
 The benignity of conser\'ative operations (resection or ignipuncture) is 
 very great, since, out of 49 cases operated upon, I have observed no acci- 
 dents. The ultimate results are most favorable. Last year (1895) 1 saw 22 
 women operated upon within six months at latest, and three years at most ; 
 13 were completely cured. Out of this number 4 became pregnant and 3 
 of these were delivered at term of living children ; 4 were greatly benefited; 
 I was only temporarily helped ; only 2 were not improved and were later 
 obliged to undergo a complementary operation. Since then 3 other women 
 operated upon have become pregnant. I have several times performed sal- 
 pingorrhaphy, that is to say, suture upon the ovary of the ampulla of a tube 
 which was healthy, but kept apart from it by adhesions which I ruptured. 
 In every case I first performed resection of a portion of the ovary. 
 
 We must remember that the good effects of removal of the ovary and 
 tubes may not be felt for weeks or even months. During this time the pa- 
 tient may continue to suffer abdominal pains, which, though certainly less 
 severe than before, discourage her by causing a belief that the operation has 
 not attained the hoped-for result. 
 
 These phenomena are to be attributed to two causes : (ist) The irritation 
 of the peritoneum near the ligature, which being upon inflamed tissue pro- 
 duces a certain amount of peripheric reaction ; (2d) the persistence of inflam- 
 mation in the stump of tube left in place. I think that we should always 
 remove as much as possible of the tube, leaving attached to the uterus only 
 the amount necessary to insure a firm ligature. Finally, every operation 
 upon the tubes should be followed by curetting of the uterus, and injections 
 of iodine solutions, to modify the accompanying endometritis, and at the 
 same time cure the inflammation of the tubal stump. I usually practise this 
 curetting about a month after the operation. 
 
 The menopause does not always follow at once after removal of both 
 tubes and ovaries. The persistence of the menses for any length of time 
 seems often to depend upon a lesion of the mucosa (endometritis, etc.) that 
 plays the part of an irritating body in the uterus ; hence the value of the sub- 
 sequent local treatment T have advised. Removal of the tubes alone, how- 
 
CYSTIC OOPHORO-SALPINGITIS. 547 
 
 ever, does not cause a cessation of the menses ; although Tait gives these 
 organs the chief role in the menstrual function. But salpingotomy without 
 oophorectomy will cause sterility. 
 
 Vagiiuxl Hysterectomy. — Vaginal hysterectomy, or utero-ovarian castration 
 by the vagina, was recommended by Pean and popularized by P. Segond as 
 the operation to be preferred in bilateral inflammatory lesions of the appen- 
 dages. The operative procedure which I prefer is that recommended by Se- 
 gond, the description of which I borrow from Baudron's thesis. The cervix 
 being firmly seized by each lip with Museux forceps, the vaginal mucosa is 
 incised. Segond always completes the classical circular incision by two 
 lateral incisions. The posterior cul-de-sac having been opened and the blad 
 der completely detached by the finger, two short forceps are placed at the 
 base of the broad ligaments upon the uterine arteries, and the portion of the 
 ligament thus rendered bloodless is cut. The cervix liberated by this 
 means is by two lateral incisions divided into an anterior and posterior flap, 
 each of which is resected. At the same time, the operator, holding the an- 
 terior portion of the uterine stump with a strong Museux forceps, makes 
 an anterior hemi-section according to Doyen's method. In many cases this 
 alone allows one to draw down the uterus. If not, we perform a conoid cen- 
 tral "hollowing out." With a curved bistoury we outline in the uterine 
 tissue a cone whose base corresponds to the Museux forceps. Before com- 
 pletely detaching this cone we insert a mouse-toothed forceps upon the con- 
 centric lip of the hollow cone just made, and then proceed to the complete 
 removal of the cone. This same manoeuvre is repeated as we advance step 
 by step from the cervix to the fundus. The important point is to keep to 
 the median line of the anterior uterine surface. If we observe this funda- 
 mental precept, even if we exert a slight degree of traction upon the uterus, 
 we, so to speak, operate in the light. Little by little, and thanks to the dis- 
 appearance of the anterior uterine wall thus resected by the successive re- 
 m.oval of the cone-shaped portions, the organ sways forward into the anterior 
 ■cul-de-sac, taking with it the superior border of the broad ligaments. It is 
 only at this point of the operation that the surgeon need think of haemo- 
 stasis. Outside the appendages, if they have been dragged after the uterus, . 
 within them if adhesions prevent their descent, we place from above down- 
 wards some small pressure forceps, usually two to each broad ligament. Each 
 ligament is then cut, and the forceps in falling cause the portion of ligament 
 which they protect from bleeding to undergo a torsion of 180°. As soon as 
 one forceps is in place, a portion of ligament equal to the length of its jaws 
 is divided, and with two or three clips of the scissors the uterus is liberated 
 and the operation finished with four to six pairs of forceps. 
 
 Should posterior adhesions prevent the anterior swaying of the uterus, we 
 must not hesitate to treat the posterior wall of the uterus in the same way as 
 the anterior wall, by hollowing out the median portion in such a way that the 
 uterus, reduced to two tubular angles, will bend at the fundus, as if on a hinge. 
 
548 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 The uterus once removed, the haemostatic forceps on the broad Hgaments 
 are gathered into a right and a left bundle, and the appendages are sought 
 for. Should their removal entail pain or danger, it is better to leave them in 
 place after having opened any purulent or cystic cavities with the finger. 
 The dressing is made with strips of sterilized or iodoform gauze, whose ends 
 are gathered together and carried beyond the teeth of the forceps. A cath- 
 eter is left in the bladder. The forceps are removed in forty-eight hours. 
 The gauze is left in place from six to eight days if the temperature remains 
 normal ; should it become elevated, the strips are removed, and antiseptic 
 vaginal injections given under low pressure night and morning. 
 
 I prefer this procedure to the systematic anterior hemi -section of Doyen, 
 or the total henii-section of Miiller-Quenu. With Segond, I hold that the 
 preliminary liberation of the uterus gives the greatest amount of security as 
 regards the ureter, which, after this step in the operation is accomplished, is 
 in no further danger of compression. 
 
 Gravity of the Operation (oophoro-salpingotomy for inflammatory lesions, 
 Tait's operation). In order that the statistics be of real value in assisting 
 us to form an opinion as to the gravity of the operation, they should be made 
 in conformity with the following classification: 
 
 1st. Acute catarrhal, non-suppurative oophoro-salpingitis. 
 
 2d. Suppurative oophoro-salpingitis — (c?) non-cystic; (Jf) cystic, which 
 can be enucleated ; {c] cystic, which cannot be enucleated. 
 
 3d. Chronic oophoro-salpingitis (hypertrophic and atrophic). 
 
 ■4th. Cystic (serous or bloody) oophoro-salpingitis (hydro-salpinx, hsema- 
 to-salpinx). 
 
 Unfortunately but few of the published records are careful to make these 
 distinctions; still we are able to assert, from what we know, that the oper 
 ation is usually beneficial. In the case of pyo-salpinx it is serious, but be- 
 comes of great gravity only when the suppurative process has invaded the 
 cellular tissue and peritoneum. The presence of a pus fistula, even where 
 the abscess is sharply limited and can be enucleated, is sufficient in itself 
 greatly to impair the prognosis. The general condition of the patient, too, 
 calls for careful consideration ; oftentimes exhaustion is so great that an oper- 
 ation performed in extremis has small chance of succeeding. Yet we have 
 seen cases that might be called absolute resurrections, and no surgeon has 
 a right to refuse to give a patient this last chance of life. 
 
 It seems to me useless to quote the statistics of the operation of oripho- 
 ro-salpingotomy as performed by various surgeons, the number having in- 
 creased so enormously during the past few years. The following are my 
 own personal statistics in the Broca Hospital during the past five years 
 (February ist, 1891, to February ist, 1896): 
 
 Out of 262 laparatomies for inflammatory lesions of the appendages of 
 varying degrees of severity, I had 255 cures, or a mortality of 2.66 per cent. 
 Of this number i ^6 were non-suppurating lesions. I have not had one death. 
 
CYSTIC OOPIIORO-SALPINGITIS. 549 
 
 in spite of the fact that the majority of these cases were cystic oophoro-sal- 
 pingitis, or parenchymatous oophoro-salpingitis with adhesions. The sup- 
 purative lesions (pyo-salpinx wdth or without suppurative perimetro-salpin- 
 gitis) numbered 86 ; there were 79 cures and 7 deaths, or a mortality of 
 8. 1 3 per cent. 
 
 I would observe that during the past two years in especial, I performed 
 vaginal hysterectomy for inflammatory lesions of the appendages much more 
 frequently than I used to do, although I remain a partisan of laparatomy for 
 the great majority of cases. 
 
 Laparatomy a)id Vaginal Hysterectomy Compared — Comparative Gravity. 
 — Many surgeons have entirely replaced laparatomy by Pean's operation of 
 vaginal hysterectomy in cases of bilateral lesions of the appendages, whatever 
 the extent of the inflammatory disorders. They claim that it is a less grave 
 operation, that the cm^e is more permanent, and that it leaves no cicatrix. I 
 forcibly opposed so positive a declaration, and I believe that I succeeded in 
 demonstrating that in that form it was incorrect. With the exception of a 
 limited number of cases which I will presently enumerate, laparatomy is 
 quite as benignant as hysterectomy. Its results are more complete and moi-e 
 durable, for it permits of a more complete removal of all lesions of the 
 appendages. Should endometritis persist it can readily be overcome by 
 curettage. The abdominal cicatrix is trifling if the methods of incision and 
 suture which I have recommended are followed. 
 
 Finally, laparatomy permits of a rectification of diagnostic errors which 
 in a clinical examination are not always avoidable ; it sometimes prevents 
 needless extirpation. It is due to laparatomy that in some cases when 
 double castration has been thought necessary we find that resection or 
 ignipuncture of the ovary are all that is required. 
 
 I therefore consider laparatomy to be the operation to be preferred in 
 nearly all non- suppurative inflammatory lesions of the appendages, and even 
 in bilateral suppurative lesions in which the tumor is distinct from the uterus 
 and can be easily separated from it. On the other hand, I believe that vag- 
 inal hysterectomy is a decided step in advance in two classes of cases : 
 I St. Suppurative or non-suppurative tumors of the appendages when they 
 are fused with the uterus and could not be detached from it without great 
 injury, in view of the great degeneration and friability of the uterus in these 
 cases. 2d. Suppurations originating in the appendages which have extended 
 to neighboring tissues and caused suppurative perimetro-salpingitis, which 
 will be studied in the next chapter. 
 
 Hysterectomy is therefore superior to laparatomy in cases of cystic or 
 non-cystic oophoro-salpingitis, markedly adherent to t/ie uterus. I must in- 
 sist upon this indication, which for me constitutes the criterium of the sur- 
 geon. It is true that before Pean's operation was suggested, these compli- 
 cated cases were often cured by laparatomy, with the aid afforded by the 
 Trendelenburg posture and evisceration, and thorough drainage with or with- 
 
550 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 out Mikulicz's tamponade. I have already published convincing data upon 
 this subject. None the less have I come to value hysterectomy more highly 
 than I did at a time when I was arguing against the extreme tendency of 
 surgeons to adopt it in every case. My opinion at present is this : Vaginal 
 Iiystcrcctoiny is to be preferred to laparatoniy in all eases %vhere the appendages 
 appear to be strongly adherent to the litems, and in those in which the suppuration 
 extends to the neighboring tissues {siipp2irative peri-metro -salpingitis) . 
 
 The question of the comparative gravity of laparatomy and hysterectomy 
 has given rise to the publication of numerous statistics which lead to dia- 
 metrically opposed opinions. I do not propose to discuss them, and will 
 merely obser\'e that in the hands of skilful operators both of these operations 
 would appear to be equally benign in simple cases ; laparatomy being per- 
 haps a little the better. In complicated cases, with adhesions or diffuse 
 inflammation, hysterectomy is incontestably less grave. 
 
 This operation has rendered great service to surgery in severe inflamma- 
 tions of the appendages. We must not, however, adopt it in all cases. In 
 my eyes it is an exceptional operation, laparatomy being practised, as a rule, 
 it being more certain, more efficacious, and more benign. Finally, the 
 women who by its means are not rendered completely sexless, either because 
 the uterus is preserved or because a segment or portion of the ovary per- 
 mits of even an irregular menstruation, appear to be less exposed to the 
 various troubles which sometimes follow castration than those from whom 
 all the internal genitalia have been removed. 
 
 Total Abdominal Hysterectomy . — In consequence of the sometimes imper- 
 fect results often given by simple extirpation of the appendages by lapara- 
 tomy, some surgeons have not hesitated to remove both tubes and uterus 
 through the abdominal opening. Performed for the first time by Polk, this 
 operation has in America found enthusiastic partisans in Baldy, Krug, and 
 Pryor. In France it has been performed only by Chaput and Delageniere. 
 
 According to Pryor, the operative procedure is as follows : The patient 
 having been placed in the Trendelenburg position, and the abdomen opened 
 as in ordinary laparatomy, the upper part of the broad ligament is divided 
 between two ligatures. The uterus may then be uplifted, the bladder de- 
 tached, and the posterior cul-de-sac opened. The uterus is now held in 
 place only by two lateral pedicles containing the uterine arteries; these are 
 tied by means of a Deschamps needle, and the uterus is removed. The 
 incised portion of the broad ligament is closed on each side by sutures; the 
 upper pedicles are cut close and left in the abdominal cavity, the lower ones 
 pushed back into the vagina. The peritoneal cavity may be entirely sewed 
 up, or the pelvis may be drained by a piece of iodoform gauze carried into 
 the vagina. In any event the abdominal wound is completely closed. 
 
 As I have already stated, I think it a mistake to exalt a manoeuvre which 
 is one of 7iccessity\n\.o a method of choice. I do not approve of hysterectomy 
 except when the adhesions of the appe7idages to the uterus cause great diffi- 
 
CYSTIC OOPHORO-SAI.PTNGITIS. 55 I 
 
 ciilties in the way of hnemostasis. In such a case, had it been possible to 
 diagnose correctly beforehand, a vaginal oophoro-hysterectomy would have 
 been preferable. The reason why American surgeons prefer total abdominal 
 hysterectomy is because they long remained without a thorough knowledge 
 of the technique of vaginal hysiQYQctomy hy morccllrvicnt with forcipressure, 
 the only procedure adapted to such cases. I do not doubt that when they 
 have become more familiar with this operation they will recognize its supe- 
 riority over abdominal oophoro-hysterectomy. 
 
CHAPTER XXVL 
 
 PERIMETRO-SALPINGITIS. 
 
 {Peri-uterine Inflaininatio7i, Perimetritis, Parametritis, Pelvic Peritonitis, 
 PJilegnion of tJie Broad Ligaments, Adeno-lymphitis, Juxta-piibic Adeno- 
 phlegmon, Pelvic Abscess, Pelvic Cellulitis.) 
 
 The confusion which has long existed in the classification and complete 
 understanding of diffuse inflammations of the pelvis still prevails to a cer- 
 tain extent. Yet, thanks to the better knowledge of tubal inflammations 
 acquired by a more enlightened study of clinical facts, aided by careful ob- 
 servations of conditions revealed by operations, we are beginning to obtain 
 more exact information, which at the same time greatly simplifies the sub- 
 ject. This is our present status: though the starting-point of inflammatory 
 processes is often in the uterus, yet it is more frequently from a salpingitis 
 that we get inflammations in the neighborhood of the uterus, the broad liga- 
 ment, cul-de-sac of Douglas, and pelvic cellular tissue. It is, therefore, es- 
 sential to include the tube in denominating the disease, and to unite all these 
 lesions under the generic name of oophoro-salpingitis, or, for the sake of 
 euphony, simply perimetro-salpingitis. 
 
 The invasion occurs with greatly, varying clinical characteristics as to 
 progress and intensity, according to the etiology. This naturally produces 
 a series of distinct clinical types, although pathology includes them under 
 one head. 
 
 Historical Sketch. — The more intense inflammations were the first to be 
 observed, and the first described are the severe and rapidly suppurating 
 forms following localized puerperal septicaemia. The works of Grisolle and 
 Bourdon mark this first stage ; phlegmon of the broad ligament was still con- 
 fused with abscess of the iliac fossa of totally different origin. 
 
 Nonat, Valleix, and their pupils advanced the clinical knowledge of peri- 
 uterine inflammations by describing the more sharply limited collections of 
 pus which are found posterior to and upon the sides of the uterus ; they con- 
 sidered them to be situated in the cellular tissue which they thought existed 
 not only between the folds of the broad ligament, but around the supra- 
 vaginal portion of the cervix, especially posteriorly, like a ring with its bezel 
 directed toward the cul-de-sac of Douglas, to use a simile of Gallard. 
 
 Interminable discussions, more theoretical than practical in their nature, 
 followed the promulgation of these views. At the same moment, almost, 
 
PERIMETRO-SALI'INGITIS, 5 53 
 
 another interpretation of the same facts was given by Bernutz and Goupil, 
 in a remarkable description of the clinical phenomena which we now attrib- 
 ute to circumscribed or diffuse inflammation of the tubes, but which they 
 thought due, without exception, to pelvic peritonitis. A few eclectic author- 
 ities, as Matthews Duncan and Simpson, admit the two preceding views of 
 the origin of the inflammation; Virchow invented the terms perimetritis and 
 parametritis to distinguish inflammation of the peritoneum from that of the 
 cellular tissue surrounding the uterus. A new^ interpretation of analogous 
 if not identical series of events came to add to the perplexity of nosologists. 
 
 The part played by the lymphatics in peri-uterine inflammations follow- 
 ing labor had been dimly apprehended by many authorities. J. L. Cham- 
 pionniere, especially, attributed great importance to them, and thought that 
 their influence extended outside the puerperal state, even to an empty uterus. 
 Alphonse Guerin believed that he had discovered a new clinical type, and a 
 different localization of the inflammation around the uterus ; he describes it 
 under the name of juxta-pubic adeno-phlegmon. The origin would seem to 
 be in a retro-pubic or obturator lymphatic ganglion and in the afferent \es- 
 sels below the peritoneum and around the uterus. According to Guerin, 
 whenever phlegmon of the broad ligament spreads into the cellular tissue of 
 the abdominal walls, we have to do with a juxta-pubic adeno-phlegmon. 
 Moreover, Guerin, Championniere, Gucneau de Mussy, Siredey, and Marti- 
 neau considered that adeno-lymphitis satisfactorily explained the more cir- 
 cumscribed peri- and parametric inflammations. 
 
 From that moment the " lymphatic interpretation" carried all before it, 
 and no active part was left to the cellular tissue or to the peritoneum. Ac- 
 cording to this theory as in all the preceding ones, the inflammation started 
 from the mucous membrane, and the initial endometritis claimed the full 
 attention of the clinician. At the very outset of these contradictor}' debates, 
 which divided the gynaecological world, a theory was timidly put forward, 
 but, because of insufificient demonstration, did not receive the attention it 
 deserved. Aran, who was the first to perceive clearly the extreme impor- 
 tance of the part taken by the ovaries and tubes in uterine pathology, may be 
 said to have anticipated this generation by attributing pelvic peritonitis to 
 inflammation of the uterine appendages. He clearly showed that these are 
 the foci around which gather pus and false membranes. Isolated observa- 
 tions by other writers which demonstrate the truth of this proposition were 
 published, but attracted no attention. At the present time, the tendency is 
 to return to Aran's views, but in my opinion there is not enough emphasis 
 laid upon this theory as the only possible solution of all peri-uterine inflam- 
 mations. The more recent writers still give a separate description of para- 
 metritis and perimetritis, to which they sometimes add adeno-lymphitis, with 
 the result that the bewildered reader can scarcely follow the subtleties of 
 diagnosis. For my part, I frankly acknowledge that I believe in Aran's the- 
 ory. The facts which I have personally observed have shown me that nearly 
 
554 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 all peri- and parametric inflammations are merely forms of salpingitis and 
 peri-salpingitis. The lymphatics certainly have an important part to play, 
 but even this is subordinated to the previous inflammation of the uterine 
 mucous membrane and its extension into the oviduct. Now, the primary 
 phenomenon is always the one whose name should be given to the disease. 
 
 I will describe in succession the various anatomical forms that may be 
 assumed by inflammation about the uterus and its appendages, beginning 
 with the mildest. These clinical types are : i. Serous perimetro-salpingitis. 
 2. Pelvic abscess. 3. Phlegmon of the broad ligament. 4. Diffuse pelvic 
 cellulitis. 
 
 Pathological Anatomy, i. Serous Perimetro-salpingitis. — This lesion can- 
 not be seen at autopsies, but may be observed during the course of certain 
 
 Fig. 405. — Serous Perimetro-salpingitis (Inflammatory CEdema). 
 
 vaginal wall. 
 
 <r, Cervix seen through opening in the 
 
 operations. For my own part, I have twice found an oedematous infiltra- 
 tion of the folds of the broad ligament about a tube which was affected 
 with purulent salpingitis. Before laparatomy, by bimanual palpation, this 
 infiltration gave the sensation of a rather large tumor, which might have 
 been mistaken for a tumor of the tube itself. Lymphangitis surely has 
 something to do with this acute oedema giving rise to inflammatory nodules. 
 The proof of this fact is seen in the engorgement often produced in the 
 inguinal glands communicating with the lymphatics of the surface of the 
 uterus by a small vessel which accompanies the round ligament (Fig, 352). 
 
 These hard oedemas may doubtless invade the loose cellular tissue sur- 
 rounding the oviduct, under the influence of an acute attack of salpingitis. 
 Neither is it impossible that an effusion of muco-pus or of blood may from 
 time to time come from the inflamed mucous membrane and irritate the cul- 
 de-sac of Douglas or the frequently prolapsed appendages. Whatever the 
 
PERIMETRO- SALPINGITIS. 555 
 
 source, there is no contesting the fact of an intermittent inflammatory oedema 
 around the diseased tubes. Direct observation has demonstrated it, and the 
 law of induction permits us to suppose it present, in those cases in which 
 voluminous masses appear and disappear in the course of a few days upon 
 the sides of the uterus — a process witnessed by all clinicians. In the same 
 way dental caries may cause a large swelling of the cheek which disappears 
 without a trace at the end of forty-eight hours. 
 
 By the side of this serous peri-salpingitis we must place serous peri- 
 metritis. There are cases in which the inflammatory oedema is produced at 
 the base of the broad ligament, around the large lymphatic vessels which 
 come from the cervix uteri (Fig. 353). This is especially noticed after cer- 
 tain operations upon this organ (Schroder's, Emmet's, etc.), if they have not 
 been perfectly aseptic. 
 
 To this inflammatory oedema of the subperitoneal connective tissue, which 
 may anatomically be compared to the experimental oedema produced by Ran- 
 vier's process, is often added a secretion of serous fluid between the adven- 
 titious membranes around the appendages, and especially in the pouch of 
 Douglas, forming serous collections of fluid. Capillary punctures performed 
 as a therapeutic measure have demonstrated their existence and proved their 
 frequency. They have, moreover, been found during some laparatomies, A. 
 Doran has published the report of a curious case in which such a collection of 
 fluid was, after opening the abdomen, mistaken for a sarcoma of the ovary, 
 which they did not dare remove : the rapid disappearance of the tumor left 
 no doubt as to its nature. 
 
 This is the first degree of peri -uterine inflammation : in the great major- 
 ity of cases, it corresponds to a well-defined clinical type, that of ephemeral 
 acute attacks during the course of inflammation of the appendages. To it 
 also may be ascribed the circumscribed and masked parametritis which has 
 been supposed to cause the relaxation or retraction of the uterine ligaments. 
 
 SuppiLrative perimetrosalpingitis is met with clinically under two \^ery 
 different types. One of them corresponds to the later stages of pelvic peri- 
 tonitis, as salpingitis and pyo-salpinx correspond to the early stages : that is, 
 pelvic abscess. The other, phlegmon of the broad ligaments, is character- 
 ized by a special mode of extension of the suppurative process, determined 
 by certain etiological circumstances. 
 
 Pelvic Abscess. — This expression must not be misinterpreted as has been 
 the case even recently. Voluminous pyo-salpinx, forming large purulent 
 cavities adhering by a large portion of their surface to the pelvis, have long 
 been taken for encysted collections of pelvic peritonitis or for abscesses be- 
 neath the peritoneal folds, and have erroneously been called pelvic abscesses. 
 Their real origin is difficult to demonstrate, as it demands a tearing apart of 
 the tubal sac, which the earlier operators, in search of pus in the abdomen, 
 would not have dared undertake, even had they supposed it feasible. Upon 
 opening the abdomen, if you find a pouch as large or larger than both fists. 
 
556 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 circumscribed by adhesions upon every side, seeming to be joined posteriorly 
 to the cul-de-sac of Douglas, which it fills, adherent laterally to the pelvis 
 and superiorly to the epiploon or even to the intestine, it is very natural to 
 suppose that an abscess has formed either in the subperitoneal tissue (para- 
 metritis), or in the peritoneum, shut in by adventitious membranes (pelvic 
 peritonitis) ; yet in the majority of cases we have to do with a purulent tubal 
 cyst, free in the beginning and afterward rendered immovable. This may 
 be demonstrated by boldly tearing apart the walls of the cyst (first emptying 
 it by aspiration). When this oftentimes laborious work is finished, we fre- 
 quently find a cyst with an internal pedicle inserted upon the horn of the 
 uterus, and we recognize it as a dilated tube. 
 
 The greater number of so-called pelvic abscesses treated a few years 
 ago by laparatomy and incision, without any attempt at total extirpation, 
 were nothing but adherent pyo-salpinx, which should really be entirely re- 
 moved. Their clinical and operative history belongs to the chapter on pyo- 
 salpinx, to w^hich I refer the reader. There remain, however, among the 
 number of encysted collections of fluid, a certain proportion of cases in which 
 the connection with neighboring parts is so intimate that total removal would 
 be impossible or dangerous. These cases may properly be differentiated by 
 a special name, and may be called peh'ic abscess if we clearly specify that 
 this name be reserved for collections of pus which cannot be enucleated. 
 The name has a surgical rather than an anatomical value. In point of fact, 
 at the autopsy it is usually impossible in advanced cases to determine the 
 exact nature of the abscess wall, and to ascertain whether it be peritoneum, 
 false membrane, or dilated tube. 
 
 For the same reasons we should include under the head of pelvic abscess 
 certain cysts within the broad ligament, certain forms of haematocele which 
 have suppurated and become transformed into a purulent mass ; a real ab- 
 scess, which adheres on every side to the soft or hard portions of the pelvis, 
 and which cannot be removed. Among the cases of pelvic abscess reported 
 cured by laparatomy and incision by Tait was one which he traces to an 
 extra-peritoneal intra-ligamental pregnancy. No vestige of a foetus was 
 found in the pus, but only the placental debris. We thus see that if an 
 extremely adherent pyo-salpinx constitute the great majority of cases of pel- 
 vic abscess, in exceptional cases the latter may be located elsewhere. In 
 some cases, moreover, the appendages, which are diseased but not greatly 
 enlarged, form the starting-point for a large pehic abscess whose cavity is 
 limited by false membranes and agglutinated loops of intestine. It is espe- 
 cially in these cases that one is tempted to attribute the most importance to 
 inflammation of the peritoneum, and apply tlie term pelvic peritonitis, not 
 attaching sufficient importance to the initial lesion of oophoro-salpingitis. 
 Finally, I have quite exceptionally observed collections of pus rather widely 
 separated from a pyo-salpinx, and probably developed around lymphatic ves- 
 sels which have been infected from a utero-tubal lesion. This primary le- 
 
PERIMETRO-SALPINGITIS. 5 5/ 
 
 sion may, however, always be found to exist. In other words, if among the 
 complex lesions which give rise to pelvic abscesses we always find either a 
 pelvic peritonitis, a lymphangitis, or a cellulitis, we must bear in mind that 
 these morbid elements are themselves only secondary ; consequently I ha\-e 
 given them the second place, from a nosological point of view, and have gixen 
 to the disease the more comprehensive name of perimetro-salpingitis, a name 
 serving as guide to both clinician and operator. Pelvic abscesses, which are 
 a variety of this species, are more especially due to peri-oophoro-salpingitis, 
 while phlegmon of the broad ligament, a second variety of pelvic suppura- 
 tion, usually follows perimetritis. The intimate adhesion of a pyo-salpinx 
 to the pelvic walls, or to the pelvic organs, is the first step toward spontane- 
 ous rupture. Its tendency is to open into the rectum ; a first evacuation 
 relaxes the sac, but it is very soon filled again, and the communication be- 
 tween sac and rectum becomes, if not permanent, at least regularly intermit- 
 tent. These fistulae are more rarely produced into the vaginal cul-de-sac. 
 Finally, if the abscess has developed soon after labor, when the appendages 
 which have been carried upward by the gravid uterus tend to fall forward, 
 the suppuration may gravitate into the anterior portion of the pelvis, and, 
 after invading the pre-vesical cavity of Retzius, spread into the groin or 
 toward the umbilicus. These fistulous pelvic abscesses are a most important 
 variety. Long after their first development, they become reduced to pas- 
 sages of no great width, but very sinuous, and surrounded by chronically 
 indurated tissue which it is exceedingly difficult to cure. 
 
 Klob has pointed out the frequency of fatty degeneration of the muscular 
 fibres of the uterus, when pelvic suppuration exists. I also have had occa- 
 sion to observe it; it is especially noticeable when one attempts to remove 
 an abscess sac which is adherent to the uterus, as the latter then tears 
 easily. 
 
 Indurated masses due to the infiltration and proliferation of connectiv^e 
 tissue are often found by the side of and extending beyond the abscess. 
 These may continue after it has been evacuated, and form residues very hard 
 to cure. Upon the omentum also may be seen the ligneous masses of chronic 
 epiploitis. All these lesions rapidly disappear after evacuation of the puru- 
 lent focus. 
 
 Phlegmon of the broad ligament is nearly always secondary to a recent 
 labor, when the cellular tissue of this serous membrane has been stretched 
 and relaxed, and the veins, which have become varicose, are the seat of 
 thrombi or may even rupture and let the blood spread more or less exten- 
 sively around. The result is an anatomical condition eminently favorable 
 to the rapid development of suppuration. 
 
 What is the exact starting-point of the process ? Does the infection 
 come from the inflamed tubes situated at the upper border of the folds of 
 the ligament.' or is it caused by a peri-lymphangitis of the large vessels at 
 its sides ? Either process is possible, and the two may indeed coexist ; the 
 
558 CLINICAL AXD OPERATIVE GYNAECOLOGY. 
 
 important fact to bear in mind is the pre-existing anatomical condition or the 
 intensity of the infective process, which permits the lesion to assume its spe- 
 cial character from the start — that of phlegmon, Avith a tendency to become 
 diffused, which is a different thing from a circumscribed abscess. 
 
 There are few exact anatomical documents upon this subject. In the 
 report of an autopsy published by A. H. N. Lewers we find some interesting 
 details. The two folds of peritoneum were separated by an abundant exuda- 
 tion which came from the inferior border of the tube and extended to the 
 base of the ligament below, and to the pelvic walls beyond. The tube was 
 stretched below the convex surface of this swelling. The writer gives no 
 details as to its anatomical condition, which he seems not to have examined ; 
 but he calls attention to a small abscess in the substance of the ovary, whose 
 surface adheres to the surface of the broad ligament by recent exudations. 
 The probabilities are that the tube was diseased, and in any case the broad 
 ligament may have been infected by the suppurating ovary. A section of 
 the broad ligament showed spongy areolar tissue the cavities of which were 
 filled with a sero-sang"uineous fluid. In an autopsy at which Carter assisted, 
 the section of the broad ligament conveyed the idea of an interstitial injec- 
 tion of plastic material which separated the normal elements, and kept the 
 veins distended and the lymphatics immobilized and gaping. 
 
 Delbet reports an autopsy upon a patient three weeks after labor, when 
 he found at the base of each broad ligament a purulent cavity containing 
 lOO gm. (3 oz., 2 dr.) of pus, traversed by thick bridles formed of arteries 
 and veins. An injection into the hypogastric artery demonstrated that 
 these vessels were the visceral branches of the internal iliac. Raffray and 
 Jayle also reported a case of post-puerperal phlegmon of the lower part of 
 the broad ligament, the pus containing the streptococcus. 
 
 The inflammatory infiltration is easily carried beneath the peritoneum, 
 along the psoas iliacus, as far as the anterior superior spine of the ilium, 
 and from there extends into the subcutaneous adipose tissue, through weak 
 points in the musculo-aponeurotic layers, the vascular orifices, and nerve 
 channels. As soon as the purulent sac comes in contact with the abdominal 
 walls it adheres to them, and gives rise to the sensation of a plaque or re- 
 sistant flattened mass. Suppuration usually follows infiltration, but it ma}' 
 be absent ; the process then stops, and the phlegmon resolves, leaving only 
 indurated masses of cellular tissue. At times I have noticed a curious and 
 little-known phenomenon, which persists for a long while after the peri- 
 uterine inflammatory phenomena have subsided : just as the whole process 
 seems at an end, we discover signs of a suppuration at a greater or less dis- 
 tance from the original site of the abscess, toward the iliac fossa, in the 
 sheath of the psoas or even in the perinephric cellular tissue. It would seem 
 as though some septic residues had been left there and developed slowh' after 
 having lost all connection with their point of origin. It is also probable 
 that the lymphatics have a share in the production of these tardy abscesses, 
 
PERIMETRO-SALPINGITIS. 559 
 
 which closely resemble those produced in situations where there has been a 
 pre-existing lymphangitis. 
 
 In all the preceding affections, septic infection is more or less localized, 
 and the lesions produced remain within clearly defined limits. This is not 
 always the case, however; following certain cases of puerperal infection, 
 the infiltration rapidly extends through the whole pelvic cellular tissue, 
 spreading in the same way as malignant erysipelas ; hence the name of ery- 
 sipelas malignum puerperale given to it by Virchow. The oedematous tis- 
 sues are livid, the lymphatics full of micrococci, the vein contain blood-clots 
 or pus ; these cases usually terminate fatally. The predominant part played 
 by the lymphatics is beyond dispute ; this is a veritable septic lymphangitis, 
 starting from the uterine wound and invading everything that surrounds the 
 generative apparatus. It is for this clinical type that I suggest we reserve 
 the name of diffuse pelvic cellulitis. 
 
 General Etiology. — I shall not repeat what has already been said about 
 the etiology of tubal inflammations, which applies perfectly to the affections 
 under consideration, since, with the exception of diffuse pelvic cellulitis, 
 which constitutes a class by itself, all, or nearly all, peri-uterine inflamma- 
 tions are merely an extension from a tubo-ovarian centre. I will only men- 
 tion the etiological factors peculiar to the various classes which I have 
 named. 
 
 Nodules of inflammatory oedema are observed during the course of every 
 varietv of acute or chronic inflammation of the tubes. 
 
 Pelvic abscesses follow pyo-salpinx, suppuration of an imprisoned ovarian 
 cyst, or pelvic haematocele in the vicinity of an inflamed tube. Temporizing 
 treatment or too prolonged or violent explorations favor their development. 
 Is phlegmon of the broad ligament ever observed outside of the puerperal 
 state, which, as I have tried to show, exercises so strong a predisposing in- 
 fluence .'' Bernutz admits that seventeen out of twenty cases are due to the 
 puerperal state. Farrier, in a work which has become widely known, held 
 that this affection was never due to any other cause. Delbet states that 
 more phlegma of the broad ligament will soon be observed outside of the 
 puerperal condition than within it. These two opinions are too exclusive. 
 Assuredly infection of the uterus from septic operations has caused the same 
 accidents as the puerperal state, but its occurrence is rare, and invariably in- 
 dicates negligence of the rules which should govern all operations. These 
 pathological conditions are still too frequently found following cases of labor 
 or abortion ; from this it follows that the puerperal state is the most usual 
 cause of phlegmon of the broad ligament. Finally, diffuse pelvic cellulitis 
 may result from labor or operation upon the genital tract under exception- 
 ally septic conditions. It may be likened to the cellulitis which used to ac- 
 company serious operations upon the bladder or rectum. 
 
 Symptoms and Diagjiosis. i. Serous Perimetro -salpingitis. — In its 
 milder forms the symptoms of an invasion by inflammation of the parts sur- 
 
560 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 rounding the tubes and ovaries are those which I pointed out in rather cursory- 
 fashion, in the chapter on salpingitis, under the name of acute attacks. Ex- 
 cellent descriptions have been giv^en by several authors, but under various 
 names. Peter, Gueneau de Mussy, mention them without specifying their 
 exact location. Martineau ascribes them to peri-uterine adenitis ; Courty 
 also believes in a lymphatic origin. Munde in America, and A. Martin 
 likewise take this view, Cantin devotes good work to the upholding of this 
 view. 
 
 Besides the signs of coexisting salpingitis, the following are some of the 
 symptoms met with : The patients complain of an increase of their usual 
 malaise ; a marked febrile state is, however, rare ; gastric disturbance is 
 slight. By vaginal touch we find increased sensitiveness in the culs-de-sac ; 
 touching one particular spot often will cause very sharp and localized pain. 
 There may be general puffiness about the affected region, especially if pre- 
 vious similar or more severe attacks have caused adhesions, which have, so 
 to speak, ankylosed the uterus. In these cases, the signs perceptible to the 
 touch may from an acute exacerbation of the trouble assume an apparently 
 serious nature, of which the experienced clinician alone will understand the 
 real significance; the mildness of the general symptoms will aid in prevent- 
 ing an exaggeratedly gloomy prognosis. 
 
 In the course of a few days the puffiness will be seen to disappear, leav- 
 ing in its place indurated masses not attached to the uterus, which may be 
 once more quite freely movable. There are usually several nodules in the 
 posterior and lateral culs-de-sac, which, as Gueneau de Mussy was the first 
 to point out, feel like rounded ganglia and are more or less sensitive to the 
 touch. These tumors so rapidly change in character that, unless the results 
 of the daily examinations are carefully noted, one might almost fancy the 
 whole thing to have been the work of the imagination. 
 
 Occasionally we may note the long duration of hard, ligneous nodules, 
 which in shape and consistence bear a marked resemblance to fibromata. 
 They may be distinguished from the latter by the lack of intimate connec- 
 tion to the uterus, and by the absence of dilatation of the uterine cavity. A 
 prolapsed ovary is larger, and forms an isolated tumor which gives rise to 
 peculiar nauseating pain and faintness. The tumor of small ovarian cysts 
 or a cyst of the broad ligament is entirely different ; it possesses elasticit}' 
 or fluctuation, is absolutely lateral, single, and perceptible by bimanual pal- 
 pation only, not by vaginal touch. .Scybala can cause an error of diagnosis 
 only to careless examiners and those who omit the rectal exploration. The 
 use of the speculum is of no value. The course and progress of these oede- 
 matous nodules and collections of serous fluid of peri-salpingitis are uncer- 
 tain and intermittent; they constitute one of the elements of the recurring 
 inflammations of the appendages described in the chapter'on salpingitis; 
 they show a tendency to return, but none to suppurate. 
 
 2. Pelvic Abscess. — This name docs not imply merely a collection of pus 
 
PERIMETRO-SALriXGITIS. 561 
 
 situated in the pelvis, otherwise pyo-salpinx would have to be included under 
 this head. The surgical characteristic of pelvic abscess is this, that it is a 
 collection of pus which is not free, not capable of being enucleated or tied 
 off and removed, but a true pelvco-parietal collection adhering to the pelvis, 
 which forms its walls. It has been described under the names of pelvic 
 peritonitis and suppurating parametritis ; even phlegmon of the broad liga- 
 ment, which is an entirely distinct clinical variety, has been called pelvic 
 abscess. 
 
 Clinically, a pelvic abscess is usually the last phase in the development 
 of pyo-salpinx, and there is no symptomatic boundary line between them. 
 Yet occasionally acute phenomena may mark the transition from circum- 
 scribed suppuration of the tubes and ovaries (pyo-salpinx, ovarian abscess) 
 to the diffused form. If the pus break into the peritoneal cavity, or if there 
 be simply an acute peripheric inflammation, we may have the sudden appear- 
 ance of sharp pain causing faintness, and accompanied with phenomena anal- 
 ogous to those of peritonitis — chills, vomiting, distention of the abdomen, 
 drawn and anxious facial expression, and thready pulse. At the same time 
 the fever (which may until then have been absent, or discovered only by the 
 most careful thermometric examination) appears, and assumes a remittent 
 form with evening exacerbations. There are functional disorders of neigh- 
 boring organs — constipation, dysuria, rectal and vesical tenesmus. If the 
 abscess project toward the rectum, there may be complete retention of faeces. 
 
 (A peculiar but quite frequent epiphenomenon of pelvic suppuration is 
 the production of diaphragmatic pleurisy. Potain noted the fact that simple 
 inflammations or ovarian or peri-ovarian irritations might act by a sort of 
 nervous reflex upon the pleura. A. Lasne took up this subject, and con- 
 siders the pleurisy to be due to a propagation of the inflammation from the 
 pelvic peritoneum to the diaphragmatic peritoneum by means of the lym- 
 phatics, more especially those which accompany the tubo-ovarian vessels and 
 go to the pillars of the diaphragm. This pleurisy is usually dry and not 
 severe.) 
 
 Touch and bimanual palpation should be used w'ith the greatest care. By 
 these we ascertain that the uterus is immovably fixed in the pelvis by plastic 
 matter, which is merely the oedema produced by intense inflammation, and 
 which has infiltrated all the adjacent cellular tissue. After a few days, this 
 oedema diminishes, and as it were unmasks the projecting abscess, which is 
 separated from the cervix by a groove. This tumor is smooth, regular, and 
 difficult to define at its upper limit : it imparts a sensation of heat to the 
 finger, and arterial pulsation due to the dilatation of the vessels may often 
 be felt. Fluctuation is rarely appreciable, because of the indurated cervix, 
 which is often as hard as pasteboard; and because of the great thickness of 
 the infiltrated tissues intervening between the examining finger and the pur- 
 ulent mass, which is often quite small, although surrounded by an inflam- 
 matory exudate. An important characteristic is the immobility of the 
 36 
 
562 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Uterus and the tumor, which are firmly united together. By means of bi- 
 manual palpation we also note that the tumor is adherent to the pelvic walls. 
 The uterus is displaced, with the cervix flattened against the pubis if, as is 
 most frequently the case, the tumor is situated in the posterior cul-de-sac. 
 The mass may also project at the sides, and more rarely it is situated be- 
 tween the uterus and bladder. 
 
 Rectal touch is of value in furnishing additional information as to the 
 connections formed by the tumor ; the speculum is useless. 
 
 The formation of protective adhesions which serve to limit the extension 
 of the abscess may cause a prolonged remission of the symptoms. But when 
 there is an attempt at evacuation, the lancinating pains and the fever become 
 intensified. If the pus point toward the posterior cul-de-sac, the vagina be- 
 comes indurated ; if toward the rectum, there is a sensation of weight on the 
 perineum, and an exceedingly painful rectal tenesmus. 
 
 Severe crises often precede the opening of the abscess into the rectum, 
 vagina, or (which is rare) the prevesical cellular tissue, and are followed by 
 short periods of calm. The abscess, as a rule, is not completely emptied, 
 and symptoms of chronic absorption appear ; or else the abscess may be com- 
 pletely emptied, but quickly refilled, and continue to discharge its contents 
 at irregular intervals with the same accompaniment of general symptoms. 
 The patient falls into an enfeebled and hectic condition similar to that de- 
 scribed in relation to fistulous pyo-salpinx. At this stage the two affections 
 are not to be clinically distinguished ; and the difference between them due 
 to the fact that the abscess may in one case be enucleated, and in the other 
 not, concerns operative medicine alone. Exceptionally the patient is cured 
 after evacuation of the pus, but the abscess usually leaves fistulse of inter- 
 minable duration. There have been a few cases of sudden death due to the 
 rupture of the abscess into the peritoneum ; their rarity is due to the forma- 
 tion of false membranes which circumscribe the focus of suppuration. 
 
 Pelvic abscess may be tuberculous, as may be the pyo-salpinx which 
 causes it ; in such cases we shall usually find signs of the disease in the pul- 
 monary tract. 
 
 The diagnosis of pelvic abscess and of pyo-salpinx is easily made wJien 
 there is any mobility of the cystic and pediculated tubal mass, but if this 
 cystic tumor is closely adherent, or has developed fistulae, the diagnosis be- 
 comes impossible; a study of the general symptoms and commemorative 
 signs will lead us to suspect that the inflammation is becoming diffused, and 
 laparatomy alone can completely decide the matter. Phlegmon of the broad 
 ligament forms a tumor laterally placed on the uterus ; it appears shortly 
 after labor. Pelvic hasmatocele from the outset shows fluctuation ; it gives 
 rise to febrile symptoms only if it suppurate and become transformed into a 
 pelvic abscess. 
 
 3. PJilcgmoii of the Broad Ligavicnt. — Foreign writers usually describe 
 this under the head of parametritis ; it seems to me highly desirable to pre- 
 
I'ERIMETRO-SALPINGITIS. 563 
 
 serve the old name under which in France it was the subject of descriptions 
 which have become classical, the more so that this name clearly indicates 
 the principal if not the initial seat of the lesions. 
 
 It usually makes its appearance toward the end of the first week after a 
 labor rendered septic by special conditions (epidemics, lack of sufficient anti- 
 .septic precautions, etc.). A severe chill may mark the onset. In some 
 cases local pain is the initial symptom; it is situated in the lumbar region 
 .and extends into the thighs. Anorexia and sleeplessness, profuse sweating, 
 slight erratic chills, fever of a remittent type, a profound alteration of the 
 facies usher in the process of suppuration. When the pus is fairly collected 
 in a mass, there may be a delusory period of relative calm. By vaginal 
 touch, we find in the early stages only a general puffiness of the culs-de-sac, 
 which renders the uterus immovable, and which usually projects upon one 
 side of it. A later examination with bimanual palpation shows that there is 
 a localized unilateral mass joined to the uterus and uniting it to the pelvic 
 wall, and reaching to the superior strait, as if the broad ligament were solid. 
 A crescentic prolongation of this mass usually surrounds the cervix, from 
 which it is separated by a groove. There is a marked lateral version of the 
 uterus toward the unaffected side. 
 
 It is not impossible that resolution may occur, and the disease terminate 
 by a resorption of the plastic products and nodular retraction of the broad 
 ligament. This, however, is very exceptional. Usually, after a short re- 
 mission, the chills reappear, with profuse perspiration and diarrhoea, the 
 general condition clearly indicating septic infection. Death may supervene 
 at this stage, but, as a rule, the pus succeeds in finding a channel for evacu- 
 ation, unless the surgeon have anticipated the efforts of nature. The puru- 
 lent infiltration invades the whole of the broad ligament, and finally goes 
 beyond its limits, toward the vagina and the sides of the pelvis ; the vaginal 
 cul-de-sac becomes thickened and indurated, and gives to the examining fin- 
 ger the sensation of what has been called pasteboard vagina. Within the 
 anterior superior spine of the ilium, or a little below it, just above Scarpa's 
 triangle, from which it is separated by the crural arch, there appears an in- 
 durated plastron, which indicates the invasion of the subcutaneous cellular 
 tissue. When this occurs, the tumor may have gone beyond the boundaries 
 of the pelvis into the iliac fossae. The plaque-like surface spreads, becomes 
 softened at the centre, and reddens, while the greenish and viscid pus is often 
 poured forth in enormous quantity from a small aperture. The opening may 
 be into the vagina, or, more rarely, into the rectum, the caecum, or even the 
 bladder. Fatal peritonitis is due rather to an extension of the inflammation 
 than to the opening into the serous cavity. The aperture may remain fistu- 
 lous, smaller and smaller quantities of pus issuing therefrom, and may finally 
 close after a protracted period. The patient may die of hectic, unless surgi- 
 cal interference open the abdomen, drain and disinfect the suppurating region. 
 
 The diagnosis offers difficulties only at the outset, when it is a matter of 
 
564 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 doubt whether the pus will remain circumscribed and form a pelvic abscess, 
 and at the termination of the process, when, the suppuration having extended 
 beyond the pelvis, phlegmon of the broad ligament has been transformed 
 into an abscess of the iliac fossa. A decisive opinion can be reached only 
 by a study of the course of the disease, which is very characteristic and not 
 in the least like that of perityphlitis, ossifluent abscess, or rapidly formed 
 cancer of the ilium. 
 
 4. Diffuse pelvic cellulitis is merely the local manifestation of a general 
 condition of septicsemia, which of itself so attracts the attention of the 
 physician that I have no need to dwell upon it. I would simply call atten- 
 tion to the rapidity of its extension, which has been compared to that of ery- 
 sipelas ; to the tendency to mortification of the cellular tissue, which may 
 give rise to emphysema; to the ulceration of blood-vessels, often causing 
 formidable hemorrhages ; and to the frequency of a fatal issue. 
 
 Prognosis. — This varies according to the variety and the degree of the 
 perimetro-salpingitic inflammation. A lack of careful observance of these 
 distinctions will account for the differing opinions entertained by various 
 authorities upon this matter of prognosis. 
 
 The prognosis in regard to serous perimetro-salpingitis is that of the 
 tubal lesion which occasions it. Its course is apt to be one of recurring 
 attacks, but it does not endanger life ; it is a prolonged infirmity rather than 
 a disease. 
 
 Pelvic abscess is more serious ; it may cause death from acute peritonitis, 
 from rapid septicaemia, or from slow consumption. The course is uncertain 
 and marked by exacerbations, as Gosselin pointed out. But this surgeon, 
 together with his contemporaries, evidently included, under the name of peri- 
 uterine phlegmon, catarrhal salpingitis, with inflammatory oedema and pyo- 
 salpinx. Though the patient may escape acute accidents, and the disease,, 
 from resorption or spontaneous evacuation of the focus of inflammation, may 
 be said to be cured, yet the future health of the patient will be constantly 
 impaired because of the chronic lesions of the tube and also because of ab- 
 normal adhesions, retractions of ligaments, and displacements of the uterus 
 and ovaries. Sanger has noticed that the ureters can be much more easily 
 felt in patients who have had peri-uterine inflammations, as if their walls 
 were thickened by the inflammatory processes in their vicinity. Some cases 
 have even been reported of accidents due to pyelo-nephritis caused by retrac- 
 tion of cicatricial tissue resulting from pelvic abscess. Freund describes 
 under the name of chronic atrophic parametritis a disease which might fre- 
 quently be due to a pelvic abscess cured by spontaneous absorption with 
 resultant sclerosis of the inflamed tissues. By this retraction the vessels are 
 compressed, and as a result there is atrophy of the whole genital canal, with 
 a premature menopause. Sanger has observed that the ureter was more 
 easily reached, larger and more indurated upon the side where a parametritis 
 had existed; this condition may be due to inflammation by contiguity and a 
 
PERIMETRO-SALPINGITIS. 565 
 
 species of consecutive parenchymatous uteritis. Phlegmon of the broad 
 ligaments is very serious. Death may take place during the inflammatory 
 stage at the outset, or supervene upon prolonged suppuration, or occur sud- 
 denly from an embolus caused by thrombosis of the pelvic veins. Diffuse 
 pelvic cellulitis is nearly always fatal. 
 
 Treatment. — Perimetro-salpingitis should be treated in the same way as 
 the salpingitis which has given rise to it. The essential features are rest, 
 revulsives, and prolonged injections of hot water. The cases which have 
 been so rapidly cured by electricity surely belong to this category. Acute 
 attacks have often been known to disappear rapidly after energetic intra- 
 uterine treatment, curetting, and injections, and this result has been adduced 
 in proof of the lymphatic origin of perimetritic affections. 
 
 These acute attacks are not the least of the indications which have led 
 surgeons to remove the appendages, thus curing the salpingitis and the peri- 
 salpingitis at the same time. 
 
 The tumors formed by acute inflammatory oedema show no tendency to 
 suppuration ; and as these are the tumors which occur most frequently, they 
 have brought about a habit of expectant treatment which has been too widely 
 applied. 
 
 I entirely disapprove of punctures for the evacuation of collections of 
 serous fluid ; they may cause suppuration and do not hasten resolution. 
 
 In pelvic abscess and abscess of the broad ligament the principal indica- 
 tion is to moderate the intensity of the inflammation by prolonged hot 
 douches, by local bleeding, etc. Then, as soon as the pus is formed, we 
 must go in search of it. 
 
 In what locality shall the collection of pus be opened, and how shall it 
 be done.'' I will successively consider the different cases which may cause 
 a variation in the surgical procedures. 
 
 A, Abscess Pointing toward the Vagina. — Is puncture with a trocar all- 
 sufficient } Simpson has recommended it, and recently Tenneson has taken 
 it up, penetrating into the posterior cul-de-sac, even in the absence of fluctu- 
 ation. He uses capillary puncture with aspiration for the evacuation of the 
 serum or the pus of perimetritis. This procedure is not to be recommended ; 
 there is danger of wounding the intestines should the abscess sac be far from 
 the vaginal wall ; it is inadequate if the sac be adherent ; its only use in the 
 latter case is to confirm the diagnosis and to serve as a preliminary measure 
 to immediate and more efficacious treatment. 
 
 Laroyenne, of Lyons, also practises puncture through the vagina into the 
 masses of inflammatory products of chronic peri-uterine disease, with latent 
 effusions of serous or bloody pus. His trocar, which is of quite large cali- 
 bre, has a groove upon the side, making it answer the purpose of a grooved 
 director and permitting the introduction of a lithotome after the puncture, to 
 make a lateral incision of from one and one-half to two and one-half inches 
 (Fig. 406). A glass tube with a bulb at one end is introduced, and through 
 
566 
 
 CLINICAL AND OPERATIVE GYNECOLOGY 
 
 it we can apply antiseptic irrigations under slight pressure. Laroyenne has 
 obtained good results from this method. I believe that the technique of the 
 operation can be simplified by following the aspiratory puncture, which has 
 revealed the presence of pus, by incision of the successive layers- 
 of the vaginal cul-de-sac, arresting hemorrhage by haemostatic 
 sutures such as Martin introduced in the early days of vaginal 
 hysterectomy. Tamponade would also control hemorrhage for 
 the time being. When the abscess is opened, a cross-shaped 
 rubber drainage tube may be inserted, and iodoform gauze packed 
 around it. This is in substance Munde's method. He supple- 
 ments it by a careful cleansing of the abscess cavity with a blunt 
 curette, which seems to me to be of use in a 
 few exceptional cases only. A dermoid cyst 
 containing hair and other debris was the nu- 
 
 B 
 
 p 
 
 cleus of one of the abscesses opened by 
 Munde. Curetting is not free from danger. 
 Laroyenne has demonstrated that the superior 
 wall of a pelvic abscess is usually very friable 
 and may be lacerated by mere forcible injec- 
 tions. 
 
 To avoid wounding the ureters and the 
 uterine and vaginal arteries, we should observe 
 the following rules in the choice of a locality 
 for the incision : 
 
 Tumor posteriorly placed : transverse or 
 vertical incision directed in accordance with 
 the axis of the tumor. 
 
 Tumor laterally situated : an oblique in- 
 cision, directed posteriorly and outward ; in 
 front it must not go beyond the prolongation 
 of the transverse diameter of the cervix. 
 
 Tumor in front : small transverse incision,, 
 combined with a longer antero-posterior in- 
 cision. 
 
 It is my opinion that incision through the 
 vagina should be reserved for a small number 
 of particularly favorable cases, and that as a 
 general mode of procedure it is far inferior to 
 laparatomy. Direct exploration alone, after 
 opening the abdomen, will show whether the sac can be removed; this is 
 curative treatment, whereas simple incision does nothing to prevent constant 
 recurrence of the trouble. Moreover, in making an opening through the 
 vagina, we can never be sure of not wounding loops of intestine agglutinated 
 in Douglas' cul-de-sac. 
 
 Fig. 406. — Larovenne's Trocar axd 
 Canula. 
 
PERI.METRO-SALPINGITIS. 567 
 
 B. Abscess Pointing tozuard the Rectum. — Does the fact of its pointing 
 in this direction oblige us to make an incision in a region so unfavorable to 
 the future antiseptic condition of the abscess cavity ? I think not. The pus 
 can be much better evacuated by means of an incision in the para-sacral 
 region or by perineotomy. 
 
 C. Abscess Situated at an Eqiial Distance from the Vagin'a and the Ab- 
 dominal Walls. — Various ways of reaching it have been suggested : 
 
 1. The perineal method. 
 
 2. The pelvic or sacral method. 
 
 3. Making an incision above Poupart's ligament and loosening the peri- 
 toneum to the abscess by means of an operation similar to the one used for 
 tying the iliac artery, and which I propose to call subperitoneal laparatomy. 
 
 4. Laparatomy properly so called, or transperitoneal laparatomy. This 
 really means two processes, according to whether we suture the abscess walls 
 to the abdomen or reset them, reducing the cavity to the smallest possible 
 dimensions and draining through the vagina. 
 
 5. Incision at two different times. 
 
 I will rapidly consider these various methods : 
 
 1. Through the Perineum. — Hegar long ago proposed to evacuate pelvic 
 abscesses through the ischio-rectal fossa, by carrying an incision from the 
 tuberosity of the ischium to the tip of the coccyx. 
 
 Vertical perineotomy recommended by Sanger is simply an enlargement 
 of Hegar's perineal method; the incision is made to one side of the median 
 line, begins at the level of the posterior third of the labia majora, and ends 
 an inch from the anus, between that orifice and the tuberosity of the ischium ; 
 by this means we may penetrate above the levator ani (Fig. 407). 
 
 Otto Zuckerkandl's transverse perineotomy, dividing the recto-vaginal 
 partition, has been especially recommended for the removal of uterine 
 cancer, and Sanger has pointed out that it may also be useful for the 
 evacuation of pus in the cul-de-sac of Douglas. The incision is carried from 
 one ischium to the other and at each end may be slightly prolonged from 
 before backward, and from within outward, giving it the form of a trapezium 
 without a base. The cul-de-sac may be deeply incised, and the pus evacu- 
 ated with less chance of infection than if done through a rectal opening. 
 But the wound, being funnel-shaped, will not allow of the manipulations 
 necessary for the removal of a pyo-salpinx (Fig. 408). 
 
 2. Pelvic or Sacral Method. — Quite recently several plans for reaching 
 the abscess have been proposed. 
 
 E. Zunkerkandl's and Wolfler's para-sacral incision, carried deeply along 
 the side of the sacrum, penetrates into the superior pelvi-rectal space, above 
 the levator ani. Temporary or permanent resection of the coccyx and sacrum 
 is a method adopted by Kraske, and modified by Hegar. This operation is 
 of use only when we need a large field, as in the removal of a tumor; it is 
 not needed for the purpose of evacuation. 
 
568 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 These various processes all show ingenuity, and may be of real service in 
 special cases, but they are inferior to laparatomy, in that the latter alone per- 
 mits of an incision large enough and so situated as to enable us to ascertain 
 where there is a removable pyo-salpinx or a pelvic abscess, which only an 
 
 Fig. 407. — Vertical Perineotomy (Hegar, Sanger). «, Anus; Ti^ tuber ischii ; wz.g/', gluteus maximus ; mra, 
 
 levator ani ; Fi7\ ischio-rectal fossa. 
 
 incision can relieve. By adopting the former means, there is always the risk 
 of simply cutting into sacs which might be more rapidly and completely 
 cured by removal. 
 
 3. Subperitoneal laparatomy possesses the decided advantage of avoiding 
 the dangers consequent upon an effusion of pus into the serous cavity; it is, 
 for this reason, more advantageous than laparatomy properly so called, or 
 transperitoneal laparatomy. But it has this drawback, that if the sac is enu- 
 cleable, even though adherent, it cannot be removed, but merely incised. I 
 am less in favor of this operation since our knowledge of pyo-salpinx has 
 become more definite; yet as it may in some cases be very useful, I will 
 give a rapid description of it. 
 
PERIMETRO-SALriNGITIS. 
 
 569 
 
 We must, in the first place, by touch and bimanual palpation, ascertain 
 the exact situation of the abscess. Then about half an inch above the crural 
 arch we make an incision of four to five inches in length, cutting through 
 the successive layers of tissues until we reach the subperitoneal cellular tis- 
 sue. The serous membrane, as in ligation of the external iliac, is separated 
 
 Fig. 408, — Tkansverse Perineotomy (O. Zuckerkandl). A, Anus; i?, rectum; J', vagina; Mra, levator ani 
 
 muscle ; F/r, ischio-rectal fossa. 
 
 by the fingers toward the horizontal ramus of the pubis. The peritoneum is 
 now pressed up from within, either by a large retractor or the fingers of an 
 assistant, while the operator carries his index finger into the wound and en- 
 deavors to find the resistant abscess. He may little by little reach the base 
 of the broad ligament, in the deepest portion of the pelvic cavity. When 
 the purulent mass is recognized by the fluctuating sensation which it im- 
 parts, it is opened, and the cavity carefully cleansed, and then drained, either 
 through the abdominal wall or b}' a cruciform tube which can readil}' be 
 introduced by the aid of Wolfler's forceps (Fig. 52). For the success of 
 the latter manoeuvre, we must ascertain, both by vaginal touch and an exam- 
 
570 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 ination of the bottom of the wound, that only a short distance separates the 
 two cavities. I have used this method several times with resulting cures. 
 A patient of mine operated upon last year, from whom I removed a collec- 
 tion of pus with staphylococci weighing about five hundred grams (more 
 than a pound), is at the present time pregnant, and free from suffering. The 
 separation of the peritoneum may at times not suffice to give us free access 
 to the abscess, either because its situation has been erroneously diagnosed, 
 or because previous inflammation has caused adhesions of the serous mem- 
 branes and it is so friable that there is danger of laceration. In such cases 
 we may at once apply the first part of Hegar's ingenious process of incisions 
 at two different times, which I shall describe later on. 
 
 4. Incision by laparatoniy properly so called, or transperitoneal section, 
 was first practised by Lawson Tait, whose example was then followed by 
 many other surgeons. The abdominal opening is rather small (from three 
 and one-half to five inches) ; the fingers are introduced for the purpose of 
 finding the abscess, which is evacuated by aspiratory puncture; the abscess 
 sac is then drawn up to the edge of the abdominal wound and opened, and 
 its walls stitched to the lips of the wound ; it is then thoroughly cleansed, 
 and filled with antiseptic gauze, or else two large drainage tubes are inserted. 
 There have been many brilliant results from this operation, and some fail- 
 ures. Several difficulties may be met with ; the sac may be so closely adher- 
 ent to the pelvis, or so small, that we cannot draw it up to the edges of the 
 abdominal wound; or else if we succeed in fixing it in position it subse- 
 quently tears apart and there is an effusion of septic matter into the perito- 
 neum. Emmet states that he has seen Lawson Tait himself abandon the 
 operation because he could not separate the sac from the loops of intestine 
 which adhered to and covered it. 
 
 When the walls of the abscess are well defined (which is rare), but its 
 enucleation is impossible, we should proceed in the following manner : The 
 sac is to be evacuated by puncture, opened with the greatest care so as not 
 to injure the peritoneum, and cleansed; its base and the posterior vaginal 
 cul-de-sac are to be explored, in order to ascertain whether drainage be pos- 
 sible in that direction. If it be found practicable, a large trocar or Wolfler's 
 forceps should be pushed through the vaginal cul-de-sac, introducing a rub- 
 ber cross drainage tube the arms of which are to be inserted in the bottom of 
 the abscess cavity. We now resect as much as possible of the purulent 
 pouch, and close it on the abdominal side by a continuous suture with a few 
 additional supporting catgut stitches. A careful " toilet" of the peritoneum 
 follows, and the abdominal wound is sewed up. 
 
 If the abscess walls are not clearly enough defined to allow of the preced- 
 ing measures, we shall have to be satisfied with a thorough cleansing of the 
 cavity, subsequently filling it with iodoform gauze according to the method 
 of antiseptic tamponade of the peritoneum described on page 62. 
 
 5. Finally, Hegar has proposed an opening in two stages, as Volkmann 
 
PERIMETRO-SALPINGlTIb. 5/1 
 
 did in the case of hydatid cyst of the liver. At the first seance we perform, 
 a laparatomy, and tampon with iodoform gauze, so as to make a channel from 
 the abscess cavity to the abdominal incision. At the second seance, four or 
 five days later, when the adhesions are strong enough, we incise the abscess 
 sac. Olshausen has employed this method with success. These proceedings, 
 may be performed through the posterior vaginal cul-de-sac. 
 
 D. Abscess Close to the Abdominal Wall. — In this case we find the pus 
 by making an incision just above Poupart's ligament, and if necessary we 
 loosen the peritoneum for a limited distance. A slight wound of this mem- 
 brane is not dangerous if the abscess sac be large and superficially placed,, 
 for the intra-abdominal pressure will push the sac between the lips of the: 
 incision and keep it there in such a manner that the pus cannot find its way 
 into the peritoneal cavity. We must not confuse subperitoneal laparatomy 
 with the incision of a collection of pus in the iliac fossa, accompanied by the: 
 separation of a very small portion of the serous membrane, but without any 
 deep penetration into the pelvic cavity. Some writers have committed this. 
 error. 
 
 In the case of a larger collection of pus, as in phlegmon of the broad lig- 
 ament, the incision should be from three to four inches long, and should be- 
 kept open by the insertion of two large drainage tubes joined together like, 
 gun-barrels, which are to be gently pushed to the bottom of the sac. We 
 may use in their stead a strip of iodoform gauze. If irrigation be used, the 
 solutions should be weak (carbolic, lo parts to i,ooo; bichloride, i in 5,000) 
 and the last injection used should be merely of filtered and boiled water, so. 
 as to avoid all danger of absorption of a poisonous fluid. If in spite of these 
 precautions we observe symptoms of sepsis, then we may fill the diverticula, 
 of the sac with iodoform gauze. Finally, if the abscess extend inferiorly 
 almost to the posterior vaginal cul-de-sac, and is recognized by vaginal touch, 
 we may drain in this direction. But we must take great care not to wound 
 the bladder, by guiding the point of VVolfler's forceps or Chassaignac's larger- 
 trocar along the finger to the posterior vaginal cul-de-sac, from above down- 
 ward, while a finger of the other hand is inserted in the vagina. Munde has. 
 twice had occasion to deplore this accident, which, however, had no serious, 
 results. 
 
 E. Abscess zvhich has Infiltrated the Pelvic Floor. — The abscess forms a 
 species of purulent sponge, the meshes being represented by thickened con- 
 nective tissue and resistant false membranes. In these cases the uterus and. 
 the appendages are imprisoned and, so to speak, cemented like stones in a 
 wall, by the products of inflammation. Intervention by laparatomy becomes 
 a serious matter. It must be restricted to opening the collections of pus, 
 tamponing and draining them through both the abdominal opening and the 
 vagina, by a counter-opening in the cul-de-sac of Douglas. A cure is long 
 and difficult, and leaves persistent indurations and fistulee. Yet I have ob- 
 tained some remarkably successful results in such cases, and so has Bouilly^ 
 
572 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Vaginal Hysterectomy was proposed by Pean in the first place for these 
 cases, though he later applied it to all bilateral inflammatory lesions of the 
 appendages. This extension of its application seems to me improper. But 
 when limited to very marked cases of diffuse suppuration, vaginal hys- 
 terectomy is sometimes superior to abdominal intervention or to the sim- 
 ple incision of the posterior cul-de-sac of the vagina recommended by 
 Laroyenne. 
 
 There is great difficulty in making an exact diagnosis between the lesions 
 which I have just described and pyo-salpinx, which is moderately adherent 
 and capable of enucleation, surrounded by a zone of serous infiltration. 
 
 Hysterectomy, however, is far from being an easy operation. The uterus 
 is immovable, and cannot be brought down ; the surrounding parts are thick- 
 ened, friable, and bleeding. To liberate an organ thus impacted requires 
 consummate skill, and even when it is accomplished, one is apt to find that 
 the peritoneal cavity has not been entered, and that it is so effectually closed 
 by inflammatory products that the fundus uteri is fixed in this ligneous mass 
 like an acorn in its cup. When once effected in these complex cases, hys- 
 terectomy puts the patients in excellent conditions for a cure. A hole has 
 been punched, so to speak, out of the whole inflammatory magma composed 
 of plastic products and pus, and this perforation permits of extensive drain- 
 age whose efficacy is assured by the dependent position. Because of this 
 loss of substance, antisepsis by means of iodoform tampons and detersive 
 injections can be carried to the very centre of the purulent sponge whose 
 meshes are often opened to a great extent by the operation. After ablation 
 of the uterus we should by the help of bimanual palpation seek out the pur- 
 ulent foci, and, as recommended by Pean and Segond, introduce the fingers 
 deeply into the vagina and search for fluctuating points, which should then 
 be opened to allow of rapid and complete evacuation. One should not, how- 
 ever, insist upon complete removal of the diseased parts as in laparatomy. 
 This might lead to the displacement of the haemostatic forceps, to the carry- 
 ing of infection to remote parts, and even to the wounding of unrecognized 
 and tense loops of intestine. 
 
 The operatory technique of vaginal hysterectomy performed for the cure 
 of peri-uterine suppuration (which I therefore propose to call evacuatiyig) was 
 first described by Pean. The uterus being usually more or less fixed by 
 adhesions can only be removed piecemeal. I will not here discuss, as in the 
 case of hysterectomy applied to cancer, the comparative advantages of liga- 
 tures and of forcipressure, the latter only being possible in this case. 
 
 Before beginning a description of the technique I will call attention to 
 the value of the long bent retractors used by Pean, to assure gaping of the 
 operatory field, and by pressure to secure temporary h^emostasis. A number 
 of strong-toothed forceps should also be at hand. They are indispensable 
 in morcellement of the uterus. Finally we should be provided with forceps 
 with short and parallel jaws for forcipressure of the broad ligaments. I 
 
PERIMETRO-SALPINGITIS. 573, 
 
 repeat, that ligatures are not to be thought of, owing to the depth of the oper- 
 ating field because of immobility of the uterus. 
 
 TecJuiiqjic of Vaginal HystcrcctoDiy for Purposes of Evacuation. — The 
 patient is placed in left lateral decubitus, or in the dorso-sacral position, the 
 vulva widely separated by means of the curved retractors, and the cervix 
 seized by a traction forceps. The vaginal mucosa is then incised all around 
 the cervix, which is then freed by detaching it as far up as possible. Then 
 begins the morcellement, which is done by successive stages, each one of 
 which is composed of four chief manoeuvres: i. Liberation of the anterior- 
 and posterior surfaces of the uterus. 2. Section of the broad ligaments. 3. 
 Division into two flaps of that part of the uterus liberated by the two pre- 
 ceding manoeuvres. 4. Excision of the two flaps thus obtained. 
 
 Liberation of the anterior and posterior surfaces of the uterus is to ber 
 accomplished by juxta-uterine detachment by the aid of the blunt end of 
 Pean's long retractor used like a rasp. This must be done with caution, the- 
 instrument being kept constantly against the uterine tissue, which will pre- 
 vent injury to the bladder and rectum, and according to circumstances the. 
 peritoneal cul-de-sac or a collection of pus will be opened out. The detach- 
 ment may possibly be concluded without any opening into either peritoneum 
 or any purulent mass, in which case the uterus may be enucleated from the. 
 mass of false membranes surrounding it. We must be prepared for all these 
 contingencies. 
 
 Section of the broad ligaments is performed in the following manner : 
 the two retractors, which have been introduced against the anterior and pos- 
 terior surfaces of the uterus either by sub-peritoneal detachment, or by- 
 breaking of the juxta-uterine collections of pus, or by intra-peritoneal pene- 
 tration, remain in situ to protect the bladder and rectum. By means of for- 
 ceps with parallel jaws, the portion of broad ligament corresponding to the. 
 uterine segment rendered accessible and visible by the retractors is seized, 
 and then divided close to the uterus. 
 
 The last two stages of the operation are as follows : the segment of 
 uterus liberated by partial section of the broad ligaments is divided into two 
 flaps which are excised successively, the precaution having been taken to fix 
 the base of each by traction forceps. Thus a section of the uterus is excised, 
 and by repeating the same manoeuvres for the remaining portion of the uter-- 
 ine body we gradually remove the whole organ without notable loss of blood, 
 and by keeping the whole process in sight. It is only exceptionally that we 
 have to leave the upper part of the organ in the depths of the wound, yet 
 even this, we are told, does not interfere with the therapeutic result of the 
 operation. The chief requisite to its efficacy, indeed, seems to be a suffi-- 
 ciently large opening for the exit of the pus. 
 
 The operation finished, the whole field is carefully cleansed with aseptic 
 sponges carried in upon forceps and deeply inserted. In this connection I 
 would state that vaginal hysterectomy is the only operation in which I still". 
 
574 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 use sponges, which are, however, completely sterilized. Tampons of absorb- 
 ent cotton are inferior in absorbing power, and the compresses which I use 
 in laparatomies are in this case not easily managed. 
 
 Drainage is secured by the introduction of strips of iodoform gauze into 
 the cavity left by removal of the uterus. These strips are placed among the 
 iorcipressure forceps which secure haemostasis, to prevent them from wound- 
 ing the vaginal walls. The bunch of forceps is then wrapped in absorbent 
 cotton, and a rubber catheter is introduced into the bladder and left there 
 until such time as the vaginal tampons can be dispensed with. 
 
 The forceps are to be removed at the end of forty-eight hours, and the 
 tampons on the third day, after which morning and evening irrigations are 
 to be given of a i : 2,000 bichloride solution, care being exercised that they 
 shall not be carried in farther than the entrance to the vagina, and shall be 
 under low pressure, and that the vagina be kept open by two fingers pressed 
 upon the fourchette. It is really necessary to give detersive injections, on 
 account of the mortification of the portions of tissue compressed by the for- 
 ceps, but it would be highly dangerous to let the antiseptic fluid penetrate 
 with force into the midst of the operatory field. 
 
 A good method to distinguish the various forceps so as not to run the 
 risk of pulling a forcipressure forceps instead of traction forceps, is to have 
 the former nickel-plated, both rings of the handles of the latter being gilded. 
 Sponge forceps may have only one ring gilded. 
 
 The residues of old peri-salpingitic inflammations, false membranes, ad- 
 hesions, etc., give rise to complex and painful phenomena, by the pressure 
 which they exert upon the ovaries and tubes, by the displacements of the 
 uterus w^hich they cause, the agglutination of loops of intestine, the adhesion 
 •of the omentum to the pubis, compression of the ureters, etc. It is particu- 
 larly in these cases that massage is of benefit, as it assists in the absorption 
 of the plastic products. When the pain is a prominent symptom and neu- 
 ralgic in character, the faradic current may give relief. 
 
 As I mentioned above in reference to the treatment of salpingitis, it has 
 been suggested that laparatomy should be performed solely for the purpose 
 of setting the compressed or displaced organs at liberty, by destroying the 
 adhesions, without removing the uterine appendages. The good results ob- 
 tained by this procedure, while they do not prove the absolute efficiency of 
 these incomplete operations, which far too often have served as an excuse 
 for errors of diagnosis, at least show how large a share should be attributed 
 to this pathological element in an interpretation of the morbid symptoms. 
 Another remote result of inflammations around the uterine appendages is 
 th3 modification in the resisting power of the ligaments, the broad, round, 
 and utero-sacral. Our knowledge upon this subject is exceedingly limited, 
 and the deductions drawn from the supposed lesions are mainly theoretic. 
 Yet it is certain that uterine displacements are often due to ligamental relax- 
 ation or contraction, the result of previous inflammatory conditions. I would 
 
PERIMETRO-SALPINGITIS. 575 
 
 especially call attention to the contraction of the broad ligament so frequently 
 observed in cases of extensive laceration of the cervix on the same side, pro- 
 ducing a certain amount of lateral displacement of the uterus from chronic 
 parametritis. It may perhaps be merely a chronic perilymphitis, sclerosis 
 of the connective tissue of the broad ligament around the numerous lymphatic 
 vessels at the base of the ligament, which go from the cervix to the iliac 
 ganglia (Fig. 352). Here again, massage may be of use. I will speak in this 
 connection of a lesion described by Freund under the name of chronic atro- 
 phic parametritis, although it would seem to be straining a point to include 
 it under the head of parametritis. In some young women the sexual organs 
 are found to be as shrivelled as if the menopause had long since been reached ; 
 the broad ligaments are contracted and indurated. It would seem as though 
 the uterine atrophy had extended to the neighboring parts. Freund recom- 
 mends hot douches and massage as treatment. 
 
 I append a few technical details of massage of the internal genital organs, 
 which I have borrowed from a monograph of Vulliet. External massage of 
 the abdominal walls is a mere preparatory measure to render the parts sup- 
 ple. Mixed massage or abdomino-vaginal massage is the kind most used. 
 However rigid may be the abdominal and vaginal walls, there is always one 
 place when the two hands may meet; it is in the suprapubic region, just 
 behind the symphysis. The heel of the external hand rests upon the mons 
 veneris, the fingers toward the umbilicus. The index and middle fingers of 
 the other hand enter the vagina together if it be large enough, otherwise one 
 after the other; their dorsal surface is now turned to the perineum, with the 
 palmar surface against the vesico-vaginal wall. The anterior commissure is 
 thus out of reach and not affected by the manoeuvres. The movements (fric- 
 tion, pressure, kneading) are to be slow and well sustained. The abdominal 
 hand pushes upon the tissues from above downward, the vaginal hand from 
 below upward. The mistake most frequently made is that of pushing too 
 hard from above and too little from below. Each hand must do its share of 
 the work. Just above the symphysis the hands are separated from each 
 other only by the abdominal walls, which they push upon, and by the blad- 
 der ; but a trifle farther back the uterus, if in normal position, will be inter- 
 posed between them. A condition of anteversion is the most favorable to 
 massage, and the uterus must be brought into this position. In chronic 
 endometritis, and in all uterine affections except neoplasms, which have pro- 
 duced hypertrophy of the organ, the following method is observed : When 
 the uterus is well to the front, the fingers in the vagina keep it immovable 
 in this position, while the external hand practises a series of frictions upon 
 its posterior surface, and then endeavors to seize the fundus and press it con- 
 centrically as is done in the obstetrical manoeuvre of expression. 
 
 If there be an infiltration of the cellular tissue around the cervix, the 
 external hand will keep the uterus down, while the fingers of the other hand 
 
576 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 gently and slowly exercise frictions around the cendx. To masses' the sides 
 of the uterus, both hands unite upon the side of the organ and push it to one 
 side; this brings the lateral region more to the centre and renders it more 
 accessible. Bands of adhesion are usually found in the antero-lateral region 
 of the uterus, uniting one side of the uterus to the pelvic peritoneum of the 
 same side ; these are stretched by the sideways pushing of the uterus. By 
 means of these movements we can determine their point of attachment. The 
 massage consists in kneading the regions where the adhesions exist, to cause 
 their absorption, and in moving the uterus to free it from the constricting 
 bands. 
 
CHAPTER XXVII. 
 
 PATHOLOGICAL ANATOMY OF OVARIAN CYSTS. 
 
 From a histogenetic point of view, tumors of the ovaries have been 
 divided into neoplasms of connective-tissue origin and epithelial neoplasms. 
 The first group, desmoid tumors, include fibromata, sarcomata, and myxomata, 
 all, especially the last two, of very rare occurrence. The second group, epi- 
 thelial tumors, include cystomata, carcinomata or alveolar epitheliomata, and 
 adenomata or mucoid epitheliomata. From a clinical point of view, the best 
 division is that which separates solid from cystic tumors. The latter, being 
 by far the more frequent, claim our first attention. 
 
 Pathological Anatomy of Ovarian Cysts. — Any portion of the tubo-ovarian 
 apparatus may be the starting-point of cystic growths ; the cortical portion 
 and medullary portion or parenchyma; the inferior border or hilum, the 
 region between the tube and ovary in which are found the remains of the 
 Wolffian bodies (Rosenmiiller's organ or parovarium, Morgagni's hydatid, 
 obliterated remains of the canal of Gartner). Essentially distinct from a 
 histogenetic and anatomical point of view, these various neoplasms may at 
 times be artificially placed in the same clinical category ; for instance, the 
 mere fact of a cyst being within the folds of the broad ligament is sufficient 
 to form a well-defined surgical class. This cyst may have been developed in 
 that situation (unilocular cyst with limpid contents), or it may have origi- 
 nated in the hilum of the ovary (papillary cyst) or the parenchyma of the 
 ovary (glandular cyst) and have insinuated itself between the ligamental folds. 
 
 I will classify ovarian cysts in the following order: 
 
 I. Proligerous or glandular proliferous. II. Proligerous or papillary pro- 
 liferous. III. Dermoid, simple or mixed. IV. Parovarian, including sev- 
 eral varieties — hyaline, papillary, dermoid. 
 
 I. and II. Proligerous or Prolifcrojis Cysts. — These tumors vary greatly 
 in appearance, yet they have a sufficient number of common characteristics 
 to admit of a description under one head, to which may be added a few spe- 
 cial details. 
 
 Both ovaries may be affected, but the lesions are not usually of equal 
 development ; for instance, on one side there may be an enormous tumor, 
 while on the other there is simply a beginning of the process with scarcely 
 any increase in size. Before closing the abdomen, the surgeon should 
 always examine the side which is supposed to be sound. 
 
 The tumor may be so voluminous as to entirely fill the abdomen, pushing 
 37 
 
578 
 
 CLINICAL AND OPERATIVE GYNECOLOGY 
 
 out the costal cartilages in such a way that after the tumor is taken out the 
 patient looks like a gutted fish. The shape is spherical or ovoid, but with 
 nodules corresponding to weak spots in the walls which have yielded to in- 
 ternal pressure. At the thickest portion of the walls the color is pearly 
 white or bluish, and marbled by the veins ; in the thinner portions the color 
 is purplish, greenish, or blackish according to the nature of the contents. 
 
 Fig. 409. — Vertical Section of the Ovary of a Bitch. Over the whole extent of the free surface of the o%-an- 
 is seen a layer of columnar endothelial cells (germinating epithelium, Keimepithal oi the Germans). At one point 
 there is a glove-finger depression which pushes a tube of this epitheUum into the substance of the ovarj". Just be- 
 neath is a layer of dense connective tissue in which are the young follicles and vesicles. To the left, near the centre, 
 are two more mature follicles, with completely developed ovules. On the right is seen the stellate cicatri.x of an old 
 follicle. Here also we see the stroma of the hilura, rich in vessels, and the tubes of the parovarium in longitudinal and 
 transverse section. The largest follicle, on the left, contains two ova, and well shows the general follicular structure ; 
 membrana fibrosa, m.embrana granulosa, and discus proligerus with the ovum ; in the ovum we can distinguish the 
 zona pellucida, vitellus, the germinative vesicle and nucleolus (Waldeyer). 
 
 The external surface, smooth and oily, is sometimes covered with small 
 papillary growths resembling frogs' spawn or the vegetations of certain mu- 
 cous patches. The tumor is usually pediculated. 
 
 The internal structure varies according to the number of pockets and 
 their contents. Cruveilhier divided cysts into unilocular, multilocular, are- 
 olar, and compound. This classification need not be retained ; but for the 
 
PATHOLOGICAL ANATOMY OF OVARIAN CYSTS. 
 
 579 
 
 purposes of description it is well to keep the words areolar, unilocular, and 
 multilocular. 
 
 We know that the first-named variety is due to the destruction of inter- 
 vening walls whose remains are found in the shape of spurs or trabecular. 
 One pocket is usually larger than the others, though there may be several 
 pockets of equal size ; by the side of cavities containing several quarts we 
 find small cysts the size of an orange or a nut. 
 
 Sometimes a large part of the tumor may be formed by the agglomeration 
 of very small cavities separated by a more or less dense tissue (occasionally 
 gelatinous) giving the section a honeycombed appearance (Fig. 411 j. In 
 
 Fig. 410. — Schema of Tubo-ovarian Apparatus, to Show the Various Points of Origin of Cystic 
 Growths (Doran). la, Multilocular glandular cyst developed in i, ovarian parenchyma ; 3, papillary cyst developed 
 in 2, tissue of the hilum of the ovary ; 4, unilocular cyst of the broad ligament free from the parovarium 10 ; 5, uni- 
 locular cyst of the broad ligament situated just above the tube but not united to it ; 6. similar cyst near 7, tubo-ovarian 
 ligament ; 8, hydatid of Morgagni, which is never the starting-point of a large cyst ; g, cyst developed at the expense 
 of the horizontal canal of the parovarium ; 11, cyst developed at the expense of the vertical tube. According to Doran, 
 these are the papillary cysts of the broad ligament ; 12, 13, course of the obliterated canal of Gartner ; papillary cysts 
 may be developed at any portion of this canal (Coblenz), and these may be the origin of papillary cysts connected 
 with the uterus, 13. 
 
 cysts which are considered to be unilocular, and which surgically deserve the 
 name, the pathologist will nearly always find a certain number of secondary 
 cavities in the thickness of the walls. 
 
 The cystic pouch can often be separated into three distinct layers, espe- 
 cially near the pedicle ; the external layer is fibrous, the middle layer of 
 connective tissue, the third is formed of a capillary network covered by epi- 
 thelium. The veins, which may be as large as the femoral or even the vena 
 cava, ramify upon its external surface, and adhere to it like sinuses, which 
 makes it a dangerous matter to wound them. We occasionally see large 
 bands of unstriped muscular tissue spread out upon the tumor, near the ped- 
 icle. The endothelium covering the external surface is columnar, thus dif- 
 fering from the flat endothelium of the peritoneum. The internal surface 
 of the cyst is covered with very low cylindrical cells. Waldeyer describes 
 
58o 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 one layer, Rindfieisch several. Malassez and De Sinety lay much stress 
 upon their polymorphism. They found a layer of sub-epithelial endothelium, 
 and showed that in the same type of cysts the most varied forms of epithe- 
 lium, metamorphosed and superposed, may be met with. They pointed out 
 the importance of the goblet cells in maintaining viscidity of the cystic 
 fluid ; and finally, they showed the analogy between the cells derived from 
 the normal type met with in cystic growths, or metatypical cells, and that 
 of the glandular epithelioma of the mam.mary gland. 
 
 In a section of the walls we find depressions of the lining endothelium, 
 which give the appearance of acinous glands with a narrowed opening. We 
 
 Fig. 411. — Proligerous Glandular Ovarl\n- Cyst of Areolar Appearance. 
 
 also find, on the internal surface of cysts, vegetations formed by a prolifera- 
 tion of the stroma, which resemble myxoma or fibro-sarcoma ; they are cov- 
 ered with a single layer of endothelium, and^have a tufted appearance. 
 Sometimes epithelial prolongations of a tubular form penetrate them from 
 below upward, and give them the appearance of carcinomata; small cysts 
 may also develop in these papillae. In spite of the hybrid forms so often met 
 with, it is well to follow Waldeyer in distinguishing neoplasms in which the 
 chief vegetations come from the epithelium and lead to the formation of 
 glandular tubes (proliferous glandular cysts), from those where the connec- 
 tive tissue of the walls is the part which develops and projects in the form 
 of vegetations into the interior (proliferous papillary cysts). To be sure, 
 the process of proliferation is the same in both cases, taking place super- 
 ficially in one variety, deeply in the other ; but the appearance of the neo- 
 plasm is, nevertheless, greatly altered, according to whether the epithelial or 
 connective-tissue elements predominate. There is, moreover, a mixed vari- 
 
PATHOLOGICAL ANATOMY OF OVARIAN CYSTS. 
 
 581 
 
 ety of papillary and glandular cyst. The proligerous or proliferous glandular 
 cyst is characterized by a great number of small glands in the cystic walls. 
 Newly formed glandular tubes are transformed into cysts by the follov/ing 
 process: Their orifices opening into the principal cystic cavity become ob- 
 structed and obliterated; the other end dilates, new glandular tubes develop 
 and in turn pass through a cystic phase and give rise to a new glandular 
 growth. The multiplication of glands may become excessively great. 
 
 Proligerous or proliferous papillary cysts show the indications of an 
 abundant proliferation of connective tissue ; this projects into the cyst cavity 
 in the shape of small buds pushing aside the epithelium and dividing into 
 
 Fig. 412. — Small Glandular Multilocular Proliferous Cyst (Doran). The section of the wall shows acces- 
 sory cavities ; in the interior of the cyst is one of these pouches broken open. 
 
 ramified papilliform masses. These branching excrescences may so distend 
 the cyst as to burst it open, and appear on the outside, either through a 
 small crack or a large tear. Then the cyst may turn its convexity inside 
 out, showing the vegetations upon its surface, and the whole tumor changes 
 its aspect. At the same time, the secretions fall into the peritoneum and 
 cause ascites and the metastatic production of disseminated papillary masses. 
 Tumors originating in this manner have often been described as superficial 
 papillomata* of the ovary, whereas they are due to a previously existing cyst 
 whose dehiscence caused their appearance. Yet vegetations may apparently 
 arise spontaneously upon the surface of the ovary. Prochaska, Gusserow 
 and Eberth, Birch-Hirschfeld, Marchand, and Coblenz quote cases in illus- 
 tration. Such cases as these, however, should really be described with de- 
 hiscent cysts, and the two cases studied by Coblenz plainly show this rela- 
 
 * The word papillotna having already received a different histological signification is unsuit- 
 able to use in this connection, and will only be employed as a descriptive appellation without 
 histological classification. 
 
582 
 
 CLINICAL AND OPERATIVE GYN.-ECOLOGY. 
 
 tionship ; the stroma of the ovary contained in both cases epithelial cells 
 which were in process of transformation into cystic cavities, and in the last 
 case papillary growths had even begun to form within tlie small cysts. Upon 
 the surface of the ovary, by the side of the large papillary mass, may be seen 
 small vegetations which spring from the depressions left by the bursting of 
 the superficial cysts. We may then assert that superficial papilloma of the 
 ovary is merely the product of the dehiscence of very small superficial papil- 
 
 FiG. 413. — Proliferating Glakdular Cyst of the Ovary. General view, slightly magnified, i, Papillse ; 2, 
 slender pedicles ; 3, space between papillae ; 4, connective tissue ; 5, new gland lumina ; 6, old gland lumina which 
 have become cystic ; 7, contents of cavities. 
 
 lar}" cysts. This will explain the cases sometimes found of a papillary cyst 
 upon one side, and a papilloma of the ovar\^ upon the other. 
 
 Papillar}' cysts are often found within the folds of the broad ligament, 
 for they arise from the remains of the Wolffian bodies, or from the hilum of 
 the ovary into which these vestiges penetrate ; originating thus from the bor- 
 der of the ovary, the tumor in delevoping naturally insinuates itself into the 
 ligamental folds. In this position they grow more slowly, and also give rise 
 to symptoms of compression, as do all intra-ligamental growths, bound down 
 against the pelvic walls. The papillary vegetations may penetrate the cap- 
 sule not only in the direction of the peritoneal cavity, but below, causing 
 adhesions between the cyst and the pelvis, bladder, rectum, or uterus. The 
 fundus uteri has been invaded by such growths. 
 
PATHOLOGICAL ANATOMY OF OVARIAN CYSTS. 
 
 583 
 
 It is not a very rare occurrence to find calcareous grains, like grains of 
 sand, in the papillary growths (corpora arenaceaj. They are somewhat anal- 
 ogous to the lime sometimes deposited in a placenta. Calcareous concretions 
 are found in other vascular tumors, as those of the arachnoid membrane, 
 cavernous angiomata, etc., which are called psammoma. 
 
 The mode of origin of proligerous cysts of the ovary ( glandular and papil- 
 
 FiG. 414.— Proliferating Glandular Cyst of the Ovary. More highly magnified, i, Loose connective- 
 tissue stroma, myxomatous in points ; 2, blood-vessels ; 3, glandular lumina of irregular form or dilated to form cysts; 
 4, smaller cavities ; 5, lacuna produced by detachment of epithelial layer ; 6, proliferated epithelium, cells collected in 
 glandular culs-de-sac. 
 
 lary ) has given rise to numberless controversies, not yet at an end. The old 
 idea of hydatids was replaced in 1807 by Meckel's theory of hydrops of the 
 Graafian follicle. Huguier and Bauchet accepted the follicular theory for 
 simple unilocular or multilocular cysts only. After the investigations of 
 Cruveilhier, Virchow, and Rokitansky, a new growth with areolar or colloid 
 degeneration of the ovary was generally admitted in cases of the more com- 
 plex forms. The stroma and its colloid degeneration at that time received 
 all the attention, and the epithelial element was entirely lost sight of ; it was 
 the same with the researches of Rindfleisch and Mayweg. 
 
 The restoration of the epithelial element in the origin of proligerous 
 
584 
 
 CLINICAL AND OPERATIVE GYN.'ECOLOGY 
 
 Fig. 415. — Proliferating Papillary Cyst of the Ovary (500 diameters), i, Myxomatous connective tissue 
 ■with anastomosing fibres ; 2, vessels full of blood ; 3, vacuolated connective-tissue cells ; 4, villosities covered with 
 small low epithelial cells with large nuclei ; 5, colloid material between papillae. 
 
 Fig. 416. — Proliferating Pai>illarv Cyst— Colloid Dege.neration of Cells (500 diameters), i, Loose 
 connective tissue in state of colloid degeneration ; 2, more or less degenerated cells ; 3, vessels ; 4, papillary villosities; 
 5, normal cuboidal epithelium ; 6, same, swollen and ruptured, allowing escape of mucus ; 7, cells still showing nuclei. 
 
PATHOLOGICAL ANATOMY OF OVARIAN CYSTS. 
 
 585 
 
 cysts was accomplished chiefly by Klebs and Waldeyer. I will give a rcsicrn.^ 
 of Waldeyer's theory, which is accepted by many authorities. It is well 
 known that in the embryo the ovary contains many epithelial tubes derived 
 from the germinal epithelium co\'ering the surface of the ovary. These 
 tubes of Pfluger are destined later to divide and diminish in order to produce 
 the Graafian follicles which are a product of secondary evolution. 
 
 (I have borrowed from De Sinety the following items of information re- 
 garding germinating epithelium, primordial ovules, and Pfiiiger's tubes. 
 
 Fig. 417. — Mixed Multilocular Cvst (Papillary and Glandular) of the Ovarv. i, Dividing connective 
 tissue ; 2, cysts lined with cylindrical epithelium filled with colloid material ; 3, projections on inner surface of cavities; 
 5, caulifiower-like branching papillary growth ; 6, space between these ; 7, infiltrating embryonal cells. 
 
 In the early stages of embryonic life, about the fourth day of incubation 
 in a chick, a slight thickening of the epithelium is seen in the anterior por- 
 tion of the Wolffian body. A small spot of connective tissue is simultane- 
 ously developed just below this epithelial thickening. Among the cylindri- 
 cal cells which constitute the larger part of the epithelial mass, called by 
 Waldeyer the germinal epithelium, may be seen a few larger, rounder, nucle- 
 ated cells; these are called primitive ova. In order to study the first stage 
 of this development in the human being, Waldeyer advises the choice of a 
 fcetus about four and a half inches in length. In a foetus of three or four 
 months, the ovary is almost entirely composed of what will later be devel- 
 oped into the cortical substance. The medullary substance, formed of blood- 
 vessels and embryonal connective tissue, looks in transverse section like a 
 
586 
 
 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 pedicle separated from the cortical substance, with which it communicates 
 to a very limited extent only. At five months the ovary shows important 
 modifications. The bundles of connective tissue are thicker and more abun- 
 dant and clearly define the utricles or tubes of Pfluger or Valentine, called 
 by some anatomists cordons glandulaires. We can at this stage study the 
 formation of the primitive follicles by the constriction of the epithelial folli- 
 cles. Some isolated primitive follicles may be seen, in which we can clearly 
 distinguish the ovum with its vesicle and germinal spot, surrounded by a 
 
 Fig. 418. — Mixed Mi'ltilocular Cvst (Papill.^ry and Glandular") of the Ovary. Portion of Fig. 417 
 (500 diameters), i. Connective tissue forming stroma of papillse, with innumerable small round cells ; 2, vessel filled 
 with blood ; 3, epithelial lining composed of several layers of irregular cells closely connected and containing irreg- 
 ularly arranged nuclei ; 4, groove between villosities. 
 
 layer of epithelial cells, and a limiting layer of connective tissue. At term 
 we still find germinating epithelium composed of two kinds of cells on the 
 surface of the ovary; but the round cells have become much fewer in num- 
 ber. The anastomosing ovarial tubes sre for the most part separated from 
 the external epithelium by a thin layer of connective tissue. Still, a few 
 may be seen in which there is direct communication between their contents 
 and the germinating epithelium ; this anatomical peculiarity has even been 
 known to persist in the adult. ) 
 
 Pfliiger's tubes are still to be found in a new-born infant, and may per- 
 sist abnormally or be formed by heterochronia in the adult. Their persist- 
 ence to quite an advanced age has been proved beyond a doubt, and Slav- 
 
PATHOLOGICAL ANATOMY OF OVARIAN CYSTS. 
 
 587 
 
 janksy has found them slightly cystic in the ovary of a woman thirty years 
 of age. These tubes may exceptionally be transformed into cysts before 
 the age of puberty, and in the newly born some have been found of the size 
 
 Fig. 4ig. — Papillary Cyst Starting from the Hilum of the Ovary (Doran). On the left lower extreme 
 of the picture is the ovary, which is almost intact. The cyst is developed within the broad ligament, which is opened 
 so that we may see above a portion of the Fallopian tube. An opening has been made in the cyst wall to show the 
 papillary vegetations within. 
 
 of a pea, increasing in size only after puberty. We may then state that not 
 only are all ovarian cysts congenital, but many of them are congenitally 
 formed and either remain stationary or develop at some later period. 
 
 Fig. 420. — Papillary Ovarian Tumor, Covering the Whole of Both Broad Ligaments. 
 
 When a cyst is formed at the expense of the glandular tubes of Pfluger, 
 the most central cells soften and liquefy, and the walls of the distended 
 tubes acquire vegetations and give rise by budding to new tubes. The most 
 
588 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 complex cyst is in the beginning nothing but a small pouch of connective 
 tissue lined with epithelium, which is merely primitive glandular epithelium, 
 partly liquefied to form the cyst contents. The fusion of several of these 
 primitive cysts may end in the formation of enormous cavities ; all unilocu- 
 lar cysts are multilocular in the beginning. I have already shown how the 
 vegetation of the walls gives rise to papillary projections whose name is 
 given to an important variety of ovarian cyst. 
 
 IMalassez and De Sinety do not admit the important role attributed by 
 Waldeyer to the tubes of Pfitiger. 
 
 In their opinion, the germinating epithelium on the surface of the ovaries 
 is the source of the neoplasmic growth, and the process begins by epithelial 
 invagination ; but this new epithelial growth, which physiologically should 
 form the tubes of Pfitiger and finally the Graafian follicles, in a pathological 
 condition becomes diverted into a less specialized and less elevated channel, 
 and is developed only into the ordinary lining epithelium, giving rise to 
 more or less spherical tubes or cavities which have but a remote resemblance 
 to the tubes of Pfliiger and the follicles. Struck with the resemblance be- 
 tween the epithelium of these tumors and the lining of norm.al mucous mem- 
 branes, Malassez proposed to call them mucoid epitheliomata. This name, 
 though histologically correct, causes some confusion clinically, where the 
 name epithelioma, by long usage, conveys a meaning of malignity; the same 
 may be said of the term cysto-epithelioma adopted by some writers. The 
 name of proligerous cysts seems to me preferable. 
 
 Is the histogenesis of papillary cysts different from that of glandular 
 cysts.' In 1S77, Olshausen suggested the hypothesis that they came from 
 the parovarium, after Waldeyer had shown that it penetrated into the hilum 
 of the ovary. The reasons given were the presence of columnar epithelium, 
 and the frequency of inclusion of these cysts within the broad ligament. 
 Fischel carried the subject further, and asserted that these tumors sprang 
 from the cells of the membrana granulosa, which, according to his opinion, 
 originated in the Wolffian bodies. In spite of the support given by Doran 
 to this view, by the exhibition of specimens in which the ovary was seen to 
 be by the side of a papillary cyst springing from the hilum (Fig. 419), we 
 could not at the present day unreservedly accept this opinion. In fact, ]\Iar- 
 chand and Flaischlen have shown that these c}"sts may develop upon the sur- 
 face of the ovary, and that in this case they contain ciliated epithelium con- 
 tinuous with the germinating epithelium. According to IMarchand, it is 
 easy to understand that the ciliated epithelium of the papillary cysts may be 
 pathologically derived from the germinating epithelium, since this filiation 
 occurs normally with the epithelium of the Fallopian tubes ; as to the papil- 
 lary structure, that also is found in the mucous lining of the tubes, and there 
 is nothing surprising in the fact of such an arrangement being produced in a 
 morbid state of tissues similar to one another. 
 
 Upon the whole, we may conclude that the germinating epithelium is 
 
PATHOLOGICAL ANATOMY OF OVARIAN CYSTS. 589 
 
 the point of origin of papillary as well as of glandular cysts. It must be 
 acknowledged that this idea of a common origin is not entirely satisfactory. 
 How shall we account for the marked differences between these two species 
 of neoplasm, and for the very special characteristics of the papillary growths. 
 How explain the fact that they are so often bilateral, so frequently subserous, 
 and so much oftener malignant ? There can be little doubt that further re- 
 searches are needed upon the subject. 
 
 In a study of the fluid contents of cysts, I will consider all the proliger- 
 ous cysts together, although they differ markedly according to whether the 
 cavity is glandular or papillary; still, we must not forget that both kinds of 
 cavity may be seen upon the same tumor. 
 
 In general, we may say that the fluid of large cavities is more tenuous 
 than that of small ones. Except in the majority of parovarian cysts, where 
 it is as clear as a mountain stream, and non-albuminous unless there be in- 
 flammation or a discharge of blood, the liquid of ovarian cysts has a more or 
 less oily consistence; it is somewhat viscid {filant), sometimes syrupy. The 
 color varies from the yellow of barley sugar, or an apple-green, to a coffee- 
 or chocolate-brown ; these darker colors are due to the presence and decom- 
 position of blood. 
 
 Cholesterin crystals are sometimes met with, and in small cysts we may 
 see rice-shaped bodies. In papillary cysts, owing to the absence of goblet 
 cells, the liquid is never as viscid as in the glandular cysts. 
 
 At one time great hopes were entertained in regard to the chemical com- 
 position of the cystic fluid, but they have been somewhat disappointed ; it 
 was hoped that in cases of doubtful diagnosis the fluid could be distin- 
 guished from that of ascites. Waldeyer considered paralbumin to be char- 
 acteristic of ovarian cyst. It seems to be nearly constant in the glandular 
 cysts ; papillary cysts may contain merely a trace. Out of twenty-three 
 cysts examined for the purpose of establishing this fact, Oerum found par- 
 albumin in eighteen cases ; in five cases it was absent. I would add that 
 this substance has been found in the sputum of bronchitis, in a cyst of the 
 neck, in the urine of patients with suppurating diseases of the bones, and 
 even in some cases of ascites. 
 
 Another valuable datum furnished by chemical analysis, and one which 
 seems more positive, is drawn from the amount of solids in the various fluids. 
 According to Mehu, if there are two ounces and two drachms to the quarts 
 it is certainly an ovarian cyst. According to Quenu, this estimation is too 
 low, and should be raised to three ounces two drachms, and it would then be 
 a valuable indication. 
 
 III. Dc7nnoid Cysts. — These are usually small, but they may become 
 voluminous by uniting with proligerous cysts, or even in consequence of an 
 acute inflammatory attack which suddenly increases their fluid contents. 
 Though they may be long unrecognized, and perhaps revealed only by 
 chance at the autopsy, as soon as they begin to enlarge they approach, from 
 
590 
 
 CLINICAL AND OPERATIVE GYNAECOLOGY 
 
 a clinical point of view, the ordinary or proligerous cysts that I have just 
 described. Poupinel has gathered data in regard to forty-four cases in which 
 both ovaries were transformed into dermoid cysts. 
 
 They are much less frequent than proligerous cysts. Olshausen col- 
 lected statistics of 2,275 cases coming from a series of ovariotomies per- 
 formed by Spencer Wells, Keith, Schroder, Krassowski, A. ]\Iartin, Billroth, 
 C. V. Braun, Esrnarch, Dohrn, and himself. Out of this number there were 
 only eighty dermoid cysts (3.5 per cent). 
 
 Fig. 421. — Dermoid Cyst of the Ovary (Pozzi). A, Myxomatous mass like Wharton's jelly ; B. fatty mass- 
 C. hair mixed with sebaceous matter ; £>. fragment of bone resembling the alveolar process with two incisors and one 
 molar ; £, close-grained fatty mass ; K, A", cyst walls. 
 
 Their internal surface is covered with a membrane which looks like the 
 skin and which has a similar structure ; we may see on it a corneous layer 
 formed of several layers of flat and then spherical cells, like those of the 
 rete Malpighii. 
 
 A panniculus adiposus separates the dermic layer from the fibrous cap- 
 sule of the cyst. Upon the surface of the derma are papillsg which may 
 look like nipples and some hairs which are insert-ed into hair follicles occa- 
 sionally provided with a sebaceous gland ; the latter were first demonstrated 
 by Friedlander. Sudoriparous glands are also found. The hairs, whether 
 free or implanted, are long, tawny, agglutinated together by sebaceous mat- 
 ter, and sometimes rolled into little balls. Sebum resembling the vernix 
 caseosa partly fills the cavity, and often forms small, isolated masses; it is 
 sometimes oily in consistence, and contains many epithelial cells, cholesterin 
 crystals, and fatty acids. Teeth and bones have been found in these cysts; 
 the bones are inserted in the wall, and more or less covered by the 
 dermic layer; they are irregular in shape, usually flat, and formed of com- 
 
PATHOLOGICAL ANATOMY OF OVARIAN CYSTS. 
 
 591 
 
 iwS-JJ 
 
 pact tissue; cartilage is present in small patches, which, according to 
 Labbe and Verneuil, sometimes articulate by means of intervening fibrous 
 bundles. 
 
 The teeth project into the cavity, and are often loosely inserted into 
 alveoli formed of bony debris. They are never perfect in shape, and cannot 
 be absolutely identified as incisors, canines, or molars; the cement is usually 
 absent. Hollaender makes the interesting statement that the teeth are 
 always placed with their crowns 
 sloping toward the median plane 
 of the body, so that an exami- 
 nation of the cyst cavity will 
 always determine the side of the 
 body upon which it originated. 
 As many as a hundred teeth 
 have been found in one cyst 
 (Schnabel). Autenrieth de- 
 scribes a case in which three 
 hundred teeth were taken out of 
 a cyst, which contained even 
 more. Some writers claim to 
 have found carious teeth, but, as 
 Lannelongue observes, Magitot 
 is probably correct in thinking 
 that this is not really caries, but 
 a phenomenon of wear and ab- 
 sorption. P. Ruge found in a 
 dermoid cyst, just below a bone 
 which resembled the inferior 
 maxillary with its molar teeth, 
 a small mass which in form, 
 size, and acinous structure had 
 every appearance of a submaxil- 
 lary gland. 
 
 Unstriped muscle fibres have 
 been found in the dermic layer; 
 
 as to the striated fibres, OlshaU- Fig. 422.— Dermoid Cyst of the Ovary. Section perpen- 
 
 1 . , . . dicular to internal surface. i, Corneous layer ; 2, INIalpighian 
 
 sen aenieS tneir existence, say- layer ; 3, connective tissue with many cells -, 4, vessels ; 5, points of 
 
 inSf that where theV are found the ongin of inflammatory embryonal cells; 6, bundles of smooth fibres; 
 
 7, sebaceous gland ; 8, sudoriparous gland ; g, same, dilated and cut 
 
 case is probably one of teratoma owiqueiy -, lo, vessel •, n, fatty tissue. 
 
 instead of dermoid cyst. In 
 
 truth, many authorities confuse the two. Cruveilhier quotes a case in which 
 
 nails were found; Baumgarten reports a most remarkable case in which the 
 
 cyst, besides skin, hairs, and teeth, contained a body which resembled an 
 
 eye, with a species of convex cornea and epithelium like that of the retina. 
 
592 
 
 CLIXICAL AND OPERATIVE GYNECOLOGY. 
 
 There vas also a mucous membrane similar to that of the intestines and 
 stomach, and encephaloid nerve substance. 
 
 The presence of gray matter in dermoid cysts is a knotty point. In one 
 case Virchow found gray matter, laminated as in the cerebellum ; Key 
 found some enclosed in a bony cavity; Rokitansky, in a species of capsule 
 
 near a bone ; other pathologists 
 have, in exceptional cases, found 
 nerve filaments supplying the 
 teeth. 
 
 Besides these solid sub- 
 stances, dermoid cysts contain 
 a milky fluid in which are often 
 found cholesterin crystals. 
 
 Mixed tumors, formed by a 
 combination of dermoid with 
 other forms of ovarian cysts, 
 have long been known. The 
 subject has recently been studied 
 by Poupinel, who states that in 
 one and the same tumor we may 
 find in closest union dermoid 
 cysts and cysts with pavement 
 epithelium, cubical, ciliated, 
 goblet, polymorphous cells, etc. 
 More than this, in the same 
 cystic cavity we may find the 
 epidermis with its appendages 
 (hairs, sebaceous and sudoripa- 
 rous glands) and a lining of vmi- 
 form or polymorphous epithe- 
 lium. Finally, the interior 
 lining of the cavity may be 
 entirely formed of skin — which 
 may, however, be incomplete. In some instances the cutaneous lining 
 is found in a few places only of the dermoid cavity, and may be in the 
 form of large papillae into which are implanted the hairs. The rest of the 
 cyst wall is smooth and fibrous, or else looks more mucous than cutaneous. 
 
 The foregoing description, v-fhich agrees with all other accounts of dermoid 
 cysts, leads one to regret the rarity of thorough histological examinations. 
 Were they more frequent, it is probable that many cases of so-called der- 
 moid cysts would be classed with mixed tumors. The fibrous stroma is usu- 
 ally formed of young connective tissue, of adult or of myxomatous tissue. 
 Yet, besides teeth, which are produced from the ectoderm and are met with 
 only when there is a cutaneous lining, we find cartilaginous and bony tissue. 
 
 Fig. 423. — Dermoid Cyst of the Ovary. Mucous glands in 
 clusters, i, Normal glands, cylindrical epithelium in place, proto- 
 plasm slightly granular ; 2, outlines of epithelium becoming less 
 distinct ; 3, slightly hypertrophied gland ; 4, epithelium forming 
 merely a diffuse granular mass within acinus; 5, gland cut obliquely, 
 cylindrical cells on the right cut transversely ; 6, glands whose 
 epitheUum isseen from the end ; 7, intra-glandular connective tissue. 
 
PATHOLOGICAL ANATOMY OF OVAKLVN CYSTS. 
 
 593 
 
 in the fibrous walls of mixed tumors. It may also be seen in tumors which 
 possess no dermoid characteristics. Poupinel reports an example of a 
 mucoid cyst of the ovary, followed by the appearance of cysts of the same 
 nature all over the body; cartilaginous nodules were found in its walls. 
 
 Mixed tumors, as well as dermoid cysts, often ossify ; but a study of 
 their structure emphasizes the interesting fact that the fragments of bone 
 are not necessarily situated near the dermoid cysts, but may indeed be quite 
 independent of them. Finally, we may find striped and unstriped muscle 
 fibres and nerve tissue in the stroma of mixed tumors. 
 
 r" 
 
 Fig! 424. — Dermoid C^■ST of the Ovary. Great development of sebaceous glands, i, Loose connective tissue 
 with long cells ; 2, lymphatics ; 3, normal lobules of small polyhedral cells possessing distinct nuclei ; 4, lobule whose 
 central cells have changed into vesicles containing an oily material ; 5, granular cells without nuclei ; 6, large lacuna; 
 full of fat ; 7, transverse sections of hair ; a, sheath ; />, hyaline layer ; c\ hair. 
 
 Both ovaries may be simultaneously affected. In that case, as in the 
 case of unilateral ovarian tumors, combinations of every variety of cyst may 
 occur. Each ovary may contain an epithelial mucoid tumor, with poly- 
 morphous epithelium or epithelium of one kind alone. For instance, both 
 cysts may be lined with ciliated epithelium. Oftentimes both ovaries are 
 transformed into mixed tumors. 
 
 There may be a dermoid cyst upon one side and a mucoid cyst upon the 
 other, or a mucoid cyst on one side and a mixed tumor on the other. The 
 
 38 
 
594 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 question of the origin of dermoid cysts is one of the most obscure points in 
 general pathology. The theory which ascribed them to extra-uterine preg- 
 nancy scarcely deserves mention, since they are often met with in children. 
 The theory of diplogenesis by foetal inclusion is also inadmissible, and is at 
 once disproved by the great number of teeth present. The term plastic 
 heterotopia, used by Lebert, is no explanation, but merely a name. 
 
 There are a few more tenable theories ; that of parthenogenesis, which 
 
 considers their formation due to a pro- 
 liferation of germinating epithelial cells, 
 is not satisfactory, because it fails to ac- 
 count for the presence of similar growths 
 in other parts of the body where there is 
 no epithelium. The theory of impaction, 
 although not beyond criticism, is on the 
 whole the most satisfactory. According 
 to this view, during intra-uterine ex- 
 istence certain portions of the blastoderm 
 become impacted by pressure within the 
 tissues, and develop there later, giving 
 rise to an irregular formation of the nor- 
 mal tissues. Verneuil was the first to 
 formulate this ingenious theory in regard 
 to cysts of the branchial clefts of the neck 
 and of the head. The demonstrations of 
 His in regard to the axis cord, from which 
 he claims that the genital organs are devel- 
 oped, assist us in understanding the com- 
 plexity of the elements found in dermoid 
 cysts of the ovary. The organs which 
 are formed by all the layers of the blasto- 
 derm are the only ones which take part 
 It is impossible by dissection to identify 
 the different germinative layers ; we can easily imagine, therefore, that por- 
 tions of tissue corresponding to the corneous layer, the medullary tube (cili- 
 ated epithelium), or the middle layer (muscles, bone) may become misplaced 
 in the ovary as in the testicle. The theory of impaction receives strong 
 corroboration from these researches. Lannelongue adopts it unreservedly. 
 He calls attention, moreover, to the fact that the development of these tis- 
 sues, foreign to the parts in which they are situated, brings about certain 
 modifications in the structure of the latter, which add to the complexity of 
 the abnormal growth. Perhaps this may explain the union of proliferating 
 ovarian cysts to dermoid cysts, and the various transitional stages in these 
 neoplasms. Still, Lannelongue does not entirely reject the idea of diplo- 
 genesis in cases in which foetal remains are found in cysts, which he terms 
 
 Fic. 425. — Switch ok Hair Five Fkki- I.dng 
 
 TAKEN' FROm DERMOID CyST (MuNdS). 
 
 in the formation of the axis cord. 
 
PATHOLOGICAL ANATOMY OF OVARIAN CYSTS. 
 
 595 
 
 foetal cysts. He considers them to be a combination of cysts and double 
 monsters ; the cause giving rise to the production of the monster being inti- 
 mately associated with that which determines the formation of a cyst. One 
 
 FrG. 426. — Dermoid Cyst of the Ovary. Section perpendicular to cyst wall at point of granulo-fatty degener- 
 ation. I, Compact connecti\"e tissue in \va\y bundles, with fusiform cells; 2, vessels • 3, centreof development of peri- 
 vascular embryonal cells ; 4, transverse section of hair ; 5, layer of round cells with many droplets of fat between, 
 forming a soft grumous mass on interior of cyst. 
 
 FiG: 427. — Sebaceous Contents of Dermoid Cyst, i, Cholesterin crystals ; 2, epithelial cells ; 3, free gIob« 
 iiles of fat ; 4, cells containing fatty droplets ; 5, cell with nucleus still visible and containing two fat globules ; 6, 
 small group of free nuclei and fat droplets ; 7, fatty granules. 
 
\g6 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 or the other may predominate, according to the case ; the higher we go in 
 the series, the more does tlie element of the monstrosity predominate, and 
 the more does the cystic element tend to diminish and disappear. Thus, in 
 the genesis of these tumors, there are two factors to be considered — the 
 production of cystic cavities, and the existence of a centre of supplementary 
 development. To admit the existence of this independent centre is to satis- 
 factorily account for the complex character of these neoplasms, but it must be 
 confessed that the admission creates problems quite as difficult of solution 
 as those which it destroys. 
 
 Fig. 428. — Mixed Dermoid Cvst of the Ovary. Diagrammatic. 1, Connective tissue; 2, smooth muscle 
 fibres ; 3, cellulo-adipose tissue ; 4, sebaceous glands ; 5, sudoriparous glands , 6, nodules of cartilage ; 7, cyst with 
 cutaneous lining ; 8, hair ; 9, cyst with lining of ciliated cells ; 10, small-celled nerve tissue. 
 
 IV, Parovarian Cysts. — From a practical standpoint, it is impossible to 
 separate cysts of the ovarian region which are independent of the ovary from 
 those properly called ovarian cysts. Therefore, although the cysts of which 
 I am about to speak are not in reality cysts of the ovary, since anatomically 
 separate from it, yet they are best described in connection with the latter, 
 being surgically and clinically so closely connected to them. 
 
 These cysts are formed into a clearly defined group, by an ensemble of 
 like characteristics. They are usually called parovarian cysts, or cysts of 
 Rosenmiiller's organ, because their origin in the broad ligament, where they 
 are situated, corresponds to the seat of these embryonic remains, and be- 
 cause it seemed natural to give a special name to a specialized structure. 
 
PATHOLOGICAL ANATOMY OF OVARIAN CYSTS. 
 
 597 
 
 But it has not been demonstrated that these unilocular cysts of the broad 
 ligament, with their thin walls and transparent contents, always originate 
 from the parovarian. A. Doran has studied and made drawings of some 
 specimens which antagonize this theory. He inclines to the belief that they 
 are simple cysts with lacunae or the subserous hygromata of Verneuil. 
 Mangin also believes that they may be developed in the connective tissue 
 independently of the parovarian. De Sinety considers it very doubtful if 
 they originate from the organ of Rosenmiiller. He believes them to be 
 similar to mucoid epitheliomata, and thinks that the difference in the fluid 
 
 
 Fig. 429. — Mixed Dermoid Cyst of the Ovary. Cavities lined with ciliated cylindrical epithelium. 1, Very 
 embryonal connective tissue ; 2, principal cyst cavity ; 3, branching diverticulum ; 4, small secondary cysts ; 5, mucus; 
 6, fatty tissue ; 7, point where ciliae are preserved. 
 
 contents is due to the simple structure of the epithelial cells, for a clear 
 fluid is also seen in proligerous ovarian cysts not lined with goblet cells. 
 De Sinety even wonders whether supernumerary ovaries may not have some- 
 thing to do with the production of these cysts. But, if their origin be the 
 same as that of ovarian cysts, how shall we explain their constant, special 
 structure .'' Moreover, how can we believe in so frequent an existence of 
 supernumerary ovaries .? There are certainly some nebulae upon this point 
 which need to be cleared away. Yet it is convenient to use the time- 
 honored expression parovarian cyst to designate cysts of the ovarian region, 
 independent of this organ which is found to be in normal condition close to 
 
598 
 
 CLINICAL AND OPEKATIVE GYNECOLOGY. 
 
 Fig. 430. — Mixed Dermoid Cyst of the Ovary. Showing different changes of the epithelium (not diagram- 
 matic). I, Ciliated columnar epithelium ; 2, transformation to squamous epithelium ; 3, cylindrical ciliated form ; 4, 
 swollen, vacuolated cells undergoing colloid degeneration ; 5, epithelial pearl; 6, desquamated squamous epithelium ; 
 7, colloid material ; 8, swollen and free granular epithelium ; g, free nuclei ; 10, connective tissue ; 11, smooth mus- 
 cle fibres ; 12, vessels. 
 
 * Fig. 431. — Mixed Dermoid Cyst of the Ovary. Nerve tissue and lymphatic spaces around vessels, i, Areo- 
 lar nerve tissue containing large and small cells ; 2, fibrillary nerve tissue ; 3, vessels full of blood ; 4, large mass of 
 fibrous ti.isue sending off prolongations into masses of nerve tissue ; 5, peri-vascular lymph space ; 6, extravasated 
 lymph. 
 
PATHOLOGICAL ANATOMY OP^ OVARIAN CYSTS. 
 
 599 
 
 the cyst, or separated by a fold of the ligament; only th^ name should be 
 understood to mean a cyst in the vicinity 
 of the ovary, rather than a cyst of the 
 parovarium. 
 
 These neoplasms are not rare : 01- 
 shausen has found them 32 times among 
 248 ovariotomies, which is 1 1. 3 per cent. 
 
 It is important to divide them into two 
 classes : the first, and more frequently 
 met with, I shall call parovarian hyaline 
 cysts ; the second, parovarian papillary 
 cysts. 
 
 Parovarian Hyaline Cysts. — These are 
 usually unilocular, but there are some ex- 
 ceptions. L. Tait reports a case upon 
 which he operated and which he carefully 
 examined, where there were six sacs joined 
 together, and he also states that Spencer 
 Wells removed a bilocular cyst. More- 
 over, even when there seems to be but one 
 cavity, a careful search will often reveal 
 secondary cavities in the cyst wall, of the size of hempseed or peas. 
 
 The sac is very thin. Its external surface, wherever it is not in contact 
 with the pelvic walls or neighboring organs, is covered by the folds of the 
 broad ligament, which do not, however, adhere to it. In many cases a sort 
 
 Fig. 432. — Unilocular Parovarian Cvst of 
 THE Broad Ligament. To the left and above 
 is the incised ovary, which is seen to be free. 
 The elongated Fallopian tube is spread over the 
 surface of the cyst (Doran). 
 
 Fig. 433. — SuB-TLBAL Hyaline Parovarian Cyst. A. Section perpendicular to internal wall of cyst (300 diam- 
 eters). I, Cyst wall of connective tissue with elastic fibres; 2, branched villosity ; 3. blood-vessels ; 4, layer of small 
 cuboidal-celled epithelium ; 5, cylindrical ciliated epithelium ; 6, point where epithelial layer is absent ; 7, mucus. 
 B. Part of villosity 2 C500 diameters), i , Compact .e:ranular tissue ; 2, nuclei ; 3, vessels ; 4, cylindrical ciliated epi- 
 thelium ; s, mucus. C. Cyst wall, with small cuboidal epithelium (500 diameters), i, Fibrous tissue with many elas- 
 tic fibres ; 2, epithelium ; 3, granular mucus on surface. 
 
6oo 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 of prolongation of the broad ligament seems to form a large pedicle. When 
 the cyst is sessile, it is but loosely joined to neighboring parts, unless there 
 have been previous inflammation. 
 
 Its color is white of a slightly greenish tint, and the fine blood-vessels of 
 ihe investing peritoneal membrane clearly show through. The tube adheres 
 to the surface of the cyst, the first effect of its development having been to 
 open out the tubal folds ; the ovary is thrown to the external side, sometimes 
 
 
 
 
 Fig. 434. — Hyaline Cyst of the Broad Ligament. Section of entire thickness of wall C2S0 diameters). 
 3, Layer of flat cells on internal wall of cavity ; 2, loose connective tissue with small cells ; 3, several layers of 
 rounded cells ; 4, layer of very fine longitudinal smooth muscle fibres ; 5, very dense fibrous tissue containing small 
 elongated cells ; 6, vessels ; 7, transversely cut bundles of smooth muscle fibres ; 8, fibrous limiting layer, with 
 wavy, smooth muscle fibres. 
 
 flattened, but always distinctly visible. The internal surface is smooth and 
 lined with ciliated epithelium, which may be accompanied by ordinary 
 columnar epithelium. The fluid is limpid and of a crystal clearness, its 
 density scarcely greater than that of water (1.002 : 1.008). It is not precip- 
 itated by heat, for it contains no albumin if there have been no suppurative 
 process nor effusion of blood. It contains a large proportion of chlorides. 
 Pai'ovcrian Papillary Cysts. — Besides the more common parovarian 
 
I'ATllOLOGICAL ANATOMY OK OVARIAN CYSTS. 
 
 60 I 
 
 hyaline cyst of the broad ligament, with its smooth walls and transparent 
 fluid contents, there is another variety characterized by the presence of 
 papillary growths. Is this variety of separate origin, or is it, according to 
 L. Tait, simply a stage of further development of the other? This question 
 we cannot answer. However that may be, it is important for us to know 
 that this variety exists. For a long time there existed a certain amount of 
 confusion in the science of gynaecology owing to our incomplete knowledge 
 of this subject. On the one hand, some writers erroneously used parovarian 
 cysts and cysts of the broad ligament as synonymous terms; on the other 
 hand, many believed that parovarian cysts always had thin walls, and trans- 
 parent, non-ropy fluid contents, poor in albumin. Now this variety, though 
 the mt)rc frequent, is not the only one. There are parovarian cysts with 
 viscid contents, for which result it is only necessary that they should have 
 papillary growths ; the contents may even be made albuminous or of various 
 colors by recent or past extravasations of blood. Yet these characteristics 
 should not lead to a confusion of these cysts with mucoid ovarian cysts ex- 
 ceptionally enclosed within the folds of the broad ligament. They possess 
 
 Fit;. 435. — Conglomerated Follici'i.ak Cvsts (Cystic Disease of the Ovary) in the Broad Ligamen-i'. 
 
 one special characteristic, in that they are always unilocular (except for the 
 almost microscopic cavities in their walls), while ovarian cysts are almost 
 invariably multilocular. Cases which have caused confusion have been only 
 apparently similar. 
 
 Exceptionally the cysts, especially if they develop in the direction of the 
 abdomen, become to a certain extent mobile, and, by dragging upon the 
 broad ligament, form a kind of laminated pedicle. These cysts, which are 
 ordinarily benign, may sometimes becomxC malignant in the extreme. L. 
 Tait quotes the case of a young girl from whom he removed a parovarian 
 cyst of apparently simple nature, and without any interior vegetations; six 
 weeks later the patient showed symptoms of ganglionic infection, and three 
 months later died from metastatic cancers in various organs. 
 
 Parovarian Dermoid Cysts. — A certain number of well-authenticated 
 free dermoid cysts of the ovary have been reported. 
 
602 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 TJie Pedicle. — Whatever the origin of ovarian cysts, one important mor- 
 phological distinction presides over their surgical history. This is the 
 presence, the disposition of, or the absence of a pedicle. It is sometimes 
 very thin, almost membranous, and the tube is separated from it by the free 
 peritoneal fold of the ovary. This mesovarium aileron is often unfolded, 
 and the tube, which is dragged upon by the tumor, adheres to it and is 
 somewhat lengthened in consequence. The pedicle then contains two par- 
 allel cords — the tube and the ovarian ligament. The narrowest part of the 
 pedicle is at the infundibulo-pelvic ligament or the fold of peritoneum going 
 from the pelvic wall to the ovary, through which the vessels go to that 
 organ. The length and thickness of the pedicle vary greatly, and often 
 depend upon the distance which separates the tumor from the edge of the 
 uterus, and upon the thickness of the broad ligament whose muscular fibres 
 are often hypertrophied, connective tissue oedematous, and veins dilated. It 
 is in the vicinity of the pedicle that the cystic walls are the most thickened 
 and that we find the remains of the ovary. 
 
 Certain cysts originating within the broad ligament (dermoid and par- 
 ovarian) may exceptionally possess pedicles, which are formed simply by 
 distention and displacement of the peritoneum ; they are large, laminated, 
 and membranous. 
 
 When there is no pedicle, the cyst is either wholly or in part within the 
 broad ligament. This is the usual situation of parovarian cysts, hyaline or 
 papillary, of some dermoid cysts, and of some proliferous, glandular, or 
 papillary ovarian cysts, to account for which circumstance Freund believes 
 in a congenital malformation consisting in impaction of the ovary. Small 
 follicular cysts and cysts of the corpus luteum may exceptionally be within 
 the broad ligament, where I have myself observed them (Fig. 435). The 
 classification of cysts within the broad ligament is necessarily an artificial 
 distinction ; it is of interest from a surgical point of view, but is of no value 
 as a nosological classification. It is a mistake for surgeons to use this term 
 as a synonym for parovarian cysts, or even for the most frequently occurring 
 parovarian cyst, the one with thin walls and hyaline fluid contents. In point 
 of fact, all of the following varieties of cyst may be situated within the folds 
 of the broad ligament : 
 
 A. Parovarian hyaline and papillary cysts (always in this situation, at 
 least in the beginning). 
 
 B. Proligerous ovarian cysts, papillary and glandular (rarely). 
 
 C. Dermoid cysts, ovarian (often) or parovarian (seldom). 
 
 The enclosed cyst may be on the external side of the ligament near the 
 pelvis, or on the internal side and adhere to the uterus, or it may fill up the 
 whole of the ligament, throwing it upward and outward from the opposite 
 side. A segment of the tumor may project beyond the broad ligament 
 toward the abdominal cavity, forming a free additional cyst to the enclosed 
 cyst, from which it is separated by a groove. 
 
PATHOLOGICAL ANATOMY OF OVARIAN CYSTS. 603 
 
 According to Terrillon, secondary impaction of proliferous cysts differs 
 from the primary impaction of parovarian cysts. In the first case, the en- 
 closed portion of the cyst forms such intimate adhesions to neighboring tis- 
 sues that we might add a second vascular pedicle to the primary utero- 
 ovarian vascular pedicle; it comes from the horn of the uterus and is due to 
 dilatation of the normal anastomosis between the superior branch of the 
 uterine artery and the termination of the utero-ovarian vessel ; the result is 
 a purplish appearance and a thickening of the broad ligament which do not 
 exist with parovarian cysts. It seems to me that such a distinction is falla- 
 cious, and based upon observations of hyaline parovarian cysts alone. The 
 remarkable tendency of some parovarian cysts to invade neighboring parts 
 and to adhere to the uterus is well known. 
 
 It is important to distinguish another variety of sessile cysts — those 
 which do not remain within the broad ligament, but go beyond it and tra\'el 
 beneath the peritoneum in the cellular interstices, quite a distance from their 
 point of origin. These might appropriately be called retro-peritoneal cysts. 
 
 Any kind of cyst may travel in this fashion ; it has especially been 
 noticed in hyaline or papillary parovarian cysts, but also in dermoid cysts and 
 glandular ovarian cysts. On the left side, the tumor may stretch the iliac 
 meso-colon and come in contact with the ilium. I enucleated a hyaline 
 parovarian cyst which had followed this course. On the right side, the 
 cyst may go as far as the caecum, or even pass beyond it within the mesen- 
 tery, to the kidney, liver, and diaphragm. Posteriorly, the cul-de-sac of 
 Douglas may be lifted up, and the cysts lodge between the rectum and 
 uterus. 
 
 Anteriorly, the vesico-uterine cul-de-sac is sometimes displaced upward ; 
 the bladder, pulled upon by it and the urachus, is enormously elongated, and 
 liable to be wounded by the knife of the operator. Laterally, the cystic 
 masses glide under the peritoneum, between it and the pelvic aponeurosis or 
 even into the iliac fossa, press upon the ureter, and are often the cause of 
 renal disease. The papillary and glandular cysts of an areolar or gelatinous 
 variety are the ones which give rise to the most extended and most serious 
 cases of retro-peritoneal migration ; contrary to the hyaline parovarian cyst, 
 they form adhesions to neighboring parts and are difficult and often impossi- 
 ble to enucleate. Dermoid cysts have been found in the retro-peritoneal 
 pelvic cellular tissue. 
 
 The mistake has often been made of supposing that they originated from 
 the walls of the bladder, rectum, or uterus to which they were adherent. 
 They have sometimes formed an obstacle to delivery. 
 
 Adhesions. — During the first stages of cystic development, the columnar 
 epithelium which covers them is an efficient protection against the formation 
 of adhesions. After it desquamates, however, adhesions may result from 
 friction and external irritation. Loose in the beginning, these adhesions 
 become closer and closer as time goes on. The anterior surface of a cyst is 
 
604 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 sometimes so closely glued to the peritoneum that operators have detached 
 the latter from the abdominal walls under the supposition that they were 
 detaching the cyst. The mesenteric attachments may be so extensive and so 
 rich in blood-vessels as to furnish the chief elements of nutrition to the cyst. 
 In a case of this kind, I found it more convenient to begin the ovariotomy 
 by cutting the pedicle, which was relatively slender, and then successively to 
 tie the various adhesions by turning the cyst from below upward. The in- 
 testines also may be so closely adherent that it is impossible to dissect out 
 the cyst, and one is obliged to split {cntamcr) the cyst to remove it. Adhe- 
 sions to the pelvic walls are serious because of the danger of lacerating the 
 ureter or a large blood-vessel, and it is sometimes impossible to destroy 
 them if they are very extensive. In the latter case we usually have to do 
 with direct adhesions of retro-peritoneal cysts, without any intervening serous 
 membrane. 
 
 Ascites. — The presence of a small amount of fluid in the peritoneal cavity 
 is not unusual, but a large accumulation is rare. Terrier seems to have had 
 an exceptional experience in finding lo cases of abundant and 25 cases of 
 slight ascites out of 100 cases of ovariotomy. Out of 68 cases of ovari- 
 otomy, Terrillon only once found this complication. 
 
 In the majority of instances in which there is ascites, we have to do with 
 papillary cysts with vegetative growths outside of the cavity, sometimes even 
 with metastatic growths upon the neighboring peritoneum. In the case of 
 glandular cysts, there may be partial fatty degeneration of the wall, or even, 
 according to Quenu, rupture of small superficial cysts whose contents irri- 
 tate the peritoneum. This author, in my opinion, attributes too much weight 
 to the phenomena of osmosis caused by the colloid matter secreted by the 
 vegetations or poured out by small cysts ; this explanation is not needed to 
 account for the ascites produced by the irritation of a pathological fluid. 
 Ascites constitutes a real protection to the peritoneum when the serous mem- 
 brane has been unable to isolate the irritating body by the production of 
 adhesions. Some have considered the vascular richness of the tumors to be 
 the cause of the ascites ; but this factor seems to me to be of small impor- 
 tance, since telangiectatic fibromata may exist without causing ascites. The 
 characters of the ascitic fluid accompanying ovarian cysts often aid in its 
 recognition. It is richer in solids than the ascitic fluid of cirrhosis, and 
 often contains characteristic cellular elements. It may be yellowish {citrin) 
 or tinged with blood, the latter characteristic seemingly corresponding to a 
 greater degree of malignity of the tumor. 
 
 Intra-cystic Apoplexy, — Small hemorrhages frequently occur within the 
 cyst, giving a dark and even chocolate-colored appearance to the fluid. 
 Hemorrhages so serious as to threaten life have even been obser\-ed ; the 
 cyst is then found to be distended with clots, and it may be impossible to 
 find the point of rupture of the vessels. Elongation and torsion of the pedi- 
 cle predispose to hemorrhage. 
 
PATHOLOGICAL ANATOMV OF OVARIAN CYSTS. 605 
 
 Suppuration. — A cystic cavity may suppurate after it has been punctured 
 for purposes of evacuation or exploration, the introduction of pathogenic 
 germs being the cause of the process. To this cause also must be attributed 
 so-called spontaneous inflammations, for the adhesions to the inflamed tubes 
 seem really to permit the introduction of germs. 
 
 Suppurative inflammation may follow mortification from torsion of the 
 pedicle. Finally, after parturition, and under the influence of attenuated 
 puerperal septicaemia, suppuration of dermoid cysts has been noticed. 
 
 Torsion of tJie Pedicle. — This accident, though infrequent, is not rare. 
 The cyst may be seen free in the abdomen, quite detached from its former 
 place of insertion, or else held by only a few filaments. When this is the 
 case, we usually have to do with polycystic areolar tumors, or dermoid cysts 
 with thickened walls, having the consistence of solid masses. I have seen 
 an excellent example of this nature. Baumgarten and Hofmeier have seen 
 dermoid cysts that had become quite free from all attachments. If the 
 tumor have not formed any adhesions before its separation, it becomes a 
 foreign body, causing reactionary troubles in the peritoneum and ascites, 
 which might be called acute. 
 
 In the contrary event, it may continue to live through its adventitious 
 roots, which in their turn, however, may become the seat of the same trou- 
 bles. If torsion takes place slowly, in a chronic manner so to speak, it has 
 been known to exercise a beneficial effect, and cause an arrest of develop- 
 ment of the neoplasm, without causing any reaction. Fatty degeneration, 
 with partial absorption, is produced ; calcification has occurred. But as a 
 usual thing, this progressive torsion is accompanied by acute attacks of 
 peritonitis, and increase in the size of the cyst from hemorrhages. One of 
 the rare results of torsion is gangrenous inflammation of the tumor; to pro- 
 duce it, the torsion must have occurred suddenly and caused mortification of 
 the neoplasm and the intestinal adhesions which serve as a means of ingress 
 to germs. 
 
 Intestinal occlusion is one of the possible consequences of torsion. 
 
 General Peritoneal Infection — Metastasis. — The metatypical proliferation 
 of the epithelium of glandular cysts, upon which Malassez justly lays so 
 much stress, colloid and carcinomatous new growths, are very similar in 
 character to the atypical malignant neoplasmata; it is therefore not surpris- 
 ing that from some influence yet unknown ovarian cysts should take on the 
 characteristics of malignant "umors, spreading into the peritoneum or even 
 farther, and recurring after removal. These various processes have been 
 included under the somewhat vague, but at this date fully established, name 
 of metastasis. We can divide them into the two following classes : 
 
 A. Metastasis from spontaneous infection. 
 
 B. Metastasis from infection due to operations. 
 
 A. Metastasis by Spontaneous Infection. — The cauliflower growths of 
 papillary cysts may remain for a long time within the cyst cavity; but at 
 
6o6 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 some given moment, whether from distention and rupture, or simply from 
 erosion and perforation of a limited portion of their wall, these vegetations 
 emerge upon the external surface of the cyst. From that time a new phase 
 in the life of the cyst begins ; on one hand, the protective epithelial covering 
 having been broken through, the peritoneum is irritated and ascites pro- 
 duced; on the other hand, the neoplasm which has burst through its boun- 
 daries tends to spread, inoculating neighboring parts, in a fashion which has 
 been compared to the contamination by contiguity {de proche en procJie) by 
 the auto-inoculation of mucous patches. 
 
 These vegetations are found in great number not only upon the ovary, 
 tube, and uterus, but upon the intestines, mesentery, parietal peritoneum, 
 and even the walls of the aorta. We may well ask ourselves whether in such 
 cases all operative measures would not be necessarily inefficient, and what 
 would be the course of the secondary growths when the primary tumors were 
 removed. Still, numerous observations show that even under these circum- 
 stances a cure may follow; it seems as if the scattered vegetations under- 
 went atrophy or a process of retrogression. In a case reported by Thornton, 
 of bilateral papillary cyst, which burst open and caused a dissemination of 
 vegetative growths upon the peritoneum, a complete cure was established at 
 the end of four years ; in another, the patient became pregnant after an 
 operation when the whole of the pelvic peritoneum was covered with papillo- 
 mata ; in a third case, in which Thornton was obliged to leave a tumor as large 
 as a walnut in the cul-de-sac of Douglas, at the end of three years this mass 
 was found to have undergone no increase in size. Flaischlen and L. Tait 
 report similar cases. 
 
 Metastatic infection of the peritoneum has been very rarely observed in 
 glandular ovarian cysts. It seems to follow spontaneous rupture of the cyst, 
 and we then find in the peritoneal cavity small sacs, with or without accom- 
 panying gelatinous masses, grafted upon the epiploon or the intestines, or 
 retro-peritoneal. I recently saw a case of this kind. The tumor was bilat- 
 eral, polycystic, and there were metastatic growths in Douglas' cul-de-sac, 
 besides a free cyst of the size of an orange which adhered to the intestines 
 and doubtless came from the rupture of one of the ovarian tumors ; there 
 was slight ascites ; the patient succumbed rapidly. Runge, in a similar 
 case, obtained a complete cure six months later. Cystic growths were scat- 
 tered upon the epiploon, bladder, and posterior abdominal wall. 
 
 Metastasis has been noticed with dermoid cysts. Kolaczek reports an 
 observation of Martin's, in which, during the course of an operation for 
 dermoid cyst with thick, smooth walls, considerable ascites was met with, 
 and several yellowish nodules of the size of peas were scattered upon the 
 peritoneum; several of them contained hair of a light color. Fraenkel, in 
 a case of Billroth's, also saw dermoid growths in the abdomen, associated 
 with a cyst of this nature. There are cases in which the infection is not 
 limited to the peritoneum, but invades the pleura through the lymphatic 
 
PATHOLOGICAL ANATOMY OF OVARLA.X CYSTS. 607 
 
 vessels, after having infected the inferior surface of the diaphragm. In a 
 case reported by Marchand the pleural tumors contained a gelatinous sub- 
 stance, and alveoli lined with columnar epithelium of which some was cili- 
 ated. In another case, reported by Terrier, the tumor of the diaphragmatic 
 pleura possessed carcinomatous properties. In fact, these metatastic prod- 
 ucts of ovarian cysts may take on a malignant histological structure. Thus, 
 a dermoid cyst may become the starting-point of an epithelioma which may 
 invade the uterus, epiploon, duodenum, liver, spleen, and lungs. Degener- 
 ation of dermoid cysts into malignant neoplasms, epithelioma, sarcoma, car- 
 cinoma, has often been observed. 
 
 B. Metastasis by Infection Following Operation. — Many cases have been 
 reported in which a little while after ovariotomy gelatinous masses have ap- 
 peared upon the peritoneum (myxoma peritonei), apparently developed from 
 the dissemination of similar substances contained within the cyst. These 
 masses are in the form of vitreous nodules, from the size of a hemp-seed to 
 that of a walnut, disseminated or gathered into a mass which may be as 
 large as a uterus at term. They have the yellow color of barley sugar or 
 are grayish in tint, and delicate partitions of connective tissue, in which 
 blood-vessels may or may not be present, may traverse them as in the vitre- 
 ous body. Werth has demonstrated that these are not real myxomata, and 
 proposes to call them pseudo-myxomata of the peritoneum. 
 
 Is the peritoneum inevitably destined to infection when there is an effu- 
 sion of the contents of dermoid cysts ? Two curious facts • observed by 
 Engstrom show that there may be a perfect recovery, even after the abdom- 
 inal cavity has been invaded by septic matter. We know, moreover, that, 
 while contamination of the peritoneum by the colloid contents of proligerous 
 cysts is of prognostic import for the success of an operation, yet it does not 
 make that success impossible. 
 
CHAPTER XXVIII. 
 
 ETIOLOGY, SYMPTOMS, COURSE, AND DIAGNOSIS OF 
 OVARIAN CYSTS. 
 
 Etiology. — Cysts of the ovary are most frequently observed during the 
 period of sexual activity. Yet it is undoubtedly true that not only do the 
 germs of many of these tumors date from foetal life, but that the actual for- 
 mation of the neoplasm has often begun at that time, to remain latent until 
 it receives some impulse which causes it to develop. This certainly occurs 
 in the case of dermoid cysts, and many observations tend to show that it also 
 occurs with proliferous cysts (mucoid cysts of Malassez, cysto-epitheliomata, 
 glandular, and papillary cysts). Doran, Winckel, and De Sinety have seen 
 in the foetus or in an infant at term small cystic cavities whose significance 
 and development are as yet unknown. Dermoid cysts may attain such a 
 growth, even in a child, as to necessitate removal. On the other hand, 
 there are cases of cyst which, develop at an advanced age, at sixty-five and 
 seventy-five years. I will return to this subject when speaking of the in- 
 dications for ovariotomy. Some curious cases of ovarian cyst have been 
 noted as occurring in the same family, among sisters, for example. The 
 affection is often bilateral. Out of i,ooo ovariotomies performed by Spencer 
 Wells, it occurred bilaterally 82 times (8.2 per cent). The proportion is 
 greater for papillary cysts, Olshausen estimating it at JJ per cent ; while 
 for glandular cysts considered by themselves, it would be only 4 per cent. 
 Scanzoni's view that chlorosis is an etiological factor is purely hypothetical. 
 
 Symptoms. — The onset is characterized by vague disturbances which do 
 not differ from those described under the head of uterine symptoms. They 
 are at first simply reflex troubles due to the congestion and stretching of the 
 appendages. Later come pressure symptoms of the rectum, bladder, or 
 nerves if the cyst be impacted beneath the peritoneum and unable to move 
 freely in the abdominal cavity. These phenomena are often absent. Fol- 
 lowing this latent or metritic (pseudo-metritic) period, suddenly appears the 
 period of tumefaction, when the abdomen becomes more or less distended. 
 The general health now begins to be affected, and a period of decline pre- 
 cedes the accidents which will surely cause death unless surgical science in- 
 terfere. 
 
 We distinguish two stages in the development of cystic tumors, each 
 one characterized by well-defined physical signs : First stage : The tumor, 
 which is small, is hidden in the pelvis, and recognized only by bimanual 
 palpation. Second stage: The tumor has become ventral, and maybe easily 
 felt through the abdominal walls. 
 
ETIOLOGY, SYMPTOMS, AND DIAGNOSIS OF OVARIAN CYSTS. 609 
 
 1. Pelvic ^ra^i'.— Usually, as soon as the tumor has attained twice or 
 thrice the size of a normal ovary, its weight causes it to fall within Douglas' 
 cul-de-sac; still, in some cases in which retroversion of the uterus opposes a 
 barrier, it may remain at the side or in front of the uterus. Bimanual pal- 
 pation will determine its presence, and its situation and connections will 
 show its ovarian nature; it is usually hard, because of the small size and 
 great tension of the capsule, rarely elastic or irregular. Hegar's manoeuvre 
 (pulling down the uterus with a tenaculum, and using rectal touch or biman- 
 ual palpation) is often of assistance in finding the pedicle. When the tumor 
 has a well-defined pedicle, it is very mobile and can be perceived through 
 the vagina only when pressed upon from above downward. When included 
 in the broad ligament, it seems to be one with the uterus, but careful ex- 
 mination will reveal a slight groove between them; we must not forget that 
 the uterus is pushed to the side or behind, or even to the front. In the case 
 of papillary cysts the tumor is often bilateral, and we may exceptionally feel 
 upon its surface, through the vaginal cul-de-sac, vegetations which resem- 
 bles cocks' combs ; there is usually some ascites. 
 
 In speaking of the pathology, I have already mentioned the existence of 
 a well-defined type of cystic lesions of the ovary, for which I suggested the 
 name of cystic disease. It is characterized by the number of sacs, their 
 small volume, which usually limits the growth of the tumor to the size of a 
 fist or a foetal head, and by the frequency of their occurrence bilaterally. 
 Owing to their small size, these tumors remain indefinitely in the pelvis ; 
 by touch and bimanual palpation we feel them either upon the sides of the 
 uterus or in the cul-de-sac of Douglas, where they may be fixed by adhesions. 
 One of the most constant symptoms which they cause is menorrhagia. L. 
 Tait incidentally but clearly pointed out this special clinical variety, which 
 he considers to be a result of follicular cysts. He noted the frequency with 
 which it accompanies uterine fibroids, but he also mentions (and I have 
 observed several cases in point) that it occurs independently of other 
 lesions. In the latter event, an exact diagnosis is rarely made, as we are 
 more apt to think there is some tubal affection (hydro-salpinx or hasmato- 
 salpinx), which is more common and which, it must be confessed, is difficult 
 to differentiate from it. 
 
 2. Abdominal Stage. — The external characters of the tumor vary greatly 
 when it may be felt at a certain height above the pelvis. If the patient be 
 very fat, or if she be a nullipara with firmly contracted abdominal walls, 
 anaesthesia may be useful to cause relaxation and permit of a careful exam- 
 ination of the relations of the cyst. It is equally useful in the first or pelvic 
 stage of the tumor. By abdominal palpation we feel a spherical tumOr well- 
 defined superiorly and laterally, less marked inferiorly; an irregular shape, 
 or protuberances upon the surface, usually indicate a polycystic tumor ; the 
 larger the tumor the more elastic and less resistant does it feel; fluctuation, 
 previously non-appreciable, is often felt after the administration of an anses- 
 
6lO CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 thetic. Percussion over the tumor gives dulness ; it must be very lightly 
 done, otherwise we will get a sonorous note transmitted from the intestines. 
 This neighboring sonorous body often makes it difficult to outline the cyst 
 with any great exactness by the use of the plessimeter. 
 
 By touch and bimanual palpation we usually find the uterus anteverted, 
 just in front of the pubis, and pushed slightly to the opposite side from that 
 of the cyst; the cervix is drawn upward and not easily accessible; it often 
 seems to disappear owing to the stretching of the vaginal culs-de-sac. The 
 sound will show decided elongation of the uterine cavity. Later, as the cyst 
 increases in size, it will push the uterus backward (Peaslee). Finally, there 
 are some cases in which the uterus is pushed downward ; I had a case of this 
 kind, in which the patient was cured after I had performed ovariotomy with 
 fixation of the pedicle into the abdominal wound. In large cysts of the 
 broad ligament, the uterus may be completely pushed to one side. 
 
 If the cyst attains enormous dimensions, the abdominal walls become 
 thin and striated, the linea alba is widened, the umbilicus protrudes. Di- 
 lated veins are seen upon the walls, especially in the region of the iliac 
 fossae, while in the ascites of cirrhosis they are most prominent in the supra- 
 umbilical region. When the tumor extends beyond the umbilicus, fluctua- 
 tion is easily felt over the greater part of its area, and is most distinctly felt 
 in thin-walled parovarian cysts. In determining the amount of its repercus- 
 sion, we get an idea of the size of the sacs, and if there are several centres 
 of fluctuation we may affirm that the tumor is polycystic. Toward the sides 
 we often find solid masses, which feel like a placenta; these are areolar and 
 colloid microcystic conglomerations. Percussion elicits flatness over an 
 irregularly spherical area; convex above, separated by a zone of resonance 
 from the hepatic dulness, unless indeed the great size of the tumor has united 
 the two dull areas. Intestinal tympanitic resonance surrounds the tumor. 
 The' resonance of the stomach may be diminished, but may always be found 
 in the epigastrium and on the left side of the thorax. A change of position 
 does not affect the dulness. In extreme cases the costal cartilages and the 
 xiphoid appendage are bent, the liver becomes horizontal and is pushed into 
 the concavity of the diaphragm, the heart is pushed upward, and the abdo- 
 men projects into the thorax. It is no longer cylindrical, but projects ante- 
 riorly, and slopes by a gentle curve from the chest, which seems to be mereh' 
 an appendage to it. Pressure upon the aorta and the crural arteries may 
 cause vascular souffles which are of no importance. 
 
 There is one sound which is perceived more by the hand than by the 
 ear, which is like the crepitation of crushed snow. According to Olshausen, 
 it is due to the displacing of colloid matter cither in one of the cavities or 
 upon the surface of the cyst if it ';? ruptured. I think that simple friction 
 of the peritoneum gives the same sensation, and I do not attach much im- 
 portance to it. 
 
 Menstrual disorders arc more rare than we should imagine a priori. 
 
ETIOLOGY, SYMPTOMS, AND DIAGNOSIS OF OVARIAN CYSTS. 6 II 
 
 Since large cysts are usually unilateral, the remaining normal ovary main- 
 tains a regular condition of the function. 
 
 Gallard studied sixty- nine cases of cysts in order to determine what 
 influence was exerted upon menstruation. Once out of every five cases there 
 was diminution of the flow or delay in its appearance; once out of eight, 
 irregularity, pain, or increase of the flow. We have already mentioned the 
 fact that menorrhagia often occurs in the case of cysts impacted in the im- 
 mediate neighborhood of the uterus. After the menopause, cases have been 
 noticed of congestive uterine phenomena causing the reappearance of a more 
 or less irregular flow of blood which leads the patient to believe in a return 
 of the menses. Under the influence of ovarian as well as uterine tumors, 
 there is often a reflex swelling of the breasts with pigmentation of the areola 
 as in pregnancy. A milky secretion has been noticed, even in quite young 
 girls. Sterility is an inevitable result only when both ovaries are affected, 
 and we know that ovarian cysts often complicate pregnancy. We must be 
 careful to make a distinction between the pressure phenomena in the early 
 stages, which appear only when the tumor is imprisoned in the pelvis (cysts 
 within the broad ligament, and retro-peritoneal cysts), and the pressure 
 symptoms caused at a more advanced stage by the weight and size of the 
 cyst rather than by its relations. 
 
 Pressure upon the bladder often produces incontinence of urine in the 
 early stages of cysts within the broad ligament ; and sharp pain from pres- 
 sure upon the nerves may arise under the same circumstances. Pressure 
 symptoms, as a usual thing, are not marked until the tumor is so large as to 
 distend the abdomen. Then there may be vesical troubles, frequent desire 
 to urinate, from diminished size of the bladder. Constipation is the rule 
 from pressure upon the rectum and interference with the physiological 
 efforts of defecation. Interference with the normal dilatation of the stomach 
 and with peristalsis of the intestines causes anorexia and vomiting, and con- 
 tributes to the advent of marasmus. When the tumor reaches very high in 
 the abdomen, the movements of the diaphragm and even of the ribs may be 
 seriously embarrassed, causing painful dyspnoea and cyanosis. Another 
 cause of dyspnoea which is frequently not recognized is the compression of 
 the ureters, causing chronic uraemia. We can scarcely exaggerate the im- 
 portance of this complication, nor the necessit)'' for careful examination of 
 the urine. 
 
 The cardiac affections noted in these cases may, perhaps, be due to the 
 renal disease. I dwelt at length upon this subject in the chapter upon 
 Fibroids, and need not repeat the details in this connection. Varicosities, 
 hemorrhoids, oedema of the extremities, purpura, pendulous belly, need no 
 more than a passing mention. 
 
 As soon as the cyst attains a certain size, the columnar epithelium which 
 surrounds and protects it desquamates in places, and then adhesions are 
 produced from friction. They are formed especially upon the anterior wall, 
 
6l2 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 which is the one most in contact with a resistant surface, but they may grow 
 in connection with every organ contained within the abdomen. This result 
 of partial peritonitis takes place quietly and without any febrile symptoms, 
 unless indeed it be caused by torsion or rapture of the cyst, in which case 
 all the signs of a more or less severe inflammation may be manifested. 
 
 The general health is rapidly impaired. Two chief factors are concerned 
 in this gradual decline of strength : compression of the various portions 
 of the digestive apparatus, which, joined to the reflex dyspepsia observed in 
 the course of all utero-ovarian diseases, prevents repair of the constant tissue 
 waste ; and compression of the ureters, which, though it may not for a long 
 while cause albuminuria, does cause serious uropoietic disturbances, and 
 adds to the malnutrition of the system, long before it is clinically recognized. 
 Pressure upon other organs, causing pain and sleeplessness, act in the same 
 way by adding to the general enfeeblement. The patients become greatly 
 emaciated, but I cannot see that the facies of ovarian disease, so strongly 
 insisted upon by some writers as almost pathognomonic, are specially 
 marked. 
 
 Accidents. Inflammation, Suppuration. — Temporary elevation of temper- 
 ature and sensitiveness over the abdomen, in women suffering from ovarian 
 cyst, indicate acute inflammation, either around or within the cyst. Sup- 
 puration of the cyst itself will cause regularly recurring and intense fever, 
 with chills and sweating, accompanied by intense pain. A slight effort of 
 memory will probably recall the cause of these accidents (contusion, punc- 
 ture, torsion of the pedicle). 
 
 Torsion of the Pedicle. — This accident was first pointed out by Roki- 
 tansky. Many studies have since been made of this especial point. Thorn- 
 ton has recently collected the reports, adding the results of his large per- 
 sonal experience. Out of 600 ovariotomies he found torsion of the pedicle 
 57 times. This accident is less frequent than in Rokitansky's time. It 
 was then about 13 per cent, and is now about 9.5 per cent. This is ac- 
 counted for by the fact that at the present day cysts are operated upon at a 
 much earlier stage. In the etiology we must mention pregnancy ; out of 6 
 cases of cyst complicated by pregnancy, upon which Thornton operated, tor- 
 sion was present 5 times, and in 9 cases the acute symptoms were first 
 manifested after labor or abortion. In 4 instances there was arrest of 
 menstruation from cold ; 4 followed puncture of the cyst ; in 8 cases 
 there was no discoverable lesion. Torsion of the pedicle has been produced 
 by exploration of a very movable tumor and by the change of position due 
 to evacuation of the cyst. Anything adding to the mobility of the tumor — 
 as ascites, length and slenderness of the pedicle — is a predisposing cause. 
 Dermoid cysts are especially liable to it, however movable they may be, be- 
 cause of their weight. 
 
 Lawson Tait has seen torsion more often upon the right side, Olshausen 
 on the left. Veit, Rohrig, and Thornton have seen it on both sides. 
 
ETIOLOGY, SYMPTOMS, AND DIAGNOSIS OF OYARIAN CYSTS. 613 
 
 If this torsion is slowly acquired, it has been claimed that a gradual 
 decrease in the size of the tumor may result; I cannot look upon this as a 
 fa\'orable symptom. A torsion which at first is slight may be rapidly fol- 
 lowed by complete torsion and lead to severe accidents. A sharp and sud- 
 den pain is the first indication. If the torsion is complete the signs of peri- 
 toneal reaction soon appear. If the pedicle is lamellated and not very 
 vascular, as in the exceptional cases of pediculated cysts of the parovarium, 
 they may be slight. More often they precede peritonitis of varying degrees 
 of intensity. It may be rapidly fatal or assume a dropsical character. 
 Meteorism and acute ascites are also developed. Sometimes these accidents 
 disappear in the course of a few days. Olshausen believes that there may 
 be temporary torsions of the pedicle ; he has seen two examples of it, which 
 he thinks conclusive. Finally, the febrile symptoms may continue because 
 of an absorption of the products of slow mortification of the tumor (septic 
 intoxication rather than infection), and the patient dies of marasmus and 
 cachexia. Rupture of the cyst often occurs at the same time as torsion of 
 the pedicle ; the latter is often complicated by extensive internal hemor- 
 rhages, the arterial supply continuing, while the veins are obliterated by the 
 torsion. These hemorrhages add acute aneemia to the grave condition of the 
 patient already existing. Symptoms of a localized peritonitis around the 
 cyst soon declare themselves, so that the formation of extensive adhesions is 
 one of the most frequent results of torsion. 
 
 RiLptiirc of the Cyst. — The rupture of small cysts due to follicular dropsy 
 seems to be of frequent occurrence and little importance; it may arise by 
 spontaneous dehiscence. 
 
 As to the large cysts, their rupture is due either to traumatism, a blow 
 upon the abdomen, a fall, the strain caused by vomiting, or to wearing away 
 of the wall, or fatty degeneration caused by thrombosis. It has been ob- 
 served during the course of a surgical exploration. This accident occurs 
 most frequently in the case of gelatinous cysts, and is often preceded by 
 torsion of the pedicle. Erosion of the sac by papillary growths may be an- 
 other cause of the rupture. 
 
 The perforation occurs into the peritoneal cavity or into some neighbor- 
 ing organ. The former is the more frequent. The fluid may be reabsorbed 
 without causing much reaction, if it be but slightly irritating, as in serous 
 cysts. Out of 127 cases the reports of which were collected by Nepveu, 
 there were 43 recoveries after the lapse of some time, 21 cases of temporary 
 disappearance, and 63 deaths. Death may be so rapid that it seems due to 
 septic intoxication from absorption of the fluid; or it may be preceded by 
 the symptoms of acute peritonitis. 
 
 Rapid disappearance of the tumor, change of form of the abdomen, with 
 the signs of a free collection of fluid in the abdominal cavit}^ which has to 
 be pushed aside by the hand in order to reach the remains of the cyst, are 
 the pathognomonic symptoms of the accident, often ushered in besides by 
 
6 14 CLINICAL AND OPERATIVE GYNECOLOGY 
 
 swooning or sharp pain. If the patient survive, there may be signs later of 
 peritoneal irritation with ascites. In rare cases the rupture may be latent 
 and accompanied by no symptoms sufficiently marked to attract attention. 
 
 This fluid may, moreover, be imprisoned by false membranes, and form 
 a new intra-peritoneal cyst. 
 
 Abandant diuresis and diaphoresis have been noticed in cases of intra- 
 peritoneal rupture of ovarian cysts. Anasarca also has been seen. Kiistner 
 calls attention to a curious symptom, peptonuria. Rupture into the intes- 
 tines usually occurs at the rectum or colon; if there have been suppuration 
 of the cyst, relief is experienced at first, but a cure is rare; on the contrary, 
 the intestinal contents are liable to infect the cystic cavity and bring about 
 septic fever. 
 
 In a very few cases the stomach or small intestines have been the seat 
 of evacuation. Severe vomiting was the first sign in a case of perforation of 
 the stomach reported by Portal. Where the intestines are perforated, diar- 
 rhoea is the initial symptom. A rupture externally by fraying the abdomi- 
 nal walls below or at the umbilicus has been observed, and is rather favora- 
 ble than otherwise. Rupture into the vagina or bladder is rare, and is 
 characterized by an evacuation of the fluid through these organs. 
 
 Evacuation of these cysts through the tubes after the formation of tubo- 
 ovarian cysts, as mentioned above, might be included under the head of rup- 
 ture of cysts. The evacuation is usually intermittent. 
 
 Internal strangulation may occur during the development of ovarian cysts, 
 from excessive pressure upon the intestines, by their twisting about the 
 pedicle, which is often twisted itself, or finally from peritoneal adhesions 
 becoming attached to the tumor; in the last case diminution in the volume 
 of the cyst by puncture may have a fatal effect. 
 
 The occurrence of pleural complications has been so positively asserted 
 that it deserves mention. According to Terrier, these complications may 
 precede or follow surgical interference, and are by no means exceptional. 
 Demons found them nine times out of fifty cases, and he contradicts the 
 generally held opinion that pleural effusions indicate malignity of the neo- 
 plasm. He considers that the impeded lymphatic circulation of the abdo- 
 men reacts upon the pleura beyond and through the diaphragm. 
 
 Prognosis. — " When ovarian tumors," writes Spencer Wells, "attain such 
 a size that the general health is affected, the length of life granted to the 
 patient will probably not exceed two years, and these two years usually con- 
 sist of a series of troubles, even of torture and despair.. The cases in which 
 expectant treatment and successive punctures have been able to prolong life 
 for several years are great exceptions to the foregoing rule." Vet we should 
 recognize the fact that in some rare cases the course of the disease may be 
 very slow. T. P. Frank speaks of a patient of eighty-eight years who had 
 had a cyst since the age of thirteen. It was in all probability either a der- 
 moid or a parovarian cyst. Olshausen observed a cyst, probably of the latter 
 
ETIOLOGY, SYMPTOMS, AND DIAGNOSIS OF OYARIAN CYSTS. 615 
 
 variety, in a woman of forty-eight, which liad been there for nineteen years. 
 Hyaline parovarian cysts or unilocular cysts of the broad ligament may rup- 
 ture into the peritoneum several times in succession, with quite a long res- 
 pite after each rupture. On the other hand, proliferous cysts may, after 
 remaining quiescent for a long time, suddenly take a rapid course. Hyaline 
 parovarian cysts of the broad ligament develop very quickly. After their 
 first appearance, the growth of papillary cysts may be arrested for a consid- 
 erable period ; but the appearance of ascites, showing that there has been a 
 perforation of the sac by vegetations, indicates that a fatal issue is imminent. 
 
 An absolute or relative spontaneous cure is not an impossibility. Intra- 
 peritoneal rupture often brings about the cure of parovarian cysts. Gradual 
 torsion of the pedicle may exceptionally cause atrophy of proliferous cysts 
 by diminution of their walls and calcification. 
 
 Death is the ordinary result of cystic development unless there be surgi- 
 cal interference. Marasmus, peritonitis, embolus, are the three chief causes 
 of death. Suppuration from repeated puncture or ill-timed treatment used 
 to be frequent. What influence has ascites upon the prognosis ? It is with- 
 out doubt an unfavorable occurrence, since it is met with in papillary cysts 
 when the vegetations have perforated the sac, and in glandular cysts when 
 rupture occurs or when there is torsion of the pedicle. Still, the reports of 
 numerous cases show that this complication is not necessarily fatal, and L. 
 Championniere, who has never seen a case of recovery from ovarian tumor 
 accompanied by ascites, has evidently happened to see a series of unfortu- 
 nate cases. 
 
 Another question which is still shrouded in darkness is that of the be- 
 nignity or malignity of papillary cysts. Many cases in which they have been 
 removed have resulted in a cure. Eighteen years ago I operated upon double 
 papilloma of the ovaries, accompanied by ascites, in a young girl, who is 
 now completely restored to health. I mentioned other similar cases when 
 speaking of metastasis. On the other hand, the fact of the frequent occur- 
 rence of metastasis or even of generalization of papillary cysts, which assume 
 a malignant type, should make our prognosis very guarded. There is prob- 
 ably some element present which the microscope is unable to reveal. It 
 would seem as if the histological instability of these neoplasms, the ready 
 transformation of their columnar epithelium into metatypical or atypical 
 epithelium, places these cysts in a state of constantly imminent malignity. 
 
 Cohn, out of fifty cases of papillary cyst, which were carefully followed 
 after ovariotomy, found twenty which seemed to him to be anatomically 
 malignant, and in fact a microscopic examination will never permit of our 
 asserting that such growths are clinically benign. It is better r.lways to 
 expect the worst, and to be on the lookout for general peritoneal :'nfection. 
 Poupinel also advises this caution. 
 
 Glandular cysts may undergo cancerous degeneration. Hofmeier, Cohn, 
 and Ruge have pointed out that a racemose appearance of the cystic masses 
 
6l6 CLINICAL AND OPERATIVE GVX^COLOGV. 
 
 often indicates malignity. Certain clinical symptoms leave no doubt in such 
 cases. These are : sudden development of a tumor which has already existed 
 for some time; rapid emaciation and cachexia; multiple adhesions, espe- 
 cially in the pelvis ; oedema of the lower limbs and abdominal walls out of 
 proportion to the size of the tumor and the amount of ascites present; pleu- 
 ritic complications, etc. Dermoid cysts also may undergo cancerous degen- 
 eration. The prognosis of operation for malignant tumors showing these 
 symptoms is very unfavorable. Still, as cases of permanent cure have been 
 known to follow where it seemed impossible, we should operate whenever 
 there seems to be any chance of success. Leopold, in view of this possible 
 degeneration, makes it a rule to remove any ovarian tumor as soon as it 
 appears, especially if it be bilateral. 
 
 Diagnosis. A. Pelvic Tumors. — In the earliest stages of ovarian cysts, 
 it is difficult to distinguish them from other tumors situated by the sides of 
 the uterus. A sessile cyst of the broad ligament might be simulated by an 
 infiammator}^ nodule of peri-metro-salpingitis. A remembrance of previous 
 symptoms, the course of the disease, with the existence of inflammation of 
 the tubes and ovaries, will prevent error. These tumors are, moreover, less 
 sharply limited, more sensitive to pressure, and subject to more rapid 
 changes of size. A small pelvic haematocele shovv's fluctuation at first, but 
 does not give the sensation of an encapsulated tumor, especially laterally, 
 where it always spreads ont more. Later it becomes hard, while the manner 
 of its appearance, with the intense peritoneal reaction which marks the 
 onset, are very diagnostic. The extra-peritoneal variety may be difficult to 
 distinguish from a beginning cyst of the broad ligament, except by the 
 course of the swelling, which shows a tendency to absorption. Tumors of 
 the tubes, especially hydro-salpirtx, may cause perplexity. A bilateral lesion 
 would seem to indicate their presence ; oftentimes laparatomy alone, which 
 is indicated in either case, can decide the question. Extra-uterine pregnancy 
 in the beginning has few distinctive symptoms, although it usually causes 
 amenorrhoea and congestion of the genital mucous membrane ; later it is 
 characterized by special signs, which will be described in another chapter. 
 
 Retroflexion of the gravid uterus at the third and fourth months is to be 
 suspected only when there are signs of beginning pregnancy, and when the 
 tumor is situated in the posterior cul-de-sac and causes acute pressure symp- 
 toms [retention of urine, constipation] ; finall}-, if it be of solid consistence 
 and continuous with the cer\nx, which is far forward, attempts at reduction 
 will settle all doubts upon the subject. The exact position of the uterus 
 should always be determined before deciding that there is a tumor independ- 
 ent of this organ. I consider stercoraceous tumors worthy of mere mention 
 only. 
 
 B. Abdominal Tumors. — Pregnancy deserves the first mention, for a mis- 
 take in regard t"> it would be the most fatal of any. An error is most likely 
 to be committed when there is hydramnios, for then we can neither palpate 
 
KTIOLO(;V, SViVIPTOMS, AND DIAGNOSIS OF OVARIAN CYSTS. 
 
 617 
 
 the foetus nor hear the foetal heart sounds. In order to avoid the opposite 
 error — of mistaking a cyst for a gravid uterus — we should never be satisfied 
 with probabili ies, but seek for absolutely certain signs ; we must remember 
 that amenorrhcea, swelling of the breasts, and even a delusory subjective 
 sensation of foetal movements (produced b)' borborygmus) may all exist in a 
 case of ovarian tumor. 
 
 The diagnosis will be settled only by a perception of the movements and 
 hearing of the foetal heart sounds by the surgeon, positive identification of 
 foetal parts, sensation of contraction of the gravid uterus, ballottement, and, 
 
 Fig. 436. — Ovarian Cyst complic.\ted r.v Prkgnanxv. O 7", Cyst pushed out <>{ the pelvis by the uterus [', which 
 is pushed against the pelvic walls ; ^//, auscultatory centre for the fcetal heart sounds. 
 
 toward the end of pregnancy, pelvic engagement of foetal parts. The use of 
 the sound is both dangerous and useless. We must not forget that preg- 
 nancy and a cyst may coexist, in which case the surgeon's task becomes 
 complicated ; the fluctuating mass and the exact situation of the positions of 
 the foetus should be carefully studied by the aid of auscultation and palpa- 
 tion. The error of thinking that there is a cyst where pregnancy exists is 
 far more serious than the opposite blunder; and when in doubt we should 
 always await developments. It is unnecessary to say that exploratory punc- 
 ture is more dangerous than an exploratory incision. 
 
 Ascites may simulate a large cyst, which fills the abdomen and is indis- 
 tinctly outlined. I will recall the signs of effusion of fluid within the peri- 
 toneal cavity ; the abdomen is more spread out, less acuminated, than in 
 cysts ; flatness is found in the dependent portions, and limited superiorly 
 
6r8 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 by a conca/e line (Fig. 437 and Fig. 438). In a position of lateral decubi- 
 tus, it gravitates to the side and to the iliac fossae, while the tympanic note 
 appears upon the opposite side, where it did not previously exist; this dis- 
 placement of the fluid is very characteristic if we can but find it, as is the 
 fluctuating sensation transmitted from one side of the abdomen to the other. 
 Some cases present greater difficulties of diagnosis, where, for instance, the 
 ascites is of rapid development, the abdomen distended, the skin smooth, 
 shining, and striated, non-depressible, giving a sensation of undulation and 
 the returning shock rather than of clear fluctuation. Dulness may not be 
 systematically present in the dependent portions ; the contents are irregu- 
 larly situated and not easily displaced by a change of position. But the 
 
 Fig. 437. — Outline of Area of Dulness in 
 Ascites. /, Intestinal resonance ; Z-, hepatic dul- 
 ness : A A, dulness of the flanks. 
 
 Fig. 438. — Dulness in a Case of Ovarian 
 Cyst. /, Intestinal resonance ; L, hepatic dulness ; 
 OT, dulness over the cyst. 
 
 rapid increase in size of the abdomen, oedema of the lower limbs, decline of 
 the general health, and the absence of a previously existent tumor are all 
 symptoms that will help the surgeon in making a correct diagnosis. An- 
 other sign to be looked for is the mobility of the uterus, which is present in 
 ascites and absent in large cysts. Finally we must examine into the con- 
 ditions of the viscera (liver, heart), disease of which usually gives rise to 
 ascites. 
 
 Difficulties of diagnosis are the greatest in tubercular or cancerous peri- 
 tonitis ; for dropsy of the peritoneum may then be encysted by adhesions. 
 In the first case, signs of intestinal and pulmonary tuberculosis, irregulari- 
 ties in the shape of the abdomen due to meteorism interfered with by adhe- 
 sions, the C7'i intestinal caused by palpation, will clear the diagnosis. In the 
 case of cancer we have the presence of irregular masses dependant from the 
 epiploon or adherent to neighboring parts, and rapid cachexia. 
 
ETK)L()G\', SYMPTOMS, AND DIAGNOSIS OF OVARIAN CYSTS. 619 
 
 Puncture may be of real service in these cases, to allow of an examina- 
 tion of the fluid and to facilitate palpation of the abdomen, which becomes 
 more flaccid after its use. Yet at the present day we usually omit it, for we 
 have learned its drawbacks. If we decide to perform it, the greatest pre- 
 cautions are to be taken; the trocar and canula are to be purified by flame; 
 instruments of small calibre are to be used for aspiration, the wound care- 
 fully closed, and the abdomen immobilized. Puncture with total evacuation 
 of the fluid is less grave with a large tumor than with a small one, for the 
 retraction of the sac prevents effusion of the fluid into the peritoneal cavity. 
 A cyst punctured with Potain's apparatus should be emptied very slowly. 
 We may replace the vacuum by the use of a simple siphon made by attach- 
 ing to the canula a long rubber tube. The size of the trocar should not be 
 greater than that of the instrument used for hydrocele. The site chosen for 
 the puncture is in the middle of a line going from the linea alba to the an- 
 terior superior spine of the ilium, or else the linea alba itself; the bladder 
 is to be evacuated beforehand; we must carefully cleanse the abdominal 
 walls with soap and bichloride, and be sure that the spot to be punctured is 
 absolutely dull on percussion. 
 
 An examination of the fluid usually suffices to establish the diagnosis ; 
 viscidity and a brown, green, or black color are the characteristics of cystic 
 fluid ; a clear fluid non-coagulable by heat comes probably from a parovarian 
 hyaline cyst of the broad ligament or from a hydatid cyst. In some cases 
 examination of the fluid does not settle the question — where, for instance, 
 it is tenacious, yellowish, amber-colored, or tinged with blood ; both ascites 
 and some kinds of cyst show these characters. The finding of paralbumin 
 points to the probable existence of a cyst. If the liquid spontaneously co- 
 agulates, the chances are in favor of ascites — although this sign is not ab- 
 solutely pathognomonic, any more than the foregoing. Klob, Martin, West- 
 phalen, Scanzoni, Olshausen, have seen spontaneous coagulation in the fluid 
 from an ovarian cyst. A proportion of solids greater than 3 iij. ~ ij. to 
 the quart favors the diagnosis of cyst. Microscopical examination, to which 
 Spiegelberg and Waldeyer attach great importance, demonstrates in the asci- 
 tic liquid the presence of amoeboid cells, pavement epithelium, and blood- 
 corpuscles, but never columnar epithelium, which is often found in glandu- 
 lar cysts ; as to papillary cysts, the anatomical elements contained within 
 their fluid contents are usually entirely destroyed. 
 
 Palpation of the abdomen after puncture, which must be cautiously per- 
 formed, gives valuable information ; by it we may recognize the ovarian 
 tumor, and also determine other changes of the viscera which were hidden 
 by the effusion of fluid. We must not forget that ascites may complicate a 
 cyst which has ruptured or a papillary cyst with external vegetations ; there 
 will be symptoms of both lesions; we may have a peculiar sensation of 
 ballottement, due to the floating of the cyst in the ascitic fluid, like a piece 
 of ice in water. 
 
620 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Puncture of a cyst done with even the greatest precs-utions is by no 
 means a harmless operation. Partial evacuation may be followed by an effu- 
 sion of the IL 1 into the abdomen, and fatal peritonitis; the neglect of anti- 
 septic precautions or some unknown influence may brmg about suppuration 
 of the cyst. This has been noticed particularly in connection with dermoid 
 cysts ; I have seen one case, which was followed by cure. Grave hemor- 
 rhages have been known to occur from wounding, the large blood-vessels -of 
 the abdominal walls or of the tumor. Weakening of the cystic walls may 
 result from the puncture and permit the exit therefrom of papillary vegeta- 
 tions, with consequent infection of the peritoneum. 
 
 Uterine fibroids have often been simulated by oligocystic tumors with 
 gelatinous contents, which give them the same elastic consistence; this error 
 is especially liable to occur if absence of a pedicle cause these tumors to 
 move by movements imparted to the uterus, as though they formed a part of 
 it. Anaesthesia will often permit the observation of fluctuation, which 
 should be carefully felt for by bimanual palpation, and the connections be- 
 tween the tumor and the uterus accurately identified. Great increase in size 
 of the uterine cavity, shown by the sound, points toward a fibroid ; still, an 
 elongation of an inch to an inch and a half may be produced by the ascen- 
 sion of and traction exerted by the ovarian tumor. Fibro-cystic tumors of 
 the uterus are especially apt to cause an error of diagnosis. The first cases 
 of hysterectomy, we remember, were done under the supposition that an 
 ovariotomy was to be performed. 
 
 Haematometra is recognized by its situation and special etiology. 
 
 Vesical distention has been the source of numberless errors, which may 
 be avoided if the surgeon himself will employ the catheter before examining. 
 In one case, I saw a distended bladder which reached to the epigastrium ; I 
 had been called in to puncture this false cyst in a patient suffering from 
 general paralysis. Spencer Wells, Atlee, and Emmet have all reported re- 
 markable cases of this kind. 
 
 Renal tumors, hydronephrosis, hydatidiform cysts, etc., have given rise 
 to mistakes. We should ascertain whether the tumor is fixed in the hypo- 
 chondrium, and free inferiorly, permitting one to pass the hand beneath it 
 quite far above the pubis ; the existence of renal ballottement ; also whether 
 the intestines, especially the colon, are interposed between the tumor and 
 the abdominal wall. When the tumor fills the abdomen, these signs will be 
 absent ; even then, however, the situation of the colon is of importance. It 
 has been suggested that, in order to make this sign very marked, the tumor 
 should first be partially emptied by puncture, and then effervescent enemata 
 be administered in order to distend the large intestines with gas. Pawlik 
 attaches great value to the persistence in the kidney of its characteristic 
 shape, which can be felt after puncture. The development of a tumor dating 
 from infancy points toward hydronephrosis and cancer of the kidney. Pus 
 and blood are to be looked for in the urine. The exploration of the kidney 
 
ETIOLOGY, SYMPTOMS, AND DIAGNOSIS OF OVARIAN CYSTS. 62 I 
 
 region by the introduction of the whole hand into the rectum has sometimes 
 furnished valuable information, but may cause injury to the patient unless 
 the surgeon's hand be exceptionally small and flexible. Examination of the 
 fluid obtained by puncture sometimes settles all doubts, but may only in- 
 crease them if the liquid be not very characteristic. Urea may be absent in 
 hydronephrosis and present in ovarian cyst; the same may be said of uric 
 acid ; still, a large proportion of these products would decidedly point toward 
 renal disease. Finall}', sounding the ureters by means of Pawlik's or 
 Simon's method should not be neglected as a last resort. 
 
 I will simply mention tumors of the liver and spleen (cyst, hypertrophy), 
 as they are very rare; the diagnosis, when difficult, can be made only by a 
 careful consideration of the relations, sometimes by exploratory incision. 
 Tumors of the mesentery and of the omentum (cysts, lipomata) and echino- 
 coccus of the abdominal cavity are usually recognized by puncture or explor- 
 atory incision ; the latter is to be preferred. 
 
 Tumors of the abdominal wall sometimes cause errors, which could be 
 avoided by the use of anjesthetics. 
 
 Pseudo-cysts, phantom tumors, tympanites associated with partial con- 
 traction of the abdominal muscles and superabundance of fat in any partic- 
 ular spot, sometimes cause the most extraordinary and unheard-off errors, 
 especially in hysterical patients. Oftentimes the abdomen has been opened 
 in such cases, more often still one has been upon the point of doing so. 
 
 The best way to avoid error in doubtful cases is first to anaesthetize the 
 patient and then carefully to palpate and percuss. 
 
 Exploratory Incision. — In the event of failure of all other methods of 
 diagnosis, shall we open the the abdomen to ascertain the nature of the 
 tumor, and operate, if possible, at the same time .^ Upon this point Lawson 
 Tait has a positive system ; he always prefers incision to exploratory punc- 
 ture ; out of ninety-four such cases he had but two deaths. He makes a very 
 small incision, large enough for the introduction of two or three fingers only, 
 and this undoubtedly accounts for the exceptionally good results obtained. 
 Terrillon, in a more extended abstract of cases from many sources, found 
 twenty-one deaths in a hundred, which seems to me too high a rate, in con- 
 sideration of the great progress made in technique of late. We must re- 
 member that under the name of exploratory incision, used for the sake of 
 euphemism, have been included many unfinished operations. 
 
 Now, it is not so long since mere incision of the abdomen was considered 
 a very grave step ; once done, operators were not content to close the wound 
 without an attempt at extirpations, even under conditions before which we 
 should hesitate at the present day ; the statistics, while correct, may lead us 
 to take too dark a view. For my part, I am a decided advocate of explora- 
 tory incision, when it seems to be the only method of establishing the diag- 
 nosis. 
 
 Diagnosis of tlic Variety of Cyst. — The previous considerations may 
 
€22 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 .aid in deciding this point ; I will simply give a resume of the principal 
 points. 
 
 A large and nodular tumor, with irregularities in the consistence of the 
 nodules, is a glandular cyst. The presence of ascites (if there be no symp- 
 toms of rupture), irregular and papillary masses in the cul-de-sac of Douglas, 
 and the presence of a tumor upon both sides point to a papillary cyst. 
 Easily appreciated and superficial fluctuation throughout the whole extent of 
 the tumor, slow course of the disease, an almost perfect general condition, 
 even when the tumor is large, intimate connection between the tumor and 
 the uterus, whether the cyst appear to be within the broad ligament or at- 
 tached to a short pedicle, are characteristic of hyaline parovarian cyst. The 
 possibility of feeling the ovary and tube upon the same side as the tumor 
 has been considered pathognomonic. For the recognition of dermoid cysts 
 we have the possibility of making an impression upon a tumor filled with 
 fatty matter, or even of hearing the friction of the contained hairs. Kiister 
 lays emphasis upon the tendency of dermoid cysts to develop upon the 
 median line, and to return to that position after they have been displaced 
 during an exploratory operation. 
 
 Diagnosis of Adhesions. — For the recognition of parietal adhesions, 
 Spencer Wells notes whether a change of position on the part of the patient, 
 or respiratory movements, cause motion of the neoplasm. In moving the 
 abdominal walls in front of the tumor, we notice whether the umbilicus 
 glides easily over it, and we may hear a grating sound, or a sound like the 
 creaking of new leather, which indicates some action of adhesive peritonitis. 
 Any tumor which has long been of large size is usually adherent to the 
 anterior abdominal wall or to the epiploon unless there be some ascites pres- 
 ent. Adhesions to the viscera can be suspected only when there are external 
 signs of acute peritonitis .after puncture, torsion of the pedicle, or rupture of 
 ,the cj's.t. 
 
CHAPTER XXIX. 
 
 TREATMENT OE OVARIAN CYSTS. 
 
 I SHALL not dwell upon the medical treatment, which I consider respon- 
 sible for the death of many patients, in having often prevented operations at 
 the proper moment. Diuretics and diaphoretics, mercurial and iodized prep- 
 arations, ergot of rye, etc., owe the success claimed for them to ignorance of 
 the pauses often met with in these diseases. The only rational internal 
 treatment consists in the administration of tonics, stomachics, and simple 
 laxatives to support the digestive system. Electrolysis, of the use of which 
 there has been an actual abuse in gynaecology, is both useless and dangerous 
 in these cases. Every ovarian cyst should, if possible, be removed. 
 
 Puncture tJirougJi the abdominal zvall was also too frequently used as a 
 palliative before ovariotomy came into general use. Some patients have had 
 cysts evacuated an incredible number of times. Where there are symptoms 
 of extreme pressure, or where the tumors absolutely cannot be operated 
 upon, puncture is sometimes urgently called for. The trocar, is then to be 
 inserted by preference in the linea alba, or at some spot where there is dul- 
 ness on percussion. Unnecessary puncture of a cyst which can be removed 
 is bad practice. Peritonitis may result, or, at the very least, the formation 
 of adhesions. Some authorities wish to make an exception in favor of cysts 
 of the broad ligament, the unilocular cysts with thin walls and transparent 
 contents, hyaline parovarian cysts. But against the few cases of recovery, 
 well authenticated but not followed a sufficient length of time to judge of 
 their permanent value, we must place the many cases of relapse. Moreover, 
 puncture is really dangerous from the point of view of metastatic generaliza- 
 tion of papillary cysts of the broad ligament, which it is almost impossible 
 to differentiate beforehand from purely serous cysts. If, on the other hand, 
 we consider the great benignity of ovariotomy in these cases, we cannot hesi- 
 tate in giving it the preference over a method which can boast of a few suc- 
 cesses, but has to acknowledge many untoward results. 
 
 Puncture has usually been practised through the abdominal walls ; it has 
 also been done through the vagina where the tumor was small ard more easi- 
 ly accessible in that way. It is a hazardous practice because of the danger 
 of consecutive infection and grave suppuration, especially in the case of a 
 dermoid cyst. Tavignot does not hesitate to recommend puncture through 
 the rectum ; I consider this a detestable operation. 
 
 Injection of iodine, enthusiastically recommended by Boinet, has few ad- 
 
624 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 vocates at present ; a few surgeons still employ it in the case of unilocular 
 thin-walled cysts. Even for these it is more dangerous than ovariotomy, and 
 was of use only in the days when the latter operation was regarded as 
 hazardous. 
 
 Draiiiage after puncture or incision was at the same date applied to cysts 
 which could have been removed with ease ; it was attended by a few good 
 results, and by man}- deaths from septic infections. Drainage should no 
 longer be used except for the remains of cyst sacs which it has not been 
 possible to remove, or when a suppurating cyst non-amenable to operation 
 has spontaneously opened externall}-. 
 
 OvARiOTO^n.'. Historical Outline. — Ephraim MacDowell of Kentucky, 
 a pupil of John Bell of Edinburgh, was the first to do an ovariotomy for 
 ovarian cyst, in 1809. The pedicle was left in the abdomen; a cure fol- 
 lowed. Another American, Nathan Smith, of New Haven, Conn., was the 
 second ovariotomist. Allan Smith was the third. His first successes date 
 from 1827. 
 
 These were isolated cases of bold operation which found no imitators. 
 J. L. Atlee, in 1843, performed the first double ovariotomy; and in the fol- 
 lowing year, Washington L. Atlee, who must not be confounded with him, 
 began his remarkable series of operations, which in 1871 reached the num- 
 ber of 246. Ov^ariotomy was thoroughly established in America after the 
 year 1863. In England, Lizars, inspired by the success of MacDowell's 
 cases, made an abdominal opening in 1824 from an error of diagnosis, and 
 the next year for ovarian cysts, of wljich he cured one out of three cases. 
 Granville had two failures, which discouraged him, and until the year 1 842 
 the operation fell into discredit. Walsh and Clay rehabilitated it b)' a re- 
 markable series of successes. Then came the operations of Bird and Baker- 
 Brown, and finally of Spencer Wells (1858). 
 
 In Germany, Chr}'sman, in 1823, made an unfortunate attempt. A few 
 isolated operators, among whom we mav mention Stilling, hazarded the oper- 
 ation, but it was not definitely adopted. 
 
 In France, Woyerskowsky U844) was probably the first to perform ovari- 
 otomy. In 1856 the operation was condemned by the Academy, with only 
 Cazeaux to protest. In 1862 Nelaton went to see Spencer Wells, and upon 
 his return performed ovariotomy without success. But Koeberle, in 1864, 
 reported nine cures out of twelve cases ; and then Pean demonstrated in a 
 striking manner that the operation could be successfully performed in Paris. 
 The adoption of ovariotomy in France is due to these two men. 
 
 At this juncture the introduction of antisepsis opened a new phase of 
 existence for the operation, which passed from the hands of a few eminent 
 specialists into those of all surgeons. 
 
 To recapitulate, ovariotomy has passed through three successive stages : 
 1st. A phase of groping, which came to an end first in America with W. L. 
 Atlee, in England with Baker Brown and Spencer Wells, in F"rance with 
 
TREATMENT OF OVARIAN CYSTS. 625 
 
 Koeberle and Pean. 2cl. A short period of excessive specialization, to which 
 is attached the names of the initiators of the movement, already given. 3d. 
 A phase of popular adoption, under the powerful impulse given by the intro- 
 duction of antiseptics. 
 
 General Indications. — It is no longer necessary to dwell at great length 
 upon this part of our subject, since many questions which were a subject of 
 debate, even recently, have been settled. Some surgeons, basing their views 
 upon the possibility of curing hyaline parovarian cysts after simple puncture, 
 as shown by Terrillon's somewhat optimistic report of one cure in three 
 cases, advise puncture, with an operation in the case of relapse. This pro- 
 cedure would assuredly be wise could we always be certain of never con- 
 founding a hyaline and papillary cyst. But inasmuch as such a distinction 
 is often impossible before puncture, and as puncture is very dangerous in 
 the second event, I cannot but feel that it is better to perform ovariotomy 
 at once, the operation being in simple cases perfectly free from danger. 
 
 We can then no longer say that laparatomy should be reserved for cases 
 in which the cyst is so large as seriously to inconvenience the patient or to 
 threaten life. As soon as an ovarian cyst is large enough to be recognized, 
 it should be removed : in the first place because the operation itself is less 
 serious, since a small incision only need be made, and there are no adhesions 
 to break down ; in the second place because the patient is spared the dangers 
 of inflammation, rupture of the cyst, or torsion of the pedicle ; finally and 
 above all, because any ovarian cyst is, if one may so express it, a neoplasm 
 of unstable equilibrium between benignity and malignity. Out of 658 cysts 
 removed by Schroder, Cohn found 100 degenerated into malignant tumors, 
 or 15. 1 per cent; Leopold counted 26 out of 116 (22.4 per cent) ; J. B. 
 Schultze, out of a small series of 33 cases, found 9 malignant cases (21 per 
 cent). This proportion may be somewhat high owing to the fact that only 
 grave and difficult cases were brought to these great operators. 
 
 Yet, beyond doubt, they may be taken as an indication of the frequency 
 of malignant degeneration of cysts. Poupinel reaches the same conclusions. 
 Now, to remove a cyst which has already undergone degeneration is to per- 
 form a much more serious operation, and to grant a mere respite to the 
 patient instead of a cure. 
 
 This neoplastic transformation is to be suspected when a tumor which 
 has long been quiescent suddenly and rapidly develops within a few months. 
 Yet, even though the diagnosis of this change be absolute, the operation had 
 better be performed. Cohn found that out of 86 patients operated upon 
 under these conditions, 19.5 per cent were still cured at the end of a year, 
 and in 5 cases the cure was maintained for from three to four and a half 
 years. Before such results there should be no hesitation. Freund has 
 reached the same conclusions. One of the most remarkable cases of perito- 
 neal metastasis of glandular cyst, followed by a cure by laparatomy, has been 
 reported by Runge. The patient was forty years old; the tumor had devel- 
 40 
 
626 CLINICAL AND OPERATIVE GYNECOLOGY, 
 
 oped in five months ; the whole of the peritoneal cavity contained scattered 
 masses of gelatinous matter, which also filled the cyst. This tumor was 
 evidently malignant, yet six months after the operation the patient was still 
 in good condition. We cannot, however, ignore the fact that the surgeon 
 may meet with cruel disappointments, and a relapse with a rapid course carry 
 off the patient in a few days. Hofmeier quotes two cases which he observ'ed, 
 in which the patients died, one seventeen and the other twenty-five days after 
 ovariotomy. In the first case no trace of generalization in the peritoneal 
 cavity could be found at the time of operation, but at the autopsy the whole 
 of the peritoneum was covered with a carcinomatous layer as thick as the 
 finger, the whole epiploon was changed to a thick, hard mass, so that it 
 seemed actually incredible that it could have been in normal condition a few 
 days previously. In the second case peritoneal metastasis had already begun 
 at the time of operation. 
 
 As I said before, it is impossible to separate from papillary ovarian cysts 
 those solid tumors erroneously called papillomata, which are usually nothing 
 but papillary cysts which have ruptured into the peritoneal cavity. In this 
 last stage of their development papillary cysts reduced to their solid portions, 
 surrounded by ascites resulting from the irritation of the peritoneum caused 
 by their falling epithelium, and scattering on every side debris that becomes 
 grafted here and there upon the serous membrane, really take possession of 
 the peritoneum and convert it into a cystic cavity. Even at this stage lap- 
 aratomy may bring about a permanent cure of these cysts, which were con- 
 sidered not so very long ago by ovariotomists as veritable noli me tangcTe ; 
 unexpected success in certain cases may be compared to that given by lapa- 
 ratomy in some cases of tubercular peritonitis. Knowsley Thornton quotes 
 a case of cure of this kind which had lasted nine years ; Leopold, one of two 
 years' standing; Cohn, a case of Schroder's of two and a half years; French, 
 also, has had some permanent cures. Lomer reports a remarkable case; 
 small papillomatous excrescences were scattered upon the epiploon, from 
 which they could be detached, and upon the intestines and the parietal peri- 
 toneum, from which they could not be detached; the cure was still perfect 
 five years after the operation. I operated upon an exactly similar case eleven 
 years ago, with Terrier's assistance, and the patient is still in perfect health. 
 These lesions, therefore, should not be considered beyond the aid of surgical 
 science, although their prognosis is always uncertain, and influenced by fac- 
 tors as yet unknown. 
 
 The age of the patient should not form a contra-indication. Quite young 
 children have been successfully operated upon : de Santa Anna extirpated a 
 dermoid cyst in a child one year old, Roehmer in a child of twenty months, 
 Schwartz in a little girl of four years. Mears, Barker, and Rein have oper- 
 ated for ovarian tumors in children of six and six and a half years. Thorn- 
 ton, Lucas, Hamaker, Cupples, and Chenoweth in those of seven and seven 
 and a half years. Spencer Wells, Mackenzie, and Duchamp performed ovari- 
 
TREATMENT OF OVARIAN CYSTS. 627 
 
 otomy in little girls of eight and eight and a half years; Polotnoff in a girl 
 of nine years, and Wagner in one of ten. Patients operated upon by Bar- 
 low and Marsh, Jonou, Heinricius, and MacGraw were twelve years old ; 
 those of Boiling, Carafy, Bell, and Cameron thirteen years. Bryant some 
 time ago reported an ovariotomy in a girl of fourteen years. 
 
 On the other hand, some very aged women have been cured by the opera- 
 tion ; we must, however, in these cases be on our guard against the evil 
 effects of prolonged decubitus (hypostatic pulmonary congestion, eschars on 
 the sacrum) and have the patients leave their beds and take a sitting posture 
 soon after the operation, as F. Barnes advises. Johnson cured a woman of 
 sixty-four years by operation ; Davis records a successful operation at sixty- 
 five years, Pinnock at sixty- seven, Spencer Wells and J. Boeckel at seventy- 
 three years, Josephson at seventy-six, Terrier at seventy-seven, Owen at 
 eighty, and Homans at eighty-two years and four months. 
 
 TccJiniqiie of Ovariotomy. Cysts with Pedicles. — It seems to me that 
 the frequent use of laxatives both before and after the operation is sufficient 
 to assure antisepsis of the digestive tract, so strongly insisted upon by 
 Terrier; it is only in exceptional cases, especially where there has been 
 evacuation of purulent matter through the rectum, that I administer /5 naph- 
 thol and salicylate of bismuth to thoroughly disinfect the intestines. 
 
 Many surgeons will not undertake ovariotomy unless they are surrounded 
 by a complete armamentarium of instruments — forceps of every shape and 
 size, bistouries, scissors, retractors, needle-holders, etc. It seems to me 
 advisable to reduce the number of instruments used to those which are abso- 
 lutely necessary, in order as far as possible to avoid infection. It will be 
 quite sufficient to have good bistouries; dissecting forceps; a female and 
 a male catheter ; a grooved director ; scissors, one pair curved laterally; a 
 few ordinary haemostatic forceps ; long forceps, straight and curved, for ad- 
 hesions ; two of Nelaton's cyst forceps ; one Museux forceps; one trocar; 
 one pair of needle-holder forceps ; needles, and one blunt mounted needle ; 
 silk, catgut, and gauze compresses. All of these instruments should be ab- 
 solutely reserved for laparatomies, and, as I have already said, have been 
 kept for an hour in an oven at 248° F. They are to be placed within reach 
 of the operator's hand in a flat dish filled with a two-per-cent carbolized 
 solution. It will be well to keep upon a neighboring table a relay of instru 
 ments — forceps, bistouries, etc. — for emergencies. [It is better to keep the 
 instruments and ligature material either dry or in sterilized water, and so 
 avoid the contamination of the peritoneum by any antiseptic] 
 
 Surgeons who use sponges advise that they be counted before and after 
 the operation, because of the danger of small sponges being lost in the ab- 
 dominal cavity ; this may happen even when they are held by forceps, as the 
 latter sometimes relax. For my part, I have entirely given up the use of 
 -sponges, and I do not fear any such accident with the gauze compresses I 
 use, whose end always protrudes through the abdominal wound. It is well. 
 
62 8 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 however, to place a pair of forceps on them, one with gilded handles if pos- 
 sible. It may be well to count the number of forceps, remembering the 
 case of Spencer Wells, w^io, owing to this precaution, reopened the abdomen 
 and found the missing instrument. But the opposite error might be com- 
 mitted if a pair of forceps had slipped under a basin or had been carried off 
 attached to the tumor or to a sponge. I think it will be quite sufficient to 
 keep a careful watch over the instruments. 
 
 The number of assistants should be limited to as few as possible : one 
 for the chloroform, one to thread and pass the needles or the ligatures 
 (which should be already cut and kept in a carbolized or weak bichloride 
 solution) ; a third skilled assistant will suffice to help the surgeon ; he should, 
 be on the left of the patient, while the one in charge of the sutures is on her 
 right and consequently on the surgeon's left, and near enough to hand the 
 sutures readily to him. If there is not a skilled assistant obtainable, there 
 must be two assistants, one to the right and one to the left. No one but 
 the assistants are to touch an instrument or any article used in the operation. 
 If an instrument falls to the ground, it must be left there. 
 
 The operation of ovariotomy may be divided into four stages : 
 
 First Stage. Openhig of the Abdomen. — It is best to begin with a small 
 opening, which can be subsequently enlarged if necessary. While the assist- 
 ant places his index finger on the umbilicus as a guide, making slight trac- 
 tion on the skin, the surgeon with a strong convex bistoury makes an inci- 
 sion three and a half inches long in the linea alba, reaching inferiorly almost 
 to the symphysis. 
 
 The skin and cellular tissue are rapidly cut through, and we then attempt 
 to penetrate in the space between the recti muscles, which is first to be 
 sought at the upper part of the wound. If their sheath should be opened it 
 is of no great importance. Next we come to the fascia transversalis and the 
 subperitoneal fat, which is not to be mistaken for the great omentum. The 
 fatty masses, which are often numerous, are to be incised, and even excised 
 if necessary, and we then reach the serous membrane. Before opening it, 
 we must assure complete haemostasis by placing two or three forceps upon 
 bleeding points. The peritoneum is grasped with the dissecting forceps at 
 the upper part of the wound, and a small buttonhole cut in the uplifted por- 
 tion; a grooved director is introduced from above downward in the median 
 line, and the peritoneum is freely incised, either with a bistoury or the scis- 
 sors. We must now lift up the peritoneum with the sound, and, if neces- 
 sary, examine it by transmitted light, to be perfectly sure that we are not 
 wounding an abnormally developed bladder. 
 
 Wounding of the bladder is an accident which has happened, even to 
 experienced operators, in cases in which a subperitoneal tumor has by traction 
 elongated the bladder, which, when emptied, is unrecognizable and might 
 easily be taken for a thickened false membrane. I myself had to render as- 
 sistance in a case of the kind in which the wound was eight inches long and. 
 
TREATMENT OF OVARIAN CYSTS. 629 
 
 included both the extra- and intra-peritoneal surfaces of the urinary reser- 
 voir. In this case I sutured the whole bladder, with the exception of a small 
 anterior buttonhole, in which I placed a siphon ; after the recovery of the 
 patient this orifice was easily obliterated. Newly published works by Rever- 
 din and Sanger advise the trial of a complete suture. In a case in which he 
 had taken away a portion of the bladder, Sanger sutured it with silk, and 
 fixed it to the lower part of the wound, drawing the peritoneum down in 
 front of it; next came pre-vesical drainage and suture of the abdominal 
 walls above the vesical stump; a cure resulted. Leopold, having removed 
 the top of the bladder in the course of a hysterectomy, made complete 
 sero-serous sutures, and cured his patient. I believe that it would be a 
 good plan to make two layers of sutures, either with separate stitches as 
 in Czerny's process for intestinal suture, or by continuous suture. By this 
 method I had a very successful result. Silk is to be preferred in ovariotomy 
 where the pedicle is dropped, because there is no danger of its secondary 
 infection. 
 
 In some rare cases the peritoneum may be so adherent to the anterior 
 wall of the cyst that it is impossible to tell them apart. We must in that 
 case prolong the incision above until we reach a point where the serous 
 membrane is free, and then proceed to detach it from above downward. 
 This is much better than cutting directly into the cyst and detaching it by 
 traction upon its internal surface. 
 
 Second Stage. Riiptiire of AdJiesiojis ; Evacuation — A. Adhesions to 
 the Abdominal Wall. — The right hand is introduced flatly into the wound 
 upon the surface of the cyst, and by working about with its ulnar edge loos- 
 ens the adhesions to the right and to the left as far as it can. We can per- 
 fectly recognize any adhesions which are too strong to be broken down by 
 simple pressure, and we do not expend any unnecessary force upon them, as 
 we can break them later after evacuation of the cysL 
 
 B. AdJiesions to the Omentum. — These are loosened in the same way, 
 using both hands if necessary. Catgut ligatures are to be immediately 
 placed upon bleeding points. If certain adhesions are too resistant, they 
 may be grasped by two pairs of forceps in juxtaposition, and an incision 
 made between the forceps, after which they are ligated with catgut. This 
 method should be substituted for Hegar's process of elastic ligature en 
 masse. 
 
 C. Adhesions to the Intestines. — Loose adhesions may be detached as de- 
 scribed above ; those which are moderately firm yield to tension and press- 
 ure combined brought to bear alternately upon the cystic and the intestinal 
 wall, and always done with the fingers well covered by gauze compresses. 
 Should the intestine bleed at any special point, a few separate catgut stitches 
 may be taken with a fine needle. Should the hemorrhage come from an ex- 
 tended surface, we must endeavor to overome it by somewhat prolonged 
 pressure; and if that be not sufficient, we must apply a strong carbolic 
 
630 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 solution, Hegar recommends radiated heat from a thermo-cautery held at 
 some distance. Finally, if separation of the intestine seem to threaten dan- 
 ger, we would better abandon our attempts to detach it, and proceed iiL 
 the manner described under myomectomy, leaving a thin layer of the; 
 cystic wall adherent to the intestine, which is freed by minute dissection. 
 But we shall have to cauterize this layer in order to destroy any epithelial 
 elements originating from the cyst wall. Moreover, before beginning ta 
 detach intestinal adhesions of any extent, . we must always ascertain their 
 number and importance, and, if there are too many of them, abandon the 
 attempt and limit our operation to an exploratory incision, or treat the cyst 
 by sewing its edges to the wound and stuffing it with gauze (marsupializa- 
 tion, see below), according to circumstances. 
 
 D. Pelvic AdJiesions. — In the case of small tumors, we must look for 
 adhesions before puncturing ; in the case of large tumors, we shall first be. 
 obliged to diminish their volume in order to glide the hand into the pelvic 
 cavity ; at the same time, we must draw them forward with Nelaton's forceps^ 
 An error to be avoided is the mistaking of an intra-ligamentous tumor for a. 
 cyst bound down by large adhesions ; a cyst of this kind could only be de- 
 tached by opening its peritoneal covering, as I shall describe later. 
 
 Pelvic adhesions may be broken with the hand ; and if we are obliged to 
 use the scissors, we must always cut between two forceps or two ligatures. 
 The pelvic portion of the pouch may be so adherent that it cannot be re- 
 moved; in that case we must content ourselves with a partial or incomplete 
 operation, whose technique I will point out later. 
 
 It is essential that small cysts should not be evacuated before all adhe- 
 sions which can be loosened by the hand are broken down; the pressure is 
 much more efficacious against a tense cyst than against a flaccid one, but 
 incision of unyielding adhesions should be reserved until puncture of the 
 cyst and its collapse permit us to see what we are doing. " 
 
 The cyst may be evacuated with the bistoury, as is the custom in Eng- 
 land; but although this method is expeditious, it exposes the wound to the 
 danger of infection so soon as the flow of the liquid becomes slackened ; the 
 trocar seems to me preferable. 
 
 It may be necessary to puncture several cavities — which can sometimes 
 be done without removing the trocar, by pushing it in more deeply or chang- 
 ing its direction. For very large cysts, it is well to have the trocar con- 
 nected with a large receiver, in which a vacuum has been previously created. 
 
 If the tumor is microcystic and areolar, and non-reducible by puncture, 
 we must not hesitate to enlarge the abdominal opening with the scissors as 
 far as the umbilicus, cutting through all the layers with one stroke ; what- 
 ever may have been said to the contrary, there is really no special object 
 gained by cutting around the umbilicus if the incision has to go beyond it. 
 
 TJiird Stage. Extraction of the Cyst and Ligation of the Pedicle. — The 
 trocar is removed with a quick motion, while the assistant presses down the 
 
TREATMENT OF OVARIAN CYSTS. 63 1 
 
 edges of the wound. Nelaton's forceps are placed over the puncture to ob- 
 literate it and facilitate traction. A second pair of similar forceps or of 
 Museux's forceps are placed on a suitable spot, and the delivery of the cyst is 
 begun by gentle traction alternating with a sidewise motion. As the cyst be- 
 comes freed, an assistant presses upon the abdominal walls and approximates 
 the lips of the wound, so that when the cyst is entirely freed the edges are 
 closed over the pedicle, thus preventing escape of the intestines. If during 
 the extraction firm adhesions have to be broken down, the assistant must lift 
 up the intestines with a warm gauze compress, and if necessary the edges of 
 the wound can be held apart by retractors, and the adhesions, which are 
 rarely vascular, cut with the scissors between two ligatures. 
 
 The pedicle is now to be tied, separated from the tumor, and left in the 
 abdomen. This intra-peritoneal method was the one adopted by the earlier 
 operators, and was abandoned later for the extra-peritoneal treatment of the 
 
 Fig. 439. — Trocar with Rounded Point and Lateral Discharge Tube. 
 
 pedicle, which remained in use until 1880, when the intra-peritoneal method 
 again came into general use. In 1841 Stilling was the one to re-introduce 
 the intra-peritoneal method in Germany ; in England, Duffin gave it a place 
 of honor in 1850, but its general adoption was due to Spencer Wells. Pre- 
 vious to this, the pedicle was simply fastened into the abdominal wound, 
 being held by needles or points of suture. 
 
 The chief objections to extra-peritoneal treatment of the pedicle are: its 
 sloughing, which is usually quite extensive and may cause infection of the 
 wound; and weakening of the abdominal cicatrix, creating a predisposition 
 to hernia. Still, this method may be used where, besides the ovarian cyst, 
 we have to overcome either a prolapsus or pronounced retroflexion of the 
 uterus, in which case it additionally performs a gastro-hysteropexy. 
 
 It is quite exceptional to find a pedicle so slender as merely to require the 
 passing around and tying of a silken ligature. It is always best to transfix 
 it and tie it with Tait's or Bantock's knot, either one of which can be tightly 
 drawn. If necessary, a chain ligature can be applied. When the pedicle 
 is short, it is well to have all the sutures in place before detaching the 
 tumor, and to have the incision at least half an inch above the threads ; or 
 successive portions may be tied and cut. We shall thus avoid the retrac- 
 tion of the pedicle, which is apt to occur when it is prematurely cut across, 
 and when it is deeply situated in the pelvis. If it is very thick and fleshy. 
 
632 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 and not easily distinguishable from the rest of the tumor, it will be advisable 
 to squeeze it tightly with strong forceps ; at the end of a few minutes we 
 shall have a groove which will hold the ligature, and hsemostasis will be 
 already partly accomplished by the crushing of the tissues. 
 
 After detaching the tumor, all the ligatures are cut a quarter of an inch 
 above the knot. In the first place, however, we look upon the cut surface 
 for the lumina of large vessels, and tie them separately with fine silk or cat- 
 gut. If the pedicle be exceptionally fleshy and soft, or if the surface of the 
 section contain tissue open to suspicion, or if there be any signs of tubal in- 
 flammation, we must employ the thermo-cautery. Neighboring parts are to 
 be carefully protected with moist gauze compresses. Some authorities, with 
 a view to avoiding future adhesions to the intestines and the production of 
 internal strangulation, advise suturing the two edges of the peritoneal wound 
 above the pedicle; this seems to be an unnecessary complication of the 
 operation, as adventitious membranes very soon encapsulate the pedicle. 
 
 The surgeon now carefully examines the ovary of the opposite side, and 
 if it be ever so slightly affected, and the patient drawing near to the meno- 
 pause, he removes it. If she is still young and the lesion slight, he might 
 follow the bold example of Schroder, who in a similar case merely removed 
 a small dermoid cyst from the ovary and sewed up the wound. The woman 
 shortly afterward became pregnant, and was safely delivered. Schroder has 
 performed this resection of the ovary four times in young women. A. Mar- 
 tin has since followed his example ; of which I heartily approve. The uterus 
 likewise should be carefully examined, and any fibroids enucleated if the pa- 
 tient is young and the situation of the tumors favorable; if the patient be 
 approaching the menopause or if myomotomy for any reason be difficult of 
 execution, the removal of the second ovary is preferable. 
 
 Fourth Stage. Toilet of the Peritoneuin and Closiwe of the Abdomen.^ 
 When the operation has been a simple one, without any effusion of irritating 
 fluid, it is unnecessary to sponge off the small amount of blood which there 
 may be in the pelvis, and which will be rapidly absorbed, as the friction of 
 the compresses unavoidably rubs off some of the endothelium from the sur- 
 face of the peritoneum, and detaches some of the small clots which plug the 
 vascular orifices ; fresh hemorrhage may result from their use. But when 
 the cystic fluid or pus has contaminated the operation field, the surgeon's 
 behavior must be radically different. In the first case, the use of gauze 
 compresses will be sufficient; the finger is covered by one and pushed into 
 every dependent portion of the pelvis ; to reach the cul-de-sac of Douglas, 
 the gauze is wrapped around the forceps. When there has been effusion of 
 pus or of very septic cystic fluid, irrigation of the peritoneum is indicated. 
 I have previously stated the conditions which call for drainage or tamponade. 
 There remains merely the closure of the abdomen ; having fully described 
 the process, I shall not repeat. My method of suture (a continuous suture 
 in two layers for the peritoneum and aponeuroses, and the interrupted suture 
 
TREATMENT OF OVARIAN CYSTS. 633 
 
 for the skin) avoids all danger of hernia, or eventration, so frequent after the 
 suture en tnassc in general use. 
 
 If there be oozing from an extended surface of the internal abdominal 
 wall because of the tearing away of large adhesions, causing us to fear capil- 
 lary hemorrhage after closure of the wound, we can insert a series of quilled 
 sutures (using little rolls of iodoform gauze instead of quills) through the 
 abdominal wall, over the area of these excoriations of the serous membrane, 
 and in this way approximate the bleeding surfaces, lifting them up into a 
 ridge, and keeping them pressed against each other. The accessory sutures 
 are to be left in place for two or three days. 
 
 The operation which I have just described is the one most generally used 
 for the removal of cysts. I will now mention two important operative con- 
 ditions sometimes met with, one relating to the absence of a pedicle, the 
 other to the impossibility of forming one. 
 
 Enucleation of Cysts Contained within the Broad Ligaments, 
 OR OF Retro-peritoneal Cysts. — I will at once eliminate from this cate- 
 gory metastatic subperitoneal masses found in the cul-de-sac of Douglas or in 
 the iliac fossse, as well as pediculated tumors of one or both ovaries. To at- 
 tempt the removal of these microcystic and colloid formations, which may 
 be said to be infiltrated beneath the serous membrane rather than to be in- 
 cluded in it, is to meet with almost certain failure; it is rarely possible to 
 remove them completely, and the enormous amount of tearing away that has 
 to be done, combined with the portions of the neoplasms which have to be 
 left in place, is quite sufficient to cause septic infection. In such cases we 
 have to content ourselves with a removal of the pediculated ovarian tumor, 
 leaving the secondary growths where they are, or we may even have to close 
 the wound again, without removing anything, if we find that there are too 
 many adhesions to allow of a successful result. 
 
 Parovarian Hyaline Cysts.— 'Y\\q^q. thin-walled cysts with limpid con- 
 tents, originating within the folds of the broad ligament, may travel under 
 the peritoneum as far as the mesocolon and the mesentery. They are easily 
 separated from the serous membrane, which does not adhere to them unless 
 there have been previous inflammation. When they are fully identified, a 
 little fold is to be taken in the peritoneum covering them, a small opening 
 made in it, and the finger introduced through this opening to loosen the 
 membrane over a small surface. The trocar is then inserted into this freed 
 space, and the fluid taken out. When the trocar has been removed, and the 
 opening closed by means of forceps, the peritoneum is disengaged from a 
 larger extent of surface, and by a series of tractions, aided by movements of 
 the fingers which break down any cellular adhesions, the whole cystic sac is 
 removed. Haemostatic forceps are at once placed upon any bleeding points. 
 The cavity left by the enucleation will close of itself. 
 
 The operation is much more difficult when there are adhesions resulting 
 from the inflammation which often follows intra-cystic hemorrhages: this 
 
634 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 occurrence is recognized by the color of the fluid and brownish deposits on 
 the cyst wall. I twice found myself in a predicament of this kind, and only 
 managed to extricate myself by recourse to the following procedure : exten- 
 sive incision of the sac ; fixation of the edges of the wound with a series of 
 forceps, held by an assistant; introduction of the left hand into the interior 
 of the cyst to determine its relations and assist in its enucleation. It is of 
 the utmost importance that all this be done methodically, and not by a 
 series of scattered efforts, and that the ovary, if normal, be spared. 
 
 Large Papillary and Glanditlar Cysts of the Broad Ligament. — Whatever 
 may be the anatomical differences between these cysts, I have chosen to de- 
 scribe them together, because of the similarity of the operative procedures 
 necessary. I have already said that papillary cysts of the broad ligament, 
 although doubtless originating from the parovarium (either from its intra- 
 ligamental portion or from the part which penetrates into the hilum of the- 
 ovary), are not the ones usually called parovarian cysts by clinicians. They 
 apply the term to the hyaline parovarian cyst alone, which is indeed the 
 more frequent of the two. The sac of the papillary parovarian cysts is thick, 
 and often contains unstriped muscle fibres which seem to unite it to the 
 uterus ; the fluid contents are turbid or milky, and they contain cauliflower 
 growths. In the thickness and vascularity of their walls they resemble the 
 glandular or papillary ovarian cysts. The latter, either because of their 
 origin from the hilum (papillary cysts), or because of a semi-heterotopic de- 
 velopment, or from congenital predisposition (glandular cysts), may, instead! 
 of becoming pediculated, push in between the folds of the broad ligament. 
 The intimate relations with the peritoneum, uterus, pelvic floor, and walls, 
 constitute additional points of resemblance. The cardinal difference, from 
 the point of view of these anatomical relations, consists in the freedom of 
 the ovary in the case of parovarian cysts, and its fusion with the tumor in. 
 the case of ovarian cysts. Important as this distinction may be anatomi- 
 cally, it is cf little value from an operative standpoint. 
 
 The separation of all cysts situated within the broad ligament is very 
 difficult on account of the adhesion of the peritoneal membrane, which often 
 can only be removed in shreds ; the presence of deeply situated blood-vessels 
 is a further complication; and there is always danger of pulling out or 
 wounding the ureter, with which the cyst has close relations. 
 
 (There is a difference between the immediate treatment demanded when 
 the ureter has been wounded and that called for at a later stage, when the 
 patient has made a good recovery, but has a persistent uretero-abdominal or 
 uretero-vaginal fistula. The second case comes under the head of urinary 
 fistulae, and I will simply remind you of the fact that Simon was the first: 
 to perform nephrectomy for a case of this kind. 
 
 The immediate treatment differs according to whether there is only a 
 small wound or a complete tearing away. In the first case it is best to 
 suture the wound and catheterize, first through the bladder and then through 
 
TREATMENT OF OVARIAN CYSTS. 635 
 
 the abdominal wound. I think that it would be prudent 1.0 have an anti- 
 septic tamponade of the peritoneum above the wounded organ, for union 
 may not occur, and the urine must be given a chance to escape. Our hopes 
 will then rest upon the formation of protective adhesions. Schopf, in a case 
 of ovariotomy for intra-ligamental cyst where the ureter was wounded, first 
 placed forceps temporarily upon the two ends, and then united the; i ends by 
 eight stitches of silk, which did not include the mucous membrane. There 
 was a temporary cure of four weeks' duration, and then various supervening 
 accidents caused the death of the patient. At the autopsy, amyloid degen- 
 eration of the kidneys and plastic peritonitis were found. In another case 
 the same operator preferred to unite the wound over an English rubber 
 catheter, which was passed in through the urethra in such a way as not to 
 take up the whole canal and obstruct the flow of urine from the other kid- 
 ney. Gusserow tied the ureter under the following conditions : During the 
 course of an enucleation of a malignant intra-ligamental cyst, a small flap of 
 the tumor which could not be removed was ligated to the lower part of the 
 wound; the ureter must have been caught in the ligature, for on the ninth 
 day a large abscess formed, and septic peritonitis supervened, the patient 
 dying on the fifteenth day. Under such circumstances Gusserow advises 
 opening the purulent mass through the posterior cul-de-sac of the vagina, in 
 order to form a uretero-vaginal fistula. I should prefer antiseptic tamponade 
 of the peritoneum. In a case of enucleation of retro-peritoneal parovarian 
 cyst, I pulled out the right ureter which was adherent to the cyst, and which 
 broke about 10 cm. below the renal pelvis; the rest of the ureter was en- 
 tirely detached and hung out of the abdomen. Instead of attempting a 
 suture which would certainly have been a failure, I decided to make a ureteral 
 fistula in the right lumbar region, and then to resect the vesical end of the 
 ureter after having tied it and sutured it to the wound. I performed a sec- 
 ondary nephrectomy, and the patient made a good recovery. More recently, 
 during a very difficult operation for the extirpation of a cyst of the left 
 broad ligament, which was everywhere adherent, and had to be dissected 
 from its deeply seated adhesions, the left ureter was divided near its vesical 
 insertion. I was unable to find its lower extremity, but I found by means 
 of an injection into the bladder that it was not permeable. I then decided 
 to insert the renal extremity of the ureter into a neighboring point on the 
 bladder. To this end I made a buttonhole opening about i cm. long at the 
 middle of the posterior surface of the bladder, and fastened the end of the 
 ureter to it by means of two rows of silk sutures, the first row taking in the 
 mucous membranes, and the second the serous and muscular tissues. The 
 results of the operation were normal and the cure a complete one. During 
 the course of a recent laparatomy upon the same patient for the removal of 
 the appendages of the right side because of a hydro-salpingitis, I found that 
 the engrafted ureter was slightly dilated ; this may possibly be due to a re- 
 flux of urine whenever the bladder is distended.) 
 
6^6 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 The cyst having been emptied, the first thing; the most prominent part 
 of its wall is then grasped with Nelaton's forceps and drawn out through the 
 abdominal wound ; with a bistoury a large ellipse is traced around as much 
 of the sac as has been drawn through the opening. The incision goes 
 through the peritoneal covering only if possible, which is then detached by 
 the help of forceps, spatula, and the finger, so as to dissect out a circular flap 
 which is deeper at the sides than in the middle, as it follows the shape of 
 the cyst. This process of detaching had better be begun at the more vascu- 
 lar portion, and the large vessels supplying the secondary branches can be 
 tied at once. An assistant should hold a sound in the uterus as a guide to 
 its position, for it is often so displaced or hidden by the tumor that we can 
 only find it with great difficulty. To detach the uterine adhesions, the 
 organ should be lifted out of the abdomen and laid upon gauze compresses. 
 In some cases we may have to perform h3'Sterectomy to simplify matters and 
 terminate an operation of long duration. 
 
 Permanent hsemostasis is to be obtained either by ligatures or by a con- 
 tinuous catgut suture, applied superficially to the whole of the bleeding sur- 
 face, to avoid wounding deep vessels. Temporary pressure with gauze com- 
 presses and application of the thermo-cautery may be needed for persistent 
 capillary hemorrhages. 
 
 If these methods fail, I would suggest tamponade of the peritoneum by 
 means of iodoform gauze, and forcipressure, bringing the handles of the 
 forceps together at the lower end of the wound. 
 
 AVhen the operation is finished, the size of the intra-abdominal wound is 
 to be diminished as much as possible by approximating the flaps of peri- 
 toneum, at the same time paring off any ragged edges. If the cavity is too 
 deep to be filled up by a continuous catgut suture of the broad ligament, 
 then we must contrive a way to isolate it from the rest of the abdominal 
 cavity. According to circumstances, we may either suture the edges of the 
 sac to the abdominal wound and tampon it with iodoform gauze, or introduce 
 a T-tube through the bottom of the sac into the posterior vaginal cul-de-sac, 
 and then sew up the side of the sac toward the peritoneum with catgut. 
 This tube may be most readily introduced through the vagina from below 
 upward, according to the rules already given. 
 
 Incomplete Operations. Mai'snpialization of the Cyst. — When the tenac- 
 ity of adhesions to the pelvic walls or to the folds of the broad ligaments 
 prevents either the formation of a pedicle or enucleation of the tumor, there 
 is still one resource left to the surgeon. This consists in fastening the 
 edges of the pouch to the lips of the abdominal wall, filling up the cavity 
 with tampons, or draining it as one would an abscess cavity, leaving to 
 nature the care of obliterating or eliminating it. Before fixing it to the 
 abdominal wall, we must close th? upper part of the wound, leaving onl}^ the 
 length necessary to the accomplishment of our purpose. The edges of the 
 open sac are held outside of the wound by an assistant ; if necessary, we 
 
TREATMENT OF OVARIAN CYSTS. 637 
 
 can take folds in them by the aid of forceps and the insertion of a stitch. 
 Then the circumference of the sac is fastened by means of a series of sutures 
 with heavy silk, which traverses the whole thickness of the sac and of the 
 abdominal walls an inch from the edge. The stitches are to be closely set 
 together. A second row of superficial sutures fastens the skin alone to the 
 sac. The interior of the cyst is carefully cleansed by removing all vegeta- 
 tions and secreting membrane and washing it with a sublimate solution j 
 then a large drainage tube with only two holes at its inferior end is inserted,, 
 and iodoform gauze is loosely packed around it. 
 
 This method, recommended in outline by Clay, Spencer Wells, and. 
 Pean, and adopted by other operators, is of course only 2. pis aller. It ma}'' 
 give good results in the case of unilocular thin-walled cysts like the par- 
 ovarian hyaline cysts, when they are surrounded by inflammatory adhesions ; 
 but we rarely have occasion to apply it in such cases. We usually have to. 
 use it for proliferous cysts, and then, especially if there are vegetations on, 
 the walls, the results are not brilliant. There is always a tendency to a re- 
 turn of the tumor, the abdominal fistula persists an indefinite length of time, 
 and endless suppuration exposes the patient to the dangers of septicaemia, 
 and exhaustion. Malignant degeneration has been knowfi to occur in the 
 wound. A careful cleansing of the interior of the sac with the fingers or- 
 the blunt curette, to remove all glandular elements, will do much to dimin- 
 ish the chances of these bad results. Rheinstadter, who strongly recom- 
 mends this method, obtained seven permanent cures by its use, four of which 
 had lasted for over two years. In the most fortunate cases the sloughs are: 
 entirely eliminated. 
 
 This process, because of its forming a pouch in front of the pubis some- 
 thing like the pouch of an opossum, has been given the name of marsupial- 
 ization by some American writers. 
 
 In cases uncomplicated by large adhesions, an ovariotomy should always.-, 
 be very rapidly performed ; the average length of the operation, including- 
 the suture of the abdominal walls, need not take longer than twenty minutes,, 
 as I know by personal experience. Every operation involving the perito- 
 neum which lasts longer than an hour is rendered grave by that fact. There: 
 are some precautions to be observed which will tend to obviate danger : The: 
 assistant should keep the abdominal wound open to the least extent possible,, 
 and not expose the intestines or omentum, which should always be covered 
 with warm, moist compresses ; the operator should do as much of the opera- 
 tion as possible outside of the abdominal cavity, and must constantly dip 
 his hands in the normal salt solution which is beside him. Eviscera- 
 tion or temporary extraction of the intestines, which are placed upon 
 the abdomen, and wrapped in warm compresses, certainly gives the- 
 operator a clear field to work in, but the procedure should be an excep- 
 tional one. It may be replaced by having the assistant forcibly push 
 and maintain the intestines high in the abdomen, his hand being covered! 
 
■638 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 with a gauze compress, or the patient may be placed in the Trendelenburg 
 position. 
 
 Dressing the wound is a very simple matter ; in fact, when the edges of 
 the wound are approximated, if the operation has been aseptic, we may say 
 that there is theoretically no need of dressing, and that immobilization and 
 compression are all-sufficient. I have had cases of perfect union when only 
 •cotton-batting was used. Still, it is best to guard against possible infection 
 by the use of antisepsis for all that is not contained within the peritoneal 
 cavity. I usually wash the abdomen with a bichloride solution, dust the 
 line of suture lightly with iodoform, apply a compress of iodoform gauze 
 torn into strips and loosely tossed over the wound, over that a layer of ab- 
 sorbent cotton, and finally a flannel bandage going all around the body. 
 There should not be too much wadding nor too heavy a pressure. 
 
 Vaginal Ovajdototny. — Vaginal incision, to which I referred in connection 
 with the treatment of oophoro-salpingitis, sometimes allows of the extirpation 
 of ovarian cysts. In spite of the efforts made to produce a reaction in favor 
 •of the vaginal method, I hold that laparatomy remains the operation to be 
 preferred for ovarian cysts. In exceptional cases when the cyst is unilateral, 
 freely movable, small, and projects frankly into either the anterior or the 
 posterior cul-de-sac of the vagina, preference might be given to vaginal inci- 
 sion. The operatory technique is simple : the vaginal mucosa and parietal 
 peritoneum are successively incised ; the cyst appearing between the lips of 
 the incision is punctured with a trocar, or, more simply still, with a bistoury. 
 The empty sac is then easily drawn out with the fingers or by the help of a 
 fiat-bitted forceps ; the pedicle is tied with silk thread as closely as possible 
 to the uterus, and returned to the abdominal cavity. The vaginal wound may 
 be completely sutured, or a small piece of sterilized gauze may be inserted 
 for drainage and removed in forty-eight hours. Should ligature of the pedi- 
 cle be impossible or too difficult, a pair of forceps may be left in for forty- 
 -eight hours. In the case of bilateral and voluminous cystic tumors of the 
 ovary, if the vaginal method is chosen, hysterectomy must be the first step 
 in order to give free access to the cysts which are successively removed after 
 evacuation of their contents. 
 
 After-treatment. Accidents. — The catheter should be passed every three 
 hours for two days at least, and longer if necessary. The bed upon which 
 the patient is placed must have been previously warmed ; her thighs should 
 be slightly elevated by a cushion placed under the knees. If she be much 
 weakened, and if syncope occur, she should be wrapped in hot cloths and 
 given subcutaneous injections of ether. 
 
 Internal hemorrhage shortly after the operation sometimes occurs, and is 
 manifested by sudden anguish, fainting, chills, cold sweats, and a feeble 
 pulse ; the face becomes pale, the extremities cold ; if a drainage tube have 
 been inserted, the blood will flow through it. In one case of this kind Hof- 
 meier, suspecting this accident in a patient upon whom Schroder had oper- 
 
TREATMENT OF OVARIAN CYSTS. 639 
 
 ated, took out two of the stitches eight hours after ovariotomy, and found 
 that the abdomen was full of clots, and that the ligature had slipped off the 
 pedicle ; he was able to save the patient. We should never hesitate to follow 
 his example. Any anaemia is to be combated by subcutaneous or intra- 
 venous injections of salt water. The solution must be tepid, and in strength 
 10: 1,000. According to the extent of the hemorrhage we may inject doses 
 varying from 200 to 1,500 gm. {6Y2 to 50 oz.) in the twenty-four hours. 
 
 The food of the patient on the first day after the operation must consist 
 of a few pieces of ice, a little cold grog or some champagne />-«/// only, nor 
 should these be given in large amount, for the best preventive of vomiting 
 is an empty stomach. Vomiting due to chloroform has no prognostic im- 
 portance. On the second day a little milk and Vichy water may be giv^en. 
 Some physicians administer opium to quiet the pain and give sleep; it is 
 bad practice, and its chief effect is to paralyze the intestines. 
 
 On the third day, if the vomiting still continue, or if it reappear, and 
 the matter vomited be of a greenish color, if the abdomen be painful and 
 swollen, and the pulse frequent even though the te^iperature remain low, 
 there is almost a certainty of septic peritonitis. It is well to remember that 
 the pulse has a greater diagnostic value than the temperature. In fact, in 
 surgical inflammations of the peritoneum the temperature is often subnor- 
 mal. Before death the vomiting (at least at first) becomes almost incessant ; 
 the patient dies without great suffering, but with a little sub-delirium. 
 Olshausen long ago pointed out the septic nature of these symptoms. Peri- 
 tonitis is rather a result than a cause of septicaemia. At the autopsy, be- 
 sides meteorism, we find only a little turbid serum in the pelvis. Olshausen 
 attaches great importance to paralysis of the intestines, and the absorption 
 of the toxic substances which they contain. Verchere, as well as Sanger, 
 further developed this theory. We must be careful not to mistake this 
 group of symptoms for intestinal obstruction, which it often simulates. It 
 is probably true toxaemia caused by leucomaines and ptomaines originating 
 either from the fluids in the abdomen or from the gas and imprisoned mat- 
 ter in the paralyzed intestine. As to the starting-point of septic peritonitis, 
 it has been said to be caused by the cessation of peristalsis due to exposure 
 to the air, either from direct action of the air upon the muscular fibre or 
 indirectly upon the nerves. It is more often due to an infection of external 
 operative origin, the paralysis and dilatation of the intestines being not the 
 cause but the immediate results of the peritoneal septicaemia. 
 
 However that may be, one of the chief symptoms of the onset of peri- 
 tonitis is intestinal paralysis, which is recognized not only by meteorism, 
 but by the absence of evacuation of gases. It is ot the utmost importance 
 to treat this paralysis, which rapidly becomes complicated by intestinal septi- 
 caemia, from the start. On the second day I usually administer an enema of 
 six teaspoonfuls of Bordeaux wine and three teaspoonfuls of glycerin, in 
 order to provoke slight peristalsis ; if this does not cause any evacuation of 
 
640 CLINICAL AND OPERATIVE GYN.-ECOLOGY. 
 
 gas, I repeat it 01. the following day, adding one or two teaspoonfuls of 
 honey of mer::ury, and I introduce into the anus a Xo. 20 rubber catheter, 
 which should penetrate five inches, in order to allow of the issue of gases 
 in spite of the tonicity of the sphincter. I think this preferable to the ad- 
 ministration, by the mouth, of purgatives, which are often rejected by the 
 stomach. 
 
 [Calomel, given in doses of Jg- to i gr. every half-hour for ten to eigh- 
 teen doses, is usually well borne by the stomach and is effective. If neces- 
 sary it may be followed by tablespoonful doses of magnesia citrate in satu- 
 rated solution, given at the same inter^'als. A somewhat more active enema 
 than that recommended by the author is composed of two ounces of glycerite 
 of oxgall, a drachm of spirits of turpentine, and a pint of strong peppermint 
 water.] 
 
 After the fourth day, if everything be favorable, the patient may take a 
 little solid nourishment. 
 
 On the eighth day the silk sutures are removed (the buried sutures re- 
 maining) ; union is usually complete by that time except in the vicinit}' of 
 any folds which may overlap. The dressing is now changed for the first 
 time if there have been no drainage, and another one put on after washing 
 the abdomen with bichloride solution. From the fifteenth to the twenty- 
 first day the patient may sit in an armchair, and a week later may walk a 
 few steps. 
 
 After removal of the sutures, an attack of coughing or vomiting has been 
 known to cause secondary disunion of the wound, with the production of 
 intestinal hernia; there have been numerous cases in which this accident 
 was without serious results if the viscera were cleaned and replaced, even 
 after a lapse of several hours ; I myself witnessed an example of this in one 
 of my patients, in whom the hernia occurred at the point of insertion of a 
 drainage tube ; a perfect cure followed. 
 
 An accident of rare occurrence is the production of emphysema of the 
 abdominal walls, caused by retching; it is not especially grave in itself, but 
 may lead to suppuration. 
 
 Superficial abscesses may form at the point of suture when antisepsis has 
 been imperfect or when the wound has been secondarily infected by a deeply 
 placed drainage tube whose lower end was in contact with pus. As soon as 
 there is induration and localized pain, we must hasten to reopen a small por- 
 tion of the wound with a canulated sound, wash it with a strong antiseptic 
 solution, and introduce two small drainage tubes. 
 
 Deep abscesses near the pedicle or sutures buried in the abdomen are 
 more difficult to recognize. If there be great elevation of temperature, and 
 if by bimanual palpation we feel puffiness of a localized area, we should not 
 hesitate to reopen the abdomen, evacuate the pus, clean the cavity, and es- 
 tablish drainage. 
 
 Paj'otiditis has been mentioned as one of the accidents liable to occur 
 
TREATMENT GF OVARIAN CYSTS. 64 1 
 
 during convalescence; it is rare, and also grave, since it indicates a certain 
 amount of septicaemia; the prognosis is serious. 
 
 Subacute peritonitis may be present from the first, or it may not appear 
 until the tenth or fifteenth day, originating doubtless in the septic mortifica- 
 tion of the pedicle, or any other ligatures en masse that may have been left 
 in the abdomen ; I saw one case which evidently started from some ligatures 
 of the omentum which had been made with poor catgut. Its onset is more 
 insidious than that of the peritonitis which occurs at an earlier stage, and it 
 assumes the form rather of peritoneal septiccemia. Elevation of temperature 
 is rare ; meteorism is observed, also vomiting of bilious and then of stercora- 
 ceous matter. 
 
 Any treatment of the peritonitis is almost powerless to arrest it. As 
 soon as it is apprehended, cold applications may be made to the abdomen, 
 either by means of a bladder filled with ice, or, better yet, by means of 
 Galante's ice coil through which constantly passes a stream of iced water. 
 Small pieces of ice may be given by the mouth to relieve the nausea. I 
 consider gaseous drinks, like Riviere's potion, more injurious than benefi- 
 cial. As to morphine injections, I order them only when the case seems 
 desperate. In these cases reopening of the abdomen has given only bad 
 results, Schroder, Hofmeier, Hegar, and Kaltenbach are unanimous in its 
 condemnation. I tried it once without success, but my one experience did 
 not seem to me conclusive. 
 
 I much prefer to combat the phenomena of infection by means of subcu- 
 taneous or intra-venous injections of artificial serum (salt solution 10: 
 1,000). At least one litre (one quart) should be injected every twenty-four 
 hours, but one may go much beyond that. Lejars did not hesitate to inject 
 25 litres (25 quarts) in five days. This veritable ivasJdng of the blood, which 
 acts by diluting the toxins and facilitating their elimination, is of value 
 only if the renal functions are unimpaired. In one grave case of peritoneal 
 septicaemia consecutive to vaginal hysterectomy, I have used with success 
 subcutaneous injections of Mannorek's anti- streptococcus serum. 
 
 Among the more rare accidents I will mention intestinal occlusion, 
 which has been attributed to adhesions near the buried ligatures or cut sur- 
 faces ; it may even be favored by the destruction of the peritoneal endothe- 
 lium caused by the use of sponges or compresses which have been soaked in 
 too strong an antiseptic solution ; hence the advice to wash them in boiling 
 water before using them, and in general to be aseptic rather than antiseptic 
 in the peritoneal cavity. Out of one thousand ovariotomies, Spencer Wells 
 observed eleven deaths from intestinal occlusion. As treatment of this acci- 
 dent Bode and Leopold recommend forced injections of hot chamomile infu- 
 sion with oil and soap; several quarts should be injected, after which the 
 patient is laid on her side. This method, in which Leopold has great faith, 
 may be tried, but there must be no delay in reopening the wound and search- 
 ing for the obstacle, which is usually an adhesion to the pedicle or to the 
 41 
 
642 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 abdominal wound. In view of the latter possibility, we should proceed with 
 great caution. 
 
 Other exceptional causes of death are tetanus, phlebitis, and embolus. 
 
 Acute or chronic uraemia has been observed, due to the congestion of 
 already diseased kidneys, by prolonged anaesthesia and traumatism. 
 
 Shock IS a vague term applied to an accident of varied pathogenesis, 
 which may be from unrecognized embolus and fatal uraemia, or paralysis of 
 a heart already impaired by general marasmus. 
 
 Gravity of the Operation. — The prognosis of ovariotomy, like that of all 
 major operations, depends largely upon whether the case be a simple or a com- 
 plicated one. Unfortunately there is no existing classification of cases made 
 with the object of bringing out this point, neither would it be easy to make 
 one. Yet, from the more recently published statistics, we may safely come 
 to the conclusion that the extirpation of a cyst without extensive adhesions is 
 at the present day a safe operation. The statistics are also very deficient 
 in the causes of death, nevertheless it may be confidently stated that the 
 greater number are due to septic peritonitis. The malignant tumors with 
 large adhesions are the ones which raise the death-rate. A few operators 
 will not undertake any but favorable cases. The following tables are bor- 
 rowed from Olshausen : 
 
 Spencer \Yells 1,000 cases. 76S cures. 
 
 Keith 381 " 340 " 
 
 Koeberlc , 306 " 231 " 
 
 Thornton 423 " 3S5 " 
 
 Tait 405 " 372 " 
 
 Olshausen 293 " 266 " 
 
 Schroder 658 " 575 " 
 
 It would be interesting to analyze these reports in order to ascertain the 
 diminution of the death-rate following a greater perfection of technique on 
 the part of the surgeon. Hofmeier did this in the case of his instructor, 
 Schroder, with the following result : 
 
 From I to 100 17 deaths. 
 
 " 100 " 200 iS " 
 
 " 200 " 300 7 " 
 
 " 300 " 400 16 " 
 
 " 400 " 500 7 
 
 ' ' 500 ' ' 600 7 
 
 " 600 " 658 II " 
 
 65S 83 deaths = 12.6 per cent. 
 
 Hofmeier remarks that of these deaths a very few were due to infection, 
 and that the majority are due to grave accidents following the removal of 
 malign tumors. Thus may be explained the high rate of 1 1 deaths out 
 of the last 58 cases. In the fifth and sixth hundred, there were two series 
 of 20 and 40 consecutive cures. Lawson Tait, who in his first series 
 of 1,000 operations had only 9.2 per cent of deaths, and in a second 
 similar series 3.3 per cent, gives the following figures for his latest ovari- 
 
TREATMENT OF OVARIAN CYSTS. 643 
 
 otomies : Parovarian cysts, i death in 24; unilateral ovarian cysts, 6 deaths 
 in 158; bilateral ovarian cysts, 2 in 78; cysts within the broad ligament, 
 12 cases without a death. 
 
 C. Braun, in his second series of 100 ovariotomies representing opera- 
 tions performed between the years 1884 to 1887, had 13 deaths, or 93.5 
 per cent of cures. But in this series he does not include 7 deaths which 
 occurred after exploratory incision. From 1888 to 1890 there were 2 deaths 
 out of 52 ovariotomies, or 3.8 per cent. Freund, out of 191 operations, had 
 17 deaths. G. Granville Bantock, in his fourth hundred series of ovari- 
 otomies performed with simple aseptic precautions, had only 4 deaths as 
 against 19 deaths in the first hundred by the Listerian method. Dohrn, out 
 of 100 ovariotomies performed between May, 1883, and April, 1889, had 
 only 4 deaths. Terrier reports 200 ovariotomies from July, 1874, to July, 
 1889, with 37 deaths, or 18.5 per cent. Terrillon, out of 278 ovariotomies, 
 from September, 1880, to 1892, had 24 deaths, or 8.6 per cent. 
 
 I am not able to give any later statistics, as for a few years surgeons 
 appear to have given up the publishing of their special statistics of ovari- 
 otomies, letting them be included in the series of laparatomies for lesions of 
 the appendages. 
 
 Results of t/ie Opemtion. — In the case of benign tumors the patient 
 usually makes a good recovery ; although there is always a liability to a pro- 
 trusion of the bowels through relaxation of the suture, unless it has been 
 done with the special care I have described. Even then it is well to have the 
 patient wear an abdominal belt to give slight compression ; but it need not 
 be of any special design as is needed when the cicatrix is of doubtful 
 strength owing to there having been but one row of sutures. 
 
 A cyst of the other ovary or broad ligament may form later and neces- 
 sitate reopening of the abdomen. The surgeon when called to do a second 
 operation should remember that there is a tendency on the part of the intes- 
 tines to adhere to the first cicatrix ; it is therefore more prudent to begin 
 the new incision a trifle above the upper end of the previous one, and to 
 insert a finger into the opening thus made and use it as a guide in finishing 
 the incision from above downward. Thanks to this precaution, I have been 
 able to avoid wounding intestines which were adherent over a large area, in 
 a case upon which I performed a second laparatomy. On the other hand, I 
 knew of a second laparatomy performed by a surgeon of large experience, in 
 which the small intestine was cut through when the cicatrix was incised; 
 the patient died. I have already spoken of the question of a return of ma- 
 lignant tumors, and of generalization. You will remember that they are 
 usually confined to the peritoneum, rarely invading the abdominal viscera 
 and walls, still more rarely the lungs and mediastinal glands. 
 
 Segond has even noted secondary degeneration of the axillary glands. 
 Secondary tumors may be of an epithelial, sarcomatous, or mixed type. 
 They develop rapidly and cause death in the same way as cancers. Is Ter- 
 
644 CLINICAL AND OPERATIVE GYNECOLOGY, 
 
 rillon correct in holding that a small-sized pedicle implies a benign tumor? 
 I believe this to be purely theoretical. The occurrence of carcinomatous 
 infection mentioned by Nicaise as following puncture of a malignant ovarian 
 cyst seems to me to be simply an error of interpretation ; he probably saw 
 the formation of a nodule near the cicatrix and attributed it to the engrafting 
 of cells brought there by the trocar. A simpler interpretation is that of a 
 metastatic neoplasm developed at the locus minoris rcsistenticz. 
 
 Menstniation aiid Pregnancy after Operation. — Patients from whom only 
 one ovary has been removed continue to menstruate and may become preg- 
 nant. If both ovaries are completely removed, premature menopause will 
 follow, but it may be delayed for several months. The fact that pregnancy 
 has been known to follow the intentional resection of a portion only of one 
 ovary after removal of the other (Schroder), as well as the persistence of 
 menstruation after cases of so-called double ovariotomy which were evidently 
 incomplete, prove that only a very small portion of ovarian tissue is needed 
 to maintain the reflex influence causing menstruation. It is difficult to be 
 certain that no trace of the ovary is left behind when removing an ovarian 
 tumor with a short pedicle, especially if it be a papillary tumor. I discussed 
 this question more in detail in the chapter upon Amenorrhoea. 
 
 Insanity following Operation. — Acute mania and melancholia are more 
 apt to follow ovariotomy than any other operation upon the female genital 
 organs. This occurs particularly where there is hereditary predisposition 
 to insanity, but in exceptional cases there may be no known cause. We 
 should always Xxy to ascertain whether alcoholism or the absorption of iodo- 
 form could account for the cerebral derangement, which, it is true, is often 
 merely temporary'- (as I once witnessed in a remarkable case), but yet which 
 may persist. 
 
 Similar occurrences have been noticed after abdominal hysterectomy, 
 and even after operations on the vulva, perineum, cervix, and mammary 
 gland. In this last case, it would seem that there must be a neuropathic 
 tendency which some'determining cause would surely sooner or later develop 
 into insanity. The surgeon, however, must bear in mind the possibility of 
 this complication, though it be rare, and even count it as a factor in the 
 prognosis, if he is dealing with a patient with hereditary predisposition to 
 insanity or simply with a neurotic taint. 
 
 Cysts Complicated by Pregnancy. Ovariotomy djiring Pregnancy. — Under 
 these circumstances, pregnancy and labor have sometimes been successfully 
 terminated without surgical interference, but only in exceptional cases. As 
 a rule, small pelvic cysts, if they do not interfere with pregnancy, are a for- 
 midable complication of labor; large abdominal cysts are almost sure to 
 cause abortion, and run a great chance of torsion of the pedicle, rupture, or 
 suppuration causing peritonitis. A comparison of the dangers of expectant 
 treatment and the relative innocuousness of timxcly ovariotomy will cause 
 no hesitancy in a choice. Yet the advisability of operation has been con- 
 
TREATMENT OF OVARIAN CYSTS. 645 
 
 tested by some authorities ; some prefer induced abortion, premature labor, 
 or even puncture of the tumor. In the first two cases the obstacle interposed 
 to the retraction of the uterus may be a cause of hemorrhage or puerperal 
 accidents ; in the last case there is danger of wounding the uterus, and abor- 
 tion usually follows under unfortunate conditions. 
 
 The question assumes a different character according to whether we are 
 called to the patient before or during labor. Before labor I do not think 
 that there should be any hesitation in performing ovariotomy. The old 
 statistics given by Remy show that out of G'] ovariotomies performed during 
 pregnancy there were 13 cases of interrupted gestation and death of the 
 patient, 22 cases of abortion followed by cure, 32 cases of labor at term with 
 cure; in other terms, 19.4 per cent of death of the mother, and 52 per cent 
 of death of the child. But the results at the present day are far more en- 
 couraging. Out of 36 cases operated upon by L. Tait, Spencer Wells, 
 and Shroder, there was but i death. In the great majority of cases the 
 life of the foetus is protected and pregnancy continues. Olshausen men- 
 tions seven cases where the gravid uterus was taken for a cyst and punc- 
 tured. The majority of the operators at once performed Caesarean section, 
 and five of the patients recovered. Before the fifth month of pregnancy, 
 the operation is far less serious than it is later. According to Schroder, 
 the reason for this is that the pedicle becomes shortened by the opening out 
 of the broad ligaments. However that may be, out of twenty-one cases 
 operated upon after that time there was only one death. 
 
 Puncture is only to be resorted to when it is absolutely impossible to 
 operate on the cyst. 
 
 During labor, forceps, version, craniotomy, and even Caesarean section 
 have all been tried. First of all, we must make the attempt to push the 
 tumor above the promontory by introducing the fingers into the rectum, the 
 patient being in the genu-pectoral position. If we do not succeed in this, 
 the cyst must be punctured through the posterior vaginal cul-de-sac. If its 
 contents are too thick to be evacuated by this means, it has been. advised to 
 make a large incision in the same place, to remove the irreducible cyst (usu- 
 ally dermoid). Forceps are likely to tear the parts ; version can rarely be 
 performed. The choice remains between craniotomy if the foetus is dead, 
 and CEesarean section if it is alive. 
 
 For my part, I should not hesitate to perform laparatomy in order to 
 ascertain whether removal of the cyst were possible ; by ovariotomy we could 
 then remove the obstacle, and labor could go on successfully. Even if this 
 were not possible, I do not think that Caesarean section or Porro's operation 
 offers greater danger to the mother than the blind and excessive violence 
 often exerted through the natural paths, and they possess the additional ad- 
 vantasre of savinsr the life of the child. 
 
CHAPTER XXX. 
 
 SOLID TUMORS OF THE OVARY. 
 
 As a rule, we include, under the head of solid tumors of the ovary, 
 fibronia, sarcoma, and epithelioma or carcinoma. A few writers add papil- 
 loma, enchondroma, and tubercle. I shall not follow their example. In 
 tact I have already described the first with the papillary cysts, of which it is 
 in reality only an appendage. Enchondroma has no real clinical existence ; 
 it is an exceedingly rare anatomical lesion. As to tubercles, they are very 
 rarely situated in the ovary, and the symptoms to which they give rise are 
 tubercular peritonitis or pyo-salpingitis, in which the microscope reveals 
 giant cells and bacilli; their symptomatology is easily confounded with that 
 of other suppurative processes of the appendages, of which I have already 
 spoken in the chapter on Cystic Oophoro-salpingitis. 
 
 Fibroma. Pathological Anatomy. — Fibroids of the ovary are rare. 
 These do not form circumscribed new growths, like fibroids of the uterus, 
 but seem rather to be a kind of fibroid degeneration of the organ which is' so 
 uniformly hypertrophied that its shape and relations are not altered. Leo- 
 pold pointed out the fact that the tube remains free instead of becoming a 
 part of the ovarian tumor, as is the case with cysts. Yet if the tumor opens 
 out the broad ligament and becomes enclosed within it, this distinction dis- 
 appears. We may then have great difficulty in distinguishing a fibroma 
 originating in the ovary from one originating in the uterus which acquires 
 the same relations. Simple fibromata are usually small. It is the fibro- 
 sarcomata and fibro-myxomata which attain such enormous proportions. Still, 
 Alban Doran removed a fibroid of the ovarian ligament which weighed no 
 less than 17 pounds, and Picque a fibroma weighing 4 kgm. 800 gm. Sim- 
 ple fibroids are hard in consistence, and have a mammillated surface; they 
 usually have a pedicle and are free from adhesions; ascites has sometimes 
 been noted. An interesting variety of fibroid, from an anatomical stand- 
 point merely, is the fibroid of the corpus luteum described by Rokitansky; 
 it is always very small; still, Klob has seen one as large as a child's head. 
 On the section we see the denticulated folds of the corpus luteum, whose 
 structure can be recognized by the microscope. Ovarian fibromata are usu- 
 ally hollowed out into little geodes containing fluid; it is difficult to decide 
 whether these cavities come from the Graafian follicles, from limited points of 
 molecular disintegration, or from the dilatations of lymphatics. Calcifica- 
 tion and even ossification of ovarian fibroids has been met with. The struc- 
 ture of these tumors is chiefly fibrous in the true sense of the word; there 
 
SOLID TUMORS OF THE OVARV. 647 
 
 are many connective-tissue fibres and few or no unstriped muscle fibres ; if 
 these are present to any extent, it is probable that the origin of the tumor 
 has been misconceived, and that it is derived from the uterus. Exception- 
 ally the vessels may be of unusual size, as in the cavernous fibromata of 
 Spiegelberg; but in these very vascular tumors there is usually an admixture 
 of sarcomatous tissue. 
 
 Fibroids of the ovary are met with relative frequency in young women. 
 Leopold mentions thirteen cases at from five to thirty years of age, and only 
 four at thirty to forty years. They are also seen in aged women. Terrier 
 removed one by laparatomy from a woman of seventy-seven years. 
 
 Sj'm/>toms. —Ascites is what usually attracts notice at first; it is caused 
 by the exceeding mobility of the tumor, thus resembling ascites caused by 
 
 Fig. 440. — FiBRO-SARCOMA OF THE OvARY. 
 
 certain pediculated fibroids of the uterus. When this symptom is absent, 
 the tumor may escape notice, or be discovered by chance if bimanual ex- 
 ploration be performed or if laparatomy be done for any other reason. 
 
 Their course is slow. Peritonitis from torsion of the pedicle has been 
 noticed, as well as some cases of inflammation. 
 
 Diagnosis. — It is almost impossiblg to distinguish fibroma of the ovary 
 from a pediculated fibroid of the uterus ; the ascites might also cause us to 
 think there was a malignant tumor. Exploratory incision alone can decide 
 the question. This is the more legitimate since the tumor must be removed 
 in any case. The prognosis is favorable in the case of a pure fibroma, which 
 is a benign tumor. It should, however, be removed by laparatomy as soon 
 as it gi\'es rise to pain, and even as soon as it is recognized, for we can never 
 be certain that it is not a sarcoma. 
 
 Sarcoma. — Pathological Anatomy. — This neoplasm is of rare occurrence ; 
 according to valuable calculations based upon Schroder's ovariotomies, Cohn 
 estimates the frequency as about one per cent in relation to cysts. Out of 
 fifteen solid tumors of the ovary Heim found seven cases of sarcoma. It is' 
 usually bilateral. The spindle-celled or fibroplastic variety is more frequent 
 than the round-celled or embryoplastic ; the first has a lardaceous consist- 
 ence, the second is much softer. Cystic cavities and foci of fatty degenera- 
 
648 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 tion are numerous in the substance of the tissue. They contain many blood- 
 vessels. Although usually medium-sized, they may attain an enormous 
 volume. According to de Sinety, proliferous cysts in which the solid element 
 
 Fig. 441. — Endothelioma of the Ovary. Showing alveolar appearance (150 diameters), i, Ovarian tissue in 
 reticular bundles, cells in the open spaces; 2, these spaces dilated and changed into alveoli full of cells ; 3, lymphatics. 
 
 predominates have often been confounded with the sarcomata. Possibly the 
 description of a mixed variety analogous to adenoma and carcinoma may be 
 due to this confusion. 
 
 While on this subject, I will speak of some researches to which the nov- 
 elty of the results obtained lends interest. There has lately been described 
 
 Fig. 442. — Endothelioma of the Ovary. Giant cells with many nuclei, i, Loose connective tissue with long 
 cells ; 2, cellular proliferation between its bundles of fibres ; 3, epithelioid cells derived from the preceding cells ; 4, 
 cells with multiple nuclei ; 5, unchanged cells ; 6, vessel filled with blood. 
 
 a variety of ovarian neoplasm, histologically intermediate between epitheli- 
 oma and sarcoma, found in certain degenerated dermoid cysts, in papillary 
 cysts, and in those solid tumors riddled with small cavities, which have 
 
SOLID TUMORS OF THE OVARY 
 
 649 
 
 hitherto been classed with the sarcomata. Eckhardt and Pomorski called 
 them endotheliomata to indicate their origin from the endothelium of the 
 S 1 -i. 0. 
 
 Fig. 443. — Endothelio:ma of the Ovary. — Gradual transformation of proliferated cells into epithelioid cells. 
 I, Loose connective tissue ; 2, round proliferated cells with shining nucleolus ; 3, same, swollen and increased in size ; 
 4, same, still more developed ; 5, cells which have completely changed and are loosely united to each other in large 
 alveolar cavity ; 6, large vessel filled with blood ; 7, lymph spaces. 
 
 lymphatic spaces or capillaries, or even of the capillary blood-vessels. They 
 were able to follow step by step on the one hand the transformation of the 
 
 
 ^^ 
 
 ^ 
 
 '^■"^ -#" 
 
 /^r, 
 
 Fig. 444. — Endothelioma of the Ovary. Individual elements at different periods of development (800 diame- 
 ters) . .-J, Small round cells with nucleolus derived from connective-tissue cells in lymph spaces ; j5, same, swollen 
 and becoming epithelioid ; C", cells more or less angular and of various forms; karyokinesis shown in that on the left; 
 jO, multinucleated giant cells. 
 
 connective-tissue elements into epithelioid cells, on the other the abundant 
 proliferation of the endothelium of the lymphatic spaces of the connective 
 
650 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 tissue. This neoplasm is therefore a mixed variety, and shares the struc- 
 ture of tumors of connective-tissue origin cr sarcoma, and tumors of epithe- 
 lial origin or carcinoma. Leopold was the first to point out this variety of 
 ovarian tumor. Two other observations, analogous from a histological stand- 
 point, although differing widely from the standpoint of the macroscopic 
 pathological anatomy, had been published by Marchand. From the facts 
 
 known, we can see that we 
 
 
 have here to do with a curi- 
 ous variety of sarcoma, either 
 primary (papillary tumor of 
 the ovary or microcystic sar- 
 coma) or secondary (degen- 
 eration of the walls of a 
 dermoid cyst). The inter- 
 est attaching to these theo- 
 ries is great, but purely his- 
 tological. From a clinical 
 point of view, it would seem 
 that these tumors are of great 
 malignity. The symptoms 
 are those of a rapidly devel- 
 oping malign tumor. 
 
 Their surface is smooth, 
 and the general form of the 
 ovary is retained ; the lesion 
 is sometimes bilateral. Preg- 
 nancy sometimes stimulates 
 it to rapid development. 
 Miinchmeyer, in a case in 
 which pregnancy caused an 
 enormous development of the tumor, was obliged to perform craniotomy. 
 Ascites is always present, and cachexia rapidly appears. This rapid course 
 is what clinically distinguishes sarcoma from fibroma. It is most often seen 
 in the young and sometimes in childhood, as in epithelioma age furnishes 
 no data for diagnosis. The only treatment is extirpation. A relapse is 
 more to be feared than in fibroma, but is less fatal than in epithelioma. C. 
 Braun reports a well-authenticated case of ovarian sarcoma in which a cure 
 had been maintained without relapse for eleven years. 
 
 Epithelioma or Carcinoma. — If we exclude the secondary cancerous 
 degeneration of cysts, primary cancer of the ovary is rare. Yet it has been 
 noted at all ages, even in infancy. 
 
 Pathological Anatomy. — Two principal anatomical forms are described; 
 one diffuse and medullary, the other superficial and papillary. 
 
 There is great confusion upon this last point, and many cases of ruptured 
 
 Fig. 445. — Endothelioma of the Ovary. Area resembling sar- 
 coma (800 diameters), i, Homogeneous granular tissue composed 
 entirely of cells varying greatly in size and shape, a large number 
 showing karyokinetic changes ; 2, tissue traversed by large number 
 of capillaries with embryonal walls. 
 
SOLID TUMORS OF THE OVARY 
 
 651 
 
 papillary cysts have been given the name of cancer or of cancerous papilloma. 
 We must, with Cohn, be careful to discriminate between the vegetations 
 distinctive of the two morbid growths, which, although they may look alike 
 to the naked eye, are seen under the microscope to possess a structure char- 
 acteristic of either carcinoma or papilloma. The diagnosis is complicated 
 by the fact that the transition from one of these forms to the other may be 
 clinically and anatomically indistinguishable. Epithelioma or medullary 
 carcinoma should also, at least theoretically, be clearly distinguished from 
 
 Fig. 446. — Endothelioma of the Ovary. Metastasis in omentum (350 diameters), i, Adipose tissue ; 2, pro- 
 liferated connective-tissue cells in its meshes; 3, proliferation especially active in vicinity of vessels ; 4, vessels filled 
 with blood ; 5, lymph spaces ; 6, preceding cells changing gradually into epithelioid cells, forming large compact 
 masses (7) ; S, connective tissue surrounding these. 
 
 the proliferous glandular cysts with colloid and gelatiniform contents and 
 with small cavities, which may have the same general appearance to the 
 naked eye. Even under the microscope, an exact distinction is often diffi- 
 cult, because of carcinomatous degeneration of the cyst walls. In fact, we 
 have to confess, with De Sinety, that " at this date it seems impossible for 
 us to trace a clear line of demarcation between cysts and cancer of the 
 ovary." But although this is absolutely true as regards a large number of 
 cases doubtful from an anatomical point of view, yet from a clinical stand- 
 point we can usually make a distinction, though even here we may fall into 
 many errors. Winter has seen the Fallopian tube perforated and invaded 
 by a cancer originating in the ovary, which distended it in such a manner as 
 to simulate a hydro-salpinx. 
 
 The symptoms are in no wise characteristic at the onset. But before 
 
652 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 long the development of ascites, the fluid of which is often tinged with 
 blood, the general wasting, and the extraordinarily rapid progress of the 
 tumor emphasize its malignant character. We may see oedema of the lower 
 limbs, thrombosis, and finally a metastatic generalization. The diagnosis is 
 doubtful only in the first stages, when we may think that there is a fibroma 
 or a sarcoma. The course of the disease soon settles all doubts. 
 
 As to treatment, there are two methods advocated. Some, among whom 
 is found Schroder, in view of the small chance of recovery held out by oper- 
 ation, and the greater risks undergone than in the case of benign tumors, 
 recommend abstention from operative procedures and the administration of 
 palliatives. Others, believing that the patient may be relieved for a while, 
 or even temporarily cured, operate, even though complete extirpation be not 
 possible. Spencer Wells, Gaillard Thomas, Ruge, Cohn, A. Martin, and 
 Duvelinx hold the latter opinion, in which I share. I believe with the last- 
 named writer that when in doubt we are justified in making an exploratory 
 incision, and that this is not as harmful as Olshausen believes. In the only 
 two cases in which I performed it, the patients, on the contrary, had a de- 
 cided diminution of the ascites for several months. 
 
CHAPTER XXXI. 
 
 TUMORS OF THE FALLOPIAN TUBES, BROAD AND 
 ROUND LIGAMENTS. 
 
 Tumors of the Fallopian Tubes. — Fibroids, or, to be more exact, 
 fibro-myomata, are rare and of small size ; Sanger and Barth have been able 
 to find the reports of only five cases. They develop toward the exterior, and 
 do not as a rule diminish the calibre of the oviduct. Epithelioma or car- 
 cinoma, as a rule, is derived from cancer of the ovary or of the uterus. 
 We may at times see advanced cancer of the ovary with a perfectly healthy 
 tube. This remarkable fact is perhaps due to the direction of the lymph 
 stream. Out of 73 cases of cancerous uteri, Kiwisch noted cancer of 
 the tubes 18 times, and Dittrich out of 94 cases of various kinds of can- 
 cer, found malignant degeneration of the oviduct 4 times only. This 
 affection is therefore infrequent. Orthmann collected the reports of 13 
 cases, in which the uterus was 9 times the starting point of the disease 
 and the ovary 4 times. In a case in A. Martins' clinic, the carcinoma 
 of the tube was primary ; it was a cancer of papillary vegetative form 
 in a woman of fifty-one years. In the first edition of this work I was 
 able to find but few records of authentic primary tubal cancer; since 
 then a number of new facts have been observed, and Sanger and Barth, 
 basing themselves upon seventeen accurate observations of primary cancer 
 of the tube, have been enabled to outline the clinical history of this affec- 
 tion. It would appear from the cases published that primary carcinoma of 
 the tube appears almost exclusively at the time of the menopause, the age of 
 the patients ranging from forty-three to sixty years. Doran and Fearn hold 
 that it is always the result of the malignant degeneration of a pre-existent 
 benign papilloma. Sanger and Barth share this opinion up to a certain 
 point, since they hold that primary cancer of the tube always develops from 
 an old chronic purulent salpingitis, at a late date when there is no longer 
 any pus, most frequently at the time of the menopause. 
 
 From an anatomical standpoint we may distinguish two varieties : a 
 nodular form, which is the more frequent, and a diffuse form. Two varieties 
 are also revealed by microscopic examination : the first having a purely 
 papillary structure, while in the second an alveolar structure predominates. 
 
 The symptoms caused by this affection are not specially characteristic. 
 Pains in the region of the diseased tube radiate towards the thigh, there are 
 disorders of menstruation, a bloody vaginal discharge with a healthy uterus. 
 
654 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 a tumefaction of the abdomen, and often ascites. Tuffier observed a case 
 which simulated retro-uterine haematocele. 
 
 Sarcomata of the tubes are extremely rare, there being only three re- 
 corded cases of sarcoma of the mucosa. These are the cases of Senger, 
 Landau, and Sanger. There is only one case of sarcoma of the muscular 
 
 Fig. 447. — Intra-tubal Dermoid. Longitudinal section of tube and tumor showing their relations to each 
 other (diagrammatic). 1, Portion of tumor which has passed through upper wall of tube ; 2, epithelium ; 3, connective 
 tissue ; 4, sebaceous glands ; 5, hair ; 5 bis, hair which has passed through villosities ; 6, racemose glands ; 7, sudori- 
 parous glands ; 8, adipose tissue ; o, tubal villosities ; 10, atrophied villosity; 11, upper wall of tube; 12, floor of tube ; 
 13, connective tissue between tubes and ovar>' ; 14, vessels ; 15, ovarj- ; 16, cysts. 
 
 layer, that of Janvrin. Ahlfeld and IMartin report a case of malignant de- 
 ciduoma of the tube, following tubal pregnancy. A. Doran describes a 
 papilloma of the tubes which he considers benignant, and which he com- 
 pares to condyloma of the vulva and vagina. He thinks that these growths 
 are not neoplasms, but simply hyperplasias due to chronic inflammation of 
 the organ. He reports two interesting cases, which, however, do not suffice 
 
TUMORS OF THE BROAD LIGAMENTS. 
 
 655 
 
 to prove that these lesions form any definite clinical type. It is very prob- 
 able that in this case, as in the case of ovarian papilloma, an anatomical 
 form of identical appearance may from some unknown cause develop into 
 either a benignant or malignant tumor. Bland Sutton, who also considers 
 papilloma of the tube to be a special and benign anatomical form of tumor, 
 attaches great importance to gonorrhoea as a predisposing cause. If this 
 theory be true, it would be difficult to account for the rarity of the affection. 
 
 Fig. 448. — Intra-tubal Dermoid. Section perpendicular to surface showing epithelial layer and sebaceous 
 glands with their hairs, i, Corneous layer ; 2, layer of stratified squamous epithelium ; 3, mouth of sebaceous gland ; 
 4, hair ; 5, sebaceous gland ; 6, bundle of smooth muscle fibres ; 7, dense connective tissue in periphery of tumor ; 8, 
 openings of capillaries ; 9, capillaries surrounded by embryonal cells ; 10, openings of lymphatics ; 11, loose connec- 
 tive tissue. 
 
 We must be careful not to confound papilloma with foliaceous hypertrophy 
 of the folds of tubal mucous membrane in some cases of salpingitis. Doleris 
 has recently reported a case of double salpingitis with echinococci. The 
 right tube was 23 inches long, the left one 21, and both together weighed 
 about 4l4 pounds. I observed an interesting case of dermoid tumor of the 
 tube (Figs. 447 and 448), These are very exceptional occurrences, and 
 it is impossible to diagnose them ; they are usually taken for ovarian cysts, 
 oophoro-salpingitis, or uterine fibroids. 
 
 Tumors of the Broad Ligaments. — The cysts have been studied with 
 ovarian cysts, to which they belong clinically. Fibroid bodies independent 
 
656 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 of the Uterus have been observed in the broad ligament. It is impossible to 
 determine whether they are primarily developed at the expense of the pro- 
 longations of connective tissue and muscular tissue belonging to these folds, 
 or whether they are due to a migration of fibroid bodies from the uterus. 
 
 Tedenat observed an enormous fibro-cystic tumor accompanied by other 
 purely fibroid tumors of the broad ligament. We must not mistake for 
 small fibroids the accessory ovaries whose possible existence has been 
 
 pointed out by Waldeyer and 
 Beigel ; they are rarely as large 
 as a cherry, and never larger. 
 
 Lipoma has rarely been ob- 
 served in the broad ligament. I 
 ^ ,_ ^ ^ saw one case which had been mis- 
 
 ^/^^^^^^'W^r^^W^'^^^^^^^i\ taken for an ovarian cyst because 
 
 ^/fVO;^i.^./#' <i\.*,M3dl€s\x^^mM ^ ^^ ^^^ misleading sense of fluctua- 
 tion. The patient suddenly died 
 of embolus three days after an ex- 
 ploratory puncture. Terrillon oper- 
 ated upon a case in which an enor- 
 mous tumor weighing sixty pounds 
 sprang from the mesentery. The 
 enucleation of these subserous tu- 
 mors leaves a large cavity which 
 must be treated in the manner de- 
 scribed for intra-ligamental fibrous 
 bodies of the uterus. 
 
 EpitJielioma and Sarcoma. — In 
 this situation these neoplasms re- 
 sult from an extension of neigh- 
 boring tumors situated either in 
 the peritoneum, the ovary, or the 
 uterus. Bandl has seen some cases in which they came from the pelvic 
 ganglia. 
 
 Parovarian Varicocele. PhlebolitJis. — Varicose dilatation of the utero- 
 ovarian veins, which was pointed out by Richet and his pupil Devalz, was 
 found no less than ten times out of three hundred autopsies performed by 
 Winckel. Their size must certainly be greater in the living subject than in 
 the cadaver. Winckel has found thrombi, and Klob and Bandl phleboliths. 
 EcJiinococci. — Freund devotes an important monograph to the study of 
 these parasites in the female pelvis ; they travel about in all the cellular in- 
 terstices communicating with the superior pelvi-rectal space, which seems 
 to be their point of entrance, and may thus reach the broad ligament, pass 
 into the iliac fossa, and pass out of the pelvis either below or above the 
 crural arch. They cause chronic inflammation with induration of the con- 
 
 FiG. 449. — IntRA-tubal Dermoid, i, Adipose tissue of 
 centre of tumor ; 2, vessels ; 3, transverse section of hair 
 with sheath ; 4, sudoriparous gland ; 5, excretory duct. 
 
TUMORS OF THE ROUND LIGAMENTS. 657 
 
 nective tissue round about them. There may be no local symptoms outside 
 of the pressure phenomena, and the general health is not affected. The 
 tumors are round and elastic, situated as a usual thing near the rectum in 
 the posterior part of the pelvis, slightly movable, not painful. With biman- 
 ual palpation we recognize the fact that they are not continuous with the 
 uterus or ovaries. There is danger that an exploratory puncture might be 
 followed by inflammation. 
 
 The diagnosis can only be made by exclusion and by the aid of medical 
 geography, which teaches us the relative frequency of echinococci in cer- 
 tain countries, Iceland, Mecklenburg, etc. The treatment varies according 
 to the seat of the tumor. If it be quite large and protrude into the abdo- 
 men, laparatomy will permit us either to completely enucleate the sac or to 
 suture it to the abdominal wound, tampon and drain it. In the case of small 
 pelvic tumors interference will be necessary only when there are accidents 
 due to compression ; then we make an incision through the posterior vaginal 
 cul-de-sac to the tumor, or else we reach it by perineotomy or para-sacral 
 incision, according to circumstances. If we have had to cut the peritoneum, 
 we must, as soon as we reach the sac and before opening it, use a tamponade 
 of iodoform gauze for twenty-four or forty-eight hours, in order to assure 
 haemostasis and the formation of protective adhesions ; at a second seance we 
 can open the sac under antiseptic precautions. 
 
 Tumors of the Round Ligaments. — Cysts or Hydrocele. — An accumu- 
 lation of encysted serum may sometimes be seen in the interior of the in- 
 guinal canal, or at its external orifice. It was quite natural to attribute this 
 lesion to a persistence of the canal of Nuck, which surrounds the round liga- 
 ment during intra-uterine existence. This origin, although admitted b)'- 
 many authorities, is denied by Duplay. Still, Schroder asserts that in a case 
 observed by himself the fluid could be pushed into the abdomen, which cer- 
 tainly seems to prove the existence of a communication between the cyst 
 and the peritoneal cavity, and an origin analogous to that of congenital 
 hydrocele in the male. Whether this be the true origin or not, another ma}- 
 be claimed for it ; the cyst might be seated in the substance of the round 
 ligament. W^e know, in fact, that the gubernaculum of Hunter, which 
 becomes the round ligament in the female, is at first hollow; there might 
 be a persistence of a foetal condition favoring the production of a pathologi- 
 cal growth. 
 
 (For symptoms, diagnosis, and treatment, see Inflammation and Cysts 
 of Bartholin's Gland.) 
 
 Fibroma. — This may occur as pure fibroma, as fibro-myoma, myxo-fibroma, 
 or fibro-myxo-sarcoma. Calcareous degeneration has been noticed. Leo- 
 pold found a lymphangiectatic myoma in the round ligament. 
 
 The most frequent situation is upon the right side, and it usually comes 
 after parturition. The tumor may be seated at the internal orifice, it may 
 be intra-peritoneal, or external in the labium majus or toward the fold of the 
 42 
 
658 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 groin. Free from the skin, often pediculated but sometimes sessile, the 
 mass, which is of varying size, is smooth or slightly lobulated, and usually 
 of a fibrous consistence; it is not painful on pressure, but causes pain by 
 the pressure which it exerts when it attains a certain volume. Cough and 
 straining efforts have no effect upon fibromata. It is only at the beginning, 
 when they are very small and externally situated, that they may be partly 
 reduced through the inguinal canal. They have been known to increase in 
 size under the influence of pregnancy and even at each menstrual period 
 The course is slow in the case of pure fibromata, but in the case of mixed 
 tumors may assume all the rapidity of malignant growths. In regard to the 
 diagnosis, we must, with Duplay, distinguish the cases in which there is a 
 pedicle from those in which there is none. If there is a pedicle which pushes 
 it beneath the crural arch, it cannot be a neoplasm of the round ligament. 
 If it pass above, the tumor may belong to the ligament or be a fatty hernia, 
 an epiplocele, or an ovarian hernia. A differential diagnosis may be reached 
 by the following signs : Fatty hernia is often reduced by pressure, is painful 
 to the touch, feels soft, and has poorly defined limits. Irreducible epiplo- 
 cele, which often acquires a fibroid consistence like that of fibroma, would be 
 impossible to distinguish, were it not for the pressure of an epiploic cord 
 stretched behind the abdominal wall. Ovarian hernia is ovoid, having" the 
 shape of the organ, and is exquisitely sensitive to pressure; its increase in 
 size at the menstrual period is even more marked than in certain fibroids ; 
 the uterus is laterally displaced. 
 
 If the tumor is non-pediculated and in the groin, we might think it a 
 ganglionic mass. But in that case it would be multilobular and never espe- 
 cially' connected with the inguinal ring. If the neoplasm is in the labium 
 majus, we should be apt to think of a cyst of Bartholin's gland; we must 
 ascertain its starting-point, by its history and by direct examination ; if the 
 tumor first appeared above the labium, and then entered it, and if its inser- 
 tion in the external abdominal ring can be clearly felt, we need not hesitate 
 to pronounce it a tumor of the round ligament. 
 
 The prognosis is indicated by the course of the disease. 
 
 The treatment is extirpation ; it is usually easy to enucleate fibromata 
 when they are situated at the external ring. The ones which are subperi- 
 toneal, behind the internal abdominal ring, and of large size, may necessitate 
 a serious operation for their removal. 
 
CHAPTER XXXII. 
 
 GENITAL AND PERITONEAL TUBERCULOSIS. 
 
 The invasion of the genital apparatus by the tubercle bacillus is rather 
 rare. Certain localities, as the vagina and the cervix, seem to possess slight 
 susceptibility to it, probably because of the protection afforded by the resist- 
 ant stratified epithelium. The Fallopian tubes are usually the starting-point 
 of the tuberculous lesions ; and from them the disease is easily transmitted 
 to the ovaries, or more rarely to the uterus itself. I shall give a description 
 of tuberculosis of the genital organs according to their anatomical order. 
 
 Histoiical Outline. — The works of Louis, Senn, Raynaud, and Cruveilhier 
 mark the first stage in the study of this subject. With the added researches 
 of Aran, Bernutz, and especially Brouardel, the pathological anatomy, al 
 though still placing too much emphasis upon macroscopical appearances, 
 began to be more accurate and the clinical knowledge more exact. Since 
 that time, the discovery of tuberculous glands and then of Koch's bacillus 
 have given a certain criterion for research, while the increasing boldness of 
 surgeons affords better opportunity for the study of fresh specimens. The 
 names of Hegar, Wiedow, Cornil, and Terrillon are conspicuous among the 
 more recent works upon the pathological anatomy and treatment of the 
 disease. 
 
 In regard to the pathogenesis, we may mention Cohnheim, who was the 
 first to suggest the idea of a possible transmission of the disease through 
 sexual intercourse; Verneuil, who vigorously upheld this theory, and showed 
 the utility of confronting the inoculated person with the inoculator — a 
 method which materially aided the progress of the etiology of syphilitic dis- 
 eases ; Verchere, a pupil of Verneuil, Fernet, and Derville, who reported 
 cases of very probable genital infection ; and Reclus, who discussed them. 
 
 Etiology and Pathogenesis. — Can there be primary genital tuberculosis } 
 Undoubtedly there can. Geil and Tomlinson, systematizing the pre\'iously 
 announced theories of Namias, Cristoforis, and Rokitansky, long ago quoted 
 numerous examples of isolated tuberculosis of the appendages. It is true 
 that observations made before the discovery of the tuberculous glands and 
 the special bacillus were not of decided importance. But later investigations 
 have quite established the fact. 
 
 Primary tuberculosis of the genital organs is not infrequent in the male. 
 One of the peculiarities of this species of local tuberculosis in both sexes is 
 the possibility of its remaining latent and unrecognized for an indefinite 
 
66o CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 period, because of its sequestration by false membranes and by the inspissa- 
 tion of pus. This is especially observed where the lesion is in the tubes, 
 and it may even be impossible^ to find the bacilli, which have doubtless been 
 destroyed during the long continuance, although the tubercular nature of the 
 focus of the disease is shown by the sudden appearance of an acute miliary 
 eruption, either in the lungs or the meninges. The history of old foci of 
 tuberculous affection in the bones or articulations furnish many analogous 
 examples. 
 
 How is the tubercle bacillus introduced into the female genital organs .•* 
 The external communications of these organs would seem to admit, a priori, 
 of their frequent infection either through the atmosphere, the introduction 
 of infectious bodies, or of tuberculous semen. This theory was inadmissible 
 before the researches of V^illemin and Koch had overturned all preconceived 
 notions of the origin of tuberculosis. Even now this theory of direct infec- 
 tion is not received without dispute by all authorities. It has had over- 
 ardent advocates, who were ready to accept it in some doubtful cases with- 
 out sufficient proof, and also some opponents who systematically disparaged 
 it. It seems probable that this method of infection may occur, but it as- 
 suredly is rare. 
 
 The frequency of primary tuberculosis as compared with secondary has 
 been a subject of research. Hosier found 8 primary cases out of 46 obser- 
 vations. Frerichs gives a proportion of 15 out of 96, and Schram only i 
 in 34. It is observed especially between the ages of twenty and forty years. 
 
 We can easily trace the infective agents in primary tuberculosis when 
 the patients have been much in the company of anyone suffering from tuber- 
 culosis ; clothes, a sound, the finger of a physician or midwife, may carry 
 the germs. Cohabitation with a person who has either genital or pulmonary 
 tuberculosis is a well-authenticated cause in many instances. We cannot 
 tell with certainty whether inoculation takes place by means of the spermatic 
 fluid, the saliva, or by the blood through some scratch , or wound. We ma)' 
 make a distinction, from this standpoint, between the cases in which the indi- 
 vidual giving the infection has tubercles on the genital organs and those 
 in which other organs only have tubercles. In the first case we may readily 
 admit that the semen may contain bacilli. Cornil and Babes have in fact 
 found bacilli in the urine of persons affected with tubercular cystitis; 
 Rosenstein made the same observation in a patient who had only a caseous 
 epididymitis. We may, then, in the absence of a positive examination of 
 the semen, suppose that it has become infected in crossing the urethra. We 
 still have to account for the cases in which there seemed to be direct infection 
 from a man whose lungs only were affected. The virulence of the semen 
 rests then only upon hypotheses; and the experiments of Landouzy and 
 Martin .show, in truth, that we may meet with a few bacilli in the testicles 
 and prostate gland of phthisical patients whose genital organs are apparently 
 healthy. But it is almost certain that these bacilli are imprisoned within 
 
GENITAL TUBERCULOSIS. 66 I 
 
 the capillary blood-vessels, and wc have no authority for believing that they 
 can escape through the membranes into the secretions. Grawitz, to be sure, 
 proved the passage of the corpuscles and the mould germs (which are larger 
 than the bacilli) through the epithelium of the glomeruli of the normal 
 kidney ; still, reasoning by analogy has never any but a theoretical value. 
 Does the infection in these cases come through the semen, the saliva, or the 
 blood of a scratch ? A positive answer cannot be given. The puerperal 
 state has a large share in primary infection; this fact is admitted by all 
 writers. The genital tract is then open to the entrance of all morbid germs, 
 and obstetrical manoeuvres themselves may assist in their introduction. We 
 must, moreover, remember that infection of any kind, septicaemic or blennor- 
 rhagic, predisposes to the bacillary infection. We know how the puerperal 
 state predisposes to the first two infections ; they in their turn pave the way 
 for the third. General pathology describes these occurrences under the 
 name of mixed or combined infection or association of microbes. A case 
 has been reported in which there was beginning tuberculosis of the uterine 
 cavity with cancer of the cervix. 
 
 Secondary genital hiherculosis, that which is developed in the course of 
 tubercular degeneration of other organs, especially the lungs, is much more 
 frequent than primary tuberculosis. Before deciding that the infection is 
 primary, we must be quite sure that there is no tubercule at the apex of the 
 lungs, and we know how difficult this is to determine. This constitutes 
 the weak point of many so-called conclusive demonstrations which have been 
 published; another weak point is the too great readiness to assert the tuber- 
 culous nature of small indurations of the epididymis or the prostate gland 
 in persons supposed to be the source of the contamination ; in many cases 
 I think this is simply begging the question. 
 
 Tuberculosis of the genital organs, occurring in the course of phthisis, 
 although one with it from an etiological point of view, is divided into two 
 varieties from the standpoint of pathogenesis. In the great majority of 
 cases, no doubt, the genital tuberculosis is secondary and metastatic, accord- 
 ing to Cohnheim's expression, and the microbe has travelled in the blood or 
 the lymph. At other times infection is produced by another process, which 
 resembles that of the primary infection of non-tuberculous individuals; we 
 might almost call it primary-secondary infection. The patient then contam- 
 inates the genital organs through the intermediary of the external medium, 
 which she has herself infected. 
 
 When a patient in advanced phthisis develops ulcerations on the vagina, 
 they are probably caused by linen soiled with her diarrhoeal discharges or 
 sputum. Finally, the inoculation of tuberculosis may be accomplished by 
 continuity, by contact or propagation through the lymphatics, where there 
 is an intestinal tuberculosis which has infected the pelvic ganglia. Bacilli 
 in the peritoneal cavity may infect the fimbriated end of the Fallopian tube. 
 Pinner has shown that dust introduced into the peritoneal cavit)' is rapidly 
 
662 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 taken into the tube and conducted into the uterus ; it must be the same with 
 germs, and in fact Jans, in a case of pulmonary and intestinal phthisis, found 
 numerous bacilli in the sections of perfectly healthy tubes ; there is no 
 doubt that they came from the peritoneal cavity, to which they may have 
 travelled from the intestines. The tube may also be infected by the adhe- 
 sion of a loop of tuberculous intestine, just as a tuberculous recto-vaginal 
 fistula may follow perforation of the wall in cases of ulceration of the large 
 intestine. 
 
 The predilection shown by tubercular lesions for the tubes may be ac- 
 counted for in several ways ; their mucous lining, which has many folds and 
 is not subjected to the menstrual sloughing like that of the uterus, forms 
 an admirable resting-place for the morbific germs which reach it. The in- 
 tense vitality of the uterine mucous membrane, and its partial desquamation 
 at the monthly period, no doubt form its principal defence against the bacilli ; 
 as to the vagina, it is protected by its thick layer of stratified epithelium, 
 and perhaps also by the struggle for existence between the bacilli and the 
 numerous other germs to w'hich it always affords a lodging. 
 
 As Verneuil well observes, there is no comparison possible between the 
 conditions of proliferation of the bacillus, which is anaerobic and develops 
 best when deeply situated, and other microbes which, like the gonococcus, 
 attack the first part of the genital canal with which they come in contact. 
 
 Tuberculosis of the Vulva, Vagina, and Cervix.- — Pathological 
 Anatomy.- — Tuberculous ulceration of the vulva is a quite exceptional lesion. 
 M. Zweigbaum, who describes a case, finds only two in the annals of science. 
 His patient, thirty-two years of age, was phthisical, and succumbed to pul- 
 monary and intestinal tuberculosis ; the writer, however, believes that the 
 genital lesion was primary. There were also ulcerations upon the vagina 
 and cervix. Bacilli in abundance were found in a small flap excised during 
 life from the seat of the vulvar ulceration. 
 
 Tubercular lesions of the vagina or vaginal portion of the cervix are rare. 
 Daurios collected the records of twenty-four cases, but it must be acknowl- 
 edged that some of them are not above criticism ; external appearances or 
 presumptions drawn from various circumstances are not enough to charac- 
 terize the affection. A certain number of incontestable facts do, however, 
 exist. 
 
 \\'e need merely mention miliary tubercles, which may be met with in 
 acute tuberculosis. We must also take special note of the primary or sec- 
 ondary tuberculization of certain fistulae between the vagina and the hollow 
 organs in its neighborhood. 
 
 I found only one case of the isolated primary ulceration of the vagina 
 observed by Max Bierfreund. As a usual thing, this lesion coexists with 
 primar)' affections of the tubes or uterus. In a remarkable case of Virchow's 
 there was tuberculosis of the urinary tract, and the vagina was infected 
 through the urine. The rectum may also be the starting-point of infection. 
 
GENITAL TUBERCULOSIS. 
 
 663 
 
 Tuberculous ulcers of the vagina have perpendicular walls, which are 
 unecjual and irregular, and have a depressed yellowish-gray base, covered by 
 a characteristic caseous coating, Around the ulceration are frequently seen 
 
 b a 
 
 uil^fcv^'^l '%^t i 
 
 Fig. 450.— Tuberculosis of the Uterus, Vagina, and Tubes (Barnes), a, i, Tuberculous masses of the muco-is 
 membrane and uterine tissue ; c, tubes transformed into a pyo-salpinx ; </, ulcerations of the vagina. 
 
 small, yellow, opaque grain-like bodies, absolutely similar to those surround- 
 ing tubercular ulceration of the tongue so well described by Trelat. The 
 
 / — >i Jill 
 
 
 ^. 
 
 W '4- 
 
 Fig. 451.— Tubercle Bacilli. ./, Sputum of phthisis; there are two granular leucocytes and bacilli. B, Pure cul- 
 ture of Koch's bacilli. 
 
 Koch bacilli found upon the surface of these ulcerations or in the vaginal 
 secretions leave no doubt as to the nature of the lesion when they can be 
 demonstrated, which is not always the case. 
 
 These tuberculous ulcerations are temporarily cured by simple methods, 
 
664 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 as applications of the tincture of iodine or lactic acid, but they soon return, 
 for with a superficial affection of the cennxwe may find tuberculous follicles 
 invading the muscular layers. 
 
 Tiiberctiloiis fistulcz of the vagina, according to Daurios, may be vesico-, 
 urethro-, or recto-vaginal. They have nothing to distinguish them from 
 
 Fig. 452. — Tuberculosis of the Cervix Uteri. Section of the surface of the mucous membrane of the cavity 
 o{ the cervix (mag. 30 diam.). ?«, Mucus upon the mucous membrane and in the depressions between the folds of 
 the arbor vitse ; /, folds of the arbor vitse and villi covered with columnar epithelium; g; g; g^ glands and depressions 
 tween the folds of the arbor vita;; «, n, «, giant cells situated in the connective tissue of the mucous membrane, sur- 
 rounded by microscopic tubercular follicles (Cornil). 
 
 ordinary fistulas of the same region. The presence alone of tubercular folli- 
 cles or of the bacilli around their orifice will allow of a diagnosis of their 
 special character. 
 
 The observations of tubercles limited to the cervix are few in number, 
 yet one case is reported by A. Laboulbene. Another was described at length 
 by Cornil ; which I will quote as a remarkable type of this rare lesion. 
 
 The case was one in which Pcan had performed complete hysterectomy. 
 The clinical diagnosis of the lesion was uncertain. The appearance of the 
 
GENITAL TUBERCULOSIS. 
 
 665 
 
 hypertrophied cervix, which was indurated, covered with irregular vegeta- 
 tions, bathed in a thick, yellow, grumous fluid, suggested cancer, and on this 
 hypothesis Pcan removed the uterus. " The opening of the cendcal cavity 
 showed that the folds of the arbor vitas were ver)' pronounced, vegetating. 
 
 Fig. 453. — Ttberculosis of the Cervix Uteri. Same section as in the preceding figure, enlarged (mag. 100 
 ■diam.). in. Mucus ; j, surface of villi and papillje ; ^, mucous glands covered with columnar epithelium ; z\ vessel ; 
 r, c, c, giant cells in the inflamed connective tissue ; /, a papilla partly covered by its epithelial layer, whose connec- 
 tive tissue (Jc) is inflamed and shows numerous small cells (Cnrnil~). 
 
666 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 agglutinated together by sticky mucus, studded with opaque clots. A histo- 
 logical examination showed that it was a case of tuberculosis of the cervix 
 of the uterus limited to that part of the organ. This specimen is very in- 
 teresting because of its rarity, and ^he limitation of the tubercular process. 
 The preparations obtained by sections perpendicular to the surface of the 
 mucous membrane, made after hardening in alcohol, show, under a low 
 power (Fig. 452), that the folds of the arbor vit?2 have secondary villosities, 
 and are separated by deep depressions, into which open the utricular or com- 
 
 FiG. 454. — Tuberculosis of the Cervix Uteri. Same section as in the preceding figures, still further enlarged 
 (mag. 150 diam.). /, Papilloe and superficial vegetations ; i^ connective tissue containing many round cells ; e, fissure 
 in tuberculous tissue, in which may be seen epithelioid cells belonging to a tubercular follicle; c, giant cells ; «, epi- 
 thelial covering of a gland near a tubercular follicle, showing large epithelial cells ; o, epithelial layer formed of elon- 
 gated cells ; w, mucus contained in the gland ; />, greatly elongated epithelial cells of a gland ; ?', vessel (Cornil). 
 
 pound glands of the cervix. The surface of the mucous membrane, as well 
 as the depressions and glandular cavities, are lined and filled with mucus. 
 The glandular cavities are enlarged and the connective tissue is filled with 
 small cells. In this connective tissue on the surface of the mucosa, at the 
 top of the folds of the arbor vitae, in the superficial layers as well as deeper 
 in between the glands, we distinguish giant cells large enough to be seen 
 under this low power. The surface of the mucous membrane, the base of 
 its folds and of its villi, as well as the cavity of the glands, are covered with 
 elongated columnar cells. Under a higher power (Figs. 453 and 454) we 
 see between the glands and in the connective tissue of the mucous mem- 
 
(JEXITAI- TUBERCULOSIS. ^6^ 
 
 brane an infiltration of small cells, and characteristic giant cells, which seem 
 of themselves to form the whole tubercular lesion. It is true that the con- 
 nective tissue surrounding" them is richer in round cells than when in a 
 normal condition; still, it contains many of these physiologically, and endo- 
 metritis of the cervix will give rise to as many as tuberculosis. Moreover, 
 as a usual thing, around the giant cells there is no agglomeration of epithe- 
 lioid cells, nor any accumulation of cells undergoing granular or necrotic 
 degeneration, from which it follows that the tuberculous follicles observed in 
 this case, at an early stage of development, were not visible to the naked 
 eye." 
 
 Tuberculous growths developed on the surface of the mucous membrane 
 which covers the outer surface of the external os, that is to say, its vaginal 
 portion, which is covered with pavement epithelium, show in this case the 
 same appearance as tubercles of the pharyngeal mucous membrane; in fact, 
 tuberculous follicles are situated on the surface of the mucous chorion. We 
 can see giant cells in the midst of a collection of small cells ; these granula- 
 tions are, at their start and for a long time, covered by the normal layers of 
 stratified pavement epithelium. Below the mucous membrane, we find a 
 small number of tuberculous follicles, situated in the midst of crossed mus- 
 cular bundles. These muscular bundles are at a given point, separated by 
 embryonal connective tissue, which forms an island in the midst of which 
 are one or several giant cells surrounded by epithelioid cells. These tuber- 
 culous granulations are larger than those situated upon the ^surface of the 
 mucous membrane, where they are arranged in a manner quite similar to 
 those seen in the muscular coat of the intestines, or in the lingual muscle; 
 that is to say, they are developed in the interfascicular connective tissue, 
 and by their growth push away the muscular fibres at their periphery. Even 
 when we have to do with a tuberculous eruption which is slight, superficial, 
 and of recent date, and which has caused no ulceration nor loss of sub- 
 stance, we must expect to find the deeper layers of the mucous membrane 
 and even the muscular layer invaded by a few tuberculous granulations. 
 These, which are not numerous, follow the course of the vessels in the inter- 
 muscular connective-tissue spaces. 
 
 When even in recently developed tuberculosis a histological examination 
 shows this deep extension of the tubercular process, we may make up our 
 minds that the physician must do more than to treat it superficially by ap- 
 plications or even by curetting, and that oftentimes total removal of the 
 organ is the only method of destroying the affected portions of the uterus. 
 
 Cornil has vainly tried to discover the tubercle bacilli in this character- 
 istic lesion; he has found them neither in the giant cells, the follicles, nor 
 in the mucus filling the glands and covering the surface of the mucous mem- 
 brane. But the inoculation of guinea-pigs with virus from this lesion gives 
 rise to bacillary tuberculosis. 
 
 Winter, on the other hand, found bacilli in the giant cells, upon flaps of 
 
568 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 mucous membrane from the body of the uterus and from the cervix. The 
 case was that of a young tuberculous woman, upon whom Schroder had, five 
 and a half years previously, performed laparatomy, followed by the introduc- 
 tion of iodoform into the abdomen for tubercular peritonitis, with such suc- 
 cess that the ascites did not return, and the patient made a perfect recovery. 
 After a long respite, however, tuberculosis was manifested in the lungs and 
 the genital apparatus ; the tubes were affected as well as the uterus. 
 
 Tubercular lesions cause a marked cervical endometritis. These inflam- 
 matory troubles affect the surface epithelium, the glands, and the chorium. 
 
 By comparing the preceding description with that of the first stages of 
 tubal tuberculosis, which I shall describe later, borrowing from Cornil, we 
 shall see that there is the closest analogy between affections of the cavity of 
 the cervix and those of the tubal mucosa. We find the same disposition of 
 giant cells at the top of the folds and villi, or in the connective tissue of 
 these folds, the same inflammatory phenomena, the same mucous secretion, 
 and the same modification of epithelial cells. 
 
 It is very possible that the inoculation of tuberculosis may occur by 
 simple contact without erosion or solution of continuity of the cervical 
 mucous membrane. At least that is what happens in the guinea-pig, as 
 shown by Cornil and Dobroklonsky's experiments; but we have, of course, 
 to be cautious in applying such examples to the human species. The diag- 
 nosis of tuberculous ulceration of the vulva, vagina, or cervix can be defi- 
 nitely made only in cases in which there is a coexistent and advanced pulmo- 
 nary disease. The discovery of tuberculous follicles and, above all, of bacilli 
 upon a fragment obtained by curetting or excision is alone pathognomonic ; 
 still, a negative result would not justify us in asserting the absence of 
 tuberculosis. In the case of primary genital lesions, we run a great risk of 
 confounding them with some disease of more frequent occurrence. In a 
 case of beginning ulceration of the cervix, Pean believed that he was dealing 
 with cancer, but after hysterectomy it was recognized as tuberculosis. 
 
 The treatment should be palliative in cases of advanced phthisis, ener- 
 s:etic in all others. The ulcerations are to be cauterized with the red-hot 
 iron and dressed with iodoform. Fistulae are to be freely incised; we 
 should not hesitate to perform hysterectomy for even a circumscribed 
 ulceration of the cervix, providing that there is no doubt as to the 
 diagnosis. 
 
 Tuberculosis of the Uterus. — Pathological Anatomy. — In the uterus 
 the disease is usually secondary. Three varieties have rather theoretically 
 been pointed out : (ist) An acute miliary form, which is rare, which possesses 
 no clinical interest, and which is merely an epiphenomenon in the course of 
 a general systemic infection, with predominance of the general symptoms ; 
 (2d) an interstitial variety of slow development, essentially chronic, and 
 equally rare, the diagnosis of which is impossible, but which may be sud- 
 denly manifested by some grave accident, as rupture of the uterus by inter- 
 
GENITAL TUBERCULOSIS. 
 
 669 
 
 TV-^- 
 
 MT 
 
 PTT -- 
 
 ference with labor, etc., resulting from the degeneration of the uterine 
 tissue, and the impediment to the physiological functions of this organ 
 caused by the interstitial tubercles ; (3d) an ulcerous form, the most frequent 
 and most important. In this last variety, the lesions at first resemble those 
 of endometritis, plus giant cells containing bacilli. Later, the tuberculous 
 follicles become confluent and the whole mucous membrane is infiltrated 
 with a tissue formed of small cells ; it then undergoes complete caseous 
 degeneration and is yellow and opaque for about one-thirty-second to one- 
 sixteenth of an inch ; the muscular tissue beneath is often hypertrophied. 
 With the naked eye we are unable to 
 distinguish, either upon the surface of 
 the mucous membrane or in a section 
 of it, any tuberculous granulation at 
 all resembling the classical description 
 of miliary tuberculosis of serous mem- 
 branes. The cavity of the uterus is 
 often filled with a thick, curdy magma. 
 It may be transformed into a pus sac 
 by the obliteration of the os. 
 
 As a usual thing, the lesion is 
 sharply limited to the lower portion of 
 the cervix, the upper portion remain- 
 ing intact ; this limitation may be 
 marked by an ulceration which looks 
 as though it had been made with a 
 punch. Here is Cornil's description of 
 the changes shown by a microscopical 
 examination of a beautiful specimen of 
 uterine tuberculosis : 
 
 " Sections perpendicular to the sur- 
 face of the mucous membrane of the body of the uterus, after hardening 
 in alcohol, showed no vestige of normal structure; neither epithelium, nor 
 glands, nor blood-vessels w^ere recognizable. The whole cheesy surface, 
 under the microscope, was seen to consist of a homogeneous layer formed 
 of small necrosed cells, which were vitreous, and no longer susceptible of 
 staining; their nuclei were stained a faint rose color by picro-carmine. 
 The cells were separated by their fibrilte, which were crossed and inter- 
 laced in every direction. 
 
 " Beneath this necrotic mass was a zone containing small living cells and 
 occasional giant cells. Next came the muscular layer, in which were seen 
 a few tubercular follicles. A complete section of the uterine walls, includ- 
 ing the peritoneum, showed, therefore, an inner layer of cheesy infiltration 
 replacing the mucous membrane, a few tubercular follicles situated in the 
 muscular wall, and granulations in the peritoneum. In ten sections of this 
 
 Fig. 455. — Primary Tuberculosis of the Ute- 
 rus. C, Cervix ; J/T, tuberculous mucosa ; Pl'y 
 uterine wall ; .FC., fundus. 
 
670 
 
 CLINICAL AND OPERATIVE GYNECOLOGY 
 
 degenerated uterine mucous membrane I have been unable to find any tuber- 
 cle bacilli." 
 
 The caseous infiltration, accompanied by superficial mortification whose 
 detached products form the clots of cheesy pus which fill the body of the 
 uterus, is the most characteristic feature of chronic tuberculosis. Cornil 
 compares this lesion to one of the same nature found in the renal pelvis and 
 calyces, and the ureters. " This resemblance is obvious. In the body of 
 
 
 
 *r^-' I-,'.' ■'r'''W^ ■ 
 
 - ■■■•|.\ • :^'",^■•.->L■^^mi'"^:■ 
 
 T^Si^ 
 
 Fig. 456. — TiBERCULOsis of the Body of the Uterus. Four tubercular nodules surrounded by tissue formed 
 of an immense number of round embryonal cells, i, Tubercular nodule; 2, giant cells; 3, embryonal connective tissue; 
 4, glands more or less dilated and distorted ; 5, normal cylindrical epithelium ; 6, same, proliferated and becoming 
 squamous ; 7, mucus containing degenerating cells. 
 
 the uterus, as in the urinary tract, we have an opaque yellow thickening with 
 induration of a completely necrotic mucous membrane whose surface disinte- 
 grates into molecular fragments which become mixed with the pus and give 
 the clotted aspect to which we have referred. Under the microscope, there 
 is the same appearance ; the more or less thickened layer of cheesy matter 
 is homogeneous, and uniformly infiltrated with small cells, without any dis- 
 tinct tuberculous foci. We are scarcely able to distinguish here and there a 
 giant cell in the deeper and still living layers. In chronic tuberculosis, with 
 caseous infiltration of the ureters and renal pelvis, it is equally diflficult to 
 find one or two bacilli. From what we have said in regard to the pathologi- 
 cal anatomy of tubercular infection of the tubes and uterus, it follows that 
 we do not find, in cither a recent or a chronic state, tuberculous granulations 
 which are perceptible to the naked eye, or even with the microscope, which 
 
GENITAL TUBERCULOSIS. 
 
 671 
 
 resemble the classical description of tubercles. As a matter of fact, granu- 
 lation of serous membranes has been taken as the type, and this type is but 
 rarely met with in affections of the genital mucous membranes." 
 
 We should not be surprised at the infrequency with which bacilli are 
 
 Fig. 457. — Tuberculosis of the Body of the Uterus. From a photograph, i, Submucous connective tissue 
 with many cells ; 2, embryonal growths appearing at surface of mucous membrane ; 3, same with cells partly dissoci- 
 ated and embedded in mucus ; 4, cylindrical-celled epithelium of uterine mucosa which has lost its ciliae; 5, epithelium 
 from altered glands surrounded by embryonal cells ; 6, dilated and distorted glands ; 7, large giant cells with many 
 nuclei ; 8, smaller cells ; 9, peripheral epithelioid cells ; 10, mucus. 
 
 found in uterine tuberculosis. They are certainly present, but, as in the 
 majority of cases of local tuberculosis (tubercles of the testicle, lupus, etc.), 
 they are few in number, probably because the lesions are of long standing. 
 Doyen lately found some at the autopsy of a young woman who had died of 
 puerperal fever, who also had tubercles of the uterine mucous membrane 
 and muscular layer. 
 
672 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 The symptoms at the onset are those of ordinary endometritis, with a 
 more pronounced increase of size of the organ; this affection, which is per- 
 haps more frequent than is usually supposed, may often be unperceived. 
 The cheesy nature of the secretions and the coexistence of other lesions in 
 the tubes and in the lungs should make us search for the granulations and 
 bacilli which are alone characteristic of the disease. Yet the histological 
 diagnosis presents many difficulties; we must not expect to find in the 
 uterine mucous membrane tuberculous follicles similar to those met with in 
 the serous membranes. Moreover, the elemental granulation of Virchow, 
 
 .0. 
 
 
 Fig. 458. — Tuberculosis of the Body of the Uterus. Partially softened tubercular nodule whose central 
 cells have disappeared, i. Connective tissue infiltrated with embryonal cells ; 2, ovoid epithelial cells at periphery of 
 nodule ; 3, polyhedral central cells ; 4, giant cells ; 5, gland whose epithelium has become stratified squamous ; 6, free 
 epithelioid cell ; 7, smaller leucocyte. 
 
 which is the only constant lesion in tuberculosis, may be difficult to differ- 
 entiate from a stroma very rich in the same elements and sometimes entirely 
 composed of them ; finally, the presence of the giant cell, which certain 
 writers claim is to be found in interstitial endometritis, is not enough to 
 warrant a positive diagnosis. According to Paul Petit, the tuberculous 
 nature of endometritis may be absolutely determined if the specimens of 
 scrapings of the del?ris possess the following characteristics : Interstitial cells 
 which are necrosed or atrophied in a diffused manner or in well-defined 
 lines; giant cells in greater or less number; embryonal nodules detached 
 from the stroma and apparently developed around the vessels whose lumina 
 may or may not be preserved ; numerous flexible and dilated glands, lined 
 with epithelial cells which are either considerably elongated or which have 
 undergone an epithelioid transformation. In order to clear the diagnosis, 
 we should always perform an exploratory curetting, which will prevent con- 
 fusion with cancer of the body of the uterus. 
 
GENITAL TUBERCULOSIS. 
 
 673 
 
 The search for bacilli in tlie sections demands much time, and is often 
 fruitless in spite of care and experience. The sections should be very thin 
 and not large. The various modifications of Ehrlich's method may be tried, 
 for a description of which see the special pamphlets on the subject, or the 
 following process maybe applied : The section is immersed for half a minute 
 in picro-carmine, and one minute in a seventy-per-cent solution of alcohol in 
 which there is 0.75 per cent of hydrochloric acid, or it may be left for 
 twenty-four hours in Ehrlich's solution of methyl violet, then for a few sec- 
 onds in an alkaline solution of one-per-cent nitric acid; it is then dried and 
 mounted in balsam. If the microscopical examination is without result, ac- 
 cording to Cornil, we should sow some of the uterine fluid in a tube of 
 
 Fig. 459. — Primary Tuberculosis oi- Tubes and Ovaries. U, Posterior surface of the uterus; in tiie poste- 
 rior lip of tlie cervix are two small mucous cysts • O.d, right ovary enclosing softened caseous masses which have been 
 evacuated by the tearing apart of the adhesions ; 7", right tube, which is dilated and adherent, and forms part of a 
 tuberculous pelvic abscess which is limited by the intestinal loop of the ileum. The left ovary and tube are tuberculous, 
 as is the uterine mucous membrane There was tuberculosis (secondary?) of the right lung (Kotschau). 
 
 glycerin jelly, or, better yet, inoculate it into the peritoneal cavity of a 
 guinea-pig. According to Daurios, after twelve days the animal may be 
 opened and the result of the experiment noted. 
 
 Treatment. — If the condition of the lungs permit of a radical operation, 
 vaginal hysterectomy should be performed, instead of causing useless delay 
 by curetting, which is usually inefficient. 
 
 Tuberculosis of the Ovaries and Tubes. — Pathologieal Anatomy. — 
 The ovaries are rarely implicated alone; a few such cases are, however, 
 given by Klob and Spencer Wells; recently Guillemeau has collected the 
 statistics of thirteen cases, in four of which the lesions were bilateral. The 
 tube corresponding to the diseased ovary nearly always has tuberculous 
 lesions. The right ovary appears to be affected more often than the left, in 
 the proportion of five to two. Lesions of the tubes are, on the contrary, very 
 frequent. Terrillon has seen simultaneous lesions of the tubes and ovaries 
 three times out of six. Tubal lesions have also been noted in the greater 
 43 
 
674 
 
 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 number of cases of tuberculous endometritis, and they no doubt form the 
 original source of the infection. With the naked eye we can perceive 
 lesions that greatly resemble those of suppurating salpingitis, with or with- 
 out cystic dilatation. The pyo-salpinx may be extensive, and possess a 
 
 Co- uJ. 
 
 CI 
 
 
 Nt 
 
 -y — Co 
 
 
 Fig. 460. — TxTBERCULOSis of the Fallopian Tubes. Section of wall in pyo-salpinx (mag. 150 diam.). (^o- S^-. 
 glandular layer: remains of the mucous coat, in which are seen dilated glands ; Cg.^ giant cell in the centre of a tu- 
 bercle formed by a collection of epithelioid cells ; Nt, tubercular nodules with giant cells ; A , transverse section of an 
 arteriole; C/, section of glandular tubes; C,r, internal layer of granulations; .1/, external muscular layer (Munster 
 and P. Orthmann). 
 
 capacity of two quarts. The formation uf adhesions and its diffusion toward 
 neighboring parts transform it into pelvic abscess (Fig. 459)- 
 
 Of however recent date may be the lesion, it soon invades the perito- 
 neum, and causes the formation of false membranes, and the serous encysted 
 effusions of perimetro-salpingitis. P'ernet has even found progressive inva- 
 sion of the pleura, and the production of subacute peritoneo-pleural tubercu- 
 losis whose starting-point is a primary lesion of the genital organs. The 
 infection is carried through the lymphatics, which Hegar once found to con- 
 
GENITAL TUBERCULOSIS. 
 
 675 
 
 tain cheesy matter. The lymphatic communications between the pleura 
 and the peritoneum through the diaphragm account for the infection. The 
 mesenteric glands are often degenerated. 
 
 The tubercles of the tube, whether primary or secondary to granulations 
 in the peritoneal cavity, are recognizable to the naked eye by the increased 
 size of the organ, by the semi-transparent or yellow granulations upon its 
 surface or in its muscular walls, and by its contents. Upon opening the 
 tube longitudinally, we can see that it is dilated, that the thickened walls 
 have tuberculous spots usually visible to the naked eye, and that it contains 
 fluid which is more or less thick, puriform, grumous, and caseous, and whose 
 characteristics are the same as those of tuberculosis of the body of the uterus 
 (Fig. 460). Transverse sections obtained after hardening in alcohol show a 
 
 Fig. 461. — Large Giant Cell (Mag. 300 diam.). i, Granular masses ; 2, irregular nuclei. 
 
 thickening of the wall and hypertrophied and branching vegetations. On the 
 internal surface and in the substance of these vegetations and villi, we often 
 find numerous giant cells, with several ovoid nuclei, which may take on the 
 form of bent, sinuous, or branched rods, and sometimes groups of crystals 
 (Fig. 461). The free surface of the villi and the folds is almost entirely 
 covered by columnar ciliated epithelium. Here and there these cells have 
 undergone mucoid or granular transformation, or they may be desquamated 
 and free in the mucus, associated with a few pus corpuscles. Staining with 
 rubine to find the bacilli is not always successful. Besides the giant cells 
 and small tuberculous follicles developed in the vegetations, we may find in 
 the muscular walls of the tube some follicles, of a greater or less size, con- 
 taining giant cells. When the lesion is of long standing, sections of the 
 purulent sac formed by the tube will show a smooth and continuous layer of 
 embryonal tissue on the internal surface. Below it is fibrous tissue dotted 
 with perfectly distinct tuberculous follicles, many of which contain giant 
 cells with several nuclei. The walls of the tube are infiltrated with small 
 cells, and have also a few tuberculous follicles. In the layer of fibrous 
 tissue intermediate between the wall and the embryonal layer, we see lines 
 
6/6 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 of epithelial cells which come from the epithelium of the mucous lining 
 of the tube ; they are in the form of tubular glands. At their periphery we 
 see an irregular paling of columnar epithelium. At the centre are small, 
 pale, rounded or ovoid cells, stained yellow by picro-carmine and whose 
 nuclei are no longer visible. It is a mass of cells which have become ne- 
 crotic, undergone mucoid degeneration, and become agglutinated together. 
 This lesion has been called coagulation necrosis. 
 
 Koch's bacilli have often been looked for in vain in cases of salpingitis 
 which w^ere certainly tuberculous ; but they have sometimes been found, 
 although in small quantity, by Orthmann, Werth, etc. The symptoms are 
 the same as those of non-tubercular salpingitis, and a probable diagnosis is 
 usually reached by the exclusion of other causes, a study of the famaly his- 
 tory, and of any signs of the disease manifested in the lungs. The nodular 
 character of the tubal tumor and the frequency of acute attacks of pelvic peri- 
 tonitis have been considered distinctive of the disease, but they are really 
 valueless, as they are met with in all cases of pyo-salpinx. The treatment 
 must be varied according to whether the lungs are or are not involved. 
 
 If the lungs are sound, the attempt should be made to remove the tubes 
 and ovaries by laparatomy. If the patient is phthisical, we shall have to 
 limit ourselves to palliative measures, among w^hich may be mentioned open- 
 ing of the focus of disease through the vagina or the abdomen, follow^ed by 
 careful disinfection with a tamponade of iodoform gauze. 
 
 If pulmonary lesions exist, but are not especially severe, the surgeon 
 must be guided in his procedures by the same considerations which would 
 guide him in the treatment of local tuberculosis in'any other situation. 
 
 Hegar advises interference in primary tuberculosis as soon as a diag- 
 nosis is reached, especially when it is probable that the process will not 
 remain sharply limited. In secondary tuberculosis surgical interference will 
 be indicated only if the pulmonary lesion remain stationary, while the geni- 
 tal lesion tends to increase. Tubercular peritonitis is not a contra-indication ; 
 on the contrar}^, laparatomy has been known to have a good effect upon it. 
 In 1886 Hegar had one death out of six operations. The remote effects 
 seem to have been satisfactory. One patient, who had been operated upon 
 three years previously, w^as in good condition, although she had had a re- 
 lapse; another suffered from a severe attack of pleurisy four months after 
 the operation, but was completely restored to health, and remained in good 
 condition for a year. In the case of the other patients, sufficient time had 
 not elapsed to allow of a definite report of the results. Terrillon has also 
 had several encouraging results. 
 
 [Tubercular Peritonitis.* — Anatomically the classifications which 
 have been made of tubercular peritonitis are not altogether satisfactory. It 
 
 * These notes on tubercular peritonitis are a rhiunc of a most excellent paper by Osier in the 
 Joans Hopkins Hospital Bulletin for tSgo. B. H. W. 
 
PERITONEAL TUBERCULOSIS. 6^*/ 
 
 is customary, and correct, to exclude the cases of scattered miliary tubercles 
 in the diffuse infective disease, and also those cases in which the peritoneal 
 surface of tubercular ulcers is alone involved. Practically, the great differ- 
 ences which we see post mortem in this condition result from the situation 
 of, the rate of growth of, and the degree of inflammation accompanying the 
 tubercles, and whether there is much or little exudation — serous, purulent, 
 or hemorrhagic. The anatomical basis in all cases is essentially the same, 
 and the variations which we meet, though distinct and marked, are scarcely 
 sufficient to warrant the elaborate subdivisions of this disease made by cer- 
 tain writers. In reviewing a number of post mortems in this disease we 
 find that they fall naturally into the following categories: i. Acute miliary 
 tuberciLlosis, characterized by a sudden onset, a rapid development, and a 
 serous or sero-sanguineous exudation. 2. CJironic caseous and ulcerating 
 tuberculosis, characterized by larger tuberculous growths, which tend to 
 caseate and ulcerate, leading often to perforations between the intestinal 
 coils, and a purulent or sero-purulent exudate, often sacculated. 3. CJirojiic 
 fibro-tuberculosis, in which the process may from the outset be subacute, or 
 may represent the final result of the miliary form. There is little or no 
 exudation and the tubercles are hard and pigmented. There exists the 
 closest analogy between tubercle as we see it on the peritoneum and as it 
 occurs in the lung — the fresh miliary eruption, the caseous, ulcerating 
 masses, and the chronic, fibroid, pigmented nodules may be studied with 
 equal facility in either structure. A few practical points in the morbid 
 anatomy may be mentioned. In many cases the process is entirely local. 
 Thus in five of seventeen cases the condition was confined to the peritoneum. 
 In from thirty to forty per cent of the cases in woman the Fallopian tubes are 
 found affected. The process is commonly confined to the distal ends, and 
 may be primary — which is usual — or is secondary to the peritoneal involve- 
 ment. A point, worthy of attention on account of its importance as an aid 
 in diagnosis, is the frequent involvement of the pleura. It is often only a 
 dry pleurisy, occurring most frequently without pulmonary action, and due 
 to direct extension through the diaphragm. The pericardium is also liable 
 in these cases to be the seat of an adhesive tubercular inflammation. 
 Tubercular peritonitis occurs at all periods of life. It is common in chil- 
 dren, in whom it is often associated with intestinal and mesenteric disease. 
 It is most common between the ages of twenty and forty. In old age it is 
 rare, but it may occur even in advanced life. The disease is certainly more 
 prevalent among females. It is stated that the disease is more common in 
 the negro than in the white race. 
 
 Clinically it is extremely difficult to make a satisfactory classification of 
 the cases of tubercular peritonitis, and we will here only refer to certain 
 special features in the mode of onset and to peculiar symptoms, not, as a rule, 
 very fully discussed. The process may be completely latent, and the erup- 
 tion take place so slowly and so painlessly that the patient may not have 
 
6/8 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 presented a single symptom of abdominal disease. The condition has thus 
 been met with in the operation for hernia, and more frequently still in asso- 
 ciation with ovarian tumor. The onset of the symptoms may be sudden, so 
 that the diagnosis of enteritis or hernia may be made. This suddenness of 
 onset is very deceptive and usually leads to the diagnosis of a simple acute 
 peritonitis. The disease may set in with "^xowoMnQ.&di gastric symptoms -dccA 
 simulate ulcer or cancer. A more common mistake is confounding tuber- 
 cular peritonitis with typhoid fever, which it may simulate very closely. 
 Ascites is a frequent symptom, but it does not, as a rule, become very 
 marked; thus Biat, in an analysis of eighty-one observations, found only 
 thirteen instances with extensive ascites. In the acute miliary tuberculosis 
 with rapid exudation the effusion may be bloody, but this is not so common 
 as in cancer, though the opposite statement is usually made. It has fre- 
 quently been mistaken for the effusion in connection with cirrhosis, of 
 which, indeed, it may sometimes be a complication. It is somewhat remark- 
 able with what frequency acute tuberculosis of the serous membranes occurs 
 in this disease. Moroux and Wagner have called attention to the involve- 
 ment of the peritoneum, which is not so often affected as the pleura. Acute 
 tubercular pleurisy may occur as a final complication in cirrhosis. Cases 
 with extreme tympanites are also common. This condition, the result of 
 impairment of the tone of the muscular coats, is a very constant feature in 
 all forms of the disease. Many writers refer to the fact that the tempera- 
 ture in tubercular peritonitis may be normal, but it is not generally known 
 that the temperature may be subnormal for weeks or months at a time. In 
 the cases of fibrous tubercle without much inflammatory process or effusion, 
 there is, as a rule, very slight fever and subnormal temperatures are common. 
 Increase in skin pigment, particularly on the face, is an occasional symptom 
 in tuberculosis of the peritoneum. 
 
 To the occurrence of tumor-like formations in tubercular peritonitis we 
 are indebted for much of the increase in our knowledge on this subject, as 
 the errors in diagnosis have shown the frequency with which these tumors 
 occur and also how amenable the condition is to surgical treatment. The 
 question has not been fully considered by any recent writer, yet its importance 
 may be gathered from the fact that in ninety-six cases in which laparatomy 
 was performed, in thirty-seven the diagnosis was tumor, ovarian or otherwise. 
 We may recognize anatomically, and possibly clinically, four groups of cases in 
 which with tubercular peritonitis tumors occur and may be felt on examina- 
 tion : First, omental tumor ; second, sacculated exudation ; third, retracted 
 and thickened intestinal coils ; fourth, mesenteric glands. 
 
 (a) Omental Tumors. — On the thin and delicate layers of the epiploon 
 tubercles will be found if present at all on the peritoneum, but they do not 
 often form large masses which can be felt through the abdominal wall. The 
 omental tumor in connection with this form of peritonitis results from a slow 
 tubercular process which gradually puckers and rolls the membrane, until it 
 
PERITONEAL TUBERCULOSIS. 679 
 
 forms an elongated, firm mass attached to the transverse colon lying athwart 
 the upper part of the abdomen. This condition, perfectly well recognized 
 by clinicians, is in many cases peculiar and distinctive. These cases often 
 occur without much exudation, and result from a slow, latent process which 
 may run its course without exciting serious symptoms. To diagnose this 
 condition from cancer is often difficult. A pronounced tubercular history, 
 subnormal temperatures- — which are not so common in cancer, and which 
 are specially likely to occur in these more chronic cases of tuberculosis — 
 and the existence of disease in the pleurae or lungs, are suggestive in- 
 dications. Fagge calls attention to the existence of a resonant per 
 cussion note above the mass, which sometimes feels as if attached to, 
 and mdeed has been mistaken for, the edge of the liver, roughened and 
 nodular. 
 
 {b) Sacculated Exudations. — These are the most common, as they are 
 undoubtedly the most puzzling, of the abdominal tumors produced by tuber- 
 culous disease; so puzzling, indeed, that, as a long list of cases shows in 
 which the operation for ovariotomy has been performed, the very elect among 
 gynaecologists may be deceived. In these cases a sero-fibrinous or puru 
 lent exudation is confined and limited by adhesions formed between the in- 
 testinal coils, the parietal peritoneum, the mesentery, and the abdominal or 
 the pelvic organs. What is felt as tumor may be entirely fluid, or it may 
 have an irregular nodular character from the presence between the coils of 
 large caseous masses. These sacculated tumors, due to tuberculosis, may, 
 as in other forms of peritonitis, be met with in the upper, middle, or lower 
 abdominal regions. In the upper zone, which includes the stomach, liver, 
 and spleen, encysted collections of fluid are extremely common. Thus we 
 have the localized peritonitis associated with gall-bladder disease, and with 
 various affections of the stomach and of the liver and spleen. The effusion 
 in these cases maybe limited entirely to the upper region of the peritoneum. 
 In tubercular disease by far the most common sacculated exudation occurs 
 here with peri-hepatitis over the surface of an enlarged liver, and may lead 
 to the suspicion of a gall-bladder tumor projecting below the edge of the 
 ribs. These encysted peritoneal tumors are less common in the upper ab- 
 dominal region. In the middle zone, which includes the peritoneal cavity 
 from the level of the transverse meso-colon to the false pelvis, and which 
 embraces the omentum and intestine, these encysted tumors are much more 
 comm(©i, and, as the record of operations shows, are very frequently mis- 
 taken for ovarian tumor. They fall into two divisions, those in which the 
 entire anterior portion of the peritoneal cavity is occupied by a large collec- 
 tion of fluid, and those in which a more limited sacculated exudation is found 
 on one or the other side of the abdomen or in the middle line. Lastly, there 
 are the sacculated exudations within the pelvis proper, in which case the 
 disease almost always starts from the Fallopian tubes. The tubercular proc- 
 ess may be exclusively upon the parietal peritoneum, and the coils of intes- 
 
680 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 tines glued to the lateral walls may shut off completely the pelvic from the 
 general cavity. 
 
 [c) Retracted and Thickened Intestinal Coils. — The matting together and 
 thickening of several coils of the intestines may form a mass of great dis- 
 tinctness and even lead to the diagnosis of a solid tumor. This is most fre- 
 quently met with in the csecal region. They are not necessarily fixed 
 tumors, but may be freely movable. The coils may not form a uniform 
 tumor, but there may be a separation into three or four irregular masses, 
 divided by fissures and covered with thick lymph. It is possible for the coil 
 to form a resonant tumor. 
 
 {d) Mesente7'ic Glands. — Less common, perhaps, in tubercular peritonitis 
 than any one of the previous conditions is the presence of tumors caused by 
 enlarged glands. So far as can be ascertained, in none of the cases of lapa- 
 ratomy did they lead to an error in diagnosis. Cases are, however, on record 
 in which extensive tuberculosis of these glands formed palpable tumors asso- 
 ciated with ascites. A question of special interest relates to the association 
 of mesenteric-gland disease with tubercular peritonitis. Gairdner has urged 
 that in a large proportion of the cases of so-called tabes mesenterica, in 
 which there is enlargement and hardness of the abdomen — the condition 
 which the French speak of as can-eau — there is involvement of the peri- 
 toneum. Jacobi has recently expressed the same opinion. 
 
 The diagnosis of these peritoneal tubercular tumors offers difficulties 
 which vary greatly in the different varieties. The omental tumor is proba- 
 bly a less frequent source of error than any other, but as an identically sim- 
 ilar condition may exist in cancer, it is not always possible, unless there is 
 marked tubercular disease elsewhere, to determine the precise nature ; and, 
 as we have seen, even an acknowledged expert like Gairdner may be led 
 astray. The lumpy, nodular character of the mesenteric tumors gives to 
 them also a certain degree of distinctness. The mistake is sometimes made 
 of confounding the large caseous nodules situated between the intestinal 
 coils with the mesenteric glands. The possibility of their recognition de- 
 pends very much on the degree of distention of the bowels, as extreme tym- 
 panites may completely cloak a very large tumor of this character. The 
 tumors formed by contracted and thickened intestinal coils usually lead to 
 error in diagnosis. The recognition of the saccular exudation, more partic- 
 ularly its differentiation from cystic ovarian disease, offers really serious 
 difficulties, the extent of which may best be appreciated by the fact that of 
 ninety-six cases of laparatomy in tubercular peritonitis, in not less than 
 thirty ovarian disease was supposed to be present. Such being the case it 
 may be worth while to discuss briefly certain diagnostic details. There is 
 no single criterion which enables us to say in a given case that the condition 
 is one of encysted peritonitis, nor, indeed, is there any special group of 
 symptoms which can be regarded as distinctive. The points most sugges- 
 tive, in individual cases, of tubercular trouble are: 
 
PERITONEAL TUBERCULOSIS. 68 I 
 
 First. The history of the patient and of the disease. Tubercular ante- 
 cedents are common. Evidence may exist of old tubercular lesions. Grad- 
 ual failure in health and strength may perhaps be taken into consideration, 
 but it must not be forgotten that in many of the cases the patients have 
 been robust and well nourished. The mode of onset is in the majority of 
 instances gradual, but this is such a variable factor that it is not of very 
 much value ; perhaps the most which can be said on this point is that there 
 can usually be elicited a history of obscure abdominal pains, irregular febrile 
 attacks, and altogether a greater degree of gastro-intestinal disturbance 
 than generally accompanies the slow evolution of ovarian cysts. If the case 
 has been under observation for some time, the fever record should be of 
 great assistance, as high or very lov/ temperatures more commonly occur in 
 this condition, though it is true that in inflamed and suppurating ovarian 
 cysts there may be fever of a hectic type. 
 
 Second. The local physical signs. If possible, these are more deceptive 
 than the history and symptoms. The question is not so much between the 
 characters of a sacculated exudation and ascites, but it is the extremely nice 
 one of discriminating between two varieties of sacculated effusion, ovarian 
 and peritoneal. In typical cases the physical signs have conformed in every 
 particular to those of cystic ovarian disease. There are a few indications 
 which may at times be useful ; thus when the sacculated tumor is limited 
 and small, the outlines may not be so definite and clear as in ovarian disease. 
 This is a point referred to by several writers. The position and form may 
 be variable, owing to alterations in the calibre of the surrounding intestinal 
 coils of which in part the walls are composed. At the periphery of the 
 tumor irregular, nodular bodies — cheesy masses — may sometimes be felt, 
 which in several instances have led to the diagnosis of malignant disease. 
 Depression of the vaginal wall is not a safe indication one way or the other, 
 as the condition may be present in ovarian tumor as well as in encysted 
 peritonitis. 
 
 Third. In every case the condition of the tubes and of the lungs and 
 pleura should be most thoroughly examined. The association of a tubal 
 tumor with an ill-defined, anomalous mass in the abdominal cavity should 
 arouse suspicion at once. So also the evidence of involvement of the pleura 
 or of the apex of one lung. 
 
 Curability. — Until within the past few years, the general opinion in the 
 profession has been that this disease is incurable ; and in looking over the 
 text-books of medicine, with but few exceptions the prognosis is given as 
 " always fatal." Evidence, however, has been rapidly accumulating to show 
 that in a considerable number of cases recovery in this disease is possible, 
 either spontaneously or after operative interference. 
 
 {a) Spontaneous Qtre. — There is no inherent improbability why tubercles 
 on the peritoneum should not undergo involution as they do elsewhere. 
 Anatomically the peritoneal growth bears in its evolution a close analogy to 
 
682 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 the pulmonary, and this is still further borne out by the retrograde changes 
 through which it passes. Just as the aggregations of miliary nodules in the 
 lung may undergo the changes which we speak of as healing, becoming hard 
 and fibroid, so in the peritoneum the tubercle tends in many cases to become 
 sclerotic, and passes into a condition in which it is practically harmless. 
 This beneficial result is more likely to be seen in cases belonging to the 
 group in which, from the outset, the process is subacute and not associated 
 with much exudation ; but there are cases on record in which recovery has 
 followed even after extensive effusion. The anatomical changes are, in 
 brief, these : Fibroid and pigmentary induration of the tubercles, absorption 
 of the exudate, transformation of the fibrinous material into connective tis- 
 sue, with the union to a greater or lesser extent of the intestinal coils and 
 of the peritoneal surfaces with each other. The cases which are most likely 
 to terminate favorably are those in which the infection is limited to the peri- 
 toneum, the inflammation of moderate grade, and the effusion slight in 
 amount and sero-fibrinous. An adhesive inflammation, as it is termed, may 
 accompany the process from the outset, and a gradual sclerosis may over- 
 take the tubercles and render them harmless. Caseation and ulceration, witli 
 a sero-purulent exudation, preclude the possibility of spontaneous cure. Ex- 
 tension to the pleura and lungs, and the coexistence of intestinal or tubal 
 disease, are conditions equally unfavorable to permanent recovery. 
 
 {b) Cure by Operation.— T\\q. beneficial effects which, in a number of 
 cases, followed the opening of the peritoneum when a sacculated exudation 
 was mistaken for ovarian tumor, encouraged surgeons to perform laparatomy 
 in ordinary cases of tubercular peritonitis accompanied with much effusion. 
 The questions remain for consideration. What cases are most suitable for 
 operation, and how can we explain the beneficial influence.'' Undoubtedly 
 cases with fresh eruption and considerable effusion, whether free or saccu- 
 lated, offer the best chance of recovery, as the disease is more likely to be 
 primary in the peritoneum, the general condition is usually better, and the 
 subsequent chances of general infection are much slighter. When the 
 Fallopian tubes are extensively diseased, and when the process has ex- 
 tended through the diaphragm to the pleura, the condition is of course less 
 favorable. The existence of marked omental tumor, in the form of a trans- 
 verse ridge, need not necessarily be an objection to operation, as spontane- 
 ous resolution of such masses may take place. In cases, then, with some- 
 what sudden onset, rapid development of ascites with fever of moderate 
 grade, we may be most sanguine of success. In the class of cases with ex- 
 tensive caseous masses in the peritoneum and a purulent exudation, the out- 
 look is necessarily less hopeful ; but even in such instances, particularly 
 when the exudation is sacculated, laparatomy may be advised as a palliative 
 measure. In the chronic adhesive form, no benefit can be expected to fol- 
 low the operation, which can only be intended to remove an omental mass 
 or to open a sacculated effusion. In the majority of the cases of this group 
 
PERITONEAL TUBERCULOSIS. 6S3 
 
 nature is effecting a cure in which she scarcely needs outside assistance; 
 and the danger lies not so much in the peritoneal disease as in the risk of 
 pulmonary infection. It is difficult to explain the beneficial results of the 
 operation. It is interesting to note that not alone in tubercular peritonitis, 
 but in other forms with effusion, the simple opening and drainage of the 
 cavity has seemed to exercise a very beneficial effect on the subsequent 
 course of the disease. Mr. Lawson Tait comments at some length on this 
 remarkable tendency of abdominal neoplasms to undergo retrograde changes 
 after an exploratory incision. His statements on this point are most inter- 
 esting and deserve the careful consideration of physicians as well as sur- 
 geons. He says that he has seen tumors disappear after laparatomy in cases 
 of disease of the liver, spleen, and head of the pancreas. He does not spe- 
 cifically mention cancer of the peritoneum. His remarks deserve quoting, 
 as they bear directly upon this subject : " The cases are far too numerous, 
 and the results indicate sequence far too clearly, for us to dismiss the phe- 
 nomena as a mere coincidence ; nor can we accept the explanation of subse- 
 quent medical treatment as having brought about this much-desired ending. 
 I am satisfied that the mere opening of the peritoneal cavity has a direct 
 influence in setting up the process of absorption of the tumor, and my con- 
 viction in this direction has increased my confidence in the principle of 
 exploration. That some emphatic physiological change is at once set up by 
 opening the peritoneal cavity is clearly indicated by the uniform onset of 
 a most distressing thirst, which lasts for days, and is not seen so markedly 
 after any other operation known to me. Let the incision in the abdominal 
 wall be made down to the peritoneum, but let the serous cavity remain un- 
 opened, and this thirst is not marked. But let the peritoneum be opened 
 but a finger's breadth and the result is marked. That a therapeutic change 
 is effected in the peritoneum itself by the mere opening of the cavity is now 
 universally recognized in the treatment of what we call tubercular peritonitis 
 by abdominal section. I have now had a large experience on this point, and 
 can say positively that we can cure permanently and speedily cases that 
 have gone even as far as suppuration, by opening and cleansing. But in the 
 bad cases in all probability the cleansing is never complete, no matter how 
 much time and care are spent on it. And in the non-purulent cases I very 
 often do no cleansing at all, but merely empty out the serum and put in a 
 drainage pipe. Yet the great majority of these cases are cured by these 
 simple means." Evidently, in whatever way brought about, the opening 
 and drainage of the peritoneum favor in a remarkable way the regression of 
 the tubercles ; and it does more than this, for with an improvement in the 
 local symptoms the fever reduces and the general condition of the patient 
 rapidly improves. It must not be forgotten that in certain cases the bacilli 
 are very difficult to find in peritoneal tuberculosis, though they may be most 
 abundant even when the tubercles are very hard and fibroid. The impor- 
 tant practical point is the relief and cure of these cases by laparatomy, and 
 
684 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 the surgeons may well leave to the pathologist the minor question of deter- 
 mining the nature of the chronic peritonitis. Among the conclusions which 
 follow from the foregoing considerations are : 
 
 I St. That tubercular peritonitis is often a latent affection, localized in 
 the peritoneum, which may even run its course without inducing special 
 symptoms. 
 
 2d. That, as in other local tubercular processes, there is in this a natural 
 tendency to healing, which takes place more frequently than has hitherto 
 been supposed. 
 
 3d. That statistical evidence shows laparatomy to be in many cases a 
 palliative, and in a certain number a curative, measure.] 
 
CHAPTER XXXIII. 
 
 INTRA- AND EXTRA-PERITONEAL PELVIC H^EMATOCELE. 
 
 Definition and Classificatioji. — A mere effusion of blood, intra-pelvic hem- 
 orrhage, should not be confounded with haematocele. The term, which has 
 both an anatomical and a clinical significance, should be reserved for en- 
 cysted collections of blood. As I shall show later, such a condition occurs 
 only under special pathogenic circumstances which impart a durable charac- 
 ter to the lesion, and give it a distinct morbid entity. The effused blood 
 may have one of two situations: ist. It may be within the peritoneum and 
 in that case usually accumulates behind the uterus; this is intra-peritoneal 
 haematocele; its clinical history was the first to be distinctly outlined. 2d. 
 The blood may spread below the serous membrane, w^ithin the broad liga- 
 ments, and into the peri-vaginal cellular tissue; it here forms a veritable 
 thrombus, and the earlier writers described it by that name. The name of 
 extra-peritoneal haematocele is less appropriate than that of haematoma, but 
 it has been fixed by custom. 
 
 Intra-peritoneal Pelvic H.ematocele. — Synonyms. — Retro-uterine, 
 peri-uterine, pelvic, peri-hysteric, uterine, circum-uterine haematocele are 
 some of the various names which have been given to the affection. I 
 have adopted the name of pelvic hsematocele, which is the most comprehen- 
 sive; but it must be acknowledged that the name retro-uterine haematocele 
 applies best to the clinical variety most frequently met with. 
 
 Historical Outline. — To Nelaton is justly ascribed the honor of having 
 been the first to inscribe this disease in the nosological tables by his mas- 
 terly description of it. It will not in the least detract from his merits to 
 mention the ideas held by Ruysch upon the effusion of blood within the peri- 
 toneum; by Bourdon upon the physical signs of these tumors, ideas which 
 were vaguely hinted at by his teacher Recamier; by Velpeau, who seems to 
 have diagnosed them without pronouncing upon their exact situation. Spe- 
 cial mention should be made of the works of Bernutz, in which he ably de- 
 lineated many of the features used later by Nelaton in his more extended 
 work. In addition, we must cite the important works of Huguier, Puech, 
 A. Voisin, Trousseau, Langier, Gallard, Besnier, Poucet, MacClintock. 
 Barnes, Schroder, Olshausen, Bandl, etc., to the greater number of which I 
 shall have occasion to refer again. 
 
 Etiology and Pathogenesis. — The effusion of blood into the pelvic cavit}- 
 is probably quite frequent : there is no doubt that at the menstrual period the 
 
686 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 tubes are the seat of an exudation of blood as well as the uterus. Many 
 menstrual disorders caused by fatigue, strain, or cold are really due to the 
 effusion of a small amount of blood into the peritoneal cavity, where it is 
 rapidly absorbed. We know by numberless physiological experiments, as 
 well as by obser^-ation of what occurs during many laparatomies, how easily 
 the blood disappears when the peritoneum is in a healthy condition. But let 
 it be impaired or destroyed, and this absorptive power disappears at once ; 
 hence the necessity for drainage in many cases of laparatomy. Here also is 
 the probable explanation of the non-resorption of blood in hsematocele, when 
 the blood is not effused in great abundance. In fact, if an extensive effu- 
 sion of blood fails to be absorbed, as occurs for instance after the rupture of 
 an extra-uterine tubal pregnancy, the clots which are formed act as foreign 
 bodies ; the peritoneum is impaired, and by the formation of its protective 
 false membranes tends to isolate the cause of irritation. The imprisoned 
 blood undergoes a slow process of molecular disintegration, and sometimes, 
 under the influence of septic infection derived no doubt from the tube, may 
 even decompose and become mixed with pus. 
 
 If the blood from an intra-peritoneal tubal hemorrhage spread slowly, 
 and be of small amount, it will be absorbed unless some previously existing 
 condition oppose, and this condition is usually an inflammation of the pelvic 
 peritoneum surrounding the diseased tubes which are the source of the hem- 
 orrhage. A great number of autopsies and examinations during laparatomy 
 have demonstrated this origin. F. Imlach reports that in flfteen cases of 
 laparatomy for haematocele he found both tubes distended by thick black 
 blood, exactly like that effused into the abdomen. Now, tubal pregnancy 
 is not to be thought of when the lesion is bilateral, nor can we admit a re- 
 flux of blood from the abdomen into the tubes. E. Sinclair Stevenson also 
 believes, from evidence furnished by specimens of extirpated tubes, that the 
 narrowed calibre of the inflamed tubes may cause hemorrhage into the peri- 
 toneal cavity at the menstrual period. Tubal inflammation prepares in ad- 
 vance for encysting the effused blood, by the formation of false membranes 
 around the fimbriated extremity of the tube; the vestiges of these membranes 
 are found in the partitions of the cyst. Slight attacks of pelvic peritonitis, 
 with relapses, are almost always obser\'ed at the outset of the disease. 
 
 The usual origin of extensive effusions of blood is undoubtedly the early 
 rupture of an extra-uterine tubal pregnancy, so that the history of pelvic 
 haematocele is really in most cases only a chapter in the subject of extra- 
 uterine pregnancy. Haematoceles from any other cause are quite the excep- 
 tion. F"or a more detailed description of this accident, consult the chapter 
 devoted to the subject. As to the progressively developed and concealed 
 haematocele, which are very rare, and usually complicate some other lesion 
 (salpingitis, fibroids), they are probably true intra-peritoneal salpingorrha- 
 phies. 
 
 This question of pathogenesis has been and still is the subject of dispute. 
 
INTRA- AND EXTRA-PERITONEAL PELVIC HEMATOCELE. 687 
 
 I will briefly review the various theories which have been successively ad- 
 vanced. Each one seems to exclude the others, and yet it is probable that 
 they all are founded upon well-authenticated cases ; one factor only is con 
 stant, and that is the impairment of the absorptive power of the pchic peri- 
 toneum, which is either a primary or secondary affection, and caused by pre- 
 existing perisalpingitis or by the abundance of the effusion, which injures the 
 peritoneum by prolonged contact and a sort of permanent imbibition. 
 
 Varicose Rupture. — The rupture of varicosities of the utero-ovarian ve- 
 nous plexus, pointed out by Ollivier in 1834, was given especial prominence 
 by Richet. But recent histological researches appear to show that even in the 
 case of apparently authentic varicose rupture there is nearly always an un- 
 recognized tubal pregnancy. The hsematocele produced during the course 
 of a tubal pregnancy may come, not from rupture of the ovum, but from 
 rupture of a dilated vein on the broad ligament. I have observed one such 
 case. The excessive pressure which follows ligature of the tubo-ovarian 
 vessels after salpingotomy sometimes occasions an intra-ligamentous rupture 
 of the veins, either as the result of some slight exertion, or else from the 
 congestion present at the menstrual epoch. Winckel has shown that the 
 phleboliths contained in the varicose veins may ulcerate through their walls 
 toward the peritoneal cavity as well as toward the interior of the broad liga- 
 ment. 
 
 Disorders of Ovulation. — This theory attributes the production of hasma- 
 tocele to some ill-defined irregularity of ovulation; if the tube is not in exact 
 contact with the ovary at the moment of ovulation, the blood will be effused 
 into the peritoneal cavity. Gallard believes that in every case of hasmato- 
 cele there is extra-uterine ovulation, whether the ovule have been impreg- 
 nated or not. 
 
 Reflux throiigJi the Tubes. — The majority of the older writers deny that 
 the tubes themselves have any part in the catamenial flow ; but they admit 
 the possibility of a reflux of the menstrual blood from the uterus, under some 
 disturbing influence. Bernutz, who admits that haematocele may be symp- 
 tomatic of the menstrual flow, supports his view upon the authority of 
 Ruysch and Haller. Guerin suggests that the troubles produced by mem- 
 branous dysmenorrhoea are of a nature to cause an effusion of blood into the 
 peritoneal cavity. He says : " The uterine mucous membrane swells to such 
 an extent during menstruation that it entirely fills the uterine cavity. When 
 the menstrual crisis is to terminate in the exfoliation and throwing off of this 
 membrane, its turgescence does not prevent hemorrhage, but merely impedes 
 its flow into the vagina ; the mucous membrane becomes detached from the 
 subjacent tissues and for a while hermeticall}^ seals the opening into the cer- 
 vix, while the tubal orifices are open." The uterine contractions then would 
 tend to expel the blood through the ostium abdominale into the peritoneal 
 cavity. Guerin quotes in support of this theory a case of membranous dys- 
 menorrhoea complicated by haematocele, and claims to have seen many other 
 
688 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 examples. This etiology seems to me to be doubtful, unless there exist an 
 acquired or congenital contraction (see Stenosis of the Cervix and Retention 
 Accidents following Genital Atresia). 
 
 Ovarian Apoplexy. — Microcystic degeneration resulting from chronic ova- 
 ritis, follicular cysts, and cysts of the corpus luteum are sometimes the seat 
 of hemorrhages, and their rupture may cause an effusion of blood into the 
 peritoneal cavity, which is, however, never very abundant. 
 
 Pachyperitonitis. — We know that meningeal hemorrhages are due to 
 the rupture of the dilated and friable vessels of the false membranes in an- 
 terior pachy-meningitis. Dolbeau was the hrst to demonstrate this interest- 
 ing fact of general pathology, and then Virchow, who is usually considered 
 to be the originator. Might not a similar process explain the formation of 
 hasmatocele .? The idea is natural in view of the formation of false mem- 
 branes due to pelvic peritonitis. Ferber, Besnier, and Bernutz developed 
 this theory, which has certainly been over-abused. 
 
 Ruptjire of Extra-uterine Pregnancy. — Huguier gives to occurrences of 
 this nature the name of pseudo-haematocele. If the rupture is accompanied 
 by extensive hemorrhage and causes sudden death, it could not legitimately be 
 given the name of haematocele. But why refuse; it to the cases in which the 
 effusion is circumscribed and encysted .-* It is even probable that these cases 
 are more frequent than is usually supposed, and that there are intra-perito- 
 neal abortions, so to speak, which are often overlooked as ai'e often the ordi- 
 nary abortions when they occur in the first weeks of conception. In excep- 
 tional cases we find a foetus which has undergone more or less alteration ; 
 more usually it has disappeared, but under the microscope, on certain por- 
 tions of the boundary wall of the haematocele, we find chorionic villi (see 
 Extra-uterine Pregnancy). 
 
 Among predisposing causes must be mentioned any general disease which 
 causes hemorrhages. But it would be absurd to give the name of haemato- 
 cele to the effusions of blood into the pelvis in cases of scorbutus, icterus, 
 phosphorus poisoning, etc. 
 
 I should not omit to point out the influence of menstruation as a deter- 
 mining cause. Haematocele usually makes its appearance at the menstrual 
 period, as we can readily understand if we consider the congested state of 
 the pelvic organs at that time. Anything adding to the existing erethism, 
 as fatigue, shock, coitus, etc., acts in the same way. 
 
 Without denying to each of the causes given some part in the etiolog}' 
 of intra-peritoneal pelvic haematocele, we may assert that the great majority 
 of cases start from some tubal lesion, hemorrhagic salpingitis with peri-sal - 
 pingitis in the case of progressive haematocele of moderate amount; foetal 
 cyst for the sudden and abundant haematocele called cataclysmic (Barnes). 
 
 PatJiological Anatomy. — The tumor is usually situated in the cul-de-sac 
 of Douglas, which is the most dependent portion of the pelvis; hence the 
 name retro-uterine haematocele, chosen by Nelaton. Previously existent 
 
INTRA- AND EXTRA-I'ERITONEAL PELVIC H.-EMATOCELE. 
 
 689 
 
 plastic inflammation may obliterate the cul-de-sac, and the blood will then 
 accumulate between the bladder and the uterus under the influence of grav-. 
 ity, and an ante-uterine hasmatocele will thus be formed. G. Braun and 
 Schroder give some examples of this kind ; other more numerous examples 
 refer to ante-uterine extra-peritoneal hasmatocele. 
 
 At the outset the blood is liquid, and forms a sort of lake which is easily 
 displaced, for it is rare to have pre-existing false membranes constituting a 
 sac. The cyst, however, is rapidly formed, and is then entirely separate 
 from the mass of intestines. It may therefore be difficult to distinguish the 
 arch formed by the new membranes from an uplifted peritoneum, and to 
 
 Fig. 462. — Retro-Uterine H.-ematocele. J7, Uterus; J\, rectum; A, intra-peritoneal hjematocele encysted by 
 
 false membrane. 
 
 differentiate between an intra- and extra-peritoneal haematocele. In the lat- 
 ter form, however, the tumor is more laterally situated, as it is chiefly the 
 broad ligament which has been unfolded and displaced. The sac adheres 
 anteriorly to the posterior wall of the uterus, which is pushed toward the 
 symphysis ; it is of a blackish color. The ovaries and tubes become less 
 and less recognizable and more easily confounded with the walls of the 
 tumor. Sometimes the tubes are filled with blood and torn ; in the case of 
 foetal cyst, only one is affected. The agglutinated intestines may adhere to 
 the cyst wall. When it is opened, we find a mass of coagulated or syrupy, 
 semi-liquid blood, according to the length of time that the lesion has existed. 
 It is black in color, like the interior of a raisin ; in the most external part 
 we may find layers of whitish fibrin. The cyst walls are thick in some 
 places, and thin in others where a rupture seems imminent. The rectum is 
 compressed and displaced (Fig. 462), 
 44 
 
690 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 We must not confound with haematocele the hemorrhages occurring 
 .within ovarian cysts ; their walls possess a characteristic structure. It is 
 also incorrect to give the name to the temporary accumulation of clots in a 
 pelvic abscess which has been punctured. The size of the tumor varies ; it 
 may reach that of the uterus at term. If it persist a long while, compression 
 of the ureters may lead to renal lesions as in the case of other abdominal 
 tumors. Suppuration frequently occurs. At autopsies signs have often 
 been found of attempted spontaneous cure — absorption of the fluid and re- 
 traction of the sac, which was filled with newly formed connective tissue, 
 stained by the pigment of the blood. 
 
 Even in cases in which there is reason to suspect the rupture of a tubal 
 pregnancy as the cause of the lesion, we do not usually find any trace of a 
 foetus; it usually disintegrates and is absorbed. This rupture occurs very 
 suddenly toward the second or third month ; when the autopsy is held soon 
 after the beginning of the accident, and when the foetus was alive only a 
 short time previous to its occurrence, it may be identified among the clots. 
 Often the patient dies so suddenly that no cyst is formed and there is merely 
 an internal hemorrhage. Still, there may have been a previously formed 
 haematocele, a second one proving fatal ; in that case the phenomena develop 
 with sufficient rapidity to allow of identification of foetal remains at the au- 
 topsy. Though the foetus leave no trace, it is not so with the chorionic villi, 
 which may be found by a careful examination and which frequently reveal 
 the cause of the lesion. L. Tait has thus proved that pelvic haematocele is 
 the ordinary termination of extra-uterine pregnancy. 
 
 Symptoms. — The appearance of haematocele is usuauy preceded by mor- 
 bid symptoms connected with the uterine appendages : pain, disorders of 
 menstruation, gastric reflexes. They indicate salpingitis or extra-uterine 
 pregnancy. It is seldom that the effusion of blood is not ushered in by acute 
 accidents, but their intensity varies. They may be what Barnes calls cata- 
 clysmic : depression, syncope, cold, sudden death. Y the patient survive 
 this internal hemorrhage, the symptoms of an abdominal tumor appear, while 
 the general symptoms gradually disappear. 
 
 In less severe cases, the onset is marked only by local pain and a sensa- 
 tion of weakness, joined to an increase in size of the abdomen. 
 
 Finally the intra-peritoneal oozing of blood may occur in an insidious, 
 almost imperceptible manner. 
 
 Upon the days following the first appearance of the morbid phenomena, 
 attacks of plastic peritonitis circumscribe the effused mass, and occasion 
 nausea, abdominal distention, pain, and fever. 
 
 The objective signs revealed by touch and bimanual palpation are those 
 of a fluctuating tumor in the cul-de-sac of Douglas, which pushes the uterus 
 upward so that the cervix is reached with difficulty. If we do manage to 
 reach it, we find it flattened against the pubis. The tumor soon loses its 
 fluctuation, and acquires a consistence like that of snow; but this consist- 
 
INTRA- AND EXTRA-PERITONEAL PELVIC HEMATOCELE. 
 
 691 
 
 ence may vary greatly, and in some places be hard and in others soft. Bi- 
 manual exploration will enable us to outline the body of the uterus, which 
 seems to be encased in the tumor that fills and more than fills the pelvis 
 (Fig. 463). Rectal touch is greatly interfered with by the compression of the 
 intestine. This compression may give rise to symptoms of internal strangu- 
 lation ; that of the bladder to retention of urine ; that of the sacral plexus to 
 acute neuralgias of the lower limbs. The general condition varies ; even when 
 there is no suppuration we frequently observe irregular attacks of fever, due 
 to the peritoneal reaction caused by the formation of false membranes. 
 
 The course of the disease is essentially chronic, but successive acute 
 attacks occur, as if additional amounts of blood were from time to time 
 
 Fig. 463. — Retro-Uterine H.«;iiatocele. U, Uterus; B, bladder; H^ hematocele. 
 
 effused. They may be manifested a few days after the onset or later at the 
 menstrual periods, no doubt under the influence of the catamenial conges- 
 tion. When the intra-peritoneal hemorrhage is caused by the rupture of a 
 foetal cyst, a relapse is especially to be feared, and may cause sudden death, 
 even when it seems as though all danger had passed. Outside' of these ex- 
 ceptionally severe cases, the disease tends to a cure by progressive absorption 
 or spontaneous evacuation ; the latter, however, which can only occur after 
 suppuration of the sac, may cause grave accidents. 
 
 In the most favorable cases the patient is unable to walk for many 
 months, and is exposed to repeated slight attacks of peritonitis during which 
 the tumor is subjected to changes of size and finally diminishes by degrees. 
 After its disappearance there may remain an indurated nodule, or simply a 
 displacement and immobility of the uterus. 
 
692 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Suppurative inflammation is ushered in by an aggravation of the general 
 symptoms, erratic chills and sweats. At the same time the tumor increases 
 in size and softness. Perforation into the abdominal cavity is rare. The 
 peritonitis which sometimes occurs in cases of suppuration of the sac is 
 usually due to direct propagation of the inflammation through the walls. 
 
 Perforation into the rectum is more frequent. It is preceded by signs of 
 rectitis, and ushered in by sudden diarrhoea with black and fetid stools, caus- 
 ing a sensation of relief and a disappearance of the tumor. The evacuation 
 may be complete and recovery follow ; but, on the other hand, death may 
 occur from exhaustion or from infection caused by the entrance of fecal mat- 
 ter. Perforation into the vagina is rare ; into the bladder it is altogether 
 exceptional. 
 
 Diagnosis.^-ThQ clinical picture given by haematocele is often so char- 
 acteristic that there is no possibility of mistake. The sudden appearance of 
 a retro-uterine tumor, coinciding with the phenomena of internal hemor- 
 rhage, is pathognomonic. The rupture of a pyo-salpinx or of a pelvic abscess 
 causes only sharp pain and symptoms of peritoneal reaction, usually more 
 intense than in haematocele, and there is no tumor. Neither will there be 
 danger of mistaking it for a retroflexed gravid uterus. One of the best 
 means of avoiding error is to endeavor to outline the boundaries of the uterus, 
 which in haematocele is enclosed in the centre of the swollen mass. This 
 examination will be facilitated by anaesthesia. Ovarian cysts and uterine 
 fibroids imprisoned within the pelvis have nothing in common with haemato- 
 cele except the objective symptoms; their manner of appearance and their 
 course are entirely different. The same may be said of extra-uterine preg- 
 nancy, which, moreover, is rarely situated directly behind the uterus. The 
 hypertrophy of the organ and persistent amenorrhoea favor the supposition 
 of ectopic pregnancy; as I have said, this is often only the starting-point of 
 later hemorrhages. 
 
 At an advanced stage, inflammatory nodules of perimetro-salpingitis can 
 only be diagnosed by the history of the case. 
 
 The diagnosis of the origin of the hemorrhage cannot be definitely made. 
 In the haematocele that is ushered in suddenly, we are usually safe in con- 
 sidering the cause to be rupture of a foetal cyst. The haematocele which 
 begins insidiously and progresses slowly is usually due to a gradual effusion 
 of blood caused by hemorrhagic salpingitis. Where large varicosities exist, 
 there might be a rupture of a vein of the broad ligament. 
 
 Prognosis. — The affection is serious ; in rare cases, sudden death occurs ; 
 there is always the danger of severe accidents before recovery is established. 
 Moreover, a cure is rarely complete ; the plastic remains around the uterus 
 are a frequent source of discomfort, and almost invariably cause sterility. 
 
 Treatment. — Active interference is justified only by the appearance of 
 accidents which may endanger the life of the patient. In the beginning, if 
 the symptoms are not severe, we may apply ice to the abdomen to combat 
 
INTRA- AND EXTRA-PERITONEAL PELVIC H.-EMATOCELE. 693 
 
 both the hemorrhage and the peritonitis. Absolute rest is indicated; the 
 bladder is to be regularly emptied by the use of the catheter and the intes- 
 tines by enemata. We must be careful not to administer too much opium 
 for the pain, on account of its constipating effect. Antisepsis of the vagina 
 is to be carefully looked out for, in order to avoid all danger of infection 
 through the genital tract. 
 
 The history of surgical interference in this affection can be divided into 
 three periods : from Recamier's time to Nelaton's it was thought necessary 
 always to puncture or incise these collections of effused blood whose sponta- 
 neous absorption seemed impossible ; later the number of unsuccessful re- 
 sults caused this method to be abandoned, and it was discovered that large 
 haematoceles were apt to become spontaneously cured ; the expectant treat- 
 ment was then systematically adopted. At the present day we leave the 
 disease to itself so long as it follows a regular and progressive course toward 
 absorption. But, thanks to antisepsis, we need no longer hesitate to inter- 
 fere as soon as the patient's life seems to be threatened by compression or 
 inflammatory phenomena. Rapid evacuation of the cyst is then obligatory. 
 
 Incision is preferable to puncture ; the latter does not permit of the evac- 
 uation of solid matter nor of a thorough cleansing, and may form a septic 
 fistula. The site of incision is to be determined by the protrusion of the 
 tumor. 
 
 If it project frankly into the posterior cul-de-sac, it should be opened 
 through the vagina. The cervix is drawn forward, the index of the left hand 
 placed in the rectum, while by the use of retractors the operating field is 
 enlarged as much as possible, and an incision is made following the axis of 
 the tumor, with care not to go too far to the sides on account of the ureters. 
 The finger in the rectum serves as a guide in avoiding the intestine. As 
 soon as the interior of the cyst is reached, the incision is enlarged with the 
 scissors, if necessary, and the evacuation of the syrupy fluid and the clots 
 aided by weak antiseptic injections. We should proceed with the greatest 
 care, and not attempt to cleanse out the cavity too suddenly, for fear of in- 
 juring the adhesions bounding it. After cleaning, we fill the cavity with a 
 loose tamponade of strips of gauze, which are to be left in place for forty- 
 eight hours ; this protects against further hemorrhage, and completes the 
 process of disinfection. When this gauze is removed, the antiseptic irriga- 
 tions are renewed, and a T-tube is inserted, which is packed about with 
 gauze, but only in the vagina, from fear of absorption. The free end of the 
 tube is to be wrapped in antiseptic dressings; injections may be made 
 through the tube once or twice a day if necessary. If the cavity be very 
 large, each antiseptic injection should be followed by one of boiled water, 
 otherwise we may have toxic symptoms. 
 
 Antisepsis has completely altered the prognosis of this operation. Nela- 
 ton, who at first advocated its use, gave it up on account of the frequent 
 cases of septicaemia following it. Gusserow gives his personal experience. 
 
694 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 consisting of eight cases, with six cures lasting from six to twenty-one days ; 
 he advocates interference in very serious cases only. Routier reports three 
 cases successfully treated by vaginal incision, which he now prefers to lapa- 
 ratomy. Vaginal incision necessitates perfect antisepsis, and is often dan- 
 gerous when the tumor is some distance away from the posterior cul-de-sac, 
 which may be obliterated, and projects into the abdomen. If the cavity is 
 very large, a vaginal incision, which must always be limited in extent, may 
 be insufficient for complete evacuation and perfect antisepsis. Under these 
 conditions I once successfully performed subperitoneal laparatomy. This 
 operation consists essentially in a long incision parallel to the crural arch, 
 the detaching of the peritoneum as far as the cyst, and penetration into the 
 latter through the surface which adheres to the pelvis, without entering the 
 large serous cavity. After having carefully emptied the blood cyst, its cav- 
 ity is to be explored by the introduction of the fingers into its most depend- 
 ent portion, and by combining vaginal touch with this procedure, we deter- 
 mine the most favorable point I'or the insertion of a drainage tube through 
 the posterior cul-de-sac. Whether the cyst be small or large, this drainage 
 with a T-tube is to be combined with drainage by abdominal incision, with 
 two tubes fastened together like gun-barrels, or a series of tubes in juxta- 
 position like the representations of Pan's flute, or with strips of iodoform 
 gauze. For two or three days at least it will be well loosely to tampon the 
 cavity with the gauze prepared in a weak solution of iodoform ; this has the 
 triple advantage of opposing secondary hemorrhage a vacuo, of completing 
 the antiseptic treatment, and of supplementing the passive action of drainage 
 tubes by more active capillary drainage. 
 
 If, during an attempted subperitoneal laparatomy, we are unable to de- 
 tach the peritoneum as far as the point where the pocket adheres to it, we 
 can always resort to the following process : We freely incise the peritoneum 
 at the bottom of the wound, and place tampons upon the pocket which is 
 intact, so as to provoke the formation of a passage closed in by adhesions 
 between it and the incision. After twenty-four hours the tampons are re- 
 moved and the cyst opened. 
 
 Laparatomy properly so called, or transperitoneal incision, has given 
 good results. If possible, we must fix the pocket to the abdominal wall by 
 veritable marsupialization, empty it, tampon, and drain. This theoretical 
 manoeuvre is rarely practicable, as there is so seldom a well-defined and re- 
 sistant pocket; the walls are usually formed merely by the agglutination of 
 neighboring organs. We may be obliged to limit ourselves to an antiseptic 
 irrigation of the cavity, and then simply abandon it in the abdomen. Capil- 
 lary drainage and a tamponade with iodoform gauze would be advisable in 
 such a case. 
 
 It seems to me that transperitoneal laparatomy should rarely be per- 
 formed, on account of the danger of septic peritonitis. 
 
 One case in particular, and fortunately a rare one, necessitates prompt 
 
INTRA- AND EXTRA-PERITONEAL PELVIC HEMATOCELE. 695 
 
 surgical interference; this is when the starting-point of the troubles is the 
 abortion of a tubal pregnancy. In such cases the hemorrhage comes in suc- 
 cessive attacks ; shall we wait for the catastrophe or anticipate it by an 
 immediate laparatomy .? Martin reports a case where he regretted having 
 abstained from operating; the patient died of a fresh hemorrhage four days 
 after the consultation. In such cases bold interference seems to me not only 
 legitimate, but absolutely called for at once by the special clinical symptoms. 
 
 ExTRA-PERiTONEAL H.EMATOCELE. — The cffusion of blood into the con- 
 nective tissue of the pelvis has been called extra-peritoneal haematoma, 
 thrombus of the broad ligaments, and pseudo-hsematocele. Some writers 
 have denied its existence outside of the puerperal state, in which thrombus 
 of the vagina and vulva may also be produced, but at the present day its ex- 
 istence is acknowledged. 
 
 Etiology. — It may be produced by the influence of pregnancy, which, as 
 we know, causes a dilatation of the entire pelvic venous system, especially 
 of the utero-ovarian plexus. But utero-ovarian varicocele may exist and 
 cause a subserous rupture, even outside of pregnancy, from rupture or ulcer- 
 ation of veins containing phleboliths. It is usually observed as a result of 
 overwork or sexual excesses, during the menstrual period, in multiparas 
 whose veins are more dilated than those of women who have never had 
 children. 
 
 According to Byrne, thrombus of the broad ligament is more frequent 
 than is usually admitted, and may often cause pelvic abscess or phlegmon. 
 Skene Keith calls attention to the fact that an ephemeral extra-peritoneal 
 hjematocele often follows salpingotomy, because of a congestive hemorrhagic 
 outbreak at the period corresponding to the next menstrual epoch. Beigel 
 believes that extra-peritoneal haematocele constitutes a considerable portion 
 of cases usually classified under the more ordinary form. 
 
 Pathological Anatomy. — The blood may form a circumscribed tumor be- 
 tween the folds of the broad ligament, which, not being a closed cavity, but 
 communicating with the pelvic cellular tissue, permit of an escape of the 
 blood if it be abundant ; the effusion then is directed toward the vagina and 
 rectum. The tumor is usually of medium size, varying from the size of a 
 fist to that of a man's head. It is frankly lateral, and, should two tumors 
 exist, one is always much larger than the other. The two may, however, 
 unite. Sometimes the tumor is in front of the uterus. A. Martin, who 
 has had the opportunity of studying the pathological anatomy in several 
 operations, has always found a pocket with an irregular surface, studded 
 with diverticula which penetrate the cellular tissue, and crossed by bridles 
 of connective tissue and broken blood-vessels. The contents are formed of 
 blood and more or less degenerated clots ; there is sometimes an admixture 
 of pus ; it may communicate with an intra-peritoneal effusion by a tear in 
 the broad ligament. 
 
 Symptoms. — This accident usually occurs to women who are apparently 
 
696 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 in a healthy condition. Sharp pain in the abdomen with a tendency to syn- 
 cope marlc the onset. There may, however, be successive attacks. The 
 symptoms of profound anasmia and troubles due to compression of the blad- 
 der and rectum are manifested, together with swelling and tenderness of the 
 abdomen. By touch and bimanual palpation we feel that the tumor is in 
 the broad ligament and not in the cui-de-sac of Douglas ; it is soft and pasty ; 
 the uterus is upon its internal surface, and more or less pushed aside, but it 
 can be distinctly outlined on every side. As to the other symptoms and 
 the course of the disease, they are the same as those given for intra-perito- 
 neal haematocele. 
 
 One special symptom, ecchymotic spots of the vagina, belongs to extra- 
 peritoneal hasmatocele. In some rare cases ecchymosis of the abdominal 
 wall has been observed. The differential diagnosis between it and extra- 
 peritoneal haematocele cannot always be made. It must be based upon the 
 etiology, the frankly lateral situation of the tumor, and its relations. 
 
 Treatment. — Expectant treatment is the rule. If the gravity of the 
 symptoms calls for interference, we cannot do a vaginal operation because 
 of the danger of wounding a large vessel or the ureters. Subperitoneal lap- 
 aratomy seems to me to be the best operation. Martin recommends trans- 
 peritoneal laparatomy, with cleansing of the cavity, and suture of the wound 
 over a T-tube which emerges through the vagina. He has had nine success- 
 ful results out of ten operations. In some cases vaginal hysterectomy might 
 give good results. 
 
CHAPTER XXXIV. 
 
 EXTRA-UTERINE PREGNANCY. 
 
 In extra-uterine or ectopic pregnancy the impregnated ovum is developed 
 outside of the normal uterine cavity. 
 
 Pathology and Etiology. — Extra-uterine pregnancy is determined by any 
 condition preventing the application of the ampulla of the tube to the sur- 
 face of the ovary at the time and place of rupture of the Graafian follicle. 
 We know that spermatozoa may penetrate to the peritoneal cavity, and that 
 they may there retain their functional life ; also that the ovule may travel a 
 considerable distance without losing its vitality. The most frequent condi- 
 tions leading to extra-uterine pregnancy are adhesions of the ovaries and 
 tubes, a result of peri-salpingitis ; loss of the ciliated epithelium ; or an 
 obstacle to the migration of the ovum in the shape of an intra-tubal polypus. 
 Emotional conditions at the time of conception have also been suggested as 
 a cause. 
 
 The condition is somewhat rare. Out of 60,000 women examined in the 
 course cf seven years in the clinics of Carl Braun and Spath, of Vienna, 
 there were but 5 cases of extra-uterine pregnancy. This proportion would 
 seem to be too low : Fasola observed an equal number of cases out of only 
 1,565 pregnancies in multiparae who had remained for some time sterile. 
 Toth observed 31 cases out of 1,700 women suffering from gynaecological 
 affections. A return of extra-uterine pregnancy in the same woman has 
 been noticed. 
 
 [Greater skill in diagnosis and early resort to laparatomy in doubtful 
 cases have proved this condition to be much more frequent than was sup- 
 posed a few years ago.] 
 
 Classification. — Numberless divisions and subdivisions of this subject 
 have been made, but are of little value. The greater number of foetal cysts 
 are situated in the tube and are tubal pregnancies. If the ovum is devel- 
 oped entirely within the tube, we have a simple tubal pregnancy; if the 
 uterine walls are also involved, it is a tubo-uterine or interstitial pregnancy ; 
 and if the foetus is partly within the abdominal cavity, a tubo-abdominal 
 pregnancy ; to these varieties may be added the tubo-ovarian. If the tube 
 should rupture and the development of the foetus continue within the abdom- 
 inal cavity, we have a secondary abdominal pregnancy. Some authorities 
 maintain that abdominal pregnancy may be primary. If the rupture occur 
 in the attached portion of the tube, the foetus may develop within the folds 
 of the broad ligament — a condition to which has been applied the name of 
 
698 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 subperitoneal. Finally, there exist several well-established cases of ovarian 
 pregnancy in which the ovum has developed upon the surface of the ovary, 
 
 Fig. 464. — Tubal Pregxanxy of Two and a Half Months, Sac Closed (Bouilly). 
 
 but their number is smaller than has been supposed. Certain anatomical 
 characteristics make the diagnosis between this variety and abdominal preg- 
 nancy difficult. 
 
 Pregnancy in a rudimentary horn of the uterus differs so essentially from 
 normal pregnancy, and so resembles foetal cysts, that its description should 
 
 Fig. 465. — Tubal Pkegnancv of Two and a Half Months, Sac Opened (Bouilly). 
 
 be included with that of extra-uterine pregnancies. For this reason the 
 term ectopic is preferable to that of extra-uterine pregnancy. 
 
 PatJiological Anatomy. Tubal Pregnancy propei'ly So-called. — Hennig 
 found the ovum occupying the central portion of the tube in J"] out of 122 
 
EXTRA-UTERINE PREGNANCY 
 
 699 
 
 cases. In 10 it was situated in the proximal portion, in 17 near the centre, 
 8 times in the outer third, and 5 in the external fourth. Out of 6:0 cases 
 collected by von Schrenck from the medical literature of 1888 to 1892, there 
 are 125 in which there is no indication as to the situation of the extra- 
 uterine pregnancy. It was tubal in 339 cases, abdominal in 33, ovarian in 
 19, and in 14 cases it was in a rudimentary horn of the uterus. The pro- 
 portions therefore are as follows: 83.5 per cent for tubal, 8.2 per cent for 
 
 Fig. 466. — Tubal Pregnancy. Section of embryo and wall of tube, i, Fibro-muscular tissue of tube ; 2, blood- 
 vessels surrounded by embryonal cells; 3, layer of large proliferated cells on inner surface of tube ; 4, villus with irreg- 
 ular branched cells, surrounded by preceding layer; 5, layer of coagulated blood and fibrin with many white blood cells. 
 
 abdominal, 4.6 per cent for ovarian, 3.6 per cent for a rudimentary uterine 
 horn. 
 
 As to the relative frequency of ectopic pregnancy upon the right or the 
 left side, von Schrenck finds that it scarcely differs, being 124 for the right 
 and 123 for the left. Hennig, in the 122 cases which he collected, notices 
 the same thing. On the other hand, Hecker out of 64 cases finds 27 on 
 the right and 37 on the left; Campbell out of 75 cases 34 on the right and 
 41 on the left ; while Martin out of yy cases finds 44 on the right and 33 on 
 the left. 
 
 Tubal pregnancy properly so called may be subdivided into interstitial 
 pregnancy, when the ovum is found in the intra-uterine portion of the tube; 
 pregnancy of the isthmus, or tubal pregnancy properly so called, when it 
 occupies the middle portion of the tube; and finally pregnancy of the am- 
 
yoo 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 puUa when, as is most frequently the case, it is found in the external por- 
 tion. J. C. Webster distinguishes an ampullar, an interstitial, and an infun- 
 dibular variety; the latter including tubo-ovarian and tubo-abdominal 
 pregnancies. 
 
 Parry out of 214 cases noted 31 interstitial, 34 infundibuliform, and 
 149 ampullar pregnancies. 
 
 Martin in his 77 cases noticed i interstitial pregnancy, 7 intra-ligamen- 
 tous, 8 isthmic, and 57 ampullar, among which were 6 tubo-ovarian and 3 
 
 
 
 Fig. 467. —Tubal Pregnancy. Single villus (350 diameters). 1, Swollen end of a villus ; 2, long irregular cells 
 surrounded by granular colloid material ; 3, fine network of fibrin enclosing many white blood cells ; 4, compact 
 limiting layer. 
 
 tubo-abdominal. Finally, bilateral tubal pregnancies have been reported, 
 and twin pregnancies in one tube. 
 
 As soon as the ovum has become fairly attached, the mucous membrane 
 of the tube undergoes a transformation similar to that of the uterine mucous 
 membrane in the formation of the decidua. Rokitansky has well described 
 the downy appearance of the mucosa, the villi of which interlace with those 
 of the chorion. Until the placenta is formed, their mutual adhesion is but 
 slight; the proximal orifice of the tube may remain open and the change 
 in the mucosa extends to the lining of the uterine cavity. 
 
 During the first three months the small tumor which is seen upon open- 
 ing the abdomen can in no wise be distinguished from an ordinary haemato- 
 salpinx, as its cavity is generally filled with effused blood. It is usually 
 egg-shaped, but sometimes resembles a bagpipe (Fig. 464), and contains a 
 
EXTRA-UTERINE PREGNANCY. 
 
 701 
 
 transparent liquid in which the embryo floats, or clots of more or less recent 
 formation, which are sometimes stratified like those found within an aneu- 
 rismal sac. In the latter case there may be some difficulty in finding the 
 little foetus, and oftentimes the nature of the foetal cyst can be proved only 
 by the identification of the chorionic villi on the walls of the tube. The 
 cyst is usually pediculated, but is sometimes broadly adherent to the surface 
 of the broad ligament, often penetrating into its substance and causing an 
 
 Fig. 468.;— Tubal Pregnancy. Wall of tube and villus (650 diameters), i, Fibro-muscular tissue of tube ; 2, 
 proliferated and hypertrophied connective-tissue cells ; 3, extravasated red blood cells ; 4, villus undergoing colloid 
 degeneration ; 5, degenerating cells ; 6, surface of endothelium. 
 
 expansion of its folds. More rarely the cyst walls are so thin and trans- 
 parent that the embryo can be seen. Hennig has noticed that the muscular 
 layer of the tube hypertrophies until the end of the second month ; later, 
 under the influence of progressive distention, it becomes thinned and the 
 fibres separate. 
 
 Early rupture is the rule in tubal pregnancy. Out of 45 cases studied 
 by Hecker, the rupture occurred 26 times during the first two months, 
 1 1 times in the third month, 7 times in the fourth, and once in the fifth. 
 Hoffmann, in 8 medico-legal autopsies, found the rupture 7 times in the sec- 
 ond month, and once in the third. In von Schrenck's valuable report, he 
 states that rupture of the sac was noted in 141 cases; it occurred 13 times 
 
702 
 
 CLINICAL AND OPERATIVE GYNECOLOGY 
 
 during the first month, 67 during the second, 28 in the third, and 12 times 
 in the fourth. The size of the ruptured cyst is usually that of a hen's egg. 
 Kaltenbach believes that adhesions preventing the expansion of the tube are 
 an immediate cause of rupture. The tearing apart of excessively vascular 
 adhesions may in itself be the cause of severe hemorrhage ; Kaltenbach has 
 reported a case in which it was fatal. Freund has had a case, thus far 
 unique, in w^hich the rupture was due to myxomatous degeneration. 
 
 Rupture of the tube usually occurs into the peritoneal cavity, causing 
 the variety of haematocele which Barnes has named cataclysmic. Should 
 
 Fig. 469. — Ruptured Tubal' Pregnancy. General view, i, Transverse sections of villi; 2, longitudinal sec- 
 tions ; 3, branching compact fibrous septa ; 4, coagulated fibrin ; 5, network of fine fibres of fibrin interlacing in all 
 directions and containing white blood cells. 
 
 the rupture occur within the folds of the broad ligament, the resulting 
 haematocele is extra-peritoneal, and the ligamental folds tend to limit the 
 extent of the hemorrhage. 
 
 The course of development of tubal pregnancy varies. In exceptional 
 cases, the embryo perishes at an early date, and is so completely disinte- 
 grated that no trace of it can be found. The sac no longer increases in size, 
 but may be transformed into a haemato-salpinx by the internal hemorrhage 
 which has caused or accompanied the death of the embryo. The clinical 
 characters and the prognosis of the lesion, of course, vary greatly. The 
 surgeon who later performs an operation for its extraction often finds the 
 greatest difficulty in establishing its true nature, even by a microscopical 
 
EXTRA-UTERINE PREGNANCY. 
 
 703 
 
 examination of the walls, in which there are usually a few chorionic villi to 
 be found. Even complete absorption of the contents of the tube may occur 
 after a longer or shorter interval. This is the result aimed at by physicians 
 who endeavor to bring about the death of the foetus by injections of mor- 
 phine or by electricity. If the foetus die at a later date, it acts as a foreign 
 body, and may become encysted and transformed into a lithopaedion, as we 
 shall see later, or may provoke the symptoms which accomplish its elimina- 
 tion. 
 
 Finally, the foetus may live to term. This occurs, as a rule, when the 
 tube distends or bursts open laterally, the expanded surfaces of the broad 
 
 Fig. 470. — Tubal Pregnancy in which Rupture has Occurred. TV, Right tube in which may be seen the 
 tear D beneath the embryo E ; Od, Ld^ right ovary and round ligament ; 7>, Lg-^ left ovary and round ligament ; C, 
 cervix. (Foetus of about two months ; the mother died in a few hours from internal hemorrhage. Specimen belong- 
 ing to Professor Hoffmann, and placed in the Medico-Legal ^luseum of Vienna.) 
 
 ligament protecting the included foetal cyst from rupture into the abdominal 
 cavity (subperitoneal variety). 
 
 In such cases we have at term the curious symptoms described as false 
 labor, when, if art do not step in to assist nature, the child dies. If the 
 woman survive, we have a train of phenomena common to all the varieties 
 of ectopic gestation reaching term, to which I shall later recur. 
 
 Tiibo-iiteinnc or Interstitial Pregnancies. — Here the ovum is developed 
 in the very short portion of the tube which is included within the uterine 
 walls. A part of its surface is free, and separated from the peritoneal cavity 
 by false membranes only. These cases are of rare occurrence ; the statis- 
 tics in regard to them have been collected by J. Baart de la Faille. When 
 the foetal cyst ruptures, there may be a hemorrhage escaping by the natural 
 passages. The placenta and foetus may follow, or may be discharged into 
 the peritoneal cavity. The duration of pregnancy is usually longer than 
 
704 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 in the tubal form ; it may go on to term, but may also be terminated by 
 fatal hemorrhages before the fourth month. Schultze considers that inter- 
 stitial pregnancy is very frequent and often unrecognized, and that numerous 
 abortions in supposed normal pregnancies could have had no other origin. 
 
 Ttibo -abdominal Pregnancy. — The ovum here develops at the distal 
 extremity of the tube ; it is but partially enveloped by it, the external por- 
 tion of the sac being covered by false membranes. It is adherent to neigh- 
 boring parts — the broad ligaments, ovaries, mesentery, intestines, bladder, 
 and even, if the cyst attain a sufficient size, the spleen, kidneys, and liver. 
 The placenta is usually situated in the pelvis. The ovary may be flattened 
 
 Fig. 471.— Interstitial Pregnancy. Rupture. /?, Tear ; C, cervix ; Td^ Ld, right ovary and round ligament; 
 Tg, Lg, left ovary and ligament. (Foetus nearly four months. The woman had an attack of vomiting in the evenmg 
 and died the following day from internal hemorrhage. Specimen belonging to Professor Hoffmann, and placed m the 
 Medico-Legal Museum of Vienna.) 
 
 and incorporated with the walls of the cyst, in which case the pregnancy is 
 termed tubo-ovarian. The possible extension of the cyst toward the abdom- 
 inal cavity by successive additions of false membranes explains the occa- 
 sional postponement of rupture to term. 
 
 Many cases of so-called tubo-ovarian or even ovarian pregnancy cannot 
 be explained upon general principles, but require special demonstration. 
 Vulliet, not without some reason, has maintained that in some cases the 
 pregnancy is developed within a pre-existing tubo-ovarian cyst. He calls 
 to mind the fact that Burnier demonstrated the presence of Graafian follicles 
 in the wall of a tubo-ovarian cyst removed by Schroder, and argues that 
 therefore impregnation is possible in the neighborhood of these cysts. 
 
 Upon Burnier's demonstration and upon a case observed by himself, he 
 bases his assertion that pregnancy may develop within these cysts, distending 
 
EXTRA-UTERINE PREGXAXCV. 705 
 
 them in the same way as contained fluid would do. Paltauf, Schaeffer, v. 
 Rosthorn, and Lihotsky have since published statistics which confirm this 
 statement. I have myself observed a case of this nature. It was a species 
 of hccmato-oophoro-salpinx evidently due to extra-uterine pregnancy, as was 
 shown by a microscopical examination. 
 
 Ovarian Preg7iancy. — The existence of this variety has been contested; 
 many of the cases claimed for it have been proved to be cases of tubo- 
 abdominal pregnancy with intimate but secondary adhesions to the ovary. 
 It is, however, not impossible that impregnation should occur in a ruptured 
 Graafian follicle in such a way as to cause the insertion of the placenta upon 
 the ovarian tissue ; but these cases are of rare occurrence. In the very full 
 collection of the Museum of Vienna, Bandl found only one specimen of 
 ovarian pregnancy, and almost questions the possibility of its existence. 
 Puech, it is true, quotes a number of cases ; but, as I have already said, 
 Dvarian tissue in the walls of the cyst does not establish a sufficiently accu- 
 rate anatomical diagnosis, as intimate secondary adhesion of the ovary may 
 account for its presence. 
 
 According to Hueppe, we must admit the following processes in order 
 to explain ovarian pregnancy : Impregnation upon the surface of the ovary, 
 after which either the follicle closes and the foetus is developed within the 
 ovary after the manner of a cyst, or the follicle remains open and the foetus 
 escapes, the placenta remaining behind in the ovary. 
 
 Besides these two varieties of ovarian pregnancy, Hueppe admits a third 
 or external ovarian pregnancy. In this class, the formation of the placenta 
 is similar to that in cases of abdominal pregnancy, with which it is apt to be 
 confounded. 
 
 Patenko has observed a case in which extra-uterine pregnancy was de- 
 veloped at the expense of the right ovary, which presented the following 
 characteristics: i. A diminution in the dimensions of the right ovary 
 (length of right ovary, 16 mm. ; of left ovary, 35 mm. ; breadth of the right 
 ovary, 19 mm.; of the left ovary, 18 mm.). 2. Transformation of a part 
 of the ovary into a cyst. 3. Ovarian structure of the wall of the cavity, 
 demonstrated by a microscopical examination, and finally the discovery of 
 the remains of the foetus and a trace of a placenta in the cavity itself. 
 
 Heinicken regards as ovarian pregnancies only those in which the pla- 
 centa develops in the interior of the ovary, the foetal sac developing in the 
 peritoneal cavity. Zmigrodsky admits two varieties — that in v.-hich the 
 ovary is the primary and only seat of the ovular development, and that in 
 which, with external development of the pregnancy, intimate union occurs 
 between the placenta and the ovarian tissue. Generally speaking, he says, 
 the site of the placental attachment plays the chief role in the classification 
 of extra-uterine pregnancv. A distinction should be observed between sim- 
 ple adhesion of the fcttal sac to the ovary and organic connection of the 
 placenta with the ovarian tissue. 
 45 
 
7o6 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Werth says that a study of ovarian pregnancy has given him but one 
 positive indication, but that this indication is of the most pronounced diag- 
 nostic vakie, and is as follows : When the fostal sac springs unmistakably 
 from the appendages, while the condition of the Fallopian tube excludes the 
 possibility of its participation in its formation, the conclusion is inevitable 
 that we have an ovarian pregnancy. Mouratoff, Sanger, Leopold, Macken- 
 rodt, and Larsen have reported cases in which ovarian pregnancy was satis- 
 factorily demonstrated. 
 
 Abdominal Pi'cgnancy. — When the ovule falls into the peritoneal cavity 
 and is there impregnated, it may attain complete development in that situa- 
 tion. As a usual thing, it becomes surrounded by a pseudo-membranous 
 sac, which may become greatly thickened by the addition of successive 
 layers, and may firmly adhere to neighboring organs. In some rare cases 
 the foetus is enveloped in a thin, transparent membrane. A condition of 
 extreme vascularization is found in the viscera in contact with the ovum. 
 There is nothing corresponding to a decidua, as there is in tubal pregnancy. 
 
 The placenta has no regular form and may attain enormous proportions. 
 It is reported that in the course of a laparatomy performed for ectopic ges- 
 tation, Gaillard Thomas was asked by one of his assistants whether the 
 placenta which he was extracting were not the liver, so greatly did it resem- 
 ble that organ. 
 
 Where compression does not strangulate the ovum, its development is, 
 as a rule, not interrupted by rupture or hemorrhages, but goes on to term. 
 The placental circulation may sometimes be continued after the death of the 
 foetus, and cause fatal hemorrhage. Ordinarily, however, this circulation 
 ceases gradually, and is completely abolished about two months after the 
 death of the embryo. It has been claimed that abdominal pregnancy is 
 always secondary and consecutive to rupture of a tubal pregnancy. It is 
 probable that this is its most frequent origin, but several well-authenticated 
 cases establish the existence of primary abdominal pregnancy. 
 
 Pregnancy in a Rndimentary Horn of the Utenis. — Cases of this class, 
 as Kussmaul has well shown, have often been mistakenly diagnosed, and 
 erroneously attributed to tubal pregnancy. The first well-described case 
 is that of Dionis. Sanger has collected all the statistics bearing upon 
 the subject up to the year 1884; the cases are thirty in number. Of 
 these twenty-three terminated by rupture in the first six months, three by 
 calcareous degeneration, while four were treated by means of laparatomy. 
 Bandl, Landau, and Wyder report similar cases. It may be difficult, even 
 at autopsy, to determine whether the cyst is developed in the tube (inter- 
 stitial variety) or in a rudimentary horn of the uterus. The diagnosis is of 
 course impossible upon the living subject. The difficulty lies in the fact 
 that the tumor developed in a rudimentary horn is separated from the rest 
 of the uterus by a species of pedicle (Fig. 472). 
 
 Careful examination will show certain characteristic relations between 
 
EXTRA-UTERINE PREGNANXY. 
 
 707 
 
 the tube and roirid ligament and the foetal cyst. In tubal pregnancy the 
 tube is greatly shortened, reduced to its uterine segment, while the round 
 ligament is found in the internal portion of the sac. When, on the contrary, 
 the rudimentary horn becomes gravid, the tube maintains its normal length, 
 and its insertion, as well as that of the round ligament, is found to be exter- 
 nal to the sac. 
 
 Condition of the Uterus in Extra-utcruic Pregnancy. — The changes un- 
 dergone by the uterus furish one of the most curious characteristics of extra- 
 uterine pregnancy. There is a general hypertrophy of the organ with in- 
 crease in the size of its cavity which may reach 12 to 14 cm. (5 to 6\ in.); 
 
 l''ic. 472. — Ectopic Pregnancy in a Rudimentaky Horn of the Uterus. Rupture. Cd, Right horn, 
 closed at the proximal end, seat of the pregnancy (at the upper part of this horn is seen the tear); Od, right ovarj' ; 
 Trt', right tube ; Ld^ right round ligament ; C^, t'^. ^^T. Lg, left uterine horn, ovary, tube, and round ligament ; Va, 
 vagina ; V, bladder. (Foetus of three months and a half; mother died of internal hemorrhage in six hours. Specimen 
 belonging to Professor Hoffmann, placed in the Medico-Legal Museum of Vienna.) 
 
 at the same time the mucous lining vmdergoes modification similar to that 
 of a gravid uterus ; a plug of mucus obliterates the cervix. 
 
 The nearer the ovum is to the uterus and the nearer pregnancy is to 
 term the more marked are these changes. 
 
 They are evidently of a mixed character, and due to reflex or sympathetic 
 trophic phenomena, analogous to those produced in the breasts, and also to 
 the increased pelvic circulation. Hennig has noted a few exceptions to the 
 rule. 
 
 The location of the uterus varies with that of the ovum. At the third or 
 fourth month the latter is usually in the cul-de-sac of Douglas, and the 
 uterus is displaced more or less anteriorly or to the side, as can be demon- 
 strated by external palpation. The situation of the uterus in cases of 
 ectopic gestation is, however, by no means always the same. It may be 
 found in front, back, or on the sides. As to the cervix, it may be displaced 
 with the uterus, in which case it will with more or less difficulty be found 
 
708 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 also in the elongated cul-de-sac, or it may be met with in the very centre of 
 the excavation. 
 
 The ovary upon the same side as the embryo usually contains a large 
 corpus luteum, the origin of which has formed the subject of many discus- 
 sions. 
 
 Cases have been reported in which a normal and extra-uterine pregnancy 
 coincided. 
 
 Anatomical Changes Consecutive to the Death of the Fcetns. — The fcetal 
 cyst may rupture at an early date, with fatal results, or it may give rise to a 
 retro-uterine haematocele in which the embryo may become lost, as it were, 
 and unrecognizable. If the foetus reach term, its life may be a trifle pro- 
 longed beyond the usual limit, but it eventually dies. One of two things 
 will then happen: either its presence is not tolerated, and a train of symp- 
 toms is produced which result in the death of the mother or expulsion of the 
 foetal debris ; or the foreign body is tolerated and undergoes fatty or cal- 
 careous degeneration. The calcified foetus, which sometimes remains for 
 years embedded in the tissue, is called a lithopaedion. 
 
 Symptoms of Ectopic Pregjiancy. — Although it may exceptionally happen 
 that an ectopic pregnancy will develop, giving only the symptoms of a nor- 
 mal uterine pregnancy, as a rule pathological symptoms will be added to the 
 physiological phenomena from the very first month of pregnancy. Numer- 
 ous observations have demonstrated the fact that the ovum may rupture as 
 early as the first month, and the symptoms which accompany this rupture 
 do not differ from those of haematocele. 
 
 If this accident occur while the patient is in apparently perfect health, 
 and soon after a meal, it may lead to a suspicion of poisoning, a fact which 
 may be of great importance in legal medicine. The phenomena are those of 
 an internal hemorrhage, sometimes of a rapidly fatal character. The attack 
 may recur, in which case death is usually produced after two or three seiz- 
 ures, or even more remotely by successive hemorrhages. As a rule, during 
 the second and third months the following" events occur : a sharp pain in one 
 of the iliac fossa which may go so far as to cause syncope (especially if there 
 be a hemorrhage) ; disorders of micturition and defecation; peritoneal or 
 hemorrhagic symptoms. Not infrequently we may at this time observe a 
 flow of blood which may last several days or weeks, and is sometimes accom- 
 panied by expulsion of the decidua. It should be weU understood that ex- 
 pulsion of decidual membrane does not necessarily indicate the causation of 
 ectopic pregnancy. Menstruation ceases just as it does in normal pregnancy. 
 Metrorrhagias are sometimes noticed, a flow of blood the color of chocolate 
 or of coffee grounds, but there is no report of any case tending to prove that 
 the patient loses blood in similar periodicity, quality, or quantity to that of 
 menstruation. 
 
 Following symptoms which indicate a rupture of the walls of the foetal 
 cyst, the ovum either dies or continues to live. In the first event we have 
 
EXTRA-UTERINE PREGNANXY. 7O9 
 
 ail the symptoms of a retro-uterine haematocele. Tiiis liaematocele often 
 becomes encysted, organizes, and is iinally reabsorbed, but in many cases 
 both cyst and contents become infected and cause symptoms of pelvic sup- 
 puration. When the pregnane is not interrupted the symptoms gradually 
 diminish, and the patient is usually able to resume her ordinary advocations, 
 simply showing the symptoms of ordinary pregnancy. Sometimes the ab- 
 dominal symptoms persist and oblige the patient to keep her bed. Freund, 
 in abdominal pregnancy, has observed intestinal colic, and diarrhoea due to 
 irritation of the intestine from adhesion of the foetal cyst. Symptoms of 
 compression of the bladder and rectum, leading in the latter case even to 
 intestinal occlusion, have been noticed. 
 
 The pains take on an expulsive character at a period more or less remote 
 from the time at which labor would normally occur. The cyst may rupture 
 into the abdominal cavity, which is rare, except when the foetus is dead and 
 the foetal cyst infected, and the patient succumb to acute or chronic peri- 
 tonitis, which sometimes takes on the character of septicaemia. If this 
 crisis be safely passed, a stage of tolerance of the foreign body may be en- 
 tered ; yet this period is not altogether to be trusted, since grave inflamma- 
 tory symptoms may occur, even after all danger seems averted. A lithopae- 
 dion dating back sixteen years has been known to cause intestinal obstruction 
 and peritonitis ; these bodies have also been eliminated by the rectum, after 
 the lapse of periods varying from one to forty-three years. 
 
 In other cases the rupture, instead of occurring into the abdominal 
 cavity, occurs within the folds of the broad ligament. The hemorrhage is 
 less in amount, limited in extent, and the resulting symptoms are less severe. 
 Further, if the life of the foetus is not compromised, this extra-peritoneal 
 development of the o\aim is more favorable to success in the event of opera- 
 tion. Finally, in extremely rare cases, rupture occurs into the uterus itself ; 
 the conditions of this result are a tubo-uterine or an interstitial pregnancy. 
 Spontaneous expulsion of the foetus may occur by suppuration of the cyst 
 and evacuation of its contents. The foetus reduced to its skeleton or to a 
 shapeless mass of debris is, as a rule, expelled through an abscess in the 
 abdominal walls, or by a perforation of the rectum. More rarely, perfora- 
 tion is into the vagina or the bladder, and without operative interference may 
 give rise to endless suppuration. 
 
 Diagnosis. — For purposes of diagnosis extra-uterine pregnancy is divided 
 into two stages, each one of which is marked by typical signs. 
 
 I. Embryonal Period, Extending from the Commenceincnt of Pregnancy 
 ■until Qjiickcning. — This stage is the one which is the more frequently met 
 with, and also the one which presents the greatest diagnostic difficulties, 
 which, however, have but slight importance from the standpoint of treat- 
 ment, as we shall see later. This period corresponds to the first four or five 
 months of foetal life, but in the event of the death of the foetus it may be 
 prolonged much beyond this time without appreciable modification of its 
 
jIO CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 conditions, unless some accident supervene, sucli as rupture or inflammation 
 of the cyst. 
 
 The rational signs present no striking characteristics ; they consist of 
 symptoms more or less marked, referred to the genital organs. Menor- 
 rhagia may be present, necessitating the tampon; in other cases, all of 
 the signs of normal pregnancy may be present— suppression of the 
 menses, changes in the breasts, and sympathetic disturbances of the 
 digestive and nervous systems. To avoid confusion we must endeavor to 
 determine the outlines of the uterus and to ascertain whether there be a 
 pelvic tumor. 
 
 Colicky pains followed by expulsion of a decidual membrane will often 
 point to disturbance in the life of the ovum, and indicate death of the em- 
 bryo. Yet this occurrence, especially if accompanied by metrorrhagia, 
 may at times falsely lead to a diagnosis of abortion, as pregnancy may 
 persist. If such be the case, we unquestionably have to do with ectopic 
 gestation. 
 
 Pain due to intestinal adhesions characterizes tubo-abdominal and ab- 
 dominal pregnancy. When the ovum is incarcerated in Douglas' pouch 
 symptoms of compression of the rectum or bladder are often manifested. 
 The ovum then is often mistaken for a fibroid tumor of the posterior wall of 
 the uterus. 
 
 Bimanual palpation may reveal the ovum at the side of the uterus, some- 
 times continuous with it, but sometimes separated by a sulcus or a pedicle. 
 It constitutes a tumor which in no wise differs from the usual tubal cyst — • 
 the hydro-, hasmato- or pyo-salpinx. If we succeed in mapping out the body 
 of the uterus, we shall find it somewhat increased in size and displaced later- 
 ally ; the cervix will not be perceptibly changed. When the tumor occupies 
 the cul-de-sac of Douglas (which is of rare occurrence), it is there encysted, 
 and ballottement after the fourth month may decide the differential diagnosis. 
 Retroversion of a gravid uterus is apt to be suggested in such a case, and 
 mistakes are probable. Either a diagnosis of retroversion is -made where 
 extra-uterine pregnancy exists, or a diagnosis of extra-uterine pregnancy is 
 made when really a retroversion is present. The sound is sometimes used 
 to establish the diagnosis in these cases. In a case of Bailey's, however, 
 with retroversion it penetrated but eight centimetres. Another sign may be 
 incidentally of value : in the case of the foetal cyst, examination never excites 
 contractions, while these may be sometimes obtained in the bimanual exam- 
 ination of the gravid retroverted uterus. 
 
 Rectal touch completes our evidence in regard to the size and relations 
 of the tumor. Such examinations should be conducted with the greatest 
 gentleness, on account of the danger of inducing rupture and serious hemor- 
 rhage. The passage of the uterine sound should be totally prohibited for 
 the reason that it provokes contraction of the uterus and tubes. 
 
 Diagnosis between extra-uterine pregnancy and pregnancy in a rudimen- 
 
EXTRA-UTERIXE PREGNANCY, 7II 
 
 tary horn of the bifid uterus is impossible upon the living subject; it is 
 made with difficulty even in the cadaver, in spite of the modifications pro- 
 duced by the development of the foetal cyst. 
 
 The diagnosis of rupture is easy when the signs of internal hemorrhage 
 become apparent. As to the death of the foetus that may be suspected 
 when, after expulsion of a decidual membrane, the sympathetic symptoms of 
 pregnancy gradually disappear. We may get an increase in the sensibility 
 and size of the tumor, corresponding to the hemorrhage into the ovum which 
 occasions the death of the embryo, and, following this, a diminution and 
 induration of the foetal cyst. 
 
 2. The Foetal Period properly So-called, Commencing with the Fifth AIo nth. 
 — The sympathetic phenomena of gestation persist, and are accompanied by 
 abdominal pains, often of so severe a character as to confine the patient to 
 bed. These pains, together with the loss of blood, the fixity, irregular con- 
 tour of the tumor, and its lateral location, prevent extra-uterine pregnancy of 
 this class from being confused with normal pregnancy. Combined manipu- 
 lation which will allow of the mapping out of the uterus, at least in its infe- 
 rior segment, will show that it is not perceptibly dilated, and that it is dis- 
 placed to the side opposite the tumor. 
 
 Diagnosis of the variety of the pregnancy is impossible. It was formerly 
 supposed that all extra-uterine pregnancy which passed the fifth month was 
 abdominal, but we know now that tubo-abdominal, tubo-ligamentary, sub- 
 peritoneal, ovarian, and tubo-ovarian pregnancies may all go on to term. In 
 the intra-ligamentary variety, the tumor is usually surrounded by a thick 
 membrane, while in abdominal pregnancy the foetal parts are easily felt be- 
 neath the abdominal walls. The location of the placenta is indicated by 
 palpation {fremissenient) and auscultation {bruit de souffle). 
 
 The existence of false labor is determined by expulsive pains. These 
 have been demonstrated in the course of a laparatomy; they are due to the 
 contractions of the uterus at regular intervals as in normal labor. False 
 labor usually occurs precisely at term, sometimes prematurely at the seventh 
 month, and more rarely beyond term. It should not be confused with the 
 painful crises associated with the phenomena of rupture. 
 
 The death of the foetus is made evident by loss of the heart sounds, by 
 increase in the volume and softening of the tumor due to venous thrombosis 
 with subsequent transudation of fluid, and by the appearance of milk. If 
 the foetus is tolerated, there now begins a work of mummification transform- 
 ing the o\aim into a solid adherent tumor, which in the absence of history 
 might be easily confused with a fibroid of the uterus, an old pelvic haemato- 
 cele, a tumor of the ovary, a dermoid cyst, or a cancer of the peritoneum, 
 etc. The evidences of pregnancy not followed by labor should be examined 
 with the greatest care. In the case of doubt, or if serious symptoms de- 
 velop, we may perform laparatomy, which may be merely exploratory, and 
 will sometimes permit us to determine exactly the nature of the cyst and its 
 
712 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 relations ; also whether it can be removed directly or whether it can be bet- 
 ter attacked from another direction. 
 
 The fistulae consecutive to a suppurating foetal cyst may be diagnosed by 
 the debris of the skeleton which pass through them or which may be reached 
 through these channels after dilatation. 
 
 Finally we sometimes have to make a diagnosis of the complications of 
 this condition. I will refer you to the treatises on obstetrics for those ex- 
 ceptional cases in which extra-uterine pregnancy, recent or remote, has com- 
 plicated uterine pregnancy; for the cases of old extra-uterine pregnancy 
 complicating that of recent date ; and finally, for the cases of extra-uterine 
 pregnancy complicated by hydramnios. 
 
 Prognosis. — During the first half of extra-uterine pregnancy, rupture con- 
 stitutes the greatest danger ; according to statistics, the patient usually suc- 
 cumbs. On the other hand, the operation for the removal of the foetal cyst 
 is of slight gravity at this period. It may be said that the prognosis is seri- 
 ous only in those cases in which the tumor is not recognized and extirpated. 
 The condition of things in the second period is totally different. The con- 
 dition in itself is grave, the question of treatment is also serious, for this 
 becomes more hazardous as we approach term, when hemorrhage is most to 
 be feared. Tc is impossible to determine from statistics the fatality of this 
 condition when not interfered with. Spontaneous recovery has been most 
 often effected through the elimination of the cyst by suppuration, and this 
 process is less or more serious according as it is or is not methodically and 
 antiseptically treated. The results are known in 499 out of 500 cases col- 
 lected by Parry. In 336 the patient succumbed, in 163 she recovered; giv- 
 ing a general mortality of 6"]. 2 per cent. 
 
 According to Himmelfarb, pregnancy in a rudimentary horn of the uterus 
 is very serious in its results if left to itself. It is probable, however, that 
 many of these cases are undiagnosed when the abortion occurs in the earl}^ 
 months before the foetus has attained a size which makes expulsion through 
 the strait separating the sac from the uterus impossible. 
 
 Treatment. — One chief fact is to be borne in mind regarding the treat- 
 ment of extra-uterine pregnancy, namely, that every stage of the develop- 
 ment is attended with formidable danger : Hemorrhage threatens in the first 
 period, peritonitis and septicasmia in the second, while internal suppuration 
 and compression may occur, even after the ovum has been transformed into 
 an apparently inert mass. In view of these accidents, there is reason in 
 Werth's suggestion that ectopic pregnancy is always to be regarded as a 
 malignant growth and treated as such. The rare cases of tolerance or of 
 spontaneous recovery do not authorize expectant treatment. 
 
 From the standpoint of the indications, the question of therapeusis is, as 
 has already been stated, very simple, It is reduced to the mere question of 
 operative opportunity and of the technique to be adopted in the extirpation 
 of the foetus. I cannot, however, pass over in silence certain modes of 
 
EXTRA- UTERINE PREGNANCY. 713 
 
 treatment, some of which are interesting for their historic value, while others 
 are still warmly advocated. These all refer to the first period of ectopic 
 gestation, and are directed to the accomplishment of the death of the embryo, 
 and the promotion of its absorption or its toleration by the tissues. 
 
 Among the methods of treatment which are now obsolete I may mention 
 weakening the patient by starvation and purgatives, the administration of 
 strychnine up to its toxic effect, the hypodermic injections of ergotin, mer- 
 curial inunctions, the administration of iodide of potassium, repeated bleed- 
 ings, and puncture of the cyst. 
 
 Two methods of producing the early death of the foetus are still em- 
 ployed, and their merits still discussed. These are the injection of mor- 
 phine and the use of electricity. 
 
 The injection of morphine by means of a hypodermic syringe is recom- 
 mended before the fifth month. Two injections of the hydrochlorate of 
 morphine of half a grain each at eight or fifteen days' interval are sufficient. 
 We cannot ignore the fact that this method, so seductive in its simplicity 
 •and apparent harmlessness, may give rise to grave accidents, as hemorrhage, 
 septicaemia, and perforation of an intestinal loop. Moreover in any case 
 where it might be efficacious, as in the beginning of the pregnancy, laparat- 
 omy in the hands of an experienced surgeon is attended with less risk. 
 
 Electricity has been employed by the following methods : electro-punc- 
 ture, galvanization, and faradization. The latter only is in use at the present 
 time. The negative pole is applied to the rectal or vaginal mucous mem- 
 brane in the neighborhood of the ovum. The positive pole is applied by 
 means of a large electrode to the abdominal wall an inch or more above Pou- 
 part's ligament. The current is passed for five or ten minutes, the strength 
 b)eing progressively increased according to the sensitiveness of the patient, 
 and the treatment is repeated if necessary. 
 
 This method has been very popular in America; it has also its ardent 
 advocates in Russia. It is very difficult, however, to arrive at any true idea 
 of its value, as exactitude of diagnosis is impossible, and as most of the re- 
 ports in regard to its results have been made by practitioners whose authority 
 is not established. 
 
 The treatment is far from being without danger, for, besides encouraging 
 temporizing in the presence of a condition which menaces life, it is itself 
 capable of exciting tubal contractions and causing rupture. Brothers has 
 reported two cases of death. Janvrin quotes a third. 
 
 Extraction of the Fcetiis, %vith or witJioiLt the Sac. — This, whether it be 
 accomplished by laparatomy or elytrotomy (vaginal incision), is, as I have 
 said before, the procedure which is gaining in favor, as applied to all the 
 stages of extra-uterine pregnancy. In order to place the indications, how- 
 ever, and to show their relations to the individual case, classification is indis- 
 pensable. 
 
 I . Pregnancy before the Fifth Month without Rupture. — As at this period 
 
714 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 we can obtain no certain signs of pregnancy, action must be based upon not 
 much more tiian a suspicion of the nature of the case. To justify laparat- 
 omy it is sufficient for us to know tliat we have a painful tumor of the ap- 
 pendages. The operation at this time does not differ materially from that 
 for the extraction of serous, bloody, or purulent cyst of the tubes, the major- 
 ity of extra-uterine pregnancies being tubal in origin; this frequency is such 
 that Lawson Tait goes so far as to deny the existence of any other variety. 
 A single distinguishing feature in the technique of these operations refers to 
 the danger from hemorrhage in case of rupture of the cyst during the efforts 
 at extraction. This accident, which may be fatal, has been noted by several 
 authors. 
 
 In operating for a non-pediculated tumor such as is found in intra-liga- 
 mental or subperitoneal pregnancy, which is in fact a species of included 
 cyst, we dissect out the cyst, incising the serous capsule at a point free from 
 blood-vessels, rapidly placing artery forceps where needed. The placenta is 
 removed at once, in order to avert the profuse hemorrhage which might occur, 
 even at this early stage. Tamponing the cavity with iodoform gauze may 
 also be of service. 
 
 Extirpation of foetal cysts of the tubes during the first three months has 
 been practised frequently of late, and the reports of societies show that such 
 operations are becoming more and more numerous. They are not danger- 
 ous : Lawson Tait has had a series of 43 successful cases; Veit reports 12 
 recoveries out of 15 cases, and Zweifel 8 cures out of 10 cases. 
 
 Elytrotomy has been performed during the first four months of extra- 
 uterine pregnancy. It amounts to the same as vaginal incision of a retro- 
 uterine haematocele ; sometimes one finds only clots, sometimes a foetus and 
 placenta. In all cases we should be conservative as to examinations and 
 manoeuvres which might lead to rupture of peritoneal adhesions. 
 
 2. Pregnmicy before the Fifth Month, complicated by Rupture and Grave 
 Ijiterjial Hemorrhage. — The question of treatment in these cases is no longer 
 subject to the uncertainty which surrounded it a few years ago. When hem- 
 orrhage from an external wound or from an internal rupture threatens the life 
 of a patient, we must at once seek its source. Temporizing, waiting for 
 spontaneous hsemostasis, is in the great majority of cases to abandon the 
 woman to her death. The responsibility of operating in such a case is a 
 much less serious alternative, for if the patient do not succumb from shock, 
 she will die from a second or a third attack of hemorrhage or from the com- 
 plications of the resulting enormous hasmatocele. The cases in which spon- 
 taneous recovery has justified such an excess of caution on the part of the 
 physician are rare. 
 
 Keller in 1872 formulated the preceding rule. Its demonstration, how- 
 ever, belongs to Lawson Tait, who has had recovery in forty out of forty- 
 two cases. It is true that in only twelve of these cases could the foetus be 
 found, but in the remaining cases the placenta rendered the diagnosis of 
 
EXTRA-UTERINE PREGNANCY. 71$ 
 
 extra-uterine pregnancy certain. His example has been followed in America 
 and Germany. Schwarz recommends in this connection that we remove the 
 whole of the blood, not placing any dependence upon the absorptive powers 
 of the peritoneum, but rather in the case of profuse hemorrhage, fearing the 
 depressive influence upon the nervous system of the accumulated clots. 
 Haemostatic tamponing of the peritoneal cavity with iodoformed gauze should 
 be used if necessary. 
 
 3. Pregnajicy beyond tJie Fifth Month, the Child being Alive. — These cases 
 of course assume a large degree of importance, but great difference of opin- 
 ion exists in regard to them on the part of different authorities. Some have 
 in mind an operation which will save both the mother and child ; while others 
 are occupied exclusively with the mother and the more or less pronounced 
 danger which attends interference with the placental circulation when it is 
 in an active condition. The foetus is a negative quantity in the problem, 
 for, they argue, as it is probably deformed, rarely viable, its preservation 
 should not weigh in the balance when it endangers the mother's life, and 
 the latter is the only factor to be considered. 
 
 The partisans of primary operation, on the other hand, say that, in the 
 case of operation after the death of the foetus, if the woman is less exposed 
 to the danger of hemorrhage, she is more exposed to that of septicsemia, the 
 likelihood of which increases rapidly during the two months necessary for 
 the cessation of the placental circulation, this being the time assigned by 
 the advocates of the expectant treatment. 
 
 On the whole, the vitality of the ectopic foetus has been greatly under- 
 rated. Many cases are known in which it has been perfectly developed. If, 
 then, through the progress of operative technique, the chances for the mother 
 are the same whether the operation is performed before or after the death of 
 the foetus, the first period is certainly the one to be preferred. 
 
 We must acknowledge, however, that the results have not thus far been 
 as a whole encouraging. Maygrier, out of 17 cases collected up to 1886, 
 found a mortality of 15 cases, or 88.2 per cent. In 10 cases the woman died 
 of hemorrhage, either at the time of the operation, from the detachment of 
 an adherent placenta, or later, following the spontaneous detachment of pla- 
 cental fragments. Of the infants, 9 lived only a few hours and the fate of 8 
 was unknown. Werth has collected 8 cases, published from 1880 to 1886, 
 with 7 deaths for the mother, and 3 only for the child; 2, however, suc- 
 cumbed soon after birth ; 2 others were well at the age of three months. 
 
 Harris has still more recently collected 30 cases of primary laparatomy, 
 performed, that is to say, before the death of the foetus. He found up to 
 1880, 20 cases with i success only for the mother and 10 for the child, life 
 persisting for a variable period. From 1880 to 1886 he found 10 cases with 
 4 successes for the mother and 6 for the child. 
 
 At the present time, however, the aspect of the question is changed. 
 Operations are now, as a rule, successful, as witness the following statistics^ 
 
7l6 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 gathered by me since those of Werth in 1886. Lazarewicz, Breisky, L. 
 Briihl, John Williams, Eastman, Olshausen, Braun (two children and two 
 women living), Treub, Lawson Tait (three operations, three infants and two 
 women living). Rein and Lihotsky, Taylor, v. Strauch, Chrobak, Schneider, 
 Frommel, M. Price, Johnson, Urbain, Gueniot, Werder, Roncaglia, Pinard, 
 Reismann, have all operated a little before term, or at term and have saved 
 both mother and child. Champneys, Braun (in a second case), Stadfeldt, 
 Gueniot, Marchand, Sippel, Lebec, saved the child alone. Spaeth and Jos- 
 eph Price lost both, but they operated in the presence of peritonitis due to 
 rupture of the sac. Hildebrandt operated upon two moribund cases, but 
 succeeded in saving one child. 
 
 G. Beisone lost the mother, but saved the child. Schauta and Olshausen 
 (in a third case) saved the mother, but the child rapidly succumbed. Rochel 
 .saved the mother, but the child seems not to have lived. To sum up, exclud- 
 ing the second case of Price and those of Spaeth and Hildebrandt, which 
 were desperate, we have, as a result of 40 operations, 29 living women, and 
 32 children who lived for at least a few days. 
 
 This success seems to be due principally to the improved technique of 
 the operation, and in particular to the complete ablation of the sac and of 
 the placenta. We can see here, as in all laparatomies, how we may with 
 experience surmount operative difficulties. We see also the evident exag- 
 geration of those persons who consiaer the ectopic foetus necessarily doomed 
 on account of deformities or congenital teebleness. Even when this feeble- 
 ness exists, we know that we have resources in " gavage" and the " couveuse," 
 by which we may at the present time save the child who in other days would 
 have been lost. We may now perform laparatomy with the expectation of 
 saving two lives. It is preferable not to wait for the phenomena of false 
 labor, as Duncan and Reed recommend, because the foetus then succumbs 
 very rapidly. According to the recommendations of Fraenkel we may de- 
 cide upon the time for intervention by the volume of the foetvis as deter- 
 mined by external examination and palpation; the operation is usually prefer- 
 ably done during the first two weeks of the ninth month. 
 
 In regard to the choice of methods, laparatomy is as a rule indicated, for 
 it permits us to cope with the operative difficulties which present themselves. 
 We would not, however, entirely proscribe elytrotomy. If on vaginal exami- 
 nation we do not find the placenta, and if the foetus be deeply engaged in 
 the pelvis, elytrotomy may be preferable even as affording drainage for the 
 placental wound which will be probably located upon the anterior wall of the 
 abdomen. This situation may be assured if on auscultation the placental 
 bruit is found synchronous with the maternal pulse. 
 
 At the inception of false labor the woman should be kept absolutely quiet 
 and the pains should be controlled by injections of morphine or enemata of 
 laudanum. Operation at this period will be ill-timed, at least unless the 
 phenomena of grave interna] hemorrhage make it necessary. 
 
EXTRA-UTERINE PREGNANCY. 71/ 
 
 Pregnancy beyond the Fifth Month, the Child recently Dead. — The ques- 
 tion of laparatomy immediately after the death of the foetus is, by the ma- 
 jority of foreign authors, and unanimously by those of our own country, 
 answered in the negative. Parry advocates indefinitely expectant treatment^ 
 and trusts to the transformation of the foetus into a lithopaedion and to its 
 spontaneous elimination. This doctrine was also held by Tarnier and Budin. 
 Litzman, Werth, Maygrier, and Pinard give a less absolute rule, but, influ- 
 enced by the older statistics and fear of hemorrhage, advise waiting until the 
 obliteration of the placental circulation. The time required for this obliter- 
 ation is uncertain; for while it has been approximately given as two months, 
 alarming hemorrhage has been known to follow detachment of the placenta 
 at the end of three months, so that the delay has not only permitted the 
 death of the child, but has also exposed the mother to new dangers. Many 
 of the deaths following secondary operation, that is to say, an operation 
 which has of deliberate purpose been delayed, may be attributed to the 
 expectant treatment, since intercurrent septicaemia or peritonitis often fatally 
 complicate the surgical intervention which a few months previously could 
 have been undertaken under the most favorable conditioris. In consideration 
 of the results obtained in recent cases of primary operation (laparatomy) we 
 shall be authorized, I think, in reforming the dictum which has been set 
 down by our predecessors and adopted as a rule. Here, as in all of the prob- 
 lems of abdominal therapeusis, the theoretical objections of the timid sur- 
 geon fall before the results of a bolder practice characterized by good tech- 
 nique. 
 
 The advent of fever and the prodromata of septicaemia, instead of contra- 
 indicating operation, but render it more urgent. In even such cases the 
 patient has been saved. 
 
 5. Pregnancy beyond the Fifth Month, the Child having been Dead for a 
 Considerable Time. — -If the death of the foetus has been remote and tolera- 
 tion seem to have been established, and there is a prospect of its transforma- 
 tion into a lithopaedion, is it wise to interfere and to subject to the dangers 
 of laparatomy a woman who is otherwise in good health.'' I believe that 
 even in such cases operation is indicated, in view of the future. It is an. 
 established fact that the tolerance accorded to the ectopic foetus is always 
 precarious, and that decomposition of the ovum with infection and consecu- 
 tive peritonitis may supervene at any time before the foetus is entirely trans- 
 formed. Even after the change has been completed infection may occur, 
 and be followed by expulsive efforts due to suppuration, causing grave com- 
 plications and great danger. 
 
 6. Old SnppJirating Fcctal Cysts, with or witJiout a Fistula. — It is appar- 
 ent that here we have simply to assist the work of nature. 
 
 If an abscess exist we should open it, whether it point toward the abdom- 
 inal wall, the rectum, or the vagina, and explore for the foetal bones. We 
 are sometimes aided by the existence of a fistula, allowing the use of a 
 
7l8 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 probe, which can be carried into the little skeleton and serve as a guide for 
 the incision. These operations compare favorably with those for the extrac- 
 tion of the foetus by laparatomy. They are without danger if care is used 
 to secure antisepsis in the matter of the sac, which is generally very foul. 
 
 I have had occasion to remove b}' the rectum the whole of the skeleton 
 of a foetus in a case in which spontaneous efforts at elimination both by rec- 
 tum and vagina had failed. Sloughing of the septum from the pressure of the 
 sac had resulted in a recto-vaginal fistula. The patient was seen in the ser- 
 vice of Gallard. She recovered rapidly, thanks to regular antiseptic injec- 
 tions of the cavity of the abscess, which was very fetid. Out of twenty-three 
 cases collected by Parr)^ of suppurating fatal cysts of long standing, only 
 three ended fatally. 
 
 7. Pregnancy in a Rudimentary Uterine Horn. — If abandoned to them- 
 selves, cases of this kind give a mortality of twenty-three out of fifty during 
 the first six months. The indication here is to interfere by laparatom}^ 
 The operation is much more simple than in the preceding class of cases, 
 and has been successful in five out of six cases, performed either at term 
 or long after. The horn of the uterus is removed, just as is the case with 
 the entire uterus in Porro's operation. A patient of Sanger was twice 
 normally delivered after such a procedure. 
 
 Technique of Extraction by Laparatomy . — I do not here intend to describe 
 every detail of the operation, since the rules already indicated in the chapters 
 on hysterectomy and ovariotomy are applicable here as well. I merely wish 
 to draw attention to a few special points relative to the difficulties to be 
 expected. 
 
 Hevi07'rhage is the complication most to be feared where the pregnancy 
 is advanced and the child is alive or but recently dead. To guard against 
 this danger in choosing a place for opening the sac, we must avoid the situ- 
 ation of the placenta. If on examination of the relations we find total re- 
 moval of the sac difficult, we must give it up and suture it to the abdominal 
 wound, being careful to obser\"e the precautions mentioned further on. Trac- 
 tion on the cord or placenta should be avoided. The best medium for con- 
 trolling hemorrhage is the tampon of iodoform gauze. Whatever the cause 
 of application, the loose tampon of iodoformed gauze may be left in position 
 without fear of decomposition for three or four days. Where used to com- 
 bat hemorrhage, it should not be removed before the eighth day. 
 
 Infection of tJie peritojienm by the contents of the cyst is to be guarded 
 against in cases in which we operate after the death of the foetus and in which 
 the patient has fever indicating septic absorption. We should try to remove 
 the sac entire without openinp^ '■'': If we cannot avoid an incision, it will be 
 better not to dissect out the sac, as the raw surface left by this procedure is 
 exposed to infection from the septic contents. 
 
 A. Retention of the Cyst. Marsnpialirjation. — Where enucleation of the 
 sac without incision is difficult, it is advisable to tampon down the abdomi- 
 
EXTRA-UTERINE PREGNANCY. 719 
 
 nal wound over the sac with iodoformed gauze, and to postpone the opening 
 of the cyst for several days in the hope of the formation of bands of adhe- 
 sion which will unite it to the abdominal wall. If the situation is urgent 
 and does not permit this delay, we may before opening the sac unite it to 
 the layers of the wound by a line of sutures or by a rapidly inserted continu- 
 ous suture. In placing these sutures which unite the al^dominal wall with 
 the sac, care should be taken not to penetrate into the interior of the cavity, 
 but to carry the needle through the superficial layers only of the wall of the 
 sac. Incision should be followed by delivery of the foetus by the feet, and 
 division of the cord between two ligatures. We should then thoroughly 
 cleanse the cavity with a solution of corrosive sublimate (i : 2,000) or if pre- 
 ferred a saturated solution of naphthol ; explore the bottom of the sac and, 
 if it reach the neighborhood of the vagina, introduce a forked drainage tube, 
 passing the longer branch through the posterior vaginal cul-de-sac. The 
 placenta may be mummified by the use of a mixture of tannin and salicylic 
 acid or powdered benzoate of sodium. Iodoform gauze is to be kept in the 
 sac, and drainage carefully attended to. Cicatrization takes place slowly by 
 granulation. The placenta comes away in fragments. 
 
 Martin has a treatment of the sac analogous to that which he uses after 
 the enucleation of intra-ligamentary fibroid tumors. He removes as large a 
 part of the wall of the cyst as possible and sutures the remainder, so as to 
 completely isolate the interior of the cyst from the peritoneal cavity, and 
 drains through the vagina. 
 
 B. Total Extirpation of the Cyst. — This is a most important modification 
 in the pperative technique. The treatment by suppuration of the sac is 
 comparable to that of certain adherent ovarian cysts. It is very tedious, and 
 may result in a permanent fist'.da, besides exposing the patient to the danger 
 of hernia. Litzmann first proposed to entirely remove the sac with its con- 
 tents, the foetus and placenta, so as to favor rapid recovery as after the re- 
 moval of hsemato- or pyo-salpinx. This procedure, called the radical opera- 
 tion, did not, however, at first give as good results as that by retention of 
 the sac. Maygrier, in 1886, knew of only 7 cases of extirpation of the sac. 
 Werth, out of 1 1 cases collected in 1886, notes 7 recoveries and 4 deaths, or 
 a mortality of 36 per cent ; while out of 40 cases with retention of the sac 
 there were 14 deaths and 26 recoveries, or a mortality of 35 per cent. Later 
 the operation has given a series of remarkable successes with a living child. 
 In several of these cases adhesions implicating the intestines did not pre- 
 clude recovery. Werth, who has collected a more recent series, embracing 
 cases of laparatomy for pregnancy at term published since 1887, has out of 
 9 operations only i without extirpation of the sac. This series has only 2 
 deaths. I have myself a larger list, including statistics for the last two 
 years, completing by continuity the series of Maygrier and of Werth in his 
 first great work. Many cases have undoubtedly escaped me ; yet I have 
 found 18 cases of extirpation of the sac (1887 to 1891), witn 26 recoveries, 
 
720 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 I death, and i result unknown. Of operations for the extraction of the liv- 
 ing child I have already cited the 9 cases of Lazarewicz, Breisky, Eastman, 
 Olshausen (i case), Traub, Schauta, Rein, Lihotsky, and de Reismann. The 
 others, in which the operation was done after the death of the child and at 
 term, are as follows : Hofmeier, i case, with a fatal result ; Kusnetzky, 2 
 cases, recovery; Sutugin, 2 cases, with recovery; Muratow, i case, with re- 
 covery; Sajaisky, 2 cases, with recovery; Kadjan, i case, with recovery; 
 Slavjansky, i case, with recovery; Quenu, i case, with recovery; Wiedow, 
 I case, with recovery; and Olshausen, 3 cases, recovery; Matlakowski, 
 I case, recovery; Rein, i case, recovery; Odenthal, i case, recovery; 
 Fantino, i case, recovery ; Schauta, i case, recovery ; Folet, i case, 
 recovery. 
 
 Technique. — Definite rules for the technique of this procedure can- 
 not be given. In its main features it resembles operation for the extir- 
 pation of an adherent ovarian cyst or for a parovarian cyst included 
 within the broad ligament. The principal operative stages are, however, 
 as follows : 
 
 1. Abdominal incision with provisional sutures uniting the sac to the 
 lips of the abdominal wound. 
 
 2. Opening of the sac at its thinnest portion, avoiding vessels if possible 
 or seizing them as they are divided. 
 
 3. Extraction of the foetus by the feet, ligature and section of the cord. 
 
 4. Removal of the provisional sutures, extraction of the sac by rupture 
 of the adhesions, and enucleation of the subserous portion ; forceps should 
 be rapidly applied to bleeding points, the fingers being used to aid in com- 
 pression if needed. 
 
 5. Final haemostasis of the base of the sac by ligature or the tampon of 
 iodoformed gauze. Even where the tampon is not employed it will be wise 
 not entirely to close the abdominal wound, but to maintain drainage from 
 the lower portion either by a rubber drainage tube or several strips of anti- 
 septic gauze. If the sac is strongly adherent to the intestine, we must re- 
 sect it up to the adherent parts, and continue the tampon of iodoformed gauze 
 of the base of the sac until complete exfoliation of the retained portions of 
 the cyst. 
 
 Ttxhniqtie of Extraction by Elytrotomy. — The vaginal incision was advo- 
 cated by Baudelocque. Maygrier, in 1886, collected 4 cases of elytrotomy 
 in the second part of pregnancy, the foetus being alive. These presented 2 
 recoveries, i doubtful, and 2 deaths, or a mortality of 50 per cent. The 
 same operation with a dead foetus has given 7 recoveries and 5 deaths, or a 
 mortality of 41.6 per cent. Schauta found from 1876 to 1891 12 cases 
 of elytrotomy, of which 5 were during the four last months of pregnancy, 
 and 7 after term. Of the 5 first cases, the placenta was left 3 times (i 
 death). Twice the placenta was removed, in i case with a living child, and 
 the patient cured ; the other patient died. In the 7 cases of elytrotomy after 
 
EXTRA-UTERINE PREGNANCY. 72 I 
 
 term 3 were followed by death ; in i case only was the placenta removed. 
 This operation, in my opinion, should be reserved only for cases in which 
 the foetus is dead. We cannot, in the absence of reliable reports, assert 
 that it is dangerous to the living child, but a priori this would seem to be 
 the case from the danger of hemorrhage. In laparatomy, hemorrhage can 
 more readily be controlled. It is altogether different where the foetus is 
 dead. Here elytrotomy is to be preferred when the cyst is impacted in the 
 pelvis, the placenta not being accessible by the vagina, and the bladder and 
 uterus displaced laterally. The first condition only constitutes the real in- 
 dication, for the presence of the placenta in the vaginal cul-de-sac causes no 
 real danger after the expiration of about two months when the foetal circu- 
 lation has ceased. 
 
 The following is the technique observed by Pinard, who successfully 
 performed two elytrotomies for two cases of pregnancy at term, the child 
 being dead : The woman is anaesthetized and placed in the obstetrical posi- 
 tion. After exploration of the vaginal cul-de-sac, puncture is made with a 
 bistoury at a point distinguished by absence of arterial pulsation. The fin- 
 ger is introduced through this mcision, which is enlarged by tearing and 
 dilatation accomplished by the fingers introduced as a cone. The hand hav- 
 ing entered the opening, the foetus is grasped by the feet, which are brought 
 to the vulva. By slow and continuous traction, the breech and the trunk are 
 made to engage ; the two arms and the head are then delivered. The cord 
 is secured and the placenta is removed if it can be easily detached. If, 
 however, there appear to be adhesions, it is left in place. The interior of 
 the cyst should be irrigated with a solution of corrosive sublimate (i : 5,000) 
 or a saturated aqueous solution of ,5 naphthol. I am inclined to think that 
 the introduction of iodoformed gauze is preferable to the frequent injections 
 recommended by Pinard. The gauze may be renewed every three or four 
 days, or even be allowed to remain undisturbed much longer. Should phe- 
 nomena of septic infection supervene, we could resort to the continuous irri- 
 gation, which has given such good results in puerperal septicaemia. 
 
 Spontaneous elimination of the suppurating sac through the bladder is 
 very rare. Winckel, in a recent work, has collected only twelve published 
 cases. Laparatomy, the vaginal incision, elytrotomy, the sub-pubic incision, 
 have all been tried. These operations can be, as a rule, avoided. It is 
 sufficient to dilate the urethra, or if necessary to incise it so as to reach the 
 orifice of the sac with the index finger, to enlarge this, to extract the bones 
 of the foetus with the forceps, and to cleanse the sac by injections. If it is 
 not possible to treat the condition in this way, or if serious accidents require 
 active intervention, we may resort to vaginal incision followed by immediate 
 suture after the evacuation and disinfection of the sac. The operation 
 through the dilated urethra may be completed in two or three seances, with 
 the aid of cocaine. Borated vesical injections should be continued until all 
 traces of cystitis have disappeared. 
 46 
 
'J22 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 In cases in which a large cyst is firmly impacted in Douglas' cul-de-sac, 
 instead of elytrotomy we may prefer perineotomy either transverse or vertical, 
 or a para-sacral incision, or we may gain access to the pelvic cavity by means 
 of a preliminary resection of the coccyx and a part of the sacrum. It be- 
 longs to the future to determine the suitable application of these new opera- 
 tions. 
 
CHAPTER XXXV. 
 
 DISEASES OF THE VAGINA. 
 
 Vaginitis. 
 
 Pathogenesis and Etiology. — The mucous membrane of the vagina, like 
 other mucous membranes in immediate contact with the air, is a dermo- 
 papillary surface markedly analogous to the external integument in its rugos- 
 ities and its stratified pavement epithelium. It is, however, distinguished 
 from the skin by the absence of the impermeable corneous layer. The con- 
 stant exfoliation of the cells of the mucous membrane and the incessant re- 
 iiewal of its exposed surface form its only protection against the action of 
 external irritants, and it is difficult to understand exactly how the mucosa 
 resists the action of the numberless germs which multiply in the vaginal 
 canal. The new pathogenic theories in regard to the comparative receptiv- 
 ity of the various tissues to infection are evidently applicable to this case. 
 The vagina is the normal habitat of indifferent microbes. Several of these 
 are pathogenic in character, but rendered inoffensive through attenuation. 
 These morbid germs gain entrance in a number of ways — through the simple 
 entrance of air, coitus, injections, etc. Inoculation shows that for these 
 germs to multiply or to exhibit their virulence we require a medium favor- 
 able for their culture. Irritation is not, as held by the older authors, a suffi- 
 cient cause. Burning with the red-hot iron and the action of caustics will 
 cause but a localized lesion, an ulcer without surrounding inflammation, if 
 injections be employed which prevent the accumulation of secretions; while 
 the same lesion, or the presence of a foreign body otherwise aseptic, such as 
 a pessary, will develop an intense vaginitis if with neglect of cleanliness we 
 have the conditions which favor the development of the microbes. These 
 considerations indicate the pathogenesis of vaginitis, and explain the predis- 
 posing influences of menstruation and parturition, as these favor the stagna- 
 tion and decomposition of secretions. 
 
 Gonorrhoeal infection is of supreme importance in the etiology of vagini- 
 tis, on account of the persistent character of the inflammation caused, and 
 the gravity of its complications. Since the discovery of Neisser, the germ 
 of this affection has been considered a specific coccus called the gonococcus, 
 present in the form of rounded or oval bodies, resembling coffee beans, and 
 sometimes adhering by their plane surfaces, producing a profile like the fig- 
 ure 8. In groups of five to ten these form globular colonies surrounded by 
 a single hyaline membrane. Associated with pus or more rarely with epi- 
 
724 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 thelial cells, they penetrate these and multiply in their interior. This proD- 
 erty appears to distinguish them from other varieties of the same form. 
 This last assertion has, however, been contradicted by Stekhoven. The gono- 
 cocci penetrate the epithelium with greater ease where the cells have been 
 dissociated by the formation of pus. The microbes are colored by methyl 
 violet and fuchsin. 
 
 Bumm states that the development of gonorrhoea is never primary in the 
 vagina, but that invasion is by v/ay of the cervix or more rarely the urethra^ 
 
 
 
 B 
 
 Tig. 473. — Microbes of Gonorrhcea. (Neisser's gonococcus.) A, Transverse section of palpebral conjunctiva 
 in a case of gonorrhceal ophthalmia which had been in existence for three days. The gonococci have penetrated the 
 epithelial layer, and are scattered in small groups through the subepithelial tissue . B, Specimen taken from the vaginal 
 secretion of a puerperal woman ; a, epithelial cell and pus corpuscle, upon and around which may be seen bacilli and 
 gonococci ; i, gonococcus from a pure culture ; c, diagram of the diplococcus of gonorrhoea (gonococcus) (Bumm),. 
 
 where the epithelium is least resistant. This is especially true of the cervix,, 
 where the epithelium is cylindrical. According to Steinschneider and Fa- 
 bay, however, the urethra is the more frequently attacked. 
 
 According to Schultz's recent investigations it appears that the cervix 
 and urethra are involved in the same proportion of cases. In 104 cases in 
 which he discovered the gonococcus, it was found 81 times in the cervix, /8 
 times in the urethra, and in only 9 instances in the vagina. 
 
 The role of the gonococcus was long undisputed, the facts proving its 
 preponderating agency appearing to be easily demonstrated. Most numer- 
 ous in the acute stage, rarer in the chronic forms, they multiply or diminish 
 in number according as the disease is active or latent. They are found in 
 gonorrhoeal discharges from the urethra, the glands of Bartholin, the rectum, 
 in gonorrhoeal salpingitis, and in purulent ophthalmia. They have even been 
 
DISEASES OF THE VAGINA. 725 
 
 discovered in the blood and in the articular synovial fluid of patients suffer- 
 ing from gonorrhoeal rheumatism. 
 
 Succeeding to this period of certainty has come a time of doubt and crit- 
 icism. The specific value of the gonococcus has been denied on account of 
 its extreme resemblance to the non-pathogenic diplococci. These microbes 
 or pseudo-gonococci, so to speak, are found in intestinal, pulmonary, and 
 buccal ulcerations, according to Eklund; according to Amicis, in simple ex- 
 perimental urethritis; and according to Sternberg, in urine, which he con- 
 siders their normal habitat (micrococcus ureae). Is, then, the gonococcus 
 but an indifferent saprophyte capable of taking on pathogenic characters 
 imder peculiar conditions ; or is it a distinct species, having definite patho- 
 genic properties and susceptible of attenuation and of preserving in a latent 
 state the noxious properties to which it reverts in a favorable medium ? 
 This is the hypothesis which appears most probable ; but, on the other hand, 
 direct experiment by means of cultures and inoculations have not given a 
 decisive result. Sometimes they produce gonorrhoea, but more often not. 
 Besides the presence of the microbe itself, there are other necessary factors 
 which can be inferred but have not yet been demonstrated. 
 
 The pathogenic microbes of suppuration and putrefaction also cause 
 vaginitis if favorable circumstances are present; that is to say, if they gain 
 access to the genital canal in sufficient numbers, and if they find there in 
 retained secretions a suitable medium for growth. These germs may be in- 
 troduced from without. A gaping vulva enfeebled by rupture of the peri- 
 neum favors their development. An opposite condition, the presence of a 
 hymen at the introitus, may have an analogous effect by a different mechan- 
 ism, namely, the retention of secretions and of the menstrual discharge in 
 the retro-hymeneal cul-de-sac. This is the predisposing cause of non-spe- 
 cific vaginitis in little girls and virgins; to it may be added masturbation, 
 which causes direct inoculation. The various kinds of vulvar inflammation 
 due to the erythemata and the exanthemata may also serve as the determin- 
 ing cause. Oxyurides, transported from the rectum, are often intermediary 
 agents. Infection may be also by means of fistulae communicating with the 
 bladder or rectum. This is, however, exceptional. A frequent and often 
 unrecognized medium is some pathological secretion from the uterus. The 
 vaginal leucorrhoea which complicates metritis has no other known origin, as 
 it disappears as a rule after curetting or efficacious medicinal applications. 
 Local irritation and hyperaemia are not sufficient to produce vaginitis. They 
 but permit the more rapid dev^elopment of the original germ or of one intro- 
 duced from without. This is the explanation of the influence of masturba- 
 tion with or without the introduction of a foreign body, of the prolonged 
 retention of a pessary with absence of care in regard to cleanliness, and of 
 stasis due to disease of the heart or li\'er or to the presence of abdominal 
 tumors or pregnancy. Bumm has made the curious statement that the latter 
 condition will provoke an excessive development of gonococci even in cases 
 
726 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 in which the date of infection lias been very remote. Von Herff has observed 
 what he has termed mycotic vaginitis, an affection whose pathological agent 
 appears to be the oidium albicans. It occurred during pregnancy fifteen 
 times in twenty-six cases, in women with gaping vaginas, and during the hot 
 months of the year. The congestion of the genital organs at the period of 
 the menopause, perhaps, determines the vaginitis of this period. To these 
 agencies may be added : exposure to cold, excessive coitus, genital excitation, 
 the use of the sewing-machine, horseback-riding, etc. 
 
 From a clinical point of view we distinguish a certain number of types : 
 
 1. The gonorrhoeal vaginitis of adults, which is the most common form, 
 and which is found also in little girls and virgins, in which case its nature is 
 often unrecognized. 
 
 2. The gonorrhoeal vaginitis of little girls and virgins, which may be the 
 result of gonorrhoeal infection of unknown origin. In regard to this affec- 
 tion it may be said that ordinarily the vagina has been previously made re- 
 ceptive by an exanthem, such as m.easles or scarlet fever, which has enfeebled 
 the whole S3-stem and caused a desquamation of the epithelium. But there 
 exists also a non-specific vaginitis due to the development of a simple sa- 
 prophyte in feeble children or to a neglect of the laws of hygiene. I have 
 indicated the role of the oxyurides, also that of narrowness of the hymeneal 
 orifice, the predisposing influence of which can be compared to that of 
 congenital phimosis in the production of balanitis in the male. 
 
 3. The vaginitis of pregnant w^omen. This is sometimes due to an old 
 gonorrhoea, but may be also of non-specific origin, and still may cause marked 
 symptoms, vegetations, discharges, etc. It is without doubt due to infection 
 by means of the staphylococcus or the streptococcus. As to the septic vagi- 
 nitis of the parturient woman, it is not a distinct morbid entity, but simply 
 a local manifestation to be ascribed, like other symptoms, to general suppura- 
 tive tendency; often it is of mixed puerpero-gonorrhosal origin. 
 
 4. The vaginitis of the menopause and of old women has usually an un- 
 defined anatomical form. The absence of hygienic care and a herpetic diath- 
 esis are ordinarily sufficient to explain its production. 
 
 Pathological Anatomy. — The vagina is rarely affected through its whole 
 extent; and then usually in the acute stage of an inflammation caused by a 
 recent gonorrhoea, an exanthem, or an active local irritation such as a caustic 
 injection or traumatism. In such cases the mucous membrane is swollen, 
 reddened, and covered with muco-pus. Most frequently the general inflam- 
 mation is preceded by inflamed isles or plaques. In some cases diseased 
 zones alternate with zones of healthy tissue. 
 
 From the standpoint of pathological anatomy, C. Ruge distinguishes three 
 forms of vaginitis: (ij granular vaginitis; (2) simple vaginitis; (3) senile 
 vaginitis. We may add a fourth, emphysematous vaginitis — a rare lesion, 
 but one which constitutes a distinct variety. 
 
 I. Gramilar Vaginitis. — This is the most common variety of vaginitis. 
 
DISEASES OF THE VAGINA. 
 
 727 
 
 the acute and chronic form being equally frequent. The epithelium is thick- 
 ened, especially in its deeper layers, which the reagents color strongly. The 
 papillas are hypertrophied, infiltrated with small cells, and by diminution of 
 the intervening" spaces so fused as to form little vnasses called granulations. 
 The epithelial reflections may become thinned, and take on a granular ap- 
 pearance, which may cause them to be mistaken for granular tissue itself; 
 in such case we are liable to the error of believing that there is a follicular 
 
 
 Fig. 474. — Granular Vaginitis (Ruge). 
 
 formation, whereas in reality there is merely a transformation of the papillae 
 and their epithelial covering, with increase of the capillary reticulum (Fig. 
 
 474). 
 
 2. Simple Vaginitis. — In this variety the epithelial surface remains quite 
 smooth, but is thickened in spots. At the thinnest portions the papillae are 
 
 Fig. 475. — Simple Vaginitis (Ruge). 
 
 swollen, and the subjacent tissue is infiltrated with small cells. This pro- 
 liferation is, however, limited to the epithelial layers, thus differing from 
 granular vaginitis (Fig. 475). 
 
 3. Senile Vaginitis (Colpitis Vetularum). — This affection is present in 
 the form of larger or smaller patches, elevated above the surface of the mu- 
 cous membrane, and fused together in some places. These patches have 
 a variable structure. Sometimes they present the characteristics of ecchy- 
 moses only; in other cases the centre of the patch is softened, and the epi- 
 thelial covering is thinned or destroyed so as to permit the formation of 
 adhesions which tend to obliterate the vaginal canal. Miliary vaginitis or 
 the vesicular vaginitis described by Eppinger belongs to this variety; also 
 the ulcerating, adhesive vaginitis of Hildebrandt. It is probable that it 
 should include too the so-called leucoplasia of the vaginal mucous membrane. 
 
72 8 CLINICAL AND OPERATIVE GYX.-ECOLOGY. 
 
 All the reported cases of this affection have been in old women, and, accord- 
 ing to the descriptions, the lesion is not different from that which has been 
 described by Ruge. The reasoning which would prove them to resemble 
 buccal psoriasis is superficial and faulty. 
 
 4. Emphysematoics Vaginitis or Cystic PacJiy-vaginitis. — I have already 
 referred to the inflammatory engorgement presented at times by the mucous 
 membrane of the vagina during pregnancy. The rugae separated by fissures 
 have been compared by Winckel to grains of corn upon the ear. These ele- 
 vations may be traversed by lacunse containing fluid or gas. Except in 
 pregnancy the affection is very rare. It has been called cystic colpo-h3-per- 
 plasia by Winckel. The gas is not, however, contained in cystic cavities, 
 but, according to Ruge, within the meshes of the connective tissue. The 
 condition should, therefore, rather be called emphysematous vaginitis. Prob- 
 ably the formation of gas is secondary to a molecular degeneration of inflam- 
 matory proliferating tissue, but this has yet to be demonstrated. Chiari 
 holds that the gas is developed within the enlarged lymphatic capillaries, 
 which are filled with swollen epithelial cells. The vesicles may rupture and 
 form small temporary ulcerations, or they may desquamate in the form of 
 scales. 
 
 Symptoms. — Where the vaginitis is the result of gonorrhoeal infection or 
 direct violence, local pain marks its invasion. Leucorrhoea is present, at 
 first serous, then of a greenish-white color, puriform or frankly purulent in 
 character. The discharge may be considerable in quantity, and give rise to 
 a most annoying \iilvar pruritus with subsequent enfeeblement of the gen- 
 eral health. After the acute stage the discharge becomes less, until finally 
 the affection can be detected only by careful examination of the culs-de-sac, 
 which form a kind of natural retreat where the remains of the old inflamma- 
 tion may for a long time linger. This fact has given rise to the designation, 
 gonorrhoea of the culs-de-sac. The glands in the neighborhood of the meatus 
 also remain for a long time infected. Gonorrhoeal infection of the vulva and 
 its glands is not alone enough to determine engorgement of the inguinal 
 glands. 
 
 In examination, Cusco's speculum is to be preferred. Digital examina- 
 tion reveals the condition of the mucous membrane — whether rugous or 
 glandular; in the acute stage it is hot and painful. 
 
 Urethritis always complicates gonorrhoeal vaginitis. To discover this 
 condition, examine the woman shortly after the passage of urine. Follow 
 the urethra with the finger from behind forward, so as to bring to the meatus 
 the drop of pus which it contains. 
 
 The general health is often affected by an intense leucorrhoea; it pro- 
 duces in particular distressing gastric derangements and a febrile condition 
 which may be either acute or subacute, due to salpingitis, with serous peri- 
 salpingitis, the affection described by Xoeggerath as recurrent parametritis. 
 
 Senile vaginitis often provokes no other symptom than a leucorrhoea, se- 
 
DISEASES OF THE VAGINA. 729 
 
 rous or tinged with blood. Chronic vaginitis of this variety tends to destroy 
 the tonicity of the vaginal wall and favors prolapse. 
 
 The symptoms of the emphysematous A-aginitis of pregnancy may also be 
 limited to the production of a discharge. 
 
 Vegetations, either benign or papillomatous, may be found on the vaginal 
 mucous membrane which is irritated by prolonged contact with a muco-puru- 
 lent secretion; they are frequent in gonorrhoeal vaginitis and are observed 
 also in the non-specific vaginitis of pregnancy. 
 
 The discharge of pieces of the mucous membrane after astringent injec- 
 tions or simply under the influence of a very active inflammation has been 
 called exfoliative vaginitis. This is a very rare phenomenon, and one which 
 is not to be confused with the expulsion of an intra-uterine or dysmenor- 
 rhoeal membrane, the microscope here showing large pavement epithelial 
 cells. 
 
 Diagnosis. — The great difficulty in diagnosis is the differentiation of 
 gonorrhoeal from non-specific vaginitis. The absence of the gonococcus is 
 not sufficient, and counter- evidence for it may be lost or become unrecogniz- 
 able in old gonorrhoeal affections, as I have already indicated. An accom- 
 panying urethritis is proof of the gonorrhoeal character of the disease. It is 
 m the urethra, then, that we should look for the characteristic microbes. 
 The course of the disease and the history of the patient will furnish impor- 
 tant evidence. If, further, the woman can be confronted with the supposed 
 author of the infection, as is often possible, the existence of even a very 
 old or latent gonorrhoea in the man will amount to a demonstration. Gonor- 
 rhoeal ophthalmia in one or several of her children will have the same diag- 
 nostic value. Pregnancy being excluded, the presence of vegetations is 
 strong presumptive evidence. Coexisting inflammation of the glands of Bar- 
 tholin is also a pretty certain index of gonorrhoeal infection. 
 
 In little girls, especially in the case of a medico-legal examination, we 
 should be careful not to pronounce too hastily upon the infectious nature of 
 the affection, as the extension of a vulvitis due to a lack of cleanliness may 
 involve the vagina, especially in a child of a lymphatic temperament ; here 
 too coincident urethritis has great diagnostic value. 
 
 The vaginitis of a pregnant woman may present conditions for analogous 
 mistakes. It should not be forgotten that it is sufificient to account for vege- 
 tations. We should not confuse an inflammatory secretion with the fetid 
 leucorrhoea of cancer or the discharge which succeeds retention of the mem- 
 branes after abortion. 
 
 Prognosis. — Gonorrhoeal vaginitis is a serious affection, on account of its 
 possible extension to the cervix and subsequently to the uterus and tubes. 
 It is besides not very amenable to treatment, and tends to return under the 
 influence of depressing agencies such as excessive coitus, chilling during 
 menstruation, excessive fatigue, and the puerperal state. In its character- 
 istics it greatly resembles an old gonorrhoea or goutte viilitairc in the male. 
 
730 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Gonorrhoea is in the female incomparably more serious than in the male; 
 this is easy to understand by comparing the prognosis of cervicitis with that 
 of a chronic gonorrhoea of the bulbous portion of the urethra ; or, again, the 
 prognosis of a tubo-ovaritis, which is so liable to suppurate, with that of an 
 epididymo-orchitis, which is very rarely a serious affection. More frequently 
 than in the male, too, the ascending lesions are bilateral and cause ster- 
 ility, obliteration of both tubes by chronic salpingitis being the rule in 
 prostitutes. 
 
 The element of gravest prognosis in the gonorrhoea of the female is the 
 fact that an apparently insignificant infection of the cervix may, under the 
 influence of the puerperal state, regain all its first virulence, and, combining 
 with septic infection, produce a mixed puerpero-gonorrhoeal infection, and 
 give rise to the gravest complications. The necessity for prompt and ener- 
 getic treatment will be appreciated. The decision of Noeggerath in regard 
 to the incurability of this disease is not without exceptions if the patient is 
 energetically treated in time. 
 
 The gravity of gonorrhoea in little girls is, as in the adult, dependent 
 upon extension to the uterus, the tubes, and the peritoneum. Saxinger has 
 observed pyo-salpingitis in virgins, where it could only be explained by the 
 contact of some infected material, and not by coitus. I have myself recently 
 operated upon a case of this kind. A case of generalized peritonitis reported 
 by Welander concerns a little girl of five years ; I have observed a case in a 
 young girl. These cases are very rare, but death by suppurative pelvic peri- 
 tonitis following pyo-salpinx may, at least at times, be a result of gonorrhoeal 
 infection. 
 
 The other varieties of vaginitis are less serious and yield more readily to 
 treatment. 
 
 Treatment. — We should first endeavor to discover what has provoked or 
 keeps up the chronic inflammation ; whether a pessary, the oxyuris, or cervi- 
 cal catarrh. In a large number of cases vaginitis is cured by treatment 
 directed to a metritis upon which it depends. Thus Schroder's operation, or 
 excision of the cervical mucous membrane, is one of the best methods of 
 treatment for certain forms of chronic vaginitis dependent upon gonorrhoeal 
 cervical infection. 
 
 Chronic granular vaginitis and senile vaginitis are best treated by tam- 
 pons of absorbent cotton soaked in borated glycerin or the glycerole of tan- 
 nin, or the application of nitrate of silver in solution (i : 20). 
 
 In the acute stage of gonorrhoeal vaginitis, emollients are to be recom- 
 mended. It is certain that prolonged baths and diluent drinks favorably 
 affect the urethritis which accompanies the vaginal inflammation. Injec- 
 tions of marshmallow or of flaxseed tea, etc., are, on the contrary, of doubt- 
 ful value, and may even do harm if not aseptic. Irrigations with several 
 quarts of boiled water (four to six) containing permanganate of potash 
 (i : 2,000) are to be preferred. A small glass nozzle should be carefully in- 
 
DISEASES OF THE VAGINA. 73 1 
 
 sertecl on account of the great sensibility of the vaginal mucous membrane. 
 It is very important to keep the nozzle after each irrigation in a solution of 
 carbolic acid (i :20). This will avoid any fresh inoculation to which the 
 patient might be exposed without this precaution. The patient should be 
 kept at rest. 
 
 The acute stage having been passed, energetic antiseptic treatment should 
 be instituted; sublimate douches (i : 2,000) should be given twice daily, tak- 
 ing care to erase the folds of the mucous membrane, and wash out the culs- 
 de-sac with the finger. After each injection, place a tampon of iodoform 
 gauze the size of a pigeon's egg against the external os; this will soak up 
 the secretions, and, while having an antiseptic influence, will also act as a 
 means of drainage. We may, if necessary, substitute for the sublimate in- 
 jections creolin, permanganate of potassium, carbolic acid, boracic acid, 
 alum, tannin, resorcin, or chloral. Sublimate is, however, incomparably the 
 most efficacious, and has never given me any bad results in these cases. 
 Fritsch praises the chloride of zinc, two drachms and a half to the quart. 
 In pregnant women, sublimate injections must be used with great care, and 
 the return flow aided by the speculum, on account of the ease with which 
 mercury is absorbed. 
 
 Balsamic treatment may be addressed to the concomitant urethritis. 
 Copaiba and cubebs are, however, badly borne by women, and, moreover, 
 urethritis is much less persistent than in the male on account of the short- 
 ness, straightness, and width of the canal. Iodoform pencils introduced into 
 the urethra and slightly crushed by pressure through the vagina are very 
 effective in chronic urethritis. When the treatment of the vaginitis is suffi- 
 ciently advanced, the secondary metritis should be attacked, and with its 
 cure we may expect the disappearance of the last remnants of the vaginal 
 inflammation. 
 
 General treatment should not be neglected. Iron and tonics should be 
 given to chlorotic subjects. Scrofulous children should have appropriate 
 treatment. 
 
 Foreign authors have described, under the title of croupous or diphther- 
 itic vaginitis, the production of a false membrane due to superficial slough- 
 ing of the mucous membrane. This has, however, nothing in common with 
 what we in France designate by the word diphtheria; it is, on the contrary, 
 but a gangrene of the vagina, less correctly called gangrenous vaginitis, and 
 is encountered in cases of intense septic infection of the vagina, in cases of 
 cancer of the uterus and sloughing fibromata, or where pessaries have been 
 indefinitely retained in the vagina without care in regard to cleanliness. It 
 has been obser\'ed also in an intense gonorrhoea, in the puerperal state, in 
 the course of acute infectious illnesses such as measles, small-pox, typhus 
 fever. It is not a distinct morbid condition, but a septic accident engrafted 
 upon an inflammatory vaginal lesion. It furnishes no special indications for 
 treatment except the prevention of the adhesions and contractions which 
 
732 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 follow exfoliation of the slough. For this purpose antiseptic tampons should 
 be kept in the vagina, so as to separate the surfaces. 
 
 Dissecting phlegmonous vaginitis or suppurative inflammation of the 
 cellular tissue of the vagina is a specially located rare variety of pelvic ab- 
 scess; it has been observed in the course of grave febrile conditions. Its 
 treatment consists in giving exit to the pus as soon as it can be localized. 
 
CHAPTER XXXVI. 
 
 TUMORS OF THE VAGINA.— CYSTS, FIBROUS TUMORS, 
 POLYPI, PRIMARY CANCER. 
 
 Cysts. — Definition. — Two very different affections are often described 
 under the same name: (ist) A chronic stationary disease presenting vesicles 
 of about the size of a millet-seed, generally distributed over the vaginal mu- 
 cous membrane, interesting from an anatomical point of view, but without 
 surgical importance ; (2d) a well-defined cyst of the vaginal wall, a condition 
 which occasions serious difficulty and which calls for active interference. 
 These cysts are well defined, usually unilocular, and of a size varying be- 
 tween that of a small nut and an ^^^, tending to increase in volume if not 
 surgically treated. The two affections, essentially distinct in pathological 
 anatomy, course, symptoms, and therapeutic indications, have sometimes 
 been confounded. In reality the first is but the variety of chronic vaginitis 
 called cystic colpo-hyperplasia by Winckel. I have already described it 
 under the name of emphysematous vaginitis in the paragraph devoted to the 
 vaginitis of pregnancy. The contents of the vesicles or lacunae are either 
 fluid or gaseous, containing trimethylamin. In the study of cysts of the 
 vagina proper, I omit this cystic pachy-vaginitis, as the origin is obscure, the 
 symptomatology presents nothing of interest, and therapeutically it may be 
 considered with chronic vaginitis. 
 
 Pathogenesis. — The most diverse theories have been advanced to account 
 for cysts of the vagina. Huguier, in a memoire which was for a long time 
 considered a classic, assigned to them a glandular origin, classifying them as 
 superficial and deep, according to their situation in the two species of glands 
 which he thought existed in the vaginal wall. Now, these glands do not 
 exist, but they may be simulated by crypts or lacunae which, by obliteration 
 of their orifices, may play the same pathological role. Virchow, Guerin, and 
 Preuschen accepted the theory of glandular and pseudo-glandular cysts ; Pou- 
 pinel admits its probability in a certain number of cases. Other authorities, 
 among whom are Eustache, Tillaux, and his pupil Thallinger, are disposed 
 to consider them as hygromata or accidental serous sacs. According to 
 Courty, they are of frequent occurrence in prostitutes. 
 
 This hypothesis is analogous to that of W. Torn for certain cysts ob- 
 served in women who have borne children, as he believes these represent a 
 traumatic serous effusion, similar in character to the traumatic serous cysts 
 in other regions described by Morel -Lavalle. 
 
 The theory which best accords with the established facts is that advanced 
 
734 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 by Veit. This finds the origin of vaginal cysts in the remains of the Wolf- 
 fian canal in species of animals where it is very prominent, called the canal 
 of Gartner. Certain cysts of the vagina have been attributed to the non- 
 union of the ducts of Miiller and to the existence of a lateral vaginal cavity 
 closed at the base and due to an aborted bifidity. Such cavities are, how- 
 ever, allied to haemato-colpos or pyo-colpos, and erroneously, I believe, de- 
 scribed as cysts. I shall return to them in connection with the question of 
 diagnosis. 
 
 Can we have a large cyst as a result of lymphatic ectasia, as is perhaps 
 the case in the gaseous lacunae of pachy- vaginitis .'' This theory, advanced 
 by Klebs, has been accepted for certain cases by a number of authors. 
 
 On reviewing the theories which have been advanced for so complex a 
 clinical group as the cysts of the vagina, we shall see that none of them cor- 
 responds to any well-defined anatomical type. One only can be logically 
 accepted. This is that of Wolffian origin, shown in the most pronounced 
 cases by several cysts disposed in a row, or having an upward prolongation 
 in the direction of the broad ligament. All the others are hypothetical in 
 character and based only on remote analogies. I believe that all vaginal 
 cysts larger than a walnut are of embryonal origin. It has been remarked 
 that they occur singly or are few in number, and then disposed in a vertical 
 series, as though resulting from the moniliform dilatation of a straight tube. 
 
 Where we have a large number of small cysts covering the whole or a 
 limited part of the vaginal mucous membrane, whether irregularly distributed 
 or disposed in groups, I consider them of pseudo-glandular formation by the 
 obliteration of the openings of crypts or lacunae, in the bottom of which epi- 
 thelium accumulates, to give place later to a fluid exudation. It is easy to 
 differentiate the two anatomical types. 
 
 Without absolutely denying other methods of origin, I believe them to 
 be excessively rare. I must not omit to mention that Porak reports a case 
 of hydatid cyst of the vagina. 
 
 Etiology. — Vaginal cysts are found at every age, and in virgins as well 
 as in women who have borne children. We think the agency of excessive 
 coitus as suggested by Courty to be very doubtful. Labor may have a cer- 
 tain determining influence, not in consequence of traumatism of the vagina, 
 but by the over-nutritive activity of the whole generative tract caused by 
 pregnancy, which has its proportional influence upon the abnormally persist- 
 ing embryonal remains as well as upon the epithelium covering the folds and 
 crypts of the vaginal mucous membrane. 
 
 Pathological Anatomy. — Cysts of the vagina are most frequently single. 
 Several cysts were present in only twenty-eight of the one hundred and 
 twenty-two cases collected by Poupinel, or twenty-two per cent. The num- 
 ber very rarely exceeds three or four. Poupinel has reported one case in 
 which fifteen were agglomerated into a single tumor, but he reasonably 
 ascribes this to a pseudo-glandular formation. The cysts which develop 
 
TUMORS OF THE VAGINA. 
 
 735 
 
 from the Wolffian body are single, as a rule, rarely multiple, and then dis- 
 posed one after the other in a row. Their size varies between that of a pea 
 and a turkey's egg. Veit has seen one the size of the foetal head. The 
 most frequent location is the upper portion of the anterior or posterior vagi- 
 nal wall. In one case, that of Bastelberger, the hymen formed part of the 
 wall of the cyst. Sometimes the cavity has a prolongation superiorly. In 
 the case_of Watts, so frequently quoted, the sound when introduced into the 
 cyst through an incision passed in the direction of the broad ligament. 
 Boursier has seen a case in which a solid pedicle was plainly to be demon- 
 
 FlG. 476.- 
 
 -Section of the Wall of a Cyst of the Vagina (Schroder). The external surface shows the pave- 
 ment epithelium of the vagina ; the internal, the cylindrical epithelium of the cyst. 
 
 strated deeply located and extending from the upper portion of the cyst. 
 Reboul has a similar case, but the pedicle was partly hollow. These evi- 
 dently belong to the list of cases of Wolffian origin. 
 
 The wall of the cyst is composed of finely fibrillated connective tissue, 
 sometimes containing muscular fibres. These, however, have not the pathog- 
 nomonic significance suggested by Poupinel, who thought they indicated 
 the origin from the ducts of Gartner. The vaginal mucous membrane usu- 
 ally covers the free surface, but it may be so thinned and degenerated as 
 to be ultimately fused with the wall of the cyst, which then becomes trans- 
 lucent in character. An analogous degeneration has sometimes resulted in 
 perforation into the bladder, as in a case reported by Veit. As a usual thing 
 the internal surface of the cyst is covered by cylindrical epithelium, but 
 pavement epithelium has also been found. The eccentric pressure resulting 
 from distention of the cavity may produce a flattened or pseudo-pavement 
 aspect in cylindrical epithelium. Ciliated epithelium has been found in a 
 few cases — six times out of fifty-two cases, according to Poupinel. 
 
 The internal wall with its epithelial covering was entirely absent in four 
 of the published cases. It is these cases which seemed, to lend some sup- 
 port to the theory of hygromata. But even if we suppose that the examina- 
 tion was made under the best of conditions, the destruction of the internal 
 coat might be otherwise accounted for in many ways. 
 
736 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Sometimes we find prominent papillae upon the internal surface. Klein- 
 wachter has demonstrated adenoid degeneration of the wall of the cyst. 
 
 The contents vary in consistence and color ; most often they are viscid, 
 transparent, and of a pale yellow tint, containing pus or altered blood. 
 
 Cheron has described a cyst of the vagina which opened into the urethra 
 
 Fig. 477. — Cyst of the Vagina. Section perpendicular to internal surface, i, Cyst cavity ; 2, epithelial lining; 
 3, denuded papillae ; 4, compact connective tissue with many nuclei; 5, connective tissue in loose bundles , 6, numerous 
 capillaries containing coagulated blood. 
 
 and contained a calculus, it was probably a simple urethrocele. Breisky 
 considers it not impossible that the cavity of an urethrocele by obliteration 
 of its orifice may constitute a pseudo-cyst. 
 
 Symptoms. — In its early stages the cyst attracts no attention, the earliest 
 sign indicating its presence being prolapse of the vaginal wall, which is 
 dragged down by the constantly growing tumor, and which the patient be- 
 lieves to be a descent of the uterus. Examination for pregnancy or a gonor- 
 rhoea leads to the discovery of the condition. The tum-or is rounded, smooth, 
 sessile or with a tendency to pediculation ; the mucous membrane which 
 covers it often preserves its normal color; rarely it is thinned and transpar- 
 ent. Fluctuation is often difficult to obtain when the cyst is small and 
 tense. It sometimes becomes evident by seizing the tumor between the two 
 fingers or by combining the rectal with the vaginal touch. On effort, the 
 
TUM(H<S OF THK VAGINA. 
 
 737 
 
 tumor can be made to appear at the vulva, then resemblinj^ a cystocele if 
 it occupies the inferior part of the vagina. 
 
 When the cyst has attained a certain size, it occasions a sensation of 
 pressure and of discomfort on walking. Leucorrhoea will be provoked by 
 the irritation of the mucous membrane, and its exposure to the air conse- 
 quent upon the procidentia of the tumor. In a case which I observed, a 
 large single cyst existed simultaneously with a vertical septum of the vagina, 
 pointing apparently to its embryonal origin. 
 
 These cysts are rarely so large as to constitute an obstacle to urination 
 or delivery ; the latter might cause rupture of the cyst, which would, how- 
 ever, soon return. 
 
 Diagnosis. — I have already distinguished between true cyst of the vagina 
 and cystic vaginitis characterized by the presence of a multitude of very 
 
 Fig. 478. — Cyst of the Vagina. Section of wall highly magnified, i, Layer of lamellated corneous cells: 2, 
 layer of long crenats cells, few showing nuclei ; 3, deep layer of cylindrical cells, mostly nucleated , 4, papilla of com- 
 pact tissue with round nuclei ; 5, less dense connective tissue ; 6, vessel filled with blood corpuscles. 
 
 small cystic cavities in the substance or upon the surface of the thickened 
 mucous membrane. I have referred to the fact that this affection is found 
 in pregnancy as a rule, although not limited exclusively to that condition, 
 and that the little cavities contain gas which sometimes escapes with a 
 crackling noise when they are opened. 
 
 Large cysts of the vagina are as a rule single, and form a prominence 
 upon the anterior or posterior wall of the canal after the manner of a cys- 
 tocele, an urethrocele, or a rectocele, especially if situated in the inferior 
 portion. Error is avoided by combining catheterization or rectal examina- 
 tion with the vaginal touch. 
 
 Vaginal cysts may be confounded with certain peri-urethral cysts of the 
 vestibule, having their origin in the crypts which surround the meatus uri- 
 47 
 
738 CLINICAL AND OPERATIVE GYNECOLOGY 
 
 narius. These are rarely larger than a bean, although Preuschen has seen 
 one the size of a walnut. It is not impossible that these cysts also have 
 their origin in the terminal extremity of the canal of Gartner. Skene be- 
 lieves them to arise from two peri-urethral glands, but the existence of these 
 glands is not yet substantiated. 
 
 Cysts of the upper part of the vagina are often distinguished with diffi- 
 culty from small tumors located in the cul-de-sac of Douglas, prolapsed 
 ovaries, cystic or non-cystic, inflammatory conditions of the tubes, and the 
 collections of peri-salpingitis. Careful examination, under anaesthesia if 
 necessary, will eliminate doubt in regard to these conditions. They should 
 not be confounded with vaginal enterocele, which is distinguished by being 
 reducible when the patient is in the recumbent position, and by increasing 
 in size after exertion. 
 
 A collection in an accessory vaginal cavity is sometimes regarded as a 
 vaginal cyst. The cavity is due to bifidity of the organ, the result of in- 
 complete fusion of Mailer's ducts. When this bifidity, as is usually the 
 case, extends to the vulva, there are two vaginse, one of which is more or 
 less atrophied, but in exceptional cases the second vagina terminates in a 
 cul-de-sac, into which opens a second os uteri, due to coexisting bifidity of 
 the uterus. The condition may be unsuspected until puberty, when the cav- 
 ity, becoming filled with menstrual blood, gives rise to a lateral haemato- 
 colpos or, if the cavity suppurates, a lateral pyo-colpos. As the bifidity of 
 the cervix is rarely evident, there will be often no indication of the particu- 
 lar character of the vaginal collection, which is therefore mistaken for a cyst 
 until it has been opened, when the discovery of a second os uteri clears the 
 diagnosis. I observed a case of this kind in which the pseudo-cyst had sup- 
 purated and given rise to a fistula. 
 
 Hydatid pelvic cysts may project either through the vesico- vaginal sep- 
 tum or the recto-vaginal septum and simulate vaginal cysts. 
 
 T^ratment. — We can here apply any of the different operations which 
 have been described for other submucous cysts, as, for example, in ranula. 
 Simple puncture or incision alone is insufficient. Puncture followed by a 
 ■caustic injection may provoke an extensive inflammation, which may be 
 propagated to the bladder or the peritoneum ; there may also be unlooked-for 
 •extensions or prolongations of the cystic cavity. The surgeon has to choose 
 between complete and partial extirpation. The first may be preferable if the 
 tumor can be easily reached, as, for instance, if it be located near the vulva. 
 Yet, even so, i;:s dissection is difficult on account of close adhesions with 
 the deeper tissues, and of the neighborhood of the urethra and bladder. It 
 may even become impossible if the cyst ruptures during the operation. To 
 avoid these difficulties, in one case I advantageously resorted to the process 
 for the removal of certain cystic tumors which I described some time ago. 
 After opening the tumor, I filled the cavity with white spermaceti wax, sub- 
 sequently solidifying it by an application of ice. I then very easily dis- 
 
TUMORS OF THE VAGINA. 739 
 
 sected out the tumor. The wound is immediately united by a continuous 
 catgut suture in layers. 
 
 Partial excision is preferable where the cyst is located in the upper third 
 of the vagina, toward the posterior wall. The tumor is to be seized with a 
 tenaculum, opened by the scissors, and a portion of the wall with the mucous 
 membrane covering it excised. Schroder recommends suturing the lips of 
 the opening to the vaginal mucous membrane in order to make the opening 
 permanent. This precaution seems to me unnecessary. It is quite suffi- 
 cient to tampon the interior of the cyst with gauze; the part of the wall 
 which has not been removed subsequently exfoliates spontaneously. 
 
 Fibrous Tumors and Polypi. — PatJiological Anatomy. — Fibrous tumors 
 of the vagina may originate in the uterus, and by their gradual descent open 
 out the recto-vaginal septum. Some tumors, however, have their origin in 
 the vagina itself. 
 
 The structure of these tumors is similar to that of uterine fibroids ; they 
 are composed of a mixture of connective tissue and unstriped muscular 
 fibres. Paget has described the only example on record of a tumor composed 
 exclusively of fibrous tissue. 
 
 The most common location for fibrous tumors of the vagina is the supe- 
 rior portion of the anterior wall. They are often very adherent to the urethra 
 and descend to the vulva. They are usually of small volume; one has, how- 
 ever, been reported which weighed over two pounds. They may be pedicu- 
 lated and have a polpoid form, or may exhibit softening or oedema, as is the 
 case with the fibrous tumors of the uterus, or may slough superficially and 
 present ulcerations. 
 
 Etiology. — These tumors are most frequently found in middle age, although 
 instances have been known in young children. 
 
 Symptoms. — These depend altogether upon the size of the tumor. If 
 very small, it is unnoticed or simply occasions leucorrhoea. If larger, hemor- 
 rhages may be present, and the symptoms of compression, especially of the 
 bladder. One case has been reported in which a fibrous tumor of the vagina 
 was the cause of dystocia. 
 
 Diagnosis. — This is complicated by changes in the tumor, such as oedema 
 and ulceration, which may cause it to resemble a cancer. A study of its 
 relations enables one to differentiate a polypus of the vagina from a polypus 
 of the uterus, a prolapsus, or an inversion. 
 
 Treatm,ent. — This consists in the enucleation of sessile tumors, and sec- 
 tion of the pedicle in a polypus. The procedure has been described in the 
 chapter on the Treatment of Fibroid Tumors of the Uterus. 
 
 Primary Cancer of the Vagina. — PatJiological Anatomy. — Most fre- 
 quently cancer of the vagina is secondary to cancer of the cervix. It may 
 also be produced by extension from cancer of the vulva. Primary cancer of 
 the vagina is very rare. A. Martin has seen it but once among five thousand 
 patients. It may occur in one of three forms : (isti papillary ; (2d) infiltrated 
 
740 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 or nodular, both included histologically under the term epithelioma ; (3d) sar- 
 coma, either diffuse involving the whole of the mucous membrane, or circum- 
 scribed and arising from a degenerated fibroid tumor. 
 
 Etiologv. — Cancer of the vagina is a rare affection. Of 24 cases col- 
 lected by Kiistner the majority were in women between thirty and forty 
 years, 2 in women between fifteen and twenty years, and 2 in women be- 
 tween twenty and thirty years. F, Bernard, in 59 cases, found 7 between 
 twenty and thirty years, 10 from thirty to forty, 10 from forty to fifty, 18 
 from fifty to sixty, 12 from sixty to seventy, and 2 between seventy and eighty 
 years. Guersant has reported a case of cancer of the introitus in a child of 
 three and one-half years ; Johannowsky, one in a child of nine years, and 
 Smith, one in a girl fourteen months of age. Kustner has noted the factor 
 of heredity once only. Hegar has seen a cancer produced in the neighbor- 
 hood of an ulceration due to the prolonged retention of a pessary. It is 
 somewhat strange that cancer has never been observed in the prolapsed 
 uterus, which is exposed to all the influences of external irritation. 
 
 EpitJielionia of tlie papillary form usually attacks the posterior wall of 
 the vagina, making its appearance as a broad-based excrescence, which first 
 invades the cul-de-sac, and then extends from above downward toward the 
 vulva, and then from below upward toward the cervix. It appears to have 
 its origin at times in the neighborhood of the plaques of chronic vaginitis, 
 which have been somewhat theoretically compared to buccal leucoplasia, the 
 point of departure for lingual cancroid. 
 
 Epithelioma of the nodular or infiltrated form appears as nodules which 
 rapidly become confluent. The growth is sometimes localized about the 
 wall of the urethra, giving rise to a well-defined clinical type, peri-urethral 
 cancer. Ulceration here advances rapidly. 
 
 Sarcoma presents two varieties: (ist) diffuse sarcoma of the mucous 
 membrane, which is peculiar in that it sometimes is found in young chil- 
 dren ; (2d) fibro-sarcomatous tumors, degenerating slowly and often revealed 
 only by the recurrence of a fibroid tumor or a polypus. In one case striated 
 muscular fibres were demonstrated. Melanotic sarcomata have been observed. 
 
 The course of cancer of the vagina is usually rapid, excepting in the 
 fibro-sarcomatous form, in which it may be excessively slow. Extension is 
 to the lymphatics and to neighboring parts. 
 
 The rational signs do not differ from those of cancer of the cer\dx ; they 
 are : a fetid discharge, hemorrhage, pain, and symptoms of pressure upon the 
 bladder and rectum. It is not necessary here to take into consideration the 
 syplnlitic chancre, as it is of rare occurrence, nor the round simple ulcer, 
 which is a rare lesion and not well defined. 
 
 Treatment. — While there are but few chances of complete recovery, we 
 may arrest somewhat the course of the disease. We shall only consider ex- 
 tirpation, if it be possible to remove the whole neoplasm; in such a case, on 
 account of the great laxity of the vaginal walls, we may obtain primary union 
 
TUMORS OF THE VAGINA. 
 
 741 
 
 of even an extended wound. Hegar and Kaltenbach recommend operation, 
 even where the bladder and rectum are involved. Munde in one case 
 opened Douglas' culde-sac, closing it with a catgut suture, and, after a 
 
 
 ' Fn;. 479.— Epithelioma of the Vagina. General view, i, Connective tissue of mucous membrane; 2, epithelial 
 ramifications cut at various angles ; 3, epithelial [)c;irls. 
 
 slight attack of pelvic peritonitis, his patient recovered. In a case of cancer 
 of the posterior wall, Rueter sutured the raw surface of the wound to the 
 
 Fig. 480. — Epithelioma of the Vagina. Portion of preceding figure (X 300 diameters), i, Loose connective 
 tissue infiltrated with small round cells ; 2, closely united epithelial cells with very irregular nuclei. Between them 
 are many small round cells derived by karyokinesis ; 3, cells undenroing karyokinetic changes. 
 
 previously freshened cervix. This plastic restoration of the parts prevented 
 a recurrence, and at the end of three years pregnancy followed. 
 
 In the case of a woman in whom the cancer involved the whole of the 
 recto- vaginal septum sloughing had given rise to a cloaca. Eiselberg, in 
 
742 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 this case, resected the coccyx, and established an artificial anus in the sacral 
 region, after having extirpated the whole of the diseased part. The wound 
 was then drawn together by sutures, and the uterus was brought down and 
 fixed, so that the cervix opened externally in the neighborhood of the cuta- 
 neous margin. Recovery was rapid. Menstruation was free, and before 
 long stools were retained. This bold operation is worthy of imitation. 
 
 In a case of primary epithelioma of the upper portion of the vagina of a 
 woman whose vulva was narrow, I reached the neoplasms by transverse peri- 
 neotomy. The recto-vaginal septum was opened, the dissection being carried 
 with scissors as far as Douglas' cul-de-sac. The vagina was incised behind 
 the cervix, then the tumor, which was about two centimetres from the latter, 
 was drawn down and freely excised. The vaginal wound was brought to- 
 gether by several sutures, the peritoneum drained by a strip of gauze, and 
 the perineum closed by three metallic sutures placed according to Lawson 
 Tait's method. The patient recovered rapidly. Some weeks later 01s- 
 hausen, who appeared to be ignorant of the appearance of my article, pub- 
 lished three cases of carcinoma of the vagina operated upon by a similar pro- 
 cedure. Thorn has twice employed it successfully. 
 
 Duhrssen exposes the operative field by a vagino-perineal incision, and 
 if the cervix is involved performs a high amputation. 
 
 Mackenrodt urges the use of the galvano-cautery for the excision of can- 
 cers of the vagina, and advises the removal of the uterus even when the dis- 
 ease is primary in the vagina. 
 
 In case extirpation is impossible we may resort to curetting, followed 
 by cauterization with the red-hot iron. Antisepsis of the vagina is to be 
 maintained as far as possible by injections and tampons of iodoform gauze. 
 
CHAPTER XXXVII. 
 
 CICATRICIAL FISTULA OF THE VAGINA. 
 
 The vagina may communicate with the neighboring cavities by perma- 
 nent cicatricial orifices or canals lined with new tissue covered with epithe- 
 lium. These abnormal means of communication or fistulae are of two classes : 
 those which give passage to urine, and those which give passage to fecal 
 matters. 
 
 Urinary Fistula. — Etiology. — We exclude from the class of cicatricial 
 fistulae, or fistulae proper, the fistulous communications produced by cancer 
 in an advanced stage of its development. 
 
 In the large majority of cases fistulae date back to a difficult labor which 
 has produced sloughing of a more or less extensive portion of the genital 
 canal. If the foetal head remains too long at the inferior strait, the vesico- 
 vaginal septum is caught against the pubes, its vitality is compromised, and 
 sloughing follows. This is the case where there is narrowness of the pelvis 
 and exaggerated size of the foetal head, or shoulder presentation ; and it is 
 the duration rather than the intensity of the pressure which determines the 
 injury. 
 
 Other causes of fistula are of less frequent occurrence. The vesico- 
 vaginal septum may be wounded by the forceps, the cephalotribe, or other 
 instrument. Sometimes the surgeon produces the perforation intentionally 
 as in vaginal incision for stone, or accidentally during hysterectomy. 
 
 Vesical calculi give rise to fistulae by ulceration in the neighborhood of 
 the calculus where it is enc3^sted or by provoking abscess at a point of ob- 
 struction. Foreign bodies in the bladder act as the exciting cause only by 
 serving as the nucleus for a calculus. 
 
 Ulcerations of the bladder secondary to chronic catarrh have very excep- 
 tionally advanced to perforation of the septum. 
 
 Tiiberculoits ulcerations of the vagina are a pathological rarity, and, if 
 they produce a perforation, this abnormal orifice does not cicatrize ; hence 
 they have no more place in the classification of fistulae than have the perfora- 
 tions of cancerous origin. 
 
 PatJiological Anatomy. — The location varies with the relations of the 
 bladder and urethra to the superior border of the pubes at the time of labor, 
 as the fistula is produced by pressure against this bony prominence. The 
 walls of the uterus itself are never the seat of perforation from this cause, as 
 the internal os always maintains a position above the pubic bone. This is 
 
744 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 not true, however, of the anterior wall of the cervix, and this is sometimes, 
 although rarely, perforated. There then results a fistula between the cervix 
 and bladder called the vesico-uterinc, or, to be more exact, the vesico-cervi- 
 cal fistula. Ordinarily the external os has retracted above the head of the 
 foetus at the time when the decisive pressure is exerted, so that it is the 
 vesico-vaginal septum which receives it and which subsequently perforates, 
 occasioning the vesico-vaginal fistula. Finally, the bladder may be retained 
 above the pubes, the urethra being extended, so that it is subjected to press- 
 sure producing the urethro-vaginal fistula. Verneuil has given the name 
 urethro-cendco-vaginal to those fistulae in which the neck of the bladder and 
 the urethra are simultaneously involved. 
 
 The vesical orifice of the ureter is situated about three centimetres below 
 the vaginal portion of the cervix, and these canals have, as has been said, a 
 short intra-parietal course. It will be seen that, as a consequence, compres- 
 sion exerted at a point between the superior and the inferior portions of the 
 bladder may result in either uretero-uterine (or, more exactly speaking, a 
 uretero-cervical) fistula or a uretero-vaginal fistula, according to whether the 
 abnormal opening be situated in the neighborhood of the cervix or lower 
 down in the vagina. 
 
 Of all fistulae, the vesico-vaginal is the most frequent. It is situated as 
 a rule very high up in the cul-de-sac. The opening is sometimes so small 
 as to make it difficult of discovery; at other times it forms a wide orifice, 
 generally oval in form, and in direction transverse or oblique. Its edges 
 are in some cases flexible, in others hard and sclerotic, and are formed by 
 the union of the two mucous membranes ; that of the vaginal mucous border 
 is usually curled inward, forming, according to the expression of Verneuil, a 
 species of entropion. The orifice is, as a rule, single, but there may be sev- 
 eral openings separated by hardened or cicatricial bands. Finally, there are 
 cases in which the vesico-vaginal septum has been completely destroyed, so 
 that there exists what Deroubaix has called a uro-genital cloaca. 
 
 The vagina often bears the incessant contact with the urine very well, 
 but it may be the cause of a chronic vaginitis of the most distressing charac- 
 ter. The canal often presents cicatricial bands resulting from sloughs coin- 
 cident with the fistula. These may by retraction form a diverticulum with 
 stagnation of urine and the formation of calculous concretions. One of the 
 most unhappy complications of the fistula, from the point of view of its 
 treatment, is the presence of cicatricial tissue uniting the walls of the vagina 
 firmly with the pelvic bones. The urethra is sometimes included in this 
 cicatricial tissue; it may be deviated from its course, retracted or even oblit- 
 erated. Where the perforation is large, the bladdef is widely open, and the 
 mucous membrane, irritated by exposure i"o the air and the vaginal secre- 
 tions, becomes inflamed ; further, as its role of urinary reservoir is lost, 
 contraction develops. 
 
 In the case of fistulas situated in the vaginal trigone of Pawlik> we can 
 
CICATRICIAL FISTUL/K OF THE VAGINA. 745 
 
 penetrate with a probe or an appropriate sound into the ureter, which opens 
 either upon its free margin or a little beyond it into the bladder; it is prob- 
 able that there exists in such cases a certain degree of ureteritis which, 
 according to Sanger, would be recognizable to the touch. Freund, in an 
 autopsy upon a uretero-uterinc fistula, found the ureter dilated, as in a case 
 of hydro-nephrosis, and with marked contraction below the fistula. 
 
 Simple uretero- vaginal fistulae without simultaneous communication with 
 the bladder are very rare. Most frequently the perforation of the ureter is 
 secondary to a vesico-vaginal fistula. In the same way the uretero-uterine 
 fistulae are but a variety of the vesico-uterine or vesico-cervical, in which as 
 a result of cicatricial contraction the wounded ureter comes into contact with 
 the cervix, which has been more or less injured and communicates with the 
 bladder. 
 
 In the course of time the part of the fistula which had relation with the 
 bladder may become obliterated by progressive concentric contraction, while 
 the portion into which the ureter opens persists because of the continual 
 dropping of the urine from this canal. 
 
 All ureteral fistulas are of an inveterate character, or, if one may so ex- 
 press it, are always half cured. Hence the difficulty in finding the small 
 orifice in the fossae and cicatricial tissue. 
 
 If the fistula is urethro-vaginal, it is located near the vulva, between 
 three and five centimetres of the meatus. A fistula of this kind may pre 
 cede a vesical fistula and the urethra be obliterated between the two open- 
 ings. These fistulae may be very small or of large size. 
 
 As a rule, metritis is present where a urinary fistula keeps the cervix in 
 a state of constant irritation. The alteration of the vaginal portion by scle- 
 rosis and ulceration may be considerable. In one case it actually resembled 
 a nodular cancer. 
 
 Symptoms. — After a difficult or instrumental delivery we often have in- 
 voluntary evacuation of urine; it is possible that this is due to a laceration 
 of the vesico-vaginal wall, but is quite as probably dependent upon a trau- 
 matic paralysis of the neck of the bladder which antedates the slough some- 
 times by several days. 
 
 The date assigned by the patient for the appearance of the trouble is 
 then of little importance; nor is it necessary to conclude with Deroubaix 
 that in the majority of cases the fistula makes its appearance immediately 
 after delivery. The incontinence of urine and the appearance of the fistula 
 are not necessarily contemporaneous, as the patient is apt to think. Not 
 until the third or the fourth day is the slough soft enough to permit the 
 escape of urine. At first this will be in an inappreciable quantity, increas- 
 ing with the amount of tissue detached; this process has sometimes been 
 deferred as long as a month. The amount of the urine lost will vary with 
 the dimensions of the orifice ; while the alterations in quality, such as the 
 addition of muco-pus or phosphates, are dependent upon a concomitant cys- 
 
746 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 titis. The decubitus of the patient will influence the amount of urine thus 
 discharged. Verneuil has seen a case in which urine was lost only when 
 the patient lay upon the side. We can easily see that, in the case of a fis- 
 tula of the base of the bladder, retention would be possible, in the upright 
 position, of fluid which would at once escape were the perforation nearer 
 the neck. The position of the edges of the wound, as well as that of neigh- 
 boring cicatricial ridges, will also have an influence. 
 
 In the case of urethro-vaginal fistula, urine is discharged into the vagina 
 only at the time of micturition. In the uretero-vaginal or uretero-uterine 
 fistulae the urine secreted by one kidney accumulates normally in the blad- 
 der, while that secreted by the other filters away drop by drop, or by a small 
 stream, into the vagina. This perpetual involuntary discharge constitutes a 
 veritable martyrdom for the patient, causing a constant wet condition and a 
 penetrating odor which nothing will control, while the vulva and nates are 
 the seat of a most distressing irritation. 
 
 The general health may be preserved; it may, however, be profoundly 
 affected by extension of the inflammation along the genito-urinary tract, giv- 
 ing rise to metro-salpingitis or pyelo-cystitis. Amenorrhoea has often been 
 noted. Sometimes, however, conception and normal delivery occur. 
 
 Diagnosis. — If immediately after labor we have an involuntary escape of 
 urine, we need not at once conclude that we have a urinary fistula, for, as I 
 have already said, such an escape of urine may be due to a paralysis of the 
 neck of the bladder or even of the body of the bladder, with consecutive 
 over-distention. A careful examination, and if still in doubt an injection of 
 milk into the empty bladder, will decide the point. If there is the least 
 perforation, the liquid will appear in the vagina. 
 
 A digital examination is sufficient for the determination of large fistula, 
 especially if combined with catheterization with a metallic sound. Exami- 
 nation by the speculum is, however, essential for the precise location of cer- 
 tain perforations of very small calibre. 
 
 To examine for fistula, first place the woman in the lateral or Sims posi- 
 tion, then in the genu-pectoral, depressing the fourchette and exposing the 
 lateral walls with appropriate specula. The latter position is most favorable 
 for bringing into view the anterior wall if at the same time we fix the cervix 
 and draw it slightly down with the fixation forceps. The examination is 
 under any circumstances difficult if the vagina is contracted, and can often 
 be accomplished only by the aid of previous dilatation, either rapid or slow, 
 according to one of the various processes of which I shall speak in connec- 
 tion with the treatment of these conditions. 
 
 When the vagina has been made sufficiently accessible, examination may 
 be still further impeded by cicatricial bands and irregularities. We must 
 smooth out the folds, and go with a fine probe into every suspected fossa. 
 At the same time a metallic sound may be made to elevate the anterior wall 
 of the bladder, and the woman should be told to make straining efforts. 
 
CICATRICIAL FISTULA OF THE VAGINA. 747 
 
 In a doubtful case we should not omit to inject milk into the bladder. 
 If the interior of the vagina be now examined, the milk may be found issu- 
 ing from the opening; yet if this opening be very small, the point of emer- 
 gence may be invisible. I would advise you in such a case to thoroughly 
 dry the anterior wall of the vagina, and apply to it a piece of absorbent 
 paper while the bladder is being filled. A spot of moisture on the paper 
 will show the location cf the orifice, which can easily be found with the 
 probe. 
 
 If we have a cervico- or a utero-vaginal fistula, the introduction of a 
 sound into the bladder and of a probe into the cervix will be sufficient for 
 demonstration if the fistula is of some size. If it is very small, we may in- 
 ject the bladder with milk until the liquid rises to the level of the fistula, 
 and appears at the external os. The diagnosis can be confirmed by dilata- 
 tion of the cervix, and exploration practised simultaneously with catheteriza- 
 tion of the bladder. 
 
 In the case of uretero-uterine fistula, the urine is discharged by the cer- 
 vix, as in the preceding case, and the diagnosis is at first impossible. We 
 may have to resort to very minute tests in order to make the distinction. 
 Injections of milk will not now traverse the cervix, unless the fistula be of 
 the uretero-vesico-uterine variety, while dilatation by the laminaria tent may 
 be followed, as in Freund's case, by pain, vomiting, and fever, the results of 
 obliteration of the canal through which one of the kidneys discharged. 
 
 An ingenious measure has been employed by Bernard. He made the 
 patient urinate ; then placed the patient upon a vessel and collected all of 
 the;, urine passed by the vagina for two hours, subsequently evacuating the 
 bladder by the catheter. He then compared the two quantities, and, finding 
 them equal, decided that each came from a separate kidney. I believe that 
 in a similar case examination for thickening of one of the ureters according 
 to Sanger's method would confirm the diagnosis and reveal ureteritis at the 
 location of the lesion. Catheterization according to the methods of Simon, 
 Pawlik, or Kelly may be practised if we can gain access to the cervix, but we 
 must remember that the ureter often contracts below the perforation, so that 
 it is penetrated with difficulty. 
 
 We may conjecture that we have a uretero- vaginal fistula, where the ori- 
 fice is one or two centimetres from the cervix, upon the vaginal wall, in the 
 neighborhood of one of the lateral boundaries of Pawlik's triangle. 
 
 When the fistula is simply of the uretero-vaginal variety, the orifice is 
 very small, and the margins abrupt or hidden by a granulation. When, as 
 is more frequent, the fistula is of the uretero-vesico-vaginal variety, the ori- 
 fice may be very large. We should seek for the ureter upon one of its lips, 
 being guided by the recognized relations of this canal. Sometimes we may 
 see the urine coming from it in little jets. We should search with the ure- 
 teral sound in the neighborhood of the posterior border, if the opening 
 is not otherwise discovered. The penetration of the sound for a consider- 
 
748 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 able distance, its direction toward the kidney, and the discharge of limpid 
 urine at a time when the bladder contains an injection of milk will remove 
 all doubts. I have in a case of this kind introduced Pawlik's sound to a 
 depth of eight inches. 
 
 Urethral exploration by catheterization should always be conducted with 
 great care. I have used for the purpose a small elastic sound which easily 
 follows the deviations of the canal. It is necessary to guard against possible 
 error pointed out by Hegar and Kaltenbach. The urethra was obstructed 
 in its posterior portion between a urethro -vaginal and a vesico-vaginal fis- 
 tula. The sound passed into the vagina through the urethral orifice and 
 entered the bladder by the vagina. It is only necessary to recognize this 
 source of error in order to avoid it. 
 
 The cervix in these cases is sometimes affected with chronic inflamma- 
 tion, hard, nodular, increased in size, covered with ulcers that have a perpen- 
 dicular margin and a shining appearance similar to that of certain varicose 
 ulceis of the legs, and giving the impression of a malignant growth. We 
 need not hastily conclude that we have to do with a cancer of the cervix; 
 the lesions will disappear or at least be greatly ameliorated after obliteration 
 of the fistula. 
 
 Prognosis. — Spontaneous recovery from urinary fistulas occurs only very 
 early during the stage of concentric cicatrization which succeeds the dis- 
 charge of the slough. At this stage one is sometimes surprised at the rapid- 
 ity with which even large perforations diminish in size or disappear. In 
 the course of time, however, this process of cicatricial reformation termi- 
 nates. The perforation has now definite margins formed by the epithelium 
 of the two mucous membranes united on their free borders ; and there is no 
 further spontaneous tendency to cure. Fistulae are an infirmity rather than 
 a disease, their gravity consisting in inflammatory complications involving 
 the bladder and uterus, with frequent extensions to the kidneys, the Fallo- 
 pian tubes, and the peritoneum. Ureteral fistulae opening into the cervix 
 are especially liable to these complications. 
 
 The curability of the different varieties of fistulae varies with their loca- 
 tion, extent, duration, and the condition of the vaginal mucous membrane. 
 
 Fistulae of the base of the bladder are treated with greater facility than 
 vesico-vaginal fistulae or even those of the urethro-vaginal variety, which a 
 priori should be easily curable. Vesico-cervical fistulae are most rebellious 
 to treatment. All of the ureteral fistulae, whether opening into the vagina 
 or the cervix, are extremely difficult to treat, their obliteration even exposing 
 the patient to new dangers from the possibility of resulting diminished per- 
 meability of the ureter itself. 
 
 Treatment. — Urinary fistulae in women were described toward the end of 
 the sixteenth century by Severin Pineau. His treatment by vivification and 
 suture was recommended in the seventeenth century by the Dutch surgeon 
 Von Roonhuysen, but the operations failed for the want of a good technique. 
 
CICATRICIAL FISTULyK OF THE VAGINA. 749 
 
 SO that in the eighteenth century all curative treatment was abandoned, and 
 Jean Louis Petit applied in such cases a kind of urinal which he called 
 '' troti d cnfcry Desault and Choppart limited treatment to the permanent 
 catheter and the vaginal' tampon in the early stage to favor spontaneous cica- 
 trization. At the beginning of the nineteenth century varicnis tentative 
 operations were practised. Delpech, Uupuytren, and Jules Cloquet recom- 
 mended cauterization. The suture was tried anew by Lewisky in 1802, by 
 Naegelc in 18 12, by Lallemand, Deyber, and Malagadi of Bologna in 1828, 
 by Roux in 1829, and by Duges in 1830. Lallemand in 1824 invented his 
 famous ''sonde erigncs" or "sonde unissanteSy' the object being to unite the 
 margins of the fistula, after previous vivification by the cautery. The alleged 
 success of Lallemand, although contested, caused an enthusiastic adoption of 
 these hooks, or '' erignes i/nissantes." Dupuytren constructed an instrument 
 of this character, and Laugier a little later invented a double vaginal hook. 
 Recamier constructed several uniting instruments, but their popularity was 
 teniporary, and soon they were altogether abandoned in favor of autoplasty. 
 
 In 1832 Velpeau proposed to close laryngeal fistulae with a skin graft, 
 recommending the same procedure for other fistulous openings. This recom- 
 mendation was adopted by Jobert de Lamballe, and in 1834 he operated by 
 elytroplasty or autoplasty of the vagina. He first revivified the fistula with 
 a bistoury, then replaced the lost tissue by a cutaneous graft derived from 
 one of the labia, the internal surface of the thigh, or the buttocks. This 
 graft was sustained in contact with the fistula by a suture passed into the 
 urethra. He obtained a good result, but subsequently numerous reverses 
 marked the operation both in his hands and in those of Roux, Velpeau, 
 Leroy, and d'Etiolles. Gerdy also invented an autoplastic method, which 
 merits preservation for certain special cases. It consists in the detachment 
 of two quadrilateral flaps from the borders of the perforation and the exact 
 union of their bleeding surfaces. 
 
 None of the different methods, however, had given any but uncertain 
 results, when Jobert proposed an operation which marked an epoch in the 
 history of the cure of fistulae. This was the operation of cystoplasty far 
 glissemeut, or vaginal autoplasty by flaps. He had a series of successes, 
 which were very extraordinary for the times. Jobert wrongly attributed 
 these to the facility afforded for bringing the margins together and the ab- 
 sence of tension. In reality they were to be ascribed to details of technique 
 which he considered accessory only but which from their influence were of 
 capital importance in the result. They consisted in the obtaining of a good 
 view of the operating field by means of flat retractors, freshening of a large 
 surface of the borders of the fistula, and the insertion of many sutures. 
 Those surgeons who, like Jobert, failed to appreciate the importance of these 
 details, were not successful in their operations, and only its author had good 
 results with cy?,tOY)\2iSty par glissement. 
 
 In Europe the first enthusiasm e.xcited by Jobert's publications war, fol- 
 
750 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 lowed by complete discouragement until toward the end of the year 1858, 
 when a young American surgeon, Bozeman, exhibited in Paris a slight modi- 
 fication of the operation of his teacher, Marion Sims, of New York. This 
 American procedure, which had previously been touched upon in some of its 
 points by other physicians, and by Hayward, of Boston, in particular, con- 
 sisted of the following improvements upon other methods. The semi-prone 
 lateral position; the use of large specula of trough-like form which serve as 
 depressors and at the same time as reflectors ; revivification of a very much 
 larger area than had been previously thought necessary, for the accomplish- 
 ment of which he recommended a complete armamentarium of instruments ; 
 sutures with many stitches of silver wire (at the same time strong and asep- 
 tic) ; and a special permanent metallic catheter. 
 
 The extraordinary success obtained by Bozeman in the hospitals of Paris 
 excited the enthusiasm of French surgeons. Follin and Verneuil in particu- 
 lar popularized the American method by their operations and practice. Three 
 years later (November, 1861) Marion Sims himself came to Paris and oper- 
 ated in the service of Velpeau. 
 
 At the same time Baker Brown and Simpson obtained in London and 
 Edinburgh similar successes, and Simon, of Rostock, modified certain man- 
 ual details. He employed silk sutures, demonstrating that silver wire was 
 not essential to the result; he formulated definite rules for vivification; and 
 finally, in cases incurable by the usual procedure, he applied the method 
 called colpocleisis or transverse obliteration of the vagina — an operation of 
 which, in truth, Vidal de Cassis had conceived the first idea. 
 
 The therapeutics of urinary fistula in the female were henceforth estab- 
 lished, and the more recent works on the subject have merely elaborated 
 the descriptions. 
 
 If we review the history of the operations which have been applied to 
 the cure of vesico-vaginal fistulae, we shall easily distinguish several periods : 
 1st. The old period or that of experimental operations, which extends from 
 Von Roonhuysen's attempt at suture to the first essays of Jobert; surgical 
 knowledge then passed successively in evolution through the stages of the 
 suture after revivification to cauterization, then to the use of instruments to 
 promote union after revivification by caustics, and finally to autoplasty. 2d. 
 A period of transition marked by Jobert's operation of cystoplasty/«/'^/?>j-^- 
 ment, and by the indirect process of infibulation by Vidal de Cassis, followed 
 by Bernard. 3d. A period of the renaissance of the suture — the old operation 
 of Von Roonhuysen, to which has been attached the names of Hayward, 
 Sims, and Bozeman in America; of Simpson and Baker Brown in England; 
 of Simon and of Hegar in Germany; of Neugebauer in Warsaw; Follin and 
 Verneuil in France, etc. 
 
 Operative Indications. — When is the best time to operate .-' Hegar and 
 Kaltenbach have fixed upon the sixth to the eighth week after delivery. At 
 this period the lochia! discharge has disappeared, the slough has been elimi- 
 
CICATRICIAL FISTULA OF THE VAGINA. 751 
 
 nated, and the margins of the fistula are sufficiently vascular and firm. 
 Earlier than this we risk an unfortunate result by exposing our wound to a 
 vaginal discharge, also from operation upon tissues too friable and over- 
 gorged with blood; later, to the difficulties associated with retracted and 
 sclerotic tissues. Age does not constitute a contra-indication. Simon has 
 operated with success upon a child of eight years in whom the fistula was 
 provoked by a large vesical calculus ; Hegar has operated upon a woman of 
 sixty, who had suffered from her fistula for thirty-five years. 
 
 A bad general condition is evidently unfavorable for the success of a 
 plastic operation. Hegar, however, did not hesitate to operate upon a hemi- 
 plegic patient. In spite of the successes of Watson and Baker Brown, it 
 seems to me imprudent to operate during pregnancy. The time immediately 
 following menstruation is to be preferred. 
 
 Operation in all vesico- vaginal and urethro- vaginal fistulae will relieve 
 incontinence of urine by one of two methods : (ist) direct obliteration of the 
 fistula ; (2d) obliteration of the genital canal below the situation of the fistula, 
 so as to incorporate it with the urinary reservoir. The last procedure is of 
 course only a last resort. 
 
 Direct Obliteration of the Fistula.— A. Vaginal Route. — I shall not dwell 
 upon cauterization, which for a long time was the surgeon's only resource 
 and was practised by means of the most various agents. It is now reserved 
 for small recent fistulae, and particularly for those presenting an oblique 
 canal. . We use preferably the galvano-cautery, first inserting the non-heated 
 platinum the whole length of the canal. Nitrate of silver is applicable 
 where the opening is very narrow; it is a good auxiliary, too, to actual cau- 
 terization after the separation of the slough. 
 
 Intermediary between cauterization and operation by suture we place the 
 process of revivification by caustics, followed by suture, sometimes desig- 
 nated as immediate secondary reunion. The following description is fur- 
 nished by its principal exponent, Amabile, of Naples. 
 
 The woman being placed in the dorsal position, the buttocks are elevated, 
 and the fistula is brought into view by means of a modified Sims' speculum 
 fixed to the operating-table. The margin of the fistula is scarified for a 
 distance of about two-fifths of an inch. The object of the scarification is 
 simply to allow the caustic to act more energetically. Amabile uses sul- 
 phuric acid for this purpose. He repeats the cauterization at the end of 
 three days, and follows with nitrate of silver to facilitate separation of the 
 slough. At the end of about twelve days he has a granulating wound which 
 he brings into apposition with an instrument called the " griff es en rateair 
 or rake-catch of Amabile. He leaves this in place for from five to seven 
 days. It will be seen that we have here a veritable return to the archaic 
 procedure of Lallemand, Tangier, and others. Experience does not justify 
 it as a general method ; at the same time it may be practised under special 
 ■circumstances. For instance, it may be applicable where treatment is at- 
 
752 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 tempted during the first days which follow the separation of the slough ; we 
 should then probably have direct union of the granulating surfaces ; in such 
 cases sutures seem to me preferable to the serrcs-fines or to the grejfes. 
 
 Primary union of the previously vivified fistula is the operation which 
 has been substituted for the preceding methods. 
 
 Preparatory Treatnie7it. — To Bozeman belongs the credit for having sug- 
 gested dilatation in cases in which narrowness of the canal and cicatricial bands 
 are present. He produces the distention gradually by a series of ovoid hard- 
 rubber balls used during several days. He aids their action by incision of 
 the cicatricial tissues. With patience, the most surprising results may be 
 obtained. Simon and his pupils prefer rapid dilatation. He first incises 
 the fibrous bands and masses with the bistoury, and then dilates by introduc- 
 ing one after another specula of gradually increasing size. Local cocaine 
 anaesthesia may be used. It is also desirable to overcome erythema, excori- 
 ations, and cystitis before proceeding to the plastic operation. This is 
 effected by means of lotions, injections, and baths. 
 
 Where we have contraction or obliteration of the urethra we should first 
 treat these conditions. For the first we may resort to divulsion or the long- 
 continued use of the sound. In case of obliteration of the urethra we may 
 do an operation analogous to that of external urethrotomy in the male ; the 
 cicatricial tissue is first to be excised, after which the vaginal mucous mem- 
 brane, liberated by means of incisions and dissections, may be sutured about 
 a permanent catheter so as to form a new canal. 
 
 Operative Technique. — First Stage — Exaininatioji for Fistula. — The posi- 
 tion to be given to the patient will vary with the height of the orifice. The 
 dorso-sacral position is available where the fistula is very low or where there 
 is at the same time prolapse of the vaginal wall. As a rule, however, Sims' 
 position or that of semi-pronation will be required. Where the fistula is lo- 
 cated high up, the genu-pectoral position will be necessary. This possesses 
 the drawback of being uncomfortable and of rendering the administration of 
 the anaesthetic difficult, notwithstanding the use of special operating-tables. 
 The patient is fastened to the table by Bozeman, and simply placed in posi- 
 tion by Neugebauer, who has a self-retaining speculum held in place by a 
 belt, also hooks and chains to which are suspended weights so as to stretch 
 the parts included in the operative field. 
 
 General anaesthesia by chloroform has always been used for this opera- 
 tion. It is probable, however, that cocaine applied by compresses or by 
 submucous injection might be used with success, and general anaesthesia be 
 dispensed with. Two assistants are required : one to expose the vaginal 
 wall and control bleeding, and the other to handle the sutures. The opera- 
 tion may be performed under continuous irrigation with lukewarm sterilized 
 water; and we may, if necessary, use in the place of sponges moistened ab- 
 sorbent cotton carried by the forceps. 
 
 The fourchctte should be depressed by a .short and broad-bladed Simon's 
 
CICATRICIAL FISTULA OF THE VAGINA. 
 
 753 
 
 speculum ; a retractor can be used to elevate the anterior vaginal wall if 
 necessary; a metallic sound introduced into the bladder may be used to bring 
 the base toward the operator ; finally, the cervix is fixed and brought down 
 by Museux forceps. 
 
 Second Stage — Vivifyuig the Lips of the Fistula.— ¥ or this purpose a 
 bistoury having a straight or angular blade is to be preferred. The scissors, 
 
 I 
 
 Fig. 481. — Instruments Used for Vivification and Suture in Vesico-vaginal Fistula, r, 2, 3, Straight, 
 convex, and bent bistouries ; 4, spatula ; 5, 6, blunt and pointed hooks ; 7, 8, Coghill's wire twister, and Denouvillier's 
 S-shaped wire twister ; 9, Collin's spring forceps. 
 
 so ingeniously varied in curve by Sims, do the work more rapidly, it is true, 
 but sometimes bruise the tissues. Denudation may be accomplished in two 
 ways. In ordinary cases, in which the mucous membrane in the neighborhood 
 of the orifice is in a healthy condition, we make an infundibuliform denuda- 
 tion, following the practice of Simon (Fig. 483, ;;/, n). Simon takes no 
 special precautions for the protection of the vesical mucous membrane, and 
 the bistoury removes all of the cicatricial tissue. In the case of extensive 
 cicatrices it is better to prepare for denudation according to the American 
 
 method (Fig. 483, x, y). The bistoury, directed obliquely, should be in- 
 48^ 
 
754 
 
 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 serted at about one-fifth of an inch from the edge of the orifice, in such a 
 way that its point perforates the tissues at the line of union of the vaginal 
 
 Fig. 482. — ViviFiCATiox in Vesico-vaginal Fistula. (The tenaculum which holds down the cen.-ix has been 
 
 omitted.) 
 
 Ill X 
 
 Fig. 483. — VlviFlCATioM in Vesico-vaginal Fistula, w, «, Infundibuliform denudation with narrow base 
 <Simon). Ji:,y, Conical denudation with broad base (American method), saving the vesical mucous membrane ; /, o, 
 American method of denudation, showing the area of tissue preser\-ed when a large mass of cicatricial tissue is freshened. 
 In Simon's process this would be excised as shown by the line r s. 
 
CICATRICIAL FISTULA OF THE VAGINA. 
 
 755 
 
 with the vesical mucous membrane so as to pass beyond the cicatricial tissue 
 which is removed. The Americans consider it most important not to wound 
 this tissue, as it bleeds freely. 
 
 In making the incision the mucous membrane is put on the stretch by 
 means of tenacula and toothed forceps, a complete collar is outlined about 
 the fistula and detachment is completed with the scissors (Fig. 482). Where 
 the margins are hardened, bleed but little, and have but a moderate degree of 
 vitality, the denuded surface is to be increased, the ring of mucous membrane 
 being removed to a depth of about 
 an inch. This American procedure 
 has but one disadvantage — that of 
 tension after the application of the 
 sutures. In a small fistula, denu- 
 dation should take an elliptical 
 form, and should be directed so as 
 to produce the least tension. In- 
 ternal hemorrhage is guarded against 
 by avoiding the vesical mucous 
 membrane. Sometimes, however, 
 the wounding of an arteriole is 
 unavoidable ; it is then better to 
 
 Fig. 484. — Suture of VESico-VACmAL Fistula ; Deep 
 AND Superficial Sutures in Place. 
 
 Fig. 485. — Suture of Vesico-vaginal Fistula; 
 Sutures Tied. 
 
 stop the bleeding by direct compression of the denuded surface by the 
 fingers. If that does not succeed, it is better to trust to suture than to seize 
 vessels in the wound. The same rules for vivification apply both to vesico- 
 vaginal and to urethro-vaginal fistulas. 
 
 When the fistula is situated near the cervix, it is well to incise the ante- 
 rior lip of the cervix or even to remove a cuneiform segment so as to give 
 access to the fistulous orifice. Then denude for a certain distance about 
 the opening, as in the case of other fistulae ; and if there is too much ten- 
 sion, instead of making free incisions, it is better to use the scissors and 
 .separate the mucous membrane from the underlying tissues for a certain dis- 
 tance around the wound. 
 
/D* 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 > 
 
 ^.-j 
 
 Third Stage — Suture. — Some operators use mounted needles, tubular 
 needles, either Simpson's or Sims' ; Startin's chasse-fil uq.^^^ or Reverdin's 
 needle. While convenient, all of these instruments make too large a wound, 
 I myself use exclusively the fine flat Hagedorn needle, carried by my own 
 needle-holder. Sutures of fine, strong silk or of silver wire are preferable 
 to catgut, which is too rapidly dissolved, while the silkworm gut is too stiff. 
 First pass the deep sutures. Excluding carefully the vesical mucous 
 membrane, pass your needle under the whole of the denuded surface, bring- 
 
 ^ _^ ing it out about a tenth of an inch from the mar- 
 
 / ^ X gin of the wound. The ends of the sutures should 
 
 k \ be immediately secured with forceps. To obtain 
 
 ^^f^ exact closure, insert superficial sutures between the 
 
 deep or supporting sutures. Use a very fine 
 
 : " thread and bring it out as close to the margin of 
 
 ; ; the wound as possible, tying it at once (Fig. 484). 
 
 Then tie the deep sutures. If silver wire is used, 
 
 \ \ ■■ • / it can be gently brought together and then 
 
 \/ twisted with a wire twister (Fig. 481). In passing" 
 
 / the sutures we may use mouse-toothed forceps, 
 
 ^ ' "'B blunt and sharp hooks, and a little forked instru- 
 
 ^:^'^Y^,^^^ ment; a catheter is to be kept in the bladder. 
 keas the Cervix. Incision of Wc prcfcr a transvcrsc dircction where it is pos- 
 
 the anterior lip in order to make ., ,^. . 
 
 the fistula more accessible. The siblc to choosc the line ot the suturcs. If the per- 
 inner dotted line shows the sur- foratlou Is cxtcnsive, it may be best to give it the 
 
 face to be freshened around the _ _ 
 
 fistula. The outer dotted line dircctioii of thc Icttcr Y, Or that of a double Y 
 
 A B shows where the mucous ^^itcd by thc StCmS (Fig. 488). 
 
 membrane may be separated, when -' ' \ o ^ 1 
 
 necessary to relieve tension. The VavioitS ModificatioilS of the Operative TecJl- 
 
 patient is supposed to be in the • t i • ^ i • i i ^i i 
 
 genu-pectorai position (Emmet). niqtie.—l havc just describcd the gcncral process 
 
 of denudation and suture, which is, in its essential 
 features, what Verneuil and Follin call the American method. Certain 
 special conditions call, for modifications of this technique. I shall de- 
 scribe them briefly, and shall indicate also certain peculiarities in the prac- 
 tice of different operators which should not be passed over in silence. 
 
 First Stage — Exposnre of the Fistjtla. — In order to limit the number of 
 assistants, several operators have invented self-retaining specula. Bozeman 
 first constructed an instrument of this kind which has served as the pattern 
 for a number of others. Neugebauer's apparatus is fixed to the patient's 
 back by straps, and the hooks, chains, and weights serve to put the parts 
 upon stretch without the aid of assistants. Simon depresses the cervix by 
 passing loops of silk through the lips ; these take up less s^^ace than forceps. 
 The larger number of surgeons who fix the cervix, a detail which I consider 
 indispensable, use for the purpose Museux forceps or ordinary extraction for- 
 ceps. Forceps may also be used in the place of the tenaculum for fixing, 
 the mucous membrane in the neighborhood of the operative field. 
 
CICATRICIAL FISTULA OF THE VAGINA. 
 
 757 
 
 Second Stage — Dciuidation. — If we have a very large perforation or if 
 the margins are specially vascular, it is better not to denude the whole of 
 the border of the fistula at once, but to denude and suture a limited portion 
 at a time. If the case is very difficult, requiring much time, it is better to 
 do a partial operation, and repeat it several times. The duration of the 
 operation is an important consideration on account of the prolongation of 
 
 Tigs. 487 and 488. — Extensive Quadrangular Vesico-vaginal Fistula, Before and After Freshening and 
 
 Suture. 
 
 anaesthesia, which is prejudicial to the patient; and also on account of the 
 fatigue to the operator ; it is a matter not to be lightly passed over when we 
 have in hand an operation demanding minute attention. 
 
 If two fistul?e are adjacent and separated by cicatricial tissue, they must 
 he united; if the bridge of mucous membrane is flexible and has a good 
 degree of vitality, we must endeavor not to injure it. 
 
 When the vagina is narrow and does not furnish tissue for a sufficient 
 ■denudation, we may have recourse to a flap-splitting process, which is the 
 basis for Lawson Tait's operation for perineorrhaphy and which was pri- 
 marily applied to operation for vesico-vaginal fistula. I shall speak later of 
 
758 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 the service which it has rendered me in the treatment of uretero-vaginal 
 fistula. 
 
 When there is a very large perforation with a considerable loss of tissue, 
 it may be necessary to have recourse to flaps derived from the vicinity, or 
 autoplasty. This operation, often confounded with that of jflap-splitting, was 
 used by Jobert, Gerdy, and others. It found a warm partisan at a relatively 
 recent period in Duboue, who proposed to incorporate it with the American 
 method. This surgeon forms two small flaps at the expense of the vaginal 
 mucous membrane by division of the septum, securing them with wire twisted 
 about ivory buttons. 
 
 Since then this operation of autoplasty by division has been revived in 
 Germany by von Herff, Sanger, Fritsch, Fenomenoff, and Walcher. The 
 last named, who has described the technique at length, unites the vesical 
 orifice with catgut, using silk for the vaginal wound. 
 
 With the methods by flap-splitting should be described the procedure 
 which Mackenrodt has successfully employed. The anterior vaginal wall is 
 rendered tense by means of forceps, and an antero-posterior median incision 
 is made, passing through the fistula. After carefully separating the vesical 
 and vaginal walls on each side of the fistula, he closes the vesical orifice, 
 preferably with a tier suture. Then, as in vaginal fixation, he draws the 
 body of the uterus into the vaginal wound and sutures the vaginal wall to 
 the anterior face of the uterus, approximating as much as possible the lips 
 of the vaginal opening. 
 
 We should add to the autoplastic operations that of obliteration of a 
 large fistula by a plug formed from the vesical mucous membrane, as prac- 
 tised by Lannelongue. In a case in which the whole vesico-vaginal septum 
 was destroyed, and in which the posterior wall of the bladder had engaged in 
 the fistula, he utilized the obturator thus offered ; and after having denuded 
 the vesical mucosa for a sufficient distance, he fixed it to the previously de- 
 nuded anterior lip. 
 
 Autoplasty, however, renders its most signal service in urethro-vesical 
 fistulas with a great loss of tissue. Marked successes of this kind have been 
 reported by Houzel, by Polaillon, and by Fritsch. 
 
 Third Stage — SiUiire. — Sims, in twisting his suture, used a catch for- 
 ceps having a right-angled extremity. This seized the two ends of the wire 
 at the same time that they were made to engage in the groove of a long- 
 handled shield. The shield was pushed by the left hand along the wire in 
 contact with the mucous membrane; torsion was then effected by rotating 
 the forceps upon its axis. Before removing the shield, he turned the wire 
 in the direction of the vaginal outlet, so that its ends should not wound the 
 posterior wall. Sims placed in the bladder a self-retaining permanent sig- 
 moid catheter of his own invention. Bozeman brings the margins of the 
 wound together by a special instrument called a suture-adjuster. It con- 
 sists of a long steel shank carrying a little flat disc pierced by a hole in its 
 
CICATRICIAL FISTULA OF THE VAGINA. 
 
 759 
 
 centre. Through this hole he passes the two ends of a suture ; with these 
 in the left hand he slides the disc down to the wound in such a way as to 
 secure its perfect coaptation and to give to the wire a circular position, when 
 it has only to be secured. Before the operation he prepares two or three 
 small strips of lead, a millimetre in thickness and of a size adapted to the 
 extent and form of the closed wound and hollowed out in the centre so as not 
 to press upon its lips. He then pierces the leaden plate, punching in it 
 holes to the number of his sutures, passing through each hole the two ex- 
 
 FiG. 489. — Flap-splitting Operation in Vesico- 
 vaginal Fistula (Walcher). a. Fistula; 3, vesi- 
 cal wall ; c, vaginal wall. 
 
 Fig. 490. — Flap-splitting Operation for Vesico- 
 vaginal Fistula. Schema of the Successive Steps 
 OF the Operation (Walcher). 
 
 tremities of each separate suture, and then, bringing the plate into close 
 contact with the vaginal wall, adjusts it with a special hook. He encloses 
 the wires with the lead, somewhat after the manner in which rubber tubing 
 is used. Sims' catheter is left in the bladder. The sutures are removed on 
 about the tenth day, the patient being in the genu-pectoral position as for 
 operation. 
 
 I am in the habit of inserting a deeply buried continuous catgut suture, 
 which does not include the vesical mucous membrane, immediately after 
 placing the silver sutures and before tying them, thus forming two layers — 
 one deep, the other superficial. In this way I secure a more perfect occlu- 
 sion, preventing the infiltration of urine during the first hom's after the oper- 
 ation. 
 
 After-treatment. — The operation terminated, wash out the vagina with a 
 
760 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 sublimate solution (i : 2,000), and powder the line of suture with iodoform. 
 Then place in the vagina a strip of iodoformed gauze to prevent wounding 
 of the posterior wall by the silver wire or the silkworm gut, which are to 
 be preferred to silk, as the latter absorbs the vaginal and uterine secretions. 
 We do not require any more elaborate dressing than this, which need not be 
 renewed until after the removal cf the sutures. Except in case of special 
 indications these should be removed on about the eighth day, with precau- 
 tions against reopening the wound. I think the permanent catheter invented 
 by Sims useful for the first forty-eight hours. I attach to it a rubber tube, 
 having its free extremity in a boracic-acid solution, the urine being thus 
 evacuated by siphonage without the introduction of air. Prolonged reten- 
 tion of the catheter is attended by danger of cystitis. It is better after the 
 first two or three days to practise repeated catheterization every three hours 
 day and night. If at the time of operation there be a vesical catarrh, or if 
 this develop subsequently, it will be well to follow each catheterization with 
 an injection of borated water, being careful not to produce too much disten- 
 tion of the organ, which is often much reduced in size. Catheterization 
 should be continued for two days after the removal of the sutures, permit- 
 ting urination upon the tenth or twelfth day. 
 
 Vaginal injections of sublimate solution may be used at this time night 
 and morning. If a small aperture remain, touch the edges with the nitrate- 
 of-silver stick, and spontaneous cicatrization will as a rule follow. If the 
 opening is large, secondary union may be attempted by suturing together 
 the granulating surfaces, having recourse again to the permanent catheter or 
 to repeated catheterization. We should not resort to a second operation for 
 at least a month after the first. 
 
 It is very important to keep the bowels free, but a restricted diet is not 
 to be recommended. 
 
 If menstruation occurs shortly after the operation, as frequently happens, 
 we simply renew daily the dressing of iodoform gauze placed in the vagina. 
 
 B. Siipra-pubic Roitte. — This operation is applied in conditions where 
 suture of a vesico-vaginal fistula offers no chance of cure. These conditions 
 are found where there is an extensive slough of the urethro-vaginal septum, 
 and where the vagina is largely filled up with cicatricial tissue, with marked 
 alteration of the surrounding tissues. Adhesion between the fistula and the 
 pelvis, complete loss of the anterior lips of the cervix — conditions which 
 make wounding of the peritoneum during denudation probable — may also 
 contra-indicate any effort at obliteration through the vagina. In such cases 
 attempts have been made to expose the fistula by a supra-pubic incision, 
 which facilitates the liberation of the edges of the opening and the applica- 
 tion of sutures to the movable surfaces, which can be approximated without 
 tension. 
 
 Trendelenburg, who first conceived this idea, approaches the fistula 
 through the bladder. He makes a hypogastric incision, and, from within 
 
CICATRICIAL FISTULyE OF THE VAGINA. 761 
 
 the bladder, separates the vesical and vaginal walls, all around the fistula, 
 sufficiently to permit the apposition and union of the edges of the orifice 
 under favorable conditions. This is done by interrupted catgut sutures. 
 This method has succeeded in vaginal and cervical fistulas. Quite recently 
 Duplay has modified it by suturing separately the vaginal wall with silk and 
 the vesical with catgut, instead of employing a single layer of sutures in the 
 wall of the bladder. In any case the incision made in the bladder, in order 
 to gain access to the fistula, should be sutured completely. 
 
 Bardenheuer does not open the bladder. He carefully separates the 
 peritoneum covering the posterior surface of the bladder as far as the vesico- 
 uterine cul-de-sac, then separates the vesico-vaginal partition to beyond the 
 fistula, which he sutures with care. The operation is thus made entirely 
 extra-peritoneal. Von Dittel, on the contrary, opens the peritoneum as in an 
 ordinary laparatomy, incises the vesico-uterine cul-de-sac, and then proceeds 
 in the same manner as Bardenheuer. 
 
 Whatever method may be employed, it is prudent to drain the space of 
 Retzius by a small tube or a small strip of sterilized gauze, which should be 
 removed after forty-eight hours. A self -retaining catheter is left in the 
 bladder for eight days after the operation. 
 
 Indirect Closin-e of the Fistula. — Finally, there are cases in which all 
 attempts at direct closure fail. These conditions determine total oblitera- 
 tion of the genital canal. In order, however, to obliterate the vagina with- 
 out risking the production of haematometra or retention of the menstrual 
 blood, the opening between the bladder and the vagina must be of large size ; 
 it may even have to be increased in size. Obliteration of the vagina, which 
 is the operation to be chosen, and which I shall describe, has received the 
 name of colpocleisis ; that of obliteration of the vulvar orifice as practised by 
 Vidal de Cassis, and to which we are exceptionally obliged to resort, the 
 name of episiorrhaphy, a better name than that of episiostenosis. It is easy 
 to apply to these the principles which I shall indicate for occlusion of the 
 vagina. 
 
 The honor of reviving the indirect operation belongs to Simon, who has 
 also established the technique. 
 
 First Stage — Denudation. — We should try to locate the obliteration as 
 high as possible, as this guards against incontinence better than where the 
 denudation is carried to the neighborhood of the urethra. It will be neces- 
 sary to bear in mind, however, that to secure union the denudation must be 
 made in vascular tissue, and to establish this condition it may have to be 
 carried completely to the vulva. Vidal de Cassis made a practice of denud- 
 ing the labia majora, but the objection to that is that it is difficult to obtain 
 complete anterior union. In operating, remove a ring of mucous membrane 
 about seven-tenths of an inch broad, carrying the dissection from above 
 downward, putting the parts on the stretch with the aid of the forceps. The 
 dissection of the posterior wall will be facilitated by having an assistant 
 
762 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 place a finger in the rectum, while that of the anterior wall will be aided by 
 placing a sound in the bladder. The surface of the wound should be care- 
 fully evened with the scissors. 
 
 Fritsch has proposed to accomplish this denudation by division after a 
 simple circular incision. 
 
 Second Stage — Siiticre. — Large Hagedorn needles threaded with silk 
 should be passed under the whole of the wounded surface from below up- 
 ward, then from above 
 downward. Care must be 
 used that neither the blad- 
 der, rectum, nor peritoneum 
 are perforated. 
 
 The first suture facili- 
 tates the remainder of the 
 operation by assisting com- 
 parison of the parts to be 
 united. Care should be 
 
 Fig. 491. — Occlusion of the Vagina, or Colpocleisis: 
 
 ViVIFICATION AND SuTURE. 
 
 Fig. 492. — Colpocleisis. (Schematically 
 drawn.) 
 
 used in placing the sutures, to avoid overlapping. Several superficial sut- 
 ures will be required (Figs. 491 and 492). 
 
 In order to appreciate the importance of this operation, we should not 
 lose sight of the miserable condition to which the woman is otherwise aban- 
 doned. Colpocleisis is often a valuable resource, although attended by in- 
 conveniences of its own; impregnation is impossible, and coitus cannot be 
 practised as a rule, unless in the exceptional case in which the obliteration is 
 very high in the vagina. The menstrual blood may excite vesical catarrh 
 
CICATRICIAL FISTULA. OF THE VAGINA. 
 
 7^Z 
 
 and the contact of the cervix with the urine produce a metritis. Sometimes 
 we have a jDyeloncphritis, and very frequently vesical calculi. 
 
 When the neck of the bladder is injured so as to cause incontinence of 
 urine, obliteration of the vagina alone is not sufficient to prevent constant 
 dribbling. For the relief of such cases, it has been proposed to transpose 
 the office of a urinary reservoir from the bladder to the rectum. In addition 
 to colpocleisis a recto-vaginal fistula is established. Baker Brown first 
 performed this operation on a patient presenting a vesico-vaginal and recto- 
 vaginal fistula, with almost complete obliteration of the vagina and destruc- 
 tion of the neck of the bladder and urethra. Maisonneuve in 185 1 pur- 
 posely produced a recto-vaginal fistula after obliteration of the vulva. In 
 
 Fig. 493. — JuxTA-CERViCAL Fistula ; Vivification. 
 
 Fig. 494. — Juxta-cervical Fistula; Suture. 
 
 this case he hoped that the sphincter ani would retain the urine, which 
 would of course have to pass per anum ; but the fistula closed spontaneously, 
 and an attempt to establish a perineal fistula was followed by death. 
 
 Rose adopted this operation under the title of rectal obliteration of the 
 vulva. He begins by establishing a permeable artificial recto-vaginal fistula 
 a short distance above the anus, incising the recto-vaginal septum and care- 
 fully uniting the two mucous membranes. Cazin and Schroder have resorted 
 to this operative procedure, which is not altogether free from danger. Se- 
 rious complications have followed from the presence of intestinal gas and 
 fecal matters in the vagina ; further, we have in the recto-vaginal fistula 
 itself a tendency toward spontaneous obliteration. Nevertheless, Fritsch 
 knew of two patients operated upon by this method, who passed their urine 
 through the anus without the least inconvenience. One of these women, 
 operated upon four years ago, was laundress in his clinic, and in no way 
 suffered from the existence of her cloaca. 
 
 Cervical Fistul.e. — Urinary fistulae implicating the neck of the uterus 
 are of two distinct varieties. In the first the fistula is simply tangential 
 to the vaginal portion, which is more or less implicated in the destructive 
 
764 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 process. According to Jobert these should be included with vesico-vaginal 
 fistulas under the name vesico-utero-vaginal fistulae, and subdivided into two 
 varieties, superficial and deep, according as the destruction of the anterior 
 lip of the cerv'ix is partial or complete. This nomenclature is, however, 
 essentially defective. It is better, I think, to include these with fistulae of 
 the cervix under the name of juxta-cervical fistulae, reserving the name intra- 
 cervical fistulas for perforations which are rather erroneously called vesico- 
 uterine fistulae. Juxta-cervical fistulae are not to be confounded with fistulae 
 simply located in the neighborhood of the cervix which remains intact. 
 One is in such a case sometimes obliged to incise the anterior lip in order to 
 accomplish the denudation or even to remove a V-shaped segment (Fig. 
 486). 
 
 I. Jnxta-cei"vical Fistiilce (Syn. vcsico-iitero-vaginah. — In the superficial 
 variety, obliteration may be secured by a good denudation, but this offers 
 liere special difficulties, for posteriorly it must be to the sclerosed anterior 
 lip of the cervix, which forms the inner boundary of the fistula. Anteriorly, 
 the denudation must be carried to the upper part of the vesico-vaginal sep- 
 tum or even to the urethro-vaginal septum. The density of the tissues con- 
 stitutes a very serious obstacle ; it is better, especially in the neighborhood 
 of the cervix, to make a very large denudation, and without hesitating to 
 remove cicatricial tissue which will interfere with union. It is better to 
 vnvify a very large surface than to have the result doubtful (Figs. 493, 494, 
 and 495). 
 
 In the case of deep juxta-cervical fistulae, we may not have room for de- 
 nudation or to bring together the lips of the wound ; denudation of the par- 
 tially destroyed anterior lip presents special dangers from its proximity to 
 the peritoneal vesico-uterine cul-de-sac, which may be fixed by cicatricial 
 contraction. Hegar's case, in which he obtained direct union, must be con- 
 sidered a happy exception and an example which it would be difficult to 
 follow. 
 
 Deep juxta-cervical fistulae which do not lend themselves to direct suture 
 must be otherwise operated upon. The posterior lip of the cervix may Le 
 sutured to the anterior or vaginal lip of the fistula in such a way that the 
 uterus opens into the bladder (Fig. 496). This operation might be called 
 vesical hysterocleisis, to distinguish it from hystero-stomatocleisis, where 
 the lips of the cer\'ix are sutured together. In this operation the denudation 
 should not be carried from the cervix to the vaginal wall, on account of tliC 
 danger of wounding the peritoneum. The cervix may be turned completely 
 into the bladder, when the prominent posterior cul-de-sac ma\- simulate a 
 posterior lip. Denudation here would certainly penetrate the peritoneal 
 cavity. 
 
 II. Intra-cei'xncal FistiilcB. — According to A. Martai, this variety is more 
 frequent than is supposed, but it has a tendency to spontaneous recovery 
 when not very large and when the ureter is not involved. As a first step, 
 
CICATRICIAL FISTULA OF THE VAGINA. 
 
 765 
 
 the orifice must be exposed by dilatation of the cervix with the laminaria 
 tent. If the opening is small and the fistulous tract of considerable length. 
 
 Fig. 495. — Superficial Juxta-cervical Fistula ; 
 ViviFiCATioN. (Schematic.) 
 
 Fig. 496. — Deep Juxta-cervical Fistula. 
 (Schematic.) 
 
 we may try cauterization with the red point of a thermo-cautery (or, better 
 yet, a galvano-cautery), repeated several tim.es at intervals of eight days. 
 
 Fig. 407. — Deep Juxta-cervical Fistula. The 
 posterior lip of the cervix and the posterior cul-de-sac 
 are, as a result of retroversion of the uterus, situated 
 upon a prolongation of the vesico-vaginal wall. 
 
 Fig. 498. — Intra-cervical Fistul.\ ; Hvstero- 
 stom atocleisis. (Diagrammatic. ) 
 
 Many other caustics have been tried, among others the nitrate of silver. 
 Neugebauer has obtained by cauterization 15 recoveries in 133 cases, but he 
 
•j66 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 has also had one death from this method of treatment. If the cauteriza- 
 tions fail, we shall have to have recourse to one of the two following opera- 
 tions for closing the fistula : 
 
 1. Denudation and suture. 
 
 2. Cystoplasty by dissection of the anterior portion of the cervix and 
 suture according to Follet's method. 
 
 Dcujidation and s2it2Lre were first successfully practised by Jobert of Lam- 
 balle (1849), i""^ ^ case which was for a long time unique. Simon has done 
 but one such operation. Successful cases have been reported by Emmet, 
 Kaltenbach, Lossen, Martin, Miiller, Schroder, Neugebauer, Zweifel, and 
 Sanger. The last has resorted to an ingenious procedure, a veritable trache- 
 lo-syringorrhaphy, analogous to Emmet's operation. The fistula opened 
 laterally. He commenced by splitting the two lips of the cervix ; then he 
 sutured the side on which the fistula was located, as in Emmet's opera- 
 tion ; then, in order to establish an adequate cervical opening on the 
 mucous lining of the cervix to the external mucosa, he sutured the other 
 side. 
 
 When the fistula is very high and in the median line, access is difficult. 
 Follet, Wolfler, and Champneys have practised cystoplasty successfully with 
 direct suture of the vesical perforation exposed by a preliminary operation. 
 Follet first dilates the urethra so as to introduce the finger ; the cervix is 
 then brought to the vulva, the anterior cul-de-sac of the vagina incised, and 
 the bladder dissected away in the neighborhood of the perforation. This is 
 then united by sutures, with the aid of the finger in the urethra. This bold 
 procedure was inspired by Jobert's cystoplasty by locomotion; it is associ- 
 ated with danger of penetrating the peritoneum, but this cannot under good 
 antisepsis be considered a serious drawback. 
 
 Otto V. Herff makes a median section of the cervix up to the fistula, 
 after which the bladder is detached from the uterus for a distance of about 
 two-fifths of an inch, which gives a freshened surface, composed of an anterior 
 and a posterior half, each half containing one of the orifices of the divided 
 fistulous tract. The freshened surface is then sutured as in an anterior 
 elytrorrhaphy. If the suture gives way at the vaginal orifice, the fistula is 
 vesico-vaginal and should be treated as such. 
 
 As a last resort we have hysterocleisis, better named hystero-stomato- 
 cleisis or suture of the two lips of the cervix (Fig. 498). The menstrual 
 discharge then passes into the bladder, and uterine colic may result when 
 the opening is small. Courty has, however, seen a number of cases in whicli^ 
 menstruation was performed without inconvenience. The patient should be 
 told that the operation entails sterility, although the existence of an orifice 
 so small that only a small probe can be introduced has sufficed for impregna- 
 tion, as in a case reported by P. Deroubaix. 
 
 Uretero-vaginal AND Uretero-cervical Fistul.e. — For a long 
 time the obliteration of this variety of fistula was regarded as beyond the 
 
CICATRICIAL FISTULA OF THE VAGINA. 
 
 767 
 
 resources of art; but at the present time we have several operations applica- 
 ble to the uretero-vaginal fistula. 
 
 I. Method of Direct ObliteTatioji — Sinioii s Method. — As a first step, 
 an artificial vesico-vaginal fistula is produced, by the side of the ureteral 
 fistula. The sound is then passed into the ureter through this opening, and 
 the ureter is opened up for the distance of about three- fifths of an inch of 
 its intra-parietal portion. The borders of this incision are prevented from 
 reunion by the daily use of the sound. When permanent cicatrization has 
 been secured, the vesico-vaginal fistula, which is now some distance from the 
 extensive denudation and transverse ureteral opening, is closed by sutures. 
 
 Fig. 4gg. — Operation for Intra-cervical Urinary Fistula ; Sanger's Method. 
 
 Diihrsseii s Method. — Diihrssen has successfully employed a method very 
 similar to the preceding. A sound having been introduced into the ureter 
 through the fistulous opening, an oblique incision is made in the vaginal 
 wall passing through the fistula, and the two lips of the wound are dissected. 
 Just beyond the fistula the bladder is opened for a short distance, the parti- 
 tion which separates ureter and bladder is divided, and vesical and ureteral 
 mucous membranes are sutured together, thus establishing a large communi- 
 cation between the ureter and the bladder. The vesico-vaginal fistula just 
 formed is then closed by the classical procedure. 
 
 Landau's Operation. — Landau also creates a vesico-vaginal fistula where 
 one does not already exist, by an oval excision. He then passes a small 
 elastic catheter into the ureter, securing it by passing its opposite extremity 
 into the bladder through the urethra. Placing the patient in the genu-pec- 
 toral position, he then denudes the vaginal mucous membrane around the 
 fistula. In closing the wound he passes his sutures in a direction parallel 
 with the catheter, which is left in place for several days. Bandl also has 
 adopted a modified form of this operation in tvyo cases. He obtained recov- 
 ery after several attempts, but not without having, in one case, to replace 
 his sutures which penetrated the ureter. 
 
768 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Schede s Operation. — Schede has performed the buttonhole operation,, 
 removing about four-fifths of an inch of the vesical mucous membrane, in. 
 the direction of the affected ureter. The ureteral fistula was found under a. 
 
 Fig. soo. — Landau's Operation for Uretero-vaginal Fistula. J/, cervix ; Ur, course of the ureter ; 5, 
 fold of vagina corresponding to the inter-ureteric ligament ; Ff, vesico-vaginal fenestra through which may be seen the 
 sound passing into the ureter. 
 
 fold of mucous membrane at the bottom of a cicatricial depression in the 
 neighborhood of an old fissure of the cervix. He sutured the vesical and 
 the vaginal raucous membranes about the line of the excision, so as to pre- 
 
 Fig. 501. — Schede's Operation Foft Uretero-vaginal 
 Fistula. (Schematically drawn.) 
 
 Fig. 502. — Operation bv Splitting for- 
 Uretero-v.\ginal Fistul.\. 
 
 vent its reclosure ; a catheter was then introduced through the artificial 
 opening into the ureter, its oiDposite extremity being carried into the bladder 
 and out through the urethra. After this, an annular denudation is done 
 about the fistula, leaving intact in its immediate neighborhood a zone of 
 mucous membrane of about three or four millimetres diameter. As a result, 
 after suturing, the edges of the fistula, covered with intact mucous mem- 
 
CICATRICIAL FISTULA OF THE VAGINA. 769 
 
 brane, were turned into the bladder, forminj^ a gutter-like depression, at the 
 extremity of which the ureter opened. Recovery followed after a series of 
 complications. 
 
 There is another procedure analogous to denudation which has been re- 
 sorted to twice by Trtlat without catheterization of the ureter. It seems to 
 me also that the preliminary formation of a vesical fenestra and the intro- 
 duction of the ureteral sound is not as essential in this case as in Landau's 
 operation. 
 
 Operation by Splitting. — In a case of uretero-vaginal fistula where the pa- 
 tient had been operated upon already eleven times by the ordinary procedure, 
 I was able to establish the diagnosis by introducing Pawlik's ureteral sound 
 to the depth of twenty-one centimetres. The vesico-uretero-vaginal orifice 
 was small, so that it would barely admit the sound. I performed the opera- 
 tion of division recommended by Gerdy and applied by Blasius, Dubouc, 
 Collis, von Herff, Walcher, and others to the ordinary vesico-vaginal fistulae. 
 I believe that it served here a special purpose by allowing the replacement 
 of the ureteral orifice in the bladder without danger of inclusion in the 
 sutures. I proceeded in the following manner : Placing the patient in the 
 genu-pectoral position, I made a transverse incision in the neighborhood of 
 the fistula, carrying it about three-tenths of an inch beyond the fistula upon 
 each side. I then made a vertical incision at each extremity, so as to give 
 to the whole the form of the letter H (lying sidewise X)? and dissected up 
 the margins of the transverse incision for a distance of three-tenths of an 
 inch, so as to obtain two small flaps from the septum. When the flaps were 
 raised, the small orifice of the fistula was seen at the centre of the bleeding 
 surface. On applying the one flap to the other above this opening, they 
 came together without the least effort. They were carefully united by three 
 deep silver-wire sutures and three superficial sutures. After suturing, the 
 location of the fistula was marked by a small depression. The sutures were 
 removed on the eighth day. Recovery was complete. This method has the 
 advantage of extreme simplicity. In cases in which the fistula is very large 
 and the duplication very important, we can bring the flaps together by the 
 aid of pierced shot compressed over the wire. 
 
 Hergott, of Nancy, without completely adopting this operation, has fol- 
 lowed its main feature in dissecting" out the ureter for the extent of three- 
 tenths of an inch and turning it into the bladder. The ureter opened on 
 one of the lips of the fistula, and was of a size which admitted a small bou- 
 gie. In the case of a large uretero-vaginal fistula in which you can obtain the 
 exact position of the ureter, it is as well to limit the operation to this divi- 
 sion of a single lip of the orifice. It frequently happens, however, as in my 
 case, that at the time of the operation the orifice cannot be detected, so that 
 it will be necessary to carry the division over the whole circumference of the 
 fistula. 
 
 2. Method of Uteteral Implantation. — The procedures which I have just 
 
 49 
 
770 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 described, and which are indicated in special cases, have been somewhat 
 abandoned ; the tendency being to give preference to various methods of 
 anastomosis of the fistulous ureter and the bladder. 
 
 a. Uretero -vesical Anastomosis by the Vaginal Route. — This method 
 should be the first attempted, as it is extremely benign. P. Segond has 
 successfully employed the following technique in two cases : He has denuded 
 the mucosa below the vaginal orifice of the fistula, and then attached at this 
 point a flap taken from the bladder wall. The ureter is thus transplanted 
 into the vesical diverticulum formed in this way. 
 
 Mackenrodt owes two successes to a similar procedure. A sound intro- 
 duced through the urethra pushes out the vesico-vaginal wall just at the side 
 of the fistula. This wall is divided transversely at that level for a distance 
 of two or three centimetres, and the fistula is circumscribed by a deep inci- 
 sion which includes the entire thickness of the vaginal wall. This forms a 
 flap shaped like a myrtle leaf, at the centre of which the fistula opens. This 
 flap is dissected close to the fistula, and is then turned down so that its vag- 
 inal face becomes intravesical. The operation is completed by suturing the 
 edges of the flap to the lips of the vaginal wound. 
 
 Tuffier proceeded as follows in a case in which a small vesical perfora- 
 tion existed on the right and a uretero-vaginal fistula on the left : He divided 
 the fistula by an incision extending through half the circumference of the 
 external part of the fistula, in order to mobilize the ureter. When this inci- 
 sion had extended several millimetres it entered the peritoneum, which was 
 tamponed with iodoform gauze. The internal vesical part of the fistulous 
 orifice was extensively denuded, and the ureter was attached to the bladder 
 by a double layer of sutures ; uretero-vesical, of catgut ; vaginal, of silk- 
 worm gut. A self-retaining catheter was placed in the bladder; the sutures 
 were removed on the eleventh day, the patient being completely cared. 
 
 b. Uretero-vesical Anastomosis by the Abdominal Route. — This was suc- 
 cessfully done almost simultaneously by Novaro and Bazy, who gave it the 
 name of uretero-cystoneostomy. Bazy at first attempted to perform the 
 ureteral anastomosis by the transvesical route without opening the perito- 
 neum, but two successive failures led him to approach the ureter by a trans- 
 peritoneal laparatomy as Novaro had done, and as I have successfully done 
 in a recent case. Bazy carries out the operation as follows : The patient is 
 placed in the Trendelenburg position, and the abdominal wall is incised for 
 a distance of twelve to fifteen centimetres beginning above the pubis. The 
 intestines are held back by a compress and the abdominal wall is retracted, 
 freely exposing the field of operation. The peritoneum is incised in the 
 direction of the ureter, then the latter is divided about one centimetre above 
 the bladder, and the vesical end is resected. A male sound or a Chassaig- 
 nac's curved trocar is then introduced through the urethra, its blunt end 
 pushing out the bladder wall near the lower end of the ureter; an incision at 
 least one centimetre long is made through the wall of the bladder. When 
 
CICATRICIATL FISTULJE OF THE VAGINA. " yyi 
 
 this has been done, a No. 14 red rubber bougie is placed in the ureter, and 
 drawing this into the bladder, emerges through the urethra. The ureter is 
 united with the bladder by interrupted catgut sutures, which include the en- 
 tire thickness of the ureteral and vesical walls. The peritoneum is closed 
 by a continuous catgut suture, and a Mikulicz tampon is left in contact with 
 the field of operation. 
 
 Novaro does not place a bougie in the ureter, but practises the following 
 manoeuvre, in order to assure an extra-peritoneal course of the stream of 
 urine in case the sutures give way: After having carefully sutured the pel- 
 vic peritoneum at the level of the incision made in order to reach the ureter, 
 he separates the vesical peritoneum from the pubis to the region where he 
 has placed his sutures, and through the space thus made he passes a strip of 
 sterilized gauze, which assures extra-peritoneal drainage of the urine if it 
 makes its way through at the level where the sutures have been inserted. 
 
 Nitzel fixes the portion of bladder, as near to the ureter as possible, to 
 the pelvic wall by several coarse catgut sutures, in order to avoid traction of 
 the bladder upon the grafted ureter. He fixes the ureter which has been 
 introduced into the bladder by two layers of catgut sutures, the deep layer 
 including only the vireteral and vesical mucous membranes, the superficial 
 taking in the muscular walls Then, in order to imitate as nearly as possi- 
 ble the normal entrance of the ureter into the bladder, he makes an oblique 
 canal four centimetres long in the vesical wall, around the ureter. 
 
 H. A. Kelly does not suture the bladder to the pelvic wall, but carefully 
 frees it at the level of the pubis, so that it can easily be drawn backward in 
 front of the ureter. 
 
 All these procedures have the advantage of leaving the ureter extra-peri- 
 toneal, and thus protecting it from intestinal adhesions which might con- 
 strict it. In this way they are, as Nitzel remarks, superior to the methods 
 employed by Krause and by Veit, in which the ureter remains free and in- 
 tra-peritoneal for a certain distance near the bladder. 
 
 Many uretero-vesical anastomoses have now been reported, and the re- 
 sults obtained have been most encouraging. In any case I consider this 
 operation, which re-establishes the ureter in the performance of its physio- 
 logical functions, far superior to implantation into the rectum or colon. 
 The occasional successes following the latter procedure should not make one 
 oblivious of the dangers to which it exposes the patient and of the disastrous 
 results which have followed its employment by skilful experimenters. 
 
 As I have previously said, I believe that there is one formal contra-indi- 
 cation to all transperitoneal attempts at uretero-vesical anastomosis, namely, 
 infection of the ureter, kidney, or bladder; for this procedure demands the 
 conditions necessary for a perfect primary union, in order to succeed and 
 not to expose the patient to the gravest dangers. In these cases and after 
 failure to secure an anastomosis by the vaginal route. I should not hesitate 
 to employ the method of indirect obliteration, which I shall now describe. 
 
772 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 2. Method of Indirect Obliteration. — ^This operation has been applied to 
 uretero -vaginal fistulae when direct denudation or anastomosis has failed. 
 It consists in either the obliteration of the genital canal below the fistula or 
 the extirpation of the kidney to which the perforated ureter belongs. The 
 first plan would possess the fewest objectionable features, were it possible 
 to perform hystero-stomatocleisis or obliteration of the vaginal portion of 
 the cervix ; but this occlusion, to be free from danger, would have to be lat- 
 eral and not terminal. Now, we know that, on the contrary, the portion of 
 the canal between the fistula and the bladder will tend to contract and to 
 become obliterated. Theoretically, we might attempt the production of an 
 artificial vesico-cervical fistula, which would permit the evacuation of the 
 urine accumulated in the uterus, or we might establish an artificial ureter in 
 the place of the segment obliterated. Both of these attempts have been 
 made by Zweifel without success. We must therefore renounce hysteroclei- 
 sis, and substitute obliteration of the vagina, or colpocleisis, after the estab- 
 lishment of an artificial opening between this canal and the bladder. This 
 is the plan which has been followed, too, by Hahn. He carefully united 
 the mucous membranes of the superior lip of the artificial opening and su- 
 tured the inferior lip to the posterior vaginal wall, in order to assure perma- 
 nency of the vesico-vaginal outlet. The patient's husband subsequently 
 desired the reopening of the vagina, and the artificial vesico-vaginal fistula 
 persisted, while the ureteral opening had spontaneously closed. Kehrer has 
 recently published an interesting observation : he very justly remarks that 
 a mere incision is not sufficient to assure permanency of the opening between 
 the vagina and bladder, but that it is necessary to excise a portion of the 
 septum, a disc about four-fifths of an inch in diameter, and then carefully 
 unite the mucosa of the bladder and vagina. 
 
 Obliteration of the vagina is consented to by women with reluctance, and 
 it frequently happens that after the operation they demand a reversion to 
 the condition of their former infirmity. It is apparent that nephrectomy 
 may be preferred, in spite of the dangers of removing one kidney where the 
 patient may already have a certain degree of unrecognized bilateral ascending 
 nephritis. This operation was first proposed by Simon. It was done by 
 Zweifel in 1878, and then by Crede ; so that in 1889 at least eleven cases 
 had been operated upon, including that of Treub. Before determining upon 
 the operation, it is very important to assure yourself of the condition of the 
 other kidney. The urine should be taken from this kidney directly by 
 catheterization of its canal, and examined chemically and microscopically, 
 
 Gj'avity of tJie Operation ; Operative Accidents ; Resnlts. — I shall consider 
 here only the direct operation for the ordinary urethro- and vesico-vaginal 
 fistula. These operations can be considered absolutely benign, although it 
 adds a little to the gravity if the fistula is near the cervix, and consequently 
 near the uterine arteries, ureter, and peritoneum. 
 
 Verneuil has published the proportion of cases in his practice in which 
 
CICATRICIAL FISTULA OF THE VAGINA. -J-Jl 
 
 operation has been followed by death. The number was five out of eighty. 
 We must call attention to the fact that the most of these cases antedated 
 the period of antisepsis ; the percentage is at the present day much 
 smaller. Hegar and Kaltenbach have lost but a single case in a series 
 of eighty. 
 
 Wounding of the posterior wall by the brutally forcible use of the spec- 
 ulum deserves mention only because it has once been observed by Courty ; 
 it is easy to see that peritonitis might follow such a procedure. 
 
 Fatal primary hemorrhage can result only in the most unfavorable cir- 
 cumstances, in the case of haemophilia for instance. Horteloup has reported 
 a case from the wounding of an extraordinarily developed uterine artery. 
 This is, however, exceptional, although in any case hemorrhage may be seri- 
 ous during the operation, either in the case of denudation of the lateral vagi- 
 nal wall, where the veins are largely developed, or if the operation is done at 
 a time when the slough has not yet separated, or finally if the vesical mucous 
 membrane is invaded. Direct compression followed by suture are the best 
 measures for its arrest. It constitutes, however, one of the conditions un- 
 favorable for primary union. 
 
 Secondary hemorrhage takes place from the third to the fifth day. I con- 
 sider it always due to some operative defect. The remedy is the tampon. 
 If the hemorrhage is into the bladder, it might pass unperceived at first, 
 and the cavity become distended with clots before it can be controlled. 
 Fragments will be discharged by the urethra with distressing tenesmus, and 
 the decomposition of the residue will be fatal to the success of the suture. 
 We should aid their expulsion by frequent vesical irrigation, and, if the 
 distention of the bladder is considerable, should not hesitate to dilate the 
 urethra and to break up the clots with a blunt curette. Lastly, if the hem- 
 orrhage continue, it will be necessary to remove the sutures and search for 
 the bleeding vessel per vaginam. 
 
 Wounding or inclusion of the ureter is evidenced by lumbar pains, vomit- 
 ing, and fever. In this case we should hasten to remove the suspected suture, 
 as the complication may be very grave. The suture may cut through the 
 ureter, however, causing a sudden explosion of uraemic symptoms. 
 
 The infections complications — phlebitis, pyaemia, lymphangitis, and diph- 
 theria — formerly rare, are now quite the exception. Peritonitis may result 
 from wounding of the peritoneum during denudation or by the sutures in 
 the absence of antiseptic precautions, or where a concomitant pyelitis or 
 cystitis produces subsequent infection of the wound. 
 
 Calcnli or calcareous incrustations have formed in the bladder in the neigh- 
 borhood of silver-wire or silk sutures which ha\'e cut through the tissues and 
 fallen into the bladder. It should not be forgotten that, in the majority of 
 patients suffering from fistula, the urine is altered by sympathetic inflam- 
 mation of the bladder, which may have extended to the pelvis or even to the 
 substance of the kidney itself. These conditions favor the formation of cal- 
 
774 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 culi. As these are, however, always phosphatic and very friable they are 
 easily broken up and removed by the lithotrite. 
 
 The results of surgical interference are altogether remarkably satisfac- 
 tory. It can be said that no case is absolutely incurable by either the direct 
 or indirect method. It is true that this last procedure substitutes a deform- 
 ity for an infirmity, or necessitates the sacrifice cf one of the kidneys. Many 
 failures are due to an imperfect diagnosis. I operated upon one woman 
 upon whom eleven unsuccessful attempts had been made to obliterate a small 
 
 Fig. 503. — Pawlik's Operatiox for Diminishing the Calibre of the Urethra. I, Urethral region as 
 seen when the patient is in the genu-pectoral position ; II, extent of the denudation to be made, estimated by traction 
 with a hook ; III, denudation ; IV, result obtained. A, Pubic arch -, C. projection of urethral canal ; Z>, posterior 
 depression of the pubis ; U, meatus urinarius; a, i, c, a', i', c\ outlines of the juxta-urethral denudation, 
 
 fistula in the anterior vaginal wall. I satisfied myself that these failures 
 were due to the fact that the ureter had opened into the fistula, and I then 
 performed the flap-splitting operation by which the ureteral orifice was 
 turned into the bladder; recovery was immediate. 
 
 Iricontinence of urine often persists for a long time after complete union 
 of the fistula, so that the patient continues to lose urine involuntarily, and 
 does not believe in her recovery. A number of anatomical conditions will 
 explain this result. Loss of tonicity in the vesical sphincter and of the 
 muscular coat of the urethra from disuse may be mentioned, as this factor 
 plays an important role in the normal retention of urine in the female. 
 
CICATRICIAL FISTUL/E OF THE VAGINA. 775 
 
 Several lines of medical treatment have been followed to remedy "this 
 condition — injections of strychnine, the hot douche, electricity, etc. Schatz 
 has recourse to a special pessary. All pessaries, and in pj3irticular that of 
 Dumontpallier, may diminish the incontinence by light pressure upon the 
 urethra. Undeniable success has been obtained by means of a small plastic 
 operation for the purpose of bridging the urethra and partly effacing its cali- 
 bre. The urine then accumulates until present in sufficient cjuantity to 
 overcome the obstacle. Schroder practised two lateral denudations with the 
 object of elongating and displacing the canal of the urethra. Pawlik re- 
 moved two lateral cuneiform fragments in order to produce lateral traction 
 upon the urethra, and bend it so as to diminish the patency of the canal. 
 His method is as follows : Seizing the urethra with a tenaculum, he dis- 
 places it as far as possible to either side, marking the points which corre- 
 spond to this displacement (Fig. 503). Having outlined his denudation he 
 proceeds to make two parallel incisions between the points. The orifice is 
 then drawn with a hook toward the clitoris, and the point marked to which it 
 can be displaced. The incision is then carried forward, taking care to give 
 it a slightly concave shape interiorly, so that after the suture the external 
 urethral orifice shall not be too constricted. Having completed the outline, 
 denudation is done and tissue removed at the side of the urethra so as to 
 give a somewhat deep wound; the sutures are then placed drawing the ure- 
 thra toward the clitoris, the sutures being directed obliquely as they approach 
 the urethral orifice, and at the posterior portion being inserted antero- 
 posteriorly. Pawlik operates in the genu-pectoral position, and uses car- 
 bolized silk, powdering the line of his sutures with iodoform. He does the 
 second operation upon the other side after cicatrization of the first, and 
 recommends frequent emptying of the bladder. He has obtained several 
 good results by this method. 
 
 Fecal Fistul.^. — I include under this common title both recto- and 
 entero-vaginal fistulae. 
 
 Recto-vaginal Fistula : Etiology. — Delivery is the most frequent cause. 
 Compression is not, however, the determining cause, as in the case of urinary 
 fistula. Recto-vaginal fistulae are a more immediate result of traumatism ; 
 they ordinarily depend upon an extensive rupture of the perineum cicatrized 
 inferiorly in the location of greatest depth, but leaving a perforation above 
 where the thinness of the septum permits the two mucous membranes to 
 come into contact and to unite in such a manner as to insure its per- 
 manency. 
 
 Among the rarer causes are : Wounds of the vagina by the forceps or 
 cephalotribe, gangrene of the septum due to prolonged retention of the head, 
 direct traumatism by a foreign body violently introduced or retained for a 
 sufficient length of time to produce ulceration and laceration in the course of 
 a vaginal hysterectomy. This complication is especially to be feared in 
 cases of pelvic suppuration, due to streptococci, situated m Douglas' cul-de- 
 
7/6 CLINICAL AND OPERATIVE GYNAECOLOGY, 
 
 sac and running an acute course. P'inally, ulceration due to various other 
 causes, such as abscess affecting either the vagina or rectum so as to produce 
 an abnormal communication between them. These perforations are some- 
 times above the sphincter. Dermoid cysts and the cysts of extra-uterine 
 pregnancy, if situated in Douglas' cul-de-sac and invaded by suppuration, may 
 produce an opening between the vagina and rectum by evacuating into both 
 simultaneously. These fistulous tracts are not, however, counted in the class 
 of fistulae proper previous to the cicatrization of their margins. 
 
 Pathological Anatomy. — I shall here consider only those fistulae which 
 can be called cicatricial, excluding such abnormal recent communications 
 as are due to fresh wounds, or such as are of cancerous origin, where the 
 fistula is but a phenomenon consecutive to a pathological process ; also pur- 
 ulent fistulae in the stage of evolution. 
 
 Verneuil classifies fistula from the standpoint of location, as : Recto- 
 vulvar, the orifice being on the vulva or f ourchette ; inferior recto-vaginal, 
 the orifice being in the lower part of this canal ; and finally, superior recto- 
 vaginal, in which the fistula opens in the vicinity of the cervix in the pos- 
 terior cul-de-sac. These are rare and usually consecutive to the evacuation 
 of an old collection in Douglas' cul-de-sac or vaginal hysterectomy. 
 
 The dimensions are variable. Recto-vulvar fistulae commonly consist of 
 but a small opening; the fistulae of the inferior part of the vagina also are 
 often very narrow, the septum being at times thinned at a certain point so 
 that they are apparently merely punched through, and are frankly ostial or 
 labiform or in other cases canaliculated, having an oblique direction in the 
 substance of the wall, their vaginal orifice being at times concealed by a 
 kind of valve formed by the posterior vaginal border, which is more or less 
 irregular and serrated. Fistulae opening in the posterior cul-de-sac may 
 have very large dimensions, being often consecutive to a large slough caused 
 by the pressure of a tumor which subsequently opened into the two canals. 
 I have observed one in a case of foetal cyst which would admit the thumb. 
 When the fistula consists of a canal, it is the vaginal mucous membrane 
 which is reflected and lines it. 
 
 The margins of the fistula are ordinarily hard and sharply defined. Cica- 
 tricial bands may also divide the vagina connecting these with vesico-vaginal 
 fistula due to the same difficult labor. 
 
 Symptoms and Diagnosis. — The passage of gas and fecal matters is the 
 pathognomonic sign for the clinician, and the most distressing symptom for 
 the patient. The discbarge of these matters is not, however, absolutely con- 
 stant, and may fail altogether if the direction of the fistula be oblique and 
 the stools solid. With diarrhoea, however, it is always present. An intense 
 vaginitis develops where the phenomenon is constant. With the finger one 
 is able to demonstrate a recto-vaginal fistula if it have any size; while the 
 speculum, aided by the sound and the rectal touch, is always sufficient for 
 its discovery. Sims' position is the most convenient for this examination. 
 
CICATRICIAL FISTULA OF THE VAGINA. TJJ 
 
 If necessary, an enema of milk may be made to filter through the orifice, 
 where it is situated behind a fold or hidden in a cicatrix. 
 
 Prognosis. — We have here a condition which is not very amenable to 
 treatment, even when it is of apparently slight importance; for the difficul- 
 ties in the way of recovery do not depend upon the extent of the lesion. 
 The most difficult cases are those complicated with multiple cicatrices in the 
 vagina. 
 
 Cases of spontaneous cure have been reported ; this takes place quite 
 frequently in recto-vaginal fistulae following vaginal hysterectomy, but these 
 ■occurrences are exceptional, and in a general way it may be said that recto- 
 vaginal fistulae are cured only by surgical interference. 
 
 Treatment. — Although it would at first seem that direct suture of the 
 fistula through the vagina would be the simplest operation, this is not at all 
 so ; in fact, oxCiy a small raw surface can be obtained in this way, and suc- 
 cess is much less certain than when the indirect method is employed. This 
 consists in including the perforation in a large area of denudation involving 
 the perineum. We may then state that in the great majority of cases, 
 •operation for recto-vaginal fistula should consist of a slightly modified colpc- 
 perineorrhaphy, that the perineal route is the better, the vaginal being only 
 exceptionally taken. 
 
 Operation by the Perineum. — The older surgeons contented themselves 
 with a vertical incision of the perineum up to the fistula, leaving to nature 
 the process of cicatrization, and performing a complementary operation if 
 necessary. Later, section of the perineum was regarded as the first step in 
 immediate perineorrhaphy; it merely transformed the recto-vaginal fistula 
 into a complete perineal tear, which was then treated as such. Isolated re- 
 ports of this method are given by Ricord, Demarquay, and Baker Brown. 
 Richet was the first in France and Simon in Germany to establish it as a 
 method ; since that time it has found many partisans. Recently the popu- 
 larity of Lawson Tait's flap-splitting method has given a wider field to perine- 
 orrhaphy ; this process indeed possesses the great advantage of large sur- 
 faces furnished at small expense, which can be brought together, and permits 
 of mobilization of the rectum, and destroys the parallelism between the rec- 
 tal and vaginal orifices of the fistula, as these are glided past each other. 
 
 Before this process of perineorrhaphy became popular, the whole series 
 of operations, which will be described later (see Lacerations of Perineum), 
 had been used. Thus Schauta employed Hegar's triangular vivification proc- 
 ess, being careful to include the fistula and join its edges by buried catgut 
 sutures. Chrobak also praises this process. But I repeat, Lawson Tait's 
 operation, which may be applied in nearly every case, is the operation to be 
 chosen. 
 
 The attempt has been made to formulate the indications for the process 
 to be adopted in operating according to the situation of the recto-vaginal 
 fistulae, or according to the condition of the perineum. These indications 
 
778 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 doubtless possess a value, but they serve chiefly as a guide to the amount of 
 tissue to be divided, and may assist in deciding whether there should be 
 a preliminary vertical section of a small cutaneous flap which is sometimes 
 
 Fig. 504.— Hegar's Process of Colpo-perineorrhaphv as Applied to the Cure of Recto-vaginal Fistula. 
 
 interposed between the fistula and the perineum, or section of a flappy non- 
 muscular but perhaps somewhat thickened perineum. 
 
 Fig. 505. — Sutures of Rectum, Vagina, and Perineum after Vertical Section and Division of the Peri- 
 neum. (Schema.) L R, Rectal flap with Lauenstein suture ; L l-\ vaginal flap. 
 
 The next step is the choice between two variations in the method of 
 performing perineorrhaphy. 
 
 {a) Should the perineum be too thin or not substantial enough to deserve 
 
CICATRICIAL FISTUL/K OF THE VAGINA. 
 
 779 
 
 consideration, it may be incised up to the fistula, after which Lawson Tait's 
 operation for perineorrhaphy should be adopted. Then I hold that we 
 should follow Sanj^er's example, and when the fistula extends far up (Figs. 
 506, 507) suture the rectum alone with stitches of silk introduced after the 
 
 method called by Lauenstein's name, 
 which this surgeon borrowed from 
 Lemibert's method for uniting serous 
 membranes. 
 
 This isolated suture of the rectum 
 appears to me to be useful only when 
 the recto-vaginal wall has been incised 
 to a considerable height ; in other 
 
 Fig. 506. — Sutures aftek Vertical Section and 
 IJivisiON OK THE 1'erineum. The rectal flap is su- 
 tured. The stitches in the vagina and perineum have 
 not yet been tightened (Sanger). 
 
 Fig. 507. — Sutures after Vertical Section and 
 Division of the Perineum. Shows arrangement of 
 sutures Vifhen operation is finished. 
 
 cases auto-plastic division will sufficiently mobilize it, and it can thus be 
 drawn down low enough to render special suture of the rectum unnecessary. 
 
 (b) Should the perineum be firm and resistant, and the fistula be situated 
 above the sphincter, which is almost intact, to begin the operation by section 
 of the perineum would possess more drawbacks than advantages. Lawson 
 Tait's method for incomplete laceration of the perineum should be adopted, 
 by first splitting the perineum and then the recto-vaginal wall to above the 
 fistula. Before suturing the perineum it would be well to close the rectal 
 orifice by inserting a series of Lembert-Lauenstein sutures (Fig. 508) from 
 the side of the wound. The vaginal orifice is to be sutured from the vagina, 
 the sutures all to be made with fine silk. Sanger has obtained many good 
 results with this process. 
 
 There are some exceptional cases in which the fistular orifice is situated as 
 high as the posterior vaginal cul-de-sac. Following Sanger's example we 
 
•8o 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 might make a lar£e and deep division of the perineum by means of a bi- 
 ischiatic division, pushed tD just above the fistula, and traversing the leva- 
 tor ani, and not hesitating to make a wound large enough to contain both 
 fists. This operation was described above under the name of transverse 
 perineotomy. I think it preferable to then suture the fistula on the vaginal 
 side, after having freshened it. The perineal wound may be a trifle nar- 
 
 FiG. 508. — Sutures of Vagina, Rectum, and Perineum akier Simple Splitting of the Perineum, with- 
 out Preliminary Vertical Section, i, 2, 3, 4, Buried sutures of Lauenstein (^silk) closing rectal orifice ; 5, 6, 
 7, 8, deep stitches (silver) for uniting perineal surfaces ; 9, 10, 11, vaginal stitches (silver) the loops of which pass in 
 front of the vaginal orifice which they are to close (Sanger). 
 
 rowed, but its middle portion should be kept open by means of wads of iodo- 
 form gauze. To this process Sanger owed his successful results in a case 
 in which the situation of the fistula was exceptionally high. 
 
 To it may be compared the process first described by Alph. Guerin, 
 then by (Juenu and Felizet. Quenu follows Guerin's example ; in addition 
 he secures relaxation of the sphincter ani by incising it posteriorly and join- 
 ing the muco.sa above it. Felizet does not suture the vaginal orifice, but 
 opens the rectal orifice as far as the anus by incising from above downward 
 all the posterior flap found by the division ; this manoeuvre seems to me to 
 possess no advantages. 
 
 Operation by the Vagina. — This is the one to be resorted to in the case 
 
CICATRICIAL FISTUL.E OF THE VAGINA. 
 
 781 
 
 of small fistukc not complicated by cicatrices which interfere with the ex- 
 tensibility of the vagina, when the perineum is nearly intact, and the fistula 
 situated so high up that to reach it by the perineum would require a great 
 destruction of tissue; but as I have already observed, the chances of success 
 by this method are less. It is, however, preferable to operation by the rec- 
 tum. The vulva is more easily distended than the anus behind, which is 
 the opposing coccyx; the vaginal mucosa is firmer, lends itself better to 
 freshening, and bleeds less. Finally, and most important, there is less 
 chance of infection. 
 
 Simple Freshening zvitk Loss of Substance. — The patient is placed in the 
 dorso-sacral position, and the vagina stretched apart by means of an upper 
 flat blade and lateral retractors. The parts near the fistula are fixed by for- 
 
 FiG. 509. — Operation for Recto-vaginal Fis- 
 tula. Freshening with loss of substance per vaginam. 
 Deep sutures. 
 
 I'iG. 510. — Operation for Recto-vaginal P"is- 
 TULA BY Vaginal Freshening. Course of deep 
 sutures. 
 
 ceps. The recto-vaginal wall may be lifted by an assistant's finger, or sim- 
 ply supported by a tampon of iodoform gauze. The surgeon would better 
 not soil his fingers by inserting them in the rectum, no matter what care 
 may have been taken to disinfect them by irrigation with a borated solution. 
 The denudation is made very deeply, and the lining membrane of the 
 fistula, if there be one, dissected as far as the rectum (Fig. 509). Sutures 
 are inserted going as deeply as to the rectal mucosa (Fig. 510), and passing 
 beneath the whole extent of the wound, which is funnel-shaped. The super- 
 ficial sutures Vv^hich include the mucosa only and which alternate with the 
 preceding are then inserted ; these are first tightened and then the deep sut- 
 ures. Silver wire is preferable on account of its being more easy to keep it 
 aseptic. The ends are protected by a lead tube which is crushed over them 
 and cut off level above. Care must be exercised to keep the line of suture 
 in the direction in which there will be the least traction ; this in large perfora- 
 tions is usually the transverse. Should the perforation be very large and in 
 the immediate neighborhood of the cervix, Simon's example should be fol- 
 lowed and the anterior lip freshened and united with the inferior border of 
 the fistula; the menstrual flow will then occur through the rectum. 
 
782 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Autoplasty by Flap-Splitting. — This method of denudation, first used for 
 vesico-vaginal fistul^e by French surgeons, and recently adopted in Ger- 
 
 ^•&^^ 
 
 k 
 
 ^•F 
 
 D 
 
 Pig. 511. — Operation for Recto- 
 vaginal Fistula through the Va- 
 gina. Autoplasty by flap-splitting. A^ 
 D, Vertical incision ; A, E, B, F, outline 
 of the split area (Sanger). 
 
 ""-"---v ' ^ 
 
 - ,:'-! 1 i 
 
 
 ' f 
 
 -■>? .^^: Vl 
 
 .}m . - / V 
 
 
 <// 
 
 ^ 
 
 Fig. 512.— Operation for Recto-vaginal Fistula. Autoplasty by 
 flap-splitting. Insertion of deep stitches. 
 
 many, and which I have already described, according to VValcher has also 
 
 been applied to cases of recto-vaginal fistula, 
 to its use. His technique is similar to that 
 used by VValcher. He adds a protecting 
 suture on the side of the rectum. Tliis is 
 his method of procedure : The index finger 
 
 Sanger owes a brilliant result 
 
 Fig. 513. — Operation for Recto-vaginal Fistula. 
 Autoplasty by flap-splitting. Suture ti/^jhtened around the 
 rectal orifice. Deep sutures of vaginal orifice not yet 
 tightened (Sanger). 
 
 Fig. 514. — OiERATioN for Recto-vaginal 
 Fistula. Autoplasty by flap-splitting. Vaginal 
 sutures in place. Insertion of protecting sutures 
 around rectum (Sanger). 
 
CICATRICIA-L FISTULA OF THE VAGINA. 783 
 
 is introduced within the rectum, the operating field exposed and kept upon 
 the stretch by suitably arranged forceps. A vertical incision extending 
 beyond the fistula, both above and below for about three-fifths of an inch, 
 is made in the median line and goes to the rectal mucosa (Fig. 511). 
 The vaginal flaps are detached around the fistula. When the edges of these 
 flaps are retracted, the fistula is in the centre of an elliptical denuded 
 .surface. 
 
 The rectal perforation is closed by from six to eight buried sutures of 
 fine silk, inserted according to Lauenstein's method (Fig. 508). The two 
 vaginal flaps are then sutured above the fistula by deep stitches (Fig. 513) 
 with silkworm gut, and superficial stitches (Fig. 515) with silk. Sanger 
 inserts a final series of protective stitches for the rectum, to prevent fecal 
 
 C.RX 
 
 4 
 
 Fig. 515. — Operation for Recto-vaginal Fistula. (Schema to show arrangement of sutures.) i, i, Sutures 
 buried beneath the rectal surface of the fistula ; 2, 2, deep vaginal sutures ; 3, 3, superficial vaginal sutures ; 4, 4, pro- 
 tecting sutures for the rectum (Sanger). 
 
 matter from oozing between the united surfaces. To apply them he puts the 
 patient in the Trendelenburg position and dilates the rectum. The exposed 
 fistula is then sutured without further denudation by stitches of fine silk 
 (Figs. 514 and 515). Sanger's patient was completely cured at the end of 
 sixteen days.'-'^' 
 
 Autoplasty by Gliding. — This process, which was suggested by the older 
 surgeons, has more recently been used successfully by Fritsch and Le Dentu 
 for small fistulse situated high up in the vagina, and very recently by P. 
 Segond for a large fistula in the posterior cul-de-sac. It is a true autoplastic 
 process, consisting in a vaginal flap cut from above the fistula which we slide 
 down before it like a curtain (Figs. 516 and 517). First a curved incision 
 
 * Sanger lays especial stress upon the method of suture of the fistulje (Lauenstein's suture). 
 There should be no hesitation in increasing the number of sutures in order to make the union more 
 exact. Chinese silk boiled in five-per-cent carbolic solution and preserved in a i : 500 bichloride 
 solution, he considers preferable to catgut which is liable to be too rapidly absorbed. 
 
784 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 A ^ is made along the upper border of the fistula F. The mucosa is detached 
 below this incision a short distance to C. A second more deeply cur\^ed 
 incision is made at A D B, at a. small distance from the fistula, and, if 
 necessary, a small crescent-shaped strip formed of indurated cicatricial tis- 
 sue is excised from between the 
 ^ I two incisions. The upper flap is 
 
 then drawn down and sutured to 
 the inferior border of the wound, 
 the stitches passing beneath the 
 denuded surface. By this process 
 
 Fig. 516. — Operation for Recto-vaginal Fistula. 
 Autoplasty with a flap. Arrangement of flaps and su- 
 tures (Fritsch). 
 
 Fig. 517. — Operation for Recto-vaginal Fis- 
 tula. Autoplasty with a flap. Stitches tightened 
 (Fritsch). 
 
 Fritsch obtained four successful results. Sanger had a failure. Le Dentu 
 successfully used a process which is identical in principle, but which differs 
 in some details of technique. This is the description which he gives of 
 autoplasty by gliding, zvith superposed flaps and valvular arrangement : 
 
 I . The index finger of the left hand covered with a rubber glovQ is intro- 
 
 FiG. 518. — Operation for Vesico-vaginal Fistula by Autoplasty and Flap-sliding. 
 
 and of denudation (Le Dentu). 
 
 Arrangement of flap 
 
 duced into the rectum. This precaution renders it possible to use the same 
 finger during the course of the operation without the risk of infecting the 
 wound. The recto-vaginal wall, which is pushed toward the vagina and 
 spread out, can thus be more easily handled. Other means may be used to 
 obtain the same result. The finger of an assistant, or even one of Petersen's 
 small balls slightly distended, may be used for the same purpose, with this 
 difference, that by using his own finger the surgeon will be better able to 
 
CICATRICIAL FISTULJE OF THE VAGINA. 785 
 
 judge of the thickness of the wall and the course of his dissection. This 
 will explain why the use of the rubber glove is the best method. 
 
 2. With a sharp-pointed bistoury the curved line of incision A B C is 
 to be traced, about two-fifths of an inch above the fistula; then the curved 
 line A F' C, which should pass along the lower border of the fistula. The 
 vaginal mucosa is then to be denuded throughout the whole extent of the 
 crescent outlined by the incisions A B 6" and A B' C (Fig. 5 18, a). 
 
 3. The vaginal mucosa to be dissected from above downward from the 
 incision A B' C to d. line represented (Fig. 518, a) by the dotted line A 
 D C. The D of this curved line representing the base of the dissected flap 
 should be a good two-fifths of an inch below the fistula, so that the distance 
 B D shall be equal to or very slightly less than B B. 
 
 4. The flap yi B' C D being turned toward the anus (Fig. 518,^) there 
 remains a large denuded surface formed in part by the denudation ABC 
 B' at the expense of the vaginal mucosa, and partly by dissection of the flap 
 A B' C D. The operation essentially consists in raising this flap and unit- 
 ing its denuded surface to the freshened surface A B C B ; but if this slid- 
 ing process were all, a cul-de-sac would be formed at the base of the flap in 
 which the matters discharged through the fistula would be deposited. It is 
 therefore necessary to destroy this cul-de-sac, which is done as follows : 
 
 5. With the scissors the triangle B I K (Fig. 518, h) is cut from the 
 tissues situated above the fistula. On each side the upper flap is liberated 
 along one-half of the lines A /and K 6^ (Fig. 518, c). By this means the 
 rectum is widely opened below the fistula and there is no longer a cul-de-sac 
 between it and the base D of the flap A D C B. 
 
 The sutures are now to be inserted, a proceeding which demands great 
 care. There should be at hand a dozen rather fine silver wires, threaded at 
 both ends into fine, slightly curved needles. According to the extent of the 
 fistula, from five to eight of these wires will have to be used, more if the 
 dimensions are very great. They are inserted as follows : 
 
 6. A needle carrying a wire is to be entered at B on the superior flap, 
 and brought out at i^ after having traversed the thickness of the flap with- 
 out, if possible, infringing upon the rectum. Then the points D (base) and 
 B^ (apex) of the inferior flap are to be traversed with each needle (Fig. 519, 
 I). Then drawing upon the two ends of the wire and pushing back the 
 inferior flap, its posterior denuded surface is to be adapted to the anterior 
 denuded surface of the superior flap. To maintain them in position it is 
 only necessary to put two Galli tubes on the ends of the wire, crushing the 
 superficial one, but being careful not to tighten the wire. Otherwise from 
 tumefaction of the flaps the tubes would become buried in the tissues and 
 perhaps cause ulceration and perforation. 
 
 Or the wires may be twisted around a little wad of iodoform gauze 
 pbced between their free extremities, upon the anterior surface of the in- 
 ferior flap (Fig. 519, 2). In any case there must be no torsion of the wires 
 
786 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 directly above the flap without the interposition of iodoform gauze, so as to 
 avoid the wrinkling which would diminish the surfaces to be united. Either 
 the use of the tubes of Galli, or torsion around a little piece of gauze will 
 stretch these surfaces and thus increase the chances of success. All the 
 wires are successively inserted in the same manner. 
 
 The sutures once inserted, the inferior flap will be found to quite cover 
 the superior flap (Fig. 519, 3). The fistula is entirely suppressed, and the 
 
 8 
 
 Fig. 519. — Operation for Recto-vaginal Fistula by Autoplasty and Flap-sliding. Arrangement of sutures 
 
 (Le Dentu). 
 
 rectal mucosa, which forms the posterior surface of the superior flap project- 
 ing slightly beyond the line of union on the rectal side, forms a little valve 
 over which the gases and fecal matter glide naturally toward the rectum, and 
 cannot get into the vagina by slipping between the flaps. 
 
 P. Segond's method consists in "removing the portion of the rectum 
 situated below the fistula without involving the perineum, freeing the por- 
 tion above the fistula, and drawing it down to the anus." It includes the 
 following steps : 
 
 1. The anus is dilated manually, slowly, rhythmically, and as completely 
 as possible. By proceeding in this way the mucous membrane is not torn, a 
 large dilatation is obtained, and the sphincter always regains its function. 
 
 2. The intra-anal cylinder of mucous membrane is liberated by dissec- 
 tion. A circular incision is made through it, two or three millimetres above 
 the muco-cutaneou3 junction. This precaution is indispensable in order 
 that the ultimate line of suture may be concealed in the anal depression. 
 After making the incision the mucosa is dissected off, by a series of small 
 snips with the scissors, over the entire region of the sphincter. The muscle 
 
CICATRICIAL FISTULA OF THE VAGINA. 
 
 787 
 
 is then Kept from contracting by two retractors, and the entire thickness of 
 the rectal walls may be seized for the succeeding step. 
 
 3. The recto-vaginal septum is split in order to mobilize, lower, and re- 
 sect the rectal segment below the fistula. The splitting of the recto-vaginal 
 partition as far as the fistula may be accomplished by the finger alone. The 
 course of the fistula is then divided with a bistoury, separating it into two 
 independent orifices, a rectal and a vaginal. Then seizing the anterior rectal 
 
 Fig. 520. — Operation for Recto-vaginal Fistula bv Sliding Flap (Segond). Antero-posterior section showing 
 manner of resecting rectum. Portion to be removed is grasped by forceps. 
 
 wall above the fistulous opening with the fingers, the splitting of the septum 
 is continued without the aid of cutting instruments, at the same time exert- 
 ing traction downward until the portion of the rectum corresponding to the 
 upper border of the rectal opening of the fistula is sufficiently lowered to 
 allow it to be sutured to the border near the muco-cutaneous junction at the 
 anus. This step of mobilization is aided by fixation of the uterus by a 
 Museux forceps previously introduced through the vagina. The rectum is 
 lowered by successive tractions and the peri-rectal separation is accomplished 
 with the thumb-nail. This manoeuvre is possible, however high the fistula 
 may be situated, and the thick peritoneum of Douglas' cul-de-sac may be 
 pushed back without danger of laceration. As the anterior rectal wall is 
 drawn down, the lateral and posterior portions of the mucous membrane of 
 the rectum become folded and stand out, but this should be overlooked at 
 first as these portions are freed, after the separation of the anterior wall is 
 complete, sufficiently to overcome this condition and allow accurate apposi- 
 tion after resection of the segment below the fistula. This resection must 
 
788 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 be oblique from above downward and from before backward, from above 
 upper border of the rectal orifice of the fistula in front to a point above the 
 postero-superior border of the sphincter, varying in distance from the latter 
 with the amount resected, that is, with the height at which the fistula is sit- 
 uated (Fig. 520). 
 
 4. The rectum is sutured to the anus with braided silk in the usual man- 
 ner ; however little the recto-vaginal flap may be drawn upon, it is prudent 
 to insert a small drain which insures the removal of the fluids which may 
 collect in that region during the two or three days after operation. 
 
 5. After freshening the vaginal orifice of the fi-Stula this is sutured 
 
 Fig. 521. — Operation for Recto-vaginal Fistula by Sliding Flap (Segonu^. Operation completed. Show- 
 ing anal suture uniting segment of rectum which has been drawn down to skin, and three stitches closing vaginal orifice 
 of fistula. 
 
 through the vagina. This might be dispensed with since the rectal com- 
 munication has been obliterated and the rectal blind blocks up the vaginal 
 window ; but it is preferable to close the vaginal opening with several catgut 
 sutures (Fig. 521), so that the utero-vaginal secretions cannot enter the 
 wound. 
 
 6. The dressing is very simple and consists in tamponing the vagina 
 with iodoform gauze, placing a rubber tube in the rectum to allow the escape 
 of gas, and applying an aseptic compress to the ano-vulvar region, keeping 
 this in place by a T bandage. The rectal tube is removed at the time of 
 the first passage, the small drain in the recto-vaginal wound after forty-eight 
 hours, and when the sutures are removed al)out the eighth day, the cure is 
 complete. . A daily movement of the bowels must be assured after the first 
 
CICATRIClAl- FISTUL.K OF THE VAGINA. 789 
 
 day without regard to the rectal sutures, which should, however, be cleaned 
 after each evacuation. 
 
 Opei'ation by Rcctnni. — Fistulas located in the upper part of the vagina 
 sometimes resist all efforts toward obliteration by this passage. In some 
 cases, too, the recto-vaginal fistula coexists with a vesico-vaginal, and the 
 incision of the cicatricial masses necessary to expose the rectal perforation 
 may result in incontinence of urine by allowing relaxation of the vaginal 
 walls. It will be better in these cases to attack the fistula from the rectum. 
 
 The woman is placed in the genu-pectoral or in the Sims position. As 
 a preliminary measure, forced dilatation of the sphincter ani must be prac- 
 tised. Having overcome its resistance, the rectal cavity is exposed with a 
 short speculum and retractors, and the borders of the fistula are seized and 
 immobilized by the forceps and tenacula. Continuous irrigation is of ser- 
 vice in removing the blood during denudation. The operation is aided by 
 the finger in the vagina. The suturing is to be done in a special manner. 
 We follow Simon's example, inserting the needle in the immediate vicinity 
 of the rectal wound, directing it in such a way that it will emerge into the 
 vagina one-fifth of an inch beyond the margins of the perforation. Some- 
 times it will be easier to place the suture per vaginam by an inverse order 
 of procedure. Care must be taken to avoid the inclusion of the rectal mu- 
 cous membrane in the wound, where it has a tendency to insinuate itself. 
 We should employ silver wire and rubber tubing, as in the case of the vagi- 
 nal suture. The extremities of the wires are placed in the rectum and cov- 
 ered by a strip of iodoform gauze, which projects through the anus. 
 
 Preliminary and After-treatment. — In the way of preliminary treatment 
 to prepare the patient for the operation, there should be repeated purgation, 
 enemata, half diet, and careful antisepsis of the vagina and rectum. It 
 would be well to add antisepsis of the intestines bv the administration of 
 naphthol and the salicylate of bismuth. 
 
 The dressings consist of powdered iodoform and antiseptic gauze renewed 
 every few days. A catheter must be used at first to prevent any flow of 
 urine on the vulva and the sutures. 
 
 Is it neces.sary to constipate the patient } Several authorities maintain 
 that it is, and give opium for from ten to twelve days after the operation, 
 trusting that by this time the cicatrix will be strong enough to resist solid 
 stools. Other surgeons, dreading the effect of this ordeal, prefer to adminis- 
 ter laxatives. In this case, however, the liquid matters are apt to enter the 
 line of the sutures and infect the wound. Hegar recommends the following, 
 which seems to be a judicious plan. He thoroughly purges the patient be- 
 fore the operation, then puts her upon a rigid milk and broth diet during the 
 first three days; on the evening of the fourth day he gives a small dose of 
 calomel, and the following morning a glass of purgative mineral water; after 
 the second stool he arrests further evacuations by a little opium. He re- 
 peats the treatment every forty-eight hours. 
 
7go CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Metallic sutures are left in place for fifteen days if they do not cut 
 through. They are always to be removed from the side where they are 
 twisted and fixed. Where silk sutures are used, they become infected at the 
 end of eight days, and cannot be retained much longer without provoking 
 inflammation. 
 
 Entero- VAGINAL FiSTUL^. — We here include all communications be- 
 tween the vagina and the intestine, the rectum excepted. According to their 
 size and the quantity of the matters to which they give passage, such a fis- 
 tula may be called an abnormal vaginal anus or a stercoro-vaginal fistula. 
 One of the first of the cases published was by MacKeever. Others followed 
 by Roux, Casamayor, Ashwell, Breitzmann, Simon, Demarquay, and others. 
 L. H. Petit has collected all the cases scattered through literature, and pub- 
 lished them in an exhaustive monograph upon the subject. 
 
 Etiology. — In the great majority of cases the lesion originates in rupture 
 of the posterior cul-de-sac during labor. An intestinal loop passes through 
 the perforation, becomes adherent, and sloughs more or less completely 
 either by the rapid process of strangulation or more slowly by ulceration. 
 Direct traumatism may produce it, but this cause is excessively rare. The 
 same is true of wounds made by the surgeon during operations, such as vagi- 
 nal hysterectomy. Suppuration of a dermoid cyst or of the cyst of extra- 
 uterine pregnancy opening into the vagina or intestine are exceptional causes. 
 As to the perforations due to cancer, these do not belong to the list of per- 
 manent lesions, to which this study is limited. 
 
 P at Jiological Anatomy. — -The posterior cul-de-sac is the almost exclusive 
 location of this abnormal opening. Breitzmann and Dahlmann have, how- 
 ever, seen a fistulous opening in the anterior cul-de-sac. The lower part of 
 the ileum is the portion of the intestine most often implicated ; fistulae of 
 the sigmoid flexure are also observed. The aperture is apt to be very large 
 where the entire intestinal loop sloughs, or it may be double, separated by a 
 spur; this is, however, rare. At other times it consists merely of a small 
 hole. Cicatricial bands are sometimes found in its vicinity, producing con- 
 traction of the vaginal canal. The cervix will be altered by metritis pro- 
 voked by the constant infection of the vagina, which will be itself in an 
 inflamed condition. 
 
 The lower segment of the intestine tends to atrophy and to become ob- 
 literated; in the case reported by Casamayor it had been transformed into a 
 solid band. Sometimes we find coincident vesico-vaginal fistula. If the 
 fistula is completed by the intermediation of a cystic cavity, it may be 
 called an ileo-cysto-vaginal fistula. 
 
 Symptoms. — Where the aperture is very large, the greater part, if not 
 the whole of the fecal matters may be passed into the vagina. In a word, 
 there then exists a vaginal anus. The discharges appear about two hours 
 after eating, and have the appearance of partially digested food mixed with 
 bile, and the consistence oi puree. The character of the stools and the time 
 
CICATRICIAL FISTUI.,^. OF THE VAGINA. 79I 
 
 of their discharge are valuable indications of the site of the intestinal per- 
 foration. The vaginal opening can be detected by the touch or is easily dis- 
 covered by exposure with the speculum and retractors, placing the patient 
 successively in various positions. 
 
 Where the perforation is very small, sometimes several examinations 
 may be neccessary for its discovery. 
 
 Menstruation is often suppressed. This has been attributed to impair- 
 ment of the general health. The patient often suffers from inanition due to 
 imperfect absorption of food. MacKeever cites a case, however, in which 
 the woman became pregnant. 
 
 A very small fistula may recover spontaneously under the influences of 
 good hygiene and minute attention to cleanliness. If the perforation is 
 large, the lesion is usually permanent and the patients die of exhaustion. 
 Petit, however, cites two exceptional cases in which, after the sloughing of a 
 loop of the small intestine, recovery followed. 
 
 Diagnosis. — This depends first upon the existence of fecal matters in the 
 vagina; when assured of the existence of an abnormal communication, it 
 remains to determine its precise location. In searching for the aperture, 
 the probe is carried into the folds of the mucous membrane. If not found 
 the cervix may be dilated and the examination extended. 
 
 The site of the intestinal perforation will be determined by the character 
 of the matters discharged. Where the small intestine is implicated, these 
 will be liquid, and of a greenish or yellowish hue ; they will also present 
 undigested food, such as the leguminous foods, which are not attacked by 
 the digestive juices. The stools appear in from two to three hours after 
 eating where the perforation is in the terminal part of the ileum. Where 
 the discharge occurs earlier, the site of the perforation is supposed to be 
 higher up. Where the discharge is later, of a more nearly solid consistence, 
 and having a fecal aspect, the perforation may be in the sigmoid flexure. 
 
 We should examine with care into the condition of the orifice, guarding 
 against the error of regarding the neighboring uterine cervix as a second fis- 
 tulous tract. Where there are two openings separated by a spur, the upper 
 one is the one which gives passage to the discharges ; the direction and the 
 permeability of the two openings should be ascertained by careful probing 
 with a flexible sound. If the vagina is too narrow to admit of this examina- 
 tion, injections of milk may be used or progressive dilatation in one or two 
 stances with section of the cicatricial bands. Rectal touch assists the probe 
 in determining the intestinal aperture, as it assures us at least of its location 
 beyond the reach of the finger. 
 
 Treatment. — Where we have a very small fistula with only a slight dis- 
 charge of fecal matters, and evidently implicating the intestine laterally, we 
 may try cauterization with the thermo-cautery, as in the case of recto-vaginal 
 fistulae. After several ineffectual efforts we can then resort to denudation 
 and suture. 
 
792 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 When the perforation is terminal and the whole of the matters are passed 
 into the vagina, we have quite a different state of things. The operative 
 plan here indicated is that which has been followed with success by O. 
 Weber and C. von Heine. It consists in the re-establishment of the digest 
 ive tube by section of the spur so as to transform the vaginal anus into a 
 stercoral-vaginal fistula; then the obliteration of this by denudation and 
 suture. 
 
 For section of the spur, these authorities used Dupuytren's enterotomv.. 
 Verneuil recommends simple long catch forceps ; in order to render the com- 
 pression less forcible and the sloughing less rapid he advises covering the 
 jaws of the forceps with rubber tubing and then increasing the compression 
 gradually from day to day by means of the ratchet catch on the handles. 
 
 In case we cannot obtain a result by this method, we are, I believe, jus- 
 tified in performing laparatomy in order to detach the two adherent portions 
 of intestine from the vaginal cul-de-sac, suture the latter, then vivify and 
 unite the two segments of intestine. This operation is the only rational 
 procedure for an entero-uterine fistula. If the inferior segment is obliter- 
 ated or much contracted, the superior segment may be united to the most 
 accessible portion of the large intestine ; the advances of abdominal sur- 
 gery at the present day having made practical this procedure, which when 
 inaugurated by Roux was considered a rather venturesome operation. 
 
 The procedure conceived by Jobert is fraught with quite as much danger ; 
 it consists in detaching the superior segment and inserting it through an 
 opening in the recto-vaginal septum, thus bringing it into the rectum. 
 
 Colpocleisis or obliteration of the vagina below the fistula, after having 
 created a large communicating opening between the vagina and rectum, was 
 suggested to Simon by his analogous operation for the cure of vesico-vaginal 
 fistula. This can only be serviceable after previous obliteration of the uterus 
 by hystero-stomatocleisis. 
 
 Casamayor's operation is preferable. It consists in the production of a 
 passage for the transmission of matters into the rectum, below the vaginal 
 fistula. To obtain this result he introduces one of the blades of a long 
 curved forceps into the intestine through the fistula, the other blade he intro- 
 duces into the rectum; he then brings the two together, and after assuring 
 himself that nothing is included between them but the walls to be divided, 
 they are closed. A slough is the result, and after its separation the fecal 
 matter passes directly into the rectum. In one case, however, the discharge 
 by the vagina continued, and the patient succumbed a month later. 
 
 Verneuil has proposed a modification of Casamayor's operation, which is 
 as follows : (ist) by the help of a curved trocar, he perforates the recto-vagi- 
 nal wall about one-fifth of an inch below the fistula, and passes a rubber tube 
 through the opening made ; (2d) in the same way he perforates the ileo-rec- 
 tal wall about one inch above the first puncture, passing through it a second 
 rubber tube ; (3d) he unites the two rectal ends ; this forms a loop whose two 
 
CICATRICIAL FISTUL/!', OF THE VAGINA. 793 
 
 ends pass out through the vagina, one by means of an artificial anus, the 
 other below it, leaving between them the portion of wall which is to be 
 divided. The rubber tubes are now tightened, and cut through the tissue. 
 
 Verneuil has not yet had occasion to put his ingenious method into prac- 
 tice. We therefore do not know whether the establishment of a rectal open- 
 ing is sufficient to induce obliteration of the vaginal perforation. 
 
CHAPTER XXXVIII. 
 
 VAGINISMUS. 
 
 Definition and Classificatioji. — Vaginismus or vaginodynia (spasmus va- 
 ginae) consists in an abnormal hyperaesthesia of the external genital organs, 
 which may induce spasmodic contraction of the constrictor (sphincter) of the 
 vagina and of the other muscles of the pelvic floor. There are three dis- 
 tinct classes of the malady, or, better, three particular types. 
 
 I St. Hyperaesthesia with contraction. 
 
 2d. Hyperaesthesia without contraction. 
 
 3d. Contraction without hyperaesthesia. 
 
 The first of these three is by far the most frequent, and the last the most 
 rare. 
 
 An attempt has been made to base the classification on the seat of the 
 malady, and to distinguish inferior vaginismus from spasm of the sphincter 
 vaginae, and superior vaginismus from spasm of the most interior and the 
 most inferior of the fibres of the levator ani. I do not think that this dis- 
 tinction should be preserved clinically, for contraction of the lower part of 
 the vagina is very unusual. As to essential or idiopathic vaginismus, it 
 probably does not exist ; only the point of origin of the reflex may remain 
 unknown. 
 
 Historical Review. — Though Marion Sims drew the most complete clini- 
 cal picture of vaginismus and gave it the name which it still bears, it would 
 be unjust to give him the entire credit for its recognition. In 1834 Huguier 
 devoted many pages to the study of spasmodic action of the sphincter vaginae 
 and established an analogy between it and similar conditions of the anus. 
 Certain valuable notes on the affection are scattered through the writings of 
 many authors — Dupuytren, Lisfranc, Hervez de Chegoin, Scanzoni, Kiwisch, 
 and Simpson. All of these writers have described hyperaesthesia of the vul- 
 va and spasmodic contraction of the vaginal sphincter, but their vague ideas 
 have now no precise nosological value. 
 
 Since Sims' description, many papers have appeared relating to both 
 the etiology and the treatment of the affection ; among which I will particu- 
 larly mention those of Debout and Michon, Charrier, Scanzoni, Visca, Pu- 
 tegnat, Lutaud, Trelat, Daude, Gallard, Budin, Verneuil, Leroux, etc. 
 
 Etiology and PatJiogeny. — Two conditions are necessary for the production 
 of vaginismus: (i) great nervous excitability, and (2) some irritation of the 
 external genitals which serves as a starting-point for the exaggerated re- 
 flexes on the part of the sensory and motor nerves, thus producing hyper- 
 
VAGINISMUS. 795 
 
 aesthesia and contraction. The majority of women affected with vaginismus 
 are young, nervous, and at times hysterical, but it is false to conclude that 
 hysteria is a necessary condition without which vaginismus cannot exist. 
 The irritation of the external genitals has its origin for the most part in the 
 beginning of the conjugal relation and the first attempts at intercourse. 
 Schroder has described a peculiar condition of the vulva in certain women, in 
 whom it is placed far toward the front of the symphysis, so that the urethra 
 and the navicular fossae are directly presented to the penis, and are hence 
 compressed against the bone during the first efforts of coitus. In some 
 cases the urethra becomes dilated, and its orifice so enlarged that an imper- 
 fect copulation becomes possible through it. Excoriation results, and the 
 hyperaesthesia becomes so acute that the lightest contact is excessively 
 painful. 
 
 There are other women in whom the hymen, though normal, is particularly 
 rigid ; and others in whom its orifice is large enough for the introduction of the 
 penis without laceration. In any of these cases in which there is a pushing 
 back or dilatation of the membrane it thickens, inflames, and becomes very 
 sensitive. Loss of erection in the male or premature ejaculation may be 
 causes of vaginismus, for they also interfere with the destruction of the 
 hymen. 
 
 Vaginismus in women after defloration may be due to inflammation of the 
 carunculae myrtiformes from some irritation, and is also noticed where the 
 vulva presents fissures. 
 
 Small polypoid tumors of the urethra or hernia of the urethral mucous 
 membrane, irritated by coitus, produce the same effects. Fissure of the 
 anus may at times cause a sphincteralgia of the vagina from irradiation of 
 the pain and reflex contraction. It has also been asserted that an affection 
 of the uterus, especially erosion of the cervix, might have the same result ; 
 and cases of superior vaginismus from disease of the uterus and ovaries have 
 been described. I think that this is a veritable abuse of language, and that 
 the name vaginismus has often been wrongly attributed to the simple phe- 
 nomena of pain without vulvar hypersesthesia and to the movements of de- 
 fence which result therefrom. 
 
 All the preceding factors relate to the usual type of vaginismus in v/hich 
 the hypersesthesia is accompanied by contraction. In other less common 
 instances this latter symptom is lacking; this is observed especially in young 
 virgins who have never attempted coitus, but in whom the suspicion of onan- 
 ism is not wholly absent. Gosselin has described cases in which the hymen 
 was very sensitive. E. Martin, Sr., attributes great importance to gonor- 
 rhoeal infection transmitted to young women in their first intercourse. 
 
 PatJiology. — As is usual when the nervous system is chiefly involved, the 
 symptoms are wholly out of proportion to the lesions. In this respect, vagi- 
 nismus resembles fissure in ano. Most often we find signs of inflammation 
 about the vulva, the hymen, or its caruncles. There may be fissures, syphi- 
 
796 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 litic or otherwise, of the anal and vulvar orifices, polypi or vascular tumors 
 of the urethra. At times there is nothing to be found. The dilatation of 
 the urethra which is occasionally present is the result of attempts at hetero- 
 topic coitus. 
 
 Symptoms. — In the ordinary type of the affection there is hyperaesthesia 
 with contraction. The origin of the symptoms is most often at the moment 
 of intercourse, which has been performed either in a brutal or, on the con- 
 trary, in a hesitating and clumsy manner. There are, however, many cases 
 in which the symptoms appear very late, after the woman has been married a 
 long time. The pain is the principal symptom and has given to the affection 
 the name of neuralgia, neurosis, or hyperaesthesia of the vulva. It is at 
 times limited to exact points or zones, which are relatively restricted to the 
 internal surface of the labia minora, the fourchette, or to certain caruncles in 
 the vicinity of the urethral orifice ; in other cases the sensitive area com- 
 prises the whole of the vulvar surface. 
 
 There is no doubt that there exists a clinical type in which there is hyper- 
 aesthesia without contraction, but such cases are rare. The sensitiveness of 
 the parts may reach such a degree that the simple touch of a feather is 
 insupportable ; more often, however, the little finger may be introduced, and 
 it appreciates that there is a spasmodic contraction provoked by the pain, but 
 this is not always present. The spasms may involve the adjacent muscles ; 
 the anal sphincter especially may become so hard as to be taken for a tumor 
 by the patient (Sims). Verneuil admits that the contraction is not in the 
 sphincter vaginae, whose fibres seem too scattered and feeble, but in the trans- 
 verse perineal muscle and in the whole muscular mass of the perineum, and 
 it may also extend to the urethra. A sensation of weight and pain in the 
 perineum renders the effort of walking difficult. The centre of the tetanic 
 contraction is at the entrance of the vagina or a little above, but the levator 
 ani may also be involved, and then the cramp extends deeply. 
 
 Coitus is impossible, and sterility is hence the rule, yet fecundation has 
 been observed, the semen thrown upon the vulva making its way into the 
 vagina by capillarity. The spasm may cease during pregnancy and reappear 
 after delivery. Benecke has reported a case in which parturition was difficult 
 because of the spasm ; but labor usually produces the complete disappear- 
 ance of all the morbid phenomena. 
 
 Neuralgic pains have been observed at many other points of the body. 
 The general condition suffers by the continuance of the pain and the moral 
 preoccupation, so that these patients rapidly become hypochondriac. 
 
 Diagnosis. — Vaginismus should not be confounded with simple pain on 
 intercourse, or dyspareunia, which is a phenomenon of almost all diseases of 
 the genital organs. 
 
 Imperforate hymen and atresia of the vagina are easily recognized on in- 
 spection, and they also coexist with absence or retention of the menses. 
 
 Simpson and Hildebrandt have described under the name of "penis cap- 
 
VAGINISMUS. 797 
 
 tivns" a contraction of the levator ani, which a woman occasionally has the 
 power of producing voluntarily. It is only a physiological curiosity, and 
 altogether different from vaginismus. When this contraction assumes the 
 character of a pathological process, it has been called superior vaginismus. 
 It is most often a contraction without hyperassthesia, and has been ascribed, 
 without proof, to opposition to fecundation. 
 
 The very rare affection described by Breisky under the name kraurosis 
 vulvae, which signifies contraction of the vulva, should not be confused with 
 vaginismus. Kraurosis occurs in women who have passed the m.enopause, 
 and is characterized by two symptoms : the presence on the vulva of brown, 
 extremely sensitive spots ; and the fibrous transformation of the perivulvar 
 subcutaneous tissue. 
 
 Treatment. — The indications are to diminish the morbid hyperaesthesia 
 and to destroy the lesions which are its immediate cause. The first care of 
 the physician should be to remove every incentive of sexual excitement. 
 Then an antispasmodic treatment may be begun, and here hydrotherapy and 
 bromide of potassium render efficient service. With these may be joined the 
 local application of cocaine, suppositories of opium and belladonna, etc. 
 But the capital indication is to abolish the local affection which is the 
 starting-point of the reflexes. Vulvitis should be treated with sitz baths, 
 frequent application of Goulard's lotion, boric-acid solution, borated or 
 iodoformed x-aselin, light cauterization in the fissures with nitrate of silver 
 solution (i:2o), iodoform in powder, etc. Then any lesions of adjacent 
 parts should be sought out and removed. If there is a fissure of the anus, 
 the sphincter should be stretched ; if there is a urethral polyp, it should 
 be excised, etc. 
 
 The thickened and inflamed hymen, incompletely torn or reduced to only 
 a trace of its original extent, is often the origin of the pains, although it is 
 not the only one, as Simpson maintained in his first publications. Its ex- 
 cision will frequently produce a cure. This little operation is easily done 
 with a pair of curved scissors after the application of cocaine, and a hem 
 suture produces immediate reunion of the small wound. At the end of a 
 few days progressive dilatation should be begun ; the patient should take a 
 sitz bath and introduce a series of bath specula of gradually increasing diam- 
 eter. If attempts at intercourse remain painful after this, the vagina must 
 be forcibly dilated under anaesthesia. We proceed as in the case of fissure 
 of the anus ; the middle and ring fingers of each hand are introduced into 
 the vagina, and by pressure at different points the greatest possible dis- 
 tention of the orifice without tearing the skin is produced. 
 
 We no longer practise section of the internal pudic nerve as proposed 
 and performed by Simpson, and but few surgeons employ Sims' section of 
 the vaginal sphincter. To perform this the patient is chloroformed and two 
 fingers of the left hand are introduced into the vagina. Then with a bistoury 
 the superficial fibres of the bulbo-cavernosus are divided on either side of 
 
798 
 
 CLINICAL AND OPERATIVE GYNECOLOGY, 
 
 tne median line to a depth sufficient to relax their tension, the incision being 
 carried from half an inch in the vagina to the border of the skin. After the 
 section, Sims dilated the orifice strongly and tamponed it with cotton, which 
 was changed to a large glass dilator on the following day ; this was worn 
 nearly continuously at first, and later left in place two hours at night and 
 two hours during the day for many weeks until all danger of contraction had 
 passed. 
 
 The following procedure by splitting and eversion of the mucous mem- 
 brane, which I have originated, has given me most satisfactory results. The 
 patient being anaesthetized, the hymen is first excised with scissors, and then 
 
 Fig. 522. — Operation for the Relief of Vagi- 
 nismus. I, Incision perpendicular to the margin 
 of the vulva at the junction of the fourchette and 
 labia minora ; 2, separation of the edges of the inci- 
 sion after section. 
 
 Fig. 523- "f^PEKATiON for the Relief of Vagi- 
 nismus. I, Retraction of the edges of the incision after 
 subcutaneous dissection ; 2, suture of the incision with 
 line of union parallel to the margin of the vulva. 
 
 the vulva is stretched with the fingers. A lateral incision is made on each 
 side at the junction of the lower and middle thirds of the vulvar orifice 
 (Fig. 522). This incision, three to four centimetres long, extends a little 
 farther below than above the line of insertion of the hymen and forms 
 a cross with it. The incision exposes the sphincter vaginae and divides its 
 superficial fibres to the extent of two or three millimetres. The lips 
 of the wound are dissected, so as to cause their separation, tl^us giving 
 the original incision the form of a lozenge whose long axis is parallel 
 to the border of the vulvar orifice. The operative wound is then closed, 
 so as to obtain a line of suture, which crosses the direction of the origi- 
 nal incision at right angles, and which is situated outside of the point 
 which was occupied by the hymen. The suture draws the vaginal mucosa 
 to the level of the lower angle of the primary incision (Fig. 523). In this 
 
VAGINISMUS. 799 
 
 way a sagittal incision has been made on each side of the vulva, followed by 
 a transverse suture, an operation analogous (though directly inverse) to trans- 
 verse flap-splitting followed by sagittal suture, which Lawson Tait employs 
 in perineorrhaphy. The vulva is thus enlarged and the vaginal mucosa is 
 everted slightly, so as to remove from the friction of coitus the region from 
 which the reflex actions arose. 
 
 The sutures of the two large incisions should be of silkworm gut or 
 silver wire, and should penetrate only the mucous membrane. The first 
 suture unites the upper and lower ends of the original incision. The small 
 wound resulting from removal of the hymen is closed by a continuous 
 catgut suture. 
 
 I will also mention the use of electricity, with which Lomer claims to 
 have obtained great success. 
 
 These patients are generally anaemic and need a tonic regimen. Great 
 attention should be paid to the mental condition of certain women, especially 
 where there is a tendency to lunacy by inheritance. Change of air and scene 
 should be prescribed wherever possible. 
 
CHAPTER XXXIX. 
 
 LACERATION OF THE PERINEUM. 
 
 Etiology and PatJiogeny. — The perineum is a resistant fibro-muscular floor 
 which closes in the abdominal cavity below and supports the weight of the 
 contained viscera. Viewed from within it has the appearance of a very wide 
 funnel with attachments to the pelvic wall, pierced eccentrically at its an- 
 terior part by the orifice for the passage of the vagina. Viewed from with- 
 out it is reduced to the space comprised between the fourchette and the 
 anus, forming the base of a triangular pyramid ; its base answering to the skin 
 and the inter-crossing of the sphincter muscles of the anus, the constrictor 
 vaginae and the transversus perinei, while its apex is lost in the recto-vaginal 
 septum. Along one of its sides runs the vagina, its lower portion re- 
 enforced by the hymen or its vestiges, while the other side is tangent to the 
 rectum. The lateral parts of this perineal prism have for their support the 
 deep internal borders of the levator muscles of the anus attached to the side 
 of the rectum, and forming by their intricate arrangement a support for the 
 whole region. 
 
 At the time of parturition the vulva gives passage to a foetus, whose di- 
 ameters are in excess of the canal through which it passes. This could not 
 happen were it not for two factors, the thickening and softening of the tis- 
 sues caused by the marked venous congestion toward the end of pregnancy, 
 and the elasticity of the miuscular and cutaneous planes. When one of these 
 elements is absent, the perineum either gives way or tears. This accident 
 may be due to various circumstances : To exceptional rigidity of the tissues 
 in a woman who becomes a mother at an advanced age, or who presents es- 
 pecial narrowness of the vulva; excessive volume of the foetal head or a 
 posterior position which has not been reduced ; too rough passage of the 
 head and shoulders ; narrowness of the pubic arch ; a too perpendicular posi- 
 tion of the sacrum, which allows the head to be carried backward, as in the 
 flat or rachitic pelvis; ill-applied forceps; too hasty version, etc. Trau- 
 matism of different forms may be the cause of perineal laceration, but this 
 is not a common origin for the accident. 
 
 In parturition it is not the cutaneo-mucous investment of the vulvar 
 commissure which forms the chief obstacle to distention of the part, but 
 fibres of the muscles which lie immediately beneath. These fibres are the 
 constrictor of the vulva; according to H. A. Kelly, they are the most in- 
 ternal portion of the levator ani at their insertion into the rectum ; Budin 
 attaches less importance to the muscular fibres, and sees in the hymen the 
 
LACERATION OF THE .PERINEUM. 80I 
 
 chief cause of rigidity of the vulva. The laceration of the hymen may 
 play the role of a scissor cut in tearing cloth, but it does not seem that the 
 tear in the superficial soft parts can be the initial phenomenon ; it is more 
 likely, I think, to be subcutaneous rupture of the mucles. This deep rup- 
 ture may be the only one if it permits the parts to dilate sufficiently, and 
 instead of a visible tear of the perineum there is only that loss of power 
 which plays so important a part in the production of genital prolapse. When 
 the fourchette is not elastic enough, even after the rupture of the muscular 
 fibres below, it gives way in its turn, and the visible laceration is produced. 
 This happens most often on the left side near the median line, and varies in 
 extent from a simple tear in the integument to a division of the anal orifice, 
 reaching up to a high point on the recto- vaginal septum. 
 
 The mechanism of central ruptures, which are very rare, is similar : The 
 head is badly directed, and passes backward to the middle of the perineum, 
 which it distends and causes to tear ; then after the delay of a few minutes 
 which follows the momentary diminution of the distention, it reascends a 
 little and then directs its passage toward the vulvar orifice, in passing 
 through which it may cause another rupture of greater or less extent. At 
 times the child may pass by the central opening. 
 
 PatJiology. — The following description is applicable only to old and cica- 
 tricial lacerations. The laceration is m.ost often found at the fourchette and 
 a little to the side of the median line, and is called incomplete when it does 
 not inv^olve the anal sphincter. 
 
 There are two degrees of incomplete laceration, in one of which the 
 fourchette alone is torn, while in the other the tear is deeper and involves the 
 muscular planes, without rupturing the sphincter ani. The \ail\a appears 
 to be elongated posteriorly, and is wide open, and at the fourchette there is 
 a soft cicatricial surface. If the lesion is of long standing, there is almost 
 always a slight degree of cystocele and uterine prolapse. 
 
 In the complete form the vulvar and anal orifices are thrown together so 
 as to form a cloaca, about which there are prominent folds of mucous mem- 
 brane. The recto-vaginal septum is rounded in a full curv^e, or like a pointed 
 arch with doubly curved sides, and at its apex there is often a small trian- 
 gular portion of rectal mucosa, which hangs like a pendant. The posterior 
 column of the vagina may be isolated by a double laceration which gives it 
 the aspect of a uvula, but more commonly the laceration has passed to the 
 left side of this projection. The cicatricial tissue deforms the parts in a 
 varying manner, one of the borders of the opening being thick and the other 
 thin, or a number of bridles may stretch across it (Fig. 524). The division 
 of the tissues may reach up to the posterior cul-de-sac of the vagina. 
 
 At the lower edges of the laceration the parts are drawn upward by the 
 action of the levator ani, and on the sides there may be a small depression 
 corresponding to the stump of the sphincter. 
 
 There are two degrees of complete rupture, according as the sphincter 
 51 
 
802 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 and the anal orifice alone are torn or the recto-vaginal septum is also divided. 
 This distinction is of value to the operator, for the repair of the septum 
 requires modification of the surgical treatment. 
 
 It is usual to find deep ruptures of the cervix with complicating metritis 
 accompany those of the perineum, and Thomas claims that the vagina also 
 remains in a condition of subinvolution. Cystocele and uterine prolapse are 
 often observed in this condition. 
 
 Diagnosis. — Examination by touch and speculum reveals the deformities 
 
 Fig. 524. — Complete Rupture of the Perineum Involving the Rf.cto-vaginal Septum. 
 
 ■which I have described. To practise this exploration, the patient should be 
 placed first in the dorso-sacral and then, if necessary, in the genu-pectoral 
 position, and the region displayed by means of a large anterior blade and 
 lateral separators. 
 
 Symptojiis. — The rational signs vary according to the extent of the lacer- 
 ation. In the incomplete form all the symptoms are attributable to the gap- 
 ing of the vulva, which favors the formation of cystocele, uterine prolapse, 
 and also metritis. It is not uncommon to see these patients suffer from 
 great difficulty in walking, and vague pains which are due to the enteroptosis, 
 
LACERATION OF THE PERINEUM. 803 
 
 and are to be referred to the disturbance of the uterine equilibrium from loss 
 of the perineal support. 
 
 In complete laceration there is incontinence of gas and liquid faeces, 
 even when the solid portions of the intestinal contents are well retained. 
 Certain patients, however, are able to retain the gas when they are in the 
 horizontal position, even when the entire sphincter has been ruptured. 
 
 Prognosis. — This lesion is a serious one, although the patient may not 
 suffer from destruction of the sphincter, for it renders her incapable of exer- 
 tion, easily fatigued, and predisposed to prolapse of vagina and uterus, and 
 the development of metritis. 
 
 Treatme7it. — -Recent Lacerations of the Perineum. — Should the repair of 
 the injury be left to nature, which is capable of accomplishing it in many 
 circumstances ; or should we aid and direct this healing process, which is 
 often defective or insufficient, by immediate suture .-' This matter has been 
 much disputed, especially during the time when ignorance of the benefits of 
 antisepsis and asepsis rendered success very doubtful. In certain cases it 
 is better not to interfere ; for instance, if the patient is very much exhausted 
 and one lacks the necessary assistants, etc. ; but such contra-indications do 
 not concern the operation itself. Every lesion should be repaired at once, 
 wherever it is possible. Cures have been obtained in this way, even when 
 the tissues appeared to be much contused and ill adapted for primary union. 
 This conduct also avoids the necessity for a late operation, which would be 
 far more complex, and also shuts the door against infection. Spontaneous 
 cicatrization, which is possible in the case of every superficial laceration, is 
 the great exception when the tear has been deep. 
 
 The simplest and easiest plan of uniting the laceration is the hem suture 
 on superposed planes, which re-establishes the previous condition of the 
 parts by taking advantage of the fresh surfaces of the laceration. This su- 
 ture is far better than the use of serre-fines, which are not strong enough for 
 anything more than slight tears of the cutaneo-mucous fold of the fourchette. 
 As the procedure is very rapid, local anaesthesia with cocaine is sufficient, 
 applied superficially or by means of the hypodermic syringe. The catgut 
 sutures disappear of themselves, and do not require to be extracted. The 
 patient should have her thighs maintained in apposition, and be forbidden 
 to sit up in bed during the first fifteen days, and the parts must be carefully 
 kept clean with sublimate solution and iodoform in powder. 
 
 When the surgeon has not interfered immediately, should he perform 
 secondary immediate union during the first month, as has been proposed, 
 either by bringing the granulating surfaces together or by scraping off the 
 fleshy granulations with the cutting curette ? Success has been obtained in 
 this way, but I think that it has more defects than advantages, and that it 
 is better to wait until the local congestion has disappeared and the woman 
 is in condition to endure an operation. 
 
 Verneuil has advised immediate secondary union even in old cases, and 
 
804 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 employs the thermo-cautery for the purpose of freshening the surfaces, sutur- 
 ing them after the fall of the eschars. This procedure must not be confounded 
 with angular cauterization of the laceration analogous to the method of 
 Jules Cloquet in fissures of the palate, which has been used in certain cases 
 to diminish the extent of a tear involving the recto-vaginal septum, which I 
 have employed at times with success. 
 
 Old Lacerations of the Perineum. Historical Review. — The first 
 operation for the repair of the perineum with sutures was performed by 
 Guillemeau, a French surgeon, in the seventeenth century. In the follow- 
 ing century La Motte, Smellie, Noel (of Rheims), Murenna, and Saucerotte 
 attempted it with more or less success. More recently Dieffenbach, in 
 Germany, advocated a method which has served as a model for many pro- 
 cedures, and has been perfected and introduced into France by Roux. The 
 characteristic of Dieffenbach's method consists in a large denudation of the 
 surfaces to be united, and in liberating incisions, of which we find a trace 
 in Mercier's, and Baker Brown's division of the sphincter; the capital point 
 of Roux's method was the quill suture, employed for a wound which was 
 much larger than those customarily closed in this manner. With Langen- 
 beck a new method arose, called perineo-synthesis, based upon a combina- 
 tion of denudation and autoplastic division, which has given birth in France 
 to the methods of Demarquay, Richet, Le Fort, Marc See, and Polaillon; 
 and in Germany to those of Simon, Wilms, Staude, Bischoff, Hegar, 
 Hildebrandt, Freund, and others. 
 
 In America Marion Sims in the year 1855 applied to the repair of the 
 perineum the same simple and precise principles which had guided him in 
 the treatment of vesico-vaginal fistula. Freeing the operation from all use- 
 less complications, especially the different planes of suture, he repeated the 
 procedure of Roux, carried the denudation higher up, and employed metallic 
 sutures. This was a great improvement, preceding and preparing the way 
 for his pupil and friend Emmet. The originality of the latter's method con- 
 sists in the suture employed, which has for its object the exact coaptation of 
 the wound surfaces as one closes a purse, and also in the care with which the 
 sphincter is reunited by a special suture of its divided ends, by the applica- 
 tion of a sub-sphincteric thread very deeply and obliquely from behind for- 
 ward. This procedure, which is derived from Marion Sims' and improves 
 it, has been generalized in France by Judes Hue and adopted by Verneuil, 
 Trelat, and the majority of surgeons. 
 
 It might be thought that the operative technique had arrived at the 
 highest point of simplicity ; but Lawson Tait perfected the method of John 
 Duncan and Simpson, and reduced the operation to a rapid division or split- 
 ting of the recto-vaginal septum followed by the application of a few sutures, 
 which altogether requires only from five to ten minutes to accomplish. This 
 has been quickly adopted in both America and Germany, with or without 
 modifications. 
 
LACERATION OF THE PERINEUM. 
 
 805 
 
 I shall not attempt to describe each of these various methods, but shall 
 limit myself to the principal ones, giving references enough to the literature 
 of the subject, so that the other methods may be readily found. 
 
 bicomplete Lacerations. — All of the procedures of colpo-perineorrhaphy 
 which I have described in the chapter on Genital Prolapse find there their 
 special application. There is only a difference in degree and great similarity 
 
 Fig. 525. — Incomplete Rupture of the Perineum ; Perineorrhaphy. Simon's method. 
 
 between relaxation of the perineum, which is one of the most important ele- 
 ments in the production of prolapse of the vagina and uterus, and these in- 
 complete lacerations. In the first case the skin resists and there is no ex- 
 ternal cicatrix, while in the second the opposite is true; but there is one 
 factor common to both; the tone of the deep muscular plane has been 
 strained, the fibrous framework of the parts has been irremediably overdis- 
 tended, and the static condition of the uterus has been similarly modified. 
 Relaxation of the perineum may thus be considered as an actual subcuta- 
 neous laceration. By seizing the recto-vaginal septum between finger and 
 thumb introduced into the rectum and the vagina, it is evident that the 
 fleshy pyramid which separate.^ these canals has diminished in size and con- 
 sistence. This coincides with the wide shape of the intact fourchette, the 
 gaping vulva, more marked when the patient is placed in the semi-prone 
 
8o6 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 position of Sims, the lessened depth of the anal orifice and the unusual 
 breadth of the perineum, which is enfeebled and lax. 
 
 Emmefs Method. — ^[As the admirable method of this distinguished au- 
 thor has not been clearly described in any of the more recent works on gynae- 
 cology, I take the liberty of substituting the following description for that of 
 Professor Pozzi. 
 
 To lessen the difficulties in the way of an intelligible description, I will 
 briefly review Emmet's views on the subject of perineal tear. He believes 
 the term " laceration of the perineum " a misnomer and only allowable where 
 the sphincter ani is involved. He denies any supporting function to the 
 perineal body, as it can be clearly demonstrated that the uterus is supported 
 and swung from above, like every other organ in the body, and, with the 
 vagina and rectum, kept in position by the connective tissue and fascia of 
 the pelvis. This fascia is in close connection with the cellular and connec- 
 tive tissue of the pelvis, and is attached alongside the vagina and rectum, 
 so as to prevent undue prolapse of the bowel from the sigmoid curve to the 
 anus. While supporting the vagina, it exerts lateral traction with the effect 
 of preserving the natural curve, and keeping the two sides in close contact. 
 
 The grooves or sulci formed by the flattened vaginal sides are the result 
 of the lifting of the posterior wall up to the anterior one, while at the same 
 time the needed degree of lateral traction is exerted by the fascia. If we 
 trace the course of the fascia forming the sulci from the starting-point at 
 the superior strait, and alongside the vagina to the point where that canal 
 pierces the muscular diaphragm at the pelvic outlet, it is seen to be reflected 
 on to these muscles. This fascia binds the whole muscular mass in a com- 
 mon sheath, strengthens it, and, so long as its integrity is preserved, main- 
 tains the pelvic circulation in normal equilibrium. When the fascia gives 
 way the vessels lose their support, no longer continue tortuous, become en- 
 gorged, and give rise to the symptoms well known to accompany cases of 
 neglected laceration. 
 
 To understand the mechanism of laceration it is necessary to recall cer- 
 tain points in the arrangement of the perineal muscles. On the outer side 
 of each levator-ani muscle, and extending along its attachment, the trans- 
 verse perinei are inserted and extend backward and outward to the ischia. 
 Normally their action binds more firmly together the muscular floor of the 
 pelvis ; but as soon as the levators are separated in front, the transverse 
 perinei can only draw them more apart, as curtains may be drawn apart be- 
 low, while united above. In injuries to the pelvic floor, a force comes into 
 play by which the fascia is torn and the levator-ani muscles in front widely 
 separated; this may occur without injury to mucous membrane or skin. 
 Consistent with this belief, the object of Emmet's operation is to catch up 
 the retracted fascia at such a point and manner as to take up its slack 
 throughout the pelvis. By his procedure the posterior vaginal wall is lifted 
 upward and forward in contact with the vesico-vaginal septum, the everted 
 
LACERATION OF THE PERINEUM. 
 
 807 
 
 tissues at the vaginal outlet are rolled in and the separated levator muscles 
 brought together so that the woman becomes apparently perfectly normal. 
 
 Fig. 526.— Colpo-Perineorkhaphy bv Emmet's 
 Method. Posterior wall of vagina showing area of 
 denudation. 
 
 Fig. 527. — Deep and Siperficial Lateral Sutures 
 IN Place and Tied on Left Side. 
 
 The first step in the operation is to determine, as closely as may be, the 
 de2:ree of retraction of the fascia along; the sulcus on either side of che 
 
 Fig. 52S. — Lateral Sutures Tied, Skin Sutures 
 in Place. 
 
 Fig. 529. — All the Sutures Tied. 
 
 vagina. With the patient on her back, the limbs flexed, find a point in the 
 middle of the projecting mass within the vagina, pick it up with the tenacu- 
 
 FiG. 530. — Emmet's Scissors. 
 
 lum, draw it forward and upward toward the neck of the bladder, and two 
 folds will be seen leading up to a point within the sulcus on each side. 
 These points indicate the limit of retraction, and show clearly that the por- 
 tion of the vagina above is still properly supported. This triangular-shaped 
 
CLINICAL AXD OPERATIVE GYX-^COLOGY. 
 
 tongue or portion of rectocele drawn forward by the tenaculum forms, after 
 the operation, the posterior wall of the vagina; and all the mucous surface 
 below it is to be denuded. The tenaculum holding it is to be replaced by a 
 stout thread to form a landmark and be held by an assistant. Then a tenac- 
 ulum is hooked into the caruncle on either side, and lateral traction made 
 by assistants. A gutter-shaped, triangular surface is thus formed on either 
 side of the canal, with its apex running into the lateral sulcus. Then draw- 
 ing down with a third tenaculum hooked into the centre of the posterior vagi- 
 nal wall at the muco-cutaneous junction, you have the whole surface to be 
 denuded clearly shown. By approximating the crest of the rectocele and 
 the two caruncles, you see how the parts will be brought together when the 
 sutures are introduced. 
 
 In inserting the sutures, begin at the apex of the triangle in each sulcus, 
 and put them in about a quarter of an inch apart until the loop in the centre 
 of the rectocele is nearly reached. Then a suture is inserted just behind the 
 caruncle on the right side, dipped into the denudation in the rectocele, and 
 brought out at a corresponding point on the left. This " crown suture" 
 draws the crest of the rectocele near the caruncles, closes the sides of the 
 vaginal outlet, and brings together the levator-ani muscles. Three or four 
 other sutures are passed in a similar direction below this, as in an ordinary 
 perineum operation. Emmet prefers sutures of silver wire. They are tied 
 in the order of their insertion. The line of union when all is complete is 
 like a rounded letter Y, the branches of which are completely hidden in the 
 vagina, while the stem bends over at a little more than a right angle, on the 
 external perineal surface.] 
 
 LazK.'son Taif s JMethod for Incomplete Ruptures. — The description here 
 given follows that of Sanger, who has made some unimportant modifications 
 in it ; the method is also applicable to simple relaxation of the perineum, 
 although open to the objection that it then leaves a pouch behind the recon- 
 stituted perineum. 
 
 Sanger advises that the rectum be first tamponed with cotton, sponge, or 
 iodoform gauze covered with vaselin and furnished with a thread; in this 
 way the posterior vaginal wall is pushed forward. Two fingers are also 
 placed in the rectum while an assistant stretches the operative field as much 
 as possible, by drawing the sides of the vulva toward the ischial tuberosities; 
 thus the posterior vaginal wall is displayed to a very large extent. To form 
 the flap, Tait uses pointed scissors, elbowed like those of Roux. One point 
 is inserted from before backward in the median line of the posterior com- 
 missure of the vulva at the muco-cutaneous junction, and the recto-vaginal 
 septum split to the depth of about a half or three-quarters of an inch, first 
 on the left side and then on the right. At the ends of the transverse inci- 
 sion thus formed, two vertical cuts are made up to the point where he wishes 
 the posterior commissure to be ; the three incisions roughly have the form 
 of a quadrilateral which lacks its upper side [or better a semicircle following 
 
LACERATION OF THE PERINEUM. 
 
 809 
 
 the muco-cutaneous junction]. The horizontal side is from 2 to 3 cm., and 
 the two vertical sides from 3 to 5 cm. When the flap is sharply drawn up- 
 ward by tenaciila and the edges of the Avound well separated, such bands as 
 still need to be divided in order to give a smooth and sufficiently large 
 wound are readily seen and cut. The vivified surface then has the form of 
 
 
 Fig. 531. — Incomplete Rupture of the Perineum ; Perineorrhaphv. Tail's method. 
 
 a quadrilateral with obtuse angles; surrounded on three sides by the skin, it 
 gives insertion by its fourth to the mucous cap resulting from the splitting 
 of the recto-perineo-vaginal septum. That the flap may not be too thin, the 
 septum must be split exactly in the middle, which is facilitated by the con- 
 trol of the fingers placed in the rectum. On the borders the incision is car- 
 ried deeply into the cellular tissue of the perineum and the labium majus. 
 The denudation may be completed in about half a minute; and if the sur- 
 face so obtained is not smooth but covered by small irregularities, these may 
 be removed by the scissors. 
 
 The bleeding is ordinarily quite free but is venous; when small arteries 
 
8lO CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 are cut, they merely require forceps and torsion. Sanger never employs 
 ligatures. Occasionally he has tied the bleeding points with fine catgut 
 when torsion and forcipressure were not sufficient ; but the apposition of the 
 lips of the wound is sufficient usually to assure control of the hemorrhage. 
 
 The sutures are passed under the control of the index and middle fingers 
 of the left hand placed in the rectum ; the point of a Peaslee's needle enters 
 the tissues within the left border of the wound, and passes transversely across 
 to emerge at the corresponding point on the other side, the skin not being 
 included at either point by Lawson Tait, though personally I do not exclude 
 this ; a silver suture is introduced into the eye of the needle, which is then 
 withdrawn in the usual manner. Four are enough, and they should pene- 
 trate the recto-vaginal septum a little beyond the point where it has been 
 divided ; they are tied between the flaps of the wound after it has been care- 
 fully washed with sublimate solution (i : i,ooo) and the rectal tampon has 
 been removed. The edges of the wound are then brought together; but as 
 the sutures of silver are obliged to emerge through the line of union, it is 
 not exactly rectilinear, although between them the apposition is perfect. 
 Toward the anus there often remains a fold which corresponds to the lower 
 transverse border of the denudation on the vaginal surface, the layer of 
 mucous membrane forming an open fold or crease anteriorly, or a small 
 rosette. 
 
 Tait does not use any sviperficial sutures. Sanger thinks it better to 
 employ them ; for if one operates antiseptically there is no need, he says, of 
 keeping the external opening for drainage, as Tait is accustomed to do. The 
 silver wires are cut short, and their ends are fastened with a shot, which is 
 crushed over them. 
 
 [Silkworm gut, which possesses many advantages over silver wire, is 
 now commonly employed, and the sutures are entered about one-eighth of an 
 inch from the skin margin, but otherwise as described above. They are tied 
 in the same order that they are inserted, from the sphincter upward. A few 
 superficial catgut sutures are usually needed to insure perfect coaptation of 
 the skin edges and of the remains of the fiap at the new posterior commissure.] 
 
 The dressing consists of insufflation of iodoform and iodoform gauze 
 which envelops the silver sutures. During the first three days the catheter 
 must be used ; on the seventh the superficial sutures are removed, and on 
 the fourteenth the deep series; then the patient may leave her bed. [See 
 also after-treatment of complete laceration, many details of which are ap- 
 plicable here.] 
 
 Martin has modified the suture in a way which I consider very advan- 
 tageous. Instead of silver at separate points, he employs juniper catgut, 
 and a continuous suture on superposed planes; the operation is thus very 
 rapid and the coaptation perfect. 
 
 Complete Ruptures of the Permemn. — The triangular denudation of Simon 
 has been adopted and perfected by Hegar. He starts with the principle 
 
LACERATION OF THE PERINEUM. 
 
 8ii 
 
 that, if the perineum has been torn from three surfaces, the suture should 
 be made in three directions, taking in successively the vagina, the rectum, 
 and the skin. Hegar makes a denudation wh,ich has the shape of a butterfly 
 with extended wings, its body corresponding to the recto-vaginal septum. 
 He does not split the septum, but merely excises the cicatricial tissue and 
 the mucous membrane to obtain a sufficient wound surface for the purpose 
 of perfect coaptation. 
 
 The following are the different steps of the operation : 
 
 Method of Shnon-Tegar : First Step. — Denudation. — To expose the field 
 
 of operation in the most complete way, an assistant lifts up the anterior 
 
 vaginal wall with a large retractor, while the surgeon seizes the posterior 
 
 wall with the toothed forceps above the point ;r (Fig. 532). Hegar intro- 
 
 FiG. 532. — Complete Laceration of the 
 Perineum ; Perineorrhaphy. Simon-Hegar 
 method; denudation. 
 
 Fig. 533. — Complete Laceration of the 
 Perineum; Perineorrhaphy. Simon-Hegar 
 method; vaginal and rectal sutures. 
 
 duces into the rectum, especially if there is prolapse of the rectal wall, a 
 sponge soaked in chlorine water and secured b)^ a string, to prevent soiling 
 the skin with fseces. The skin is then seized with forceps at the points 
 which correspond to the extremities of the new perineum ; that is to say, 
 anteriorly on the internal surface of the labium majus at a and b, and be- 
 hind near the border of the anus at the points c and d ; these points are 
 stretched apart, and the dissection begun in the triangle nx n. The point x 
 is situated in the middle line of the posterior vaginal wall, and at a distance 
 of 2 cm, above the point e, which represents the extremity of the triangle 
 vivified on the rectal surface. By the excision of the small mucous triangle 
 with its apex directed toward the posterior vaginal pouch, the projection of 
 the extremities of the flaps is prevented, which would otherwise take place 
 wlien the sutures are tightened, and the apposition of the lateral portions of 
 the denuded surface in the median line is much facilitated. Moreover, by 
 this method greater solidity is given to the recto-vaginal septum, for the 
 points ,r and e on the vaginal and rectnl surfaces represent the highest points 
 of the line of denudation, and are farther removed from each other than they 
 
8 12 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 would be if x were at the middle of a straight line between n and n ; and 
 this increased thickness assures the prevention of recto-vaginal fistula. 
 
 Starting from the points n, n, a curved incision is made, convex forward, 
 directed upward and outward, reaching to the points a, b, which when united 
 form the new fourchette ; these points are situated on the internal border of 
 the labium majus at the level of the lower caruncles. From here the inci- 
 sions a c and b d are traced, from 3 to 4 cm. in length, which by their union 
 form the raphe of the new perineum ; these incisions are directed downward 
 toward the point where the anus will be formed, and from this point the lines 
 c £ and d e are bent inward ; they are best made with the scissors. The edges 
 of the flap thus marked out are freed with the bistoury by cutting about 3 
 mm. with the knife, held fiat, and the portion of tissue so circumscribed is 
 then dissected off and the denudation completed. 
 
 Along the lateral portions of the wound there are many important veins 
 which are at times injured, and the hemorrhage is then quite free; the 
 bleeding points may be compressed with a small tampon of wet cotton, or if 
 necessary by forceps for a few minutes ; it is seldom necessary to tie them. 
 When forcipressure has been employed, the portions of tissue which have 
 been compressed between the jaws of the forceps should be cut away before 
 tying the sutures, the exact apposition of the flaps sufficing to stop the hem- 
 orrhage completely. 
 
 As Hegar remarks, when the operation is performed for the first time, 
 the fault is usually committed of making the denuded surface too large, 
 Avhich uselessly extends the wound surface and increases the difficulties of 
 exact reunion. The other fault, of denuding the surface to be united in 
 such a way that the points c, d are situated too far outward, should also be 
 avoided, for then there is great difficulty in bringing the lines ^c/and cc ex- 
 actly together (Fig. 532). 
 
 Second Step. SiitiLTc. — When the wound has been equalized, we begin 
 by suturing the edges of the triangle nxn (Fig. 532). For this purpose 
 Hegar uses curved needles in a needle-holder. The needle enters the mu- 
 cous membrane 3 mm. from the border of the wound, passes transversely 
 through the whole extent of the denuded surface, and emerges 3 mm. outside 
 of the opposite edge. If the triangle nxn is very large, too great a mass of 
 tissue must not be included in the suture, but the needle goes through a por- 
 tion of the wound, and omits part of its extent in the median line; in this 
 way the apposition of the two sides is better secured. 
 
 When the vaginal suture has been completed, a few sutures are taken in 
 the rectum. Here the needle is passed 2 or 3 mm. from the border of the 
 freshened surface from below upward ; after traversing a certain extent of 
 the tissue, it is drawn out, seized anew by the needle-holder, and passed 
 through a corresponding point of the opposite surface, and then directed from 
 above down and out toward the skin ; the ends of the threads hang in the 
 rectum. Instead of passing the sutures as I have described, a needle may 
 
LACERATION OF THE PERINEUM. 813 
 
 be used on each end and passed from above downward, and from within out- 
 ward on either side of the lateral portion of the denuded surface. As it is 
 very difficult to remove metallic sutures from the rectum when they are very 
 short, Hegar consequently employs catgut or fine silk for the rectal sutures 
 and abandons them altogether. 
 
 The sutures may be fastened in either of two ways : 
 
 Fig. 534. — Complete Laceration of the Perineu.m ; Perineorrhaphy. Simon-Hegar method; general dispositioir 
 
 of the sutures. 
 
 1. All of the threads may be passed and then tied, as Hildebrandt is 
 accustomed to do. 
 
 2. Or, as Hegar prefers, the first, which is situated most deeply, may be 
 passed, drawn tight, and tied; then the second and so on, thus continuously 
 equalizing the lips of the wound, and proportionately modifying the position 
 of the sutures and correcting the shape of the denuded portion. 
 
 When the rectal and vaginal sutures are all in place and fastened, the 
 perineal series is to be introduced (Fig. 534). Here the ordinary rules are 
 followed. During the process of securing the sutures, the thighs of the 
 
8 14 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 patient should be brought together to diminish the tension ; it is advanta- 
 geous to place the patient in the dorso-sacral position for this step of the 
 operation. 
 
 The disposal of the deep and the superficial sutures varies. Dieffenbach 
 employs deep sutures only on the perineum; Simon attaches great impor- 
 tance to sutures of both the vagina and the rectum. More recently Simon 
 regards it as of great benefit to apply the deep sutures from the rectum, and 
 those which are more superficial from the vagina. Hegar prefers deep su- 
 tures on both rectum and vagina, although he does not limit their application 
 wholly to these surfaces ; the capital point, he says, is to leave no space 
 where the walls are not exactly in apposition and where fluids might collect. 
 
 When the laceration is very extensive, Hegar modifies his usual proce- 
 dure. If the laceration reaches up the rectum more than four centimetres, 
 the denuded surfaces on the recto-vaginal septum are so narrow that a single 
 series of sutures will be sufficient, which embrace the whole thickness of the 
 partition and are tied upon the vaginal surface ; if two series be employed, 
 they may not include a sufficient amount of tissue. On the other hand, with 
 a single series we might fear that the apposition would not be quite regular; 
 but this inconvenience may be avoided by alternating the deeper set which 
 include the whole septum with others which take in the vagina alone. 
 Lower down on the perineum, where the vivified surfaces are more exten- 
 sive, a double suture may be employed, as described above. If the solution 
 of continuity is very great, a terrace suture on several planes may be em- 
 ployed. A certain extent of the surface is denuded and a suture applied at 
 this point; then another portion, which is treated in the same way; by oper- 
 ating thus, we avoid free bleeding, and a large extent of wound is not ex- 
 posed to the action of the air for any length of time. 
 
 When the sutures are all in place, the little collection of blood between 
 the flaps should be squeezed out, and rectum, vagina, and perineum well irri- 
 gated with antiseptic fluid. 
 
 Hegar then performs a subcutaneous or open section of the anal sphincter 
 by making two lateral incisions in its posterior edge. This procedure some- 
 times gives rise to free hemorrhage, but it is easily controlled by ligature or 
 forcipressure. According to Hegar, the section of the sphincter is an ad- 
 vantage, in that it permits the free issue of fasces and gas during the first 
 few days, which if allowed to accumulate would distend the walls of the 
 canal and thus interfere with proper union ; it also prevents all dragging 
 upon the rectal suture. Baker Brown also cut the sphincter, but his incision 
 was made posteriorly toward the coccyx. Hegar has returned in recent 
 years to the lateral liberating incisions of Dieffenbach, which he had formerly 
 employed ; these are incisions parallel to the line of union of the denuded 
 flaps, extending to the cellulo-fatty subcutaneous tissue. But the tension is 
 not very great when the operator has been careful not to make the denuded 
 surface too large; and the presence of two open wounds so close to the line 
 
LACERATION OF THE PERINEUM. 815 
 
 of suture is not free from danger, for they may be means of entrance for 
 infection. 
 
 Frciind's MetJiod. — Freund has insisted with much force upon the neces- 
 sity of making the denudation in such a way that we reproduce the state in 
 which tlie perineum is found immediately after the tear. If the flaps are 
 made in the usual manner, the suture includes with great traction parts 
 which normally are never in apposition. Freund, therefore, dissects out a 
 surface whose form is wholly subordinated to that of the solution of con- 
 tinuity. 
 
 Hildebrandf s MetJiod. — In this procedure the denuded area has the form 
 of a trefoil, and the sutures are fastened on the cutaneous surface except for 
 a small part of the wound. The vaginal sutures are first passed, then the 
 rectal, then the deep sutures which are tied on the perineum ; thus he avoids 
 the production of a space between the rectal, vaginal, and perineal wall, 
 which may serve for the accumulation of blood and the formation of abscess. 
 
 Heppner s MetJiod of Suture. — Heppner has had the same object in view 
 in proposing a suture of the shape of the figure " 8," which ig intended to 
 assure at the same time complete apposition on both the vaginal and perineal 
 surfaces. 
 
 Lauenstcin s MetJiod of Suture. — This procedure has for its object the 
 prevention of infection of the sutures from the rectal and vaginal secretions. 
 Lauenstein introduces the sutures about one-half centimetre from the bor- 
 ders of the wound and within the bleeding surface, making buried sutures of 
 catgut at separate points, according to Werth's plan. When the rectal and 
 vaginal mucous membranes are sufficiently coapted, he diminishes the depth 
 of the wound posteriorly by a few more hidden sutures, and then completes 
 the perineum with silver wire (Figs. 535 and 536). 
 
 Marthi s MetJiod of Suture. — Martin denudes the part in the same man- 
 ner as Simon, but employs a method of suture which is very rapid and com- 
 pletely prevents the imperfect apposition for which Hildebrandt and Hepp- 
 ner have invented their ingenious but complicated procedures. He makes a 
 continuous catgut suture, starting as for colporrhaphy at the superior angle 
 of the wound, closing the rectum first by a few points which start from the 
 intestinal mucous membrane, penetrate the bleeding surface, and come out 
 again in the rectum. When the intestinal suture is complete up to the 
 anus, with the same thread, but in a contrary direction, a first plane of suture 
 is placed in the wound itself, going up to the superior angle in the vagina, 
 from which the suture first started. If this one plane is sufficient, the lips 
 of the vaginal wound are united, and then the perineum ; but if the bleeding 
 surface is of great extent, a second plane of suture is employed before unit- 
 ing the edges (Fig. 537). 
 
 Le Forfs inetJiod resembles Demarquay's, from which it was derived, 
 although with a number of ingenious modifications. 
 
 It is applicable to complete lacerations which involve the entire length 
 
8i6 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 of the recto-vaginal septum. After separation of the sides of the vulva, an 
 incision is made in the central intact portion of the septum at the point C 
 (Fig. 538, I ), one centimetre in length, and including only the vaginal aspect 
 
 Fig. 535. — Inxo:\iplete Laceration of the Perineum ; Lauenstein's Suture, i, Suture of the anterior an- 
 gle by the usual method ; 2. submucous suture of the vaginal wall ; 3, buried sutures in the depth of the wound 
 
 FiG. 536. — Incomplete Laceration of the Perineum ; Lauenstein's Suture, i, Introduction of the sutures 
 which coapt the vaginal and rectal mucous membranes ; 2, introduction of the perineal sutures after the vaginal and 
 rectal have been fastened. 
 
 of the septum ; then a sHghtly convex incision is made from C, following the 
 lines C, D, E, and rising to the point E ; from the same point C another 
 incision C G \s carried along the rectal portion of the remains of the septum,. 
 
LACERATION OF THE PERINEUM. 
 
 817 
 
 but without involving the rectal mucous membrane, to the sides of the anus. 
 These two incisions are separated by an acute angle ; their extremities 
 are united by a third curved incision E I G, which with them describes the 
 triangle H, over which area the skin and cicatricial tissue are removed, so 
 that there is a freshened triangle on each side. At this point of the opera- 
 tion the vaginal part of the septum is seized at the edge of the incision C D E 
 with toothed forceps, and split as far as the dotted line C E, which liberates 
 the vaginal layer D, destined to be united by its deep and bleeding surface 
 to the similar layer from the other side. This union is made in three planes 
 
 Fig. 537. — Complete Laceration of the Perineum; Perineorrhaphv. Martin's method. <;, Deep plane of 
 continuous suture ; b, passage from the deep to the superficial. 
 
 as regards the septum : a rectal plane, formed by the suture of the two rectal 
 edges; a vaginal plane, consisting of the two small flaps D ; and a large in- 
 termediate plane formed by the junction of the two denuded triangles H. 
 
 To repair the rectal portion, a series of interrupted sutures is placed 
 along the lines C, G, beginning at the flap C ; the needle is introduced on 
 the left border and passed from the rectum toward the vagina, then in the 
 right flap (Fig. 538, 2) from the vagina toward the rectum. When the first 
 suture has been drawn tight, a second is placed in the same manner, then 
 a third and a fourth, until the anterior wall of the rectum is wholly recon- 
 structed clown to the anus, although the separation from the vagina is by a 
 very thin partition. Next the intermediate portion of the septum is formed 
 by adjusting the triangles B ; the first thread is introduced outside of the 
 line CE (Fig. 538, 3), at the point where the small triangle is inserted. 
 The needle passes from above downward and from right to left in the thick- 
 
8i8 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 ness of the tissues, turns at the median line, ascends at the same depth in 
 the substance of the opposite side of the wound, to emerge at one-half centi- 
 metre from the line C E ; three or four such threads are passed in the same 
 manner through the part which is to be the deepest portion of the septum. 
 During this entire step of the operation the finger is kept in the rectum to 
 serve as a guide and prevent the sutures from entering the cavity of the rec- 
 tum ; the sutures are placed, but not tightened until those for the perineum 
 and the sphincter are in position ; these are three or four in number accord- 
 
 
 Fig. 538.— Complete Laceration of the Perineum. Le Fort's method, i, Lines of incision ; 2, repair of the 
 rectal wall, line of the sutures ; 3, repair of the vaginal septum ; 4, vertical section showing the disposition of the 
 
 ing to the dimensions of the perineum. For the perineal series the needle 
 enters at one and one-half centimetres from the perineal border of the de- 
 nuded triangle H (Fig. 538, 3) penetrating to the depth of i cm. ; the first 
 suture being introduced near the point E, the second at G, and if necessary 
 a third between the preceding. The ends of the three are united on either 
 side by a quilled suture formed with a piece of rubber tube pierced with 
 holes. The action of these sutures is exerted upon the deeper portions of 
 the denuded surface and tends to bring the recto- vaginal septum toward the 
 surface of the perineum. Before applying the rubbers and tying the sutures, 
 the vaginal sutures are drawn tight, and in proportion as this is done a few 
 superficial stitches are taken in the small vaginal flaps D^ D; when the su- 
 
LACERATION OF THE PERINEUM. 819 
 
 tures are complete, Le Fort makes Dieffenbach's incisions if there is much 
 tension. 
 
 RicJief s Method. — This procedure is derived, like the preceding, from 
 Demarquay's, but it presents many points which are original. It has been 
 well described by Picque, from whom I take my description. 
 
 In the first step a curved incision is made a little distance from the free 
 border of the recto-vaginal defect, circumscribing it, and permitting the 
 ■division of the vaginal wall from the rectal portion of the septum. This in- 
 cision is prolonged upward on each side at the muco-cutaneous border as far 
 as the cicatricial surface caused by the laceration extends, which is then 
 denuded in the form of a butterfly. When the incision and the denudation 
 have been performed, Richet splits the septum in such a way that the area 
 of surface thus exposed increases in proportion to its vicinity to the peri- 
 neum, but even at its broadest portion the denuded surface does not exceed 
 8 to 10 mm. In this condition when the two portions of the divided peri- 
 neal body are finally united, the flaps of the horizontal laceration are pressed 
 together and form a projecting median fold. 
 
 In the second step the borders of the vaginal flap are brought together 
 by their bleeding surfaces and secured with a few sutures whose ends are 
 laid over the mons veneris. The posterior sutures are placed first. The 
 anterior sutures should not be completed before the perineum is united, ex- 
 cept where the defect is of small extent. The apposition of the flaps by 
 their bleeding surfaces produces a projecting median fold. 
 
 The third step includes the formation of the perineal body by the union 
 of the lateral denuded surfaces by three or four quill sutures deeply placed 
 to secure as perfect apposition as possible. Richet thinks that this method 
 of suture makes the coaptation very sure. To avoid ulceration at the inser- 
 tion of the sutures, he ties them over bits of rubber tube with compresses of 
 carbolic or iodoform gauze beneath, which keep them from the skin, each 
 suture being independent of the others. When the rectal and vaginal su- 
 tures are complete, he adds, if necessary, a few superficial stitches on the 
 perineum. This method requires, therefore, two lines of sutures, perpen- 
 dicular to each other ; Richet employs no suture in the rectum. 
 
 Emmef s MetJiod. — This method has been made known in France by 
 Judes Hue's writings, who followed Gaillard Thomas in his description, 
 and clearly brought out the original points of the method, by which he had 
 obtained many successes. The exposition of the subject and the figure 
 which he gave do not, however, seem to correspond exactly to the original 
 operation of the author, especially as regards the anterior portion of the de- 
 nudation and the suture. It is not absolutely necessary, as he repeatedly 
 says, to have a long curved needle mounted on a handle. Emmet uses an 
 ordinary needle, which he inserts in the upper part of the denuded area and 
 reintroduces, after passing it a certain distance, through the same point from 
 Avhich it emerged. With these reservations, the following is borrowed from 
 
820 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Kirmisson, and the figures from an article by Hanks, a colleague of 
 Emmet. 
 
 The patient is anaesthetized and placed in the lithotomy position, two 
 assistants supporting the lower limbs on either side. The operator first 
 carefully cleanses the anal, vaginal, and perineal regions with antiseptic 
 fluid, and then proceeds with the denudation as in the other methods. On 
 each side of the lacerated perineum a denuded triangle is formed whose base 
 is the skin, from the anus to the lower caruncle, the apex being just above 
 the upper limit of the rectal tear. These two triangles are united in the 
 
 Fig. 
 
 -Complete Rupture of the Perineum ; Perineorrhaphy. Emmet's method ; the 
 and the sutures in place Cafter HanksJ. 
 
 freshened surface 
 
 median line above the tear in the septum for about three centimetres. The 
 resulting figure has the form of a butterfly with extended wings, the central 
 portion of the denuded area representing the body of the insect, and the 
 lateral portions the wings (Fig. 539). 
 
 The limits of the vivified surface should first be traced with the bistoury 
 to assure their symmetry, for it is necessary that they should correspond in 
 every point. A very important precaution is to begin the dissection below 
 at the median line, for otherwise one is incommoded by the blood flowing 
 from the upper and lateral parts of the denudation. The finger of the as- 
 sistant, in the rectum, stretches the septum and makes it project forward, 
 rendering the vivification of the median part more easy; during the dissec- 
 
LACERATION OF THE PERINEUM. 
 
 821 
 
 tion on the lateral portions it is eciually necessary to have the assistant draw 
 the part under the knife tense by gentle traction outward. When the re- 
 quired surface has been prepared, the field of operation should be cleared of 
 blood and all oozing stopped by the application of a cold antiseptic solution 
 (weak boric or carbolic acid or bichloride). Then the suture is begun, which 
 is the special point in Emmet's method. The sutures are placed with a 
 needle mounted on a handle and strongly curved, or with a large Hagedorn 
 needle, and medium-sized silver wire is used; they are passed from behind 
 
 Fig. 540. — Complete Laceration of the Perineum ; Perineorrhaphy. Emmet's method ; tightening the poste- 
 rior suture, which includes the sphincter (after Hanks). 
 
 forward. On the left side of the perineum the operator inserts the point of 
 the needle held in the right hand, about one centimetre external and posterior 
 to the posterior margin of the anus. It then traverses the lower part of the 
 recto-vaginal septum, to emerge on the right side of the anus at a point ex- 
 actly opposite its insertion. If the tissues are very thick, it is better to pass 
 the needle in two motions, penetrating first to the septum, withdrawing it 
 and reintroducing it so that it exactly reaches its point of exit. During the 
 whole of this step the introduction of the finger into the rectum is absolutely 
 indispensable ; it stretches the septum, guides the needle, and prevents its 
 issue in the cavity of the rectum. This manoeuvre of passing the sutures 
 demands great attention on the part of the operator, and should be performed 
 with a certain gentleness, in order that the needle may not enter the rectum 
 or lose itself in the tissues, and emerge at a point which is not symmetrical 
 
822 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 with its insertion. Four or five sutures are placed in this manner. Intro- 
 duced one centimetre from the line of denudation, they pass parallel across 
 the septum at the distance of about one-half centimetre from each other, and 
 appear on the opposite side of the perineum. 
 
 It is of great importance to pass the first suture in an exact manner, as 
 it unites the severed ends of the sphincter and restores the anus as nearly 
 as possible to its former condition. It should penetrate the bleeding surface 
 very near its posterior border, and pass deeply in the angle of division of the 
 septum, where it is to secure its supporting point. Generally five or six 
 deep sutures are all that are necessary. If the region of the fourchette is 
 not accurately adjusted, a superficial suture at this point will be necessary. 
 The same is true if the skin flaps of the perineal incision are not brought 
 
 Fig. 541. — Diagram of the Su- 
 ture OF THE Sphincter ev Emmet's 
 Method. 
 
 Fig. 542. — Complete Laceration of the Perineum and the 
 Recto-vaginal Septum; Perineorrhaphy. Emmet's method. 
 (Vertical section showing the plan of the sutures.) 
 
 into perfect apposition, when a few complementary sutures will be required 
 superficially. The operation is terminated by a careful cleansing of the 
 parts with an antiseptic solution, after which the dressing is applied. 
 
 As is evident from the preceding description Emmet's procedure for 
 complete rupture is a method of a single series of sutures, except in unusual 
 cases. Here there is no rectal suture and no vaginal ; all the stitches are 
 passed on a single plane, from the skin through the recto-vaginal septum or 
 the vaginal wall, thus producing a great simplification of the operation. But 
 that is not the principal object. What was proposed, according to Emmet 
 and Thomas, was to pass the lower suture in such a way that the extremities 
 of the retracted sphincter would be drawn forward and the muscular ring 
 restored to its normal form and function. However that may be, the appli- 
 cation of this posterior suture demands careful attention. When the ojDera- 
 tion has been finished, the surgeon should pass his finger into the rectum to 
 assure himself that this suture has not contracted the calibre of the rectum, 
 for in that case there would not be an easy exit for the gas and f?eces. 
 
 A great advantage of this method is that, by closing the defect in the 
 recto-vaginal wall by a constricting suture, the solution of continuity is ob- 
 literated as one shuts a purse by drawing its strings; and as the septum is 
 
LACERATION OF THE PERINEUM. 
 
 823 
 
 brought lower, the isolated suture of the vagina may be dispensed with. 
 Thus is realized the exact occlusion of the vaginal wound and the protection 
 of the line of union which Langenbeck endeavored to obtain by his auto- 
 plastic flap, an^ the absence of the rectal suture diminishes the risk of 
 infection. 
 
 If a very higli division of the septum renders its suture necessary, Emmet 
 freshens only the vaginal surface of this laceration, and passes his sutures 
 under the bleeding area in its whole extent, avoiding the intestinal canal, 
 fastening them by leaden shot in the interior of the vagina (Fig. 542). But 
 this suplementary operation is seldom necessary, and the type of the method 
 remains that of the single perineal suture. 
 
 Lawson Taif s Method. — This procedure differs but little from that ap- 
 
 FiG. 543. — Laceration of the Perineum ; Perineorrhaphy. Lawson Tail's method, a b c if. Line of incision for 
 incomplete laceration ; a b c d e f, line of incision for complete laceration. 
 
 plied to partial lacerations. The surgeon begins by splitting the recto- 
 vaginal septum and thus forming a rectal and a vaginal flap, the extent of 
 this depending on the size of the laceration ; according to Sanger, it is best 
 made with the bistoury. Laterally this division of the septum is carried to 
 the vertical lines which unite the labia minora, to the labia majora, which is 
 sufficient in partial laceration ; and to these lilies a posterior incision may be 
 added which with them produces a figure like the letter H, the transverse 
 bar which joins the two sides being nearer to the lower part of the letter 
 (Fig. 543). The division may be begun with the bistoury and completed 
 with the scissors. Then the vaginal flap of the septum is carried upward 
 and the rectal downward, so that the mucous surfaces may be carefully liber- 
 ated by the scissors between the angles of the lines of section. 
 
 The two flaps, vaginal and rectal, when they are separated, form a quad- 
 rilateral, at the bottom of which is the intact portion of the septum (see Fig. 
 
824 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 545) ; laterally they are attached to the soft parts by a thick margin, which 
 must be divided, following the H -shaped cutaneous incision, to effect the 
 denudation. 
 
 Great care should be employed in placing the first sutufe to see that it 
 traverses the ends of the sphincter, whose situation may be recognized before 
 the denudation by the small dimple on each side of the cicatrix. This su- 
 ture is made by Tait and Munde of silkworm gut, but by Sanger of silver, 
 as in partial laceration. All the sutures appear on the perineum and none 
 
 Fig. 544. — Incomplete Laceration of the Perineum. Lines of incision in modified Tail's operation (Pozzi). 
 
 are tied in the rectum. Tait does not include the skin in the deep series ; 
 Munde advises to do so ; Martin employs the continuous catgut suture on 
 superposed planes. 
 
 Iodoform in powder is used for the dressing, and the sutures are removed 
 on the seventh and fourteenth days. 
 
 MetJiod of Lawson Tait, Modified {Pozzi). — I now use almost entirely, 
 for lacerations of the perineum, whether complete or incomplete, Lawson 
 Tait's method of flap-splitting with extensive modifications both in denuda- 
 tion and in suturing. For incomplete lacerations I make a U-shaped or an 
 H-shaped incision, the lower parts of the vertical incisions in the latter case 
 being very short, the transverse incision passes through the remains of the 
 perineum, the vertical portions extend forward two or three centimetres from 
 this, and, if the soft parts are very thick, are carried a short distance back- 
 
LACERATION OF THE PERINEUM. 
 
 825 
 
 ■ward, changing the U-shaped into the H-shaped incision (V\g. 544). Ten- 
 sion upon the skin by forceps applied on each side of the held of operation 
 facilitates this incision. I use straight scissors, one of whose branches is 
 pointed, or, better, scissors bent on the edge. I divide the recto-vaginal 
 septum to a height of two or three centimetres, and on each side I dissect the 
 posterior vaginal and the anterior rectal wall, so as to form a wound about the 
 
 Fig. 545. — Modified Taii's Oi'Ekation (Pozzi). Flaps 
 made and deep sutures in place. IJurie d sutures begun. 
 
 F'G. 546. — Modified Tait's Oi'iiRAiioN 
 (Pozzi). Sutures all tied. Dotted lines show 
 the course of the deep silver sutures. 
 
 size of the palm of the hand. This often bleeds freely : the arteries are tied 
 with catgut and the venous hemorrhage is checked with tampons, as the 
 subsequent suture will arrest it. 
 
 During the whole dissection I am guided by the index finger inserted in 
 the rectum. Without this it would be almost impossible to avoid injuring 
 the intestine, which I liberate very high up if the laceration is complete, so as 
 to be able to draw down the rectal tear so low that all its sutures may be ex- 
 ternal. By proceeding cautiously and following the anterior surface of the 
 rectum, neither this nor the vagina should be opened. If such an accident 
 should happen, the opening should be closed at once by a buried catgut 
 .suture passed according to Lauenstein's method. 
 
 This extensive splitting and extreme drawing down of the rectum is one 
 of the points of modification of Lawson Tait's method, and the suture is 
 
826 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 another. It is important that the coaptation should be very exact without 
 dead spaces which might allow the accumulation of liquid and interfere with 
 union. I secure this by combining a catgut suture in tiers with deep sup- 
 porting sutures of silver wire, the latter being the first passed. A loop of 
 silk is employed to draw three loops of silver wire entering and emerging 
 one-half centimetre from the edges of the wound and passing beneath the 
 entire raw surface. Their middle corresponds to the deepest part of the split 
 in the recto-vagina septum, near the point where the rectum and vagina sepa- 
 rate. Two or three of these sutures are passed with either a very large half- 
 curved Hagedorn needle or a needle with a handle (erroneously called Em- 
 
 FiGs. 547 AND 548. — Complete Laceration of the Perineum ; Perineorrhaphy. Simpson's method ; vivifica- 
 
 tion; sutures. 
 
 met's needle). The loop of each suture emerges on the right side, and the 
 two free ends of each on the left (Fig. 545). Before tying these sutures 
 the tier suture of catgut is inserted, beginning at the deepest part of the 
 wound (Fig. 546), then the skin is closed by a running catgut suture or 
 separate stitches of silkworm gut. A roll of iodoform gauze is then placed 
 in the loop of each wire suture, and one between the face ends of each, and 
 after exerting a certain amount of traction the sutures are twisted. I crush 
 a piece of lead over the ends of the sutures in order to avoid sharp points 
 (Fig. 546). Great care shovdd be used in passing the deep silver sutures, 
 which must traverse the entire raw area near its surface, witnout penetrating 
 the vagina or rectum ; they must not even enter the muscular coat of the in- 
 testine on account of the danger of producing ulceration, which would lead 
 to infection of the whole wound. I employ a dressing of iodoform gauze 
 and of equal parts of powdered iodoform and subnitrate of bismuth. The 
 sutures are not removed until the eighth or tenth day, unless especially 
 indicated. 
 
LACERATION OF THE PERINEUM. 
 
 827 
 
 Simpsons MetJiod. — From the chronological standpoint this procedure 
 should be described before the preceding, which it much anticipated ; but 
 as it is less important, I will treat it as an appendix. It resembles Tait's 
 in the manner of denuding the tissues, but differs from it in the sutures ; 
 my description is taken from Hart and Barbour. 
 
 The first incision starts from the end of the recto-vaginal septum, enters 
 both rectum and vagina, follows the internal face of the labium majus from 
 within outward, and emerges at the point i ; another incision is made 
 
 Fig. 549. — Laceration of the Recto-vaginal Septum ; Method of Splitting (Fritsch-Walzberg). .S, 
 ■Recto-vaginal septum ; y", laceration of the same ; L^ labium majus ; /, labium minus ; /', perineum: F, rectal portion 
 of the septum. 
 
 from the point <r?, parallel to the orifice of the vulva, passing by the external 
 extremity of the first incision and stopping at b, at the end of the sphincter. 
 This is repeated on the other side. The two triangular flaps thus obtained 
 are dissected (Fig. 548) ; the flap alS is lifted forward on each side, so that 
 the angles marked /in the first figure reunite with each other in the second. 
 The vaginal flaps are sutured with silver or silk, taking care to tie them on 
 the vaginal surface ; the ends are left long, and hang out of the vagina. In 
 the rectum it is better to employ catgut and cut the ends short. To close 
 the bleeding cavity which results, two deep perineal sutures are passed, and 
 tied over metal plates. A few superficial stitches complete the operation. 
 
 FritscJi s Method. — This procedure still more closely resembles Tait's, 
 and like it is based on the principle of splitting the septum, instead of de- 
 nuding the tissues, with the object of avoiding the formation of new cica- 
 tricial tissue. Fritsch detaches the rectum from the vagina in the partial 
 lacerations, and adds to this a lateral incision for the sphincter when its ends 
 are retracted; he unites these by a provisional stitch, which ser\'es during" 
 
828 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 the operation to restore the shape of the orifice and permit the regular proc- 
 ess of reunion. Ke then sutures the rectal mucous membrane with separate 
 catgut points placed in the vagina and tied at the bottom of the wound. To 
 avoid infection of the wound, according to Lauenstein's teaching, these 
 sutures should not penetrate the rectum. The same sutures close the vagina 
 without penetrating it. The perineum is then completed by a series of buried 
 sutures on superposed planes, which Fritsch prefers to the continuous catgut 
 suture in terraces. 
 
 If the laceration of the septum extend very far upward, it may be neces- 
 sary to split it and suture it according to Walzberg's plan (Fig. 550). 
 
 1 2 3 
 
 Fig. 550. — Laceration of the Recto-vaginal Septu.m ; Method of Splitting (Fritsch-Walzberg). Dia- 
 gram. R^ Rectum ; f ', vagina ; a b b' , incision ; i, incision ; 2, division ; 3, reunion. 
 
 After-treatment. — The dressing includes great cleanliness and the local 
 application of iodoform powder. It is well also to catheterize the patient 
 for the first few days, to avoid having the vulva soiled. 
 
 A very important question is whether the patient shall be kept consti- 
 pated during the first few days. It is certain that the contact of fecal mat- 
 ters will infect the wound, especially if the sutures traverse the mucous 
 membrane; but, on the other hand, the passage of hardened masses is apt 
 to tear the uniting surfaces apart. Constipation not only presents a mechan- 
 ical danger, but is also harmful by the trouble which it causes in the general 
 condition of the patient, thus interfering with the process of repair. It is 
 well, I think, to put the patient on a fluid diet for the first week, and to ad- 
 minister a gentle laxative at about the fifth day. When one or two stools 
 have been produced, no attempt should be made to excite others, and if the 
 simple laxative effect has been exceeded, give a little opium ; four days after- 
 ward a new evacuation may be provoked. During the first few days the pa- 
 tient is apt to be tormented by intestinal gas ; if that is the case, a soft rub- 
 ber tube is carefully passed into the rectum several times a day to the depth 
 of three to four inches. 
 
 The thighs should be placed close together and lightly tied, and the pa- 
 tient should not be allowed to assume the sitting posture before the third 
 week. The greatest cleanliness mu.st be maintained, the vulva and the peri- 
 neum being washed after each act of micturition or defecation. 
 
LACERATION OF THE PERINEUM. 829 
 
 The temperature must also be carefully watched, fever announcing the 
 infection of the wound or the formation of an abscess. This occurs when 
 part of the wound surface has not been exactly coapted and there remains a 
 dead space for the accumulation of blood or serum in the deeper portions of 
 the perineum, which furnishes an excellent nidus for the development of bac- 
 teria introduced during an operation which was not sufficiently aseptic or 
 along the sutures. The part then becomes tense, painful, and oedematous, 
 and the sutures sink deeply into the swollen tissues. If not quickly re- 
 lieved, the inflammation becomes more intense and causes the total disunion 
 of the flaps ; at times, by an opportune removal of one or two sutures, the 
 inflammatory process may be limited to a small area and the disunion is only 
 partial. If this occurs in the perineal aspect of the part, only a portion of 
 the wound fails to unite by first intention ; but if it involves the recto-vagi- 
 nal septum, there is great danger of the formation of fistulse. If the perfora- 
 tion is very small, it may be obliterated by the granulation with the aid of 
 cauterization; but if it is more extensive, it persists, and necessitates a new 
 operation, which should not be undertaken before a month after the perineor- 
 rhaphy. The pathognomonic symptom of this deep separation is inconti- 
 nence of gas, complained of anew by the patient. 
 
 In general, the perineal sutures of silver, silkworm gut, or silk are re- 
 moved on the tenth or twelfth day, when they begin to cut and irritate the 
 tissues ; if there is no sign of local inflammation, we may wait a little longer, 
 especially when silver has been used. The vaginal sutures are removed the 
 last ; catgut may be left alone. 
 
 The patient may begin to walk at the end of two months, and the sexual 
 relation be resumed at the end of six. 
 
 Prognosis and Results of Perineorrhaphy. — The operation is not really a 
 grave one. There is no fear of great hemorrhage or of septicaemia ; the cases 
 of the latter complication are all, with rare exceptions, of very ancient date. 
 
 The results are also very much better since we ceased to fear suppuration. 
 Before that, the absence of antiseptics and the multiplication of sutures in 
 the rectum and the vagina made infection of the wound almost a certainty ; 
 and when the union was complete superficially, there was often a cavity left 
 more deeply, with a resulting recto-vaginal fistula. This accident has seldom 
 happened since the employment of antiseptics and since more care has been 
 taken in the apposition of the deeper parts, and since the sutures in the great 
 majority of cases have been passed through the perineum entirely (Emmet's 
 and Tait's methods). 
 
 Moreover, the care taken in the union of the deep muscular planes and 
 in the junction of the divided ends of the sphincter has improved the results 
 obtained as regards the function of the intestine. It was not uncommon to 
 see women whose perinea had the appearance of being perfectly restored, 
 and yet who had no power of retaining the gaseous and liquid contents of 
 the intestine. 
 
830 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Many cases prove that parturition may be accomplished without the pro- 
 duction of any new rupture of the perineum, even when the operator has di- 
 minished the size of the vulva considerably ; this latter is an operative fault, 
 and should be guarded against. 
 
 CJioice of MetJiods. — Each one of the procedures described has given 
 good results, and they may therefore be said to be all good. But the pref- 
 erence should be given to the method which is most simple and rapid of exe- 
 cution. I have had very constantly good results from my modification of 
 Lawson Tait's method, and use it now almost to the exclusion of all others. 
 However, in cases of incomplete laceration without great relaxation, I recom- 
 mend Hegar's procedure also, and in cases of relaxation without laceration 
 Emmet's newer method. If the two lesions are combined, and especially if 
 the laceration is complete, the flap-splitting method which I have described 
 seems infinitely superior. 
 
 Usually, perineorrhaphy should be preceded by curetting the uterus and 
 an operation on the cervix for the accompanying metritis. 
 
CHAPTER XL. 
 
 INFLAMMATION, CEDEMA, GANGRENE, ERYSIPELAS, EC- 
 ZEMA, AND HERPES OF THE VULVA. 
 
 Vulvitis. — PatJiology. — The vulva is formed of parts which are very- 
 distinct anatomically, comprising: Cutaneous folds, the labia majora; mu- 
 cous folds, the labia minora and the hymen; and orifices of canals, the uri- 
 nary meatus and the ducts of Bartholin's glands. 
 
 The inflammations which affect these various parts have very diverse 
 characters, and the attempt has been made to indicate the chief differences 
 by the use of the term sebaceous vulvitis for an inflammation which is local- 
 ized in the integument, and mucous vulvitis where it is internal. But com- 
 monly all the parts found in this region are involved together by a diffuse 
 inflammation. The sebaceous and sudoriparous glands in the skin are most 
 frequently the starting-point for the inflammation of acne and furunculosis 
 of the labia majora. On the other hand, the orifices of the excretory ducts 
 of Bartholin, the mucous crypts which are found about the meatus and which 
 Skene has described as glands, and the meatus itself are the principal foci 
 for inflammation on the mucous surface. Inguinal adenitis is a frequent 
 consequence of vulvitis of the cutaneous type. It is rarely seen unless in 
 the puerperal state there has been suppuration of the labia majora in their 
 loose cellular tissue ; but it often attacks the vulvo-vaginal glands. 
 
 Symptoms. — A sharp local pain, which is increased by walking and the 
 contact of the urine, is the first sign which the patient notices. A fairly 
 abundant and at times fetid discharge bathes the region, irritates the inter- 
 nal surfaces of the thighs and, in children, the intergluteal fold. On the 
 grayish floor of these erosions there may appear ganglionic engorgement 
 which resembles syphilis. The mucous membrane of the labia minora and 
 the fourchette is red and swollen ; pus mingled with smegma accumulates 
 between the labia; the latter become oedematous and present very small pus- 
 tules at the bases of the hairs ; the larger of these resemble furuncles, and 
 circumscribed abscesses may result. 
 
 Huguier has described a cutaneous form of this affection under the name 
 of vulvar folliculitis, which presents three periods — eruption, suppuration, 
 and decline. The affection may terminate by induration, the small tumor 
 which results resembling sebaceous acne ; this is the acne varioliforme of 
 Bazin and the vulvar exdermoptosis of Huguier. The small buttons thus 
 formed are of the size of a hempseed, and although indurated have no inflam- 
 mation about them ; the skin between is completely healthy. 
 
832 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 The intensity of the inflammation varies. When it is very acute it may 
 cause fever, and there is then usvially a complicating lymphadenitis of the 
 inguinal region, with suppuration. Probably it is to this lymphangitis that 
 suppuration of the labium majus, or phlegmonous vulvitis, has always been 
 attributed ; it is rarely observed. Inflammation of the meatus provokes 
 dysuria. If the inflammation involves the glands of Bartholin, it is mani- 
 fested by the tumor which forms, and the pus which may be expressed from 
 its duct. 
 
 Diagnosis. — It is easy to recognize vulvitis, but the important point is 
 to determine the complications of the urethra, the vulvo -vaginal glands, and 
 the vagina. 
 
 The etiology is very obscure in certain cases. It must not be forgotten 
 that, in lymphatic infants who are deprived of all hygienic care, a very in- 
 tense vulvar catarrh may arise without any contagion, by simple decomposi- 
 tion of the smegma, and cause erosions and even ulceration. In a medico- 
 legal examination, therefore, we should not too hastily assume either violation 
 or contagion in the absence of other proof. Phlegmon of the labium majus 
 may be distinguished from abscess of the vulvo-vaginal gland by the situa- 
 tion of the tumor and the fluctuation toward the external or cutaneous aspect 
 of the part. 
 
 Etiology. — Of all the causes of vulvitis, the most frequent is certainly 
 gonorrhoeal contagion. This is the cause even in those cases in which we hesi- 
 tate to make the assertion, as in the epidemics of vulvitis and vulvo-vaginitis 
 which are observed where a number of children are herded together in board- 
 ing houses and hospitals. For the details I refer to the chapter on vaginitis. 
 There is no doubt, on the other hand, that saprogenic microbes may develop 
 independently of the gonococcus in children and poorly nourished women, 
 and cause attacks of vulvitis which might be termed sordid. Small lym- 
 phatic children and obese women are particularly disposed to this form, es- 
 pecially in the poorer classes. With children the oxyuris may also share in 
 the production of the affection. 
 
 In the case of vesico-vaginal fistula, the incessant contact of the urine 
 irritates the vulva and the internal surface of the thighs, but this chronic 
 irritation does not cause hypersecretion, and resembles more closely chronic 
 erythema of the parts than vulvitis. 
 
 Treatment. — In the acute stage baths, abundant lotion with boric-acid 
 solution or white wash (Goulard's lotion), extreme cleanliness, and repose 
 are to be recommended. If there is a suspicion that the inflammation is 
 gonorrhoeal, painting with a weak solution of nitrate of silver may be em- 
 ployed (i : 50) ; this lessens the pain and is an excellent antiseptic. Lotions 
 and injections of bichloride are also employed (i : 5,000). The vulva may be 
 powdered with talc to which has been added one-tenth part of iodoform. If 
 the orifice of the vulvo-vaginal gland is inflamed, it should be cauterized 
 with a nitrate-of-silver pencil after enlargement with Weber's small knife 
 
INFLAMMATION, (EDEMA, ETC., OF THE VULVA. 
 
 833 
 
 which is used for incision of the lachrymal ducts. If the crypts about the 
 urethra seem to be the seat of the inflammation, they should be penetrated 
 with a fine cautery point, or simple igni-puncture may be practised. Abscess 
 and bubo should be at once opened. 
 
 CEdema and Gangrene. — Localized oedema has been observed in the 
 vulva during pregnancy, from the disturbance of the circulation in the lower 
 pelvis and varix of the external pudic veins. 
 
 In the puerperal state, shortly after dellivery, if there is oedema of one 
 side of the vulva alone, it is a sure sign of infection from a laceration in the 
 vagina or an eschar or a phlegmon. 
 
 In general anasarca the labia majora, whose tissue is very lax and lamel- 
 lated, may swell to an enormous size, rendering micturition or even the pas- 
 
 FiG. 551. — Hard Hypertrophic CEdema of the Left Nympha, Following a Syphilitic Lesion (MacClintock). 
 
 sage of a catheter difficult. Spontaneous fissures, or incisions made for the 
 purpose, give issue to serous fluid, but are often the starting-points for ery- 
 sipelas also. 
 
 In syphilitic affections of the vulva, especially in the case of infecting 
 chancre, there is at times a hard oedema which attracts the attention of the 
 patient more than the chancre, which is considered only an excoriation, of 
 no importance. This oedema, which persists a long time after the ulcer has 
 been cured, is often situated on the nymphae, or the preputium clitoridis, 
 which are transformed into sclerous hypertrophied tissue with the appear- 
 ance of elephantiasis. In one such case I excised a tumor which had existed 
 many months and had not been modified by the internal treatment. These 
 are probably the cases which MacClintock describes as syphilitic hypertrophy 
 of the vulva. 
 
 Gangrene of the vulva may be caused by traumatism during parturition, 
 when to this local cause there is added the infl.uence of a general infection 
 as puerperal fever. Other forms of septicaemia may have the same result ; 
 typhoid, scarlatina, variola, etc. 
 53 
 
S34 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Weak and scrofulous infants have gangrene of the vulva as they have 
 noma of the mouth ; this may also be epidemic and fatal. 
 
 The treatment consists in maintaining the vagina aseptic and keeping its 
 walls separated to prevent the formation of adhesions. 
 
 Erysipelas. — Primary erysipelas of the vulva appears quite often in the 
 new-born, just as it occurs also at the umbilicus ; it is very serious and fre- 
 quently ends in death. 
 
 In menstruating women there is often an attack of erysipelas which ap- 
 pears periodically at the time of the catamenia, and it has even been obser\-ed 
 at the menstrual epoch in the absence of the flow, for which reason a supple- 
 mentary character has been attributed to it. It is probable that the microbes 
 persist in the part, but are latent until aroused each month by the catamenial 
 molimen. 
 
 As regards treatment the local application of oxide of zinc in powder and 
 bandaging with ethereal tincture of camphor, may give some relief. H liter 
 and Bockel recommend the injection of one or two syringefuls of carbolic 
 solution (2 or 3 : lOO) hypodermically about the edges of the inflamed area, 
 repeated night and morning. Liicke prescribes friction with turpentine. 
 
 Eczema. — This affection may occur on the labia majora or the mons 
 veneris as an acute or chronic inflammation. 
 
 In the acute form its onset is sudden, manifested by heat and followed 
 by swelling and an intensely red color. Small transparent vesicles form, of 
 the size of the head of a pin, scattered over the skin, but at times the}^ are 
 difficult to distinguish, as the scratching removes them ; to discover them, 
 the skin should be inspected by oblique light. There is often some disturb- 
 ance of the stomach and catarrhal fever. The eruption is produced in the 
 rheumatic especially in spring. At the end of about a fortnight the acute 
 stage is over, and the patient passes to the chronic stage. 
 
 Chronic eczema most often appears as eczema rubrum. In the acute 
 form it is chiefly the labia majora which are attacked, but from here the in- 
 flammation spreads to the thighs, the perineum, and the anus. The labia 
 are swollen, the vulva is patulous, and, as it is bathed in pus, at the first 
 sight it resembles gonorrhoeal voilvitis. The heat and itching are intoler- 
 able ; painful fissures are produced at the fourchette, anus, and genito-crural 
 folds, and to the excoriation succeeds the formation of crusts. 
 
 According to Hebra, in the majority of these cases there are complicat- 
 ing menstrual troubles, and the same fact has been mentioned for herpes by 
 Lagneau. The influence of diabetes mellitus has been suggested; that of 
 the rheumatic diathesis is unquestionable. 
 
 The excoriations and fissures which follow chronic eczema must be dis- 
 tinguished from syphilitic lesions. Herpes differs in the disposition which 
 presents toward the collection of large vesicles, and the derma is thicker in 
 eczema. Simple pruritis vulvas causes no eruption. 
 
 The treatment in the acute stage requires the application of poultices and 
 
INFLAMMATION, OEDEMA, ETC., OF THE VULVA. 835 
 
 frequent laxatives ; spices and pork should be forbidden. In the chronic 
 form, bichloride lotions (i : 1,000) are advantageous, and also inunctions 
 with the following : 
 
 I^ lodoformi, .......... i gm. 
 
 Zinci oxidi, . . . . . . . , . . 2 " 
 
 Lanolini, . . . . . . . . . . 30 " 
 
 M. ft. ungt. 
 
 The general treatment of the arthritic or scrofulous diathesis, or of dia- 
 betes if it be present, should not be neglected. 
 
 Herpes. — This affection is characterized by the formation of small 
 transparent vesicles of the size of a pin's head to that of a pea, and either 
 very few in number or multiple, from which fact it is divided into discrete 
 and confluent. A very rare form is solitary herpes, which appears as a sin- 
 gle erosion of large extent at times, resulting from the excoriation of a sin- 
 gle group of vesicles. 
 
 At first herpes always causes a sensation of heat and smarting. 
 
 It begins as an area of redness either diffuse or confined to one spot, 
 which soon covers itself with agminated vesicles ; many of these patches 
 fuse and produce a large pemphigoid bulla. When the vesicle is fully 
 formed, it remains as a red or pale vesication, looking as if covered with a 
 false membrane ; the edges of the ulcer are scalloped ; the whole is covered 
 with a crust under which cicatrization goes on after eight to fifteen days. 
 When this falls, the skin is rosy and turgid and sometimes resembles a syphi- 
 litic papule. The inguinal ganglia are often engorged, but they seldom sup- 
 purate. They are also painful, which distinguishes them from the subacute 
 adenitis of syphilis. 
 
 Gastric disturbances occur with fever in the confluent form of the affec- 
 tion. The eruption usually appears two days before the menses. With 
 some women this is repeated every month, and it often occurs in pregnancy. 
 The congestion of the genital organs is then evidently the predisposing 
 cause. 
 
 Any irritation of the vulva may produce an accidental herpes ; such as 
 gonorrhoeal and syphilitic infection and neglect of ordinary cleanliness ; the 
 affection may also be constitutional, according to classic language ; that is, 
 caused by some trifling local irritation in a herpetic individual. 
 
 Diagnosis. — Fournier warns against confounding solitary herpes with 
 chancre, and the ulcerations which follow discrete and confluent herpes with 
 mucous plaques. But the syphilitic chancre presents more of the character 
 of an erosion than of an ulceration ; its surface is smooth, varnished, and of 
 a deep red color. Sometimes, however, its centre is slightly excavated ; it 
 is then called the ulcerative form. But in the erosive form the principal 
 lesion seems to be constituted not so much by an actual loss of substance 
 as by the formation of a small indurated plaque resembling parchment, 
 which may be at once recognized by grasping it between the finger and the 
 
836 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 thumb, at a certain distance from the lesion and parallel with its surface. 
 The indolent engorgement of the ganglia, in the form of the Pleiades, is 
 characteristic, and there is neither itching nor smarting with chancre. The 
 evolution of the herpetic lesions in a typical manner every eight to fifteen 
 days, and the coexistence of other characteristic symptoms, will also help to 
 make the diagnosis evident ; but in certain cases it may still be doubtful for 
 a long time. Simple chancre may be confounded with confluent herpes. 
 This affection is then always multiple, but the appearance of the syphilitic 
 and the herpetic ulcers is not the same. The base of the sore is uneven, 
 fissured, and of a greenish color ; the edges are sharply punched, and the 
 discharge is abundant and thick ; bubo or suppurative adenitis is very fre- 
 quent. Inoculation gives positive proof ; but it is better not to employ this 
 method of diagnosis, as it may give rise to accidents. 
 
 Syphilides of the vulva, which appear as papules, erosions, and ulcers, 
 are generally disseminated, more abundant, and distributed over a larger sur- 
 face than is the case in herpes. They should not be confounded : the ero- 
 sive form alone presents no peculiar character and can be distinguished only 
 by the other syphilitic symptoms ; the ulcerative form presents ulcers with 
 a circular outline, blended in places, coexisting with mucous patches in the 
 mouth or about the anus and the spaces between the toes, with other lesions 
 of syphilis ; the papular form consists of a flattened plateau, of round or oval 
 shape, coppery red in color, with a dry or ulcerated surface. It is evident 
 how such a lesion differs from herpes ; it is also seldom localized to the 
 vulva, but is scattered over the whole integument. 
 
 Herpes of the vulva cannot be inoculated. 
 
 Treatment has for its object the calming of the pain by prolonged baths 
 and by poultices ; the ulcers are powdered with a mixture of equal parts of 
 oxide of zinc, subnitrate of bismuth, and iodoform ; they may also be touched 
 with nitrate of silver solution (i : 50). The predisposing diathesis should 
 be treated at the same time, to avoid the return of the malady. 
 
CHAPTER XLI. 
 
 LUPUS (ESTHIOMENE) OF THE VULVA. 
 
 Definition. — The name of esthiomene {IgO'.z'.'j, to devour; or lupus of the 
 vulva has retained since the days of Huguier, who first described it, a purely 
 clinical signification. It is applied to lesions of a variable nature which pre- 
 sent the common characters of a tendency to hypertrophy and a slow ulcera- 
 tion which has a progressively destructive effect on the vulvar region. This 
 affection has been justly compared to lupus of the face on account of its ap- 
 pearance and course. The demonstration of the tuberculous nature of lupus 
 of the face has now been made, and it seems to have been demonstrated for 
 •esthiomene also. 
 
 Pathology. — As every ulceration whose borders had a tendency to hyper- 
 trophy has been called lupus, it is not astonishing that the most diverse his- 
 tological changes have been encountered in this disease, comparable to ele- 
 phantiasis, tubular epithelioma, the syphiloma of Wagner, or gummy tumors 
 in different stages of nodulation, ulceration and sclerosis. Again, the only 
 lesion found has been that of inflammation of the derma with an infiltration 
 of embryonic cells into the connective tissue, especially about the vessels 
 which were in a dilated condition. 
 
 Li a case which I have examined the microscope revealed tuberculous 
 nodules with giant cells (Figs. 553 and 555). Martin and Nicolle have 
 found tubercular masses and have even been able to stain a few of Koch's 
 bacilli in chronically oedematous tissue, forming nearly the whole of the neo- 
 plasm, in a case of the hypertrophic variety. 
 
 Symptoms. — There are two clinical types, according as the ulceration or 
 the hypertrophy predominates. 
 
 I. Ulcerative Form. — Several varieties have been described. Erythem- 
 atous lupus is a very superficial ulceration, like the same variety on the 
 face, with a livid red color ; tuberculous lupus is constituted by a number of 
 liypertrophied papillae scattered over the base of the ulceration ; the latter 
 has its borders bevelled, and is of a violet color. One of the most important 
 ■characters is the tendency to heal on one side while the ulceration progresses 
 on the other; thus the process of repair may build up a part several times, 
 only to be broken down again. The ulceration is called serpiginous when 
 it sends out prolongations toward the vestibule, and perforating when it 
 produces deep excavations. 
 
 The discharge which comes from the ulcerations is not very abundant. 
 Deep perforation and fistula of both rectum and bladder may be produced; 
 
838 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Fig. 552. — Lupus of the Vulva CMacClintock). 
 
 ^^^0^^0^-0l^4/':^ ^M^^'^:^-^-?:^ 
 
 Fig. 553. — Lupus of the Vulva. Section perpendicular to surface of tumor, i, Corneous layer ; 2, layer of 
 Malpighi ; 3, derma with many eonnective-tissue cells ; 4, branching capillaries ; 5, collection of inflammatory embry- 
 onal cells ; 6, tubercular nodule with giant cell ; 7, vessels surrounded by zone of inflammation. 
 
LUPUS OF THE VULVA. 
 
 839 
 
 and partial cicatrization of an ulcerated surface may cause retraction of the 
 urinary meatus. 
 
 2. Hypertrophic Form. — The hypertrophy, which is never absent even in 
 the preceding form, assumes here very great importance ; the nymphaj and 
 the prepuce of the clitoris may become of double or triple their normal size, 
 seeming to be infiltrated with oedema which gives them a firm and elastic 
 
 Fig. 554. — Lupus OF THE Vulva. Varicose vessels. Photograph of injected specimen, i, Fibrous stroma of 
 derma infiltrated with numerous cells ; 2, tubercular nodules ; 3, varicose or enlarged vessels, ending at the periphery 
 of tubercular areas ; 4, accumulation of embryonal cells around vessels. 
 
 consistence; in many other points in the adjacent skin there are tubercles 
 or hypertrophic nodules which may invade the whole surface of the peri- 
 neum ; the surface is polished and glossy, of a red or violet color. In cer- 
 tain cases the hypertrophy of the labium majus reaches such a development 
 that it suggests the idea of elephantiasis. These indurated parts are seldom 
 painful, except when they are inflamed, while urethral caruncles are ordi- 
 narily very sensitive. 
 
 These two forms are at times isolated, but usually they are found to- 
 gether. 
 
 Diagnosis. — The slow course of the affection, its accompanying hyper- 
 trophy, and the absence of any great engorgement of the ganglia serve to 
 
840 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 distinguish it from phagedaenic chancre, tertiary syphilis, and cancer. It 
 can be confounded with elephantiasis only where there is no marked indura- 
 tion of the tissues or spontaneous ulceration. 
 
 Prognosis. — The disease is a grave one, although it has such a slow 
 course that it may progress eight or ten years. Death may occur from ex- 
 tension to the rectum or from peritonitis. 
 
 Etiology. — Lupus of the vulva is a rare affection. It is most often ob- 
 served between the twentieth and the thirtieth year and in the lower classes, 
 especially prostitutes. A predisposing cause of great importance is tuber- 
 
 FiG. 555. — Lupus of the Vulva. Tubercular nodule unth giant cell, i, Giant cell containing large numbers of 
 nuclei ; 2, loose connective tissue with many round cells ; 3, large vessel ; 4, space between giant cell and surrounding 
 tissue. 
 
 culosis, of which it is often the cutaneous manifestation, although this has 
 not yet been demonstrated anatomically. But it may be noted that two of 
 Bernutz's patients, two of Piquet's, and one of Le Fort's had very evident 
 tuberculous antecedents. Whatever causes an abnormal physiological con- 
 dition, like privation, excess, hereditary syphilis, etc., predisposes to lupus. 
 
 Treatment. — This consists essentially in cauterization of the ulcers and 
 excision of the hypertrophic portions. The actual cautery is preferable to 
 potential cauteries, such as nitric acid, caustic potash, and sulphuric acid. 
 As to the scarification and scraping with the curette which have rendered 
 such service in lupus of the face, they are of benefit here only in the erythem- 
 atous form. Dressing with iodoform and application of tincture of iodine 
 have also been successful. 
 
CHAPTER XLIL 
 
 TUMORS OP^ THE VULVA. 
 
 Varicose Tumors. — During pregnancy it is not uncommon to see vari- 
 ces of the labium majus, which may reach a great size. Holden in one 
 case found the labia majora of the size of the foetal head; the patient died 
 of phlebitis. 
 
 Usually such tumors produce only a feeling of discomfort and weight in 
 waking. They are of a bluish color, which becomes violet on the mucous 
 surface. When they rupture, under the effect of some effort, or from trau- 
 matism, or spontaneously, they cause serious or fatal hemorrhage. 
 
 The varicose region should be sustained and lightly compressed with a 
 "p-bandage. [The patient should also wear an abdominal corset to lift the 
 uterus and lessen the pressure on the pelvic veins, and should dress loosely, 
 and with no constriction about the waist.] 
 
 H.EMATOMA OR Thrombus. — The subcutaneous rupture of a varicose vein, 
 often unrecognized before the accident, causes thrombus of the vulva. It 
 occurs usually during labor, after violent manoeuvres, exaggerated efforts, or 
 the sudden issue of the head. In the non-pregnant condition it has been 
 observed as the result of a blow or a fall, and its dimensions are then very 
 much smaller. 
 
 Most commonly but one labium is distended with blood ; it then presents 
 a violet color, and may assume the proportions of the foetal head. It is a 
 grave complication of parturition ; in one hundred and twenty cases collected 
 by Girard there were twenty-four deaths. 
 
 The tumor thus formed may rupture and cause death, or suppurate and 
 produce septicaemia. To avoid this complication the parts about the tumor 
 should be incised, the cavity cleaned out, and, if necessary, a permanent 
 forceps placed on the bleeding vessel, and the pouch stuffed with iodoform 
 gauze. When, however, the tumor is very small, it may be trusted to nature 
 to be absorbed, and all that is required is to keep the vagina aseptic. 
 
 Simple Vegetations. — This affection is also known under the name of 
 papilloma or condyloma. 
 
 The tumor has the appearance of a cauliflower, at times very voluminous, 
 formed by hypertrophy of the papillae of the skin or vulvo-vaginal mucous 
 membrane. As they are often isolated, they have received the name of 
 "cock's combs " ; when massed, they may be of the size of the foetal head. 
 Their color is either pale red or of a deep wine-tint ; they are usually situ- 
 
842 
 
 CLINICAL AND OPERATIVE GYNECOLOGY 
 
 ated on the vulva, the perineum, or the margin of the anus, but may also 
 occur in the vagina. 
 
 In the enormous mass which is formed by the junction of these vegeta- 
 tions we may distinguish groups of different orders separated by furrows 
 more or less deep. They are accompanied by a sanious and fetid discharge, 
 and the irritation of walking may inflame them and render them painful. 
 The fissures which are produced at their base sometimes become the seat 
 of hyperaesthesia. 
 
 These vegetations have for a long time been considered as a reliable 
 index of venereal infection, either gonorrhoeal or syphilitic. There is no 
 
 Fig. 556.— Si.mple Vegetations of the Vulva (Tarnier). 
 
 doubt that they are often caused by the irritation of a gonorrhoeal discharge 
 or the oozing of mucous patches of the vulva, especially in women who neg- 
 lect the ordinary cleanliness of the parts. But the cock's-comb formation 
 may also be observed in pregnant women attacked by simple leucorrhoea; 
 they seem to be the result of sordid irritation of the papillae rather than of 
 the contamination of a virus. 
 
 Their transmission by contact has been demonstrated. 
 
 Treatment. — The best and most simple treatment is excision with the 
 scissors, under continuous irrigation, followed by cauterization of their bases 
 with the thermo-cautcry, and a hem suture of the linear wound. This oper- 
 ation may be performed without pain by the use of cocaine, and may be 
 
TUMORS OF THE VULVA. 
 
 843 
 
 divided over several sessions if the tumor is of large size. There is no need 
 of hesitation in operating during pregnancy, for the traumatism is unimpor- 
 tant, and it is very necessary that the genital canal should present no source 
 of infection at the moment of parturition. Zweifel has described a case in 
 his practice in which fatal suppuration in the pelvis took its origin from con- 
 dylomata of the vulva, causing infection of a laceration of the vagina which 
 had occurred during labor. 
 
 Elephantiasis Arabum (which must not be confounded with elephan- 
 tiasis Graecorum) is caused by hyperplasia of the skin and subcutaneous cel- 
 lular tissue. It is most common on the lower 
 extremity (ninety-five per cent) and takes its 
 name from the resulting resemblance to the 
 foot of the elephant. It is also seen in men 
 involving the penis and scrotum, and in 
 women upon the labia and clitoris. It is a 
 rare affection in our climate. 
 
 Pathology. — The largely hypertrophied 
 labia majora form voluminous masses which 
 may exceed the dimensions of the adult 
 head and the weight of 10 kgm, (41^ lb.). 
 Their base is often broad, but at other times 
 there is a pedicle and the tumor takes on 
 the appearance which the older writers de- 
 scribed as molluscum pendulosum — a clini- 
 cal term which comprehends all forms of 
 tumor of the integument, whether elephant- 
 iasis, lipoma, fibroma, or myxoma. Many 
 of the cases published as elephantiasis with 
 a normal skin seem to me explicable by this 
 confusion. 
 
 According to Cornil and Ranvier, there 
 are histologically three principal forms of elephantiasis of the vulva : 
 
 1. In the first the entire derma is hypertrophied and returns to the em- 
 bryonic condition. In the midst of this transformed tissue there are vast 
 dilatations of the lymph spaces, comparable to those which are found in 
 lymphangioma. 
 
 2. In the second form, which often succeeds to repeated oedema, the en- 
 gorgement of the tissue extends over a large area, there is a stagnation of the 
 lymph in the capillaries, larger trunks, and lacunas of the lymph system ; and 
 particularly in this variety the ganglia become the seat of fibrous alteration. 
 
 3. The third variety is chiefly remarkable for the enormous increase in 
 the thickness of the derma. There is an abundant proliferation of all the 
 elements of the derma, involving the connective tissue, the elastic fibres, and 
 the smooth muscular cells, and, as in the other two forms, the lymph spaces 
 
 Fig. 557. — Elephantiasis of the Vulva. 
 
844 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 are notably dilated. The obliteration of the lymphatics by proliferation of 
 the endothelium has also been described. Certain pathologists have consid- 
 ered that the stagnation of the lymph, and its great abundance, play an im- 
 portant part in the pathogeny of the affection, as if it caused hypertrophy of 
 the elements which it bathed. However that may be, there is no doubt that, 
 in whatever form we consider it, the constant and predominant lesion is a 
 wide dilatation of the lymph-vessels. 
 
 Symptoms. — The principal symptom is the tumefaction, which may reach' 
 
 Fig. 558. — MoLLUSCCM of the Vulva. Section perpendicular to surface of tumor, i, Thickened superficial 
 corneous layer ; 2, layer of flattened granular cells ; 3. Malpighian layer ; 4, deep pigmented layer; 5, connective tissue 
 in wavy bundles ; 6, centre of development of embryonal cells near vessels ; 7, blood-vessels ; 8, lymphatics. 
 
 such a degree that both walking and urination are interfered with. Ulcera- 
 tion may also be produced by friction, but the ulcers have a natural tendency 
 to heal. The thickening of the tissues may invade the entire vulvar, peri- 
 neal, and anal regions, and form enormous tumors, but usually without pain. 
 Amenorrhoea is often observed. 
 
 The elephantiasis is called glabrous when the skin is smooth, verrucous 
 when it is covered with warty projections, papillomatous when the papillae 
 are very much hypertrophied, hard when its consistence is firm, and soft 
 when it yields to pressure, leaving an indentation as in oedema. 
 
 Diagnosis. — There are no great difficulties in determining the nature of 
 the affection; the hypertrophic tumefaction of lupus always accompanies 
 
TUMORS OF THE VULVA. 
 
 84s 
 
 ulceration, and is confined within very narrow limits. Papillary vegetations 
 are situated on the skin, while the thickening of elephantiasis involves also 
 the framework of the derma. Pedicled fibromata and myxomata, which are 
 sometimes called elephantiasis by an abuse of language, are always isolated 
 and circumscribed tumors, while elephantiasis is essentially diffuse. 
 
 Etiology. — This affection is very rare in our climate, but is common in. 
 
 Fig. 5sg.— Molluscum of the Vulva. Section of pedicle. Injected specimen, i, Superficial corneous layer; 
 2, layer of Malpighi ; 3, deep layer of pigmented cylindrical cells ; 4, dense^fibrous tissue ; 5, transverse section of large 
 injected vessel ; 6, branching capillaries ; 7, sebaceous gland whose cavity is filled with desquamated epithelium ; 8, 
 isolated sebaceous lobules ; g, lymphatic ; 10, transverse section of smooth muscular fibres. 
 
 the Antilles and particularly in Barbadoes. In these countries the period of 
 onset is often marked by acute lymphangitis and intense fever. Traumatism, 
 has been observed in some cases. 
 
 Treatment. — The only rational treatment is ablation with the bistoury, 
 which I prefer to either ecraseur or thermo- or galvano-cautery. Care must 
 be taken to have the wound unite by first intention, as suppuration would 
 here be peculiarly dangerous, on account of the number of the lymphatics 
 and their great dilatation. 
 
 ¥iBV.OMA.—Fibromyoina — Myxoma. — These tumors ordinarily occwr in 
 the labium majus, although they may be found in the nymphae or the peri- 
 neum. They are made up of fibrous tissue alone or in varying proportions 
 with smooth muscular fibres or myxomatous tissue. They are at times of a 
 
846 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 soft consistence, forming when they are large one of the varieties of mollus- 
 cum pendulum, or what has recently been described as molluscum simplex. 
 
 These tumors are benign and of slow course ; they may be enucleated or 
 their pedicles may be cut, without danger of hemorrhage. 
 
 Lipoma. — Lipoma of the vulva arises in the fatty tissue of the mons 
 veneris, and may reach such a development that it appears more like elephan- 
 tiasis. Stiegele operated on one which weighed ten pounds ; in one of Brunt- 
 zel's cases the tumor increased greatly in size during pregnancy. 
 
 On section of the tumor, it is seen to be made up of lobuli, traversed by 
 strong bands of fibrous tissue. The tumor is easily extirpated. 
 
 ExcHONDROMA. — Enchondroma of the vulvar region is a pathological 
 curiosity. Cartilaginous tumors of the clitoris have been seen as large as 
 the fist, furnished with a pedicle and presenting portions which were calci- 
 fied. A case of pretended ossification of the clitoris reported by Beigel is 
 of this class, and also the curious case of Bartholin, so often cited, of the 
 Venetian courtesan who wounded her paramours with her ossified clitoris. 
 
 Neuroma. — I have found only two cases of this tumor in medical liter- 
 ature. One was a case of Simpson's, where there was a painful nodule near 
 the urinary meatus ; the other is reported by Kennedy, where there were 
 tubercles which could be appreciated by touch, but could not be seen by a 
 magnifying glass ; this latter case is not indisputable. 
 
 Cysts of the Vulva. — I will describe the cysts of Bartholin's glands, 
 which are the most frequent tumors of this class, in a later section. 
 
 Besides those of Bartholin's glands, cysts occur in other ways on different 
 portions of the vulva. 
 
 A. /;/ tJie Labia Majara. — Superficially, sebaceous cysts are found ; 
 Winckel operated on one which was of the size of an &gg. 
 
 More deeply, serous cysts occur, which according to many authors are 
 encysted hydrocele of the round ligament, and which Duplay declares to be 
 almost always sacculated cysts developed in the sac of an old hernia. Blood 
 cysts have also been observed in the greater labia, which by their position 
 at the upper portion of the fold are very distinct from cysts of Bartholin's 
 glands, of which I shall speak later. They are due, according to Koppe, to 
 haematocele in the interior of the terminal portion of the round ligament. 
 Weber has demonstrated that in the embryo this cord is hollow, and that the 
 cavity may persist abnormally in later life. Other authors consider the 
 cysts, like serous collections, as always originating in the sac of an old hernia 
 (see chapter on Tumors of the Round Ligament). In this region also cysts 
 have been observed whose origin is very obscure ; in structure they resemble 
 ovarian cysts, and the opinion has been advanced by Klob that they develop 
 about the seat of a thrombus or else by dilatation of lymph-vessels. Lastly, 
 there arc many cases in which the cyst contains epidermic structures, hair, 
 teeth, etc. — the so-called dermoid cyst. 
 
 B. In the Vestibule. — Between the meatus and the clitoris small cysts 
 
TUMORS OF THE VULVA. 847 
 
 have been seen of the vohime of a bean, containing a yellow or greenish 
 fluid, and invested with a layer of cylindrical epithelium ; they probably 
 come from the sebaceous glands. 
 
 C. /;/ the Urinary Meatus. — Kocks has described a cul-de-sac which cor- 
 responds to the terminal vestige of Gartner's duct; the small cysts which 
 are encountered in this situation may be derived from this structure. On 
 the other hand, Skene has found and described two glands between the 
 mucous membrane and the muscular layer of the urethra whose excretory duct 
 measures from 2 to 3 cm., and admits a No. i bougie and opens near the 
 meatus ; but whether a cyst may be formed in these glands is a question 
 which needs further observation in order to decide it. 
 
 D. In the Jiymcn, congenital cysts have been observed by Winckel which 
 are of very small size and contain the products of disintegration of the pave- 
 ment epithelial cells. Doderlein considers that they are due to the fusion 
 of the two layers of the hymen, and has seen them in the process of forma- 
 tion, resembling a similar cystic development in the vagina. 
 
 Vascular Tumors of the Urinary Meatus. — As I have endeavored 
 to demonstrate, the hymen is not an isolated structure, but only the greater 
 portion of a hymeneal apparatus which comprises : 
 
 1. The masculine frgenum vestibuli. 
 
 2. The ring inclosing the urinary meatus. 
 
 3. The hymen. If the meatus of a young girl is closely examined by 
 drawing the hymen downward, the upward prolongation of this membrane is 
 clearly seen to surround the external orifice of the urethra by a ring, which 
 forms the superior portion of a figure of eight, of which the hymen forms 
 the inferior and far larger part ; this upper ring is surmounted by a thin ver- 
 tical band, the masculine fr?snum, which starts from the meatus and loses 
 itself in the upper third of the vestibule. This arrangement of the urethra 
 in some women forms a decided projection, upon whose lower portion we 
 may see a small tongue which lies detached within the urethra like a uvula. 
 This appendage to the hymen is at times so distinct that it might be called 
 a urethral hymen. Like the same structure in the vagina, it may be a con- 
 tinuous membrane, and cause imperforate urethra, or it may present an erec- 
 tile structure which corresponds to its homology with the corpus spongiosum 
 of the penis, of which the hymen represents the undeveloped matrix tissue, 
 the fibro-elastic framework which has not become erectile. These consider- 
 ations throw a certain light on the pathogeny of vascular tumors of the ure- 
 thra and meatus. 
 
 Pathology. — First described by Morgagni and noted by Boyer and other 
 authors, these tumors, which are for th^ most part pediculated and polypoid, 
 have been for the first time made the subject of histological examination by 
 G. Simon and Verneuil. The latter author has given them the name of 
 papillary polyps and lays great stress upon their vascularitv- To these 
 tumors the term urethral hemorrhoids has been applied, and Wedl compares 
 
848 CLI>;iCAL AND OPERATIVE GYNECOLOGY. 
 
 the vessels of the pathological tissue to the vasa vorticosa of the choroid. 
 According to Virchow, the difference between these tumors and ordinary 
 telangiectasis consists in the fact that the vessels are not dilated nor are 
 their walls thickened. Jondeau found, in two tumors of this class which he 
 examined, connective tissue of the adult type mingled with elastic fibres, 
 and between the trabeculae were dilated vessels, which had preserved their 
 normal walls, and which formed by their frequent union veritable lacunae. 
 A section following the axis of the tumor divided nearly all these vessels 
 obliquely, and some of them longitudinally, which demonstrated their gen- 
 eral direction parallel to the axis of the pedicle. More deeply there suc- 
 ceeded to the adult connective tissue an embryonic tissue characterized by 
 fine connective bands and fibres ; here also and up to the periphery of the 
 tumor there were dilated vessels, though of less volume, and not provided 
 with a distinct wall. All about the circumference of the tumor there were 
 hypertrophied papillse covered with pavement epithelium, and apparently sec- 
 ondary or accessory in their formation. In other words, the condition was 
 that of an erectile tissue which in the male is normal, but of which the 
 female is deprived ; efforts of micturition had without doubt contributed to 
 the development of the pedicle. 
 
 There are other cases in which the tumor is formed more by the prolapse 
 of the mucous membrane than by a definite polyp. I do not think that this 
 prolapse is essentially different from the mode of origin of polypi, for they 
 always coincide with a marked increase in the vascularity of the part; it is 
 more a question of degrees, but the general relaxation of the mucous mem- 
 brane due to idiosyncrasy or constitutional weakness plays here an important 
 part. 
 
 Etiology. — This affection is frequently met in little children ; Larcher 
 and Dollez have collected a number of such cases, and Benicke and Ruge 
 have observed it in patients of the age of seven to eleven years. But it is 
 toward the period of middle life that these lesions are most commonly seen, 
 though they may also be encountered in the aged; one of Trelat's patients 
 was seventy-five years old. All the causes of local irritation of the meatus, 
 or of congestion of the pelvic organs, or of inflammation of the urinary pas- 
 sages in adults, and debility or cachexia in children favor the production of 
 these lesions. 
 
 Symptoms. — To bring these tumors well into view, the nymphae must be 
 separated and pressure made on the urethra by a finger in the vagina so that 
 the small tumor which is hidden within the urethra will spring forward out 
 of the meatus. Their size is variable, being as small as a pin's head or as 
 large as a nut. I have removed one from an old woman which had the ap- 
 pearance and volume of a raspberry. It is possible that the entire circum- 
 ference of the meatus projects in a circular prolapse, like the condition of 
 the rectal mucous membrane which is sometimes seen in hemorrhoids. 
 
 The most frequent seat of the tumor is in the lower portion of the meatus,. 
 
TUMORS OF THE VULVA. 849 
 
 where is found the uvula which I have described as normal in some cases, 
 and its insertion is apt to be broad; but it may be pediclcd or constricted 
 at the base. The color of these tumors is often violet or wine color, and 
 pressure turns them pale and also diminishes their volume. The surface is 
 smooth, easily torn, and bleeds with great freedom. General prolapse forms 
 a cylindrical tumor, which occupies the normal place of the meatus and pre- 
 sents at its end an opening which is at times difficult to discover; it is sel- 
 dom reducible. These tumors cause pain spontaneously and at the moment 
 of urination or coitus, and they may be the origin of vaginismus ; there are 
 also occasionally crises of dysuria and retention by reflex action. 
 
 Diagnosis. — The painful nature of the complaint, in the absence of a 
 local examination, would suggest either cystitis, vaginismus, or metritis. 
 From the character of the tumor it is impossible to mistake it for epithe- 
 lioma. Prolapse of the urethral membrane is not an essentially distinct 
 lesion ; it is the diffuse and less vascular form of the tumor whose circum- 
 scribed type is the polyp. 
 
 Treatment. — When the tumor is well pedicled, its base may be ligated 
 with an elastic band, and its mortification thus produced. But the simplest 
 and least painful treatment is excision, with cauterization, after applying 
 cocaine. When the thermo-cautery is employed, there is no need of fearing 
 hemorrhage, which may be annoying if a cutting instrument is used. The 
 meatus will not be abnormally contracted if we do not cauterize the entire 
 circumference of its orifice, which is unnecessary even when the prolapse of 
 the membrane occupies the whole of the opening. The ablation of two seg- 
 ments and their cauterization is sufficient even in the latter case ; hemor- 
 rhage is easily controlled by a catgut suture. 
 
 Cancer of the Vulva. Pathology. — Primitive cancer of the vulva is 
 rare, especially as compared with the same affection of the uterus. In 7,479 
 women who suffered with cancer, Gurtl found 72 cases of cancer of the vulva, 
 about I per cent ; this proportion seems too large, for it is probable that 
 many of these cancers were secondary. Wassermann has recently collected 
 24 cases of cancer of the urethra in women. 
 
 Cancer of the external genitals in the female presents many histological 
 and anatomical forms. Histologically there may be epithelioma, either 
 pavement or tubular, or sarcoma with its variety melano-sarcoma. Topo- 
 graphically there are two types, according as the neoplasm is developed in 
 the clitoris or nymphae, forming the variety known as cancer of the vesti- 
 bule, or is situated about the urethra, infiltrating its tissues and giving rise 
 to the peri-urethral variety. 
 
 Epithelioma presents no peculiar features histologically, and I refer to 
 the chapter on Cancer of the Uterus for its description. It usually starts 
 from the groove which separates the smaller from the greater labium ; less 
 often from the clitoris and meatus, under the form of nodules which are 
 covered by thick layers of epithelium ; these scales are of older date than 
 54 
 
850 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 the cancer, and are the result of psoriasis of the part which has favored the 
 development of the epithelioma. L. Mayer has reported several cases, and 
 since then others have been observed. Later in the course of the disease 
 the nodules ulcerate and invade the adjacent parts, but there is no tendency 
 to involve the vagina except in the case of cancer starting at the urinary 
 meatus, which may be propagated along this canal and so attack the anterior 
 vaginal wall ; the inguinal ganglia are rapidly engorged. 
 
 Sarcoma of the vulva may exist in the simple form, or as myxo-sarcoma, 
 but it is more common to find it as melano-sarcoma. In a case reported by 
 Taylor, the small fusiform cells were filled with a brownish pigment; in 
 one of Terrillon's, the cells were round and pigmented, and both in the blood 
 and in the urine there were dark granules to be discovered. 
 
 Etiology. — Cancer of the vulva is most frequent from forty to sixt}' years 
 of age, but it has been observed much earlier. St. Germain operated on a 
 patient at the age of five, and Arnott reports one of twenty ; on the other 
 hand, there are many cases known in the very old. 
 
 I have already mentioned the predisposing influence of psoriasis. Hutch- 
 inson asserts that the lesions of a former syphilis have a positive etiological 
 value, but this does not appear probable. 
 
 Symptoms. — The cancerous nodules may pass unnoticed for a long time, 
 the only symptom being pruritus vulvas, wihch is very severe, in some cases 
 presenting crises when it torments the patient, interspersed with periods of 
 calm. When the tumor becomes excoriated, there is a discharge of serous 
 or bloody fluid with a fetid odor. The neoplasm at first resembles a wart of 
 the size of a nut and is hard, mammillated, sessile, or furnished with a small 
 pedicle. When the nodules become multiplied and confluent, the whole re- 
 gion takes on a wooden consistence, as in the case of scirrhous cancer of the 
 breast ; the vaginal orifice is contracted, and in the peri-urethral form the 
 meatus is partly obliterated. By vaginal touch, the urethra is felt as a hard 
 cylinder. The ulceration has uneven borders covered with scales and crusts 
 from the concretions of the discharge, and the adjacent skin is infiltrated 
 and hard from oedema, presenting the appearance and consistence of orange 
 peel ; the pubic hair may fall out completely, and thus the vulva becomes 
 entirely smooth. The secretion is serous or purulent ; hemorrhage is rare. 
 The ganglia of the groin rapidly swell and show all the signs of cancerous 
 infection ; from here the disease may become general, and death is hastened 
 by some complication, as phlebitis or pleurisy. The vagina the rectum, and 
 the bladder are finally involved, and the pain caused by inflammation of 
 these parts is then very severe. 
 
 Course and Progress. — The latent period of simple pruritus may be quite 
 long but as soon as the ulceration is established the various accidents suc- 
 ceed each other very rapidly ; in melano-sarcoma the course is a little slower. 
 In general, death occurs by the end of the second or third year. Cases 
 in which the patient has lived from ten to twenty years are of doubtful diag- 
 
TUMORS OF THE VULVA. 85 I 
 
 nosis. Cornil has reported a case in which the tumor was a tubular epithe- 
 lioma and a portion of it was eliminated, and the loss of tissue restored 
 by a cicatrix. 
 
 Diagnosis. — Papillary vegetations of the vulva do not resemble cancer in 
 the least, and in the case of polyp of the meatus the absence of ulceration 
 would be a certain criterion. 
 
 Chancre occurs as a superficial ulceration or as an eroded and slightly 
 projecting papule with very little discharge; and the early swelling of the 
 ganglia in the characteristic form, together with other specific manifesta- 
 tions, will render the diagnosis clear. 
 
 Syphilitic papulo-erosions are multiple, flattened, and form a kind of 
 rounded plateau looking like a small pastil placed upon the skin and varying 
 in size from that of a pea to that of a franc piece ; the surface is denuded, 
 moist, and secreting like a blistered part ; and under the influence of local 
 and general treatment they disappear rapidly — a circumstance which may be 
 used to distinguish them in doubtful cases. 
 
 When the papules are confluent, they may form plates of from 6 to 8 
 cm. in diameter, covering the whole vulvar region and encroaching upon 
 the perineum. At first sight this lesion appears like that of total infiltration 
 of the derma with cancerous process as in the so-called " cancer en curiasse," 
 but attentive examination will quickly demonstrate the peculiar characters of 
 the syphilitic papule. The enormous vegetations of hypertrophic papular 
 syphilide (Fournier) have a malignant appearance only to the inexperienced. 
 
 Chancroid has an acute course without induration, is surrounded by 
 healthy skin, and the ulceration is made up of many little sores in various 
 degrees of development; for, according to the picturesque expression of 
 Ricord, "the soft chancre lives with its family, surrounded by offspring." 
 
 Lupus presents the double characters of ulceration and hypertrophy, the 
 latter often being the more prominent. This affection is also of an uncer- 
 tain course with alternate destruction and repair, the edges of the ulceration 
 being marked by cicatrices and bridles. Its contour, moreover, is sinuous : 
 it is disposed on different levels with a tendency to invade the perineum and 
 groin, and often at the bottom of the fissures a red, pink, or yellow base can 
 be seen covered with cicatricial cuticle. Nothing like this is to be observed 
 in cancer, whose course is continuous and destructive, and the ganglia, which 
 are not involved in lupus, are here rapidly invaded. 
 
 Treatment. — Complete extirpation of the diseased part is the only means 
 of arresting its course, and this ablation it has been advised to make with 
 the thermo-cautery to avoid hemorrhage ; but by proceeding rapidly with the 
 bistoury and the scissors the loss of blood is very small, and we obtain a 
 wound which will unite by first intention when sutured. In one case I thus 
 procured primary union over a large surface after dissecting off a cancer 
 which had destroyed the vestibule and the greater portion of the nympha^. 
 Especial care must be taken to restore the meatus by exact apposition of the 
 
852 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 mucous membrane. Where the cancer is peri-urethral a sound introduced 
 into the bladder will assist in the dissection, and it may be necessary to fol- 
 low the neoplasm up to the neck of that organ. If the inguinal ganglia are 
 im-olved, they should also be extirpated, but we are not able to postpone the 
 recurrence of the disease for a very long time. Where ablation would ex- 
 pose too large a surface, we must have recourse to palliative measures. The 
 symptoms which especially disturb the patient should be attacked, such as 
 the ichorous discharge, the fetid odor, and the irritation of adjacent parts. 
 P'requent application of antiseptic fluid should be made, and iodoform gauze 
 packed into the ulcerations and frequently renewed. Borated vaselin should 
 be applied to the groin and the inner surface of the thighs to prevent the 
 erythema which is caused by the irritating leucorrhoea. In certain cases we 
 may employ the method proposed by Kraske, who suggested covering" the 
 ulcerated surface with healthy skin, to render the course of the disease 
 slower and the symptoms less painful. For this purpose the part to be 
 treated should be first scraped carefully, and then the flaps of healthy skin 
 swung over and applied to the denuded surface. 
 
 [Tumors of the Clitoris are extremely rare. They may be the result 
 of simple hypertrophy, elephantiasis, or other benign growths, or of malig- 
 nant degeneration. The study of their pathology and histology is very in- 
 complete. In most of the cases noted the growth has followed syphilitic 
 infection or eczematous or other chronic inflammatory conditions of the ad- 
 jacent tissues. The tumors are often accompanied by warty excrescences 
 and vegetations, are usually pedunculated, are accompanied by singularly 
 insignificant symptoms, and, except where carcinomatous, seldom recur after 
 removal by surgical measures. Peckham has observed a cyst of the clitoris 
 containing about 60 gm. of a chocolate-colored liquid.] 
 
CHAPTER XLIII. 
 
 INFLAMMATION AND CYSTS OF BARTHOLIN'S GLANDS. 
 
 Etiology and PatJiogeny. — The glands of Bartholin, which Huguier pro- 
 posed to call the vulvo-vaginal, have also been termed Duverney's or Cow- 
 per's glands, and the latter name has the advantage of suggesting their anal- 
 ogy with similar structures in the male. They are of the size of a bean and 
 are situated deeply on the internal aspect of the labium majus, where they 
 may be felt in a thin patient. The excretory duct is about 2 cm. in 
 length and opens immediately in front of the hymen near the middle of the 
 side of the vulva, and it admits the point of a Pravaz syringe. 
 
 The pathology of these glands may be almost said to have been created 
 by Huguier. Since his time but little has been added to the descriptions 
 which he gave, but we have learned that nearly all the lesions of the part, 
 whether cysts or inflammation, are due to one great cause, namely, gonor- 
 rhoea. Breton was the first to demonstrate that this malady might remain 
 for a long time dormant in the excretory duct of the gland after the vagina 
 was free from it, and, starting from this point, renew its infection; Zeissl 
 confirmed these statements. Suppuration of the duct is the rule in vaginitis, 
 as is easily seen by pressing on the part after carefully cleaning it and thus 
 obtaining a drop of pus from the opening of the gland, which is surrounded 
 by a purple-red areola, which resembles a flea-bite and has been called the 
 gonorrhoeal macule by Sanger. To cure this inflammation, the duct should 
 be opened with a Weber knife, such as is used in division of the lachrymal 
 puncta, following it with the nitrate of silver crayon or a weak solution of 
 chloride of zinc (i : 50). 
 
 The intense infection which is propagated to the entire gland or some of 
 its acini causes abscess ; the obliteration or constriction of the duct produces 
 cysts, among which are distinguished, arbitrarily and without anatomical 
 proof, cyst of the duct, which is superficial, small, and transparent, and cysts 
 of the gland. These expressions are no more justifiable than that of abscess 
 of the duct applied to simple suppuration of the canal, which I have mentioned 
 as the initial lesion in this group. 
 
 Cysts. — Symptoms. — The cyst may be single or multilocular ; that is, 
 formed at the expense of the whole gland or of one of its lobules, the rest 
 being pushed aside. Its form is ovoid and its surface smooth; it is seldom 
 transparent. Its contents are viscous, colorless or yellow, or at times mixed 
 with blood and of a chocolate hue ; in size it may vary from a nut to an q.^%. 
 The tumor is usually unilateral, and on the left side elongated in the axis of 
 
854 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Fig. 560. — Cyst of Bartholin's Gland. 
 A sound has been passed into the urethra. 
 
 the greater lip, whose posterior portion it occupies nearer to the mucous than 
 the cutaneous surface ; on pressure it is elastic and compressible rather than 
 fluctuating. 
 
 Cysts cause some discomfort in walking, but more in coitus, and they 
 have a tendency to inflame and suppurate. 
 
 Since the time of Huguier all authors have distinguished two varieties 
 
 — those of the duct and those of the gland 
 proper. In the absence of any demonstrative 
 dissection we ignore a distinction which re- 
 fers to different parts of the gland in the 
 production of the cyst, but clinically we know 
 that there are two distinct types of the affec- 
 tion. 
 
 In the case of so-called cyst of the duct, 
 which might better be termed the superficial 
 variety, the tumor is generally very small, of 
 the size of a nut, situated on the base of the 
 labium minus, which it stretches out, making 
 a projection in the vagina, and apparently 
 placed directly under its mucous membrane, 
 which glides freely over it ; sometimes the 
 tumor is transparent. The opening of the 
 duct in certain cases remains pervious, and a small stylet may be introduced 
 or pressure may force out a little viscous fluid ; it seems then that the 
 alteration in the consistence of the excretion plays here the double role of 
 temporarily obstructing the duct, and also of contracting it and thus pro- 
 ducing the cyst. 
 
 In the case of cyst of the gland itself, which I prefer to call deep cyst, 
 the tumor is large and is situated behind the labium majus, between the en- 
 trance of the vagina and the ascending ramus of the ischium, elevating both 
 labia. The duct is not permeable, and the fluid contained is often discol- 
 ored by old extravasation. The case reported by Hoening, where the tumor 
 reached into the pelvis, appears to me to belong to cysts of the vagina rather 
 than to those of the labium majus; it was undoubtedly of Wolffian origin, 
 and, being developed at the entrance of the vulva, it projected into the 
 greater labium. 
 
 Diagnosis. — Reducible tumors should be first eliminated, and we should 
 determine whether we have a solid or a fluid swelling to deal with. Fluctu- 
 ation and transparence are not sufficient to indicate the nature of the affec- 
 tion certainly, as in case of similar collections in the scrotum. Transpar- 
 ence is usually absent in deep cysts of the labium majus, and fluctuation 
 may also be lacking if the tumor is very tense; or the partial softening of a 
 solid tumor, as, for instance, a fibroma, may simulate it. In doubtful cases, 
 puncture with the aspirating needle will decide the question if we are un- 
 
INFLAMMATION AND CYSTS OF BARTHOLIN'S GLANDS. 855 
 
 willing to wait till the moment of exploratory incision, which constitutes the 
 first step of the extirpation in any case. After ascertaining that the tumor 
 is licjuid, we should then determine its exact situation. Hydrocele in the 
 female, or cyst of the labium majus apart from the vulvo-vaginal gland, which 
 has given rise to so much theoretic discussion, occupies the upper part of the 
 labium ; fluid collections, which may be either blood or serum, are reducible 
 from the clinical standpoint to a few varieties, whose brief description will 
 suffice to make clear the diagnosis (see the chapter on Tumors of the Round 
 Ligament). 
 
 1. Small cysts of the size of an almond which enter and emerge from the 
 more or less dilated inguinal canal, or even retire within the abdominal cav- 
 ity under gentle pressure and come out as readily; sacculated cysts of old 
 hernial sacs which have become obliterated and filled with fluid. 
 
 2. More voluminous cysts, not reducible, situated in the upper part of 
 the labium majus, containing serum or a brownish fluid mixed with blood, 
 which has given them the name of haematocele ; at times furnished with a 
 pedicle, which is continued into the inguinal canal. According to some 
 authors, these are hydroceles of the canal of Nuck or cysts arising in the 
 thickness of the round ligament, or sacculated cysts of old hernial sacs. 
 
 3. Occasionally a cyst may develop in front of a hernia which is retained 
 by a truss, from the friction, but this clinical curiosity has nothing in com- 
 mon with the subject under discussion. 
 
 There remain the solid tumors, and among them the irreducible epiplo- 
 celes, whose pasty consistence and lobulated form are easily recognized. The 
 best sign is furnished by the presence of a pedicle, which may be felt by 
 drawing down the tumor as much as possible, and palpating at the external 
 ring. If there is no sign of a connection at this point between the tumor 
 and the contents of the abdomen, the case is not one of hernia ; and the diag- 
 nosis will be confirmed if the impulse of coughing can be felt at the ring but 
 not in the tumor. As to reducible enterocele, it is very rare in this region, 
 and its sonorous percussion note is characteristic. A difficulty in diagnosis 
 may be caused by the presence of fluid in the sac ; and when there are both 
 a hernia and a tumor of the labium majus in the same case, the diagnosis 
 beomes enormously complicated. Ovarian hernia into the labium majus has 
 been seen, although it is usually arrested at the level of the ring ; the gland 
 preserves its usual form and sensibility, and pressure on the anterior face of 
 the uterus causes a retraction of the tumor ; but if there is a layer of fluid 
 about an ovary which is atrophied and pressed against the wall of the sac, 
 the case is very obscure. 
 
 Several cases of primary cancer of the glands of Bartholin have been 
 observed, but they are very rare. Extension to adjoining parts will rapidly 
 put one on the right path in regard to diagnosis. 
 
 Treatmerit. — If the contents of the sac are merely emptied, they reappear 
 very quickly, and consequently the cyst cavity should be modified in some 
 
856 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 way, for which purpose a number of methods have been proposed. The in- 
 jection of from ten to twelve drops of chloride of zinc solution (i : 10) with 
 a Pravaz syringe, after aspiration of a quantity of the fluid equal to the 
 amount injected, has been successful, but the inflammation thus produced 
 may be so extreme as to cause suppuration. Free incision followed by tam- 
 poning with iodoform gauze until the cyst wall exfoliates is a very sure 
 method, but also very long. Extirpation of the cyst with immediate suture 
 of the wound is to be preferred. To facilitate the dissection, which is ren- 
 dered very difficult as soon as the cyst is opened, I apply to the operation 
 my procedure of injecting spermaceti. The cyst is first punctured with a 
 trocar as in the case of hydrocele, washed with hot water, and the melted 
 paraffin introduced at a low temperature. When the cavity is distended ice 
 is applied, and at the end of a few minutes we obtain a mass which is very 
 easily extirpated with the anaesthesia of the cold and cocaine if necessary. 
 
 Abscess. — Symptoms. — Suppuration of Bartholin's glands may supervene 
 after inflammation of a cyst or originate de novo. The swelling and periph- 
 eral oedema are considerable and extend over the posterior portion of the 
 vulva or even to the anus ; the pain is acute, lancinating, and there is al- 
 ways a certain degree of fever and at times retention of urine. The fluc- 
 tuation is apparent first on the inner surface of the labium majus, and the 
 purulent matter is voided by one or many openings situated below the orifice 
 of the duct. The pus is abundant and fetid as is usual in the neighborhood 
 of the natural canals, and the presence of the gonococcus may often be de- 
 termined. The fistulse persist for a long time after the inflammation has 
 disappeared, communicating with distinct foci which correspond to the dif- 
 ferent lobules of the gland. But more often the whole of the gland and the 
 adjacent tissues are involved by the suppuration, and the many fistulse which 
 result open into a common cavity. Exceptionally they open on the perineum 
 or into the rectum, giving rise to recto-vulvar fistulae. If the integument has 
 been destroyed, there is a vast ulcerating surface of the inner aspect of the 
 labium. 
 
 To the acute form the chronic may succeed ; it is clinically distinct from 
 the other, and has been well described by Hamonic and Fauvel as an obsti- 
 nate seat of gonorrhoea. Huguier has applied the term of purulent hyperse- 
 cretion to this condition. There are no signs of inflammation, no tumor, but 
 only a simple hypertrophic induration of the gland, whose duct gives vent 
 on pressure to a milky or greenish pus, which also escapes spontaneously by 
 the fistulous openings. It is the last refuge of the gonorrhoeal inflammation, 
 a frequent and unsuspected source of infection for the man, and capable of 
 lighting up anew an ascending specific inflammation of the genital canal of 
 the woman after labor or abortion. 
 
 Diagnosis. — A fecal abscess from the margin of the anus and extending 
 to the posterior part of the labium majus may be distinguished by the greater 
 disturbance on the part of the rectum and the wider diffusion of the inflam- 
 
INFLAMMATION AND CYSTS OF BARTHOLIN'S GLANDS. 857 
 
 mation. Phlegmon of the labium majus, which is often of angioleucitic ori- 
 gin, is situated usually on the external and cutaneous surface of the part, 
 while abscess of the vulvo-vaginal gland occupies the internal and mucous 
 surface. Furuncles are found in the skin and present a special appearance 
 and evolution. Ulceration of a part of the wall of a purulent focus must 
 not be confounded wdth soft chancre; merely mentioning it is enough to 
 prevent the error. 
 
 Treatjucnt. — Free incision of the cyst should be practised as soon as the 
 inflammation appears; the bistoury is plunged in at the junction of skin and 
 mucous surfaces within the free edge of the labium majus; care should be 
 taken, by making the opening large enough, that no cul-de-sac or pockets 
 are left ; drainage tubes are insufficient. It is good practice to extirpate the 
 gland when the first incision is made, excising all the internal surface of 
 the cavity with the curved scissors, washing the wound with strong carbolic 
 solution, and tamponing with iodoform gauze. If there are old fistulse from 
 the spontaneous evacuation of the cyst, the gland should be extirpated in the 
 same way, which is the only method of curing the interminable suppuration 
 of these fistulas, which close and open again continuously. The wound can 
 be closed immediately with catgut sutures buried on superposed planes. 
 
CHAPTER XLIV. 
 
 PRURITUS VULV/E— COCCYGODYNIA. 
 
 Pruritus VuLVyE. Definition. — The sensations of itching and heat which 
 accompany eruption of the vulva or the irritating leucorrhoea of vaginitis, 
 metritis, and cancer, and also, especially in children, symptoms of oxyuris, 
 constitute only a symptom and not a disease ; the characteristic of idiopathic 
 pruritus is the absence of every lesion which could explain the intolerable 
 itching which drives these patients to scratch and excoriate themselves. 
 
 Etiology. — In the absence of all apparent causes, certain authors have 
 supposed the existence of a central origin. 
 
 The arthritic diathesis, which G. de Mussey considered a cause and 
 whose influence is incontestable, produces no alteration of the derma which 
 can be determined clinically. 
 
 As there are many cases in which there is no lesion of any of the genital 
 organs, so there are also many in which the uterus or the ovaries are involved, 
 and seem to act by a sort of reflex on the vulva ; it is thus that vesical cal- 
 culus causes acute itching of the glans penis. 
 
 Diabetes is one of the most frequent causes of this affection, but it is 
 difficult to decide whether it acts by the local irritation of the abnormal 
 urine or by the central nervous system. Pregnancy also favors the appear- 
 ance of pruritus, especially at the end and at the beginning of the period, 
 when the congestion of the genital apparatus is most annoying. 
 
 Symptoms. — The itching sensation may be continuous or intermittent, 
 returning at certain hours, especially during the night, when the heat of the 
 bed aggravates it. Cases are also cited in which it appeared every two or three 
 days. Many women suffer from it at the menstrual periods, others only 
 when they are pregnant. The seat of the sensation is most often over a 
 large surface comprising the clitoris, the mons veneris, and the labia majora, 
 or the clitoris may alone be involved. The patient scratches, and the ex- 
 coriations thus produced become the source of new itching. Finally, the 
 friction of the parts leads to onanism (masturbation), and the profound ex- 
 citement of the nervous system results in serious disturbance of the general 
 health and the mental powers, leading to anaemia and lunacy. 
 
 Diagnosis. — Any local source of the irritation must be carefully sought, 
 and the uterus and its adnexa examined with thoroughness, as well as the 
 urinary system and the rectum, and the presence of diabetes should be 
 determined. 
 
PRURITUS VULV^ — COCCYGODYNIA. 859 
 
 The prognosis is variable according to the cause of the affection, the 
 most rebellious cases being those in which the cause is most obscure. 
 
 Treatment. — In the first place the patient must be freed from every con- 
 comitant malady. The general nutrition should be modified by appropriate 
 regimen when we have reason to think that she is arthritic or herpetic; 
 causing her to abstain from alcoholic drinks, spices, fish, and Crustacea, etc. ; 
 giving slightly alkaline beverages, frequent laxatives, prolonged baths, and 
 arsenic internally. If there is diabetes, the proper treatment should be 
 employed. 
 
 Locally, the eruption should be treated. Topical applications of various 
 kinds have been recommended for idiopathic pruritus; the best for the 
 pain and discomfort is cocaine solution [\ : 10). Light cauterization has 
 also been advised with nitrate of silver or strong carbolic solution ; chloro- 
 form water, white wash, Van Swieten's fluid, menthol, etc., have all been 
 tried. Internally, the antispasmodics have been administered, but espe- 
 cially bromide of potassium and cannabis indica. Schroder and Lohlein 
 have obtained success, the former in four cases, the latter in one case, by 
 the excision of small portions of skin where the pruritus was localized; on 
 histological examination Schroder was unable to find any change. 
 
 CoccYGODYXiA. — Definition. — Under this name has been described an 
 intense pain, situated at the coccyx, which appears only in women and is 
 often related to disease of the genitals. It was first described by Nott as 
 neuralgia of the coccyx; Simpson then published the first complete memoir 
 on the point, and gave the affection its present name ; Scanzoni also devoted 
 some attention to the subject. 
 
 Etiology. — In the majority of the typical cases there is no appreciable 
 lesion, and the disease seems to be simply a neuralgia. But in other cases 
 there is some affection of the uterus, such as metritis, deviation, prolapse of 
 the ovaries, etc., which does not explain the location or the intensity of the 
 pain, but which seems to be bound up with it in some way. In a third class 
 of cases there is some lesion of the coccyx itself or of its ligaments, which 
 may be the cause of extreme pain occasionally. Of this kind are the cases 
 in which there is abnormal mobility of the bone, due perhaps to torsion or 
 luxation during parturition, with anchylosis, abnormal length, or osteitis of 
 the part. 
 
 The influence of labor seems beyond doubt. Scanzoni in 34 cases 
 of his own which he collected found no case in which the woman had 
 not borne children ; in 9 cases the pain appeared during the labor, and 
 5 were delivered with forceps ; it is natural to suppose that the bone was 
 luxated in these cases. It is interesting to notice that Hyrtl found 34 
 cases in which there was some vestige of luxation, and subsequent anchy- 
 losis in 180 pelves which he examined for the purpose; we must then admit 
 that the lesion is both very frequent and not very painful. It evidently does 
 not constitute the only explanation of pain, for cases of coccygodynia are 
 
S6o CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 far more frequent than cases of luxation. Von Graefe observed 6 cases in 
 women who had had unusually easy labors, and attributes no importance to 
 luxation ; in 2 of these cases the pain appeared at the end of pregnancy, and 
 he thought that it was due to the pressure of the foetal head upon the termi- 
 nal portion of the sacral plexus, causing a neuritis. 
 
 Though the importance of coccygeal lesions may. be slight, it must, how- 
 ever, be admitted. In a young girl observed by Zweifel the pain followed 
 a fall which had probably fractured the bone ; it disappeared at the end of a 
 year. Scanzoni had two cases in which riding horseback was of some influence. 
 Zweifel and Courty have observed the affection in virgins, and Beigel in 
 children ; these latter cases are altogether exceptional. 
 
 Symptoms. — The capital symptom is pain limited to the coccyx and the 
 parts immediately adjacent. It is intense, is worse on pressure, on sitting, 
 in coitus, defecation, and all other efforts. Everything which jolts the part 
 increases the pain, which is at times so intense that Scanzoni compares it 
 with dental neuralgia. To assure one's self of the anatomical condition of the 
 coccyx, rectal touch may be practised, and the bone seized between the index 
 and thumb after local anaesthesia with cocaine. 
 
 Treatment. — The cure of concomitant disease, especially of retroflexion, 
 will often cure the pain also. To diminish the suffering, hypodermic in- 
 jection of cocaine may be employed (i cgm.). Morphine injections and 
 belladonna suppositories are also of benefit. 
 
 When there is no lesion of the bone. Von Graefe recommends faradiza- 
 tion, and has had good success with this means. He places one electrode on 
 the coccyx and the other on the sacrum, and increases the strength of the 
 current at each session, which vary in number from three to eight. The sur- 
 gical treatment is the only one in many cases which promises any assistance. 
 With the design of preventing movements of the bone, Simpson made a series 
 of subcutaneous sections of the muscles and tendons which isolated the bone 
 completely ; but this treatment is often unsuccessful. The best plan is to 
 have recourse to complete extirpation of the bone, first performed by Nott. 
 Many cases have thus been successfully treated which had resisted all other 
 therapeutic agents. It has yielded, in my hands, a complete and durable 
 cure of .a very rebellious case. 
 
CHAPTER XLV. 
 
 WOUNDS OF THE VULVA AND VAGINA. ATRESIA AND 
 STENOSIS. FOREIGN BODIES. 
 
 Wounds of the Vagina and Vulva. — Etiology.— ^lost frequently 
 lacerations of the vulva and vagina result from coitus or parturition; they 
 have also been observed after traumatism. 
 
 Coitus brutally performed at the first voluntary approach, or with vio- 
 ence, may lacerate the hymen, or even tear it off entirely ; at other times 
 the tear extends beyond the insertion of the membrane toward the nympha 
 or vestibule ; the vaginal wall is less often involved, but cases have been 
 published in which the posterior wall of this canal was ruptured by violence. 
 Sabin has reported a case in which the recto-vaginal septum was lacerated 
 from the vulva to the cul-de-sac of Douglas ; and Barnes mentions a speci- 
 men in the museum of St. George's Hospital in which the vaginal laceration 
 penetrated the peritoneum ; it had been produced by coitus with an aged 
 woman whose vagina was probably the seat of atrophic contraction. Breisky 
 cites a case, followed by cure, which may also be attributed to senile invo- 
 lution. 
 
 During parturition the hymen is often ruptured, for Budin observed it 
 thirteen times in seventy-five primiparas in whom it had been intact up to 
 the end of pregnancy ; and this rupture may extend to the perineum (see 
 the chapter on Laceration of the Perineum). The vagina has been torn 
 during labor by the forceps and the cephalotribe. 
 
 Surgical traumatism which may cause the rupture of the vagina may be : 
 violent manoeuvres to reduce an old inversion of the uterus, extraction of a 
 large fibroma, etc. The most frequent accidents observed are injuries by 
 the horns of animals, falls upon a pointed object, the rough introduction or 
 the long sojourn of foreign bodies. 
 
 Symptoms. — The seat of the laceration varies with the cause which has 
 produced it. 
 
 The hemorrhage, which is at times very serious in laceration of the hy- 
 men, may be attributed to the occasional presence of erectile tissue in the 
 membrane, which Henle has described. The laceration may extend to the 
 vestibule and the bleeding be so profuse as to threaten the life of the patient. 
 
 When Douglas' pouch has been opened, a loop of intestine mav escape ; 
 if not reduced, it becomes strangulated and gangrenous and leaves an ileo- 
 vaginal fistula when death is not the result of the accident. 
 
862 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 If the rectum or the bladder be opened, there may be a persistent fecal 
 or urinary fistula left. 
 
 The diagnosis raises important questions of a medico-legal bearing. 
 There is a tendency to attribute all lacerations of the vulva in young girls 
 to attempts at violent intercourse. Hofman and Maschka have shown that 
 simple manipulations may have the same effect, and have therefore advised 
 against a hasty decision, as there is frequently an attempt at blackmail con- 
 nected with the charge of attempted rape. 
 
 Prognosis. — The hemorrhage is dangerous only when the woman is de- 
 prived of all assistance. 
 
 The inflammatory and septic complications which may follow the 
 wound depend upon the care with which the injury is treated. It is worthy 
 of note, and difficult of explanation, that lacerations which opened the peri- 
 toneum have been cured in the pre-antiseptic era, and also more recently in 
 spite of the absence of all proper precaution against infection. On the 
 contrary, an insignificant wound, like the bite of a leech, if neglected, may 
 cause grave suppuration. Laceration of the vagina is especially serious dur- 
 ing labor when there is any source of infection in the canal, such as vegeta- 
 tions, gonorrhoea, etc. 
 
 Treatment. — When the vulva and vagina are abnormally narrow, a prophy- 
 lactic treatment should be begun during pregnancy. For the laceration 
 itself, the general rules for all traumatic lesions should be followed : arrest 
 of the bleeding by ligature, permanent f orcipressure, or haemostatic suture ; 
 closure of the wound after reduction of any viscera which have extruded by 
 the solution of continuity; antisepsis of the region. Loose tamponing of 
 the vagina with iodoform gauze should follow its suture, and gentle compres- 
 sion of the parts be maintained by a T-bandage. 
 
 Acquired Stenosis and Atresia. — Etiology. — In the great majority 
 of cases the contraction (stenosis) and obliteration (atresia) of the vagina or 
 vulva are the result of difficult labors. If the eschars produced involve the 
 whole extent of the wall, they may leave fistulae when they fall, either fecal 
 or urinary; if only a portion of the thickness of the wall has been destroyed, 
 the cicatrix which succeeds may undergo retraction, and often the parts in 
 contact unite by immicdiate secondary union. 
 
 It is possible that the cicatrix may be due to injury by a foreign body 
 which has violently penetrated the vagina and transfixed it, or by its long 
 sojourn has caused ulceration, as in the case of forgotten pessaries. Cauter- 
 ization for surgical purposes or to produce abortion, eschars due to gangrene 
 in an infectious disease, lupus of the vulva and syphilitic ulceration, suppura- 
 tion in the lower pelvis (phlegmonous dissecting peri-vaginitis) may all be 
 the causes of contraction by cicatrices. Vaginitis alone, both in children 
 and adults, may produce a fusion of the walls of the canal. 
 
 There is a rare cause which acts almost wholly on the upper portion of 
 the vagina in the neighborhood of the cervix, namely, senile atrophy. The 
 
STENOSIS AND ATRESIA. 863 
 
 canal contracts, becomes infundibuliform, and at the bottom of the cone thus 
 formed the atrophied cervix may be perceived with difficulty. It is at times 
 hard to distinguish these cases from those in which the contraction is the re- 
 sult of cicatrices or cancer. This contraction is seen only in women who 
 have not been accustomed to coitus ; I have seen one curious case. 
 
 Symptoms. — The cicatrices may occupy the entrance of the vagina when 
 they are the result of traumatism, or of gangrene in young children, but the 
 great majority of these adhesions and contractions are the effect of wounds 
 received during parturition, and hence their situation is deeper, actually in 
 the vagina. The disturbance which results is developed very slowly and at 
 times for a long while retarded by the constant dilatation of coitus ; a slight 
 degree of permeability suffices for the escape of the menstrual fluid and the 
 performance of coitus. It may thus happen that the patient has had a very 
 pronounced lesion without having her attention attracted to it. If, however, 
 the orifice is very narrow, there may be dysmenorrhaea of the variety which 
 is termed obstructive. 
 
 If the obliteration is complete (atresia), the menstrual blood accumulates 
 above the obstacle and distends the vagina in whole or in part, as well as the 
 uterus and the tubes (haemato-colpos, haematometra, hsemato-salpinx). (See 
 Retention Accidents following Atresia of the Genital Passages.) On the 
 contrary, accidental obstruction of the genital canal has occasionally pro- 
 duced amenorrhoea — a fortunate circumstance which prevents serious results. 
 
 The stenosis may present as an annular cicatrix forming a sort of dia- 
 phragm, whose projection acts as an obstacle to the escape of the uterine 
 secretions which accumulate above it. The ring is often incomplete, in the 
 form of a falciform band stretching across the external os, which it may 
 altogether conceal, so that it is inaccessible to the touch except through the 
 cicatricial membrane. 
 
 Certain deviations of the uterus seem to be due to this cause, as I have 
 frequently observed. At the same time there is almost always metritis, pro- 
 duced no doubt by the presence of an obstacle to the ordinary drainage of 
 the uterine cavity. The contraction may be so narrow that the orifice which 
 gives passage to the menstrual flow is discovered only with difficulty. 
 
 The treatment of the acquired atresias resembles that of the congenital ; 
 an artificial vagina may have to be created either to permit coitus, or for the 
 remedy of grave retention effects. 
 
 Cicatricial bridles which produce simple contractions or stenoses may 
 require the interference of the surgeon in three different sets of circum- 
 stances ; when the uterus is not gravid, during pregnancy, and at the moment 
 of parturition. 
 
 I. /;/ tJie Non-gravid Condition. — It is not only to destroy an obstacle to 
 the performance of the conjugal relations that the affection requires treat- 
 ment, for these bridles form the starting-point of abnormal reflexes, like for- 
 eign bodies, producing pain and metrorrhagia. 
 
864 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 
 The simplest method of dividing them consists in removing them with 
 the finger without the aid of the speculum, but depressing the cervix and 
 adjacent parts if necessary with forceps ; then they may be cut in successive 
 strokes with the long scissors, taking great care not to wound the vaginal 
 wall. This section may be accomplished in several sessions, each followed 
 by dilatation ; at first by tamponing with iodoform gauze, then with cylin- 
 ders of rubber or Bozeman's dilators, which are used in the preliminary 
 
 treatment of vesico-vaginal fistula. Later it is well 
 to introduce a Dumont pallier or Hodge pessary to 
 keep the vaginal walls separated. If the cicatrix 
 is very thick and of great extent, it is better to ex- 
 cise it, and cover the loss of substance by a healthy 
 flap of mucous mem_brane dissected from the im- 
 mediate vicinity. 
 
 With vaginal cicatrices which contract the ca- 
 nal, there may also exist a rectal or vesical fistula; 
 where this is the case, the destruction of the former 
 may enlarge the fistula, and this fact may lead the 
 surgeon to decide in favor of indirect treatment by 
 obliterating the vagina by colpocleisis. 
 
 2. During Pregnancy. — Contractions and sten- 
 oses of the vagina in the gravid female raise seri- 
 ous questions as to operation — whether to provoke 
 abortion or premature labor, or simply to destroy 
 the obstacle, and allow the pregnancy to proceed. 
 Oldham in a case of this sort caused premature labor and saved his patient \ 
 Doherty could not bring himself to adopt this plan, and his patient died. 
 Churchill declares in favor of such interference with the object of prevent- 
 ing rupture of uterus and vagina, which is frequently the result of tempor- 
 izing. But progressive section of the bridles may allow sufficient dilatation, 
 and at the time of labor the parts are so much softened that a cicatrix is 
 rendered very elastic, which before seemed inextensible. 
 
 3. At the Time of Parturition. — It may happen that the condition of 
 the vagina has been ignored until the labor has begun, and we find ourselves 
 in the presence of the obstacle. Where spontaneous dilatation is manifestly 
 impossible, Churchill and Doherty recommend vaginal incisions, taking the 
 risk of seeing them extend to become lacerations and cause fistulae ; after 
 that, craniotomy must be employed. These measures of necessity in a very 
 narrow and easily torn vagina are not free from danger, and I consider 
 Porro's operation preferable, for it eliminates new risk to the woman and 
 thus is better than the Caesarean section. Porro's operation is absolutely 
 indicated if the contraction is so complete that the escape of the lochia is 
 impossible, and especially, as in a case of Levy's, if contraction over a large 
 extent has occurred during pregnancy. 
 
 Fig. 561. — Falciform Cicatri- 
 cial Band from the Vaginal 
 Wall to the Cervix (Barnes). 
 
FOREIGN BODIES. 865 
 
 Foreign Bodies. — The list of foreign bodies introducied into the genita\ 
 passages, and left there, includes pessaries, sponges, tampons, spools, pomade 
 jars, boxes, bottles, pencils, hairpins, etc. ; intestinal worms and insects 
 have also been found there. 
 
 Etiology. — Children will at times pass various objects into the genital 
 canal in play, but most often it is some instrument which serves for mastur- 
 bation which escapes the fingers, and glides into the deeper parts of the 
 canal ; occasionally broken canulae or fragments of glass specula may be left 
 there by accident. Very rarely a foreign body in the rectum or bladder will 
 ulcerate through into the vagina. 
 
 Symptoms and Course. — If the object is hard and not porous, it may be 
 aseptic for a long time and so be tolerated, as is the case with pessaries of 
 hard rubber pr metal. But the steady pressure upon one point ends in 
 ulceration of the tissues, and I have seen a case in which the pessary had 
 been forgotten, had burrowed under the mucous membrane for a certain 
 extent, and then the membrane had healed over it like a bridge, so that it 
 was necessary to cut the loop thus formed in order to extract the instrument. 
 
 In other cases the foreign body becomes tolerable by a peculiar process 
 which resembles that found in certain neoplasms, namely, by calcification; 
 pointed objects, like pins, are thus prevented from wounding the parts. 
 Getschel has observed one of these calculi which recalled those formed in 
 the bladder in similar circumstances. Some of the cases, cited by the older 
 authors, of vaginal stones may be only fibromata of the uterus which had 
 become calcified, or vesical calculi which had ulcerated through the anterior 
 vaginal wall. 
 
 If the object is porous, it may become infected and cause inflammation 
 and progressive ulceration ; thus, a hairpin has been extracted from the 
 vagina, where it had been for sixteen years, and had produced a vesico-vagi- 
 nal fistula, and a pomade jar which, after sixteen years had caused a recto- 
 vaginal fistula. In 1887 I saw in Freund's service at Strasburg a woman 
 who had suffered for ten years after the introduction of a hairpin into the 
 uterus to provoke abortion ; laparatomy was performed and pyo-salpinx dis- 
 covered, and, stuck in the purulent pocket, the hairpin was found, rusty and 
 eroded. 
 
 Pelvic suppuration has followed immediately or after the lapse of a cer- 
 tain time, with peritonitis. 
 
 The irritation produced about a foreign body of some size may cause a 
 circular contraction of the vagina. Pearse, Kottmann, Carter, Breisky, 
 Broer, and Winternitz have each seen almost complete obliteration of the 
 canal below a spool which had become encysted in the superior portion of the 
 vagina. 
 
 Usually the foreign body, even when tolerated, causes a profuse leucor- 
 rhoeal discharge, which may become purulent, and be accompanied by hem- 
 orrhages. The bleeding comes not so much from the ulceration of the 
 55 
 
866 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 vaginal wall as from the uterus, whose mucous membrane has been infected 
 from the vagina. 
 
 The diagnosis may be very difficult when the foreign body is buried in 
 the tissues and hidden by contraction; the assertions and memories of the 
 patient are never trustworthy. Exploration with a sound, aided by vaginal 
 touch and at times rectal palpation, will be found of great service. 
 
 The treatment consists first in removing the foreign body, and then in 
 curing the lesions which it has caused. 
 
 Small free objects in the vaginal pouches, like insects, intestinal worms, 
 etc., are extracted without difficulty by irrigation through a wide speculum 
 which separates the walls freely. If there is a contraction of the vagina 
 below a hard round body, it may be expelled by pressure through the rectum. 
 It is usually advisable not to employ the speculum in extracting the object 
 after its situation has been determined with the aid of this instrument, but 
 sometimes a short blade is useful to depress the fourchette. 
 
 The forceps are passed along the finger, which is held close to the object 
 to be removed, and, if there are bridles, they should be cut with the scissors, 
 using the finger as a guide more than the sight. Hairpins are an important 
 class by themselves, and are almost always found with their points directed 
 forward, so that they must first be disengaged and then removed. If the 
 foreign body is large and covered with asperities, no effort of extraction 
 should be made unless the vaginal wall is protected with retractors, and the 
 object has been seized with a lithotomy forceps. If the object is very large 
 and hard, it may be extracted with Segond's instrument for polypi ; if stony, 
 it may be crushed with the instruments used for large vesical calculi. 
 
 The vagina should be carefully disinfected with antiseptic solutions, 
 especially where the object was lodged, and the metritis which is almost 
 always present treated by the curette. 
 
CHAPTER XLVI. 
 
 MALFORMATIONS OF THE VULVA, AND HERMAPHRODISM. 
 
 The genital organs of the two sexes have the same origin, being devel- 
 oped from the Wolffian body, M tiller's ducts, and the genital glands. 
 
 The organ of Wolff or of Oken, or the primordial kidney, is a temporary 
 organ which is already well developed by the thirty-fifth day, but disappears 
 at the end of the second month. It extends from the summit of the thorax 
 to the pelvis on either side of the vertebral column. It consists first of two 
 longitudinal ducts, and then there develop a series of straight tubes which 
 afterward become flexuous, and empty into the two primitive conduits ; these 
 are situated in front of the glandular mass and outside of it, and seem to be 
 the excretory ducts. They end posteriorly in the lower part of the genito- 
 urinary sinus, a large depression which later becomes the vulva, the peri- 
 neum, and the margin of the anus. On the inner portion of the Wolffian 
 body, there appear in the fifth and sixth months the genital glands which 
 develop into either ovaries or testicles ; as they increase, the Wolffian body 
 lessens, atrophies, and is finally shut off by a fold of peritoneum. 
 
 The permanent kidneys develop behind the Wolffian body, and remain 
 independent of the rest of the genital apparatus ; their excretory ducts, 
 formed from a diverticulum of the Wolffian duct, open into the bladder, and 
 this viscus, as also the urethra, is formed at the expense of the allantois, 
 which is a process derived from the rectum in the foetus. That portion of 
 the allantois which extends from the upper part of the bladder to the umbil- 
 icus forms the urachus and becomes the superior ligament of the bladder. 
 Two other ducts are formed parallel with those of the Wolffian body, situ- 
 ated above and external to them, which are called Midler's ducts ; they fuse 
 below and open into the inferior part of the allantois below the vesical dila- 
 tation at the place where the urethral canal is formed. The cavity where 
 the Mlillerian ducts empty communicates freely behind with the rectum, and 
 this junction is termed the cloaca (see Fig. 564, i and 2). 
 
 Up to the third month the embryo has no sex, or rather has the elements 
 of both sexes — its sex is indifferent and indeterminate ; but at that time the 
 internal organs begin to develop toward the masculine or the feminine type. 
 
 If the first shall be developed, the ducts of Miiller disappear and leave 
 only a vestige of their lower extremity, fused and opening into the uro-geni- 
 tal sinus, to become the prostato-membranous portion of the urethra ; they 
 open at this point by a common orifice, terminated by a cul-de-sac, the pro- 
 
868 
 
 CLINICAL AND OPERATIVE GYNECOLOGY 
 
 Static Utricle or uterus masculinus. At the same time the median portion 
 of the Wolffian body forms the head of the epididymis and the tail of that 
 organ, the vas deferens and ejaculatory ducts coming from the Wolffian 
 ducts; the genital gland is transformed into the testicle (Fig. 562, i and 3), 
 
 Fig. 562. — Diagram of the Development of 
 THE Genito-Urinarv APPARATUS (Henle). I, Em- 
 bryonic condition ; 2, feminine type ; 3, masculine 
 type. A , Kidney ; £, ureter ; C, bladder ; £>, urach- 
 us ; £, urethra ; iT, Wolffian body which in the male 
 forms the epididymis ; G.'excretory duct of the Wolf- 
 fian body, which forms the vas deferens ; I/, Miil- 
 ler's duct, which forms the tube, etc.; /, uterus, 
 formed by fusion of Miiller's ducts, which in the 
 male form the uterus masculinus ; A', seminal glands ; 
 X, primitive ligament of the kidney, which forms the 
 round ligament of the uterus ; Jf, uro-genital sinus ; 
 iV, genital tubercle ; ?/, «, corpora cavernosa ; o, gen- 
 ital groove ; J>, Cowper's glands. 
 
 If the individual is to be of the feminine sex, the genital gland becomes- 
 the ovary, Miiller's duct persists, the Wolffian body and canal atrophy and 
 almost entirely disappear, leaving only the organ of Rosenmiiller as their 
 vestige in the broad ligament. 
 
 The upper portion of Miiller's ducts forms the Fallopian tube, the mid- 
 dle and lower parts blend and constitute the vagina and uterus ; this union 
 
MALFORMATIONS OF THE VULVA, AMD HERMAPHRODISM. 
 
 869 
 
 begins at the inferior portion, and the short conduit so formed communicates 
 with the cloaca. At the end of the second month the two Miillerian canals 
 are in apposition but still separated throughout their whole extent, except at 
 the orifice, by a septum which results from their junction, and which per- 
 sists at the upper part until the fourth month. 
 
 The round ligament is formed from the ligament of the Wolffian body, 
 and is inserted at the junction of the superior with the middle third of Miil- 
 ler's duct; this point is important for the appreciation of arrested develop- 
 ment (Fig. 562, 2). 
 
 The external organs are developed at the expense of the genital tubercle, 
 which appears, according to Kolliker, at the sixth week of foetal life, and is 
 Avell dev'eloped at the end of the two following weeks. On each side two 
 folds become prominent which are called the genital folds. At the end of 
 
 s. 
 
 Fig. 563.— Development of the External Genital Organs (Ecker). i. Lower portion of an embryo at 
 the eighth week ; hermaphrodite stage, enlarged two diameters, e, Glans at the summit of the genital tubercle ; _/, 
 genital groove ending behind at the anus and thus forming part of the cloaca ; /z/, genital folds ; s, extremity of the 
 body of the embryo ; n, umbilical cord. 2. Embr>-o at about the tenth week, female, a, Anus ; ag; uro-genital 
 sinus ; «, edges of genital furrow or labia minora. 3. Embryo a Uttle younger than the preceding, to show the stage 
 -which precedes the indication of the sex. 4. Male embr>-o at the end of the fourth month. 
 
 the second month the genital tubercle becomes prominent, and on its pos- 
 terior aspect we can then recognize the presence of a furrow directed toward 
 the orifice of the cloaca which gives it a bifid appearance, and is termed the 
 genital groove. The perineum also advances under the form of a median 
 projection and two lateral folds which meet in the middle line, forming the 
 raphe, toward the point where the allantois empties into the rectum, trans- 
 forming the recto-allantoid cloaca into two portions, the uro-genital sinus 
 situated anteriorly, and the anus behind. The inferior segment of the allan- 
 tois retracts to form the urethra, and the IMiillerian ducts fuse to form the 
 vagina (^Fig. 564, 3, 4, 5). 
 
 This transformation of the cloaca is effected during the third month, and 
 at the same time the difference in the sexes may be determined (Fig. 563) ; 
 in the male embryo the genital tubercle becomes the penis and the genital 
 furrow forms the penile portion of the urethra, while the genital folds, situ- 
 ated behind, blend to form the scrotum ; in the female these folds become 
 the labia majora, and the edges of the furrow are the labia minora, the geni- 
 tal tubercle appearing as the clitoris. 
 
 The genital groove does not close more in front than behind, and thus 
 
8/0 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 the female lacks the clitoridian portion of the urethra; and this canal in the 
 adult opens at a point homologous with that where it was found in the foetus 
 of eight weeks — a disposition which is found in the male when the proper 
 development of the parts has been arrested (hypospadias). The corpus spon- 
 giosum of the urethra, the product of the erectilized borders of the genital 
 furrow, is also completely developed in the male, and entirely surrounds the 
 canal in the pendulous portion. But in the female it aborts in the inter- 
 mediate or vestibular portion, and is reduced to its two extremities below, 
 to the bulb of the vestibule, homologue of the bulb of the male urethra, but 
 divided by the persistent genital opening ; and above it forms the glands of 
 the clitoris which covers the corpora cavernosa clitoridis, homologues of the 
 similar structures in the male penis. At the internal part of the bulb of the 
 vestibule there are vestiges of a membranous organ which reaches its full 
 development in the male, namely, the bulb of the urethra; it is this which 
 forms the hymen. Above, joining bulb and hymen to the clitoris, and 
 representing the vertical or cylindrical portion of the masculine corpus spon- 
 giosum, there is in the female a band with a vascular bundle running in it, 
 the frsenum masculinum vestibuli, which I first described, and the inter- 
 mediate plexus (pars intermedia) of Kobelt. 
 
 To appreciate the homology between the external organs of the two sexes, 
 it is only necessary to suppose the penis split from the meatus to the bulb ; 
 the section of the urethra in the male just where it enters the bulb exactly 
 represents the urinary meatus of the female surrounded by the bifurcation of 
 the fraenum masculinum, which is a vestige of the corpus spongiosum of the 
 male. To complete the symmetry, the penis may be considered as elevated 
 and applied to the pubic symphysis, placing the glans in the same subpubic 
 situation that the glans clitoridis occupies. It is then easy to recognize the 
 following homologies, which I have sought to establish since 1884 : 
 
 Glans clitoridis. Glans penis. 
 
 Prepuce of clitoris. Upper part of prepuce. 
 
 Corpora cavernosa of clitoris. Corpora cavernosa of penis. 
 
 Frcenum masculinum and intermediate plexus of Cylindrical portion of corpus spongiosum of 
 
 Kobelt. urethra. 
 
 Hymen and bulb of vagina. Veru montanum and bulb of urethra. 
 
 Frcenum of clitoris. Fraenum of penis. 
 
 Labia minora. Deeper layer of scrotum, 
 
 Labia majora. Superficial layer of scrotum and sheath of penis. 
 
 Vestibule and small portion of vagina behind Membranous and prostatic portions of urethra 
 
 hymen (i to 2 mm.). to prostatic utricle, which is analogous to the 
 
 ]Miillerian vagina. 
 
 Bartholin's glands. Cowper's glands. 
 
 The uro-genital sinus is at first relatively long, and is directly continuous 
 with the allantois, that is, with the urethral canal. Later in the course of 
 the development there remains only a vestige of it as a very short canal, 
 which might be called the vulvar canal, which prolongs the vestibule imme- 
 diately behind the hymen (Fig. 564, 4 and 5). This space, which almost 
 
MALFORMATIONS OF THE VULVA, AND HERMAPHRODISM. 8/1 
 
 wholly disappears in the adult female, is still very noticeable in the young 
 girl, and to that fact is due the deeper situation of the hymen in children, as 
 described by Budin. The unequal development of these various parts com- 
 pletely hides their primitive relations after birth ; it is thus that the vulvar 
 or vestibular canal, the last vestige of the anterior portion of the uro-genital 
 sinus, seems directly continuous with the Miillerian vagina, while in the 
 embryo it exists as an independent structure and forms the lower portion of 
 the prolongation of the allantois or the urethral canal (Fig. 564, 4). In other 
 words, it is primitively the Miillerian vagina which seems to empty at the 
 entrance of the urethra at the vestibular expansion, while later it is the ure- 
 
 FiG. 564. — Development of the External Genital Organs. Diagrammatic. (Schroder.) i. i?, Rectum, 
 continuous with All, allantois (bladder), and M, Miiller's canal (vagina); jr, depression of the integument below the 
 median tubercle, which by its progress inward forms the vulva. 2. The depression has extended inward to become 
 continuous with the rectum and the allantois to form the cloaca CI. 3. The cloaca has spht into the uro-genital sinus, 
 Sti, and the anus, a, by the downgrowth of the perineal septum. The Miillerian canals are fused to form the vagina 
 V, behind the bladder B and the orifice of the urethra u. 4. The perineum completely formed. 5. The upper portion 
 of the uro-genital sinus contracts to form the urethra, the lower portion persists and forms the vestibule a, into which 
 both urethra and vagina empty. 
 
 thra which appears to open in the vaginal orifice which has become blended 
 with the vestibule (Fig. 564, 5). This distinction which I have drawn be- 
 tween the Miillerian vagina and its vestibular antechamber is of the greatest 
 importance in considering malformations of the parts. 
 
 If the development of the parts be arrested at this time, the following 
 forms may be produced : 
 
 I . Complete atresia of the urethra and vagina, resulting from absence of 
 the division of the genital tubercle and of the genital furrow which prolongs 
 the opening of the uro-genital sinus forward ; in this case there is no vulvar 
 opening. According as the cloacal septum has been perfect or incomplete, 
 the rectum, the bladder, and the genital canal are separated or in communica- 
 tion (Fig. 565, I, 2). Infants with this malformation are seldom viable. 
 The urethra being absent or imperforate, the bladder and the genital canal 
 are enormously distended with urine. 
 
 The absence of the cloacal septum is at times observed alone, the uro- 
 genital sinus being open and communicating freely with the rectum, v/hich 
 does not reach the anus but appears to end in the vagina ; this form is called 
 
872 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 ano-vulv^ar, vestibular, and ano-vaginal atresia (atresia ani vestibularis, seu ani 
 vaginalis, Fig. 564, 3). In reality it is not into the vagina that the rectum 
 opens, but into the uro-genital sinus, which receives also the vagina, at times 
 imperfectly separated from the rectum by a septum, and the urethra. This 
 renders the homology difficult to establish, and the relations of the parts 
 have been subordinated to their dimensions, which are altogether accessory. 
 The malformation may be simply a congenital ano-vaginal fistula. 
 
 Hypospadias in the female corresponds to an analogous arrest, though 
 not so pronounced. The perineum has developed normally, but the uro- 
 genital sinus has presented its embryonic condition. In certain cases of the 
 
 Fig. 565. — Malformations of the External Genital Organs. Diagrammatic. (Schroder.) i. Complete 
 atresia of the vulva, r. Rectum ; g^ genital canal ; 3, bladder, communicating with both. 2. Complete atresia of the 
 vulva ; r, rectum separated from the allantois ; h, bladder, and^, genital canal, distended with urine. 3. Atresia of 
 vagina and anus, d^ Perineum, incomplete ; 3, bladder ; %', vagina, and r, rectum, open by a common cloaca. 
 4. Hypospadi; in the female. First degree coincident with hypertroph)' of the clitoris, j, Persistent uro-genital 
 sinus, to which succeeds the long vestibular canal ; ti, urethra, and z', vagina, opening into the vestibular canal ; <r, hy- 
 pertrophied clitoris. 5. Hypospadias in the female, properl)' so called ; the allantois wholly transformed into a bladder 
 which opens directly, without the intermediate urethra, into the uro-genital sinus ; that is, into the vestibule. 
 
 first degree of this malformation, the vulvar or vestibular canal is long and 
 narrow, like the urethra, and receives high up the urethra and vagina. This 
 condition has wrongly been considered only a simple opening, at a high 
 level, of the urethral canal into the vagina, retracted below ; hypertrophy 
 usually involves the clitoris in this malformation (Fig. 565, 4). 
 
 Hypospadias proper occurs when the uro-genital sinus has regularly dis- 
 appeared, but the lower portion of the allantois which should form the ure- 
 thra has been taken to form the inferior part of the bladder. The urethra 
 is lacking altogether, and bladder and vagina open into the vestibular canal, 
 which gives the clinical appearance of the vesical orifice being in the vagina. 
 
 Epispadias. — This is a rare condition in the female, and its mode of ori- 
 gin is still a matter of doubt; it may coincide with ectropion of the bladder 
 and defect in the pubic symphysis, as well as with atresia of the anus. It 
 is certainly related to defective disposition of the allantois which forms an 
 obstacle to the development of the urethra and the occlusion of the anterior 
 portion of the vulva ; the clitoris is occasionally bifid. 
 
 I will not speak of ectropion of the bladder, which does not belong to my 
 
MALFORMATIONS OF THE VULVA, AND IIERMAPHRODLSM. 873 
 
 subject, but only of those cases in which the lesion is confined to the urethral 
 canal, which is one of the external genital organs in the female. Instead of 
 the vestibule and meatus, we find at times a wide furrow, opening above, or 
 a horseshoe orifice with its convexity applied to the symphysis ; the vesical 
 mucous membrane may project like a collar from this opening, and the cli- 
 toris may be absent, as in a case of Nunez, or bifid. The labia majora 
 diverge above, and the nymphae are attached to the fissured clitoris ; often 
 the symphysis presents a separation. The incontinence of urine is never 
 complete, and the patients may have the power of retaining it for a long 
 time ; but the least effort causes it to issue, and it must be passed as soon as 
 the necessity is manifest. 
 
 The ureter very rarely opens into the vagina or the vulva, but it is of in- 
 terest on account of the congenital incontinence of urine which it causes. 
 Independently of the cases in which the two ureters emptied into the vagina 
 in the absence of the neck of the bladder and of the urethra, one of these 
 canals has been seen to open near the meatus. This anomaly has been ex- 
 plained as follows : The ureter is formed by the budding of the Wolffian 
 canal in the form of a tube toward its cloacal portion; at a certain level this 
 tube receives lateral buds which are to form the urinary canaliculi, which 
 terminate its superior extremity, and its lower end is partly of the cloacal 
 extremity of the Wolfifian body and presents thus a portion which is common 
 with that canal, of very short extent and temporary duration. The duct of 
 Miiller, which descends along the canal of Wolff, empties into the cloaca 
 near the canal of which it remains the neighbor but inferior to the ureter. 
 The anomaly arises when the ureter is tardy in its development if the origi- 
 nal bud on the Wolfifian canal appears not near its lower end, but high up in 
 the uro-genital sinus, and thus the ureter loses its normal relations ; it does 
 not empty high enough but follows the course of the Wolffian duct, which 
 descends to the vestibule, and confounds its origin with the vestiges of that 
 embryonic organ. 
 
 Total absence of the vulva is characterized by the simple opening of the 
 nro-genital sinus at the vulvar region, although none of the parts constitut- 
 ing that region have been formed. This malformation may coincide with 
 the normal development of the other genital organs according to many cases 
 cited by the older authors, but the fact is not beyond question. Foville re- 
 ports one case which seems to be explicable by the fusion of the labia majora 
 rather than by their non-development. There is generally an absence of all 
 projection of the vulvar region in those infants, usually still-born, which 
 present total atresia of the vulva and urethra, but the first part of this mal- 
 formation is wholly accessory. 
 
 Absence of the greater labia is the rule in cases of ectropion of the blad- 
 der, and it may also be observed independently of all other anomalies, as I 
 have myself seen. The nymphae may also be absent, and this condition is 
 often related to incomplete development of the clitoris. It is more frequent 
 
8/4 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 to see them hypertrophied. At times they form two or more juxtaposed 
 leaflets, or they may exceed the labia majora in size, and project beyond 
 them. This condition, which is common in certain tribes, has been termed 
 the " Hottentot apron." Absence of the clitoris coincides at times with 
 epispadias. 
 
 The infantile condition of the vulva is observed in certain weak patients, 
 and also in imperfect development of the uterus and tubes. According to 
 Freund, this state of the tubes predisposes to inflammation. The indica- 
 tions furnished by examination of the vulva have then a certain clinical 
 value. 
 
 Hypertrophy of the clitoris is unusual in our climate, but quite frequent 
 in the tropics. It may render the sex uncertain when it coexists with ap- 
 parent occlusion of the external genitals. Hypertrophy of the clitoris has 
 also been observed as an accessory malformation in certain cases of hypo- 
 spadias and division of the genital canal (Fig. 570). Union of the nymphse 
 appears to be always a congenital anomaly, but it may result from a process 
 like that which joins prepuce and glans in phimosis in little boys; thus in 
 very young girls the nymphae may be found united up to the urethra in such 
 a way as to impede micturition. These adhesions may be easily separated 
 by simple traction. The labia majora may also be united over a certain ex- 
 tent anterior to the fourchette. 
 
 Development and Malformation of tlie Hymen. — The hymen develops 
 slowly in the female embryo; it is only at the nineteenth week that we no- 
 tice a fold about the vulvar opening at the anterior extremity of the vaginal 
 canal, which is formed above by the fusion of the Miillerian ducts and below 
 by the remains of the vestibular canal of the uro-genital sinus. At first 
 there are two linear projections which advance to the median line, where 
 they meet ; the hymen is at this time a double fold, and the band which 
 forms each side of the opening extends from meatus to the base of the cli- 
 toris. When the vulvar orifice and the hymen are formed, this band sur- 
 rounds both openings, forming at the first the collar of the hymen, and at 
 the second a ring, which is very plain in children, continuous with the hymen 
 below, and above with the median projection analogous to the frasnum in 
 masculine hypospadias. The hymeneal apparatus thus comprises the hymen, 
 the ring about the meatus, which is sufficiently marked to merit the name of 
 urethral hymen, and the frjenum masculinum of the vestibule. Anomalies 
 of development may involve all three of these divisions ; and their intimate 
 connection, until now unrecognized, permits us to explain all the difficulties 
 which occur. 
 
 This theory of the origin of the hymen is contrary to that which is gen- 
 erally accepted. Since the teachings of Blandin in France and of Henle of 
 Germany it has been supposed that the hymen was only a projection from 
 the vagina. 
 
 Infantile Hymen. — In the infant at birth the entire hymeneal apparatus 
 
MALFORMATIONS OF THE VULVA, AND HERMAPHRODISM. 
 
 875 
 
 is well developed and its three portions are very distinct. The hymen pre- 
 sents a considerable size, so that it may be mistaken by the inexperienced 
 for the nymphae, and the erroneous conclusion may be drawn that the hymen 
 is absent or destroyed ; this error might be of importance in medico-legal 
 inquiries. 
 
 The usual form of the hymen is the labiated (Brouardel), although it may 
 be found as a projecting collar, more prominent at its lower part, or like a 
 purse folded in the form of a tobacco pouch. In the labiate form an antero- 
 posterior opening separates the two valves which go from the bulb of the 
 vagina to the posterior part; in the new-born a bougie of 9 mm. may be 
 
 Fig. 566. — Infundibuliform Hymen and Fr^num 
 Masculinum in the New-Born, h. Hymen; ov^ vul- 
 var orifice; ^, frsenum ; w«, meatus. 
 
 Fig. 567. — Remains of the Hymen and Fr/Enum 
 in a Woman who had Borne Children, b^ Frae- 
 num ; wfM, meatus ; /«, hymen ; ov, vulvar orifice. 
 
 passed in; this form persists throughout life. In the infant of seven years 
 a bougie of 10 mm. may be passed, and in the marriageable woman the end 
 of the finger may be introduced with little effort. 
 
 The left lip of the hymen may project posteriorly, and the other anteri- 
 orly ; there is then an intercrossing like the crura of the diaphragm, and this 
 disposition on different planes forms an orifice which enters the vagina 
 obliquely from right to left. 
 
 Brouardel's remarks on the medico-legal importance of the hymen in 
 little children are very weighty. If the thighs are widely separated, the 
 hymen is stretched, and will not permit the passage of the finger ; but ii the 
 limbs are brought together, it folds in a gusset and its posterior valve is 
 depressed, leaving a large orifice which permits a great deal of stretching. 
 Penetration of this opening offers no difficulty, and it is well to note that 
 there was no more obstacle to the penis of the accused person than to the 
 finger of the expert. 
 
 It often happens that the crescentic portion of the membrane which is 
 
S76 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 inserted near the anterior column of the vagina suffers an arrest of develop- 
 ment, and the free border then present notches ; two of these are fairly con- 
 stant, being situated nearly symmetrically at the junction of the superior 
 with the middle third of the structure, and 2 or 3 mm. in extent. In 
 certain cases there is but a single notch, and the other branch, is intact. 
 More rarely there are four of these impressions, two situated behind at the 
 junction of the inferior third with the upper two-thirds, and the others as 
 above anteriorly; so that the membrane of the hymen is formed by two 
 projections posteriorly, two more on the sides, and two smaller ones anterior- 
 ly. The seat of these notches and the integrity of their free borders when 
 unfolded permit us to distinguish an arrest of development from lacerations. 
 
 Injur}^ to the hymen as the result of coitus is not constant. Penetration 
 may be accomplished without laceration of the membrane, especially if the 
 woman consents. Budin has seen the hymen in its normal condition thirteen 
 times in seventy-five primiparse. 
 
 Brouardel and Laugier have shown that laceration of the hymen may heal 
 completely in a few days after it has been torn by intercourse, but attentive 
 examination will suffice to discover the white fibrous cicatrices. 
 
 On the other hand, the normal furrows of the part are often mistaken by 
 the inexperienced for old lacerations ; this error may be avoided by intro- 
 ducing the finger and tracing the cicatrix. 
 
 In little girls there. are other morphological peculiarities of congenital 
 origin, with which the physician should be familiar in order to prevent se- 
 rious mistakes. The small white points which resemble grains of hemp, 
 caused by hypertrophy of the sebaceous glands, are not, as has been asserted, 
 the proof of masturbation. Dolbeau has described a special deformity of the 
 vulva which depends on attempts at coitus with too narrow genital passages. 
 He applies the term \njlvar canal to the infundibulum or false passage, made 
 by the penis above the fourchette ; a very similar vestibular canal is found in 
 the abnormally developed foetus, and at times is a family characteristic. 
 Brouardel reports a case in which he had found a vulvar canal in a little girl 
 into which he could pass the thumb. The mother accused the father of 
 attempting intercourse with his daughter while she was absent with another 
 child. Brouardel examined both children and found the same condition, 
 which was evidently a family peculiarity. 
 
 Anomalies of Situation. — In the child at birth the hymen is placed far 
 more deeply than in later years, the vestibule being sunken, and this condi- 
 tion is very pronounced in the negro race. In the adult the hymen may be 
 placed very high, Kirmer having found it in one case, where the woman was 
 twenty years old, at a depth of 2 cm., the vulvar orifice seeming on first 
 sight to lack the membrane altogether. 
 
 Anomalies in Number. — Cases are reported in the literature of the sub- 
 ject of double hymen. Some of these are due to occlusion of the vagina, 
 by membranes, especially in the new-born, following adhesions between the 
 
MALFORMATIONS OF THE VULVA, AND HERMAPIIRODISM. 
 
 877 
 
 walls of the canal, with a collection of mucus above ; other cases in the adult 
 are probably only an analogous lesion which has persisted from foetal life or 
 from infancy. The reversal to the condition which is normal in some ani- 
 mals may perhaps be found, as I will describe farther on ; thus, Frisco, of 
 Metz, found five membranes* in a pregnant woman who had had the hymen 
 divided at puberty for the retention of menstrual fluid. 
 
 Anomalies of Form. — If the theory which I have formulated be accepted, 
 we shall not be surprised at the great variety in the form of the hymen. 
 
 FiG. 568. — Fleshy Sculptured Hvmem in a Young Virgin. 
 
 which we encounter. We have not to do with a fixed organ, but with the 
 vestige or embryonic residuum of the corpus spongiosum, which is completely 
 developed in the male but aborted in the female, in whom it persists as a> 
 membrane except at the most external portion, which becomes erectile to 
 form the bulb of the vestibule. This extreme variability is as easily ex- 
 plained as that of the organ of Rosenmiiller in the female or the organ of 
 Giraldes in the male. 
 
 However that may be, there is one form which is very common in the- 
 adult, namely, the annular ; the hymen is termed circular when it has an 
 exactly central orifice ; semilunar when it is chiefly attached at the superior 
 border, which gives it the shape of a crescent ; falciform when the opening is 
 very large, and leaves only a small fold at the bottom. 
 
 These varieties have been described under many names ; the denticulate 
 
8/8 
 
 CLINICAL AND OPERATIVE GYNECOLOGY 
 
 hymen (Fig. 568) is usually thick and fleshy, and is a persistence of the in- 
 fantile type; in a medico-legal examination it must be unfolded to determine 
 whether it has been lacerated, as the irregular folds would lead one to think. 
 
 The linguliform hymen is a variety of the preceding. 
 
 The fringed variety is very rare. The infundibuliform hymen, turned 
 forward like the calyx of a flower, is a reproduction of the infantile type ; if 
 very pronounced, it is termed hypertrophic, and is often associated with very 
 grave malformation of the genital organs. The hymen septus or bi septus 
 presents two openings separated by a band, which is usually enlarged at its 
 posterior part. This disposition, which is not common, is considered a de- 
 
 
 Fig. 569. — ^VuLVA and Vagina Opened on the Side in a Fcetus of Eight Months. The vaginal folds are 
 seen to be continuous with those on the ceirix and the posterior surface of the hymen, ca, Anterior column of the 
 vagina ; c/, posterior column ; c. clitoris ; //, fraenum vestibuli ; //, nymphae ; gl, labia majora ; mu^ urinary meatus ; 
 h, hymen ; ?<, uterus ; cu^ cervix uteri. 
 
 cisive proof of the Mlillerian origin of the membrane, but it has no real 
 value, as is evident from the occasional completely imperforate condition. 
 
 The two openings are often not at all regular, but form two unequal 
 fenestrae (hymen bifenestratusj ; or the membrane may be pierced with 
 holes, forming the cribriform hymen. 
 
 The columnar hymen is formed by a thick pillar on its posterior face, 
 which is often a vestige of one of the columns of the vagina, especially the 
 posterior; in the foetus they are prolonged upon the hymen as are also the 
 rugae of the vagina (Fig. 569). The hymen is formed by two lamellae which 
 are always distinct at the fifth month. The external is derived from the 
 vulva and is the fundamental structure of the hymen; the other is an invest- 
 ment from the vagina; these two lamellae fuse later on, and the posterior 
 face becomes smooth by the effacement of the vaginal folds, while the epi- 
 thelium of the anterior surface comes from the vestibule. 
 
 Atresia of the Hymen. — Whenever the v^agina is found occluded by a 
 thin membrane, it is usually supposed that this represents the hymen; it is 
 
MALFORMATIONS OF THE VULVA, AND HERMAPHRODISM. 879 
 
 most often, however, a terminal iniperforation of the vagina or an adhesion 
 between its walls, and the hymen, distended by the accumulation of fluid 
 behind it, is simply applied to the membrane, and may be separated from it 
 after evacuation of the haematocolpos. Duncan has often found a circular 
 hymen in such cases in which atresia was claimed, and has described an ex- 
 cellent example. Schroder expressly mentions this error, and has discovered 
 at the lower portion of the obturating membrane the opening of the hymen 
 for which it was mistaken. There are cases, however, in which the hymen 
 forms a complete septum, as in one reported by Godefroy, where the mucus 
 which accumulated behind it in the vagina of an infant of two months had 
 produced compression of both rectum and urethra. 
 
 Cases of the greatest interest have been published which show very 
 clearly the close relation between the different parts of the hymen and the 
 ring which surrounds the meatus. In the normal condition there is often a 
 prolongation in the form of a valve or uvula which covers the meatus in part, 
 and cases have been observed in which there was a very distinct hymen pro- 
 vided with fringes covering the meatus ; and at times the hymen has entirely 
 covered this orifice, causing a retention of the urine in the new-born. This 
 is a superficial atresia which might be called imperforate urethral hymen. It 
 should not be confounded with aplasia of all or a part of the urethra which 
 may exist by itself, or with persistence of the urachus which permits the 
 evacuation of the urine. 
 
 Anomalies of Striicture. — The hymen is usually thin and membraniform, 
 apparently formed by the simple apposition of the two lamellae covered with 
 pavement epithelium, at times fused, at times perfectly distinct. The vari- 
 ations in structure which it presents are: (i) Increase in thickness, which 
 renders it fleshy without augmenting its tenacity ; and (2) a peculiar rigid- 
 ity, which gives it a sclerous consistence and renders its division with the 
 knife imperative, intercourse in the natural manner being impossible. Ac- 
 cording to Budin, this rigidity may be the principal factor in laceration of 
 the perineum posteriorly and an obstacle to the progressive dilatation of the 
 vulva ; and, on the other hand, the hymen may be so elastic that no lacera- 
 tion can be discovered in it after labor ; it has been found intact after abor- 
 tion at the sixth month ; (3) excessive vascularity of the membrane has 
 caused grave and even fatal hemorrhage at the time of the first coitus. Such 
 cases, difficult of comprehension if we suppose that the hymen is only a fold 
 of the vaginal membrane, become easily understood when we consider it as 
 the organ of the corpus spongiosum (urethro-penile mucous membrane of 
 the male), which has persisted in the embryonic state, and may by anomaly 
 present in the female an erectile tissue like its homologue in the male. 
 Henle has removed all doubt from the latter case, for he found exceptionally 
 an erectile tissue in the hymen. 
 
 Conorenital Absence. — The older observations of the entire absence of the 
 hymen should be received with doubt ; they are all probably erroneous from 
 
88o 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 causes which I have mentioned. Devilliers, Tardieu, and Brouardel have 
 never seen such a case among the large number of infants which they have 
 examined for medico- legal purposes. 
 
 Hermaphrodism. — True hermaphrodism would be constituted by the 
 presence in one person of the organs of both sexes in a condition of perfect 
 function ; I will discuss the pre- 
 tended cases of this kind further 
 on, and demonstrate their folly. 
 But the appearance of a double sex 
 may arise from malformation of the 
 genitals or their arrest in the em- 
 bryonic phase in the male, or their 
 excessive development in the fe- 
 male. The individuals of the first 
 category are far more numerous 
 than those of the second, and the 
 great majority of the pseudo-her- 
 maphrodites which have been de- 
 scribed have been males with hypo- 
 spadias. The criterion of the sex 
 in a doubtful case is the presence 
 of the testicles or ovaries, and the 
 
 Fig. 570. — Pseudo-Hermaphrodisim in a Female 
 BY Hypertrophy of the Clitoris (Gynandry). 
 The external genitals of a child of three weeks, natural 
 size ; specimen deposited in the Museum of Legal 
 Medicine at Vienna, by Hofmann. The integuments 
 show the effects of long action of alcohol. The pro- 
 iecting labia majora surround the clitoris and conceal 
 tne vulvar openmg. The fra;num vestibuli is very 
 large. 
 
 \: 
 
 
 '^'' 
 
 /)/ 
 
 
 Fig. 571. — Partial Pseudo-Hermaphrodism in the 
 Male (Androgyny). Hypertrophy of the fra;nura 
 and prolongation along the raphe, with bifid pro- 
 jection simulating the nymphae. This young sub- 
 ject, named Jan , presented also hypertrophy of the 
 
 breasts . the left testicle was atrophied and retained in 
 the ring. 
 
 great difficulty in determining the sex on the living person is the impossi- 
 bility of deciding what is the nature of the genital gland placed in the 
 insruinal canal or hidden within the abdomen. 
 
MALFORMATIONS OF THE VULVA, AND HERMAPHRODISM. 88 1 
 
 To present the complete classification of hermaphrodism, it seems useful 
 to establish the following divisions on a practical basis rather than on a 
 theoretical : 
 
 1. Pseudo-hermaphrodism : certain parts of the sexual organs of both 
 sexes with evident predominance of one. This comprises two varieties, gyn- 
 andry and androgyny, according as the individual is really male or female. 
 
 2. True hermaphrodism. 
 
 Pseudo-JicrmapJu'odisvi. — A. Gynandry. — In this class there might be 
 distinguished one variety in which the principal reason for doubt as to the 
 
 ..-4 
 
 Fig. 572. — Androgyxv. Breasts of Jan . 
 
 actual sex is the absence of the breasts, or rather the presence of breasts of 
 the masculine type, and which I propose to call andromasty. This anomaly 
 is usually accompanied by a masculine appearance, the development of hair 
 upon the face, and a deep voice. Usually there are malformations of the 
 external genitals, sometimes even complete occlusion of the vulva and 
 absence of the vagina, but there are present a uterus, more or less rudimen- 
 tary, and ovaries. 
 
 A second variety of gynandry is constituted by hypertrophy of the cli- 
 toris which resembles a penis. The masculine appearance is often in- 
 creased by fusion of the labia majora, and perhaps also of the nymphae, sim- 
 ulating the scrotum and concealing the vulvar opening (Fig. 570). The 
 resemblance is still more striking when there is an ovarian hernia at the 
 anus or into the labium majus. 
 56 
 
882 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 The hypertrophy of the clitoris does not change its form, but only its 
 dimensions and those of its prepuce. It may reach a length of 4 or 5 
 cm. (Huguier). The internal organs of the female are at times irregularly 
 developed. 
 
 B. Androgyny. — Several clinical divisions may be made in this class. 
 One contains those individuals in whom the marked feature is the femi- 
 nine development of the breast, gynecomastia. They are usually mon- 
 orchid or cryptorchid males, presenting an incomplete development of the 
 penis and testicles, and degenerate physiologically and psychologically. 
 
 7.r ^ if 
 
 Fig. 573. — Pseudo-Hermaphroditism (Androgeny). External genital organs of Marie C . 
 
 Here the type is masculine, the scrotum is fused and surmounted by a 
 perforate penis ; but the absence of testicles in the scrotum and the median 
 depression which seems like the space between the labia majora, the large 
 breasts which may be developed as in the female, and lastly, as in a case 
 which I have seen (Fig. 578) the presence of two smaller labia, formed by 
 a crease in the scrotal arch, give the individual a very feminine aspect. The 
 development of the breasts, a frequent corollary in the male of arrested de- 
 velopment of the genital organs, is a fact of organic sympathy which is in- 
 explicable, but it is of great interest in connection with the facts of the 
 physiological relations of these organs (Fig. 572). 
 
 A second division includes individuals of that variety of pseudo-her- 
 maphroditism which I have proposed to call regular androgeny. These 
 
MALFORiMATIONS OF THE VULVA, AND HERMAPHRODISM. 
 
 883 
 
 persons possess external genital organs of the normal feminine type and 
 proportionate size, including the clitoris, labia majora, nymphas, and even 
 the vagina (Fig 573). The dominating feature of hermaphroditism in these 
 
 Fig. S74.— Testicle and Uterus of Marie C . Anterior view. C, Left horn of a rudimentary unicorn uterus; 
 
 T, testicle; /", tunica vaginalis; P, pedicle. 
 
 cases is the presence of testicles instead of ovaries, either in the abdomen or in 
 inguinal herniae. The uterus and tubes are always incompletely developed 
 and the vagina is often so also. In view of the general appearance, these 
 
 Fig. 575. — Posterior View of Organs Shown in Fig. 574. 
 
 peculiarities pass unobserved, and the individuals are declared to be women* 
 at the time of their birth, and remain so throughout life in name and appear- 
 ance. In such a case I have examined the testicles and rudimentary uterus. 
 
884 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 An arrested development of their finer structure was obsen^ed, recalling the 
 foetal condition and characterized by the abundance of the interstitial cells of 
 Hofmeister (Figs. 576 and 577). 
 
 A third class is that of irregular androgeny or hypospadias. The exter- 
 nal genitals are of the feminine type, but disproportionately developed, an 
 
 
 
 ra^ 
 
 
 ^ ^\*«^ 
 
 (f^A'^'-'^v --if^f'^!/^.^ ^*^{:. 
 
 Fig. 576. — Structure OF THE Testicle of APsErDO-HERMAPHRODiTE (Marie C ). A^ Section perpendicular 
 
 to the surface CX 150 diam.). i, Connective tissue ; 2, section of large seminiferous tubes forming the peripheral portion 
 of the organ ; 3, section of much smaller tubes forming a well-defined central mass ; 4, masses of special interstitial 
 cells surrounding the tubes ; 5, the same cell masses about the small tubes ; 6, large lymphatic space separating the 
 two areas ; 7, blood-vessel B^ Small seminiferous tube from the central zone ; i, Elongated cells about the spaces 
 occupied by the tubes ; 2, Epithelial cells with large granular nuclei ; 3, spaces produced by the retraction of the 
 epithelial layer. 
 
 
 
 
 Fig. 577.— Structure of the Testicle of a Pseudo-Hermaphrodite (IMarie C .) A, Large seminiferous tube 
 
 from the peripheral zone (X 500 diam.). B, The large interstitial cells (X 1,000 diam.). 
 
MALFORMATIONS OF THE VULVA, AND HERMAPHRODISM. 
 
 !5 
 
 enormous clitoris accompanying a rudimentary vulva. These cases comprise 
 the great majority of those reported. They are usually men with hypospa- 
 dias in whom there is a perineo-scrotal fissure, and numerous autopsies have 
 determined their exact signification. I have described three cases from the 
 living individual, and all three were built upon exactly the same plan, in ac- 
 cord with cases described by my predecessors. These persons are generally 
 
 
 
 
 Pig. 578. — PsEUDO-HERMArHRODisM Proper, l;^■ Hypospadias. Externa! p:enital organs of Julie D Cman). 
 
 Masculine appearance of the parts with the penis depressed and the thighs together. 
 
 regarded as of the feminine sex at their birth, are registered as girls, and are 
 dressed and educated as of the female sex. Many of them have been mar- 
 ried, and nearly all were able to have intercourse with their husbands by 
 the urethral orifice, which was transformed into an infundibulum, rather than 
 by the depression which existed below; but, at the same time, many of them 
 have had a taste for women and performed a more or less complete coitus. 
 In some of these cases there was the appearance of irregular menses from 
 hemorrhages of the dilated and irritated urethra ; but there are other cases 
 
886 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 in which there was undeniable evidence of menstruation, although feeble and 
 intermittent, and the anatomical condition of the parts was fully explanator}^ 
 of the fact. 
 
 The external conformation resembles that of an embryo seen through a 
 magnifying glass; the penis projects or is fastened to the pubes and main- 
 tained below by a fraenum ; the glans is as large as in the child or youth, 
 and is imperforate, but its extremity is marked by a groove with a fleshy 
 
 11111 
 
 Fig. 579. — Pseudo-Hermaphrodism Proper. External genitals of Julie D (man). Feminine appearance of the 
 
 parts with the penis raised and the thighs separated, b, Frsenum ; niu, meatus : ov, vulvar orifice. 
 
 band prolonged from its inferior part toward the perineum. This bridle, 
 well described by Bouisson from a surgical point of view, and which I have 
 shown to be homologous with the fraenum vestibuli, extends from the glans 
 to the urinary meatus, situated i or 2 cm. below the root of the penis. 
 The vulvar orifice is found below this, of varying size, but usually so narrow 
 that the finger is introduced only with difficulty. 
 
 A perfectly formed hymen may exist at the vaginal opening, as I have 
 seen in two cases. It is maintained intact owing to the hyperaesthesia which 
 is often found in the parts. The vagina varies in extent up to lO cm. The 
 Mullerian canals may reach the same complete development in the male in 
 cases of even slight malformation of the external genitals. This is known 
 as uterus masculinus. 
 
MALFORMATIONS OF THE VULVA, AND HERMAPHRODISM. 
 
 887 
 
 In the pathological museum at Wurzburg there is a specimen described 
 by Franque where there are the external organs of the male, and above them 
 a vagina opening into the prostatic portion of the urethra, as well as a uterus 
 and oviducts, both well developed. Zweifel cites a case in which at the 
 
 cjiy 
 
 Fig. 580. — Pseudo-Hermaphrodism Proper, by 
 Perineo-scrotal Hypospadias. External organs of 
 Julie D (man). 
 
 Fig. 581. — Details of the Hymen and FrvEnum 
 Vestibuli in the Same Subject, g, Glans : gl, labia 
 majora ; //, nymphae ; ?«?<, meatus ; ov, vulvar orifice ; 
 k)\ hymen ; y, fourchette. 
 
 autopsy of a child of six months there was found a hypospadias with testi- 
 cles, but also Miillerian canals completely developed into vagina, uterus, and 
 tubes. 
 
 Ahlfeld has collected several similar cases. It is in the interior of this 
 canal that ejaculation occurs at the moment of orgasm. During erection 
 the penis is held in a curved position by the bridle. 
 
 The prepuce is open below and is disposed as in the case of the clitoris ; 
 there are rudimentary labia minora and well-marked labia majora. The tes- 
 ticles are always rudimentary and secrete a semen which is sterile like that 
 
888 
 
 CLINICAL AND OPERATR^L: GYNECOLOGY. 
 
 of cryptorchids ; at times they descend, at other times they remain at the 
 ring or within the abdomen. 
 
 The development of the breasts is often feminine, as also the appearance 
 of the buttocks and thighs, where the panniculus adiposus is usually very 
 
 Fig. 582. — Pseido-Hermaphrodism Proper. External organs of Louise B (man), g^ Glans ; 1^, frsenum ; w«, 
 
 meatus ; ov, vulvar orifice ; hy^ hymen ; y, fourchette ; //, nymphae ; gl, labia majora 
 
 thick. The larynx does not project and the voice is womanish; the pelvis 
 is masculine and the beard is either very scanty or well grown ; and when 
 the latter character accompanies well-developed breasts, the case is particu- 
 larly striking. Ordinarily, .-ectal touch and the use of the catheter fail to 
 discover any trace of a uterus, or generally of a prostate, and bimanual pal- 
 pation does not reveal the presence of ovaries. 
 
 These individuals are of feeble spirit, or, if intelligent, are not well bal- 
 
MALFORMATIONS OF THE VULVA, AND HERMAPHRODISM. 889 
 
 anced ; their antecedents are often marked by nervous phenomena ; and the 
 coincidence of similar deformities in the same family has been observed. 
 
 True HermapJirodism. — Although admitted without hesitation by the 
 older writers, who have instanced a number of examples, the existence of 
 true hermaphrodism is to-day strongly contested. 
 
 Klebs offers the following theoretic classification of true hermaphrodites: 
 
 1. Bilateral, where there is a testicle and an ovary on each side; also 
 termed vertical hermaphrodism. 
 
 2. Unilateral, where there is a testicle and an ovary on but one side. 
 
 3. Lateral, where on one side there is a testicle and on the other an 
 dvary. 
 
 The first two varieties may be quickly dismissed; no case of unilateral 
 hermaphrodism has ever been seen , only two cases of the bilateral have been 
 observed,' and these are more than doubtful ; the third variety has received 
 the credence of late writers, it seems to me unnecessarily, and therefore 
 shall be considered at length. 
 
 A real importance can be accorded to a case only when it has been con- 
 trolled by autopsy ; the case of Katharina Hohmann, so often cited, was not 
 thus controlled, as has been wrongly asserted. It is easily seen by the de- 
 tails of the case that it was one of pseudo-hermaphrodism by perineo-scrotal 
 hypospadias. The right testicle alone had descended into the labium. The 
 subject claimed to have a regular menstrual discharge, but it was discovered 
 too late that the pretended menses were the result of a trick. Rokitansky, 
 thus deceived, concluded that menstruation was real, and imagined the pres- 
 ence of ovaries and Graafian follicles— in other words, supposed that he had 
 found a case of true hermaphrodism. The breasts in this case were devel- 
 oped like a woman's. 
 
 The well-known subject of Heppner's, of St. Petersburg, has been cited 
 as conclusive proof of the existence of true hermaphrodism by the partisans 
 of this idea, and at first sight it seemed incontestable, but on close examina- 
 tion the doubt was removed. The case was one of an infant of two months 
 with the external organs of the female or of perineo-scrotal hypospadias. 
 The uterus, tubes, and ovaries were well developed on each side, and there 
 was an additional gland which resembled a testicle. Between the fundus 
 and the ovary there was a parovarium or the shrivelled Wolfifian body at- 
 tached to the supposed testicle. Under the microscope this indeterminate 
 body showed a number of tubes directed toward a hilum, with hyaline walls, 
 which gave no striae or nodules with acetic acid ; there was no vas deferens. 
 Upon these elements Heppner based his opinion that it was a testicle. 
 Slavjansky declared that he was not convinced that it was not an ovary. 
 Beigel has quite frequently found supernumerary ovaries. As regards this 
 question, it is well to remember that the primitive condition of the ovary so 
 closely resembles that of the testicle that it is a matter of the greatest deli- 
 cacy to decide between them. 
 
890 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 The autopsy of the pretended hermaphrodite (lateraHs vera) of Meyer is 
 open to the same objections. The small body which resembled an ovary, 
 and was found on the left side, was probably an atrophied testicle ; the large 
 cells discovered in it were without doubt male ova; it was impossible to 
 find any Graafian follicles. 
 
 I will not stop to discuss others, which are too old to have any value 
 from a histological standpoint, or too incomplete to be believed. 
 
 A recent work upon this subject, by G. F. Blacker and Lawrence, proves 
 that of the twenty-eight reputed cases of true hermaphroditism only three 
 
 Fig. 583. — Pseudo-Hermaphrodism Proper, by Perineo-scrotal Hypospadias (Zweifel). Diagrammatic 
 figure of the deep connections, v^ Bladder ; w/, prostatic vesicle (pseudo-vagina); r, rectum ; p, penis ; J, symphy- 
 sis ; /, testicle. 
 
 are worthy of recognition : that of Heppner, which seems to us so improb- 
 able, they believe to be probably an example of bilateral hermaphroditism ; 
 the cases of Obolonsky and of Schmorl they hold to be examples of lateral 
 hermaphroditism. Finally they claim to have observed a foetus of eight and 
 a half months with an ovo-testis of one side (unilateral hermaphroditism). 
 
 As a matter of fact, then, there is actually one single case of true herma- 
 phrodism, in which testicles and ovaries coexist. This anomaly does not seem 
 improbable a priori ; it is frequent in the batrachia, and almost the rule in 
 the toad ; but it is rare in the higher vertebratDS. True hermaphrodism has, 
 however, been found in the goat and the pig; hypospadias with pseudo- 
 hermaphrodism has been observed more frequently, and I have seen an excel- 
 lent example in the dog. 
 
 Treatment. — These various malformations which I have mentioned are 
 
MALFORMATIONS OF THE VULVA, AND HERMAPHRODISM. 89I 
 
 of more interest for the anatomist than for the surgeon, and interference is 
 seldom opportune. 
 
 The fusion of the labia may be remedied by traction or the knife. 
 
 Hypertrophy of the labia and clitoris may require amputation of the ex- 
 cess of tissue, especially if the friction of the clothing is painful. The oper- 
 ation may be performed under cocaine with the knife, and the hemorrhage 
 controlled with the haemostatic suture or forcipressure or the thermo-cautery 
 applied to the corpus cavernosum of the clitoris. 
 
 In epispadias, the parts may be sutured after freshening their edges ac- 
 cording to the shape of the orifice, as Roser, Schroder, Richelot, and Dohrn 
 have done. In one case Testelin occluded the canal which existed above 
 the urethra by means of caustic potash, but it is not advisable to adopt this 
 method. 
 
 Malformations of the hymen may require incision or partial excision, 
 
 Pseudo-hermaphrodism may perhaps give rise to surgical indications. In 
 one case which I saw, the erection of the penis was much interfered with by 
 the frsenum, and the patient requested me to destroy it. A simple section 
 seemed insufficient, and I decided upon excision of the bridle and autoplastic 
 repair ; but when I proposed to perform the operation the patient refused to 
 allow it. 
 
CHAPTER XLVII. 
 
 MALFORMATIONS OF THE VAGINA AND THE UTERUS. 
 
 MGller's ducts form the entire genital canal, vagina, uterus, and tubes; 
 the vagina and the uterus develop from the inferior segments of these ducts 
 enclosed between the uro-genital sinus and the insertion of Hunter's liga- 
 ment in the Wolffian body. These inferior segments fuse in the median 
 line to form a single canal, called the genital canal or the utero-vaginal ; 
 their upper portions, diverging between the ends of the genital cord and the 
 round ligaments, become the uterine cornua. Normally, these horns are 
 little developed in the human species, being absorbed into the fundus of the 
 organ as part of its further development. But if the space included between 
 the insertion of the round ligaments and the end of the genital canal is oblit- 
 erated, as is the rule in certain animals and the abnormal exception in the 
 human female, the uterine fundus is diminished or suppressed; the organ 
 then develops singly at the expense of the cornua, which become very promi- 
 nent and open into the vagina by distinct orifices; this is the case in the 
 rabbit, the squirrel, and the hare. If the limit between the vagina and the 
 uterus is increased from the insertion of the round ligaments a little below 
 the summit of the genital canal, the uterine body remains very small, as is 
 the case in the rat and the guinea-pig. Finally, the body of the uterus may 
 be produced beyond the summit of the genital canal, as in carnivora, pachy- 
 derms, ruminants, solipeds, etc. In the cheiropters the uterine cornua are 
 much prolonged, and in the monkeys they disappear. In the human type 
 this simple disposition of the uterus reaches its highest degree in the nor- 
 mal condition, but an entire series of malformations may be derived from 
 embryonic arrangements which reproduce the types which I have indicated 
 in the animal scale by reversive anomaly. 
 
 Such cases should be referred to their proper place by the aid of com- 
 parative anatomy. In most of the marsupials the ducts of Miiller do not 
 fuse, but evolve separately, and produce two viteri and two vaginae opening 
 by two distinct orifices into the vestibule. At other times the two vaginae, 
 though separate by their median portions and distinctly two canals, fuse at 
 their upper parts, and receive the two uteri and also at the lower end, which 
 opens into the vestibule (halmaturus). Traces of the internal division of the 
 genital canal into two exist more or less clearly in all animals with the ex- 
 ception of man and monkeys. In many rodents, the hares, for example, 
 there is thus a double uterus and a double vagina; in others, like the mice, 
 the septum is found only at the superior part of the uterine canal. 
 
MALFORMATIONS OF THE VAGINA AND THE UTERUS, 895 
 
 The preceding considerations are of the greatest interest in appreciating 
 the malformations of the vagina and the uterus, for they complete and ex- 
 plain the facts of human embryology. It is not only in comparative anat- 
 omy that phylogeny and ontogeny should be associated, but also in teratol- 
 ogy; and thus we are able to account for the arrest of development which. 
 the parts may undergo, by understanding the various stages of their growth. 
 
 The Miillerian ducts are disposed side by side in the genital cord and 
 fuse excfept at their lower extremity at the end of the third month. At this- 
 time the genital canal shows no trace of a division into its uterine and vagi- 
 nal portions, and it is lined by the primitive epithelium of the Miillerian 
 ducts. The whole lower portion of the genital canal is still imperforate, and 
 the walls of the future vagina are fastened together, as are also the glans and 
 prepuce and the eyelids and eyeballs at the same period. 
 
 At the end of the third month the lumen of the duct at the vestibule be- 
 gins to enlarge and increase steadily as it advances from that point ; the two 
 Wolffian canals burrow under the utero-vaginal conduit, and open into the 
 vestibule behind the urethra. This canal, which is separated by a septum 
 into two halves up to the vestibule, becomes single by the disappearance of 
 the partition, which progresses from below upward and is complete about the 
 fifth month. The differentiation of the canal into vagina and uterus begins 
 at the end of the third month by the appearance of the cervix, which is com- 
 pleted one month later. 
 
 The internal surface of the uterus remains uneven and folded during the 
 entire foetal period; the furrows of the arbor vitae apparently reaching to the 
 fundus because the fundus is not yet developed, but is formed later by the 
 thickening of that portion of the organ which is situated between the inser- 
 tion of the tubes ; these latter structures are at first provided with a simple 
 opening, but soon acquire a fringed pavilion. 
 
 The development of the lower portion of the vagina is not clearl)' under- 
 stood. Hofmann supposes that the Wolffian canals take part in this forma- 
 tion, and Tourneux and Legay have lately maintained a similar theory, which 
 seems very contestable. But with the facts of teratology, there appears to 
 me to be no doubt that the region which we may term, with Legay, the ves- 
 tibular canal and which is usually confounded with the vagina, is independent 
 from an embryogenic point of view ; for we often see that a very short ves- 
 tibular canal may coexist with complete absence of the Miillerian vagina. 
 This region, which is almost wholly effaced in the adult by the deformation 
 and depression caused by coitus and parturition, is very clearly defined in 
 young girls, and extends from the border of the labia majora to about i mm. 
 below the hymen. I am inclined to think that it is a vestige of the uro- 
 genital sinus. However that may be, from the standpoint of comparative 
 anatomy, this short region is wholly distinct from the vagina, and should be 
 considered as a dilated portion of the urethra which receives the Miillerian 
 vagina. It is this vestibular canal which forms by its great elongation the 
 
894 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 major portion of the vagina in the pseudo-hermaphrodite (hypospadias in the 
 male). It is evident then that it may be provided with a hymen which is 
 ectodermic, I think, and not derived from the Miillerian ducts. 
 
 The hymen, which, according to the partisans of the commonly received 
 theory, comes wholly from the ducts of Midler, is formed by an invagination 
 of these canals in the uro-genital sinus. Dohrn places its appearance at the 
 beginning of the nineteenth week. According to Legay and Tourneux, this 
 membrane results from the transformation of the primitive projection from 
 the posterior wall of the uro-genital sinus, which crosses the canal of Miiller 
 to end in the sinus, or rather to apply the epithelium of these canals to the 
 part which it is to cover. I have already briefly stated that the membrane 
 does not form an isolated diaphragm (page 874), but belongs to an entire hyme- 
 neal apparatus which is homologous with the urethral mucous membrane 
 which forms the corpus spongiosum of the male urethra. However that may 
 be, the hymen takes its characteristic form and becomes prominent in the 
 vestibular canal only after the vagina has been dilated by the accumulation 
 of pavement epithelial cells which begin to distend it as with a caseous mass 
 toward the end of the fifth month. At this time the vaginal rugae and col- 
 umns are prolonged upon the posterior surface of the hymen, which seems 
 to confirm the opinion that these two membranes are absolutely one. This 
 continuity of the investment of parts which have a different origin is not 
 unusual in embryology and is a secondary fact of development. The consti- 
 tution of the hymen is essentially different from that of the vagina — for in- 
 stance, in the absence of smooth muscular fibres in it. O. Schaeffer has 
 shown the primitive form of the two independent lamellae which unite only 
 after the fifth month. Only the superior layer is a prolongation from the 
 vagina ; and certain teratological facts tend to prove that the portion of the 
 canal situated immediately above the hymen, which it covers and binds to 
 the vagina, is really of ectodermic origin and formed the upper portion of 
 the vestibule. 
 
 At birth the uterus still preserves an appearance which is very different 
 from its adult form. The cervix constitutes its major part, and the fundus 
 seems to be wholly secondary ; the length of the cervix is double that of the 
 body, and its walls are much thicker. The external os is large, the anterior 
 lip exceeding the posterior ; and this disposition, like the muzzle of the tapir, 
 is often found in the adult as a vestige of the embryonic condition. If the 
 two walls are separated, there is found on each a ridge directed longitudi- 
 nally which serves as the axis of the oblique folds which run from above 
 down and out ; these ridges, which begin near the vaginal orifice of the cer- 
 vical canal, reaching to within a half-centimetre of the fundus of the uterus, 
 fit into a furrow on the opposite side formed by the transverse folds of the 
 arbor vitae ; the anterior axis is to the right, the posterior to the left. I 
 insist on this disposition, as it has been employed in the decision of the 
 variety of malformations and arrests of development when there is no real 
 
MALFORMATIONS OF THE VAGINA AND THE UTERUS. 895 
 
 advantage in separating them; the uterus is called foetal where the arbor 
 vit^ has the aspect which I have described, and infantile when it ceases at a 
 great distance from the fundus or where there is a clear demarcation between 
 the cavity of the cervix and that of the body. These distinctions are inter- 
 esting from a purely theoretic point of view, but of no practical importance. 
 
 During the first years of life the uterus does not appear to participate in 
 the growth of the body; its life remains latent until the moment of puberty. 
 Then, however, the change is rapid in both form and volume. It is the fun- 
 dus especially which undergoes this increase, and the result is that it be- 
 comes far more prominent than the cervix, which becomes only an appendage 
 of half the size and less than half the thickness ; at the same time the folds 
 in the uterine cavity disappear, and the internal os becomes more pronounced. 
 It is of interest to notice that this complete development may not be reached 
 at puberty, but that pregnancy may produce it. 
 
 With the object of classifying malformations of these parts L. Fiirst has 
 established five divisions in the embryonic period : 
 
 First Period— From Fecundation to the Fifth Week. — This is the indiffer- 
 ent period where there is no marked tendency toward either sex ; the ducts 
 of Miiller and the Wolffian body are not yet atrophied ; the ducts of Miiller 
 are separated by a septum ; there is a cloaca into which empty both intestine 
 and urachus ; the genital tubercle and fissure do not show any sexual indica- 
 tions. 
 
 Second Period— From the Eighth to the Twelfth Week. — At the end of 
 this time, the septum in the genital canal has wholly disappeared; the fu- 
 sion of the Miillerian canals is prolonged far upward; the insertion of the 
 round ligament is clearly separated from what will be the tube above and 
 what will be the uterine cornu below ; and at the end of the period the 
 cloaca has divided into anal and uro-genital portions. 
 
 Third Period— From the Twelfth to the Tiventieth Week. — The uterine 
 horns are fused, the arbor is distinct in the cavity of the organ, while the 
 vagina is still smooth ; the cervix is formed ; the perineum is enlarged ; the 
 vagina is developing, and the uro-genital sinus, which has been stationary, 
 seems now to open into the genital canal, and after this time forms the ves- 
 tibule of the vagina, where the hymen appears ; the genital tubercle is re- 
 duced to the proportions of the clitoris, and the edges of the genital fissure 
 form the nymphae. 
 
 Fourth Period^From the Twentieth Week to the End of Foztal Life. — 
 During this time, the folds in the vaginal mucous membrane are formed, as 
 well as in the cervical canal, and the fundus of the uterus develops more 
 appreciably. 
 
 Fifth Period— From Birth to Puberty. — The uterus increases in thick- 
 ness a little; at the sixth year the uterine mucous membrane, which has 
 been folded up to this time, becomes smooth, and there remains only one 
 vertical ridge. 
 
896 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Etiology. Pathogeny. — For a long time all malformations of an organ 
 were considered only caprices of nature. The first attempts at a rational 
 explanation, based upon arrest of development, were made by E. L. Meissner 
 and \V. H. Busch, but it was Kussmaul who developed these ideas, and ren- 
 dered them classic in a work which caused his predecessors to be forgotten. 
 In France the new classification was described first by Le Fort. After him 
 many cases were published. Flirst contributed much to the exact definition 
 of the embryonic epoch which corresponded to each of the anomalies. 
 
 What is the initial cause of anomalies in the genital organs .'' Is it arrest 
 of development, or shall we suppose a higher cause, namely, atavism, repro- 
 ducing sporadically in one species the forms of some other by the effect of 
 what Darwin terms reversion .'* I will not do more than indicate this inter- 
 esting view. 
 
 The predisposing causes are very obscure. There is no doubt that hered- 
 ity plays some part, although it is paradoxical to suppose that total absence 
 of the uterus may be thus explained. Squary mentions the cases of three 
 sisters who had never menstruated, three of whose aunts were sterile. 
 
 The immediate cause, the anatomical condition of the malformation, in 
 the great majority of the cases is a simple arrest of development in the mor- 
 phological evolution or the organic gro\\i:h of the parts, but it is important 
 to make a clear distinction between the facts of these two categories. In 
 the first the organ may have the adult dimensions, but the type is embr)"onic; 
 in the second, which may exist alone or combined with the first, an organ of 
 the adult type is affected with aplasia and remains too small in whole or in 
 part. 
 
 Finally, there are cases which we can explain only by supposing that 
 there is a pathological process which has produced adhesions during the 
 period of foetal life. Of this order are certain vaginal bridles, and also the 
 peritoneal bridle, which passes between the posterior wall of the bladder and 
 the anterior wall of the rectum, which is often found in cases of bicornate 
 uterus. But we must employ such comparisons sparingly, for they lead 
 only to the neglect of all other investigation. The pathological influence 
 which has been mentioned has been strongly questioned, and the vaginal ad- 
 hesion explained by an arrest of development at the time when there is as 
 yet no lumen in the canal ; as to the peritoneal bridle, it is natural to admit 
 that it is the effect of the malformation of which I have suggested the cause, 
 
 Malformations of the uterus and vagina are frequently solid, there may 
 be complete absence of one of the segments of the canal with incomp^'ete 
 partition of the other. But as these may exist separately, it is of clinical 
 value to describe them in distinct chapters. 
 
 Malformations of the Vagina. — Complete Absence or Rudimentary 
 Development — Pathology and Symptoms. — Anatomically there is a radical 
 difference between these two varieties, but clinically this disappears. In 
 the complete form, there is no trace of vaginal tissue between the rectum 
 
MALFORMATIONS OF THE VAGINA AND TliE UTERUS. 
 
 897 
 
 and the bladder; in the rudimentary, there is a fibrous cord of connective 
 tissue occupying tlie position of the vagina. 
 
 The uterus may be entirely absent or reduced to a rudimentary nodule; 
 in other cases it is normal and there are ovaries, but no menstrual molimen. 
 Von Swiecicki has reported a case of absence of the vagina, uterus, and left 
 ovary. Exceptionally there are periodic pains at the time of ovulation. L. 
 
 Fig. 584. — Absence of Vagina and Uterus (or Rudimentary Uterus), with Well-developed Hymen. 
 f/, Clitoris ; gl, labium majus ; //, labium minus ; b, fraenum masculinum ; mu, meatus urethrse ; ov, closed vagina ; 
 ky, hymen ; y, fourchette. 
 
 Le Fort observed one case in which the uterus existed and there were extreme 
 pains at each menstrual period, with vicarious hemorrhages from the con- 
 junctivae or the skin of the legs which split spontaneously, or haemoptysis. 
 The vulva and the vagina may both be entirely absent at the same time, but 
 more often the vulva is well formed and there is a funnel-shaped depression 
 behind the well-developed nymphae, and the hymen may also be perfectly 
 normal (Fig. 584). The urethra is at times dilated by coitus. 
 
 There are two important varieties to be distinguished according as this 
 complete absence or rudimentary development involves the whole length of 
 57 
 
898 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 the canal or only one of its parts. The vagina is formed from the Miillerian 
 ducts, and the process always goes on from above downward. It is there- 
 fore difficult to understand why it is the lower portion of the vagina which 
 most frequently exists in these cases of arrested development. It seems to 
 me that it is the normal elongation of the vestibular canal which persists, 
 the anterior portion of the uro-genital sinus ; this ectodermic opening, which 
 is insignificant in the normal condition, takes on a new importance, predom- 
 inating as it did in the embryo before the development of the ]\Iiillerian 
 ducts exceeded it. This pouch, which is often found in the absence of the 
 vagina and the uterus, may be 2 or 3 cm. in length and wide enough to ad- 
 mit the finger; but efforts of coitus increase these dimensions very consider- 
 ably. The vestibular cul-de-sac is closed by a pearly, reticulated membrane 
 with a cicatricial appearance. 
 
 The vagina may be absent in its middle portion, and its tw^o ends are 
 then separated by a membrane of variable thickness which is at times per- 
 forated; there is then without doubt an arrest of development in the Miil- 
 lerian portion and a compensatory increase in the vestibular canal which 
 endeavors to reach the upper part and fuse with it. These two segments 
 have been seen to impinge upon each other without union of their canals. 
 To suppose that in such cases one of the ducts of IMiiller is lacking in its 
 lower part, and the other in its upper part, is to formulate a very improbable 
 theory. My explanation seems more natural. 
 
 Rectal touch with the vesical sound, or even with the finger in the blad- 
 der, should always be carefully employed in such cases, and the expansion 
 of the urethra produced by attempts at intercourse still more widely dilated 
 by Hegar's bougies if necessary. The fibrous cord which exists in the case 
 of rudimentary development will thus be felt, and will serve as a guide dur- 
 ing operation. When the uterus is absent or rudimentary, rectal touch per- 
 mits the sound to be felt both below and above it. The ovaries should be 
 sought with care by bimanual palpation combined with rectal touch. The 
 examination should always be made under anaesthesia. 
 
 Treatment. — The absence of all or a part of the vagina offers different 
 indications according as the uterus is developed; if this organ is normal, the 
 phenomena of hasmatometra occur at puberty and require interference, as I 
 will describe later. 
 
 If there is no uterus, and the ovaries are well developed, the painful 
 dysmenorrhoea which appears at the time of ovulation may be a sufficient 
 reason for the performance of castration, which has been done several times 
 with success. 
 
 Where there is only a deformity which renders the person sexually in- 
 competent, and the woman demands the creation of a vagina simply for the 
 purposes of coitus, are we justified in operating unless there are accidents 
 from retention .-' The question has been answered in various ways. Schroder, 
 Hegar, and Kaltenbach are inclined to the negative, considering the danger 
 
MALFORMATIONS OF THE VAGINA AND THE UTERUS. 899 
 
 and the risk of injury to the adjacent organs when there is no uterine tumor 
 to serve as a guide. But Le Fort justly remarks that there are circumstances 
 where the operation of compliance might become one of necessity. It was 
 first performed by Amussat. 
 
 If we decide to make an artificial vagina, we proceed with the greatest 
 precaution to the liberation of the septum at the bottom of the vulvar de- 
 pression, using the fingers chiefly in the division of the soft parts, and pro- 
 ceeding step by step by combined tearing and dissection, the finger of the 
 operator or an assistant being kept in the rectum and a sound in the 
 bladder. 
 
 When the depth of 6 to 8 cm. has been reached, the second step of the 
 operation should be performed, which is the investment of the funnel so 
 created with integument to prevent cicatricial contraction. For this purpose 
 the skin and mucous membrane of the adjacent parts may be employed; and 
 the first incision must therefore be carefully made in the form of a trans- 
 verse cut with two lateral branches, like the letter H. After the sutures have 
 been applied, the artificial canal must be packed with iodoform gauze, and 
 this treatment continued until cicatrization is complete; then a Gariel 
 pessary may be substituted. 
 
 In spite of every care in the operation, of which Picque has published an 
 excellent example, the primary result is maintained with difficulty, for the 
 angle which forms the bottom of the cavity is very hard to cover with graft, 
 and, even when the graft has adhered well, there is an invincible tendency to 
 draw the flap outward and gradually fill up the canal. Fortunately the sur- 
 geon's efforts find an auxiliary in the daily practice of coitus, which in cer- 
 tain cases has given results which surpassed hope. 
 
 Mackenrodt has covered the infundibulum which he had just formed with 
 pieces of vaginal mucous membrane taken from cases of prolapsus. 
 
 Polaillon, who was able to reach to the uterus in one case, operated in 
 two sessions after an interval of three weeks ; and this method of several 
 operations was advised by Amussat, who was the first to create an artificial 
 vagina. 
 
 Le Fort has obtained remarkable success with electrolysis in a case 
 in which there was a uterus and the menses were replaced by vicarious hemor- 
 rhages. He made a cylinder of boxwood, furnished with a copper end, 
 which was connected to a six-element battery of florin sulphate-of-copper 
 cells, and a metallic plate placed on the abdomen with some wet compresses 
 interposed, made the connection ; this apparatus was used during the night. 
 After a short time the cylinder had created a canal of about 8 cm. depth, 
 which Le Fort enlarged progressively, at first with a forceps like a glove- 
 stretcher, one of whose branches was tipped with copper, and afterward with 
 a wooden dilator. The result was satisfactory, but we do not know whether 
 it was permanent. 
 
 Ufiilateml Vagina. — It is probable that in this case but one of Mliller's 
 
900 CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 ducts sen-es to form the vagina, although this anomaly of development may 
 not be apparent; it is certainly the case in the one-horned uterus. It might 
 be suspected from the narrowness of the canal. In cases of partially double 
 vagina there is an incomplete development of one of the ducts, and the 
 vagina is partly unilateral, but it is better to class these cases with the 
 following. 
 
 Double Vagina. — When there is a septum which divides the entire va- 
 gina, the uterus is also double or divided. The hymen may be furnished 
 with two openings, simulating a double hymen ; or it may have the annular 
 form, separated from the septum by a decided interval. The septum is gen- 
 erally placed in the middle in such a way that one of the canals is situated 
 a little anterior to the other ; when coitus is practised, it is by the larger of 
 the two conduits. 
 
 An important variety of this condition is seen in what may be termed lat- 
 eral vaginal atresia, constituted by the rudimentary development of one of 
 the halves, whose lower end remains closed, but whose superior extremity 
 receives one cendx of the double uterus ; this condition is almost always 
 found on the right side. Thus, there is a blind pouch by the side of the 
 principal vagina, Avhich may remain unnoticed until it becomes filled with 
 blood at puberty, or with pus from an infection through a weak part of the 
 septum; thus occur peculiar cases, which for a long time escape diagnosis, 
 which are called lateral haematocolpos or pyocolpos. 
 
 The first, due to the retention of the menstrual blood, often coincides 
 with lateral haematometra, but the collection of pus may be limited to the 
 vaginal pouch without distention of the corresponding segment of the uterus, 
 for it quickly makes an exit for itself by perforating the septum, as I have 
 seen in one case. There may also be pyometritis, which is a grave condi- 
 tion ; and the evacuation of the pus does not remove the danger, for the per- 
 foration may take place high up on the septum, even within the uterus, and 
 the purulent material collects again. 
 
 When there is haematometra, the collection may be mistaken for an intra- 
 peritoneal pelvic haematocele. If the vaginal tumor alone is present, it may 
 be considered as a cyst of the vagina, and Freund has even asserted that 
 certain cysts were of this origin, which seems to me to confound two lesions 
 Vv-hich are really distinct. 
 
 The partition of the vagina may be only partial, and it is then the supe- 
 rior portion of the septum which is lacking, for the Miillerian ducts coalesce 
 from above downward. But when the uterus is double, the upper portion of 
 the vagina may be found to contain the septum, as if the division of the 
 uterus were carried down into the vagina, while the fusion is comp^'^ite 
 below. 
 
 Usually the septum is thick and fleshy, resembling the recto-vaginal par- 
 tition, but it may be very thin or even perforated in places ; or the only 
 traces which exist may be merely a few bridles stretching from side to side. 
 
MALFORMATIONS OF THE VAGINA AND THE UTERUS. 9OI 
 
 These lesions have been considered alternately as vestiges from the fu.'5ion of 
 the canals of Muller and as adhesions formed during foetal life. 
 
 The partition of the vagina may not be incompatible with normal labor. 
 Dunning reports a case in which there were two vaginaD separated by a septum 
 which began just above the vulva, and extended to the interval between the 
 two small cervices, and the sound demonstrated that the division continued 
 into the uterus. Pregnancy occurred on the right side, where the uterine 
 cavity was larger, the cer\-ices swelled equally, and the septum between the 
 two uteri disappeared, probably by absorption. During labor the vaginal 
 septum was torn from top to bottom, and only its lower portion persisted; 
 the labor was accomplished without difficulty. The absorption of the sep- 
 tum during pregnancy is not unusual ; the abnormal tissues seem to suffer 
 great disturbances in their nutrition on account of the changes which take 
 place in the puerperal state. The danger of uterine rupture is not great on 
 account of the ease with which the septum is torn and the congenital bridles 
 stretch. But it may happen that incomplete septa form an obstacle to the 
 passage of the fcetal head, and in this case they should be divided during 
 parturition; there is no danger-of hemorrhage. 
 
 For the symptoms and treatment of hsematometra complicating lateral 
 heematocolpos, I refer to the following chapter. 
 
 Simple pyocolpos without dilatation of the uterus, requires free incision, 
 without which the suppuration cannot be controlled. I think that the indi- 
 cation is to make an excision of the whole wall of the purulent pouch at the 
 same time; this may be performed with the scissors and the hemorrhage 
 controlled by the thermo-cautery or the catgut suture, followed by antiseptic 
 injections and tamponing with iodoform gauze. A septum or a bridle re- 
 sulting from an incomplete septum which was an obstacle to coitus might 
 "be excised in the same manner. 
 
 Congenital Atresia and Stenosis — -Transverse Bridles. — The histor}'- of 
 atresia of the vagina, from an anatomical point of view, is confounded with 
 that of imperforate hymen and of absence or imperfect development of the 
 vagina, as already described. For the treatment of haematometra, I refer to 
 the following chapter. 
 
 Stenosis or contraction of the congenital form, when it presents the ap- 
 pearance of partial adhesions or of transverse bridles, is undoubtedly due to 
 the persistence of the fusion of the vaginal walls as Geigel has demonstrated 
 on a foetus of four months. But it may also be due to arrested development 
 of Miiller's ducts at a definite point of their course; the contraction may be 
 so complete that the end of the sound will hardly pass, and it may occupy 
 only the superior third of the canal, where contractions of this kind are 
 ■usually found. 
 
 In the case of one-horned uteri the vagina may be very narrow, due to 
 the fact that the canal is formed from only one of the ducts of Miiller, the 
 other having aborted throughout its entire length. 
 
g02 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 Contractions in the form of transverse bridles may take the form of cres- 
 cents or of incomplete disphragms ; these are probably the cases which are 
 described as supplementary hymens. These atresise cause the retention of 
 the menstrual blood within the uterus when any obstacle temporarily ob- 
 structs their lumen ; then an overflow occurs, followed by new accumulation 
 of fluid ; and serious accidents may occur in this way. 
 
 The obstacle to copulation and to parturition may require operative in- 
 terference. But here, also the tissues swell so much under the influence of 
 pregnancy that they stretch to an unexpected degree, which may render the 
 proposed operation unnecessary. This elasticity has certain limits, and 
 there should be no hesitation in cutting the bridle with the. scissors if it 
 offered a manifest obstacle at the moment of parturition ; too long delay has 
 permitted the uterus to rupture. 
 
 The anomaly which consists in the presence of transverse bands may be 
 compared with the same condition which is normal in the vaginae of certain 
 animals. The vagina of the Cetaceae has been found to contain as many as 
 eight successive folds ; in the chimpanzee the vaginal folds form crescents 
 of great extent ; and in the sheep these rings or diaphragms extend up to the 
 cervix. 
 
 Malformations of the Uterus. — I. Absence and Rndime^itary Devel- 
 opment of the Utejiis. — These two malformations do not require separate 
 description, for the differences which distinguish them have no importance 
 clinically, however interesting from the standpoint of teratology; in either 
 case there is no uterus, whether we can find no trace of it or only an insig- 
 nificant vestige. 
 
 Complete absence (defectus uteri) is extremely uncommon, and many 
 cases of the anomaly which have been published are probably due to an 
 error of interpretation ; there are numerous autopsies where the rudimentary 
 horns of the uterus were taken for the non-existent tubes. The exact inser- 
 tion of the round ligaments is a valuable point in the decision of the ques- 
 tion. In complete absence of the uterus the rectum and the bladder are in 
 apposition, and the round ligaments are lost in the cellular tissue which 
 separates these two viscera; the ovaries may also be wanting. A similar 
 anomaly is met, with other grave deformities of the viscera, in non-viable 
 infants. 
 
 The rudimentary uterus (uterus rudimentarius) is constituted by a mass 
 of small size and variable form which occupies the place where the uterus 
 should be. This vestige of the organ may be either a slight thickening of 
 the posterior wall of the bladder, or, if reinforced with a few fibro-muscular 
 bands, part of the broad ligament, or a small band stretched between the 
 tubes. When it is joined to the cervix in the form of a T, it is called uterus 
 bipartitus, being reduced to its two cornua and reproducing the type of some 
 of the lower animals ; these cornua may be hollow and carpeted with mu- 
 cous membrane. The ovaries may be altogether wanting, or, if present. 
 
MALFORMATIONS OF THE VAGINA AND THE UTERUS. 
 
 903 
 
 maybe atrophied, flattened, and shrunken; but they may also be perfectly 
 developed (Figs. 585, 586). 
 
 Ovulation occurs in such cases, but causes no molimen as a general rule, 
 and there is no menstruation. As to the rest of the genital organs, the va- 
 
 FiG. 585. — Rudimentary Uterus (Veit). «, Imperforate uterus ; b h^ rudimentary cornua ; c c^ round ligaments; 
 
 d (/, tubes ; e <?, ovaries. 
 
 gina is most often wanting in whole or in part throughout its entire Miil- 
 lerian portion, its place being taken below by a short vestibule ; the external 
 parts are well formed. 
 
 In rare cases, however, the vagina is completely developed, of which I 
 have seen one example, and Munde and Leopold have also observed one. 
 Another case which is quite certain, in which castration was performed for the 
 
 Fig. 586. — Rudimentary Uterus, Variety Bipartitus (Rokitansky). a, Vagina, closed ; jf, cervix; </, rudimen- 
 tary cornu ; b^ Fallopian fube ; c, ovary ; e, round ligament. 
 
 pains caused by ovulation, belongs to Max Strauch. It is sometimes neces- 
 sary to remove the ovaries when they have developed normally in spite of 
 the atrophy of the uterus, as ovulation may cause periodic pain and nervous 
 disorders. This is one of the indications for Battey's operation. 
 
 Women who present these anomalies have nothing externally which would 
 lead one to suspect it ; the form of the body, the voice, and the psychical 
 characteristics are those of a well-made person, and the development of the 
 breasts is normal. Usually they have relations with the other sex, and the 
 result is to deepen the cul-de-sac of the vestibule till it becomes a large 
 
904 
 
 CLINICAL AND OPERATIVE GYNECOLOGY, 
 
 canal ; at other times it is the urethra which serves the purposes of copula- 
 tion. 
 
 The diagnosis between a normal and an atrophied uterus is easily made 
 by the aid of bimanual palpation and rectal touch, the latter combined with 
 the sound or the finger in the bladder. At the same time the abdominal 
 parietes should be strongly depressed above the pubes by an assistant. To 
 determine upon the living patient whether the uterus is rudimentary or 
 wholly absent is generally impossible. 
 
 Breisky has established a particular class for cases of absence or atrophy 
 of the cervix, which often coexists with absence of the upper portion of the 
 vagina. The uterus is atrophied, but differs from the rudimentary organ by 
 
 Fig. 587. — Diagram of an Infantile Uterus ^vITH only the Left Cornu (T. Muller). a, Cer\-ix ; i5, 
 fundus ; c d, longitudinal axis of the body of the organ ; _/", tube ; g^ ova^^' ; /;;, ovarian ligament ; /, round ligament ; 
 k^ parovarium. 
 
 the presence of a cavity where menstruation occurs, constituting haemato- 
 metra. The cervix is wholly lacking or represented by a small fold. If 
 there is no effusion of blood into the uterine cavity, the symptoms do not 
 differ from those of a rudimentar}' uterus ; in the contrary case there is 
 hasmatometra* 
 
 II. Ujiicorn Uterus. — The uterus is developed from only one of the Miil- 
 lerian ducts, the other being atrophied ; starting from the cervix, the organ 
 is elongated and strongly curves toward the tube with which it is directly 
 continuous, and of which it is simply the inferior expansion; its summit 
 sustains the ovary. There is actually only a small part of the fundus of the 
 organ and its cavity is small relatively to that of the cervix ; the vagina 
 is very narrow (Fig. 588). On the opposite side there may be no ves- 
 tige of the other Mlillerian canal, and then the uterus is absolutely 
 unicorn. 
 
 An important variety is constituted by the presence of a rudimentary 
 body. This may be formed of a band of compact muscular tissue, or it may 
 be hollow with a small cavity which communicates with the larger cornu and 
 forms a diverticulum from it. The rudimentary cornu is inserted at the 
 
MALFORMATIONS OF TJiE VAGINA AND THE UTERUS. 
 
 905 
 
 level of the internal os (for in such cases the fundus does not exist), and is 
 very long, as if drawn out, and subject to many variations of form. 
 
 The unicorn uterus is an organ which is mutilated in its origin, but. 
 
 Fig. 58S. — Unicorn Uterus (Schroder). The left cornu is developed normally and in communication with the 
 ■uterine cavity ; the right cornu presents only an elongated band whose junction with the tube is indicated by the inser- 
 tion of the hypertrophied round ligament. 
 
 when it arrives at the adult state, it functionates as a normal uterus ; men- 
 struation is regular, and pregnancy is accomplished without danger in the 
 larger cornu. It is otherwise if the ovule is arrested in the rudimentary 
 
 Double Bicorn Uterus (Barnes). 
 
 cornu ; then its walls are incapable of furnishing the necessary material to 
 form the cavity required for the growing contents, and it ruptures from the 
 third to the sixth month. Pregnancy of this kind is classed with ectopic 
 pregnancies and studied in the same chapter with extra-uterine pregnancy, 
 with which it has many points in common. 
 
go6 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 The diagnosis is seldom made ; but the malformation may be suspected 
 when the vagina is very narrow, the cervix large and short, and the uterus, 
 on bimanual palpation, of an elongated and curved form. 
 
 Pregnancy in the rudimentary horn is almost always taken for tubal be- 
 cause of the pedicle which separates the tumor from the larger tube, which 
 simulates the body of a well-formed uterus. 
 
 III. DojLble Uterus. — The uterus is really double when the ducts of Miil- 
 ler do not fuse or are only partially joined, and undergo each a complete 
 development. There are many kinds of this anomaly : 
 
 I. The bicorn uterus (uterus bicornis), where the two parts of the organ 
 
 Fig. sgo. — Bicorn Unicervical Uterus (Barnes). 
 
 are separate from each other. If the division reaches the cervix, which is 
 at the same time furnished with a septum, we have a double bicorn uterus 
 (uterus bicornis duplex or septus). Then the coalescence is more pro- 
 nounced, the cervix presents no trace of a septum, but is very large; this 
 is the unicervical bicorn uterus (uterus bicornis unicollis). Finally, when 
 the two uterine segments are almost complete, and this bifid condition is 
 manifested only by a depression at the fundus, we have the arched bicorn 
 uterus Tuterus arcuatus), which is a transition form and the last stage before 
 the normal organ (Figs. 589, 590, 591). 
 
 Usually the left cornu is directed forward in such a way that the uterus 
 is twisted round its vertical axis. Frequently there is a bridle which goes 
 to the anterior face of the rectum from the posterior aspect of the bladder 
 above the notch in the fundus of the uterus; this is the result of a malfor- 
 
MALFORMATIONS OF THE VAGINA AND THE UTERUS. 
 
 907 
 
 mation ; its importance is very great in pregnancy, for it may be the cause 
 of dystocia. 
 
 The two portions of the uterus are seldom equal, and there are many 
 transitions between the unicorn and bicorn varieties ; the less developed 
 side is apt to be the seat of a haematometra. The external organs and the 
 breasts present no peculiarities, but the vagina is often double, and on one 
 side there may be hsematocolpos. 
 
 Fig. 591. — Arcuate Bicorn Uterus (Barnes). 
 
 If both sides are developed equally, menstruation may occur in each, 
 segment, and pregnancy then interrupts the menstrual flow only on one 
 side. 
 
 Pregnancy follows its normal course and the foetus reaches full term, the 
 hypertrophy of the non-gravid side keeping pace with that of the other, and 
 membranes have been expelled from it ; during labor both cornua contract. 
 
 Gontermann has reported a case in which the pregnancy seemed to occur 
 alternately in either side. Twin pregnancies have been obsei-v^ed where 
 there was a foetus in each cornu ; at other times both children will be devel- 
 oped in the same segment of the uterus. With the arcuate form of the organ 
 transverse positions are frequent. This malformation of the uterus, like all 
 the others, may be a cause of vicious attachment of the placenta ; rupture of 
 the organ has also been observed. 
 
 The vesico-rectal bridle may present an obstacle to the passage of the 
 foetal head. At times it is sufficient to alter the obliquity of the gravid 
 
90J 
 
 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 portion and allow the patient to lie on the opposite side ; but it may be nec- 
 essary to perform podalic version and extract the child. Bands in the vagina 
 should be divided, and, if there is lateral haematometra, it should be evacu- 
 ated. Finally, it is well to notice how often an anomaly of the uterus passes 
 unrecognized through pregnancy and parturition, to be discovered much 
 later; the septum is mistaken by the touch for the wall of the vagina or 
 uterus. 
 
 2, Biloadar Uterus {Uterus Biloatlaris, Septus, Bipartitiis). — The charac- 
 teristic feature of this variety consists in the normal external configuration of 
 the organ, while its cavity is separated into two by a median partition. This 
 division may be complete or it may cease inferiorly, forming the uterus 
 
 Fig. 592. — BiLOCULAR Uterus and Vaginal 
 Septum ; Vertical Section (Kussmaul). i/, 
 Partition which divides the uterus into two 
 lialves ; 3", tubes ; K, vagina divided by the 
 •uterine septum prolonged. 
 
 Fig. 593. — DiDELPHic Uterus and Divided Vagina 
 (Olivier). «, Right segment ; b^ left segment ; c </, 
 right ovary and round ligament ; _f <?, left ovary and 
 round ligament ; gj\ left cer\'ix and vagina ; k^ vaginal 
 septum ; Ji z, right cervix and vagina. 
 
 subseptus ; or the septum may be pierced with openings which leave only a 
 number of bands across the cavity. The vagina may be either single or di- 
 vided, and in the latter case each of its cavities corresponds to one of the 
 segments of the cervix (Fig. 593). Corazza has reported an exceptional 
 case in which the vagina was divided, and the uterus was not. 
 
 What has been said of the bicorn uterus as regards menstruation, preg- 
 nancy, and atresia of the segments^ with hasmatometra, applies also to the 
 bilocular variety of malformation. 
 
 3. Didelphic Uterus {Uterus Duplex, Separatus, Diductus). — In these cases 
 there are actually two uteri, separated as far as the cervix and including it, 
 and not two bodies more or less divergent as in the case of the bicorn va- 
 riety. Here each segment presents the appearance of a complete uterus, 
 
MALFORMATIONS OF THE VAGINA AND THE UTERUS. 9O9 
 
 and may be said to be two unicorn uteri equally developed and apposed with- 
 out fusion. It was thought that this malformation occurred only in non- 
 viable embryos with deformities of a serious nature affecting other organs, 
 and it has been seen with ectropion of the bladder, atresia of the anus, and 
 persistence of the cloaca. Cases observed in adults are of comparatively re- 
 cent date; but it is probable that many of the older cases of bicorn uterus 
 ought to be revised and placed in this class. The most conclusive case of 
 the didelphic uterus in the adults is that of Olivier, in which at the autopsy 
 of a woman of forty-two years, the mother of six children, this malforma- 
 tion was discovered, Heitzmann reported a case of a young woman of twenty- 
 three years where the vagina was double, with a septum which divided the 
 cervix ; and a sound in the two uterine cavities proved that they diverged 
 from their cervical union and became two distinct and movable organs. 
 
 The recto-vesical ligament which so often passes above the bicorn uterus 
 has not been described with the didelphic form. 
 
 In clinical examinations it is always difficult to decide whether the case- 
 is one of complete bicorn or of didelphic uterus; it can be certainly decided 
 only on anatomical examination. The clinical histories of the two forms 
 seem to be the same in each case, as far as we can judge by the few speci- 
 mens of the didelphic form which we possess. 
 
 Atresia of one of the segments may produce lateral haematometra ; preg- 
 nancy may occur in each side simultaneously, 
 
 4. Fcetal or Infantile Uterus. — This anomaly is produced when the 
 uterus is completely developed in its general formation, but remains sta- 
 tionary and preserves the proportions and nearly the dimensions which it 
 had at birth. A subtle distinction has been drawn between the foetal type 
 which represents the last stage of the embryonic evolution, with the mucous 
 folds extending even into the fundus of the organ, and the infantile type 
 where the organ resembles the uterus of the new-born child 
 with the folds only in the cervix. It is but a refinement of 
 anatomy which deserves mention merely; from all other points 
 of view the two varieties are identical. The characteristic of 
 both is the unequal development of the cervix and the fundus, 
 reproducing the foetal type. The cervix is twice or thrice 
 the length of the body, and, while its walls are relatively 
 thick, those of the fundus are thin or even membranous. 
 The whole length of the cavity does not exceed 4 cm. ; the 
 cervical orifice is small, and the cervix is conical or tapi- „ , 
 
 ' _ _ J^ _ Fig. 594.— In- 
 
 roid (in the shape of the tapir's muzzle). The vagina is fantilb Uterus 
 usually short and narrow; the external organs may be chkoder . 
 well developed and the breasts small. There is complete amenorrhoea. 
 
 If the uterus is atrophied, the condition may be easily recognized on 
 bimanual palpation with the aid of rectal touch. To distinguish the foetal 
 from the pubescent uterus, which presents the same reduced dimensions and 
 
giO CLINICAL AND OPERATIVE GYNAECOLOGY. 
 
 occasionally the same amenorrhoea, we may be guided theoretically by the 
 size of the cervix. In the uterus of the foetal type, the cervix is quite firm, 
 -especially in its supra-vaginal portion ; in the pubescent uterus, on the con- 
 trary, the cervix is thin and relaxed. As a matter of fact, however, these 
 distinctions are clinically without practical value, and are also a little 
 illusor}^ 
 
 Minor Uterine Anomalies. — It is convenient to describe under this head 
 a number of slight malformations which do not belong in the classes already 
 treated. 
 
 Congenital Obliquity and Latero-position of tJie Utenis. — This condition 
 is due to asymmetry of the organ where one part predominates and causes a 
 distortion of the other, inclining it toward the well-developed side; the re- 
 
 FiG. 595. — Congenital OBLiQuiTi' of the Uterus ; Incomplete Development of the Right Side (Tiedemank). 
 
 suit is a relative shortening of the broad ligament. In the cases in which 
 this is not very pronounced a simple latero-version is found, which may be 
 compared to congenital anteversion. When w^ell marked, this anomaly might 
 be confounded with the unicorn uterus if w^e were not apprised of the pos- 
 sible error. 
 
 Duplicity of the External Os {Utenis Biforis). — A double os may be found 
 where the uterus itself is single. This anomaly has been the cause of acci- 
 dents during deliver)% but usually the bridle is either torn or pushed aside ; 
 serious bleeding has followed its laceration. If the physician is not aware 
 of this deformity, he may easily be perplexed by it ; if he recognize it, he 
 will attempt to keep the band on one side and disengage the foetal part which 
 presents, or, if this fails, he will cut it between two ligatures. 
 
 Incomplete Tra7isverse Division of the Cervix. — P. Miiller described for 
 the first time the presence of a transverse fold in the cervix which projected 
 into its cavity. After dilating the part he found a second cervix fitted into 
 the first one. Breisky has also seen this anomaly, but his case is not pub- 
 lished. In both these cases, observed in the non-gravid uterus, the band 
 appeared to be the cause of hemorrhages, acting like a fibroma or a polyp, 
 and its excision caused the cessation of the symptoms. 
 
MALFORMATIONS OF THE VAGINA AND THE UTERUS. 9II 
 
 Such bands may be an obstacle to delivery. Bidder has published a very 
 instructive case of this kind. Recently Budin has again drawn attention to 
 the subject by reporting two personal cases in which the septum was not a 
 cause of dystocia, and two cases of Mme. Henry's in which the bands were 
 situated at the internal os in one and about 2 cm. above it in the other, in 
 the lower segment of the uterine cavity. Two similar cases are reported by 
 E. Blanc. These bands may disappear with the labor or persist after it. 
 
 This anomaly has been compared with the transverse bands which exist 
 normally in the genital canals of certain animals, as I have mentioned in the 
 case of vaginal bridles. 
 
CHAPTER XLVIII. 
 
 RETENTION ACCIDENTS FROM GENITAL ATRESIA. 
 
 H.EMATOMETRA ; H.-EMATOCOLPOS ; Hydrometra ; Pyometra • Pyocolpos;-, 
 
 H.EMATO-SALPIXX. 
 
 Etiology and Symptoms. — I have described in what conditions the genital 
 canal may be closed by atresia situated at different parts of its course from 
 the hymen to the distant portions of a rudimentary cornu. This occlusion 
 may completely obstruct the canal, entirely closing one of the portions which 
 are derived from its division, or may simply shut off a diverticulum which 
 has arisen from defect in the conformation of its parts. However that may 
 be, at the time of puberty, if the ovaries and the mucous membrane of the 
 tubes permit the appearance of the menstrual phenomena, the blood which is 
 voided from the tubes into the uterus may find no way of escape; it there- 
 fore accumulates in the closed spaces, which retain it, and distends them in 
 various situations. 
 
 Haematocolpos occurs in imperforate conditions of the hymen and the 
 lower portion of the vagina, under the form of a tumor which fills the cavity 
 and exerts pressure on the rectum, and bulges forward the membrane which 
 limits it at the vulva. The uterus is pushed upward, and at first only the 
 cervix is distended, the cavity of the fundus resisting for a long time. Bi- 
 manual palpation and rectual touch perceive fluctuation, but the small hard 
 tumor which surmounts the collection, which is the non-dilated portion of 
 the uterus, often causes hesitation in diagnosis (Fig. 596). 
 
 When the inferior portion of the vagina is lacking, the collection is 
 limited to the part about the cervix, but here also the uterus is not at first 
 dilated, and if it become so it is only after the lapse of some time. When 
 the pouch is opened and the fluid removed, the finger perceives no demarca- 
 tion between the vagina and the distended cervix. 
 
 That haematometra may develop, the cavity of the uterus must alone re- 
 ceive the blood which accumulates ; this occurs when the entire vagina is 
 absent or when the internal os is occluded. Then the uterus becomes trans- 
 formed into a pouch with fairly thick walls, seldom thinned, where fundus 
 and cervix are continuous. If the atresia is at the internal os, the fundus 
 alone may dilate and the cervix preserve its normal proportions (Fig. 597). 
 In all cases of ha^matometra, and in many of haematocolpos, the tubes also 
 are dilated, and we have hasmato-salpinx. The blood in the tubes does not 
 come from reflux from the uterus, as is proved by the fact that there may be- 
 
RETENTION ACCIDENTS FROM GENITAL ATRESIA, 
 
 913 
 
 no communication between the two collections, and that the former may be 
 found by itself. We cannot refuse to admit that the blood in the tubes has 
 come from the mucous membrane of the part, for its own discharge coincides 
 with that from the uterus during menstruation. As the walls of the tubes 
 are thinner, they may be widely distended when the pressure in the genital 
 canal increases by the occlusion of the lower portion of the vagina, while 
 the thick walls of the uterus resist for a long time. 
 
 These irregular and twisted tumors of the tube may acquire an enormous 
 size. Small quantities of blood escape from time to time by the abdominal 
 
 Fic. 596.- 
 
 -H>EMATOCOLPOS FROM ATRESIA OF THE 
 HVMEN (SCHRODEU). 
 
 Fig. 597.— H^matometra from Atresia of 
 THE Internal Os. 
 
 end, and produce attacks of pelvic peritonitis (perimetro-.salpingitis). If the 
 amount of blood in the perineal cavity is large, it may not be absorbed, and 
 then we have pelvic hsematocele, which may coexist with general peritonitis. 
 
 The contents of these pouches formed by the retention of the menses will 
 generally be thickened blood of a chocolate color and a syrupy consistence 
 like tar, with its red corpuscles very much distorted. After puncture, the 
 pouch may suppurate and transform the case into one of pyocolpos or pyo- 
 metra ; decomposition of the fluid may produce gases and physometra. 
 
 Besides the tumor which appears at puberty and gradually enlarges, we 
 usually find pain at the time of menstruation in the form of colic, which is 
 attributed to the distention and the escape of blood into the peritoneum. 
 The pain becomes more frequent and then constant, causing the exhaustion 
 of the patient. 
 
 In certain cases, in which the flow of blood is probably very slight owing 
 to particular conditions of the o\'aries and of the mucous membrane of the 
 uterus, the accumulation of blood is slow and the principal symptom is the 
 pain. The menses may be supplied by vicarious hemorrhages taking place 
 at different points, and thus preventing the formation of haematometra. Fi- 
 nally the obliteration of the genital canal has at times coincided with a real 
 58 
 
914 
 
 CLINICAL AND OPERATIVE GYNECOLOGY, 
 
 or apparent amenorrhoea ; certain patients suffer only at the menstrual periods, 
 and there are others in \vhom there is no pain, and in whom the ovaries 
 probably do not functionate. 
 
 Diagnosis. — The absence of the menses, the imperf oration more or less 
 accessible to examination, and the appearance of a tumor which occupies the 
 normal position of the genital cavities are the signs which together are 
 pathognomonic. 
 
 Atresiae at the hymen and a little behind it are often confounded, with- 
 out any practical importance in the mistake. In either case the membrane 
 
 Fig. 598. — H.r.MATocoLi'os .\xd H/EMatometra fro.m Atresia of the Inferior Portio.v of the Vagina 
 ( Barnes), i', Distended vagina ; 011, internal os. 
 
 is depressible, although so thick that spontaneous perforation is very rare. 
 The vulva and the perineum are prominent, their tension being comparable 
 to that of the membranes before parturition. 
 
 The examination of the uterine and tubal tumors should be undertaken 
 with care and without insisting on finding fluctuation, for fear of producing 
 rupture. This symptom may in any case be absent; when the pouch is very 
 tense, it is simply elastic. 
 
 There may be very grave doubts when there is ha^matometra from atresia 
 
RETENTION ACCIDENTS FROM GENITAL ATRESIA.. 915 
 
 of the internal os with a normal cervix ; then we have to decide between 
 pregnancy, fibroma, cancer of the fundus, and the h^ematometra, according 
 to the signs proper to each and the statements of the patient. 
 
 Where there is complete or partial division of the canal by a septum, the 
 ■difificulties in the way of diagnosis are very great for haDmatocolpos or haema- 
 tometra (I'ig. 599) of one side. Lateral hxmatocolpos does not form a tumor 
 which coincides with the vagina, but on account of an evolution, which 
 Jkeisky has well described, it undergoes a semi-spiral torsion, so that its 
 lower portion may be anterior and its upper posterior, or vice versa. Cysto- 
 •cele, vaginal cyst, vaginal enterocele, thrombus, and retro-uterine hasmatocele 
 •could hardly be confounded with hasmatometra or haematocolpos if proper 
 care were exercised. The difficulty is, however, great when, with a divided 
 vagina, the accumulation of blood takes place in one segment of a bicornate, 
 bilocular, or didelphic uterus. We should endeavor carefully to mark out 
 the limits of the tumor by the aid of bimanual palpation, and to discover the 
 non-dilated portion of the organ, which is generally pushed far to the side. 
 It is especially in the case of hnematometra of a rudimentary cornu that there 
 would be doubt, and a danger of mistaking it for a cystic tube, all the more 
 if the other tube were dilated; fibroma should also be excluded. Pregnancy 
 may occur in the free portion of the uterus and complicate the signs still 
 more. Exploratory puncture I consider very dangerous, and prefer explora- 
 tory incision if necessary in a doubtful case. 
 
 Prognosis. — Left to themselves, collections of blood from atresiae of the 
 genital canal are very serious. Spontaneous evacuation does not produce a 
 eure, but only a temporary relief, followed later by a return of the retention 
 symptoms aggravated by suppuration. The spontaneous perforation is 
 also generally insufificient, and c[uickly closes after permitting a partial 
 evacuation and also tlie infection of the sac. When, as seldom happens, the 
 accumulation is voided through an adjacent organ, like the intestine or even 
 the stomach, the result is not the less fatal ; renewed menstruation fills the 
 pouch again and the patient succumbs. Death occurs from septicaemia after 
 spontaneous rupture of the sac or from peritonitis after opening into the 
 peritoneum. 
 
 In astresia of a single segment of a double canal, the prognosis is not so 
 grave; lateral haematocolpos frequently terminates by rupture into the per- 
 meable vagina at the intra-cervical septum. But the suppuration of this 
 cavity, which generally occurs, causes a pyocolpos which may be fatal if the 
 opening is not freely enlarged. In partial haematometra of a rudimentary 
 segment, the accumulation of blood may cease and the tumor remain sta- 
 tionary. 
 
 Before the period of antiseptics, opening a large collection of blood in 
 the genital canal was frequently followed by septicaemia, whether the opera- 
 tion was a free incision without sufficient cleansing of the sac afterward, or a 
 simple puncture with the idea of preventing the entrance of the air, which 
 
9l6 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 was held responsible for all accidents, or to avoid the hasty removal of the 
 pressure, which was considered the cause of internal rupture. These acci- 
 dents are, as a matter of fact, produced by other causes, either primarily by 
 too violent exploration, or, secondarily, from alteration in the wall of the sac 
 as the result of septicaemia. The gravity of the operation has been consid- 
 ered so great that iBoyer, Dupuytren, and Cazeaux have advised against it ; 
 and within recent years interference was strongly opposed. But many suc- 
 
 FiG. 599. — Lateral HvEMatocolpos and H^matometra, with Double Uterus and Vagina, fko.m Com- 
 plete Atreslv or One of the Vagina and Imperforate Septum in the Genital Canal. Diagrammatic 
 (Martin). 
 
 cessful cases prove that it is not an operation which is necessarily fatal if we 
 proceed boldly and antiseptically ; consequently, the therapeutic prognosis 
 is completely changed. 
 
 Treatment. — i . Total Hce^natocolpos and Partial ( Cervical ) Hceniatometra ; 
 Atresia at tJie Hymen or Behind It. — Simple puncture not followed in the 
 same session by incision appears to be a prudent operation, but it is really 
 very grave and rash as it exposes to suppuration. We should therefore begin 
 by slowly evacuating the fluid by a very small opening, a simple puncture 
 with the bistoury, letting it escape gently for a half or a whole hour; then 
 the incision should be enlarged in the form of a cross. It is worse than use- 
 less to excise the obturating membrane. The sac must be cleaned out with 
 weak antiseptic solutions delivered with little force and the vagina lightly 
 packed with iodoform gauze. 
 
 It has been objected to this manner of slowly but progressively evacuat- 
 ing the fluid that the tubes might be ruptured if they were distended and ad- 
 herent to the adjacent j:)arts ; but this distention is very rare in hnsmatocol- 
 
RETENTION ACCIDENTS FROM CJENITAL ATRESIA. 
 
 917 
 
 pos with the atresia inferior, and the danger of rupturing the tubes is not so 
 great when their walls are intact as it becomes by temporizing until they are 
 altered by a certain degree of decomposition of their contents. 
 
 2. Partial Hcvviatocolpos and Partial or Complete Hcsniatonictra ; Atresia 
 of a Great Portion or the Whole (if the Wigina. — In this case we must pro- 
 ceed b)f an actual dissection, which is \'ery dangerous on account of the close- 
 ness of the bladder and rectum. Amv.ssat, who was the first operator bold 
 
 Fig. 600. — Lateral H.bmatometra in a Segment of a Double Uteris. Diagrammatic (Staude). «, b. 
 Insertion of the right tube and round ligament; c, iliac bone; d, symphysis ; f^ ut«rus ; g-^ h, insertion of left tube and 
 round ligament ; ?", umbilicus. 
 
 enough to propose the creation of an artificial vagina permitting the imme- 
 diate evacuation of the fluid and the regular escape of the menses afterward, 
 operated in several sessions, each time securing the part acquired by packing 
 it with prepared sponge; he rejected the cutting instrument, and used his 
 fingers alone in the separation of the tissues. It is better, however, to oper- 
 ate in one session. When the case is one of haematometra, the presence of 
 the tumor is a valuable guide in our dissection. When we arrive in its im- 
 mediate vicinity, which we may recognize by rectal touch, a trocar is plunged 
 into the fluctuating point; and as soon as it has penetrated, as is shown by 
 the escape of the fluid, the opening should be rapidly enlarged by small cuts 
 with a narrow -bladed bistoury on each side of the trocar. 
 
 Breisky recommends a bistoury with its blade concealed in a canula, but 
 this instrument is not indispensable. The calibre of the canal must be 
 maintained afterward by the use of c}']inders of hard rubber or glass. 
 
 Puncture by the rectum has been advised by Dubois, Boyer, Scanzoni, 
 and Baker Brown, but it should be rejected. Puncture or incision by the 
 bladder, which was proposed by Simon and Spiegelberg in cases in which the 
 perineal incision was too dangerous, should be taken into consideration ; we 
 
91 8 CLINICAL AND OPERATIVE GYNECOLOGY. 
 
 could thus certainly evacuate such a collection without opening the perito- 
 neum where there was the danger of immediate rupture. But the penetra- 
 tion of the urine into the sac and its possible infection from cystitis, which 
 the altered blood might produce, constitutes an actual danger. The para- 
 sacral or pararectal incision might be utilized in these cases. 
 
 3. Total Hcematometra ; Atresia of the Uterine Cervix. — The obliteration 
 may be at the external or at the internal orifice. In the latter case we begin 
 by dilating the cervix with laminaria tents, and we attempt to introduce a 
 sound. If this fails, or if there is atresia of the external os, we should 
 puncture with a trocar first, and then employ the bistoury or the scissors to 
 enlarge the opening. After repeated washing with a feeble antiseptic solu- 
 tion with the aid of an intra-uterine catheter, the cavities of the cervix and 
 the fundus should be tamponed with iodoform gauze, and thus an exagger- 
 ated degree of dilatation maintained for a few days. Afterward a glass 
 canula or a cross-shaped rubber tube should be left in the uterus for a long 
 time. When the uterus returns to its normal dimensions, the metritis which 
 is the consequence of the first lesion should be treated by the curette. 
 
 4. Lateral Hoematocolpos and Hcematometra ; Atresia of Part of a Double 
 Canal. — All these lesions which I have passed in review may exist in one 
 half of a double genital canal. No special indications are found; the pre- 
 cepts already formulated apply here also. 
 
 In lateral haematocolpos, Schroder advises not to excise the septum toO' 
 freely, so that the penis may not pass into the vagina which was occluded, to 
 avoid a pregnancy on that side; such a precaution seems to me illusory, 
 for the spermatozoa find their way into the smallest openings. It appears to 
 me preferable to excise the septum as freely as possible and transform the 
 double vagina into a single canal. 
 
 There is a great difficulty in the treatment, as in the diagnosis, where 
 there is an accumulation in a rudimentary cornu with a pedicle, which is 
 often elongated, thus forming a tumor which appears to be independent of 
 the uterus. It has been advised to reach the collection through the vagina,, 
 and Hegar recommends the practice, either by the cautery or by incision of 
 the cul-de-sac and iodoform tamponing carried up to the tumor, to provoke 
 adhesions. This seems to me more dangerous than laparatomy followed by 
 the ablation of the cornu and the corresponding tube, which is distended 
 by the blood. If extensive adhesions render the ablation too dangerous, we 
 may suture the sac to the abdominal wall, open it, and provoke its oblitera- 
 tion by granulation. 
 
 Hysterectomy could also be performed in certain cases of bicorn uterus. 
 The tumor is generally easy to furnish with a pedicle at the cervix, which is 
 fixed externally. I think that this operation should be reserved for those 
 cases in which it is not easy to reach the tumor by perineal dissection and 
 those in which the evacuation of the blood offers difficulties from the solidi- 
 fication of the contents of the sac, which may be transformed into fibrous 
 
RETENTION ACCIDENTS FROM GENITAL ATRESIA. 9I9 
 
 masses, as in a case of Jeannel's. Hysterectomy miy;ht be done immediately 
 if the conditions could be recognized beforehand, or it could follow the at- 
 tempt to evacuate b)- the vagina. Manoeuvres through this canal must not 
 be too prolonged, for they cause pressure which may rupture the tubal dila- 
 tation. Hysterectomy has been performed with success by John Homans 
 for a case of lateral haematometra in the bicorn uterus. 
 
 5. HcBinato-salpinx. — The hsemato-salpinx which so often complicates 
 atresias of the genital canal should not be neglected, for the rupture of a 
 thin-walled collection may produce death. Fuld has collected 66 cases of 
 atresia, either congenital or acquired, in which the accident has occurred, 
 and in 48 of them it was followed by death. Among these, 39 had fol- 
 lowed a previous operation, and 9 occurred without surgical interference. 
 Haemato-salpinx existed in 27 in which there was atresia without a septum, 
 and 12 in which the canal was double. 
 
 In order to appreciate the operative indications, we must know the natu- 
 ral evolution of a tubal collection after the vaginal or uterine tumor has been 
 evacuated. In many cases, if the way of escape provided is sufficiently large 
 and well maintained, the haemato-salpinx empties itself and disappears. But 
 there are cases in which the tumor of the tube suffered no change or in which 
 it was renewed at every menstrual period ; it is in these cases that we must 
 operate ; salpingotomy has given good results in the hands of Sutugin. 
 
 Simple evacuation of the haemato-salpinx by puncture has been proposed ; 
 but though less important in appearance, this is really more dangerous than 
 ablation. Puncture by the vaginal pouches has been followed by success, 
 but there is a risk of injury to the intestines and of effusion of blood into 
 the peritoneum, as well as of suppuration of the sac. Puncture through the 
 abdominal wall is open to the same objections. 
 
 There is one other occasion when salpingotomy is required. It is when, 
 after or before operation upon the vagina and uterus which are the seat of 
 atresia, the tumor of the tube suddenly disappears without the external issue 
 of a corresponding amount of blood ; it is then very probably that rupture 
 has occurred into the peritoneum ; symptoms of grave internal hemorrhage 
 render the diagnosis certain and demand immediate laparatomy. 
 
GENERAL INDEX. 
 
 Akdominal hysterectomy for fibroma, 238 
 
 hysterectomy for lesions of appendages, 
 550 
 
 palpation, 72 
 
 pregnancy, 706 
 Abscess of Bartholin's glands, 856 
 
 pelvic, 552 
 
 pelvic, etiology, 559 
 
 pelvic, historical sketch, 552 
 
 pelvic, origin and differentiation, 555 
 
 pelvic, prognosis, 5O4 
 
 pelvic, symptoms and diagnosis, 560 
 
 pelvic, treatment, 565 
 
 uterine, 114 
 Abscesses after ovariotomy, 640 
 Adenitis, pelvic, simulating pyo-salpinx, 540 
 Adeno-lymphitis, 552 
 Adenoma of uterus, 339 
 Adhesions in ovarian cysts, 603 
 
 in ovarian cysts, diagnosis, 622 
 
 in ovariotomy, treatment, 629 
 Alexander operation for retroflexion, 389 
 
 operation for uterine prolapse, 441 
 Alumnol, 10 
 
 Amputation, intra-vaginal, in cervical can- 
 cer, 308 
 
 intra-vaginal, of the cervix, statistics, 
 
 311 
 Amenorrhoea, after f)variotomy, 470 
 
 pathology and etiology, 469 
 
 primary, 470 
 
 secondary, 471 
 
 symptoms, 471 
 
 treatment, 472 
 Anesthesia, accidents during, 33 
 
 by suggestion, 29 
 
 chlorofcjrm, 30 
 
 cocaine, 27 
 
 ether, 30 
 
 general, 29 
 
 local, 27 
 
 mixed, 31 
 
 prolonged, 31 
 Anaesthetics, 30 
 
 Anaesthetics, administration, 33 
 Anastomosis, abdominal uretero-vesical, 
 770 
 vaginal uretero-vesical, 770 
 Androgyny, 882 
 
 Anteflexion, cervical, discission in, 373 
 uterine, 366 
 
 uterine, congenital, 369, 371 
 uterine, diagnosis, 370 
 uterine, etiology, 366 
 uterine, fibroma, mistaken for, 370 
 uterine, pathology, 366 
 uterine, pessary for, 372 
 uterine, symptoms, 369 
 uterine, treatment, 371 
 Anteposition of the uterus, 412 
 Anteversion of the uterus, 363 
 diagnosis, 363 
 etiology, 363 
 pathology, 363 
 pessary for, 364 
 symptoms, 363 
 treatment, 364 
 Antiphlogistic vaginal tamponade, 66 
 Antisepsis of cervix, 10 
 of instruments, 2, 17 
 of ligatures, 23 
 of operator. 1,15 
 of patient, 3, 15 
 of surroundings, 2, 15 
 of sutures, 23 
 of uterine cavity, 12 
 Antiseptic spray, 22 
 Apoplexy, ovarian intra-cystic, 604 
 
 ovarian, in haematocele, 688 
 Apostoli's uterine electrode, 216 
 Appendages, lesions of, 481 
 classification, 485 
 etiology. 487 
 haemato-salpinx, 528 
 hydro-salpinx, 527 
 pathology, 487 
 
 pyo-salpinx, course and duration, 
 540 
 
92 2 
 
 GENERAL INDEX. 
 
 Appendages, lesions of, pyo-salpinx, diag- 
 nosis, 538 
 pyo-salpinx, pathological anatomy, 
 
 523 
 pyo-salpinx, ovarian lesions, 531 
 pyo-salpinx, treatment, 542 
 pyo-salpinx, tubo-ovarian cysts, 528 
 salpingitis, 487 
 salpingitis, broad-ligament lesions, 
 
 510 
 salpingitis, contamination from ex- 
 ploration, 490 
 salpingitis.course and prognosis, 51 8 
 salpingitis, differential diagnosis, 
 
 516 
 salpingitis, endometritis, 488 
 salpingitis, gonorrhoeal infection, 
 
 488 
 salpingitis, ovarian lesions, 500 
 salpingitis, palpation, 515 
 salpingitis, pathological anatomy, 
 
 491 
 salpingitis, puerperal infection, 489 
 salpingitis, treatment, 519 
 salpingitis, tubal lesions, 491 
 Aristol, 10 
 
 Arnold's sterilizer, 20 
 Ascites in ovarian cysts, 604 
 Atresia, cervical, 456 
 
 genital, retention accidents from, 912 
 of hymen, 878 
 of vagina, 862 
 of vagina, congenital, 901 
 of vulva, 862 
 Atrophy, acquired, of cervix and uterus. 464 
 
 congenital, of cervix and uterus, 463 
 Autoclave, 18 
 Autoplasty m recto-vaginal fistula, 782 
 
 Baer's total abdominal hysterectomy, 261 
 Bandages, abdominal, 164 
 Bardenheuer's total abdominal hysterec- 
 tomy, 262 
 Bartholin's glands, inflammation and cysts, 
 
 853 
 
 Bed -pan, 6 
 
 Beta-naphthol, 4 
 
 Bimanual examination, 79 
 
 reduction of retroflexion, 380 
 
 Bischoff's colpo-perineorrhaphy. 433 
 
 Bladder, compression, in uterine fibroma, 
 20 1 
 injury in hysterectomy, 268 
 lesions in cervical cancer, 297 
 ulcerations with vaginal fistulse, 743 
 
 Bladder, wound in ovariotomy, 628 
 Bode's gastro-hysteropexy^ 410 
 Bodies, foreign m vagina, 865 
 Borgnet's pessary, 426 
 Braun's intra-uterine syringe, 171 
 Byford's colpo-cystorrhaphy, 443 
 Byrne's supra-vaginal cervical amputation,. 
 309 
 
 Calculi after fistula operation, 773 
 Cancer of cervix, 290 
 
 anatomical forms, 291 
 
 cauterization, 335 
 
 complicating pregnancy, 302, 337 
 
 diagnosis, 302 
 
 etiology, 306 
 
 extending to vagina and bladder or 
 
 rectum, treatment, 333 
 extension, 294 
 histological varieties, 292 
 invading vagina, treatment, 333 
 nodular form, 292 
 of cavity, 292 
 
 of external os, treatment, 308 
 of entire cervix, treatment, 309 
 papillary form, 291 
 pathological anatomy, 290 
 prognosis, 306 
 symptoms, 300 
 treatment, 308 
 treatment, palliative, 333 
 vaginal form, 292 
 vaginal hysterectomy, 313 
 with deep extension, treatment, 332 
 with extension to body of uterus, 
 
 treatment, 313 
 with fibroma, treatment, 338 
 with ovarian cyst, treatment. 338 
 Cancer, uterine, 339 
 
 uterine, deciduoma malignum, 351 
 uterine, epithelioma, 341 
 uterine, fibro-sarcoma, 349 
 uterine, sarcoma, 348 
 uterine, treatment, 356 
 vaginal, 739 
 vulval, 849 
 Carcinoma of Fallopian tube, 653 
 of ovary, 650 
 
 of uterine mucous membrane, 341 
 Cellulitis, pelvic, 552, 564 
 Cervical anteflexion, 370 
 
 fistulas, 763 
 Cervix, amputation in metritis, 181 
 antisepsis, 10 
 atresia, 456 
 
GENERAL INDEX. 
 
 9^5 
 
 Cervix, atrophy, acquired, 464 
 
 atrophy, congenital, 463 
 
 bilateral division, 94 
 
 cancer, 290 
 
 cysts, 129 
 
 dilatation, in uterine fibroma, 220 
 
 ectropion, 134 
 
 erosions, 129 
 
 excision, commissural, for stenosis, 461 
 
 fibroma, 191 
 
 fibroma of vaginal portion, 221 
 
 fibrous tumors in pregnancy, 2S5 
 
 folliculitis, 129 
 
 granulations, 129 
 
 hypertrophy, in prolapse, 416, 446 
 
 hypertrophy, intra-vaginal, 466 
 
 hypertrophy, supra-vaginal, 465 
 
 incomplete transverse division, gio 
 
 laceration, 136 
 
 lesions of, 126 
 
 malformations, 456 
 
 malignant diseases, rare, 303 
 
 normal mucosa, 112, 113 
 
 ovules of Naboth, 129 
 
 section, bilateral, in uterine fibroma, 221 
 
 stenosis, 457 
 
 superinvolution, with uterine atrophy, 
 464 
 
 tuberculosis, 662 
 
 ulcerations, 129 
 Chloroform anaesthesia, 30 
 Chrobak's total abdominal hysterectomy, 
 
 260 
 Cleveland's laparatomy table, 74 
 Clitoris, tumors, 852 
 Castration, definition, 276 
 
 for uterine fibroma, 276 
 
 for uterine fibroma, after-treatment, 281 
 
 for uterine fibroma, by median incision, 
 278 
 
 for uterine fibroma, contra-indications, 
 
 277 
 
 for uterine fibroma, mortality, 281 
 
 for uterine fibroma, operative technique, 
 277 
 
 for uterine fibroma, results, 281 
 
 for uterine fibroma, statistics, 281 
 
 in dysmenorrhoea, 478 
 
 in metritis, 186 
 
 technique, 479 
 Catheterism, 75. 99 
 Catheters, 12, 102 
 Catgut, 24 
 Cauterization in cervical cancer, 335 
 
 in metritis, 169 
 
 Cocaine anaesthesia, 28 
 Coccygodynia, 859 
 Collin's hysterotome, 373 
 Colpo-hysterectomy, 313 
 
 pelvic, 400 
 Colpo-hysteropexy, 393 
 Colpo-perineoplasty by flap-splitting, 434 
 Colpo-perineorrhaphy after-treatment, 440 
 
 Bischoff's, 433 
 
 for prolapse, 429 
 
 Hegar's, 429 
 
 Martin's, 431 
 
 Stoltz's, 436 
 
 results, 440 
 
 Winckel's, 433 
 Continuous intra-uterine irrigation, 64 
 Copulation, excessive, causing metritis, 147 
 Corpus luteum cysts, in salpingitis, 508 
 Cough, uterine, 154 
 Cowper's glands, inflammation and cysts. 
 
 853 
 Creolin, 4 
 Curettage, in uterine fibroma, 220 
 
 technique, 172, 173 
 Curette in salpingitis, 519 
 Curettes, 172, 333 
 Cystocele in prolapse, 415 
 Cystoplasty, Jobert's, 749, 766 
 Cystoscope, 104 
 Cysts, broad- ligament glandular, 634 
 
 broad-ligam.ent papillary, 634 
 
 of Bartholin's glands, S53 
 
 of vulva, 846 
 
 ovarian, 577 
 
 ovarian, abdominal stage, 609 
 
 ovarian, accidents, 612 
 
 ovarian, adhesions, 603 
 
 ovarian, ascites, 604 
 
 ovarian, blood, 534 
 
 ovarian, complicated by pregnancy, 644 
 
 ovarian, dermoid, 589 
 
 ovarian, diagnosis, 616 
 
 ovarian, etiology, 609 
 
 ovarian, follicular in salpingitis, 505 
 
 ovarian, exploratory incision in. 621 
 
 ovarian, iodine injections, 623 
 
 ovarian, lymphatic, 536 
 
 ovarian, metastasis m, 605 
 
 ovarian, ovariotomy. 624 
 
 ovarian, papillary, 577 
 
 ovarian, pedicle, torsion of, 605 
 
 ovarian, pelvic stage, 609 
 
 ovarian, prognosis, 614 
 
 ovarian, proliferous, 577 
 
 ovarian, proligerous, 577 
 
924 
 
 GENERAL INDEX. 
 
 Cysts, ovarian, purulent, 535 
 
 ovarian, rupture, 613 
 
 ovarian, serous, 532 
 
 ovarian, sj-mptoms, 6o3 
 
 ovarian, suppuration in, 605. 612 
 
 ovarian, treatment, 623 
 
 parovarian, 596 
 
 parovarian dermoid, 601 
 
 parovarian hj-aline, 599. 633 
 
 parovarian papillar\', 600 
 
 retroperitoneal, enucleation of, 633 
 
 tubo-ovarian, 528 
 
 vaginal, 733 
 
 vaginal, definition, 733 
 
 vaginal, diagnosis, 737 
 
 vaginal, etiology, 734 
 
 vaginal, pathogenesis, 733 
 
 vaginal, pathological anatomy, 734 
 
 vaginal, symptoms, 736 
 
 vaginal, treatment, 738 
 Czemj-'s gastro-hysteropexy, 404 
 
 suture, 38 
 
 Deciduoma malignum of uterus, 351 
 Decortication in uterine fibroma, 263 
 Dermatol, 10 
 Dermoid cysts, ovarian, 589 
 
 cysts, parovarian, 601 
 Dermoid of Fallopian tube. 655 
 Dilatation by tents, 91 
 
 cer%'ical, in uterine fibroma, 220 
 uterine, examination by, 89 
 Dilator, Hegar's, 94 
 
 uterine, 93 
 Disinfection, vaginal, 5 
 Displacements of the uterus, 360 
 
 Alquie - Alexander - Adams opera- 
 tion, 369 
 
 anteflexion, 366 
 
 anteposition, 412 
 
 anteversion, 363 
 
 classification, 361 
 
 colpo-hysteropexy, 393 
 
 gastro-hysteropexy, 400 
 
 historical review, 361 
 
 pelvic colpo-hysterectomy, 400 
 
 retrodeviations. 374 
 
 retroposition, 412 
 
 upward, 413 
 
 vaginal hysterectomy, 411 
 
 vaginal hysteropexy, 393 
 Divulsion, uterine dilatation by, 92 
 Doleris' colpo-perineoplasty, 434 
 Doyen's total abdominal hysterectomy, 261 
 Drainage, gauze, 60 
 
 Drainage, in metritis, 167 
 
 intra-uterine, 64 
 
 Mikulicz gauze, 61 
 
 of wounds, 55 
 
 of peritoneal cavity, 56 
 
 peritoneal, indications, 57 
 
 through vagina, 58 
 
 vaginal, after hysterectomy, 247 
 Drainage tubes, 25, 60 
 Dropsy, follicular, of ovary, 505 
 Dudley's gastro-hj-steropexy, 410 
 Diihrssen's operation for uretero-vaginal 
 fistula, 767 
 
 vagino -fixation, 394, 396 
 Dumontpallier's pessary, 364, 383 
 Dysmenprrhoea, castration, 478 
 
 in congenital anteflexion, 369, 372 
 
 in metritis, 153 
 
 in stenosis cervicis, 457 
 
 inter-menstrual, 476 
 
 membranous, 117, 159 
 
 of nervous origin, 474 
 
 of ovarian origin, 475 
 
 of uterine origin, 475 
 
 vaginal incision, 480 
 Dyspepsia, uterine, 154 
 
 EcHiNococci, in broad ligament, 656 
 Ecouvillon, Doleris', i6g 
 Ectopic pregnane)', 697 
 Eczema of vulva, 834 
 Electricity in amenorrhoea, 472 
 
 in ectopic pregnancy, 713 
 
 in salpingitis, 520 
 
 in uterine fibroma, 214 
 Elephantiasis arabum, 843 
 Elytrorrhaphy for prolapse, 429, 435 
 Elj'trotomy in ectopic pregnancy, 713, 720 
 Emmet's perineorrhaphy, complete rup- 
 ture, 819 
 
 perineorrhaphy, incomplete rupture, 806 
 
 scissors, 807 
 
 trachelorrhaphy, 184 
 Enchondroma of vulva, 846 
 Endoscopy, Kelly's, 104 
 Endometritis (see also Metritis) 109 
 
 acute, 116 
 
 chronic, 118 
 
 chronic glandular, 121 
 
 chronic polypoid, 122 
 
 post-abortum, 126 
 Endothelioma of ovary, 648 
 Entero-vaginal fistula, 790 
 Enucleation for encapsuled uterine fibroma, 
 242 
 
GENERAL INDEX. 
 
 925 
 
 Enucleation in submucous uterine fibroma, 
 
 224 
 Epispadias, 872 
 Epithelioma of broad ligament, 656 
 
 of cervix, atypical, 294 
 
 of cervix, cylindrical, 294 
 
 of cervix, pavement, 293 
 
 of ovary, 650 
 
 of uterine mucous membrane, 341 
 
 of vagina, 740 
 
 of vulva, 849 
 Ergot in uterine fibroma, 213 
 Erysipelas of vulva, 834 
 Esthiomene of vulva, 837 
 Ether anassthesia, 30 
 Ethyl bromide anaesthesia, 30 
 Evacuation of pelvic abscess, 572 
 Examination, bimanual, 79 
 
 by palpation, 72 
 
 by rectal touch, 78 
 
 by speculum, 80 
 
 by uterine sound, 87 
 
 by vaginal touch, 77 
 
 by vesical touch, 78 
 
 in dorsal position, 69 
 
 in erect position, 68 
 
 in knee-chest position, 72 
 
 in Sims' position, 71 
 
 in Trendelenburg position, 70 
 
 with anaesthesia, 76 
 
 with intra-uterine touch, 89 
 
 with traction of uterus, 88 
 Extra-peritoneal supra-vaginal hysterec- 
 tomy, 247 
 Extra-uterine pregnancy, 697 
 Exudations, sacculated, in tubercular peri- 
 tonitis, 679 
 
 Fecal fistulas, 775 
 
 Fehling's pessary for anteflexion, 372 
 
 Fibroids causing inversio uteri, 449, 453 
 
 of broad ligament, 656 
 
 uterine, simulating ovarian cyst, 620 
 Fibroma, cervical, 191 
 
 ovarian, 646 
 
 in round ligament, 657 
 
 uterine, 188 
 
 uterine, abdominal treatment, 238 
 
 uterine, alterations, 195 
 
 uterine, cancerous degeneration, 198 
 
 uterine, castration, 276 
 
 uterine, choice of methods, 274 
 
 uterine, connection with neighboring 
 organs, 194 
 
 Fibroma, uterine, connection with uterine 
 tissue, 192 
 
 uterine, course, 210 
 
 uterine, decortication for intra-ligamen- 
 tous. 263 
 
 uterine, degenerations, 195 
 
 uterine, diagnosis, 204 
 
 uterine, electricity in, 214 
 
 uterine, enucleation for encapsuled, 242 
 
 uterine, etiology, 212 
 
 uterine, mflammation, 197 
 
 uterine, gangrene, 197 
 
 uterine, histogeny, 188 
 
 uterine, interstitial, 190, 205 
 
 uterine, intra-ligamentous abdominal, 
 208 
 
 uterine, intra-ligamentous, decortica- 
 tion, 263 
 
 uterine, intra-ligamentous pelvic, 209 
 
 uterine, lesions, adjacent, 199 
 
 uterine, medical treatment, 213 
 
 uterine, of external os, 191, 205 
 
 uterine, pathology, 188 
 
 uterine, pedicled intra-uterine, 222 
 
 uterine, pedicled, myomectomy, 241 
 
 uterine, pelvic, 199, 220, 263 
 
 uterine, polypoid, 190, 206 
 
 uterine, prognosis, 210 
 
 uterine, structure and texture, 193 
 
 uterine submucous, 190, 206, 224 
 
 uterine subperitoneal, 190 
 
 uterine subperitoneal, pedicled, 207 
 
 uterine subperitoneal, sessile, 20S 
 
 uterine subvaginal, 192 
 
 uterine, suppuration, 197 
 
 uterine, supra-vaginal hysterectomy 
 for nodulated, 243 
 
 uterine, surgical treatment, 221 
 
 uterine, symptoms, 201 
 
 uterine, with cervical cancer, treat- 
 ment, 338 
 
 vulval, 845 
 Fibromata with hsemato-salpinx, 530 
 Fibro-myoma of vulva, 845 
 Fibro-sarcoma of uterus, 349 
 Fibrous tumors complicating pregnancy, 284 
 
 tumors of the vagina. 739 
 Fistula, cervical, 763 
 
 cicatricial vaginal, diagnosis, 746 
 
 cicatricial vaginal, direct closure, 71 
 
 cicatricial vaginal, indirect closure, 761 
 
 cicatricial vaginal, operative indica- 
 tions, 750 
 
 cicatricial vaginal, operative treatment, 
 752 
 
926 
 
 GENERAL INDEX. 
 
 Pistula, cicatricial vaginal, pathological an- 
 atom3% 743 
 
 cicatricial vaginal, prognosis, 748 
 
 cicatricial vaginal, sj'mptoms, 745 
 
 cicatricial vaginal, treatment, 748 
 
 entero-vaginal, 790 
 
 fecal, 775 
 
 intra-cervical, 764 
 
 juxta-cervical, 764 
 
 recto-vaginal, 775 
 
 uretero-cervical, 766 
 
 uretero-vaginal, 745, 747, 766 
 
 nrethro-vaginal, 745 
 
 vaginal, tuberculous, 664 
 
 vaginal, urinary, 743 
 
 vesico-vaginal, 744 
 
 vesico-utero-vaginal, 764 
 Plap-splitting in uretero-vaginal fistula, 769 
 
 in vaginal fistula, 757 
 Poetus, changes after death, in ectopic 
 pregnancy, 70S 
 
 in ectopic pregnancy, 713 
 Folliculitis, cervical, 129 
 Forceps, Collin's spring, 753 
 
 Collin's tumor, 222 
 
 Doyen's, for vaginal hysterectomy, 320 
 
 fixation, 89 
 
 haemostatic, 53, 55, 232 
 
 Aluseux, 222 
 
 Pean's morcellation, 231 
 
 2)rehension, 313 
 
 tongue, 33 
 
 toothed, 174 
 
 uterine dressing, 177 
 Forcipressure, haemostasis by, 53 
 Foreign bodies in vagina, 865 
 Freund's perineorrhaphy, 815 
 Fritsch's autoplasty, 783 
 
 perineorrhaphy, 827 
 
 Gangrene of vulva, 833 
 Oastro-hysteropexy, 400 
 
 Bode's method, 410 
 
 Dudley's method, 410 
 
 indications for, in retroversion, 408 
 
 Polk's method, 410 
 
 prognosis, 406 
 
 shortening the round ligaKient in, 409 
 
 shortening the utero-sacral ligaments 
 in, 409 
 
 without laparatomy, 406 
 
 Wylie's method, 410 
 Gastro-hysterorrhaphy for displacements, 
 
 401 
 Gauze sponges, 21 
 
 Gehrung's pessary, 427 
 
 Genital neuroses, 154 
 
 Genital organs, external, antisepsis, 3 
 
 organs, internal, xnassage, 575 
 
 organs, prolapse, 414 
 
 organs, tuberculosis of, 659 
 Genu-pectoral position in reduction of retro- 
 flexion, 379 
 Glandular cysts of broad ligament, 635 
 Gonococcus in metritis, 140 
 
 in vaginitis, 723 
 Gonorrhoea, a cause of salpingitis, 488 
 
 in vaginitis, 723, 729 
 Gussenbauer's suture, 38 
 Gynandry, 8S1 
 Gynaecological examination, after catharsis, 
 
 73 
 examination, bimanual, 79 
 examination, by palpation, 72 
 examination, by rectal touch, 78 
 examination, by speculum, 80 
 examination, by uterine sound, 87 
 examination, by vaginal touch, 77 
 examination, by vesical touch, 78 
 examination, catheterization, 74 
 examination, in dorsal position, 69 
 examination, in erect position, 68 
 examination, in knee-chest position, 7c 
 examination, in Sims' position, 71 
 examination, in Trendelenburg posi- 
 tion, 70 
 examination, with anesthesia, 76 
 examination, with intra-uterine touch, 
 
 89 
 examination, with uterine traction, 88 
 
 HyEMatocele, extra-peritoneal, 695 
 intra-peritoneal pelvic, 685 
 intra-peritoneal pelvic, diagnosis, 692 
 intra-peritoneal pelvic, disorders of 
 
 ovulation in, 687 
 intra-peritoneal pelvic, etiology, 685 
 intra-peritoneal pelvic, history, 6S5 
 intra-peritoneal pelvic, ovarian apo- 
 plexy in, 688 
 intra-peritoneal pelvic, pachy-perito- 
 
 nitis in, 688 
 intra-peritoneal pelvic, pathogenesis, 
 
 685 
 intra-peritoneal pelvic, pathological 
 
 anatomy, 688 
 intra-peritoneal pelvic, prognosis, 692 
 intra-peritoneal pelvic, rupture of extra- 
 uterine pregnane}' in, 688 
 intra-peritoneal pelvic, symptoms, 690 
 
GENERAL INDEX. 
 
 927 
 
 Heematocele, intra-peritoneal pelvic, syn- 
 onyms, 685 
 mtra-peritoneal pelvic, treatment, 692 
 intra-peritoneal pelvic, tubal reflex in, 
 687 
 
 retro-uterine, 685 
 Hsematocolpos, 912 
 Haematoma of vulva, S41 
 Haematometra, 912 
 Haemato-salpinx, 528, 912 
 Haemostasis, by forcipressure, 53 
 t)y ligature, 48 
 
 in abdominal hysterotomy, 240 
 Hagedorn needles, 36 
 Heart lesions, in uterine fibroma, 203 
 
 lesions, in cervical cancer, 297 
 Hegar's colpo-perineorrhaphy, 429 
 
 dilator, 94 
 
 perineorrhaphy, 810 
 
 supra-vaginal hysterectomy, 247 
 Hemorrhage after abdominal hysterectomy, 
 269 
 
 after vaginal hysterectomy, 322 
 
 in operation for fistula, 773 
 
 in uterme fibroma, 201 
 Haemostatic vaginal tamponade, 65 
 Heppner's perineorrhaphy, 875 
 Hermaphrodism, 880 
 
 pseudo-, 881 
 
 true, 889 
 Herpes of vulva, 835 
 Hewitt's anteversion pessary, 366 
 Hildebrandt's perineorrhaphy, 815 
 Hodge's pessary for retroflexion, 384 
 Horn, uterine, 706 
 
 pregnancy m, 718 
 Huguier on prolapse, 418 
 Hydrocele of round ligament, 657 
 Hydrometa, 912 
 Hydro-salpinx, 527 
 Hymen, anomalies, 876 
 
 atresia, 878 
 
 congenital absence, 879 
 
 development, 874, 894 
 
 infantile, 874 
 
 malformation, 874 
 Hypnosis in anaesthesia, 29 
 Hypospadias, 872 
 Hysterectomy, abdominal, 238 
 
 abdominal, accidents, operative, 267 
 
 abdominal, Bardenheuer's, 262 
 
 abdominal, death after, 269 
 
 abdominal, extra-peritoneal method, 
 statistics, 272 
 
 abdominal, for fibromata, 238 
 
 Hysterectomy, abdominal, haemostasis dur- 
 ing, 240 
 abdominal, in appendageal lesions, 550 
 abdominal, indications, 239 
 abdominal, intra-peritoneal method, 
 
 statistics, 273 
 abdominal, methods compared, 273 
 abdominal, mortality, 271 
 abdominal, statistics, 272 
 abdominal, synonyms, 239 
 abdominal, total, 257 
 abdominal, total, Baer's, 261 
 abdominal, total, Chrobak's, 260 
 abdominal, total. Doyen's, 261 
 alidominal, total, Martin's, 259 
 abdominal, total, Pean's, 261 
 abdominal, total, Richelot's, 262 
 supra-vaginal. 243 
 supra-vaginal, extra-peritoneal method, 
 
 247 
 supra-vaginal, for nodulated fibroma, 
 
 243 
 supra-vaginal, intra-peritoneal, 246 
 s'jpra- vaginal, mtra-peritoneal method, 
 
 246 
 supra-vaginal, mixed method, 254 
 supra-vaginal, of gravid uterus, 287 
 supra- vaginal, partial, 244 
 supra-vaginal, technique, 244 
 Thiriar's cuneihysterectomy, 373 
 vaginal, 313 
 vaginal, accidents, 321 
 vaginal, by forcipressure, 313 
 vagina], by ligature (Martin), 316 
 vaginal, causes of death, 322 
 vaginal, in lesions of, appendages, 547, 
 
 549 
 vaginal, in prolapse, 444 
 vaginal, in pelvic abscess, 572 
 vaginal, in uterine fibroma, 233 
 vaginal, modified Martin's, 319 
 vaginal, mortality, 321 
 vaginal, Pozzi's, m prolapse, 444 
 vaginal, sacral method, 330 
 vaginal, statistics, 324 
 vagina], survival after, 324 
 
 Hystropexy, vaginal, 393 
 
 Hysterotomy, abdominal, 239 
 
 ICHTHYOL, 9 
 
 Implantation, ureteral, for fistula, 769 
 
 Incision m haematocele, 693 
 
 Infection, peritoneal, in ovarian cysts, 605 
 
 puerperal, a cause of salpingitis. 489 
 Inflammation of Bartholin's glands, 853 
 
92 8 
 
 GENERAL INDEX. 
 
 Inflammation of the uterine appendages, 
 general considerations, 4S1 
 of the uterine appendages, oophoro-sal- 
 
 pingitis, non-cystic, 4S7 
 peri-uterine, 552 
 of vulva, 831 
 Injection in uterine fibroma, 220 
 Insanity after ovariotomy, 644 
 Instruments, antisepsis, 2 
 preparation, 17 
 sterilization, 17 
 used in ovariotomy, 627 
 Intestinal coils in tubercular peritonitis, 
 680 
 occlusion after abdominal hysterec- 
 tomy. 271 
 sutures, 38 
 Interstitial pregnancy, 703 
 Intra - peritoneal supra- vaginal hysterec- 
 tomy, 246 
 Intra-uterine disinfection, 12 
 drainage, 64 
 injections, 11 
 touch, 89 
 Inversion of the uterus, 448 
 diagnosis, 452 
 etiology, 448 
 
 pathological anatomy, 450 
 pathology, 448 
 prognosis, 453 
 reduction, forcible, 453 
 reduction, gradual, 454 
 removal in, 454 
 symptoms, 451 
 treatment, 453 
 Iodine injections m ovarian cysts, 623 
 Iodoform crayons, 11 
 
 gauze, 8 
 Irrigation, continuous intra-uterine, 64 
 Irrigator, vaginal, 5 
 
 Kangaroo tendon, 50 
 Kelly's cystoscope, 104 
 
 pads, 69 
 Kidney degeneration, in uterine fibroma, 
 202 
 
 effect of antesthesia on, 32 
 
 extirpation, in fistula, 772 
 
 lesions, m cervical cancer, 296 
 Knee-chest position, 72 
 Knee-elbow position, 72 
 Kiichenmeister's scissors, 94 
 
 Labor, ovariotomy during, 644 
 Laceration of the perineum, boo 
 
 Lamp-wick drainage, 61 
 
 Landau's operation for uretero-vaginal fis- 
 tula, 767 
 
 Laparatomy in appendageal lesions, 549 
 incision by, in abscess, 570 
 in ectopic pregnane)', 713, 718 
 in hsematocele, 694 
 preparation for, 14 
 subperitoneal, m abscess, 568 
 
 Laroyenne's trocar, 565 
 
 Lauenstein's perineorrhaphy, 815 
 
 Le Fort's operation of vaginal closure, 437 
 perineorrhaph}', 815 
 
 Leg-holders, 70 
 
 Lembert's suture, 38 
 
 Leopold's gastro-hysteropexy, 403 
 
 Leucorrhcea m metritis, 152 
 
 Ligament, broad, cysts, 602 
 
 broad, cysts in salpingitis, 511 
 broad, enucleation of cysts, 633 
 broad, marsupialization of cj'st, 636 
 broad, papillary and glandular cysts, 
 
 635 
 
 broad, phlegmon, 552, 562 
 
 broad, tumors, 653, 655 
 
 round, Alexander's operation of short- 
 ening, 389, 411 
 
 round, shortening, for uterine prolapse, 
 441 
 
 round, utero-sacral, shortening, in gas- 
 tro-hysteropexy, 409 
 
 round, tumors, 653, 657 
 Ligator, Pozzi's, 53 
 Ligatures, absorption of, 51 
 
 chain, 244 
 
 elastic, 25, 52 
 
 in hysterotomy, 240 
 
 methods of using, 48 
 
 preparation, 23 
 Lipoma of broad ligament, 656 
 
 of vulva, 846 
 Lupus of vulva, 837 
 Lymphatics, uterine, 483 
 Lysol, 10 
 
 Mackenrodt's vagino-fixation, 3()4 
 Malformations of vagina and uterus, 892, 
 896 
 
 of vulva, 867 
 Marsupialization in ectopic pregnancy, 718' 
 
 of broad-ligament cyst, 636 
 Martin's colpo-perineorrhaphy, 431 
 
 perineorrhaphy. 815 
 
 total abdominal liysterectomy, 259 
 
 vaginal hysterectomy, 316 
 
GENERAL INDEX. 
 
 929 
 
 Massage in metritis, 180 
 
 in salpingitis, 520,- 
 
 of internal genitals, 575 
 Meatus, urinary, vascular tumors, 847 
 Menorrhagia, 473 
 
 pathology and etiology, 473 
 
 symptoms, 473 
 
 treatment, 474 
 Menstruation after ovariotomy. 644 
 
 amenorrhcea from removing ovaries, 470 
 
 disorders of, 46S 
 
 influence of ovarian cysts on, 611 
 
 in metritis, 147 
 
 precocious and protracted, 468 
 
 vicarious, 472 
 Mercury bichloride, 3 
 Methyl violet, 10 
 Methylene aneesthesia, 30 
 Metritis, acute, 113, 157 
 
 acute inflammatory, 112 
 
 bacteriolog}', 140 
 
 castration, 186 
 
 catarrhal, 112, 158, 166 
 
 cervical, 135 
 
 chronic, 117 
 
 chronic glandular, 121 
 
 chronic interstitial, 120 
 
 chronic, painful, 112, 159, 179 
 
 chronic polypoid, 122 
 
 classification, no 
 
 course, 160 
 
 definition, 109 
 
 diagnosis, 160 
 
 dysmenorrhoea, 153 
 
 erosion complicated by laceration, 178 
 
 etiology, 147 
 
 general condition, 156 
 
 general treatment, 164 
 
 gonorrhoeal, 141 
 
 gonorrhoea! , treatment, 166 
 
 hemorrhagic, 112, 158, 178 
 
 leucorrhoea, 152 
 
 local treatment, 165 
 
 metrorrhagia, 153 
 
 pain in, 151 
 
 pathogeny, 139 
 
 pathology, 112 
 
 physical signs, 156 
 
 prognosis, 160 
 
 prophylaxis, 163 
 
 pseudo-, no 
 
 symptoms, 151 
 
 symptoms from adjacent organs, 153 
 
 treatment by cauterization, 169 
 
 treatment by curettage, 172 
 
 Metritis, treatment by drainage, 167 
 
 treatment by intra-uterine irrigation, 
 
 167 
 treatment by tampon, 168 
 treatment of acute gonorrhoeal, 166 
 
 Metastasis m ovarian cysts, 605 
 
 Metrorrhagia, 473 
 m metritis, 153 
 
 Morcellation in submucous uterine fibroma, 
 228 
 
 Morgagni, hydatid of, in salpingitis, 511 
 
 Miillerian cysts m salpingitis, 510 
 ducts, development, 867, 892 
 
 Miiller's vaginal hysterectomy for prolapse, 
 442 
 
 Munde's pessary for retroflexion, 385 
 
 Myomectomy for pedicled fibroma, 241 
 simple, of gravid uterus, 2S6 
 
 Myxoma of vulva, 845 
 
 Naboth, ovules of, 129 
 
 Needle-holders, 37 
 
 Needles, 35 
 
 Nervous disorders and dysmenorrhoea, 476 
 
 Neuralgia of genital origin, 154 
 
 lumbo-abdominal, 517 
 Neuroma of vulva, 846 
 Neuroses of genital origin, 155 
 Nicolitis' vaginal hysteropexy, 398 
 Normal salt solution, 23 
 
 Obliteration, direct, of uretero-vaginal fis- 
 tula, 767 
 
 indirect, of uretero-vaginal fistula, 772 
 Occlusion, intestinal, after hysterectomy, 
 271 
 
 intestinal, after ovariotomy, 641 
 CEdema of vulva, 833 
 Olshausen's gastro -hysteropexy, 403 
 Oophoro-salpingitis, cystic (see Pyo-sal- 
 pinx), 523 
 
 non-cystic (see Salpingitis), 487 
 Oophoro-salpingotomy, 548 
 
 in pyo-salpinx. 542 
 
 in salpingitis, 521 
 
 statistics, 54S 
 Oophorectomy in dysmenorrhoea, 478 
 Operation, conservative, in pyo-salpinx, 546 
 
 irrigation during, 13 
 
 preparation for abdominal, 14 
 Ovarian apoplexy, intra-cystic, 604 
 
 cysts, abdominal stage, 609 
 
 cysts, accidents m, 612 
 
 cysts, adhesions in, 603 
 
 cysts, ascites in, 604 
 
930 
 
 GENERAL INDEX. 
 
 Ovarian cysts, complicated by pregnancy, 
 644 
 
 cysts, diagnosis, 616 
 
 cysts, etiology, 608 
 
 cysts, exploratory incision, 621 
 
 cysts, influence on menstruation, 611 
 
 cysts, iodine injections, 623 
 
 cysts, metastasis, 605 
 
 cysts, ovariotomy, 624 
 
 cysts, pathological anatomy, 577 
 
 cysts, pedicle, 602 
 
 cysts, pedicle, torsion of, 605 
 
 cysts, pelvic stage, 609 
 
 cysts, peritoneal infection m, 605 
 
 cysts, prognosis, 614 
 
 cysts, proligerous or proliferous, 577 
 
 cysts, rupture. 613 
 
 cysts, suppuration, 605, 612 
 
 cysts, sj'mptoms, 608 
 
 cj'sts, torsion of pedicle, 612 
 
 cysts, treatment, 623 
 
 cysts, Waldeyer's theory of origin, 585 
 
 pregnancy, 705 
 Ovariotomy, accidents, 638 
 
 in ovarian cysts, 624 
 
 results, 643 
 
 statistics, 642 
 
 vaginal, 638 
 Ovaritis, chronic, in salpingitis, 501 
 
 chronic disseminated, in salpingitis, 502 
 
 chronic hypertrophic, in salpingitis, 502 
 
 chronic (Edematous, 533 
 
 classification. 486 
 
 cortical, m salpingitis, 500 
 
 cortical sclerotic, in salpingitis, 501 
 
 cystic, 531 
 
 diffuse, in salpingitis, 501 
 
 suppurative, in salpingitis, 501 
 
 total sclerotic, in salpingitis, 503 
 Ovary, blood cysts, 534 
 
 carcinoma, 650 
 
 castration, for uterine fibroma, 276 
 
 cauterization, in castration, 279 
 
 cirrhosis, in salpingitis, 504 
 
 cyst of, 531 
 
 cyst, with cervical cancer, treatment, 
 338 
 
 cystic disease, 502, 533 
 
 degeneration, fatty, in salpingitis, 502 
 
 degeneration, micro-cystic, in salpin- 
 gitis, 502 
 
 dermoid cysts, 589 
 
 diseases of, simulating salpingitis, 516 
 
 endothelioma, 648 
 
 epithelioma, 650 
 
 Ovary, fibroma, 646 
 
 follicular cyst, in salpingitis, 505 
 
 lesions, in salpingitis, 500 
 
 lymphatic cysts, 536 
 
 parovarian cysts, 596 
 
 partial resection, Pozzi's, 545 
 
 pedicle in cysts, 602 
 
 purulent cysts, 535 
 
 removal, causing amenorrhoea, 470 
 
 removal, causing uterine atrophy, 465 
 
 sarcoma, 647 
 
 suppuration, m salpingitis. 513 
 
 tuberculosis, 673 
 
 tumors, solid, 646 
 Ovulation, disorders of. in ha;matocele, 687 
 
 Pachy- PERITONITIS m hsematocele, 688 
 Pachy-salpingitis, 496 
 Pachy-vaginitis, cystic, 728 
 Palpation, abdominal, 72 
 in prolapse, 424 
 in pyo-salpinx. 538 
 in salpingitis, 515 
 ureteral, 97 
 Papillary cysts (jf broad ligament, enuclea- 
 tion, 634 
 Papilloma of Fallopian tube, 654 
 Parametritis, 552 
 Parotiditis, after ovariotomy, 641 
 Parovarian cysts, 596 
 
 hyaline cysts, enucleation, 633 
 varicocele, 656 
 Parturition, causing metritis, 148 
 Pawlik's ureteral catheters, 102 
 
 urethral operation for incontinence, 775 
 Pean's morcellation forceps, 231 
 retractors. 233 
 
 total abdominal hysterectomy, 261 
 Pedicle in hysterectom}', extra-peritoneal 
 treatment, 247 
 Hegar's extra-peritoneal treatment, 
 
 247 
 intra-peritoneal treatment, 246 
 Sanger's mixed method, 256 
 Schroder's intra-peritoneal treat- 
 ment, 24(1 
 Wolfler-Haeker's method, 255 
 Zweife]"s treatment, 253 
 in ovarian cyst, 602 
 in ovarian cyst, torsion, 605, 612 
 m ovariotomy, treatment. 631 
 Pediculated ovarian cysts, operation for, 627 
 Pelvic abscess. 552. 555. 560, 564 
 abscess, method of treating, 567 
 cellulitis, 552, 564 
 
GENERAL INDEX. 
 
 931 
 
 Pelvic peritonitis. 552 
 Pental anaesthesia, 30 
 Perimetritis, 552 
 Perimetro-salpingitis, 552 
 . diagnosis, 559 
 
 historical sketch, 552 
 
 prognosis, 564 
 
 pathological anatomy, 554 
 
 serous, 554, 559 
 
 suppurative, 555 
 
 symptoms, 559 
 
 treatment. 565 
 Perineauxesis for prolapse, 431 
 Perineotomy for pelvic abscess. 567 
 Perineorrhaphy, after-treatment, 828 
 
 Emmet's, complete rupture, 819 
 
 Emmet's, incomplete rupture, 806 
 
 Freund's, 815 
 
 Fritsch's, 827 
 
 Heppner's, 815 
 
 Hildebrandt's, 815 
 
 in recto-vaginal Hstula, 777 
 
 Lauensrein's. 815 
 
 Le Fort's, 815 
 
 Martin's, 815 
 
 Pozzi's, 824 
 
 prognosis and results, 829 
 
 Richet's, 819 
 
 Simon's, complete rupture, 810 
 
 Simon's, incomplete rupture, S05 
 
 Simpson's, 827 
 
 Tait's, complete rupture, 823 
 
 Tait's, incomplete rupture, 808 
 Perineal laceration, complete, 810 
 diagnosis, 802 
 etiology, 800 
 incomplete, 805 
 pathology, 801 
 symptoms, 802 
 treatment, 803 
 Peritoneal drainage, 56 
 
 drainage tubes, 60 
 Peritonitis, pelvic. 552 
 
 septic, after ovariotomy, 639 
 
 subacute, after ovariotomy, 641 
 
 tubercular, 676 
 
 tubercular, exudations, 679 
 
 tubercular, omental tumors, 678 
 
 tubercular, intestinal coils, 680 
 Peritoneum, care, 22 
 
 flushing, 22 
 
 infection, in ovarian cysts, 605 
 
 tamponade, 6r 
 Pessary, Borgnet's, 426 
 
 Dumontpallier's anteversion, 364 
 
 Pessary. Dumontpallier's retroflexion. 383 
 
 Fehling's, 372 
 
 Gehrung's, 427 
 
 Hewitt's, 366 
 
 Hodge's, 384 
 
 in anteflexion, 372 
 
 in anteversion, 364 
 
 in prolapse, 426 
 
 in retroflexion, 383 
 
 Mund6's, 385 
 
 Roser-Scanzoni. 426 
 
 Schultze's, 388 
 
 Simpson's, 372 
 
 Smith's, 3S3 
 
 Thom.as' anteflexion, 372 
 
 Thomas' anteversion. 366 
 
 Thomas' retroflexion, 384 
 Pfliiger's tubes, 585 
 
 Phlegmon of the broad ligament, 552, 562 
 Placenta, normal, 115 
 Polk's gastro-hysteropexy, 410 
 Polj'pus, cervical, 137 
 
 vaginal, 739 
 
 vpith inversio uteri, 452 
 Positions for gynaecological examinations, 
 
 68 
 Pozzi's enucleator, 225 
 
 operation for vaginismus, 798 
 
 perineorrhaphy, 824 
 Pregnancy, abdominal, 706 
 
 after ovariotomy, 644 
 
 after vagino-fixation, 397 
 
 extra-uterine, changes after death of 
 foetus, 708 
 
 extra-uterine, classification, 697 
 
 extra-uterine, condition of uterus in, 707 
 
 extra-uterine, diagnosis. 709 
 
 extra-uterine, elj'trotomy in, 713, 720 
 
 extra-uterine, etiology, 697 
 
 extra-uterine, laparatomy in, 713, 718 
 
 extra-uterine, pathological anatomy, 698 
 
 extra-uterine, pathology, 697 
 
 extra-uterine, prognosis, 712 
 
 extra-uterine, rupture of, in hsemato- 
 cele, 688 
 
 extra-uterine, sj'mptoms, 708 
 
 extra-uterine, treatment, 712 
 
 fibrous tumors complicating, 284 
 
 in rudimentary titerine horn, 706 
 
 interstitial, 703 
 
 ovarian, 705 
 
 tubal, 698 
 
 tubo-abdominal, 704 
 
 tubo-uterine, 703 
 
 with cervical cancer. 302. 337 
 
932 
 
 GENERAL INDEX. 
 
 Prolapse of genital organs, 414 
 
 colpo-perineorrhaphy, 429 
 course, 425 
 cystocele, 415 
 diagnosis, 425 
 elytrorrhaphy, 429 
 etiology, 414 
 Huguier on, 418 
 
 of uterus, shortening round liga- 
 ments, 441 
 of vagina alone. 415 
 of vagina without cervical hyper- 
 
 troph)', 446 
 of vagina and uterus from primary 
 
 cervical hj'pertrophy, 417 
 of vagina and uterus with cervical 
 
 hypertrophy, 416, 446 
 of vagina and uterus without cervi- 
 cal hj'pertrophy, 421, 447 
 palpation, 424 
 pessary, 426 
 prognosis, 425 
 rectocele, 415 
 sound, 424 
 
 surgical treatment, 428 
 s^'raptoms, 423 
 therapeutic indications, 445 
 treatment, 425 
 vaginal closure, 437 
 vaginal hj'sterectomy. 444 
 ventro-fixation, 441 
 Pruritus vulvse, 858 
 Pr\-or's fixatio uteri, 399 
 Puncture in ovarian C5'sts, 619 
 
 in pyo-salpinx, 539 
 Pyocolpos, 912 
 Pyoktanin, 10 
 Pyometra, 912 
 Pyo-salpinx, 523 
 course, 540 
 diagnosis, 538 
 duration, 540 
 
 ofiphoro-salpingotomy, 542 
 pathological anatomy, 523 
 prognosis, 540 
 symptoms, 536 
 termination, 540 
 treatment, 542 
 tubercular, 527 
 
 R£camier's curette, cutting, 334 
 Rectocele in prolapse, 415 
 Recto-vaginal fistulee, anatomy, 776 
 
 diagnosis and symptoms, 776 
 
 etiology. 77? 
 
 Recto-vaginal fistulae, prognosis, 777 
 
 treatment, 777 
 Rectum, compressi<m, in uterine fibroma. 
 202 
 operation by. in recto-vaginal fistula, 
 789 
 Reduction of retroflexion, 379 
 
 bimanual, 380 
 
 fixation, 383 
 
 genu-pectoral position, 379 
 
 pessary, 383 
 
 sound, 381 
 Reindeer tendon, 50 
 Respiration, effect of anaesthesia on, 33 
 Retrodeviations of the uterus, 374 
 
 Alexander's operation, 389 
 
 pessary, 383 
 
 reduction of retroflexion, 379 
 Retroflexion of uterus, 376 
 
 choice of operations, 411 
 
 diagnosis, 378 
 
 etiology, 376 
 
 pathology, 376 
 
 reduction, 379 
 
 salpingitis in, 377 
 
 symptoms, 377 
 
 treatment, 378 
 Retroposition of the uterus, 412 
 Retroversion of the uterus, 374 
 
 diagnosis, 375 
 
 etiology, 374 
 
 gastro-hysteropexy, 408 
 
 pathology, 374 
 
 symptoms, 375 
 
 treatment, 376 
 Richelot's total abdominal hysterectomy, 
 
 262 
 Richet's perineorrhaphy, 8ig 
 Roser-Scanzoni pessary, 426 
 Rupture, varicose, m pelvic hsematocele, 687 
 
 Salpingitis, acute catarrhal and purulent, 
 
 487 
 acute purulent non-cystic, 492 
 atrophic, 498 
 catarrhal, 491 
 contamination from exploration, a 
 
 cause, 490 
 chronic hypertrophic, 498 
 chronic parenchymatous, 487 
 classifications, 485 
 course, 518 
 
 cysts of broad ligament, 511 
 cysts of corpus luteum, 508 
 differential diagnosis, 516 
 
GENERAL INDEX. 
 
 933 
 
 Salpingitis, electricity in, 520 
 
 follicular cyst of ovary in, 505 
 
 gonorrhceal infection as cause, 4S8 
 
 hydatid of Morgagni in, 511 
 
 in retroflexion, 377 
 
 intestinal origin, 491 
 
 lesions of ovary in, 500 
 
 lesions of tubes in, 491 
 
 massage in, 520 
 
 Miillerian and Wolflian cysts in, 510 
 
 oophoro-salpingotomy, 521 
 
 ovaritis, chronic disseminated, 502 
 
 ovaritis, chronic hypertrophic, 502 
 
 ovaritis, chronic sclerotic, 501 
 
 ovaritis, cortical, 500 
 
 ovaritis, diffuse, 501 
 
 ovaritis, suppurative, 501 
 
 ovaritis, total sclerotic, 503 
 
 ovary, fatty degeneration, 502 
 
 pathological anatomy, 491 
 
 perimetro-, 552 
 
 prognosis, 518 
 
 puerperal infection a cause, 489 
 
 supra-tubal cyst, 511 
 
 suppuration of ovary, 513 
 
 symptoms, 514 
 
 tubercular, 490 
 
 treatment, 519 
 Salpingostomy, Skutsch's, 545 
 Salt solution, normal, 23 
 Sanger's autoplasty, 783 
 
 gastro-hysteropexy, 403 
 
 vagino-fixation, 394 
 Sarcoma, diffuse, of uterine mucous mem- 
 brane, 348 
 
 of broad ligament, 656 
 
 of Fallopian tube, 654 
 
 of ovary, 647 
 
 of vagina, 740 
 
 of vulva, 850 
 Scarilicators, cervical, 166 
 
 intra-uterine, in fibroma, 221 
 Schede's operation for uretero-vaginal fis- 
 tula, 768 
 Schimmelbusch's sterilizer, 19 
 Schroder's cervical amputation, 183 
 
 supr a - vaginal cervical amputation, 
 309 
 
 supra-vaginal hysterectomy, 246 
 Schiicking's vagino-fixation, 393 
 Schultze's pessary for retroflexion, 388 
 Scraping in metritis, 168 
 S6gond*s autoplasty, 786 
 
 hysterectomy for appendageal lesions, 
 547 
 
 Septicaemia, after abdominal hysterectomy, 
 270 
 
 after vaginal hysterectomy, 323 
 Shock, after abdominal hysterectomy, 270 
 
 after ovariotomy, 642 
 
 after vaginal hysterectomy, 323 
 Silk, preparation, 23, 38 
 Silkworra-gut suture. 25, 38, 39 
 Silver wire suture, 25, 38 
 Simon's catheterism, 103 
 
 cervical amputation, 182 
 
 cutting spoon, 334 
 
 operation for uretero-vaginal firtula, 
 767 
 
 perineorrhaphy, complete rupture, 810 
 
 perineorrhaphy, incomplete rupture, 
 805 
 Simpson's perineorrhaphy, 827 
 
 stem pessary, 372 
 Sims' curette, cutting, 334 
 
 operation for vaginal fistula. 750 
 
 position, 71, 76 
 Skutsch's salpingostomy, 545 
 Smith's retroflexion pessary, 383 
 Sound, m reduction of retroflexion, 381 
 
 uterine, 86 
 
 utefine, in prolapse, 424 
 Specula, vaginal, 81 
 Speculum, examination by, 80 
 Sponges, gauze, 21 
 
 in ovariotomy, 627 
 
 sterilization, 20 
 Spray, antiseptic, 22 
 Stenosis, acquired, of vulva and vagina, 862 
 
 of cervix, 457 
 
 diagnosis, 458 
 dysmenorrhoea in, 457 
 of vagina, 901 
 prognosis, 459 
 sterility in, 458 
 treatment, 459 
 Sterility in stenosis cervicis, 458 
 Sterilization of dressings, 18 
 
 of instruments, 17 
 
 of ligatures, 23 
 
 of ponges, 20 
 
 of sutures, 23 
 Sterilizers, 17 
 
 Stoltz's colpo-perineorrhaphy, 436 
 Stomatoplasty for cervical stenosis, 461 
 Suppuration in ovarian cysts, 605 
 Supra-pubic route, m operation for vaginal 
 
 fistula, 760 
 Supra-vaginal hysterectomy, 243 
 Suture, buried. 46 
 
934 
 
 GENERAL INDEX. 
 
 Suture, continuous, 41 
 
 continuous, in layers, 42 
 
 interrupted. 40 
 
 intradermic, 44 
 
 materials, 38 
 
 methods, 40 
 
 mixed, 43 
 
 quilled, 47 
 Sutures, preparation of, 23 
 Syndroma, uterine. 151 
 Syphilides of vulva, 836 
 
 Table, laparatomy, 16 
 Tait's gastro-hysteropexy, 401 
 
 perineorrhaphy, complete rupture, 823 
 
 perineorrhaphy, incomplete rupture, 808 
 Tampon in metritis, 168, 180 
 Tamponade of the peritoneum, 61 
 
 of vagina, 65 
 Tents, dilatation by, 91 
 
 laminaria, 11 
 Terrier's gastro-hj-steropexy, 405 
 Thiol, 10 
 Thiophane, 10 
 
 Thiriar's cunei-hysterectomy, 373 
 Thomas' anteflexion pessary, 372 
 
 anteversiou pessary, 366 
 
 curette, serrated, 334 
 
 retroflexion pessary, 3 84 
 Trachelorrhaphy, Emmet's, 1S4 
 Traumatism causing metritis, 149 
 Trocar m ovarian cysts, 630 
 Tubal pregnancy, 698 
 Tube, cysts, 523 
 
 diseases, 487 
 
 lesions, 491 
 
 tuberculosis, 673 
 
 tumors, 653 
 Tubes, removal of both, one being diseased, 
 
 545 
 Tuberculosis cervicis, 662 
 
 genital and peritoneal, 659 
 
 genital, 659, 662, 668, 673 
 
 genital, primar}', 659 
 
 genital, secondary, 66i 
 
 ovarii, 673 
 
 peritoneal, 676 
 
 tubae, 673 
 
 uteri, 668 
 
 vaginas, 662 
 
 vulvae, 662 
 Tubo-ovarian cysts, 528 
 
 Tumors, abdominal, in diagnosis of ova- 
 rian cysts, 616 
 
 fibrous, complicating pregnancy, 284 
 
 Tumors, fibrous uterine, 188 
 of clitoris, 852 
 of Fallopian tube, 653 
 of round ligaments, 657 
 of vulva, 841 
 
 pelvic, in diagnosis of ovarian cysts, 6i6> 
 peritoneal tubercular, 678, 680, 681 
 simulating ovarian cyst, 620 
 varicose, of vulva, 841 
 vascular, of urinary meatus, S47 
 
 Ulcerations, vaginal tuberculous, 743 
 Uretero-vaginal fistulae, 766 
 Ureters, catheterization, Kelly, 104 
 
 catheterization, Pawlik. 99 
 
 catheterization, Simon, 103 
 
 exploration of, 97 
 
 lesions, in cervical cancer, 296 
 
 palpation, 97 
 Urethrocele, 425 
 Uterine abscess, 114 
 
 dyspepsia, 154 
 
 reflexes, 154 
 
 sounds, 86 
 
 s^mdroma, 151 
 Uterus, absence, 902 
 
 adenoma, 339 
 
 anomalies, 910 
 
 anteflexion, 366 
 
 anteversion, 363 
 
 antisepsis, 10 
 
 atrophy, congenital, 463 
 
 bicornis, 906 
 
 bilocular, 908 
 
 cancer of bod}-, 339 
 
 carcinoma, 341 
 
 condition, m extra-uterine pregnancy^ 
 
 707 
 deciduoma nialignum, 351 
 development, 892 
 didelphic, 908 
 dilatation by divulsion. 92 
 dilatation by incision, q4 
 dilatation by sounds, 93 
 dilatation bjf tents, 90 
 dilatation, permanent, 95 
 disinfection of cavity, 12 
 displacements, 360 
 double, 906 
 epithelioma, 341 
 
 examination by downward traction, 88 
 exploratory incision and curetting, g6 
 fibromata, i38 
 fibro-sarcoma, 349 
 infantile, 909 
 
GENERAL INDEX. 
 
 935 
 
 "Uterus, inflammation, mistaken for salpin- 
 gitis, 517 
 
 inversion, 448 
 
 malformations, 902 
 
 normal mucosa of, 11 1 
 
 normal mucosa during menstruation, 
 114 
 
 pregnancy in rudimentary horn, 706 
 
 prolapse, 416 
 
 prolapse in inversio uteri, 452 
 
 prolapse, shortening round ligaments, 
 441 
 
 retroflexion. 376 
 
 retroversion, 374 
 
 sarcoma, 348 
 
 tuberculosis, 668 
 
 unicorn, 904 
 
 ventro-fixation for prolapse, 441 
 
 'Vagina, absence, 8g6 
 
 atresia, 862 
 
 cancer, 739 
 
 closure, for prolapse, 437 
 
 congenital atresia and stenosis, 901 
 
 development, 892 
 
 diseases of, 723 
 
 double, 900 
 
 fistulse, cicatricial, 743 
 
 foreign bodies in, 865 
 
 malformations, 867, 896 
 
 obliteration, for fistula, 772 
 
 operation by, in recto-vaginal fistula, 
 780 
 
 prolapse. 415 
 
 prolapse, with cervical hypertrophy, 446 
 
 stenosis, acquired, 862 
 
 tamponade, 65, 66 
 
 tuberculosis, 662 
 
 tuberculous fistula, 664 
 
 tumors, 733 
 
 unilateral, 899 
 
 wounds, 861 
 "Vaginal disinfection, 5 
 
 drainage, 58 
 
 examination, 77 
 
 hysterectomy, 313 
 
 hysterectomy in prolapse, 444 
 
 hysteropexy, 393 
 
 incision in dysmenorrhoea, 480 
 
 ovariotomy, 638 
 
 route in operation for vaginal fistula, 
 751 
 
 specula, 8 I 
 "Vaginismus, classification, 794 
 
 diagnosis, 796 
 
 Vaginismus, etiology, 794 
 
 history, 794 
 
 pathology. 795 
 
 symptoms, 796 
 
 treatment, 797 
 Vaginitis, diagnosis, 729 
 
 emphysematous, 728 
 
 etiology, 723 
 
 granular, 726 
 
 pathogenesis. 723 
 
 pathological anatomy, 726 
 
 prognosis. 729 
 
 senile, 727 
 
 simple, 727 
 
 symptoms, 728 
 
 treatment, 730 
 Vagino-fixation, 393 
 
 Diihrssen's, 394, 396 
 
 Mackenrodt's, 394 
 
 pregnancy after, 397 
 
 Sanger's. 394 
 
 Schiicking's, 393 
 
 von Rabenau's, 393 
 Varicocele, parovarian, 656 
 Varicose rupture in haematocele, 687 
 Vegetations of vulva, 841 
 Ventro-fixation for displacements, 400 
 
 for prolapse, 441 
 Vesical examination by Kelly's method, 
 
 105 
 Vulva, atresia, 863 
 
 cancer, 849 
 
 cysts, 846 
 
 eczema. 834 
 
 elephantiasis Arabum, 843 
 
 enchondroma, 846 
 
 erysipelas, 834 
 
 fibroma, 845 
 
 hsematoma, 841 
 
 herpes, 835 
 
 lipoma, 846 
 
 lupus, 837 
 
 neuroma, 846 
 
 oedema and gangrene", 833 
 
 pruritus, 858 
 
 stenosis, acquired, 862 
 
 syphilides, 836 
 
 tuberculosis, 662 
 
 tumors, 841 
 
 vegetations, 841 
 
 wounds, 861 
 Vulvitis, 831 
 
 Walueyer's theory of origin of ovarian 
 cysts, 585 
 
93^ GENERAL INDEX. 
 
 Wiesnegg's sterilizing oven, 21 Wounds, drainage of, 55 
 
 Winckel's colpo-perineorrhaphy, 433 of vulva and vagina. 861 
 Wolffian body, development, 867 
 
 cysts in salpingitis, 510 Zweifel's pedicle treatment in hysterec- 
 
 Wolfler-Hacke's pedicle treatment in hys- tomy, 253 
 terectomy, 255 
 
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 with 456 illustrations in black and numerous tints, and a chromo-litho- 
 graphic plate. Eighth revised and enlarged edition. Muslin, $5.50 ; 
 leather, $6.50. 
 
 Ziemssen, H. Von, M.D. Munich. 
 
 CYCLOPEDIA OF THE PRACTICE OF MEDICINE. By Vari- 
 ous Authors. Complete in twenty volumes, royal Svo. Price per 
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